Starlix

Julie C. Kissack, PharmD, BCPS, FCCP

• Professor and Chair, Department of Pharmacy Practice, Harding University College of Pharmacy, Searcy, Arkansas

A recent evaluation from Pakistan exemplifies the role of the private sector in terms of improving family planning services as part of maternal health care antiviral juicing buy 120 mg starlix. The health-care system in Pakistan has suffered a lot hiv infection blood contact buy generic starlix online, not only due to organisational disintegration hiv infection rate swaziland purchase cheap starlix on line, insufficient resources hiv infection rate singapore order starlix pills in toronto, and lack of efficiency and limited functional specificity hiv infection kidney disease buy discount starlix 120mg online, gender insensitivity and inaccessibility but also due to internal law and order antiviral y retroviral generic starlix 120 mg visa, as well as economic and socio-political volatility. Pakistan has been ranked as the 13th most fragile state on the global map by the Fund for Peace, creating additional pressures on an already struggling health-care system (61). However, a few public-private or private-public partnership pilots have shown some remarkable accomplishments. Greater acceptance of private sector-based approaches within the public sector will be a gradual process. Advocating this approach should take this factor into account, highlighting the advantages of adopting private sector-based approaches and providing solutions for any 41 perceived disadvantages or bottlenecks. Nonetheless, whatever approaches or initiative taken by the private sector or by any other partnership model cannot stand alone provide a long-term solution and sustainable contribution to general health or family planning services as compare to the public sector potential which can rapidly adapt to evidence based decision programming and policy and reach the most underserved. However, it requires some bold-steps such as the utmost political-will; pragmatic allocation of funds as well as human resources for health and family planning services; integration of health and family planning and an uninterrupted long-term plan which is protected by the constitution and not affected by any change in political canvas. In 1901, the area that is now Bangladesh supported a population of roughly 25 million and population growth was negligible. The poverty rate is highest in rural areas, at 36%, compared with 28% in urban areas. With the help of international development assistance, Bangladesh has reduced its poverty rate from over half of the population to less than a third, achieved Millennium Development the national family planning programme was initiated as a response to this rapid population growth, and fertility has been falling rapidly since the early 1980s. This was followed by a decade-long plateau which was the consequence of a 'tempo effect3. The age at marriage did not change and there was no delay in age at first birth, and as such, no tempo effect was operating on first births. Now, however, fertility levels are quite uneven remarkably low in the west of the country (below replacement, on average) and worryingly high in the east (up to 1. This has been possible in spite of widespread poverty, illiteracy, early marriage, and various social taboos. Although there is huge investment in family planning, the current trend makes it very thinly spread across a large population. Less than one million induced abortions took place in 2010 in public health facilities. It indicates areas of problems that need to be addressed, including: Unmet need; Early marriage and childbearing; Low performance regions like Sylhet, Chittagong and Dhaka divisions; Pockets of hard to reach areas where service accessibility is limited and Lack of well-defined service delivery network in urban areas. Bangladesh has largely overcome the barriers posed by illiteracy and low level of awareness, religious preferences, and poverty. Although there is great potential to accelerate the family planning adoption in the future, there are issues? that pose barriers to entry for the clients, and obstacles for the supply side. Population trajectories of Bangladesh and West Bengal during the43 twentieth century: A comparative study. Nearly 10,000 women die every year from preventable pregnancy-related complications such as postpartum haemorrhage, puerperal sepsis and eclampsia (45). The present population of married women of reproductive age in Pakistan is 31 million. However, these targets appear increasingly difficult to achieve based on the trends observed in recent decades (see Figure 8). Reaching these targets is becoming more challenging as about 21% of the population is currently between the ages of 15-24 years (67, 68). The median age at which women in Pakistan have their first baby (22) has stayed stagnant since the 1990s (30, 44). About 26% of couples in Pakistan use a modern contraceptive method (see Figure 9), while 9% use traditional methods, as shown in Figure 9 (30). Moreover, there is a constant increase in the predominantly used methods other the years. Of the women using contraception in Pakistan, only 30% are using long acting or permanent methods, while 70% opt for short-term methods (see Figure 11a). One may infer that short-term methods are being used to limit fertility, meaning that families are not using the most suitable method for limiting the number of births, as shown in Figure 11b. Figure 11a: Type of method used for contraception (%)(30) Short Acting Long Acting or Permanent Type of 70 30 method Figure 11b: Purpose of using contraception (%)(30) Limiting Spacing Purpose 74 26 51 1. Women and girls have an unmet need for family planning when they are sexually active and wish to avoid a pregnancy completely, or space or limit future pregnancies, but are not using a modern method of contraception. According to the World Bank data, self-reported exclusive breastfeeding till six months in Pakistan is 38% (69). Furthermore, 19% of married women have expressed the wish to delay their next birth, while 42% do not want to have another child, indicating high levels of unmet need for contraception. As with contraceptive use, significant disparity exists in unmet need between women belonging to the highest and poorest wealth quintile and between rural and urban geographic settings (30). According to the latest nationally representative estimates, 7 million women of reproductive age in Pakistan have an unmet need for family planning (30). More than 96 percent of currently married men and women have heard of at least one method of contraception. Unfortunately, it does not translate into practice and use of modern family planning methods limits to 26%. Education: Universally, the contraceptive use has a positive association with education and the uptake increases with level of education especially girls/women education. This percentage increases sharply to 29% among women with one or two children, rises to 46% among women with three to four children, and peaks at 48% among women with five and more children. Poor quality of care is another critical area that numerous studies have linked to low contraceptive uptake (72). The Bruce-Jain framework (developed in 1990) is often considered the central paradigm for quality in international family planning. The demand-side barriers to unmet need for family planning at the individual, family or community levels can be attributed to low 54 perception of risk, fear of side effects and health concerns and opposition or unfavourable opinion among women, their husbands, families and communities (74, 75). Although no empirical evidence exists, but some limited data suggests that the quality of general health care provided at private facilities is better than that at public facilities (76) including family planning but validity of such data still questionable (77, 78). However, some indicators such as counselling information about side effects and choice of method are still sometimes not addressed adequately even in the private sector. It has been reported earlier that two-thirds of the women are not informed about possible side effects while an even greater number of women are not informed about what to do if they experience a side effect (30). And, importantly with regard to choice, 70% of the public sector and 75% of the private sector clients are not informed about the wide range of contraceptive methods available, as seen in Figure 13 (30). Figure 13: Informed choice(30) 100 80 73 75 70 70 65 66 60 40 20 0 Public Private Public Private Public Private Not informed about Not informed about Not informed about possible side what to do in case other methods effects of side effects 55 Similarly, the data from verbal autopsy from Pakistan also displayed signs of poor quality and provision of care especially when people reached the public or private facilities (79). This has been identified as the main as well as consistent type of delay in all categories of maternal, new-born, and child deaths, emphasising the need to strengthen health systems strengthening and improving the standards of the quality of care (79). Heavy reliance on less effective contraceptive methods (short-term and traditional) and poor quality of information provided to the clients result in a high first-year method discontinuation of 37% (30). The highest discontinuation rate is seen with injectable (61%), followed by the pill (56%). Even more important to note is that, of the women who discontinue one method, very few switch to another method. Importantly, a higher percentage of women reported becoming pregnant while using condoms (20%) and withdrawal (25%) method compared to other methods (see Figure 15). An interesting finding of the study was the inaccurate perception of women as regards their husbands? negative attitude to contraceptive use. Women are more likely to use a contraceptive method if the decision is jointly taken by the husband and wife (82). Another study substantiates and identifies the husband as the decision-maker for family planning use (41). The five-country study (including Pakistan) by Mason and Smith in the year 2000 documented an association between women with unmet need and their husbands? fertility preferences. The authors suggest that men often control their wives? use of contraception in highly gender stratified societies, husbands? fertility preferences can account only for a small proportion of the total unmet need, particularly in communities where unmet need is high. This happens as very few wives in such settings would openly disagree with their husbands about having more children (83). These authors were 58 of the view that better communication between couples would improve contraceptive use (81). Probability of wanting another child is significantly higher among women who do not have boys. However, despite a stronger preference for sons over daughters in Pakistan, surprisingly the effect of sex preference on fertility control has not been demonstrated as a strong influence on the motivation to adopt contraception (89). Hamid and Stephenson (2007) examined the health service factors that influence contraceptive uptake among women attending health facilities in urban Pakistan (90). Low utilisation of services provided by the public sector is a barrier to increasing the coverage of services. According to Abbas et al, the public sector is the major provider of services to the poor; however, the low take up of services reflects clients? mistrust in the quality of services provided, and inadequate referrals (91). Interestingly, this study reveals that current public sector family planning funding is not a primary reason behind the low coverage (92). A family planning association was established in 1953, the National Population Programme begun in 1955 and the Population Welfare Programme has been part of the national five-year plans since 1960. The government of Pakistan and the private medical sector are both the leading source of contraception provision (41-43, 92). Meanwhile 48% of pill users and 56% of injection users obtained their supply from a government source, as compared to 36% and 40% of the respective private sector (30). To reduce population growth and fertility through voluntary family planning, the following key objectives were established: achieve replacement level fertility i. However, given the consistently high fertility rates and unmet need for family planning, major challenges remain in terms of achieving the objectives of the population policy (30, 45). Abortion in Pakistan is permitted in a vague but rather debatable sense and even the definition is unclear among legal professionals (94). Due to ambiguity and the socio-cultural taboos associated with the practice, safe abortion services are not easily accessible. Moreover, considerable reluctance is found among qualified health professionals to provide post-abortion care to women in need due to restrictive abortion laws in Pakistan. As a result of this, women end up terminating unintended pregnancies at the hands of unskilled providers, which results in a significant number of deaths (99). The 2006-07 Pakistan Demographic and Health Survey revealed that 6% of all maternal deaths occurred as a result of abortion-related complications (45). Moreover, in 2002, it was estimated that approximately 37% of all unintended pregnancies are terminated by induced abortion (96). Around 40% of abortions are performed by unskilled workers in backstreet clinics (40, 100). Given these statistics, it is not surprising that unwanted pregnancies are the leading cause of induced abortions in Pakistan (101). By 2012, the abortion rate had almost doubled to 50 per 1,000 and the rate of post-abortion complications rose to 15 per 1,000, indicating an increase of almost 90% in the abortion rate between 2002 and 2012 for women aged 15-49 (40). The almost doubling of the abortion rate between the years 2002-2012 suggests a possible dependency on abortion to avoid unwanted births by women (40, 101). One of the key reasons for seeking unsafe abortion is poor household economy and limiting number of children (102), which again substantiates the fact that abortion may be used as a method of birth spacing or limiting. Medical procedures are preferred by women for the treatment of incomplete abortion because it is perceived as less painful, easy to employ and with fewer complications. A relatively positive element is that nearly three-quarters of the women seeking post-abortion care services adopt a family planning method (103). This provides some future protection against unintended pregnancies and subsequent unsafe abortions(103). And, of the adopters, 66% of the women opt to use short-term methods while the rest use long-term reversible methods. It is recommended that knowledge of the existing abortion law should be improved among legal professionals to facilitate women accessing abortion-related care. Moreover, the implications of unsafe abortion and its consequences on maternal health and life must be publicised in the community as a public health preventative measure (94). The Population Welfare Programme and the National Family Planning Council (later to become the Population Welfare Division of the Health Ministry) were also initiated in the 1960s(104). Despite this history, fertility has declined more slowly in Pakistan than in most other Asian countries (105). One of the primary responsibilities of the Lady Health Workers? programme is to provide family planning services to communities, particularly in rural, underserved areas (107). Evidence also suggests that the family planning programme did not do as well as it could have because of lack of endorsement from the religious scholars from the onset (43). It was revealed that the programme had greater impact on poor 63 households, which were the focus of the intervention (109). Social marketing of contraceptives and public-private partnerships are also central components of the Population Welfare Programme (30). Hence, regardless of ongoing efforts to improve upon the fertility rate and various other factors, such as the infant mortality rate, success has been limited (30, 45). To improve upon the long-term capacity of Pakistani citizens of all socio-economic demographics to access health care, 65 policy must be shifted to support the improvement of health programmes and related policy in the future (113). Through a shift in focus upon how health-care access is supported by policy, those lacking in the resources to pursue health care may have a greater ability to do so. Preventative contraceptive education and services, alongside an expansion in access thereto, will decrease the rate of unwanted pregnancies in the nation, and further, decrease the number of abortions conducted to address unwanted pregnancies (42, 75). Programmes have been undertaken through which cash transfers have been facilitated to address global health inequity.

If they lose their main job hiv infection rate south africa trusted 120 mg starlix, their earnings from the part-time job can be less than they would receive in Unemployment Insurance benefts for the days they work at the side job anti virus ware for mac purchase line starlix. Their income is actually reduced for continuing to work the side job while they receive Unemployment Insurance benefts early symptomatic hiv infection symptoms 120 mg starlix mastercard. The Department of Labor recognizes that this can cause fnancial hardship for claimants who are trying to do the right thing hiv infection rate in peru buy 120mg starlix. If you fnd yourself in this situation hiv infection and aids-ppt safe 120mg starlix, we suggest you frst try to reschedule your part-time job hours into one to two days per week hiv infection from blood test generic starlix 120mg on-line. However, the Department of Labor must investigate whether you had good cause to quit your side/part-time job. This may temporarily stop your benefts and possibly lead to a determination that is not in your favor. You may be able to use recent military service to establish a claim if you meet certain conditions. If your service was within the past 18 months, call the Telephone Claims Center* for more information. Members of the state Army National Guard or reserves of the Army, Navy, Air Force, Marine Corps or Coast Guard are not eligible to receive Unemployment Insurance benefts while in annual feld training. However, your monthly drill sessions do not afect eligibility for your full weekly beneft amount. If you are an employee of an educational institution, you are not eligible for benefts when school is not in session if your employer has given you reasonable assurance that you will be employed and paid in a similar manner once school is back in session. You have a contract to continue working after a school vacation, holiday recess or break between terms. You could be eligible for benefts if you have wages from other, non-educational employment during the same period of time. If you were not ofered similar work by the educational institution for the new term or year, you may be eligible to get benefts. While we review your claim, you must continue to claim weekly benefts (certify for benefts) each week during the period of your unemployment, even if you are not getting beneft payments. If you have retired and are not looking for work, you are not eligible for Unemployment Insurance benefts. If you retired from a job and are actively looking for other work, you may be eligible for Unemployment Insurance benefts. Your benefts will be reduced by 100 percent of the amount of the pension if your base period employer contributed to it, even if you also contributed to the pension. If you were the sole contributor to the pension, your benefts will not be reduced. If we fnd that you acted fraudulently, you may also forfeit future days of benefts and be subject to monetary penalties. However, you must be available for and looking for work with no restrictions while collecting benefts, just like all other claimants. If you are receiving workers? compensation but you are available and physically able to perform work, you may be eligible for Unemployment Insurance benefts. However, receiving workers? compensation benefts may cause your weekly Unemployment Insurance beneft rate to be reduced. The total weekly amount of your workers? compensation and Unemployment Insurance benefts cannot be more than the average weekly wage you earned during your base period. Please also be prepared to send us a note signed by your doctor that says you are able to return to work. You must notify the Telephone Claims Center* about any workers? compensation benefts you receive during the same weeks you collect Unemployment Insurance benefts. Important: If you do not notify us, you may receive an overpayment which you will need to pay back. You may be able to participate in an education or training program while collecting benefts if you are accepted into the 599 Program. If your training is approved under this program, you are not required to look for work. Important: You must apply for the 599 Program within the frst 13 weeks of your claim to receive maximum benefts. A delay in notifying the Department of Labor about your training may result in a reduction of any extra benefts that may be available to you. If you fail to tell us that you are in training while you are collecting benefts, you may be subject to penalties and you could lose future benefts. If funds are not available, it is possible that you will not receive any extra benefts and these benefts could stop before you fnish your training. You must submit a 599 application to the Department of Labor as soon as you are accepted into a school or training facility. Important: Notify the Department of Labor as soon as you are enrolled in training. If you indicated that you are attending or will attend a training program when you fled your claim, you must submit a training application immediately to the Department of Labor to the address provided on the application. You may request an application or obtain general information by contacting the 599 Central Review Unit at 518-402-0189. Trained counselors at the Career Center will assist you with your training needs and provide you information about training programs in your area. To fnd the nearest Career Center, please view the online Career Center locator at labor. If you have limited English skills, you may also be approved to attend English as a Second Language class training. If you are interested in participating in a Registered Apprenticeship Program, contact your local Apprenticeship ofce for more information. Important: To be eligible for this program, you must be identifed by us as likely to exhaust your Unemployment Insurance benefts before fnding work. To be eligible for these benefts, the United States Department of Labor must certify that foreign trade was an important reason that you lost your job. A representative of a state or local agency at a New York State Career Center You can get a petition form and fling instructions online at doleta. The petition must be fled with the United States Department of Labor within one year of the date you lost your job. Once a valid petition is received by the United States Department of Labor, a decision should be made within 40 days. For more detailed information about assistance and services you may be eligible for under this program, contact a New York State Career Center. A dislocated worker? is someone who lost their job due to one of the following situations: You were terminated or laid of from your job, are eligible for Unemployment Insurance benefts and are identifed by us as unlikely to return to your previous industry or occupation. You have been unemployed for a long time and are unlikely to get another job in the same or similar occupation. You were self-employed and are unemployed due to general economic conditions or a natural disaster, or. You are a spouse of a member of the Armed Forces on active duty who has experienced a loss of employment as a direct result of relocation to accommodate a permanent change in duty station of such member You may also be considered a dislocated worker if you have been away from the labor force for many years. For example: you were a full-time homemaker and you must now return to the labor force because you have lost your source of income. Contact a New York State Career Center for information about services available under this program. If you have not worked in New York State in the last 18 months, you must fle your claim with one of the states where you worked. What if I worked in New York State and one or more other states in the last 18 months? If you worked in New York State and one or more other states in the last 18 months, notify the Department of Labor as soon as possible. By using wages from other states, you may have enough wages to qualify monetarily for benefts or receive a higher beneft amount. If wages from other states are missing from your Monetary Beneft Determination, complete and submit the Request for Reconsideration form at the back of this handbook. Unemployment Insurance benefts are taxable Unemployment Insurance benefts are subject to federal, New York State and local taxes. You can have federal and/or state tax withheld from your Unemployment Insurance benefts. If you decide to have federal tax withheld, ten percent of your weekly beneft amount will be withheld. Federal and/or state tax will be withheld only after any mandatory deductions, such as child support payments, are made. Click the Update Your Personal Information? button on the Unemployment Insurance Benefts Online page. Year-end tax statement (Form 1099-G) In early January, your tax statement (Form 1099-G) will be available. It will show the total Unemployment Insurance benefts paid to you during the calendar year and any taxes withheld. Or, you can call the Telephone Claims Center* (after you select your language, follow the prompts to obtain your 1099 form) to have a copy mailed to you. Form 1099-G information is also sent to the federal Internal Revenue Service and to the New York State Department of Taxation and Finance. If you have questions about state taxes, call the New York State Department of Taxation and Finance at 518-457-5181 or visit tax. It is against the law for any employer to force you to give up your rights to fle for Unemployment Insurance benefts. It does not matter whether your employer considered you an independent contractor or an of-the-books worker. It does not matter whether you were paid in cash, check, part cash/part check or otherwise. If you think you may be eligible for benefts, you should apply and let the Department review your case. If you have been misclassifed as an independent contractor or paid of the books, your wages may not appear on your Monetary Beneft Determination form. Please see If wages and/or employers are missing from your Monetary Beneft Determination notice? in Chapter 4. Complete and return the Request for Reconsideration form found at the back of this handbook. You may receive a questionnaire to fll out or you may be contacted by the Telephone Claims Center* about your employee classifcation status. Please Note: Independent contractor/of-the-books payment issues can take more than six weeks to resolve. If you know of other workers who have been misclassifed, call the Employer Fraud Hotline at 866-435-1499 (24 hours) or the Unemployment Insurance Fraud Unit at 518-485-2144 from 8 a. If you are still unemployed and want to know what other benefts may be available to you, visit the mybenefts. After your beneft year ends, if you are still unemployed, you may fle another claim to see if you are eligible. If you are applying for other types of government benefts, you may be required to show proof that you are receiving or have received Unemployment Insurance benefts. You must have been paid a minimum amount of wages in these four quarters in order to qualify for Unemployment Insurance benefts. Basic Base Period: the frst four of the last fve completed calendar quarters before you fle for benefts. The quarter in which you fle for benefts does not count as part of your base period. Alternate Base Period: the last four completed calendar quarters immediately before you fle for benefts. The quarter in which you fle for benefts does not count as part of the Alternate Base Period. Extended Base Period: Your Basic Base Period, plus the one or two quarters preceding it, make up your Extended Base Period. Available only to claimants who received workers compensation or volunteer frefghters? benefts and who do not qualify on the basis of earnings in their Basic or Alternate Base Periods. Beneft Rate: the beneft rate is the amount of money you receive if you are eligible for a full week of Unemployment Insurance benefts. Beneft Year: the beneft year is the one-year period that begins the Monday after the week you fled your original claim. You can be paid benefts for up to 26 weeks or the equivalent during your beneft year. If you remain unemployed or become unemployed during the week immediately following the end of your beneft year, you must fle a new claim immediately following the end of your beneft year. Beneft Year Ending Date: the beneft year ending date is the date your Unemployment Insurance claim ends. After the beneft year ending date, you can no longer collect Unemployment Insurance benefts on that claim. If you were employed for part of your beneft year, but are unemployed after the beneft year ending date, you can fle a new claim on our website or by calling the Telephone Claims Center. This is because when you answer the questions that are part of claiming weekly benefts, you are certifying to the Department of Labor that your answers are true and correct and that you are still ready, willing and able to work. Civil Penalty: the monetary penalty for willfully (knowingly) making false statements or withholding relevant facts to receive benefts. If we approve your application and you are receiving benefts, we will also refer to your open Unemployment Insurance case as your claim. Covered Employment: Employment that can be used to establish a claim for Unemployment Insurance benefts.

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Informa Healthcare, Loden M (2003) Role of topical emol other skin barrier disorders. Dermatol 4(11): 771?88 these conditions, it is vital to ensure Soriatane (acitretin) capsules. It will also protect skin from hyperkeratosis) and its interrelation ship with B-complex vitamins. Mosby, St Louis 3M? Cavilon? Durable Barrier Skinner H, Fitzpatrick M (2008) Cur Cream + Honey provides a barrier and rent Essentials: Orthopedics. Hum If you would like more information about Cavilon skin care products, Mol Genet 14 (13) to receive product samples or to arrange a representative visit, call 0800 616066 (answer phone) or visit Her leadership and substantive expertise are reflected both in the way she has We also appreciate the many individuals who shared their guided the completion of the overall project and in her expertise with us and provided input throughout this project. In the development of this Special thanks go to Margaret Schlegel, a science writer who document, she refined the basic conceptual frame for the developed the initial organization and an early draft of manuscript and maintained the highest standards for the sci the material. She reviewed literature and directed the manuscript review process, integrating recent research findings as well as experts? suggestions and com We offer Developing Adolescents as an information resource ments into the text. Her meticulous editing included detailed for many professionals, including psychologists, as they deal attention to the nuances of translating specialized scientific with adolescents in varied roles? as health professionals, reports into material that is accessible to a wide range school teachers and administrators, social service staff, juve of professionals. School social they work with adolescents, need substantive knowledge workers, for example, are often called on to provide about the trajectory of youngsters? lives from late guidance to families or to conduct parenting groups and elementary school ages through high school years. Physicians, who play an important role in nurses, school-based health providers, social workers, interpreting normal physical development to teens and dentists, and dieticians, to name a few? understand parents, are also often the first contact for consultation crucial aspects of normal adolescent development and about behavioral issues such as substance abuse. Developing Adolescents presents, in an accessible way, research findings on the cognitive, physical, social, emotional, and behavioral Legal statutes govern some behavior of professionals. Matters of confidentiality are pertinent to all professionals and are generally addressed in law as well There is currently no standard definition of adolescent. What is most important is to consider Am erican Psychological Association, Am erican School carefully the needs and capabilities of each adolescent. For the purposes of this document, adolescents are generally defined as youth ages 10 to 18. That being said, professionals who work with young adults over age 18 m ay still find the inform ation contained in this report to be relevant for understanding their clients. Each professional must keep abreast of changes in codes and laws pertaining to his or her professional conduct with adolescents and their families. These codes and laws, which sometimes vary from state to state and can apply differently in different settings, always supersede guidance provided in this or similar publications. Although this publication presents a substantial amount of research on topics related to behavioral and mental health, its aim is not to train professionals to do psychological counseling. Rather, it is intended to describe the characteristics of adolescents and aspects of the contexts in which they live that make a difference in promoting healthy adolescent development. Psychotherapy or counseling, whether provided by a licensed psychologist, psychiatrist, social worker, nurse, or other trained mental health professional, requires many years of specialized graduate education and supervised experience. Professionals who are knowledgeable about normal adolescent development are in a good position to know when an adolescent needs this kind of professional psychological help. In the professional literature, too, adolescence is with a focus on preventing these problems and frequently portrayed as a negative stage of life? a period enhancing positive outcomes even under adverse of storm and stress to be survived or endured (Arnett, circumstances. So, it may not be surprising that a 1999 survey of understanding and working with adolescents in the the general public by Public Agenda reported that for context of larger systems (Lerner & Galambos, 1998); 71% of those polled, negative terms, such as rude,? although working with adolescents and families is wild,? and irresponsible,? first came to mind when critical, systemic change is sometimes needed to they were asked what they thought about American safeguard adolescent health. This report also indicates that adolescents differences, guide decision making, give financial whose parents are more involved in their lives (as meas guidance, and so on (Scales, Benson, & Roehlkepartain, ured by the frequency of eating meals together regularly, 2001). However, fewer actually act on these beliefs to a simple measure of parental involvement) have signifi give young people the kind of support they need. Effective communication requires that an substance abuse or involvement with violence. With all emotional bond form, however briefly, between the of the attention given to negative images of adolescents, professional and the adolescent. Professionals must find a however, the positive aspects of adolescents can be way to relate comfortably to adolescents, and be flexible overlooked. Professionals can play an important role in enough to accommodate the wide range of adolescents shifting perceptions of adolescents to the positive. And, professionals must truth is that adolescents, despite occasional or recognize that developing effective communication with numerous protests, need adults and want them to be the adolescents with whom they work requires effort on part of their lives, recognizing that they can nurture, their part. It may take a number of sessions of teach, guide, and protect them on the journey to nonjudgmental listening to establish the trust needed for adulthood. Directing the courage and creativity of a particular adolescent to share with an adult what he or normal adolescents into healthy pursuits is part of what she is thinking and feeling. It may take even longer successfully counseling, teaching, or mentoring an before an adolescent feels comfortable asking an adult for adolescent is all about. Discussing options for using birth control with a physician or telling a school psychologist or social worker that one is feeling depressed or sad generally requires both time and trust. Professionals may find that the strategies they use to A growing number of households in the United States provide information and offer services to adults just include individuals who were born in other countries. Young people need Immigrants enter the United States for diverse reasons; adults who will listen to them? understand and some may be escaping a war-torn country, just as others appreciate their perspective? and then coach or are in the country to pursue an advanced education. The number of foreign-born in the United States consequences of high-risk behaviors is not enough. People born in Having an understanding of normal adolescent other countries now constitute 10% of the U. Thus, research on most population of adolescents in the United States is areas of normal adolescent development for minority becoming increasingly racially and ethnically diverse, youth is still lacking; so caution should be used in gen with 37% of adolescents ages 10 to 19 today being eralizing the more global findings reported here to Hispanic or members of non-White racial groups (see all adolescents. Data are continually being analyzed, and new findings are em erging regularly about various aspects of adolescent health and m ental health. The study is particularly im portant in that it is based on a large nonclinical sam ple of norm al adolescents and includes an ethnically diverse large sam ple. Organization of Developing Adolescents: A Reference for Professionals the physical changes that herald adolescence? the development of breasts and first menstrual periods for girls, the deepened voices and broadened shoulders for boys? are the most visible and striking markers of this stage. However, these physical changes represent just a fraction of the developmental processes that adolescents experience. Their developing brains bring new cognitive skills that enhance their ability to reason and to think abstractly. They develop emotionally, establishing a new sense of who they are and who they want to become. And, they begin to experiment with new behaviors as they transition from childhood to adulthood. In Developing Adolescents, we thus discuss Population of Adolescents adolescent development with reference to physical, 8 Ages 10-19 by Race: 2000 cognitive, emotional, social, and behavioral develop ment. Each section presents basic information about what is known about that aspect of adolescent Race Percent of total development and suggests roles professionals can play to help support adolescents. White only 70* Of course, no adolescent can truly be understood in Black only 15 separate parts? an adolescent is a package deal. Furthermore, no adolescent can be fully understood Pacific Islander only 4 5 outside the context of his or her family, neighborhood, school, workplace, or community or without considering American Indian/ such factors as gender, race, sexual orientation, disability Alaska Native only 1 or chronic illness, and religious beliefs. Hopefully, this will make it just a bit easier and more comfortable for professionals to relate to adoles cents in the context of their particular professions. Relatively little research has examined Physical differences in the course of puberty among different D evelopm ent ethnic groups; this is clearly an area that deserves additional attention (Lerner & Galambos, 1998). Entering puberty heralds the physical changes of Professionals who work with children and their families adolescence: a growth spurt and sexual maturation. Professionals can what is normative and what represents early or late also offer helpful advice to parents and other adults physical development in order to help prepare the about how to discuss puberty with younger adolescents. Even in schools where sex education is taught, many girls and boys still feel unprepared for the Research findings suggest that adolescent girls who are changes of puberty, suggesting that these important unprepared for the physical and emotional changes of topics are not being dealt with in ways that are most puberty may have the most difficulty with menstruation useful to adolescents (Coleman & Hendry, 1999). When 157 ninth grade girls were asked to suggest how younger girls should be prepared for menstruation, they recommended that mothers provide emotional support Puberty and Sexual Developm ent and assurance, emphasize the pragmatics of menstrual hygiene, and provide information about how it will Although it sometimes seems that adolescents? bodies actually feel, emphasizing positively their own first change overnight, the process of sexual maturation experiences with menstruation (Koff & Rierdan, 1995). The the girls also recommended that fathers not comment sequence of physical changes is largely predictable, but on their daughters? physical changes, and that mothers there is great variability in the age of onset of puberty not discuss these changes with fathers in front of the and the pace at which changes occur (Kipke, 1999). There are numerous factors that affect the onset and progression of puberty, including genetic and biological influences, stressful life events, socioeconomic status, Although research on boys? first experiences of sexual nutrition and diet, amount of body fat, and the presence maturation is limited, some evidence suggests that boys, 7 of a chronic illness. The growth spurt, which involves too, are more comfortable with the physical changes of rapid skeletal growth, usually begins at about ages 10 to adolescence when adults prepare them. For most adolescents, sexual upon experiencing their first ejaculations of semen maturation involves achieving fertility and the physical during dreaming or masturbation (Stein & Reiser, 1994). For girls, these changes the implication of these findings is that adolescents involve breast budding, which may begin around age 10 should be prepared for the upcoming changes early, at or earlier, and menstruation, which typically begins at about 9 or 10 years of age, so they will not be caught off age 12 or 13. The development of secondary sexual characteristics, such as body hair and (for boys) voice 9 African Am erican girls begin m enstruating an average 6 changes, occurs later in puberty. Many adults may still believe that the magic age of 13 is the time to talk about puberty, but for many boys and 10 Health care professionals and researchers refer to the 5 girls, this is years too late. A recent study of 17,000 point Tanner scale, which describes the external physical changes that take place during adolescence. Others, including parents and non m edical professionals, can also learn to use this scale puberty by age 7. The findings of this study suggest 11 Several reasons have been proposed for this early onset of that onset of puberty may be occurring about 1 year puberty in girls, including increased body weight, genetics, earlier in White girls and 2 years earlier in African exposure to horm ones in m eat or m ilk, and increased American girls than had previously been thought. For a recent dis cussion in the popular press of why som e girls are reaching However, studies have not yet been completed on puberty at earlier ages, see the Tim e m agazine cover story, October 30, 2000. Early or Late Sexual Development development, and not to the level of physical development, whether early, on time, or late. For It is important for adults to be especially alert for signs example, 13-year-olds should be given earlier curfews of early and late physically maturing adolescents? and be more closely supervised than older teens, even if particularly early maturing girls and late maturing they physically appear to be much older. Likewise, an boys? because these adolescents appear to be at adolescent whose physical maturity is behind his or her increased risk for a number of problems, including peers may still be ready for increased independence. For example, early maturing girls have been found to be at higher risk for depression, Physical Appearance and Body Im age substance abuse, disruptive behaviors, and eating disorders (Ge, Conger, & Elder, 2001; Graber et al. Likewise, there is take place during adolescence, this is a period in which growing evidence that boys whose physical development physical appearance commonly assumes paramount is out of synch with their peers are at increased risk for importance. Early maturing boys have been found to be hours concerned about their appearance, particularly in more likely to be involved in high-risk behaviors such as order to fit in? with the norms of the group with whom sexual activity, smoking, or delinquency (Flannery et al. At the same time, they wish to have 1993; Harrell, Bangdiwala, Deng, Webb, & Bradley, their own unique style, and they may spend hours in the 1998). Although early physical maturation does not bathroom or in front of the mirror trying to achieve appear to pose as many problems for boys as it does for this goal. Because of their smaller Adults should take adolescents seriously when they stature, late maturing boys may also be at higher risk for express concerns about aspects of their appearance, such being bullied (Pollack & Shuster, 2000). If an adolescent is concerned, for example, that he is overweight, it is important to spend the time to listen, Adults, including parents, may not be aware of the risks rather than dismissing the comment with the of early maturation for girls and be unprepared to help 8 reassurance that you look fine. Professionals can talk openly with early maturing youth Physical Activity and Weight and their parents about the likelihood that they will confront peer pressure to engage in activities that they Approximately 14% of adolescents aged 12 to 19 years are not yet emotionally ready to handle, such as dating are overweight? nearly 3 times as many as in 1980 and sexual activity. In addition, they may suffer identify and practice strategies in advance for dealing from social discrimination, particularly from their peers, with or avoiding these situations. One factor is that levels of physical activity tend to decline as adolescents get older. Puberty, by its very nature, is associated with weight Furthermore, enrollment in physical education drops gain, and many adolescents experience dissatisfaction from 79% in 9th grade to 37% in 12th grade; in fact with their changing bodies. In a culture that glorifies some of the decline in activity is due to fewer being thin, some adolescents? mostly girls? become opportunities to participate in physical education classes overly preoccupied with their physical appearance and, and to reduced activity time in physical education in an effort to achieve or maintain a thin body, begin to classes. Participation in sports, which has important direct health benefits, is one socially sanctioned arena in which adolescents? physical energies can be positively Between 0. Other activities in which physical energy can United States are anorexic, and 1% to 3% are bulimic, be channeled include dance, theatre, carpentry, with perhaps 20% engaging in less extreme but still cheerleading, hiking, skiing, skateboarding, and unhealthy dieting behaviors (Dounchis, Hayden, Wilfley, part-time jobs that involve physical demands. Although boys can also have these eating activities provide adolescents with opportunities for disorders, the large majority are female (over 90%). Factors that appear to place and building character and self-discipline girls at increased risk for anorexia or bulimia include (Boyd & Yin, 1996). Daughters of women with eating Despite the considerable rewards of sports and other disorders are at particular risk for developing an eating extracurricular activities, many adolescents do not disorder themselves (Striegel-Moore & Cachelin, 1999). Barriers to participation in organized sports activities include costs, lack of transportation, competing time commitments, competitive pressures in the sport, and lack of parental permission to participate (Hultsman, 1992). Other barriers can include lack of access to safe facilities, such as recreation centers or parks, particularly in inner city or rural areas. Some youth may also have other important obligations, such as working or caring for younger siblings, that prevent their participation. Youth with disabilities or special health needs may especially experience difficulty identifying recreational opportunities that accommodate their particular needs 13 the March 2002 Supplem ent to the Journal of the (Hergenroeder, 2002). Professionals should examine Am erican Dietetic Association (Volum e 102, Num ber 3), each of these impediments to determine how to Adolescent Nutrition: A Springboard for Health, focuses on overcome them to reduce barriers to participation. Information is limited about the prevalence of eating disorders among different ethnic groups, although there is some evidence to suggest that patterns of disordered eating differ.

Syndromes

• Normal muscle jerks and twitches that disturb the sleep
• The condom may make noise (using the lubricant may help). The newer version is much quieter.
• You have crusting or scaling of your eyelids
• Heart attack or stroke
• Adults: 26 to 120
• Tonsillitis
• Nosebleed
• Skin diseases (such as eczema)

Recently Panteleyev keratinized epidermal cells anti viral herb generic starlix 120 mg line, which began the and Bickers [22] produced a hypothesis to explain proximal? Age and West Germany (Daded-Wuerttembergs) from 1993 to concentration-dependent elimination half-life of 2003 hiv infection from dried blood purchase starlix with visa. Arch Dermatol Res survey of workers in the pentachlorophenol section of 292(11):577?81 hiv infection rates california purchase starlix mastercard. Toxicopathology charac nyl poisoning: 14-year follow-Up of the Taiwan teristics of the halogenated aromatics hiv infection in zimbabwe generic starlix 120mg online. Clinical and ultrastruc tiation pattern of human keratinocytes in organotypic tural characterization of human skin after exposure to culture hiv infection rates miami buy starlix master card. It is not a life-threatening condi Dermatology Unit process of hiv infection at the cellular level buy discount starlix 120 mg on line, Kaplan Medical Center, tion; however, it lasts for years; it can cause scars 76100 Rechovot, Israel e-mail: bdavidovici@yahoo. Wolf disease that has caused more insecurity and most popular myths and beliefs regarding acne feelings of inferiority than acne? [2]. Unfortunately, after reviewing the high prevalence of acne vulgaris in adolescents existing data, there is no clear proof to deter the overall knowledge pertaining to the causes, mine whether most of these issues are facts or natural course, and therapy was found in several misconceptions. We can just promise that the studies to be very low not only among patients jury is still out [12 ]. In a study from mentioned before, the public perceives the role of Greece, high-school students implicated diet food in acne causation as pivotal. In an attempt to advise them knowl ance and dirt were the major causes of acne [10]. Unfortunately though, convincing trials are hormonal and genetic factors, although diet, poor lacking as it turns out that there are no meta skin hygiene, and infection were also implicated analyses, or well-designed scienti? In another study that analyzed the knowledge follow evidence-based guidelines for providing of acne causation among English teenagers, 11 % solid proof in dealing with this issue [13 ] [ 14 ]. Schaefer [15], a general practitioner arguments and the evidence base for some of the who spent almost 30 years treating Inuit (Eskimo) 26 Myths and Beliefs of Acne Pathogenesis: Diet, Smoking, Hygiene 197 people as they made the transition to modern life, that: Circumstantial evidence is a very tricky and later Bendiner [16] reported that acne was thing. It may seem to point very straight to one absent in the Inuit population when they were thing, but if you shift your own point of view a still living and eating in their traditional manner. More convincing is the study conducted on schoolchildren from Could milk cause acne? Out of 1,925 patients who kept food diaries and found that a total of 9,955 children (age 6?16 years), only milk was the most common food implicated in acne 2. The diet of the adolescence was associated with history of teenage Kitavan people as well as the Ache community acne. This association was more marked for includes mainly traditional foods? composed of skimmed milk than for other forms of milk, sug mainly locally cultivated foods. The authors hypothesize that 15?25 years) and 115 Ache subjects (including this association may be caused by the presence of 15 aged 15?25) found not a single case of acne of hormones and bioactive molecules in milk. The authors suggested that the absence shown that acne in teenagers correlates with hor of acne in non-Westernized societies is attribut monal activity [25]. In addition milk contains a multitude of these isolated regions live in close-knit and growth-stimulating hormones [27]. The effect of dietary fat content on insulin some of the effects of comedogenic factors, like resistance has been a subject of controversy. On androgens, growth hormone, and glucocorticoids the one hand animal studies almost uniformly [31]. Although the biologic explanation seems plau show increases in insulin resistance accompa sible, the study is not innocent from methodological nying high-fat diets, particularly saturated fats pitfalls. However, the results of clinical inves tantly recalled eating habits and vaguely de? Moreover, since the analy Whereas some studies indicate a link between sis of this study was cross sectional a causal rela dietary fat intake and insulin resistance [44 47 ], tionship cannot be determined. In a cross-sectional most studies show no such relationship [48 53 ], study a temporal correlation cannot be established; and the general consensus among the experts thus, the direction of the association between the today is that the available valid scienti? A very consequence a reverse causation cannot be ruled similar situation exists with the in? Therefore, the association between acne and bohydrate contained in foods (?glycemic index?) milk found in this study should be treated with and insulin sensitivity. The concentration of iodine in milk has an inverse correlation between a high glyce been shown to vary according to the season and mic index, hyperinsulinemia, and insulin resis geographic location, but signi? Thus, it was concluded that the observed such an effect [59 61], and most of the experts association of dairy products with acne might be have taken the position that not enough valid sci secondary to the iodine content of the dairy prod enti? Moreover, it is generally accepted that the concentration causes true acne is debatable. It has been hypothesized that high-fat [37] and iodine was also recognized as causing or high-carbohydrate foods may exacerbate acne an acneiform eruption. However, the comedo, the by production of more comedogenic sebum? initial lesion in acne, is not part of this eruption. Several experimental studies on animals (most of them dated) have demonstrated that feeding high-fat or high-carbohydrate diets 26. These stud Foods ies have been criticized by many experts for using faulty techniques [65]. Similarly, several human Dietary factors especially chocolate, oily, or studies have also demonstrated that diet may fatty foods and high sugar content foods were change the amount and composition of excreted repeatedly nominated as causing or exacerbating sebum, i. The stud regarding the nutrition in relation to acne ies of acne and chocolate of Grant and Anderson etiology. The subjective self-assessed measure of global beliefs concerning acne pathogenesis, and there dietary quality in Chiu et al. But the black color of open comedones is crossover study performed in American hospital probably not composed of any extraneous dirt. It acne clinic attendees and male prisoners, found was initially thought to be result of oxidation of no effect of chocolate on acne or on sebum pro fats; however, melanin staining has been incrimi duction or composition. This surface suggest no role for the cocoa content of choco oil is also perceived as dirty, and washing away late bars in acne genesis, the role of the complete these oils from the skin will stop pores blocking product remains open to question. But in fact these surface lipids treatment period for both chocolate and placebo have little to do with acne production, and while bars was just 4 weeks. Given the 4-week treatment it is true that pores do get functionally blocked, periods and 3-week washout period in the cross this blockade occurs at a depth beyond washing over design, it may be that there was insuf? A small study, 16 subjects and 13 matched For generations, patients and physicians controls [76], of patients with acne found no dif believed that successful treatment of acne ference in sugar consumption between the two depended on the degreasing of the skin to an groups?though patients with seborrheic derma extent, which produces noticeable peeling [85 ]. In fact, soap has been advocated in the treatment In another study by Fulton et al. Although the cleansing revealed that they are mostly too small study by Adebamawo et al. Improvements in acne have been noted in a ten Additionally, in the past commonly used soaps subject uncontrolled study of a medicated face and shampoos have been found to be comedo wash [88 ]. Similarly, improvement was noted in authors admitted that, at best, face washing for an open uncontrolled and incompletely reported acne continues to be empirical therapy? [89 ]. It contributes to a feeling of with unmedicated soap, but in which, again, no well-being as well as improving the appearance non-wash comparison was studied [92, 93]. Rather than promoting Reported randomized controlled studies of a 4 % health, its importance is in the feeling; therefore chlorhexidine gluconate skin cleanser prepara there is no surprise that most patients will resort tion with controls using in one study 5 % benzoyl to cleansing products long before consulting a peroxide and, in another two studies, the vehicle dermatologist [7 ]. The combined data of the two chlorhexidine/vehicle studies showed Numerous clinical studies have documented signi? However, posed as being traumatizing, and so exacerbating reviewing the available studies, which show vary acne [96, 97] and as increasing the skin irritation ing results, it seems that the relationship between adverse effects of topical tretinoin and isotreti tobacco smoking and acne remains unclear. As a consequence, in the tion between acne and smoking and demonstrated 1980s, pharmaceutical companies began suggest a low prevalence of smokers among 165 patients ing that irritation of the skin was not necessary with severe acne treated with isotretinoin [108 ]. However, due to the cross-sectional ease and whether the results are applicable to the nature of the study it was not possible to char situation in the general population where mild acterize the time sequence of acne and smoking. The data of In view of the controversial association these acne patients were not compared with a between acne and smoking, some studies have control group derived from the study base, but shown that cigarette smoking aggravates acne; with expected prevalence derived from national others did not con? Information on possible confounders or ver lining of this dark and smoky cloud is still not quantity of smoking was also not available. In another large-scale cohort of young men with severe acne, active smokers showed a signi? However, this study had also methodological limitations: the inclusion Patients believe that acne is an infection and that of only males and only severe acne and the exclu they are infectious to others. Propionibacterium acnes has a role in the involu Also, owing to the cross-sectional nature of the tion of the disease from simple comedones to study, it was not possible to delineate the time in? However, it is a secondary sequence of severe acne development and smok phenomenon once the disease has been initiated. Some subjects may have started smoking Propionibacterium acnes is an obligate anaerobe after the onset, or even as a consequence, of acne, living in the oxygen-free environment of the or vice versa. Although acne is associ cross-sectional study of 896 citizens of the City ated with androgen metabolism at the level of the of Hamburg [112] acne prevalence was sig sebaceous glands, there is no basis to either of these 202 B. Coping with literature is that of a decreased quality of life and acne: beliefs and perceptions in a sample of secondary sexual satisfaction among women who suffer from school Greek pupils. Beliefs, perceptions and psychological impact of acne vulgaris among patients in the Assir region of Saudi Arabia. Acne preva ies mostly of unsatisfactory quality and the lence, knowledge about acne and psychological mor bidity in mid-adolescence: a community-based study. The effect of a high-protein, low glycemic-load tions and beliefs prove to be fact or misconcep diet versus a conventional, high glycemic-load diet on tion is more than an academic issue. It is of biochemical parameters associated with acne vul importance due to the practical implications of garis: a randomized, investigator-masked, controlled these beliefs for acne management, adverse trial. Challenges to the hierarchy of evidence: effects, expense, and potential psychological does the emperor have no clothes? Disastrous trade-off: Eskimo health for gating these questions, which are prevalent and white civilization. The age distribution of common skin disor ders in the Bantu of Pretoria, Transvaal. Epidemiological survey of skin diseases in school References children living in the Purus Valley (Acre State, Amazonia, Brazil). Hormonal correlates of acne and hirsut professional advice advocating therapeutic sun expo ism. Patient concepts and miscon androgen metabolism: basic research and clinical per ceptions about acne. Role of hormones in Comparison of the effects on insulin sensitivity of pilosebaceous unit development. Acneform eruptions induced by drugs and lycerols is not associated with change in glucagon chemicals. Iodine content diets enriched in saturated (palmitic), monounsatu in drinkingwater and other beverages in Denmark. Amylopectin starch muscle insulin resistance after liver insulin resistance promotes the development of insulin resistance in high-fat?fed rats. Development of has a higher potential than energy restriction to insulin resistance in the rat is dependent on the rate of improve high-fat diet-induced insulin resistance in glucose absorption from the diet. Relationship ordinary diet affect insulin action and muscle sub dietary fat and serum cholesterol ester and phospho strates in humans. Variatin in tinic acetylcholine receptor regulating cell adhesion sebum fatty acid composition among adult humans. Effect of nico A population-based study of acne vulgaris, tobacco tine on the immune system: possible regulation of smoking and oral contraceptives. P a r t V Acne: Clinical Aspects Understanding Acne as a Chronic 2 7 Disease Christos C. The majority of lay people, but also many physicians, believe that acne is a self-limiting disorder so that treatment is only required in extreme cases. Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Dessau, Germany 27. Gollnick In most cases acne is not an acute disease but Department of Dermatology, Otto von Guericke Universitaet Magdeburg, Magdeburg, Germany rather a condition that continuously changes in e-mail: harald. The psychological and similarities between the two diseases are strik emotional impact of acne and the effect of treatment ing. Coping with acne vulgaris: evaluation of the chronic psychologically damaging condition that lasts skin disorder questionnaire in patients with acne. Prevalence of into the management of acne: an update from the facial acne in adults. The preva study of acne in female adults: results of a survey con lence of acne in adults 20 years and older. The beginning of acne frequently occurs during the prepubertal period when adrenal androgens stim ulate the pilosebaceous unit. Consequently, acne vulgaris Department of Dermatology, Andreas Syngros Hospital, can begin in children as young as 6 or 7 years National and Capodistrian, University of Athens, Athens, Greece depending on the onset of adrenarche. A relative decrease in sebaceous linoleic acid may account for the increase in the proliferation rate of the basal kera 28. In most patients, several Comedogenesis is one of the four major etiologi types of comedones coexist (Fig. In the normal follicle, the keratinocytes are shed as single cells to the lumen 28. In acne, keratinocytes Microcomedones are not visible by the naked eye hyperproliferate and are not shed as in the normal and represent a histological entity. Also, they become densely packed along tions of normal-looking skin in patients with with mono? Different factors fact that the microcomedone is the initial acne seem to play a role. Drug-induced comedones may result from treat ment with oral, topical, intranasal, or intrathecal corticosteroids or oral steroids [15, 18].

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