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At the federal level blood vessels ks3 generic procardia 30mg, the so- psychiatric treatment and care coronary heart jumping buy discount procardia 30mg, increasing the capacity of called States General on Road Traffic Safety in 2015 spelled specialized centers as well as facilitating access for intern- out 20 recommendations cardiovascular institute of scottsdale purchase procardia with a mastercard, which were an inspiration for ees to 14 blood vessels of the heart generic procardia 30mg amex conventional and regular care in view of optimizing many actions taken since then, such as efforts to simplify re-integration into society (3. Other measures aim to offenders, to increase objective and subjective probability improve access to care for a series of particularly vulner- of detection through the use of a reliable and continuously able groups (such as detainees, low income households, updated database, and to improve the quality of alcohol homeless people, newly-arrived immigrants, sex workers, and drugs screenings. At the Flemish level18, policy rec- drug users, people with mental disorders) which tend to ommendations are centered around the 4E’s: Education & have only weak links with standard medical care, guided Awareness, Engineering, Enforcement, Evaluation. These by the operational recommendations which were formu- recommendations have been taken on board when a road lated by the National Institute for Health and Disability safety plan (2015)19 and a cycling policy plan (2016)20 Insurance24. Focusing specifically on high quality child were developed, with a focus on awareness-raising, infor- care and well-being, the Office for Birth and Childhood25 mation and sensitization on safe traffic behavior. A specific of the French-speaking Community provides prenatal program21 confronts 17 year olds with the testimonies and childhood consultations, mobile clinics, vaccination by road traffic victims on their lives before and after the programs, free medical consultations and home visits, thus accident. The W alloon Government promotes safe road supporting both children and their parents, medically as behavior through awareness-raising campaigns for the well as socially (3. A new an action plan on youth assistance, and creating ‘Houses Flemish air quality plan is being prepared, based on the of the Child’. Flanders Care acts as a catalyzer for system evaluation of the previous one (2012-2015). W allonia innovation in the organization of care services, putting the has set up its own environment and health policy cell that patient central stage and adapting the services offered to has been working out several plans that should improve society’s needs. This also answers to the (youth, elderly) the W alloons’ environment and hence their health and population’s changing needs in terms of care. More generally speaking, adapt this approach to other vector-borne diseases than within the 14% of funds allocated by the Belgian devel- malaria (such as dengue fever). Belgian health experts par- opment cooperation to the health sector, 22% are consti- ticipate in countries’ external evaluations in the framework tuted by the provision of medicines, which is an especially of the 2005 International Health Regulation, and our own interesting figure given that Belgium also has one of the Belgian system and procedures in that regard will be crit- most stringent legislations on the quality of vaccines and ically assessed in the course of 2017. W e host- federal and subnational authorities alike: it twins with ed a highly successful international conference for the southern counterparts in order to introduce evidence- Global Fundraising Initiative She Decides in March 2017 30 Plan vagues de chaleur et pics d’ozone (2008). In Rwanda, Belgium has been the principal donor transfusion, and capacity building for rural health centers to fight mental health problems including substance abuse both in terms of surgery competences (including caesarian nationwide for nearly a decade and we helped establishing section skills) as well as in upgrading ambulance services. In countries such as Senegal, there has been a significant uptake in the 2012-2015 period in the intervention areas Belgian development actors consider mutual health of Belgian projects, in terms of coverage (new ailments insurance schemes as a key component of achieving treated, +49%) and of professionally assisted deliveries universal health coverage (3. A sol- sets, as well as to the need to foster intercultural under- id baseline exists, with high standing, tolerance and mutual respect in a society that quality education, commit- is becoming increasingly multicultural and multiethnic. Education gaps varying along from age 6 to 18, there is an almost universal participation to socio-economic status and migration backgrounds need free pre-primary education. This vision finds its concrete applica- to address the low proportion of students and graduates in tion in, inter alia, a major reform of the educational system areas of science and technology. This pact, the result lifelong learning and the inclusion of specific vulnerable groups of a highly participative process, is organized around five given the high educational inequality related to socio-economic strategic axes and aims to ensure accessibility, to provide and migration status and wide gaps in performance between pupils with the skills and knowledge needed to address those enrolled in general secondary school programs compared current-day challenges, to reinforce the vocational training to vocational secondary tracks. The Federation of Enterprises tion5), and the governments of the French-speaking in Belgium equally wants to build a bridge between Community, the Brussels Capital Region and W allonia youngsters (17-27 years old) and the corporate world, have concluded a cooperation agreement with a similar attempting to involve them in reflections about the func- objective (4. Topics such as sustainable life styles, human rights, towards the most vulnerable target groups. The Flemish program for nature and environment tailored outreach with local communities and involvement education12also aligns itself to the 2030 Agenda, while the of parents (4. Starting from each one’s respective competences, W al- lonia and the French-speaking Community in Belgium join In April 2016 we organized the Council of Europe’s forces in order to link education and training with access 25th Standing Conference of Ministers of Education, and return to the labor market10. Actions involve alternat- which discussed the role of education and training in ing education, strengthening the link between the jobs of the fight against radicalization and violent extremism. They include youth parliaments14, associations of scholarships for higher education programs ranging of ‘young change makers’15, training programs16 and plat- from undergraduate, master degree, PhD to research forms connecting government, civil society and youth17 in level as well as short term trainings for professionals and the endeavor to build a sustainable, solidary and partici- study visits for thesis directors and scholars. Roughly one with multi-year un-earmarked federal funding in support third of the successful applicants are women. This reflects the importance Belgium attaches may be somewhat challenging, given that the total num- to the global efforts to deliver high quality education to bers of scholarships handed out has remained fairly stable all girls and boys18, while prioritizing the poorest, most over the past few years20. The Royal Museum for Central vulnerable and those living in fragile and conflict-affected Africa also trains some one hundred African scientists a countries (4. Various bilater- en and men to affordable and quality technical, vocational al cooperation initiatives aim at skills development and and tertiary education. In addition, reference can be technology is used to improve educational standards and made to support provided by the W alloon government to management through enhanced communication between the activities undertaken in this area by the Organisation schools and the authorities. Through innovative to initiatives implemented through Belgian associations19 approaches and attention for digital solutions it aims to in countries like Vietnam or Morocco. At the same time, integration of the gender perspective in awareness-rai- more work remains to be done, and traditional gender roles, sing campaigns concerning the prevention of psychoso- for example, continue with women spending 8. These include migrants; and in the federal plan to fght poverty and its the gender career gap or the dynamics proper to multiple dis- template used for progress reporting. Gender mainstreaming – the integration of a gender perspec- the Flemish government has included a specifc gender tive into each policy area and each phase of the policy-making dimension in its government-wide equal opportunities process – remains another cross-cutting priority. Moreover, it helps the educa- lopment of a risk assessment tool concerning partner tion sector to implement a statement of commitment on violence. All French-spea- unions and advisory boards to parents’, pupils’ and stu- king subnational governments jointly adopted a plan8 dents’ associations. Another initiative was taken by a nu- containing 176 measures focusing on six thematic areas: mber of organizations on awareness-raising against5 partner violence and violence against children, forced gender segregation in toys, involving consultations with marriages, female genital mutilation, honor- based the sector in order to take corrective action. In 2016, the violence, sexual violence and gender-based violence French-speaking Community launched a campaign and a (5. The paramount importance Belgium attaches to gender equality and the empowerment of all women and girls Wallonia established its frst gender mainstreaming is also refected in our multilateral, bilateral as well as plan in 2014, and developed various measures to fght indirect development cooperation. Legal provisions6 strategy and action plan for the Belgian Development were adopted to fght gender-based and similar. Our bilateral cooperation programs membership in government institutions, publicly listed contain important sectoral programs dedicated to the companies or state-owned enterprises (5. The recently concluded Belgian- Another crucial element is combating gender-based Moroccan bilateral cooperation program (2016-2020) violence. A mobile app, Eye and protection of the human rights of women is an W itness, allows to gather evidence and safely store it in overall priority of the Belgian foreign policy. The international conference for the Global Fundraising the elimination of female genital mutilation (5. During co-organized with the governments of the Netherlands, the last decade, signifcant legislative and political pro- Sweden and Denmark further underscored this gress was made in this regard in several partner coun- long-standing engagement. In Morocco, for example, cusing on royalty-free licensing and the facilitation of support for women’s cooperatives producing argan oil clinical trials in southern African countries. Support for has enhanced entrepreneurial and marketing skills local women’s rights fora, for example in Mozambique, is (4. Mozam- humanitarian initiatives (strengthening prevention of bique) or in the artisanal. The equivalents at the re- Water is not a scarce resource in Belgium, generally speaking. However, due to the inten- sity of habitat, industry and agriculture, most water systems Each river basin district in W allonia is managed via a are heavily used and face multiple pressures including a risk management plan, the second version of which covers of future water shortages. The latter aims to protect, im- bodies achieve a good or better ecological status, while 45% prove and restore surface water bodies, groundwater of groundwater bodies achieved good chemical status and bodies and protected areas. In addition, a public water 81% of groundwater bodies are in good quantitative status. This allows distribution companies to ensure a supply of drinking water of sufficient quality and quantity for all the main pressure on the Belgian surface waters occurs (6. The Brussels-Capital Region aims through diffuse pollution, flow regulation and morphological at integrated water management4, taking into account alterations. Agricultural pressures on water remain high with the specific challenges connected to its implementation eutrophication and pesticides affecting most surface waters in a highly urbanized environment. Belgium Flemish region implements its objectives towards inte- reaches very high compliance rates of 99-100 % for the set grated water management through a series of decrees5. By joining efforts in areas water demand and water availability, Belgium’s interna- that enjoy special protection, both in terms of drinking wa- tional work in support of sustainable management of water ter supply and conservation of nature, win-win situations and sanitation emphasizes both demand-side (policies for in the different policy areas are created (6. Generally speaking, the the local implementation of river contracts in W allonia provision of climate financing by the regional and federal – 16 to date – contributes to participatory river basin level is considered by all actors involved as a necessary management.

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Case 4 (number 19 in the report) presented with a febrile tonic-clonic seizure lasting 10 minutes while febrile and right side hemiparesis with hyperrefexia 9 days after administration of a measles blood vessels under greatest pressure order procardia now, mumps capillaries 1 cell thick order procardia 30 mg on line, and rubella vaccine arteries elasticity and contractility order procardia cheap. Case 5 (number 21 in the report) presented with a febrile seizure blood vessels problems order procardia once a day, exanthem, meningismus, and right side hemiparesis 10 days after receiving a measles, mumps, and rubella vaccine. Physical examination showed hyperemic pharynx, rhinitis, conjunctivitis, and a maculopapular exanthem over the entire body. Weight of Mechanistic Evidence Fever is a prodromal symptom beginning after the 10- to 14-day incu- bation phase for wild-type measles virus and the 16- to 18-day incubation period for wild-type mumps virus (Gershon, 2010a; Litman and Baum, 2010). In addition, acute measles encephalitis is associated with fever and seizures (Gershon, 2010a). The publications presented a symptomology of fever with seizure developing within the incubation phases for measles and mumps viruses. In addition, some of the cases presented with exanthems and other neurologic symptoms consistent with measles infection. The failure to demonstrate vaccine-strain virus in the cases described above detracted from the weight of evidence. The latency between vaccination and the development of the sympto- mology described above ranged from hours to 28 days after administration of a vaccine containing measles, mumps, and rubella alone or in combina- tion; however, most of the cases discussed above presented between 7 and 14 days after vaccination. This retrospective cohort study did not observe an adequate number of children with afebrile seizures to estimate a relative risk; the authors only report that one child had afebrile seizures 1 and 3 days after vaccination. The risk period began the day after im- munization and continued for 30 days; the control period began 3 months before immunization and continued for 30 days, ending 2 months before immunization. A total of 18,036 children aged 10 to 12 years and 8,514 children aged 4 to 6 years were included in the analysis. Clinic, emergency department, and hospital visits for seizures were obtained from the medi- cal records, and chart validation was performed to confrm the event. The 10- to 12-year-olds reported more seizure diag- noses during the risk period (three cases) compared to the control period (no cases). The three seizures were described as one grand mal seizure, one syncopal seizure, and one partial complex seizure. Of the 716 validated diagnoses of frst seizure, 137 were afebrile seizures; seizures among children with diagnoses of epilepsy or residual seizure disorder were also classifed as afebrile sei- zures. See Table 4-3 for a summary of the studies that contributed to the weight of epidemiologic evidence. Mechanistic Evidence the committee identifed 10 publications reporting afebrile seizures de- veloping after the administration of measles, mumps, and rubella alone or in combination. One publication identifed the development of sta- tus epilepticus in one patient after administration of a measles vaccine, but details including the time frame between vaccination and the development of symptoms were not provided (Scholtes et al. Eight publications did not provide evidence beyond temporality, some too short based on the Copyright National Academy of Sciences. Adverse Effects of Vaccines: Evidence and Causality 135 Copyright National Academy of Sciences. Adverse Effects of Vaccines: Evidence and Causality 136 Copyright National Academy of Sciences. The medical record of each case was reviewed to validate the meningitis diagnosis and ensure the absence of a prior underlying disease; the controls also had no evidence of underlying illness. Cases of aseptic meningitis identifed in the nationwide hospital discharge register that occurred within 3 months of vaccination were validated with information from the patients’ medical records, and the exact dates of vaccination were verifed. The risk period was defned as 3 months after vaccination; the control period was defned as subsequent 3-month postvaccination intervals until 24 months was reached. The analysis did not fnd an increase of aseptic meningitis hospitalizations within 3 months of vaccination (p =. The cases were identifed using insurance claims data and included if they were hospitalized at the time of their diagnosis. A parental telephone survey was used to collect information on prior vaccinations; only patients that pro- vided the vaccination date and place of vaccination from a vaccine record were included. Since neither Urabe nor Hoshino strain were used in the United States, the committee only looked at the results of the subset of patients Copyright National Academy of Sciences. The risk period was defned as 42 days before disease onset and the control period extended to 1 year before onset excluding the risk period (cases were self-matched). Although power was limited in all the studies, they were generally well done and results were consistent, supporting the committee’s conclusion that the evidence overall reached a moderate level of confdence for a null association. See Table 4-4 for a summary of the studies that contributed to the weight of epidemiologic evidence. Mechanistic Evidence the committee identifed eight publications reporting meningitis after the administration of vaccines containing measles, mumps, and rubella alone or in combination. Two publications described multiple cases, some of which did not provide evi- dence beyond temporality or attributed the symptoms to another etiology (Ehrengut and Zastrow, 1989; Fescharek et al. Four publications did not provide evidence of causality beyond a temporal relationship between vaccination and the development of symptoms (Jorch et al. In addition, two publications attributed the development of meningitis postvaccination to concomitant Copyright National Academy of Sciences. Adverse Effects of Vaccines: Evidence and Causality 140 Copyright National Academy of Sciences. Adverse Effects of Vaccines: Evidence and Causality 141 Copyright National Academy of Sciences. Described below are three publications describing clinical, diagnostic, or experimental evidence that contributed to the weight of mechanistic evidence. Ehrengut and Zastrow (1989) reported fve cases of meningitis after vaccination against either mumps or measles and mumps. Case 3 described a 6-year-old boy presenting with vomiting, dizziness, and fever 21 days after receiving a mumps vaccine containing the Jeryl Lynn mumps strain. Cell culture ex- amination showed that the isolated virus produced fewer syncytia, smaller inclusion bodies, and induced less cell damage to monkey kidney cells than wild-type mumps virus, suggesting vaccine-strain virus. Case 8 describes a 6-year-old boy presenting with diarrhea and vomiting 1 day after, and headache, fever, abdominal pain, and meningism 9 days after receiving a measles and mumps vaccine. Case 12 describes an 8-year-old boy (whose friend’s sister was suffering from mumps) presenting with fatigue, and malaise 9 days after, and vomiting and fever 12 days after receiving a mumps vaccine. Weight of Mechanistic Evidence Meningitis develops in 1–10 percent of persons infected with wild-type mumps virus (Litman and Baum, 2010). Furthermore, mumps meningitis can present before, during, or after parotitis (Litman and Baum, 2010). The three publications described above did not present evidence suff- cient for the committee to conclude the vaccine may be a contributing cause of meningitis after administration of a vaccine containing measles, mumps, and rubella alone or in combination. The committee assesses the mechanistic evidence regarding an as- sociation between mumps vaccine and meningitis as weak based on knowledge about the natural infection and four cases. The committee assesses the mechanistic evidence regarding an as- sociation between measles or rubella vaccine and meningitis as lacking. Mechanistic Evidence the committee identifed eight publications reporting ataxia after the administration of vaccines containing measles, mumps, and rubella alone or in combination. Seven publications did not provide evidence beyond tem- porality (Ehrengut and Zastrow, 1989; Fescharek et al. Landrigan and Witte (1973) retrospectively analyzed cases of neu- rological disorders developing within 1 month after administration of a measles vaccine from 1963 to 1971 reported to the Immunization Branch of the Center for Disease Control. Laboratory analysis including infectivity titer, plaquing, and tissue culture sensitivity suggest the isolated virus to be vaccine-like. Weight of Mechanistic Evidence While rare, infection with wild-type mumps is associated with cerebel- lar ataxia (Litman and Baum, 2010). In addition, invasion of the central nervous system by wild-type measles virus is common (Gershon, 2010a). The committee considers the effects of natural infection one type of mecha- nistic evidence. The publication described above did not present evidence suffcient for the committee to conclude the vaccine may be a contributing cause of ataxia. However, the publication did not defnitively report the isolation of vaccine strain measles virus. The latency between vaccination and the development of ataxia in the publication described above was 7 days, suggesting direct viral infection as the mechanism. The committee assesses the mechanistic evidence regarding an as- sociation between measles or mumps vaccine and ataxia as weak based on knowledge about the natural infection and one case. The committee assesses the mechanistic evidence regarding an as- sociation between rubella vaccine and ataxia as lacking. The children were identifed from computerized special needs or disability registers.

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Drought and floods are also detrimental disasters coronary heart artery trusted 30mg procardia, however their share of total loss is relatively smaller compared to cardiovascular system models order discount procardia other geographical regions capillaries and xylem purchase procardia online now. The extreme vulnerability to coronary heart magazine order procardia 30mg on line rainfall variability in the arid and semi-arid areas of the continent and the poor capacity of many soils to retain moisture result in an often devastating impact on the sector. Between 2005 and 2015 droughts were frequent and severe in many African countries (map below): there were 84 reported drought occurrences in 30 countries, which led on average to a loss of 3–4 percent from potential agricultural production, a number that can rise to 10 or even 20 percent in certain cases. Despite the importance of this loss, a persistent limited availability of data and information is hampering proper understanding of the economic consequences of drought in the agricultural sector. This makes agriculture a high-risk endeavour and can stifle investment, pushing the country into a cycle of underproduction, low income and persistent poverty. Therefore, the case for investing in resilience and drought risk reduction, including in data and information generation, is very strong. Turn to Chapter 3 for a more detailed account of recent droughts in Ethiopia and their cost to the local and national crop and livestock sector. The analysis covers 332 disasters occurring in 87 developing countries across Africa, Latin America and the Caribbean, Asia and the Pacific Islands. Furthermore, the analysis considers the crop and livestock sector as a whole, looking at every reported commodity produced in each country (an average of 114 commodities per country). Hazardous events considered are those that have affected 100 000 people or more, or at least 10 percent of the national population. Agricultural production is subject to signifcant year-to-year variability for many different reasons that are unrelated to the occurrence of disasters. By and large, annual production of each commodity can vary due to market trends and expected demand, normal climate variability, disease outbreaks or other immediate reasons at regional, national or local level. The use of “expected” production, as a starting point to measure the impact of disasters on production implies that none of these non-disaster related factors would have significantly affected production in the absence of a disaster. Both are assumed as impacts of the disaster on production, implying that positive deviations from trends in a disaster year are considered as increases in production, occurring as a consequence of the disaster. Finally, the procedure employed assumes that the impact of the disaster on production is entirely exhausted in the same year in which the disaster occurs, and disregards cumulative impacts that may occur over more than one year. While this assumption is consistent with the emphasis on loss as opposed to damage (see Introduction, Key terms), it can still be problematic for certain products, such as perennial crops. Despite such possible limitations, this approach represents a good and viable option to run large- scale comparative assessments in the absence of more accurate data. All main types of natural disasters are considered, including geophysical (earthquakes, tsunamis, mass movements), climatological (droughts, wildfires), meteorological (storms, extreme temperatures) and hydrological (floods). A second threshold is used when in any given country disasters occur in two or more consecutive years. In this case, the average number of people affected in each of these disaster occurrences is calculated and only those disasters whose effect exceeds the resulting average are considered. Following the establishment of relevant thresholds, the analysis proceeds with estimates of long-term production trends – linear, polynomial second order, polynomial third order, logarithmic – for the production (yields) of every commodity in every country for the period 1980–2015. A goodness-of-fit test is applied to determine and select the model that predicts actual production most adequately for each commodity. Deviations from trends in the years in which a disaster occurred, for each country and commodity, are assumed to constitute estimates of production loss. This chapter presents, applies and calibrates the foundations of that methodology through analysis of two contrasting disasters: the rapid-onset Typhoon Haiyan in the Philippines (2013) and the slow-onset drought in Ethiopia (2008-2011). Even during the preparation of this report, the count of events kept growing as hurricanes Irma and Maria devastated the Caribbean, a deadly 7. Chapter 2 shows the cumulative impact of disasters on agricultural production, resulting in significant loss to the crop and livestock sectors. While the analysis exposes the great challenges posed by the general incidence of disasters, the particular consequences of individual events for the sector and its subsectors There is limited availability remain poorly analysed and largely under-reported. There is limited availability of of agriculture-specifc agriculture-specific, systematic estimates of damage and loss following disasters, systematic estimates of particularly those of smaller- and medium-scale. Furthermore, each subsector is divided into two main components: production and assets. This allows for an estimation of the extent and value of damage and loss for all components in each subsector and for the formulation of a globally standardized assessment of the impact. The production component measures disaster impact on agricultural inputs and outputs. On the other hand, production loss refers to declines in the value of agricultural production resulting from the disaster. The assets component measures disaster impact on facilities, machinery, tools, and key infrastructure related to agricultural production. The monetary value of the monetary value of (fully or partially) damaged assets is calculated using the damaged assets is calculated replacement or repair/rehabilitation cost, and is accounted for under damage. Therefore, it is important to demonstrate that it constitutes a reliable, holistic and universal tool across all agricultural sectors (crops, livestock, forestry, fisheries and aquaculture) for a varied range of disasters, and one that accommodates the various levels of data availability. Before FaO’s methodology can be more widely applied as the single framework for damage and loss assessment in agriculture, it must be put to the test. This chapter takes a first step toward that end, employing the new methodology to quantify the impact of two very different disasters in two very different contexts: the sudden- impact event of Typhoon Haiyan in the Philippines, and the slow-onset disaster of drought in Ethiopia. Its winds reached more than 300 km per hour, the strongest wind speed ever recorded in the country during a cyclone landfall (Takagi & Esteban, 2016). At least 6 300 people died in the cyclone and its immediate aftermath, which affected an estimated 16 million people, and damaged or destroyed more than 1. Although Typhoon Haiyan struck after the harvest, sparing the country even greater devastation, it nevertheless caused extensive damage to the agriculture sector, especially in areas heavily dependent on crop production and fishing. Over one million fishermen and farmers were estimated to be in need of urgent assistance to restore their livelihoods and productive assets. Gaps in primary data were addressed through estimation procedures using secondary information. Main components of the agriculture sector in the philippines a Corn a White potato a Sugar cane a Cassava a Tobacco a Abaca a Palay (rice) Crops a Banana a Mango a Coconut a Papaya a Pineapple a Hog (pig) a Cattle a Goat Livestock a Poultry a Duck a Carabao (water buffalo) a Commercial fisheries Fisheries a Marine municipal fisheries a Inland municipal fisheries aquaculture a Aquaculture In order to conduct a damage and loss assessment, the components relevant to each subsector must be identified. Based on data available at national and subnational level, 22 components were selected and analysed to quantify the monetary value of damage and loss in crops (annual and perennial), livestock, fisheries (inland and marine fisheries), and aquaculture (Table 1). Given that the analysis is largely based on a set of assumptions and externally- derived parameters, assessment results may be biased for a variety of reasons: a lack of data requires the use of estimates; errors may occur due to externalities or a lack of sensitivity in measurements; the knowledge-based features of the methodology itself may influence outcomes depending on the information source. The margin of error in In order to represent at least part of this threefold variability in the outcome estimating the damage measurements and provide a margin of error for the results, a two-step error and loss caused by Typhoon analysis is employed which considers the variability in defining the exogenous Haiyan complements parameters. Based on various information sources, an average, approach and ensures the a minimum and a maximum value is defined for each parameter. Table 2 does so while noting the margin of error for each figure, towards which both the min-max and confidence intervals contribute. The high value of coconut plantations, combined with the long time required for new coconut trees to become fully productive again, caused extensive setbacks in agricultural value added. Furthermore, the country’s food security outlook was severely dented by the reduced rice production, since the majority of affected provinces are the largest rice producers in the country. The destruction of boats and other assets as a result of the strong winds and ocean surge had a significant impact on means of production, causing a decline in fish catch in many of the affected regions and provinces. Hog production accounted for the majority of impacts, followed by chicken, carabao, cattle and goats. The two assessments differ, however, with regard to monetary values between damage and loss; assigned to the damage and loss categories. Further testing is needed to confirm this is the case universally, and to see if the methodology goes beyond that by facilitating damage and loss assessment in those situations where data is less available. Only then can it be considered a reliable framework for a holistic assessment of damage and loss in agriculture. Drought in Ethiopia Radically different to the physical menace of strong winds and high wave surges, the slow-onset character of drought presents a particular challenge for any methodological approach. However, the impact of drought on agriculture is significant and its quantification crucial for effective Drr policy. The number of drought-affected areas has grown in recent years, frequently compromising agricultural production, eroding livelihoods and triggering malnutrition and famine. While direct damage to agricultural assets and infrastructure is low (compared to destructions caused by typhoons, floods or earthquakes), drought-related loss from crop failures and livestock mortality can be substantial. Drought can therefore be a prominent cause of food insecurity in developing countries. Yet systematic assessment of drought-related impact on agriculture is crucial to inform evidence-based and cost-effective prevention and response strategies. This is especially relevant in countries where agriculture is of prime economic importance and where vulnerability to various shocks, weather abnormalities and climate change is particularly high.

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Serial ultrasound examinations to cardiovascular or strength training 30mg procardia with mastercard determine the rate of 236 Guidelines for Perinatal Care Box 7-2 capillaries 2 order procardia 30 mg without a prescription. Risk Factors for Intrauterine Growth Restriction ^ • Maternal medical conditions — Hypertension — Renal disease — Restrictive lung disease — Diabetes (with microvascular disease) — Cyanotic heart disease — Antiphospholipid syndrome — Collagen-vascular disease — Hemoglobinopathies • Smoking and substance use and abuse • Severe malnutrition • Primary placental disease • Multiple gestation • Infections (viral cardiovascular system unit test buy cheap procardia 30mg, protozoal) • Genetic disorders • Exposure to cardiovascular consultants medical group order genuine procardia teratogens American College of Obstetricians and Gynecologists. If any test result is abnormal (eg, decreased amniotic fluid volume or abnormal Doppler assessments), more fre- quent testing, possibly daily, may be indicated. If pregnancy is remote from term or if delivery is not elected, the optimal mode of monitoring has not been established. The fetus should be delivered if the risk of fetal death exceeds that of neonatal death, although in many cases these risks are difficult to assess. Early delivery may yield an infant with all the serious sequelae of pre- maturity, whereas delaying delivery may yield a hypoxic, acidotic infant with Obstetric and Medical Complications 237 long-term neurologic sequelae. Gestational age and the findings of antenatal surveillance should be taken into account. The decision to deliver is based often on nonreassuring fetal assessment or a complete cessation of fetal growth assessed ultrasonographically over a 2–4-week interval. When extrauterine sur- vival is likely despite significantly abnormal antenatal testing, delivery should be seriously considered. Isoimmunization in Pregnancy ^116^248 When any fetal blood group factor inherited from the father is not possessed by the mother, antepartum or intrapartum fetal–maternal bleeding may stimu- late an immune reaction in the mother. The formation of maternal antibodies, or alloimmunization, may lead to various degrees of transplacental passage of these antibodies into the fetal circulation. Depending on the degree of anti- genicity and the amount and type of antibodies involved, this transplacental passage may lead to hemolytic disease in the fetus and neonate. Undiagnosed and untreated, alloimmunization can lead to significant perinatal morbidity and mortality. Historically, most of the cases of Rh alloimmunization that caused transfusion reactions or serious hemolytic disease in the fetus and newborn were the result of incompatibility with respect to the D antigen. For this reason, the designation Rh positive usually indicates the presence of the D antigen and Rh negative indicates the absence of D antigen on erythrocytes. However, the use of antepartum anti-D immune globulin to prevent red cell alloimmunization has led to a relative increase in the number of cases of non–Rh-D alloimmuniza- tion, which causes fetal anemia and hemolytic disease in the newborn. Anti-D immune globulin prophylaxis is indicated only in Rh-negative women who are not previously sensitized to D. If the initial antibody titer is 1:8 or less, the patient may be monitored with maternal serum antibody titer assessment every 4 weeks. Note that for a woman with a history of a previously affected 238 Guidelines for Perinatal Care fetus or neonate, serial titer assessment is inadequate for surveillance of fetal anemia. Additional evaluation is required for patients with a critical titer (rang- ing from 1:8 to 1:32 at most institutions), which is associated with a significant risk of severe erythroblastosis fetalis and hydrops. Similar titer levels are used to guide care for alloimmunization involving antigens other than D except in Kell-sensitized patients because Kell antibodies do not correlate with fetal status; fetal surveillance may be required even in the absence of critical antibody titers. Antepartum Management the initial management of a pregnancy involving an alloimmunized patient is determination of the paternal erythrocyte antigen genotype status to assess the risk of hemolytic anemia in the fetus. If the father does not carry a gene for the antigen of interest and paternity is certain, then further assessment is unneces- sary. However, if the father’s genotype is heterozygous or unknown, the fetal antigen type should be assessed by amniocentesis. Measurement of the peak systolic velocity in the fetal middle cerebral artery via Doppler ultrasonography is used to assess the severity of erythroblastosis in utero. Moderate or severe anemia is predicted by values of peak systolic velocity in the fetal middle cerebral artery above 1. Doppler measurements also are used to predict severe fetal anemia in patients with Kell alloimmunization. Correct technique is a critical factor when determining peak systolic velocity in the fetal middle cerebral artery with Doppler ultrasonography. This procedure should be used only by those with adequate training and clinical experience. Intrapartum Management It is reasonable to proceed with delivery by induction of labor at 37–38 weeks of gestation if the history and antenatal studies indicate only mild fetal hemolysis. Induction may be considered earlier if fetal pulmonary maturity is documented by amniocentesis. With severely sensitized pregnancies requiring multiple inva- sive procedures, the risks of continued umbilical cord blood sampling and transfusions must be considered and compared with those neonatal risks asso- ciated with early delivery. Given that the overall neonatal survival rate after 32 weeks of gestation in most neonatal intensive care nurseries is greater than 95%, it is prudent to time procedures so that the last transfusion is performed at 30–32 weeks of gestation, with delivery at 32–34 weeks of gestation after maternal steroid administration to enhance fetal pulmonary maturity. Obstetric and Medical Complications 239 Multifetal Pregnancy the incidence of twin and high-order multiple gestations has increased signifi- cantly over the past 20 years primarily because of the availability and increased use of ovulation induction agents and assisted reproductive technology. There is increased fetal, neonatal, and maternal morbidity and mortality associated with multifetal gestations. The practicing obstetrician managing these high-risk patients should be familiar with their special antepartum and intrapartum prob- lems, and consultation with maternal–fetal medicine specialists may be necessary. Antepartum Management Antepartum management of multifetal pregnancies requires special consider- ations in the areas of nutrition, prenatal diagnosis, antepartum surveillance, ultrasonography, and in the diagnosis and treatment of commonly associated pregnancy complications. It is recommended that maternal dietary intake in a multiple gestation be increased by approximately 300 kcal more per day than that for a singleton pregnancy. The optimal weight gain for women with multiple gestations has not been determined. The usual indications for prenatal diagnosis and counsel- ing in a singleton pregnancy apply to twin and high-order multiple gesta- tions (see also “Antepartum Genetic Screening and Diagnosis” in Chapter 5). The presence of multiple fetuses increases the mathematical probability that one or more fetuses will be affected and, thus, results in a higher risk for the pregnancy than that attributed to maternal age alone. Amniocentesis or chorionic villous sampling may be technically difficult to accomplish in patients with multiple gestations, and only experienced physicians should perform these procedures in high-order multiple gestations. Technical problems unique to high-order multiple gestation include the need to traverse another fetus’ sac to reach a different fetus for sampling, incorrect 240 Guidelines for Perinatal Care fetal karyotype caused by cross contamination with other sacs, difficulty in accurately mapping the fetuses and determining which fetus is being sampled, difficulty in accurately determining whether any of the fetuses are monochori- onic twins, and difficulty in locating and reducing only the affected fetus in the event an aneuploidy is diagnosed and termination chosen. The nonstress test and the fetal biophysical profile have been shown to be effective in identifying the compromised twin or triplet gestation; however, the most effective fetal surveillance system for such pregnancies is not known. It is also not known at what gestational age testing should be initiated, whether testing should be performed once or twice per week, or whether there is a need to test normally growing dichorionic twins. Ultrasonography can be useful in both prenatal diagnosis and surveillance of multiple gestations. Early ultrasonography should be used for evaluation of chorionicity, given its importance regarding prognosis and risk of certain complications. Beginning at viability, serial estimations of fetal growth by ultrasonography (every 4–6 weeks after viability, or more closely spaced should indications arise) are a prudent measure because physical exami- nation is less reliable. Complications associated with multiple gestations include ges- tational diabetes, hypertension and preeclampsia, premature delivery, growth restriction, discordant growth, death of one fetus, and twin–twin transfu- sion syndrome. The risks associated with tocolytic agents are amplified in multiple gestations and thus they should be used judiciously. The effect of ante- natal steroid administration and the effects of steroid dose in multiple gestations have not been examined. Nonetheless, the National Institutes of Health recommends that all women in preterm labor likely to give birth between 24 weeks and 34 weeks of gestation who have no contra- Obstetric and Medical Complications 241 indications to steroid use be given one course of steroids, regardless of the number of fetuses. There currently is no evidence that prophylactic use of cerclage, hospitalization, bed rest, or home uterine monitoring improves outcome in these pregnancies. Current evidence does not sup- port the routine use of progesterone in women with multiple gestations (see also “Preterm Birth” later in this chapter). One obvious etiology is pla- cental pathology; multiple gestations are at increased risk of having at least one fetus with a suboptimal placental implantation site or abnormal umbilical cord morphology. The threshold at which discordant growth is most strongly associated with adverse outcomes is unclear, even in twin gestations. If both fetuses are of normal weight and are progressing appropriately on their own growth curve, then discordance may not indicate a pathologic process. Discordance can be caused by structural or genetic fetal anomalies, discor- dant infection, an unfavorable placental implantation or umbilical cord insertion site, placental damage (ie, partial abruption), or complications related to monochorionic placentation, such as twin–twin transfusion syndrome (discussed on the following page). The workup should include a review of all prenatal exposures, a specialized ultrasound examination and, depending on the gestational age, tests of fetal well-being.

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