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Other causes include certain prescribed and over-the-counter medicines diabetes test list buy metformin 500mg without prescription, environmental poisons diabetes insipidus blood sugar levels order 500 mg metformin mastercard, and autoimmune hepatitis diabetes definition fasting glucose order metformin 500mg online, a condition in which a persons own immune system attacks the liver as if it were a foreign body diabetes prevention education program metformin 500 mg overnight delivery. This prevents blood from flowing through the liver easily and causes the build-up of pressure in the portal vein, the vein that brings blood to the liver. To relieve this pressure, the blood goes around the portal vein, through other veins. Some of these veins, called varices, can be found in the pipe that carries food from your mouth to your stomach (the esophagus) or in your stomach itself. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 4 Portal hypertension also causes blood to back up into another organ called the spleen. With cirrhosis, blood is blocked from entering the liver and toxic substances that the liver normally filters escapes into general blood circulation. Aside from the problems with liver blood flow, when cirrhosis is advanced, there arent enough healthy liver cells to make good substances, such as albumin (a protein) and clotting factors that the liver normally makes. This cancer can occur if some of the sick liver cells start to multiply out of control. There may be no signs of liver cancer until the cancer has grown very large and causes pain. In fact, a person may live many years with cirrhosis without being aware that her liver is scarred. This is because the pressure in the portal vein is not yet too high and there are still enough healthy liver cells to keep up with the bodys needs. But if nothing is done about the cause of cirrhosis (for example, if the person continues to drink alcohol, or if hepatitis or other causes of cirrhosis are not treated), the pressure in the portal vein gets higher and the few remaining healthy liver cells are not able to do all the work for the entire liver. At that point, you may notice symptoms like low energy, poor appetite, weight loss, or loss of muscle mass. As the disease progresses symptoms become more severe and may be life threatening. At this stage you can also develop the following Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 5 serious problems: bleeding varices internal bleeding from large blood vessels in the esophagus ascites (pronounced “a-sigh-tees) a buildup of fluid in the belly, encephalopathy (pronounced “en-sef-a-lop-a thee) confusion from the buildup of toxins in the blood Jaundice yellowing of the eyes and skin, Sometimes, if the damaging agent (such as alcohol) is removed, the liver can slowly heal. Other times, the only way to cure cirrhosis is to replace the sick liver with a healthy liver – this is called liver transplantation. Backup of blood from the scarred liver may cause the veins in the wall of the esophagus to enlarge. The pressure inside the enlarged veins, called esophageal varices, is higher than normal. The increased pressure can cause the Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 6 veins to burst, leading to sudden and severe bleeding. Signs of bleeding varices include vomiting of large amounts of fresh blood or clots. People who have signs of bleeding varices should go to an emergency room immediately. If you vomit blood or your stool turns black and tarry, you must Unless the varices break and go to the emergency room bleed, patients have no symptoms immediately. Larger varices have a higher risk of breaking and bleeding, and if you have them your doctor will start treatment with medications called Beta Blockers. They include Propranolol (Inderal ), taken twice a day Nadolol (Corgard ), taken once a day Carvedilol (Coreg ), taken twice a day Your doctor will generally start you on a very low dose of one of these drugs and check your heart rate (pulse. The goal of treatment is to give you enough of one of these drugs to reduce your heart rate by 25%. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 7 Most people with low blood pressure tolerate beta blockers well. With this procedure the doctor creates an internal tunnel in the liver that reduces blood flow and pressure in varices. Managing ascites Another problem caused by high pressure in the veins of the liver is ascites. The most dangerous problem associated with ascites is infection, which can be life threatening. If you have ascites and you suddenly get a fever or new belly pain, you must go to the emergency room immediately. Abdominal Anatomy the abdominal cavity (the belly) contains the digestive organs such as the stomach, intestines and liver. Ascites is a medical condition in which excess fluid begins to puddle within the abdominal cavity. This fluid is outside of the intestines and collects between the abdominal wall and the organs within. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 8 Causes of Ascites Liver disease is the most common cause of ascites. The word "cirrhosis" means "scar tissue," so this condition is often called “cirrhosis of the liver. This scar tissue changes the normally smooth liver surface to a lumpy surface that blocks the blood from exiting the liver. This condition causes the surface of the liver to "weep" fluid into the abdominal cavity. The liver also sends signals to the kidney to “hold on to salt, resulting in fluid retention in the legs or abdomen. There may be a loss of appetite, frequent heartburn, fullness after eating, or abdominal pain. Eventually, there is swelling of the abdomen that looks similar to the later stages of pregnancy. During the day, gravity may carry some of the fluid down into the scrotum (the sac that hold the testicles) or legs causing swelling, (edema. As the condition worsens, however, the swelling may spread up the leg and be present day and night. As more fluid builds up, it may spread up to the chest and cause difficulty breathing. If infection, cancer, or heart failure is the cause, the treatment is directed appropriately to the underlying problem. However, in the majority of patients, ascites is a sign of advanced liver failure, or cirrhosis of the liver. The basis of treatment includes: Avoiding further liver damage Patients who drink alcohol must stop all alcohol consumption. Dietary sodium intake is usually restricted to less than 2000 mg per day (about 1 teaspoon. Most salt in a persons diet comes from processed foods, not from the salt shaker. If there is no weight loss in the first two weeks, the dose is gradually increased up to a maximum of 400 mg of spironolactone and 160 mg of furosemide daily. Response to treatment varies and finding out which treatment plan works best for you takes time, as the doctor adjusts the dose of medications over a period of weeks or months. Tap provides a very quick relief of ascites symptoms, but it does not correct the underlying cause so the fluid eventually returns. You must follow strict sodium restriction and diuretic therapy in order to slow down the re-accumulation of fluid. Tap also has some serious side effects: o Removing 5 liters or more at one time can cause a drop in blood pressure, and kidney damage. This is especially true in patients taking diuretics (which may cause reduced kidney function and changes in the blood levels of sodium and potassium. The best way, you, the patient, can help the doctors manage your fluid problem is by recording your weight and dose of water pills (diuretics) you take every day. Use the log on page 27 of the toolkit to record your weight and diuretic dose daily. Symptoms include fever and abdominal pain but these symptoms may be absent during the early stages. After the first episode of peritonitis you will have to take an antibiotic pill to prevent recurrence of peritonitis.

Seniors are the fastest growing population Discrimination based on age (ageism) and group in Canada diabetes medications breastfeeding discount metformin 500mg online. While there are many not being treated with dignity and respect diferences between most people in their can afect mental health diabetes type 1 markers buy metformin 500mg on line. Most notably diabetes definition ada purchase metformin 500mg, the tendency to assume that conditions such Rates of mental illness for adults between as anxiety or depression are a normal part the ages of 70 and 89 diabetic diet vs renal diet safe metformin 500mg, including but not of aging and that nothing can be done to limited to dementia, are projected to be delay the onset of dementia or slow its higher than for any other age group by course must be countered. Not health, meaningful activities, and secure only do these stereotypical views dis and supportive relationships all contribute count the contributions that seniors have to good mental health and quality of life for made throughout their lives, but they also seniors, just as they do for people of any underestimate their on-going contribu age. Age-friendly communities facilitate tions to our communities and social life in 63, 64, 65 access to appropriate housing and trans general. Seniors Mental Health Outreach Team, Alberta A mobile multidisciplinary outreach team has been supporting agencies and caregivers to improve the care ofered to seniors experiencing mental health problems in southwestern Alberta. The team provides non-emergency assessment and consultation, short-term care, therapeutic interventions, and referrals for seniors with mental health concerns, and builds up the capacity of collaborating agencies and family members. In 2008-2009, the most common reasons for referral were depres sion, bipolar disorder, schizophrenia, behavioural issues and anxiety. Referrals come from family physicians, hospitals, psychiatrists, community mental health, home care, continuing care, family members, police and self-referral. Within a year, 80 per cent of people referred were being contacted by the receiving agency within 72 hours, and 100 per cent were contacted within seven days. During a six-month period, 326 people participated in 16 formal education sessions and 311 people received informal education sessions. Strategic Direction 1 31 On talking and sharing about mental health “I really do believe in having a national strategy. Theres just so much misinformation or so much ignorance about mental health and addictions that we need a strategy to educate on things. It is with information and education that hopefully more people will seek the services they need before it becomes a crisis. As noted at the outset of this Strategy, the concept of recovery refers to living a satisfy ing, hopeful, and contributing life, even with on-going limitations from mental health problems and illnesses. A recovery-oriented mental health system is organized to support and sustain people throughout this journey. Whats helping me now in my recov ery process are therapy, medication that I fought for some time not to be on, but realized that I needed, and also the support from my family and the tools that I learned to get better as quickly as I can. When I go fishing it takes my mind of everything and I sort of create an empty space in my brain and clear all of the issues or struggles Im dealing with so that it becomes easier for me to continue after. My ultimate goal in my life is to have as many tools as I can and know myself as much as I can to be able to get back on my feet as quickly as I can when Im triggered, or after Im triggered. My advice for people who have other mental illnesses would be that you can get better but its really hard if you want to do it on your own. Here in Canada, recovery has strong roots in the advocacy eforts of people with lived experience and in the psychosocial rehabilita tion field. It has been over five years since Out of the Shadows at Last, the final report of the Senate Committee, called for recovery to be “placed at the centre of mental health reform. There are significant pockets of practice oriented toward recovery and well-being across the country. Despite the evidence to support it, there are many challenges and misconceptions to overcome in explaining recovery and putting it into practice. On the contrary, recovery is about supporting each individuals journey toward a meaningful life even with symptoms of mental illness. Rather, recovery seeks to promote peoples ability to choose and to ensure that options are available to meet the full range of peoples needs. Still others are concerned that recovery is only relevant for adults, or for people living with severe mental illnesses, or just for people living with more moderate mental ill nesses. Investing in recovery and well-being has the potential to provide hope and opportunities to thousands of people living with mental health problems and illnesses, and will also benefit families, communities and the country as a whole. Drawing on the recovery principles of hope, informed choice, dignity and responsibility will contribute as much to the well-being of children and seniors as to that of adults who are living with mental health problems and illnesses. A recovery-oriented system strives to encourage partnerships with service providers, families, and friends to support people on their journey toward recovery and well-being. It encourages mental health professionals, health professionals and other service providers to build on peoples strengths and to create genuine partnerships with people living with mental health problems and illnesses (and their families. The expertise gained from lived experience should be complemented by professional expertise, not overwhelmed by it. All stand to benefit from ensuring that there are as few imbalances as possible in the distribution of power throughout the mental health system. This will not only enable people who use services to be actively engaged in all aspects of the mental health system, but will also allow the people who provide services to have a more positive context in which to ofer their skills, experience, and knowledge. Consistently upholding the rights of people living with mental health problems and illnesses is an integral part of fostering recovery and well-being. Barriers that can contrib ute to discrimination against people living with mental health problems and illnesses and hinder their full and efective participation in society must be eliminated. These barriers can be rooted in peoples attitudes and behaviour, in the ways in which programs and institutions are organized, or in the ways in which our schools, workplaces and other everyday environments are structured. The over-representation of people living with mental health problems and illnesses in the criminal justice system highlights the importance of respecting their right to the same level of services and supports that are available to all Canadians. Experience in other countries and here defined, along with related indicators at home tells us that it will take sustained and examples. Guidelines, training for all types of service providers indicators, tools, competencies, standards, (from mental health to health, education, curricula, leadership, on-going training justice, and social services) include a focus and education, policies and legislation on recovery and well-being while also can all play a role in re-orienting policy helping everyone to learn how to build and practice. This should be done tives in Canada must be developed and with the active involvement of people implemented. They should include a living with mental health problems and strong evaluation component to enhance illnesses, and their families. In the case of our understanding of what works best for mental health professionals themselves, people of all ages and backgrounds. In particular, by describing what recovery principles look like in practice, recovery Just as with the treatment of physical guidelines can be an efective instrument health problems, there is great benefit to for promoting change. Eight and illnesses should be actively involved in standards, including those for individual, developing and managing individual care family, and community participation, are plans that are oriented to recovery and well-being. One is through programs that let people People who live with severe mental health directly manage a portion of their social problems and illnesses may be able to service and health budgets. These directives their service funding manage better in express an individuals preferences for ser the community and have higher quality vices, treatments and supports if he or she of life, without increasing costs. They ofer an opportunity Canada to develop self-directed care for people living with severe mental health models for people living with physical and problems and illnesses, their families, and developmental disabilities. In contrast to service providers to discuss issues and a block funding approach, some agencies build their partnership. They can also help have enabled people to directly manage to strike a balance between facilitating a portion of their funding for social families desire to provide support and services, such as personal attendants respecting the rights of individuals. Strategic Direction 2 37 Families—whether relatives or people drawn from broader circles of support—are critical partners in the recovery journey. Families often provide the bulk of support and care, and can be overtaken by stress and grief from the impact of mental illness and suicide. It is critical that they have access to the information and resources they need to sustain themselves, and that their voices be heard in the mental health system. The unique role of families in fostering recovery and well-being across the lifespan must be better recognized. The false blaming of families must be stopped, and everything possible should be done to facilitate their becoming partners in the care and treatment of their loved ones. People living with mental health problems provided and to contribute to the on and illnesses and their family members going transformation of the mental health are experts by experience. The mental health workforce must also — Father of a woman with schizophrenia do more to welcome people with lived experience into positions at all levels, both to enhance the quality of the services Implementing the Recovery Approach in a Hospital Setting, Restigouche, New Brunswick the Restigouche Hospital Centre in northern New Brunswick, when designing its new facility in 2008, took advantage of the opportunity to adopt a recovery-oriented service delivery model that would more efectively facilitate a return to community living and improve quality of life. New tools and programs are being implemented with on-going support from recovery experts at Yale University. Service users are more actively engaged in designing their treatment plans and in overall service delivery, greater use is being made of less coercive treatment approaches, and the annual rate of discharges has increased. A satisfaction survey in 2011 found that 86 per cent of service users and staf agreed with the activities, values and practices of the recovery-oriented model as implemented at the centre. The touchstone for legislation, policies, and Convention highlights the need to imple regulations that afect people living with ment these protections on a day-to-day mental health problems and illnesses.

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Federal Housing Finance Agency blood sugar 73 500 mg metformin with mastercard, “Mortgage Market Note 10–2: the Housing Goals of Fannie Mae and Freddie Mac in the Context of the Mortgage diabetes medications weight loss purchase metformin 500mg fast delivery, February 1 diabetes type 1 jewelry buy 500 mg metformin otc, 2010 blood sugar levels type 2 diabetes buy 500 mg metformin overnight delivery. Daniel Mudd, letter to Brian Montgomery re affordable housing goals, December 21, 2007. Montgomery, Federal Housing Commissioner, to Daniel Mudd, Fannie Mae, typed let ter, April 24, 2008; Brian D. Federal Home Loan Mortgage Corporation, Form 10-K, for the fiscal year ended December 31, 2009, filed February 24, 2010, Item 6, Selected Financial Data, p. Under the terms of the pay-as-you-go swap, if the referenced mortgage-backed security does not receive the full interest and principal payments, the pay-as-you-go protection seller is required to pay the buyer the amount of the shortfall. For long investors—the protec tion provider under the swap—the advantage was the leverage embedded in the trade: they did not have to come up with the cash up front for the principal amount of the bond; they simply agreed to receive quarterly swap fees in return for accepting the risk of loss if the securities experienced a shortfall. From July through December 2006, several hedge funds with average assets under management of $4–$8 billion accumulated positions totaling more than $1. Document of Magnetar Investments in Norma, Attachment G-13 (showing Magnetar purchases of equity tranche in Norma); provided by Merrill Lynch. Federal Reserve Bank of New York, Federal Reserve Board, Office of the Comptroller of the Cur rency, Securities and Exchange Commission, U. Federal Reserve Bank of New York Bank Supervision Group, “Operations Review Report, De cember 2009. The board reversed a 15% reduction that had been implemented when the issues began and then added a 5% raise. Federal Reserve Bank of New York, letter to Vikram Pandit and the Board of the Directors of Citi group, April 15, 2008, pp. Office of the Comptroller of the Currency, Treasury; Office of Thrift Supervision, Treasury; Board of Governors of the Federal Reserve System; Federal Deposit Insurance Corporation; and Securi ties and Exchange Commission, “Interagency Statement on Sound Practices Concerning Complex Struc tured Finance Activities (Notice of interagency statement with request for public comments),May 13, 2004. Basel Committee on Banking Supervision: Joint Forum, “Credit Risk Transfer, Bank for Interna tional Settlements, March 2005, pp. Andrew Kimball, internal email, October 21, 2007, attaching memorandum, “Credit policy is sues at Moodys suggested by the subprime/liquidity crisis. Subprime and Alt-A mortgages are defined as those included in subprime or Alt-A securitiza tions, respectively. Edward Pinto, “Memorandum: Sizing Total Federal Government and Federal Agency Contribu tions to Subprime and Alt-A Loans in U. Moodys Investors Service, “Early Defaults Rise in Mortgage Securitizations, Structured Finance: Special Report, January 18, 2007, pp. Bingham Letter, Tab 3; Tab 1, “Repurchase Collections by Top Ten Sellers/Servicers. Moodys Investor Service, “Default & Loss Rates of Structured Finance Securities: 1993–2009, Special Comment, September 23, 2010. Those fore casts were based, the analysts said, on a scenario in which house prices fell an average of 30% across the country. Bernanke, “The Economic Outlook, testimony before the Joint Economic Committee, U. David Viniar, written testimony, Wall Street and the Financial Crisis: the Role of Investment Banks, Senate Permanent Subcommittee on Investigation, 111th Cong. Michael Dinias, email to David Viniar and Craig Broderick, December 13, 2006, Senate Permanent Subcommittee on Investigations, Exhibit 2. Kevin Gasvoda, email to Genevieve Nestor and others, December 14, 2006, Senate Permanent Subcommittee on Investigations, Exhibit 72. David Viniar, email to Tom Montag, December 15, 2006, Senate Permanent Subcommittee on In vestigations, Exhibit 3. Stacy Bash-Polley, email to Michael Swenson and others, December 20, 2006, Senate Permanent Subcommittee on Investigations, Exhibit 151. Fabrice Tourre, email to Marine Serres, January 23, 2007, Senate Permanent Subcommittee on Investigations, Exhibit 62. Lloyd Blankfein, email to Tom Montag, February 11, 2007, Senate Permanent Subcommittee on Investigations, Exhibit 130. Matt Tannin, Bear Stearns, email from Gmail account to Ralph Cioffi, Bear Stearns, at his Hotmail account, April 22, 2007. Steven Eisman and Tom Warrack, Standard & Poors Structured Finance, July 10, 2007, teleconfer ence, transcript, p. Henry Paulson, quoted in Kevin Carmichael and Peter Cook, “Paulson Says Subprime Rout Doesnt Threaten Economy, Bloomberg, July 26, 2007. Moodys Investors Service, “Moodys Performance Overview: Rhineland Funding Capital Corpora tion, June 30, 2007. As noted, in the United States, there was a minimal capital charge for liquidity puts equal to 10% of the base 8%, or 0. Eric Sieracki, quoted in Mark DeCambre, “Countrywide Defends Liquidity, TheStreet. Federal Reserve Staff, memo to Board of Governors of the Federal Reserve System, “Background on Countrywide Financial Corporation, August 14, 2007, pp. Kenneth Bruce, “Liquidity Is the Achilles Heel, Merrill Lynch Analyst Report, August 15, 2007, p. Scott Reckard and Annette Haddad, was titled “Credit Crunch Imperils Lender: Worries Grow about Countrywides Ability to Borrow—and Even a Possible Bank ruptcy. Suarez, “The Evolution of a Financial Crisis: Panic in the Asset-Backed Commercial Paper Market, August 24, 2009, p. Moodys Investors Service, “Moodys Update on Structured Investment Vehicles, Moodys Special Report, January 16, 2008, p. Harrington and Sree Vidya Bhaktavatsalam, “Bank of America to Liquidate $12 Billion Cash Fund, Bloomberg, Decem ber 10, 2007. Smith, Paper Fortune$: Modern Wall Street: Where Its Been and Where Its Going (New York: St. Moodys Investors Service, “Structured Finance Rating Transitions: 1983–2006, Special Com ment, January 2007. Tobias Brushammar, James Hua, Graham Jackson, and Subra Viswanathan, Citigroup memoran dum to Nestor Dominguez, Janice Warne, Michael Raynes, and Jo-Anne Williams, subject: Liquidity Put Valuation, October 19, 2006. Notes on Senior Supervisors Meeting with Firms, meeting between Citigroup and Federal Re serve Bank of New York, Federal Reserve Board, Office of the Comptroller of the Currency, Securities and Exchange Commission, U. Notes on Senior Supervisors Meeting with Firms, meeting with Citigroup, November 19, 2007, p. Federal Reserve Board of New York, letter to Vikram Pandit and the Board of the Directors of Citigroup, April 15, 2008, p. Prince, interview; Charles Prince, email to Robert Rubin, re, September 9, 2007, 9:43 A. Andrew Forster, email to Joseph Cassano and Pierre Micottis, November 9, 2007, enclosing marks from Merrill Lynch, 90. For those 327 securities, 313 suffered a downgrade and 206 became materially impaired. Joe Cassano, email to Bill Dooley, November 27, 2007, attaching memo from Andrew Forster, “Collateral Call Status. Standard & Poors, “Detailed Results of Subprime Stress Test of Financial Guarantors, Ratings Direct, February 25, 2008. Bill Lockyer, State of California 2008 Debt Affordability Report: Making the Municipal Bond Mar ket Work for Taxpayers in Turbulent Times (October 1, 2008), p. Jacqueline Doherty, “The Sad Story of Auction-Rate Securities, Barrons, May 26, 2008. Different numbers are provided in Jeff Mayer and Thomas Marano, “Fixed Income Overview, March 29, 2007, p. The large volume of novations away from Bear Stearns during the week of March 10, 2008 and the previous week was confirmed by the New York Federal Reserve and Interna tional Swaps and Derivatives Association. Stuart Smith, email to Bear Stearns, March 11, 2008; Marvin Woolard, email Stuart Smith et al. Debby LaMoy, email to Faina Epshteyn, March 12, 2008; Faina Epshteyn, email to Debby LaMoy, March 12, 2008. Yalman Onaran, “Bear Stearns Investor Lewis May Increase His Stake, Bloomberg News, March 11, 2008.

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Dyspareunia Dyspareunia is defined as pain perceived within the pelvis associated with penetrative sex diabetes diet no carbs metformin 500mg otc. It is usually applied to penile penetration diabetes short definition buy discount metformin 500 mg on-line, but is often associated with pain during insertion of any object diabetes control quotes buy 500mg metformin with mastercard. Perineal pain syndrome Perineal pain syndrome is a neuropathic-type pain that is perceived in the distribution area of the pudendal nerve diabetes 71 purchase metformin 500 mg amex, and may be associated with symptoms and signs of rectal, urinary tract or sexual dysfunction. It is often associated with negative cognitive, behavioural, sexual and emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. Perineal pain syndrome should be distinguished from pudendal neuralgia which is a specific disease associated with pelvic pain that is caused by nerve damage. In the authors and others opinion, this is an inappropriate term, although it is recognised that it has a long history of use. The term prostadynia has also been used in the past but is no longer recommended by the expert panel. Localisation of the pain can be difficult by examination, and consequently, another localising symptom is required. Scrotal pain Scrotal pain syndrome is the occurrence of persistent or recurrent episodic pain syndrome localised within the organs of the scrotum, and may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction. Scrotal pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences. Scrotal pain syndrome is a generic term and is used when the site of the pain is not clearly testicular or epididymal. The pain is not in the skin of the scrotum as such, but perceived within its contents, in a similar way to idiopathic chest pain. Testicular pain Testicular pain syndrome is the occurrence of persistent or recurrent episodic pain syndrome perceived in the testes, and may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction. Testicular pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences. Epididymal pain Epididymal pain syndrome is the occurrence of persistent or recurrent episodic pain syndrome perceived in the epididymis, and may be associated with symptoms suggestive of lower urinary tract or sexual dysfunction. Epididymal pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences. Penile pain Penile pain syndrome is the occurrence of pain within the penis that is not primarily in syndrome the urethra, in the absence of proven infection or other obvious local pathology. Penile pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Urethral pain Urethral pain syndrome is the occurrence of chronic or recurrent episodic pain syndrome perceived in the urethra, in the absence of proven infection or other obvious local pathology. Urethral pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. Post-vasectomy Post-vasectomy scrotal pain syndrome is a scrotal pain syndrome that follows scrotal pain vasectomy. Post-vasectomy scrotal pain syndrome is often associated with negative syndrome cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract and sexual dysfunction. Post-vasectomy pain may be as frequent as 1% following vasectomy, possibly more frequent. The mechanisms are poorly understood and for that reason it is considered a special form of scrotal pain syndrome. If physical findings are present, the patient is said to have vulvar pain due to a specified cause. Generalised vulvar Generalised vulvar pain syndrome refers to a vulvar pain syndrome in which the pain/ pain syndrome burning cannot be consistently and precisely localised by point-pressure mapping via probing with a cotton-tipped applicator or similar instrument. The vulvar vestibule (the part that lies between the labia minora into which the urethral meatus and vaginal introitus open) may be involved but the discomfort is not limited to the vestibule. This pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences. Previous terms have included “dysesthetic vulvodynia and “essential vulvodynia, but are no longer recommended. Localised vulvar Localised vulvar pain syndrome refers to pain that can be consistently and precisely pain syndrome localised by point-pressure mapping to one or more portions of the vulva. Clinically, the pain usually occurs as a result of provocation (touch, pressure or friction. Localised vulvar pain syndrome can be sub-divided into vestibular pain syndrome and clitoral pain syndrome. Vestibular pain Vestibular pain syndrome refers to pain that can be localised by point-pressure syndrome mapping to the vestibule or is well perceived in the area of the vestibule. Clitoral pain Clitoral pain syndrome refers to pain that can be localised by point-pressure mapping syndrome to the clitoris or is well-perceived in the area of the clitoris. Gynaecological system: internal pelvic pain syndromes Endometriosis Endometriosis-associated pain syndrome is chronic or recurrent pelvic pain in patients associated pain with laparoscopically confirmed endometriosis, and the term is used when the syndrome symptoms persist despite adequate endometriosis treatment. Many patients have pain above and beyond the endometriotic lesions; this term is used to cover that group of patients. Endometriosis may be an incidental finding, is not always painful, and the degree of disease seen laparoscopically does not correlate with severity of symptoms. It has been suggested that this phenotype should be removed from the classification because the endometriosis may be irrelevant. Chronic pelvic Chronic pelvic pain syndrome with cyclical exacerbations covers the non pain syndrome gynaecological organ pain that frequently shows cyclical exacerbations (e. This condition is different from dysmenorrhoea, in which pain is only present with menstruation. Dysmenorrhoea Dysmenorrhoea is pain with menstruation that is not associated with well-defined pathology. Dysmenorrhoea needs to be considered as a chronic pain syndrome if it is persistent and associated with negative cognitive, behavioural, sexual or emotional consequences. Two or more of the following are present at least 25% of the time: change in stool frequency (> three bowel movements per day or < three per week); noticeable difference in stool form (hard, loose, watery or poorly formed stools); passage of mucus in stools; bloating or feeling of abdominal distension; or altered stool passage (e. Extra intestinal symptoms include: nausea, fatigue, full sensation after even a small meal, and vomiting. Chronic anal pain Chronic anal pain syndrome is the occurrence of chronic or recurrent episodic pain syndrome perceived in the anus, in the absence of proven infection or other obvious local pathology. Chronic anal pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. Intermittent Intermittent chronic anal pain syndrome refers to severe, brief, episodic pain that seems chronic anal pain to arise in the rectum or anal canal and occurs at irregular intervals. It was previously known as “proctalgia fugax but this term is no longer recommended. Musculoskeletal System Pelvic floor muscle Pelvic floor muscle pain syndrome is the occurrence of persistent or recurrent episodic pain syndrome pelvic floor pain. This syndrome may be associated with over-activity of or trigger points within the pelvic floor muscles. Trigger points may also be found in several muscles, such as the abdominal, thigh and paraspinal muscles and even those not directly related to the pelvis. Coccyx pain Coccyx pain syndrome is the occurrence of chronic or recurrent episodic pain syndrome perceived in the region of the coccyx, in the absence of proven infection or other obvious local pathology. Coccyx pain syndrome is often associated with negative cognitive, behavioural, sexual or emotional consequences, as well as with symptoms suggestive of lower urinary tract, sexual, bowel or gynaecological dysfunction. For each recommendation within the guidelines, there is an accompanying online strength rating form which addresses a number of key elements namely: 1. The strength of each recommendation is represented by the words strong or weak [16]. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including certainty of estimates), and nature and variability of patient values and preferences. Extensive use of free text ensured the sensitivity of the searches, resulting in a substantial body of literature to scan. Searches covered the period January 1995 to July 2011 and were restricted to English language publications. In 2017, a scoping search for the previous five years was performed, covering all areas of the guideline with the exception of the gynaecological aspects, and the guideline was updated accordingly. For the 2018 print, a scoping search was performed, covering all areas of the guideline starting from the last cut-off date of May 2016 with a cut-off date of May 2017. A total of 938 unique records were identified, retrieved and screened for relevance of which 17 publications were selected for inclusion in the 2018 guidelines. The gynaecological aspects of the guideline will be reviewed and fully updated in the 2019 edition.

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Three days later Lehman announced it was replacing Chief Operating Ofcer Joseph Gregory and Chief Financial Ofcer Erin Callan blood sugar monitor reviews metformin 500mg with amex. This proposal would re move the illiquid assets from the market and potentially avert a fre sale that could render Lehman insolvent diabetic diet uk safe metformin 500 mg. Thus blood glucose levels fasting buy cheap metformin 500 mg line, there was no way to know who would be owed how much and when payments would have to be made—information that would be critically impor tant to analyze the possible impact of a Lehman bankruptcy on derivatives counter parties and the fnancial markets diabetes signs type 2 discount 500 mg metformin visa. Parkinson suggested accelerating the formation of this group while being careful not to signal concerns about any one market participant. Gerald Corrigan, the Goldman Sachs executive and former New York Fed president who had co-chaired the Counterparty Risk Management Policy Group re port, to form an industry group to advise on information needed from a troubled in vestment bank. On Monday, September, more than New York Fed ofcials were notifed of a meeting the next morning “to continue the discussion of near-term options for deal ing with a failing nonbank. Regarding option, Mosser said it “should be done in a way that requires minimal temporary support. If the Fed agrees to another equity investment, it signals that everything [the Fed] did in March in terms of temporary liquidity backstops is useless. Because of this history, Lewis expressed his concerns to Paulson that Fuld would not want to sell the entire company or would not be willing to sell at a realistic price. His insistence kept the Bank of America executives working, but on Friday, September, Lewis called Paulson to repeat his assessment—no government support, no deal. Lewiss wife told Fuld that Lewis would not come to the phone and to stop calling. If we dont provide the cash, they refuse to clear, we fail, was the message circulated in an email to Lehman executives on Friday, September. So Lehman “delivered the billion in cash only by pulling virtually every unencum bered asset it could deliver. He stayed behind in Washington, in case he had to convene the Feds board to exercise its emergency lending powers. Paulson told them that a private-sector solution was the only option to prevent a Lehman bank ruptcy. A sudden and disorderly wind-down could harm the capital markets and pose the signifcant risk of a precipitous drop in asset prices, re sulting in collateral calls and reduced liquidity: that is, systemic risk. He could not of fer the prospect of containing the damage if the executives were unable to fashion an orderly resolution of the situation, as had been done in for Long-Term Capital Management. Paulson did offer the Feds help through regulatory approvals and access to lending facilities, but emphasized that the Fed would not provide “any form of ex traordinary credit support. It was said on more than one occasion that it would be very politically dif cult to rescue Lehman. Thain thought that was more than the assembled executives would be willing to fnance and, therefore, Thain believed Lehman would fail. By Sunday, the two agreed that Bank of America would acquire Merrill for per share, payable in Bank of America stock. Barclays would purchase Lehman, excluding to billion of as sets fnanced by the private consortium (even though the bankers in the consortium had estimated those assets to be signifcantly overvalued. Michael Klein, an adviser to Barclays, had told Lehman President Bart McDade that Barclays was willing to purchase Lehman, given the private consortium agreement to assist the deal. He believed that the real reason Barclays said it could not guarantee Lehmans obliga tions was the U. Im here writing the usg coms [United States government communications] plan for orderly un wind. According to McDade and Kirk, the government ofcials—led by Baxter— made it plain they would not permit Lehman to borrow against the expanded types of collateral, as other frms could. There would be some lag in terms of having to put all the papers together to actually fle it. We would like both events to happen tonight before the opening of trading Monday morning. And Im not trying to convince you that that belief was a crazy belief because they had seen that happen in the Bear case. And then he had to have discussions with the Lehman Board because they had a fduciary duty to resolve what was in the best interests of the company and its shareholders and other stakeholders. Miller remembered telling his colleagues as they left the building, “I dont think they like us. Cox and Baxter conferred for a few minutes, and then answered that the decision was the boards to make. It would create pressure on Merrill and Morgan Stanley, if not Goldman, which it eventually did. It would probably bring the short-term money markets into crisis, which we didnt fully anticipate; but, of course, in the end it did bring the commercial paper market and the money market mutual funds under pressure. He explained that this “meant there was a run in the money market mutual funds, which meant the commercial paper market spiked, which [created] problems for General Motors. The resulting liquidity crunch showed that frms had overly relied on this short term funding and had failed to anticipate how restricted the commercial paper market could become in times of stress. It fostered a negative reaction that endangered the viability of the fnancial system. From a legal standpoint, Bernanke explained, “We are not allowed to lend without a reasonable expectation of repayment. But the troubles at Lehman had been well known for some time, and investors clearly rec ognized—as evidenced, for example, by the high cost of insuring Lehmans debt in the market for credit default swaps—that the failure of the frm was a signifcant pos sibility. Thus, we judged that investors and counterparties had had time to take pre cautionary measures. They noted that letting Lehman fail was the only way to provide credibility to the assertion that no frm was “too big to fail and one member stated that the market was beginning to “play the Treasury and Federal Reserve. Bernankes view was that only a fscal and perhaps regulatory response could address the potential for wide-scale failure of f nancial institutions. The group of us should have just grabbed them and shaken them and said, Look, you guys could not do this. You were still going to have the runs on the other banks and you were going to have absolute fear and panic in the global markets. As Baxter put it, “I think that if the Federal Reserve had lent to Lehman that Monday in a way that some people think—without adequate collateral and without other security to ensure repay ment—this hearing and other hearings would have only been about how we wasted the taxpayers money. Lehmans failure resulted in part from signifcant problems in its corporate governance, including risk management, exacerbated by compensation to its ex ecutives and traders that was based predominantly on short-term profts. After the fact, they justifed their decision by stating that the Federal Reserve did not have legal authority to rescue Lehman. Now came this emergency meeting regarding another beleaguered American institution. But over the summer, New York Fed ofcials had begun to consider providing emer gency collateralized funding to even more large institutions that were systemically important. Put simply, we have seen this credit overhang story before with another stock in our coverage uni verse, and foresee outcomes similar in nature but on a much larger scale. Ira Selig, a manager at the New York Fed, emailed the Goldman report to Coffey and others. Their risk exposures are concentrated among the largest international banks (both U. The pros included avoiding a messy collapse and dislocations in markets such as commercial paper. Lehmans bankruptcy “was the end of the private-sector solution, she told the Commission. You get companies starting to take actions like that, thats what a Great Depression is. So out of maybe the, of the most important fnancial institutions in the United States, were at risk of failure within a period of a week or two. Other parties with direct connections to Lehman included the hedge funds, in vestment banks, and investors who were on the other side of Lehmans more than, over-the-counter derivatives contracts. However, any additional amount owed to them had to be claimed in the bankruptcy proceeding.

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