A randomized treatment that works order risperidone 4mg otc, double-blind treatment kitty colds proven 2mg risperidone, placebo-controlled pilot study of naltrexone in outpatients with bipolar disorder and alcohol dependence symptoms 9 weeks pregnancy buy risperidone 4mg with visa. Do atypical antipsychotics effectively treat co-occurring bipolar disorder and stimulant dependence? A randomized medicine 832 buy 3mg risperidone with mastercard, placebo-controlled trial of citicoline add-on therapy in outpatients with bipolar disorder and cocaine dependence treatment goals and objectives buy risperidone 2mg without prescription. Methylphenidate combined with aripiprazole in children and adolescents with bipolar disorder and attention-deficit / hyperactivity disorder: a randomized crossover trial medicine 95a pill 3mg risperidone overnight delivery. Randomized medicine quotes 4 mg risperidone fast delivery, placebo-controlled trial of risperidone for acute treatment of bipolar anxiety medications safe while breastfeeding discount 4 mg risperidone overnight delivery. Quetiapine monotherapy as treatment for anxiety symptoms in patients with bipolar depression: a pooled analysis of results from 2 double-blind, randomized, placebo-controlled studies. Placebo-controlled study of quetiapine monotherapy in ambulatory bipolar spectrum disorder with moderate-to-severe hypomania or mild mania. Randomized, double-blind, placebo-controlled study of divalproex extended release loading monotherapy in ambulatory bipolar spectrum disorder patients with moderate-to-severe hypomania or mild mania. Divalproex Sodium Versus Placebo in the Treatment of Bipolar Depression [Abstract]. Lamotrigine in the acute treatment of bipolar depression: results of five double-blind, placebo-controlled clinical trials. Quetiapine and classical mood stabilizers in the long-term treatment of bipolar disorder: a 4-year follow-up naturalistic study. Effectiveness of maintenance electroconvulsive therapy in rapid-cycling bipolar disorder. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Major depressive disorder with subthreshold bipolarity in the National Comorbidity Survey Replication. Doubleblind, placebo-controlled trial of divalproex monotherapy in the treatment of symptomatic youth at high risk for developing bipolar disorder. Low-dose quetiapine for patients with dysregulation of hyperthymic and cyclothymic temperaments. Tolerability of atypical antipsychotics in the treatment of adults with schizophrenia or bipolar disorder: a mixed treatment comparison of randomized controlled trials. Weight gain and changes in metabolic variables following olanzapine treatment in schizophrenia and bipolar disorder. Effects of orally disintegrating vs regular olanzapine tablets on body weight, eating behavior, glycemic and lipid indices, and gastrointestinal hormones: a randomized, open comparison in outpatients with bipolar depression. Ziprasidone with adjunctive mood stabilizer in the maintenance treatment of bipolar I disorder: long-term changes in weight and metabolic profiles. Long-term metabolic effects of aripiprazole adjunctive to lithium, valproate, or lamotrigine. Cardiometabolic risk of secondgeneration antipsychotic medications during first-time 43 Yatham et al. Effects of a multimodal lifestyle intervention on body mass index in patients with bipolar disorder: a randomized controlled trial. Prevalence of diabetes in patients with bipolar disorder in Taiwan: a population-based national health insurance study. Metabolic syndrome in patients enrolled in a clinical trial of aripiprazole in the maintenance treatment of bipolar I disorder: a post hoc analysis of a randomized, double-blind, placebo-controlled trial. Comparison of insulin resistance, metabolic syndrome and adiponectin in overweight bipolar patients taking sodium valproate and controls. Association between mood stabilizers and hypothyroidism in patients with bipolar disorders: a nested, matched case-control study. Treatment of suicide attempters with bipolar disorder: a randomized clinical trial comparing lithium and valproate in the prevention of suicidal behavior. Metaanalyses of cognitive functioning in euthymic bipolar patients and their first-degree relatives. A meta-analytic investigation of neurocognitive deficits in bipolar illness: profile and effects of clinical state. Effects of atypical antipsychotics on neurocognition in euthymic bipolar patients. A comparison of neuropsychological dysfunction in first-episode psychosis patients with unipolar depression, bipolar disorder, and schizophrenia. Comparison of neuropsychological effects of adjunctive risperidone or quetiapine in euthymic patients with bipolar I disorder. Cognitive enhancement in euthymic bipolar patients with pramipexole: a placebo-controlled adjunctive trial. A double-blind, placebo-controlled pilot study of galantamine to improve cognitive dysfunction in minimally symptomatic bipolar disorder. The association between carbamazepine and valproate and adverse cutaneous drug reactions in patients with bipolar disorder: a nested matched case-control study. Rash in adult patients receiving lamotrigine to treat bipolar I disorder in Korea: a multicenter, prospective, naturalistic, open-label trial. Feasibility of a slower lamotrigine titration schedule for bipolar depression: a naturalistic study. Incidence, onset, and duration of treatment emergent somnolence with asenapine in patients with schizophrenia or bipolar disorder. Risk of neuroleptic malignant syndrome in patients with bipolar disorder: a retrospective, population-based case-control study. Evaluation of akathisia in patients with schizophrenia, schizoaffective disorder, or bipolar I disorder: a post hoc analysis of pooled data from short- and long-term aripiprazole trials. Selective serotonin reuptake inhibitor use and bone mineral density in women with a history of depression. Chapter 4 Requirements Engineering Lecture 1 Chapter 4 Requirements engineering 1 Topics covered ІFunctional and non-functional requirements ІThe software requirements document ІRequirements specification ІRequirements engineering processes ІRequirements elicitation and analysis ІRequirements validation ІRequirements management Chapter 4 Requirements engineering 2 Requirements engineering ІThe process of establishing the services that the customer requires from a system and the constraints under which it operates and is developed. Chapter 4 Requirements engineering 4 Requirements abstraction (Davis) "If a company wishes to let a contract for a large software development project, it must define its needs in a sufficiently abstract way that a solution is not pre-defined. Once a contract has been awarded, the contractor must write a system definition for the client in more detail so that the client understands and can validate what the software will do. Chapter 1 Introduc;on 6 Insulin pump control system ІCollects data from a blood sugar sensor and calculates the amount of insulin required to be injected. Chapter 1 Introduc;on 7 Insulin pump hardware architecture Insulin reservoir Needle assembly Pump Clock Sensor Controller Alarm Display1 Display2 Power supply Chapter 1 Introduc;on 8 Activity model of the insulin pump Blood sensor Analyse sensor reading Blood sugar Compute insulin Insulin log Insulin dose Insulin pump Control insulin pump Pump data Compute pump commands Log dose Chapter 1 Introduc;on 9 Essential high-level requirements ІThe system shall be available to deliver insulin when required. Chapter 1 Introduc;on 10 A patient information system for mental health care ІA patient information system to support mental health care is a medical information system that maintains information about patients suffering from mental health problems and the treatments that they have received. The system supports data summaries so that doctors can quickly learn about the key problems and treatments that have been prescribed. Wherever possible, the system should warn medical staff about potentially suicidal or dangerous patients. Chapter 1 Introduc;on 16 Wilderness weather station ІThe government of a country with large areas of wilderness decides to deploy several hundred weather stations in remote areas. Each of these instruments is controlled by a software system that takes parameter readings periodically and manages the data collected from the instruments. Chapter 1 Introduc;on 19 Types of requirement ІUser requirements § Statements in natural language plus diagrams of the services the system provides and its operational constraints. Defines what should be implemented so may be part of a contract between client and contractor. Chapter 4 Requirements engineering 20 User and system requirements User requirement definition 1. Chapter 4 Requirements engineering 21 Readers of different types of requirements specification User requirements Client managers System end-users Client engineers Contractor managers System architects System requirements System end-users Client engineers System architects Software developers Chapter 4 Requirements engineering 22 Functional and non-functional requirements ІFunctional requirements § Statements of services the system should provide, how the system should react to particular inputs and how the system should behave in particular situations. Chapter 4 Requirements engineering 25 Requirements imprecision ІProblems arise when requirements are not precisely stated. Chapter 4 Requirements engineering 26 Requirements completeness and consistency ІIn principle, requirements should be both complete and consistent. Chapter 4 Requirements engineering 27 Non-functional requirements ІThese define system properties and constraints. Chapter 4 Requirements engineering 28 Types of nonfunctional requirement Non-functional requirements Product requirements Organizational requirements External requirements Efficiency requirements Dependability requirements Security requirements Regulatory requirements Ethical requirements Usability requirements Environmental requirements Operational requirements Development requirements Legislative requirements Performance requirements Space requirements Accounting requirements Safety/security requirements Chapter 4 Requirements engineering 29 Non-functional requirements implementation ІNon-functional requirements may affect the overall architecture of a system rather than the individual components. Chapter 4 Requirements engineering 30 Non-functional classifications ІProduct requirements § Requirements which specify that the delivered product must behave in a particular way. Chapter 4 Requirements engineering 32 Goals and requirements ІNon-functional requirements may be very difficult to state precisely and imprecise requirements may be difficult to verify. Chapter 4 Requirements engineering 33 Usability requirements ІThe system should be easy to use by medical staff and should be organized in such a way that user errors are minimized. After this training, the average number of errors made by experienced users shall not exceed two per hour of system use. Chapter 4 Requirements engineering 36 Train protection system ІThis is a domain requirement for a train protection system: ІThe deceleration of the train shall be computed as: § Dtrain = Dcontrol + Dgradient § where Dgradient is 9. Chapter 4 Requirements engineering 37 Domain requirements problems ІUnderstandability § Requirements are expressed in the language of the application domain; § this is often not understood by software engineers developing the system. Chapter 4 Requirements engineering 38 Key points ІRequirements for a software system set out what the system should do and define constraints on its operation and implementation. Chapter 4 Requirements engineering 39 Chapter 4 Requirements Engineering Lecture 2 Chapter 4 Requirements engineering 40 the software requirements document ІThe software requirements document is the official statement of what is required of the system developers. Chapter 4 Requirements engineering 41 Agile methods and requirements ІMany agile methods argue that producing a requirements document is a waste of time as requirements change so quickly. Chapter 4 Requirements engineering 42 Users of a requirements document Specify the requirements and read them to check that they meet their needs. System customers Managers Use the requirements document to plan a bid for the system and to plan the system development process. System engineers Use the requirements to understand what system is to be developed. System test engineers Use the requirements to develop validation tests for the system. System maintenance engineers Use the requirements to understand the system and the relationships between its parts. Chapter 4 Requirements engineering 43 Requirements document variability ІInformation in requirements document depends on type of system and the approach to development used. These are mostly applicable to the requirements for large systems engineering projects. Chapter 4 Requirements engineering 44 the structure of a requirements document Chapter Preface Description this should define the expected readership of the document and describe its version history, including a rationale for the creation of a new version and a summary of the changes made in each version. It should also describe how the system fits into the overall business or strategic objectives of the organization commissioning the software. Introduction Glossary User requirements Here, you describe the services provided for the user. The nonfunctional definition system requirements should also be described in this section. This description may use natural language, diagrams, or other notations that are understandable to customers. System architecture this chapter should present a high-level overview of the anticipated system architecture, showing the distribution of functions across system modules. Chapter 4 Requirements engineering 45 the structure of a requirements document Chapter Description S y s t e m this should describe the functional and nonfunctional requirements in more detail. System models this might include graphical system models showing the relationships between the system components and the system and its environment. Examples of possible models are object models, data-flow models, or semantic data models. This should describe the fundamental assumptions on which the system is based, and any anticipated changes due to hardware evolution, changing user needs, and so on. This section is useful for system designers as it may help them avoid design decisions that would constrain likely future changes to the system. These should provide detailed, specific information that is related to the application being developed; for example, hardware and database descriptions. Hardware requirements define the minimal and optimal configurations for the system. Database requirements define the logical organization of the data used by the system and the relationships between data. As well as a normal alphabetic index, there may be an index of diagrams, an index of functions, and so on. Chapter 4 Requirements engineering 46 System evolution Appendices Index Requirements specification ІThe process of writing don the user and system requirements in a requirements document. Chapter 4 Requirements engineering 47 Ways of writing a system requirements specification Notation Natural language Description the requirements are written using numbered sentences in natural language. Structured natural the requirements are written in natural language on a standard form or language template. Design description this approach uses a language like a programming language, but with more languages abstract features to specify the requirements by defining an operational model of the system. This approach is now rarely used although it can be useful for interface specifications. M a the m a t i c a l these notations are based on mathematical concepts such as finite-state specifications machines or sets. They cannot check that it represents what they want and are reluctant to accept it as a system contract Chapter 4 Requirements engineering 48 Requirements and design ІIn principle, requirements should state what the system should do and the design should describe how it does this. Natural language specification ІRequirements are written as natural language sentences supplemented by diagrams and tables. Chapter 4 Requirements engineering 50 Guidelines for writing requirements ІInvent a standard format and use it for all requirements. Problems with natural language ІLack of clarity § Precision is difficult without making the document difficult to read. Chapter 4 Requirements engineering 54 Form-based specifications ІDefinition of the function or entity. A structured specification of a requirement for an insulin pump Chapter 4 Requirements engineering 56 A structured specification of a requirement for an insulin pump Chapter 4 Requirements engineering 57 Tabular specification ІUsed to supplement natural language. Chapter 4 Requirements engineering 60 A spiral view of the requirements engineering process Requirements specification System requirements specification and modeling User requirements specification Business requirements specification Start Requirements elicitation System req. Chapter 4 Requirements engineering 63 Requirements elicitation and analysis ІSoftware engineers work with a range of system stakeholders to find out about the application domain, the services that the system should provide, the required system performance, hardware constraints, other systems, etc. Chapter 4 Requirements engineering 64 the requirements elicitation and analysis process 1. Requirements prioritization and negotiation Chapter 4 Requirements engineering 65 Process activities ІRequirements discovery § Interacting with stakeholders to discover their requirements. Key points ІThe software requirements document is an agreed statement of the system requirements. It should be organized so that both system customers and software developers can use it. Chapter 4 Requirements engineering 68 Chapter 4 Requirements Engineering Lecture 3 Chapter 4 Requirements engineering 69 Requirements discovery ІThe process of gathering information about the required and existing systems and distilling the user and system requirements from this information. Chapter 4 Requirements engineering 73 Interviews in practice ІNormally a mix of closed and open-ended interviewing. Manager Export statistics Medical receptionist Generate report View record Nurse Edit record Doctor Setup consultation Chapter 4 Requirements engineering 79 Requirements validation ІConcerned with demonstrating that the requirements define the system that the customer really wants. Can the requirements be implemented given available budget and technology ІVerifiability. Chapter 4 Requirements engineering 81 Requirements validation techniques ІRequirements reviews § Systematic manual analysis of the requirements. Chapter 4 Requirements engineering 82 Requirements reviews ІRegular reviews should be held while the requirements definition is being formulated. Good communications between developers, customers and users can resolve problems at an early stage. Chapter 4 Requirements engineering 83 Review checks ІVerifiability § Is the requirement realistically testable? Chapter 4 Requirements engineering 84 Requirements management ІRequirements management is the process of managing changing requirements during the requirements engineering process and system development. You need to establish a formal process for making change proposals and linking these to system requirements. Chapter 4 Requirements engineering 85 Changing requirements ІThe business and technical environment of the system always changes after installation. These may conflict with end-user requirements and, after delivery, new features may have to be added for user support if the system is to meet its goals. Chapter 4 Requirements engineering 86 Changing requirements ІLarge systems usually have a diverse user community, with many users having different requirements and priorities that may be conflicting or contradictory. Chapter 4 Requirements engineering 87 Requirements evolution Initial understanding of problem Changed understanding of problem Initial requirements Changed requirements Time Chapter 4 Requirements engineering 88 Requirements management planning ІEstablishes the level of requirements management detail that is required. Chapter 4 Requirements engineering 89 Requirements change management ІDeciding if a requirements change should be accepted § Problem analysis and change specification · During this stage, the problem or the change proposal is analyzed to check that it is valid. This analysis is fed back to the change requestor who may respond with a more specific requirements change proposal, or decide to withdraw the request. Once this analysis is completed, a decision is made whether or not to proceed with the requirements change. Ideally, the document should be organized so that changes can be easily implemented. Chapter 4 Requirements engineering 90 Requirements change management Identified problem Problem analysis and change specification Change analysis and costing Change implementation Revised requirements Chapter 4 Requirements engineering 91 Key points ІYou can use a range of techniques for requirements elicitation including interviews, scenarios, use-cases and ethnography. Removal of the corpus luteum prior to the development of adequate placental function results in spontaneous pregnancy loss (1). Given the importance of ovarian progesterone production to implantation and early pregnancy, the potential for ovarian inadequacy as a cause of infertility or pregnancy failure seems plausible.
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Damaged nerve fibers and myelin sheath caused by lack of normal blood supply Table 1 86 treatment ideas practical strategies buy generic risperidone 3mg on-line. Some of the uses that have shown promise include prevention of migraine medicine 831 cheap risperidone 4mg with amex, pain of diabetic neuropathy symptoms 1974 buy risperidone 2 mg low cost, fibromyalgia medicine ok to take during pregnancy generic risperidone 4mg with mastercard, vasovagal syncope (fainting) treatment 3rd degree av block generic risperidone 3 mg free shipping, and premature ejaculation treatment zit buy risperidone 2mg. This guide will help with that by: Letting you know what changes to expect and helping you understand them symptoms graves disease order risperidone 4 mg visa. Here are some tips: Ask someone like your mom or older sister to answer your questions medications 6 rights buy 2mg risperidone with mastercard. Your pituitary gland sends a signal to two other glands your ovaries telling them to make a special chemical, or hormone, called estrogen. You may compare yourself to your friends and feel like something is wrong with you. Feeling good about your body is a great start to boosting your overall self-esteem. Find something you do well, like a sport, an art or a school subject, and focus on succeeding at it. You know puberty has kicked in when you grow taller and begin to take on a more feminine shape. You also need complex carbohydrates (like whole wheat breads, pasta and cereals) and fresh fruits and vegetables. During early puberty, the first stage of breast development happens, called "budding. Once your breasts develop, wearing a bra provides support and coverage that can help you feel more comfortable. Plus, bras come in tons of fun colors and designs so you can find ones that match your personal style. Now find your bust line size by measuring around your chest over the fullest part of your breasts. Many stores that sell bras have experts who can tell your correct size by measuring you. Or, you can have a friend or trusted adult measure you using the following guide: 1. You can keep it under control, though, most of the time with a daily routine of skin care. Take a daily multivitamin, eat plenty of fruits and vegetables, and drink lots of water. Puberty may cause your hair to become oilier, thicker, coarser even curlier or straighter. Body odor is triggered by your apocrine glands Hair Shaft Epidermis Sebaceous Gland the kind of sweat glands Dermis Eccrine Gland that kick in at puberty. Subcutaneous Apocrine Gland Tissue Your other sweat glands eccrine glands start working at birth. Eccrine glands produce clear, odorless perspiration, but apocrine glands produce perspiration that can smell bad when it comes in contact with bacteria on your skin. Pores Since a lot of apocrine glands are under your arms, many people use underarm deodorants or antiperspirants. Since these are the main causes of body odor, anti-perspirants help prevent odor before it starts. So their deodorants and antikind you need or want depends perspirants are different, on you. Perspiration 13 Vaginal Discharge Vaginal discharge a sign that your period is on its way. Vaginal discharge is a clear or whitish fluid that comes from your vagina (an opening between your legs). When you notice it in your underwear (a creamy white stain) for the first time, it usually means your first period is coming soon. To avoid getting discharge in your underwear between periods, you can wear a pantiliner (for more info, see pages 26, 27 and 30). If you have any discharge that is thick, yellowish or darker, smells unpleasant or causes itching or burning, it could be a sign of a vaginal infection. Your period is when you shed tissue, fluid and blood from your uterine lining (also called menstrual discharge). For most girls and women it usually happens each month and lasts between 3 and 7 days. But understanding the menstrual cycle will help take the mystery out of your period. It will also help you predict when your period will come each month, once your cycle starts. After the egg is released it travels along the fallopian tube to the thickening endometrium. The endometrium leaves the body through the vagina as a reddish fluid containing blood. Position inside body Eggs 16 Your Period Uterus Ovary Vagina the cycle repeats itself. A complete menstrual cycle runs from the first day of one period to the first day of the next. The average time this takes is 28 days, but anywhere between 21 and 35 days is normal. Many girls and women prepare for their next period by tracking their cycle on a calendar. Most girls get their first period between the ages of 9 and 16, but there is no "right" time. As a rough guide, your period will probably start: About two years after your breasts begin to develop. You can still go to school, help at home, see your friends, play sports and so on. The average female loses about 4 to 12 teaspoons of menstrual fluid during her period. A lot of girls and women experience "period cramps" caused by the contraction of the uterus. If you get cramps, you may feel aches in your abdomen, your lower back or even down your legs. Do some mild exercise that you enjoy, like walking your dog or riding your bike with a friend. If cramps continue to be a problem for you, make sure you check with an adult before taking any kind of medication. These symptoms are caused by changing hormone levels and may include headaches, backaches, food cravings, depression, moodiness, breast tenderness, pain in the joints, general tiredness, and weight gain or a bloated feeling. Feminine protection refers to the products girls and women use to absorb their menstrual flow or to stay feeling fresh, comfortable and confident every day. Some girls and women prefer pads and pantiliners, some prefer tampons, and some like to use pads on some days and tampons on others. We recommend you start off with pads and pantiliners, and if you want to use tampons, talk to your mom, school nurse or another trusted adult. You can buy pantiliners, pads or tampons in many places like supermarkets, pharmacies and discount stores. If you feel a little funny about buying them at first, just ask someone like your mom or older sister to make the purchase for you. Feminine Protection 23 Pads are worn in your underwear during your period to absorb your menstrual flow. A pad has a soft, cottonlike layer on the top and a sticky tape on the back to keep it firmly placed in your underwear. To find the pad that works best for you, ask someone like your mom or a school nurse for help, see page 31, or go to beinggirl. They wrap securely around your undies to protect you from side leaks and to keep your pad where it belongs. A thin pad that provides great protection and comfort without the bulk of a maxi pad. Feminine Protection 25 Pantiliners can be part of your daily hygiene routine, like brushing your teeth, to help keep you feeling clean and confident. A pantiliner is worn on the inside of your underwear like a pad, but most are smaller and thinner than pads and can feel invisible. Pantiliner types Girls and women are all different shapes and have different levels of natural moisture. So pantiliners, such as Always, are available in different lengths and absorbencies. Until your cycle becomes regular, your period may take you by surprise especially your first one. Feminine Protection 27 Tampons provide protection that is worn inside your body, in your vagina, during your period. A tampon is made of soft absorbent material compressed into a small oblong shape with a string securely sewn through it for removal. It is held into place by the muscular walls of your vagina and gently expands to absorb your flow. Some girls find them more comfortable to wear when they are active in sports during their period. Many girls find that a tampon with a rounded tip, like Tampax Pearl Plastic, is comfortable for first-time users. Position inside body Endometrium Fallopian Tube Eggs Ovary Vagina 28 Feminine Protection Uterus How often do you change a tampon? It depends on how heavy your flow is, but a tampon should be changed regularly, about every 4 to 8 hours. Although a tampon can be worn for up to 8 hours, never leave a tampon in for longer than that, and only use it during your period. If you are going to use a tampon at night and sleep longer than 8 hours, you should use a pad instead. For your first time, try Tampax Pearl Plastic with a rounded tip; it may be more comfortable for you to insert. Tampons are a great choice for athletic activities because they allow you to move fully and comfortably. Of course, tampons are the only suitable form of period protection for swimming, since they are worn inside your body. Be sure to read and keep the leaflet that comes in every box of tampons and talk to an adult if you have questions. The most important thing to know is that if you get a fever and feel sick while you are using a tampon, take it out right away. Always has different products to fit your body type, menstrual flow and preferences. Acne An inflammatory disease of the sebaceous glands that causes pimples to break out, especially on the face. Antiperspirant A substance used to reduce perspiration under the arms in order to prevent body odor. Apocrine glands Sweat glands (mostly under the arms and in the genital area) that produce perspiration that can mix with bacteria to cause body odor. Deodorant A substance used under the arms to counteract or mask odors caused by perspiration. Eccrine glands Sweat glands (all over the body) that produce clear, odorless perspiration. Endometrium the soft, spongy lining of blood and tissue that thickens inside the uterus. It nourishes the developing baby during early pregnancy, or else it is shed during menstruation. Estrogen the female hormone produced in the ovaries that is responsible for many of the changes that take place in females during puberty. Fallopian tubes Two tubes through which eggs travel from the ovaries to the uterus. Feminine protection the products girls and women use to absorb their period flow and to stay fresh, comfortable and confident. Fertilize When a male sperm joins a female egg to form an embryo (the beginning of a baby). Hormones the special chemicals that regulate the growth and activity of body tissues and organs. Menopause the stage at which women stop having their periods (usually around age 50). Menstrual cycle the time measured from the beginning of one period to the beginning of the next. Pituitary gland A small gland beneath the front of the brain that is responsible for triggering the production of hormones that start puberty. Progesterone A female hormone that causes a soft, spongy lining of blood and tissue (endometrium) to thicken inside the uterus. Puberty the stage of life when human males and females develop physical and emotional changes and become capable of reproduction. Testosterone A male hormone that is responsible for the changes that take place in males during puberty. Uterus the female organ lined with soft, nourishing tissue that carries a baby until it is born. Vagina A flexible passageway leading from the uterus to the outside of the body through which menstrual fluid flows. These materials have been reviewed by the American Association for Health Education and accepted as educationally appropriate. The blood then flows from the lungs back to the left side of the heart to be pumped out to the rest of the body. Depending on how big a clot and number of vessels involved, it can be a life-threatening event. Embolism (Em-bo-liz-m) refers to a blood clot (embolus) that has broken off and is floating freely in the blood vessel. All veins in the body drain blood into larger veins that carry blood to the right side of the heart and on into the pulmonary arteries. From the right side of the heart it enters the main pulmonary artery and can get stuck there or move further into one of the lungs. If there are several clots, they can go into different areas of one or both lungs. When a blood clot is in a pulmonary artery, it blocks the flow of blood to the lung that needs to pick up oxygen. If not enough blood gets oxygen and moves to the left side of the heart, the oxygen level in the body drops dangerously low which can cause stress and damage to all the organs in body including the brain, kidneys, and heart. Pulmonary Embolism Right atrium Right ventricle Left atrium Left ventricle In addition, because of blockage, pressure increases back on the right side of the heart. This can also affect the left side of the heart which get squeezed because of ballooned up (distended) right heart. All of these effects can lead to death, either suddenly, or if left untreated, in a short period after the pulmonary embolism occurs. There are people who are at higher risk of a blood clot because of: An inherited condition such as a blood clotting disorder. In some cases, a family history of blood clots will be a clue to get checked for a genetic problem Am J Respir Crit Care Med Vol. An echocardiogram (type of ultrasound) of the heart is often done to evaluate the severity of pulmonary embolism on heart function and pressures. Blood tests can be done to look for blood clotting abnormalities, strain on the heart, or damage to other organs. There are medications that can be used to help break up the blood clot (thrombolytics). Medicines that help prevent the clot from getting bigger or new ones from forming are also given (blood thinners called anti-coagulants such as warfarin or heparin). Shortness of breath (usually sudden in onset) Light-headedness Chest pain Rapid heart beat Loss of consciousness Coughing up blood How severe is Pulmonary Embolism? Pulmonary embolism can be grouped based on the location of clot or how sick a person is. Types based on how sick the person is can divided into low, moderate or high risk pulmonary embolism. To define risk and severity, the healthcare provider needs to order various blood tests and imaging (x-rays or scans or ultrasound of the heart). Ultrasound R Action Steps If you have any symptoms of a possible blood clot in your leg or arm or lungs, seek medical help right away. If your healthcare provider tells you that you are at increased risk of a blood clot, follow advice to try to manage your risk and avoid blood clots. If you are prescribed anti-coagulant medication, take doses as prescribed and get follow-up blood tests as directed by your healthcare provider. Depression takes a big toll in suffering, costs industry billions of dollars, and can lead to suicide in some severe cases. Family, friends, health, work, or school can all be seriously impacted by the disease. We have designed this workbook with three main goals in mind: First, for those who have already been diagnosed with a form of depression and are in treatment, we want to help you learn as much as you can about depression. We believe that the more you understand about depression and the challenges you may face like medication side effects, the more likely you are to get the full benefit of treatment.
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Accurate treatment yeast uti buy 3 mg risperidone amex, timely medications ocd buy risperidone 3mg low cost, and reliable financial information is necessary for making sound decisions, assessing performance, and allocating resources. The "Financial Section" of this report presents our audited financial statements and Notes. Greater detail can be found in the "Notes to the Principal Financial Statements" in the "Financial Section" of this report. Balance Sheets the table below summarizes current and prior year information concerning components of our financial condition as of September 30 each year. A discussion of stewardship assets is presented in Note 20 and in the "Required Supplementary Stewardship Information" within the "Financial Section. Consistent with federal accounting standards, we recognize the responsibility for future program participants of Medicare as a social insurance program, rather than a pension program. Accordingly, we have not recognized a liability for future payments to current and future program participants. The estimated longterm cost for Medicare is included in the Statement of Social Insurance and discussed later in this analysis. A more extensive discussion is provided in the "Notes to the Principal Financial Statements" located in the "Financial Section" of this report. Statement of Changes in Net Position Our net position represents the difference between assets and liabilities. Changes in our net position result from changes that occur within the Cumulative Results of Operations and Unexpended Appropriations. Statement of Net Cost Our Net Cost of Operations represents the difference between the costs incurred by our programs less associated revenues. We receive the majority of our funding through Congressional appropriations and reimbursement for the provision of goods or services to other federal agencies. For more information on the budget functions, see the "Consolidating Statement of Net Cost by Budget Function" in the "Other Information" section of this report. For further details, see the "Combining Statement of Budgetary Resources" in the "Financial Section" of this report. The Chart to the right illustrates a summary of spending by select programs as of September 30, 2015 and 2014. For more information on services and items purchased, see the Combined Schedule of Spending by Object Class in the "Other Information" section of this report. Future expenditures are expected to arise for current and future program participants. This projection is considered to be important information regarding the potential future cost of the program. These projected potential future obligations are not included in the Consolidated Balance Sheets, Statements of Net Cost and Changes in Net Position, or Combined Statement of Budgetary Resources. Actuarial present values are computed under the intermediate set of assumptions specified in the Annual Report of the Medicare Board of Trustees. Such solvency is indicated, for any point in time, by the maintenance of positive trust fund assets. From the end of 2014 to the end of 2024, assets are expected to increase, from $197. After 2022, the trust fund ratio starts to decline quickly until the fund is depleted in 2030, the same date projected last year. Program cost exceeded total income in 2014, and thereafter, income is projected to exceed costs for several years before falling below it in 2024 and later. The percentage of expenditures covered by tax revenues is projected to decrease from 86 percent in 2030 to 79 percent in 2039 and then to increase to about 84 percent by the end of the projection period. The primary reasons for the projected long-term inadequacy of financing under current law relate to the fact that the ratio of the number of workers paying taxes relative to the number of beneficiaries eligible for benefits drops from 3 percent in 2014 to about 2 percent by 2089. In addition, health care costs continue to rise faster than the taxable wages used to support the program. In particular, the actual future values of demographic, economic, and programmatic factors are likely to be different from the near-term and ultimate assumptions used in the projections. The Trustees assume that the various cost-reduction measures-the most important of which are the reductions in the annual payment rate updates for all categories of Part A providers by the growth in economy-wide private nonfarm business multifactor productivity-will occur as the Affordable Care Act requires. The Trustees believe that this outcome is achievable if health care providers are able to realize productivity improvements at a faster rate than experienced historically. However, if the health sector cannot transition to more efficient models of care delivery and achieve productivity increases commensurate with economy-wide productivity, and if the provider reimbursement rates paid by commercial insurers continue to follow the same negotiated process used to date, then the availability and quality of health care received by Medicare beneficiaries would, under current law, fall over time relative to that received by those with private health insurance. While differences between the two accounts exist, the financing mechanism for each part is similar in that the financing is determined on a yearly basis. The Part B account is generally financed by premiums and general revenue matching appropriations determined annually to cover projected program expenditures and to provide a contingency for unexpected program variation. The Part D account is financed by premiums, general revenues, and transfers from state governments. Unlike the Part B account, Part D appropriation has generally included an indefinite authority provision allowing for amounts to be transferred to the Part D account on an as-needed basis. This provision allows previously apportioned amounts to change without additional Congressional action if those amounts are later determined to be insufficient. Consequently, once an appropriation with this provision has been made, no deficit will occur in the Part D account, and no contingency fund will be necessary to cover deficits. Since both the Part B and Part D programs are financed on a yearly basis, from a program perspective, there is no unfunded liability in the short or long-range. Therefore, in this financial statement the present value of estimated future excess of income over expenditures for current and future participants over the next 75 years is $0. However, from a government-wide perspective, General Fund transfers as well as interest payments to the Medicare Trust Funds and asset redemption, represent a draw on other federal resources for which there is no earmarked source of revenue from the public. Hence, from a government-wide perspective, the corresponding estimate of future income less expenditures for the 75-year projection period is $(24. Table of Key Measures 4 Financial Condition Summary (in Billions) Net Position (end of fiscal year) Assets $418. This reconciliation identifies those components of the change that are significant and provides reasons for the changes. However, changes in economic and health care assumptions and legislation changes increased the present value of future cash flows by $754. The "Required Supplementary Information" section presents required long-range cash flow projections, the long-range projections of the ratio of contributors to beneficiaries (dependency ratio), and the sensitivity analysis illustrating the effect of the changes in the most significant assumptions on the actuarial projections and present values. The "Required Supplementary Information" section assesses the sufficiency of future budgetary resources to sustain program services and meet program obligations as they come due. The information is drawn from the 2015 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, which represents the official government evaluation of the financial and actuarial status of the Medicare Trust Funds. Limitation of the Principal Financial Statements the principal financial statements in the "Financial Section" have been prepared to report our financial position and results of operations, pursuant to the requirements of 31 U. The statements should be read with the realization that they are for a component of the U. The upgrades are key components of the Department-wide strategy to mature our overall financial systems environment and ensure the continued reliability, availability, and security of our core financial system. We also expanded the use of business intelligence to further enhance the availability and analysis of financial management information to facilitate effective decision making. Began the transition from Government-wide Accounting to the Central Accounting and Reporting System. This change will standardize Treasury Account Symbol formatting and allows agencies to report transactions in real-time to the U. The auditors disclaimed providing an opinion on the Statement of Social Insurance and the Statement of Changes in Social Insurance Amounts, primarily due to the uncertainties surrounding provisions of the Affordable Care Act and the impact of potential changes in law that would impact underlying assumptions of financial projections. These statements were developed based upon current law using information from the 2015 Medicare Trustees Report, as required by standards issued by the Federal Accounting Standards Advisory Board. Please refer to the "Report of the Independent Auditors," "Principal Financial Statements," and "Notes to the Principal Financial Statements," in this section for further information. The achievements depicted in this report are a reflection of their tireless dedication to our mission and the American people. Department of Health and Human Services Report on the Financial Statements We have audited the accompanying consolidated balance sheets of the U. We were engaged to audit the statements of social insurance as of January 1, 2015, 2014, 2013, 2012, and 2011, the related statements of changes in social insurance amounts for the periods ended January 1, 2015 and 2014, and the related notes to these financial statements. Except as discussed in the Basis for Disclaimer of Opinion paragraphs with respect to the accompanying statements of social insurance as of January 1, 2015, 2014, 2013, 2012, and 2011, the related statements of changes in social insurance amounts for the periods ended January 1, 2015 and 2014, and the related notes to these financial statements, we conducted our audits in accordance with auditing standards generally accepted in the United States, and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States, and Office of Management and Budget Bulletin No. Those standards and bulletin require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the financial statements. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluating the overall presentation of the financial statements. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our audit opinion on the consolidated balance sheets as of September 30, 2015 and 2014, and the related consolidated statements of net cost and changes in net position, and the combined statements of budgetary resources for the fiscal years then ended, and the related notes to these financial statements. In preparing the statement of social insurance, management considers and selects assumptions and data that it believes provide a reasonable basis for the assertions in the statement. Because of the large number of factors that affect the statement of social insurance and the fact that future events and circumstances cannot be known with certainty, there will be differences between the estimates in the statement of social insurance and the actual results, and those differences may be material. Projections of Medicare costs are sensitive to assumptions about future decisions by policymakers and about the behavioral responses of consumers, employers, and health care providers as policies, incentives, and the health care sector change over time. Management has developed an illustrative alternative scenario and projections intended to quantify the potential understatement of projected Medicare costs to the extent that certain payment provisions were not fully implemented in all future years. The range of the social insurance liability estimates in the scenarios is significant. Absent an unprecedented change in health care delivery systems and payment mechanisms, the prices paid by Medicare for health services will fall increasingly short of the costs of providing these services. As a result of these limitations, we were unable to obtain sufficient audit evidence for the amounts presented in the statements of social insurance as of January 1, 2015, 2014, 2013, 2012, and 2011, and the related statements of changes in social insurance amounts for the periods ended January 1, 2015 and 2014. Such information, although not a part of the basic financial statements, is required by the Federal Accounting Standards Advisory Board which considers it to be an essential part of financial reporting for placing the basic financial statements in an appropriate operational, economic or historical context. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide any assurance. The Other Financial Information is the responsibility of management and was derived from and relates directly to the underlying accounting and other records used to prepare the basic financial statements. Such information has been subjected to the auditing procedures applied in the audit of the basic financial statements and certain additional procedures, including comparing and reconciling such information directly to the underlying accounting and other records used to prepare the basic financial statements or to the basic financial statements themselves, and other additional procedures in accordance with auditing standards generally accepted in the United States. In our opinion, the Other Financial Information is fairly stated, in all material respects, in relation to the basic financial statements as a whole. The Other Information has not been subjected to the auditing procedures applied in the audit of the basic financial statements, and, accordingly, we do not express an opinion or provide any assurance on it. The purpose of those reports is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, misstatements on a timely basis. A significant deficiency is a deficiency, or a combination of deficiencies, in internal control that is less severe than a material weakness, yet important enough to merit attention by those charged with governance. Our consideration of internal control was for the limited purpose described in the first paragraph of this section and was not designed to identify all deficiencies in internal control that might be material weaknesses or significant deficiencies and, therefore, material weaknesses or significant deficiencies may exist that were not identified. Given these limitations, during our audit, we did identify certain deficiencies related to Financial Information Management Systems, described below, which we concluded to be a material weakness. We also identified certain deficiencies related to Financial Reporting Systems, Analyses, and Oversight, and Financial Management Close and Review Processes described below, which we concluded to be significant deficiencies. The following summarizes some of the improvements achieved that resulted from this increased attention. A focused effort is still necessary to more completely remediate the long outstanding deficiencies in access controls, configuration management, and segregation of duties. The remaining deficiencies continue to constitute a material weakness in internal control. In addition, procedures for adding or removing users were not consistently followed. Secure access configuration settings were not consistently implemented or reviewed. Several vulnerabilities related to system configurations were identified with the Central Office and Medicare fee-for-service information systems. Evidence supporting testing of claims processing software changes was not always retained. We found several deficiencies that may result in a potential lack of segregation of duties at both the Medicare fee-for-service contractors and across the enterprise. Such conditions will lead to insufficient protection of sensitive or critical resources. Patch management the Department does not have an effective process for timely implementation of critical system patches. Contingency planning the Department does not have an effective process for managing contingency plan documentation and performing a timely review. Additionally, the Department does not have sufficient oversight over testing of contingency plans. The following are some specific considerations: · Continue to identify, assess, modify, and monitor access controls, configuration management, and segregation of duties to further enhance the security posture of all applications. However, a focused effort should still be made to remediate weaknesses identified across all systems currently in operation, including systems that will be retired in the coming years, so as to mitigate risk and exposure to exploitation. Within the context of the approximately $1 trillion in departmental net outlays, the ultimate resolution of our specific 2015 findings was not material to the financial statements taken as a whole. However, these matters are indicative of systemic issues that should continue to be resolved. Financial Analysis and Oversight Because deficiencies continue to exist in the financial management systems, management must compensate for the deficiencies by implementing and strengthening additional controls to ensure that errors and irregularities are detected in a timely manner. Consistent with prior years, we found that certain controls were not consistently performed to ensure that differences were properly identified, researched, and resolved in a timely manner and that account balances were complete and accurate. These manual and compensating controls may include monitoring of budgets, reconciliations of accounts, analyses of fluctuations, aging of accounts, and manual and supervisory reviews. During our audit, we found that certain controls still required further improvements. However, we noted that further improvements are necessary at the OpDiv level in performing analysis of its financial data and amounts and communication of newly adopted, unique and/or complex financial management activities to the Department. This primarily relates to differences that were either timing differences or differences that were not adequately researched and cleared from the suspense accounts. Many of the stale differences presented on the Out of Balance report were carried over from the previous financial systems upgrade. Finally, we identified several Fund Balance with Treasury reconciliations prepared in the Indian Health Service area offices, which were either not reviewed or were improperly prepared. Property, Plant, and Equipment We found that sufficient documentation was not readily available to support certain amounts and disclosures related to property, plant, and equipment. We have been informed that the active processes will also be transferred from the commercial financial shared service center to Coast Guard in January 2016. With certain policies requiring updating, laws being passed and requiring implementation, and as internal control processes change, the Department has not completed its updating of procedural manuals to ensure that sufficient knowledge of financial management systems/processes or consistency and adequacy of internal control exist. For each required reconciliation, the preparers and approvers are required to sign off and provide a date of completion. In that report, we outlined details of deficiencies noted and made recommendations for improvement in its financial management controls. To the extent more robust analysis occurs within Centers and Offices, identifying, evaluating, and reviewing such analysis would assist in ensuring that a perspective that incorporates a financial reporting point of view is captured and considered. We identified areas where improvements could be made in the control environment related to the oversight of third-party contractors. Continue to focus on reducing the number of manual journal vouchers by determining the cause and the ability to upgrade systems to allow for automated posting of certain highvolume routine transactions. Continue to update and implement the Department-wide policies and procedures and other guidance to enable the collection of consistent financial data and consistency in the processing of financial activity among its accounting centers and headquarters. As policies and procedures are developed, training should be developed and delivered across all OpDivs to determine consistent application of the new policies. Additionally, ongoing monitoring processes should be enhanced to ensure appropriateness and consistency over the long-term and continued compliance. Strengthen policy and controls surrounding the property, plant, and equipment and related processes to ensure that documentation is maintained and that balances are accurate and supportable. Strengthen controls surrounding Fund Balance with Treasury reconciliations to ensure differences are remediated properly and timely. Establish a policy individual or group to analyze the accounting and reporting of unique, newly implemented, non-routine, or significant transactions; enhance the financial reporting process; and address or identify transactions that required cross-functional input. In addition, prepare the required presentations and disclosures to ensure adequate time for analysis and feedback from key stakeholders. The process to correct these balances included a series of large dollar balance journal entries. That report states that because of the matters described in the Basis for Disclaimer of Opinion paragraphs, the scope of our work was not sufficient to enable us to express, and we do not express, an opinion on the statement of social insurance as of January 1, 2015, and the related statement of changes in social insurance amounts for the period ended January 1, 2015. However, providing an opinion on compliance with those provisions was not an objective of our audit and, accordingly, we do not express such an opinion.
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