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Maternal vaccination is administered at a time when the patient is cautious about various behaviours pregnancy 9 weeks 3 days generic nolvadex 10 mg otc, including taking medications and vaccinations women's health clinic yarraville generic 10 mg nolvadex mastercard, and feels responsible for not just her own life but of that foetus pregnancy videos giving birth discount nolvadex 20mg amex. Depending on the cultural context, different norms are also established around the time of pregnancy. Rates of tetanus protection and transplacental tetanus antibody transfer in pregnant women from different socioeconomic groups in Peru. Tetanus immunization in pregnant women: evaluation of maternal tetanus vaccination status and factors affecting rate of vaccination coverage. Tetanus toxoid coverage as an indicator of serological protection against neonatal tetanus. Acceptability of tetanus toxoid vaccine by pregnant women in two health centres in Abidjan (Ivory Coast). Coverage and factors associated with tetanus toxoid vaccination status among females of reproductive age in Peshawar. Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in medicaid ­ Michigan, 2011­2013. Intention to accept Bordetella pertussis booster vaccine during pregnancy in Mexico City. Vaccine attitudes and practices among obstetric providers in New York State following the recommendation for pertussis vaccination during pregnancy. Attitudes and practices of obstetrician­gynecologists regarding influenza vaccination in pregnancy. Pandemics and vaccines: perceptions, reactions, and lessons learned from hardto-reach Latinos and the H1N1 campaign. Prenatal care providers and influenza prevention and treatment: lessons from the field. Missed opportunities: a national survey of obstetricians about attitudes on maternal and infant immunization. Challenges to the reproductive-health needs of African women: on religion and maternal health utilization in Ghana. Seasonal influenza and 2009 H1N1 influenza vaccination coverage among pregnant women ­ 10 states, 2009­10 influenza season. Influenza vaccination coverage among pregnant women ­ United States, 2012­13 influenza season. Failure of the vaccination campaign against A(H1N1) influenza in pregnant women in France: results from a national survey. Cross-sectional study on factors associated with influenza vaccine uptake and pertussis vaccination status among pregnant women in Germany. Pertussis vaccination programme for pregnant women: vaccine coverage estimates in England September to December 2014. Tetanus toxoid immunization to reduce mortality from neonatal tetanus (structured abstract). Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007­2012. Whooping cough and pregnancy the safest way to protect yourself and your baby: what you need to know and do to help protect your baby. Insuffisance de couverture vaccinale grippale A(H1N1)2009 en population gйnйrale et dans les groupes а risque durant la pandйmie 2009­2010 en France. Determinants of uptake of influenza vaccination among pregnant women ­ a systematic review. Factors associated with uptake of vaccination against pandemic influenza: a systematic review. Perceptions of neonatal tetanus and immunization during pregnancy: a report of focus group discussions in Kaduna, Nigeria.

All patients should be asked about their tobacco use and menopause test buy 10mg nolvadex fast delivery, where relevant women's health clinic eagle river alaska purchase 10 mg nolvadex free shipping, given advice and counselling on quitting breast cancer outfits cheap nolvadex 10 mg visa, as well as reinforcement at follow-up. There is evidence that advice and counselling on smoking cessation, delivered by health professionals (such as physicians, nurses, psychologists, and health counsellors) are beneficial and effective (125­130). Several systematic reviews have shown that one-time advice from physicians during routine consultation results in 2% of smokers quitting for at least one year (127, 131). Similarly, nicotine replacement therapy (132, 133) can increase the rate of smoking cessation. Nicotine may be administered as a nasal spray, skin patch or gum; no particular route of administration seems to be superior to others. In combination with the use of nicotine patches, amfebutamone may be more effective than nicotine patches alone, though not necessarily more effective than amfebutamone alone (135, 136). Nortriptyline has also been shown to improve abstinence rates at 12 months compared with a placebo. Both agents have appreciable discontinuation rates because of sideeffects (135­137). Data from observational studies suggest that passive cigarette smoking produces a small increase in cardiovascular risk (138­140). Whether reducing exposure to passive cigarette smoke reduces cardiovascular risk has not been directly established. The interventions described above targeted at individuals may be less effective if they are implemented in populations exposed to widespread tobacco advertising, sponsorship of sporting activities by the tobacco industry, low-cost tobacco products, and inadequate government tobacco control policies. There is evidence that tobacco consumption decreases markedly as the price of tobacco products increases. Bans on advertising of tobacco products in public places and on sales of tobacco to young people are essential components of any primary prevention programme addressing noncommunicable diseases (140). The cholesterol-raising properties of saturated fats are attributed to lauric acid (12:0), myristic acid (14:0), and palmitic acid (16:0). Stearic acid (18:0) and saturated fatty acids with fewer than 12 carbon atoms are thought not to raise serum cholesterol concentrations (146, 147). The effects of different saturated fatty acids on the distribution of cholesterol over the various lipoproteins are not well known. Trans-fatty acids come from both animal and vegetable sources and are produced by partial hydrogenation of unsaturated oils. Metabolic and epidemiological studies have indicated that trans-fatty acids increase the risk of coronary heart disease (145, 152, 153). It has also been demonstrated that replacing saturated and trans-unsaturated fats with monounsaturated and polyunsaturated fats is more effective in preventing coronary heart disease events than reducing overall fat intake (145, 153, 155). Current guidelines recommend a diet that provides less than 30% of calories from dietary fat, less than 10% of calories from saturated fats, up to 10% from polyunsaturated fats, and about 15% from monounsaturated fats (86, 88, 148). Metabolic studies have shown that dietary cholesterol is a determinant of serum cholesterol concentration (156­158). Reducing dietary cholesterol by 100 mg a day appears to reduce serum cholesterol by about 1% (147). However, there is marked individual variation in the way serum cholesterol responds to dietary cholesterol (159); dietary cholesterol seems to have a relatively small effect on serum lipids, compared with dietary saturated and trans-fatty acids (88, 104, 158). Studies have demonstrated that, in controlled conditions, it is possible to modify behaviour, but in daily life the required intensity of supervision may not be practicable. The effects of advice about reducing or modifying dietary fat intake on total and cardiovascular mortality and cardiovascular morbidity in real-life settings were assessed in a systematic review of 27 studies, comprising 30 902 person­years of observation (160). The interventions included both direct provision of food and, in most trials, dietary advice to reduce intake of total fat or saturated fat or dietary cholesterol, or to shift from saturated to unsaturated fat. The pooled results indicate that reducing or modifying dietary fat reduces the incidence of combined cardiovascular events by 16% (rate ratio 0. The reduction in cardiovascular mortality and morbidity was more pronounced in trials lasting at least 2 years. The protective effect of polyunsaturated fats is similar in high- and low-risk groups for both sources (seafood and plants), and in women and men (104, 155, 161, 162). Epidemiological studies and clinical trials suggest that people at risk of coronary heart disease benefit from consuming omega-3 fatty acids (104, 161, 163, 164).

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Monitoring of weight and blood pressure pregnancy quant levels generic nolvadex 20mg online, directed physical exams menopause forgetfulness cheap nolvadex 20 mg, routine health questions focused on risk factors and medications women's health clinic hampton park buy nolvadex 20 mg otc, complete blood counts, renal and liver function, lipid and glucose metabolism should be carried out. Key issues include maintaining testosterone levels in the physiological normal male range and avoidance of adverse events resulting from chronic testosterone therapy, particularly erythrocytosis, liver dysfunction, hypertension, excessive weight gain, salt retention, lipid changes, excessive or cystic acne, and adverse psychological changes (85). Because oral 17-alkylated testosterone is not recommended, serious hepatic toxicity is not anticipated with the use parenteral or transdermal testosterone (98, 99). Key issues include avoiding supraphysiological doses or blood levels of estrogen, which may lead to increased risk for thromboembolic disease, liver dysfunction, and development of hypertension. There have been several reports of prolactino- mas occurring after long-term estrogen therapy (100­102). Up to 20% of transsexual women treated with estrogens may have elevations in prolactin levels associated with enlargement of the pituitary gland (103). In most cases, the serum prolactin levels will return to the normal range with a reduction or discontinuation of the estrogen therapy (104). The onset and time course of hyperprolactinemia during estrogen treatment are not known. Prolactin levels should be obtained at baseline and then at least annually during the transition period and biannually thereafter. Given that prolactinomas have been reported only in a few case reports and were not reported in large cohorts of estrogen-treated transsexual persons, the risk of prolactinoma is likely to be very low. Studies of the effect of testosterone on insulin sensitivity have mixed results (106, 108). Evaluate patient every 2­3 months in the first year and then 1­2 times per year afterward to monitor for appropriate signs of feminization and for development of adverse reactions. Serum estradiol should not exceed the peak physiological range for young healthy females, with ideal levels 200 pg/ml. For individuals on spironolactone, serum electrolytes (particularly potassium) should be monitored every 2­3 months initially in the first year. Routine cancer screening is recommended in nontranssexual individuals (breasts, colon, prostate). In individuals at low risk, screening for osteoporosis should be conducted at age 60 and in those who are not compliant with hormone therapy. Evaluate patient every 2­3 months in the first year and then 1­2 times per year to monitor for appropriate signs of virilization and for development of adverse reactions. Measure serum testosterone every 2­3 months until levels are in the normal physiological male range:a a. For testosterone enanthate/cypionate injections, the testosterone level should be measured midway between injections. For parenteral testosterone undecanoate, testosterone should be measured just before the next injection. For transdermal testosterone, the testosterone level can be measured at any time after 1 wk. For oral testosterone undecanoate, the testosterone level should be measured 3­5 h after ingestion. Measure estradiol levels during the first 6 months of testosterone treatment or until there has been no uterine bleeding for 6 months. Measure complete blood count and liver function tests at baseline and every 3 months for the first year and then 1­2 times a year. Monitor weight, blood pressure, lipids, fasting blood sugar (if family history of diabetes), and hemoglobin A1c (if diabetic) at regular visits. If cervical tissue is present, an annual pap smear is recommended by the American College of Obstetricians and Gynecologists. If mastectomy is not performed, then consider mammograms as recommended by the American Cancer Society. Long-term studies from the Netherlands found no increased risk for cardiovascular mortality (93). Likewise, a meta-analysis of 19 randomized trials examining testosterone replacement in men showed no increased incidence of cardiovascular events (113).

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Conversely women's health menstrual issues purchase nolvadex 10 mg with amex, state science is a useful heuristic for considering the medical and psychiatric pathologization of trans* and gender-nonconforming subjects womens health 4 quality 20mg nolvadex. Nomadology is the study of wandering subjectivities menopause questions and answers buy discount nolvadex 20 mg line, of beings that drift from predetermined or normative paths, particularly those paths determined and regulated by apparatuses of the state. For Deleuze and Guattari, nomadism is a form of life that is shaped by continual embarkation on lines of flight-that is, modes of escape, moments of transformation, ways of becoming other-than-normative, and ways of acting in excess of, or insubordinately in relationship to, repressive forces. Lines of flight have the capacity to deterritorialize, to undo, to free up, to break out of a system or situation of control, fixity, or repression. Nomad science, by extension, concerns itself with experiments and inventions that are fundamentally deterritorializing, while state science is, by counterpoint, fundamentally reterritorializing. To territorialize an entity is to set and define its limits, to organize component parts into a coherent whole determined by a specific end. Deleuze and Guattari write that ``state science continually imposes its form of sovereignity on the inventions of nomad science' (1987: 365); in other words, state science imposes a particular logic of organization on nomadic beings, curtailing and taming the creative inventiveness of these beings. State science is incapable of conceptualizing beings as they are caught up in fluid processes of becoming. Fluids are known for their malleability, their capacity for transformation, their capacity to adjust and recalibrate at the molecular level; when one investigates fluid phenomena, one asks what a fluid is doing in a given situation, interaction, or milieu. When investigating solids, on the other hand, very different properties are assumed, and these assumed properties generate very different sets of questions. They have stable boundaries rather than blurred or porous ones; they exist as beings unto themselves. Thus a science concerned with solids tends to also be concerned with establishing the characteristics that make delimited entities what they are. Unlike dealing with fluids, where the emphasis is on transformation, with solids the emphasis falls on questions of essence that seek to establish attributes that render a solid what it is through contradistinction with what is not. It is important to bear in mind that Deleuze and Guattari insist on understanding this alternative view of materiality as a science. This is because they propose a formal conceptual system consisting of a set of theorems that help elicit a different understanding of embodiment. They propose a series of rules of thumb (rather than laws-eschewing the juridical language of conventional scientific practice) that enable one to encounter the physical world anew, and to counter the hidebound cognition of materiality enforced by state science. The tactic of establishing essence through contradistinction is central to the medical pathologization of trans* and gender-nonconforming subjects, which utilizes this tactic to produce gender stereotypes used in the diagnoses of gender identity disorder and gender dysphoria. These stereotypes are necessary to the functioning of the state science of diagnosing gender difference; they are utilized to establish dyadic essences of gender that are then codified within diagnostic criteria. Although the medicalization of gender nonconformance has led to development of guidelines and protocols for transition and would thus seem to be linked to a more fluid conception of gender, these practical protocols are nevertheless built upon conservative typologies of maleness and femaleness. They are not concerned with transition as a (potentially always unfinished) process but Downloaded from read. A nomad science of transition, however, would focus on the specific, resistant, and creative ways in which trans* and gender-nonconforming subjects reinvent and reconstruct themselves in manners irreducible to the medical logic of transition. We can track a resonant preoccupation with thinking embodiment beyond static, dimorphic understandings of gender in a number of foundational texts in trans* studies. Susan Stryker asserts, early in her career, that trans* bodies should be understood as in excess of what is commonly understood as natural and that they therefore destabilize ``the foundational presupposition of fixed genders upon which a politics of personal identity depends' (1994: 238). Sandy Stone, similarly, takes issue with the narrative of transsexuality offered by clinicians and calls for a counternarrative of embodiment, writing that ``for a transsexual, as a transsexual, to generate a true, effective and representational counterdiscourse is to speak from outside the boundaries of gender, beyond the constructed oppositional nodes which have been predefined as the only positions from which discourse is possible' (1991: 300). This shared conception of trans* embodiment as in excess of conventional understandings of materiality has its afterlives in contemporary criticisms of the regulatory mechanisms of trans* diagnosis and medical treatment. Dean Spade has written extensively on this topic (2003, 2006, 2011), as has Lucas Cassidy Crawford, who utilizes the conceptual vocabulary of Deleuze and Guattari to think about trans embodiment as a kind of ``affective deterritorialization' rather than a way of ``coming home' to one of two ideal gender types (2008: 134). Her recent publications include ``The Waiting Room: Ontological Homelessness, Sexual Synecdoche, and Queer Becoming' (Journal of Medical Humanities, June 2013) and ``Utopian Pragmatics: Bash Back! Despite the lack of a long history of normality, however, critiques of normality occupy a central position in many areas of critical theory, which have examined the way the ``regime of the normal' (Warner 1999) has come to shape the lives of those whose sexualities, genders, and/or bodies do not conform to normative assumptions about them. The ongoing proliferation of such critiques is a reflection of how privileged the idea of normality remains. For Warner, the desire for normality is one of the definitive characteristics of the late twentieth century: ``Everyone, it seems, wants to be normal. Given its cultural ubiquity and its centrality to contemporary studies of embodiment, it is curious that the term normal and the history of which it is a part have been subject to so little critical interrogation. What has been overlooked, in consequence, is that the history of the normal is much more recent, and its meaning much more unstable, than generally recognized.