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Some are predominantly dose 33 related and others are a combination of dose and length of use herbals in chennai purchase genuine v-gel. During the phase of chronic herbals hills generic v-gel 30gm, high-dose consumption of amphetamines herbals used for pain order generic v-gel canada, many 35 amphetamine users may have the experience of paranoia and hallucination zip herbals discount 30gm v-gel mastercard. This conclusion has been supported by at least two experiments, which found that most amphetamine users became psychotic within a week after a continuous administration 36, 37 of amphetamines. The main characteristics of this psychosis are delusion of persecution, delusion of 38 reference, auditory hallucination, and visual hallucination. With further consumption, the individual becomes increasingly exhausted, loses insight into his or her actions, and 39 may become violent and increasingly psychotic. Although amphetamine psychosis may last longer than cocaine psychosis, it usually abate rapidly (within days) with the 40 cessation of amphetamine intake and the excretion of amphetamines. However, about 41 5-15% of the users who develop an amphetamine psychosis fail to recover completely. However, the results of a recent study found that mental health problems, including hallucinations 42 and paranoia, significantly correlated with 4 factors. Those are: i) increasing severity of dependence on amphetamines, ii) a larger number of mental health symptoms experienced before starting to use amphetamines, iii) a larger average quantity of amphetamine used in a day of use, and iv) a greater number of days on which benzodiazepines had been used in the previous 6 months. This prevalence is as high as those of opiate withdrawal (91%) and cocaine withdrawal (86%). The findings of a factor analysis of amphetamine withdrawal symptoms suggest that this clinical 45 condition may be comprised of three factors. The hyperarousal factor comprises drug craving, agitation, and vivid or unpleasant dreams. The reversed vegetative factor comprises decreased energy, increased appetite, and craving for sleep. The anxiety factor comprises loss of interest or pleasure, anxiety and slowing of movement. Depressive mood is a prevalent symptom and should be considered as a symptom incorporated in more than one factor or more. Although the symptoms occurring during amphetamine withdrawal may be over in four or five days, some of the symptoms may 41, 46 continue for weeks or months. Use during pregnancy and perinatal period lRelated with more pregnancy complications lAnaesthesia related complications lSmall for gestational age children lInfants are also psychosocially disadvantaged and are at greater risk for abuse and 47, 48 neglect 3. Consequences of amphetamine use in the context of polydrug use lMethamphetamine toxicity is increased when taken in combination with alcohol, cocaine or opiates. Methamphetamine can also disguise the effects of alcohol, which may increase the risk of alcohol poisoning and accidents due to a false sense of feeling sober and in control. In addition, the use of ascorbic acid can accelerate the renal elimination of 53 amphetamines. The severity of withdrawal is dependent upon the dose and frequency of use, type of stimulant used, mode of administration, other drug use, current health problems and the duration of use. During and after withdrawal, users must be regularly monitored for their physical and mental state as withdrawal can lead to severe depression. However, no medication has been demonstrated to be effective in alleviating amphetamine withdrawal, but some medications may be useful with some symptoms. Mirtazapine is used at Drug and Alcohol Services South Australia and has resulted in some improvement in symptoms. Care should be taken to limit access to large quantities of medications and to avoid development of benzodiazepine dependence. Modafinil is also used at Drug and Alcohol Services South Australia and has been demonstrated to result in some improvement in symptoms, but this is not an approved medication for amphetamine 54 withdrawal treatment. Antagonist therapy approaches use medications that block the action of the agonist to attenuate or eliminate the positive reinforcing effects of acute methamphetamine intoxication. Antagonists compete with endogenous monoamines but have no intrinsic activity at the receptor site. In contrast, agonist therapies are medications that bind to and trigger responses from receptors involved in the addiction process, often mimicking the action of monoamines involved in the reinforcement, withdrawal symptoms and motivational aspects of methamphetamine or amphetamine 55 use. The results of an open-label trial of naltrexone for amphetamine dependence 56 were encouraging. A Swedish randomized trial included 80 treatment-seeking © Indian Psychiatric Society 2016 105 Newer and Emerging Addictions in India 57 amphetamine-dependent adults who were grouped to placebo or 50 mg of naltrexone. In an intention-to-treat analysis, naltrexone outperformed placebo in terms of both mean numbers of negative urine samples and continuous abstinence rates. However, the limitation of study was that the retention and adherence was suboptimal. It is important to note the exclusion criteria: the trial required a two-week period of abstinence prior to randomisation, which might have excluded severely dependent 55 patients. Tiihonen et al, (2012) assessed the naltrexone implant in a 10-week trial in randomized manner for individuals with comorbid opioid and amphetamine dependence. The results were encouraging for naltrexone in term of retention and proportion of drug-free 58 urine samples. A randomised trial of quetiapine and risperidone in 80 adults hospitalised with bipolar disorder and co-occurring cocaine or methamphetamine dependence reported that both equally reduced bipolar symptoms and drug cravings, with reductions in cravings associating with reductions in stimulant use. However, in experimental condition, neither haloperidol nor risperidone attenuated the euphorigenic effects of methamphetamine in healthy volunteers, dampening rationale 61, 62 for further evaluation of dopamine antagonists. There is a strong and growing case for rigorous evaluation of substitution therapies combined with tailored psychosocial interventions to achieve improved outcomes for amphetamine users. A randomized study included 41 long-term dependent amphetamine user seeking treatment. Half of treatment seekers were given amphetamine and another half were kept on counseling only. There was reduction in use of street amphetamine, 64 however treatment subjects appeared attended counseling session regularly. Dexamphetamine increases extracellular levels of dopamine through a carrier mediated exchange at presynaptic vesicles. A 12 weeks randomized trial assigned methamphetamine-dependent participants to receive up to 110 mg/day sustained release dexamphetamine (N = 23) or placebo (N = 26) for 12 weeks. Those in the dexamphetamine condition completed an average of 86 days compared with the placebo condition (49 days) but no effect on methamphetamine use was observed. Although some decrease in craving for methamphetamine was observed with dexamphetamine treatment, no improvement in drug use or retention were observed in 66 a subsequent trial. In this 20-week, randomised, double-blind, placebo-controlled trial of aripiprazole, methylphenidate or placebo among participants dependent upon injection use of amphetamine, participants assigned to the 54 mg/day slow-release methylphenidate condition (N = 17) had significantly fewer amphetamine-positive urine samples than placebo-treated patients (N = 19; odds ratio=3. Anderson et al, (2012) completed a trial of 210 methamphetamine dependent individuals randomised to placebo, or 200 mg, or 400 mg of modafinil. There was no evidence of benefit for either medication condition in terms of percentage of participants with a week of abstinence or retention. The authors caution, however, that due to poor medication compliance, the trial does not represent a definitive test of the 68 efficacy of modafinil. Bupropion is a nonselective inhibitor of the dopamine and norepinephrine transporters and also acts as an antagonist at nicotinic acetylcholine receptors. Bupropion increases dopamine transmission in both the nucleus accumbens and the prefrontal cortex through inhibition of the dopamine transporter. Various randomized placebo-controlled double-blind trials with sample 69-71 sizes between 30-150 in different type of population are available. On primary outcomes of retention and Methamphetamine-free urine samples, Methamphetamine use and cravings, bupropion sustained release did not outperform placebo. Two hundred and twenty-nine participants were assigned to sertraline only, sertraline and contingency management, placebo and contingency management, or placebo only. Contingency management significantly improved methamphetamine use outcomes, while participants assigned to the sertraline-only condition resulted in poorer retention 5 and lower likelihood of sustained abstinence than the other treatment conditions. The evidence-base for the treatment of amphetamine use disorders is rather limited. The small number of treatment studies may reflect the fact that this issuehas been received less attention than the treatment for other substances. The evidence shows that fluoxetine, amlodipine, imipramine and desipramine have been tried but demonstrate very limited benefits foramphetamine dependence and abuse. Imipramine mayincrease duration of adherence to treatment in medium-term treatment.

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Kozinets (2002) investigates how the anti-commer cial Burning Man Festival reproduces notions of market and exchange that it sought to herbals benefits buy v-gel mastercard escape in the rst place herbals best best v-gel 30gm. Mook (1983) persuasively argues the need to bajaj herbals fze 30gm v-gel visa distinguish between population and the oretical generalizability (see also Stewart herbals shoppe discount v-gel 30gm with mastercard, 1998). Mook advocates using extraordinary contexts to examine how constructs operate at extremes or as venues where complex inter actions between constructs surface. He views extraordinary contexts as opportunities for uncovering the boundaries of how, when, where and under what conditions our theories apply. For example, research in more mundane contexts has shown the unfolding and dynamic character of satisfaction, and the power of ‘extras’ even in brief, everyday service settings (Fournier and Mick, 1999; Price, Arnould and Deibler, 1995), both theoretical insights established in the extreme context of river rafting. How to make context work for you In applied marketing research, a focus on context has fueled something of a revolution in practice, including the propagation of qualitative research as a valued research tool. Research context choices foreground or background particular theoretical arguments (Alford, 1998). Some researchers highlight the features of a specic context to argue that it can make some constructs, construct relationships or processes salient to observation. An individualistic focus may background the role of social collectivities in shaping the consumption of Harley Davidson motorcycles (Holt, 1997), world systems theory may silence the gendered voices in descriptive participant observation (Thompson, Stern and Arnould, 1998), or a focus on rituals may background the role of myth in patterning commercialized celebration (Stern, 1995). One role of foregrounding context in studies employing qualitative data has been to highlight bias in previous studies in terms of both the populations and the processes studied. Research foregrounding samples of homeless, illiterate, middle-class minority, Making contexts matter 111 women, European migrant and non Euro-American consumers has examined the bound aries of our knowledge by sampling understudied consumer groups. Research has also foregrounded neglected consumption processes through context selection such as gift giving, disposition, presumption, play, ritual and so on. In this section of the chapter we will focus selectively on research addressing sociocultural, experiential, symbolic and ideological aspects of consumption published in the Journal of Consumer Research to uncover how to make contexts work. For example, the theoretical insights garnered by Kozinets (2002) from his exploration of the Burning Man Festival depend on a spatial and temporal environment that contrasts with everyday consumer life, Foreground variations across spatial or temporal circumstances What is different that we can What is different that we understand about some can understand about consumer phenomena by some consumer examining the interaction of phenomena by studying understudied consumers and consumers in this context Coulter, Price and Feick (2003) Kozinets (2002) Crockett and Wallendorf (2004) Tian and Belk (2005) Foreground Background variations in What is different that we can What is different that we can variations in consumers understand about some understand about some consumers consumer phenomena by consumer phenomena by examining how understudied applying a different consumers respond Allen (2002) Fournier (1998) Adkins and Ozanne (2005) Coupland (2005) Background variations across spatial or temporal circumstances Figure 9. His research asks: what is dierent that we can under stand about some consumer phenomena by studying consumers in this context Specically, what boundary conditions of consumer resistance and marketplace emanci pation may we nd at the Burning Man Festival In another case, Tian and Belk (2005) study how work self and home self contend for dominance in the domain of the work place. Researching valued possessions and the extended self in a novel spatial–temporal context. By contrast, Allen’s contributions (2002) do not depend on particular spatial or tem poral circumstances. He could have studied choice contexts other than students’ choices of higher education institutions. Instead, his research asks: what is dierent that we can understand about some consumer phenomena by examining how understudied con sumers respond Here sampling consumers across levels of cultural capital helped to gen erate his theoretical contribution. In another paper, Adkins and Ozanne (2005) study low-literate consumers in order to understand the impact of literacy on buying behav ior. Their implications derive from understanding how stigma linked to a consumer characteristic that varies among consumers is negotiated and mediated in market trans actions. In a third study, Bernthal, Crockett and Rose (2005) reveal how individual dierences in cultural capital resources pattern lifestyle regulation through credit cards and consumer debt. Theoretical insights contributed by Crockett and Wallendorf (2004) depend on the interaction between consumer dierences and spatial circumstances. They focused on African Americans in neighborhoods that varied in their racial composition to investigate the interplay between African-American families’ everyday provisioning and political ide ology. Their research asks: what is dierent that can we understand about some consumer phenomena by examining how an understudied consumer and spatial sampling interact Specically, how do African-American consumers employ normative political ideologies to make marketplace choices when their marketplace access is inhibited Similarly, Coulter, Price and Feick (2003) examine a novel context (a transitional economy that represented something of a tabula rasa as far as brands are concerned) to explore varia tion in the way consumers’ brand loyalty and commitment develop out of new political ideologies. Finally, theoretical insights may come from the way a phenomenon is studied rather than from variations in consumers or settings. For example, Fournier’s (1998) now classic article investigating consumers’ relationships with brands was not particularly dependent on the context (other than North American) or the variation in consumers, but rather her insights were gleaned from the theoretical and metaphorical template of relationships that she brought to her study of consumers and brands. Her research asks: what is dierent that we can understand about some consumer phenomena by applying a dierent metaphorical and theoretical template More recently, Coupland (2005) examines house hold practices that surround brands that we do not think much about but are just there – invisible brands. As with Fournier (1998), her theoretical insights derive from examining common customer activities with a new template that reveals hidden theoretical over sights. Although the gure provides a starting point for thinking about what theoretical argu ments to foreground in our selection of a sample and context, a more nuanced read of the Making contexts matter 113 way aspects of a context enable a theoretical payo is required. In the next section, we select interpretive research examples corresponding to four dierent areas of theoretical contribution to consumer culture theory in order to uncover some of the particulars of the interplay between theory and context. The table follows Arnould and Thompson’s (2005) framing and is organized around four categories of theoretical contributions associated with inter pretive research in the Journal of Consumer Research, including consumer identity pro jects, marketplace cultures, sociohistoric patterning of consumption and mass-mediated marketplace ideologies and consumers’ interpretive strategies. It is important to keep in mind that, although we have elaborated a particular point of contribution for the research represented, often this is not the only or even the most important contribution made by this piece of research. Much research that makes an equivalent or greater contribution to our understanding of con sumer culture is not represented because of space constraints. One thing that stands out in the table is that the value of contexts lies sometimes in its isolation of a group, process, variable or relationship that is critical for theoretical development. Moreover, across the four domains of theoretical contribution, a parti cular foregrounding strategy is often dominant, although multiple foregrounding strategies are present in each domain. In addition, many studies illustrate the theoreti cal value of selecting contexts that allow researchers to observe extreme values in domains of interest. These extreme values uncover and test our taken-for-granted assumptions about consumer beliefs and activities and help us identify the range over which particular patterns of behavior apply (Davis, 1971; Mook, 1983). Finally, examination of the table reveals that interpretive researchers often employ variants of quasi-experimental designs in order to uncover processes and dierences among con sumer responses. Implicit in the table is that many perspectives are not yet represented (Fiske, 2004). For example, Adkins and Ozanne (2005), listed rst in the table, make theoretical contribu tions to our understanding of consumer identity projects by studying illiterate consumers in a society where illiteracy is stigmatized. Further fruitful contributions might be made by exploring marketplace choices and behaviors of illiterate consumers in environments where illiteracy is not stigmatized, such as some third world contexts, or by exploring how consumers with other stigmas such as disabilities manage or negotiate those stigmas through marketplace choices (Baker and Kaufman-Scarborough, 2001; Kaufman Scarborough, 2000). Alternatively, rather than isolating a group of consumers who are illiterate we might look for purchase contexts, such as gray markets or second-hand stores that may stigmatize consumers (Bardhi and Arnould, 2005) and examine how con sumers negotiate and respond to that stigma. Hence, for each of the theoretical perspec tives represented in the table, other fruitful theoretical perspectives are not represented, but could be. Next we detail how isolating groups, processes and variables, going to extremes and drawing on some of the principles of experimental design in researcher choice of context, can facilitate theoretical payos. Notice that such studies have made theoretical contributions in each of the four domains outlined in Arnould and Thompson (2005). For instance, studies of the homeless test the boundaries of theories of self-possession relationships contributing to our understanding of consumer identity projects (Hill and Stamey, 1990). Belk’s (1988) theory suggests that homeless and other dispossessed groups are likely to seek self-restoration through objects, a pursuit that focuses on a more limited range of options than those of middle-class consumers. Numerous interpretive studies isolate a group to enhance our understanding of mar ketplace cultures. Kates (2004) argues this subculture provides a good case of an internally heterogeneous subculture given its ‘rich oral and written histories that support a wide variety of dynamic contents, forms, and meanings’ (p.

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A nickname herbs menopause cheap 30gm v-gel with visa, or nicknames khadi herbals buy v-gel online now, which could be given by other people or invented by the person himself or herself herbals for hot flashes buy generic v-gel from india. The practice of using nicknames can partly be explained by the name avoidance custom: the real name of the person was regarded as taboo herbals shoppes purchase v-gel 30gm free shipping, oshidhila (Aarni 1982, p. Of course, giving individual bynames is also a universal phenomenon which can be found in all personal nam ing systems and which serves various social functions. In Ndonga, the closest term for the English nickname is edhina lyoponto or oshilukadhina (Tirronen 1986, p. Nicknames are sometimes be stowed by friends, sometimes by enemies, and sometimes by admirers in appreciation of a feat performed, in derision, or even in anger. The type of name given to an individual depends largely on the circumstance, and the recipient usually has no power to stop people calling him by it. Thus nick names are one of those names one cannot easily change, legally or other wise. It is reasonable to assume that they were given according to the same principles as the nicknames of the local people. Edes (1889–1975), native commissioner in Owambo (uule ‘height’) Nakambalekanene Martti Rautanen (1845–1926) Nandago personal name; August Pettinen (1857–1914) (ondago ‘bulbous plant with small edible bulbs’) Nashimwele Nestori Waananen (1882–1941) (oshimwele ‘bad dagger’) Shongola major C. Hahn (1886–1948) (shongola ‘catch fish with a trap; limp, walk lame, hobble’) the fourth name in this list, which is the Ambo name of Martti Rautanen, the Finnish pioneer missionary among the Ambo people, is an illustra tive example as such. As the Ambo people had never seen such a hat before, they gave Rautanen the name Nakambale (< okambale ‘little palm bas ket’). Later Rautanen was also called Nakambale Kanene (or Nakambalekanene) ‘big Nakambale’, whereas his son Reinhold Rautanen was known as Nakambalegona ‘little Nakambale’. Most probably, all these alternative names used in Ambo cer emonies were temporary. A special characteristic of southern African anthroponymy – and oral poetry – is the use of so-called praise names. It is sometimes difficult to make a distinction between an ordinary nickname and a praise name, as they often look similar. Many sources also talk about nick names, when they should, more specifically, talk about praise names. Nevertheless, a praise name is a kind of a nickname which shows re spect and admiration and which typically has a praise poem attached to it – or the whole poem, be it short or long, may be understood as the name. A praise name is often created by the person himself, but it may be given by other people as well. The act of praising focuses on identifying a person, embodying his or her personal ity through the process of naming and also in essence providing a link with his or her community, lineage and origins. Also the naming is a process of objectifying, so that once a name has been given, or self-given, it is in a way outside the power of the individual to remove it or contest it. It is a part of their identity, one which may be used even after their death when their praises are called out on ceremonial or public occasions. A single praise name is formed by nominalising either a single word, a phrase, a sentence, or a suc cession of sentences, so that the whole becomes a name. The verb tanga means ‘praise, extol, glorify’, the verb itanga ‘recite one’s presentation poem (speaking well of oneself, boast)’, and the noun eitango is trans lated as ‘self-presentation poem (telling boastingly of oneself)’. As an example, Rautanen mentions the praise names of King Kambonde237, which among other things praised his beautiful body and his running speed. In a leaflet of the Rhenish Mission (Erstlinge von den Arbeitsgebieten der rheinischen Mission 1899, p. The text in quotation marks, also in the original German text, most probably forms a praise poem, or a part of one, which was attached to this name. It has been pointed out that praises of kings and chiefs are the most developed form of praise poetry in Africa (Koopman 1987b, p. He states that the real name of the king was never mentioned in the praise poem, only his praise name:238 Onime (‘lion’): Mandume gaNdemufayo (King of Oukwanyama 1911–1917)239 Ondilimani (‘dynamite’): Iipumbu yaShilongo (King of Uukwambi 1908–32) Okangwe (‘small leopard’): Nehale lyaMpingana (King of Eastern Ondonga 1885–1908) Olukaku halu tandula emusati (‘a shoe that breaks mopani trees’): Tshaanika Natshilongo (King of Uukwaluudhi 1887–1930)240 Mbenzi (op. King Mandume received the name with the meaning ‘lion’, because he was regarded to be as strong as a lion; he was also fearless when fighting against the Portuguese and South African armies. King Iipumbu was seen as dynamite, because he was willing to annihilate alien forces, and King Nehale was given the praise name meaning ‘leopard’ for he was as cruel as a leopard and ruled eastern Ondonga as a tyrant. Beside kings’ praises, traditional Ambo praise poetry included ritual praises, such as deity praises, praises of initiates, subclan praises, and non-ritual praises, such as self praises, animal praises (praises of domestic and wild animals), praises of ethnic groups, praises of war riors, praises of localities and praises of natural phenomena (Mbenzi, Manuscript on Oshiwambo praise poetry, p. Nevertheless, it is mainly the kings’ praises and self praises that are of interest here, as these two deal with the names of people. They also tell that praise names were given by the parents to their children, who then lengthened them later in life. However, we shall say more about Ambo praise names when analysing the contemporary naming system of the Ambo people. Collective Bynames: Patronyms and “Clan Names”; Other Forms of Address As Ambo children were often named after other people, there were usu ally a number of people in the community, even within individual fami lies living in the same homestead, who carried the same names. The tradition of giving children one real name only meant that people 127 Developments in the Ambo Anthroponymic System could not be distinguished from each other with additional real names either. Another means, and an important one, was the use of collective bynames, especially patronyms. Contrary to individual bynames, col lective bynames do not refer to the individual only, but to the groups to which he or she belongs, such as family or clan. It seems that patronyms were used systematically by the Ambo people in the late 19th and early 20th centuries (Savola 1924, p. The name of the father was added as a kind of a surname243 to the real name of the individual: if the father (in Oukwanyama) was Hamuyela and his child Houfiku, the child’s full name was Houfiku yaHamuyela, i. The name of the father was attached to the child’s name with a possessive concord, its form depending on the class of the noun that the child’s name was based on. It is difficult to say how old the custom of using patronyms really is among the Ambo people. In books dealing with the history of Ambo subgroups, patronyms are used for Ambo kings in as far as they are known by people living today, i. Their usefulness in retaining family history and the history of the community is evident, hence patronyms are fre quently used in the Ambo praise poetry and other oral literature as well. However, judging from the written sources and oral tradition, one can not say much about the use of patronyms in everyday speech during all these centuries. Especially if the father in question was dead, it was feared that ancestral spirits might attack the ones who carelessly mentioned his name. In any case, it is reasonable to suggest that as the Ambo communities grew larger, patronyms became increasingly impor tant as a means of differentiating people from each other in the community. In a way, it is interesting that the father’s name was used as a person’s additional byname, even if the traditional Ambo culture was matrilineal. As was already noted, clan and lineage affiliation ran through the mother in the Ambo communities, and inheritance and succession followed the matrilineal line as well. Hence, it may not be an overstatement to claim that the patronym, to gether with the bestowal of the real name, was one of the strongest ties between a father and his child in the Ambo culture. Hence, instead of referring to the lineage or the clan of the child, the patronym referred to the family consisting of the father and his wife, or wives, and their children, who all lived in the same homestead and formed an important social and economic unit in the Ambo community. In many African societies, addressing people by their clan names has been more common than the use of patronyms. She will go on living there, supported by him and looked after by a niece or granddaughter the rest of her life. It is curious to note that after establishing herself thus independently the old woman changes her name, or rather the name of her father’s clan comes to be used instead of her former name. Thus people are heard to speak of Mukwanangombe (“The Woman of the Ox Clan”), Mukwanime (“The Woman of the Lion Clan”), etc. Even if the old names were dropped from the daily usage, on some level the “real” name of the woman had to be retained as her only proper name. This would at least be in line with the general idea of personal names in the Ambo culture: the real name of the person, i. It is also interesting to note that women were addressed by their fathers’ clan names, not by their own ones.

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Catheter insertion per urethra, is done in all of the following conditions, except Among the following, the tests that would be useful to diagnose a case of cataract include Among the following, the drugs that are of use in a case of Ectopic pregnancy include Diabetes mellitus in pregnancy, is associated with following abnormalities in the foetus Laparoscopic assisted vaginal hysterectomy---trans abdominal hysterectomy in chronic cases. Chlamydia trachomatis Ans: D, E most common cause is gonorrhoea [ref: robbins]. A non-alcoholic, diabetic patient with increased serum ferritin levels and hyperpigmentation, may be suffering from A patient presented with headache, and his blood pressure was found to be 190/120. A patient was brought to the emergency with dehydration, Blood pressure was 90/70 mm of Hg, and blood examination revealed a pH of 7. Differential diagnosis of arthritis affecting the right knee joint in a young patient include Xrays of Abdomen is useful Ans: [c], [e] all features of ankylosing spondylitis Q103. The age at which an infant can follow horizontally for 180 degress and has almost full head control but cannot sit without support is Cyclophosphamide and levamisole are used in the management----------2nd line if steroids fail Ans: A, D, E Q125. Among the following, the ones that are selective serotonin reuptake inhibitors are Mirtazapine----Enhances release of both Noradrenaline & Serotonin by blocking alpha2 receptors. The drugs that are preferred in a patient who develops cyclosporine induced hypertension are Oxygen saturation in capillaries Ans: A, B Swan ganz catheter the pressure in the left atrium of the heart may be estimated by measuring the pulmonary wedge pressure. Since this blocks the local flow, the pressure in the capillary bed of the lungs can be measured. The pressure across the capillary bed of the lungs is small and so this approximates to the left atrial pressure. Such catheters can be positioned without fluoroscopic (Xray) assistance and can be used for medium-term monitoring in the intensive care unit as well as in the cardiac catheter laboratory. A 70 yr old patient presenting with abdominal pain, in a state of shock, was found to have abdominal aneurysm. Short bowel syndrome is a problem if intestinal resection is undertaken ans [c], [e] Q163.

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Patients with other primary or acquired immunocompromising conditions were excluded from study participation herbs for anxiety order v-gel 30 gm online. Patients were included in the control group if they did not receive treatment with immunosuppressive agents except for low-dose prednisolone (<10mg/day) herbalshopcompanycom purchase v-gel 30 gm overnight delivery, topical corticosteroids or topical 5-aminosalicylates herbs and uses purchase v-gel 30gm free shipping. Serotype-specific pneumococcal IgG concentrations were measured using an in house 23-plex multiplex immunoassay (Luminex technology) herbs lower blood pressure generic 30gm v-gel with amex, as described previously (11, 12). Specific antibody concentrations were calculated using a standard calibrated with reference serum 007sp (14, 15). Definitions Defining seroconversion in response to pneumococcal vaccination is complex, because consensus on the correlates of protection is lacking. However, this cut-off is not serotype-specific, and a recent study showed that this concentration may be an underestimation of the real protective concentration for several serotypes (19), even more so in adults. For each individual serotype, we calculated the fold increases in antibody concentrations post-vaccination, and the proportion of patients with post-immunization antibody concentrations 1. The chi square test was used for dichotomous variables and the student’s T-test or Mann Whitney U test for normally or non-normally distributed continuous variables respectively. The Wilcoxon Signed Rank test was used to compare median pre and post-vaccination antibody concentrations. Simple and multivariable logistic regression were used to analyze associations with the primary outcome. This difference was also significant for serotypes common to both vaccines (50% (52/104) vs. Table 3 and Figure 2A+B show median pre and post-vaccination antibody concentrations per serotype for all groups. Median post-vaccination antibody concentrations were higher than pre-vaccination antibody concentrations for all measured serotypes in both treatment and control groups (p<0. Median pre-vaccination antibody concentrations were similar in the treatment and control groups; except for serotypes 1, 14, 19A, 19F and 8, which were significantly higher in the treatment group (Table 3; Figure 2A+B). Serotype 2 was the most immunogenic, with high median concentrations and 95-97% of patients reaching concentrations above 1. Fold 97 changes ranged from 3 (serotype 12F) to 35 (serotype 4) in the control group and from 1. Patients using immunosuppressive drugs were less likely to seroconvert after vaccination compared to controls. Efficacy, safety and tolerability None of the vaccinated patients developed pneumococcal disease during the follow up period. Swelling, erythema and pain in the vaccination arm were reported most frequently (n=9). Two patients reported intestinal complaints following vaccination which were assessed as most likely not vaccination-related. However, the definition of seroconversion used in that study (IgG concentration >0. A recent study showed that this cut-off value leads to overestimation of the actual protection against some serotypes (19). Antibody concentrations of all vaccine serotypes significantly increased following vaccination. Furthermore, a specific characteristic of serotype 3 is capsular polysaccharide release to which the antibodies attach in case of an infection. This is problematic, since serotype 3 has been identified as one of the emerging serotypes after the introduction of conjugate vaccines (28). Another explanation could be that the immunological advantage of priming with a T-cell dependent vaccine might be limited in the scope of immunosuppressive treatment regimens that impair T cell immunity. This is consistent with previous pneumococcal and hepatitis A vaccination studies in patients using immunosuppressive medication (32-34), and can be explained by the fact that different steps in the immune response are simultaneously inhibited (35). However, this difference was not statistically significant when adjusting for disease type. The major strength of this study is that we evaluated serotype-specific antibody responses of 23 different serotypes separately. Most studies only use 2 serotypes as a surrogate for the assessment of immunogenicity (4, 5). Therefore, our study provides a more comprehensive picture of the immune response to pneumococcal vaccines. Importantly, the present study evaluated the short-term immune response to pneumococcal vaccination only. The lower post-vaccination peak antibody concentrations for several serotypes in patients using immunosuppressive medication indicate a shorter duration of serologic protection. This has been described previously, and has implications for the timing of a booster vaccination (7). To the best of our knowledge, there are no published pneumococcal vaccine efficacy studies in patients using immunosuppressive medication. This highlights the need for clinical studies establishing standardized correlates of protection against pneumococcal disease in adults. Therefore, we recommend pneumococcal vaccination before starting immunosuppressive therapy. However, vaccination is still beneficial in the majority of patients using immunosuppressive medication. Further studies are needed to assess the response to pneumococcal vaccination at additional time points, to explore the possibility of hypo-responsiveness, to investigate alternative vaccination strategies and to provide more information on the duration of protection after vaccination. Acknowledgements We thank the study participants and laboratory analyst Ben de Jong, who measured all the serotype-specific pneumococcal IgG concentrations. Incidence of invasive pneumococcal disease in immunocompromised patients: A systematic review and meta-analysis. Initial and subsequent response to pneumococcal polysaccharide and protein conjugate vaccines administered sequentially to adults who have recovered from pneumococcal pneumonia. A Systematic Review and Metaanalysis of Antirheumatic Drugs and Vaccine Immunogenicity in Rheumatoid Arthritis. The effect of immunosuppressive agents on immunogenicity of pneumococcal vaccination: A systematic review and meta-analysis. Initial Serological Response after Prime-boost Pneumococcal Vaccination in Rheumatoid Arthritis Patients: Results of a Randomized Controlled Trial. Immunogenicity and persistence of a prime-boost re-vaccination strategy for pneumococcal vaccines in patients with rheumatoid arthritis. Pneumococcal and influenza vaccination rates in patients treated with corticosteroids and/or immunosuppressive therapies for systemic autoimmune diseases: A cross-sectional study. Obstacles and motivations to influenza and pneumococcal vaccination in patients with rheumatoid arthritis. Comment on: << Pneumococcal and influenza vaccination rates in patients treated with corticosteroids and/or immunosuppressive therapies for systemic auto-immune diseases: A cross-sectional study" by Assala et al. Pneumococcal conjugate vaccination response in patients 106 after community-acquired pneumonia, differences in patients with S. Response to pneumococcal vaccination in mannose-binding lectin-deficient adults with recurrent respiratory tract infections. Assignment of Weight-Based Antibody Units for Seven Additional Serotypes to a Human Pneumococcal Standard Reference Serum, 007sp. Assignment of weight-based antibody units for four additional serotypes to a human anti-pneumococcal standard reference serum 007sp. Serological criteria for evaluation and licensure of new pneumococcal conjugate vaccine formulations for use in infants. Use and interpretation of diagnostic vaccination in primary immunodeficiency: a working group report of the Basic and Clinical Immunology Interest Section of the American Academy of Allergy, Asthma & Immunology. Ann Allerg Asthma Im: official publication of the American College of Allergy, Asthma, & Immunology. Cordonnier C, Ljungman P, Juergens C, Maertens J, Selleslag D, Sundaraiyer V, et al. Immunogenicity, safety, and tolerability of 13-valent pneumococcal conjugate vaccine followed by 23-valent pneumococcal polysaccharide vaccine in recipients of allogeneic hematopoietic stem cell transplant aged >/=2 years: 107 an open-label study. Commentary on paradoxical observations pertaining to the impact of the 13-valent pneumococcal conjugate vaccine on serotype 3 Streptococcus pneumoniae infections in children.

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