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The management of a super morbidly overweight parturient delivering twins by caesarean part. Dose requirement of intrathecal bupivacaine for cesarean supply is similar in overweight and normal weight girls. The influence of body mass index on sensorimotor block and vasopressor requirement during spinal anesthesia for elective cesarean supply. The impression of body mass index on the risk of high spinal block in parturients present process cesarean delivery: a retrospective cohort examine. Analgesic efficacy and adverse results of epidural morphine in comparison with parenteral opioids after elective caesarean section: a systematic evaluation. A randomised comparison of regular oral oxycodone and intrathecal morphine for post-caesarean analgesia. A retrospective evaluation of the incidence of respiratory melancholy after neuraxial morphine administration for postcesarean delivery analgesia. Local anaesthetic wound infiltration for postcaesarean part analgesia: a systematic evaluate and meta-analysis. Quadratus lumborum block versus transversus abdominis airplane block for postoperative pain after cesarean supply: a randomized controlled trial. Patient-controlled epidural ropivacaine as a post-cesarean analgesia: a comparability with epidural morphine. Ideal versus corrected physique weight for dosage of sugammadex in morbidly obese sufferers. Insufficient sugammadex impact in an obese pregnant lady undergoing cesarean section under general anesthesia. Wash-in and wash-out curves of sevoflurane and isoflurane in morbidly overweight sufferers. Practice guidelines for the perioperative administration of patients with obstructive 139. Women have greater charges than men of many psychiatric problems, such as nervousness, feeding and consuming issues, and melancholy; the reproductive years coincide with the greatest period of risk. Further, pregnant girls with psychiatric problems could resist drug treatment due to their desire to keep away from fetal harm. Psychiatric issues throughout being pregnant could additionally be related to different elements of poor maternal health and deficient prenatal care, which may have an effect on anesthesia care. Pregnancy is extensively thought-about a time of elevated vulnerability to psychiatric disorders. However, studies counsel that the prevalence is analogous between pregnant and nonpregnant women. Identified risk elements for growing psychiatric problems throughout being pregnant include youthful age, single status, publicity to traumatic or tense life events, pregnancy issues, and poor overall health. Postpartum Depression Postpartum despair describes a major depressive episode that occurs within the first 4 to 6 weeks after birth. It is essential to differentiate postpartum depression from the "baby blues," which impacts as much as 70% of girls in the first 10 days after delivery and is transient with out functional impairment. It can be essential to differentiate postpartum despair from delirium that arises from bodily causes. Biologic effects corresponding to hormonal adjustments and psychological and social position changes that occur with childbirth may increase the chance for postpartum depression. Risk factors for melancholy throughout pregnancy include a historical past of despair or bipolar disorder, childhood mistreatment, being a single mom or having more than three kids, marital issues, undesirable being pregnant, smoking, low income, age younger than 20 years, poor social support, and domestic violence. Typical features embrace prominence of cognitive symptoms corresponding to disorganization, confusion, impaired sensorium, disorientation, and distractibility. Closely related to anxiousness disorders are trauma- and stressor-related disorders, which incorporates posttraumatic stress disorder and obsessivecompulsive dysfunction. Patients with eating disorders have a higher danger for psychiatric comorbidity, including nervousness and postpartum melancholy,1 and are at greater danger for fetal development restriction and cesarean supply. Affected girls experience discrete episodes of intense concern or discomfort in the absence of a true hazard; these episodes are accompanied by somatic or cognitive symptoms corresponding to palpitations, sweating, shaking, dyspnea, choking, chest pain, nausea, paresthesias, chills, and/or flushes.
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The most important potential mechanisms are (1) an enhancement of contractility or an impairment of relaxation of airway smooth muscle, (2) a neural imbalance, (3) airway irritation, and (4) changes in the operate of the airway epithelium. Epidemiology Asthma is an more and more common downside among younger, in any other case healthy women of childbearing age. From 2001 to 2010, the prevalence of bronchial asthma in the United States increased from 7. For many years, an enhancement of airway smooth muscle responsiveness to contractile agonists was assumed to be a major mechanism of bronchial asthma. To test this hypothesis, investigators tried to correlate airway responsiveness in vivo and in vitro in humans5�9 and within the basenji-greyhound dog model of asthma. Instead of an enhancement in responsiveness to contractile stimuli, a discount in responsiveness to relaxant stimuli might contribute to airway obstruction. One research demonstrated impaired relaxant responses to isoproterenol in airway easy muscle from human asthmatic subjects as compared with the responsiveness of airway smooth muscle from controls. Neural Components A stability between constricting and dilating influences additionally exists with respect to the autonomic nervous system. A shift on this steadiness, with an increase in constricting influences, could additionally be a mechanism of bronchial asthma. Efferent cholinergic fibers travel within the vagus nerve to synapse in ganglia inside the airway wall. Muscarinic autoreceptors, or receptors on the nerve ending,14 are also activated by acetylcholine and inhibit further release of acetylcholine from the nerve terminal. The significance of exaggerated cholinergic efferent activity in the pathogenesis of airway hyperreactivity has been debated extensively. However, this mechanism seems to be crucial within the perioperative management of asthmatic subjects. Reflex stimulation of airway smooth muscle by placement of a tracheal tube represents some of the important causes of bronchospasm in the perioperative interval. An various mechanism by which the parasympathetic nervous system could contribute to airway hyperresponsiveness is through dysfunction of the muscarinic autoreceptors. Dysfunction of these receptors permits increased postganglionic launch of acetylcholine after reflex stimulation. In distinction to the parasympathetic nervous system, sympathetic innervation of airway easy muscle in human topics is either sparse or absent. The alpha-adrenergic system is thought to play a relatively minor role in figuring out the state of airway responsiveness. Although alpha-adrenergic receptors are current in human airways,20 the protecting effects of alpha-adrenergic antagonists have been disappointing and could be attributed to different properties, corresponding to antihistamine exercise. Afferents from the airway originate within the epithelium and are activated by airway irritation, as happens with tracheal intubation. Airway Inflammation Airway irritation appears to serve primarily as a modulating influence in bronchial asthma. Although irritation appears to modulate the course of asthma, other factors definitely contribute to the pathogenesis. Interaction with Pregnancy Effects of Pregnancy on Asthma the general course of bronchial asthma has been reported to improve, worsen, or remain the same throughout being pregnant. Even gentle bronchial asthma can turn into significantly extra severe if ladies discontinue their prescribed medicine throughout being pregnant. Most research have used either medical signs or necessities for pharmacologic therapy as indicators of the course of the illness. Although these findings counsel a discount in airway hyperresponsiveness throughout being pregnant, the restricted examine population (16 subjects) makes extrapolation of the data to the overall population unclear. An improve within the progesterone stage is thought to be one mechanism that improves asthma during being pregnant. Progesterone relaxes uterine and gastrointestinal clean muscle and should or might not have related effects on airway smooth muscle.
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During being pregnant, peripartum cardiomyopathy as reason for ventricular arrhythmias ought to be ruled out. Idiopathic ventricular tachycardia is mostly monomorphic, originating from the proper ventricular outflow tract. Ventricular fibrillation can be efficiently terminated with biphasic units that use decrease power than is required with monophasic units. If hemodynamically important or severely symptomatic arrhythmias develop throughout pregnancy, electrophysiologic interventional management may be performed. Successful radiofrequency catheter-based ablation has been reported in pregnant women with no or minimal ionizing radiation publicity. The threat for pulmonary aspiration of gastric contents related to sedation (with an unprotected airway) should be weighed against the dangers related to common anesthesia and tracheal intubation. The considered use of sedation somewhat than general anesthesia is often most popular. Regardless of whether or not sedation or general anesthesia is selected, a nonparticulate oral antacid ought to be administered; administration of a histamine-2 (H2)-receptor antagonist to enhance gastric pH also wants to be considered. The use of metoclopramide in these sufferers is controversial owing to its possible affiliation with tachyarrhythmias. Myocardial infarction throughout pregnancy is associated with maternal use of tobacco, dyslipidemia, household history of myocardial infarction, hypertension, African race, Hispanic ethnicity, and diabetes. Angiographically regular coronary arteries are seen in 13% of patients166; in these circumstances, myocardial infarction doubtless outcomes from coronary artery spasm or embolism. Maintenance of Sinus Rhythm Development of atrial fibrillation may trigger important hemodynamic compromise, particularly in pregnant ladies with stenotic valvular lesions (aortic stenosis or mitral stenosis) or hypertrophic cardiomyopathy with its related diastolic dysfunction. Hemodynamic compromise results from the diminished diastolic filling time and lack of the atrial contraction contribution to ventricular filling. However, revealed studies are largely not relevant to pregnant girls, and it appears affordable to maintain sinus rhythm and management heart price on this inhabitants. Rate management is particularly necessary in patients with stenotic valvular lesions and hypertrophic cardiomyopathy as a end result of the hemodynamic condition of those sufferers might quickly deteriorate within the presence of tachycardia. The current Universal Classification of Myocardial Infarction acknowledges five kinds of myocardial infarction (Box 41. Septic and metastatic neoplastic coronary embolism after abortion have been described. Atherosclerosis is extra generally the reason for myocardial infarction in the antepartum interval than within the peripartum or postpartum period, whereas spontaneous coronary artery dissection is noticed extra incessantly in the peripartum and postpartum intervals. Importantly, bigger doses of heparin are wanted to achieve the desired degree of anticoagulation in pregnant than in nonpregnant sufferers. Percutaneous coronary interventions for therapy of myocardial infarction embrace standard "plain old balloon angioplasty" and stent placement. Dual antiplatelet remedy is necessary after placement of a coronary artery stent to forestall stent thrombosis (Table forty one. However, the security and efficacy of those newer antiplatelet brokers in pregnancy are unknown. Radial arterial access for the percutaneous coronary intervention process is preferable as a result of it has fewer bleeding problems and a lower mortality rate than femoral arterial entry. Systemic anticoagulation with unfractionated heparin appears most Stent Type Choice In sufferers with a nonacute coronary syndrome. When both bare-metal stents or drug-eluting stents are placed in a patient with any acute coronary syndrome. The advantage of drug-eluting stents is a decreased risk for in-stent restenosis than happens with bare-metal stents. However, drug-eluting stent technology is advancing, and in the future, new technology drug-eluting stents might enable for shorter durations of twin antiplatelet therapy. Overall charges of dying and myocardial infarction are similar with drug-eluting and bare-metal stents. The threat for stent thrombosis may be decrease with up to date drugeluting stents than with bare-metal stents.
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Similarly, knowledge from the United States have demonstrated a higher case-fatality rate with general anesthesia compared with neuraxial anesthesia. Despite widespread use of neuraxial anesthesia for operative delivery, general anesthesia may still be required in emergency conditions, if neuraxial anesthesia is contraindicated or patients refuse it, or, mostly, if neuraxial anesthesia fails to present adequate anesthesia. Incidence and Epidemiology the incidence of failed intubation in obstetrics has lengthy been thought of to be approximately 1 in 250 to 300 (Table 29. Importantly, the authors highlighted the perceived emphasis on the need to obtain tracheal intubation. This emphasis (see later discussion) might encourage repeated efforts with their accompanying danger for morbidity. Significant physiologic and anatomic changes of pregnancy (see later discussion) have an result on the airway, oxygenation, and metabolism. The majority of obstetric general anesthetics are administered for emergency deliveries, often during off-hours24; these anesthetic procedures may be performed by inexperienced anesthesia providers with much less proficiency in difficult airway management. Excessive cricoid stress applied by a poorly skilled assistant can worsen the glottic view at laryngoscopy,25 as can positioning the parturient with left lateral tilt. With a decrease in the variety of cesarean deliveries carried out under common anesthesia, trainees have fewer opportunities to become acquainted with challenges of the obstetric difficult airway. Therefore, the abilities required to handle a challenging tracheal intubation are much less more probably to have been gained earlier than working on the labor and delivery unit with out direct supervision. Changes in maternal demographics, most notably an increase in the prevalence of maternal weight problems, might enhance the danger for problems from general anesthesia, especially when carried out for emergency procedures. Obese ladies are at increased risk for obstetric interventions requiring anesthesia29 and are at elevated threat for failed neuraxial anesthesia,30 necessitating the usage of basic anesthesia for emergency delivery (see Chapter 49). Certainly the presence of experienced anesthesia employees throughout induction of basic anesthesia is really helpful and should reduce the morbidity and mortality, and perhaps the frequency, of problem with airway administration. In the report covering the 2012 to 2014 triennium, pregnancy-related mortality from anesthetic causes was the eleventh most common cause, accounting for 1% of maternal deaths. This enchancment probably reflects the super efforts by national anesthesia organizations in defining standards of care that result in improved maternal safety. Compared with neuraxial anesthesia, common anesthesia is associated with a greater threat for maternal mortality (Table 29. Physiologic and Anatomic Changes in Pregnancy Of the multitude of anatomic and physiologic modifications that occur in being pregnant (see Chapter 2), some have a major effect on the degree of issue of laryngoscopy and tracheal intubation (Box 29. Nasal congestion, loud night time breathing, and voice adjustments all occur extra incessantly in advanced pregnancy. The airway edema that has been observed throughout labor may be exacerbated by expulsive efforts through the second stage of labor,forty eight after extubation after cesarean supply,12 or by fluid resuscitation for obstetric hemorrhage. It is therefore prudent to reevaluate the airway earlier than induction of basic anesthesia somewhat than rely solely on a prelabor evaluation. However, the consequences of topical agents on both the prevention of epistaxis and maternal hemodynamic parameters and uteroplacental perfusion must be evaluated, and the relative threat related to this process ought to be assessed on a person basis. Respiratory and Metabolic Changes As being pregnant progresses, the gravid uterus more and more encroaches on the diaphragm and lung volumes are reduced. This lower is extra marked in the supine than in the upright place, and within the overweight than in the lean affected person. These modifications make pregnant girls more prone to turn into hypoxemic during times of apnea corresponding to in the course of the induction of general anesthesia. Preoxygenation and the speed of hemoglobin desaturation have been investigated by pc modeling. Alternatively, if rocuronium is used instead of succinylcholine and air flow and oxygenation are inconceivable, emergency reversal of neuromuscular blockade with sugammadex 16 mg/kg is really helpful. However, ventilatory despair resulting in a big fall in oxygen saturation was extra probably in obese topics. Studies of emergency sugammadex reversal in obstetric sufferers are at present missing. A number of bedside exams have been used, either singularly or together, to predict the airway difficulty. Second, varied predictive components which might be associated with troublesome airway management have been examined on completely different sample populations of sufferers. Despite having both moderately excessive sensitivity and specificity, many predictive checks have limited use within the clinical environment as a end result of failed intubation is uncommon; the variety of false-positive checks (those predicted to be tough which are not) will always be considerably larger than the variety of true-positive tests (those predicted to be tough that are). Combining troublesome airway exams can raise the index of suspicion for difficulty with airway management.
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Local Anesthesia for Cesarean Delivery Rarely, the infiltration of native anesthesia could also be used as a main anesthetic approach for emergency cesarean supply within the affected person with an anticipated troublesome airway. This approach, which has been properly described, is most often utilized in growing countries, where contemporary anesthetic techniques will not be readily available (see Chapter 26). Alternatively, the obstetrician would possibly start surgery and deliver the infant with assistance from native infiltration. Temporary hemostasis may be achieved until the airway is secured and then surgical procedure accomplished after the induction of basic anesthesia. If oxygenation is possible, a choice should then be made relating to whether or not to proceed with surgery. The scenario should be declared to all members of the operating room staff, and specialist help. Laryngospasm must be excluded and neuromuscular block ensured; 100 percent oxygen must be administered. Front-of-neck entry (see later discussion), with either a needle or surgical cricothyroidotomy may be essential. If front-of-neck entry fails to restore oxygenation, maternal superior life assist and perimortem cesarean delivery could additionally be required. Several factors (maternal and fetal situation, expertise of the anesthesia supplier, maternal obesity, anticipated surgical difficulty, aspiration threat, and possible different anesthetic techniques) ought to be addressed before induction of anesthesia. Two elements (availability of airway units, presence of air flow and airway hazards) are assessed after failed intubation. Once that is accomplished, different anesthetic choices, corresponding to an awake intubation or a neuraxial anesthetic approach, should be considered. If the state of affairs is immediately life-threatening to the mother secondary to hemorrhage. Significant angst and controversy often accompany decision-making in the management of a secure mother with evidence of life-threatening fetal compromise, such as fetal bradycardia on account of a prolapsed umbilical twine. In such cases, if mask air flow is straightforward and adequate, the risk-benefit ratio of proceeding with an unsecured airway and an increased danger for aspiration ought to be weighed towards the advantages of prompt delivery of the toddler. In cases during which the maternal threat for aspiration is considered low and mask ventilation is simple, it could be reasonable to continue masks ventilation and keep away from further intubation attempts. The anesthesia provider should fastidiously contemplate the maternal dangers of continuing with cesarean supply in a mom with an unsecured and unprotected airway, especially if no urgency exists and/or masks ventilation is tough. If the affected person is to be woke up, oxygenation ought to be maintained and cricoid pressure continued except it impedes air flow. The patient is positioned head-up or within the left-lateral place, and, if essential, neuromuscular blockade is reversed. Once awake, the urgency for delivery should be reviewed and different anesthetic options thought of. In situations by which surgery is to proceed, anesthesia must be maintained with consideration of controlled or spontaneous air flow. Aspiration danger should be minimized by sustaining cricoid strain, emptying the abdomen, minimizing fundal strain, and administering antacids. If uterine tone is poor, propofol may be substituted for risky agents to preserve anesthesia. These essential documents tackle problems specific to the obstetric affected person; an accompanying editorial by Preston151 highlights some important administration features. The emphasis is now on oxygenation quite than air flow, with bag-and-mask ventilation not forbidden. The choice to awaken the affected person and perform one other technique is often a tough one. A gastric tube can be passed down this drainage lumen to assist in emptying the stomach contents. The drainage conduit has been shown to be efficient in venting both passive and lively regurgitation156,157 and can accommodate the passage of a gastric tube, which can assist in decompressing or emptying the stomach. None of the patients required tracheal intubation, and only one affected person skilled regurgitation of gastric contents into the mouth. Before beginning this maneuver, the dangers and benefits of an intubation try must be weighed. The laryngeal tube is inserted into the oropharynx until resistance is met, which ought to end in positioning of the ventilation apertures instantly above the glottic opening.
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Exposure to hydroxyurea and being pregnant outcomes in patients with sickle cell anemia. Thromboelastography as a perioperative measure of anticoagulation resulting from low molecular weight heparin: a comparability with anti-Xa concentrations. International consensus report on the investigation and administration of major immune thrombocytopenia. Pseudothrombocytopenia: an immunologic research on platelet antibodies depending on ethylene diamine tetra-acetate. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. The prenatal prediction of thrombocytopenia in infants of mothers with clinically diagnosed immune thrombocytopenia. Estimation of the risk of thrombocytopenia in the offspring of pregnant women with presumed immune thrombocytopenic purpura. Maternal traits and risk of extreme neonatal thrombocytopenia and intracranial hemorrhage in pregnancies difficult by autoimmune thrombocytopenia. Anesthetic administration of pregnant women with sickle cell disease� impact on postnatal sickling problems. Maternal and perinatal outcomes amongst haemoglobinopathy carriers: a scientific evaluate. Clinical implications of sickle-cell trait and glucose-6-phosphate dehydrogenase deficiency in hospitalized black male sufferers. Hemostasis in the uteroplacental and peripheral circulations in normotensive and pre-eclamptic pregnancies. Prospective longitudinal study of thromboelastography and normal hemostatic laboratory exams in healthy ladies during normal pregnancy. Assessment of changes in coagulation in parturients with preeclampsia utilizing thromboelastography. Relationship between platelet aggregating issue and von Willebrand factor in thrombotic thrombocytopenic purpura. The affiliation of pregnancy with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Unexpected frequency of Upshaw-Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Changes in health and disease of the metalloprotease that cleaves von Willebrand factor. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent being pregnant outcomes. Comparison of plasma change with plasma infusion within the remedy of thrombotic thrombocytopenic purpura. Bleeding danger of surgical procedure and its prevention in patients with inherited platelet issues. A systematic evaluation of the management and outcomes of being pregnant in Glanzmann thrombasthenia. Drug-induced immune thrombocytopenia: incidence, clinical options, laboratory testing, and pathogenic mechanisms. Unfractionated heparin versus low molecular weight heparins for avoiding heparin-induced thrombocytopenia in postoperative sufferers. Aspirin prolongs bleeding time in uremia by a mechanism distinct from platelet cyclooxygenase inhibition. The results of "anti-platelet" medication on bleeding time and platelet aggregation in regular human topics. Comparison of equimolar concentrations of iloprost, prostacyclin, and prostaglandin E1 on human platelet function. Von Willebrand disease and pregnancy: a sensible method for the diagnosis and treatment. Perioperative management of von Willebrand disease: a review for the anesthesiologist. Von Willebrand disease and other bleeding issues in ladies: consensus on prognosis and management from a world skilled panel. Update on the pathophysiology and classification of von Willebrand disease: a report of the subcommittee on von Willebrand issue. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals.
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Eclampsia is a form of hypertensive encephalopathy that features headache, visual disturbances, nausea, vomiting, seizures, stupor, and coma. Headache is a severe premonitory sign, present in additional than 50% of women in whom eclampsia develops. Occipital or frontal thunderclap headache, blurred vision, scotomas, photophobia, and altered mental standing are a variety of the potential presenting signs. Other hypertensive disorders, with or with out superimposed preeclampsia, are additionally related to complications both antepartum and postpartum and will lead to encephalopathy. The accompanying vasogenic edema can be reversed by immediate recognition and supportive therapy. The evaluation and treatment of stroke during being pregnant ought to mimic that carried out for nonpregnant patients. In addition to supportive care, acute reperfusion remedy with fibrinolytic agents (recombinant tissue plasminogen activator) and intraarterial mechanical thrombectomy should be considered in pregnant ladies with qualifying strokes. Conditions related to hemorrhagic stroke include preeclampsia/ eclampsia, aneurysms, and arterio-venous malformations. Associated signs might include neck stiffness, nausea, vomiting, decreased stage of consciousness, and focal neurologic deficits. Subdural Hematoma Although often associated with head trauma, subdural hematomas can occur spontaneously during being pregnant or could be related to dural puncture (see later discussion). With magnesium sulfate, blood stress management, and cesarean delivery, the patient had full resolution of imaging findings (C, D) and signs. The imaging spectrum of posterior reversible encephalopathy syndrome: A pictorial evaluation. Spontaneous subdural hematomas have been reported in parturients with ailments associated with angiopathy, similar to preeclampsia and fatty liver disease of being pregnant. Diagnosis was made after carotid vessel ultrasonography or magnetic resonance angiography. Carotid Artery Dissection A uncommon, vascular cause of postpartum headache is spontaneous carotid artery dissection. Thrombolysis may be a therapeutic possibility in a select group of sufferers with small hemorrhagic infarct and continued neurologic deterioration. Spontaneous intracranial hypotension has been reported during being pregnant and in the postpartum period. Idiopathic Intracranial Hypertension Parturients with idiopathic intracranial hypertension. The features of postpartum pseudotumor cerebri mimic the standard chronic headache signs skilled by the affected person. The solely distinction is the shortage of a previous neuraxial Pneumocephalus the subdural or subarachnoid injection of air used for identification of the epidural space could also be related to the sudden onset of severe frontotemporal headache, typically accompanied by neck pain, again pain, or changes in mental status. The headache sometimes happens soon after air entrance into the intrathecal area and resolves within 3 to 5 days with reabsorption of the air. Administration of oxygen by nasal cannula or face masks may hasten resorption of the air and speed recovery, though this therapy has but to be proven for pneumocephalus after neuraxial anesthesia. Headache is accompanied by fever, nuchal rigidity, and the presence of Kernig and Brudzinski indicators. Various strains of Streptococcus, organisms usually found in the upper airway and vagina, have been linked to bacterial meningitis after neuraxial procedures. Sinusitis Headache attributable to infected paranasal sinuses is associated with purulent nasal discharge and, occasionally, fever. Pain may be unilateral or bilateral, depending on the extent of the disease, and the pores and skin over the affected sinus may be tender. Although caffeine-withdrawal headache has not been documented as a cause of postpartum headache, the diagnosis should be thought-about if the parturient has been consuming caffeinated drinks during the being pregnant. Onset of complications occurred inside the first few minutes of breast-feeding, and the headaches resolved after cessation of nursing. The headaches have been related to an increase in plasma vasopressin concentration. Headaches have additionally been described in women with breast engorgement who either have elected to not breast-feed or have reduced the frequency of breast-feeding. Several hours later, she developed a severe frontal headache that was worse within the upright position and within the morning and night hours.
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Proponents assume that these techniques are easily used throughout labor and delivery; nonetheless, Copstick et al. They found that patients had been capable of use the coping methods in the early first stage of labor but that the profitable use of the coping abilities turned much less and fewer widespread as labor progressed. By the onset of the second stage, less than one-third of moms were capable of use any of the respiratory or postural strategies taught during their childbirth lessons. Most present lessons credit Lamaze with the most important components of childbirth preparation, despite the very fact that Dick-Read was the primary to promote patient training, rest coaching, respiration workout routines, and paternal participation. In addition, some instructors and training manuals declare different advantages of childbirth preparation (Box 21. In addition, a quantity of ladies have written about their disappointment with the dogmatic approach of their childbirth instructors; these ladies described instructors who rigidly defined the "correct" method to have a "proper" start experience. Psychology, nursing, obstetric, anesthesia, and lay journals provide intensive discussions of childbirth preparation, however most articles describe uncontrolled medical experiences. Despite these shortcomings, supporters of childbirth preparation assume that it offers advantages for mother and child. Some researchers have reported a decreased use of analgesics37�39 or regional anesthesia,37�41 shorter labor,42 decreased efficiency of instrumental37,38,41 and cesarean delivery,forty one and a lower incidence of nonreassuring fetal status,41 whereas others have reported no change in the use of analgesics41�45 or neuraxial analgesia,forty three,forty four length of labor,38,39,41,43�46 efficiency of instrumental43�45 and cesarean supply,38,43�45 or incidence of nonreassuring fetal standing. To elucidate the effect of the coping techniques taught in childbirth courses, several investigators have attempted to quantify changes in ache threshold, pain notion, anxiety levels, and physiologic responses to standardized stimuli. Several research have evaluated nonpregnant and nulliparous girls in laboratory settings,47�50 and another examine evaluated pregnant ladies in the antepartum, intrapartum, and postpartum intervals. Together, these studies suggest that working towards these strategies facilitates their efficacy and that Minimal Training/Equipment � Emotional assist � Touch and massage � Therapeutic use of warmth and chilly � Hydrotherapy � Vertical place Specialized Training/Equipment � Biofeedback � Intradermal water injection � Transcutaneous electrical nerve stimulation � Acupuncture � Hypnosis newer cognitive methods. Further studies may assist refine childbirth preparation to maximize the optimistic psychophysiologic effects. However, medical proof is insufficient to kind the premise for an in-depth dialogue of some of the more modern therapeutic ideas, similar to music remedy, aromatherapy, and chiropractic manipulation. Parturients may consider these benefits an integral and essential a half of their labor expertise. Continuous Labor Support Some strategies that require minimum equipment and specialised training are taught as integral elements of childbirth preparation lessons. This assist seems most helpful for the parturient who lives in a steady family unit. At least one study noted that husband participation was related to decreased maternal anxiousness and medicine necessities. In one study, girls randomly assigned to obtain intrapartum support from a good friend or feminine relative (who was chosen by the parturient and skilled as a doula) have been extra more probably to have optimistic feelings about their delivery and had a higher rate of breast-feeding 6 to 8 weeks after delivery than girls who were randomly assigned to receive ordinary care. The affected person populations studied characterize special conditions, and the results will not be reproduced in all populations. For example, a big randomized, controlled trial in a North American hospital (in which intrapartum medical intervention is routine) found no variations within the rate of cesarean delivery or different labor outcomes between ladies randomly assigned to obtain steady labor assist from a specially trained nurse and ladies who received ordinary care. Touch and Massage Various contact and massage methods are discussed with girls and their support individuals during childbirth preparation lessons. These strategies embody effleurage, counterpressure to alleviate again discomfort, gentle stroking, and merely a reassuring pat. These measures could additionally be utilized by the parturient, her support individual, or the skilled employees members offering intrapartum care. More usually, touch and therapeutic massage transmit a sense of caring, which fosters a way of security and well-being. Therapeutic Use of Heat and Cold Another simple technique for alleviating labor ache is the therapeutic use of temperature (hot or cold) utilized to numerous regions of the body. Warm compresses may be positioned on localized areas, or a warm blanket could cowl the whole body. Alternatively, ice packs could additionally be placed on the low back or perineum to lower ache notion. The therapeutic use of warmth and cold throughout labor has not been studied in a rigorously scientific method. Aromatherapy Aromatherapy is the utilization of essential oils, that are aromatic, unstable natural compounds obtained by distillation of plant material.
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A randomized trial of labor analgesia in girls with pregnancy-induced hypertension. Randomized trial of labor analgesia: a pilot research to compare patient-controlled intravenous analgesia with patient-controlled epidural analgesia to decide if analgesic technique impacts delivery end result. Effects of epidural lidocaine analgesia on labor and supply: a randomized, potential, controlled trial. Epidural analgesia and operative delivery: a ten-year population-based cohort study in the Netherlands. The effect of a rapid change in availability of epidural analgesia on the cesarean supply rate: a meta-analysis. The affect of the obstetrician within the relationship between epidural analgesia and cesarean section for dystocia. Risk of cesarean delivery with elective induction of labor at term in nulliparous girls. The effect of early epidural block administration on the progression and end result of labor. Early in contrast with late neuraxial analgesia in nulliparous labor induction: a randomized managed trial. The effect of instituting an elective labor epidural program on the operative supply price. The affect of continuous epidural bupivacaine analgesia on the second stage of labor and technique of delivery in nulliparous ladies. The effect of low concentrations versus excessive concentrations of native anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis. Effects of epidural labor analgesia with low concentrations of local anesthetics on obstetric outcomes: a systematic review and meta-analysis of randomized managed trials. Does station of the fetal head at epidural placement affect the place of the fetal vertex at supply Is epidural analgesia a danger issue for occiput posterior or transverse positions during labour Does the station of the fetal head throughout epidural analgesia affect labor and delivery Changes in fetal place throughout labor and their association with epidural analgesia. Intrapartum sonography head transverse and asynclitic prognosis with and with out epidural analgesia initiated early in the course of the first stage of labor. Episiotomy, operative vaginal delivery, and significant perinatal trauma in nulliparous girls. Obstetric anal sphincter rupture in older primiparous women: a case-control research. Effects of lumbar epidural analgesia on prostaglandin F2-alpha release and oxytocin secretion during labor. Effect of epidural analgesia on fundal dominance during spontaneous active-phase nulliparous labor. The relationship of maternal nervousness, plasma catecholamines, and plasma cortisol to progress in labor. A randomized study evaluating 1 per cent mepivacaine with 1 per cent lidocaine plus epinephrine. Obstetric epidural analgesia with mixtures of bupivacaine, adrenaline and fentanyl. Is combined spinal-epidural analgesia related to extra rapid cervical dilation in nulliparous sufferers when compared with conventional epidural analgesia Beta2-adrenergic receptor genotype and other variables that contribute to labor pain and progress. Oxytocin and catechol-O-methyltransferase receptor genotype predict the size of the first stage of labor. Second stage of labor and epidural use: a bigger effect than beforehand instructed.
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A prospective, randomized, blinded-endpoint, managed study-continuous epidural infusion versus programmed intermittent epidural bolus in labor analgesia. Intermittent epidural bolus in contrast with continuous epidural infusions for labor analgesia: a systematic evaluate and meta-analysis. Intrathecal migration of an epidural catheter while utilizing a programmed intermittent epidural bolus method for labor analgesia upkeep: a case report. Distribution of catheter-injected native anesthetic in a model of the subarachnoid house. Posterior column sensory impairment throughout ambulatory extradural analgesia in labour. Dorsal column perform after epidural and spinal blockade: implications for the safety of strolling following low-dose regional analgesia for labour. Walking reduces the post-void residual quantity in parturients with epidural analgesia for labor: a randomized-controlled examine. Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin throughout spinal anesthesia for elective cesarean supply. The effect of maternal administration of ephedrine on fetal heart rate and variability. Combined spinal-epidural analgesia in labour: comparison of two doses of intrathecal bupivacaine with fentanyl. Intrathecal sufentanil for labor analgesia�sensory adjustments, unwanted side effects, and fetal coronary heart rate modifications. Prophylactic ondansetron for the prevention of intrathecal fentanyl- or sufentanil-mediated pruritus: a meta-analysis of randomized trials. Intrathecal fentanyl-induced pruritus throughout labour: the impact of prophylactic ondansetron. Nalbuphine is better than naloxone for remedy of side effects after epidural morphine. Complications of labor analgesia: epidural versus combined spinal epidural methods. A randomized trial of the consequences of antibiotic prophylaxis on epidural-related fever in labor. Elevated maternal and fetal serum interleukin-6 levels are associated with epidural fever. Maternal corticosteroids to forestall intrauterine publicity to hyperthermia and inflammation: a randomized, double-blind, placebo-controlled trial. Effect of combined spinal-epidural analgesia versus epidural analgesia on labor and delivery period. The impact on maternal temperature of delaying initiation of the epidural element of mixed spinal-epidural analgesia for labor: a pilot study. Shivering and shivering-like tremor throughout labor with and with out epidural analgesia. Effect of adrenaline, fentanyl and warming of injectate on shivering following extradural analgesia in labour. Post-void residual quantity in labor: a potential study comparing parturients with and without epidural analgesia. Post-partum urinary retention: a comparability between two strategies of epidural analgesia. Urinary catheterization in labour with high-dose vs cellular epidural analgesia: a randomized controlled trial. Patient-controlled epidural analgesia: the function of epidural fentanyl in peripartum urinary retention. Herpes labialis in parturients receiving epidural morphine following cesarean section. An investigation of relationships between rate of infection, injection pressures and extent of analgesia. Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines replace for cardiopulmonary resuscitation and emergency cardiovascular care.
Walsh TJ, Schembri M, Turek PJ, et al: Increased risk of high-grade prostate cancer among infertile men, Cancer 116:2140n2147, 2010.
Reuther J. [Animal experimental studies on the healing of pressure stabilized free bone grafts in the mandible] (German). Dtsch Zahnarztl Z 1980;35:45-48.
Thompson R: Venous thoracic outlet syndrome: paraclavicular approach, Op Tech Gen Surg 10:113-121, 2008.
Al-Kayat A, Bramley P. A modified preauricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 1979;17:91-103.
Gelbard M: Myofibroblasts and mechanotransduction: do forces in the tunica albuginea contribute to Peyronieis disease?, J Sex Med 5(12):2974n2976, 2008.
Winters JC, Dmochowski RR, Goldman HB, et al; American Urological Association; Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction: Urodynamic studies in adults: AUA/SUFU guideline, J Urol 188(6 Suppl):2464n2472, 2012.
Spann A, Poteet J, Hyatt D, et al: Safe and effective obtainment of access for percutaneous nephrolithotomy by urologists: the Louisiana State University experience, J Endourol 25:1421-1425, 2011.


The close-mid central unrounded vowel, or high-mid central unrounded vowel, is a type of vowel sound, used in some spoken languages. The symbol in the International Phonetic Alphabet that represents this sound is ⟨ɘ⟩. This is a mirrored letter e, and should not be confused with the schwa ⟨ə⟩, which is a turned e. It was added to the IPA in 1993; before that, this vowel was transcribed ⟨ë⟩ (Latin small letter e with umlaut, not Cyrillic small letter yo). Certain older sources transcribe this vowel ⟨ɤ̈⟩.
The ⟨ɘ⟩ letter may be used with a lowering diacritic ⟨ɘ̞⟩, to denote the mid central unrounded vowel.
Conversely, ⟨ə⟩, the symbol for the mid central vowel may be used with a raising diacritic ⟨ə̝⟩ to denote the close-mid central unrounded vowel, although that is more accurately written with an additional unrounding diacritic ⟨ə̝͑⟩ to explicitly denote the lack of rounding (the canonical value of IPA ⟨ə⟩ is undefined for rounding).
To type this symbol on Windows, press and hold the ALT key while typing "600" using the number pad keys.
Azerbaijani Tabriz qız قیز [ɡɘz] 'girl' Typically transcribed in IPA with ⟨ɯ⟩.
Cotabato Manobo [example needed] May be transcribed in IPA with ⟨ə⟩.
Dinka Luanyjang ŋeŋ [ŋɘ́ŋ] 'jawbone' Short allophone of /e/.
Southern Michigan [bɚ̝ːd] Rhotacized; typically transcribed in IPA with ⟨ɚ⟩.
Kaingang [ˈᵐbɘ] 'tail' Varies between central [ɘ] and back [ɤ].
Kalagan Kaagan [miˈwə̝ːʔ] 'lost' Allophone of /ɨ/ in word-final stressed syllables before /ʔ/; can be transcribed in IPA with ⟨ə⟩.
Kensiu [ɟɚ̝h] 'to trim' Rhotacized; may be transcribed in IPA with ⟨ɚ⟩.
Kera [t͡ʃə̝̄wā̠a̠] 'fire' Allophone of /a/; typically transcribed in IPA with ⟨ə⟩.
Lizu [Fkə̝][clarification needed] 'eagle' Allophone of /ə/ after velar stops.
Mono dœ [də̝] 'be (equative)' May be transcribed in IPA with ⟨ə⟩.
Temne pər [pə̝́r] 'incite' Typically transcribed in IPA with ⟨ə⟩.
Xumi Upper [LPmɘ̃dɐ] 'upstairs' Nasalized; occurs only in this word. It is realized as mid [ə̃] in Lower Xumi.
Zapotec Tilquiapan ne [nɘ] 'and' Most common realization of /e/.
^ For example Collins & Mees (1990).
^ Mokari & Werner (2016).
^ a b Asu & Teras (2009), pp. 368–369.


According to Apple, iOS 9 has the biggest adoption rates compares to all other iOS version before. At September 19th, 50% of iOS devices already made the switch to the latest version of iOS. With this many devices upgrading, there was no doubt that there will be some sort of problems with the first version of the latest iOS. This time, it's all about your mobile data.
A big number of users reported spikes in their mobile data usage, direct after upgrading to iOS 9. This problem is connected to the newest iOS feature Wi-Fi Assist. This setting, which is switched on by default on iOS 9, is supposed to support you "stay connected to the Internet even if have a poor Wi-Fi connection", by switching over to mobile data, if you have a bad Wi-Fi reception or if the connection is slow in general. However, Wi-Fi Assist might cause more problems than actually help you.
Indeed, Apple was slapped with a $5 Million USD class-action lawsuit for not notifing users of increased data usage and enabling this draining setting by default on all devices running iOS 9.
After the initial complaint Apple changed its website saying that Wi-Fi-Assist "may use more cellular data".
Turn off Wi-Fi Assist is totally easy. Simply open your Settings, go to Mobile Data (Cellular), go down to the very bottom and toggle the On/Off switch next to Wi-Fi Assist.
If you've done that you'll likely see an overall decrease in your mobile data usage in the future.
However, there are some additional features you should change to save a good amount of your precious mobile data, if you're not on an unlimited data plan.
You also might want to completely turn off mobile data access for some apps that you won't need all the time. In this case, we have App Store, Game Center and Music disabled at all times.
Again open Settings > Mobile Data (Cellular) > scroll through the list of apps and switch off mobile data for those you don't need, or only use when you have a Wi-Fi connection available.
If you have more thoughts on how to save mobile data on iOS devices like the iPhone, please leave a comment. We always appreciates a helpful tip and will expand this article,if it's really useful!


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Obviously deals with a relationship that may make some people uneasy, the old rumor that Dave wrote it about his 8th grade girlfriend who is black. But there does not seem to be a lot of proof to that rumor, and Dave has commented that this version is his favorite interpretation of the song, but not confirmed it to be truth. In a 1994 interview, Dave admitted it was about his relationship with Julia Grey, and how she was much more outgoing than he, and facilitated him breaking out of his introverted shell.
Spring 1998 Rarity: 27.2727
Average Slot: 8
9 Spring 1998 Appearances
DMB 1998-04-21 The Tabernacle, Atlanta, GA 5 8:36
DMB 1998-04-26 New Orleans Jazz and Heritage Festival, Fair Grounds Race Course, New Orleans, LA 8
DMB 1998-05-02 Jarry Park Tennis Theatre, Montreal, Quebec, Canada 11
DMB 1998-05-05 Arrow Hall, Mississauga, Ontario, Canada 17
DMB 1998-05-10 Jack Singer Concert Hall (ECPA) , Calgary, Alberta, Canada 2
DMB 1998-05-21 Desert Sky Pavilion, Phoenix, AZ 11
DMB 1998-05-25 Red Rocks Amphitheatre, Morrison, CO 13
DMB 1998-06-02 Riverbend Music Center, Cincinnati, OH 1
DMB 1998-06-07 Giants Stadium, East Rutherford, NJ 6

redpajama_set_name: RedPajamaCommonCrawl


please send solution as possible as you can..
If you realy want to make your own input box then it is very simple, you just need to follow the concepts of j2me Canvas.
1. Create a InputBox class.
2. Draw a rectangle onto it for appropriate text size whatever you want.
3. Start writing the text from the left hand corner whatever you press from the key.
4. if you want to enter ABC... then you will have to assign keys like on press of 2 it should type either of A/B/C/2 fix a timer which can run for each key press event and when it is more than 2 second then it should let you type another character.
5. you will have to refresh your screen after each key press event.
6. make sure you are using correct logic for typing and clearing the text.


Thereafter you will abide solely in Me. There is no doubt about it."
Then seek to attain Me through the yoga of repeated practice."
you shall attain perfection (in the shape of My realization) even by performing actions for My sake."
Then, subduing your mind and intellect etc. relinquish the fruit of all actions."
"Knowledge is better than practice ( without discernment ), meditation on God is superior to Knowledge, and renunciation of fruit of actions is even superior to meditation; for peace immediately follows from renunciation. "


text:
Q: Studies that do not provide 2x2 table in metafor I am trying to understand meta-analyses with metafor and I stumbled upon a problem regarding studies that directly provide OR and p-value/C.I.
I can not write a correct code, can you please show me examples? How should I construct the dataset?
Thanks in advance!

redpajama_set_name: RedPajamaStackExchange


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text:
Man to be sentenced on 3rd child abuse case
Becky Metrick
bmetrick@publicopinionnews.com
CHAMBERSBURG - A Chambersburg man recently convicted by a Franklin County jury in his third child abuse case is scheduled to be sentenced Wednesday.
Christopher Lynn Grooms, 40, was found guilty of misdemeanor child endangerment and simple assault, and one summary citation of harassment, for an Oct. 10, 2014 incident where court documents show he threw a 12-year-old boy to the ground.
The incident occurred in two phases, first with the boy being pushed onto a couch during an argument, then later Grooms finding the boy outside and throwing him onto the concrete, according to court documents.
The boy suffered shoulder pain and red marks were seen by police on on his back and right shoulder area. He also had a headache after the incident, he said.
At the time, police wrote in court documents that Grooms admitted to losing his temper with the boy.
Grooms' prior convictions date back to 1998, with his most recent charge being a domestic violence related conviction in 2009.
In 2005, Grooms received his second child abuse conviction, and a report was filed from Franklin County Children and Youth Services to act as an advocate for the children involved.
On Aug. 16, 2006, Grooms was sentenced to less than a year in jail and was prohibited from having any contact with the victim in the case or any unrelated minor children.
After violating his parole in that sentence in 2009, Grooms was ordered to return to jail, to enter a domestic violence treatment program and was once again prohibited from being around any minor children.
There was a note on the order that should there be proof of a request from the victim that the no contact order be lifted, the request would be granted.
However, documents show Grooms violated his parole once again in 2011 and was ordered to complete nine months in a state prison facility, according to court documents.
Grooms' prohibition of having contact with minor children was still in place at the time.
The most recent conviction does not involve the same people involved in Grooms' first set of domestic violence and child abuse cases.
Grooms is expected to be sentenced at 9 a.m. by Franklin County Judge Angela Krom.
Becky Metrick 717-262-4762


A crack impinging normally upon a frictional interface is studied theoretically. We employ a solution technique which superposes the solution of a crack in a perfectly-bonded elastic medium with a continuous distribution of dislocations which represent slippage at the frictional interface. This procedure reduces the problem to a singular integral equation which is solved numerically. Specifically, we consider the problem of an infinite sheet subjected to uniaxial tension containing a finite crack which lies normal to the tension axis and has both crack tips impinging normally on frictional interfaces. The limiting problem of a semi-infinite crack impinging on a frictional interface is considered as well. Posed as model problems for cracking in weakly bonded fiber composites, these studies reveal the effective blunting that can result when a weak interface serves to deflect a propagating crack.
Dollar A, Steif PS. A Tension Crack Impinging Upon Frictional Interfaces. ASME. J. Appl. Mech. 1989;56(2):291-298. doi:10.1115/1.3176081.


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Q: Disparity Map post processing in OpenFrameworks After long hours I finally managed to get a stereo disparity map with a single camera. The result is rather spotty as one would expect, so I would like to apply some filter to improve the quality. The problem is that I'm not using pure OpenCV, but the plugin for OpenFrameworks (ofxCv), meaning I can't use this:
http://docs.opencv.org/3.1.0/d3/d14/tutorial_ximgproc_disparity_filtering.html
There has to be a way how I can apply the WLS filter, or something similar in this situation. WLS appears to be implemented in OpenCV, but I can't access it through the plugin, and direct access also doesn't seem to work.
Does anybody know how I can apply that filter, or has any other, general, disparity map post-processing advice?

A: I'm not sure what OpenCV functionality is available to you. But just a suggestion, maybe use the implementation from OpenCV in your project. Look at the file: https://raw.githubusercontent.com/opencv/opencv_contrib/master/modules/ximgproc/src/disparity_filters.cpp
Copy any additional files you may need to your project and try building. With basic OpenCV support you might be able to make it work.


Apple could be set to introduce a subscription feature into its News app that would offer users access to news and magazine content for a single recurring fee, according to reports.
The touted model is in the vein of that operated by music app Spotify and Apple's own Apple Music, which offer users unlimited access to music for a monthly fee.
According to Bloomberg, which quotes sources familiar with the matter, the upgrade could launch within the next year and signed-up publishers would receive a cut of the subscription revenue.
Currently the News app is available free of charge and shares content only from publishers and broadcasters who are signed up to it.
Pubishers can keep all revenue from ads they sell, 70 per cent when Apple sells the ads for them, or 50 per cent from pooled ads.
The app also prompts users to sign up for a subscription with individual publishers who use a paywall, and manages those subscriptions, but the new feature would mean a simplified payment system granting access to all content from signed-up publishers for a single fee.
The plan comes after the US tech giant bought magazine subscription app Texture last month, which offers users access to 200 magazines for $9.99 a month. Apple declined to comment.
In the UK, a rival magazine subscription service already exists through Swedish company Readly. Users are given unlimited downloads of digital magazines, including the likes of Empire, GQ and Heat, for a monthly fee.


Canada is currently in the midst of a postal strike. Although the strike is currently "rotating" in nature, with different communities being subject to the strike on different days, it is possible that the strike could become country wide should negotiations remain unsuccessful. Although concern may immediately turn to the potential impact of a full strike upon online holiday shopping, a full national strike could also have an impact upon the legal world in relation to the service of documents.
Canada Post remains a vital service to the legal community, amongst other things remaining one of the official means of service upon a lawyer of record pursuant to rule 16.05 of the Rules of Civil Procedure. Although there are alternate service mechanisms available to serve documents upon a lawyer of record should the strike become national, such as potentially using a courier, there are certain documents which the Rules of Civil Procedure provide may only be served by mail.
Although such a rule typically assists the Applicant in serving the Application to Pass Accounts in a streamlined and cost effective manner, as otherwise personal service of the Application to Pass Accounts would be required pursuant to rule 16.01 as an "originating process", the rule does not contemplate what is to occur in the circumstance that service by regular lettermail is not possible (i.e. in a full work stoppage). In such circumstances, how can the Applicant ensure that the Application to Pass Accounts is properly served as required by the Rules of Civil Procedure?
From a common sense standpoint there are likely alternatives readily available to serve the Application materials other than by regular lettermail, including potentially by courier or by personal service. From a strict reading of rule 74.18(3) however, service of the Application to Pass Accounts by any means other than "regular lettermail" is not proper service, such that it is possible that a beneficiary may argue that they have not been properly served should you serve them by any other means. Should this occur, it is possible that an Order validating service and/or substituting service for alternative means under rule 16.04 may be required.
Thankfully at present the strike is only "rotating" in nature, such that we can continue to mail out documents such as Applications to Pass Accounts to be served in accordance with the Rules of Civil Procedure (subject to any potential daily interruptions should your community be striking on a particular day). Should circumstances change however, and there is a full work stoppage, it is possible Orders may have to be sought validating and/or substituting service for service in a manner other than by regular lettermail for those items such as Applications to Pass Accounts which the Rules provide may only be served by mail.
Can a drafting lawyer be sued by the beneficiaries under a prior Will?
People can become upset when they find out that they have been written out of a Will. This frustration can often become multiplied when the individual in question received a significant bequest under a prior Will, believing the that the prior Will in which they received a more significant interest should govern the administration of the estate. In looking for recourse or answers, the "disappointed beneficiary" can often lash out against the drafting lawyer who was retained to prepare the new Will, believing that it was somehow improper or negligent for them to have prepared the Will, and that they have suffered damages in the form of the lost bequest. Some "disappointed beneficiaries" will even go as far as to commence a claim against the drafting lawyer for having seen to drafting the new Will. But can such claims be successful?
In order for the "disappointed beneficiary" to successfully have a claim against the drafting lawyer, the court must find that the drafting lawyer owed a "duty of care" to the beneficiaries under the prior Will. Generally speaking, the only individual to whom a drafting lawyer owes a duty of care when seeing to the preparation of a Will is the testator (and the beneficiaries listed in the new Will by extension). Although the court will sometimes in limited circumstances extend a duty of care to "disappointed beneficiaries", such circumstances typically exist when the testator advised the drafting lawyer of an intention to benefit a certain individual, however as a result of the actions of the drafting lawyer such an individual did not end up receiving the intended bequest (see White v. Jones and Hall v. Bennett Estate). Such circumstances appear notably distinct from bequests to beneficiaries under a prior Will, for by creating a new Will the testator is in effect communicating to the drafting lawyer an intention to no longer benefit the individuals under the prior Will.
As cases such as Graham v. Bonnycastle suggest, the court appears unwilling to extend a duty of care from the drafting lawyer to a beneficiary listed under a prior Will. If no duty of care exists, no claim may now be advanced by the disappointed beneficiary against the drafting lawyer for any perceived "damages" they may have suffered on account of the new Will having been drafted. This appears true even if it is ultimately found that the testator lacked testamentary capacity at the time the new Will was signed.
Can there be a "break" in a common law relationship?
As anyone who has ever watched the show Friends can attest, "breaks" can happen in any relationship. For those attempting to claim common law spousal status however, what impact, if any, do such "breaks" have upon the length of time that the couple has to be together? Do you have to re-set the clock of the relationship after every "break", or can the "breaks" be ignored?
Part V of the Succession Law Reform Act incorporates the definition of "spouse" from section 29 of the Family Law Act. Section 29 of the Family Law Act in turn defines "spouse" as including "two persons who are not married to each other and have cohabited continuously for a period of not less than three years". This definition is often what is being referred to when someone says that a relationship is "common law", with significant corresponding legal rights potentially being given to the two individuals if they are found to be "spouses".
As the word "continuously" is included in the definition, one would be forgiven for thinking that there cannot be any "breaks" in the relationship, and that you must have a continuous three year period of "cohabitation" for two people to be considered spouses. As we will see below however, this may not necessarily be the case.
I have previously blogged about the factors that the court may look to in determining whether two people are "cohabitating", with the Supreme Court of Canada in M. v. H. having confirmed that you look to the factors listed in Molodowich v. Penttinen to determine whether to individuals are "cohabitating" to the extent that their relationship becomes spousal. For the purpose of this blog however, the interesting question which follows is whether a couple who otherwise meets enough of the factors from Molodowich to be considered to be "cohabitating", but had a "break" in their relationship during the three year period, could still be considered "spouses".
As Boothe v. Gore suggests, a "break" in a relationship should not necessarily preclude a finding that two persons are common law spouses. Rather, the court is to attempt to ascertain the intentions of the parties at the time of the "break", with the spousal status only coming to a close if either of the parties regards the relationship as being "at an end", or the period of separation lasts for a "meaningful period of time".
Alterations to a Will – When are they valid?
People change their mind all of the time. When someone changes their mind about the terms of their Will however, things can become more complicated. Going to a lawyer to formally make a change to the Will may seem daunting. If the change to the Will is relatively minor, an individual may be tempted to forgo meeting with a lawyer to draw up a new Will or Codicil, and simply make the change to the Will themselves by crossing out or inserting new language by hand on the face of the old Will. But would such handwritten changes be valid?
Although the advice to any individual thinking of changing their Will would always be to speak with a lawyer about the matter, people do not always adhere to such advice. If someone has made handwritten changes to their Will after the document was originally signed, such changes can under certain circumstances alter the terms of the Will.
As a result of section 18(1) and 18(2) of the SLRA, any handwritten change to a Will does not validly alter the terms of the Will unless the testator and two witnesses sign in the margins of the Will near the alteration (subject to certain exceptions listed). If the handwritten change is not accompanied by such signatures it is not a valid alteration and has no impact upon the original terms of the Will, unless the handwritten change has had the effect of "obliterating" the original language of the Will by making it no longer readable.


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Q: how to show a link parameter details in another page using javascript only? I was searching and found nothing , I have a page specifications.html which has three link like details.html?id=1 and details.html?id=2 and details.html?id=3 , I want to show the details of each link if someone click on details.html?id=1 link on specifications.html page then it show id =1 on details.html page , I can do it with php but my teacher said me to do it with javascript only and I dont know how to do it , so please if anyone help me out I will be highly thankfull to you

A: As far as I get it, you want to know the value of the "id" search param when accessing the "details.html" page. As stated in this answer to the question "How can I get query string values in JavaScript?", you can use URLSearchParams which is simple and has good browser support.
const urlParams = new URLSearchParams(window.location.search);
const id = urlParams.get('id'); // for a search "&id=2", the value of "id" will be 2.

This will create an URLSearchParams object which parses the window.location.search string and is able to return one specific param, like "id".


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The accommodation is situated in Boseja North (route 6).


text:
Zinke leaves unfinished business at the Interior Department
The questionable legality of the Trump administration's aggressive deregulatory and development-friendly policies could end up being its undoing.
Carl Segerstrom Analysis Jan. 23, 2019
On the second day of 2019, Interior Secretary Ryan Zinke tweeted out his resignation letter to President Donald Trump. After less than two years in office, he claimed to have "restored public lands 'for the benefit & enjoyment of the people,' improved public access & shall never be held hostage again for our energy needs."
That appears to be Zinke's view of the legacy his abbreviated tenure will leave on the Interior Department's more than 500 million acres of land and roughly 70,000 employees. Critics might interpret his garbled syntax as a confession: that he turned over public land to industry — pushing oil and gas leases in sensitive habitat, rescinding environmental protections and shrinking national monuments. But what, really, did Zinke accomplish?
Ryan Zinke wore many hats as Interior Department Secretary, effective bureaucrat wasn't one of them.
The answer: Probably not much. The methane Zinke allowed gas drillers to flare can't be unburnt, the oil and gas leases he sold are probably good for at least 10 years, and the institutional knowledge of departed agency workers will be difficult to restore. Still, the flippant way Zinke executed his many rollbacks and policy changes leaves them vulnerable to be overturned, either by the next administration, Congress or the courts.
"The cumulative landscape impact is significant," said Brett Hartl, the government affairs director for the Center for Biological Diversity. "(But) I am optimistic that almost everything they've done can be undone. We can win in court because most of the things they are doing violate the laws they are addressing."
Zinke — a Navy veteran, former oil pipeline functionary and Montana congressman — was not coy about his determination to achieve something he called "energy dominance." Nor was he shy about favoring industry over all other public-lands users. Following the lead and executive orders of President Donald Trump, Zinke cut environmental regulations, shrank Bears Ears and Grand Staircase-Escalante national monuments, and censored climate science while pushing out agency scientists and staff. By reducing fracking safeguards, slashing methane waste regulations and cutting protections for migratory birds, Zinke's Interior Department has made it easier to develop oil and gas on public lands.
The Interior Department's deregulatory agenda
Yet only a handful of rules — which create policies that require a lengthy and public process to undo — have been finalized in the last two years. Many of the actions taken by the administration have been done through secretarial orders, internal memos and staffing decisions, many of which can be reversed on day one of a new administration.
For example, policies that have lead to the censoring of climate science could be immediately discarded. New leadership at Interior could also terminate every politically appointed agency head and staffer. For instance, Zinke's childhood friend Steve Howke, a former credit union executive with no Interior Department experience, would no longer be in charge of reviewing the department's grant applications.
From a staffing standpoint, Zinke's legacy will come less from temporary political appointees than from the loss of rank-and-file workers. The departures of career staffers, who left after questionable reassignments, interference in climate research, and policies that incentivized early retirements, will make it harder to rebuild a workforce that is shrinking despite increased visitation on public lands.
The legal actions of the Trump administration's Interior Department are also vulnerable in federal courts. "We see a pattern of attempts to suspend compliance with agency rules" that doesn't adhere to the Administrative Procedures Act, said Hana Vizcarra, the staff attorney for Harvard Law's Environmental and Energy Law Program.
As Rep. Raúl Grijalva, D-Ariz., takes the lead oversight role as the chairman of the House Committee on Natural Resources, Trump's opponents could gain more leverage. "Information from oversight in the house could give ammunition to litigants or spur interest in further lawsuits," Vizcarra said. If, for example, the committee unveiled new information that showed rules were made at the request of regulated industries, "it could impact what a court considers reasonable or arbitrary," and undermine the agency's ability to defend its actions, she said.
In the end, Zinke will probably be remembered more for his hat collection, bluster, multiple scandals and ethics investigations and vacations taken on the taxpayer dime than for any policies he implemented, good or bad. One thing is certain, though: The drive for "energy dominance" at the expense of the environment will endure for as long as Trump remains president, particularly under the leadership of now acting-Interior Secretary David Bernhardt, who is generally seen to be more competent than Zinke.
"In some sense, Ryan Zinke really was Trump's mini-me in terms of flailing around and fumbling very loudly, but really not having a clear policy direction other than deregulation and handing over federal authority to manage public lands," said Erik Molvar, the executive director of Western Watersheds, a conservation group that opposes grazing and energy development on public land. "Now, we could be turning over the helm to cold-blooded professionals who are industry lobbyists that really know how to get things done."
Carl Segerstrom is a contributing editor at High Country News, covering Alaska, the Pacific Northwest and the Northern Rockies from Spokane, Washington. Email him at [email protected] or submit a letter to the editor.
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As Christmas approaches, I always think of Pam H.
On Christmas Eve, 1962, around 8 p.m., our front door buzzer announced a caller. I opened the door to see Pam, wife of Jimmy, whose family owned a large nursery and landscaping business. Jimmy had a profitable side gig plowing driveways, which in a Northern Michigan winter was profitable from November to mid-March.
I was puzzled. I'd never seen her at our house before, but she stood on the porch and commanded: "Your mother."
Mom showed Pam into the kitchen, and seated her in the breakfast nook. Something was said in that choice: not the barroom with its mural and harlequin floor, not even the living room's squashy sofa, but the kitchen, a cozy, female domain.
She was madder, as Mom would say, than a wet hen, weeping into a glass cup of nutmeg-dusted, rye-spiked eggnog, with Mom holding her hand, saying, "I know, I know." I was allowed to pull up a chair and have a "minor's version." I guess Mom figured I'd listen in from the top of the staircase anyway.
Jimmy and Pam had an early Christmas Eve dinner; they set out a few toys for their toddler and presented each other with their gifts. Then, Jimmy went out to plow so that families could get to church services or parties. After he finished, he'd head over to his brother's for a beer and a shot.
So Pam already had her gift, and produced it from her handbag: one pair of pantyhose, still in a J.C. Penney bag; no card, no wrapping. She inferred a message just the same: that she was not loved, appreciated or even seen: the pantyhose were Small and Pam was definitely not.
When Jimmy rolled in at midnight, he too had a visitor—Dad—who explained why Pam was sleeping off the eggnog in our guest room, and why Jimmy better shape up—unless by next Christmas, he wanted to be one of those sad sacks down at the Elks Club nursing a beer by himself.
Pam could have walked home safely (the town was a hive of deep social rest), but that time out was a useful intervention.
Frugality is fine and I suppose cheapness is a modus vivendi if both parties sign on for it; some couples find one another and pinch pennies to the end. But Pam's situation was different. On the lot, she worked side by side with Jimmy and his brothers; I see her still, hauling shrubs to trucks—and then put in a second shift of homemaking and child care. And that's why Mom found Jimmy unconscionably cheap.
That evening was the first time I saw how little women's work was valued; tiny seeds of feminism found soil. At fourteen I could not articulate it, but knew she deserved better.
Pam walked home at dawn. Mom suggested she leave the gift and its bitter memory behind, and said, "Give him another chance, you have a beautiful family."
That was far beyond cheap, or frugal. It was thoughtless. It was almost as if she had become some kind of utility to him.
Many people now decide not to exchange gifts in reaction to the "stuff" overload, but usually enjoy experiences of some kind together. In Québec, many extended families draw lots so that, in principle if not always in practice, one is buying a gift for a single family member.
By the way, this is also a splendid "short-short story".
What a charming photograph! It perfectly evokes Christmases past.
I had a cheap husband. He's a wonderful human being and I actually like him, but I never was a priority. This sounds like a horrid situation for Pam-it would be fascinating to hear what followed after this episode...did things get better? Did her son learn to treat women well? And an aside-I adore that house. It's so much like one I always wished were mine.
I had wondered what happened to it. It was a great read and good commentary. I'm glad you re-posted it.
Gretchen: It's a craftsman home built in 1905. I was able to tour it two years ago (after 45 years) and the current owner has invited us to stay next time. Not sure I could bear it. The inside has been heavily "updated" but the outside is exactly as originally built. A bit of trivia is that this was also a childhood home of Katie Brown, the cookbook author. The Browns bought it from my family.
re Pam and Jimmy: The landscaping business has stayed in the family, through three generations. Dad told me decades later that Jim's father had beaten all three sons as "discipline". I suspect Pam and Jim stuck it out, because I looked up their address and both names are still listed as residents. People can learn and grow at any point in life and I hope he did.
Oh, poor Pam - such a painful situation. We all come from our own families and however our Christmas was celebrated, is what we bring with us to our marriages/partnerships. I've been married almost four decades and it took years to get some balance between what we each wanted/expected. My family was more generous/extravagant and I found it difficult that my husband and his family weren't that way. They used to say "It's the thought that counts" when clearly there was no thought at all. It took years to get some balance. You can tell I'm not bitter at all.
If you care about people, you share what you have and you take time to select a gift that shows that you know the person. We all want to be appreciated and valued.
I'm glad this story has reappeared, and think it has a great deal of resonance for many.
I was laughing about thoughtless gifts and it morphed into "bad-taste gifts", and noted that Canadian Tire of all the staid places was featuring a toilet plunger with the business end in the shape of a ... turd. Franchement... This is in their latest flyer.
Many men, not all by any means, are not good gift buyers. They don't lack the will, they lack awareness perhaps. So they need help...as you pointed out in a previous post. And I have known some women who so little value themselves that they give a message of...no I don't want anything, I can't think of anything. Years of that and then the explosion when the lousy gifts become too much. Not blaming Pam at all, that 'gift' was the lowest of the low. Just saying that sometimes people need strong clear signals about what you would like to see under the tree.
I had a friend whose boyfriend gave her for her birthday, I think, a magazine on weight loss, with a torn-out ad. I was so furious that I had a telegram sent to him (when they came over the phone with a loud voice) saying "No self-respecting prig would sit next to you, you pig!
Kim: I agree that family background is a major influence, and when customs differ, it takes work to reach a mutually comfortable position (or agreement to not let it matter). A friend's longtime boyfriend, whom she eventually married after twenty-five years, would buy the same identical gift for his two teenaged daughters from a previous marriage, and her. He thought he was "being fair".
LauraH: It all comes down, in my mind, to whether he 'gets' the notion of giving, not in the material sense, but in that, too. Some partners just hate the idea of 'legislated giving' such as Christmas, Valentine's Day etc. OK, I see the point. Then I watch to see if the person is using it as an excuse, or enjoys giving at other times.
Another friend's partner took her to a concert of the kind of music he knew she loves, jazz, even though he is not a fan. A thoughtful, loving gesture.
Unknown: There is a message in that gift, and I'd like to know what she did. I had forgotten how telegrams could be used!
lagatta: Oh no. I'm surprised that was in an ad.
Lily: Many persons I know have discontinued Christmas gifts, and made the holiday a out caring for others, which is wonderful. And if you are going to give a gift, I think it should be one given with thought. I've written many posts over the past ten years on the deep and ancient rituals attached to giving. Lewis Hyde's "The Gift" is illuminating.
"Gift" also includes sharing one's talents and work. This blog is a gift. Every now and then someone says. thanks, which is lovely.
Such a rich post in so many ways -- the seeds of feminism remarked, retrospectively, in their planting. . . and I agree with Lagatta that, while non-fiction, this reads as a wonderful short story. You're such a good writer.
"A cheap man is a dreadful partner." Couldn't have said it better myself. And cheap people seem to pride themselves on it, too. Generosity of spirit and generosity with money go hand in hand, in my experience. My husband, from whom I'm amicably separated, was always a generous giver, with tipping, with refusing to nickel-and-dime the check after a night out with other people, with his time, and with his attention. That said, he wasn't particularly good at figuring out the perfect gift, but would gladly take a suggestion and then cheerfully go out and get it.


It seems that twitter new site, introduced some issue resulting in a worm exploiting a stored Xss.
It search for "#!" in the Url and assign the content after that to the window.location object. And it is present in (almost?) every page on twitter.com main site.
According to DOM Xss Wiki the location object is one of the first objects identified for being dangerous as it is both a source and a sink.
After spotting the issue, I sent an email to twitter warning them about it but not without apologizing for finding it in the middle of worm spreading.
The response was quite funny because, even if the issue was very straightforward, they cannot reproduce it because of safari antiXss filter.
Obviously I checked on every browser but Safari ... and guess what ? Safari blocked it! We'll talk about it later.
So I told them that it worked on Firefox, Chrome and Opera and after that they confirmed the issue, thanked me and so long. No more mails.
Thanks Gaz for the title.
Data Validation. 'c' is not validated as directed, that means every character but ":" is allowed. Data validation is about limiting the set of every possible input to an expected subset. Question is do we need to allow everything but one char?
BlackListing. It is widely known that blacklisting could lead to bypasses if it is done loosely.
No output encoding is applied. Since location assignment calls the URL Parser the context is quite known and have it's own metacharacters and structure. encoding in the URLParser context is also known as URLEncoding.
string for the first occurrence of searchString. Let m be 0.
The analysis tells that the fix is wrong, and in fact is possible to bypass the replace by doubling the colon ':' char.
The replace just deletes the first occurrence of ':' so we just add two ':'.
It has also the drawback to bypass several client side filters, Safari included.
if it breaks things use a whitelist of allowed chars before going to assign a to the location.
which at least let you stay on the same domain (not sure it works on every browser), but I don't know if it's ok for twitter.
Also, please, send me an email when the fix is done, cause I don't want to set a cron job to get when the fix is deployed.
Which resolves the multiple colons attack, but, IMHO, it is not really correct because of what I've said previously.
As a side consequence of the twitter DOM Xss I found myself playing with the Safari anti Xss filter.
It seems that it tries to find a match between the payload used in the assignment to location and the values in the Url in browser location bar.
After checking a bit in order to understand the behavior of the filter, I figured out that it urldecode the Url and then search for the pattern.
The problem comes because of that.
And there you have the bypass.
Twitter finally set a working patch to the second wrong fix (see comments).
Still not the best,IMHO, but at least it works...well, until there will be a bypass.
Also, since the patch just blocks ':' still remains an arbitrary redirect issue.
As it was to be expected, there is a bypass (already public) which works on IE8 (~26% market share).
I found it yesterday independently by Gareth Heyes and Yusuke Hasegawa and reported to Twitter security team.
The bypass takes advantage of the html entity version of ':' which is : or :.
Internet Explorer 8, unlikely other browsers, when finds an entity converts it to its original value when it is assigned to the location object.
will let the browser to go to ':' and not to literally "&x58;"
So, when the patch tries to replace ':' to an empty value, it won't find it, but the assignment to the location will convert it again to a colon.
is still valid (not in blacklist).
As I suggested in my first email.
What happens here is that the assignment is performed on the correct attribute (the pathname) so that it is parsed in the right context with no possible bypasses to force a new URI scheme.
Now everything *should* be really ok... well, if all browsers will behave in the right way!
It seems twitter did not test the patch on every browser.
IE doesn't recognize the third argument.
For the readers, this attack is also stealth since everything that follows "#" is not sent to the server!
Another update, I just wrote to them telling about the new issue since the last fix implemented by twitter seems to work _only_ on Firefox.
As the default, all of their testers should have browsers with XSS filters and pop-up blockers turned off.
Even if its not on their main browsers they should have access to browsers with those settings via their VM's.
I also raised an XSS issue in IE but it only ran with the XSS filter turned off (and at first they also couldn't reproduce it).
I thought it may have been due to the fact the users had to be logged out (the XSS was on the login form) however I'm now thinking it was due to their browsers having all of the filters turned on.
That could be a good explaination of what happened.
It still means that some process needs to be improved.
no you did not miss anything...it's known.
as we already said in the comments.
They failed fixing it. The fix works only on Firefox.
I haven't seen anything like that in the newtwitter interface, have you had a look at it?
I cant understand what you mean.
The story, finally seems to have come to a good ending..
Patched using a correct context aware assignment!
And this time no open redirects as well!


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text:
Death rate from heart attack higher in U.S. territories than on mainland
There is a 17% greater risk of dying after a heart attack if you are treated in a hospital located in a U.S. territory than in a hospital in the mainland U.S.
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There is a 17% greater risk of dying after a heart attack if you are treated in a hospital located in a U.S. territory-i.e. the U.S. Virgin Islands, Guam, Puerto Rico, American Samoa, and Northern Mariana Islands-rather than in a hospital in the mainland United States, according to new findings published in the Archives of Internal Medicine.
The study by Yale School of Medicine researchers shows that many U.S. citizens who call the U.S. territories home, are at a major healthcare disadvantage.
Led by Marcella Nunez-Smith, M.D., assistant professor at Yale School of Medicine, the authors used data from Medicare to study all patients suffering from a heart attack who were admitted to 57 hospitals in the U.S. territories. They compared these to heart attack patients admitted to 4,799 hospitals in the mainland between July 2005 and June 2008. They found that the risk of death within 30 days after a heart attack was substantially higher for patients in all of the U.S. territories.
"We were shocked by these findings," said Nunez-Smith. "These are serious and substantial differences and translate into increased lives lost in the U.S. territories."
Nunez-Smith and her colleagues sought explanations for these findings by exploring whether patients overall just got sicker in the U.S. territories, but found the answer was "no."
"This work does put the spotlight on the need for increased resources in the U.S. territories to improve the quality of care," said Nunez-Smith. "One potential policy area for follow-up would be Medicare reimbursement rates. Hospitals in the U.S. territories have the lowest reimbursement rates of anywhere in the nation. We plan to do follow-up work with hospitals in the U.S. territories and policymakers to identify opportunities to improve health outcomes for people who live, work and play in the U.S territories."
Other Yale authors on the study include Elizabeth H. Bradley, Jeph Herrin, Calie Santana, M.D., Leslie A. Curry, Sharon-Lise T. Normand and Harlan M. Krumholz, M.D.
Nunez-Smith's work was partially funded by the Yale Clinical and Translational Science Award (CTSA) grant from the National Center for Research Resources at the National Institutes of Health.
Citation: Arch. Intern. Med. doi:10.1001/archinternmed.2011.284. (June 27, 2011).
— By Karen N. Peart
Karen N. Peart: karen.peart@yale.edu, 203-980-2222
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