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• Consultant in Paediatric Dentistry,
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The latter pre four carboxylases in the mitochondria and one in the cytosol women's health clinic greenville tx generic 5 mg aygestin, sents with progressive motor deterioration women's health clinic elko nv discount aygestin 5mg visa, schizophrenia-like an inactivity of all carboxylases results womens health 4 buy generic aygestin 5mg line. Homocystinuria and elevated serum concentra recognize because prompt treatment with biotin may result in tions of homocysteine with reduced or normal serum methio dramatic improvement pregnancy implantation symptoms cheap 5mg aygestin mastercard. Homocystinuria can ketoacidosis and a characteristic pattern on organic acid be caused by several other amino acid disorders as well menstrual days purchase cheapest aygestin and aygestin. Dietary supplementation with folic acid menstrual vitamins buy generic aygestin canada, betaine, and methio Electrographically, a burst-suppression pattern or multifocal nine has proven beneficial. Definitive diagnosis can be made by methionine has been effective in stopping seizures (45). Treatment with biotin Defects in methionine biosynthesis are also associated with (10 mg/day) produces clinical improvement (51). Convulsions are frequent and are predominantly gen eralized, although myoclonic seizures with hypsarrhythmia Late-Onset Multiple Carboxylase have been reported. Diagnostic laboratory findings are mega Deficiency (Biotinidase Deficiency) loblastic anemia, homocystinuria, decreased methionine, and this disease is also screened for in certain states via expanded normal folate and cobalamin concentrations in the absence of newborn screening. Inborn Errors of Creatine Metabolism When not diagnosed early, seizures are a prominent feature Creatine represents a storage depot of adenosine triphosphate occurring in 50% to 75% of affected children. Creatine Symptoms often begin at 3 to 6 months of age, with hypotonia forms via a two-step enzymatic path, with arginine converted and developmental delay. Seborrheic or atopic dermatitis to guanidinoacetate via arginine:glycine amidinotransferase and alopecia are common. Development can be delayed from the beginning or after a Diagnosis is typically made via abnormalities in urine regression beginning between 3 months and 2 years of age. Other clinical fea with high-dose oral biotin should be considered in infants tures may include dystonia, dyskinesias, microcephaly, and with developmental delay and persistent seizures of unknown autistic behaviors (48). A mild form presenting with severe speech delay, mild autism, and infrequent seizures has also been identified (49). Menkes Disease (Kinky Hair Disease) Diagnosis is typically via quantifying urine, plasma, and/or An X-linked disorder of copper absorption, Menkes disease spinal fluid guanidinoacetate and creatine. Affected Early-Onset Multiple Carboxylase Deficiency boys may be premature and may have neonatal hyperbiliru (Holocarboxylase Synthetase Deficiency) binemia or hypothermia. Progressive neurologic deterioration Early-onset multiple carboxylase deficiency presents in the with spasticity is present by 3 months of age, and children first week of life with lethargy, respiratory abnormalities, irri may have associated bone and urinary tract abnormalities as tability, poor feeding, and emesis. Generalized tonic convulsions, Seizures are a prominent feature in Menkes disease, with partial motor seizures, and multifocal myoclonic jerks develop intractable generalized or focal convulsions. Stimulation-induced myoclonic first few days of life with respiratory abnormalities, hypoto jerks may be present. Multifocal spike and slow-wave activity nia, lethargy, hepatomegaly, irritability, and convulsions. Neurologic sequelae can be prevented by Neuroimaging may show brain atrophy, focal areas of necro avoidance of hypoglycemia. Daily copper injec tose and sucrose can be eliminated from the diet before signif tions may be beneficial if administered early in the course of icant cerebral injury occurs (67). Phenotypic overlap exists between Menkes disease and occipital horn syndrome (57). It is now known that both Mitochondrial Disorders Menkes and occipital horn syndrome conditions are allelic due to mutations in the same gene (57). Disorders of energy metabolism typically present with later onset epilepsy outside of the immediate newborn period. However there are exceptions to the rule, especially when dis Disorders of Carbohydrate Metabolism cussing the dizzying and ever-growing array of mitochondrial phenotypes. Glut-1 Transporter Deficiency Syndrome Mitochondria are the cells energy factories, though they the Glut-1 transporter deficiency syndrome was first also have a key role in initiating apoptosis, and reactive oxy described in 1991 (58). Clinical features include develop ment and lactic acidosis were initially described as sine qua mental delay, ataxia, hypotonia, infantile seizures, and nons of the disease, these findings are not reliably present and acquired microcephaly. Additional confirmation of impaired glucose and often unrelated symptoms prior to our current knowledge transport can be performed through assays in erythrocytes of the disease. We now know that almost any unexplained (60) and clinical genetic testing is available. The epilepsy may occur in isola tified feature of this syndrome though patients with later onset tion, or with other neurologic problems including optic nerve and mild epilepsy have been described. About 10% of patients have no clinical been associated with mitochondrial disease, but patients with seizures. Diagnostic testing initially involves looking for a combi recognized as an allelic variant of Glut-1 deficiency (64,65). These studies allow for focused genetic testing in threatening disorder of gluconeogenesis, presents within the select cases (70). Chapter 32: Epilepsy in the Setting of Inherited Metabolic and Mitochondrial Disorders 389 Treatment varies and includes preventing worsening during A variety of different seizures, including focal and general metabolic or physiologic stresses, avoiding mitochondrial tox ized seizures, have been described (81). Infantile spasms and ins and poisons, use of select cofactors and supplements, and hypsarrhythmia may occur (82,83). The E1 enzyme is itself a complex structure, Organic Acids Metabolism a heterotetramer of two and two subunits. The E1 subunit is particularly important, as it contains the E1 active Amino and organic acids predominantly form from the catab site. Acidosis and hyperammonemia ensues leading clinical presentations, ranging from acute lactic acidosis in to encephalopathy and at times, seizures. These disorders, infancy with severe neurologic impairment in affected males, when most severe (a severe enzyme deficiency), typically pre to a slowly progressive neurodegenerative disorder in some sent in the newborn period, especially after an infant is males and more commonly females. Structural abnormalities, exposed to a protein or carbohydrate challenge in the diet. For such as agenesis of the corpus callosum, are often present on some, this means after feeding in the 1st day, while for others it neuroimaging (72). Milder enzyme deficiencies may present with a later sudden-onset epileptic encephalopathy (later infancy, Pyruvate Carboxylase Deficiency childhood, or in the adult years) in the midst of a physiologic Pyruvate carboxylase is a biotin-responsive enzyme that stressor (illness, surgery, fasting) that leads to accelerated converts pyruvate to oxaloacetate in the citric acid cycle. Thus, many of these metabolic disorders should be predominant clinical presentations occur with pyruvate car considered in a patient with an acute to subacute epileptic boxylase deficiency. The neonatal type (type B) manifests with encephalopathy of later onset as well when an etiology for the severe lactic acidemia and death in the first few months of life. Developmental delay, failure to thrive, hypo of metabolism are now diagnosed and treated before they lead tonia, and seizures, including infantile spasms with hypsar to neurologic symptoms. A benign form (type C) also has or methylmalonic acidemia, and other relatively well-known been described with recurrent metabolic acidosis and normal amino or organic acid and fat metabolism disorders have neurologic development (75). Mosaicism of the phenotypes become chronic conditions with improved neurologic out mitigates a prolonged survival (76). Treatment with the eases screened for still vary from state to state and country to ketogenic diet or corticotropins may markedly exacerbate the country. Thus, while many inborn errors of metabolism may disorder and should be avoided (77,78). As genetic Leigh Syndrome knowledge of these conditions has evolved, we have moved Leigh syndrome (subacute necrotizing encephalomyelopathy) from making an analyte-based diagnosis from blood and urine is both a clinical and radiologic phenotype and may be related testing to confirmatory molecular genetic diagnostic studies. It is genetically heterogeneous, and depending catabolism with dextrose-containing fluids, and prescribe any on the etiology, may be autosomal recessive or dominant, X metabolic scavengers if available. Below we discuss a few of the disorders where seizures are the clinical presentation is often acute to subacute, involv a prominent feature. The disease progresses with spasticity, abnormal Phenylketonuria eye movements, and central respiratory failure. As a consequence of the metabolic defect, toxic levels of along with cortical and cerebellar atrophy (80). Mutations in this gene account for more than 99% of the Pathologic studies reveal diffuse myelin loss and increased cases (88). Cystic degeneration of the white If untreated, severe mental retardation, behavioral distur matter associated with gliosis is observed. Dialysis or findings and seizure types has been observed since a 1957 exchange transfusion rarely is necessary. Infantile spasms and hyp protein restriction, thiamine supplementation, and elimina sarrhythmia predominate in the young infant. Donker and colleagues showed propor Histidinemia or histidase deficiency is also associated with tionate increases in delta activity as levels rose during phenyl infantile spasms and myoclonic seizures. Feeding difficulties, irritability, and lethargy are observed during the first few weeks of life. A characteristic odor can toms of propionic acidemia also appear during the neonatal be detected in the urine and cerumen, but this may not be period, with 20% of affected newborns having seizures as the detectable until several weeks after birth. Generalized seizures are typical, although partial tion in branched-chain amino acids/branched-chain keto acids seizures have also been reported. Definitive testing can be performed by enzyme develop in later infancy, and older children may have atypical assay and molecular genetic studies (96). Forms responsive to vitamin B Typically, affected newborns present with poor feeding, eme 12 have been reported (104). Stomatitis, glossitis, developmental sis, hyperventilation, lethargy, or convulsions 1 to 5 days after delay, failure to thrive, and seizures are the major features. Brain imaging and pathology reveal cerebral edema Diffuse tonic seizures and partial seizures with secondary with pronounced astrocytic swelling (110). Seizures Later onset disease due to partial enzyme deficiencies can may be characterized by eyelid clonus with simultaneous present with progressive spasticity of the lower extremity, upward deviation of the eyes. Some individuals may be symptom in seven patients, consisting of multifocal spike discharges and free until in the midst of a physiologic stressor that leads to an depressed background activity in two, excessive generalized acute metabolic decompensation (111). In contrast, metabolic acidosis and ketosis frequently occur with disorders of organic acid or pyruvate metabo 3-Methylglutaconic Aciduria lism. Severe devel organic acids, along with measurements of urine orotic acid opmental delay, progressive encephalopathy, and seizures can help differentiate among the various enzymatic defects. Definitive diagnosis is established a mutation on chromosome 9 in the gene encoding the enzyme via gene sequencing if the enzymatic defect is identified by 3-methylglutaconyl-CoA hydratase. If the third of cases, and infantile spasms have been reported early in enzyme defect needs further defining or confirmation, bio the course of the disorder. The typical organic acid abnormal chemical analysis in skin fibroblasts or liver can be per ity includes marked elevations in 3-methylglutaconic acid and formed (112). In the presenting symptom in 10% of patients with 3-hydroxy-3 patients with acute neonatal citrullinemia, a burst-suppression methylglutaric aciduria, a disorder caused by a deficiency in pattern has been described (115). The chromo medical therapy aimed at lowering serum ammonia are rec some location for this disorder is 1pter-p33 (107). Seizures are often the Fatty Acid Oxidation Defects first clinical sign of metabolic decompensation after a febrile illness. Vigabatrin, L-carnitine, baclofen, and riboflavin sup the multienzyme, multistep process of fatty acid oxidation, plementation have been suggested (108). A deficiency in carnitine acylcarnitine translocase also to remove waste nitrogen that forms from protein and car may produce seizures, apnea, and bradycardia in the neonatal bohydrate catabolism. Seizures may occur in other defects of fatty acid oxida high as 1:25,000, though later onset diseases from partial tion, most notably in short-chain acyl-CoA dehydrogenase defects are often underdiagnosed. Development appears to be normal until 4 to 6 months of Diagnosis is made via sending a peroxisomal panel which age, when hypotonia and loss of motor skills are evident. The classic cherry-red spot is pre test, though one must keep in mind that the degree of eleva sent in the ocular fundi of more than 90% of patients. Myoclonic jerks are frequent and are often triggered Within the first week to several months of life, the affected by an exaggerated startle response to noise (2). Multisystem abnormalities of the brain, kid spike and sharp-wave activity may be noted with acoustically neys, liver, skeletal system, and eyes may occur. The presence of the latter, along with hypo an isolated absence or deficiency in hexosaminidase A activity. The seizures do not culminate in gener association with a particular ethnic group. N-acetylglucosamine-containing oligosaccharides in the urine Presently, only symptomatic treatment is available for this and foam cells in the bone marrow is also diagnostic. Acyl-Coenzyme A Oxidase Deficiency Krabbe Disease (Globoid Cell Leukodystrophy) Acyl-CoA oxidase deficiency was initially described in two Another lysosomal disorder occurring in this age group is siblings by Poll-The and colleagues (125). The majority of cases associates in 1991, is characterized by infantile spasms, arrest begin within the first 3 to 6 months of life with irritability, of psychomotor development, hypotonia, hypsarrhythmia, poor feeding, emesis, and rigidity. Blindness and optic atrophy include epicanthal folds, midfacial hypoplasia, protruding ensue. Initially, increased tendon reflexes are present and ears, gingival hypertrophy, micrognathia, and tapering fingers. Based on infantile spasms, are seen, which may be difficult to distin the pattern of inheritance associated with the disease, it is pre guish from muscular spasms (132).

However pregnancy sex cheap 5 mg aygestin free shipping, our survey was done at a single point in time and during a time period when collegiate experiences are more salient pregnancy diarrhea buy aygestin 5 mg fast delivery, so it may be that subjects had difficulty recalling sexual assaults that occurred before entering college breast cancer keychains cheap aygestin 5 mg with visa. On the other hand menopause rash cheap aygestin uk, it is important to point out that our since entering college estimates do not reflect the samples entire collegiate experience because the sample includes freshman menstrual 1 generic aygestin 5 mg free shipping, sophomores pregnancy vs pms buy cheapest aygestin, and juniors (and even seniors had not completed their senior year), which means that the true rate of sexual assault during the entire college experience is likely higher. It is important to note, however, that although the cumulative prevalence estimates of sexual 6-1 this document is a research report submitted to the U. This pattern indicates that women who are victimized during college are most likely to be victimized early on in their college tenure. This finding is consistent with a recent study employing a convenience sample of university women, which found that 84% of the women who reported sexually coercive situations experienced the incident during their first four semesters on campus (Gross, Winslett, Roberts, & Gohm, 2006). Our multivariate analyses identifying risk factors for sexual assault among university women indicate that several factors are differentially associated with specific types of sexual assault. Specifically, compared to whites, Hispanic women were more likely to be victims of physically forced sexual assault. In contrast, none of these risk factors were significantly associated with being a victim of forced sexual assault. Ever having been threatened, humiliated, or physically hurt by a dating partner was a risk factor for all three measures of sexual assault. Other studies have found that previous victimization is a risk factor for future victimization, but this is the first study we are aware of that has determine that being a victim of a certain type of sexual assault puts one at risk of being a victim of that type of sexual assault, and not necessarily another type of sexual assault. In other words, the risk posed by previous victimization is specific to the type of victimization experienced. Descriptive analyses of the context, consequences, and reporting of sexual assault also confirm that differences exist between forced and incapacitated sexual assault. For example, 23 While the past 12 month prevalence is also high among freshmen, they were excluded from these comparisons of sexual assault prevalence because they had not experienced 12 months of college. Forced assaults were also more likely to be perpetrated by a stranger to the victim or an ex-dating partner or ex-spouse, whereas incapacitated sexual assaults were more likely to be perpetrated by a friend or acquaintance of the victim. Additionally, more than a quarter of incapacitated sexual assault victims were victimized by a member of a fraternity. Not surprisingly, victims of incapacitated sexual assault were considerably more likely to have been using alcohol before and be drunk during the assault. Incapacitated assaults were more likely to happen at a party and between midnight and 6 a. Victims of forced sexual assault were more likely to be injured and to consider the incident to be rape. Victims of forced sexual assault were more likely to report the assault to friends or family, crisis centers, and law enforcement, but they were also less satisfied with how the report was handled and more likely to regret reporting the assault than incapacitated sexual assault victims who reported their assaults. Overall, victims of forced sexual assault were also more likely to make changes in their lives in reaction to the assault, such as dropping a class, moving, and changing majors, and were more likely to seek psychological counseling as a result of the victimization. One out of five undergraduate women experience an attempted or completed sexual assault since entering college. Moreover, attention must be paid to the following facts: the majority of sexual assaults occur when women are incapacitated due to their use of substances, primarily alcohol; freshmen and sophomores are at greater risk for victimization than juniors and seniors; and the large majority of victims of sexual assault are victimized by men they know and trust, rather than strangers. It is thus critical that sexual assault prevention strategies and messages be designed such that undergraduates are educated (and as soon after enrollment as possible) about these facts. Most importantly, because most sexual assaults experienced by university women are enabled by alcohol or other drugs, one clear implication is the need to address the risks of substance use, particularly the risk of drinking to excess, in sexual assault prevention messages presented to university students. For many students, college offers an environment notorious for encouraging excessive drinking and experimenting with drugs. Most students are simply unable to gauge the amount of alcohol consumed, are unaware of 6-3 this document is a research report submitted to the U. Students may also be unaware of the image of vulnerability projected by a visibly intoxicated individual. Despite the link between substance use and sexual assault, it appears that few sexual assault prevention and/or risk reduction programs address the relationship between substance use and sexual assault. In a review of 15 university-based prevention interventions conducted between 1994 and 1999, only three included references to alcohol use (Bachar & Koss, 2001). Universities should continue to be mindful of this phenomenon and educate students about the potential dangers and consequences of clandestinely giving someone a drug or being given a drug. Universities must address the dangers of voluntary alcohol consumption rather than focusing on the rare phenomenon of coercive drug ingestion. Finally, the very low rates of reporting sexual assault to crisis centers and law enforcement suggest that perhaps more can be done to encourage reporting. When reports of sexual assault are handled properly and effectively, the process can be important to the recovery and healing of the victim, as well as the identification, punishment, and deterrence of perpetration. Universities and law enforcement should thus seek out and implement strategies that encourage reporting of sexual assault and ensure reports of sexual assault are being handled properly. The fact that a large proportion of sexual assault victims had been drinking before the incident may particularly discourage reporting, given victim concerns about reprisal for violating campus policies on drug and alcohol use. Other studies have suggested that university administrators believe policies allowing for confidential and anonymous reporting encourage reporting (Karjane, Fisher, & Cullen, 2005). In addition, even though some women experience their first sexual assault after entering college, many women who experience sexual assault during college had been sexually victimized before coming to college. Since women who have experienced sexual assault before entering college have a much greater chance of experiencing sexual assault during college, it is important that sexual assault programming reflects this reality. Victimization is committed by the perpetrator, and therefore the sole responsibility for the assault lies with the perpetrator; Educating women about different types of sexual assault, especially since there appears to be continuity in the type of sexual assault experienced over time (physically forced or incapacitated sexual assault); Teaching effective sexual assault resistance strategies to reduce harm, particularly with respect to strategies for protection from men that women know and trust; Educating women about how to increase their assertiveness and self-efficacy; Conveying knowledge about how to report to police or school officials, the availability of different types of services on and off campus; Stressing the importance of reporting incidents of attempted and completed sexual assault to mental and/or physically health service providers and security/law enforcement personnel, and the importance to seeking services, especially given the well-documented negative impacts sexual assault can have on psychological and physical functioning. Programs for men to prevent sexual assault perpetration could include: Providing accurate information on legal definitions of and legal penalties for sexual assault; Informing men that they are ultimately responsible for determining (1) whether or not a women has consented to sexual contact, and (2) whether or not a women is capable of providing consent; and Educating men that an intoxicated person cannot legally consent to sexual contact and that having sexual contact with an intoxicated or incapacitated person is unacceptable. First, the data are cross sectional in nature, which precludes us from knowing exactly how concepts relate to each other temporally, particularly with respect to risk factors for sexual assault. For example, it appears that the frequency with which undergraduate women get drunk is associated with their risk for being victims of sexual assault; however, it is possible that victims of sexual assault increase the frequency with which they got drunk as a result of the victimization, in which case frequency of getting drunk is not a risk factor for, but a consequence of, being sexually assaulted. Although the response rates were not lower than what most Web based surveys achieve, they are lower than what we typically achieve using a different mode of data collection. However, other modes of data collection are considerably more expensive and time consuming. Additionally, other modes would not have given respondents the same degree of anonymity and privacy and thus could have reduced data quality. Therefore, we feel that the trade-offs associated with low response rates are in many ways overcome by the benefits of cost-efficiency and data quality (in terms of respondent anonymity and privacy, which are associated with more accurate reporting of sensitive behaviors). In addition, it is important to note that the nonresponse bias analyses that have been conducted to date have been encouraging and that we were able to weight the data to adjust for the observed nonresponse bias. It is also encouraging that the sexual assault prevalence rates generated from this study are consistent with data from other university-based studies on sexual assault. The response rates for males were disappointingly low, which creates concerns regarding the external validity of the data. Furthermore, the self-reported rates of sexual assault perpetration were extremely low (particularly when compared with the limited previous studies that have explored self-reported perpetration among university men), which makes us seriously doubt the validity of these data. Several explanations for the extremely low self-reported rate of sexual assault perpetration exist. First, perhaps perpetrators were much less likely than nonperpetrators to participate in the survey, which would result in artificially deflated estimates. Second, among the males who did participate in the survey, it is certainly possible that some did not respond honestly to the questions about sexual assault. Actual perpetrators may not have believed the answers they provided would remain anonymous and believed they might face serious consequences associated with reporting their criminal behavior. Finally, although we used parallel wording for the victimization and perpetration questions, it is possible that men and women view certain sexual encounters differently. A woman might answer affirmatively to a question asking about whether she had experienced a particular type of unwanted sexual contact because someone used physical force or because she was incapacitated and unable to provide consent. In contrast, a man may view the same encounter as consensual and answer negatively to a question asking whether he has had sexual contact with someone by using physical force or when the person was incapacitated and unable to provide consent. It is also unclear whether the male data on victimization are accurate, because there is such limited prior research with which to compare the estimates. Sexual assault is a serious social, public safety, and public health problem that affects men and women across the country. University students may be at increased risk for sexual assault, particularly certain types of sexual assault. Universities may be able to take several steps to reduce the prevalence of sexual assault, as well as improve the resources for and response to sexual assault victims, by better educating males and females about what constitutes sexual assault, how prevalent it is, when it is most likely to happen, and subgroups who may be at greatest risk; including information about the use and abuse of alcohol and how it can increase ones risk for sexual assault in all prevention and education messages; making sure all students are aware of the various resources available on and off campus to victims of sexual assault; ensuring that crisis centers and law enforcement have appropriate protocols and staff in place to deal with victims of sexual assault; and educating students about what they should do if they witness a sexual assault, experience a sexual assault, or have a friend who is sexually victimized. Specifically, we plan to explore in more detail the data on dating violence, examining gender differences in dating violence victimization and perpetration (both emotional and physical) and identifying risk factors for dating violence among our university sample. In addition, we anticipate that the participating universities will be particularly interested in the data on attitudes toward sexual assault. Therefore, we plan to identify particular subgroups of students (both male and female) who might be appropriate targets for sexual assault prevention programming. Finally, we plan to fully explore the data on substance use, once again for the purpose of informing prevention programs at the participating universities. Second, we plan to use the survey data to assist in developing sexual assault prevention programming at the participating universities. We have begun preliminary prevention discussions with key officials at the universities and intend to further contribute to prevention messages that are grounded in empirical data reflecting actual experiences with sexual assault at the participating universities. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U. Acquaintance rape and alcohol consumption on college campuses: How are they linked National College Health Assessment: Reference Group Executive Summary Spring 2004. From prevalence to prevention: Closing the gap between what we know about rape and what we do. The role of offender alcohol use in rape attacks: An analysis of National Crime Victimization Survey data. The roles of victim and offender alcohol use in sexual assaults: Results from the National Violence Against Women Survey. Risk factors for traumatic physical injury during sexual assaults for male and female victims. Sexual victimization among sorority women: Exploring the links between sexual violence and institutional practices. The role of alcohol expectancies and alcohol consumption among sexually victimized and nonvictimized college women. The incidence and prevalence of women abuse in Canadian University and college dating relationships. The role of family factors, physical abuse, and sexual victimization experiences in high risk youths alcohol and other drug use and delinquency: a longitudinal model. Reporting sexual victimization to the police and others: Results from a national-level study of college women. The generalized exponential model for sampling weight calibration for extreme values, non-response, and post-stratification. Dating aggression, sexual coercion, and aggression-supporting attitudes among college men as a function of participation in aggressive high school sports. Motives to drink as mediators between childhood sexual assault and alcohol problems in adult women. Situation-specific assertiveness in the epidemiology of sexual victimization among university women. Risk factors for sexual victimization in dating: A longitudinal study of college women. Rape-related Pregnancy: Estimates and Descriptive Characteristics from a National Sample of Women. Rape supportive attitudes and sexual victimization experiences of sorority and nonsorority women. A 2-year longitudinal analysis of the relationships between violent assault and substance use in women. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Hidden rape: Sexual aggression and victimization in a national sample of students in higher education. Discriminant analysis of risk factors for sexual victimization among a national sample of college women. Male and female recipients of unwanted sexual contact in a college student sample: Prevalence rates, alcohol use, and depression symptoms. Recommendations for toxicological investigations of drug-facilitated sexual assaults. The contribution of alcohol to the likelihood of completion and severity of injury in rape incidents. Alcohol consumption, outcome expectancies, and victimization status among female college students. An exploratory analysis of suspected drug-facilitated sexual assault seen in a hospital emergency department. National Victim Center and Crime Victims Research and Treatment Center, University of South Carolina, Charleston. The role of womens alcohol consumption in evaluation of vulnerability to sexual aggression. Womens substance use and experiences of intimate partner violence: A longitudinal investigation among a community sample.

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They have less impact on the kidney due in part to poor renal tissue penetration and can be given in higher doses of the parent drug pregnancy workouts order 5mg aygestin overnight delivery. The poor renal tissue penetration breast cancer 9mm mass discount aygestin 5mg otc, in turn women's health center jackson mi discount 5mg aygestin amex, makes them a poor option for renal fungal disease women's health center bar harbor buy aygestin 5 mg. Amphotericin crosses the placenta womens health 02 2013 chomikuj generic aygestin 5 mg with amex, but does not seem to be toxic or teratogenic to the fetus pregnancy 6 weeks symptoms cheap aygestin 5mg on-line, so treatment does not need to be withheld during pregnancy. No information is available on amphotericin use dur ing lactation; however, poor oral absorption means the infant is unlikely to absorb significant amounts. Incremental treatment is not appropriate, and a first test dose is not necessary in a neonate. Liposomal formulation: AmBisome and Abelcet are the most widely studied products in neonates, but there appears to be no clinical advantage of one preparation over the other. Supply and administration Ready-to-use pre-filled syringes (which should be stored in the dark and used within 48 hours but which do not need to be protected from light during administration) may be dispensed by some pharmacies. The different preparations of amphotericin vary in their pharmacodynamics, pharmacokinetics, dosage and administration and should not be considered interchangeable. Prepare the powder immediately before use by adding 10 ml of sterile water for injection into the vial through a wide bore needle to give a solution containing 5mg/ ml. Then further dilute the drug by adding 1 ml of this colloidal solution to 49ml of 5% glucose to give a solution containing 100 micrograms/ml. Do not employ a less than 1m filter, expose to bright light or mix with any other drug. Add 12 ml of water for injection to obtain a solution containing 4mg/ml and shake vigorously until the powder is completely dispersed. Remove the required volume of the suspension and dilute to a concentration of 2 mg/ml using 5% glucose. Compatibility: Do not let any of these product come into contact with any fluid other than 5% glucose. If using a pre-existing cannula, this must be flushed with 5% glucose before and after the infusion. Pharmacokinetics, outcome of treatment, and toxic effects of amphotericin B and 5-fluorocytosine in neonates. Antifungal therapy in children with invasive fungal infection: a systematic review. Treatment of candidaemia in premature infants: comparison of three amphotericin B preparations. Liposomal amphotericin B: a review of its use in empirical therapy in febrile neutropenia and in the treatment of invasive fungal infections. Candida infection in very low birth-weight infants: outcome and nephrotoxicity of treatment with liposomal amphotericin B (AmBisome). Pharmacology Ampicillin is a semi-synthetic broad-spectrum aminopenicillin that crosses the placenta. A little appears in human milk, but it can safely be given to a lactating mother since the baby is known to receive less than 1% of the weight-related maternal dose. Maculo-papular drug rashes are not a sign of serious drug sensitivity and are relatively rare in the neonatal period. The drug is actively excreted in the urine and, partly as a result of this, the plasma half-life falls from about 6 to 2 hours during the first 10 days of life. Ampicillin was, for many years, the most widely used antibiotic for treating infection with Listeria, lactamase-negative Haemophilus, enterococci, Shigella and non-penicillinase-form ing Proteus species. It is also effective against streptococci, pneumococci and many coliform organisms. Ampicillin has frequently been used prophylactically to reduce the risk of infection after abdominal surgery (including caesarean delivery). Ampicillin is resistant to acids and moderately well absorbed when given by mouth, but oral medication can alter the normal flora of the bowel (causing diarrhoea), and the absorption and bioavailability of ampicillin when taken by mouth do not approach that achieved by amoxicillin. The arrival of ampicillin on the market before amoxicillin probably explains the formers continued common use, even though most authorities now consider amoxicillin the better product for this and a range of other reasons. Care in spontaneous preterm labour Similar prophylaxis does not delay delivery, or improve outcome, when labour threatens to start prematurely before the membranes rupture, but high-dose penicillin during delivery can reduce the risk of early-onset neonatal group B streptococcal infection. One recent study has suggested that a combination of these two strategies would result in 80% of all the babies currently dying of any bacterial infection of intrapartum origin. It means giving antibiotics to between 40 and 60 women during labour to provide optimum treatment for one baby with bac terial sepsis of intrapartum origin. Many policies treat even more patients than this, and it seems possible that this could increase the risk of late-onset infection. In other situations, a dose of 50mg/kg is more than adequate, given (when the patient is well enough) by mouth. Oral medication can sometimes be used to complete treatment even though absorption is limited. No sugar-free oral suspension is currently available (a sugar-free oral suspension of amoxicillin is available and is a suitable alternative). Changing patterns in neonatal Escherichia coli sepsis and ampicillin resistance in the era of intrapartum antibiotic prophylaxis. Antibiotic treatment in preterm and premature rupture of membranes and neonatal morbidity: a meta-analysis. Association of intrapartum antibiotic exposure and late-onset serious bacterial infections in infants. Risk factors and opportunities for prevention of early-onset neo natal sepsis: a multicenter case-control study. The posterior retinal blood vessels become dilated and tortuous (plus disease), and abnormal blood vessels grow out of the retina and into the vitreous. Not only does this usually require sedation or anaesthesia, but it is difficult to perform and results in destruction of the peripheral retina. Ranibizumab is a smaller monoclonal antibody fragment derived from the same parent antibody as bevacizumab and is considerably more expensive. Both drugs are injected into the vitreous humour under local anaesthesia and sedation. In adult studies, there is less systemic leakage of ranibizumab and the potential for the adverse effects on other developing organs is, theoretically at least, lower. There is some evidence to suggest that these doses may be excessive; the doses above are half the doses used in adult retinopathies and are those reported to have been used in most studies. Lower doses may be as effective and have less potential for systemic effects; in adults with retinopathies, a bevacizumab dose of 1. Bevacizumab (Avastin) for retinopathy of prematurity: wrong dose, wrong drug, or both Intravitreal bevacizumab (Avastin) in the treatment of proliferative diabetic retinopathy. Short-term outcome after intravitreal ranibizumab injec tions for the treatment of retinopathy of prematurity. Significant treatment failure with intravitreous bevacizumab for reti nopathy of prematurity. Serum concentrations of bevacizumab (avastin) and vascular endothelial growth factor in infants with retinopathy of prematurity. In some urea cycle disorders, l-arginine also facilitates nitrogen excretion, along with sodium phenylbutyrate and sodium benzoate (q. Biochemistry Arginine is a naturally occurring amino acid needed for protein synthesis. Since it is produced in the body by the urea cycle, it is not, ordinarily, an essential nutrient. Dietary supplementation becomes essential, however, in most patients with urea cycle disorders because the enzyme defect limits arginine production, while dietary protein restriction limits arginine intake. Further supplementation also aids nitrogen excretion in citrullinaemia and argininosuccinic aciduria because excess arginine is metabolised to citrulline and argininosuccinic acid, incorporating nitrogen derived from ammonia and aspartic acid. As citrulline and argininosuccinic acid can be excreted in the urine, treatment with arginine can lower the plasma ammonia level in both these conditions. Treatment with arginine needs to be combined with a low-protein diet and supervised by a consultant experienced in the management of metabolic disease. Treatment with oral sodium phenylbutyrate and/or sodium benzoate is also usually necessary. Treatment Note: Treatment with l-arginine should be initiated only after consultation with a specialist metabolic diseases centre. Citrullinaemia and argininosuccinic aciduria: Up to 175 mg/kg of arginine four times a day can be given by mouth to promote nitrogen excretion. Hyperchloraemic acidosis can occur in patients on high-dose arginine hydrochloride: pH and plasma chloride concentrations should be monitored and bicarbonate given if necessary. High arginine levels are thought to contribute to the neurological damage in arginase deficiency, and it is recommended that plasma arginine levels should be monitored during long-term use and kept between 50 and 200mol/l. Supply and administration l-Arginine can be made available (as hydrochloride) in powder form for oral use; 100g costs 12. Add 185 ml of purified water to the contents of the bottle to obtain 200ml of a 100mg/ml liquid which remains stable for 2 months. Most pharmacies can obtain supplies from special-order manufacturers or specialist importing companies. Arginine supplementation prevents necrotizing enterocolitis in the premature infant. Arginine, an indispensable amino acid for patients with inborn errors of urea synthesis. Enteral L-arginine supplementation for prevention of necrotizing enterocolitis in very low birth weight neonates: a double-blind randomized pilot study of efficacy and safety. Pharmacology Extracts of the herb Artemisia annua (sweet wormwood) have been used to treat fever in China for many centuries. The key ingredient seems to be the sesquiterpene lactone called qinghaosu (or artemisinin), which was first isolated by Chinese chemists in 1971. Artemisinin and its derivatives, artemether and artesunate, have since been shown to clear malarial parasites from the blood more rapidly than other drugs. Parasitic recrudescence is common unless a second antimalarial is taken at the same time, or the drug is taken for at least 7 days. They also reduce gametocyte carriage (the sexual form of the parasite capable of infecting any blood-sucking mosquito), but they have no sporontocidal activity. Artemisinin and its derivatives are all hydrolysed quite rapidly in the body to the active metabolite dihydroartemisinin which then accumulates within the cytoplasm of the parasite, disrupting calcium homeostasis. Treatment with a single dose is unreliable because the half-life is much shorter than that of most other antimalarial drugs. Combined treatment with a second antimalarial is generally considered essential to stop the parasite becoming as resistant to this new drug as it has already become to most of the other drugs used in the past. A product containing 20 mg of artemether and 120 mg of lumefantrine (Coartem) is the most widely studied combination. Published reports of the use of artemisinin in over 900 pregnancies have not identified any adverse treatment-related pregnancy outcomes, but animal experiments suggest that use can cause the early embryo to die and be resorbed. Managing severe malaria Additional supportive care is necessary in any seriously ill child, as outlined in the monograph on quinine. Children too ill to take a drug by mouth Early treatment is critically important and, in rural settings where it may take more than 6 hours to get definite care started, a strategy for giving a rectal suppository before the child reaches medical care can halve the risk of death or long-term disability. Give babies under 9kg one 40mg suppository daily until oral treatment can be started. Babies over 9 kg should have a loading dose of 80 mg (two suppositories) on the first day and 40 mg/day thereafter. A dispersible tablet has also been developed to aid administration to young children. Similar tablets (costing 1) are available in Europe under the trade name Riamet. Suppositories containing 40mg of artemether are available from Dafra Pharma in Belgium. Dispersible formulation of artemether/lumefantrine: specifically developed for infants and young children. Efficacy and safety of artemether-lumefantrine dispersible tablets compared with crushed commercial tablets in African infants and children with uncomplicated malaria: a randomised, single-blind, multicentre trial. Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in children in Uganda: randomised controlled trial. Efficacy of rectal artesunate compared with parenteral quinine in initial treatment of moderately severe malaria in African children and adults: a randomised study.

Without disaggregating data breast cancer in men purchase aygestin on line, it is very hard to identify the differential impacts on male and female workers in the workplace menstrual cycle day 4 order aygestin 5 mg without a prescription. The company aims to ensure that at least 100 women's health evergreen buy cheap aygestin line,000 women are empowered to reach their full potential women's health zinc order aygestin 5mg online, while at the same time strengthening their families and communities pregnancy category c cheap generic aygestin canada. Grievance mechanisms should be formalized and have a gender-balance structure that processes complaints pregnancy diarrhea buy aygestin 5mg cheap. The codes of conduct can be a good channel for companies to communicate their values to stakeholders. A clear statement in the preamble on where the company stands regarding gender and promoting gender equality at work will both show leadership and corporate commitment and will raise awareness among suppliers. By addressing the impacts of their own purchasing practices, companies have a direct impact on the way suppliers treat their workers. Poor buyer/supplier communication, frequent changes in product specication, short lead times, and aggressive price-setting lead to pressure on time and cost for the supplier, who in turn transfers these pressures onto workers. It is therefore essential that companies put in place or review existing sourcing practices that support rather than undermine womens rights, and that companies clearly state what suppliers can expect from them with regards to these practices in codes of conducts. Effective dissemination of the code of conduct and other related policies and procedures to suppliers, as well as to all women and men workers, can be a powerful tool to raise awareness and foster change. Women workers in particular are often less aware of their rights and in vulnerable positions because, for example, they are illiterate, immigrants not uent in the local language, or submissive due to local cultural norms. Companies can encourage communication and awareness-raising by including it as an expectation in their code of conduct. Note | Communicating with Suppliers It is fundamental to ensure that suppliers understand the specic changes to codes of conduct and how the integration of these gender-sensitive provisions impact their own management systems. Effective communication of requirements is essential to developing and maintaining support for your responsible sourcing program. Since these changes will require additional supplier engagement and effort, it is important to clearly articulate the business case to suppliers (in particular productivity gains and reduced turnover), but also to jointly agree on a realistic implementation plan to factor in timing for any necessary adjustments. Building your suppliers awareness and capacity to adjust to these new requirements is key. Collaborating with other brands on capacity-building efforts can be a cost-effective way to do this and reaffirm that these requirements are becoming mainstream for international buyers. Suppliers who demonstrate a strong commitment to gender equality should be encouraged to take part in local as well as global initiatives such as the Womens Empowerment Principles. Some of these sections also propose Leadership Areas that are important for addressing gender equality holistically, which most labor standards fail to consider. These critical issues represent opportunities for business to apply a gender lens to their sourcing decisions, supplier training, and capacity-building, and more widely to their approach to multi stakeholder collaboration. It is also a cross-cutting challenge affecting many of the other principles in codes of conduct, and one that is diffcult to assess in audits. Discrimination is often addressed in codes of conduct through either the principle of nondiscrimination or of equal opportunities pertaining to all aspects of the employment relationship, where gender is one among other potential factors for discrimination. Some of these gender-related practices may be very subtle and diffcult to identify without an in-depth analysis and understanding of the context. Others are quite obvious and linked to women-specifc matters, such as maternity or motherhood. In production job categories, there are fewer women supervisors and they tend to take jobs that require less technical skill and are also lower paid. This may suggest biases in recruitment, access to training, as well as access to career progression. For example, women represent around 80 percent of Vietnams 700,000 light manufacturing workers, but they tend to be in lower-paid positions as seamstresses and helpers, while men are in higher-paid occupations such as cutters and mechanics. Horizontal segregation happens as well, with women1 often concentrating or primarily being employed in certain sectors that are traditionally low paying. There is evidence of women not being hired at all if they are married or have children. They a Gender Perspective: A Preliminary are sometimes required to pre-sign termination letters during recruitment to avoid Exploration of Worker Surveys with a Focus on Vietnam. Their duties as caregivers Finance Corporation and International of children and sick family members may also increase their absenteeism and Labor Organization. There are also cases where policies determining bonuses discriminate against women due to the way they are calculated or attributed (see Wages and Benefts). Tasks that are more technical and require more skills are often dominated by male workers. For example, trainings might be scheduled at times or places that are inaccessible to them. Women who are promoted are also more likely to suffer abuse in the workplace or at home, or other types of retaliation. Although the female supervisor does a better job than her male colleagues, as can be seen from the number of pieces she produces, she relates the diffculties she faces in her work to the fact that she is a woman. In many factories in Bangladesh, there is no proper system for performance review. Supervisors and workers are evaluated according to the impressions their bosses have of them. Female supervisors often fnd it more diffcult because they do not want to use sexually explicit profanity, but they dont always see how they have a choice. Recommended Revisions General nondiscrimination and equal opportunities clauses can be strengthened. We recommend that language be included to specify that the principle of nondiscrimination applies to both women and men and that roles and needs specifc to women, such as those related to pregnancy, may not be used to undermine, cut, or in any way diminish their equal rights to men when it comes to any aspect of the employment relationship. Examples of gender-sensitive 1 provisions regarding Discrimination: Women and men workers should be protected against discrimination on the basis of marital status. In Cambodia, for example, participating women were promoted three times faster than those not participating. Figure 1 | Global improvements and key indicators, percentage improvement over period 35 Self-esteem 49% 52 26 Self-efficacy 65150% 27 Work efficacy 119 % 59 32 Workplace inuence 100% 64 In fact, globally, women continue to be underrepresented in high-level and decision making positions and often face barriers to their advancement. As mentioned above, women and men are still largely segregated in different types of paid work, with women occupying production jobs that require less technical skills and are lower paid. Cultural norms that value a subordinate role for women, for instance, can restrict womens access to education and training and development of self-awareness. The expectation that women should play a subservient role in the workplace can make them more vulnerable to violence and harassment. In addition, norms relating to communication can result in women not standing up against poor working conditions. Business can take several measures to promote the advancement of women workers: By promoting the employment of women and men in nontraditional occupations for their gender by undertaking concrete, verifable actions to recruit and retain candidates from traditionally underrepresented groups. In other cases, the minimum wage may be high enough in theory but is not applied or enforced in practice. They can also be prejudicial to business by affecting productivity, turnover, and reputation. Women workers are particularly affected because they outnumber men in the lowest-paid positions in most sectors in global supply chains. But women also face particular challenges in terms of wages and access to benefts that are linked to their specifc roles and needs. There are a few interlinked considerations:1 the attribution by societies of different values to the work performed by women and men. There is evidence that these workers frequently lack labor protection in law and/or practice (see Employment Relationship). They tend to be less aware of their rights and more vulnerable to unfair employment contracts/relationships and unlawful deductions. Childcare and associated costs in particular can be an incredible burden for women. With maternity, women may face a number of discrimination and employment issues even when maternity leave is guaranteed by law. Fear of termination may drive women to conceal pregnancy, which may result in health issues for them and their baby. They also might continue working beyond the date they should reasonably be expected to work or continue performing work that might be hazardous to them and their baby, which can lead to health problems. On the other hand, pregnant women might also be denied overtime, which they often rely on to make enough additional money because the basic wage is not suffcient. These benefts are all the more important since paternity benefts, which could help reduce the burden of unpaid responsibilities for women, are often not recognized or are very limited. Women may also face different kinds of issues when returning to work, such as being demoted or fnding that their jobs are not available anymore or are posted with lower pay. Men, on the other hand, may not pursue sick leave at all due to cultural stigmas that may associate it with being weak or un-masculine. Often piece-rate remuneration limits the capacity of workers to absorb fnancial loss from taking sick leave. This also applies when women workers have children in their care and no support structure. It is also important to consider the specifc issues that may affect women differently than men when living wages are not paid. For example, women often bear most of the childcare responsibilities and could beneft greatly from pay scales that take childcare costs into account. Women may also not truly beneft from maternity leave benefts because such benefts are usually based on a workers basic salary, which may not be enough given that a large proportion of a workers income often comes from overtime. While we recognize the complexity of the living wage debate and, more importantly, the associated implementation challenges, it is essential that companies also understand the broader impacts of living wage and how it is dependent on, supportive of, and a precursor to other code of conduct principles as well as to basic human rights. Consider that women are more often employed in precarious situations or lower job categories and include provisions to guarantee their job security, safety, and access to basic benefts such as maternity and sick leaves. Consider including living wage so that women can truly reap the benefts of their employment and continue being employed when they become mothers. Examples of gender-sensitive provisions for Wages and Benefts: Fair and comparable wages, hours, and benefts are guaranteed to all workers for comparable work. Childcare benefts and special leave or working time arrangements for workers with family responsibilities should apply to both men and women. Ensuring that women have the proper knowledge, skills, and attitudes about fnancial services and that they are 2 able to participate in the formal fnancial sector can help them save, build Sound fnancial management and the use of secure, formal fnancial products and services helps people smooth consumption when their income fuctuates and prevents them from slipping back into poverty as a result of unexpected shocks, such as illness, unemployment, or death. Women who have greater fnancial independence have more bargaining power at home and more infuence over family decisions. And when women are given increased fnancial means they typically invest 90 percent of their income back into the health, nutrition, and education of their families, as opposed to 30 percent to 40 percent for men. Workplace-based programs also make the workplace an effective demand generation point for products and services that are essential to workers livelihoods. By improving their fnancial behaviors, female and male employees are better able to take advantage of fnancial products, manage their incomes, prioritize their spending on things they value most, and increase their rates of savings. It can also signifcantly improve relationships between employees and management, thereby improving the working environment and employee retention, reducing negative perceptions of management, and improving worker and managements ability to address workplace challenges before they escalate to more serious problems. But despite the severity of the market, remittance outlets and banking platforms have refused to decrease the transaction fees for payment transfers and remittances. As a result, banking and remittances have become services that the average Bangladeshi can scarcely afford. Capitalizing on the limitation of existing nancial platforms, bKash emerged in 2011 as a mobile service and solutions provider. Because of the incredibly high smartphone adoption rate in Bangladesh, with over 100 million Bangladeshis using smartphones or advanced mobile devices, bKash began to evolve as a mainstream nancial and mobile application, surpassing the growth rate and capital of local banks and nancial institutions. In 2015, bKash recorded 17 million users on its network, serving more than 10 percent of the population. Local employee Rebecca Sultana described how bKash is being used as a payroll system by most companies in the country, enabling users to quickly send money back to their families. Because of the high cost of traditional nancial services, Sultana explained, many workers used to hire individuals to physically deliver money to their villages. Traditional nancial services are often not accessible to the working poor because these institutions have high minimum balances, charge fees that dont support small-scale transactions, or provide access points that are too distributed and not physically accessible. In addition, factory workers generally spend six days a week at work, which leaves them little time to travel to conduct a transaction at a formal nancial institution. Women in particular face challenges with traditional banking because they have less mobility than men. By using mobile banking, they can address many of the issues faced by workers, especially women workers. Companies will also benet by reducing payroll administrative costs, risks from theft and loss, and fraud that can occur when conducting payroll in cash. Strengthening payroll processes and worker well-being programs will also help with compliance and overall relationships with clients, who are increasingly looking at suppliers labor practices when engaging in long-term contracts. Digitized payrolls also increase the transparency of supply chains, particularly with regard to how much workers are being paid as well as how they are being paid. This can provide some assurance that workers are less susceptible to payroll fraud. Business can take several measures to promote nancial inclusion: By investing in payroll digitization and thereby including workers in the formal nancial system; By offering capacity-building and training programs focused on nancial education for women in their workforce or supply chain. Noeun left school in grade 5 and after several other jobs eventually began working at the factory in order to provide money for her family.