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The values for the two process indicators related to children are much more similar across regions than are the values for the structural indicators diabetes prevention 400 order 2.5 mg micronase otc. The values for the first indicator diabetic diet 30 day menu buy discount micronase 2.5 mg online, the percentage of children with acute respiratory infection taken to health providers, range from a high of 70 percent in Europe and Central Asia; to East Asia and Pacific and the Middle East and North Africa, with values of 69 percent and 68 percent, respectively; to a low of 50 percent in Sub-Saharan Africa. The lowest value is fully 70 percent of the highest value, which is significantly better than the differential that exists for structural indicators. The same is true for the second process indicator related to children, the percentage of children under age five years receiving oral rehydration solution for diarrhea. The difference between the highest and 286 Reproductive, Maternal, Newborn, and Child Health Table 15. Structure (including human resources) Nurses and midwives (per 1,000 people) Physicians (per 1,000 people) Hospital beds (per 1,000 people) B. Indicators Related to Women the percentage of births attended by skilled health staff reaches 98 percent in Europe and Central Asia. The highest value is observed again in Europe and Central Asia, followed even more closely by Latin America and the Caribbean (94. Innovations to Expand Access and Improve Quality of Health Services 287 Immunizations the recent push to increase coverage in immunizations is reflected in the relatively high rates shown in table 15. The percentage of newborns protected against tetanus is slightly lower overall; the highest value is 86 percent in the Middle East and North Africa. Both Latin America and the Caribbean and Europe and Central Asia have values similar to those of the Middle East and North Africa, 15. Vitamin A Supplementation the percentage of children receiving vitamin A supplementation varies widely from 95 percent in Europe and Central Asia to 31 percent in Latin America and the Caribbean. Based on the literature review referred to above, and documented in the 2012 recommendations, the Guidance Panel made 119 recommendations for tasks that could be potentially shifted: 36 for lay health workers, 23 for auxiliary nurses, 17 for auxiliary nurse midwives, 13 for nurses, 13 for midwives, 8 for associate clinicians, 8 for advanced-level associate clinicians, and 1 for nonspecialist doctors. In addition, if higher cadres are compensated on a fee-forservice basis, shifting tasks may affect their income and hence encounter resistance. In addition, lower cadres will likely need higher levels of supervision and support, which should be included in any analysis of the financial implications of task-shifting. Task-Shifting Related to Other Approaches Several innovative approaches unrelated to personnel have been reported. A community-based approach in a rural area was tested at three health posts and one health center. Instead of tasking physicians with attributing cause of death, this approach trained priests, traditional birth attendants, and community-based reproductive health agents in reporting all births and deaths to the community health post (Prata, Gerdts, and Gessessew 2012). The authors recommend expanding its use for tropical and noncommunicable diseases (Groen and others 2011). Although for child health in particular, many essential interventions are in the home and community, we focus here on improving access to and quality of care in clinical settings-clinics, health centers, or hospitals. Expanding Coverage the Millennium Development Goals proposed ambitious maternal and child health targets: two-thirds reduction in under-five mortality and three-quarters reduction in maternal mortality between 1990 and 2015. Bhutta and others (2010) review the progress on provision of 26 key maternal and child health intervention in 68 countries that accounted for more than 90 percent of maternal and child health deaths globally in 2010. Coverage tended to be highest for interventions that can be delivered vertically through specialized programs or campaigns and can be scheduled in advance. In contrast, coverage of curative interventions, and those that were more complex or required treatment on demand, was lower. The coverage gaps for curative and complex interventions result from weak health systems in which health workers are few and often unmotivated; facilities are deteriorating; and supplies, equipment, and medicines are lacking. Perhaps most important, accountability for results is weak: only one in three of the countries reviewed had policies for maternal death notification, and fewer than one in two had robust vital registration systems (Bhutta and others 2010).

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The lines are also blurred between trafficking and human smuggling diabetes test center buy 5mg micronase amex,28 as well as between trafficking or human smuggling on the one hand blood glucose and yeast infections order micronase 5 mg with visa, and legitimate migration for employment on the other. For instance, some organizations use scare tactics to discourage all migration (Evans and Bhattarai 2000). Concerns for human smuggling mean that many undocumented migrants are screened for illegal migration alone, ignoring the fact that they may have been trafficked and may thus need different interventions. There is also a concern that the way awareness raising is conducted may intensify gender biases. Awareness raising materials tend to use fear to discourage women from leaving their homes, rather than providing the necessary information to enable women to make informed decisions (Evans and Bhattarai 2000). It also may dissuade women who are migrating for legitimate reasons like employment. Finally, repatriation and rehabilitation continue to be a challenge for all countries in the region, due in part to the lack of formal agreements or procedures between key source and destination countries, such as India and Nepal (Sijapati et al. The stigma attached to trafficking impedes reintegration as well, and it is unclear to what extent interventions maintain the confidentiality of trafficked victims to minimize such stigma and enable reintegration. In such cases, their parents take responsibility, which poses risks for those who may have been trafficked by family members (Aurat Foundation 2012). Re-trafficking is a major concern also when viable alternative livelihood opportunities do not exist (Pandey et al. Looking across Forms of Violence: Key Lessons and Challenges Our mapping and analysis of interventions reveals that there is a commendable amount of action across forms of violence in the region. As such, it is perhaps inevitable that success will be accompanied, at least early on, by a spike in violence. Yet, the central non-negotiable requirement for all interventions across forms of violence and across levels of the social ecology has to be to do no harm. We did not find evaluations or other program documentation that specifically discussed how to effectively address potential backlash. For instance, the Kishori Abhijan program found that parents who delayed marriage for their daughters ended up having to pay larger dowries. Thus, child marriage prevention programs working in areas where dowry is prevalent need to take this possibility into account when planning their interventions (Amin 2011). The astonishing array of programs, campaigns, advocacy, networking, and other forms of interventions we identified testifies to the commitment of actors at all levels of society to address violence against women and girls. Yet, the lack of competent evaluation means that a great deal of learning is lost and financial and human resources wasted. Competent evaluation does not have consist of randomized control experiments, though that does remain the most statistically rigorous way to attribute change to an intervention. For organizations that either do not wish to or cannot undertake such experiments, the evaluations we did find provide a multitude of methods that can be used more effectively than at present. A case in point is the evaluation of the Girl Power Project or the many evaluated child marriage prevention interventions. Evaluations are particularly weak and thus need particular attention in the case of efforts to address sexual and physical violence against girls (as against all children), sexual harassment, honor killings, trafficking, and custodial violence. Shelters, helplines, and crisis centers critically need evaluation since these approaches are used everywhere. Finally, evaluated interventions-such as those for vocational training, life skills, and other similar 4. Men and boys, however, need to be engaged at all levels and across all forms of violence for several reasons. First, such violence is primarily a result of underlying gender norms and structures, and "gender" includes women and men. This is all the more important when one recognizes that rigid norms related to gender and power differentials mean that many men feel pressure to prove their manhood by using violence against women or other men. Second, the nature of violence is an interactive exchange between a woman or girl who experiences the violence and the perpetrator. A focus solely on women and girls places the onus of responsibility of addressing violence on them, leaving the perpetrator out of the equation. While perpetrators are not always men, for the types of violence considered in this book they are mainly men and boys. We identified 14 evaluated interventions that engage men and boys in addressing intimate partner violence, gender-based violence more broadly, and gender equality and norms of masculinity (appendix K).

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Cyanide inhibits the activity of some enzymes by binding to their metallic moiety diabetic service dogs order micronase online pills. By blocking the action of cytochrome c oxidase diabetes medications in renal failure buy micronase 2.5mg otc, histotoxic hypoxia/anoxia develops rapidly in exposed organisms (Smith 1996). The ability of cyanide to bind to some metallic ions is utilized with antidotes that induce methemoglobinemia in exposed organisms. Cyanide binds to the ferric ion of methemoglobin to form inactive cyanmethemoglobin (see Section 3. The disadvantage of these antidotes is that the methemoglobinemia further aggravates the depletion of oxygen from tissues; therefore, antidote-induced methemoglobin levels need to be closely followed in clinical practice. Experimentally, the antagonistic effect of sodium nitrite is improved by co-administration with atropine, an effect attributed to the suppression of bradycardia (Vick and Von Bredow 1996; Yamamoto 1995). A complex of diethylamine/nitric oxide reduced the toxicity of cyanide in mice (Baskin et al. This compound was found to have a high affinity for cyanide due to its low molecular weight, and it allows administration in 3-fold molar excess of binding sites over a lethal dose of cyanide. Interactions of cyanide with carbonyl groups of these compounds lead to formation of inert cyanohydrin intermediates (Bhattacharya and Vijayaraghavan 2002; Hume et al. In rabbits injected (subcutaneous) with high doses of potassium cyanide, the beneficial effect of dihydroxyacetone and sodium thiosulfate diminished after 1 hour, which the authors attributed to metabolism of dihydroxyacetone with concomitant release of bound cyanide; additional treatment with dihydroxyacetone was needed to prevent the death of the animals. These studies did not address the problem of lactic acidosis that follows cyanide exposure. Pharmacological approaches to finding antidotes for cyanide are also under investigation. They reported that H-7 partially prevented cellular energy depletion and increased the number of surviving cells. Neurological damage following exposure to cyanide has been associated with an influx of calcium ions and the subsequent release of biogenic amines. Accordingly, calcium channel blockers have been tested for their efficacy in preventing typical cyanide-induced changes. Diltiazem pretreatment, but not cotreatment prevented a cyanide-induced decrease in dopamine (and increase in L-dopa) in the corpus striatum of rats (Mathangi and Namasivayam 2004b). The calcium channel blockers procaine (also an anesthetic) and verapamil antagonized the toxicity of potassium cyanide in mice (Jiang et al. Both compounds extended the time to death of a lethal dose of potassium cyanide and prevented the cyanideinduced rise in total brain calcium. Dietary supplementation with antioxidant vitamins A, C, and E partially antagonized cyanide-induced reductions in superoxide dismutase in the liver, kidney, and lung and catalase in the kidney and lung of rabbits (Okolie and Iroanya 2003). Cyanide-induced histopathology was ameliorated by vitamin treatment; vitamin supplementation eliminated hepatic congestion in the liver (but not necrosis or fatty degeneration), eliminated glomerular, but not tubular necrosis in the kidney, and eliminated alveolar congestion and pulmonary edema in cyanide-treated rabbits. Melatonin and 6-hydroxymelatonin protect against cyanide-induced neurotoxicity (seizures, neuronal cell death) by suppressing the formation of superoxide anion radicals and lipid peroxidation (Choi and Han 2002; Maharaj et al. L- and D-cysteine reduce the toxicity of cyanide to hepatocytes by increasing the pool of thiosulfate available for thiocyanate formation (Huang et al. Dexamethasone retarded hepatocyte toxicity by reducing the hydrolysis of membrane phospholipids induced by cyanide (Pastorino et al. They showed that the mechanism does not involve methemoglobin formation and suggested that nitric oxide might antagonize the respiratory depressant effects of cyanide. Other more efficient nitric oxide generators may be very useful cyanide antidotes. Fructose, but not glucose, protected primary cultures of rat hepatocytes against time-dependent toxicity of 2. The difference in efficacy between the two glycolytic substrates was attributed to fact that fructokinase has a low Km for the phosphorylation of fructose compared to the relatively high Km for hepatic glucokinase. Further research for a potent and safe antidote to mitigate cyanide toxicity is desirable, particularly among smoke inhalation victims who have carbon monoxide poisoning. In summary, the efficacy and safety of experimental treatments discussed in this section have not been compared systematically and therefore, do not replace the current therapeutic practice.

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No histopathological changes were observed in kidneys of rats and monkeys exposed to 25 ppm cyanogen (12 diabetes test liquid generic micronase 5 mg mastercard. T3 levels in high exposure workers were also elevated relative to unexposed workers (p<0 diabetes mellitus essay generic micronase 5 mg with visa. Data for T4 were not presented, but the investigators indicated that the absence of T4 abnormalities could be accounted for by the time lapse between exposure and examination (median 10. The endocrine effect may be due to formation of thiocyanate, a metabolite of cyanide. However, exposure to other chemicals such as cleaners and cutting oils also occurs during electroplating operations. Thyroid 131I uptake was significantly higher when compared with the control group. Since the workers were away from work on the 2 days preceding the test, the results may be explained on the basis of acute cyanide withdrawal, as with other anti-thyroid agents, where sudden cessation of the drug leads to rapid accumulation of iodine in the iodine-depleted gland (El Ghawabi et al. No studies were located regarding endocrine effects in animals after inhalation exposure to cyanide. Cyanide caused a rash in 42% of workers exposed to 15 ppm hydrogen cyanide (Blanc et al. Brick-red chemical burns on the skin were observed in a man who was occupationally exposed to 200 ppm hydrogen cyanide for an unspecified length of time (Singh et al. No studies were located regarding dermal effects in animals after inhalation exposure to cyanide. Cyanogen caused eye irritation in volunteers during acute exposure to 16 ppm (8 ppm cyanide) (McNerney and Schrenk 1960). Slight loss of peripheral vision was the only persistent finding from a case report of a man who had been exposed to 452 ppm hydrogen cyanide (for 13 minutes while cleaning a chemical tank (Bonsall 1984). During chronic occupational exposure, eye irritation occurred in workers of two electroplating factories (exposure levels not specified) (Chandra et al. In other studies, cyanide caused eye irritation in 58% of workers exposed to 15 ppm hydrogen cyanide (Blanc et al. The eye irritation may not be due solely to cyanide exposure, as electroplating workers may be exposed to a variety of chemicals that are irritating to the eyes. Information regarding ocular effects in animals after inhalation exposure is limited to a report of eye irritation in rats acutely exposed (7. In an occupational setting, loss of appetite was reported in 58% and weight loss (approximately 8%) in 50% of workers exposed to 15 ppm hydrogen cyanide (for an unspecified duration in a silver-reclaiming facility (Blanc et al. Acute exposure of humans to fatal levels of hydrogen cyanide causes a brief stage of central nervous system stimulation followed by depression, convulsions, coma with abolished deep reflexes and dilated pupils, paralysis, and in some cases, death (Bonsall 1984; Chen and Rose 1952; Peden et al. Though clinical symptoms of cyanide poisoning are well recognized, specific dose-response data are generally not known. Acute exposure to lower concentrations can cause lightheadedness, breathlessness, dizziness, numbness, and headaches (Lam and Lau 2000; Peden et al. Impaired short-term memory was reported as a delayed effect in a female 1 year after treatment for convulsions following acute exposure to cyanide gas (Lam and Lau 2000). Chronic exposure of humans to potassium cyanide and other chemicals may have produced severe neurological effects such as hemiparesis and hemianopia (Sandberg 1967). During chronic occupational exposure, workers exposed to 15 ppm hydrogen cyanide for an unspecified duration reported fatigue, dizziness, headaches, disturbed sleep, ringing in ears, paresthesias of extremities, and syncopes (Blanc et al. A dose-effect was demonstrated on high- and low-exposure jobs; however, exact cyanide concentrations in the air were not known. Neurological effects persisted in some workers even after a 10-month nonexposure period. Clinical symptoms included headaches, weakness, changes in taste and smell, dizziness, disturbances of accommodation, and psychosis. Loss of delayed and immediate memory and decreases in visual ability, psychomotor ability, and visual learning were reported in workers exposed to unspecified levels of hydrogen cyanide for an unspecified duration (Kumar et al.

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There is clear recognition of continuing and potential economic dilemmas blood sugar highs and lows order genuine micronase line, including the major problem of the potential exercise of market power by large players strategically located in the resource system diabetes type 2 without retinopathy micronase 2.5mg overnight delivery. There is also an awareness that one of the more critical risk factors in this market-driven environment is the creation of "bottlenecks" in the delivery of services to customers. The lack of such an appropriate signaling mechanism may result in the foreclosure of markets for certain services (e. Historically, this potential loss was traded off against the benefits of lower uncertainties associated with the simpler interconnection environment. Volume and destinationbased value accounting resulted not only from architectural constraints, but were also a "satisficing" response to residual uncertainty of who should pay whom. Other value proxies would have introduced higher uncertainties and bargaining costs. Uncertainties over how to allocate (shared or standalone) costs, especially across multiple Areas (when multi-homed) involving different contracts, may raise the risks of peering bargaining failures. In some cases, reputational constraints and the power of social norms may be effective; in others, vertical integration may become a necessary step. Before more interventionist regulatory approaches are applied, we believe any policy focus should be on improving transparency into the workings of the Internet ecosystem in general and interconnection markets, more specifically. This stimulates a search for new authority in the nation state, which is the incumbent institution with primary responsibility for tending to 127 the key realms of social order. Yet, every one of the internal challenges that strain the Internet resource system management mechanism would strain the state. Moreover, the state suffers other types of problems that hinder its ability to provide responses to the maturation challenges, without undermining the Internet resource system. Because information flows are so fluid and multinational, it is argued that the challenge to national authority is well beyond the typical international challenge. It is frequently noted that the "bad" acts and actors are beyond the borders of state authority, but it should be noted that the good acts and actors are too. Third, the model of an expert agency relied upon to implement broad goals has been undermined by the politicization of the regulatory process. The traditional approach to formal, notice and comment regulation was based on the belief that expert agencies could do a better job than political bodies like legislatures in designing regulation to deal with the day-to-day functioning of industries. In the Internet case we have the extreme situation in which governments 128 were also the last actors to be involved in the management of a system that had self-managed itself for years. One approach is to note that the maturation challenges can be lined up with the Internet hourglass introduced earlier, as shown in Figure V-1. While the correspondence is not one-toone, the argument can be made that the modalities of regulation that address each of the various challenges map reasonably well across the layers of the hourglass. Addressing higher-level problems with solutions at lower layers risks paying a heavier price in terms of harm to the resource system than is necessary. The reason as suggested earlier is that these two are essential outcomes of the resource system, the primary purposes and function that the system serves in society. As noted above and suggested by Figure V-2, the Internet was dependent on the dominant telecommunications resource system for its growth. Over time, while that underlying relationship remains, as the 130 Internet matures, it captures more and more of the function of the pre-existing resource system. Second, the governance structure of the incumbent telecommunications resource system is fundamentally different than the emergent system. Economic Development My discussion of the role of nondiscriminatory access takes an long view to underscore the enduring importance of the principle. As noted earlier, North deals with long sweeps of human history to locate the key factors and dates in the process of economic change. North identifies two economic revolutions: the first being the invention of agriculture 10 millennia ago, the second being the knowledge revolution, one millennium ago. The 2nd economic revolution, dating from the Renaissance, gathered speed in the wake of the 1st industrial revolution. The growth in population reflect the underlying improvement in the material conditions of the species.

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