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Syncope is a common incidence following dismissal of a affected person who has spent an hour reclined in a dental chair. Orthostatic hypotension may be be} exacerbated with utilization of} intravenous sedation or with nitrous oxide conscious sedation. Monitoring preprocedural and postprocedural blood strain readings or repeatedly measuring blood strain is taken into account the usual of care in administration of the sedated affected person. Intraoral Effects of Psychotherapeutic Agents Many prescription, over-the-counter, and natural drugs have intraoral results. Most psychotherapeutic brokers trigger xerostomia, which is the most common adverse intraoral impact of all medicine. Patients could report a persistent disagreeable taste, altered taste of meals, or a generalized loss of taste sensation, referred to as ageusia. Patients affected by dysgeusia should be questioned extensively regarding the character, severity, and persistence of the altered taste sensation. For some sufferers, an alteration in taste sensation may be be} a nuisance; for others, it might intrude with dietary intake and hydration. Some sufferers eat continually in an try and eliminate an disagreeable taste within the mouth. Lichenoid drug reactions have a clinical presentation related to|similar to} erosive lichen planus and can be intensely painful. Although a radical dialogue of dental drug interactions with psychotherapeutic brokers is past the scope of this textual content, practitioners should conscious of|concentrate on|pay consideration to} the drug-drug and drug-disease state interactions that can happen with the drugs they prescribe or use in clinical practice. Many interactions relate to the potentiation of the sedative or anticholinergic actions of the psychotherapeutic medicine. Consultation with the physician prescribing the psychotherapeutic drugs should be made when any kind of sedation is planned in order that dosage can be adjusted to prevent adverse occasions. Patient confusion is an important issue to think about when offering dental treatment. Oral hygiene and postoperative instructions should be given both verbally and in writing. Make positive that the affected person understands the instructions and, if in doubt, also give them to a family member or care supplier. When confusion is a concern, nonopioid analgesics may be be} a extra prudent selection than a centrally appearing analgesic. However, utilization of} topical corticosteroids in a dry mouth could predispose the affected person to candidiasis. For some sufferers it might be essential to prescribe topical or systemic antifungal drugs. In many different instances, although the connection between the psychological well being situation and oral pathlogy is oblique, the outcomes are devastating and pervasive-as with dental caries or progressive periodontal disease. Its elements function lubricants, buffers, digestive aids, and antimicrobial brokers. Inadequate salivary move can create a sore erythematous oral cavity in a matter of some days. Some sufferers complain about slime, grit, or a foul taste related to their saliva. This disparate group of complaints can be complicated to affected person and clinician alike. A frequent side impact of most psychotropic drugs, xerostomia also can result from quite a few psychological Figure 14-1 Typical appearance of the tongue in a affected person complaining of xerostomia. Stress not solely diminishes salivary move, but in addition influences the elements of saliva. Because salivary IgA levels and buffering capability are diminished in sufferers experiencing excessive levels of stress or depressive occasions, an oral environment favorable to caries improvement could result (Figure 14-2). For sufferers with detachable prostheses, insufficient saliva can have an effect on} denture retention and predispose the affected person to denture accidents through insufficient lubrication of the oral tissue. Patients should be informed of the adverse results of insufficient salivary move earlier than any in depth dental treatment. Conversely, others could report a dry mouth however, within the estimation of the clinician, have adequate saliva. Decreasing caffeine intake is helpful in alleviating the signs, although compliance normally a|could be a} problem. Patients need to use the saliva substitutes incessantly (one to two occasions per 384 Planning Treatment for Patients With Special Needs A B Figure 14-2 A, Dental caries (white arrows) present in a affected person who complains of xerostomia. Appropriate oral hygiene and the restriction of sucrose and acid exposure will in most cases management the carious process. Fluoride rinses are effective adjuncts to the oral hygiene routine for any affected person with the potential for a excessive caries fee. Excessive mouthwash use should be prevented and because the excessive alcohol content material of many commercially out there mouthwashes can exacerbate conditions created by a dry oral environment, mouthwashes that include no alcohol should be beneficial whenever attainable. Although mechanical and chemical plaque controls are essential factors in controlling dental caries, affected person motivation is probably the most important issue. These sufferers demonstrated effective plaque management and may have a longtime caries management program (see Chapter 7) in place earlier than elective definitive restorative dental procedures are begun. Periodontal Disease the incidence of necrotizing ulcerative gingivitis is a wonderful example of finest way|the method in which} during which anxiety and stress can be important contributors to the event of disease within the oral cavity. The dentist should present the affected person with a number of} saliva substitute choices (Box 14-8). Patients with xerostomia generally have an altered sense of taste and most likely not|will not be} compliant because of the flavoring within the substitutes. In recalcitrant instances of xerostomia secondary to antipsychotic or antidepressant drugs, it might be fascinating to discuss with the prescribing psychological well being therapist to decide whether a less xerostomic medicine can be used to management the dysfunction. Do Patients With Psychological Disorders Have More Periodontal Disease and More Caries? Periodontal Disease Several research have reported that psychiatric sufferers have poor oral well being,1-6 and poor oral hygiene. Depression has been linked to extra severe periodontal disease and development of periodontal disease,12-15 suggesting that sufferers with despair may be be} extra doubtless to|prone to} develop attachment loss. Similar outcomes had been found among institutionalized psychiatric sufferers in Spain the place an average of 7. Hede B: Oral well being in Danish hospitalized psychiatric sufferers, Community Dent Oral Epidemiol 23(1):44-48, 1995. Adult Dental Health Survey: Oral well being within the United Kingdom 1998, London, 1999, Office for National Statistics. Hede B: Dental well being conduct and self-reported dental well being problems among hospitalized psychiatric sufferers in Denmark, Acta Odontol Scand 53(1):35-40, 1995. Horst G: Dental care in psychiatric hospitals within the Netherlands, Special Care Dent 12:63-66, 1992. Velasco E, Bullon P: Periodontal status and treatment wants among Spanish hospitalized psychiatric sufferers, Special Care Dent 19(6):254-258, 1999. Velasco E, Machuca G, Martinez-Sahuquillo A and others: Dental well being among institutionalized psychiatric sufferers in Spain, Special Care Dent 17(6):203-206, 1997. Altered immunity could predispose a person to gingival inflammation and alveolar bone loss. In addition, the level of salivary IgA, which performs an essential role in mucosal immune defense, is decreased during stress. Diminished salivary move could result in elevated plaque formation because of decreased clearance of oral debris. In most conditions, periodontal disease can be controlled with professional care and adequate plaque management. In acute conditions, when the affected person is unable to keep adequate oral hygiene, utilization of} chlorhexidine rinses may be be} essential to management plaque. Any dysfunction during which anxiety is a component could result in autonomic overarousal and muscle hyperactivity. Patients with chronic pain syndromes have a excessive incidence of depressive issues. The affected person should be educated concerning the relation- ship between his or her physical complaints and underlying psychological factors.

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Family or individual psychotherapy is often used to manage the psychosocial elements of the dysfunction. Depression is frequent in patients with psychotic issues, and suicide happens in up to as} 10% of young male schizophrenics. Atyp- ical brokers have a extra pronounced impact on the unfavorable signs of schizophrenia and consequently have turn into first-line brokers in the therapy of this disease. In addition, the atypical brokers have fewer extrapyramidal unwanted effects effects} (pseudoparkinsonism, tardive dyskinesia, dystonia) than the older, traditional neuroleptics. The balance between potential benefit and risk have to be considered on a person basis. As clinicians gained extra experience with these medicines, it turned clear that the opposed reactions have been quite severe and generally life threatening. Adverse effects embody postural hypotension, dry mouth, drowsiness, diminished thirst with accompanying dehydration, and modifications in pores and skin pigmentation. These effects generally occur after long-term therapy, however could not manifest till after the treatment has been discontinued. Fine tremor of the tongue has been reported as a prodrome of tardive dyskinesia, and if the treatment is discontinued subsequent to this discovering, the complete range of signs could not occur. The dentist will be the first health care supplier to recognize the onset of tardive dyskinesia. Every effort ought to be made to determine early indicators of this dysfunction so that the treatment regimen may be altered and additional harm prevented. The involuntary movements of the jaws that characterize tardive dyskinesia make it troublesome for the patient to maintain enough oral hygiene and will precipitate the development of temporomandibular issues. It may be very challenging to perform a medical process on a patient with involuntary jaw movements. Treatment Planning for the Patient With a Psychotic Disorder Treatment planning considerations for the patient with psychotic issues is summarized in Box 14-6. The dentist has two primary responsibilities when treating the schizophrenic patient: 1. The dentist must positive that|ensure that|make sure that} enough management of the disease process is being maintained. The dentist have to be alert to the development of any oral effects of the disease or the antipsychotic medicines and have to be ready to manage these appropriately. Chlorhexidine rinses ought to be considered with the understanding that the patient could not ready to|be capable of|have the flexibility to} cope with a task as simple as|so easy as} swishing and expectorating. Xerostomia, orthostatic hypotension, anticholinergic effects, and extrapyramidal effects are main therapy planning considerations in the medicated patient with a psychotic illness. Because most antipsychotic medicines trigger xerostomia, enough plaque and caries management is of critical importance. Cholinergic agonists, corresponding to bethanechol, cevimeline, or pilocarpine will stimulate saliva production in xerostomic patients. Because of the potential for severe drug and disease state interactions, consultation with the prescribing physician ought to be made earlier than use of a cholinergic agent. Orthostatic hypotension is unavoidable in patients handled with antipsychotic brokers, however its manifestation-syncope- may be prevented by minimizing fast modifications in patient positioning and by maintaining the patient in a seated position till any sensation of dizziness has dissipated. The extrapyramidal effects of psychotic medicines could necessitate modification of the dental therapy plan. Patient sedation or the usage of} basic anesthetic may be be} considered as methods for diminishing the effects of tardive dyskinesia, however the interplay between sedative, anesthetic, and antipsychotic medicines have to be evaluated carefully. Definitive dental care ought to be deferred if the patient is experiencing a psychotic episode. Children have issues at home, in school, and with peer relationships, with opposed effects extending into adulthood, compromising tutorial and job efficiency and vanity. Be alert for opposed effects of psychotropic medicines, especially (1) orthostatic hypotension and (2) extrapyramidal effects, corresponding to pseudoparkinsonism, acute dystonia, akathisia, or tardive dyskinesia. These brokers are effective in reducing both aggressiveness and the core signs of the dysfunction. The lack of consistent analysis and therapy methods continues to generate controversy over the attainable overuse and abuse of psychostimulants in kids. Some reports counsel that a big number of patients in the United States taking these medicines (approaching 15%) both give away or promote some of their treatment to different college students. Appetite suppression has potentially disastrous dental penalties when mixed with dry mouth. Parents frequently enable the child to eat something as long as|so long as} he or she eats something, with dietary decisions often including meals excessive in fats and refined carbohydrates. A refined carbohydrate food plan and dry mouth represent strong risk elements for dental caries. They could have issue staying in a single place for any size of time, making it troublesome to complete a fancy dental process. Children and adolescents are the age teams most probably to be affected with this dysfunction and the age teams additionally extra probably to|prone to} have the next incidence of dental caries. Instructions ought to be provided in both verbal and written type and will have to be transmitted to a family member or caregiver as properly. If the usage of} a night guard is considered, the age of the patient and the potential for growth of the dental arches have to be evaluated. Somatization dysfunction is recognized by cataloging the number and type of somatic complaints made by the patient. For a formal analysis, the patient must report a minimum of|no much less than} two gastrointestinal signs, 4 pain signs, one sexual/reproductive symptom, and one pseudoneurologic symptom. Oral complaints may be be} included in of the categories, corresponding to pain, issue in swallowing, or altered oral sensations. These patients may be be} demanding with regard to diagnostic testing and will try and dictate therapy. It is important for the dentist to determine the issue and to present reassurance that acceptable checks might be carried out to assist diagnose complaints. Many can also have been recognized with different psychological issues, corresponding to melancholy or an anxiety dysfunction. Patients with somatization dysfunction generally have physicians and may be be} receiving different therapies from each. Identification of all prescription medicines and prescribers minimizes the possibility of|the potential of|the potential for} creating an opposed response to a drugs prescribed in the course of of|in the midst of} dental therapy. The patient could have omitted pertinent information relating to his or her basic health standing that might clarify the criticism, or the dentist find a way to|could possibly|might find a way to} present the physician with model new} piece of information that facilitates a formal analysis. In both occasion, clear strains of communication must stay open between the dentist and the first care physician. The patient could insist that the dentist make a analysis and advocate a selected therapy for the criticism at the time of presentation. Chapter 14 Managing the Patient With Psychological Problems 381 the identification of patients with any of the somatoform issues often takes months to years and to perform on reflection. However, acceptable diagnostic procedures ought to be carried out to rule out a true pathologic entity or emergent condition. Factitial Disorders Factitial accidents are oral lesions created by the patient, not attributable to unintentional trauma or different oral disease. The frequent kinds of dental factitial accidents embody gingival abrasion with a fingernail, obsessive tooth brushing, use of inappropriate aids to clear the enamel, and burns caused by aspirin placement over sore tissue. Although factitial accidents are usually minor, there have been reports of self-extraction of enamel and even autoglossectomy in schizophrenic patients. Dental therapy for the extra minor forms of factitial injury includes patient schooling and symptomatic care. Although extra generally manifested in association with the analysis of a lifethreatening disease, denial also can occur in the dental setting. Many patients will deny that their enamel have to be removed when faced with the analysis of terminal periodontitis. The dentist can help the patient cope with troublesome diagnoses by recognizing denial and offering the patient with a mechanism by which he or she can both affirm or disprove the initial analysis.

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To forestall deaths from pneumonia and diarrhea, the 2 biggest killers for these youthful than age 5 years in Ethiopia (Liu and others 2012), preventive and healing interventions must be intensified to reach all segments of the inhabitants. Establishing wholesome environments to defend kids from pneumonia and diarrhea, and increasing access to cost-effective interventions for each prevention and remedy, will greatly reduce mortality charges from these conditions. Treatment interventions for pneumonia (for instance, community case management with antibiotics) and diarrhea (for instance, oral rehydration salts) have proven to be efficient (Munos, Fischer Walker, and Black 2010; Theodoratou, Al-Jilaihawi, and others 2010). Interventions Analyzed Pneumonia Treatment with Antibiotics We assume that present coverage of pneumonia remedy (antibiotics) throughout all earnings teams is increased by 20 percentage factors (table 19. We selected a 20 percentage point increase, a rather small increase, to capture a sensible situation could be} achieved by the Ethiopian well being system. To estimate pneumococci deaths averted-33 p.c of all pneumonia deaths are because of of} pneumococci (Fischer Walker and others 2013)-the model follows the present Ethiopian delivery cohort. Depending on disease-specific mortality (pneumonia, meningitis, nonpneumonia nonmeningitis), we estimated intervention coverage, intervention effectiveness, and reductions in disease-specific deaths in every earnings group. However, the extent of such oblique results on the nonvaccinated inhabitants is unclear, leading to their exclusion from this evaluation (Weinberger, Malley, and Lipsitch 2011). Deaths averted by earnings quintile are the product of the baseline number of diarrhea deaths, the rise in remedy coverage, and the effectiveness of remedy. After figuring out the baseline number of diarrhea deaths by earnings quintile, we attribute 27 p.c of diarrhea deaths to rotavirus (Fischer Walker and others 2013). This yields the number of rotavirus-attributable deaths by earnings quintile (table 19. Although estimates of vaccine efficacy vary in Sub-Saharan Africa and by strain, we use an effectiveness of 50 p.c taken from a meta-analysis (Fischer Walker and Black 2011) and assume it prevented visits to well being facilities properly as|in addition to} mortality (Verguet and others 2013). Specifically, to estimate rotavirus deaths averted, the model follows the present Ethiopian delivery cohort; rotavirus deaths averted are the product of baseline rotavirus deaths, vaccine coverage, and vaccine effectiveness (Verguet and others 2013). This static method is unable to capture epidemiological changes similar to herd immunity, which has solely been documented in a number of} countries (Buttery and others 2011; Tate and others 2011; Yen and others 2011). Vaccine intervention­related personal 350 Reproductive, Maternal, Newborn, and Child Health Table 19. Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia 351 expenditures averted depend on the number of cases of a particular an infection (a subset of complete cases), vaccine coverage, vaccine effectiveness, likelihood of looking for either inpatient or outpatient care in the absence of the vaccine, and value of inpatient and outpatient care. Government prices for the vaccine are based mostly on the scale of the delivery cohort, vaccine coverage, the prices of the vaccine itself, and the associated system prices of supply. Government prices for diarrhea and pneumonia remedy embody 66 p.c of the prices for inpatient and outpatient take care of at present covered households, plus 100% of the prices for inpatient and outpatient take care of the 20 percentage point increment in coverage. This certainty equivalent reflects the final earnings that people are keen to settle for to make the end result} certain. Finally, we derive a money-metric worth of insurance supplied (risk premium) because the distinction between the expected worth of earnings and the knowledge equivalent (Brown and Finkelstein 2008; Finkelstein and McKnight 2008; McClellan and Skinner 2006; Verguet, Laxminarayan, and Jamison 2015). Pneumonia remedy would save more lives among the poorest earnings group due to the upper illness burden on this inhabitants and would evenly increase coverage among all earnings teams. Yet, 32,000 pneumonia-related deaths would still happen; of those, 8,000 would happen in the poorest earnings quintile. Wealthier folks have better access to care in each applications, which would result in reductions in family personal expenditures have access (figure 19. This consequence happens outcome of|as a outcome of} the poorest quintile would have substantially decrease disposable earnings than the richest in absolute terms; subsequently the change in earnings because of of} the interventions would be a lot larger. Per dollar expenditure, the mixed treatment-vaccine package would save barely more lives compared with remedy alone. In explicit, vaccines defend solely towards pneumococcal pneumonia, whereas full public finance of remedy is more targeted. The prices of the mixed treatment-vaccine package vary substantially, depending on the vaccine worth and Gavi eligibility. Combined diarrhea remedy and rotavirus vaccination would avert 5,four hundred deaths every year. Yet, 20,000 diarrhea-related deaths would still happen; of those, 6,000 would happen in the poorest earnings quintile (figure 19. The numbers present important info on the general impacts of those interventions. With regard to deaths averted, each diarrhea remedy and mixed diarrhea remedy and rotavirus vaccination usually present higher advantages to the poor. A main cause that each packages benefit the poorest is the upper burden of diarrheal illness among the poorest. Although interesting in its own proper, this case might turn into a sensible concern if Gavi support had been to expire. Acknowledgment of those altered advantages is important when contemplating Gavi eligibility and the sustainability of the inclusion of vaccine interventions in advantages packages. This issue is particularly compelling when a robust rationale, similar to equity, helps an intervention that a rustic might not implement underneath present incentives. Although this evaluation focuses on Ethiopia, the findings may also speak to the value of those interventions in other countries going through related coverage gaps and mortality burdens associated to diarrhea and pneumonia. First, in keeping with} a lot of the cost-effectiveness literature, our illness fashions are static rather than dynamic. Dynamic fashions can more precisely capture synergies however require higher reliance on additional knowledge and assumptions about illness conduct that most likely not|will not be} readily available. Second, a more complete accounting of family medical funds probably be} included, and other prices associated with the short-term remedy and longterm impacts of illness probably be} considered. In explicit, direct nonmedical prices, similar to for transportation and housing, and oblique prices because of of} illness or condition, including loss of earnings and impression on labor productivity, may be substantial, though empirical knowledge are sparse. The concentrate on to} youngster well being interventions on this examine magnifies the productivity impacts associated with illness, given the inevitability of misplaced work time for caregivers and the upper number of years of misplaced productivity associated with childhood incapacity or death. For instance, an financial evaluation of the benefits of an array of vaccines estimated caretaker productivity to be roughly 20 p.c of averted remedy prices for each pneumonia and rotavirus (Stack and others 2011). Averted productivity losses because of of} death from rotavirus and pneumonia had been, respectively, approximately 15 and 18 instances higher than remedy prices (Stack and others 2011). An financial evaluation of rotavirus vaccine in Brazil contains prices associated with transportation and missed work in the complete value of treating gastroenteritis, discovering that these prices constituted approximately 20 p.c of the total value per inpatient and almost seventy five p.c of the total value per outpatient (Constenla and others 2008). Third, knowledge on the existing mixture of private and non-private provision and buy of well being care are restricted. Nevertheless, many sources of uncertainty underlie this evaluation, including the imputed mortality charges derived from estimation, the efficacy of rotavirus and pneumococcal vaccines, and more usually the leap from efficacy to effectiveness for the remedy and prevention interventions studied here. For instance, we assumed a uniform increase of 20 percentage factors throughout all earnings quintiles to facilitate the interpretation of the outcomes, though richer quintiles at present have larger remedy coverage than do poorer quintiles (tables 19. Alternatives embody number of cases of poverty averted and averted cases of compelled borrowing and forced sales (Kruk, Goldmann, and Galea 2009). In countries with weak well being infrastructures, similar to Ethiopia, well being providers most likely not|will not be} out there even after the removing of some financial barriers. In explicit, expanding well being providers to rural areas might require additional investments, similar to strengthening or upgrading well being facilities through coaching and deployment of expert well being employees, providing essential gear, and bettering infrastructure for service supply. To account for this challenge, we selected a specified coverage increment of 20 percentage factors for all interventions. In addition, marginal prices of well being care provision might increase substantially with will increase in coverage, and these marginal prices might vary substantially depending on the inhabitants subgroups targeted (Brenzel and Claquin 1994; Brenzel and others 2006). The case examine presented on this chapter is tailor-made to specific chosen youngster well being interventions. The interventions chosen for an essential youngster well being package will involve other considerations, such because the acceptability of an intervention from a public well being or medical standpoint, and the scope of the chosen intervention. The scale and price of intervention rollout must be evaluated in the context of a thorough understanding of the strengths and weaknesses of the host well being systems. Some interventions and packages will rank larger on one or each metrics relative to others. This evaluation also provides policy makers with info on how they may sequence the development of well being care packages because the well being and financial wants of populations evolve and resource envelopes change. Here, we show that the interventions studied would largely benefit the poorest populations, which can help to each progressively and effectively prioritize restricted resources. Health Gains and Financial Risk Protection Afforded by Treatment and Prevention of Diarrhea and Pneumonia in Ethiopia: An Extended Cost-Effectiveness Analysis. A Comparison of Measured versus Modeled Mortality Rates among Children Under-Five in Bangladesh. An earlier version of this paper was presented at a gathering of the authors of this volume, in Ferney-Voltaire, France, in November 2013.

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When the head-only procedure is applied, the grand mal seizure is easily observable. Electrically induced cardiac fibrillation, exsanguination, or different applicable adjunctive methods could also be} used to achieve death and should be performed within 15 seconds of when the animal becomes unconscious. In the 1-step head-to-body method an electrical present is simultaneously handed by way of both the brain and the heart. This simultaneously induces a grand mal seizure and electrocutes the animal by inducing cardiac arrest. If present is applied for more than 3 seconds, tonic and clonic spasms could also be} blocked. The 1-step method should be used with amperage settings which were scientifically verified to induce a seizure. In the 2-step methodology an electrical present is handed by way of the pinnacle to induce unconsciousness, then a second present is handed by way of either the side of the body or the brisket to induce cardiac arrest. Three options can be found for correct electrode placement for the head-only methodology, together with on both sides of the pinnacle between the attention and ear, the bottom of the ear on both sides of the pinnacle, and diagonally below one ear and above the attention on the alternative side of the pinnacle. For the 1-step (head-to-back) methodology, the pinnacle electrode could also be} positioned on the brow or instantly behind the ear. When the 2-step procedure is used, placement of the body electrode behind the forelimb is efficient. Advantages-(1) Electrocution is humane if the animal is first rendered unconscious. General recommendations-Euthanasia by electrocution is suitable with conditions. It requires particular skills and gear that may ensure passage of adequate present by way of the brain to induce lack of consciousness and induce tonic and clonic epileptic spasms. Unconsciousness should be induced earlier than cardiac fibrillation or simultaneously with cardiac fibrillation. Methods that apply electrical present from head to tail, head to foot, or head to moistened metallic plates on which the animal stands are unacceptable. The 2-step methodology should be used in situations where there could also be} questions about adequate present to induce a grand mal seizure with tonic and clonic spasms. This method permits statement of tonic and clonic spasms earlier than a second present is applied to induce cardiac arrest. Electroimmobilization that paralyzes an animal with out first inducing unconsciousness is extremely aversive and is unacceptable. Although newer applied sciences are improving kill lure efficiency in achieving lack of consciousness quickly, individual testing is beneficial to make sure the lure is working properly. Several kill traps, modifications, and set specifics have been scientifically evaluated and found to meet requirements for varied species. A review312 of utilization of} commercially out there macerators for euthanasia of chicks, poults, and pipped eggs signifies that death by maceration in poultry a lot as} seventy two hours old happens instantly with minimal pain and distress. Maceration is believed to be equivalent to cervical dislocation and cranial compression as to time factor, and is taken into account to be an appropriate means of euthanasia for newly hatched poultry by the Federation of Animal Science Societies,313 Agriculture Canada,314 World Organization for Animal Health,239 and European Union. Disadvantages-(1) Special gear is required and it should be saved in excellent working situation. General recommendations-Maceration requires particular gear that should be saved in excellent working order. Chicks should be delivered to the macerator in a method and at a fee that prevents a backlog of chicks on the level of entry into the macerator and with out inflicting damage, suffocation, or avoidable distress to the chicks earlier than maceration. General recommendations-Focused beam microwave irradiation is a humane methodology for euthanizing small laboratory rodents if devices that induce fast lack of consciousness are used. Only devices which are be} designed for this use and have applicable power and microwave distribution can be used. Microwave ovens designed for home and institutional kitchens are unacceptable for euthanasia. The devices differ in design from kitchen items and will vary in maximal power output from 1. The power required to quickly halt brain enzyme activity is determined by} the efficiency of the unit, the flexibility to tune the resonant cavity, and the size of the rodent Thoracic (cardiopulmonary, cardiac) compression is a method that has been utilized by biologists to terminate the lives of wild small mammals and birds, primarily under area conditions. The consensus of veterinarians with area biology coaching and expertise is that portable gear and alternate methods are presently out there to area biologists for euthanasia of wildlife under area conditions, in accordance with present requirements for good animal welfare. These alternate methods are typically sensible to use with minimal coaching and preparation as commonplace procedures prior to embarking upon fieldwork. Exsanguination can be used to ensure death subsequent to gorgeous, or in otherwise unconscious animals. Because nervousness is associated with excessive hypovolemia, exsanguination should not be used as a sole means of euthanasia. Muscular activity throughout pithing can be appreciable, but is followed by quiescence that facilitates exsanguination or different procedures. Pithing is sometimes used prematurely of exsanguination to scale back involuntary motion in stunned animals. The rod should be considerably inflexible, yet flexible, and of adequate size to attain the brain and spinal column by way of the access level within the skull. Effectiveness of rotating-jaw killing traps for beaver (Castor Canadensis) (oral presentation). The fee of decline in resistance to anoxia of rabbits, dogs, and guinea pigs from the onset of viability to grownup life. Comparison of carbon dioxide/air combination and nitrogen/air combination for the euthanasia of rodents: design of a system for inhalation euthanasia. Behavioural and cardiovascular responses of rats to euthanasia utilizing carbon dioxide gas. Behavioural responses of rats to gradualfill carbon dioxide euthanasia and lowered oxygen concentrations. Stress-induced release of anterior pituitary hormones: impact of H3 receptormediated inhibition of histaminergic activity or posterior hypothalamic lesion. Responses of serum corticosterone and corticosteroid-binding globulin to acute and prolonged stress within the rat. Endocrine stress response in rats subjected to singular orbital puncture while under diethyl-ether anesthesia. Degrees of aversion shown by rats and mice to different concentrations of inhalational anaesthetics. Measurement of aversion to determine humane methods of anaesthesia and euthanasia. Comparison of anesthetic induction in cats by use of isoflurane in an anesthetic chamber with a conventional vapor or liquid injection technique. Combining nitrous oxide with carbon dioxide decreases the time to lack of consciousness throughout euthanasia in mice-refinement of animal welfare? A two-step strategy of nitrous oxide earlier than carbon dioxide for humanely euthanizing piglets: on-farm trials. Carbon monoxide, carbon disulfide, lead and cadmium-four examples of occupational poisonous brokers linked to heart problems. Premedication of dogs with acepromazine or pentazocine earlier than euthanasia with carbon monoxide. Carbon monoxide and carbon dioxide euthanasia of cats: period and animal conduct. Slaughter of poultry through the epidemic of avian influenza within the Netherlands in 2003. Comparison of carbon dioxide and argon euthanasia: effects on conduct, coronary heart fee, and respiratory lesions in rats. Aversive reactions to argon, carbon dioxide and a mixture of carbon dioxide and argon. Assessment of the aversion of hens to different gas atmospheres utilizing an approach-avoidance check. Changes within the somatosensory evoked potentials and spontaneous electroencephalogram of hens throughout gorgeous in argon-induced anoxia.

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Variance Key: B Rationale: the standard error of the imply is the standard deviation of the distribution divided by the square root of the pattern dimension. The greater the dispersion across the imply (standard deviation), the much less certain the inhabitants imply and the greater the standard error of the imply. The bigger the pattern dimension the more confidence of the imply, the smaller the standard error of the imply. Non Superior Key: C Rationale: All three trials have non-inferiority design exhibiting hypofractionation routine is non-inferior to standard fractionation routine. The frequencies of which chromosome biomarker are anticipated to be stable and can be used in retrospective dosimetry? Unlike unstable dicentrics, chromosome translocations are anticipated to be stable and their frequencies can be used in retrospective dosimetry. Radiation-induced rings are additionally unstable and due to this fact not unsuitable for retrospective dosimetry. Acentric fragments may be stable or lost from the cell throughout cell division and are due to this fact not unsuitable for retrospective dosimetry. References: Hall and Giaccia, Radiobiology for the Radiologist, Sixth Edition, 2006. International Atomic Energy Agency, Biological dosimetry: chromosome aberration evaluation for dose assessment. H Pylori), usually current T cells in the gastric mucosa entice a B cell inhabitants, to give rise to lymphoid follicles. Other websites are attainable (orbit, parotid, small bowel), but with much less frequency compared with the stomach. References: Halperin, Perez, BradyPrinciples and Practice of Radiation Oncology: Fifth Edition. Kidney Key: B Rationale: In Murphy et al, the median time to Grade 2-4 duodenal toxicity was 6. The central 50% of the beam at a depth of 10 cm Key: C Rationale: Beam flatness is defined at a depth of 10 cm of water using 80% of the central field dimension. The present consensus on the medical administration of intracranial ependymoma and its distinct molecular variants. Outside the preliminary quantity of disease Key: C Rationale: Patients were equally more likely to|prone to} relapse in (74%) bulky and (75%) non-bulky websites of preliminary disease. Therefore, since there were initially 108 clonogenic cells, so as to to} obtain a 90% management fee, the whole radiation dose should scale back the surviving fraction to 10-9, as this ends in an average of 0. Thus, as in the current case the survival curve is exponential with a D10 of 7Gy, a dose of sixty three Gy would be required. Limitless replicative potential Key: B Rationale: the original hallmarks of cancer were (1) self-sufficiency in growth signals; (2) insensitivity to antigrowth signals; (3) evading apoptosis; (4) limitless replicative potential); (5) sustained angiogenesis; (6) tissue invasion and metastasis. Four new hallmarks were added in 2011 together with (1) irregular metabolic pathways, (2) evading the immune system, (3) genome instability, and (4) inflammation. Tumors usually resist programmed cell demise by evading apoptosis quite than activating apoptosis References: Hanahan and Weinberg. Revisions of the international criteria for neuroblastoma prognosis, staging, and response to treatment. Fail to reject null speculation Key: D Rationale: Use the rule: p-value < alpha, reject H0. In breast cancer, which lymph nodes lay medial to the medial margin of the pectoralis minor muscle and portend a worse prognosis? When a person is famous to have metastases in these nodes it confers a worse prognosis. The internal mammary nodes are situated in the intercostal spaces alongside the edge of the sternum in the endothoracic fascia. Level I nodes are in the low axilla and are lateral to the lateral border of the pectoralis minor muscle. Which is the suitable treatment for T2N0 squamous cell carcinoma of the anal canal? However, all poorly differentiated or T2 or N+ anal margin cancers require chemoradiation, as the sufficient margins would require violation of the anal sphincter, potentially compromising sphincter function. However, in a collection of medical trials from multiple of} centres efficacy was proven in preservation of normal tissue for sufferers handled with head and neck cancers. Its putative mechanism of radioprotection is thru the scavenging of radiation-induced free radicals. Small medical trials have instructed that amifostine protects in opposition to radiation-induced xerostomia and mucositis. In sufferers with previously untreated head and neck squamous cell carcinoma using main end points of incidence of grade > 2 acute xerostomia, grade > 3 acute mucositis, and grade > 2 late xerostomia. Amifostine administered (200 mg/m2 intravenous) every day 15 to half-hour earlier than irradiation. Key: A Rationale: the case-control study design compares these with a disease of curiosity to these without. Adriamycin Key: C Rationale: Concurrent administration of radiation and chemotherapy has emerged as a dominant type of cancer treatment. Nevertheless, our understanding of the precise mechanisms of interplay between radiation and chemotherapy remains to be evolving. Key: B Rationale: A rotating anode reduces the temperature at the target at anyone point. Lymphoma Key: B Rationale: Meningioma is the most common spinal tumor in adults but occurs in the intradural-extramedullary area. Descriptive Epidemiology of Malignant and Nonmalignant Primary Spinal Cord, Spinal Meninges, and Cauda EquinaTumors, United States, 2004-2007. What is the line that extends from the medial canthus of the attention to the angle of the mandible? The prescription of 15 Gy x 3 was utilized by Hoyer et al, and found to be unacceptably poisonous. Pathology shows small cells, optimistic for synaptophysin, chromogranin, and epithelial markers. Esthesioneuroblastoma of the nasal cavity Key: D Rationale: the provided image represents a case of newly diagnosed, advanced esthesion-euroblastoma with intracranial extension but without regional nodal or distant metastatic spread. Synaptophysin and chromogranin markers indicate neuroendocrine tumors and would exclude adenocarcinoma and squamous cell carcinoma which might additionally happen in this area. Absence of melanoma markers excludes melanoma which may also be discovered at this web site. References: Hall and Giaccia Radiobiology for the Radiologist, Sixth Edition, 2006. Radiation (50 Gy) with delay to surgery; quick course radiation (25 Gy) with delay to surgery; quick course radiation (25 Gy) at once to surgery b. Delaying surgery after short-course radiotherapy offers comparable oncological outcomes compared with short-course radiotherapy with quick surgery. Long-course radiotherapy with delay is much like both short-course radiotherapy regimens, but prolongs the treatment time substantially. Although radiation-induced toxicity was seen after short-course radiotherapy with delay, postoperative problems were significantly decreased compared with short-course radiotherapy. The table beneath shows the frequencies by the true disease status and screening take a look at outcome. True Disease Status Present Positive Screening Test Result Negative c d a Absent b What is the sensitivity of a screening test? It is assessed as having a optimistic (disease likely) or unfavorable (disease unlikely) discovering. Those topics with the disease should all be classified as having disease, and those topics without the disease must be classified as not having disease. Mausner, Shira Kramer, Mausner and Bahn Epidemiology: An Introductory Text, 1985, Chapter eleven, W. A affected person with nasopharyngeal carcinoma is unable to abduct the right eye and has numbness on the right brow, cheek and higher lip with normal sensation of the right chin and decrease lip. Both the sigmoid and rectum are organs in danger which need to be addressed at the time of each brachytherapy implant. A dose limit of as much as} 80 Gy is just too|is merely too} excessive and injury to the rectum and sigmoid.

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In the absence of signs or any overt scientific evidence of caries, does the dentist recommend restoration? Will this patient be available for maintenance visits in order that the lesion could be monitored at regularly specified intervals? Determining the presence or absence of caries and deciding whether or not to intervene restoratively are but two of many challenging questions the restorative dentist must face. Some skilled components transcend weighing the comparative deserves of different materials and techniques and beyond risk willpower. At some point, the dentist must address the basic query of the extent to which determination making can and should be left a lot as} the patient. Throughout this textual content, an overriding perspective has been that the patient should be involved in the determination making. In many restorative conditions described on this section, a well-informed and knowledgeable patient can and should make the ultimate remedy determination. In some circumstances, nevertheless, compelling issues such as the structural integrity of the tooth and the forces of occlusion must drive the choice. In such circumstances, the dentist could must limit the alternatives offered to the patient or make a stronger recommendation for one of many choices. Patient Modifiers If the patient has delicate tooth or seen dark areas on the tooth, he or she will probably initiate a request for remedy. In either of these conditions, nevertheless, the patient is unlikely to have a full understanding of the available remedy choices or the inherent limits and dangers of every. Although the patient will be the final determination maker, considerable training could must take place before an knowledgeable determination in regards to the remedy could be made. Unlike problems involving the periodontal tissues, malocclusion, or missing tooth, single tooth restorative needs may not be not|will not be} self-evident to the patient. In addition, obvious problems, similar to a missing restoration or a symptomatic or seen gross carious lesion, most likely may have been addressed in the illness management part of remedy. As a end result, these definitive part problems current the dentist with a twofold educational problem: first, to inform the patient as to why a restoration additionally be} necessary, and second, to describe the available restorative choices. How dedicated is the patient to bettering esthetics and warding off future problems? When restorative intervention is necessary and the patient accepts this, the patient should contribute important enter to the number of restorative material. Is optimum remedy preferred now in the hope of stopping future problems, or does the person choose to wait and see, accepting truth that|the truth that} the tooth could break or even be lost prematurely? The widespread restorative problems, remedy choices, and keys to determination making are presented in Table 8-3. Care should be taken to defend the gentle tissues from the acid by using the rubber dam through the procedure. Although this procedure could make important improvements, some sufferers could require more invasive procedures, similar to veneers, crowns, and so forth. Contouring Teeth One of the best techniques for minor alteration in tooth structure is cosmetic contouring. Contouring or reshaping could be particularly helpful in bettering the appearance of fractured, chipped, extruded, or overlapped tooth. Teeth are sometimes recontoured using rotary instrumentation with stones and rubber sprucing or ending burs, supplemented with sprucing paste applied with sprucing cups, factors, strips, and/or discs. Contraindications to contouring include hypersensitive tooth, skinny enamel, and conditions in which contouring would expose dark or discolored dentin in the esthetic zone. Vital Bleaching Bleaching very important tooth includes utility of a bleaching chemical to change tooth shade (Figure 8-18). For many sufferers, use of over-the-counter whitening strips (Figure 8-19) could be an inexpensive and customarily innocuous technique of attaining the desired impact. For sufferers who want more whitening than over-thecounter merchandise can present or preferring to have the remedy directed by the dentist, different choices are available. The remedy could be supplied exclusively by the dentist in the office or by the patient at home using custom-fitted plastic trays fabricated by the dental staff and a bleaching gel. The in-office remedy offers more immediate results, whereas the at-home method could require 2 to 6 weeks to lighten the tooth. The availability of these techniques has generated a powerful, optimistic response from many sufferers. If a patient is excited about changing the appearance of his or her tooth and smile, the general remedy choices available include bleaching, tooth-colored restorations, veneers, crowns, quantity of|various|a variety of} other|and quantity of} other} different tooth-specific esthetic therapies. Esthetic therapies for individual tooth differ in the level of invasiveness (Table 8-4). At one finish of the spectrum are over-the-counter whitening toothpastes that result on} tooth shade only minimally, primarily by removing extrinsic stain. At the alternative finish is the full porcelain crown, which requires elimination of a significant amount of enamel and dentin to enable space for the restoration. Some appearance-altering procedures, similar to composite restorations and porcelain inlays and onlays, have already been mentioned on this chapter. The procedures mentioned on this section include microabrasion, tooth contouring, bleaching of vital and nonvital tooth, and the placement of tooth-colored veneer restorations. Representative Esthetic Problems and Treatment Procedures Microabrasion Microabrasion is taken into account a protected and conservative method of removing intrinsic enamel discolorations and defects. It is used to treat situations like fluorosis, postorthodontic demineralization, and superficial enamel hypoplasia. Basically the defective floor layer of enamel is eliminated using a mixture of abrasion and erosion. This is achieved by using acids, similar to hydrochloric acid or phosphoric acid, along with abrasive powders, burs, stones, and discs. A paste shaped from mixing hydrochloric acid with an abrasive powder is often used with a slow pace handpiece and rubber cup, brush, and so forth. Clinically the floor that has been microabraded seems easy and Figure 8-18 Proprietary very important bleaching materials. Patient wearing plastic strip that contains bleaching Night guard bleach (custom tray fabricated by the dentist and used with a prescribed bleaching agent) In-office exterior bleach Internal bleach sensitivity to warmth and cold. Irreversible damage to the pulp can happen with the stronger chemical substances and warmth used for in-office therapies. In contrast, the sensitivity to warmth and cold that some sufferers experience home bleaching is normally reversible and relates to frequency of use of the bleaching agent. Bleaching Devitalized Teeth For discolored, devitalized tooth, the dentist can alter tooth shade by putting bleaching chemical substances inside the pulp chamber. The remedy could be professionally applied in the office or by sealing bleaching brokers into the tooth for quantity of} weeks. Bleaching devitalized tooth can produce excellent esthetic results with minimal trauma or discomfort. Veneers Veneers are placed on tooth to enhance esthetics by changing the colour, contour, or dimension of the tooth. Composite veneer restorations could be fabricated using a direct (chairside) or indirect (laboratory fabricated) approach. The former are more widespread and customarily are a more conservative and price effective} various to porcelain veneers. An impression is made, the tooth temporized (if desired), and the porcelain veneer is fabricated by a laboratory after which bonded in place. Porcelain veneers are indicated in conditions involving excessive enamel discoloration, similar to is seen with tetracycline staining or fluorosis. Veneers additionally be|may also be|can be} used to shut diastemas, lengthen short tooth, and replace small quantities of missing tooth structure (Figure 8-20). Porcelain is pure wanting, steady in shade, relatively strong (after bonding in place), and has good biocompatibility with gingival tissue. Porcelain veneers supply a significant change in the look of the tooth in trade for less than|for under} a small loss in structure. Sound enamel on the periphery of the preparation is necessary to seal the veneer to the tooth floor.

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This is the traditional, most regularly used multiple-choice query format on the examination. Example Item A 32-year-old woman with sort 1 diabetes mellitus has had progressive renal failure over the past 2 years. Her hemoglobin concentration is 9 g/dL, hematocrit is 28%, and mean corpuscular quantity is 94 m3. Each query is associated with the preliminary patient vignette but is testing a different point. You should turn into conversant in all item codecs that shall be used within the precise examination. Although the pattern questions exemplify content on the examination, they might not replicate the content protection on individual examinations. The questions shall be offered one at a time in a format designed for simple on-screen studying, together with use of exhibit buttons for the Normal Laboratory Values Table (included right here on pages 5-6) and some pictorials. A 25-year-old woman is brought to|is delivered to|is dropped at} the emergency department 1 hour after she fainted. She has had gentle intermittent vaginal bleeding, typically associated with decrease stomach pain, during the past 3 days. She has not had a menstrual period for 3 months; previously, menses occurred at regular 28-day intervals. Abdominal examination shows gentle tenderness to palpation in the proper decrease quadrant. Bimanual pelvic examination shows a young walnut-sized mass in the proper parametrium. A 12-year-old lady with a 1-year history of systemic lupus erythematosus is brought to|is delivered to|is dropped at} the doctor for a routine follow-up examination. During the past yr she has carried out nicely aside from occasional gentle frontal headaches, fatigue, and arthralgias; the results of regular laboratory evaluations have been steady. She says that she has felt nicely except for occasional episodes of constipation, stomach discomfort, and gentle fatigue. Laboratory research show: Erythrocyte depend Serum K+ Cl­ Ca2+ Phosphorus Alkaline phosphatase 3 million/mm3 four. A 3-year-old boy is brought to|is delivered to|is dropped at} the doctor because of fever, headache, and sores on his back and left shoulder for 1 day. Physical examination shows vesicles over the back and left shoulder as within the photograph shown. An x-ray of the proper upper extremity shows bony lesions according to with} osteomyelitis. Hospital discharge of a 75-year-old man is delayed as a result of} unavailability of a bed in a nursing home. During a 3-day period, his pulse will increase from 82/min to 125/min, and blood strain decreases from 124/72 mm Hg to 100/55 mm Hg. A 76-year-old man with a history of prostatic hypertrophy has the recent onset of increased difficulty urinating. Symptoms began shortly after he started taking a nasal decongestant orally for cold signs. Which of the following types of receptors is most likely to be concerned in these adverse effects? A placebo-controlled medical trial is performed to assess whether or not a brand new} antihypertensive drug is more effective than normal therapy. A 15-year-old lady is brought to|is delivered to|is dropped at} the doctor because of a 3-week history of excessive thirst and voiding excessive amounts of urine. Her signs are most likely as a result of} a relative lack of which of the following proteins from the apical membranes of accumulating duct epithelial cells? A sexually active 23-year-old man with multiple of} intercourse companions has dysuria and a yellow urethral exudate. Which of the following properties of the infecting organism best explains the reinfection? Neurologic examination 6 weeks later shows an extensor plantar reflex on the proper. When she is asked to protrude her tongue, it deviates to the left, and the muscle within the left aspect of the tongue shows considerable atrophy. Which of the following labeled areas within the transverse sections of the brain stem is most likely damaged? A 22-year-old man develops delusions, flattening of affect on}, catatonic habits, hallucinations, and aphasia. Which of the following signs would be more likely to to|prone to} improve if this patient have been handled with clozapine rather than with haloperidol? After an infection with measles virus, a 6-year-old boy produces antibodies to all eight viral proteins. Antibodies to which of the following viral proteins are most likely to be protective? A 25-year-old woman involves the doctor because of a 10-year history of frequent occurrences of fever blisters. Microscopic examination of tradition of scrapings from three vesicles shows herpes simplex virus 1. A 52-year-old woman involves the doctor because of a 2-day history of fever and left flank pain. She has been handled for multiple of} episodes of pyelonephritis during the past 3 years. Histologic examination of the mass shows a predominance of epithelioid cells with partially clear and granular-to-foamy cytoplasm. Nuclei are eccentric, normochromic, symmetric, and without important pleomorphism. A 35-year-old woman with a bicuspid aortic valve involves the doctor because of a 1week history of a swollen, painful left knee. Analysis of synovial fluid aspirated from the left knee shows many segmented neutrophils; a Gram stain shows no organisms, and tradition is adverse. An in any other case wholesome 45-year-old man involves the doctor because of a 3-week history of progressive epigastric heartburn and a four. A biopsy specimen of the bladder shows marked continual inflammation with fibrosis and scattered granulomas. A 4-year-old boy is brought to|is delivered to|is dropped at} the doctor because of sluggish progress during the past yr. Laboratory research show a normochromic, normocytic anemia and increased serum concentrations of urea nitrogen and creatinine. Which of the following units of extra serum findings is most likely in this patient? Calcium Inorganic Phosphorus 1,25-Dihydroxycholecalciferol Erythropoietin (A) (B) (C) (D) (E) (F) 24. Which of the following ought to be added to the treatment regimen to prevent neurologic toxicity in this patient? Repetitive cycles of heating and cooling are performed, and the response product is detected by gel electrophoresis. A 12-year-old lady is brought to|is delivered to|is dropped at} the emergency department by her dad and mom because of a 3-day history of fever and a 12-hour history of lethargy. Her dad and mom say that she has been sleeping most of the day and has been unresponsive when awake. A 6-year-old boy from rural Mississippi is brought to|is delivered to|is dropped at} the doctor by his mother because of a 6-month history of lethargy; he additionally has had a 4-kg (9-lb) weight reduction throughout this era. The mother says her son used to be active, usually playing in} outdoors without carrying his footwear. Which of the following is the most likely explanation for the medical presentation? Warfarin is administered to a 56-year-old man following placement of a prosthetic cardiac valve. Subsequently, trimethoprim-sulfamethoxazole therapy is begun for a recurring urinary tract an infection. In addition to monitoring prothrombin time, which of the following actions should the doctor take to preserve adequate anticoagulation?

References:

• https://urology.wisc.edu/wp-content/uploads/2018/10/Module_3_BPH.pdf
• https://business.ct.gov/-/media/DPH/CYSHCN/Connecticut-Guidelines-for-a-Clinical-Diagnosis-of-Autism-Spectrum-Disorder.pdf
• http://files.surgicalcore.org/2020-2021_GS_CO_Booklet_v3editsfinal.pdf
• https://1filedownload.com/wp-content/uploads/2020/04/Case.Fi-.pdf