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Pelle G research on women's health issues buy generic female viagra, Shweke N menstrual upper back pain order female viagra online from canada, Van Huyen J-P menopause 100 years ago female viagra 100mg lowest price, Tricot L menstrual epilepsy cheap 50 mg female viagra, Hessaline S menstrual cramps 8 months pregnant buy generic female viagra 100 mg online, hemolytic uremic syndrome in a patient with metastatic pancreFremeaux-Bacchi V breast cancer her2 100 mg female viagra amex, Hiesse C, Delahoussse M. Garcfia-Martfin P, Alarcon-Payer C, Lopez-Fernandez E, Pang Z, Wang L, Liu D, Wang Q, Gao C. Transplansafety of sirolimus-based graft-versus-host disease prophylaxis tation-associated thrombotic microangiopathy in patients treated in patients undergoing allogeneic hematopoietic stem cell transwith sirolimus and cyclosporine as salvage therapy for graftplantation: a meta-analysis of randomized controlled trials. The incidence varies based on the diagnostic criteria and transplant-associated risk factors. Therefore, therapeutic rationale is undefined and consistent with the uncertain clinical efficacy. Abnormalities the identified articles were searched for additional cases and trials. Posttransplant thrombotic microangiopathy: sensitivity of proassociated thrombotic microangiopathy: real progress or are we still posed new diagnostic criteria. Small vessels, big trouble graft-versus-host disease after allogeneic hematopoietic stem cell in the kidneys and beyond: hematopoietic stem cell transplantationtransplantation. Oran B, Donato M, Aleman A, Hosing C, Korbling M, Detry microangiopathy in hematopoietic stem-cell transplantation. Christidou F, Athanasiadou A, Kalogiannidis P, Natse T, Bamichas G, tacrolimus following allogeneic stem cell transplantation: risk Salum R, Sakellari I, Anagnostopoulos A, Fassas A, Sombolos K. Peffault de Latour R, Xhaard A, Fremeaux-Bacchi V, Coppo P, pura: a ten-year experience. Transplantation-associated in a patient with posttransplant thrombotic microangiopathy. Posttransplantation thrombotic thrombocytonostic criteria for hematopoietic stem cell transplant-associated penic purpura: a single-center experience and a contemporary microangiopathy: results of a consensus process by an International review. Plasmapheresisrefractory following pediatric hematopoietic stem cell transplantation. Stx binds to multiple cells in the kidney and causes a spectrum of renal injury, including vascular endothelial cell damage, thrombotic occlusion of the capillary lumen, glomerular endothelial cell swelling, apoptosis of glomerular and tubular cell, and extensivecortical necrosis in the kidneys. The severity of acute illness, particularly central nervous system impairment and the need for dialysis is strongly associated with a worse long-term prognosis. Current management/treatment Supportive care is the mainstay of therapy including fluid management, treatment of hypertension and renal replacement therapy. Stx has been shown in vitro and in vivo to activate the alternative complement pathway. Similarly in the same outbreak, a French group found no difference in patient outcome with the use of eculizumab however suggested that as potentially more severely ill patients were treated with eculizumab, and that they still showed a comparable outcome compared to untreated patients, this may point toward an advantageous use, at least for severe cases (Delmas, 2014). Decisions of duration or to discontinue should be made based upon patient response and condition. Validadrome with early plasma exchange in adults from southern Dention of treatment strategies for enterohaemorrhagic Escherichia mark: an observational study. Outbreak of Escherichia coli O104:H4 haeHarambat J, Brun M, Ranchin B, Bandin F, Cloarec S, Bourdatmolytic uraemic syndrome in France: outcome with eculizumab. Update on noadsorption in patients with Escherichia coli O 104:H4-associStreptococcus pneumoniae associated hemolytic uremic synated haemolytic uraemic syndrome: a prospective trial. Corticosteroids are often used as an adjunct at 1 mg/kg/day; however, no definitive trials proving their efficacy have been performed. Other adjuncts include cyclosporine, azathioprine, vincristine, and other immunosuppressive agents. Platelets should only be transfused for significant clinical indications such as potential life-threatening bleeding. Allergic reactions and citrate reactions are more frequent due to the large volumes of plasma required. One recent study showed that the use of cryoprecipitate poor plasma as replacement may be associated with more frequent acute exacerbations. Solvent detergent treated plasma may be used for patients with severe allergic reactions. Albumin alone without any plasma replacement or infusion however has never shown efficacy. Platelet count and prothrombotic thrombocytopenic purpura, plasma exchange, plasmapheresis, thrombin time help distinguish thrombotic thrombocytopenic apheresis and rituximab reports published in the English language. Referenpurpura-hemolytic uremic syndrome from disseminated intravasces of the identified articles were searched for additional cases and trials. Caplacizumab for acquired thrombotic thromboClinical experience in 108 patients. Comparison of plasma exchange with plasma infuexchange in the treatment of thrombotic thrombocytopenic purpura. Scully M, McDonald V, Cavenagh J, Hunt B, Longair I, Cohen C, Poullin P, Malot S, Vanhille P, Azoulay E, Galicier L, Lemiale V, H, Machin S. Antibodies to von Willebrand factorPourrat J, Hamidou M, Coppo P; French Thrombotic Microancleaving protease in acute thrombotic thrombocytopenic purgiopathies Reference Center. Efficacy of rituximab in acute refractory purpura with a suboptimal response to plasma exchange. Experior chronic relapsing non-familial idiopathic thrombotic thromboence of the French Thrombotic Microangiopathies Reference cytopenic purpura: a systematic review with pooled data analyCenter. Platelet recovery rate durdaily plasma exchange therapy in patients with acquired thrombotic ing plasma exchange predicts early and late responses in patients with thrombocytopenic purpura. Mariotte E, Blet A, Galicier L, Darmon M, Parquet N, Lengline E, for chronic recurring thrombotic thrombocytopenic purpura: a case Boutboul D, Canet E, Traineau R, Schlemmer B, Veyradier A, report and review of the literature. Symptoms are usually, not always, precipitated by infection, trauma, surgical emergencies, withdrawal of anti-thyroid medications, operations (particularly thyroidectomy), radiation thyroiditis, diabetic ketoacidosis, severe emotional stress, cerebrovascular disease, use of tyrosine-kinase inhibitors, toxemia of pregnancy, or parturition. Amiodarone-induced thyroid storm is more prevalent in iodinedeficient geographic areas. Crises are usually sudden in patients with pre-existing hyperthyroidism that had been partially or untreated. Burch and Wartofsky created a scoring system to help standardize its diagnosis using body temperature, central nervous system involvement, gastrointestinal-hepatic dysfunction, heart rate, and presence or absence of congestive heart failure and/or atrial fibrillation. The clinical picture is one of severe hypermetabolism: fever (may be > 408C), marked tachycardia and arrhythmias, potentially with pulmonary edema or congestive heart failure, tremulousness and restlessness, delirium or frank psychosis, nausea, vomiting, abdominal pain, and, as the disorder progresses, apathy, stupor, and coma, and hypotension. This clinical picture in a patient with a history of pre-existing thyrotoxicosis, with goiter or exophthalmos, is sufficient to establish the diagnosis, and emergency treatment should not await laboratory confirmation. There is no serum T3 or T4 concentration that discriminates between severe thyrotoxicosis and thyroid storm. Current management/treatment American Association of Clinical Endocrinologist recommends a multimodality treatment approach. Their management includes medications which stop the synthesis (propylthiouracil or methimazole), release (iodine), blocking T4 to T3 conversion (dexamethasone), enhancing hormone clearance (cholestyramine), peripheral effects of the thyroid hormones (beta-blockers such as propranolol), manages high fever (acetaminophen, cooling blankets), and hypotension (hydrocortisone). Aspirin or other salicylates should not be used because they increase serum hormone levels. While the literature contains conflicting reports, most patients had a decrease in the hormone concentrations. However, albumin provides a larger capacity for low-affinity binding of thyroid hormones. Preoperative therapeutic plasma exchange in patients As of February 21, 2015, using PubMed and journal published in with thyrotoxicosis. Plasmapheresis in the storm, hyperthyroidism, therapeutic plasma exchange, and plasmatreatment of hyperthyroidism associated with agranulocytosis: a pheresis. American Thyroid Association and American Association of Amiodarone-induced thyrotoxicosis. The effects of plasmapheresis on thyroid hormone and plasma Plasmapheresis as a potential treatment option for amiodaronedrug concentrations in amiodarone-induced thyrotoxicosis. Thyrotoxic autoimmune encephalopathy in mapheresis in a patient with hydatidiform mole. They are characterized by mucocutaneous lesions leading to necrosis and sloughing of the epidermis. In the early stages of the disease, skin pain may be prominent and out of proportion to clinical findings. Skin lesion distribution is symmetrical, starting on the face and chest before spreading to other areas. Delayed removal of the causative drug and drugs with long half-lives are associated with worse prognosis. Supportive care, typically in an intensive care unit or burn center, is the mainstay of treatment and includes skin care, fluid and electrolyte management, nutritional support, eye care, temperature management, appropriate analgesia, and treatment of infections (Seczynska, 2013). Fluid and electrolyte losses may occur due to the extensive mucocutaneous lesions. Aggressive culturing and sterile precautions are important in minimizing this risk. Beyond supportive care, there are no universally accepted therapies for this disease. Discontinuation has been guided by clinical improvement including pain relief, the lack of appearance of new skin lesions, or evidence of skin healing. Balint B, Stepic N, Todorovic M, Zolotarevski L, Ostojic G, epidermal necrolysis: is cytokine expression analysis useful in Vucetic D, Pavlovic M, Novakovic M. Prognosis, sequelae, diagnosis, differential diagnecrolysis: review of pathogenesis and management. Seczynska B, Nowak I, Sega A, Kozka M, Wodkowski M, icant treatment effect of plasma exchange in the treatment of Krolikowski W, Szczeklik W. Description of the disease Vasculitis involves inflammation in blood vessels including arteries, veins, and capillaries. It can involve the peripheral nerves and skin, but can be seen in other organs such as the heart, kidney, and gastrointestinal tract. It is a chronic relapsing-remitting immuno-inflammatory disorder with a variety of clinical manifestations including orogenital ulceration, ocular, vascular, central nervous system, articular, mucocutaneous, and gastrointestinal symptoms. Most manifestations are self-limiting, but repeated attacks of uveitis are a major cause of blindness. In addition, immunosuppressions such as cyclophosphamide have been used for patients with severe disease manifestations. More than 90% of patients can be managed with steroid initially and achieve remission. Patient with renal symptoms, gastrointestinal tract involvement, cardiomyopathy, central nervous system involvement, loss > 10% of body weight, and age > 50 years may have poor prognosis and require maintenance treatment. Guillevin L, Lhote F, Sauvaget F, Deblois P, Rossi F, Levallois lished in the English language. Guillevin L, Mahr A, Cohen P Larroche C, Queyrel V, sentation, treatment, and outcome in pediatric and adult patients. Treating polyarteritis nodosa: current state E, Cohen P; French Vasculitis Study Group. Groh M, Pagnoux C, Baldini C, Bel E, Bottero P, Cottin V, and impact of treatment in 115 patients.

Hopelessness Q: Does the plaintiff have a history of hopeless feelings before the injury in questionfi Q: Does the plaintiff have a history of any medical or psychological conditions that may cause feelings of hopelessnessfi The plaintiff with an identity problem may experience an uncertainty about identity pregnancy after tubal ligation cheap female viagra 50 mg line, long-term goals menstruation videos for kids cheap female viagra, career choices menstrual cycle calendar buy female viagra 50mg fast delivery, friendship patterns women's health center kennesaw 50 mg female viagra for sale, sexual behavior breast cancer walk 2014 safe female viagra 50 mg, religious identification menopause signs and symptoms cheap female viagra 50 mg online, value systems, and group loyalties. The plaintiff may be unable to make decisions, may feel empty or isolated, have a distorted time perspective, and may feel Hopelessness negative or hostile toward others. The disorder is most common for late adolescents, (continued) but also occurs in young adults and in middle age when earlier life decisions are questioned. The plaintiff feels a loss of control, becomes passive, depressed, and withdraws from social support. Even without complications, the plaintiff may feel a sense of loss and vulnerable to further injury. Weakness and tiredness are the single most distressing symptoms of the depression. A negativistic (passive aggressive) personality passively resists both the demands of work and society. The plaintiff may experience an appetite disturbance, weight change, sleep disturbance, psychomotor agitation or retardation, decreased energy and emotional capacity, feelings of worthlessness, difficulty thinking or concentrating, and recurrent thoughts of death or suicide. Many plaintiffs with major depressive disorder have a psychiatric history of anxiety, depressive illness, long term pathology or familial patterns of depression. Other plaintiffs may be experiencing depression from the transient effects of medications, endocrine disorders, or other illnesses. Has the plaintiff sought to mitigate his or her harm through treatment for depressionfi Rule out history of prior depressive illness Rule out familial depression Rule out transient depression from Rx or other substances Rule out depression from non-proximate medical illness Rule out depressive personality (lifelong imbedded characteristics) Rule out severe, non-proximate stressors such as bereavement, divorce, etc. Most plaintiffs claim to suffer from chronic depression but very few expert witnesses take a complete clinical history and conduct a differential diagnosis to determine the cause of the depressive illness. Defense counsel should note that depression can be the basis for a pseudo dementia. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Note: this exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition. If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features: Mild; Moderate; Severe Without Psychotic Features/ Severe With Psychotic Features Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode: In Partial Remission, In Full Remission Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Major depression requires a markedly diminished interest or pleasure in most all activities or a depressed mood most of the day, nearly every day for at least a two week period. The plaintiff must indicate at least five other symptoms that occur with the depression. The symptoms cannot be due to a physical condition, mood-incongruent delusions or hallucinations, incoherence, or a marked loosening of associations. The Major Depressive Episode cannot be better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. Note: the following five disorders are a group of psychotic conditions that often begin in adolescence or young adulthood. They are characterized by fundamental alterations in concept formations, a misinterpretation of reality, and associated affective, behavioral, and intellectual disturbances. Schizoaffective disorder: this disorder is defined by a period of illness in which there is a major depressive, manic, or mixed episode concurrent with symptoms that meet criterion A for schizophrenia. The plaintiff with schizophrenia often becomes incapable of experiencing any pleasant emotion. For the diagnosis of major depressive disorder, there cannot have been a manic episode, a mixed episode, or a hypomanic episode. Symptoms related to a general medical condition, mood-incongruent delusions or hallucinations are not included in the symptom requirements for a major depressive episode. In order to be diagnosed with a major depressive disorder, the possibility of an organic cause of the symptoms must be eliminated. Criteria for Melancholic Features Specifier (a specifier for major depressive disorder) A. Either of the following, occurring during the most severe period of the current episode: (1) loss of pleasure in all, or almost all, activities (2) lack of reactivity to usually pleasurable stimuli B. Three (or more) of the following: (1) distinct quality of depressed mood (2) depression regularly worse in the morning (3) early morning awakening (at least two hours before usual time of awakening) (4) marked psychomotor retardation or agitation (5) significant anorexia or weight loss (6) excessive or inappropriate guilt Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Copyright 2000 American Psychiatric Association. The plaintiff, for example, may experience a depression every year between the beginning of October and the end of November. Seasonal depressions should not be diagnosed if the depression is associated with an obvious seasonally related stressor such as regular unemployment every winter. If the witness indicates that the plaintiff may have a seasonal depression, the symptoms may be unrelated to the injury in question. Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year. In the last two years, two Major Depressive Episodes have occurred that demonstrate the temporal seasonal relationships defined in Criteria A and B, and no nonseasonal Major Depressive Episodes have occurred during that same period. Q: Does the plaintiff have a history of depressed mood before the injury in questionfi Some people only have a single major depressive episode and return to normal functioning. Approximately half of the people who have a major depressive episode, however, may eventually have another major depression. Periods of major depression can recur after many years of normal functioning, can occur in clusters, or may gradually become more frequent with age. A family history of depression may double or triple the risk of depression for the plaintiff. Mood (continued) Q: Did you rule out mood disorder due to a general medical condition. This group of disorders is characterized by a mixture of schizophrenic and affective or major depressive and manic syndromes. Cyclothymic disorder is a chronic, fluctuating mood involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. Cognitive symptoms include a short attention span, impaired recent memory, and an exaggerated startle response. Viral illnesses, such as infectious hepatitis, mononucleosis, and influenza, may produce significant depressive symptoms in the plaintiff. These self-limited illnesses may result in suicidal ideation, loss of appetite, libido, and fatigue. If a major depressive episode, manic or mixed episode occurs within four weeks following childbirth, it would be diagnosed as a mood disorder with postpartumonset. Symptoms that are common in postpartum-onset episodes include fluctuations in mood and preoccupation with infant well-being, the intensity of which may range from over-concern to frank delusions. Adults with antisocial personalities fail to conform to social norms with respect to lawful behavior. A prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following: (1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities (2) elevated, expansive, or irritable mood B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Mood Disorder that is not substance induced. Note: this diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. Mood (continued) the abrupt cessation or reduction of cocaine, after several days use, may cause the plaintiff to feel tired, dysphoric, irritable, depressed, and to crave more of the drug. Unlike schizophrenics, they are able to talk in detail about their hallucinations. The initial euphoria is often followed by apathy, unpleasant mood, psychomotor retardation, impaired judgment, and impaired social or occupational functioning. During Mood the final stages of withdrawal, the plaintiff may experience over-concern for bodily (continued) discomfort, poor self-image, and a decreased ability to tolerate stress. The user can be social and sympathetic one minute then become hostile and negative the next. Other symptoms may include psychomotor agitation, impaired judgment, impaired social or occupational functioning, increased blood pressure or heart rate, numbness to pain, ataxia (incoordination of voluntary muscles), dysarthria (impaired speech), muscle rigidity, seizures, and hyperacusis (painful sensitivity to sounds). After a four to six hour high, the plaintiff may feel depressed, irritable, paranoid, belligerent, assaultive, irrational, suicidal, or homicidal. Mood disorders may develop shortly after use and are characterized by feelings of self-reproach, guilt, fearfulness, excessive talking, difficulty sleeping, and thoughts that they have destroyed their brains or driven themselves crazy. Behavioral symptoms may include disinhibition of sexual or aggressive impulses, mood lability, impaired judgment, and impaired social or occupational functioning. Physical symptoms may include slurred speech, incoordination, unsteady gait, psychomotor retardation, and impaired memory or attention span. While taking the drugs, they may experience euphoria, severe mania, severe depression, delirium, paresthesia (abnormal tightness or tingling around a limb or trunk), insomnia, restlessness, or agitation. Antihypertensive medications are a particular class of drugs that may cause a depressed mood. Diminished Interest or Q: When and how often does the plaintiff experience a diminished interest or Pleasure pleasure in activitiesfi Interest or Q: Does the plaintiff have a history of diminished interest or pleasure in activitiesfi Pleasure (continued) Q: Does the plaintiff have a history of any medical or psychological conditions that may cause a markedly diminished interest or pleasure in activitiesfi S/he may express this through procrastination, dawdling, stubbornness, intentional inefficiency, and forgetfulness. A borderline personality disorder is characterized by unstable interpersonal Pleasure relationships, behavior, mood, and self-image. The plaintiff may experience (continued) temporary mood shifts including depression, irritability, and anxiety. They may also have chronic feelings of emptiness or boredom, inappropriate anger, and recurrent suicidal thoughts. The plaintiff with this disorder has very stressful recurrences of depersonalization. Associated symptoms may include dizziness, depression, obsessive rumination, somatic concerns, anxiety, fear of going insane, and difficulty with a sense of time and recall (reference 7, p. Premenstrual dysphoric disorder is characterized by emotional and behavioral symptoms which usually occur during the last week before the menstrual cycle and remit within a few days after menses begins. Appetite (continued) Q: Does the plaintiff have a history of any medical or psychological conditions that may cause a significant change in weight or appetitefi Bulimia nervosa features recurrent episodes of binge eating, a rapid consumption of a large amount of food in a discrete period of time. The plaintiff will have feelings of lack of control over eating and use self-induced vomiting, laxatives, diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain. Associated symptoms may include depressive moods and self-deprecating Weight or thoughts. S/he may also have chronic feelings of emptiness or boredom, inappropriate anger, binge eating, and recurrent suicidal thoughts. Social contrariness and a generally pessimistic outlook often accompany the disorder. It is often thought that the manic high represents an escape from inner depression and pain. The plaintiff may experience an appetite disturbance, weight change, sleep Weight or disturbance, psychomotor agitation or retardation, decreased energy and emotional Appetite capacity, feelings of worthlessness, difficulty thinking or concentrating, and (continued) recurrent thoughts of death or suicide. Masked depression is a depressive state in which the dysphoric mood is covered or masked by gastrointestinal problems, chronic pain, insomnia, weight loss, or other bodily complaints. The Kleine-Levin syndrome, occurring primarily in adolescent males, is characterized by episodes or excessive sleep and overeating, lasting up to several weeks. If the witness indicates the possibility of dysthymic disorder, see the section on dysthymic disorder for further questions. Mild nausea, vomiting, and weight or appetite change are common symptoms Appetite during the first four months of pregnancy. Symptoms may include sneezing, itching of the nose, a stuffy nose and postnasal drainage. The plaintiff with allergies generally feels ill or uncomfortable and may not be interested in eating. Rheumatoid arthritis is a progressive disease that causes long-lasting pain in the joints and muscles. The most (continued) notable psychiatric symptoms include depression, lethargy, poor concentration, impaired memory, apathy, and syncope. The plaintiff may commonly experience the depressive symptoms for days or weeks after the illness. These self-limited illnesses may include suicidal ideation, loss of appetite, libido, and fatigue. Hypersomnia Q: When and how often does the plaintiff have insomnia or hypersomniafi Insomnia may be caused by life stressors such as marital difficulties, problems at work, guilt over sexual conflicts, or concerns about health. Rebound insomnia is a worsening of sleep following intermediate term use of drugs, such as: (reference 9, pp. These hesitations may cause the plaintiff to awaken periodically throughout the night.

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Similarly teva women's health birth control female viagra 50 mg low price, both institutions 28 Investment Climate Reforms pay particular attention to lowerand lower-middle-income countries menstrual vacuum purchase female viagra 100 mg, where 8 of 10 interventions are implemented menopause 30 symptoms buy female viagra 50 mg fast delivery. All interventions have active projects women's health center greenville nc female viagra 100mg for sale, with regulation pregnancy 12 weeks buy female viagra 100 mg cheap, investment policy womens health 4 way body toner buy female viagra 50 mg low price, trade, and tax being 25 the most common and competition and labor the least. However, when in the World Bank these are part of lending operations, the average length is substantially higher. World Bank development policy operations with investment climate components are completed on average in less than two years; projects that include mostly investment climate components are implemented on average over six years. In terms of income the distribution of interventions shows that almost half of interventions are in low-income countries, whereas entry and exit almost equally distributed between the three income groups. In a few countries, for example, Cambodia, interventions focus on specifc areas such as trade promotion. In Vietnam, the World Bank supported investment climate reform through fve Poverty Reduction Support Credits. These projects supported trade and economic integration, tax regulations, land regulations, and labor skills. The program supported drafting and approval of an economic zoned act and assisted the Bangladesh Export Processing Zones Authority in developing an An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 29 Table 1. NotE: Regional projects are excluded because they mostly include knowledge management activities, data collection, and analytical products. The investment climate reform program was designed as a programmatic series of Advisory Services operations. Projects were coded based on whether they included an explicit targeting criterion for the benefciaries of the intervention and whether they reported results for the specifc group that was targeted. Only 8 percent of all projects specifcally aimed to target women, and a similar percentage targeted frms based on their industry and formality status. Targeting based on age, geographical area, or export status is even rarer (Table 1. Moreover, only a minority of projects with a specifc target actually report on results for the An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 31 Table 1. As for gender, fewer than 4 of 10 closed projects that had a gender target report any gender-disaggregated result or gender-relevant results. The increase in gender targeting in the last two fscal years likely refects the renewed focus on gender mainstreaming by the World Bank Group. According to the gender fag, 66 percent of World Bank investment climate operations are gender informed; based on the targeting criteria, however, only 23 percent are. The prevalence of specifc targeting in project design also varies by networks and regions. A close analysis of projects targeting gender reveals that many are small in size and mostly focused on capacity-building activities or on flling an information gap relative to genderbased barriers in the business enabling environment. Most of those projects target women as participants of training or consultative working groups rather than as entrepreneurs (or potential entrepreneurs) who may directly beneft from investment climate reforms. The gender dimension was also more easily found in activities aimed to produce diagnostic and baseline assessments. Whether investment climate interventions should explicitly target specifc subgroups of the population rather than promoting reforms aimed at improving the general business environment of a country is a question without a straightforward answer. On the one hand, by their very nature reforms are supposed to be general, and any specifc provision could be perceived as An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 33 Table 1. On the other hand, normally the playing feld is not leveled for everybody, and certain entrepreneurs or frms, current or potential, experience obstacles that are specifc to their group and, if not addressed, not only raise issues of fairness and equity, but can also hinder the growth potential of the whole economy. Gender-specifc obstacles make it harder for women than for men to start and grow enterprises. Fewer women than men own and manage businesses worldwide (Kelley and others 2012). Also, in all regions of the world, including in developed economies, female-owned enterprises are substantially and signifcantly smaller (Bardasi, Sabarwal, and Terrell 2011; Minniti 2010), partly because women are more likely to operate in industries where frms are smaller and less effcient, but also because women face disproportionate obstacles in obtaining licenses and permits (because of limited mobility, time constraints, and sometimes discrimination and higher exposure to bribes and sexual harassment) and in accessing a number of things: fnance, markets, courts and dispute resolution systems, networks, and assets and property. In addition to de facto constraints such as those highlighted above, in some countries women also suffer legal discrimination, as has been documented in the World Bank Group report Women, Business, and the Law. In several countries women have lower legal status and fewer property rights than men; they may be subject to travel restrictions; or they may be forbidden from pursuing certain trades or professions in the same way as men (World Bank 2014). Investment climate reforms may be designed with knowledge of legal or de facto constraints and explicitly aim to address those constraints to ensure inclusion. Alternatively, investment climate reforms may claim to be gender neutral, although they might be implemented in environments where specifc gender constraints exist. More specifcally, in 81 percent of interventions, investment climate reforms do not include gender targeting when there are no gender-specifc legal constraints (although other relevant constraints may exist), and in 8 percent of interventions investment climate reforms target businesswomen because of other nonlegal constraints. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 35 Table 1. NotE: the percentage in each cell refers to investment climate interventions (in client countries included in the database) for each case. The legal constraints considered four types of restrictions, based on the Women, Business, and the Law database: unequal ownership rights to property; inability to sign a contract in the same way as a man; inability to register a business in the same way as a man; and inability of opening a Bank account in the same way as a man. That is, investment climate reforms do not target women when there are legal constraints that would make such reforms not gender neutral. Moreover, several of these countries implement interventions that tend to be woman friendly, even if there is no explicit gender targeting. These are examples where targeting may not have been correctly done, as obstacles for businesswomen were not in the regulatory environment for businesses but in the discriminatory legal framework. The intervention (ongoing) aims to give married women the same economic An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 37 opportunities that men have (activities include support for legal reforms, communication along the reform process, and development of evaluation tool for measuring their effective impacts). According to the Project Appraisal Document, this will result in an improvement of the economic situation of women, measured by the increase in the number of individual enterprises owned by women. Investment ClImAte PortfolIo: fCs overall, 15 percent of investment climate projects are implemented in fCs countries. IfC shows a slightly higher share of investment climate projects in fCs countries than the World Bank. However, in absolute terms, both institutions have approximately the same number of investment climate projects. In terms of interventions, the most common interventions in fCs countries (accounting for over 50 percent of all) are regulation, investment promotion, trade, and public-private dialogue. Moreover, most of the population in developing countries lives in rural areas and depends on agriculture for its livelihood. Ineffcient market for inputs, overregulation, and costly trade logistics in turn make domestic products uncompetitive. It is second to agriculture in terms of employment generation per unit of investment and is a valuable source of foreign exchange. However, a range of impediments continues to inhibit investment, including complicated and nontransparent approval processes for tourism licenses; ineffective institutional structures of public or private sector agencies responsible for tourism development; weak institutional capacity to develop appropriate policy, plans, and processes for tourism investments; accessibility; complex land issues/limited availability of land for tourism development; ineffective aviation policies; and lack of access to fnance. The relevant portfolio includes both projects mapped under the Investment Climate for Industry practice and those not mapped to it but that cover sector-specifc sector reforms in agriculture and industry, including regulatory reforms. First, as part of the broad review of all investment climate projects, the portfolio analysis identifed projects within the investment climate portfolio that (i) promoted sector-specifc reforms in agribusiness or tourism; (ii) identifed agribusiness or tourism as industries of interest; and (iii) had components and/or project development objectives that mentioned developing the agribusiness and tourism sectors. Second, the team reviewed evidence from 19 completed case studies to consider if country strategy identifed these sectors as development priorities and if specifc interventions promoted Investment Climate for Industry in these two sectors. Thirteen percent of its investment climate industry advisory projects are not in any one region, but are global in focus. Many of the activities supported under investment climate for industry do not ft strictly within the confnes of the legal and regulatory focus of the investment climate portfolio. Instead, sectoral studies often identify a much broader variety of constraints, opportunities, and challenges and often map out relevant value chains or supply chains. In fact, both the investment climate for industry and the competitive industries practices often employ value chain approaches to promote sectoral development and increased sectoral competitiveness. When it comes to agricultural trade, specifc interventions are aimed at reducing compliance, transport, and transaction costs for agribusiness products and related inputs that can result in a more effcient and competitive trade and transport environment. The 2011 Philippines Agribusiness Trade Competitiveness and the Honduras Agribusiness Trade Logistics Projects are examples of this. When a project is aimed at improving the agricultural industry per se, reforms address the main regulatory and policy constraints hindering priority commodities (national produces) that aim to improve input market and storage capacity and modernize food safety, roads, and agricultural infrastructures (such as irrigation) and product certifcation system to facilitate investments in the sector. Another approach is to simplify procedures related to agriwaste processing and production of renewable energy, as in the Ukraine Investment Climate: Agribusiness and Cleaner Production Project. The interventions also support individual producers, community groups, and agricultural processors; they help test and develop technology appropriate to identifed market opportunities and facilitate access for individual small and medium-size farmers to fnance for small capital improvements and working capital through existing eligible microcredit organizations. An example of this is the Small-Scale Commercial Agriculture Development Project in Bosnia and Herzegovina. In tourism, interventions are typically less specifc and coincide with the creation of a diagnostic tool such as a database, interpretation and presentation of fndings and scores on the preparedness for sustainable development of the tourism sector, or benchmarking of destinations. This is the case of the Tourism Investment and Development Advisory Services Global Project. Sometimes, the interventions become more explicit and entail assisting the government in structuring hotel deals, attracting foreign investors, and updating the land legislation. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 41 Given the focus on sectoral promotion and value chain deepening in agriculture and tourism, many of the activities supported under investment climate for industry go well beyond the confnes of the legal and regulatory focus of the investment climate portfolio. Notes 1 See Sinha, Holmberg, and Thomas (2013) and World Bank (2004b) for surveys of the literature on this issue. Similarly, different types of frms are likely to be affected differently by the business environment. Many studies have found that small, medium-size and large frms face very different constraints within the same country (Clarke 2011; Gelb and others 2006; Hallward-Driemeier and Aterido 2009). The broader debate on determinants of economic growth is beyond the scope of this evaluation. The purpose and benefts of each tool is explained and applied to different phases of confict, along with a discussion on the drawbacks of the approaches. The 2002 World Development Report (World Bank 2001) focused on institutions and overlapped with the 2005 World Development Report. The 2002 report, however, did not focus on investment and did not rely primarily on frm-level evidence. It links to offcial government sources (that is civil laws, commercial laws, and so forth) when possible. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 43 Bardasi, E. Rebuilding War-Torn States: the Challenge of Post-Confict Economic Reconstruction. Apples: How to Make (More) Sense of Subjective Rankings of Constraints to Business. Private Sector Development in Confict-Affected Environments: A Review of Current Literature and Practice. Stimulating Youth Entrepreneurship: Barriers and Incentives to Enterprise Start-Ups by Young People. Gender Dimensions of Investment Climate Reform: A Guide for Policy Makers and Practitioners. Creating an Enabling Environment for Private Sector Development in Sub-Saharan Africa. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 45 World Bank. Women, Business and the Law 2014: Removing Restrictions to Enhance Gender Equality. The main constraints are lack of competition, barriers to establish and operate businesses, costs of doing business, and regulatory burdens. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 2 47 this chapter presents evidence on the extent to which support for regulatory reforms has been a strategic priority for the World Bank Group and whether it has been relevant to client countries. Between 2007 and 2013, the Bank Group supported regulatory reforms in 119 countries through nearly 15 types of interventions. These countries signifcantly varied in terms of their development levels and challenges, but they all pursued investment climate reforms with the goal of improving the regulatory environment for private sector development. Overall, World Bank Group strategies intend to enhance competition, foster enterprise creation and growth, facilitate international trade and investment, and unlock sustainable investment opportunities in key sectors, such as agribusiness and tourism (World Bank 2002, 2013). They pursue these objectives by reducing time, costs, and procedures and by simplifying regulations. Basically, these reforms assume that what is good for frms is also good for society, although some (de)regulations may have signifcant consequences for different stakeholders in society.

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Alternative surgical strategy is the fundus first apdiagnostic tests and eventually the removal of the stones menopause goddess discount generic female viagra uk. The combination of patient and disease related mical tests have a negative predictive value of 97 % women's health newsletter cheap female viagra generic, risk factors increases the conversion rate [113] pregnancy ultrasound discount female viagra 50 mg without a prescription. According whereas the positive predictive value of any abnormal liver to Giger et al menopause relief products female viagra 50 mg with mastercard. The diagnostic acand symptomatic disease; Barkun et al combined age > 55 women's health clinic jber purchase 50 mg female viagra free shipping, curacy increases for cholestasis tests such serum bilirubin elevated serum bilirubin pregnancy 20 weeks cheap female viagra line, dilated common bile duct and with the duration and the severity of obstruction. A recently published meta-analysis stratified according to the proposed classification, modified investigated the diagnostic potential of ultrasound [131]: from the American Society of Gastrointestinal Endoscopy sensitivity ranged from 0. Sensitivities diagnostic accuracy and did not differ significantly showed a weak statistical difference (p =0. A systemModified from [139] atic review assessed the difference between these Ansaloni et al. World Journal of Emergency Surgery (2016) 11:25 Page 14 of 23 different techniques [151]. The removal of the infected material, in elderly patients and patients with complications; howin addition to antimicrobial therapy, can result in a reever, there is a lack of good quality evidence to support duced inflammation with an improvement of the clinthe statement. A major limitation of the study was the vative treatment followed by delayed laparoscopic choleinclusion of patients with both acute acalcolus cholecystectomy [162]. Grey areas still remain in scribed as a procedure reserved for those patients who the cases of patients not fit for urgent surgery or for lapfailed the conservative treatment after a variable time of 24 aroscopic surgery secondary to general conditions. None of the examined studies the former diagnostic uncertainty may not be relevant reported the specific drug agent. No evidence exists supin healthy patients and the latter invasive radiological porting the need for a peculiar antibiotic regimen. For the investigation should therefore be applied only in highantimicrobial therapy, please see the dedicated section. Data on criteria demiological analysis in 2012 showing that only 40 % of for a definition of a high-risk patient other than that of patient underwent delayed laparoscopic cholecystectomy septic shock, are scarce and of poor level of evidence. No randomized trial comparing the need for decholecystectomy and low threshold for conversion layed laparoscopic cholecystectomy exists currently. Therefore, prospective and multicentre studies to compare different risk factors and scores are necessary Timing 5. In people with more than 10 days of symptoms, delaying cholecystectomy for 45 days is better than immediate surgery. However, it should be noted that earlier surgery is associated with shorter hospital stay and fewer complications. World Journal of Emergency Surgery (2016) 11:25 Page 19 of 23 Secretariat, Organization Committee and Scientific Committee according to Milan, Italy. Raul Coimbra (United States) David Costa (Spain) Orsola-Malpighi Alma Mater Studiorum, University of Bologna, Bologna, Italy. Abe Fingerhut (France) 43Division of General Surgery, Rambam Health Care Campus, Haifa, Israel. The natural history of silent gallstones: the Selman Uranues (Austria) innocent gallstone is not a myth. Epidemiology and risk factors for gallstone disease: has the Dieter Weber (Australia) paradigm changed in the 21st centuryfi Influence of laparoscopic the authors declare that they have no competing interests. J Gastroenterol cholecystectomy for acute calculous cholecystitis: a meta-analysis. Improving diagnostic accuracy based on a review at a Complicated intra-abdominal infections worldwide: the definitive data of regional hospital. Sonographic diagnosis of acute cholecystitis in patients with Complicated intra-abdominal infections in Europe: a comprehensive review symptomatic gallstones. Current trends in imaging infection in adults and children: guidelines by the Surgical Infection evaluation of acute cholecystits. World J Emerg beneficial effect in patients with symptomatic gallstones awaiting Surg. Factors associated with septic shock and mortality in generalized peritonitis: Lancet. Bench-to-bedside review: appropriate antibiotic therapy in cholecystitis: non-operative management is an option in some patients. Bacteriology of the gallbladder bile in up showed that operation was the preferred treatment. Brazzelli M, Cruickshank M, Kilonzo M, Ahmed I, Stewart F, McNamee P, Bacteriological studies of bile from the gallbladder in patients with et al. Clinical effectiveness and cost-effectiveness of cholecystectomy carcinoma of the gallbladder, cholelithiasis, common bile duct stones and compared with observation/conservative management for preventing no gallstones disease. Simultaneous uncomplicated symptomatic gallstones or cholecystitis: a systematic review bacteriologic assessment of bile from gallbladder and common bile duct in and economic evaluation. Counts cholecystectomy versus observation/conservative management for of bacteria and pyocites of choledochal bile in controls and in patients with Ansaloni et al. World Journal of Emergency Surgery (2016) 11:25 Page 21 of 23 gallstones or common bile duct stones with or without acute cholangitis. Bacteriology and delayed laparoscopic cholecystectomy for acute gallbladder disease. Microbiology and antibiotic susceptibility laparoscopic cholecystectomy for acute cholecystitis: A prospective of organisms in bile cultures from patients with and without cholangitis at randomized study. Cholecystectomy for the elderly: no Acute cholecystitis: early versus delayed cholecystectomy, a multicenter hesitation for otherwise healthy patients. Laparoscopic approach to acute abdomen from the Consensus cholecystitis in elderly patients with comorbidities. J Trauma Acute Care Development Conference of the Societa Italiana di Chirurgia Endoscopica e Surg. Laparoscopic cholecystectomy: consensus conference-based diabetes on outcomes in patients undergoing emergent cholecystectomy guidelines. A of delaying same-admission cholecystectomy on outcomes in patients with meta-analysis of results. The safety of a laparoscopic cholecystectomy in Randomized clinical trial of open versus laparoscopic cholecystectomy for acute cholecystitis in high-risk patients older than sixty with stratification acute cholecystitis. Ausania F, Guzman Suarez S, Alvarez Garcia H, Senra del Rio P, Casal Nunez response after open versus laparoscopic cholecystectomy in acute cholecystitis: a E. Gallbladder perforation: morbidity, mortality and preoperative risk prospective randomized study. Surg Laparosc Endosc Percutan acute cholecystits in the laparoscopic era: results of a prospective, Tech. Laparoscopic cholecystectomy Randomized trial of early versus delayed laparoscopic cholecystectomy for versus open cholecystectomy in elderly patients with acute cholecystitis: acute cholecystitis. Diagnosis and treatment of Mirizzi syndrome: 23versus laparoscopic cholecystectomy in acute cholecystitis. Clinical cholecystectomy for patients with liver cirrhosis and symptomatic characteristics of acute cholecystitis with elevated liver enzymes not cholecystolithiasis. Ultrasound versus liver function tests for diagnosis of morbidity after cholecystectomy in patients with cirrhosis. Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholangiography. Prospective analysis of fundus-first laparoscopic cholecystectomy: lessons learned. Conversions during laparoscopic cholecystectomy: risk stones in patients with cholelithiasis. Laparoscopic cholecystectomy for acute cholecystitis: how do fever cholecystectomy. Laparoscopic A systematic review and economic evaluation of magnetic resonance cholecystectomy for the various types of gallbladder inflammation: a Cholangiopancreatography compared with diagnostic endoscopic retrograde prospective trial. Endoscopic ultrasound versus magnetic resonance Prevalence of common bile duct stones according to the increasing cholangiopancreatography for common bile duct stones. Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, et al. Laparoscopic ultrasonography versus intra-operative cholangiogram for the detection of common bile duct stones during laparoscopic cholecystectomy: a metaanalysis of diagnostic accuracy. Preoperative versus intraoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones: system review and meta-analysis. Systematic review of cholecystostomy as a treatment option in acute cholecystitis. Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial. Management of acute calculous cholecystitis in high-risk patients: Submit your next manuscript to BioMed Central percutaneous cholecystotomy followed by early laparoscopic and we will help you at every step: cholecystectomy. More advanced liver damage leads to a feeling of fullness or pain in the upper right abdomen, itching, jaundice (yellowing of the skin and whites of the eyes), easy bruising, fatigue, and fluid retention. No specific treatment is necessary as it does not cause any symptoms, but weight loss along with control of blood cholesterol levels will usually rid the liver of the extra fat and should be encouraged in any patient that has fat deposits. Autoimmune hepatitis can lead to liver scarring (cirrhosis) and permanent liver damage if not treated. If gallstones try to leave the gallbladder and block the ducts, pain, nausea, and vomiting occurs. Scarring of the bile ducts and eventually the liver is caused by the inflammation. The Foundation does not provide medical or other health care opinions or services. Unless the duct is obstructed or occluded, bile can be seen to discharge from it intermittently. Keywords Anatomical variations; bile ducts; blood supply; gallbladder the gallbladder (Figures 1 and 3) the biliary ducts (Figure 1) the normal gallbladder has a capacity of about 50 ml of bile. As it passes behind the pancreas, the common bile duct either the gallbladder is divided for descriptive purposes into grooves the posterior aspect of the pancreatic head or actually a fundus, body and neck, the latter opening into the cystic duct burrows through it. Under pathological conditions, a pouch is frequently duct joins that of the main pancreatic duct (the duct of Wirsung), present on the ventral aspect of the organ, just proximal to the to form a common vestibule, the ampulla of Vater, whose neck, in which lies a solitary, or impacted collection, of calculi. Structure However, examination of a normal retrograde pancreaticothe gallbladder and the sphincter of Oddi contain involuntary cholangiogram will show, in the great majority of cases, that muscle, but there are only scattered muscle fibres in the the junction results in a simple tube without any obvious sac-like remaining parts of the biliary tract. The cystic artery may arise from the left, or from the main hepatic artery, or even from the gastroduodenal artery, Cystic artery Left hepatic artery and may pass in front of, instead of behind, the bile ducts. In addition, the gallbladder receives numerous arterial twigs from the right hepatic artery via the gallbladder bed in the liver. These are readily seen at laparoscopy and are of great clinical Figure 6 the hepatic artery and its branches. They drain into the radicles of the right supply means that ischaemia of the gallbladder is unlikely to portal vein in the liver bed. Stone analysis revealed a composition of 20% weddellite (calcium oxalate dehydrate) and 80% apatite (calcium phosphate). Histologic examination of the gallbladder revealed no signifcant pathologic changes.

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