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American Journal of Orthodontics and Den to symptoms when pregnant cheap nootropil online mastercard facial Orthopedics Suri treatment diabetes type 2 generic nootropil 800mg mastercard, Gagari medications and mothers milk 2016 buy discount nootropil 800mg on line, and Vastardis 445 Volume 126 treatment 4th metatarsal stress fracture cheap nootropil express, Number 4 129. Oral Surg Oral Med Oral Pathol Oral Radiol Endod children after chemotherapy treatment for acute lymphoid 1997;84:293-6. The nature and extent of jaw involvement in Gaucher tion associated with pheny to in therapy. Delayed dental development in a patient with growth resulting in delayed eruption of the primary dentition. Proc R Soc Med medullary cavities of the metacarpals and phalanges, aortic 1962;55:1066-70. Diffuse but unilateral of deciduous dentition in a Chilean sample with Downs gingival enlargement associated with von Recklinghausen neu syndrome. Cologuard was not clinically evaluated for the following types of patients: fi Patients with a his to ry of colorectal cancer, adenomas, or other related cancers. A false positive result occurs when Cologuard produces a positive result, even though a colonoscopy will not find cancer or precancerous polyps. Cologuard is a screening test that uses a s to ol sample (your bowel movement) to detect colorectal cancer and precancer. As part of this process, normal cells along with abnormal cells from precancer or cancers are shed in to the colon. After you collect your s to ol sample following the instructions in this Patient Guide, the collection kit will be delivered to a lab. Note: You are not required to change your diet or medications to use this screening test. Cologuard is intended for people who are typical candidates for colorectal cancer screening, which include: Men and women 50 years or older At average risk for colorectal cancer Is Cologuard Right for Youfi Talk with your doc to r about using Cologuard if any of the following apply to you: A his to ry of colorectal cancer, adenomas, or other related cancers. Only remove the items you need to collect your sample following the steps in this guide. The box, zippered bag and cardboard tray inside the bag will be used to send your sample to the lab. Do not use this kit to collect a s to ol sample if you have: o Bleeding hemorrhoids o Bleeding cuts or wounds on your hands o Rectal bleeding o Menstrual period o Diarrhea For questions or help call Exact Sciences at 1-844-870-8878 Page 12 Check the items in your box and make sure you have the following: Bracket Sample Sample container Tube Guide Bottle of liquid (preservative) Shipping labels (attached to to p of box) Samplelabels If any items are missing from your kit, do not use the kit. Lift the s to ol sample container from the Leave container bracket and set the container on a flat, open stable surface. Scrape the surface of your s to ol sample until the end of the probe has s to ol on it. Use all the liquid the empty bottle and cap can be recycled or thrown in the trash. Lid with gap Wrong: loosen and tighten again For questions or help call Exact Sciences at 1-844-870-8878 For best results, use a ballpoint pen and write the labels on a hard, flat surface. If you have questions about when to ship your samples, call Exact Sciences at 1-844-870-8878. Colon: A part of the human digestive system sometimes known as the large intestine. Colorectal Cancer: A disease of abnormal growths in the colon or rectum that, if left untreated, may spread throughout the body. Colonoscopy: A medical test where a flexible tube is placed in to the colon so the surface of the colon can be seen by a camera. Instruments can be placed through the tube to remove growths found on the colon wall. Blood or hemoglobin in the s to ol that cannot be seen by the naked eye is referred to as occult blood or occult hemoglobin. Precancerous Polyp (Adenoma): A growth on the wall of the colon that may become cancer. Lot Number S to rage Catalog Expiration Temperature Number Date Manufacturer Contains In Vitro Caution Sufficient Diagnostic for (n) Tests Use Clinical Study Results Cologuard was studied in a large clinical trial to determine the effectiveness of the test. Each person in the study completed Cologuard and a fecal occult blood test before having a standard colonoscopy. The main purpose of the study was to find out the performance of Cologuard for finding cancer and precancer compared to a colonoscopy. In the clinical study, Cologuard correctly detected 92% of colorectal cancers and 42% of advanced adenomas in the study population that had disease. The Cologuard test correctly gave a negative screening result for 87% of the study subjects that did not have colorectal cancer or advanced adenomas. Cologuard test results should be interpreted with caution in older patients as the rate of false positive results increases with age. A false negative result occurs when Cologuard does not detect a precancerous polyp or colorectal cancer even when a colonoscopy identifies the positive result. Patients should be careful when opening and closing the lids to avoid the risk of hand strain. Some types of cancer can be found before symp to ms are present or when the disease is in an early stage of development. Checking for cancer (or for conditions that may lead to cancer) in people who have no symp to ms is called screening. Being screened for colorectal cancer is the first and most important step in finding and preventing colorectal cancer for all adults 50 years of age and older. It is the third most diagnosed cancer, and the second leading cause of cancer deaths in 2 both men and women 50 years of age and older. Despite these facts, colorectal cancer is one 1 of the most treatable cancers if it is found early through screening. Yet, one in 3 adults 50 3 years of age or older are still not getting screened as recommended. Colorectal cancer grows 1 slowly, generally starting from small, noncancerous polyps in the colon or rectum. A polyp is simply an abnormal growth in the inner wall of your colon or rectum, and is relatively common 1 in people over 50 years of age. While polyps are common and typically dont cause symp to ms, 4 some are dangerous and can turn in to cancer over time. If polyps are found and removed 5 early, the chance of developing colorectal cancer can be reduced dramatically. If colorectal cancer is detected in its early stages through screening, treatment is most likely to be 5 successful. Regular colorectal cancer screening for all adults 50 years of age and older is worth doing because it has the potential to save lives. That is why it is important to talk to your health care provider about when to begin screening for colorectal cancer and how to choose among the different colorectal cancer screening methods and procedures available to day. Fac to rs to discuss include: fi Your age, medical his to ry, family his to ry, general health fi the ability of the test to find both precancer and cancer fi How the test is performed fi If sedation is necessary fi the preparation and amount of time required to take the test fi the convenience of the test fi the potential harms of the test fi Follow-up care after the test What is Cologuardfi Cologuard is an accurate noninvasive colorectal cancer screening test for men and women, 50 years of age and older, who are at average risk for colorectal cancer. As part of this process, if precancer or cancer is present, abnormal cells will shed in to the colon, along with normal cells. When you have a bowel movement, your s to ol picks up the shedding cells as it passes through your colon. Unlike other noninvasive colorectal cancer screening tests, Cologuard can detect both precancer and cancer. Cologuard is easy to use: fi Cologuard allows you to easily collect a s to ol sample for testing in the privacy of your own bathroom. Cologuard does produce some false positive results, so any positive should be discussed with your doc to r and followed by a diagnostic colonoscopy. Once a health care provider prescribes Cologuard, Exact Sciences Labora to ries makes it easy to complete the Cologuard sample collection process: fi A collection kit is sent directly to your preferred mailing address. You can s to re your kit until you are ready to use it just s to re at room temperature in a cool, dry place. This means the test result is Positive, but no cancer or precancer is actually present.


  • Foods high in nitrites (such as bacon and preserved meats)
  • Shoulder
  • Blood in the stool
  • Vision changes
  • Antibiotics
  • Help with feeding and diapering
  • Blood in the urine
  • Propranolol may cause fatigue, stuffy nose, or slow heart beat, and may make asthma worse
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Groupings of symp to treatment wrist tendonitis buy nootropil 800 mg ms that have been previously used: Schneiderian first-rank symp to chi royal treatment order genuine nootropil on line ms (1) Delusional perception: abnormal belief attached to medications held before dialysis generic 800 mg nootropil fast delivery a normal percep tion treatment urinary tract infection purchase generic nootropil online, arising de novo. M: Involve family/carers, as they need to be supported and educated about the illness. There has been a shift to wards mainly community-based care rather than hospital-based care for those with schizophrenia. Well-organ ised community follow-up that is integrated with hospital services can increase compliance with medication, reduce the need for hospi talisation and reduce social isolation. C: Personal and social cost: hospitalisation, strain on relationships, dropping out of education, time off work/job loss. Pa tients are diagnosed with schizoaffective disorder only if they satisfy the criteria for schizophrenia and mood disorder occurring during the same epi sode, but where psychosis is not secondary to mood disturbance. A/R: Psychosocial: single, high education and social class, low self-esteem, low mood, general anxiety. Patients with dysmorphophobia have a persistent irrational fear that some particular part of the body (often the nose or ear) is so grotesquely misshapen as to attract attention in public. Symp to ms and avoidances are similar to social phobia, but the focus of the fear is anxiety at others perceived revulsion caused by the offending body part. Soma to form disorder 81 D: A group of chronic disorders that are characterised by inappropriate or maladaptive illness behaviours. Majority of patients also experience de pression and anxiety and the somatisation is usually an expression of personal/social distress. Somatisation disorder the patient has a 2-year his to ry of multiple recurrent and frequently changing physical symp to ms that cannot be explained by a physical disorder. Soma to form pain disorder the patient has at least a 6-month his to ry of severe distressing pain which cannot be explained by a physio logical process. Hypochondriacal disorder the patient has a preoccupation with, and persistent belief in, the presence of one or more serious progressive diseases. Patients tend to have a low threshold for worrying about symp to ms and consulting doc to rs. Often such attitudes are acquired during childhood when illness behaviour/role is learnt through family/ cultural influences. The patients current psychological status and social situation also determine illness behaviour. Cognitive features: fear, preoccupation with the belief that there is a physical basis to the symp to ms. I: Refusal to accept reassurance leads to multiple investigations for organic aetiology of symp to ms. Patients with somatisation disorder have the same risk of developing a new physical disorder as others. Differential diagnoses for unusual illness behaviour: dementia, substance misuse, learning disability. Consider schizophrenia and depressive psychosis (delusions/dis to rted body image) as differentials for hypochondriacal disorder. Do not arrange investigations/treatment/re ferrals unless indicated and always explain why. Explore the relationship between somatic complaints and possible psychosocial causes. If there is no improvement in the first 1 or 2 years, a chronic course is more likely. Specific phobia 83 D: Persistent fear of a specific object or situation, out of proportion to the threat of the situation. Phobias are non-randomly distributed, people more likely to fear natural pre-technological things. Psychological unpleasant feeling of anticipation and threat inability to relax fear of dying/losing control exaggerated startle response urge to escape the situation Biological sweating trembling dry mouth nausea difficulty breathing choking sensation chill/hot flushes Most phobias cause tachycardia. But blood/injury phobia causes an initial tachycardia followed by vasovagal bradycardia and hypotension. Avoidance reinforces fears be cause the patient feels better and safer away from the stimulus. Modelling: therapist shows that the stimulus is harmless, then the pa tient tries. C: Disruption of normal daily life if the phobic stimulus is something that must be routinely encountered. Most phobias do not inter fere with normal life if the stimulus can be easily avoided. Substance misuse 85 A broad term, which may be divided in to acute in to xication, abuse and depend ence. D: Acute in to xication transient disturbance of behaviour, cognition or perception after taking a substance. Abuse maladaptive and recurrent use of substance leading to signifi cant impairment or distress. Physical de pendence may manifest as withdrawal states, increasing to lerance to the substance and increasing use of the substance. Psychological de pendence means the patient feels compelled to use the substance, feels out of control and uses despite being aware of adverse conse quences of using. The Royal College of Physicians uses meas ures of alcohol consumption in relation to whether they are harmful or not. One unit of alcohol is defined as 10ml or 8g of absolute alcohol, approximately: 1=2 pint (284ml) ordinary strength beer or lager. D: Alcohol misuse: consumption of alcohol sufficient to cause physical, psy chiatric or social harm. Hazardous drinking (intake likely to increase the risk of alcohol related harm): men 2250 units/week. A/R: Genetic fac to rs, culture, religion, family his to ry, availability and price of alcohol, males. Overall, 27% of men, and 13% of women drink over the recommended low-risk level of 21 and 14 units/week. E: Physical examination for alcoholic stigmata, and those of chronic liver disease. Acute withdrawal delirium tremens (usually starts within 4872 hours after drinking cessation). M: De to xification support, benzodiazepines to prevent seizures and con trol hallucinosis. Physical treatments: Disulfiram blocks alcohol dehydrogenase so leads to an unpleasant reaction on drinking. Acamprosate reduces conditioned aspects of drinking and prevents craving-induced relapses. Someone in delirium tremens may experience confusion, hallucinations, ataxia, fits, delu sions and anxiety. Wernickes encephalopathy ataxia, nystagmus, ophthalmoplegia and acute confusion. If untreated may develop in to Korsakoffs psychosis profound loss of short-term memory. It can be difficult to distinguish between those that were intended to be fatal and those that were acts of deliberate self-harm. M: (1) Prevention At individual level: detection of people at risk of psychiatric disorders At social level: reduce ease. E: Prevalence decreased following introduction of penicillin, now making a comeback. Primary infected painless hard ulcer at site of infection (usually an abrasion). C: the longer the delay before treatment, the more irreversible changes will occur. Copper is deposited in various sites throughout the body, including cerebrum dementia basal ganglia tremor, rigid akinetic syndrome, choreoathe to sis liver cirrhosis, jaundice, hepa to splenomegaly eyes KayserFleischer rings bones osteoporosis, osteoarthritis kidneys renal impairment A: Au to somal recessive, chromosome 13. The attachment theory developed by John Bowlby is an important psycho logical theory that is often taught; it relates to a childs social development. Social, emotional & behavioural Freudian Age miles to nes stage 0 to 6 months Smiling, social responsiveness Oral 6 months to 1 year Separation anxiety Oral Put food in mouth 1 to 2 years Self-help skills, feeding, begin to Anal attain continence, symbolic play with to ys, stranger shyness 3 to 5 years Attain continence, can dress and Phallic undress, can play on their own or alongside others, subsequently learn interactive play Middle childhood: Operational thought practical and Latency 6 years to puberty tied to immediate circumstances and specific experiences, increased au to nomy and involvement with peer group Adolescence Abstract thought develops Genital reasoning, concepts, testing hypotheses, relate mostly to peer group Freuds theories of child development and identity are very much concerned with the body and with family relations. At about 67 months of age they start to become attached to a particular individual, known as the attachment figure. The attachment is not dependent on the amount of time spent, it is the intensity of the social interactions that matters.

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It is typically fertilized in the to treatment 1860 neurological purchase nootropil line p section of the fallopian Sperm and Ovum at Conception tube and continues its journey to symptoms 6 days past ovulation discount nootropil 800mg on line the uterus treatment 24 seven buy genuine nootropil. This cell symptoms checker purchase nootropil in india, containing the combined genetic information from both parents, is referred to as a zygote. The inner group of cells, or embryonic disk will become the embryo, while the outer group of cells, or trophoblast, becomes the support system which nourishes the developing organism. Approximately 50-75% of blas to cysts do not implant in the uterine wall (Betts et al. Some of the reasons for this include the egg and sperm do not join properly, thus their genetic material does not combine, there is to o little or damaged genetic material, the zygote does not replicate, or the blas to cyst does not implant in to the uterine wall. The placenta is a structure connected to the uterus that provides nourishment and oxygen from the mother to the developing embryo via the umbilical cord. Growth during prenatal development occurs in two major directions: from head to tail called cephalocaudal development and from the midline outward referred to as proximodistal development. This means that those structures nearest the head develop before those nearest the feet and those structures nearest the to rso develop before those away from the 44 center of the body (such as hands and Figure 2. The head develops in the fourth week and the precursor to the heart begins to pulse. However, by the end of this stage they disappear and the organism takes on a more human appearance. Some organisms fail during the embryonic period, usually due to gross chromosomal abnormalities. As in the case of the germinal period, often the mother does not yet know that she is pregnant. It is during this stage that the major structures of the body are taking form Pho to by Lunar Caustic making the embryonic period the time when the organism is most vulnerable to the greatest amount of damage if exposed to harmful substances. Potential mothers are not often aware of the risks they introduce to the developing embryo during this time. The embryo is approximately 1 inch in length and weighs about 8 grams at the end of eight weeks (Betts et al. The Fetal Period From the ninth week until birth, the organism is referred to as a fetus. By the third month, the fetus has all its body parts including external genitalia. In the following weeks, the fetus will develop hair, nails, teeth and the excre to ry and digestive systems will continue to develop. The respira to ry system continues to develop, and reflexes such as sucking, swallowing and hiccupping, develop during the 5th month. The first chance of survival outside the womb, known as the age of viability is reached at about 24 weeks (Morgan, Goldenberg, & Schulkin, 2008). The majority of the neurons in the brain have developed by 24 weeks, although they are still rudimentary, and the glial or nurse cells that support neurons continue to grow. At 24 weeks the fetus can feel pain (Royal College of Obstetricians and Gynecologists, 1997). The fetus gains about 5 pounds and 7 inches during this last trimester th of pregnancy, and during the 8 month a layer of fat develops under the skin. This layer of fat serves as insulation and helps the baby regulate body temperature after birth. By week 37 all of the fetuss organ systems are developed enough that it could survive outside the mothers uterus without many of the risks associated with premature birth. The fetus continues to gain weight and grow in length until approximately 40 weeks. The location of these stem cells in the embryo is referred to as the neural plate. By the end of the third week, two ridges appear along the neural plate first forming the neural groove and then the neural tube. The open region in the center of the neural tube forms the brains ventricles and spinal canal. By the end of the embryonic period, or week eight, the neural tube has further differentiated in to the forebrain, midbrain, and hindbrain. Brain development during the fetal period involves neuron production, migration, and differentiation. From the early fetal period until midgestation, most of the 85 billion neurons have been generated and many have already migrated to their brain positions. Neurogenesis, or the formation of neurons, is largely completed after five months of gestation. One exception is in the hippocampus, which continues to develop neurons throughout life. Neurons that form the neocortex, or the layer of cells that lie on the surface of the brain, migrate to their location in an orderly way. Neural migration is mostly completed in the cerebral cortex by 24 weeks (Poduri & Volpe, 2018). Once in position, neurons begin to produce dendrites and axons that begin to form the neural networks responsible for information processing. Regions of the brain that contain the cell bodies are referred to as the gray matter because they look gray in appearance. The axons that form the neural pathways make up the white matter because they are covered in myelin, a fatty substance that is white in appearance. Although cell differentiation is complete at birth, the growth of dendrites, axons, and synapses continue for years. The developing child is most at risk for some of the severe problems during the first three months of development. Unfortunately, this is a time at which many mothers are unaware that they are pregnant. Today, we know many of the fac to rs that can jeopardize the health of the developing child. Tera to gens are environmental fac to rs that can contribute to birth defects, and include some maternal diseases, pollutants, drugs and alcohol. Fac to rs influencing prenatal risks: There are several considerations in determining the type and amount of damage that might result from exposure to a particular tera to gen (Berger, 2005). These include: the timing of the exposure: Structures in the body are vulnerable to the most severe damage when they are forming. For example, the ears and arms reach their critical periods at about 6 weeks after conception. If a mother exposes the embryo to certain substances during this period, the arms and ears may be malformed. This is suggested by fraternal twins exposed to the same prenatal environment, but they do not experience the same tera to genic effects. The genetic make up of the mother can also have an effect; some mothers may be more resistant to tera to genic effects than others. It is believed that the Y chromosome, which contains fewer genes than the X, may have an impact. Alcohol use during pregnancy is the leading preventable cause of intellectual disabilities in children in the United States (Maier & West, 2001). Alcohol consumption, particularly during the second month of prenatal development but at any point during pregnancy, may lead to neurocognitive and behavioral difficulties that can last a lifetime. Based on animal studies, it has been hypothesized that a mothers alcohol consumption during pregnancy may predispose her child to like alcohol (Youngen to b, Molina, Spear, & Youngen to b, 2007). When a pregnant woman smokes the fetus is exposed to dangerous chemicals including nicotine, carbon monoxide and tar, which lessen the amount of oxygen available to the fetus. A woman being exposed to secondhand smoke during pregnancy has also been linked to low birth weight infants. In addition, exposure to thirdhand smoke, or to xins from to bacco smoke that linger on clothing, furniture, and in locations where smoking has occurred, results in a negative impact on infants lung development. Rehan, Sakurai, and Torday (2011) found that prenatal exposure to thirdhand smoke played a greater role in altered lung functioning in children than exposure postnatally.

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Substantial effcacy of bariatric surgery on weight loss has been demonstrated in severely obese women symptoms non hodgkins lymphoma discount 800 mg nootropil mastercard. Potential benefts need to symptoms 9 weeks pregnancy buy nootropil 800 mg otc be balanced with the delay in infertility treatment and pregnancy for surgery and stabilisation of weight symptoms 3 weeks into pregnancy buy 800mg nootropil with mastercard, the risks of bariatric surgery and the potential risks of pregnancy after bariatric surgery symptoms vaginal cancer purchase nootropil without a prescription. Controversy persists around effcacy for fertility and pregnancy outcomes, optimal timing, adverse effects and comparative effcacy with other treatments, as well as on adverse effects on subsequent pregnancies. Adjustable gastric banding, once the choice for women planning pregnancy is now less common given complications and overall lower long-term weight loss [556]. Bariatric surgery can cause malabsorption and psychological issues including disordered eating [254] and may adversely affect maternal and neonatal health. Adequate intake and absorption of iron, folate, iodine and other nutrients are of concern. While supplement use is widely recommended following bariatric surgery especially for pregnant women, there are reports of poor compliance [561] and challenges to lerating fortifed foods such as bread. National registries (surgery, pregnancy, infants) show that obese women who undergo bariatric surgery and conceive compared to similarly obese controls, had more small for gestational age babies, shorter gestations, and a trend to wards increased neonatal mortality [562], with similar fndings in retrospective studies [563]. If pregnancy occurs, the following need to be considered: fi awareness and preventative management of pre-and post-operative nutritional defciencies is important, ideally in a specialist interdisciplinary care setting fi moni to ring of fetal growth during pregnancy. However, evidence in relation to fertility and pregnancy outcomes is limited, with some concerns about potential perinatal adverse effects of bariatric surgery. No statistically signifcant differences were found between groups for clinical pregnancy rates, miscarriage rates, number of oocytes collected, cancellation rates, and multiple pregnancy rates. There does not appear to be an increase in undesirable side effects with an antagonist down-regulation approach. Summary of narrative review evidence this question was addressed in a Cochrane review in 2014 [577]. Hence clinical choice of gonadotrophin should depend on availability, convenience and costs. Therefore, clinical gonadotropin choice depends on availability, convenience, and cost. Careful moni to ring of follicular development during ovarian stimulation is critical. No statistically signifcant differences were found between groups for the amount of gonadotropins used, the duration of ovarian stimulation, miscarriage rates, number of oocytes collected, and multiple pregnancy rates. Summary of narrative review evidence A Cochrane review [595] was identifed by the search, however it included studies that did not meet the selection criteria for this question. Mild generally self-limiting side-effects were noted with adjunct metformin, as outlined in Chapter 4. Gastrointestinal side effects were recognised, but noted as mild and self-limiting and may be minimised with lower metformin starting dose and extended release preparations. Metformin was noted to be low cost and readily available, and while off label use was generally allowed, explanation is required for use. Extensive international health professional and consumer engagement informed the gaps, needs, priorities and core clinical outcomes for the guideline. They were supported by an experienced project management, evidence synthesis and translation team to develop the guideline. Sixty prioritised clinical questions were addressed with evidence synthesis involving 40 systematic and 20 narrative reviews, generating 170 recommendations and practice points. Feedback from the thirty-seven engaged societies and their convened special interest groups of experts and consumers as well as public consultation have informed the fnal guideline. Consumer representatives are also extensively engaged and are partnering in the guideline translation activities. The translation of the guideline allows for adaptions on cultural and ethnicity grounds. Clinical question development and prioritisation An International survey and Delphi exercise was conducted to develop and prioritise clinical questions to be addressed. Systematic reviews were performed for highly prioritised questions and for those areas of greatest controversy. Where evidence was inadequate only research recommendations were made and are captured in a separate document. The importance of outcomes may vary across cultures and from different perspectives. Table 6: Steps for considering the relative importance of outcomes What Assessment and prioritisation of outcomes as critical, important but not critical, or low importance. Requires judgement of the balance between the desirable and undesirable health outcomes of an intervention. Why To focus attention on those outcomes that are considered most important when conducting evidence review and to resolve or clarify disagreements. To support making a recommendation and to determine the strength of the recommendation. Evidence these judgments are ideally informed by a systematic review of the literature focusing on what the target population considers as critical or important outcomes for decision-making. Prior knowledge of the research evidence through systematic reviews; and information about values, preferences or utilities has been explored in the original guideline, that was systematic in nature, will inform this process. To facilitate ranking of outcomes according to their importance the following scale was be used [15]. The evidence reviews for each question can be found in the supplementary Technical report. Details of the selection criteria for each question can be found in the supplementary Technical report. Where a systematic review met the benchmark criteria but did not meet the selection criteria, or synthesised studies that did not meet out selection criteria, the risk of bias appraisals from that systematic review were adopted. The search terms used to identify studies addressing the population of interest. Details of the search strategies and search results for each evidence review can be found in the supplementary Technical report. Inclusion of studies To determine the literature to be assessed further, a reviewer scanned the titles, abstracts and keywords of every record retrieved by the search strategy. Full articles were retrieved for further assessment if the information given suggested that the study met the selection criteria. Where there was any doubt regarding these criteria from the information given in the title and abstract, the full article was retrieved for clarifcation. Appraisal of the methodological quality/risk of bias of the evidence Methodological quality of the included studies was assessed using criteria developed a priori according to study design. Individual quality items were investigated using a descriptive component approach. Using this approach, each study was allocated a risk of bias rating (see Table 8). Quality appraisal tables for each evidence review can be found in the supporting document titled Technical report. Moderate Some of the criteria have been fulflled and those criteria that have not been fulflled may affect the conclusions of the study. High Few or no criteria fulflled or the conclusions of the study are likely or very likely to be affected. Insuffcient information Not enough information provided on methodological quality to be able to determine risk of bias. Data extraction Data, according to the selection criteria, were extracted from included studies using a specially developed data extraction form [604]. Information was collected on general details (title, authors, reference/source, country, year of publication, setting), participants (age, sex, inclusion/exclusion criteria, withdrawals/losses to follow-up, subgroups), results (point estimates and measures of variability, frequency counts for dicho to mous variables, number of participants, intention- to -treat analysis) and validity results. Data extraction tables for each evidence review can be found in the supporting Technical report. Data synthesis In order to make a summary statement about the effect of the intervention and thus inform evidence-based recommendations, data were presented qualitatively by presenting the fndings narratively in tables or discussion text; or quantitatively, using statistical methods such as meta-analyses. A meta-analysis is a statistical technique for combining (pooling) the results of a number of studies, that report data for the same outcome for the same intervention, to produce a summary statistic to represent the effect of one intervention compared to another. When high-quality trials are used, a meta-analysis summary statistic can be more powerful than an individual study to confrm or refute effectiveness of an intervention and thus to inform an evidence-based recommendation. Data were summarised statistically using meta-analyses if data were available, suffciently homogenous, and of suffcient quality. Clinical homogeneity was satisfed when participants, interventions, outcome measures and timing of outcome measurement were considered to be similar. Where appropriate, subgroup analysis was conducted according to fac to rs that may cause variations in outcomes, are likely to be a confounder, or may change the way the treatment works.

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