How does Elinest work as a birth control pill. What are the common side effects of Elinest. How should Elinest be taken for maximum effectiveness. What precautions should be considered when using Elinest. Can Elinest interact with other medications.

Understanding Elinest: A Hormonal Contraceptive Option

Elinest is an oral contraceptive medication used primarily for birth control. It belongs to the class of drugs known as combination hormonal contraceptives, containing both estrogen and progestin. These hormones work together to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the uterine lining.

While primarily prescribed for contraception, Elinest may also be used to regulate menstrual cycles, reduce menstrual cramps, and manage other hormonal-related conditions. Its effectiveness as a birth control method is high when used correctly, but it’s important to understand proper usage and potential side effects.

How does Elinest prevent pregnancy?

Elinest prevents pregnancy through three main mechanisms:

• Suppressing ovulation: The hormones in Elinest prevent the release of eggs from the ovaries.
• Thickening cervical mucus: This makes it more difficult for sperm to reach the egg.
• Thinning the uterine lining: This reduces the likelihood of a fertilized egg implanting in the uterus.

Proper Administration of Elinest for Optimal Effectiveness

Taking Elinest correctly is crucial for its effectiveness as a contraceptive. Here are the key points to remember:

1. Take one pill daily at the same time each day.
2. Follow the order of pills in the pack, starting with the first tablet.
3. For 21-day packs, take active pills for 21 days, then no pills for 7 days.
4. For 28-day packs, take 21 active pills followed by 7 inactive (reminder) pills.
5. Start a new pack immediately after finishing the previous one, regardless of menstruation.

Is it necessary to take Elinest at the exact same time every day? While it’s ideal to take Elinest at the same time daily for maximum effectiveness, there is typically a window of a few hours that won’t significantly impact its contraceptive efficacy. However, consistency is key in maintaining hormone levels and preventing pregnancy.

Common Side Effects and What They Mean

Like all medications, Elinest can cause side effects. It’s important to be aware of these potential effects and discuss any concerns with a healthcare provider. Common side effects include:

• Water retention
• Breast tenderness or pain
• Acne
• Dizziness
• Headaches
• Nausea
• Abdominal bloating

Are these side effects permanent? Most side effects of Elinest are temporary and often subside as the body adjusts to the medication. However, if side effects persist or worsen, it’s important to consult with a healthcare provider.

Managing Common Side Effects

To minimize side effects, consider these strategies:

• Take the pill with food or at bedtime to reduce nausea.
• Stay hydrated to help with water retention.
• Use over-the-counter pain relievers for headaches or breast tenderness.
• Practice stress-reduction techniques to manage mood changes.

Rare but Serious Side Effects: When to Seek Medical Attention

While rare, some side effects of Elinest can be serious and require immediate medical attention. These include:

• Blood clots in deep veins (deep vein thrombosis)
• High blood pressure
• Liver tumors
• Severe abdominal pain
• Sudden severe headache
• Chest pain or shortness of breath
• Visual changes or loss of vision

How can one recognize the signs of a blood clot? Symptoms of a blood clot may include swelling, pain, or redness in one leg; sudden shortness of breath; chest pain; or severe headache. If any of these symptoms occur, seek medical attention immediately.

Interactions and Precautions: What to Consider When Taking Elinest

Elinest can interact with other medications and medical conditions. It’s crucial to inform your healthcare provider about all medications, supplements, and health conditions before starting Elinest. Some important considerations include:

• Smoking, especially in women over 35, increases the risk of serious cardiovascular side effects.
• Certain medications, such as some antibiotics and anti-seizure drugs, can reduce Elinest’s effectiveness.
• Women with a history of blood clots, certain cancers, or liver disease may not be suitable candidates for Elinest.
• Elinest may affect blood sugar levels in diabetic patients.

Can Elinest be used while breastfeeding? While some hormonal contraceptives are safe for use during breastfeeding, Elinest is typically not recommended as it may decrease milk production and pass hormones to the infant. Consult with a healthcare provider for suitable contraceptive options while breastfeeding.

Maximizing Effectiveness: Tips for Consistent Use

To ensure Elinest works as effectively as possible, consider these tips:

1. Set a daily alarm as a reminder to take the pill.
2. Keep pills in a visible location you encounter daily.
3. Use a birth control tracking app to monitor your pill schedule.
4. Carry an extra pill with you in case you’re away from home.
5. Have a backup method of contraception available in case of missed pills.

What should be done if a pill is missed? If you miss a pill, take it as soon as you remember. If you miss more than one pill, consult the patient information leaflet or your healthcare provider for specific instructions, as you may need to use a backup contraceptive method.

Long-term Considerations and Alternatives to Elinest

While Elinest can be used long-term, it’s important to have regular check-ups with a healthcare provider to monitor for any potential issues. Some long-term considerations include:

• Potential impact on bone density
• Changes in libido
• Effects on menstrual cycles after discontinuation
• Increased risk of certain cancers (though also protective against others)

Are there non-hormonal alternatives to Elinest? Yes, non-hormonal contraceptive options include copper IUDs, barrier methods like condoms and diaphragms, and natural family planning methods. Each has its own set of benefits and considerations, and the best choice depends on individual factors and preferences.

Comparing Elinest to Other Contraceptive Methods

When considering Elinest, it’s helpful to understand how it compares to other contraceptive methods:

• Effectiveness: With perfect use, Elinest is about 99% effective, similar to other combined oral contraceptives.
• Convenience: Daily pill taking is required, unlike long-acting reversible contraceptives (LARCs) like IUDs or implants.
• Non-contraceptive benefits: Elinest may help with acne, menstrual regularity, and reducing risk of certain cancers.
• Reversibility: Fertility typically returns quickly after stopping Elinest, unlike some long-acting methods.

Understanding the Composition of Elinest

Elinest contains two active hormones: ethinyl estradiol (an estrogen) and norgestrel (a progestin). The specific formulation of these hormones distinguishes Elinest from other oral contraceptives and contributes to its effects and side effect profile.

How do the hormones in Elinest work together? The estrogen component primarily suppresses ovulation and stabilizes the endometrium, while the progestin component thickens cervical mucus and also contributes to ovulation suppression. Together, they provide effective contraception and help regulate the menstrual cycle.

The Role of Inactive Ingredients

In addition to the active hormones, Elinest contains inactive ingredients that form the pill and may include:

• Lactose
• Magnesium stearate
• Microcrystalline cellulose
• Polacrilin potassium

These ingredients help in the formation and stability of the pill but do not contribute to its contraceptive effects. However, individuals with lactose intolerance or allergies to any of these components should inform their healthcare provider.

Elinest and Menstrual Cycle Regulation

Beyond its primary use as a contraceptive, Elinest can have significant effects on the menstrual cycle. Many users experience:

• More regular periods
• Lighter menstrual flow
• Reduced menstrual cramps
• Predictable timing of menstruation

Can Elinest be used to skip periods? Yes, Elinest can be used for menstrual suppression by continuously taking active pills and skipping the placebo week. However, this should only be done under the guidance of a healthcare provider, as it may increase the risk of breakthrough bleeding.

Managing Breakthrough Bleeding

Breakthrough bleeding, or spotting between periods, is a common side effect when starting Elinest or any hormonal contraceptive. To manage this:

1. Continue taking the pill regularly, even if bleeding occurs.
2. Use panty liners or light pads as needed.
3. If bleeding persists beyond 3 months, consult your healthcare provider.
4. Avoid smoking, as it can increase the likelihood of breakthrough bleeding.

Elinest and Other Health Benefits

While primarily used for contraception, Elinest and similar combined oral contraceptives can offer additional health benefits:

• Reduced risk of ovarian and endometrial cancers
• Improvement in acne
• Management of polycystic ovary syndrome (PCOS) symptoms
• Reduction in menstrual migraines
• Decreased risk of pelvic inflammatory disease

How significant is the cancer risk reduction with Elinest? Studies have shown that use of combined oral contraceptives like Elinest can reduce the risk of ovarian cancer by up to 50% after 5 years of use, with benefits persisting for decades after discontinuation. The risk reduction for endometrial cancer is similarly significant.

Elinest and Bone Health

The impact of hormonal contraceptives like Elinest on bone health has been a subject of research:

• Some studies suggest a slight decrease in bone density with long-term use.
• This effect appears to be reversible after discontinuation.
• The clinical significance of these changes is still debated.
• Women with risk factors for osteoporosis should discuss this with their healthcare provider.

Traveling and Storage Considerations for Elinest

Proper storage and planning are important when using Elinest, especially when traveling:

1. Store Elinest at room temperature, away from direct sunlight and moisture.
2. When traveling across time zones, try to take the pill at the same time relative to your usual schedule.
3. Carry pills in your carry-on luggage when flying to avoid loss or exposure to extreme temperatures.
4. Consider bringing extra packs if traveling for an extended period.
5. Be aware of local laws regarding contraceptives when traveling internationally.

How should Elinest be disposed of safely? Unused or expired Elinest pills should not be flushed down the toilet or thrown in the trash. Instead, check with your local pharmacy about medication take-back programs or follow FDA guidelines for safe disposal of medications.

Emergency Contraception and Elinest

While Elinest is not designed as emergency contraception, in some cases, it can be used as such under the guidance of a healthcare provider:

• Taking multiple pills at once may be recommended as emergency contraception.
• This method is less effective than dedicated emergency contraceptive pills.
• It may cause more side effects due to the higher hormone dose.
• Always consult a healthcare provider for proper guidance on emergency contraception.

Financial Considerations and Insurance Coverage for Elinest

The cost of Elinest can vary depending on location, insurance coverage, and pharmacy pricing. Consider these points:

• Many insurance plans cover oral contraceptives like Elinest under the Affordable Care Act.
• Generic versions may be available at a lower cost.
• Some family planning clinics offer contraceptives at reduced costs.
• Prescription savings programs or manufacturer coupons may help reduce out-of-pocket expenses.

Are there programs available for those without insurance coverage? Yes, several programs and clinics offer low-cost or free contraceptives to those without insurance. Check with local health departments, Planned Parenthood, or other family planning clinics for options in your area.

Elinest and Reproductive Health Education

Using Elinest provides an opportunity for broader reproductive health education:

1. Understanding menstrual cycles and fertility
2. Learning about sexually transmitted infections (STIs) and prevention
3. Discussing future family planning goals with healthcare providers
4. Exploring other aspects of sexual and reproductive health

By engaging in these discussions, users of Elinest can make more informed decisions about their overall reproductive health and future contraceptive choices.

Elinest Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing

Read the Patient Information Leaflet provided by your pharmacist before you start using this product and each time you get a refill. The leaflet contains very important information on when to take your pills and what to do if you miss a dose. If you have any questions, ask your doctor or pharmacist.

Take this medication by mouth as directed by your doctor, usually once daily. Pick a time of day that is easy for you to remember, and take your pill at the same time each day.

If you are taking the chewable tablet, you may either swallow it whole or chew it thoroughly and swallow. Carefully follow the manufacturer’s directions for your brand.

It is very important to continue taking this medication exactly as prescribed by your doctor. With certain brands of birth control pills, the amount of estrogen and progestin in each active tablet will vary at different times in the cycle. It is very important that you follow the package instructions to find the first tablet, start with the first tablet in the pack, and take them in the correct order. Do not skip any doses. Pregnancy is more likely if you miss pills, start a new pack late, or take your pill at a different time of the day than usual.

Vomiting or diarrhea can prevent your birth control pills from working well. If you have vomiting or diarrhea, you may need to use a back-up birth control method (such as condoms, spermicide). Follow the directions in the Patient Information Leaflet and check with your doctor or pharmacist for more details.

Taking this medication after your evening meal or at bedtime may help if you have stomach upset or nausea with the medication. You may choose to take this medication at another time of day that is easier for you to remember. No matter what dosing schedule you use, it is very important that you take this medication at the same time each day, 24 hours apart. Ask your doctor or pharmacist if you have any questions.

Your pill pack contains 21 pills with active medication. It may also contain 7 reminder pills with no medication. Take one active pill (with hormones) once daily for 21 days in a row. If you are using a product with 28 tablets, take an inactive pill once daily for 7 days in a row after you have taken the last active pill unless otherwise directed by your doctor. If you are using a product with 21 tablets, do not take any tablets for 7 days unless otherwise directed by your doctor. You should have your period during the fourth week of the cycle. After you have taken the last inactive tablet in the pack or gone 7 days without taking an active tablet, start a new pack the next day whether or not you have your period. If you do not get your period, consult your doctor.

If this is the first time you are using this medication and you are not switching from another form of hormonal birth control (such as patch, other birth control pills), take the first tablet in the pack on the first Sunday following the beginning of your menstrual period or on the first day of your period. If your period begins on a Sunday, begin taking this medication on that day. For the first cycle of use only, use an additional form of non-hormonal birth control (such as condoms, spermicide) for the first 7 days to prevent pregnancy until the medication has enough time to work. If you start on the first day of your period, you do not need to use back-up birth control the first week.

Ask your doctor or pharmacist about how to switch from other forms of hormonal birth control (such as patch, other birth control pills) to this product. If any information is unclear, consult the Patient Information Leaflet or your doctor or pharmacist.

Common and Rare Side Effects for Elinest oral

COMMON side effects

If experienced, these tend to have a Severe expression i

Sorry, we have no data available. Please contact your doctor or pharmacist.

If experienced, these tend to have a Less Severe expression i

• water retention
• breast pain
• acne
• dizziness
• headache
• nausea
• abdominal bloating

INFREQUENT side effects

If experienced, these tend to have a Severe expression i

• excessive fat in the blood
• high blood pressure
• blood clot in a deep vein of the extremities

If experienced, these tend to have a Less Severe expression i

• altered interest in having sexual intercourse
• throat irritation
• bronchitis
• urinary tract infection
• enlarged breasts
• abnormally long or heavy periods
• increased sensitivity of the skin to the sun
• yellow-brown patches on skin
• weight gain
• weight loss
• vomiting
• stomach cramps
• abnormal glucose tolerance test results
• intense abdominal pain

RARE side effects

If experienced, these tend to have a Severe expression i

• benign hepatic cell adenoma, a type of liver tumor
• a breast tumor
• high amount of triglyceride in the blood
• hemolytic uremic syndrome, a condition that affects the kidney and the blood
• a clot in the small veins that carry blood to or from the retina of the eye
• clouding of the lens of the eye called cataracts
• sudden blindness and pain upon moving the eye
• a heart attack
• a clot in the lung
• abnormal bleeding in the brain resulting in damage to brain tissue, called a hemorrhagic stroke
• a stroke
• obstruction of a blood vessel by a blood clot
• a blood clot in an artery
• a blood clot in a vein of the liver
• a blood clot
• inflammation of the large intestine
• inflammation of the liver called hepatitis
• gallstones
• disease of the gallbladder
• a blockage of the bile duct that resulting in high bilirubin levels
• decreased kidney function
• an ovarian cyst
• unconsciousness
• trouble breathing
• a significant type of allergic reaction called anaphylaxis
• a type of allergic reaction called angioedema
• a hypersensitivity reaction to a drug
• generalized weakness
• pancreatitis
• cervical dysplasia, the development of abnormal cells in the cervix
• a liver tumor
• liver cell carcinoma
• focal nodular hyperplasia of liver, a type of liver tumor
• an acute blockage of the mesenteric vein
• a clot or thrombosis of the mesenteric artery of the intestines

If experienced, these tend to have a Less Severe expression i

• mood changes
• breastmilk production not associated with childbirth or nursing
• inflammation or infection of the vagina
• vaginal dryness
• pain with menstruation
• premenstrual syndrome
• itching
• hair loss
• hirsutism, a condition of hair growth on parts of the body normally without hair
• backache
• muscle spasm
• difficulty sleeping
• low energy
• a skin rash
• visible water retention
• fluid retention in the legs, feet, arms or hands
• changes in appetite
• diarrhea
• pelvic pain
• nervousness
• a decrease in how often a woman menstruates
• discharge of fluid from the cervix
• anxious feelings

Elinest Delivery Options, Uses, Warnings, and Side Effects

Elinest Delivery Options, Uses, Warnings, and Side Effects – Nurx.com

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Product details

Elinest is a once-daily combination oral contraceptive tablet containing the hormones progestin and estrogen. Elinest works to prevent pregnancy by preventing both ovulation and fertilization. Elinest prevents ovulation by inhibiting the release of an egg. Elinest also creates changes to the lining of the uterine wall to prevent a fertilized egg from attaching. Elinest thickens vaginal fluid to prevent sperm from penetrating an egg. Elinest may treat mild to moderate acne and over time, lessen the risk of developing ovarian cysts. Our team at Nurx™ can prescribe Elinest at special request or can offer the generic equivalent Cryselle for as low as $0 with insurance or as little as $15 without insurance.

FAQ

• How Is Elinest Used?

  Elinest comes in tablet form in a blister pack of 28 color-coded pills. The first 21 pills contain both estrogen and progestin and the remaining seven pills contain inert ingredients and are primarily there to keep you in the habit of taking a pill each day. Elinest is most effective when pills are taken in the correct order and no more than 24 hours apart. Elinest does not prevent or protect against HIV or other STIs.

• Is Elinest Easy to Get?

  Elinest is available at most pharmacies with a doctor’s prescription. Your insurance provider might cover part or all of the cost of Elinest, so check with your provider to see if your medication is covered.

• What Precautions Should I Take Before Starting Elinest?

  While oral contraceptives are generally safe, speak with your doctor if you have a history of blood clots, stroke, or heart attack, as this medication might increase your risk. Although allergic reactions are rare, seek medical attention if you experience allergy symptoms such as hives, difficulty breathing, or swelling of the face or tongue.

• Are There Any Known Side Effects?

  As with any medication, there may be a risk for minor side effects that typically dissipate over time. The most common side effects reported are nausea, vomiting, spotting, cramping, and headache. Nausea and vomiting can usually be avoided by taking your pill with a meal or at bedtime.

  More serious side effects are uncommon and include changes in appetite or mood as well as severe headache and dizziness. Alert your physician if your symptoms persist or are cause for concern.

• Will Elinest Interfere With Other Medications?

  If you are being treated for hepatitis C, some estrogen-based oral contraceptives may increase liver enzymes. Talk to your doctor to see if Elinest is right for you, or contact us here at Nurx to learn more about the mini-pill, a progestin-only oral contraceptive. Talk to your doctor about over-the-counter medications (acetaminophen) and supplements (St. John’s Wort) you’re taking, as oral contraceptives can be compromised when combined with some OTC and herbal medicines.

• Is Elinest Effective Birth Control?

  Yes, it is. When used correctly and consistently, Elinest is 99% effective in preventing pregnancy. Like other estrogen-based oral contraceptives, Elinest can reduce the length and heaviness of your period. Elinest contains progestin, which makes it an effective acne treatment by interfering with the production of pore-clogging sebum. Be sure to give the medication two to three months of consistent use to see clearer skin and a brighter complexion.

• Is Elinest a Combination Pill?

  Yes. Elinest is a monophasic contraceptive, which means each active tablet contains the same dose of both progestin and estrogen. These hormones work in combination to prevent ovulation and fertilization while clearing skin and reducing the risk of developing ovarian cysts. Elinest is optimally effective when taken consistently.

• How Does Nurx Work?

  Nurx is a free platform offering easy online access to doctors and seamless delivery of medications. No more time-consuming trips to the clinic and no more frantic pharmacy runs. We put you in control of your own health, empowering you to get the care you need, when you need it. From diagnosis to delivery of prescriptions, we make every part of getting healthy and staying healthy, better.

  For more information and to sign up, visit www.nurx.com and follow us @nurxapp on Twitter and Instagram.

We are doctors, nurses, nurse practitioners, pharmacists, and physician assistants who are passionate about providing patient care. The Nurx medical team believes that everyone deserves access to personalized, non-judgmental healthcare, and that open and honest communication is key.

Dr. Nancy Shannon

MD, PhD

How It Works

You Choose

Select your medication, or get guidance from our medical team. Answer a few questions and enter your insurance info (if you have coverage – if not, no problem)

We Prescribe

A Nurx provider in your state will review your request and write a prescription, if appropriate

Delivered Free

We deliver your medication directly to you. On time, in a discreet package, and with no added costs

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“Demand for Nurx’s services skyrocketed — order volume for emergency contraception, birth control, sexually transmitted infection tests grew 40%, 50% and 100%, respectively. Its total sales climbed 80% year-over-year in 2020”

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Best for: Anyone who hasn’t been tested for STIs in more than a year (or ever) and just wants a no-rush STI checkup.”

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Ethinyl Estradiol and Norgestrel | Memorial Sloan Kettering Cancer Center

This information from Lexicomp^® explains what you need to know about this medication, including what it’s used for, how to take it, its side effects, and when to call your healthcare provider.

Brand Names: US

Cryselle-28; Elinest; Low-Ogestrel; Ogestrel [DSC]

Warning

• Smoking cigarettes while using this drug raises the chance of severe heart and blood-related side effects. This chance is raised with age (mainly older than 35 years of age). It is also raised with the number of cigarettes smoked. It is strongly advised not to smoke. Do not use this drug if you smoke and are older than 35 years of age.

What is this drug used for?

• It is used to prevent pregnancy.
• It may be given to you for other reasons. Talk with the doctor.

What do I need to tell my doctor BEFORE I take this drug?

• If you are allergic to this drug; any part of this drug; or any other drugs, foods, or substances. Tell your doctor about the allergy and what signs you had.
• If you have had any of these health problems: Blood clots, blood clotting problem, breast cancer or other cancer where hormones make it grow, diseased blood vessels in the brain or heart, heart valve problems, heart disease, a certain type of abnormal heartbeat (atrial fibrillation), chest pain caused by angina, heart attack, stroke, high blood pressure, liver tumor or other liver problems, severe headache or migraine, or diabetes.
• If you have had any of these health problems: Endometrial cancer, cancer of the cervix or vagina, or vaginal bleeding where the cause is not known.
• If you turned yellow during pregnancy or with estrogen-based or hormone contraceptive use.
• If you are taking ombitasvir, paritaprevir, and ritonavir (with or without dasabuvir).
• If you are pregnant or may be pregnant. Do not take this drug if you are pregnant.
• If you are breast-feeding or plan to breast-feed.

This is not a list of all drugs or health problems that interact with this drug.

Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take this drug with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.

What are some things I need to know or do while I take this drug?

• Tell all of your health care providers that you take this drug. This includes your doctors, nurses, pharmacists, and dentists. This drug may need to be stopped before certain types of surgery as your doctor has told you. If this drug is stopped, your doctor will tell you when to start taking this drug again after your surgery or procedure.
• This drug may raise the chance of blood clots, a stroke, or a heart attack. Talk with the doctor.
• Talk with your doctor if you will need to be still for long periods of time like long trips, bedrest after surgery, or illness. Not moving for long periods may raise your chance of blood clots.
• If you have high blood sugar (diabetes), talk with your doctor. This drug may raise blood sugar.
• Check your blood sugar as you have been told by your doctor.
• High blood pressure has happened with drugs like this one. Have your blood pressure checked as you have been told by your doctor.
• Have blood work checked as you have been told by the doctor. Talk with the doctor.
• Be sure to have regular breast exams and gynecology check-ups. You will also need to do breast self-exams as you have been told.
• This drug may affect certain lab tests. Tell all of your health care providers and lab workers that you take this drug.
• Certain drugs, herbal products, or health problems could cause this drug to not work as well. Be sure your doctor knows about all of your drugs and health problems.
• This drug does not stop the spread of diseases like HIV or hepatitis that are passed through having sex. Do not have any kind of sex without using a latex or polyurethane condom. If you have questions, talk with your doctor.
• Do not use in children who have not had their first menstrual period.
• If you have any signs of pregnancy or if you have a positive pregnancy test, call your doctor right away.

What are some side effects that I need to call my doctor about right away?

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
• Signs of liver problems like dark urine, feeling tired, not hungry, upset stomach or stomach pain, light-colored stools, throwing up, or yellow skin or eyes.
• Signs of gallbladder problems like pain in the upper right belly area, right shoulder area, or between the shoulder blades; yellow skin or eyes; fever with chills; bloating; or very upset stomach or throwing up.
• Signs of high blood pressure like very bad headache or dizziness, passing out, or change in eyesight.
• Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight.
• Depression or other mood changes.
• Swelling.
• A lump in the breast, breast pain or soreness, or nipple discharge.
• Vaginal itching or discharge.
• Spotting or vaginal bleeding that is very bad or does not go away.
• Eyesight changes or loss, bulging eyes, or change in how contact lenses feel.
• Call your doctor right away if you have signs of a blood clot like chest pain or pressure; coughing up blood; shortness of breath; swelling, warmth, numbness, change of color, or pain in a leg or arm; or trouble speaking or swallowing.

What are some other side effects of this drug?

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Feeling dizzy, tired, or weak.
• More hungry.
• Weight gain or loss.
• Headache.
• Upset stomach.
• Stomach pain or cramps.
• Gas.
• Bloating.
• Enlarged breasts.
• Tender breasts.
• Feeling nervous and excitable.
• Pimples (acne).
• Period (menstrual) changes. These include spotting or bleeding between cycles.
• This drug may cause dark patches of skin on your face. Avoid sun, sunlamps, and tanning beds. Use sunscreen and wear clothing and eyewear that protects you from the sun.

These are not all of the side effects that may occur. If you have questions about side effects, call your doctor. Call your doctor for medical advice about side effects.

You may report side effects to your national health agency.

You may report side effects to the FDA at 1-800-332-1088. You may also report side effects at https://www.fda.gov/medwatch.

How is this drug best taken?

Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely.

• Take this drug at the same time of day.
• Take with or without food. Take with food if it causes an upset stomach.
• After starting this drug, you may need to use a non-hormone type of birth control like condoms to prevent pregnancy for some time. Follow what your doctor has told you to do about using a non-hormone type of birth control.
• Do not skip doses, even if you do not have sex very often.
• If you throw up or have diarrhea, this drug may not work as well to prevent pregnancy. Use an extra form of birth control, like condoms, until you check with your doctor.
• If you miss 2 periods in a row, take a pregnancy test before starting a new dosing cycle.
• If you also take colesevelam, take it at least 4 hours before or after you take this drug.

What do I do if I miss a dose?

• If a dose is missed, check the package insert or call the doctor to find out what to do. If using this drug to prevent pregnancy, another form of birth control may need to be used for some time to prevent pregnancy.

How do I store and/or throw out this drug?

• Store at room temperature protected from light. Store in a dry place. Do not store in a bathroom.
• Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
• Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.

General drug facts

• If your symptoms or health problems do not get better or if they become worse, call your doctor.
• Do not share your drugs with others and do not take anyone else’s drugs.
• Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
• Some drugs may have another patient information leaflet. Check with your pharmacist. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.
• If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

Consumer Information Use and Disclaimer

This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine. The use of this information is governed by the Lexicomp End User License Agreement, available at https://www.wolterskluwer.com/en/solutions/lexicomp/about/eula.

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Elinest Coupon – Birth Control Card

Elinest (Ethinyl Estradiol/Norgestimate) Dosing Information

Usual Adult Dose for Contraception:

Ethinyl estradiol-norgestimate products are packaged in 21 or 28 day dosage preparations. The last seven tablets in 28 day dosage preparations are hormonally inert.

Regardless of the number of tablets in a package, the cycle length for oral contraceptives is generally considered to be 28 days. (The first day of menstrual bleeding is counted as day 1.)

Initiation of Oral Contraceptive Therapy

This product can be administered in two ways.

When initiating a Sunday start regimen, the first tablet may be taken on the first Sunday after menstruation begins. If a period begins on a Sunday, the first tablet may be taken on that day. When initiating a Sunday start regimen, another contraceptive method should be used until after the first 7 consecutive days of administration. For a 28 day package, one tablet is taken daily for 28 days and a new package begun on the following day. For a 21 day package, one tablet is taken daily for 21 days followed by 7 days with no medication. A new package of contraceptives is begun on the following day.

When initiating a Day 1 start regimen, the first tablet is taken on the first day on menstruation. Such initiation may increase the risk of spotting and breakthrough bleeding but decrease the risk of early ovulation and pregnancy. For a 28 day package, one tablet is taken daily for 28 days and a new package begun on the following day. For a 21 day package, one tablet is taken daily for 21 days followed by 7 days with no medication. A new package of contraceptives is begun on the following day.

Many clinicians recommend that additional contraceptive methods be used during the first cycle of hormonal therapy in order to reduce the risk of unintended pregnancy.

Missed Doses

If a woman misses one dose of active tablets, the missed dose should be taken as soon as it is remembered and the normal schedule should be resumed.

If a woman misses two doses in week 1 or week 2 of the cycle, 2 tablets may be taken as soon as they are remembered and 2 tablets taken the next day and the normal schedule may be resumed. (Additional contraceptive methods should be used for 7 days.)

If a woman misses two doses in week 3 or three doses at any time in the cycle, Day 1 starters should discard the current package and begin a new package that same day. Sunday starters should take 1 tablet daily from the current package until Sunday, when the current package is discarded and a new package begun. (Additional contraceptive methods should be used until the woman has taken at least 7 days of hormonal therapy from the new package.)

Norgestrel: Uses, Interactions, Mechanism of Action

Birth Control Pill Reviews – The Best Birth Control Pills

Thanks to breakthroughs in science, there are more birth control types than ever to choose from, so it’s always a good idea to study up on all the pros and side effects of each to make a game plan with your doctor. Below, read our primer on the best birth control Pills for your needs, from options for clearer skin to ones that allow you to get your period just once a year 🙌. Plus, check out our guide on what to expect once you decide it’s time to stop using the Pill for good.

GET-YOUR-PERIOD-ONCE-A-YEAR PILLS

WHAT THEY ARE: Lybrel is the first FDA-approved no-period Pill to give you the same amount of synthetic estrogen and progestin every day so there’s no monthly “withdrawal bleed” (the period you get with regular Pills). Currently, it’s discontinued by the manufacturer, but is still sold in its generic form, Amethyst.

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The once-a-year-period Pills are ideal for women who experience cramping, heavy bleeding, or pain with their periods and/or for those who just think they’re a drag.

If you’re already taking monophasic Pills (which are all the same except for during your period week), you can build a do-it-yourself Lybrel by just skipping the placebos. One caveat: Insurance usually won’t cover the Pills, since it only funds one pack per month.

THE DOWNSIDE: Breakthrough bleeding. When you’re on other Pills, the lining of the uterus remains thin (that’s why Pill Periods are so light). On continuous hormones, the lining is even thinner and can become unstable and shed at random. Give it time: One study in the journal Contraception showed that 93.9 percent of women experienced bleeding in their first Pill pack, but by pack 13, that percentage had dropped to 21. “If you are flipped out by being surprised, don’t use this Pill,” says Yale University OB/GYN Dr. Mary Jane Minkin. Also, many women feel nauseated during the first few packs of these.

Without a period, will you know if you’re one of the 1 to 2 percent of women who get knocked up even with perfect use? Not unless you stay alert to other symptoms of pregnancy.

IS IT BAD FOR YOU? These Pills are still controversial, despite their FDA approval. Most doctors believe there’s no scientific reason you need to have a period every month. The Pill was designed to give you one so it would gain approval from the public and from religious leaders — and to reassure women that they weren’t pregnant. (When the Pill came on the market 48 years ago, there were no at-home pregnancy tests.) Detractors are concerned that the two big studies published so far followed women for only one year and that there’s still a possibility that the lining could build up and raise the risk of endometrial cancer. But Minkin notes that doctors have been prescribing constant-use birth-control pills “off label” for decades, with no known ill effects.

PMS-BE-GONE PILLS

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WHAT THEY ARE: Yaz is the only oral contraceptive allowed to state on the label that it’s approved for the prevention of premenstrual mood disturbances such as irritability, moodiness, bloating, fatigue, headaches, and muscle aches. (It’s the only one that has submitted the required studies to the FDA.) Many doctors think other oral contraceptives may also help with severe PMS (called PMDD), since they prevent hormonal swings.

THE DOWNSIDE: The Pill doesn’t counter PMS in everyone, and for some, PMS may get worse, says Minkin.

NO-BLOAT PILLS

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WHAT THEY ARE: Yaz and Yasmin use a new kind of progestin called drospirenone. (Actually, it’s a diuretic that acts as a progestin.) It eliminates sodium from your tissues, preventing the water retention that many women swear comes with other Pills. While it may prevent bloating, “it’s not a weight-loss pill,” says Northwestern University OB/GYN Dr. Lee Shulman. The difference between Yaz and Yasmin: Yaz contains fewer placebos (see “Pills for Shorter Periods,” next page) and slightly less estrogen.

THE DOWNSIDE: Drospirenone helps your body hold on to potassium, which is usually a good thing. But if you’re a heavy user of anti-inflammatories such as ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn) or if you have kidney, liver, or adrenal disease, extra potassium could cause serious heart and health problems.

NO-ACNE PILLS

Getty Images

WHAT THEY ARE: All contraceptives that contain both estrogen and progestin increase the amount of a molecule called sex-hormone-binding globulin, which acts like a sponge that mops up free testosterone. Less testosterone means less acne. Currently, only brands like Yaz, Estrostep, and Ortho Tri-Cyclen have received FDA approval for acne claims (because they’re the only ones that have submitted the clinical studies needed for FDA approval). But it’s likely other combination Pills will reduce it, too

THE DOWNSIDE: It’s theoretically possible that lower levels of free testosterone may result in lower libido. But so far studies fail to prove it. And many women feel a greater sex drive on any Pill since they’re no longer worried about getting pregnant.

PILLS FOR SHORTER PERIODS

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WHAT THEY ARE: All Pill packs used to contain 21 “active” Pills and seven placebos. Now, some—like Yaz and Loestrin 24 Fe—offer 24 days of hormones and four of placebos. That may mean shorter, lighter periods.These Pills may be more effective at preventing pregnancy for women who forget to take theirs on time. “With seven days of placebo, a certain percentage of women will start to get some development of follicles [which means a higher likelihood of producing an egg],” says Dr. Paula Hillard, OB/GYN professor at Stanford University. But having only four hormone-free days prevents that.These pills may also lower your risk of headaches and PMDD. Many women feel their worst—with bloating, headaches, and breast tenderness—during the hormone-free segment of the Pill pack. By being on hormones longer, you may suppress these symptoms.

THE DOWNSIDE: Yaz may cause high potassium levels, which aren’t healthy for your heart (see “No-Bloat Pills”).

PILLS FOR ESTROGEN-PHOBES

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WHAT THEY ARE: They’re not new, but women don’t always know about Pills (including Ortho Micronor, Ovrette, and Errin) that contain no estrogen, only progestin. Unlike combination estrogen-progestin pills, they don’t suppress ovulation—these just thicken the cervical mucus so it’s difficult for sperm to unite with an egg. They can cause breakthrough bleeding, especially if they’re not taken at the same time each day.

These Pills, often called “mini pills,” are best for nursing moms (estrogen impairs milk flow) and for people who shouldn’t take estrogen, such as those with high blood pressure, a risk of blood clots and strokes, or extreme migraines, or those over age 35 who smoke or are obese. The progestin-onlys also help lower LDL (bad) cholesterol and triglycerides. (The trade-off is that they lower “good” HDL too.)

THE DOWNSIDE: These may worsen acne, and they’re less reliable at preventing pregnancy than combination Pills.

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90,000 following The Lancet, the whole world started talking about “Sputnik-V”

One of the main news discussed by the media around the world is the Russian vaccine against the COVID-19 coronavirus “Sputnik-V”. Or rather, the publication about her in the authoritative international scientific journal The Lancet, which recognized the results of the first two stages of clinical trials as incredibly successful.

This publication has caused the strongest resonance! After it, the whole world is already talking about the Russian Sputnik-V vaccine! Moreover, in a positive way: arguing with the most authoritative international scientific journal The Lancet is at least stupid.

The American New York Times immediately started talking about the fact that Russian scientists have achieved incredible results: the vaccine gives only mild side effects. “In a small group of volunteers, scientists found that the vaccine produces moderate levels of antibodies against the coronavirus, while causing only mild side effects,” the newspaper writes.

The same aspect was noted by United Press International, recalling that Sputnik-V was tested by people of different age groups: “The British medical journal The Lancet published preliminary data showing that the Sputnik-V vaccine did not cause serious adverse effects in 76 adults who participated in drug trials. “

Bloomberg writes about the enormous potential of the Russian drug, which has already been tested by both physicians and volunteers. “According to experts, the Russian coronavirus vaccine has demonstrated its potential,” the agency said.

More restrained reaction to CNN. However, they did not dare to speak with sharp criticism and gave the floor to the editor-in-chief of The Lancet. “We can say that the results of trials of the new Russian vaccine are encouraging. But, of course, we need to wait until the full completion of the studies,” said Richard Horton, editor-in-chief of The Lancet.- To be absolutely sure that our conclusions are not premature. But now we can say that it works. Antibodies are produced, side effects are minimal. “

CNN Philippines also speaks about encouraging research results and theoretical advantages of the Russian vaccine over the rest. “The use of two adenoviral vectors gives the Russian vaccine a theoretical advantage. The studies are encouraging,” notes the author of the article, entitled “The Russian vaccine against COVID-19 has elicited an immune response.”

American The Daily Beast writes about Sputnik-V with cautious, but still optimistic. The publication draws attention to the one hundred percent result in the production of antibodies. “The potential Russian vaccine against COVID-19 provides a strong antibody response and does not appear to cause serious negative side effects,” the newspaper admits.

The Greek Ministry of Health is enthusiastic about the Russian drug. They are looking forward to the third round of vaccine trials.And the Greek University of Petri called it “very good.” “The Russian vaccine has a very good immune response, almost 100%,” said Charalambos Gogos, a member of the expert committee of the Greek Ministry of Health.

The media in the United Arab Emirates is full of joyful headlines: “Good news about the Russian vaccine – it works!”

The reaction from India was not long in coming.They do not hide their enthusiasm about the effectiveness and safety of the Russian drug. “Studies have shown that the Russian vaccine is safe, well tolerated and does not cause side effects in healthy adult volunteers,” the media noted.

And on the American SNBC they decided not only to cite the publication from The Lancet and express their opinion, but also to communicate directly with the head of the Russian Direct Investment Fund (RDIF) Kirill Dmitriev.

“The test results are very good,” said Kirill Dmitriev, head of the Russian Direct Investment Fund.- The vaccine helps the body to secrete antibodies, immunity reacts in one hundred percent of cases. We continue testing, we will cooperate with many countries. Including – the UAE, Saudi Arabia, the Philippines, India. Of course, our vaccine will be available not only in Russia, we are happy to share it with the world. “

For many countries, the Sputnik V vaccine is the main hope for victory in the fight against the virus. The number of people infected with COVID-19 in the world has exceeded 26.5 million. And the Russian drug “arrived” just in time, doctors say.

Scientists have recognized the side effects of the AstraZeneca vaccine

https://ria.ru/20210609/vaktsina-1736357943.html

Scientists have recognized the side effects of the AstraZeneca vaccine

Scientists have recognized the side effects of the AstraZeneca vaccine – RIA Novosti 5 09.06.2021 9000 recognized the side effects of the AstraZeneca vaccine

British scientists analyzed data on the well-being of two and a half million Scots who received the first dose of Oxford-AstraZeneca vaccines or… RIA Novosti, 09.06.2021

2021-06-09T20: 00

2021-06-09T20: 00

2021-06-09T20: 00

science

Scotland

astrazeneca

health

biology

vaccines

covid-19 coronavirus

astrazeneca vaccine

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MOSCOW, June 9 – RIA Novosti. British scientists analyzed data on the well-being of two and a half million Scots who received the first dose of Oxford-AstraZeneca or Pfizer-BioNTech vaccines. The results showed that some of those who received the AstraZeneca vaccine had mild bleeding disorders and related bleeding. Less commonly, there was a reverse reaction – increased thrombus formation. The authors did not find such side effects with the Pfizer vaccine.Published in the journal Nature Medicine, researchers led by Aziz Sheikh of the University of Edinburgh used anonymous linked data collected in real time from the EAVE II nationwide pandemic tracking and vaccine introduction project in Scotland for their analysis. includes more than 2.53 million Scottish adults who received their first dose of COVID-19 vaccine between December 2020 and April 2021 – about 57 percent of all Scottish adults.Over 1.7 million people received ChAdOx1 from AstraZeneca and about 800,000 received BNT162b2 from Pfizer. Results showed that both vaccines are generally well tolerated, but few reports of side effects related to blood clotting have been reported for AstraZeneca … In particular, the British Medical and Health Agency recorded 209 cases of thrombocytopenia (blood clotting disorders) and thromboembolism (thrombosis) in these patients after 22 million first and 6.8 million second doses of ChAdOx1 vaccine.The authors found that AstraZeneca vaccine was associated with a small increased risk of an autoimmune bleeding disorder known as primary immune thrombocytopenia or idiopathic thrombocytopenic purpura (ITP) and bleeding and other vascular disorders. All medical information for selected patients up to September 2019, including physician records of vaccinations, hospitalizations, death records and laboratory results, and compared with those of those who have not yet been vaccinated.Scientists have found that the incidence of side effects associated with bleeding disorders in those vaccinated with the AstraZeneca vaccine is 1.13 cases per 100 thousand people. The most common were open and internal bleeding in the form of small bruises, manifested up to 27 days after receiving the first dose, as well as rare cases of blood clots. People who are older or have chronic diseases such as coronary heart disease, diabetes, or chronic kidney disease tend to be at greatest risk.The authors note that these are in any case very small risks, comparable to those for other vaccines – against hepatitis B, measles, mumps and rubella, as well as influenza, and they are much lower than the risk of serious complications or death from COVID-19.

https://ria.ru/20210603/saturatsiya-1735480882.html

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scotland, astrazeneca, health, biology, vaccines, covid-19 coronavirus, astrazeneca vaccine

MOSCOW, June 9 – RIA Novosti. British scientists analyzed data on the well-being of two and a half million Scots who received the first dose of Oxford-AstraZeneca or Pfizer-BioNTech vaccines. The results showed that some of those who received the AstraZeneca vaccine had mild bleeding disorders and related bleeding.Less commonly, there was a reverse reaction – increased thrombus formation. The authors did not find such side effects with the Pfizer vaccine. Published in the journal Nature Medicine, researchers led by Aziz Sheikh of the University of Edinburgh used anonymous linked data collected in real time as part of EAVE II, a nationwide pandemic tracking and vaccine introduction project in Scotland.

A sample of more than 2.53 million Scottish adults who received their first dose of COVID-19 vaccine between December 2020 and April 2021 – about 57 percent of all Scottish adults.More than 1.7 million people received the ChAdOx1 vaccine from AstraZeneca, and about 800,000 received the BNT162b2 vaccine from Pfizer.

Results indicated that both vaccines were generally well tolerated, but there were few reports of coagulation-related side effects for AstraZeneca. In particular, the British Medical and Health Agency recorded 209 cases of thrombocytopenia (blood clotting disorders) and thromboembolism (thrombosis) in these patients after 22 million first and 6.8 million second doses of ChAdOx1 vaccine.

June 3, 5:32 p.m. Science Scientists explain why blood oxygen drops with COVID-19

Authors found that AstraZeneca vaccine is associated with a small increased risk of an autoimmune bleeding disorder known as primary immune thrombocytopenia, or idiopathic thrombocytopenic purpura (ITP) also bleeding and other vascular disorders.

To rule out the possibility of an individual predisposition to ITP and bleeding, the authors reviewed all medical information for selected patients for the period up to September 2019, including physician records of vaccinations, hospitalizations, death registrations and laboratory results, and also compared them with those of those who have not yet been vaccinated.

Scientists have found that the incidence of side effects associated with bleeding disorders in those vaccinated with the AstraZeneca vaccine is 1.13 cases per 100 thousand people. The most common were open and internal bleeding in the form of small bruises, manifested up to 27 days after receiving the first dose, as well as rare cases of blood clots. People who are older or have chronic diseases such as coronary heart disease, diabetes, or chronic kidney disease tend to be at greatest risk.

The authors note that these are in any case very small risks, comparable to those for other vaccines – against hepatitis B, measles, mumps and rubella, as well as influenza, and they are much lower than the risk of serious complications or death from COVID- 19.

June 1, 21:00 Science Scientists have proven that vitamin D does not help against coronavirus 90,000 Very long covid. Four versions of the origin of post-coronavirus syndrome (PCS) and its most dangerous consequences

• Nikolay Voronin
• Science Correspondent

May 31, 2021

Photo author, Getty Images

A few months after the official recovery -19 million people around the world are still unable to return to normal life.Some people do not have shortness of breath, increased fatigue, lack of smells and tastes. Others who have disappeared have had coronavirus symptoms suddenly reappearing after a few weeks – and sometimes new ones are added to them. In still others, covid even turns into a serious chronic disease, affecting almost any organs.

Scientists and doctors of different specialties are jointly trying to understand how and why in 10-15% of infected people the coronavirus develops into a “long covid” (doctors call it PCD – “post-covid syndrome”) – a disease that does not yet have a formal definition. no established name.In the United States, there are already calls to equate it with disability.

The BBC Russian Service tells which versions seem most plausible to scientists today, and tries to answer the question of what awaits patients, some of whom have not been able to recover for more than a year.

“This is a disaster”

Muscovite Polina T. was ill with Covid-19 last fall. In September, when the first mild symptoms appeared, she mistook them for a common cold and decided to lie down for a couple of days – but just in case she ordered a coronavirus test – and he tested positive.

Polina’s sense of smell disappeared the next day, after the diagnosis was made, when in the morning she “went to smell mustard and did not feel it.” But in general, according to her, “the disease proceeded very calmly – without high temperatures and any complications: I was just very weak, and my temperature was kept at about 37.2”.

The temperature did not subside for more than three weeks. During this time, Polina managed to pass the test twice: the first again showed the presence of the virus in her body, the second came already “clean”.Around the same time, the temperature returned to normal, but general weakness and increased fatigue dragged on after the official recovery for another month. The missing smells returned even later – by the New Year.

Polina decided that she had recovered completely, but her joy over this did not last long: literally a couple of weeks later, strange things began to happen again with her sense of smell. Habitual aromas began to turn one after another into an extremely unpleasant smell, which Polina herself describes as “a compost pit, such fermented rotten vegetables.”

At first, Bulgarian pepper began to smell like that, then other products – meat, poultry, cauliflower – became infected with the stench from it, but the most unpleasant thing happened when, with exactly the same disgust, a Muscovite began to perceive the smells of the human body – both her own and and someone else’s.

This continues to this day, and no improvements have been observed – although four months have passed since January, and the tests stopped determining the presence of the virus in Polina’s body in mid-October, that is, more than seven months ago.

The story of Polina is not the most common case, but it is far from unique. Smell impairment is one of the symptoms of “long covid”, now well known to doctors and described in detail in the scientific literature. It is unpleasant, of course, but not fatal – and there is even hope for a complete cure.

However, it also happens that after “recovering” from Covid-19, a patient is left with a whole bunch of symptoms that fall under the description of ACL. For example, Ashley Nicole, a 35-year-old attorney from Alberta, described her condition.

“This morning I woke up for the 255th time with a blinding headache: the picture blurred before my eyes, so that almost nothing is visible. It was as if they had pushed broken glass down my throat, and my chest was twisted so that I could catch my breath …”

The tweet was published in December last year, although Ashley suffered the coronavirus back in March, at the very beginning of the epidemic, and was officially cured back in April 2020. Only now the symptoms of the disease have not gone anywhere to this day – except that they have slightly weakened.

In addition to fatigue (one of the most common symptoms), Ashley has lost almost all of her hair in the 14 months since the onset of her illness; the skin on the hands became hypersensitive, as after a burn, and the nails were loosened and darkened.

All these are quite rare, but also occurring symptoms of “long covid”, which manifest themselves in different patients very individually and differ in surprising variety.

“The real problem”

The UK National Institutes of Health proposes to consider post-covid syndrome “ signs and symptoms that appear during or after an infection that fits into the clinical picture of Covid-19, and last more than 12 weeks if they cannot be explained by another, alternative diagnosis . “

The WHO has been trying to compile a list of such “signs and symptoms” for several months, but it is much more complicated than it might seem at first glance.

Photo author, Getty Images

Since Covid-19 is transmitted mainly by airborne droplets, we are used to considering it a respiratory disease: entering the body through the nose or mouth, the virus infects the upper respiratory tract, and then “descends” into the lungs.

This means that long-term complications of Covid-19 can manifest themselves almost anywhere.

“PCS affects a variety of organs, so this is clearly an interdisciplinary problem,” agrees Maria Van Kerkhov, WHO’s chief technical officer for the fight against the Covid-19 pandemic. According to Maria, over the past year, she has met with many patients who complained of a very protracted illness and asked the WHO to at least publicly admit that the ACL is real – that the syndrome really exists, and is not a figment of the imagination of the patients themselves.

And on this issue, the position of WHO is unambiguous.“We know that this is a real problem,” Van Kerkhov assured the BBC correspondent. “We know that ACL affects a wide variety of organs. so that any person, wherever in the world he is, can get the help he needs. ”

So far, according to Maria Van Kerkhs, one thing is quite clear: “This is actually a dangerous virus […] Even if a person suffered from covid relatively easily and recovered from the disease itself rather quickly, it can have extremely unpleasant long-term consequences.” …

Three long covid months

Statistics confirm her words. According to the UK’s National Statistical Office, nearly one in seven patients with a confirmed Covid-19 diagnosis have symptoms of coronavirus stretching for at least three months.

Given that by March of this year, the number of confirmed cases of infection worldwide exceeded 110 million, it can be assumed that today, to one degree or another, at least about 15 million people may experience signs and symptoms of “long covid”.

Photo by Getty Images

Given the problems with counting and testing for the virus in different countries and at different stages of the pandemic, this figure could be higher. In the UK alone, by the end of February this year, almost 500,000 people complained that they had not been able to get rid of their ACD symptoms for at least six months. But this half a million, by definition, does not include the patients of the second wave, which began in the country in October.

Francis Collins, head of the US National Institutes of Health, speaking in Congress at the end of April, estimated the number of Americans in whom Covid-19 has already provoked chronic health problems at 3 million.”This is such a huge problem for the health of the nation that it is difficult to overestimate it,” he said.

At the same time, experts pay special attention to an interesting fact: the overwhelming majority of patients who develop post-covid syndrome (90%) did not have concomitant chronic diseases that usually complicate the infection before infection, and suffered Covid-19 itself in a relatively mild form – and even if they went to a doctor, they did not need hospitalization. So they never expected that in a couple of months the virus would remind of itself again.

Basically, for several months the symptoms of Covid-19 are delayed in relatively young patients (the average age of people with signs of ACS is 40 years), and there are much more women among them than men (70-80%).

Fog in the head

So what are these symptoms – is there even a rough list of them? Yes and no. Most of the authoritative studies that have been validated by the scientific community are not large enough and describe at best a hundred patients with ACD.

The largest study in this area to date is an Internet survey conducted last fall by British and American scientists in conjunction with a group of activists from among the coronavirus patients themselves. It was attended by almost 3800 people who listed a total of 205 different manifestations of the disease. A third of these symptoms, according to those surveyed, haunted them for at least six months.

The format of the Internet survey itself assumes a rather distorted sample.And the perception by patients of their own symptoms, of course, is inferior in reliability to laboratory tests. Therefore, the results of such studies should be treated with caution.

Nevertheless, the results of the survey can give some general idea about the well-being of patients, as well as about when and in what combination certain symptoms appear and how long they persist.

Most survey respondents listed a bunch of symptoms, but the most debilitating long-term manifestations of the disease were usually severe breathlessness, incredible fatigue and post-exertional malaise or brain fog …

The authors of the study pay special attention to the syndrome of increased fatigue. Most of the observed patient respondents experienced incredible weakness, barely allowing to get out of bed.

Six months after infection, three quarters of those who remained symptomatic (i.e. developed PCD) continued to complain of a catastrophic lack of energy. Up to the point where even the simplest household chores – for example, getting dressed, having breakfast or going to the toilet – are exhausting enough to require a good rest.

“You feel as if you were just hit by a truck and left to die on the side of the road – so not a word to say , “, – one of the “long covid” patients Shannon Riley describes her feelings.

Many patients described problems with concentration and inability to hold attention, difficulty in solving simple problems or making decisions. These problems started from the first week of illness and increased over the course of three months.Only after this does the condition begin to improve, however, even after six months, if the symptoms do not go away completely, about every second survey participant complains of blurred consciousness to one degree or another.

Further everywhere

At the same time, scientists are absolutely sure that, in addition to fatigue, breathing problems and impaired cognitive functions, ACS can give a lot of other side effects – sometimes completely unexpected.

For example, if in the spring of last year we learned that one of the characteristic symptoms of Covid-19 is a temporary loss of smell (anosmia), now patients who have already had coronavirus are increasingly experiencing disruption of the normal functioning of the olfactory receptors (parosmia) – when the most The usual things suddenly start to smell like sewers, rotten fish or burnt plastic.

This is the diagnosis that Muscovite Polina T. should have been diagnosed with in January: “When I came to the doctor with a complaint about distorted odors, he told me that this is a very popular treatment related to covid, and that most likely it will go away by itself.” …

Professor Nirwal Kumar, head of the British Association of ENT Physicians, also assured journalists that parosmia is a reversible disorder of the sense of smell, which sooner or later goes away on its own, although this process can be accelerated with the help of special therapy.

In April, Academician of the Russian Academy of Sciences Alexander Chuchalin, head of the Russian Respiratory Society, said that doctors began to often diagnose the so-called “postcoid myocarditis” in patients with ACD. According to him, along with the lungs, the main attack of the virus falls on the heart muscle.

Photo author, Getty Images

In addition, Chuchalin said, Covid-19 can provoke fibrosis (that is, scarring) not only of the lungs, but also of any organ to which the virus has reached.This happens when the patient’s immune system stops coping with the infection and begins to actually “brick” the virus, converting the working cells of the liver, kidneys, pancreas, spleen, or other organs into connective tissue.

It has also been proven that the virus sometimes causes blood clotting disorders and increases the risk of thrombosis. In the long term, this can cause very unexpected symptoms in some patients. In particular, medical journals describe cases of loosening of teeth and hair loss in coronavirus patients: according to doctors, changes in blood vessels could lead to impaired blood circulation in the gums or around hair follicles in patients.

Four theories and cautious optimism

However, Covid-19 is by no means the first and certainly not the only disease that causes such unpleasant and such varied long-term consequences, says Amy Proal, head of research at the PolyBio Research Foundation, which specializes in on the study of autoimmune diseases.

In an interview with the BBC, Dr. Proal listed four possible causes of the “long covid”.

First: during the acute phase of the disease, coronavirus severely damages any organ – for example, due to the aforementioned fibrosis.When the acute phase passes, the affected organ cannot always restore its functions in full, that is, in fact, Covid-19 provokes a chronic disease not directly related to the virus .

Second: Despite the fact that PCR tests cannot detect the virus, it does not leave the patient’s body completely, but remains in one or another organ (“reservoir”) – for example, in the liver tissue or in the central nervous system. In this case, it is the presence of the virus itself that can cause chronic symptoms , since it interferes with the normal functioning of the organ.Such cases have been described in patients who have “recovered” from the Zika or Ebola viruses.

Third: coronavirus Sars-Cov-2 disrupts from childhood the inherent settings of the body’s immune system and knocks down the signals of interferon proteins , which restrain other viruses constantly living in our body, as a result of which these other viruses are activated and begin to actively multiply . For example, according to Dr. Proal, during the pandemic there have already been several studies proving the reactivation of herpes viruses in coronavirus patients.

“You and I are not sterile: trillions of microorganisms – bacteria and viruses live in our body,” she explains. under control, causing some kind of chronic symptoms. Such cases [in covid patients] have also been documented in several studies at once. ”

Finally, fourth a possible reason is due to genetics, when, as a result of a coincidence, the coronavirus actually comes into conflict with the patient’s DNA, turning Covid-19 into a chronic autoimmune disease .This happens when one of the proteins produced in the patient’s body turns out to be similar in shape and size to the protein of the virus itself. This phenomenon is known as “molecular mimicry”, and even if the composition of the two protein molecules has almost nothing in common, such an overlap may be sufficient. An aggressive immune response to infection triggered by the body will inevitably destroy the patient’s own cells, which produce the proteins he needs.

All of the above explanations, says Dr. Proal, are not mutually exclusive and can occur in a particular patient with ACL in any combination.

Amy Proal pauses for a long time before answering the question of whether patients who have had unpleasant symptoms for more than a year should wait for a complete recovery.

“I think … I think the patients will get better,” she finally replies. “Yes, I’m optimistic.”

90,000 Side effects of the COVID-19 vaccine on eyesight

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Diseases

Fear of side effects, including possible vision problems, is considered the main reason , people still hesitate to get vaccinated.However, there is still no evidence that the most common side effects of vaccines are related to vision.

At the same time, it is worth noting that at least one case of a side effect related to vision has been reported in the United States: an eye edema was observed in a healthcare worker vaccinated against the COVID-19 coronavirus infection. Local safety organizations are investigating this side effect, as well as other rare allergic reactions that can develop with the coronavirus vaccine produced by Pfizer and BioNTech.Other side effects are characterized by WHO as “predominantly mild to moderate in severity.”

In the vaccinated participants, the most common side effects were:

• Pain, swelling and redness at the injection site.

• Systemic symptoms such as fatigue, muscle pain, chills, joint pain and fever.

• Other symptoms such as headache and nausea.

Similar side effects have been reported with the Moderna vaccine against COVID-19 infection, according to a WHO report.

Ophthalmologists respond to COVID-19

In many parts of the world, ophthalmologists and ophthalmic medical personnel are identified as a high priority group for vaccination.

The UK Board of Optometrists recommendation states: “Ophthalmic workforce, defined as frontline health and social workers, is the second high priority group in the vaccination program.”

When available, early vaccination will protect ophthalmic healthcare providers and their patients by slowing or stopping transmission of the virus during clinical practice.

US ophthalmologists are also actively involved in the fight against COVID-19.

Dr. William Culbertson, Professor of Ophthalmology, Institute of Eye Diseases. Bascoma Palmer in Miami, USA, shared with the Ophthalmology Times that ophthalmologists and institute staff began vaccinating on December 15, 2020.

“Although we are not frontline medical professionals, we all see patients in person with slit lamp examinations and eye surgery.As such, we are all at significant risk until we get vaccinated, ”says Culbertson.

In addition, another ophthalmologist at the Beth Israel Deaconess Medical Center (Boston, USA), Dr. Jorge Arroyo, took part in a clinical trial of the Moderna vaccine against COVID-19 coronavirus infection. In addition, it was the Chinese ophthalmologist who in December 2019 warned the whole world about the so-called coronavirus infection COVID-19; as a result, the disease led to his death.

Eye problems in children with COVID-19

Although COVID-19 vaccines do not cause serious vision problems, researchers have found eye problems in some children with the condition. One study found that a quarter of children treated for COVID-19 at a Chinese hospital in January, February and March 2020 had mild eye problems. These problems included eye discharge associated with conjunctivitis (“pink eye”), rubbed eye, eye pain, and eyelid swelling.

Research data are limited. The researchers studied the disease in only 216 pediatric patients.

Eye problems associated with other vaccines

While COVID-19 vaccines have not yet caused alarming vision-related side effects, vaccines for a number of other diseases have caused eye and vision problems. Below is a short list of these problems:

Seasonal influenza vaccine

In rare cases, some patients who received the influenza vaccine have experienced general reactions that generally affect the body and manifest themselves as fever, malaise, headache. pain.

Most important fact

While various vaccines can cause mostly mild eye side effects, there is no scientific evidence that COVID-19 vaccines cause eye side effects …

READ MORE: Delta COVID Strain and Your Eyes: What We Know

Page published in Feb 2021

Page updated September 2021

90,000 Side effects after vaccination were observed in 71 people – Nurmat Atabekov – Gazeta.uz

In Uzbekistan, since the beginning of vaccination of the population, side effects have been identified in 71 vaccinated persons, Deputy Head of the Sanitary and Epidemiological Welfare and Public Health Service Nurmat Atabekov said at a briefing on Wednesday.

According to him, 45.7% of the vaccinated had an increase in temperature (above 37.5 degrees), 21.2% of citizens felt mild pain in the body, in 14.1% of cases – itching at the injection site, 11, 2% – pain at the injection site, another 2.7% of them complained of “nervousness, weakness, fear”.”Not a single person who received the vaccine had serious side effects,” said Nurmat Atabekov.

He also said that as of April 6, a total of 49602 citizens were vaccinated in Uzbekistan, 29860 of them were vaccinated with the AstraZeneca vaccine, the rest 19,742 with the Chinese-Uzbek vaccine ZF-UZ-VAC2001.

Data on vaccination of the population by region / Ministry of Health.

The Deputy Head of the Sanepid Service also confirmed that the coronavirus is still more common among young people.For example, on April 6, 206 cases were registered, of which 54 accounted for young people under 19 (26.2%), he said. This figure differs from the statistics of the Ministry of Health, according to which 192 cases were detected on Tuesday.

On April 1, the process of vaccination of the population against coronavirus began in Uzbekistan. As we already wrote, at the first stage, citizens over 65 years old and medical workers at risk of COVID-19 infection will receive the vaccine free of charge. For now, citizens can choose between the AstraZeneca vaccine and the Sino-Uzbek ZF-UZ-VAC2001 vaccine.

Recall that vaccination coverage of the population will expand gradually: April – Tashkent, Nukus and regional centers, May – other cities and regional centers, from June – all vaccination points in all regions. In the country, 3138 vaccination points and 862 mobile teams have been created (for more details, the addresses of the vaccination points). By the end of June, it is planned to vaccinate more than 4 million people from risk groups against coronavirus.

90,000 Opioid Side Effects and Control – Pro Palliative

Contents

Opioid Toxicity

Opiate Tolerance

Conclusion

Opioids, like all drugs, have side effects.They cause some inconvenience, but they are not dangerous. Among them: constipation, drowsiness, nausea, dry mouth. An excerpt from the book “Introduction to Palliative Care” by the British doctor Bruce Cleminson on how to deal with the side effects of opioid drugs. The full version of the book is available here.

Obstipation

There are usually several reasons for constipation in patients with incurable diseases: inactivity, changes in diet, medications.Taking morphine will aggravate the situation, since it interacts with μ-receptors in the gastrointestinal tract and reduces peristalsis in the same way as loperamide. Therefore, prescribe a laxative when prescribing an opioid drug. According to the results of randomized placebo-controlled trials of cancer patients, it is best to start with stimulant laxatives, gradually increasing their dose until it is sufficiently effective. If normal, regular bowel movements cannot be achieved within 3-4 days, you can start taking softening drugs.

Drowsiness

Drowsiness is usually a temporary problem. It usually lasts 2-3 days after starting
doses or increasing the dose. It is important to warn the patient and his family about this side effect, as they may refuse to take the medication if they do not know that this is a temporary phenomenon. Part of the drowsiness may be due to the patient’s accumulated fatigue. The pain could prevent the patient from fully resting, and after its elimination, the patient needs time to sleep and recuperate.

Nausea

Nausea often occurs in patients who have started taking weak or strong opiates
for the first time. As with other side effects, it is important to warn the patient about the possibility of nausea in advance, and if it occurs, prescribe an antiemetic drug for regular use. Opioid nausea tends to go away after about a week, so be sure to stop taking antiemetics after a few days.

Dry mouth

This side effect is common and easily remedied by continually moisturizing the mouth with small sips of water.

Opioid toxicity

CNS toxicity

Mild CNS intoxication is the first signal of opioid poisoning. It is important to identify mild intoxication in time in order to prevent the development of severe damage to the central nervous system.

The first signals are usually too colorful dreams and clonic convulsions.These
symptoms are so mild that it does not occur to the patient to tell the doctor or nurse about them. Therefore, it is important to regularly ask the patient about the presence of such manifestations. Patients often describe a mild form of myoclonus, saying that they have begun to drop things. If, as a clinician, you suspect opioid poisoning, check to see if the patient has an infection, dehydration, or kidney failure. All these conditions can provoke intoxication. Ask the patient to drink more.

Introduction to Palliative Care Book Basic Information on the Key Aspects of Palliative Care

Pain relief can be another cause of intoxication. For example, as a result of palliative radiation therapy for tumor lesions of the bones, pain is reduced. As the pain decreases, the dose of opiates that the patient receives becomes too large – signs of toxicity appear. The dose of narcotic analgesics should be reduced and the problem will be resolved. If there is no obvious cause of toxicity that can be influenced, reduce the dose of the drug and prescribe additional adjuvant therapy to reduce toxicity, but leave the analgesic effect at the same level.If you can use other opioids such as fentanyl or buprenorphine, you should switch to another drug. If you have transferred a patient to another opioid due to toxicity, always reduce the dose when switching.

On the other hand, if the patient’s symptoms are mild, then you can not change the treatment regimen,
but carefully observe the patient’s condition. To give an example: I had a patient with local metastatic skin cancer that covered almost the entire scalp.The pain was very difficult to control.

When we achieved the greatest possible pain relief, the patient developed myoclonic seizures. After discussing the situation with the patient, he expressed a desire to take painkillers in the same dose and put up with the presence of myoclonus. My colleagues and I monitored his condition closely to watch for new symptoms of opioid toxicity, but his condition did not change over the next several months.

Another example that shows that sometimes additional therapy should be prescribed to
reduce the symptoms of opioid intoxication, even if they are mild.A patient with a pain syndrome that was difficult to treat, developed mild hallucinations at the moment when the pain syndrome had just been arrested. After discussing the situation with the patient, I gave him a small dose of haloperidol, leaving the opiates unchanged.

Drowsiness and slurred speech

Taking opioids can be accompanied by drowsiness and slurred speech, sometimes there is a pronounced myoclonus without respiratory depression. This level of intoxication is not dangerous, but requires measures to be taken to prevent increased intoxication.It is necessary to reduce the dosage of opioids for basic analgesia and additional injections to relieve breakthrough pain by 1 / 3-1 / 2, prescribe plenty of fluids or subcutaneous administration of fluids (saline), then assess the causes of intoxication, as described above.

Respiratory depression

Respiratory depression is one of the most significant medical fears when prescribing opioids. However, respiratory depression is a sign of advanced intoxication, and it is preceded by other symptoms of toxic damage to the body.Thus, respiratory depression is rare in palliative medicine, since the selection of the dose of opioids occurs gradually and with caution, the patient’s condition is regularly assessed for the first signs of CNS damage.

Respiratory depression is thus rarely a side effect of opioid use. If, nevertheless, the patient’s respiratory rate has decreased to 12–8 per minute, then the opioid dose should be reduced by 1/3 1/2; you should consider canceling the next scheduled administration of the drug; prescribe a heavy drink or the introduction of saline solution subcutaneously.

The patient should not be prescribed an opioid antagonist in such a situation because the patient’s life is not at risk. If an antagonist is introduced in such a situation, then the patient will develop acute uncontrolled pain, which will not be able to be relieved for several hours until the antagonist’s action ends.

If the respiratory rate is more than 8 per minute, the patient is in a coma (unconscious) and / or cyanosis of the skin is observed:

1) Immediately inject 100-200 mcg of naloxone intravenously;
2) then give 100 μg IV every 2 minutes until respiratory function returns to normal.

If the overdose is associated with long-acting opioids such as MCTs or transdermal opioids, “the duration of the opioid will be longer than the duration of the naloxone. Therefore, there may be a need for further intravenous injections of naloxone for 24 hours, and sometimes longer. ”

Addiction

Simple ways to reduce chronic pain Algologist Andrey Danilov on how sleep, positive emotions and meditation affect the perception of pain

Addiction is another fear that often appears in doctors and patients.Robert Twycross did interesting research in this area in the early 1970s while working on his doctoral dissertation. He found that patients taking morphine during treatment did not show 90,480 signs of addiction. Moreover, after palliative pain-relieving treatments such as radiation therapy or nerve blockade, the opiate dose may be gradually reduced until completely withdrawn.

However, if the use of opioids was suddenly interrupted, then physical ailments may occur
from abrupt withdrawal of the drug: diarrhea and anxiety, since the body is used to the constant use of opioids and it takes time to adapt to their absence.If the drug is withdrawn gradually, there is no withdrawal syndrome.

Tolerance to opiates

This concept implies that the effect of the same dose decreases over time. When morphine is used in patients with incurable diseases, the phenomenon of tolerance that develops over time is not of great importance. Research by Dr. Robert Twycross has shown that tolerance does not usually develop. It is for this reason that the average opioid dose in a patient 6 months after starting is only slightly higher than the average dose that the patient received after 3 months of administration.

As can be seen from the graph in Fig. 5, dose increases from 12 to 24 weeks are significantly less than in the first 12 weeks. Robert Twycross was able to prove that people suffering from cancer pain can stay on a fixed dose of an opioid for up to 1 year without having to increase the dose. In rare cases, there is a decrease in the analgesic effect and the need to increase the dosage of morphine in order to remain at the same effective level of pain relief.

Medium doses of diamorphine used at 1, 5, 3, 6, 12 and 24 weeks after the start of analgesic therapy.The graph shows that addiction does not occur and a sharp increase in dose is not required with careful use of the opioid (R. Twycross)

Usually, an increase in dosage is associated with the progression of the disease. True drug tolerance is extremely rare, in which case opioid change is the best solution.

Double effect: “I don’t want to kill my patients!”

“Patients deserve to be anesthetized” Oncologist Anton Usov on why doctors are afraid of opioid prescription, imperfections in medical education and legislation

The idea of ​​a “double effect” is that a doctor, using strong analgesics to eliminate pain, can shorten the patient’s life.In fact, there is no evidence for such a theory. In fact, by relieving pain, you help the patient not to be exhausted by it and improve their quality of life. Thanks to this, the patient’s life may even be longer. The quality of life is much more important than the duration; Again, it has not been proven that the use of strong analgesics by all the rules shortens the patient’s life.

Example

A patient was dying of pancreatic cancer and received 400 mg MCT twice a day to eliminate
pain, which is a fairly large dose.He took this dose of morphine for several weeks. On the night before his death, he independently, without outside help, was able to reach the living room. He enjoyed watching TV: an international rugby match, and then wrestling, then he went to bed. The next day he no longer regained consciousness and died by noon.

Conclusion

Opioids are an extremely important group of drugs for relieving pain in the terminal period of cancer
. The correct use of opioids – following the principles outlined in this chapter – can significantly improve the quality of life for patients and their families.

Scientists have recognized the side effects of the AstraZeneca vaccine: June 10, 2021, 16:23

Scientists from the UK have recognized the side effects of the British-Swedish company AstraZeneca’s coronavirus vaccine, Tengrinews.kz reports with reference to Nature Medicine.

A team of specialists analyzed data on the well-being of two and a half million Scots, vaccinated with the first dose of the drug against the coronavirus AstraZeneca or Pfizer / BioNTech. More than 1.7 million people have received the vaccine from AstraZeneca and about 800,000 from Pfizer.

Some patients who received the AstraZeneca vaccine experienced mild bleeding disorders and related bleeding. Less commonly, there was a reverse reaction – increased thrombus formation. At the same time, no such side effects were found with Pfizer.

Researchers found that the incidence of side effects associated with bleeding disorders in those who received the AstraZeneca vaccine was 1.13 cases per 100 thousand people. At the same time, scientists led by Aziz Sheikh from the University of Edinburgh came to the conclusion that both vaccines are generally well tolerated.

As a reminder, Denmark is the first country to completely abandon the AstraZeneca vaccine. In March, several European countries suspended the use of the drug due to the increased incidence of thrombosis after vaccination. So, after vaccination with the drug from AstraZeneca in Austria, a patient died.

Then vaccination was suspended in Canada, Germany, Italy, Latvia, Iceland, France, Spain, Indonesia, Slovenia, the Netherlands, Ireland and a number of other countries. However, later vaccination in a number of countries was resumed on the recommendations of the EMA and WHO.Against the backdrop of these events, the AstraZeneca vaccine received a new name. The Ministry of Health answered whether Kazakhstan will buy this vaccine, since Russia plans to produce it for export.

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