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Conditions and requirements of the Marketing Authorisation fi Periodic Safety Update Reports the marketing authorisation holder shall submit the first periodic safety update report for this product within 6 months following authorisation herbals india chennai buy 60caps ayurslim mastercard. Suhartono fi following characteristics are the intensity of high color Abstract—South Kalimantan is a province of Indonesia herbals 4play purchase 60caps ayurslim free shipping. It is (brownish red) herbals himalaya order ayurslim 60caps amex, low pH wicked herbals amped order 60 caps ayurslim overnight delivery, high content of organic matter, located in Kalimantan, the Indonesian territory of Borneo. It makes Characteristics of swamp water as mentioned above the water conditions in south Kalimantan is swamp water. However, due to the amount of the swamp water, the water is showed that the swamp water is less favorable to be used as used as a source of public drinking water. However, due to the amount of the resulted in many residents have abnormalities in the teeth. These swamp water, the water is used as a source of public drinking can make a demineralization of the tooth resulted the dental water. The relation between water condition in south follows low pH acidity levels can cause tooth decay and pain kalimantan and demineralization of tooth that can caused the stomach. These conditions impact on health, especially the dental erotion were never been investigated, thus our study aimed to evaluate the potential effect of water in South health of tooth [2]. Kalimantan on demineralization of dental which can caused Low pH levels can cause tooth decay. The combination of Index Terms—Acid water, dental demineralization, dental erotion, tooth. Administratively the government is divided into 13 Regencies Evidence based on case reports, clinical trials, and 2 Cities, namely Regency of Tanah Laut, Regency of epidemiological, cohort, animal, in vitro and in vivo studies Kotabaru, Regency of Banjar, Regency of Tapin, Regency of have described acids that could cause dental erosion as Hulu Sungai Selatan, Regency of Hulu Sungai Tengah, originating from gastric, dietary or environmental sources [6]. Regency of Hulu Sungai North, Regency of Tabalong, Dental erosion may have a multifactorial etiology, Regency of Tanah Bumbu, and Regency of Balangan as well attributable to intrinsic and extrinsic causes. The intrinsic as 2 Cities, namely Municipality of Banjarmasin and causes are associated with gastric acids, and may present Municipality of Banjarbaru. The widest regency is Regency intra-orally following vomiting, regurgitation, of Kotabaru (14,489. The most rainfall occurs between involved in erosion include environmental factors, dietary 2000 and 3000 mm yearly and the temperature is 25. It makes the water conditions in studies have identified some particular foods and drinks as south Kalimantan is swamp water. The dietary habits of program of dentistry, school of medicine, Lambung Mangkurat university, the high-progression group changed very little between the South Kalimantan, Indonesia (email: Rosihan adhani@yahoo. Overall, the School of Medicine, Lambung Mangkurat of University, South Kalimantan, high-progression group had four or more acid intakes per day. In other studies in children and adults who consumed acidic 20 foods and drinks is known associated with the presence and 15 progression of dental erotion [9]. Thus our study aimed to evaluate the potential effect 0 2 4 6 of water in South Kalimantan on demineralization of dental that Day can caused dental erotion by measuring their correlation. Preparation of Dental Sample Tooth samples were incubated at pH = 4 and pH = 7 is 49,5 cleaned and crushed to 40 mesh size. After that, 1 gram 49 sample was diluted to 200 mL with aquadest (sample 48,5 solution). A total of 50 mL of sample solution was added 2 mL of ammonium molybdate and 5 drops of SnCl2. Data Analysis (mg/ml) For analyzing of the data, Excell software 2010 was used and was examined by linear regression. The increasing number of days of exposure can breech the thin layer of enamel that protects your teeth. From Table I, also this breech has occurred, calcium, phosphate ions, and other showed that the decrease of pH will accelerate the rate of important minerals begin being leeched out of the teeth and decreasing mineral concentration. The condition occurs when the pH of the solution surrounding the enamel surface is lower than 5. It indicates that the calcium enamel, through the crystal lattice and prismatic enamel release will be followed by the release of other minerals such tubules containing water and organic matrix proteins. The hydrogen ions readily dissolve the mineral, the correlation between Ca with Zn. Tooth enamel minerals such as zinc is used for the maintenance of healthy is the hardest and most highly mineralised substance in the tooth. It is 96% mineral, with water and protein content for the tooth framework structure contributing to the organic other is 4%. The minerals found in human of healthy tooth is formed by inorganic minerals such as teeth that give them their hardness and strength belong to a calcium and phosphorous. Concentrations of zinc in surface enamel of teeth from Na, Cl, Al, Mn, Ca, and P were determined by neutron different areas range from 430 to 2100 p. In terms of activation analysis, K, Mg, Zn, Cu, and Fe by the atomic molar concentrations the concentrations are frequently of the absorption method, and F with the fluoride specific electrode. In enamel the major Most elements were present in higher concentrations in the deposition of zinc takes place before tooth eruption. In enamel than in the dentin: Mg, however, was higher in the contrast to fluoride, posteruptive deposition of zinc appears to dentin. Zinc is readily acquired by synthetic contained more K and Mn in enamel and K and Mg in dentin, hydroxyapatite, competing with calcium for positions on the but less Na and Zn in enamel [11]. Zinc pretreatment of Because the enamel of teeth is made of minerals, it has been hydroxyapatite produces a resistance to acid dissolution referred to as “the living stone” in mouth. Stones, as we know, similar in magnitude to that produced by equivalent molar are difficult to damage, but it is possible. Well, just the same, Demineralization caused by the acidic conditions known to the teeth can wear due to the things that eat or expose to the cause dental erosion. In fact, other than extreme trauma to the teeth, one of demineralization of the enamel, which can cause dissolution the most common ways to damage the teeth is through the of the subsurface layers and eventual loss of tooth structure. Any acid with a pH below the critical pH of dental enamel can Demineralization occurs when the enamel of teeth is dissolve the hydroxyapatite crystals in enamel [18]. The Dental erosion is a common condition, and its prevalence bacteria that forms around teeth due to improper oral hygiene seems to be trending higher in recent decades. It is difficult to accurately assess the prevalence of dental erosion from 140 International Journal of Chemical Engineering and Applications, Vol. Rytomaa, “Mineral composition of enamel and standard for clinical evaluation of this condition. The reported prevalence of dental erosion varies greatly importance to dental practicioner, World Dental Press, vol. The median “Microstructure and mineral composition of dental enamel of prevalence of dental erosion is 34. Boscol, “In vitro induction of enamel for evaluation of diagnostic imaging of dental erosion in different age groups, there is a clear trend methods,” J Appl Oral Sci, vol. Dental erosion: etiology, diagnosis and Dental erosion has been considered a common condition prevention. Radlinska, “Influence of the mineral compotition of drinking water Dental erosion starts from the release of calcium ions, and taken from surface water intake in enhancing regeneration processes in if this continues, it will cause the loss of some of the enamel mineralized human teeth tissue,” Polish J of Environ. Kulkarni, immersion in acid solution according to previous studies, “A method for rapid demineralization of teeth and bones,” the Open saying that if there is a decrease of one unit of pH, will cause Dentistry Journal, vol. Widmer, “Dental the pH or the more acidic media, it is increasingly high erosion: understanding this persasive condition,” Journal of Esthetic and Restorative Dentistry, vol. Sandor, Obtained enamel hardness test becomes soft, and can be lost “Dental erosion in gastroesophageal reflux disease,” Journal of the due to brushed, after contact with the acid, especially lemon Canadian Dental Association, vol. He graduated master of public health from Indonesia the results of this study concluded that chronic exposure to University, Jakarta, Indonesia and graduated Doctorate water in acid pH can caused demineralization of the tooth and degree administrative sciences from 17 Agustus University of Surabaya, Indonesia. Indrabudi, Forestland: Its dynamics, disorganised uses and He is a dentist who graduated from Gadjah Mada planning in South Kalimantan, ch. Nur, “River water quality assesment research is mainly focused on orthodontic and dental of the past district of Gambut and Aluh-Aluh South Kalimantan,” public health. Lloret, “Acid induced demineralization of bovine enamel and its effects at Bayu Indra Sukmana was born in Makassar, molecular level,” Resumen sem, 2009.

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Evaluation of efficacy and safety of oral sildenafil citrate therapy for men with erectile Hong B herbals on york generic 60 caps ayurslim fast delivery, Ji Y H herbals interaction with antihistamines purchase ayurslim 60caps amex, Hong J H et al vaadi herbals products review buy ayurslim 60 caps with amex. Pharmaceutical Journal of Chinese Peoples crossover study evaluating the efficacy of korean red Liberation Army 2002;18(4):205-208 lotus herbals quincenourish review discount ayurslim 60caps on-line. Apomorphine: An function and gonadal hormones in patients taking update of clinical trial results. Comments on "Prolactin Levels and Erectile Function in Patients Treated With Risperidone. Tadalafil has no responses by color Doppler ultrasonography studies detrimental effect on human spermatogenesis or reproductive between sildenafil non-responders and responders. 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Phosphodiesterase 5 inhibition: Effects on the decrease in testosterone is significantly exacerbated in coronary vasculature. The metabolic syndrome and erectile dysfunction: erectile dysfunction observed in these menfi. Testosterone Impotence and chronic renal failure: a study of the supplementation for erectile dysfunction: results of a meta­ hemodynamic pathophysiology. The effectiveness of combining hormone therapy and problems in elderly men: osteoporosis and erectile radiotherapy in the treatment of prostate cancer. Characterization of analysis of double-blind trials of the efficacy and calcium channel blocker induced smooth muscle relaxation tolerability of doxazosin-gastrointestinal therapeutic using a model of isolated corpus cavernosum. Efficacy of of male erectile dysfunction: a pharmacokinetic, extended-release doxazosin and doxazosin standard in pharmacodynamic and interaction study with intravenous patients with concomitant benign prostatic hyperplasia nitroglycerine in healthy male subjects. Erectile dysfunction in the Therapeutic effect of essential phospholipids on Africa/Middle East Region: Epidemiology and experience with functional sexual disorders in males. Prolactin levels and adverse events in patients treated with Khan M A, Raistrick M, Mikhailidis D P et al. Venlafaxine extended release for treatment of men with idiopathic hemochromatosis. Am J Cardiol 1999;84(5B):11N­ penile cavernosal artery: comparison of intraurethral instillation 17N. Time course of the interaction between tadalafil and Kim N N, Dhir V, Azadzoi K M et al. Comparison of the synergistic between the phosphodiesterase 5 inhibitor, tadalafil effects of tamsulosin versus phentolamine on penile erection: In and 2 alpha-blockers, doxazosin and tamsulosin in vitro and in vivo studies. Risk factors for an early increase in dose of vasoactive agents for intracavernous Kloner R A, Mitchell M, Emmick J T. A Randomized OpenLabel Study of the Impact of Quetiapine Versus Risperidone on La Vignera S, Calogero A E, Cannizzaro M A et al. Psychiatr Ann crossover study using yohimbine and isoxsuprine versus 1999;29(12):683 pentoxifylline in the management of vasculogenic impotence. Adult-onset Dysfunction: Management via Avoidance, Switching idiopathic hypogonadotropic hypogonadism presented with Antidepressants, Antidotes, and Adaptation. A meta-regression analysis of treatment effect modifiers in trials with flexible-dose oral Larson T R. Current treatment options for benign sildenafil for erectile dysfunction in broad-spectrum prostatic hyperplasia and their impact on sexual populations. Ocular safety in patients using sildenafil citrate therapy for erectile dysfunction. Is high-dose yohimbine hydrochloride effective in the treatment of mixed-type Laties A M, Fraunfelder F T, Flach A J et al. A prospective, randomized, controlled double-blind safety of Viagra, (sildenafil citrate). Longitudinal differences in disease specific quality of life in men with erectile dysfunction: Results from the Kupelian V, Shabsigh R, Travison T G et al. Is there a exploratory comprehensive evaluation of erectile relationship between sex hormones and erectile dysfunctionfi The efficacy Prevalence and Correlates of Erectile Dysfunction by Race and of tadalafil in clinical populations. Br J Sex Med Ethnicity Among Men Aged 40 or Older in the United States: 2005;2(4):517-531. Use of oral sildenafil (Viagra) in the impotence in the male dialysis patient: experience with treatment of erectile dysfunction. Ann N Y Acad Sci 2002;962(pp 378­ novel combination of L-arginine glutamate and yohimbine 388):-388. The role of androgen deprivation therapy combined dysfunction in anticoagulated cases: a study of with prostate brachytherapy. Phosphodiesterases as discontinuing intracavernous injection therapy with therapeutic targets. What is the incidence of sexual dysfunction Lenze E J, Karp J F, Mulsant B H et al. Somatic symptoms in in males following rectal excision for benign and late-life anxiety: Treatment issues. A goal-oriented, coston sexual experiences and nocturnal penile effective approach to the diagnosis and treatment of 24 male tumescence and rigidity in erectile dysfunction. Potential confusion between erectile Evaluation 2004;2(8):223 dysfunction and premature ejaculation: An evaluation of men presenting with erectile difficulty at a sex therapy clinic. The prospective and randomized control study of Viagra combined with Andriol in the treatment Manning M, Junemann K P, Scheepe J R et al. Chinese Journal of Andrology term followup and selection criteria for penile 2003;17(3):194-196. Impotence after radical pelvic surgery: physiology and function, and response to treatment in men receiving management. Journal of Clinical Endocrinology & Metabolism Lukkarinen O, Tonttila P, Hellstrom P et al. Predictors of Scandinavian Journal of Urology & Nephrology 1998;32(1):42­ erectile function improvement in obstructive sleep 46. Impotence following pelvic fracture urethral injury: Maan Z, Arya M, Shergill I et al. The pathophysiology Vardenafil (Levitra) for erectile dysfunction: a of erectile dysfunction related to endothelial dysfunction and systematic review and meta-analysis of clinical trial mediators of vascular function. Moxisylyte: A review of its pressure and arterial wave reflection in treated hypertensive pharmacodynamic and pharmacokinetic properties, men. Andrological findings in young patients under long-term antidepressive therapy with clomipramine. Visual erotic stimulation test for initial screening of psychogenic erectile dysfunction: a Manasia P, Pomerol J, Ribe N et al. Br J Urol and safety of 90 mg versus 20 mg fluoxetine in the treatment of 1997;157(1):134-139. Medical treatment of erectile release bupropion for selective serotonin reuptake dysfunction.

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From here, the antigens seemed to jump from one species to another, Jenner wondered go to the bloodstream, where they stimulate B cells to divide to whether exposing a healthy person to cowpox lesions might proyield plasma cells that produce antibodies that coat the small tect against smallpox. A slightly different virus causes cowpox, intestinal lining, protecting against pathogens in food. Potatoes but Jenner’s approach worked, leading to development of the and tomatoes have also been genetically modified to function first vaccine (the word comes from the Latin vacca, for “cow”). Jenner tried his first vaccine on a volunteer, 8-year-old Whatever the form of vaccine, it is important that a subJames Phipps. Jenner dipped a needle in pus oozing from a stantial proportion of a population be vaccinated to control an infectious disease. This establishes “herd immunity”—that is, if unvaccinated people are rare, then if the pathogen appears, it does not spread, because so many people are protected. If the population includes unvaccinated individuals who come into contact, the disease can spread. An infectious disease such as flu that is mild or harmless to most people can kill a person who has a compromised immune system. Diseases that had been nearly eradicated thanks to vaccination have returned in areas where people either refuse to have their children vaccinated, or cannot due to war. Monoclonal Antibodies Boost Humoral Immunity When a B cell recognizes a single foreign antigen, it manufactures a single, or monoclonal, type of antibody. A large amount of a single antibody type could target a particular pathogen or cancer cell because of the antibody’s great specificity. First, they injected a mouse with severe case of smallpox that the lesions joined. They then isolated a 342 Part 5 Immunity and Cancer to radioactive isotopes or to drugs deliver treatment to cancer 1 cells. However, it has been difficult to develop these body chemicals into drugs because they act only for 3 short periods. They must be delivered precisely where they are Cancer cells needed, or overdose or side effects can occur. Colony-stimulating factors, which so that newly formed cells (hybridomas) live cause immature white blood cells to mature and differentilonger. Treatment with these factors enables a patient to withstand higher doses of a conventional drug. Monoclonal antibodies are pure preparations of a single When a car breaks down, replacing the damaged part often antibody type that recognize a single antigen type. The same is sometimes true for the human are useful in diagnosing and treating disease because of body. Today, thousingle B cell from the mouse’s spleen and fused it with a cansands of transplants are performed annually and recipients cerous white blood cell from a mouse. The challenge to successful transplantation a hybridoma, had a valuable pair of talents. Like the B cell, lies in genetics because individual inherited differences in cell it produced large numbers of a single antibody type. Like the surfaces determine whether the body will accept tissue from a cancer cell, it divided continuously. An autograft transfers tissue from one part of a person’s and injected into a patient or applied to a sample of tissue or body to another. A skin graft taken from the thigh to body fluid binds its target—an antigen found mostly or only replace burned skin on the chest, or a leg vein that on cancer cells—fluorescence indicates disease. The immune Chapter 17 Genetics of Immunity 343 Isograft system does not reject the graft because the Genetically tissue is self. Same Organ Identical species recipient twin Because the twins are genetically identical, the recipient’s immune system does not reject the transplant. An allograft comes from an individual who is species not genetically identical to the recipient, but is a member of the same species. A xenograft transplants tissue from one species to between members of the same species, and a xenograft is between another. Bioethics: Choices for the Future Pig Parts In 1902, a German medical journal reported an astonishing drugs, Pennington’s body tolerated the pig liver’s help for the few experiment. A possible danger of xenotransplants is that people attachment almost immediately. Viruses can “jump” Nearly a century later, in 1997, a similar experiment took place. However, several with his blood circulating outside of his body through a living liver dozen patients who received implants of pig tissue did not show removed from a 15-week-old, 118-pound pig named Sweetie Pie. That study, though, looked only at pig liver served as a bridge until a human liver became available. We still do not know what effect pig viruses can have on a Sweetie Pie was no ordinary pig. Because many viral infections take years to cause and bred so that her cells displayed a human protein that controlled symptoms, introducing a new infectious disease in the future rejection of tissue transplanted from an animal of another species. Fetal brain tissue Heart From pigs valves Heart Heart Liver Liver Pancreatic cells that secrete insulin Kidneys Blood vessels From baboons Bone marrow Figure 1 Baboons and pigs can provide tissues and organs for transplant. In the novel and film Never Let Me Go, Kazuo Ishiguro describes a society in which certain people are designated 1. Discuss the pros and cons of the organs will be removed, one by one, until they die, to following systems for rationing human organs: provide transplants for wealthy recipients. Discuss the issues that people might find disturbing about h those who are not responsible for their condition, such creating animals such as pigs or primates that have certain as a nonsmoker with hereditary emphysema versus a human molecules that make their organs more likely to be person who has emphysema caused by smoking. Rejection Reactions—Or Acceptance patient’s new bone marrow is so similar to the old marrow that it is equally unable to fight the cancer. The best tissue for transthe immune system recognizes most donor tissue as nonself, plant may be a compromise: different enough to control the and launches a tissue rejection reaction in which T cells, anticancer, but not so different that rejection occurs. The greater the difference between recipient and donor cell surfaces, the more rapid and severe the rejection reaction. How does a vaccine protect against an infectious another type of animal is usually destroyed in minutes as blood diseasefi How are monoclonal antibodies and cytokines used Physicians use several approaches to limit rejection clinicallyfi Immunosuppressant drugs inhibit production of the antibodies and T cells that attack transplanted tissue. Gene expression profiling Immunity against infectious disease arises from interactions of can identify transplant recipients unlikely to reject their new two genomes—ours and the pathogen’s. Still experimental, this approach can spare some people mation is revealing how the immune system halts infectious taking immunosuppressants, which have side effects. Information from pathogen genomes reveals how they Rejection is not the only problem that can arise from an make us sick. Graft-versus-host disease can develop when Researchers can use such genomic information to betbone marrow transplants are used to correct certain blood defiter understand not only how an infection affects the human ciencies and cancers. The transplanted bone marrow, which body, but how infections spread, causing outbreaks and epiis actually part of the donor’s immune system, attacks the demics. Genomic information can translate into new treatrecipient—its new body—as foreign. Following are two examples of how a genomic approach helped restore public health. Reverse Vaccinology Hospital-Acquired Pneumonia Older vaccines consisted of parts of pathogens that were detected using standard microbiological approaches.

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Blunt injury from motor vehicle accidents herbs de provence recipes buy 60caps ayurslim visa, pedestrian accidents herbs life is feudal purchase 60 caps ayurslim mastercard, and falls are the most common causes kairali herbals malaysia cheap ayurslim 60caps with mastercard. Pneumothorax in the setting of blunt trauma occurs secondary to herbs uses purchase ayurslim 60 caps with mastercard (1) pleural laceration or lung puncture due to penetrating rib fractures; (2) increased intrathoracic pressure with rupture of alveoli; (3) or air leak into the pleural space from tracheobronchial disruption. On physical exam, diminished breath sounds may be noted on the affected side during auscultation or subcutaneous emphysema may be felt on palpation of the chest wall. With percussion of the chest, hyperresonance is suggestive of a pneumothorax, while dullness is associated with a hemothorax. A pneumothorax is seen on screening chest radiograph as a collapsed lung with a visceral pleural line outlined by free pleural air. Management for a traumatic pneumothorax in a stable patient requires the placement of a tube in the pleural space, in order to remove trapped air and allow lung reexpansion. Early intervention is necessary because the pediatric mediastinum is at increased risk of tension physiology, due to its increased mobility. Chest tube size should be determined by patient size and if there is an associated hemothorax present (Table). Small chest tubes are sufficient for isolated pneumothoraces, while larger tubes should be used to evacuate both air and blood in the case of a hemopneumothorax. To place a chest tube, the affected chest is prepped and draped in sterile fashion allowing exposure of the nipple, which serves as a landmark for 304 th the 4 rib. After the administration of local anesthesia, a small transverse th th incision is then made below the 4 or 5 intercostal space, anterior to the midaxillary line. Sharp dissection is carried through the subcutaneous tissues above the rib into the pleural cavity. A rush of air or bloody drainage may be noted upon entry into the intrathoracic space. A chest tube is then inserted into the pleural space directed cephalad towards the thoracic apex for a pneumothorax, or caudad and posteriorly for a hemothorax to optimize drainage. The chest tube is connected to a drainage device and evaluated for initial output. Non-absorbable suture is used to secure the tube in place and an occlusive dressing is applied. A chest x-ray is obtained to verify tube position and evacuation of the pneumothorax or hemothorax. In cases of small or occult pneumothoraces, supportive care with oxygen supplementation and close monitoring with serial chest x-rays may be pursued. However, in children who require mechanical ventilation, tube thoracostomy is recommended because positive pressure ventilation can convert a simple pneumothorax into a tension pneumothorax. Tension pneumothorax occurs with progressive accumulation of air in the pleural space, resulting in severe ipsilateral lung compression and mediastinal shift to the contralateral hemithorax. Diagnosis is established clinically by diminished breath sounds on the affected side, tracheal deviation to the contralateral side, jugular venous distention, and hypotension. Management should not be delayed for radiographic confirmation, and prompt 305 evacuation of the pleural air should be performed with a 14 gauge needle thoracostomy at the second intercostal space, mid-clavicular line. Hemothorax secondary to thoracic trauma typically only requires evacuation with tube thoracostomy and surgery is rarely indicated. In order to adequately drain hemothoraces and avoid tube obstruction from clots, large chest tubes are preferred. Chest tubes should be placed in the dependent position to permit adequate drainage in a supine patient. Inadequately drained blood can lead to the development of fibrothorax and lung entrapment. Massive hemothorax is characterized as hemorrhage exceeding 20% to 30% of the child’s blood volume at initial tube insertion, or persistent bloody drainage at a rate more than 3 cc per kilogram per hour. In these cases of severe hemorrhage, emergent thoracotomy should be considered to achieve hemostasis. Rib Fractures Rib fractures are less common in the children when compared to adults, secondary to the greater flexibility of the pediatric chest wall. It occurs in only 1% to 2% of pediatric trauma victims and most commonly is the result of blunt trauma from motor vehicle accidents, pedestrian accidents, or child abuse. Physical exam rarely identifies substantial clinical findings and diagnosis is established most frequently by a screening chest radiograph performed at the 306 initial presentation. Although rib fractures alone are usually of minimal clinical significance, 70% of patients with multiple rib fractures have associated injuries in other organ systems. Consequently, the presence of rib fractures in blunt trauma necessitates thorough evaluation for other concomitant injuries. In patients less than 3 years of age, child abuse should be strongly considered in the absence of a plausible mechanism for major trauma or underlying metabolic condition predisposing to fractures, such as rickets or osteogenesis imperfecta. When reasonable causes are excluded, the positive predictive value of rib fractures for child abuse in children younger than 3 years of age is 95% to 100%. In cases suspicious for abuse as the primary etiology, further imaging with a skeletal survey and bone scintigraphy should be pursued and social work involvement should be initiated. The location of rib fractures may prompt further examination for associated organ injuries. First rib fractures indicate a high-energy impact and may be associated with multisystem injury, including shoulder girdle injury, clavicle fracture, pulmonary contusion, hemopneumothorax, vertebral spine injury, or intra-abdominal trauma. However, fractures in the first and second rib are no longer considered to be markers for major vascular injury, nor are they indicators for further angiographic examination. Fractures of the lower ribs, depending on laterality, are associated with hepatic or splenic injuries. Non-steroidal anti-inflammatory medications, intravenous or oral narcotics, and epidural anesthesia are effective options for analgesia and should be used judiciously. This results in an unstable chest wall and is clinically diagnosed as paradoxical chest wall motion with respiration. Two main factors associated with the morbidity of flail chest are paradoxical wall motion and underlying pulmonary contusion. The primary goal in treating flail chest is supportive respiratory measures and adequate analgesia. However, in cases of severe respiratory compromise, such as hypoxia or hypercarbia, intubation and mechanical ventilatory support may be necessary. Rib fixation for the treatment of flail chest has been described in the adult literature with promising results. Open reduction and internal fixation of flail rib segments stabilizes the chest wall and improves pulmonary mechanics. Morbidity is consequently reduced because there is an appreciable reduction in time on the mechanical ventilator, as well as length of stay in the intensive care 308 unit. Available prosthesis includes stainless steel wires, metal plates or struts, and absorbable plates and screws. Reports of rib fixation in children are sparse in the pediatric literature and it is still largely uninvestigated. Although it has been shown to be beneficial in adults and short-term results may potentially be reproducible in children, there are concerns regarding rib fixation with metal plates or struts in children. One primary concern is that hardware implanted on a developing child’s rib cage may inhibit future chest wall growth or result in chest wall deformity. Other concerns include the long-term risk of infection of embedded hardware and need for subsequent surgeries to modify or remove hardware. Additional studies are required to define the appropriate indications in the pediatric population and assess long-term outcomes in children. On physical exam, a chest wall contusion may be visualized and pain may be elicited with palpation of the sternum. The most common location of fracture occurs at the sternomanubrial junction of the sternum. Although the majority of sternal fractures are usually isolated injuries, they are associated with cardiac dysrhythmias. A significant amount of energy transfer is required in order to fracture the scapula and associated injuries are seen in 90% of patients with this injury. Scapular fractures that are non-displaced can be managed non-operatively with a sling, while surgical intervention may be required for deformed or significantly displaced fractures. Tracheobronchial Injuries Tracheobronchial injuries in children are rare, occurring in less than 1% of pediatric traumas. Although rare, these injuries have a 30% mortality and half of the deaths occur within the first hour of injury. Disruption of the trachea or bronchi may result from a direct penetration injury or from high energy blunt chest trauma.

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To reduce the burden on awardee institutions herbals in chennai purchase 60caps ayurslim with visa, different federal funding agencies should adopt uniform public-access policies herbs pregnancy buy cheap ayurslim 60 caps line. Uniformity will not only reduce the burden on institutions gayatri herbals buy 60caps ayurslim mastercard, but increase compliance and potentially reduce costs herbals shoppe hedgehog products 60caps ayurslim sale. We could support mandatory public access for any work which arises from publicly funded research, is voluntarily published or presented by the author, generates no royalties for the author, and is not classified. This would cover many peer-reviewed journal articles (or author manuscripts), book chapters, books, conference proceedings, theses and dissertations, and open educational resources. However, we think these are secondary issues and must not delay a policy to require public access to peer-reviewed journal articles (or author manuscripts) arising from publicly funded research. We are not prepared to list all the types of content to which a federal public-access policy ought to apply. Another reason —as in our response to Question 5— is that public access to research articles is urgently needed and cannot wait for the policy nuances for other categories to be hammered out. Embargoes therefore limit the return on the public’s investment in research, and compromise the public interest. If federal policy initially allows embargoes, then it should reduce their maximum permissible length over time, eventually to zero. We could support a plan to do this gradually rather than suddenly in order give publishers time to prepare. If publicly funded 14 researchers make a patentable discovery, and wish to apply for a patent before publishing, the public-access policy would only kick in at the time of publication. If government policy is to allow embargoes, even temporarily, it might allow different embargoes in different fields, on the ground that the demand for articles seems to drop off at different rates in different fields. In any case, variable embargo periods would burden universities by making compliance with an agency in one field different from compliance with an agency in another field (in tension with Question #6 above). Similarly, if publishers believe that short embargo periods would harm them, they should release data showing it. Until there is data to show harm, we must act in the public interest and provide early or immediate public access to publicly funded research. If publishers provide data showing substantive harm, then it may become appropriate to consider what kind of compromise with the public interest might be justified. The advent of the Internet allows scientists to quickly share new research and also reduces the burden of making results and publications publicly available. As the Internet has grown, we have the capacity not only to share written articles but raw data itself. Articles can be read but with the actual data, results can be double checked, other researchers in academia, industry, members of the public, anyone can look over the data and draw their own conclusions. Nevertheless, despite the capacity for sharing and making data and articles publicly available, the system is still holding on to the antiquated ways of the past-professional journals where no data is published and the articles themselves are only accessible to members of universities or those who can afford the high price of their own subscription. The motto of the University of California system is fiat lux-let there be light. The Office of Science and Technology Policy is in a unique position to address these issues and better science and the American public. First by requiring all publications resulting from federally funded research to be published in open access journals. Further, requiring the data collected with federal funds to be deposited in a public repository. One concern with publicly shared data is that the original collectors may not receive adequate credit. All federally funded articles would have to not only be open, but indicate what data set was used for the research. This would ensure that federally funded research had both the articles and data made publicly available. It would also mean that the original collectors of the data would have to be given credit, inhibiting data theft or plagiarism. First, if the public pays taxes to support it, they should be able to access the results. Second, with the data, it is easier to verify that analyses and conclusions drawn in articles accurately reflect the data. If many such studies are carried out, it is possible to use meta-analysis to combine results and drawn more reliable, accurate conclusions by pooling data from many studies. Theoretically many journals require authors to share data for purposes of verification or meta-analysis, but my experience is that reality falls woefully short of this ideal. Public access to data would greatly enhance the ability of researchers to accurately combine and synthesize the results of many studies. Some data sets contain sensitive data and mechanisms would be required to maintain confidentiality in this case. Some change can come organically from the ground up, other change requires a top down approach. There have been some efforts to develop data repositories and open access journals, but the most benefit would come from something similar to the A centralized place for articles and data where researchers and public alike can read and learn. I am Dean of Libraries at Grand Valley State University, a Midwestern university with a Carnegie Classification of Masters Large. Our University, located on the west side of Michigan, is deeply committed to helping our state recover from the severe downturn in the economy. We are, no doubt, reflective of the country as a whole—trying to leverage the opportunities emerging from an increasingly globalized, hyper-connected and hyper-competitive world into a stronger economy for our region. Timely access to information facilitates all three, making your inquiry into federal information policy of huge importance to our University and to our region. Gaining access to all non-classified, federally funded research would unlock countless valuable resources that are not currently available to our university or to the citizens of our region because they are too costly for us to purchase. In sum, there are compelling reasons for the United States to adopt an Open Access policy for non-classified, federally funded research. Taxpayers provide the billions of dollars the government invests in research each year. Not just on principle, which is important enough, but because it can make a real and immediate difference in their lives at a personal level and across their communities. In addition, a broad Open Access policy for taxpayer-funded research would help economic growth. They recognize that information drives discovery and innovation and they want, for their countries, a more robust return on their investment in research. Our global economic competitors will have a competitive advantage if their research and data are open and ours are still locked away behind unnecessary tollgates in the form of subscription fees. Encouraging commercialization the single most important step to grow existing and new markets using results of federally funded research is to require public access to the resulting research results as quickly after publication as possible (typically this means deposit of the final version of the author’s manuscript after peer-review and before final formatting as a published journal article within 12 months of publication). A shorter window—6 months—would still provide a reasonable window of protection to the publishers who have invested in the formal presentation of the article, and it would double the speed with which the returns on our investment in research begin to manifest themselves in the market. For-profit publishers have pushed hard to protect their economic interest in the existing publishing model. Yet no publisher has been able to provide hard evidence to suggest a 6-month embargo results in cancellations of subscriptions to publisher’s journals. Even before the recent economic cuts in higher education, which certainly have caused deep cuts in journal subscriptions in most academic libraries, there was no viable evidence that librarians would cut a subscription to a scientific or medical journal because the articles would be free in six months. Six months is too long to wait for the article if you are teaching and supporting research in those fields. Publishers are using their fear of such an outcome to try and block needed reforms in the dissemination of research findings. When all of the factors that lead libraries to cancel journal subscriptions are considered, there is simply no compelling evidence to suggest that the publishers’ concerns about the market should outweigh even more compelling evidence about the positive benefits to the populace and the economy when information is free and accessible to all. There is no question that Open Access improves research productivity in a number of ways. It improves the visibility of existing research, making prior research more discoverable and less likely to be needlessly duplicated.

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