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The session began with Zack watching as his therapist used a finger prick blood test kit (the type that someone with diabetes might use to check blood sugar) to draw blood from her own finger buy permethrin 30 gm without a prescription acne facial. Initially buy permethrin no prescription acne gender equality, Zack was able to use the applied tension exercises to control his feelings of faintness cheap 30 gm permethrin fast delivery acne 2nd trimester. Although Zack was unwilling to practice any exposure homework over the next week order permethrin toronto cystic acne, he agreed to continue practicing the tension exercises. Hewasdiscouragedaboutwhathadhappenedat the last session and was thinking about discontinuing his treatment. His therapist encouraged Zack to keep his appointment, offering reassurance that Zack would not be forced to do anything before he was ready. At the next session, his therapist suggested that they begin with some easier items from Zack’s hierarchy. He was then ready to once again watch his therapist prick her finger while he used the tension exercises. His therapist then pricked several more fingertips and encouraged Zack to watch the blood on her fingers. Although his anxiety level was quite high, he was suc- cessfully able to prevent himself from fainting. In the remaining hour of the session, Zack practiced pricking his own finger and then practiced let- ting his therapist prick his finger. At one point he felt as though he might faint, but the feeling passed after he lay down for a few minutes. Once the faintness passed, he resumed the exposure exercises until his anxiety decreased. For homework over the coming week, Zack practiced the finger prick tests daily with the help of his parents and his girlfriend. The following week, Zack and his therapist prac- ticed watching several surgery videos, at first using the applied tension exercises, and later watching them with- out tensing. At the end of the two hours, Zack was able to watch videos depicting cardiac surgery, removal of a facial mole, and a patient receiving stitches, all with only minimal anxiety. In the end, Zack was quite happy with his progress, and he was glad he had stuck with the treatment. Although he was still nervous about watching live 92 overcoming medical phobias surgery, he decided to work on that fear on his own, after starting medical school. Jacob—dentists Jacob had been fearful of the dentist for as long as he could remember. As soon as he became an adult, he stopped going on a regular basis and only saw a dentist if he had a problem that was causing him pain (which happened about every five years). When he did see the dentist, he insisted on being knocked out with a general anesthetic. His main concern was that the experi- ence would be painful; he remembered having a number of uncomfortable visits to the dentist as a child. By the time Jacob decided to seek treatment at age forty, he had several cavities that needed to be filled and his teeth hadn’t been cleaned for years. His children were aware of his fear, and he worried that some of his fear might rub off on them. When he made the appointment, he had a choice of several hygienists, so he requested to see the one with the reputation for being the most gentle. He had several teeth to fill and one that was likely to require a root canal and crown. When he made his first appointment, Jacob asked whether the dentist and hygienist could begin with less frightening procedures, such as examining his teeth and taking X-rays, and save more difficult procedures such as cleanings, injections, and fillings for subsequent appoint- ments. In fact, the dentist offered to spend an entire appointment just helping Jacob get used to the feeling of having various dental instruments (mirror, probe, scaler, suction tube, and so forth) in his mouth. First, he decided to focus just on the procedures he would have done at each appointment, rather than thinking about all the dental work he needed to have done. He also thought about how his wife, coworkers, and friends often told him that the discomfort they experience at the dentist is always manageable, and how the procedures used during dental treatment have changed since he was younger. Finally, he asked the dentist and hygienist to describe to him what procedures would be done, what they were likely to feel like, and how long they would take. Although the first visit was frighten- ing, he was reassured because he knew he wouldn’t have any dental work done that day. After having his teeth cleaned and his cav- ities filled, he decided to get his root canal and crown done. Although terrified of the procedure, he was 94 overcoming medical phobias reassured when his dentist said that the discomfort would be no worse than that he experienced during the other procedures. In the end, he felt almost no pain despite the reputation root canals have for being painful. Ella—doctors and hospitals Ella had been afraid of visiting doctors and hospitals since she was a teenager, though she was unsure what ini- tially triggered the fear. She was uncomfortable being examined and undergoing tests and, to some extent, was afraid she might find out she had a problem that she didn’t know she had. She wasn’t sure why she didn’t like hospitals, but she avoided them at all costs, even if it meant not visiting friends and relatives in the hospital. Now, at age fifty-five, Ella had become increasingly con- cerned about her phobia. She was at an age when it seemed more important than ever to have regular medical checkups. Also, her parents were older, and she worried that they might soon need to spend time in a hospital and thatshewouldn’tbeabletovisitthem. Shefinally decided to seek treatment when her husband was sched- uled to have his hip replaced. Ella’s treatment began with developing two hierar- chies—one for doctor visits and the other for hospitals. The hierarchy took into account the variables confronting your fear 95 that contributed to her fear, including the sex of the doc- tor (female doctors were easier than males), the age of the doctor (doctors younger than forty and older than sixty made her more anxious), the type of procedure being done (she was most nervous about procedures used to detect cancer, such as a mammogram), and the type of doctor (family doctors were easier than specialists). The hospital hierarchy included items ranging in difficulty from relatively easy (for example, spending time in the lobby or cafeteria of a hospital) to more difficult (for example, walking through the halls in the emergency room or visiting someone in a hospital room). She made appointments for physical exams three times per week over a two-week period. The next four exams were with other doctors (recommended by her family doctor), starting with female physicians and working up to male physicians. Ella also arranged to have a number of tests done, including blood work, a mammogram, and a colonoscopy. Over the course of these two weeks, her fear of doctors decreased to a mod- erate level. Ella decided to continue her exposure prac- tices with doctors about once per week over the next month while also starting to confront her fear of hospitals. During the next few weeks, Ella made a point of vis- iting hospitals about four times per week for an hour or two, usually on her way home from work. She visited the hospital where her husband was scheduled to have his 96 overcoming medical phobias surgery, as well as several others. She began with the eas- ier items on her hierarchy (for example, visiting her fam- ily doctor, who was a woman in her early fifties) and worked her way up to the more difficult items (for exam- ple, seeing a young male dermatology resident for a spe- cialist appointment).

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We briefly sketch the proof ideas for analyzing the asymptotic behavior of U(a purchase permethrin american express skin care zinc, t) when d(a) and f(a) are reasonably smooth [114 30gm permethrin skin care doctors, 123] generic permethrin 30 gm with visa acne executioner. Solving along characteristics − a d(v)dv with slope 1 purchase generic permethrin from india acne attack, we find U(a, t)=B(t − a)e 0 for t ≥ a and U(a, t)=u0(a − a − a−t d(v)dv t)e for t0, the age distribution is (d + q)e−(d+q)a, because the increasing inflow of newborns gives a constantly increasing young population, so that the age distribution decreases with age faster than de−da, corresponding to q =0. In this case, d(a) is zero until age L and infinite after age L, so that D(a) is zero until age L and is infinite after age L. Of course, the best approximation for any country is found by using death rate information for that country to estimate d(a). The factor w(a)=e−D(a) gives the fraction of a birth cohort surviving until age a, so it is called the survival function. The rate of death is −w (a), so that the expected ∞ ∞ age a of dying is E[a]= a[−w (a)]da = wda. When the death rate coefficient 0 0 d(a) is constant, then w(a)=e−da and the mean lifetime L is 1/d. This demographic model with age groups has been developed from the initial boundary value problem in the previous section for use in age-structured epidemiologic models for pertussis [105]. It consists of a system of n ordinary differential equations for the sizes of the n age groups defined by the age intervals [ai−1,ai], where 0 = a0 1. The second method is to do a local stability analysis of the disease-free equi- librium and to interpret the threshold condition at which this equilibrium switches from asymptotic stability to instability as R0 > 1. Here we use the appearance of an endemic steady state age distribution to identify expressions for the basic reproduction number R0, and then show that the disease-free steady state is globally asymptotically stable if and only if R0 ≤ 1. The age distributions of the numbers in the classes are denoted by M(a, t), S(a, t), E(a, t), I(a, t), and R(a, t), where a is age and t is time, so that, for example, the number of susceptible individuals at time t in the age interval [a1,a2] is the integral of S(a, t) from a1 to a2. Because informa- tion on age-related fertilities and death rates is available for most countries and because mixing is generally heterogeneous, epidemiology models with age groups are now used frequently when analyzing specific diseases. However, special cases with homogeneous mixing and asymptotic age distributions that are a negative ex- ponential or a step function are considered in sections 5. For example, the negative exponential age distribution is used for measles in Niger in section 7. Here it is assumed that the contact rate be- tween people of age a and age a˜ is separable in the form b(a)˜b(˜a), so that the force of infection λ is the integral over all ages of the contact rate times the infectious ∞ fraction I(˜a, t)/ 0 U(˜a, t)da˜ at time t. The division by the total population size ∞ 0 U(a, t)da makes the contact rate λ(a, t) independent of the population size, so the contact number is independent of the population size [57, 97, 102, 159]. One example of separable mixing is proportionate mixing, in which the contacts of a person of age a are distributed over those of other ages in proportion to the ac- tivity levels of the other ages [103, 174]. If l(a) is the average number of people contacted by a person of age a per unit time, u(a) is the steady state age distribu- ∞ tion for the population, and D = 0 l(a)u(a)da is the total number of contacts per unit time of all people, then b(a)=l(a)/D1/2 and b(˜a)=l(˜a)/D1/2. An- other example of separable mixing is age-independent mixing given by b(a)=1and ˜b(˜a)=β. Thus the boundary conditions at age 0 are ∞ M(0,t)= f(a)[M + E + I + R]da, 0 ∞ S(0,t)= f(a)Sda, 0 while the other distributions at age 0 are zero. For each age a the fractional age distributions of the population in the epidemi- ological classes at time t are m(a, t)=M(a, t)/U(a, t), s(a, t)=S(a, t)/U(a, t), etc. Because the numerators and denominator contain the asymptotic growth factor eqt, these fractional distributions do not grow exponentially. Determining the local stability of the disease-free steady state (at which λ = kb(a)=0ands = 1) by linearization is possible following the method in [40], but we can construct a Liapunov function to show the global stability of the disease-free steady state when R0 ≤ 1. Consider the Liapunov function ∞ V = [α(a)e(a, t)+β(a)i(a, t)]da, 0 where the positive, bounded functions α(a) and β(a) are to be determined. The formal Liapunov derivative is ∞ V˙ = {α(a)[λs − εe − ∂e/∂a]+β(a)[εe − γi − ∂i/∂a]}da 0 ∞ = {λsα(a)+e[α (a) − εα(a)+εβ(a)]+[β (a) − γβ(a)]i}da. Then ∞ ∞ ∞ ∞ ˙ εa −εz ˜ −D(˜a)−qa˜ V = sb(a)εe e β(z)dzda b(˜a)iρe da˜ + [β − γβ]ida. Then ∞ ∞ ∞ ˙ εa (γ−ε)z ˜ −D(x)−qx−γx V = sb(a)εe e b(x)ρe dxdzda − 1 0 a z ∞ ˜ −D(˜a)−qa˜ × b(˜a)i(˜a, t)ρe da. The set with V˙ = 0 is the boundary of the feasible region with i = 0, but di(a(t),t)/dt = εe on this boundary, so that i moves off this boundary unless e =0. Thus the disease-free steady state is the only positively invariant subset of the set with V˙ = 0. If there is a finite maximum age (so that all forward paths have compact closure), then either Corollary 2. If R > 1, then we have V>˙ 0 for points sufficiently close to the disease-free 0 steady state with s close to 1 and i>0 for some age, so that the disease-free steady state is unstable. Although the endemic steady state would usually be stable, this may not be true in unusual cases. For example, in preferred mixing, certain age groups are more likely to mix with their own age group [103].

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It is this estimate that exactly explains the overall decline in missing women in sub-Saharan Africa with this alternative benchmark generic 30gm permethrin with visa skin care 6 months before wedding. Therefore generic 30 gm permethrin with mastercard skin care lotion, to argue that blacks in the United States form a better reference group quality permethrin 30gm tretinoin 05 acne, we have to be certain that the reasons for “missing” black women in the United States (relative to developed regions) stem entirely from biological differences and not from the possibility that black women in the United States suffer more discrimination than their white counterparts in developed countries cheap permethrin 30 gm line acne yahoo. Likely, it is a combination of these two factors (and perhaps others) which explain missing black women in the United States. In contrast, deaths from injury tend to be the most variable across countries, as well as across communities within countries. Special methodological considerations Recall (3) from Section 2, which yields a “reference” death rate for women by age and disease: dm(a, k) w u (a, k) = dm(a, k)/dw(a, k) and the corresponding expression for excess female deaths by age and disease: w w w mw(a, k) = d (a, k) − u (a, k) π (a), where πw(a) is the starting population of women of age a. If we simply add these numbers up, we obtain an estimate for missing women that excludes compositional effects due to the epidemiological transition (refer to Section 2. The most significant of these is maternal mortality, for which a male death rate is not defined, so equation (8) is invalid. We therefore construct the reference death rate for maternal mortality in each age group by using the ratio of maternal to overall female mortality in each age group in the reference region, and then scaling this by age-specific female mortality for the country in question. That is, dw(a, mm) w w u (a,mm)= d (a), (9) dw(a) where the index k = mm stands for maternal mortality. Maternal mortality is very low in developed regions, so that this procedure will treat practically all maternal deaths as excess female deaths, which is as it should be. A second set of exceptions concerns diseases for which relative death rates for devel- oped countries by age are unreliable, because there are so few deaths. Particularly important examples are malaria, childhood cluster diseases (such as measles), diarrhoeal diseases, and tuberculosis. In these cases, we have nothing to base our estimates on and simply use a reference death ratio of 1:1 as a benchmark. We consider all such categories for which there are at least 2000 female deaths in our country of interest. For malaria, the total number of deaths over all ages and over all developed regions was less than 100 in the year 2000. For diarrhoeal diseases and tuberculosis, the situation is somewhat different: there are a substantial number of deaths recorded in developed regions for these two categories of disease, but these primarily occurred at ages 60 or older. Yet in less developed regions, younger age categories account for a large number of deaths from these diseases, particularily in the case of diarrhoeal deaths. We therefore cannot form reliable reference ratios from developed regions in the younger age categories in this case. For a given disease–age category, we consider fewer than 100 female deaths in developed regions to be too small to form reliable reference death ratios. Alternatively, following the same strategy as above, we could have instead used the overall death rates from all communicable diseases within each age group in developed countries to compute our reference death ratios. However, there is an implicit circularity here: to trust the medical estimates, which are often obtained in developing countries, one must believe, a priori, that there is no gender bias in those countries to begin with. General observations We report our estimates in Tables 5 (India), 6 (sub-Saharan Africa), and 7 (China). In a world with accurate data (including reliable reference death rates) for every conceivable disease, these group sub-aggregates would be built by adding up all missing females from the diseases in that group. Intentional 0 2 29 8 10 3 2 0 mwB = 1637 320 64 191 100 139 236 318 83 mwA = 1712 310 93 258 93 120 241 300 113 Notes: Figures are rounded to the nearest thousand. If we did not do this, and treated all diseases as one composite ailment, we would be entirely unable to separate out the influence of a change in the disease composition. By forcing ourselves to add over these categories, we freeze the disease composition to that in the country of interest, and therefore pick up the “within-disease” component of missing women. The epidemiological transition is located in the difference mwA − mwB, as Observation 1 makes clear. The penultimate line records mwB, as discussed above, pro- viding estimates for every age category as well as a total, obtained by adding in the estimate for missing girls at birth. Recall that mwB deliberately eliminates the effect of the changing composition of disease across developed and developing countries, while mwA includes all changes in disease composition. Yet there is little difference between the two sets of totals at most ages, and the two grand totals mwA and mwB practically agree. By Observation 1, we must conclude that few, if any, of the missing women in India can be attributed to the epidemiological transition. First, it is evident that the bulk of missing females at younger ages come from Group 1 diseases. Group 1 disease accounts for fully 260,000 missing females between the ages of 0 and 4, which is over 15% of the total. Of these, about half is due to infectious disease, while the remainder may be attributed to respiratory and perinatal ailments. To provide some idea of how big this number is, consider maternal mortality in India, which is widely acknowledged to be a serious issue (see, e. Maternal deaths account for about 130,000 excess female deaths, no small number, but of the same magnitude as excess female deaths caused by infectious and parasitic diseases within the age 0–4 category alone. As we have already seen, much of the Indian discrepancy is to be found at older ages. At these ages, the excess burden falls mainly on non-communicable Group 2 diseases. Women die at a rate closer to men from cardiovascular disease relative to developed countries. The plight of older women in the Indian subcontinent, especially of widows, has received some attention in the literature (see, e. One rather sinister observation is that the number of excess female deaths from “Injuries” is high in India. Excess female deaths for women from “Injuries” exceed 225,000, a number that dwarfs maternal 39. Still, it should be noted that despite the incompleteness of the data, the numbers obtained by summing across the diseases in each sub-category are, in fact, not that far from the group aggregates that we do use. For instance, add items A through E in Group 1 for India and compare it to the Group 1 aggregates for every age group. For example, the death rates from cardiovascular disease for the age group 70–79 for males and females in India are 26. The category 15–29 stands out in this regard, where the number of excess female deaths from “Injuries” outpaces excess deaths from maternal mortality at the same age. Two other factors that point at violence, this time possibly at female infanticide, are the large number of excess deaths under perinatal and congenital conditions. The former accounts for 38,000 excess female deaths and the latter for over 13,000; again, these are large numbers, comparable to excess deaths from “intentional injuries” in the 15–29 age category. As in the case of India, we begin with a comparison of the penultimate row, which adds up excess female mortality over the three groups of disease, with the very last row, which records overall excess deaths by age with no thought given to particular disease groups. The difference, as before, proxies the effect of a change in disease composition across the three main groups. Once again, the correspondence between the two sets of numbers is quite strong, and in particular there is no evidence that the epidemiological transition per se accounts for too many missing women. The majority of excess female deaths in sub-Saharan Africa fall into the age groups 0–4, 15–29, and 30–44, with a particularly large number in 15–29.

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Does the project have the potential to increase efficiency or lead to cost savings? Approach Are the overall strategy purchase permethrin overnight acne grading scale, methodology buy 30 gm permethrin with visa acne wipes, and analyses well-reasoned and appropriate to accomplish the specific aims of the project? Are potential problems order 30gm permethrin mastercard skin care with ross, alternative strategies generic 30 gm permethrin with visa acne images, and benchmarks for success presented? If the project is in the early stages of development, will the strategy establish feasibility and will particularly risky aspects be managed? If the project involves clinical research, are there plans for 1) protection of human subjects from research risks, and 2) inclusion of minorities and members of both sexes/genders, as well as the inclusion of children, justified in terms of the scientific goals and research strategy proposed? Does the application propose to use evidence-based interventions or strategies in the research plan? If the project is in the latter stages of development, will the strategy establish scalability? Environment Will the scientific environment in which the work will be done contribute to the probability of success? Are the institutional support, equipment and other physical resources available to the investigators adequate for the project proposed? Will the project benefit from unique features of the scientific environment, subject populations, or collaborative arrangements? Does the project support key stakeholder involvement throughout the research process? Additional Review Criteria As applicable for the project proposed, reviewers will evaluate the following additional items while determining scientific and technical merit, and in providing an overall impact/priority score, but will not give separate scores for these items. If your proposed research involves the use of human data and/or biological specimens, you must provide a justification for your claim that no human subjects are involved in the Protection of Human Subjects section of the Research Plan. Inclusion of Women, Minorities, and Children When the proposed project involves clinical research, the committee will evaluate the proposed plans for inclusion of minorities and members of both genders, as well as the inclusion of children. For additional information on review of the Inclusion section, please refer to the policy on the Inclusion of Women and Racial and Ethnic Minorities in Research (http:// www. For additional information on review of the Vertebrate Animals section, please refer to the Worksheet for Review of the Vertebrate Animal Section (http://grants. Biohazards Reviewers will assess whether materials or procedures proposed are potentially hazardous to research personnel and/or the environment, and if needed, determine whether adequate protection is proposed. For more information about this Policy and other policies regarding dual use research of concern, visit the U. Additional Review Considerations As applicable for the project proposed, reviewers will consider each of the following items, but will not give scores for these items, and should not consider them in providing an overall impact/priority score. Does the applicant adequately address the additional review criteria detailed in the Special Interest Project they are applying for? As applicable for the project proposed, reviewers will evaluate the following additional items while determining scientific and technical merit, and in providing an overall impact/priority score, but will not give 17 of 57 determining scientific and technical merit, and in providing an overall impact/priority score, but will not give separate scores for these items. Budget and Period of Support Reviewers will consider whether the budget and the requested period of support are fully justified and reasonable in relation to the proposed research. As part of the scientific peer review, all applications: Will undergo a selection process in which all responsive applications will be discussed and assigned an overall impact/priority score. Following initial peer review, recommended applications will receive a second level of review. The following will be considered in making funding decisions: Scientific and technical merit of the proposed project as determined by scientific peer review. 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The law requires that federal agencies use "clear Government communication that the public can understand and use" and requires the federal government to write all new publications, forms, and publicly distributed documents in a "clear, concise, well-organized" manner. These policies build on the current federal commitment to reduce exposure to secondhand smoke, which includes The Pro-Children Act, 20 U. Tobacco: 23 of 57 Tobacco: Tobacco-free indoors – no use of any tobacco products (including smokeless tobacco) or electronic cigarettes in any indoor facilities under the control of the applicant. Tobacco-free indoors and in adjacent outdoor areas – no use of any tobacco products or electronic cigarettes in any indoor facilities, within 50 feet of doorways and air intake ducts, and in courtyards under the control of the applicant. Tobacco-free campus – no use of any tobacco products or electronic cigarettes in any indoor facilities and anywhere on grounds or in outdoor space under the control of the applicant.