Cozaar

Kristin E. McKinney, MD

• Assistant Professor of Radiology
• Division of Ultrasound
• University of Colorado Hospital
• Aurora, Colorado

Caregivers feel isolated; they often report that their lives are not "normal" and that no one else can possibly understand what they are going through diabetic stroke cheap cozaar 25mg amex. Families helping a person with a disability in daily living activities spend more than twice as much on out-of-pocket medical expenses than families without a disabled person diabetic ketoacidosis in dogs cozaar 50 mg cheap. Frequently the caregiver must make sacrifices at work to attend to duties at home puppy diabetes signs symptoms discount cozaar 25mg overnight delivery. You learn to deal with the frustration while learning how to best get the job done diabetes insipidus in dogs diagnosis buy cozaar 50mg fast delivery. Here are a few caregiving tips compiled by Paralysis Resource Center Information Specialists: Rule number one for all caregivers is to take care of yourself diabetic polyneuropathy discount cozaar 50 mg otc. Providing care while holding down a job diabetes medications weight gain discount cozaar 50mg visa, running a household, or parenting can burn anyone out. A person who is exhausted or sick is more likely to make bad decisions or take out frustrations inappropriately. The more you keep your own well-being in balance, the more you will enhance your coping skills and stamina. By taking care of your self, you will be better able, both physically and emotionally, to provide care for your loved one. Share and learn and benefit from the collective wisdom of the caregiver community. It is important that caregivers connect with one another to gain strength and to know that they are not alone. And, if you dont freely choose this with your whole heart, I dont see how you can make it, because theres going to be some part of you that is always mad, that always somehow resents this oth er person for what theyve taken away from you. It really helps to have a sense of humor; but, I think the most important thing isnt really how you communicate. For many, the isolation that comes with the job is eased by attending support group meetings with others in similar situations. Support groups provide emotional support and caregiving tips, as well as information on community resources. The Reeve Foundation supports active community forums and discussions about all issues related to caregiving. Coun seling can help one cope with feelings of anger, frustration, guilt, loss or competing personal, work and family demands. Be informed about medical issues and how the disease or disability can affect a person physically, psychologically, behaviorally, etc. And facing the new normal, facing the adjustments, the lossyou have to grieve for the loss. But at the same time, once you do that, youre opening up a whole new area where you can have tremendous hope. Doctors and other health professionals can help you understand how a loved ones condition might change and how that change might affect the demands on the caregiver. An extended vacation may not be real istic, but it is essential for caregivers to schedule some down time. See Resources at the end of this chapter for some possible connections to help you get a break. Keep in mind you may be the only one equipped to speak out on your loved ones behalf or to ask difficult questions. Issues such as financing long-term care, protecting assets, obtaining the authority for surrogate decision making, and other matters often need attention. Make an appointment with an attorney knowledge able in estate planning, probate, and, if possible, public benefits planning. Other areas often requiring planning include coordination between community services and involved friends and family members. Decisions about placement in a nursing home or other care options can often be facilitated by a professional familiar with brain impairments, caregiving and community resources. In some cases, it is necessary to make end-of-life decisions regarding your loved one. Understand as best as you can how the system works for insurance, Social Security and others means of public assistance. Many caregivers are so accustomed to providing help and seeing to another persons needs that they dont know how to ask for aid themselves. Spouses, brothers and sisters, children, and other relatives can do a lot to ease your caregiving burden. Encourage your loved ones friends and neighbors to provide what comfort they can. It is essen tial that caregivers know about the homecare products and services that might make their jobs easier. See the Tools chapter in this book, page 229, for ways to stay current and up-to-date on all that technology has to offer. As you settle into the role of caregiver, you may find yourself making deci sions for people who used to decide for you. But its important to respect the right of the person being cared for to make choices. Paralysis Resource Guide | 344 10 Gain confdence in your abilities and pride in your achievements. The Caregiver Action Network offers the following principles of empowerment caregivers are urged to live. We fall into caregiving often because of an unexpected event, but somewhere along the line you need to step back and consciously say, "I choose to take on this caregiving role. Youre doing a very hard job and you deserve some quality time, just for yourself. Remember, your own good health is the very best present you can give your loved one. When people offer assistance, accept it and suggest specific things that they can do. Caregiving, especially at its most intense levels, is definitely more than a one-person job. Asking for help is a sign of your strength and an acknowledgment of your abilities and limitations. Honor your caregiving role and speak up for your well-deserved recognition and rights. Become your own advocate, both within your own immediate caregiving sphere and beyond. Addresses issues common to family caregivers: anger, guilt, fear, isolation, grief, and financial threat; Active and helpful message board for loved Paralysis Resource Guide | 346 10 ones and caregivers of people living with paralysis. The organization played a major role in gaining passage of the Ameri cans with Disabilities Act and continues to take its message to the streets so people with disabilities can live in the community with real supports instead of being locked away in nursing homes or other institutions. Numerous discussion areas on topics related to spinal cord injury and paralysis, including active living, relationships, caregiving, cure research, clinical care and creature comforts. Activity-Based Therapy: a rehabilitation modality based on the theory that activity affects neurologic recovery, that patterned activity can stimulate spinal cord plasticity and "reawaken" nerve pathways related to movement. Acute: the early stages of an injury (as opposed to chronic, which is long term); in spinal cord injury, better early management of acute trauma may be the reason for an increased number of "incomplete" injuries. Theoretically, early intervention with drugs or cooling will limit functional loss. If the progres sive cascade of secondary effects of trauma at the cellular level. Allodynia: condition in which pain arises from a stimulus that would not normally be experienced as painful. Alpha blockers: Medications that can relax the urinary sphincter and prostate and therefore allow better bladder emptying. Many find the energy expen diture to "walk" is too much for too little function; they are more functional in their wheelchairs. Ankylosis: fixation of a joint leading to immobility, due to ossification or bony deposits of calcium at joints. Anticholinergics block certain receptors (acetylcholine), resulting in inhibition of certain nerve impulses (parasympathetic). Language, not understood or not formed, is often restored once swelling is reduced. Arachnoid membrane: the middle of three membranes protecting the brain and spinal cord. Arachnoiditis: inflammation and scarring of the membranes covering the spinal cord, sometimes caused by the dye used in a myelogram. Arachnoiditis is often misdiagnosed as "failed back surgery syndrome," multiple sclerosis or chronic fatigue syndrome. Astrocyte: star-shaped glial cells that provide the necessary chemical and physical environment for nerve regeneration. These cells proliferate after injury and are believed to break down toxins such as glutamate. The astrocyte also has a bad side: Reactive astrocytes contribute to the formation of glial scar, which may be a major obstacle to nerve regrowth following trauma. Can be a problem for high quadriplegics who are unable to clear lung secre tions. Augmentation cystoplasty: A surgery that enlarges the bladder by sewing a piece of intestine onto the top of the bladder. Autoimmune response: Normally, the immune system recognizes foreign substances; the system produces antibodies against the invader to eliminate it. Autonomic nervous system: the part of the nervous system that controls involuntary activities, including heart muscle, glands and smooth muscle tissue. The autonomic system is subdivided into the sympathetic and para sympathetic systems. Sympathetic activities are marked by the "flight or fight" emergency response; parasympathetic activities are marked by lowered blood pressure, pupil contraction and slowing of the heart. Axon: the nerve fiber that carries an impulse from the nerve cell to a target, and also carries materials from the nerve terminals. When an axon is cut, proteins required for its regeneration are made available by the nerve cell body. In the spinal cord, a damaged axon is often prepared to regrow, and often has available a supply of material to do so. Scientists believe it is the toxic environment surrounding the axon, and not the genetic programming of the axon itself, that prevents regeneration. Biofeedback: a process that provides sight or sound information about functions of the body, including blood pressure and muscle tension. Bladder outlet obstruction: any type of blockage that restricts urine from flowing freely from the bladder. Botulinum Toxin: better known as Botox, a neurotoxin used clinically to treat crossed eyes, wrinkles, and other muscle related issues, including overactive bladder and spasticity in people with paralysis. Bowel program: the establishment of a "habit pattern" or a specific time to empty the bowel so that regularity can be achieved. Brown-Sequard Syndrome: a partial spinal cord injury resulting in hemiplegia, affecting only one side of the body. Bladder stones are easily removed; kidney stones may require lithotripsy (shock wave shattering) or surgery. Carpal tunnel syndrome: painful disorder in the hand caused by inflammation of the median nerve in the wrist bone; commonly caused by repetitive motion, including pushing a wheelchair. Splints might help; surgery is sometimes indicated to relieve pressure on the nerve. Catheter: a rubber or plastic tube for withdrawing or introducing fluids into a cavity of the body, usually the bladder. Cauda equina: the collection of spinal roots descending from the lower part of the spinal cord (conus medullaris, T11 to L2), occupying the vertebral canal below the spinal cord. For diagnostic purposes, a lumbar puncture (spinal tap) is used to draw the fluid. Clinical Trial: a human research program usually involving both experimental and control subjects to examine the safety and effectiveness of a therapy. Clonus: a deep tendon reflex characterized by rhythmic contractions of a muscle when attempting to hold it in a stretched state. Colostomy: surgical procedure to allow elimination of feces from a stoma that is formed by connecting part of the large intestine to the wall of the abdomen. People with paralysis sometimes get colostomies because of bowel care issues or skin care hygiene. Paralysis Resource Guide | 356 Complete Lesion: injury with no motor or sensory function below the zone of cord destruction, at the site of primary trauma. By immobilizing the "good" limb a patient is forced to use the affected limb, leading in some cases to improved function. This is made possible by using a section of the stomach or intestine to create an internal pouch. Contracture: a body joint which has become stiffened to the point it can no longer be moved through its normal range. After the spinal cord terminates, the lumbar and sacral spinal nerves continue as a "freely moving" bundle of nerves within the vertebral canal and are called the cauda equina (literally, horse tail).

By way of a compromise after deadly controversies diabetic ketoacidosis lab values cozaar 25mg, post-iconoclastic Orthodox doctrine con demned idol-image worship (latreia) while prescribing reverence (dulia) diabetic peach cobbler purchase on line cozaar, such as might be given a king diabetes insipidus gestational order 50 mg cozaar with amex, though the Virgin Mary rated hyperdulia diabetes physical signs cheap cozaar 50 mg. But the acheiropoieta not made by humans were different because they could effect miracles in themselves diabetes test perth purchase cozaar with a mastercard, including their own miraculous reproduction blood sugar monitor walmart safe 25 mg cozaar. Holy relics and sacred images were only part of the overpowering experience that awaited pilgrim worshippers and all visitors who at tended services in the great churches of Constantinople and especially the Hagia Sophia. A delegation had supposedly been sent by Vladimir I, the Varangian (= Scandinavian) ruler of Kievan Rus, to search for a suit able faith for himself and his people, fellow Scandinavians and native Slavs no longer satis ed by Perun the Slav thunder god or the imported Nordic deities. Upon its return, the delegation reported as follows, ac cording to the Primary Chronicle under the year 6494 (= 986): When we journeyed among the [Muslims] we beheld how they worship in their temple, called a mosque. Then we went among the [Catholics] and saw them perform many cere monies in their temples; but we beheld no glory there. Then we went on to [Constantinople] and the Greeks led us to the edi ces where they worship their God, and we knew not whether we were in heaven or on earth. For on earth there is no such splendor or such beauty, and we are at a loss how to describe it. We only know that God dwells there among men, and their service is fairer than the ceremonies of other nations. The year before, in 986, a Byzantine missionary, revealingly de scribed as a "scholar" in the Primary Chronicle, had supposedly jour neyed to Kiev to present himself and preach at Vladimirs court. The Christianized, increasingly Slavic, Bulgarians were not a bit less troublesome than their pagan Turkic Bulghar predecessors had been, and as Christians themselves, their most successful tsars even challenged the primacy of the Byzantine emperor over the Christian world. In the wake of the dele gations glowing report, or independently of it for all we know, Vladi mir converted himself and his people in 988. By way of explanation, the Primary Chronicle unreliably recounts that he sacked the important Byzantine outpost of Cherson in the Crimea, threatening to do the same to Constantinople unless he was given Basils sister Anna in marriage: After a year had passed in 6496, Vladimir marched with an armed force against Kherson, a Greek city. Vladimir and his retinue entered the city, and he sent messages to the Emperors Basil and Constantine, saying, "Be hold, I have captured your glorious city. Unless you give her to me to wife, I shall deal with your city as I have with Kherson. His own family and other aristocratic families having ral lied to his cause, as did the eastern troops of Anatolia, early in 988 Bardas Phokas advanced on Constantinople. He crossed with the [Rhos], attacked the enemy without a second thought and easily subdued them. Vladimir was not yet baptized in early 988 when he sent the Varangians, and he may have attacked the Byzantine coastal possession of Kherson in Crimea just before converting. But in the moment of supreme crisis he did provide vital help to the emperor and the head of his church. But the treaty had been signed under duress in the wake of utter defeat, and Svjatoslav himself was killed by Pechenegs before he could return to Kiev. More broadly, conversion expanded the Christian-Orthodox ambi ent within which the empire was at least assured of a central position. W chapter 5 the Uses of Imperial Prestige the metropolis of Constantinople with its spiritual and earthly attrac tions was itself a most powerful instrument of persuasion, at least be fore and after the miseries of the seventh and eighth centuries, when successive sieges, recurring pandemic plague, and the especially severe earthquake of 740 temporarily reduced it to a shrunken remnant. Even so, Constantinople remained the largest city within the sphere of Euro pean civilization, as it had been since the fth-century decline of Romes population. It was also by far the most impressive city, with its spectacular mari time setting on a promontory projecting into a strait and its array of majestic palaces and churches. To enhance the effect, official visitors were carefully guided in their movements around the city, to expose them to its most impressive vistas and sometimes to glimpses of well equipped soldiers on parade. That the Byzantines were immensely proud of their capital is to be expected, but what mattered for their diplomacy was its impact on for eign visitors, and that was all the more overwhelming because so many of them came from a world of huts, tents, or yurts. Turn ing his eyes hither and thither, he marvelled as he beheld the situation of the city, the coming and going of the ships, the splendid walls, and the peo ple of divers nations gathered like a ood of waters streaming from differ ent regions into one basin. So too, when he saw the army on parade he said "Truly the Emperor is a god on earth, and whoso raises a hand against him is guilty of his own blood. To the Slavs nearby in what is now Bulgaria and Macedo nia, or farther away in Russia, Constantinople was Tsargrad, the "city of the emperor," the capital of the world, even the outpost of God on earth. In distant Scandinavia and most remote Iceland, it was Miklagard, Mikligardr, or Micklegarth, the "great city" immensely ad mired in the sagas. The emperor himself was the focus of elaborate court rituals per formed by officials in resplendent robes, to better overawe foreign en voys at court. If that was not enough, there was a period when hydrau lic machinery elevated the imperial throne just as visitors approached, and activated lions that stamped their tails and roared convincingly enough to shock and awe the unprepared. Much of what they did was calculated to preserve and enhance the prestige of the imperial court even as it was being ex ploited to impress, overawe, recruit, even seduce. Unlike troops or gold, prestige is not consumed when it is used, and that was a very great vir tue for the Byzantines, who were always looking for economical sources of power. At times the court was also the venue of artistic, lit erary, and scholarly endeavors, but always it was the seat of the em peror himself, sacred to Orthodox Christians as Gods secular vicar on earth, and the most important man on earth for many non-Christians too, both nearby and very far. For visiting potentates and chieftains who had only known the rude pleasures and brutish manners of wooden halls, yurts, or rough-hewn forts, the Byzantine palaces and court with their stately audiences, pro cessions, and ceremonies must have been unimaginably impressive, star tling visions of unearthly elegance. They came in the name of the Abbasid caliph, still the supposed ruler of all Islam, but by then the caliphate was entirely powerless, and the en voys who arrived in May and then in August 946, to discuss truces and prisoner exchanges, represented less cosmic but very real powers: fron tier warlords and more substantial regional rulers. Among the former was the emir of Tarsos or Tarsus in Cilicia (near modern Turkeys Mersin) on the empires southeast frontier, whose summons to jihad were sometimes heeded far and wide across the Muslim world; his fel low jihadi and competitor the emir of Amida (Diyarbakir in modern Turkey, Amed in Kurdish) facing the empires east-central frontier; the altogether more powerful Buyid or Buwayhid (Nl-i BAya) ruler Ali, het erodox Shia military potentate from Iran who had just seized control of Baghdad, whose great strength was the sturdy infantry of his fellow Daylami highlanders;4 and Ali Abu Al-Hasan ibn Hamdan, of the very heterodox Nusayri or Alawite sect better known by his soubriquet Sayf ad-Dawlah, "Sword of the Dynasty," meaning of the caliphate, but in fact founder of his own Hamdanite power in Syria, whose eventual de feat marked the ascent of Byzantine fortunes during the tenth century. From the Book of Ceremonies we learn just how elaborate were the preparations for receiving these Arab envoys. That too was not considered decorative enough, so the eparch, or prefect of the city, borrowed additional orna ments from travelers hostels, old-age homes, more churches, and the shops of the silversmiths; he was also given the more normal task of su pervising the decoration of the processional route through the city and the Hippodrome. When the moment came, there was a row of imperial standards on either side of the steps leading up to the palace; the chief oarsmen held two standards and the commander of the Hetareia palace guard held the emperors own preeminent gold-embroidered silk standard. Inside the palace, Roman scepters, diptychs, and military ensigns were ranged on either side of the throne; and the borrowed silver organs of the green and blue circus factions were added to the golden imperial organ. Silk draperies transformed the arboretum into a strolling reception area, while precious robes, enamel, silverware, Persian carpets, laurel wreaths, and fresh owers added to the display. The oors were strewn with lau rel, ivy, myrtle, and rosemary with roses in the principal reception hall. The degree of magni cence of the robes of court officials was strictly determined by their rank; but on this occasion less exalted officials were given more resplendent higher-ranking robes, and even humble palace servants down to the bath attendants, literally "soapers," the saponistai, were kitted out in fancy capes. Or is it a calculated psychological move to dress up the Muslim en voys as well, so as to engulf them in the splendid celebrations, instead of leaving them out as shabby spectators Both is the only right answer, es pecially considering what ensued after the rst grand reception: many days passed without any actual negotiations. Instead there was a ban quet enlivened by the two choirs, except for intervals of organ music as each course was served. When the envoys rose, they received gifts in gold and in kind, and there were tips for their retinues. The envoys were next entertained at the Hippodrome with a special performance, the Feast of the Trans guration on August 8 was cele brated with extra pomp, and there was another full-dress banquet on August 9, with a variety show. But[later, when stronger, they] disregarded the Muslims, insist ing that the rule of Islam stopped to exist. The shift in the balance of power in favor of the Byzantines during the tenth century was a matter of degree, while the prisoner exchanges (daU) had started in Umayyad times from circa 805. Moreover, Byzantine prestige was enhanced more broadly by the wide circulation of reports by the envoys, who were obviously greatly impressed. There were amenities, comforts, banquets, decorous entertainment, lit erary declamations at times, the ladies could wear their best at their own occasions, and there was always gossip, educated conversation, guarded talk of policies, and furtive talk of politics. White House identity cards are often worn outside the office in apparent forgetfulness, casually dangling in full view. And in the quest for office, even expensive professionals eagerly donate their services to presidential candidates during the interminable electoral campaigns. In the court of Constantinople the attraction of power was much greater because it was a power unlimited by laws, regulations, audits, parlia mentary interventions, or judicial review: the emperor could castrate, blind, behead, and provide succor; promote to any position and demote and exile; give the most valuable gifts and con scate, endow a man with a rich estate or take away all his possessions. In ex change, all these claimants offered all manner of things, military alli ances or just the temporary loan of their forces, job lots of warriors for the emperors guard, or just their own body and loyalty for military ser vice. And they came to Byzantium, walking on foot, and themselves carrying cloaks slung over their shoulders, and when they arrived they had in these cloaks nothing more than the [dry biscuit] which they had put in at home; and the Emperor enrolled them in the ranks of the soldiers and designated them for the palace guard [the newly established Excubitores, a select unit of 300]. Before the dis covery of the vast gold deposits of the Americas, Siberia, Transvaal, and Australia, gold was altogether more rare than it is today, and corre spondingly more valuable in relation to other goods. Only the emperor in Constantinople could command a steady supply, derived from the cir culation of scal gold, gathered into his treasuries as tax payments and then paid out in salaries that ultimately generated the money incomes that would in turn be taxed. Two kinglets are ro bustly vying for leadership by displaying their wealth in gold: Then Harald had a large ox-hide spread out, and turned the gold out of the caskets upon it. Then scales and weights were taken and the gold sepa rated and divided by weight into equal parts; and all people wondered ex ceedingly that so much gold should have come together in one place in the northern countries. But it was understood that it was the Greek emperors property and wealth; for, as all people say, there are whole houses there full of red gold. Harald took it in his hands and said, "Where is the gold, friend Magnus, that thou canst show against this piece Born in Norway in 1015, he died in battle at Stamford Bridge in what is now Greater London in 1066, in a failed attempt to conquer England just be fore his distant Norman kin tried it with better luck. In between, Harald had lived in Kiev as a warrior captain for its ruler prince Yaroslav, had served as an officer of the Varangian guard in Constantinople, and had successfully returned to claim the throne of Norway after a brief deten tion in France: held as a suspected marauder because of all the gold he was carrying, he was released when a letter arrived from Constantino ple con rming that the gold was his severance bounty. Foreigners frequently attacked the empire in the hope of seizing some of its gold or extracting it in tribute, and as often served the empire loyally to earn its gold. But there was also another attraction: the possi bility of acquiring imperial titles refulgent with the immense prestige of the imperial court, some of which came with an annual salary and pre cious robes of office, with or without the obligation to perform civil or military duties. It is the "as frequently happens" that gives the game away: titles and the robes of office that went with them were routinely given to "northerners and Scythians" for services rendered, and of course the emperors own robes were neither requested nor given. Salaried titles without duties, sinecures that is, became annuities in modern terms when sold to raise capital sums, and they could be espe cially valuable gifts for useful foreigners. But even titles that came with no position or salary or robes of office were much in demand, for they signi ed imperial recognition and an implied promise of some contin ued access to the court with its banquets, ceremonies, and entertain ments. Patricius, for example, a rank once reserved for the more ancient families of the rst Rome, was also available to especially favored for eigners by the seventh century. But no single honori c title could possi bly have sufficed to accommodate the great diversity of competitive claims for honors. The Book of Ceremonies lists a great many titles suit able for foreign potentates. If a chieftain proudly bearing the mag ni cent title of megaloprepestatos encountered a most distinguished megalodoxos, both could feel that they had received the greater honor from the emperor, and both could therefore feel impelled to show the greater loyalty. The imperial court could bene t from a confused disorder of titles but its elaborate ceremonials needed clarity and order. These could hardly be improvised, because for each ceremony many people had to be in the right place at the right time, and in the right order of precedence. A strict protocol was accordingly imposed on all things, including the ex act wording of official greeting and welcoming statements. They could not just be made up on the spot without risking misunderstandings that might even be dangerous. Unless it was their purpose to cause offense, the many foreign envoys who came to the court needed help to prepare their formal statements, and learn their steps for the elaborately staged ceremonials; and such help was duly provided.

Two low dose studies using glyphosate and glyphosate-based herbicides with exposures ranging from 1 blood sugar over 300 purchase cozaar in united states online. However diabetes mellitus journal 2013 buy discount cozaar 25mg, male albino rats orally exposed to Roundup for 12 weeks showed testicular degeneration and increased sperm abnormalities in doses as low as 3 managing diabetes after kidney transplant order cozaar now. While most studies on male rodents showed reproductive effects blood sugar 59 buy cheap cozaar 25mg on-line, reproductive effects in female rodents exposed to glyphosate or glyphosate formations were not observed consistently blood glucose screening order cozaar 50 mg amex. In female rats exposed to 126 mg/kg/day of a glyphosate-based herbicide for 60 days managing diabetes in hemodialysis patients order generic cozaar, relative ovary weight decreased by 38% compared to controls (Hamdaoui 2018). In pregnant rats acutely exposed, ovaries were lighter, implanted sites decreased by 42%, total number of corpus luteum were reduced, and pre-implantation loss increased following exposure to 500 mg/kg/day (Almeida et al. However, no reproductive effects were reported in pregnant female C57B1/6 mice orally exposed to 420 mg/kg/day (Teleken et al. In multi-generational studies on female rodents, reproductive effects varied by generation. Results found that the percentage of sperm motility in Roundup-treated samples upon one hour of incubation was significantly lower than in controls; after three hours of incubation, the percentage of sperm motility in Roundup-treated samples was also significantly lower than in controls. Consequently, findings suggest glyphosate disrupts the development and maturation of oocytes by generating oxidative stress and inducing early apoptosis (Zhang et al. During the first 24 hours of treatment, glyphosate at concentrations ranging from 10 ppm to an agricultural dilution 1000 times greater did not impact cell viability, while glyphosate-based formulations resulted in dose-dependent cell death. Additionally, glyphosate-based formulations induced accumulation of intracellular lipids. Both glyphosate and glyphosate-based formulations resulted in mitochondrial dysfunction signified by reduced Succinate dehydrogenase activity. The authors concluded that herbicide-induced mitochondrial function alterations are formulation-dependent. Glyphogan formulants at sub-agricultural doses were able to rapidly penetrate and accumulate in cells. Given that only one study examined each endpoint and the lack of quantification of glyphosate exposure across studies, these results were not considered sufficient for drawing conclusions on the risk of developmental toxicity associated with glyphosate exposure in humans. No associations were found between paternal exposure and risk of miscarriages (Savitz et al. Similarly, no associations were found between maternal glyphosate exposure and birth weight (Sathyanarayana et al. This dose level resulted in maternal toxicity, thus the developmental effects noted may be secondary to the maternal effects. Increased incidence of kidney tubular dilation was reported for F3b male weanlings in a 3-generation study of glyphosate technical (98. No developmental effects were seen in rat pups exposed to 2 mg/kg/day every 48 hours on post-natal day 1 to 7 (Guerrero Schimpf et al. However, on a per litter basis, there was no statistically significant difference between controls and glyphosate-treated groups. Offspring in the F1 generation showed delays in puberty in males and decreases in weaning weights of both sexes. More serious effects were observed in the F2 and/or F3 generations: significant increases in testis disease, prostate disease, kidney disease, ovary disease, obesity, tumors and parturition abnormalities. Almost a third of F2 generation females (7/20) died during late gestation or experienced litter mortality, whereas neither of these abnormalities were observed in the 16 controls. Male offspring were assessed for reproductive effects after sacrifice at 5 days, 20 days, 35 days, or 8 months old. Significant decreases in sperm counts were observed in males prenatally exposed to both formulations of glyphosate: 0. Exposure to glyphosate technical was associated with decreased serum testosterone and altered testes morphology in rats sacrificed at 20 days old. Developmental endpoints were evaluated in three open-literature studies that employed oral exposure to glyphosate formulations. An additional study on C57B1/6 mice also documented developmental effects on the reproductive system when male F1 offspring exposed to 420 mg/kg/day Roundup in utero through the end of lactation showed increased age at testes descent (Teleken et al. Multi-generational rat studies using intermediate oral exposure to glyphosate-based herbicides found developmental effects of varying severity. Increased anogenital distance was also observed in offspring of F0 dams exposed to glyphosate technical, but, unlike Roundup Bioflow exposure, glyphosate exposure was only associated with this effect in male offspring (Manservisi et al. F1 females from the higher exposure group gave birth to offspring that showed increased fetal anomalies (conjoined fetuses and abnormal limbs) compared to controls, as well as the fetal growth effects found in the lower exposure group (Milesi et al. In a study on rats exposed from gestation day 0 to post-natal day 21, exposure to a glyphosate formulation was associated with impaired neurological development. In male offspring, impaired memory was only seen at higher doses of 200 mg/kg/day. At 100 mg/kg/day, striatum acetylcholinesterase activity was inhibited by 23%, in addition to other effects seen in females at the same dose (Gallegos et al. Serum triglyceride levels increased in gestational day 19 fetuses and postnatal day 21 female offspring and total cholesterol was elevated in postnatal day 7 (males) and 21 (female) offspring. Histological examination revealed clustering of monocytes, indicative of inflammation, in postnatal day 7 females and hepatic lipid droplets in hepatocytes of the offspring mice, with effects more pronounced in males (Ren et al. Overall, offspring mice exhibited hepatic steatosis and excessive lipid droplets formation within hepatocytes suggesting glyphosate alters lipid metabolism (Ren et al. From 2014 to 2016, several meta-analyses were conducted for lymphohematopoietic cancers. The primary literature used in these meta-analyses is discussed later in this section. Schinasi and Leon (2014) conducted a systematic review and meta-analysis of 21 pesticide active ingredients and chemical groups including glyphosate. The Working Group reanalyzed the data, but used the most fully adjusted risk estimates for the studies by Hardell et al. Epidemiological Studies A number of case-control and prospective cohort epidemiology studies have examined possible associations between use of glyphosate-containing compounds and increased cancer risks. The majority of the studies examined individuals who were occupationally exposed to pesticides and used self-reported or proxy-reported (ever/never use of glyphosate-containing compounds) use as the marker of exposure. The cohort studies utilized data on participants from the Agricultural Health Study, a prospective study of cancer and other health outcomes. The cohort consisted of >89,000 licensed pesticide applicators and their spouses (52,394 applicators and 32,345 spouses) who were recruited between 1993 and 1997 from Iowa and North Carolina. Study limitations included self-reported exposure information, few cases for many of the cancer subtypes, limited information regarding the timing and duration of exposure, and recall bias. A small number North Carolina (Agricultural Health Study) Intensity weighted exposure days p-trend: 0. Outcomes/endpoints: Breast exposure-response relations cancer incident cases identified were only available for the Glyphosate analysis for wifes pesticide through state cancer registries husband, lack of information on use among all wives in the cohort from enrollment to 2000 (mean how long each woman had been included 82 exposed and 227 unexposed follow-up period: 4. Data analysis: Poisson regression associations for less commonly Further analysis of husbands pesticide Adjustments: Age, race, and state used pesticides, pesticide use use among wives who reported never of residence. Confounders considered included parental age at childs birth, childs sex, childs birth weight, history of parental smoking, paternal history of cancer, and maternal history of miscarriage. Adjustments: Age at enrollment, race, state, family history of prostate cancer, smoking, fruit servings, and leisure-time physical activity in the winter. Separate glyphosate analyses were conducted by disease aggressiveness and family history of prostate cancer (yes, no). Potential recall 225 exposed and 67 unexposed for multivariate logistic regressions. Adjustments: Age, cigarette smoking, diabetes, and subject type for ever/never pesticide exposure (applicator versus spouse). Confounders considered included marital status, smoking (age started smoking, average number of cigarettes, pipe or cigars smoked per day, total years smoked), and ethnicity. Controls were frequency-matched by sex and age to the combined distribution of the stomach and esophagus cases. Limitations: the major limitation Data analysis: Unconditional was the large proportion of proxy Glyphosate analysis (only conducted logistic regression. Most of the among male farmers) included 17 cases analyses by sex and respondent associations observed were and 32 controls among farmers compared type (self versus proxy-reported) limited to proxy respondents. Among these, self Adjustments: Age, sex, and reported respondents included respondent type. Controls were frequency-matched by sex, age, and vital status to the combined distribution of the cases. Glyphosate analysis included 36 exposed registries, except in Quebec, and 321 unexposed cases and where hospital ascertainment was 147 exposed and 1,359 unexposed used. Data analysis: Conditional logistic Potential controls were selected randomly regression. Analyses were control interviews that were with and 786 unexposed cases and separately conducted with or proxies. House and garden pesticide use: Glyphosate analysis included 51 exposed and 747 unexposed cases and 76 exposed and 1,099 unexposed controls. Analysis included 28 exposed and 410 unexposed cases and 75 exposed and 1,066 unexposed controls excluding proxy respondents. Randomly-selected, population-based controls were frequency-matched within a state. Set 3: 40,719 applicators, additionally excluded those missing data on Sets 1 and 3: Age at enrollment, additional pesticide use. Potential inaccuracies in the and 49 controls who used glyphosate evaluation of pesticide exposure herbicide compared to never-farmers Data analysis: Unconditional could lead to exposure (243 cases and 547 controls). Multiple statistical comparisons make it Controls were a population-based, Adjustments: Vital status, age, difficult to separate real stratified sample of white men state, tobacco use, family history of association from chance findings. Limitations: Small number of cases and controls, multiple 173 cases and 650 frequency-matched Data analysis: Logistic models statistical comparisons, and controls from random digit dialing, adjusted for vital status and age. Glyphosate analysis included 11 exposed and 162 unexposed cases (n=173) for multiple myeloma and 40 exposed and 610 unexposed controls (n=650). Glyphosate analysis included Adjustments for age, gender, four exposed B cell lymphoma cases education, center. Glyphosate analysis included Registry from 1981 to 1983 from 36 exposed and 614 unexposed cases males 30 years of age. In (n=650) and 61 exposed and Minnesota, cases were ascertained 1,872 unexposed population based from a surveillance system of matched controls (n=1,933). Minnesota hospitals and pathology laboratories from 1980 to 1982 in males 30 years of age. In Kansas, cases were randomly selected from statewide cancer registry from males 21 years of age. Data analysis: Two models were used: (1) standard logistic regression and (2) hierarchical regression adjusted for age and study site. December 1, 1999 and April 30, Ever (>10-year latency): pesticide exposure, no 2002. Data analysis: Conditional logistic regression analysis adjusted for both univariate and multivariate. Excluding proxy >2 days/year (exclude proxies): respondents, analysis included Data analysis: Logistic regression. Glyphosate analysis included from September 1, 1991 to Potential for recall bias and for 38 exposed and 278 unexposed December 31, 1994. Low response rates province of residence, personal resulted in inability to evaluate and family medical history. Cases identified through 684 controls for non-asthmatic non Nebraska Lymphoma Study group farmers (reference), 53 cases and and area hospitals between July 91 controls for non-asthmatic farmers, 1983 and June 1986 (n=346). Data analysis: Unconditional logistic regression adjusted for these data were used in the pooled age, state, vital status. December 31, 1991 from cancer for exposure, but demonstrated a registries for five providences, in Exposure >2 days/year: dose-response relationship. Limitations: Potential for recall cases (n=517) and 133 exposed and bias and misclassification of 1,373 unexposed age-matched controls Data analysis: Conditional logistic pesticide exposure. Because of limited statistical power, analysis was restricted to exposure that at least 1% of respondents ever used. Multiple Glyphosate analysis included 4 exposed Swedish Cancer Registry from comparisons may result in some and 107 unexposed cases (n=111) of 1987 to 1992. These data were used in pooled Data analysis: Logistic regression analysis by De Roos et al. Glyphosate analysis included 32 exposed and 310 unexposed cases Data analysis: Conditional logistic (n=342) and 133 exposed and regression adjusted for age, 1,373 unexposed controls (n=1,506). The epidemiological studies on the association between glyphosate use and solid-type tumors are presented in Table 2-7. Overall, these studies did not detect a statistically significant association between glyphosate use and all cancer types studied, including melanoma, childhood cancers, soft tissue sarcoma, colorectal cancer, and cancers of the lung, oral cavity, colon, rectum, pancreas, kidney, prostate (including total prostate and aggressive prostate cancers), testes, breast, bladder, stomach, and esophagus. A statistically significant association with glyphosate use and solid tumors was reported in one study. Overviews of epidemiological studies that focused on the association between glyphosate use and lymphohematopoietic cancers are presented in Table 2-8. A majority of the studies did not report statistically significant associations between glyphosate use and many of the lymphohematopoietic cancer subtypes.

Discount cozaar amex. - FORD BREWER MD MPH.

Carici-Narthecietum scardici metabolic disorder vitamin d generic 25mg cozaar with visa, Saxifraga aizoides diabetes type 2 left untreated effective 50 mg cozaar, Saxifraga stellaris alpigena diabetes mellitus urinalysis purchase on line cozaar, representatives of the families Cyperaceae and Juncaceae diabetes symptoms legs bruising purchase genuine cozaar on-line, as well as the bog spe cies Drosera rotundifolia diabetes prevention 7 foods discount cozaar 25mg line, Sphagnum sp blood glucose journal template order 25mg cozaar with mastercard. The 132 different plant communities illustrate the ecological diversity within Macedonia, including: 21 aquatic and swamp communities; 8 halophytic communities; 2 steppe commu nities; 50 forest communities and 51 alpine communities: Aquatic Communities: Aquatic vegetation consists of floating. It develops in the natural lakes of the Republic, is well studied and is represented by six associations, two alliances, two orders and two classes (Potametea and Lemnetea). In the past, aquatic plant communities also used to develop within marshes but, as a result of drainage activities, they were completely destroyed. Wetland Communities: Lowland marsh vegetation is well studied and represented by 13 as sociations, five alliances, three orders and two classes (Phragmitetea and Isoeto-Nanojun cetea). In the past, these communities were widely distributed within numerous marshes and swamps, but drainage activities in the major valleys (Pelagonia, Strumitsa, Skopye, Ohrid Struga, and Polog) and the Ovche Pole Plain destroyed large portions of these communities, and the areas they occupied were converted into arable land. Meadow Communities: Lowland meadows extend from 80 to 1,000 m in almost all valleys. The areas on which they develop are now considerably reduced, especially on moist soils. The meadows of the mountain belt (1,000-1,400 m) belong to the alliance Rumicion thyrsiflori. Halophytic and Steppe-like Communities: these develop in the central portion of Macedo nia, in the region between Negotino, Shtip and veles. Halophytic communities are present on small areas within the Ovche Pole Plain and in the steppe-like zone (between Negotino and veles). Taxonomically, they belong to the vegetative class Thero-Salicornietea, in which the halophytes Camphorosma annua, Camphorosma monspeliaca, Salicornia herbacea, Suaeda maritima dominate. Steppe-like vegetation develops on Palaeogenic and Neogenic marls and has a high concentration of steppic species, such as: Astragalus parnassi, Hedysarum mac edonicum, Morina persica, Onobrychis hypargyrea. These communities are often of secondary origin and are formed primarily by the destruction of lowland forests. They are represented by over 10 associations belonging to the vegetative class Festuco-Brometea. Forest Communities: Such communities cover a large portion of the land area of the Repub lic of Macedonia at elevations of 150-2,200 m. Assessment of Biodiversity 39 Hop-hornbeam, Chestnut and Beech), while evergreen forests (Pine, Fir and Spruce) as well as mixed forests (Fir-Beech) are distributed in small areas. Due to over-harvesting, they have been degraded in the lowland areas and completely destroyed in some places. They are repre sented by over 80 pure forest stands and include species from seven classes. Sub-alpine and Alpine communities: these are distributed at the upper boundary of the for ested areas, at 1,600-2,700 m, where climatic conditions are the most unfavourable (long winters, short summers and short growing seasons). Here, the various communities develop on heterogeneous substrates (acid soils, carbonate substrates, eroded cliffs, mountain peats, mountain streams, rocks). Species Diversity Notwithstanding the fact that the entire territory of the Republic of Macedonia encompasses an area of 25. On regional scale the biodiversity of Macedonia, in diverse taxonomic groups, covers 70-90% of the entire Balkan biodiversity (Kottelat & Freyhof, 2007; Gasc et al. Simple comparative analysis shows that the concentration of Biodiversity Richness in Mace donia ranges from 54 times (in fishes) up to 246 times (in birds) higher than the mean Euro pean Species Diversity Richness. Fungi (Fungi) Assessment of Fungi Fungi represent a very heterogeneous group of organisms; however, studies to date have dealt mainly with the phyla Ascomycota and Basidiomycota. Most belong to the orders Ascomy cota (83), Basidiomycota (946), Zygomycota (1), Neocallimastigomycota (13), Myxomycota (7) and Oomycota (3). Lichens (Lichenes) Assessment of lichens Lichens (Lichenoid Fungi) (Lichenes) number approximately 354 species. Algae (Algae) Assessment of Algae With regard to the lower plant groups, Algae represent an especially diverse group of organ isms. To date, 2,169 species of Algae have been identified, of which Silicate and Green Algae form a majority. Most have been recorded in Ohrid and Prespa Lakes, with lesser numbers in Doyran Lake, on Pelister Mountain and the Babuna River. The Silicate Algae (Bacillariophyta) have the highest diversity, represented by 1,206 spe cies (166 endemics); Charophytes (Charophyta) 393 species (12 endemics), Blue-Green algae (Cyanophyta), by 283 species and (15 endemics) and Green Algae (Chlorophyta) by 209 spe cies (2 endemics). The other phyla are less represented: Euglenozoa 27 species (1 endemic), Heterokontophyta 25 species, Dinophyta 16 species, Rhodophyta 8 species, Cryptophyta 1 species and Glaucophyta 1 species. Flora (Plants) the flora of the Republic of Macedonia is quite rich, with a mosaic of diverse floral elements (Tertiary relicts, Mediterranean, Greek-Anatolian, Ilyric, Caucasian, Middle-European, Eura sian, Arctic-Alpine and Cosmopolitan) and large number of endemic species (Macedonian, South Balkan, Balkan). The most numerous group is flowering (Angiosperm) plants, with about 3,200 spe cies, followed by Mosses (350) and Ferns (42). The class Hepaticae includes 25 families, 36 genera and 66 species; the class Anthocerotae includes one family, one genus and one species, while the class Musci includes 41 families, 130 genera and 331 species. This group is represented by six species which mainly inhabit moist areas and bogs in mountain and high mountain areas. The species Diphasium alpinum, Huperzia sellago, Isoetes phrygia and Lycopodium clavatum have very restricted distribution. Horsetails are represented by seven species which may be found in very moist places, from lowlands to high mountain areas (by rivers, mountain streams, val leys, gorges, marshes and moist meadows). The following species are characterised by a restricted distribution: Adiantum capillus-veneris, Blechnum spicant, Crytogramma crispa, Ophioglossum vulgatum, Osmunda regalis, Phyllitis scolopendrium, Thelipteris palustris, as well as the endemic species Asplenium macedonicum (in the vicinity of Prilep). This group also includes the two species of aquatic ferns (Marsilea quadrifolia and Salvinia natans). These are represented by four families, six genera and 18 indigenous species (the most polymorphic are the genera Juniperus and Pinus, each with five species). Some species have been introduced (exotic), mainly from the genera Abies, Junipe rus, Picea, Pinus, Sequoia, Taxodium etc. Angiosperms are represented by 120 families, 720 genera and approximately 3,200 species (5,000 taxa). The most polymorphic families of the class Di cotyledonae are the families Caryophyllaceae (345 species), Compositae (c. The class Dicotyledonae is represented by 109 endemic species and the class Monocotyledonae by five. The families with the most endemic species are: Compositae (18), Caryophyllaceae (17), La biatae (12), Violaceae (10), Scrophulariaceae (9), and Rosaceae (9). Species endangered by these activities are: Alopecurus creticus (Mon ospitovo Marsh); Carex elata, Ranunculus lingua, Rumex hydrolapathus and Senecio palu dosus (Ohrid and Struga Marshes); Carex pseudocyperus, Scirpus sylvaticus expansus and Thelipteris palustris (Marsh near Gostivar); Cladium mariscus, Juncus maritimus, Molinia coerulea, Ophioglossum vulgatum, Shoenus nigricans etc. The following species are considered to be extinct: Acorus ca lamus (Crni Drim River) and Sagittaria sagittifolia (Pelagonia Marsh Novatsi). By inundating large areas of river gorges, the existing phytocenoses present in the lower vertical profiles of the rivers suffer degradation and partial destruction, and the cover of relict, endemic and rare plant species is reduced. In the Treska River gorge, where the Kozyak hydropower reservoir has been con structed, type localities of 13 plant species have been present. Among them, the relict endemic species Thymus oehmianus and Viola kosaninii are particularly threatened. With the planned construction of the Chebren hydropower reservoir in the gorge of the Crna River near Mari ovo, natural habitats of the endemic species Silene paeoniensis will be covered with water. The construction of the Mavrovo Lake caused two species, Gentiana pneumonanthe and Lysi machia thyrsiflora, which originated on the Mavrovsko Pole Plain, to become extinct. The cultivation of the salty soils of the Ovche Pole Plain has endangered some halophytic species and communities. This especially refers to the species Camphorosma monspeliaca, but also to other halophytes such as: Cryp sis aculeatus, Puccinelia convoluta, Suaeda maritima etc. This activity endangers the following species: Aconitum diver gens, Adonis vernalis, Althaea officinalis, Anacamptis pyramidalis, Arctostaphylos uva-ursi, Centaurium erythraea, Colchicum bivonae, C. Assessment of Biodiversity 43 Uncontrolled collection of rare plants by profession al collectors. The result of this activity is the endangerment of many local endemic plants with restricted distributions: Astragalus cernjavskii, Astragalus physocalyx, Crocus cvijici, Sambucus deborensis, Thymus oehmianus, Tulipa mariannae, Tulipa scardica. Alshar: Knautia caroli-rechingeri, Onobrychis degeni, Thy mus alsarensis, Viola allchariensis and V. These endanger rare species occurring in mountainous areas, especially on mountain peaks. Bistra: Colchicum pieperianum; Shar Planina-Popova Shapka: Gentianella ciliata and Picea abies; yakupitsa Solunska Glava: Rhododendron myrtifolium; Krushevo: Viola slavikii. Fauna (Animals) Assessment of Fauna A general characteristic of the fauna of Macedonia is its high degree of taxonomic diver sity, represented by 10,354 species. In addition, the complex zoogeographical structure, with faunal elements of various origins and zoogeographical affiliations is manifested by a high degree of relict and endemic forms. The diversity of this group of organisms is mainly concen trated in the waters of the three natural lakes (Ohrid, Prespa and Doyran). A total of 113 species has been recorded, of which 79 belong to the group of free-living Protozoans. Of the parasitic Protozoans, there are five subphyla; however, only the subphylum Ciliophora has been studied (34 species). From the Subphylum of Turbellaria (Turbellarian Worms), 65 species have been recorded, with the dominant representatives from the Suborder Tricladida, with a total of 40 species. From the Subphylum Neodermata (Neodermates), the classes Trematoda (Flukes) and Ces toda (Tapeworms), are represented by 10 species each. The largest centre of biodiversity of this group of organisms is Ohrid Lake, with 48 recorded species. These are represented by the Class of Hydroid Zoophytes (Hydrozoa) in freshwater ecosystems, of which two species have been recorded. Found in the sublittoral zone of Ohrid Lake, Sti chostemma graecense is the only recorded species. The data on Rotifera originate from the analyses of the plank ton communities of the three lakes, recognising 269 species. As planktonic organisms, they are characterised by a wide area of distribution and have no endemic species. Research to date has identified a total of 553 species of Nematodes in Macedonia, which is likely to be much less than the actual number of species. In the first study of roundworms in Ohrid Lake, 23 aquatic, Free-living Nematodes were found. Later, greater stress was given to the study of terrestrial Nematodes, mainly in forest ecosystems (450 species), as well as Nematodes which parasitise early vegetables, animals and humans (80 species). With regard to the Class Oligochaeta (Oligochaetes), 157 species have been recorded, while the Class Hirudinea (Leeches) is represented by 29 species. This group has numerous representatives in the animal world and is also well represented within the Republic of Macedonia with a large number of species (8,234). The Subphylum Chelicerata (Chelicerates) is reperesented by the Class Arachnida (Arach nids) with total number of 993 species. Among the six orders in this class, the order Aranea (Spiders) is dominant with 702 species. The order Pseudoscorpiones (Pseudo-scorpions) is represented by 51 species and the Order Opiliones (Harvestmen or Daddy Longlegs) by 40 species. The Order Scorpiones (Scorpions) is represented by three species, and the Order Solpugida (Sun Spiders) by one species only. The Order Acarina (Ticks and Mites) is repre sented by 196 species, most of which belong to the group of terrestrial mites (123 species), with the remainder being aquatic mites (73 species). The western portion of Macedonia is an important centre of biodiversity for this group, which is present in various types of habitats. The Subphylum Crustacea (Crustaceans), represents one of the most thoroughly studied groups of organisms, with a total of 476 species. Of the Class Maxilopoda, the subclass Copepoda (Copepods) is represented by 145 species, separated into three orders. The Order Cyclopoida is represented by 58 species, the Order Harpacticoida by 54 species and the Order Calanoida by 30 species. From the Subclass Branchiura (Branchiurans), only three species have been recorded to date. Summer Cep (Boletus reticulatus) Scarlet Elf Cup (Sarcoscypha coccinea) Sponge Morel (Morchella spongiola) Sweet Vernal (Adonis vernalis) Alshars Violet (Viola allchariensis) Insectivorous Plant Drosera (Drosera rotundifolia) 3. Assessment of Biodiversity 47 the Class Branchiopoda is represented by 94 species, of which the Order Anostraca by six species, the Order Notostraca by two species and the Order Diplostraca by 86 species. The Class of Malacostracans (Malacostraca) is represented by 69 species, separated into four orders. The Order Isopoda is represented by 15 species, the Order Amphipoda by 47 species, the Order Bathynellacea by 2 species, and the Order Decapoda by five species. Since the Crustaceans in Macedonia are linked with freshwater ecosystems, the largest centres of biodi versity occur in the three natural lakes, especially Ohrid Lake. The Subphylum Myriapoda (Myriapods) includes 98 species, separated into two classes: the Class Diplopoda (Millipedes) with 62 species and the Class Chilopoda (Centipedes) with 36 species. The Class Entognatha (Ametabolous Arthropods) has a small number of recorded species (14) belong ing to three orders: Collembola (6), Protura (2) and Diplura (6). The Class Insecta (Insects) has a total of 6,653 species, devided in numerous orders. The orders have the following number of recorded species: Ephemeroptera (Mayflies) 112 species, Odonata (Dragonflies) 62 species, Plecoptera (Stoneflies) 93 species, Orthoptera (Grasshoppers) 184 species, Isoptera (Termites) 2 species, Psocoptera (Book-Lice) 48 species, Thysanoptera (Thrips) 4 species, Heteroptera (True Bugs) 778 species, Homoptera (Homopterans) 332 species, Trichoptera (Caddisflies) 285 species, Diptera (Flies and Mosquitoes) 759 species, Hy menoptera (Ants and Bees) 178 species, and Coleoptera (Beetles) 1527 species and Lepi doptera (Moths and Butterflies) with a total of 2,289 recorded species. The most important diversity centres of insects are the mountain massifs of Shar Planina, Galichitsa, yakupitsa, and the refugial centres in the gorges of the Treska, Babuna, Topolka, Crna and vardar Rivers.

Ongoing Clinical Studies Information on ongoing clinical studies that have been submitted to the U diabetes mellitus type buy cozaar online. National Institutes of Healths registry of publicly and privately-supported studies ( We focused on randomized controlled trials comparing proton beam therapy alone to an alternate treatment modality with a projected study enrollment of more than 50 patients treatment of diabetes insipidus purchase cozaar with visa. We concentrated on trials evaluating the various conditions that are the focal point of this review diabetic diet hummus buy cozaar 50mg with visa, and excluded comparative studies of carbon ion therapy diabetes prevention dpp buy cozaar uk, as this treatment modality is not currently available in the U diabetes vision buy cheap cozaar 50mg on line. Methods Objectives the primary objectives of the systematic review were to: Evaluate and compare the published evidence on the impact of proton beam therapy relative to other radiotherapy modalities and non-radiation treatment alternatives on survival diabetes mellitus type 2 definition who order cozaar canada, control of cancerous and noncancerous tumors, health-related quality of life, and other patient outcomes for populations with both primary and recurrent disease; Evaluate and compare the harms of proton beam therapy and treatment alternatives, including generalized effects. A total of 19 categories (16 cancer types, three types of noncancerous tumors) of disease were selected for this review (see "Patient Populations" on page 27). We do recognize and make explicit mention, however, of clinical areas in which simulation studies are likely to remain the cornerstone of evidence, given logistical and ethical challenges posed by conducting clinical trials in these areas. One notable exception to this rule was the use of modeling to answer questions of cost and/or cost-effectiveness, as clinical outcomes in these studies were typically derived from actual clinical outcome data from other published studies. In addition, because the risk of secondary malignancy is felt to be of great interest because of its link to radiation of normal tissues, these outcomes were abstracted when reported. Analytic Framework the analytic framework for this review is shown in the Figure on the following page. Some studies are randomized or observational comparisons focused directly on survival, tumor control, health-related quality of life, and long-term harms, while in other studies a series of conceptual links must be made between intermediate effectiveness measures. The condition categories of interest are listed below, and included 16 cancer types and three types of noncancerous conditions as listed in Table 1 below. All levels of disease within each condition type were considered for this evaluation. Comparators All relevant comparators of interest were included in this evaluation. Other treatment alternatives were specific to each condition type treated, and may have included chemotherapy, surgical procedures, and other devices. We accepted unadjusted rates of these measures if that was the only method used to report them. Examples included visual acuity for ocular tumors and shunt requirements for arteriovenous malformations. Potential Harms While the focus of attention was on adverse effects requiring medical attention, all available data on treatment-related harms were abstracted where available. Where reported as such, toxicities were separated into early (90 days following treatment) or late (>90 days following treatment) effects. We also collected information on secondary malignancy risk due to treatment radiation exposure where reported. There is considerable controversy on extrapolating cancer death risks from those experienced by adults with high radiation exposure at Hiroshima and Nagasaki to the potential risks at much lower radiation doses. Linear extrapolation has been the approach generally used, although the uncertainties inherent in this approach become progressively greater at lower doses. Also controversial is whether a natural threshold of radiation exposure exists before excess risk from specific exposures can be realized. The current guidance from a variety of regulatory authorities is that no threshold exists, but this has also been intensely debated. On the other hand, exposure to ionizing radiation has increased; a recent estimate indicates that the average per capita annual exposure in the U. These studies have not provided definitive answers, however, due to concerns regarding selection bias, changes in technology over long periods of follow-up, and sensitivity to assumptions made in dose-extrapolation models. We therefore opted to abstract effective radiation dose where reported, and to include explicit measures of the incidence of secondary malignancy where available. Timeframe Data on all relevant measures were abstracted at all relevant timepoints, regardless of study duration. No limits were placed on study selection based on sample size, duration, location, or frequency of outcome measurement. As mentioned previously, studies that involved simulated outcomes only were not included in this review. Studies were not further restricted by instrumentation, manufacturer, or testing protocol. Data from all retrieved studies were included in evidence tables regardless of study quality. A "no evidence" rating is made when no studies meeting entry criteria for the review are identified. For example, if we have given an overall rating of an incremental net health benefit, we give information on whether that rating was based on evidence demonstrating small increases in effectiveness with no difference in harms, or on evidence demonstrating equivalent effectiveness and a small reduction in harms. Detailed evidence tables are presented in Appendices C, D and F for all key outcomes and study designs evaluated in this review. Detailed descriptions of the evidence base for each key question can be found in the sections that follow. The level of comparative evidence was extremely limited for certain conditions and entirely absent for others. Major differences in patient demographics and baseline clinical characteristics as well as duration of follow-up were often noted between groups. Importantly, however, the strength of evidence was low or moderate for all of these conditions. We determined the evidence base for all other condition types to be insufficient to determine net health benefit, including two of the four most prevalent cancers in the U. The situation is more complex with adult cancers, particularly those that are more prevalent. Summary table assessing strength of evidence, direction of benefit, and consistency with relevant guideline statements and coverage policy. Coverage Policies (per 100,000) Health Benefit Evidence Recommendations Comparators Cancer Bone 1. Note that, given the paucity of comparative studies, all studies are summarized regardless of quality. Two thirds of patients in each group were male, but groups differed substantially in terms of age (mean of 68 years in the radiation-only group vs. For patients with primary tumors, Kaplan-Meier estimates of local control, disease-free survival and overall survival exceeded 90% among those treated by surgery and radiation (n=14). Patients in both groups were followed for a median of 24 months; dose was >50 GyE or Gy in approximately 75% of patients. We identified six case series of brain, spinal, and other nervous system cancers (see Appendix F, Table 2 for specific citations). Two gynecologic case series were identified in 40 patients (see Appendix F, Table 6 for specific citations). Five-year survival ranged widely by and even within cancer type; for example, survival ranged from 50-100% for skull base tumors. No statistically-significant differences between groups were observed in three-year actuarial estimates of local control, progression-free survival, or overall survival. A total of 15 case series were identified with information on outcomes in patients with lung cancer (see Appendix F, Table 9 for study citations). Overall 2-year survival (the most common measured timepoint) ranged from 64-98% depending on cancer stage. Ocular Tumors In comparison to other cancer types, the evidence base for ocular tumors was relatively substantial. Three of the cohort studies were all fair-quality and involved comparisons to surgical enucleation in patients with uveal melanoma at single centers (Mosci, 2012; Bellman, 2010; Seddon, 1990). Outcomes were also assessed in three comparisons of noncontemporaneous case series. Eight-year actuarial estimates of overall survival, freedom from metastasis, and biochemical failure did not statistically differ between groups. Two additional studies were deemed to be of poor quality due to a lack of control for confounding between study populations. Five-year estimates of disease-free survival (using biochemical failure definitions) did not statistically differ between groups. Statistical changes were assessed within (but not between) each cohort immediately following treatment as well as at 12 and 24 months of follow-up, and were also assessed for whether the change was considered "clinically meaningful" (>0. Statistically-significant differences between treatment groups were observed for many baseline characteristics, only some of which were adjusted for in multivariate analyses. We identified eight case series with information on effectiveness in prostate cancer (see Appendix F, Table 13 for specific citations). Two case series were identified in 41 patients (see Appendix F, Table 14 for specific citations). Unadjusted outcomes were reported for the entire cohort only; reduction in tumor thickness, resolution of retinal detachment, and stabilization of visual acuity were observed in >90% of the overall sample. Rates of disease progression, progression-free survival, and distant metastases were numerically similar between groups, although these rates were not statistically tested. Across all conditions, a total of seven comparative studies were identified that included patients with recurrent disease or prior failed treatment. In addition, some of these studies included a mix of primary and recurrent disease without formal subgroup or stratified analyses to differentiate outcomes between them. Both comparative studies and case series are described in detail in the sections that follow. Among patients in the radiation/surgery group, four patients died of disease 4-10 years after treatment; the remainder was alive with disease at last follow up. No case series were identified that were comprised of all or a majority of recurrent cancers. Two case series were identified with information on recurrent or persistent disease in 32 patients (McDonald, 2013; Lin, 1999). The rate of local tumor control was 78%, and did not differ between treatment groups. Overall survival was estimated to be 47% and 33% at one and two years respectively. Findings were similar after Cox proportional hazards regression adjusting for tumor volume and year of retreatment as well as patient age. No local recurrences were found in the enucleation group, which is not surprising given the nature of the treatment. Three case series were identified in which most or all patients had recurrent ocular cancers (Lumbroso LeRouic, 2006; Marucci, 2006; Wuestmeyer, 2006). Two case series were identified in which most or all patients had recurrent disease (Chang, 2011; Hug, 2002b). We identified no case series that focused on patients with recurrent prostate cancer. In the three photon patients, one had local progression at 12 months but no further progression as of year 19 of follow-up, one patient was free of progression and metastases as of five years of follow-up, and one patient had unknown status. In addition, summary statistics from case series data on harms requiring medical attention are provided for each cancer type, with a focus on severe (grade 3) or life-threatening (grade 4) events only. Kaplan-Meier analyses were conducted to control for differential follow-up but no adjustments were made for other differences between groups. Patients receiving radiation alone reported numerically lower rates of abnormal bowel or bladder function as well as difficulty ambulating in comparison to those receiving combination therapy, but rates were not statistically tested. Toxicities were minimal in all but one study, which reported late grade 3 and 4 effects in 15% and 16% of patients respectively (Ciernik, 2011). In two case series grading severity of adverse effects in 39 patients with glioma or glioblastoma (Hauswald, 2012; Mizumoto, 2010), grade 3 and 4 hematologic effects occurred in 65% and 30% of patients respectively. In one study, 10% of patients also developed grade 3 leukoencephalopathy (Mizumoto, 2010). Two case series graded the severity of treatment-related harms in breast cancer (MacDonald, 2013; Bush, 2011). Acute effects grade 3 or higher were recorded in 0% and 8% of patients in these studies respectively. No differences in the rate of gastrointestinal complications were observed for any treatment comparison. Nearly all outcome and toxicity measures were reported for the entire cohort only. Of the six case series evaluating esophageal cancer, five reported data on harms in 278 patients. Commonly reported acute effects were grade 3 pneumonitis (2-7%) and esophagitis (5-12%). Three studies identified late grade 5 effects in 2-5% of patients (Lin, 2012; Mizumoto, 2010; Sugahara, 2005). Grade 3 and 4 acute effects consisted primarily of hematologic and gastrointestinal harms, ranging from 0-100%. Reported late effects also varied (0-20%) with two studies reporting late grade 5 events in 2-3% of patients (Takatori, 2013; Terashima, 2012). One of two identified case series reported on late effects in 25 patients with uterine cervical carcinoma (Kagei, 2003). Grade 4 gastrointestinal and genitourinary harms were each identified in 4% of patients. Rates of severe complications such as temporal lobe damage and cerebrospinal fluid leakage were <5% in most studies. Two comparative studies were identified with comparative information on radiation-related harms. Rates of grade 3 toxicities ranged from 0-23% (higher rates observed with hematologic events). Grade 4 events were reported in one series (rib fracture in 4%, bile duct stenosis and hepatic failure in 7%). Rates of grade 3 or worse effects ranged from 0 21% (higher rates were observed for pulmonary effects).