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However, it is an optionif themotherisnolonger breastfeeding, or breastfeedingless frequently six months afterchildbirth. Thesemethods include combined oral contraceptives andcombinedinjectable contraceptives (Mesigyna andCyclofem). Best choice: Alternative choice: Less preferable: combined oestrogen non-hormonal methods progestin-onlymethods progestinmethods. Allmodernfamily planning methods can be used immediatelyafterpost-abortion care, providedthat: Youshould advise womennot to have sexualintercourse until theirbleeding stops (usually? Summary of StudySession In Study Session 11,you have learnedthat: 1 Postpartumfamilyplanning is theinitiationand useoffamilyplanning methods in the? The aimistoprevent unintendedpregnancy, toosoon afterchildbirth,whenanother pregnancy couldbeharmful to thehealth of themotherorbreastfeedingbaby. Progestin-onlymethods arethe next choice, andcombinedoral contraceptives arethe last choice foranon-breastfeedingmother. Before sheleaves forhome, she asks you to restart her former contraceptivepills (Microgynon). However, the numberofcouples whoare actually infertile is very low, about 5% globally. In this study session, you will learnabout theproblemsassociatedwiththe fertility of couples. Family planning can help couples by providing appropriate counsellingtoidentifyand manage anyinfertility problems. Learning Outcomesfor StudySession 1 When you have studied this session, youshouldbeableto: 12. Although oftenthe woman is blamed,infertilityoccurs in bothmen andwomen (Figure12. Inmany developing countries, including Ethiopia, having childrenisone of the principalmechanisms maintainingthe cohesion of thefamily. If acoupleis unabletohavechildren, it can createanunhappy marriageand result in divorce, even when boththe husband andwifeare infertile. In ruralareas, children areanimportant asset,astheywillworkonthe land and carefor theiragedparents. Primaryinfertility is when acouplehavenever hadchildren, or have been unabletoachieve pregnancyafter one year of livingtogether despitehaving unprotected sexual intercourse. Secondaryinfertility is when acouplehavehad children or achieved pregnancypreviously,but areunabletoconceive at this time, even afterone year of having unprotected sexual intercourse. Secondary infertility occurs more commonlythanprimary infertility,especially in developing countrieswhere sexually transmittedinfections arecommon. In many countries, induced abortion (intentionally done)contributes much to secondary infertility. According to studiesfrom around theworld,bothmen andwomen areaffected by infertility: about 40? 60% of causes arelinkedtofemalefactors, and20?40% arerelated to male factors. It is important foryou to understand theanatomical,physiological and psychological conditions affectingfertilityinwomen andmen,bothofwhom shouldnormally be able to conceive. Inmanywomen fertility declines as they age, especially over35yearsofage when thequality of eggs remaininginthe ovariesislower than when thewomen were younger. In men, sperm motility is reduced as they age, but overall fertilityisnot affected as much. Infections fromuntreated sexually transmitted infections,suchas gonorrhea andchlamydia, can also ascend viathe urethra. Problems of spermproduction andquality Many disorderslead to abnormalorreduced sperm production, andcan result in it stopping altogether. For example, mumps (in Amharic, joro degif) contracted in childhood can lead to in? Drinking large amountsofalcohol can also reduceproductionoftestosterone (themale hormone)and cause shrinking and/or weakness of thetestes. Otherfactors such as thetestes failingtodescend fromthe abdomen,excessive smoking anddrugabuse, excessive heat due to wearingtight underwear,orworking for long periods near aheat source, can reduce theproductionand motility of sperm. Sexualproblems Certainpsychological conditions,likeemotional, psychological or physical stress, can result in theinability to maintain an erection, andthe inability to ejaculate normallyinsidethe vagina. Otherfactorswhich contributetoamannot achieving normalsexualintercourse include neurological damage due to leprosy, taking medications such as methyldopa (ananti-hypertensivedrug),surgery involving thepenis,scrotum,prostateorpelvis, that can cause nervedamage, and alcohol consumption.

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If I lose my full-time work and have a part-time job on the side, do I have to keep the part-time job? This question can arise for people who work two jobs, such as a full-time job and a part-time side job that pays less than the main job. If they lose their main job, their earnings from the part-time job can be less than they would receive in Unemployment Insurance benefts for the days they work at the side job. Their income is actually reduced for continuing to work the side job while they receive Unemployment Insurance benefts. The Department of Labor recognizes that this can cause fnancial hardship for claimants who are trying to do the right thing. If you fnd yourself in this situation, we suggest you frst try to reschedule your part-time job hours into one to two days per week. However, the Department of Labor must investigate whether you had good cause to quit your side/part-time job. This may temporarily stop your benefts and possibly lead to a determination that is not in your favor. You may be able to use recent military service to establish a claim if you meet certain conditions. If your service was within the past 18 months, call the Telephone Claims Center* for more information. Members of the state Army National Guard or reserves of the Army, Navy, Air Force, Marine Corps or Coast Guard are not eligible to receive Unemployment Insurance benefts while in annual feld training. However, your monthly drill sessions do not afect eligibility for your full weekly beneft amount. If you are an employee of an educational institution, you are not eligible for benefts when school is not in session if your employer has given you reasonable assurance that you will be employed and paid in a similar manner once school is back in session. You have a contract to continue working after a school vacation, holiday recess or break between terms. You could be eligible for benefts if you have wages from other, non-educational employment during the same period of time. If you were not ofered similar work by the educational institution for the new term or year, you may be eligible to get benefts. While we review your claim, you must continue to claim weekly benefts (certify for benefts) each week during the period of your unemployment, even if you are not getting beneft payments. If you have retired and are not looking for work, you are not eligible for Unemployment Insurance benefts. If you retired from a job and are actively looking for other work, you may be eligible for Unemployment Insurance benefts. Your benefts will be reduced by 100 percent of the amount of the pension if your base period employer contributed to it, even if you also contributed to the pension. If you were the sole contributor to the pension, your benefts will not be reduced. If we fnd that you acted fraudulently, you may also forfeit future days of benefts and be subject to monetary penalties. However, you must be available for and looking for work with no restrictions while collecting benefts, just like all other claimants. If you are receiving workers? compensation but you are available and physically able to perform work, you may be eligible for Unemployment Insurance benefts. However, receiving workers? compensation benefts may cause your weekly Unemployment Insurance beneft rate to be reduced. The total weekly amount of your workers? compensation and Unemployment Insurance benefts cannot be more than the average weekly wage you earned during your base period. Please also be prepared to send us a note signed by your doctor that says you are able to return to work. You must notify the Telephone Claims Center* about any workers? compensation benefts you receive during the same weeks you collect Unemployment Insurance benefts. Important: If you do not notify us, you may receive an overpayment which you will need to pay back. You may be able to participate in an education or training program while collecting benefts if you are accepted into the 599 Program. If your training is approved under this program, you are not required to look for work.


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The following people patiently answered questions and contributed to this report from their wealth of experience and knowledge. Based on a continuation of the trend of fertility decline and method mix from 1993 to 1998, by 2005 the method mix would be as follows: 15% using traditional methods (down from 21% in 1998 and 36% in 1989). Both providers and clients appreciate the ease and speed with which the method can be administered. In jectables are the most popular method in Kenya, used by 30% of users and 9% of all women. They are used by women of all parities, in all age groups, but are used less by low-parity women and the youngest and oldest age groups. Access and availability are generally good; the biggest reasons for nonuse and discontinuing are health concerns and side effec ts. They are safe and very effective when taken consistently and correctly, and they can be used from adolescence to menopause. Some studies show relatively high failure (pregnancy) rates for oral contraceptive users in Kenya, but a high proportion of failures are due to noncompliance. It has no hormonal side effects, is immediately reversible, has no effect on breast milk, and can be inserted immediately after childbirth. Use increases with education level, and use is more common among urban women, perhaps because of their education levels or better access. The percent of users relying on the public sector as a source is higher than for any other method. Female sterilisation is a safe and simple procedure that can usually be done with local anesthesia and light sedation. Advantages of sterilisation are that it is an effective and permanent method with nothing to remember, does not require supplies, does not interfere with sex, has no effect on breast milk, and has no known long-term side effects or health risks. It is one of the most cost-effective contraceptive methods (although it is much more expensive to provide than male sterilisation). Disadvantages include that it requires surgical training, aseptic conditions, medications, and technical assistance. It requires a health facility with a minor theatre, the appropriate equipment, the ability to provide infection prevention measures, and the drugs and equipment to handle emergencies. It is most popular with uneducated women and with currently married or widowed women. More than 50% of acceptors were operated on in a public sector hospital or clinic. Perfect-use effectiveness in preventing pregnancy is estimated at 97%; typical-use effectiveness is 86% because of errors in use. Advantages of male condoms include that they encourage male participation in contraception and protection from infection, are accessible, are inexpensive, are portable, and have no hormonal side effects. Male condoms interrupt sexual spontaneity, are coitally dependent (some find it embarrassing to suggest or initiate use), require cooperation, and occasionally slip off or break during intercourse. Among those who reported having sexual intercourse with someone other than their spouse, 42% of men and 15% to 16% of women reported using a condom during their last sexual intercourse with someone other than their spouse. In 1998 about 67 million public sector condoms were distributed in Kenya, an additional 10 million Trust condoms were distributed, and a small, unknown amount were sold privately. The highest percent of use is among sexually active unmarried men and among people with an extramarital partner or partners. People are less likely to use condoms with their spouse, and users of another method are unlikely to be dual users. The Norplant implant is effective for 5 years but can be made ineffective at any time by removal. Implants are not coitus -dependent, and the user has no day-to -day responsibility. Implants seem to be popular for spacing purposes with women of most ages, except the youngest and oldest groups. Urban women are more likely to use implants, because of better education or better access. The percent of users relying on the private sector is higher than for any other method.

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In particular his contribution to the understanding, diagnosis and prognosis of manic-depressive illness was enormous. However, the elimination of the distinction between unipolar and bipolar forms, and the inclusion of all types of affective disorders in the unitary concept of manic-depressive illness, proved later to be a step back (Angst 1997a, Marneros 1999, 2000a). He expressed his unanswered questions and he was always seeking solutions, as he demonstrated in his last important work in 1920 ("Die Erscheinungsformen des Irreseins", "The phenomenological forms of insanity"). The unification of "circulares Irresein" ("circular insanity") with unipolar types into "manisch-depres sives Irresein" (manic-depressive insanity) was carried out in two funda mental publications in 1899: the first of them was "Die klinische Stellung 10 A. Angst der Melancholie" ("The clinical position of melancholia", 1899a), published in the Monatsschrift fur Psychiatrie und Neurologie, and the second was the sixth edition of his textbook (1899b). This unification was a new conclusion of Kraepelin, which is contradictory to his former opinions. The first roots of the unification and development of the concept of "manic depressive insanity" originated at the beginning of the 1890s. In the edition of 1893 the concept is already clear and in 1899 complete: He wrote in "The clinical position of melancholia": "Unfortunately our textbooks do not help us at all in distinguishing between circular depression and mania in cases where the course itself is not informative. The description of melancholic states is absolutely identical with that of circular depres sion and we can hardly doubt that the most beautiful and exciting descriptions of melancholia are mostly derived from observations of circular cases" (1899a, p. And some pages later: "Apart from our experience that in a whole series of manic episodes a depressive one can occur unexpectedly, and those cases are immensely rare in which apart from manic irritability not the slightest feature of depression is visible, it is absolutely impossible to distinguish these manic fits of circular insanity from periodic mania. But if periodic mania is identical with circular insanity we cannot deny the possibility that also periodic melancholia, or at least some of the cases designated so, must in fact be understood as a kind of circular insanity in which all the episodes take on a depressive hue, just as in periodic mania they all have a manic tinge" (1899a, p. Kraepelin himself was not rigid or dogmatic concerning his taxonomies or concepts. The opposite is true; he was open to persuasion by data-orientated research, even by his own fellows, and he corrected his concepts. Doubts and remaining questions regarding his taxonomies and concepts were not taboo, but were discussed in his publications, such as his last very important publication of 1920 (already cited above). His epigones, however, lacking his elasticity, ignored the important contributions of Wernicke, Kleist, Leonhard and others. The consequence was stagnation for almost 70 years with regard to new developments in the field of bipolar disorders (Angst 1999, Marneros 1999). In 1926 Benon proposed separating periodic depression from manic-depressive disorder, but this met with little approval. For example, he distinguished five different types of melancholia: affective melancholia, depressive melancholia, melancholia agitata, melancholia attonita and melancholia hypochondriaca (Wernicke 1900, 1906). Single episodes of mania or melan cholia including recurrent depression or recurrent mania without changing into one another are something different from manic-depressive insanity (Wernicke 1900). The opinion of Wernicke was the basis for the work of his fellows, such as Kleist, Neele and Leonhard (Angst 1997a, 1999, Marneros 1999, Pillmann et al. Kleist differentiated between unipolar ("ein polig") and bipolar ("zweipolig") affective disorders (Kleist 1911, 1926, 1928, 1953). The concepts of Wernicke and Kleist were completed by Karl Leonhard (a colleague of Kleist and later head of the Charite in Berlin), who classified the "phasic psychoses" into "pure phasic psychoses" (such as "pure melancholia", "pure mania", etc. To the last-mentioned category belong manic-depressive illness and the cycloid psychoses (Leonhard 1957, 1995). Neither Kleist nor Leonhard considered monopolar mania to be a component of bipolar disorders in present-day terms. On the contrary, they described monopolar mania separate from manic-depressive disorders (Leonhard 1957). This does not detract from the great significance of their role in stimulating research and paving the way for further develop ment (Angst 1997a, Marneros 1999). The classification of Wernicke, Kleist and Leonhard was nevertheless very complicated, with its multiple subgroups and distinctions, and did not find broad acceptance. Unfortunately, one of the most important aspects of their system, namely the unipolar/bipolar distinction, remained almost unrecog nized by international psychiatry. The first was the monograph of Jules Angst in Switzerland: Zur Atiologie und Nosologie Endogener Depressiver Psychosen (On the Aetiology and 12 A. Both publications supported, independently of one another, the nosological differentiation between unipolar and bipolar disorders.

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The term teratogen is usually limited to envi to the interaction of different genes and environmen ronmental agents,such as drugs,radiation and virus tal factors. The disruptive effects include congenital abnor quency among family members of an affected indi malities, embryonic and fetal death, intrauterine vidual in an inverse frequency to their relationship. The recur tive to morphological alterations than the embryo, rence risks used for genetic counselling of families but changes in functional capacity, intellect, repro with congenital anomalies determined by multifacto duction or renal function may occur. Mechanical rial inheritance are empirical risks based on the fre effects may be due to vascular disruptions and the quency of the anomaly in the general population and amnion disruption sequence. In individual fam ilies, such estimates may be inaccurate, because they Chemicals, Drugs, Hormones are usually averages from the population rather and Vitamins than precise probabilities for the individual family. Drugs with a known teratogenic effect are relatively Digenic inheritance in human diseases has been few (Gilbert-Barness and Van Allen 1997; Laxova demonstrated in an increasing number of diseases 1997; Shepard 1998; Moore et al. Examples in (Ming and Muenke 2002),including retinitis pigmen clude alcohol, cocaine, thalidomide, lithium, retinoic tosa, deafness, Hirschsprung disease, Usher syn acid, warfarin and anticonvulsant drugs (Table 3. Maternal chronic or excessive alcohol lated compounds such as vitamin A, the dietary pre consumption, in particular during the first trimester cursor of retinoic acid) had been long known to be of pregnancy, may lead to the fetal alcohol syndrome potent teratogens, and the drug Accutane was not to (Clarren et al. The newborn baby is small and may show dental exposures occurred, resulting in a surprising craniofacial anomalies. Brain anomalies are variable 108 Chapter 3 Causes of Congenital Malformations and unspecific, in contrast to the more common neural tube closure in rats resulted in an increased craniofacial anomalies. In humans, epidemiological studies suggest Maternal Conditions that an elevation of maternal body temperature by A variety of maternal diseases, either genetic or ac 2 C for at least 24 h during fever can cause a range of quired, and deficiency states may affect the develop developmental defects, but there is little information ing embryo. In other disorders, such as epilepsy, the on the threshold for shorter exposures (Chambers et therapy is most likely damaging. Maternal diabetes mel virus, cytomegalovirus and herpes/varicella virus) litus type 1 is a risk factor for all sorts of congenital are screened for in the case of permanent cerebral anomalies. Good control can prevent birth defects, impairment in the neonate (Becker 1992; Stray-Ped however. Radiation effects on the devel to developmental delay, psychomotor retardation oping brain were extensively studied after the atomic and seizures. The infection ultimately leads to destruction of cerebral most conspicuous effect on brain development is an tissue with the formation of cystic spaces in the increased occurrence of severe mental retardation, brain. They have been described as porencephaly with or without microcephaly at specific gestational (Tominaga et al. When the border of cystic lesions is fertilization appeared to be the most vulnerable. In all instances the nature and the de the two patients exposed at the eighth or ninth week gree of the brain disturbances is a function of the following fertilization, large areas of ectopic grey time of the infection. Early infections may lead to in matter were seen,due to failure of neurons to migrate trauterine death, lissencephaly may result from cy properly. The two individuals exposed in the 12th or tomegalovirus onset between 16 and 18 weeks of ges 13th week showed no readily recognized ectopic grey tation, whereas polymicrogyria may be due to onset areas but did show mild macrogyria, which implies of infection between 18 and 24 weeks of gestation some impairment in the development of the cortical (Barkovich and Linden 1994; de Vries et al. The one individual who was exposed in the 15th the fetus is aborted early, the lesions may be restrict week did not show such changes. The brain was small ed to foci of macrophages around glial or neuronal with an apparently normal architecture. Rubella virus is embryopathic but also has a migration, differentiation and apoptosis are all ad recognizable fetopathic effect. Its features are cardiac versely affected by elevated maternal temperature, defects, congenital cataract and deafness. A pregnancy may be at high risk of abnormality because of a par ticular family history or the advanced age of the mother. Higher-risk groups for chromosome abnor malities include older mothers, those with a previous chromosomally abnormal child, and when one par ent is a translocation carrier. Usually, these women are offered chorion villus sampling or amniocentesis routinely. An increasing number of single gene disor ders and chromosome abnormalities can now be identified at the molecular level. Population screen ing programmes may identify women at increased risk of fetal abnormalities (Brock et al.

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Facial surgery to correct congenital, acquired, traumatic, or developmental anomalies that may not result in functional impairment, bur are so severely disfiguring as to merit consideration for corrective surgery. Surgery for therapeutic purposes which coincidentally also serve some cosmetic purpose E. Insertion or injection of prosthetic material for significant deformity from disease or trauma F. Pulsed dye laser therapy for the treatment of congenital port wine stains of the face or neck G. Surgical treatment of congenital hemangiomas when any of the following are met: 1. The hemangioma is interfering with the functionality of the nose, eyes, ears, lips or larynx; 2. Low-dose radiation (superficial or interstitial) as an adjunctive therapy immediately following excisional surgery (within 7 days) in the treatment of keloids when criteria for keloid removal are met L. Testicular prostheses for replacement of congenitally absent testes, or testes lost due to disease, injury, or surgery M. Skin tag removal when located in an area of friction with documentation of repeated irritation and bleeding O. External facial prosthesis when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect, regardless of whether or not the facial prosthesis restores function P. Chin, cheek, or jaw reshaping (facial implants or soft tissue augmentation) for deformities of the maxilla or mandible resulting from trauma or disease and to be distinguished from orthognathic surgery Q. Punch graft hair transplant may be considered reconstructive when it is performed to correct permanent hair loss that is clearly caused by disease or injury. Otoplasty (ear pinning) for absent or deformed ears such as microtia (small, abnormally shaped or absent external ears) or anotia (total absence of the external ear and auditory canal) with functional deficiencies resulting from trauma, surgery, disease or congenital defect when performed to improve hearing by directing sound into the ear canal. Post-mastectomy or post significant lumpectomy resulting in asymmetry: breast reconstruction, including nipple reconstruction, tattooing and surgery on contralateral breast to restore symmetry; T. Removal of a breast implant, periprosthetic capsulotomy or capsulectomy for mechanical complications of breast prosthesis such as rupture, extrusion, painful capsular contracture with disfigurement, inflammatory reaction to implant, siliconoma, granuloma, interference with diagnosis of breast cancer U. Flesh color tattooing for the treatment of port wine stains, hemangiomas or birth marks F. Rhinoplasty for external nasal deformity not due to trauma or disease (non covered services) I. Surgery to correct a condition of moon face? which developed as a side effect of cortisone therapy L. Otoplasty (ear pinning) for lop ears, bat ears or prominent or protruding ears without M. Injection of any filling material (collagen) including but not limited to collagen, fat or other autologous or foreign material grafts unless treatment for facial lypodystrophy N. Excision excessive skin, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, other areas R. Electrolysis or laser hair removal unless specified (ie gender reassignment surgery) S. Hair transplants to correct male pattern baldness (alopecia) or age related hair thinning in women W. Vermilionectomy (lip shave), with mucosal advancement Background Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors or disease. It is generally performed to improve the functioning of a body part and may or may not restore a normal appearance. Functional impairment is a health condition in which the normal function of a part of the body or organ system is less than age appropriate at full capacity, such as decreased range of motion, diminished eyesight or hearing, etc. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the appearance and self-esteem of a patient. This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. Added references Removed Nasal Surgery (S) and section on pectus excavatum (T) and Nuss 11/19 11/19 procedure (U) from medically necessary section since all have Interqual criteria References 1. National Breast Reconstruction Utilization in the Setting of Postmastectomy Radiotherapy. Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes.

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No correlation between the decreased number of highly fluorescent pores and treatment efficacy was found. No significant 2 2 differences between red light at the dose 99 J/cm and blue light at the dose 7. Two consecutive illuminations at an interval of 24h between treatments caused a decrease in the viable count of the culture by five or more magnitudes. Evaluation of fluorescence spectra Porphyrin amounts were found to increase as a function of growth time. Spectral peaks were found at about 580 nm and 620 nm, and a small shoulder at about 635 nm. This acne score is one of the most accepted for grading acne, but still it is not a precise scale and the judgment could differ between the three investigators when comparing patients? acne with images of different acne scores. It is not always obvious how to grade an acne lesion appropriately as papule, pustule, nodule/cyst or comedone. The results might have been more reliable with two independent investigators at each center. The patients were enrolled between October 2004 and May 2005, summer excepted, which could have affected their acne status. There was no control of whether the patients were tanning from sun exposure or using sun beds. The acne patients were asked to quit their acne treatment 3 months before the study, but patient compliance was not monitored. Split face studies involving light are difficult to assess, as it is difficult to control the effect of cytokines which may be released but not necessarily localized to the treated area only. Nodular or cystic lesions were prepared using a cannula (1-2 mm) to facilitate cream penetration, and in some patients a small bleeding occurred. This could theoretically decrease the light reaching into the lesion and the photodynamic reaction would be less effective. Information given to the patients by study personnel is therefore likely to have affected patients? perception of the treatment. However, we chose this scoring because the Leeds score would be too detailed in these small groups of patients. The reasons for leaving the study were different, but patients with acne belong to that age when life changes a lot. A number of the patients had so many things going on in their lives that they had problems with attending the follow-up visits. One has to consider that it could be a selection of patients who dropped out from the study, but one does not know if they are the good or the bad responders to treatment. In these split face studies the systemic effect cannot be eliminated, as mentioned in paper I. These clinical trials were designed with uncontrolled before?after design, which does not take the intrinsic volatility of acne into account. However, the tool has been used at our clinic earlier with good results, which is the reason why we chose this technique. It is possible that the sampling method was inadequate, making it difficult to detect changes in P. This short period was used because we wanted to include as many patients as possible and patients were eager to receive treatment. None of the patients had been on isotretinoin during the last year before inclusion. In some cases there was too much background light in the room when the fluorescence images were taken. When all the images were analyzed, several fluorescence images were overexposed and had to be excluded. The fluorescence images were limited in number and hence there could be a risk of introducing a type 2 error, i. It is known that autofluorescence can be detected from the porphyrins in a pilosebaceous-rich skin. It is likely that sebum contains some components that are necessary for the porphyrin production. This is most likely explained by a depletion of porphyrins after the first illumination. Even though porphyrins might have been present during the second illumination, the amounts were expected to be lower.

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Antihypertensive therapy has been shown to reduce the risk of a severe maternal hypertensive crisis but has not been shown to improve overall peri natal outcome. Experts in the United States have recommended that pregnant women with hypertension in the blood pressure range of 150?160/100?110 mm Hg should be treated with antihypertensive therapy, and that their blood pressure should be kept lower than 150/100 mm Hg. It would seem reasonable to withhold antihypertensive therapy in women with mild hypertension who become pregnant unless their blood pressure is 150/100 mm Hg or greater or they have other complicating factors (eg, cardiovascular or renal disease) and to either stop or reduce medication in women who are already taking antihyper tensive therapy. Based on the overall low rate of adverse effects and good effi cacy, labetalol is a good option for first-line treatment of chronic hypertension 234 Guidelines for Perinatal Care in pregnancy. Calcium channel blockers or antagonists, the most commonly studied of which is nifedipine, also have been used in pregnant women with chronic hypertension. Methyldopa has been used for decades to treat hyper tension in pregnancy, and it appears to be safe for this indication. However, its strong association with significant maternal sedation at therapeutic doses is a limitation to the use of this medication. Thiazide diuretic therapy used in women before pregnancy does not need to be discontinued during pregnancy. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in all trimesters of pregnancy. Pregnant women with uncomplicated mild chronic hypertension generally are candidates for a vaginal delivery at term because most of them have good maternal and neonatal outcomes. Women with hypertension dur ing pregnancy and a prior adverse pregnancy outcome (eg, stillbirth) may be candidates for earlier delivery after documentation of fetal lung maturity. Women with severe chronic hypertension during pregnancy often either give birth prematurely or need premature delivery for fetal or maternal indications. The combination of chronic hypertension and superimposed preeclampsia, particularly if it is preterm, represents a complicated situation, and the clinician should consider consultation with a subspecialist in maternal?fetal medicine. Women with severe hypertension or hypertension that is complicated by car diovascular or renal disease may present special problems during the intrapar tum period and should be collaboratively managed by the primary obstetrician and a maternal?fetal medicine subspecialist or an intensivist. Women with severe hypertension may require antihypertensive medications to treat acute elevation of blood pressure. Women with chronic hypertension complicated by significant cardiovascular or renal disease require special attention to fluid load and urine output because they may be susceptible to fluid overload with resul tant pulmonary edema. General anesthesia may pose a risk in pregnant women with severe hypertension or superimposed preeclampsia. Intrauterine Growth Restriction Intrauterine growth restriction is a term used to describe a fetus whose esti mated weight appears to be less than expected, usually less than the 10th per centile. Perinatal morbidity and mortality is significantly increased in the presence of low birth weight for gestational age, especially with weights below the third percentile for gestational age. Screening All pregnancies should be screened with serial fundal height assessments, reserv ing ultrasonography for those fetuses with risk factors (see Box 7-2), lagging growth, or no growth. Physicians should consider an early ultrasound examination to confirm gestational age, as well as subsequent ultrasonography to evaluate sequential fetal growth, in women with significant risk factors. Diagnosis There are two essential steps involved in the antenatal recognition of growth restriction: 1) the elucidation of maternal risk factors associated with growth restriction (see Box 7-2) and 2) the clinical assessment of uterine size relative to gestational age. Several methods are available for clinical determination of uterine size, the most common of which is the measurement of fundal height. Serial ultrasound examinations to determine the rate of 236 Guidelines for Perinatal Care Box 7-2. Maternal medical conditions Hypertension Renal disease Restrictive lung disease Diabetes (with microvascular disease) Cyanotic heart disease Antiphospholipid syndrome Collagen-vascular disease Hemoglobinopathies. If any test result is abnormal (eg, decreased amniotic fluid volume or abnormal Doppler assessments), more fre quent testing, possibly daily, may be indicated. If pregnancy is remote from term or if delivery is not elected, the optimal mode of monitoring has not been established. The fetus should be delivered if the risk of fetal death exceeds that of neonatal death, although in many cases these risks are difficult to assess. Early delivery may yield an infant with all the serious sequelae of pre maturity, whereas delaying delivery may yield a hypoxic, acidotic infant with Obstetric and Medical Complications 237 long-term neurologic sequelae. Gestational age and the findings of antenatal surveillance should be taken into account. The decision to deliver is based often on nonreassuring fetal assessment or a complete cessation of fetal growth assessed ultrasonographically over a 2?4-week interval. When extrauterine sur vival is likely despite significantly abnormal antenatal testing, delivery should be seriously considered.

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Compared with modern contraceptive methods, these methods neither entail cost nor require visits to a health facility. While there is the view that the Catholic Church has a strong influence on the reproductive and contraceptive use of Catholics, this is not captured in the study. The Catholic Church has been steadfast in its opposition of modern contraceptive methods. Pastoral letters are often issued by the Catholic Church hierarchy criticizing any effort to promote use of modern contraceptives. The low proportion of Filipino women who have correct knowledge of the fertile period over the ten years covered in the study suggests that greater efforts should be exerted in education on the fertility cycle, especially among women who are using the rhythm method. By identifying which subgroups of women are most likely to be using the rhythm method, the task of convincing these women to switch to a similar but more scientific method is already half-done. The decline of radio and print media as sources of family planning messages, as well as the absence of the effect of the television and print media on the contraceptive use of women, may point to waning popularity of the traditional media. The traditional forms of media such as radio, print, and television do not seem to exert an influence on the contraceptive behavior of women (even if a majority of the women get family planning messages from television). The identification of the characteristics of women who use traditional contraceptive methods can provide a basis for more targeted policies and programs to promote the more effective modern contraceptive methods, including programs that encourage traditional contraceptive method users to switch to the more effective modern contraceptive methods. The findings of the study also warrant further research, both quantitative and qualitative, to explore the continued preference for traditional contraceptive methods in the Philippines. With fear of side effects as the dominant reason for nonuse of contraceptives (Abejo et al. Research about contraception from the point of view of men should merit equal attention in order to fully understand the continuing popularity of traditional contraceptive methods in the Philippines, particularly withdrawal, and the reasons behind the apparent resistance of Filipino men to modern male-dependent methods such as the condom and vasectomy. Rather, it is limited to identifying the patterns and trends of traditional contraceptive use between 2003 and 2013. Quezon City/Manila and Maryland: University of the Philippines Population Institute, Demographic Research and Development Foundation, National Statistics Office and Macro International. Contraceptive Failure Rates in the Developing World: An Analysis of Demographic and Health Survey Data in 43 Countries. However, until recently rates of unintended conceptions to British teenagers were well above the western European average. Editorial control was with the authors, Dr Jennifer Gill and Professor David Taylor. The new evidence offered here shows that in England one woman in seven strongly believes that existing provisions could be made more convenient. Dissatisfed service and contraceptive product users are at raised risk of unwanted conceptions. Over a half of the female population agrees with the statement women should be able to obtain items like the Pill directly from their pharmacist, rather than after seeing a doctor or a nurse if that is what they prefer. Evidence from less advantaged communities such as Lambeth and Southwark in South London confrms benefts for young women at raised risk of unintended conceptions. Well-designed, a national programme based on the results such projects could also provide greater convenience for women with established contraception preferences and address unmet needs amongst women in their 30s and over. This may generate a strengthened consensus on how an optimally effective nationwide community pharmacy service should be established. Achieving the best affordable outcomes will require complementary efforts aimed at meeting service users? needs on the parts of all those involved. This may in part be achieved through greater involvement in new service models such as primary care home based provision. Pharmacy should also seek to communicate to decision makers why improving access to contraception and other forms of sexual and reproductive health care is central to protecting the health of the nation. In Britain, for example, average life expectancy at birth was still under 50 years in 1900, despite the many achievements of the Victorian era. Similar developments have taken place in countries ranging from France and Sweden to China and Brazil (Roser, 2017), albeit those nations that commenced their demographic transitions more recently that is, since the 1940s have undergone faster changes than those which started their mortality and fertility reduction processes in the nineteenth century. They have aided the achievement of greater be restricted because of cultural factors and/or local equality between men and women in the educational, service limitations.

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Aside from commodities, nonpublic facilities receive very little government support, but about half of public facilities receive government support. Cost-recovery and cost-sharing schemes are difficult to implement equitably and efficiently. Setting prices that do not exclude the indigent or discourage use, collecting and tracking fees, and planning for optimum usage of fees are all challenges in Kenya. The survey used a measure of burden? that found that public sector clients should pay half as much as private sector clients to have an equal burden. A five step process is useful for developing action plans that support policy: 1. Specify objectives that detail desired accomplishments related to the achievement of goals. Once the five -part framework is developed, a resource envelope for implementation must be developed. At this point, it is useful to project alternative cost scenarios, using the goals and objectives as model assumptions. If the projections show that short-term objectives are financially unrealis tic, the objectives or the strategy may need to be changed. In the short term, of course, strategies are constrained by current levels of supplies, numbers of users, and funding commitments. Nevertheless, in addition to financial feasibility, every strateg y has advantages and disadvantages, or harms and benefits, that should be weighed. Substantial and constantly growing numbers of Kenyans rely on the public sector to meet their health care needs, including family planning. Public health goal: Increase cost recovery while maintaining equitable access for clients of all incom e levels. The current contraceptive method mix in Kenya is heavily weighted by dependence on ineffective traditional methods and on methods with high public sector costs in terms of couple years of protection. Public health goal: Improve the cost effectiveness of the public sector mix without compromising freedom of choice and quality of care. Among the 70% of reproductive-age Kenyan women not using contraception, some have never used a method, and others tried a method but discontinued. Public health goal: A maturing family planning programme reaches a point at which the hard-to reach nonusers must be targeted in order to increase contraceptive prevalence and ensure equity of services to people of all socioeconomic levels in all areas of the country. In the 1970s, the next phase of the demographic transition began with the median age at marriage among women increasing and the initial practice of family planning being confined to urban and more-educated women. Rising levels of education and exposure to modern ideas and services led to declines in ideal family size and increases in the number of women who said they wanted no more children. Thus, supply met demand, contraceptive prevalence rates began rising, and fertility began falling. Probably two-thirds of this fertility decline is due to increases in contraceptive use?higher prevalence and bigger proportions using modern, effective methods. The Family Planning Programme in Kenya faces a number of challenges in the next decade: the pace of the demographic transition has slowed. Therefore, one challenge is continuing to serve users while contacting and convincing resistors. Another challenge is continuing a commitment to quality of care while seeking ways to pay for future needs. Goal and objectives the goal of this study is to provide a synthesis of information relevant to a contraceptive commodity strategy. Defining such a strategy requires making policy decisions dependent on qualitative judgements and decisions that reflect ethical values and goals. However, all relevant technical information must be reviewed before those policy decisions are made. In particular, developing a contraceptive commodity strategy requires an understanding of commodity needs for the next several years. These needs should take into account advantages and disadvantages of different methods, including how many women can use them and how many women are using them (the current method mix).