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The main limitation of this study was its pilot character due to heart attack 45 years old cheap bisoprolol 10 mg amex its small sample size. However, this study was performed in preparation of a larger multi-centre study; providing us with useful information concerning the sample size calculation, study design and questionnaire. Novel web-designed applications and/or questionnaires could help receiving more specific information from participants travelling to remote countries. Acknowledgements We thank the patients and controls who participated in this study. We thank our colleagues who consulted the participants and asked their consent for participation. Travel advice for the immunocompromised traveler: prophylaxis, vaccination, and other preventive measures. Travel-related health risks in moderately and severely immunocompromised patients: a casecontrol study. International travel by persons with medical comorbidities: understanding risks and providing advice. Knowledge, attitudes and practices in travel-related infectious diseases: the European airport survey. Trends in the knowledge, attitudes and practices of travel risk groups toward prevention of hepatitis B: results from the repeated cross-sectional Dutch Schiphol Airport Survey 2002-2009. Symptoms of infectious diseases in immunocompromised travelers: a prospective study with matched controls. Epidemiology and Risk Factors for CommunityAssociated Clostridium difficile Infection: A Narrative Review. An extra priming dose of hepatitis A vaccine to adult patients with rheumatoid arthritis and drug induced immunosuppression - A prospective, open-label, multicenter study. Immunocompromised Travelers: Demographic Characteristics, Travel Destinations, and Pretravel Health Care from the U. This is of particular relevance since unawareness of the importance of this vaccination by physicians and patients is identified as a significant factor for a low pneumococcal vaccination coverage worldwide (2-5). This underpins the importance of current pneumococcal vaccination recommendations. Nonetheless, these studies emphasized that more research is needed; applying uniform and internationally accepted definitions and correlates of protection, and investigating the immunogenicity of innovative vaccination schedules. Furthermore, the importance, and need for implementation in current vaccination guidelines, of antibody concentration measurements post-vaccination is underscored. However, most importantly, further research in this field, using uniform definitions and correlates of protection, is needed. Therefore, pneumococcal vaccination is recommended in infants, the elderly, and risk groups (18, 19). The frequency at which an infection occurs, thus the incidence rate, is one of the fundamental building blocks at which such a vaccination recommendation should be built. In included studies seroconversion was most often defined as a two-fold increase in antibody concentrations pre- and post-vaccination. One meta-analysis in immunocompetent individuals showed no relation between pre- and post-vaccination antibody concentrations (36). We concluded that immunosuppressive treatment negatively affects intervals of protection after pneumococcal vaccination. Therefore antibody concentration measurements and possibly a booster vaccination in the years after pneumococcal vaccination are needed. However, hyporesponsiveness, by which an initial dose of pneumococcal vaccination limits the number of responding B-cells after subsequent doses of pneumococcal vaccination, has been described (42, 43). This prospective cohort study was one of the first studies that evaluated immunogenicity of the currently recommended schedule in patients receiving immunosuppressive therapy. This finding implicates that hyporesponsiveness can indeed play a role in the immunogenicity of vaccination schedules with subsequent pneumococcal vaccinations. Furthermore, vaccination should best be administered before the start of immunosuppressive therapy.

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There have been reports of decreased fetal heart-rate modulation (Yogev 2002) blood pressure upper number bisoprolol 5mg sale, sedation, jitteriness or other withdrawal symptoms in the newborn (Gentile 2004). There are reports on more than 200 pregnancies exposed to olanzapine (McKenna 2005, Levinson 2003, Ernst 2002, Mendhekar 2002, Biswas 2001, Malek-Ahmadi 2001, Nagy 2001, Neumann 2001, Goldstein 2000, Kirchheiner 2000, registry data of the producer), none of which indicate teratogenicity. There were three retrospective reports with neonatal seizures after exposure until the end of pregnancy (Goldstein 2000, observations of the authors). Glucose intolerance and onset of gestational diabetes have also been reported after the use of olanzapine in pregnancy (Gentile 2004). Olanzapine has also been associated with pre-eclampsia (Yonkers 2004, Kirchheiner 2000). Based on about 40 published case observations and 150 pregnancies registered by the producer, there is no indication to date for 2 Pregnancy 2. There are about 60 pregnancies exposed to risperidone in the published literature (McKenna 2005, Yaris 2004B, Ratnayake 2002, MacKay 1998), and approximately 200 pregnancies collected by the producer, none of which indicate teratogenic effects. With respect to amisulpride and ziprasidone, there is insufficient experience with their use in pregnancy. However, up to now there are no reports indicating a specific teratogenic potential in humans. Atypical antipsychotics may be used during pregnancy when treatment of acute psychosis or chronic psychotic illness is necessary. If possible, olanzapine or quetiapine are preferred because these have the most documented experience in pregnancy. Furthermore, a pregnant patient who is stable with one of the less well-known antipsychotics should not be changed to another drug, because this may worsen her health. However, a detailed fetal ultrasonography may be offered after their use in the first trimester. Observation of the neonate for withdrawal symptoms or adaptation problems for at least 2 days is recommended when atypical antipsychotics have been used up to delivery. Tiapride has only weak neuroleptic properties, and is used for the treatment of tardive dyskinesia caused by neuroleptic drugs (see section 2. Furthermore, a pregnant patient who is stable with these drugs should not be changed to another drug because this may worsen her health. Regular psychiatric and obstetric care is recommended to diagnose in time a relapse or pregnancy complications (intrauterine growth retardation, premature contractions). Observation of the neonate for withdrawal symptoms or adaptation problems for at least 2 days is recommended when neuroleptics have been used up to delivery. They are well-absorbed from the gastrointestinal tract, and are excreted by the kidneys. Lithium crosses the placenta, and fetal plasma concentrations are similar to or higher than maternal plasma concentrations. Based on their findings, Viguera and colleagues suggest that clinicians managing women with bipolar disorders who are planning to conceive should consider the high risk of relapse associated with lithium discontinuation in the overall risk/benefit assessment (Viguera 2000). The teratogenic risk of first-trimester lithium use now appears to be lower than previously suggested (Yonkers 2004, Viguera 2002, Cohen 1994, Jacobson 1992, Zalzstein 1990). Other adverse effects which have been reported occasionally are polyhydramnios after fetal polyuria, stillbirth, fetal and neonatal 306 2. During delivery, the renal clearance of lithium decreases considerably, possibly resulting in toxicity for both the mother and the neonate. A "floppy infant syndrome" was described in this context, characterized by lethargy, poor sucking, tachypnea, tachycardia, respiratory stress syndrome, cyanosis, and hypotonia (Kozma 2005). Therefore, lithium should be discontinued prior to delivery (or the dose should be decreased by 30­50%). Immediately after delivery the pre-pregnancy dose should be reinstituted in order to prevent relapse. Some authors recommend controlling thyroid function in both the pregnant woman and the neonate (Frassetto 2002, Llewellyn 1998). The pharmacological treatment of bipolar disorders also includes the known teratogens valproic acid and carbamazepine, and some of the newer anticonvulsants, such as gabapentin and lamotrigine. First-trimester use of carbamazepine and of valproate is associated with an increased risk of spina bifida of 0.


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There is no information on toremifene and fulvestrant blood pressure qof buy 5 mg bisoprolol amex, an estrogen antagonist, during pregnancy. Some case reports with aminoglutethimide describe masculinization of female fetuses as well as normal development (overview in Schardein 2000). The aromatase inhibitor letrozole is prescribed to postmenopausal women with hormone-dependent breast carcinoma. Recently, letrozole has also found application in the treatment of sterility, in order to stimulate ovulation ­ for example, as alternative to clomiphene. A recently published retrospective study on 911 newborns from women who conceived following clomiphene (n 397) or letrozole (n 514) treatment found no difference in the overall rates of major and minor congenital anomalies (Tulandi 2006). There are no data on the use of the aromatase inhibitor exemestane during pregnancy. In contrast to thalidomide, lenalidomide does not produce limb malformations in rabbits, but deaths, abortions and total litter losses (Christian 2006). There were no cytotoxic or mutagenic effects in in vitro tests with amniotic fluid (Bussing 1995). However, because viscum album therapy may provoke fever and clinical data are insufficient to rule out prenatal toxicity, exposure should be avoided during pregnancy. However, according to the available information, a causal relationship can be neither proven nor eliminated (Stucker 1990). During pregnancy, regular professional handling of cytostatic drugs should be discontinued. However, if a nurse or pharmacist has been working in a relevant department before the pregnancy was known, there is no need to take any diagnostic measures and no justification for the termination of the pregnancy on the basis of an assumed risk. Cardiotoxic tranplacental effect of idarubicin administered during the second trimester of pregnancy. Methotrexate/misoprostol embryopathy: report of four cases resulting from failed medical abortion. Outcome of discontinuation of imatinib therapy after achieving a molecular remission. Combined chemotherapy and radiotherapy during conception and two trimesters of gestation in a woman with metastatic breast cancer. Teratogenic effects in a case of maternal treatment for acute myelocytic leukaemia ­ neonatal und infantile course. Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children. Acute leukemia in pregnancy: report of five cases treated with a combination which included a low dose of adriamycin. Multiple congenital anomalies associated with weekly low-dose methotrexate treatment of mother. Neoadjuvant chemotherapy followed by radical hysterectomy for invasive cervical cancer diagnosed during pregnancy: report of a case and review of literature. Different pattern of developmental effects for structurally similar drugs, thalidomide and lenalidomide . Successful fetal outcome after exposure to idarubicin and cytosine-arabinoside during the second trimester of pregnancy ­ a case report. Hydroxyurea use during pregnancy: a case report in sickle cell disease and review of the literature. An endodermal sinus tumor diagnosed in pregnancy: case report and review of the literature. Successful treatment of acute promyelocytic leukemia in pregnancy with all-trans retinoic acid. Treatment of metastatic breast cancer with trastuzumab and vinorelbine during pregnancy. Clinical teratology counseling and consultation case report: low dose methotrexate exposure in the early weeks of pregnancy. Management of an advanced ovarian cancer at 15 weeks of gestation: Case report and literature review. The safety of 6-mercatopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study. Chemotherapy with epirubicin and paclitaxel for breast cancer during pregnancy: case report and review of the literature.

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Thus as academic marketing and consumer researchers our main heart attack vol 1 pt 3 generic 10 mg bisoprolol with amex, or only, model of focus group research is drawn from the extensive practitioner literature on the subject. We discuss the three key issues in undertaking focus group research, namely the role of group dynamics, the theories that inform focus group research approaches, and focus group implementation practices. In doing so we argue that there is far more variety, innovation and creativity in focus group research than is generally assumed. However it is more likely that the focus group emerged in a number of different geographic and disciplinary locations over a period of 30 years. Additionally, the focus group emerged from a number of different disciplinary locations including anthropology (Wilson and Wilson, 1945), sociology (Merton and Kendall, 1946), psychology (Bogardus, 1926), education (Edmiston, 1944) and advertising (Smith, 1954), all of which provide different theoretical perspectives on focus group research today. The emergence of the focus group in the advertising industry seems to have been a chance discovery (Goldman and McDonald, 1987). In Britain, Mark Abrams (1949) was one of the first market researchers (anywhere) to publish a detailed account of the group discussion method and how it could be usefully employed for testing advertising copy and illustrations. Similarly, George Horsley Smith undertook his first group interview in 1951 for a client that needed information on consumer behaviour within a few days. Since a survey could not be completed within the time available, the group interview was devised as a solution. Herbert Ableson, of Opinion Research Corporation, discovered the group by accident in 1957, when some respondents recruited for individual interviews turned up early and others late. Rather than interview them one at a time, he interviewed them collectively (Goldman and McDonald, 1987). The individual depth interview was their method of choice and had been since the origins of motivation research in the late 1920s. However, by the end of the 1960s, individual depth interviews had been comprehensively superseded by focus groups (Bellenger, Bernhardt and Goldstucker, 1976). This remarkable turnaround in the fortunes of the individual interview appears to have been due to its time and cost disadvantages when compared with focus groups. A project that involved a programme of individual interviews would require a number of suitably qualified interviewers, then in short supply, whereas a single moderator could undertake all of the focus groups necessary to complete a project. Additionally the individual interview project would take longer to complete and eat up costly researcher time. Thus the individual depth interview lost its once pre-eminent position in qualitative market research because it was too difficult and expensive to implement and not because the focus group was considered to be the more desirable technique. Indeed there was little discussion in the early market research literature on the theoretical underpinnings or methodological justification for the technique. An exception to this was the assumption that group dynamics would have a positive impact on the data generated in groups. In other words the primary methodological justification for the focus group is the role that group dynamics plays in generating data that would not be accessible if respondents were interviewed individually (Morgan and Krueger, 1997). In the discussion that follows we explore this methodological justification for focus groups. Group dynamics at the heart of focus group methodology One of the most consistent findings from the small group research literature in psychology is that all groups, no matter how temporary, will be subject to group processes or dynamics. These group dynamics are of benefit in focus groups in that the group environment provides greater security and anonymity for its members, encourages participants to speak out in front of others, and is also supportive and exciting. Simultaneously group dynamics are considered to be the main drawback of focus groups (Bristol and Fern, 1993). The discussion in the group may be dominated by one or two forceful individuals who suppress or unduly influence the views of other participants. As a result, individual attitudes and opinions can be contaminated or polluted by group interaction (ibid. Focus groups in marketing research 257 Thus the only distinctive methodological feature of the focus group is represented as its primary strength as well as its main weakness. Market researcher practitioners have appealed to the group literature in psychology to justify the benefits of group interaction in generating data.

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A randomized blood pressure yoga asanas bisoprolol 10mg amex, double-blind, hemodynamic evaluation of nifedipine and labetalol in preeclamptic hypertensive emergencies. Congenital hypertrophic cardiomyopathy associated with in utero verapamil exposure. Sodium nitroprusside for control of severe hypertensive disease of pregnancy: a case report and discussion of potential toxicity. Fetal distress after hydralazine therapy for severe pregnancy-induced hypertension. Acute effects of dihydralazine mesylate, furosemide, and metoprolol on maternal hemodynamics in pregnancy-induced hypertension. Adverse pregnancy outcomes associated with maternal enalapril antihypertensive treatment. Neonatal suppurative parotitis possibly associated with congenital cytomegalovirus infection and maternal methyldopa administration. Acute pulmonary oedema during nicardipine therapy for premature labour report of five cases. A randomized, double-blind trial of oral nifedipine and intravenous labetalol in hypertensive emergencies of pregnancy. Do commonly used oral antihypertensives alter fetal or neonatal heart rate characteristics? Pregnancy outcome after exposure to calcium-channel blockers during first trimester. Chronic measurement, using a Doppler probe, of uterine artery flow in the gravid guinea-pig. Pulmonary vascular disease and pregnancy: currrent controversies, management strategies, and perspectives. Lupus-like syndrome in a mother and newborn following administration of hydralazine: a case report. As described historically by Virchow, there are, in his opinion, three factors that predispose an individual to the development of venous thrombosis: hypercoagulability, vascular damage, and stasis. Fibrinolytic activity decreases due to the increased levels of plasminogen activator inhibitors produced by the placenta. These changes represent the physiological preparation for the hemostatic challenge of delivery (Greer 1999, Dizon-Townson 1998). In addition, venous flow decreases from the lower extremities (stasis), and delivery and placental separation create vascular damage (Dizon-Townson 1998). Management of pregnant women with thrombophilias is still subject to debate in the recent literature (see section 2. Universal agreement regarding thromboprophylaxis during pregnancy has not been established to date, because of the lack of reliable data on the specific risks and the efficacy of thromboprophylaxis. A prior thrombotic event or thrombophilia is not currently viewed by all clinicians as an indication for thromboprophylaxis during pregnancy (see section 2. When administered in prophylactic, low dosages (subcutaneous), it is mainly factor Xa that is neutralized; in higher therapeutic dosages, thrombin will also be neutralized. Heparins can initiate plasminogen activator release by endothelial cells, and this accounts for their fibrinolytic activity. Heparins are broken down in the gut, and require a parenteral route of administration (intravenous or subcutaneous). They have a poor bioavailabilty (10%), are metabolized in the liver, and have a half-life of about 4­6 hours. Heparin does not cross the placental barrier due to its high molecular weight and its negative charge. They are heparin fragments produced by chemical or enzymatic depolymerization, and their molecular weight ranges from 4000­6000 daltons. Long-term heparin therapy (>1 month) may be associated with increased bone loss, particularly during pregnancy, which is probably a cause of reversible bone demineralization in itself. Low molecular-weight heparins have now largely replaced unfractioned heparin, because of their improved safety profile. This was confirmed in several publications, which included the use of enoxaparin, dalteparin, nadroparin, tinzaparin, and certoparin. At present, thromboprophylaxis during pregnancy is still controversial (Cetin 2005, Bates 2004, Greer 2003, Brenner 2003, Gebhardt 2003). However, consensus has been reached on thromboprophylaxis for recurrent pregnancy loss in patients with antiphospholipid syndrome.


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  • Medicines through a vein (IV) to prevent infection
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Medications for treating gout attacks include (in addition to hypertension guidelines jnc 7 order bisoprolol 10 mg on line nonsteroid antiphlogistics such as ibuprofen) phenylbutazone and the mitosis inhibitor colchicine. Assuming 636 References the maximum value mentioned, close to 10% of the maternal weightrelated dosage would be calculated for the infant. These four infants and other exposed infants followed by the author for 2 years developed unremarkably (Ben-Chetrit 1996). Phenylbutazone, which has a strong antiphlogistic effect and a weak analgesic and antipyretic effect, is distinguished by an immune toxic effect on hemopoiesis, fluid retention, and a long half-life of 30­170 hours. Probenecid is the drug of choice for interval treatment of gout during breastfeeding. Colostrum morphin concentrations during postcesarean intravenous patient-controlled analgesia. Epidural sufentanil for post caesarean pain: breast milk level and effects on the baby. Intravenous propofol during caesarean section: placental transfer, concentrations in breast milk and neonatal effects. Toxic hemolytic anemia in the newborn infant following ingestion of a phenazone derivative (Cibalgin) via breast milk . Buprenorphine and norbuprenorphine concentrations in human breast milk samples determined by liquid chromatographytandem mass spectrometry. Prospective follow-up of adverse reactions in breast-fed infants exposed to maternal medication. Opiate addiction in adult offspring through possible imprinting after obstetric treatment. Analgesia and side effects after a single bolus dose during elective caesarean section. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Passage of paracetamol into breast milk and its subsequent metabolism by the neonate. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. The excretion of ketorolac tromethamine into breast milk after multiple oral dosing. Exogenous opioids in human breast milk and acute neonatal neurobehaviour: a preliminary study. Rarely, mild restlessness, sedation or weak sucking ­ none of them needing treatment ­ are described in the breastfed baby (see, for example, Moretti 1995). Loratadine and cetirizine are the most used new-generation H1-blockers, which have practically no sedative effect, and do not cross the blood­brain barrier. The plasma half-life of astemizole is 26 hours, and that of the metabolites up to 9 days. There was shown to be an accumulation of the substance when very high doses were administered (information from the manufacturer). In connection with the use of brompheniramine plus d-isoephedrine during breastfeeding, a hyperexcitable infant was described (Mortimer 1977). The half-life of 9 hours is quite short, and the medication has scarcely any sedative or atropine-like action. Stiff neck, hyperexcitability, and sleepiness were observed in the infant of a mother being treated with clemastine, and 5­10 g of the substance per liter was detected in the milk. This common H1-blocker has a short half-life of 5­7 hours, and there are recommended doses for children beginning at 1 year. Dimetindene has relatively little sedative action, but has an atropinelike effect that should not be overlooked. Diphenhydramine was recommended by the American Academy of Pediatrics for the breastfeeding period. However, because of the strong sedative effect, its use as an antiallergic can no longer be justified. Following a single dose of 40 mg of loratadine, a transfer to the infant of about 1% of the effective substance (including metabolite) was calculated, compared to the maternal weight-related dosage (Hilbert 1988). There were no symptoms observed among the breastfed infants of 51 women treated with loratadine (Merlob 2002).

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However pulse pressure variation normal values purchase bisoprolol 10 mg online, tinnitus usually "sneaks up" on you, so that the onset of tinnitus often goes unnoticed until it is too late. Therefore, everybody should receive tinnitus education and wear ear protection after age 40 - 50 during piano practice, especially if there is any noticeable tinnitus, which is the easiest measure of hearing loss - louder tinnitus indicates greater hearing loss, so avoid activities that increase tinnitus. Ear protection is initially an abhorrent idea to most pianists but when you consider the consequences, it is definitely worthwhile. Moreover, once you start to use it regularly, you may start to feel sorry for those not wearing protection, because you know how soon they will start to suffer ear damage. Before wearing protection, do everything possible to reduce sound intensity, such as soundproofing the room (adding carpets to hard floors, curtains to hard walls, etc. Ear damage is cumulative and partly self-healing, so occasional loud sounds can be harmless. Soundproofing a room is easy because you only need to prevent multiple reflections, which can be accomplished by soundproofing only two or three surfaces. An alternative to ear protection is to practice on digitals with the volume turned down. Ear protectors (noise canceling is not necessary) are readily available from hardware stores because many workers using construction or yard equipment need such protection. For pianists, an inexpensive unit or light headphones will suffice because you need to hear some music. Commercial noise canceling protectors completely surround the ear and provide a better sound barrier; turn off the noise cancellation, and you will still get sufficient protection. Although the sound through the headphones will be different from the original, the human ear adapts quickly and you will get used to the new sound. For example, you will realize that the piano makes many strange (mechanical) sounds you never noticed before! For lower quality pianos, ear protection will result in sound simulating a higher quality instrument because the undesirable high harmonics and extraneous sounds are filtered out; that is, sound filters tend to preferentially filter out the more harmful sounds. The brain automatically processes any incoming data, whether you want it to or not. In the future, piano students will wear ear protection (or turn the volume down for digital pianos), just as many athletes and construction workers use helmets today. This type of music hits the same note repeatedly, thus over-stressing that part of the auditory system. Concert grands that transfer energy efficiently into the strings with long sustain probably do not cause as much damage as medium quality pianos in which a large amount of energy is imparted into the initial, percussive bang associated with the hammer striking the strings. In this regard, the condition of the hammer is important, since a worn hammer can produce a much louder initial bang than a properly voiced hammer. This is why worn hammers cause more string breakage than new or well voiced hammers. Thus proper voicing of the hammer may be more important than many people realize, for practicing pianissimo, playing musically, technical development, and protecting the ear. If you have to close the lid of a grand in order to play softly, or to reduce the sound to a pleasant level, the hammers probably need voicing. Some of the loudest sounds are produced by even tiny ear phones used to listen to music. Parents should warn their youngsters not to keep turning up the volume, especially if they subscribe to the culture that plays loud music. Some youngsters will fall asleep with their ear phones blasting; this can be very damaging because ear damage is cumulative. It is a bad idea to give gadgets with ear phones to youngsters - postpone it as long as possible. Important: On the other hand, this the time to introduce them to the "right type" of music; you must learn how to give them recordings of music you want them to listen to, and how to play them on their devices. Then they can listen to a lot of good music while walking to school or riding in a car. Except for some special cases of tinnitus (such as those in which you can alter the sound by moving your jaws, etc. Large doses of aspirin can cause tinnitus; in that case, stopping its use can sometimes reverse the damage.

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This also holds true for breast cancer (Merlob 2004) arteria pack order 10mg bisoprolol free shipping, which is, however, frequently noticed only at a later stage of 2. Except for melanoma, there are no case reports regarding metastases in the placenta or fetus. When a cancer is diagnosed during the first trimester, many couples opt to terminate the pregnancy in view of the potential teratogenic risk of the ensuing treatment; therefore, experience is limited. However, the cases that have been documented demonstrate that malformations are by no means mandatory. Depending upon the chemotherapy and the dose administered, multi-agent chemotherapy given during the second or third trimester may lead to fetal growth restriction and/or transient bone marrow depression, involving fetal anemia, leucopenia, and thrombocytopenia. Surprisingly, the fetus tolerates chemotherapy in most cases without persisting damage. So far, no impairment of intellectual development has been observed (Nulman 2001). Premature delivery is often discussed during the third trimester in order to have a "free hand" in the choice of therapy, and to avoid exposure of the fetus to potentially toxic substances. As women in many countries are delaying childbearing, it seems probable that the incidence of breast cancer during pregnancy will increase. Compared to other malignant diseases, there is already a large amount of experience regarding breast cancer treatment which was indicated in the second or third trimester during pregnancy. A number of case reports and some studies provide evidence that neonatal related morbidity is low, including the following (see also various sections below): 2 Pregnancy 2. Following chemotherapy for cancer, a general waiting period is recommended, prior to conceiving, of 2 years for women and 6 months for men. However, there is no reason to terminate an intact and wanted pregnancy should conception occur earlier than this. Cancer during pregnancy is rare, and requires the largest possible interdisciplinary expert medical and psychosocial support. Each type of cancer during pregnancy requires individual consultation and treatment. Cancer and other malignant diseases are treated according to optimized therapy protocols which also apply to pregnancy, in order to ensure the best chances of survival for the pregnant woman. For this reason, this chapter does not contain suggestions for therapy from an embryo-toxicological perspective. Apart from careful gynecological monitoring, in any case of cancer therapy during pregnancy a detailed fetal ultrasound examination should be offered to evaluate morphological development. There are no general recommendations concerning storing sperm or eggs before cancer therapy; the decision should be made on an individual basis. Cytostatics, by far the largest group, are subdivided into six subgroups: vinca alkaloids and their analogs podophyllotoxin derivatives alkylating agents (nitrogen mustards and analogs, and other alkylating agents) antibiotics with antitumor properties antimetabolites other cytotoxic drugs. Other antineoplastics, including: platinum compounds other agents monoclonal antibodies. Endocrine antineoplastics, including: hormones hormone antagonists enzyme inhibitors. Apparently, antimetabolites possess the strongest teratogenic potential after transretinoic acids such as tretinoin (see Chapter 2. Like the related vincristine, it inhibits cell division by interfering with the mitotic spindle. There are more than 15 case reports concerning the use of vinblastine during the first trimester, mostly in combination with other cytostatic drugs. However, there are also reports of children with malformations: a child with hydrocephalus after intrauterine exposure to vinblastine alone in week 3; a second with cleft palate whose mother had received vincristine and other cytostatic drugs from week 9 until delivery, following treatment with vinblastine until week 6; and a spontaneous miscarriage shortly after injection of vinblastine in week 6 (Mulvihill 1987). There is also a report of a spontaneous miscarriage of a male fetus with only four toes on each foot and syndactyly in week 24 of pregnancy (Garrett 1974), as well as a male infant delivered at 37 weeks weighing only 1900 g with a defect of the atrial septum who died of respiratory distress syndrome and whose mother had been treated with vincristine and vinblastine (Thomas 1976). The mothers of these latter four children had received vinblastine in combination with several other agents. There are some reports with normal outcome after exposure during the second and third trimesters (Doll 1989). There are more than 20 case reports regarding apparently normal children following vincristine therapy during the first trimester (for an overview, see Schardein 2000 and

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Visual genealogy hypertension headache cheap bisoprolol 10mg with amex, critical analysis and research insights Many insights emerge from critical visual analysis that would be difficult to generate with traditional social science approaches. Links to the tradition of fine art serve to remind us that advertisements have a visual and historical genealogy. Genre analysis produces generalizable insights into contemporary marketing images. Quoting or mimicking an art historical tradition helps ground it for the viewer, drawing associations to the visual tradition. Drawing upon aspects of the group portrait contributed to understanding the perceptual categorization of people pictured within a frame as belonging to a group, or having something in common, what I call the ideology of the group portrait. Rather we have built up this cultural association to Critical visual analysis 319 the point where it now underlies perceptual and cognitive processes of group attribution: when we see people together in a picture, we assume that they belong to some group. Once again, as sophisticated ad viewers, we should realize that they may or may not actually use the endorsed product, and that their group membership lasted only a day or two for the shoot. In contrast, we assume that the Militia companies and guilds in Dutch portraits constituted a group before, during and after the portrait making. Finally, critical visual analysis points out limitations in an information-processing model of consumption, one in which culture, history and style are attenuated. In contrast, critical visual analysis points out how white space imbues images with meaning. Critical visual analysis points to the cultural and visual context of ads within the flow of mass culture, underscoring the powerful role marketing plays both in the political economy and in the constitution of consuming subjects. A key element of critical visual analysis often entails constructing a visual genealogy of contemporary images, to contextualize and historicize them, and point to the cultural domain of contemporary visual consumption (see Schroeder and Zwick, 2004). Most consumers are not necessarily visually literate, and art historical references and conventions may not consciously inform their viewing of an ad. Likewise, most language speakers have a limited awareness of the linguistic horizon that shapes their use of vocabulary, grammar and syntax; nor do they have a well developed sense of how language developed over time. Furthermore the renewed popularity of Dutch Art, spurred by the success of books, exhibitions and films such as of the Girl with the Pearl Earring, demonstrate how Dutch images recirculate through culture. Conclusion the interactions of identity, consumption and image represent one of the critical imperatives of contemporary consumer culture. Critical visual analysis affords new perspectives for investigating specific cultural and historical references in contemporary images. Researchers can take advantage of useful tools developed in art history and cultural studies 320 Handbook of qualitative research methods in marketing to investigate the poetics and politics of images as a representational system. Constructing a visual genealogy of contemporary images helps illuminate how marketing acts as a representational system that produces meaning beyond the realm of the advertised product, service or brand, connecting images to broader cultural codes that help create meaning. References Alpers, Svetlana (1984), the Art of Describing: Dutch Art in the Seventeenth Century, Chicago: University of Chicago Press. Barnet, Sylvan (2002), A Short Guide to Writing About Art, 7th edn, New York: Longman. Barrett, Terry (2005), Criticizing Photographs: An Introduction to Understanding Images, New York: McGrawHill. Bloom, Lisa (1999), With Other Eyes: Looking at Race and Gender in Visual Culture, Bloomington: University of Minnesota Press. Gaines (1994), Obsession: the Lives and Times of Calvin Klein, New York: Carol Publishing Group. Schiff (eds), Critical Terms for Art History, Chicago: University of Chicago Press, pp. Francis, Mark and Margery King (1997), the Warhol Look: Glamour, Style, Fashion, Boston: Bulfinch Press. Goffman, Erving (1979), Gender Advertisements: Studies in the Anthropology of Visual Communication, New York: Harper & Row. Jackson (1994), Fables of Abundance: A Cultural History of Advertising in America, New York: Basic Books.

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And over the silk counter in the main hall there was the miracle heart attack manhattan clique edit remix buy bisoprolol 10 mg otc, the altar of this cult of white-a tent made of white curtains hanging down from the glass roof. Muslin, gauzes, and guipures flowed in light ripples, while richly embroidered tulles and lengths of oriental silk and silver lamй served as a background to this gigantic decoration, which was evocative borh of the tabernacle and of the bedroom. It looked like a great white bed, its virginal whiteness waiting, as in legends, for the white princess, for she who would one day come, ali powerful, in her white bridai veil. We now need no intermediaries in this novel ontological explora tion, and characters become the most perfunctory pretexts for what is virtually an autonomous unfolding of sense data, as in the virtuoso chapter on the cheeses, in which the two hostile observers, Mme. Des port-salut, semblables а des disques antiques, montraient en exergue le nom imprimй des fabricants. Et, derriиre les balances, dans sa boоte mince, un gйromй anisй rйpandait une infection telle que des mouches йtaient tombйes autour de la boоte, sur le marbre rouge veinй de gris. On che cwo shelves ac che back of the stail were huge blocks ofbutter: Brittany butter overllowing its baskets; Normandy butter wrapped in cloch, looking like models ofbellies on co which a sculptor had chrown sorne wet rags; ocher blocks, already eut into and looking like high rocks full of valleys and crevices. Under che display counter of red marble veined with grey, baskets of eggs shone like white chalk; while on layers of straw in boxes were bondom placed end co end, and gournays arranged like medals, forming darker patch es timed with green. Two of them, very dry, were ac che full; che chird, in its second quarter, was melting away in a white cream, which had spread into a pool and llowed over che chin boards chat had been put chere in an attempt co hold it in check. Sorne port-salut, shaped like anciem diseuses, bore che printed names of cheir makers. The warm afternoon had softened the cheeses; the mould on the rinds was melting and glazing over with the rich colours of red copper verdigris, like wounds thar have bad! Here, however, the world multiplies and pullulates over against the observing subject, delirious from the cascading names as they begin to translate them selves into infinite space itself. That peculiar taste has suddenly left Zola free in the present to collect the names of our own richly commercial and exploratory world in a present open to the senses. Yet names are not enough, and now the piles and well-nigh infi nite variety of commodities find their way into the other senses at the same time that they barrow their distinct temporalities, and along with smell, a sonorous dimension appears which reorganizes 11 the Bel/y ofParis, 2 1 0- 1 1. We must then here distinguish two distinct allegorical levels: the sensory one, in reality itself multiple, which is necessary in order to endow the inert multiplicity of these material things-fish or cheeses-with their appropriate intensities; and then the parallel with the gossiping women, for whom the multiplicity ali around them is in fact the multiplicity of Rumor itself, as it sends its horde of messages and distortions into an outside world as vast as outer space. Rather, as the theorists of film theory have suggested, from Eisler to Marie-Claire Ropars, there must be an essential disjunction of the image and the sound track, no longer to be considered as background music or voice-over, but rather in its semi-autonomy to be counter pointed with the visible events, syncopated with them as Gertrude Stein says about drama, either a little too early or a little too late. So it is that this delirious multiplicity, itself already animated by figures and metaphors of ali kinds, will now, from its status as a kind of background music, sonorous, from silent partner in the "vile" drama of gossip and incitement, become agents and actors in its own right. Puis, le vent parut tourner; brusquement, des rвles de limbourg arrivиrent entre les trois femmes, aigres et amers, comme soufRйs par des gorges de mourants. The smell of the marolles seemed strongest; it released powerful whiffs into the air, like the stink of stable liner. Then the wind changed, and suddenly the deathly presence of the limbourg struck the three women, pungent and bitter, like the last gasps of a dying man. Cependant, au milieu de cette phrase vigoureuse, le parmesan jetait par moments un filet mince de flыte cham pкtre; tandis que les bries y mettaient des douceurs fades de tambourins humides. This cheese, with its gamy odour, had overpowered the milder smells of the marolles and the limbourg, its power was remarkable. Every now and then, however, a slight whiff, a flute-like note, came from the parmesan, while the bries came into play with their soft, musty smell, the gentle sound, so to speak, of a damp tambourine. The livarot launched into an overwhelming reprise, and the gйromй kept up the symphony with a sustained high note. They ali seemed to stink together, in a foui cacophony: from the oppressiveness of the heavy Dutch cheeses and the gruyиres to the sharp alkaline note of the olivet. Then the smells went wild and became completely jumbled, the port-salut, limbourg, gйromй, marolles, livarot, and pont-lлvиque combining into a great explosion of smells. The stench rose and spread, no longer a collection of individual smells, but a huge, sickening mixture. For such an onslaught of sensation seems to require something like a zero degree, what Deleuze calls a surface of inscription, in arder to sound its specifie note and make its effect. In Zola that role will often be played by cleanliness: Mais, au dйjeuner, il fut repris par la douceur fondante de Lisa. As he listened to her, his plate piled high, he was affected, in spite of himself, by the prim comfort of his surroundings. The matting beneath his feet seemed very soft; the glitter of the brass hanging lamp, the yellow tint of the wallpaper, and the bright oak of the furniture filled him with a sense of appreciation for a!


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