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Arterial blood gases are rarely required generic 15mcg mircette with amex birth control pills during menopause, only being indicated in severely unwell patients (eg order mircette 15 mcg with visa birth control tri sprintec. It should be remembered that access to the arterial system for percutaneous coronary intervention is often via the radial artery effective mircette 15 mcg birth control pills meaning, so avoiding damaging the vessel by repeated punctures is advisable order mircette 15mcg with mastercard birth control for women with depression. Additionally, if a patient is thrombolysed they are liable to bleed from sites of previous arterial puncture. X-ray the chest x-ray is likely to be normal in an acute coronary syndrome, so is not generally essential. Here the definition proposed by the European Society of Cardiology, the American College of Cardiology and the American Heart Association is used. Initiate rapid reperfusion to limit infarct size and minimise the risk of pump failure and arrhythmias 5. Risk assessment for longer term management and commence secondary prevention Patients should be rapidly assessed on arrival to hospital as previously described. All patients (unless strongly contra-indicated) should be treated with aspirin 300mg, followed by 75mg daily. Patients should be placed on cardiac monitoring to allow prompt identification of arrhythmias. Thrombolysis the greatest benefit is gained within the first 2 hours of onset of pain with a subsequent progressive decrease of 1. Beyond 12 hours there is no clear evidence whether the benefit outweighs the risk of major bleeding. The patient should be continuously monitored for arrhythmias and any haemodynamic compromise. This should be suspected especially in patients with known hypertension or connective tissue disease. Presentation Symptoms are usually of severe, tearing retrosternal chest pain, often radiating through to the back and intrascapular region. More rarely it can present with dyspnoea, sudden paralysis if the cerebral or spinal arteries are affected, or limb ischaemia. Blood pressure may or may not be raised and there may be a pulse and blood pressure deficit between the arms. The patient should be continuously monitored either on a coronary care or high dependency unit. It is important to watch for signs of haemodynamic compromise or extension of dissection (often heralded by more pain), that may lead to loss of peripheral pulses, renal or cerebral infarction etc. Acute Pericarditis the commonest causes of pericarditis are viral (most frequently parvovirus B19 or coxsackie) and post myocardial infarction. The presentation is typically of sharp, substernal chest pain that is relieved by sitting forward and made worse by lying down. On examination the patient may be pyrexial and there may be a friction rub audible. Myocarditis Myocarditis may present in association with pericarditis or as an acute disease characterised by a febrile illness and heart failure. The cause is frequently unidentified and can be idiopathic, infective (viral, bacterial or protozoal) or autoimmune. Investigations include viral antibody titres, transthoracic echo which may show a regional wall motion abnormality and rarely, endomyocardial biopsy. Aspirin, heparin and thrombolytic therapy in suspected acute myocardial infarction. An international randomised trial comparing four thrombolytic strategies for acute myocardial infarction. Primary angioplasty versus thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Task Force on the Management of Acute Coronary Syndromes of the European Society of Cardiology. Advances in medical care have made it possible for people with Marfan syndrome to live a normal lifespan if they are diagnosed and treated properly. Marfan syndrome most often a ects the heart, blood vessels, bones, joints, and eyes. Connective tissue holds all parts of the body together and helps control how the body grows. Because connective tissue is found throughout the body, Marfan syndrome features can occur in many di erent parts of the body. Most often the condition af fects the heart, blood vessels, bones, joints, and eyes. Marfan syndrome features can appear at any age—including in infants, teens, and older adults—and they can get worse as people age. If you suspect that you or a family member may have Marfan syndrome, find a doctor who is knowledgeable about the condition. Ideally, the diagnostic process should be coordinated by a medical geneticist (a doctor who specializes in genetic conditions. It is possible to have some Marfan syndrome features, but not enough for a con rmed diagnosis. The only way to know for sure is to be checked by a doctor who understands Marfan syndrome. You can download the family health history kit from our website to compile the details, including: • Past illnesses, operations, and hospitalizations • Medications • Reasons you think you or your family member might have Marfan syndrome • Family members who have, or might have, Marfan syndrome • Family members who died of a heart or vascular problem How is Marfan syndrome diagnosed A Marfan syndrome diagnosis can often be made after exams of several parts of the body by doctors experienced with connective tissue disorders. The evaluation includes: • A detailed medical and family history, including information about any family member who may have the disorder or who had an early, unexplained, heart-related death • A complete physical examination You should also have tests to identify Marfan features that are not visible during the physical exam, including: • Echocardiogram.

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Grodman believes that because of advances in technology since the early 2000s buy mircette 15mcg without prescription birth control for 18 year olds, this “then-and-now comparison unfairly favor current applications 15 mcg mircette mastercard birth control zoloft. Reed and Salisbury believe that the recent advances in genetic diagnostic technology 15 mcg mircette visa birth control pill 50 years old, the relative completeness of the current commercial test mircette 15mcg for sale birth control viorele, and the greater awareness of clinicians and patients of genetic testing also casts serious doubt on the validity of this comparison. Keating thought were likely to be more complicated and scientifically less productive. Towbin suggests 116 that it is unreasonable to expect a non-research laboratory to acquire the necessary clinical data. Reed and Salisbury believe such registries should be set up under the auspices of an independent institution with Institutional Review Board approval, as Dr. The companies have also presented data at national 120 meetings and published their findings in abstract form. In a few cases, however, test results and/or 123 their interpretation appear to have differed. Monitoring standards for molecular genetic testing in the United Kingdom, the Netherlands, and Ireland. Reed: “We encourage our customers to inform us if there is any question or concern regarding a result or an interpretation. If a mistake on our part is found, we will rectify it and improve any process that might have been faulty. Research labs are generally headed by exactly the expert individual capable of sorting out discrepancies 126 and/or differences in interpretation. The company also emphasized that it does not prevent research labs from 128 conducting research. External quality assurance of molecular analysis of haemochromatosis gene mutations. In the first quarter of 2004, Genaissance concluded agreements with the University of Utah and Yale University covering an estate of more than 50 issued and pending patents 132 relating to the five known mutant genes predisposing to cardiac channelopathies. The University of Utah Technology Commercialization Office declined to speak with us for this study. Those sending samples for testing cannot know in advance which 148 mutations will be found, and yet neither testing service has rights to test for the full range of mutations. Discounting to payers and 152 inability to collect copayments/deductibles from patients leads to a notably lower value to the lab. By our calculations, GeneDx was screening about 33% of the five genes 154 approximately 13. Bale S, "Interview with Sherri Bale, PhD, President and Clinical Director of GeneDx. Reed notes her companys “…significant investment in Clinical Datas sales and marketing efforts, infrastructure and payer contracting. It is worth noting that in 2002, if we assume one amplicon per exon, GeneDx charged ~ $129 per amplicon ($2200) for its partial primary 161 screen of 17 exons selected from the five genes. Securing an exclusive license is therefore not necessarily hypocritical, if it is a strategy to induce negotiation in the face of existing exclusive rights. This was not an appealing proposition to us…[This is] a business dispute where one party simply wants rights to a market the other company has built diligently 165 through entrepreneurial investment of time and resources. This case is thus a stark illustration of two features of how exclusive licensing of patent rights can influence diagnostic testing: the potential for mutual blocking situations, and the “penumbra effect (discussed in the hearing loss case study also) in which exclusive rights to one or a few common genetic variants can in effect drive business for all genetic testing—even for variations that have been discovered but not patented or that have never been discovered before—to the rights holder. That is, rights on one set of mutations can be leveraged to drive business for other mutations not covered by patent claims. This cannot be resolved by those seeking genetic test results because they cannot know in advance which mutations will be found. Reed, this shows Clinical Datas “…willingness to cede markets to others where we are 169 not equipped to provide services. Ackerman, on the other hand, pointed out that the test continued to lack both Medicare and Medicaid 165 Reed C, Salisbury B, "Written comments of Carol Reed, M. Heidi Rehm, Associate Molecular Geneticist at the Harvard Medical School-Partners Healthcare Center for Genetics and Genomics, confirmed this assertion (as did another provider off the record. This sales force makes calls on pediatric electrophysiologists and cardiologists and, increasingly, their adult equivalents. Based on the initial positive results of this effort, the company expanded the size of the sales force in 2008. Clinical Data has 178 also recently added resources to focus on the provider and payer markets and has a dedicated customer 179 service group. Genetic testing for cardiac channelopathies: ten questions regarding clinical considerations for heart rhythm allied professionals. In one case, there was a sequencing problem; in the other there was an informatics issue. Chung 184 expressed fear that many cardiologists will interpret these as definitive disease-causing variants. Chung believes that having only a single commercial provider denies clinicians the opportunity to solicit a second opinion. Milunsky, who is a past and would-be provider of commercial testing, shares this 187 view. Their assumption is that multiple providers would reach consensus interpretations, and alternative providers would be accompanied by more public availability of data and more open discussion of its interpretation. In bi-annual proficiency testing, “there 191 has been an occasional conflict, although Dr. Chung [is] a paid consultant to a competitor company that desires access to the patents under discussion. Chung has herself engaged in discussions with the company as to the difficulty in interpreting these variants.

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Bobins Professor of Economics mircette 15mcg cheap birth control nausea, University of Chicago Session : Macroeconomic Factors and U buy cheap mircette 15mcg online birth control pills 831. Monetary Policy Pierre-Olivier Gourinchas buy mircette 15 mcg with amex birth control pills make me sick, Associate Professor of Economics buy mircette 15 mcg fast delivery birth control pills quiz, University of California, Berkeley Session : Risk Taking and Leverage John Geanakoplos, James Tobin Professor of Economics, Yale University Session : Household Finances and Financial Literacy Annamaria Lusardi, Joel Z. Nestor Dominguez, Former Co-head, Global Collateralized Debt Obligations, Citi Markets & Banking, Global Structured Credit Products Thomas G. Department of the Treasury Session : Perspective on the Shadow Banking System Timothy F. Department of the Treasury; Former President, Federal Reserve Bank of New York Session : Institutions Participating in the Shadow Banking System Michael A. Lewis, Senior Vice President and Chief Risk Ofcer, American International Group, Inc. Bensinger, Former Executive Vice President and Chief Financial Ofcer, American In ternational Group, Inc. Financial Services David Lehman, Managing Director, Goldman Sachs Group, Inc David Viniar, Executive Vice President and Chief Financial Ofcer, Goldman Sachs Group, Inc. Bernanke, Chairman, Board of Governors of the Federal Reserve System Session : the Federal Deposit Insurance Corporation Sheila C. Session : Local Housing Market Gary Crabtree, Principal Owner, Afliated Appraisers Lloyd Plank, Lloyd E. Black, Associate Professor of Economics and Law, University of Missouri–Kansas City Ann Fulmer, Vice President of Business Relations, Interthinx; Co-founder, Georgia Real Estate Fraud Prevention and Awareness Coalition Henry N. Pontell, Professor of Criminology, Law & Society and Sociology, University of Cali fornia, Irvine Session : Uncovering Mortgage Fraud in Miami Dennis J. Prices increased at least 50% in 401 cities, at least 75% in 217 cities, at least 100% in 112 cities, at least 125% in 63 cities, and more than 150% in 16 cities. Updated data provided by James Kennedy and Alan Greenspan, whose data originally appeared in “Sources and Uses of Equity Extracted from Homes, Finance and Economics Discussion Series, Federal Reserve Board, 2007-20 (March 2007. In 2007, the weekly wage of New York investment banker was $16,849; of the average privately employed worker, $841. See also Federal Reserve Consumer Advisory Council transcripts, March 25, 2004; June 24, 2004; October 28, 2004; March 17, 2005; October 27, 2005; June 22, 2006; October 26, 2006. Gramlich, “Tackling Predatory Lending: Regulation and Education, remarks at Cleveland State University, Cleveland, Ohio, March 23, 2001. Gramlich, “Predatory Lending, remarks at the Housing Bureau for Seniors Conference,, January 18, 2002. Rob Barry, Matthew Haggman, and Jack Dolan, “Ex-convicts active in mortgage fraud, Miami Herald, January 29, 2009. Kirstin Downey, “Many Buyers Opt for Risky Mortgages, Washington Post, May 28, 2005. Sheila Canavan, comments during of the Federal Reserve Consumer Advisory Council Meeting, October 27, 2005, transcript, p. Rajan, Fault Lines: How Hidden Fractures Still Threaten the World Economy (Prince ton: Princeton University Press, 2010), p. David Sambol, email to Angelo Mozilo, April 17, 2006, re: Sub-prime seconds (cc Kurland, McMurray, and Bartlett. Mortgage Insurance Companies of America, quoted in Kirstin Downey, “Insurers Want Action on Risky Mortgages; Firms Want More Loan Restrictions, Washington Post, August 19, 2006. Alan Greenspan, “The Evolution of Banking in a Market Economy, remarks at the Annual Confer ence of the Association of Private Enterprise Education, Arlington, Virginia, April 12, 1997. Charles Calomiris and Gary Gorton, “The Origins of Banking Panics: Models, Facts, and Bank Regulation, in Calomiris, U. Prior to the end of the Civil War, banks issued notes instead of holding deposits. Alton Gilbert, “Requiem for Regulation Q: What It Did and Why It Passed Away, Federal Re serve Bank of St. Mishkin, “Asymmetric Information and Financial Crises: A Historical Perspective, in Financial Markets and Financial Crises, ed. Thereafter, banks were only required to lend on collateral and set terms based upon what the mar ket was offering. Order Approving Applications to Engage in Limited Underwriting and Dealing in Certain Securities, Federal Reserve Bulletin 73, no. Jacobsen, “The Business of Banking: Looking to the Future, Busi ness Lawyer 50 (May 1995): 798. Till man, Big Money Crime: Fraud and Politics in the Savings and Loan Crisis (Berkeley: University of Califor nia Press, 1997), p. Treasury Department, “Modernizing the Financial System: Recommendations for Safer, More Competitive Banks (February 1991), p. McKinney is quoted from the transcript of the hearing before the House Committee on Banking, Housing, and Urban Affairs. The 1992 Federal Hous ing Enterprises Financial Safety and Soundness Act repealed this provision and replaced it with more elaborate provisions. Bush, “Presidents Remarks to the National Association of Home Builders, Greater Columbus Convention Center, Columbus, Ohio, October 2, 2004. ONeill, remarks before the Conference on Appraising Fannie Mae and Freddie Mac, Washington, D. An options contract grants the right but not the obligation to purchase or sell a commodity or financial instrument at a particular price in the future; the option holder derives a benefit if the price moves in his or her favor. In a swaps contract, the two parties exchange streams of payments based on different benchmarks. For example, an interest rate swap based on changes in interest rate on a $100 million loan would likely involve only a small percentage of the $100 million notional amount. On the other hand, price changes on an oil swap based on $100 million worth of oil could be even more than the notional amount, depending on the volatility in oil prices.

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The sound wave echoes are picked up head generic mircette 15mcg with amex birth control for pmdd, clenched fists with overlapping fingers purchase mircette 15 mcg otc birth control pills yaz side effects, and displayed on a television screen buy mircette 15mcg without prescription birth control libido. This test is mental retardation purchase 15mcg mircette visa birth control for female bodybuilders, heart defects and other organ used to monitor pregnancy and to identify some malformations. In the context of disease, the inheritance is normally recessive and Trisomy 13: (Also Patau syndrome) A leads to disease in boys, since they only have one X chromosomal condition that occurs when there are chromosome, and there is generally no equivalent three copies of chromosome 13 instead of two. Women who are Trisomy 13 is associated with severe mental carriers have a disease allele on one X chromosome retardation, small eyes that may exhibit a split in and a normal allele on the other, and so do not the iris (coloboma), a cleft lip and/or palate, weak usually express the disease. In some cases, however, muscle tone (hypotonia), an increased risk of heart the carrier may show mild or even severe forms of defects, skeletal abnormalities and other medical the disorder. East Mediterranean Health research in the state of Minas Gerais, Bra Journal, 9(3):344–352. Eastern Mediter tended families for genetic haemoglobin ranean Health Journal, 3(3):415–419. The frequency of screening and abortion and the influence consanguineous marriages in the state of of religious ruling (Fatwa. Journal of Genetic dations for introducing genetics services Counselling, 11(2):97–119. National In New England Journal of Medicine, stitute of Neurological Disorders and 341:1485–1490. Autonomy in moral uity in relation to prioritization and al and political philosophy. Measuring costs and benefits medical and societal consequences of the in public health: some ethical issues in Human Genome Project. New England relation to antenatal screening for Frag Journal of Medicine, 341(1):28–37. Journal of Medi rights: Integrating medicine, ethics and cal Ethics, 28(6):335–336. Convention ternal serum screening for fetal open neu for the protection of human rights and ral tube defects and aneuploidy. Convention ity of prenatal diagnosis of sickle cell on human rights and biomedicine. Effectiveness proposal for guidelines in genetic coun of gene expression profiling for response selling, prenatal diagnosis and screening. Establishment of the national screening policy to pre of prenatal diagnosis for a-thalassaemia: vent thalassemia major in Iran. Kyoto a step towards its control in a develop Institute of Economic Research, Kyoto ing country. GenePool glossary of clinical genetics privacy and the law: an end to genetics terms. Sex ratio at birth in Journal of Health Services, 31(2):445– China, with reference to other areas in 461. Choosing eugenics: New England Journal of Medicine, how far will nations go to eliminate a 343(2):141–144. European Society for Hu by preimplantation genetic diagnosis in man Genetics. Journal of Biosocial Science, services in the state of Rio de Janeiro, 30(2):261–279. Clinical genetics and nd nity genetic services in Latin America and genetic counselling, 2 ed. Preva genomic research for the prevention of lence of albinism in the South African common diseases with environmental Negro. United Nations Eco edge, action and resistance: the selective nomic and Social Commission for Asia use of prenatal screening among Bedouin and the Pacific women of the Negev, Israel. Report of the 1 Asian Workshop policy on the number and sex composi on Genomics and Community Genet tion of children in China. Nature and nurture— National Society of Genetic Counsel lessons from chemical carcinogenesis. Ge for sickle cell disease, Tay-Sachs disease, nomic priorities and public health. Personal communi fective genetic testing in the United States: cation, 19 February 2005. The changing face of 20and%20selection%20and%20abortion, epidemiology in the genomics era. Genetic as Desigualdades e Ampliando o Acesso testing and counselling in ethical poli a Assistencia a Saude no Brasil 1998– cies on the human genome, genetic re 2002, Serie G, Estatistica e Informacao search and services em Saude. The history for sickle cell disease: public health im of community genetics: the contribution pact and evaluation. Public health genet Center (authorized government portal ics: an emerging interdisciplinary field site to China), China International Pub for the postgenomic era. Delivery of Adopted at the Inter-American Special genetic services in developing countries. Genetic serv pharmacogenomics on neglected dis ices in Latin America (guest editorial. Human genome tility society: imbalance of the sex ratio epidemiology, a scientific foundation for at birth in Korea.

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The Medical and Surgical Clinical OutcomeReview and the Child Health Clinical Outcome Published 3 May 2019 All healthcare is represented both by theseand learning points that emerge from their reviews quality mircette 15 mcg birth control arm implant. However order mircette 15mcg without a prescription birth control pills zarah, despite the ability towithin those organisations cheap 15mcg mircette amex birth control pills 8667, potentially have access 5 order 15mcg mircette birth control joint pain. It is possible that thisrequired by organisations to correct the issues each programme link later in this review. Theseprogrammes collate the endeavours of many that is disseminated, which is, paradoxically, tooperception arises due to the quantity of information differing points in maturity, often articulatehealthcare workers, and although they are at this review has been written to attempt tomuch to easily assimilate. We hope that by working together as a mortality reviews collaborative, dissemination and embedding of common recommendations will be further enhanced. Reports were previously produced on a trien nial basis, because the number of maternal deaths from individual causes is small, and three years worth of data is required to identify consistent lessons learned for future care and to maintain anonymity and confdentiality. Clearly the need to undertake annual reporting does not change this requirement, therefore, each topic-specifc chapter which appeared in the previous triennial report now appears in an annual report once every three years on a cyclical basis, alongside a surveillance chapter reporting three years of statistical data. All causes of maternal death have now been covered once in this three-year cycle; this report is the third in the second three-year cycle: • 2014 report: Surveillance data on maternal deaths from 2009-12. Confdential Enquiry reports on deaths from psychiatric causes, deaths due to thrombosis and thromboembolism, malignancy, homicides and late deaths. Confdential Enquiry reports on deaths and severe morbidity from cardiac causes, deaths from pre-eclampsia and eclampsia and related causes and deaths in early pregnancy, messages for critical care. Confdential Enquiry reports on deaths from psychiatric causes, deaths due to thrombosis and thromboembolism, malignancy and homicides, and morbidity from major obstetric haemorrhage. Confdential Enquiry reports on deaths from cardiac causes, deaths from pre-eclampsia and eclampsia and related causes, accidental deaths and deaths in early pregnancy, morbidity from newly diagnosed breast cancer and messages for critical care. Alongside the confdential enquiries into maternal deaths we also conduct enquiries into maternal morbidity topics, which can be proposed by anyone. Maternal Morbidity Women are identifed for the Confdential Enquiries into Maternal Morbidity in diferent ways according to the topic. A geographically representative sample of 34 women was drawn at random from this group. A full set of medical records was requested from each hospital and general practice concerned. The records then underwent expert assessment in exactly the same way as the records of the women who died. Consent was requested from women in Northern Ireland to participate, since legis lation does not exist to allow inclusion of their data without consent. Hospitals provided only 30 of 34 requested sets of records; the care of these 30 women is described in Chapter 4. A new confrmed diagnosis of breast cancer during pregnancy determined from the medical records. The main elements of multiple disadvantage were a mental health diagnosis, substance use and domestic abuse. Maternal deaths from direct causes are unchanged with no signifcant change in the rates between 2012-14 and 2015-17. Thrombosis and thromboembolism remain the leading cause of direct maternal death during or up to six weeks after the end of pregnancy. It is reassuring that there is no evidence of an increase in maternal mortality rates, either overall, direct or indirect. The statistically non-signifcant decrease in direct maternal deaths is predominantly due to a decrease in maternal deaths from haemorrhage and amniotic fuid embolism. Rolling three year rates for individual causes are presented for fve overlapping triennial reporting periods (2011-13, 2012-14, 2013-15, 2014-16 and 2015-17) (Table 2. Direct deaths There was no statistically signifcant change in the rate of direct maternal deaths from any cause between 2009 and 2017. Thrombosis and thromboembolism continues to be the leading cause of direct deaths occurring within 42 days of the end of pregnancy, followed by deaths by suicide and deaths due to obstetric haemorrhage (Figure 2. As noted above, the rate of maternal mortality from haemorrhage reassuringly shows a statistically non-signifcant decrease. The maternal death rate from pre-eclampsia and eclampsia continues to be low but remains higher than the lowest observed rate, in 2012-14, and therefore the messages for prevention identifed in chapter 5 remain important. Although maternal mortality rates from early pregnancy causes remain low, a number of messages to prevent future deaths are clearly identifed in chapter 6. As in previous reports, cardiac disease remains the largest single cause of indirect maternal deaths (Figure 2. Neurological causes are the second most common indirect cause of maternal death, with a statistically non-signifcant increase in mortality rate such that neurological causes are now the third commonest cause of death overall. This increase is due to an increase in both deaths from epilepsy and stroke, with fourteen women dying from epilepsy during or up to six weeks after pregnancy in this trien nium (compared with eight in the triennium 2013-15), a mortality rate of 0. Coincidental deaths Most womens deaths from malignancy during or after pregnancy are classifed as coincidental deaths, together with deaths of women due to accidents. Many messages for improving the care of women with malignancy were identifed in the 2018 report, further messages for improving care have been identifed from the confdential enquiry into breast cancer morbidity and these are considered in chapter 4. It is impor tant to note that not only are a number of maternal deaths not ascertained through routine data (false negatives), there is also a signifcant false positive rate. This emphasises the importance of the additional case identifcation and checking undertaken to give an accurate maternal mortality estimate. Women who died between six weeks and one year after the end of pregnancy In the triennium 2015-17, 313 women died between six weeks and one year after the end of pregnancy, representing a mortality rate of 13. Maternal suicides continue to be the leading cause of direct deaths occurring between six weeks and one year after the end of pregnancy. The remaining 132 women gave birth to a total of 144 infants, 96 (67%) survived, 48 died (40 babies were stillborn and 8 died in the neonatal period.

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