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Dweck: The amount of choices can be over the time scheduling may impact natural lubrica whelming for women cheap prometrium 100 mg with visa symptoms of pregnancy. I typically make very spe tions 200mg prometrium free shipping symptoms just before giving birth, so we often recommend they use adjunc cifc recommendations discount prometrium 100 mg free shipping symptoms strep throat, usually beginning with tive products order 100 mg prometrium medications during breastfeeding. It is an over-the-counter water-based lubricant, such marketed specifcally for the couple trying to con as K-Y Jelly or Astroglide. Silicone lubri vaginal pH levels—some lubricants change the cants are very slick, last longer, and are compatible level in a way that is negative toward sperm motility. They are so slick, in fact, that just Fertility-friendly lubricants are designed to mini a little bit needs to be used with each sexual act. We do not have cone lubricants during water play, such as in the clear evidence about which lubricants are better shower or bath, because they are so slick that they than others, but couples often have so much anxiety can cause slipping. Kingsberg: We always think about lubricants so-called fertility-friendly products to them, I think and moisturizers with regard to vaginal penetra it will reduce some anxiety. Dweck: The 2 ingredients that are talked about There are gels specifcally designed to be used as most in my patient population are glycerin and anal lubrication that are thicker and last longer, al parabens. Parabens are used lubricant or moisturizer should have an osmolal as preservatives to increase shelf-life and are often ity of not greater than 1,200 mOsm/kg, and this is ingredients in various lubricants; they also have an important feature to consider when choosing a been considered possible hormone disruptors, product to recommend. Dweck: Hyaluronic acid is naturally found in still out on them, I think it is best to avoid products the body and is “all the rage” right now as an anti with parabens if a patient is particularly sensitive aging and smoothing ingredient. As a vaginal gel, hy and other organizations have stated that, in such aluronic acid has been shown to improve vaginal low quantities, these chemicals are not causative itching, painful intercourse, and vaginal burning agents of cancer. In addition, many An ideal water-based lubricant of the compounding pharmacies are making com pounded moisturizers for vaginal use that contain or moisturizer should have an hyaluronic acid with good result. Krychman: I recommend Lubrigyn Cream, when choosing a product to with hyaluronic acid (a little goes a long way). Cost is always an issue; it is not necessarily the There are emerging data indicating that some more you pay, the better the product. We have to be that may actually strip away the natural protective very cautious about some additives. The vagina, the vulva, the clitoris, and the whole genital pelvic area can be Consider plasma osmolality and sensitive with estrogen decline, so vulvar washes hyaluronic acid are becoming more common. Larkin: Another important topic is plasma os I like several water-based lubricants, like Good molality. We have known for a long time that when Clean Love, which also has very good osmolality; cells are exposed to hypertonic fuid, it causes the K-Y products, which are tried, tested, and true; fuid shifts and this can cause cellular disruption and Sylk, which is all natural, too. The same is true in the mend Überlube, which is silicone and a little vita vagina. Normal plasma osmolality is somewhere min E, as well as the Wet products, which seem to between 285 and 295 mOsm/kg; human semen is be very well tolerated and afordable. Kingsberg: I like products that ofer a variety learned that most water-based lubricants on the of choices, such as a sensitive skin gel, a thicker for market have a very high osmolality, somewhere mula gel, a silicone option, a water-based liquid, in the range of 2,000 to 6,000 mOsm/kg, so they and paraben-free. This can cause fuid shifts in the good clinician is going to have several samples the vaginal cells, and cellular compromise can be in his or her ofce. I think letting patients hesitant to use anything over the counter that sample products is very helpful because some of might contain a concerning ingredient, so the one preference is related to sensation—the tackiness, that I use contains hyaluronic acid, vitamin E, and the slipperiness, perhaps the scent. It can be compounded at any compounding are prone to irritation, particularly postmenopausal pharmacy, and I get a very good result from it. Krychman: I will add that Luvena is a hybrid; lubricants more problematic than benefcial. Replens and tients appreciate having all the options listed in a RepHresh also can be helpful for many patients. Krychman: For academic centers or other in Just in our small group, we have a variety of stitutions that are not allowed to have samples, a recommendations and suggestions for selection. Patients can then fll out a card after and send it back to If you do not want to spend a receive a full bottle of their favorite lubricant. The lot of time talking about it, be site also has downloadable patient education ma sure to have a handout that terials about moisturizers and lubricants. T eir sampler package is a great way for patients to moisturizers and from treating try diferent products. I have seen that vulvar washes can be very helpful in this As clinicians, we need to individualize product setting; I like Lubrigyn. I believe many of the companies that pro lubricants, Good Clean Love is certainly popu duce the products mentioned would be happy to lar in my practice. For a silicone-based product, send the readership samples and information, so I frequently recommend Pjur. Kingsberg: I would urge readers to take into ucts, I do like Lubrigyn and Luvena very much, account how important it is to have this conversa and patient feedback has been positive for both. I try to give them one example each the use of lubricants and moisturizers for women of of a water-based and silicone-based. Simply talking about these naturally inclined patient I recommend coconut issues validates patients’ sexuality, and I think that oil—the best oil for moisturizing and lubricating increases patient satisfaction with you and their the area. Lubrigyn is definitely my “go to” for my Moisturizers and lubricants are not just for post menopausal population. The average age at menopause is 51 activity helps in maintaining a healthy weight years, although some women might go through it and high energy levels and decreases the risk of heart disease and other age-related much earlier or a little later.

There is much current research into the effects of Maca Root with respect to 100mg prometrium with mastercard medicine etymology building immunity to purchase prometrium 200mg mastercard medicine 657 invasive infection cheap 100 mg prometrium otc medicine to induce labor. Researchers at Johns Hopkins University found that the protein (called nrf2) spurs cells to discount prometrium 100mg fast delivery medicine used for adhd produce enzymes that detoxify harmful substances, and members of the Brassicaceae family are known to contain this helpful chemical. The studies claim that by "elevating the level of nrf2 detoxifying enzymes, we can enhance the resistance to carcinogens. Medical Uses: Maca Root is believed to help sexual performance and act as an aphrodisiac that boosts libido in both men and women. Chemical research has demonstrated that Maca Root contains a chemical called p-methoxybenzyl isothiocyanate, which has reputed aphrodisiac properties. Because Maca is thought to balance hormonal activity, it is believed to be useful in cases of sterility and other reproductive and sexual disorders. In men, it is believed to treat male impotence and erectile dysfunction and may, in fact, increase seminal volume and sperm motility. There are also claims that Maca especially enhances sexual performance and endurance. The April 2000, issue of Urology reported that the sexual performance claims made by those who used Maca were consistent with the legendary reports coming from Peru. Menopausal women and those who suffer menstrual difficulties may be helped with the use of Maca. Research has shown that Maca Root contains no plant hormones, but its action relies on plant sterols, which act as chemical triggers to help the body produce a higher level of hormones appropriate to the age and gender of the person taking it. Maca Root is believed to increase energy and stamina and boost endurance in athletes. It is also thought to help in cases of chronic fatigue syndrome and to restore lost vitality and vigor. In the past, Spanish chroniclers described Inca warriors who consumed boiled Maca Root before battle to increase their strength, as well as using it to bolster their reserves for endurance activities. Today, it is still employed as a fatigue-fighter and general tonic to counter lethargy, memory loss and other disorders resulting from depleted energy stores. It is the highest source of nutrients growing in the Andean region and is rich in sugars, protein, vitamins, essential nutrients (especially iodine and iron) and carbohydrates that resemble healthy cereal grains. If one has hypothyroidism, it is most likely caused by a hormonal imbalance, because the thyroid gland does not produce enough thyroid hormones. The chemical element, iodine, is a major component of thyroid hormones and a deficiency of this element is a leading cause of hypothyroidism; consequently, the high iodine content and hormone balancing properties in Maca may be responsible for its use in improving this condition. Maca Root is thought to be an adaptogen or agent that helps to balance bodily systems and normalize bodily functions during stressful situations that might alter those functions, helping the body to adapt and return to an overall sense of well-being. Precautions: None * * * * * Magnolia Bark In Chinese medicine, Magnolia Bark has been associated with the stomach, lungs, spleen and large intestine for over two thousand years and has been used to treat abdominal bloating, gas, nausea, diarrhea, menstrual cramps and indigestion. Recent studies have found that the herb inhibits the production of cortisol (the substance that encourages fat storage) and may be effective in weight loss programs. Plant Description: Magnolia is a magnificent family of forest trees that are revered for their beautiful, large, showy and deliciously fragrant flowers. Magnolias may be both evergreen and deciduous with luxuriant foliage and rich flowers and can reach a height of more than eighty feet, with some species much smaller. Magnolias can survive in both moist and dry soils (preferring well drained moist) that can be neutral-to-acid-to-alkaline, in sun or partial shade with shelter from cold winds and late frosts. It is in flower from June to September, and the flowers are hermaphrodite (has both male and female organs) and are pollinated by beetles. History: In 1703, Charles Plumier named the genus after Pierre Magnol, the most illustrious botanist in France at that time. For the most part, the genus is North American, where it was originally included in many herbal remedies of the Native Americans. There are also several species that are native to China and Japan (Magnolia officinalis, Magnolia hypoleuca, etc. Several species were listed in the United States Pharmacopoeia from 1820 through 1894 as a tonic, stimulant and diaphoretic. Magnolia Bark is collected in the autumn, and the unopened flowers are harvested in the springtime and used in herbal medicines. Some of the constituents in Magnolia Bark include volatile oils (eudesmol, bornyl-acetate, etc. Medical Uses: Magnolia Bark has been used in Chinese herbal medicine for at least two thousand years as an aromatic, pungent and warming stimulant that treats various disorders of the digestive system and strengthens stomach function. It is a bitter relaxant herb that acts as a tonic and improves digestion, relieving stomach pains, gastroenteritis and flatulence. It calms diarrhea and vomiting associated with indigestion, stimulates poor appetite and alleviates fullness and distension of the abdomen. As a mild diaphoretic, Magnolia Bark is said to increase perspiration and sweating and thus reduce fevers and cool the body. It has been historically used in cases of malarial fevers and fevers of a typhoid type. Magnolia Bark is believed to have antiseptic, antibacterial, antifungal, antispasmodic, expectorant and anti-inflammatory properties. As such, the bark is thought to relieve the pain and inflammation of rheumatism and gout, counteract yeast infections (such as leukorrhea) and combat upper respiratory tract infections and spasms, including asthma, coughs, profuse phlegm in the lungs, shortness of breath and fullness and pressure in the chest area. In the fight against obesity and weight management, Magnolia Bark has recently been recognized as an efficient fat burner. Magnolia Bark itself has been chewed as a substitute for tobacco and is said to "cure the habit.

The byproduct of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes pain effective prometrium 100mg symptoms anemia. Spoke in front of Congress in Washington for employment discrimination for people with epilepsy discount prometrium 100mg mastercard medicine hunter. Appeared on four talk shows to generic 200mg prometrium with mastercard medications hair loss discuss epilepsy focusing on the importance of understanding epilepsy generic prometrium 100mg with visa symptoms to pregnancy, how to help someone having a seizure and giving people with epilepsy encouragement and hope for the future. Chillemi enjoys helping people achieve optimal health by relieving their pain, strengthening their bodies, and revolutionizing their lifestyles through implementation of evidence-based, treatment and training protocols. Chillemi is licensed in the state of New Jersey, New York, Florida, and Pennsylvania. He is certified by the National Board of Chiropractic and by the American International Sports Association. He is also certified in Flexion Distraction, Functional Capacity Evaluations, and Certified in Cardiac Resuscitation. Chillemi maximizes his treatments with postural, strengthening and stretching exercises. He has adopted and mastered cutting edge examination methodology and has developed a system of X-ray analysis to screen out potential risks. Chillemi offers extensive care and treatment ranging from acute to chronic injuries, cervical and lumbar disc conditions, sports related injuries, shoulder dysfunction, knee dysfunction, and rehabilitation of the functional body. Dr Chillemi believes strongly in educating people in all aspects of health and fitness. His diverse background and skill set allow him to administer effective integrated treatment and therapy to assist in the areas of pain management, acute-injury care, post-surgical rehabilitation, functional training and rehabilitation, weight loss and balanced nutrition, increasing muscle mass, improving athletic performance, flexibility, cardiovascular fitness, stress management and sport specific personal training. Michael Chillemi has pursued his passion for herbal and alternative medicine one of the reasons for his participation and hard work to help with the completion of this book. Randomized study of the efficacy and safety of oral elderberry extract in the treatment for influenza A and B virus infections. Efficacy of an extract of North American ginseng containing poly-furanosyl-pyranosyl-saccharides for preventing upper respiratory tract infections: a randomized controlled trial. Effect of a dietary supplement containing probiotic bacteria plus vitamins and minerals on common cold infections and cellular immune parameters. Consumption of nitrate, nitrite, and nitrosodimethylamine and the risk of upper aerodigestive tract cancer. Randomized, double-blind study of freeze-dried Urtica dioica in the treatment for allergic rhinitis. Bromelain exerts anti-inflammatory effects in an ovalbumin-induced murine model of allergic airway disease. Butterbur Ze339 for the treatment for intermittent allergic rhinitis: dose-dependent efficacy in a prospective, randomized, double-blind, placebo controlled study. Anti-inflammatory activity of an extract of Petasites hybridus in allergic rhinitis. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. A systematic review of the effectiveness of garlic as an anti-hyperlipidemic agent. Effect of niacin on lipid and lipoprotein levels and glycemic control in patients With diabetes and peripheral arterial disease. Effectiveness of once-nightly dosing of extended release niacin alone and in combination for hypercholesterolemia. Efficacy and safety of plant stanols and sterols in the management of blood cholesterol levels. Effects of nicotinic acid and lovastatin in renal transplant patients: a prospective, randomized, open-label crossover trial. Treatment effect of Niaspan, a controlled-release niacin, in patients with hypercholesterolemia: a placebo-controlled trial. Lipoprotein responses to treatment with lovastatin, gemfibrozil, and nicotinic acid in normolipidemic patients with hypoalphalipoproteinemia. Effects of flavonoids on parietal cell acid secretion, gastric mucosal prostaglandin production and Heliobacter pylori growth. Monograph: Glycirrhiza glabra Leguminacae the Protocol Journal of Botanical Medicine 1996;Winter:9-14. Eradication of small intestinal bacterial overgrowth reduces Symptoms of irritable bowel syndrome. Hepatic injury associated with small bowel bacterial overgrowth in rats is prevented by metronidazole and tetracycline. A syndrome of cirrhosis, achlorhydria, small intestinal bacterial overgrowth, and fat malabsorption. Teo, Marcus, Chung, Stephen, Chitti, Lauri, Tran, Cuong, Kritas, Stamatiki, Butler, Ross, Cummins, Adrian. Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both. Current Treatment Options in Gastroenterology 2001, 4:7-14 Balogh Z, Ordogh J, Gasz A, Nemet L, Bender T. Effectiveness of balneotherapy in chronic low back pain - a randomized single-blind controlled follow-up study. Improvement in automatic postural coordination following alexander technique lessons in a person with low back pain. Chiropractic manipulation in the treatment for acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial.

Which of the following medications would you (E) Varicella zoster (A) Erythropoietin 165 cheap prometrium 100 mg online medicine kit for babies. A 32-year-old male presents with sore throat that prescribe for the treatment of subacute thyroiditis? A 37-year-old female presents with itchy buy generic prometrium 200 mg medicine wheel, bleeding order 100mg prometrium with amex symptoms rotator cuff tear, (C) Prednisone symptoms of a head cold order 200mg prometrium amex treatment 4 letter word. Physical exam reveals (B) Antibiotics non-healing lesions on the lips, mouth and tongue. Strep screen was (C) Corticosteroids Biopsy of affected areas reveals the presence of (E) Vitamin D negative. Which of the following physical examination, which of the following is (E) Thyroid hormone courses of treatment would you prescribe for this 178. The electrocardiogram shown below was obtained (A) Peritonsillar cellulitis (A) Chemotherapy suffer from chronic illness and are at increased from a middle-aged patient admitted to the emer (B) Sinusitis (B) Complete eradication of the lesions risk for community-acquired pneumonia? Minimizing exposure to ultraviolet radiation is (E) Polyvalent pneumococcal vaccine signs of respiratory distress. Chest X-ray shows suggested to decrease the risk of developing which air bronchograms, a “ground glass” appearance of the following ocular disorders? Based on (A) Cataracts treatment for which of the following conditions the patient’s presentation and test results, which (B) Detached retina caused by thePseudomonas aeruginosabacterium? A 22-year-old female is underweight and ema (D) Transient tachypnea (E) Tuberculosis (B) Right-sided congestive heart failure ciated. Electrocardiogram performed in the which of the following is the accurate diagnosis? The patient’s (B) Non-small cell lung carcinoma (B) Erythema multiforme electrocardiogram is illustrated below. Which of the following medications is administered (B) Atrial fibrillation (E) Malingering rhonchi. Chest X-ray was performed and appeared to a hypertensive pregnant female who must deliver (C) Atrial flutter 189. Which of the following medications is approved her baby early, to ensure fetal lung maturity? Based on patient symptoms and physical (D) Junctional rhythm for treatment of gestational diabetes? Which of the following is the most appropriate (B) Glucophage (C) Labetalol (B) Acute epiglottitis treatment for keratoderma? Prolonged use of phenothiazine medications, such (E) Tuberculosis (C) Lindane 190. Meniere’s disease is characterized by distention as compazine and thorazine, can cause which of (D) Liquid nitrogen of the endolymphatic compartment of the inner the following eye disorders? Which of the following is used as an emergency for maintenance therapy for Meniere’s disease? A 42-year-old female presents by stating she finds (E) Prothrombin complex concentrate no pleasure in anything in her life. Which of the following radiological procedures is experiencing anorexia, weight loss, depression, V1 is the most definitive for diagnosing viable myo and sleep disturbances. V5 (B) Coronary angiography (A) Atypical depression (C) Echocardiogram (B) Catatonic depression 212 Which of the following treatment (C) Hormone-impregnated vaginal ring (E) Leads V4, V5, and V6 options would you prescribe? Electrocardiogram reveals tachy (D) Ophthalmic steroids for maintenance therapy for myasthenia gravis? A 60-year-old female presents with pain in the (D) Leads V1, V2, and V3 (A) Bronchiectasis (B) Cellulitus big toe and states she is unable to find shoes that (E) Leads V4, V5, and V6 (B) Cystic fibrosis (C) Deep venous thrombosis fit her properly. A 60-year-old male presents with progressively deformity of the proximal phalanx at an angle of (D) Pulmonary embolism (E) Phlebitis worsening shortness of breath, excessive cough, approximately 25 degrees. A 24-year-old male was a victim of an occupational reveals decreased breath sounds and early inspi the proper diagnosis? A 38-year-old male presents with intermittent accident and presents in the emergency room ratory crackles. Similar readings were obtained on previous the accumulation of air in the pleural space with lungs and a flat diaphragm. Physical exam reveals presentation and test results, which of the following (D) Gout and blood pressure reading, which of the following impaired ventilation. Which of the following treatment options, along (B) Chronic obstructive pulmonary disease (B) Hypoglycemia (B) Congestive heart failure with antibiotics, would be indicated for a patient (C) Emphysema (C) Malignant hypertension (C) Primary pneumothorax who presents with dacryocystitis? A 70-year-old female presents with shortness motherapy and radiation therapy for lung cancer (D) Ophthalmic steroids diagnose which of the following gastrointestinal of breath, persistent non-productive cough, and presents to the Intensive Care Unit. Auscultation of the chest normal with a blood pressure of 130/70 mmHg and (A) Celiac disease reveals enlarged apical impulse, diminished first 203. The day following the procedure, (B) Crohn’s disease heart sound, an S3 gallop, and an S4 gallop. Blood culture is positive for (E) Ulcerative colitis presentation, physical exam, and test results, which Gram-negative bacteria. Which of the following forms of contraception and patient’s condition, which of the following is (A) Cystic fibrosis is characterized by the implantation of a single the accurate diagnosis? A 62-year-old female recently underwent coronary sexual intercourse, painful bowel movements, 228.

They must be able to buy 200 mg prometrium with visa medications vs medicine diagnose cases order prometrium 200 mg on-line counterfeit medications 60 minutes, recognize outbreaks cheap 100mg prometrium otc medicine 93 3109, report these to 200mg prometrium medicine hat weather public health authorities and work with authorities to limit the spread of the outbreak. A common example includes physicians working in nursing homes and being asked to assist in the control of an outbreak of influenza or diarrhea. Key Objectives 2 Know the defining characteristics of an outbreak and how to recognize one when it occurs. Enabling Objectives 2 Define an outbreak in terms of an excessive number of cases beyond that usually expected. A physician is expected to work with regulatory agencies to help implement the necessary interventions to prevent future illness. Physician involvement is important in the promotion of global environmental health. Key Objectives 2 Recognize the implications of environmental hazards at both the individual and population level. Enabling Objectives 2 Identify common environmental hazards and be able to classify them into the appropriate category of chemical, biological, physical and radiation. Due to variations in factors such as physical location, culture, behaviours, age and gender structure, populations have different health risks and needs that must be addressed in order to achieve health equity. Hence physicians need to be aware of the differing needs of population groups and must be able to adjust service provision to ensure culturally safe communications and care. Key Objectives 2 Understand how variation in the determinants of health in different populations promotes or harms their health status. Aboriginal health centres, Traditional healers) in providing services to the population. Enabling Objectives First Nations, Inuit, Métis Peoples First Nations, Inuit and Métis peoples are the original inhabitants of Canada. Collectively, they have a special relationship with the federal government due to their treaty status, and many historical events have had a strong impact on their health expectancy. Global health and immigration Increasing transportation of people, food and consumer goods is breaking down previous geographic boundaries. Persons with disabilities Persons with physical, mental, or sensory disabilities have unique needs and may require health and social services to be provided in alternative ways. Homeless persons Homeless persons have unique needs due to their physical lack of basic shelter and ability to bath and prepare food safely. In addition, being homeless is associated with many other conditions such as mental health and may require health and social services to be provided in alternative ways. Challenges at the extremes of the age continuum the elderly and very young children both share the challenges of being at high risk for certain medical conditions. Hemolytic Uremic Syndrome) as well as being very vulnerable to changes in the determinants of health. For example, children living in poverty or poor seniors living in isolation are both at high risk for adverse health outcomes. Hypoaldosteronism (type 4 renal tubular acidosis, aldosterone deficiency/resistance, adrenal insufficiency, dysfunction of distal renal tubule) ii. Decreased tubular flow rate (severe effective arterial volume depletion or cardiomyopathy) Key Objectives 2 Differentiate severe, true hyperkalemia, a potentially lethal condition for which treatment is the first consideration, from pseudohyperkalemia, and then assess for causal conditions. Outline the relationship between potassium intake, the distribution of potassium between intracellular and extracellular fluid compartments, and urinary potassium excretion. Redistribution (alkalemia, insulin therapy for diabetic ketoacidosis,β-adrenergic drugs) 3. Diarrhea (villous adenoma, laxative abuse) Key Objectives 2 Assess intake and shift of potassium into cells, but select increased loss as the category into which most problems fall. Objectives 2 Through efficient, focused, data gathering: ­ Differentiate between gastrointestinal and renal losses (ask about diuretic use, vomiting, diarrhea, whether patient is diabetic). Identify the principal cells of the cortical collecting tubule as the main determinant of potassium secretion; list factors that stimulate potassium secretion. List factors affecting translocation of potassium between the intracellular and extracellular fluid compartments. This means that psychosocial issues as well as biological issues need to be addressed. Pre-labor (counsel for preparation of labor) Key Objectives 2 Develop an appropriate relationship and rapport with prenatal patients; if possible, counsel about pregnancy prior to conception; determine whether the patient is pregnant and estimate the date of confinement. Objectives 2 Through efficient, focused, data gathering: ­ Elicit factors that contribute to estimation of date of confinement. Non-pregnant women of childbearing age who may become pregnant should receive all clinically indicated immunizations at least three months prior to conception. This included immunity as a result of disease or immunization to measles, mumps, rubella, hepatitis B, tetanus, diphtheria, poliomyelitis, and varicella. Individuals at high risk for hepatitis A or pneumococcal infections should also receive these immunizations. Vaccines may be given to non-immune women during pregnancy when there is a high risk of exposure to infection, the infection is hazardous to mother or fetus, and the immunizing agent is not likely to cause harm. Inactivated virus vaccines, toxoids, and immune globulin are generally considered safe for pregnant women since there is no evidence that they have harmful effects on the fetus or pregnancy. Nevertheless, it is preferable to delay administration of these medications until the second trimester because a theoretical risk to the fetus cannot be excluded. As a consequence, prenatal counseling must be non-directive, and testing must not be restricted to those willing to have an abortion. Moreover, reproductive decisions must not be coerced on the basis of test results. Analysis of many studies identified a high cumulative work fatigue score as the strongest (odds ratio of 1.

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