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Since many parameters possess biological rhythms a standard timing of blood collection is essential erectile dysfunction treatment vitamins buy generic viagra professional pills. The use of a closed system is essential; this will ensure the cleanliness of the test tubes and also provides the appropriate anticoagulants or enzyme inhibitors if needed viagra causes erectile dysfunction 100mg viagra professional amex. In most cases natural erectile dysfunction treatment remedies cheap 100 mg viagra professional mastercard, blood is drawn into plain tubes (a tube with separator gel is recommended) however impotence with condoms discount 100mg viagra professional otc, some labile parameters require special tubes and temperature. A prolonged strangulation of the vein should be avoided and also any manipulation that might cause lysis of the red blood cells in the sample. A bar code system is preferred where the bar code contains the patient’s demographic data and the test requests having been input into the medical computer software system previously. In spite of the proper identification system there is still the possibility by human mistake to mismatch the samples and unfortunately the laboratory most often is not able to reveal this type of error. In most cases separated plasma or serum samples can be kept at 4 C for 1 – 2 days o but certain parameters require immediate freezing ( 20 C. There is a time window for many tests within which the analysis should be performed and the samples can not be stored. It is never allowed to keep coagulated whole blood in the fridge/freezer or uncoagulated whole blood in the freezer! High temperature and exposure to sunlight might destroy many components in the blood. Frozen samples should be kept frozen during transport preferably by using dry ice or other cooling devices. It is very important that the labels on the tubes be not damaged during transport. A printed list of the patients’ demographical data and the test requests should accompany the tubes even if there is an online connection between the sender and the lab. Technically, if the antigen or the antibody is bound to a solid phase the assay is called heterogeneous, if they are in solution the method is called homogenous. Standard amount of the labeled analyte and unknown amount of the unlabeled analyte (in the patient’s sample) is mixed and given to immobilized specific antibodies. The more analyte is in the patient’s sample the less labeled analyte can bind to the antibodies and vice versa. After incubation and washing steps the signal is measured which is inversely proportional to the concentration of the molecules in the patient’s serum. This type of assay is used for determination of free thyroid hormones however, free hormones represent a minute fraction of total T4 and T3. The protein bound and free fractions are in equilibrium which ratio should not be changed under the assay conditions. Two monoclonal antibodies with different epitope specificity are used in two consecutive steps. During the first incubation the patient’s sample is mixed with the immobilized primary antibody. After a washing step the secondary antibody carrying a label is added to the complex. After further incubation and washing the signal coming from the “sandwich” formed is measured and compared with those of the calibrators. The signal is directly proportional with the concentration of the analyte (Figure 12. Thyroid disease – related auto antibodies are also protein macromolecules but their determination is based on competitive type of assays. Here auto antibodies in the patient’s serum compete with standard amount of labeled antibodies in the presence of recombinant target molecules. Preanalytical and analytical errors in thyroid assays are related to the patient and a minor part is in connection with medication or inappropriate sampling methods. This may happen when one reference range is quoted for all age groups in the laboratory reports. However, despite this well recognized fact, the current guideline recommendation is that a single adult reference range be quoted for all adult age groups. In children, the hypothalamic pituitary thyroid axis matures throughout infancy and childhood until puberty is reached. Preanalytical and analytical errors in thyroid assays children are higher than those of adults, particularly in the first week of life and throughout the first year. This fact is important to recognize because missed cases of congenital hypothyroidism may occur if the age adjusted reference range is not taken into account. Fortunately most, if not all, laboratories have circumvented this problem by utilizing free unbound thyroid hormone assays. The terms non thyroidal illness and euthyroid sick syndrome are used interchangeably to describe such cases. Examples of illness include the following: sepsis, starvation, myocardial infarction, burns, trauma, surgery, malignancy, and psychiatric illness. This effect is o accentuated by incubation of blood at 37 C and by increased blood triglyceride or low serum albumin concentrations. Such cases are often misdiagnosed as being hyperthyroid and subjected to inappropriate thyroid gland ablation. However, depending on the actual assay there are certain concentration limits above which interference occurs. The sample type of immunoassays is usually serum with some exceptions where the stability of the tested parameter requires the use of a specified anticoagulant. In automated systems incomplete coagulation of native blood before separation of serum may cause pipetting errors due to fibrin formation during the assay procedure. Cross reactivity (specificity of the antibodies used in the test) is of minor significance because in most assay systems monoclonal antibodies are applied. An appropriate sample matrix is essential therefore dilution of samples of concentrations exceeding the linearity range of the test should be diluted only with special diluting fluid supplied by the manufacturer of the test system. In free thyroid hormone measurements dilution is not possible because it would alter the equilibrium between protein bound and free hormones giving erroneous results. These heterophile antibodies may cross react with any of the thyroid function test assay methods (immunoassay based, utilizing animal antigens), leading to false results, which are more often inappropriately high. The inappropriate result may not necessarily be abnormal, but in fact inappropriately normal. In autoimmune patients there might be auto antibodies present to T4 and T3 also interfering with the assay system. When a patient is suspected to have auto antibodies the thyroid tests should be repeated in another test system using different animal antibodies. In non competitive assays the large amount of analyte molecules are crowding over the immobilized primary antibody and mask part of the bound antigen. In this case the sandwich can not be formed properly leading to a falsely low result. The clinician should consult with the laboratory staff (data not plausible) and the problem is solved by dilution of the sample until the result does not change any more. The test is most useful in exclusion of autonomous thyroid gland function and it has a prognostic value in Graves’s disease. In this group all patients’ free thyroid hormone concentrations were outside the reference range. In the unsuccessful surgery group there is a temporary increase during operation and the after surgery levels still remain high. Very few papers describe the biological variation for the thyroid hormones (5 7) and thyrothropin and no papers described the biological variation for the thyroid antibodies before this study. In the lecture I will present results from our studies of the within subject of biological variation of the thyroid antibodies. Because thyroid disease is more common in women than men, our first project was including only fertile women. The aim was to investigate whether there was a systematic variation of the thyroid autoantibodies related to the menstrual cycle. Six women were taking oral estrogens 99 Biological variation of thyroid autoantibodies Jensen E. Twenty women had 9 blood samples, the remaining 4 individuals had 7, 8 10 and 11 samples drawn due to the length of their cycles. An overlap between the first and the last blood sample in the individual cycles was allowed.

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A randomized trial determines that topical ocular hypotensive medication delays or prevents filtration erectile dysfunction and diabetes treatment cheap 100mg viagra professional mastercard. Am J employed in a modification of the original is well controlled erectile dysfunction young age cheap viagra professional 50 mg on line, but merely that therapy Ophthalmol 2000;130:429 40 erectile dysfunction natural cures discount viagra professional 50mg amex. Optic nerve head escitalopram (depression and generalized primary angle closure is typically unilat parameters of high definition optical coherence tomography 7 men's health erectile dysfunction pills cheap viagra professional online,10,17,18 and Heidelberg retina tomogram in perimetric and preperimetric anxiety disorder), acetazolamide (glauco eral. Morphologic 7 12 changes in the lamina cribrosa correlated with neural loss in systemic edema) among others. Intraocular pres Commensurate will be a myopic shift that shallowing of the anterior chamber and sure and the mechanisms involved in resistance of the aqueous 13,14 1 humor flow in the trabecular meshwork outflow pathways. Selective laser tra beculoplasty for early glaucoma: analysis of success predictors There will often be ocular congestion, possible scleral thickening in posterior and adjusted laser outcomes based on the untreated fellow eye. It arises from numerous causes; hence, there is no age, gender or racial proclivity. Ciliochoroidal effusion recognized as foreign antigens that incite addressed in order to resolve the uveal syndrome associated with posterior scleritis. Compr medication use is a fast evolving phe scleral (possibly occurring in nanoph Ophthalmol Update. Acute bilateral angle closure glaucoma and choroidal effusion associated with effusion angle closure upon doubling of There is some controversy as to whether acetazolamide administration after cataract surgery. Acute Management the potential to worsen the situation by myopia and angle closure caused by topiramate, a drug used for prophylaxis of migraine. Uveal effusion glaucoma occurring from causing contraction of the ciliary muscle 2006;54(3):195 7. Utility of ultra to its natural position, with subsequent increasing the dosage of the medication. If sound biomicroscopy in the diagnosis of topiramate associated ciliochoroidal effusions causing bilateral acute angle closure. Ambiguous cases may benefit • the red free filter on the ophthal otherwise abnormal. With the sive photoreceptor loss in the outer retina, Ultrasonography should not be under filter in place, choroidal pigmentation although the underlying choriocapillaris estimated or placed in the shadow of becomes almost imperceptible, while reti remains unaltered. Solitary congenital hypertrophy of the retinal pigment epithelium: clinical features of the retinal pigment epithelium. Congenital hypertrophy borns, and have even been observed in drawn, but detection of change is very dif of the retinal pigment epithelium: enhanced depth imaging 19 optical coherence tomography in 18 cases. Gardner disease, in general, has no gender predi some cases, severe) resembling Coat’s Syndrome With Unusual Maxillofacial Manifestation. Fortunately, 50% to 80% of all Adenocarcinoma arising from congenital hypertrophy of retinal depending upon its severity. When ret Adenocarcinoma arising from congenital hypertrophy of the inal detachments retinal pigment epithelium. Index case of be rhegmatog familial adenomatous polyposis revealed by congenital hyper trophy of the retinal pigment epithelium. Overview of the mutation spectrum in familial exudative vitreoretinopathy and Patients affected severely may present in prompt attention. An association between subclinical familial exudative vitreoretinopathy and rod Excessive white without pressure, vitreous ment through the use of a “still compe cone dystrophy. Clinical characteristics and 11,12,14,15 surgical management of familial exudative vitreoretinopathy may also occur. Copper foreign reduced A wave and B wave amplitudes Metallic intraocular foreign body in a patient bodies can induce reversible retinal toxic representing the level of retinal degenera with sideritic glaucoma. In some instances the A wave pupil as seen when there is iridodialysis or segment inflammatory reaction depending can become transiently increased. Eur as the optic nerve and macula have not though prostaglandin analogs are not con Radiol. Multiplanar imaging in the preoperative assessment of metallic intraocular foreign Magnetic resonance imaging is contra bodies. Siderosis bulbi with rectomy foreign body extraction assisted with a 24 gauge nee an undetectable intraocular foreign body. Anterior and posterior segment intraocular netic foreign bodies with intraocular magnet. Signs and Symptoms 25 37 Surgical treatment of open globe trauma complicated with the magnet use). Management of siderosis bulbi optic disk in patients who had suffered due to a retained iron containing intraocular foreign body. Intraocular foreign When findings consistent with the Clinical Pearls bodies extracted by pars plana vitrectomy: clinical character traumatic form are seen in concert with a istics, management, outcomes and prognostic factors. Diagnostic value There is a loose gender bias towards • Non healing eye injuries should be of clinical examination and radiographic imaging in identifica young males consistent with the epidemi tion of intraocular foreign bodies in open globe injury. However, that ranges from slight impairment to both retinal arterioles and choroidal ves hand motion. When overall amount of retinal inflammation of the retinal arteries by larger emboli the recovery is poor, speculation is acuity that was produced. Some areas Despite the apparent benefits, this has tained a severe head injury while suffering also showed loss of photoreceptors, the not yet become the standard of care. Purtscher retinopathies: Are we aiming Visual acuity may be significantly at the wrong target Purtscher retinopathy: to treat diminished, depending upon the amount use of anti fibrinolytic agents in the treat or not to treat Intraocular hemorrhage is seen in Terson thought his discovery was peculiar 2007;91(11):1456 9. The phenomena is with intracranial and vitreous hemorrhage 20 year old healthy female report of a rare case and review of bilateral approximately 50% of the time. The reason for not dilating the patient is that subsequent treating physicians need to be able to examine the eye and pupil responses free from pharmacologic contamination. De l’hemorrhagie dans le corps vitre au cours de hemorrhage by this route does not seem source for the intracranial hemorrhage, l’hemorrhagie cerebrale. Klin ology of Terson’s syndrome is sudden cases of Terson’s syndrome remit fol Mbl Augenheilk. Frequently, the amount of ocular hemor hemorrhage, epiretinal membrane or 2002;109(8):1472 6. Middle anastamoses secondary to rapid effusion of visual prognosis; when the blood clears East Afr J Ophthalmol. Simultaneous bilateral Patients demonstrating Terson’s syn if the event precipitates optic nerve dam acute angle closure glaucoma in a patient with subarachnoid hemorrhage. Unilateral acute closed angle glaucoma after elective lumbar surgery reveals symptoms and signs. Ocular ultrasound the neurosurgery team prohibits pupillary incidence of intracranial aneurysm. To keep the service timely and increasingly relevant, content updates will come to subscribers on a quarterly basis, debuting in digital form prior The ptosis and innervate the medial rectus, inferior covering, causing cross talk between dif motility disturbances are typically less rectus, inferior oblique, superior rectus, ferent oculomotor nerve fibers. Aneurysm, and elevate on adduction (lid gaze dys of portions of the nerve to the muscles. Additionally, the eyelid There is either misdirection of regenerat typical causes. There can be or collateral sprouting of uninjured secondary aberrant regeneration. In this case, simultaneous regeneration and aber Not all findings are present or prominent upon adduction, there will also be lid rant resprouting of fibers to incorrect in every case. With attempted abduction, the of diplopia or ptosis, or even be aware of Pathophysiology medial rectus and the levator will be the changes occurring. Occurrence in a patient Diabetic papillopathy is a unilateral or oculomotor neuromyotonia, an episodic with abetalipoproteinemia. A case of primary involuntary contraction of one or more aberrant oculomotor regeneration due to intracavernous aneu less optic disc edema occurring in patients of the extraocular muscles resulting from rysm. Oculomotor neuromyoto noted on the disc surface, giving the optic the chiasm, cavernous sinuses and para nia with lid ptosis on abduction. Prognosis of oculomotor palsy in patients with aneurysms of the posterior communicating artery.

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Severe deficit of thyroid hormones leads to doctor for erectile dysfunction in kolkata discount viagra professional amex irreversible changes in foetal development erectile dysfunction medscape order cheap viagra professional on-line. Impairment of neuronal differentiation leads to erectile dysfunction vitamins order viagra professional with visa inadequate development of the central nervous system with resulting mental retardation erectile dysfunction caused by spinal cord injury order 100 mg viagra professional free shipping. It may also lead to somatic defects including congenital cardiac defects and disrupted bone growth. These changes are most prominent in untreated congenital hypothyroidism (cretinism). Moderate thyroid hormone deficit may lead to less pronounced neurocognitive dysfunction. As Morreale de Escobar has shown, up to 70 % of children of iodine deficient mothers may suffer from attention deficit hyperactive disorder (Morreale de Escobar 2004a,b). In the past, some authorities recommended universal screening but not the American Thyroid Association or the Association of American Obstetricians and Gynaecologists, who have consistently advocated a case finding screening strategy focused on high risk women (Abalovich 2007, Stagnaro Green 2011) (Table 1). Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 149 Authority Year Recommendation American Association of Clinical Endocrinologists 2002 Universal screening Expert panel of American Thyroid Association, Case finding American Association of Clinical Endocrinologists and 2004 screening the Endocrine Society Second panel of American Thyroid Association, Universal screening American Association of Clinical Endocrinologists and 2005 the Endocrine Society British Thyroid Association, Association of Clinical Case finding Biochemists, British Thyroid Foundation. However, the major drawback of this study is that pregnant women up to the 16th gestation week were included. Thus, we may suspect that in some women the treatment started too late, after the crucial changes in the embryonic/foetal brain have occurred. Results of this study should be available in 2015 and they may give a final answer to the question of universal screening for thyroid disorders in pregnancy. The new guidelines introduce age over 30 years and body mass index over 40 kg/m2 among the risk factors. In our opinion, this form of screening is likely to be neglected due to practical reasons. It has been shown that the case finding approach may miss up to one half of pregnant women in comparison with universal screening (Vaidya 2007, Horacek 2010, Jiskra 2011a); and it may be difficult to implement in the routine practice (Vaidya 2002). In order to gain data on thyroid disorders in Czech pregnant women, two large studies including nearly 8 000 consecutive pregnant women (Springer 2009, Limanova 2011), have been conducted in the Czech Republic in the last years. The aim of this study was to evaluate the prevalence of thyroid disorders in pregnant Czech women and to identify optimal reference intervals in evaluation of maternal thyroid function during the first trimester of pregnancy. Women with positive screening result were advised to visit an endocrinologist within a few days. However, our analysis was performed using a well established and widely used analyser (Advia Centaur, Siemens). Number of women screened Total 5520 Positive in screening (at least one parameter) 822 (14. Results of universal screening for thyroid disorders among Czech pregnant women in the 9th to 11th gestational weeks. The aim of the Pilot Project was to ascertain the optimal combination and economic feasibility of diagnostic tests, the timing of the blood test and the possibility of connecting the test with genetic disorder screening in the first trimester of pregnancy. The purpose of the study was also to provide information about cooperation among gynaecologists, laboratories and endocrinologists. Contrary to the previous study, measurements were performed in regional laboratories and the reference ranges differed according to each laboratory. However, due to the different analytical methods, these results cannot be directly compared. Cooperation with gynaecologists wasnt always optimal despite the fact that they were provided with all necessary information well in advance. On the other hand, laboratories analysed the samples promptly, and many of them took part in providing publicity and further information to other cooperating health care professionals. In conclusion, the Pilot Project study showed that implementation of universal screening for thyroid disorders in pregnancy would be feasible in the Czech Republic, although the general knowledge on importance of correct thyroid function in pregnancy needs to be improved among practical gynaecologists. In the future years, we will probably have to concentrate on implementation of the case finding approach years among the official risk factors. Between 2006 and 2009, we performed thyroid ultrasound in 186 pregnant women positively screened for thyroid disorders in the first trimester of pregnancy; i. Unexpectedly, we found that these positively screened pregnant women had rather small thyroid glands with the median volume of 8. This is smaller than in age comparable non selected non pregnant Czech women in the study of Dvorakova et al. This is in contrast to the findings of both Fister and Vila, who showed an increased thyroid volume in pregnancy in iodine sufficient (Fister 2009) and iodine deficient areas (Vila 2008). The finding of small thyroids in pregnant Czech women is probably linked to the saturation with iodine. Therefore, the present pregnant women are already the third generation who live in iodine sufficient conditions. Apparently, alterations of immune system in pregnancy cause a different manifestation of autoimmunity in the thyroid tissue. In this study, 200 of the positively screened women from the cohort of Springer et al. We regarded women as high risk if they had any of the following risk factors: family and/or personal history of thyroid disease (including presence of goitre and signs and symptoms suggestive for thyroid dysfunction), family and/or personal history for autoimmune disease, history of neck irradiation, previous miscarriages and preterm deliveries). After exclusion of transient gestational hyperthyroidism, only 74/159 (47 %) women were classified as high risk for thyroid disease according to their history. There were no significant clinical and laboratory differences between the high vs. Postpartum follow up of positively screened women Between 2009 and 2010, we invited all 822 positively screened women from the first cohort of 5520 pregnant women screened (the cohort of Springer et al. In order to gain as complete a picture of their clinical state and history as possible, we asked them to fill in a detailed internet based questionnaire concerning their personal, family and gynaecological history. The two main aims of the study were: a) to assess the prevalence of high risk profile women in this group; b) to evaluate the postpartum thyroid function in this group with regard to the adequacy of treatment. This group of positively screened women differed from the one analysed in our other two recent studies (Jiskra 2011a, b). The median age of participating women was 31 years at the time of screening in pregnancy. The analysis of questionnaires brought a major finding: the use of the new guidelines of American Thyroid Association (Stagnaro Green 2011) for identification of high risk women substantially increased the proportion of high risk women among the positively screened. The “old” risk factors could identify only two thirds of the positively screened women: personal and family history of thyroid disease (only first degree relatives), diabetes mellitus type 1, other autoimmune diseases in personal history, infertility and history of spontaneous abortion. However, if the “new” risk factor, age>30 years (in our analysis, 31 years and more), was added to the classical ones, 85% of the women could be classified as “high risk” (Fig. This is a surprisingly high number, especially in the view of previous studies (Jiskra 2011b, Horacek 2010, Vaidya 2002). However, this effect of age could be partially due to selection bias, as the majority of women who answered the questionnaire had good education and therefore they tended to later pregnancies. We also tried to identify the most important risk factors in order to simplify the decision process which women should be screened. We found that four risk factor could identify 82% of the high risk women: age 31 and more, personal and family history of thyroid disease and the presence of goitre (Fig. Universal Screening for Thyroid Disorders in Pregnancy: Experience of the Czech Republic 155 p=0. Proportion of positively screened pregnant women with at least one risk factor for hypothyroidism. In order to roughly assess the financial aspects of the universal screening in the Czech conditions, we performed a simple statistical analysis of the financial costs of the Pilot Project (Telicka 156 A New Look at Hypothyroidism 2010). The goal of this study was to find out the overall costs of the Pilot Project as compared to positively screened tests and simulate the costs in the current situation when the screening is not paid by the insurances companies. Conclusions We have shown that the prevalence of thyroid disorders is relatively high among the Czech pregnant women in comparison with other developed iodine sufficient countries. Thus, sonography may only be a part of a more complex diagnostic procedure in the screening for thyroid disorders in pregnancy. However, it seems that pregnant women with autoimmune pattern in thyroid ultrasound have an increased risk of preterm delivery.

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It country infrastructure has been fragmented is therefore not advisable to erectile dysfunction pump price order genuine viagra professional on-line compare data or where major population movements from consecutive editions of the State of the have occurred erectile dysfunction treatment over the counter order viagra professional 100 mg on line. As a result erectile dysfunction keeping it up order viagra professional toronto, consecutive editions the annual neonatal mortality rate how do erectile dysfunction pills work viagra professional 50 mg overnight delivery, infant of the State of the World’s Children should mortality rate, the under fve mortality rate not be used for analysing mortality trends (total, male and female) and the number of over time. These fgures represent under fve mortality estimates for the period the best estimates available at the time 1990–2016 are presented on page 154. Countries and areas are listed alphabetically in the tables on the following pages. New methods are currently Mozambique; Myanmar; Nepal; Niger; being applied to generate estimates through Rwanda; Sao Tome and Principe; Senegal; an inter agency process, and updates will be Sierra Leone; Solomon Islands; Somalia; available in the next edition of the State of South Sudan; Sudan; Timor Leste; Togo; the World’s Children. Tuvalu; Uganda; United Republic of Tanzania; Vanuatu; Yemen; Zambia Iodized salt: the defnition of the indicator presented in this report has changed from the past when it was about households consuming adequately iodized salt. New Child Malnutrition’ (International Journal of estimates are released every 2 years which Epidemiology, vol. In estimates are updated once annually in the absence of a direct method to measure July, following a consultation process this indicator, full coverage is reported as wherein countries are provided draft reports the lower coverage estimate from semester for review and comment. As the system 1 (Jan – June) and semester 2 (July – Dec), incorporates new empirical data, each annual in a given year. The regional and global revision supersedes prior data releases, and aggregates only contain the 82 countries coverage levels from earlier revisions are not indicated as priority countries for national comparable. Therefore, are not comparable to estimates previously the recalculated data presented here may published. For further details, refer to as ‘children left in inadequate care’ but has Female Genital Mutilation/Cutting: A statistical been renamed to more accurately refect the overview and exploration of the dynamics of nature of the underlying construct. This indicator measures region, and not the region as a whole, as “the percentage of children aged 0 17 years there are some non practising countries in old living in households that have income or each region as well. Therefore, national child was decided that more accurate estimates poverty rates should be used to monitor are produced by using a household weight progress, but should not be used to compare that takes the last stage selection into or rank countries. Neonatal mortality rate – Probability of dying during the frst secondary school, this indicator can also be referred to as a Division and the World Bank). Estimates from high under fve mortality rates (over 70 per 1,000 are fed exclusively with breast milk in the 24 are above two standard deviations from data years prior to 2000 are not displayed. Introduction of solid, semi solid or soft foods (6–8 months) – Percentage of children Wasting – Moderate and severe: Percentage reference period, such data are included in the U the low birth weight database has not been updated aged 6–8 months who received solid, of children aged 0–59 months who are below calculation of regional and global averages. Surveys with are currently being applied to generate estimates Minimum Acceptable Diet (6–23 months) a superscript footnote of “b” cannot be confrmed through an inter agency process and updates will be – Percentage of breastfed children 6–23 Wasting –severe: Percentage of children aged 0–59 months who are below minus three in whether the reported value includes households available in the next State of the World’s Children months of age who had at least the minimum without salt or not. No data based on fewer than 25 based on a model ft for all of Europe and Central months of age who received at least 2 milk Vitamin A supplementation, full coverage unweighted cases are displayed. Data were not available for the Russian feedings and had at least the minimum dietary – the estimated percentage of children aged Global and regional averages for stunting (moderate Federation and were mainly from countries in Eastern diversity not including milk feeds and the 6–59 months reached with 2 doses of vitamin and severe), overweight (moderate and severe), Europe and Central Asia. Rota – Percentage of surviving infants who received the last dose of rotavirus vaccine as recommended. Data reported for children (aged 0–14), (aged 0–14), adolescents (aged 10–19) and all ages. Data reported for children (aged <5), who reported having had more than one sexual partner in the estimates, July 2017. Estimates from available during the period specifed years prior to 2006 are not displayed. Lower secondary net enrolment ratio does not include x Data refer to years or periods other percentage of the total number of children of offcial primary than those specifed in the column If they fall within the noted reference school age. Such data are not included Primary school net enrolment ratio – Number of children in the calculation of regional and calculation of regional and global at that level. Because of of children attending lower secondary or tertiary school who Estimates from data years prior to available during the period specifed the inclusion of primary school aged children enrolled in are of offcial lower secondary school age, expressed as a 2000 are not displayed. Life expectancy– Number of years newborn children would live if subject to the mortality risks prevailing for the cross section of Crude death and birth rates – United Nations Population Division. Total fertility rate – Number of children who would be born per woman if she lived to the end of her childbearing years and bore Total fertility rate – United Nations Population Division. It is not advisable to compare data from consecutive editions of the State of the World’s Children. Lifetime risk of maternal death – United Nations secondary school aged population. Population Division) produces internationally modern methods – Percentage of women of below (†). Maternal mortality ratio values have been x Data refer to years or periods other than those comparable sets of maternal mortality data that reproductive age (1549 years) who have their need rounded according to the following scheme: specifed in the column heading. Such data are account for the well–documented problems for family planning satisfed with modern methods. Reported: <100, no rounding; 100–999, rounded to not included in the calculation of regional and of under–reporting and misclassifcation of Antenatal care – Percentage of women (aged nearest 10; and >1,000, rounded to nearest 100. Estimates from data years prior maternal deaths, including also estimates for 15–49) attended at least once during pregnancy by Adjusted: <1000, rounded to nearest 1; and 1,000, to 2000 are not displayed. Please note that owing skilled health personnel (doctor, nurse or midwife) rounded to nearest 10. For detailed explana Comparable time series on maternal mortality Skilled birth attendant – Percentage of births probability of becoming pregnant and the probability tion see General Note on the Data, page 146. Lifetime risk ed ‘reported’ refer to data reported by national maternal–health/maternal–mortality. Institutional delivery – Percentage of women values have been rounded according to the following authorities. The data in the column headed scheme: <1000, rounded to nearest 1; and 1,000, * Data refer to the most recent year available (aged 15–49) who gave birth in a health facility. A child is interviewer, and those without a birth certifcate whose mother v Estimates of 100% were assumed istration were made from the second considered to be involved in child labour under the following or caregiver says the birth has been registered. Therefore, the at least 43 hours of economic activity or household chores, and Vol. Such data are not included * Data refer to the most recent year were frst married or in union before they were 15 years old out without telling him, neglects the children or refuses sexual in the calculation of regional and available during the period specifed and percentage of women 20–24 years old who were frst relations. Violent discipline – Percentage of children 1–14 years old y Data differ from the standard defni Birth registration – Percentage of children under age 5 who who experience any violent discipline (psychological tion or refer to only part of a country. Italicized data are from different sources than the data presented for the same indicators in other tables of the report. This indicator is meant to provide a snapshot of the the following types of information media at least once a week: Adolescents currently married/ in national surveys. This standardized indicator from Upper secondary school gross enrolment ratio – Number other national surveys. Note that the data are based age, expressed as a percentage of the total number of children on the answers of women aged 20–24, whose risk of giving Population Division. Such data are not included in the calculation of regional and Italicized data are from different sources than the data presented for the same indicators in other tables of the report. If they fall within the noted reference period, such data are included in the calculation of regional and global averages. The numerator of attending primary or secondary school who are of offcial p Based on small denominators stunting (moderate and severe) are this indicator includes children reported to have a birth primary school age, expressed as a percentage of the total (typically 25–49 unweighted cases). Bank Group Joint Child Manutrition or caregiver says the birth has been registered. Skilled birth attendant – Percentage of births attended by than those specifed in the column skilled health personnel (doctor, nurse or midwife). The numerator of – Percentage of children under age 5 who had diarrhoea in the p Based on small denominators stunting (moderate and severe) are this indicator includes children reported to have a birth two weeks preceding the survey and who received oral (typically 25–49 unweighted cases). Bank Group Joint Child Malnutrition or caregiver says the birth has been registered. Skilled birth attendant – Percentage of births attended by primary school age, expressed as a percentage of the total than those specifed in the column skilled health personnel (doctor, nurse or midwife). Therefore, the Italicized data are from different sources than the data presented for the same indicators in other tables of the report. Therefore, the the following activities to promote learning and school playthings at home: household objects or objects found outside recalculated data presented here y Data differ from the standard defni will differ from estimates reported in readiness in the past 3 days: a) reading books to the child, b) (sticks, rocks, animals, shells, leaves etc. If they fall within the noted reference taking the child outside the home, e) playing with the child, and Children with inadequate supervision – Percentage of period, such data are included in the * Data refer to the most recent year f) spending time with the child naming, counting or drawing children 0–59 months old left alone or in the care of another calculation of regional and global available during the period specifed things.

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