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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Menachem Weiner, MD
Reliance on brain-damaged patients to delineate systems can be tricky because lesions may not indicate site of damage erectile dysfunction treatment time order tadapox 80mg visa, and many aphasics are stroke patients with a fairly wide area of damage erectile dysfunction treatment clinics 80mg tadapox sale. Difficulties in detecting the features of sound erectile dysfunction medications causes symptoms cheap 80 mg tadapox with amex, such as how long a vowel versus a consonant sound might resonate statistics of erectile dysfunction in us tadapox 80 mg mastercard, can result in higher level language disturbance. One theory of autism considers the idea that autistic people may not be tuned in to the frequency of human speech, but instead have a propensity for lower frequency environmental sounds such as those made by machines. If human speech is an aversive and even fear-producing noise, then there would be a withdrawal from the sound of human speech. Many difficulties can emerge if the primary building blocks of sound detection and recognition are not intact. The auditory system contains mechanical receptors designed to detect sound frequency. These hairlike receptors are located in the fluid of the long, coiled, snail-like cochlea of the inner ear. As the mechanical mechanisms of the middle ear respond to external sound waves, they cause vibrations in the fluid of the inner ear, thus vibrating the hairs of the auditory receptors. The auditory nerve from each ear projects ipsilaterally to the cochlear nuclei of the medulla. From there, each pathway branches to project auditory information to both the ipsilateral and contralateral superior olivary nuclei of the medulla. In this way, the auditory system differs from the visual system in that each hemisphere receives input from both ears, resulting in bilateral representation of sound. The auditory pathways then course through the lower brainstem and ascend through the thalamus, where they are projected to the primary auditory cortex (Figure 8. The primary auditory cortex of each hemisphere lies deep within the temporal lobe, largely on the medial aspect of the superior temporal gyrus, within the valley of the lateral fissure. This cortical area processes the "fragments" of sound, much as the visual system processes individual visual stimuli. The primary auditory cortex is organized into frequencyspecific bands that parallel the layout of auditory frequency ranges mapped on the cochlea (see Figure 8. In this way, a tonotopic map projects onto the auditory cortex, similar to the retinotopic map of the visual system. Because the cortical bands can respond to multiple frequencies, there is no strict one-to-one correspondence; rather, some bands are more attuned to certain frequencies than others. In addition to frequency, the features of sound include loudness, timbre, duration, and change. Vowels have a slightly different frequency from consonants, and different consonants are differentiated from each other. Learning a language, as anyone who has tried to master a second language knows, involves much more than being able to understand and articulate words in a spoken fashion. Language also requires putting meaning to word fragments (morphemes), words, and groups of words (semantics). This requires learning information regarding subjectverb agreement (for example, "girls run"), how to use articles and propositions (for example, the, to , but, if, and), and how to put strings of words together to make meaningful sentences. The secondary auditory processing area serves to connect sound from the primary auditory areas to word meaning stored in the cortex. Additional cortical processing areas are required to integrate the comprehension of individual words into grammatically correct phrases and sentences, and to link spoken words with the written symbols of language necessary for reading comprehension. These higher association areas serve to bring together visual and spatial information from the occipital and parietal lobes with auditory information. The angular gyrus plays a role in reading comprehension by matching words and word sounds (phonemes such as the sound of /ba/) to written symbols of language (graphemes such as b). Damage to the left hemisphere auditory processing areas results in the partial or total inability to decipher spoken words. Conversely, right hemisphere damage has the opposite effect: the patient accepts words at face value but loses the nuances of jokes and emotional intention. Another hallmark of right hemisphere damage is impaired harmonic and melodic ability. As an example of a problem with recognition of environmental sounds, one patient with a right hemisphere auditory processing deficit repeatedly had to have starters replaced in her car. Speech understanding, therefore, conveys word analysis, as well as emotional intentions, through tone of voice, pitch, intensity, and rhythm. The inferior frontal gyrus is a premotor area of the frontal lobes, and thus is concerned with aspects of speech planning before output coordinated by the nearby motor strip. This is possible because the arcuate fasciculus permits reciprocal interaction between the two areas (Yeterian & Van Hoesen, 1978). This interaction also makes logical sense, because syntax depends on the words used and the words selected also depend on the emerging syntax of the sentence (Bradshaw & Mattingly, 1995). The basal ganglia and the thalamus have also been implicated in language functioning via their participation in a cortico-striato-pallido-thalamo-cortical loop (see Crosson, 1992). This loop, or perhaps set of loops, connects the language centers of the cortex to the putamen and caudate nucleus of the striatum, to the globus pallidus, to specific nuclei in the thalamus, and back to the cortical language centers. The current thinking regarding the function of these loops is that they play a role in regulating language; this role involves initiating language production more than constructing speech content (Crosson, 1992). This means that the left cerebral cortex preferentially processes speech sounds, whereas the right processes nonspeech sounds. Not surprisingly, the functional dominance of the left hemisphere for speech corresponds to preferential treatment for speech sound processing in the larger planum temporale of the left hemisphere. Although sound from each ear projects bilaterally, there is an opposite hemisphere advantage; in this case, the left hemisphere preferentially processes sound from the right ear. Because the left hemisphere shows a preference for analyzing speech in most people, speech sounds processed through the right ear will be understood faster and more accurately than speech sounds processed through the left ear. The left hemisphere also has a propensity for rhythm of both speech and music as it codes for the sequence of sounds. To check your left hemisphere dominance for rhythm, try keeping a metronome-like beat with your left hand and beat out the rhythm of a familiar tune, such as Jingle Bells, with your right hand. Most people find this easy if their left hemisphere, which controls their right hand, is dominant for rhythm. After doing this, try reversing what each hand is doing (right keeps the beat, and left taps out the rhythm) and see if you have more or less difficulty. The secondary auditory cortex of the right hemisphere, by contrast, is specific for aspects of tonality, including the melody of music and the intonation of speech, which is commonly referred to as speech prosody. The right hemisphere is adept at recognizing the relation between simultaneous sounds, such as the harmony of chords, or the musical interval between notes. It also shows an advantage for recognizing nonspeech or environmental sounds such as those made by machines and cars, as well as animals, birds, the pounding ocean surf, or a babbling creek. The left hemisphere specializes in processing word sounds, or morphemes; semantics; and the grammatical rules of language. The right hemisphere, long thought to be "mute," plays a role in the emotional intention of both vocalization and understanding. The right hemisphere may have no speech or understanding of grammatical rules; however, a number of people, and more women than men, have some bilateral representation of speech. The right hemisphere is nonetheless capable of considerable comprehension and expression. Although frank aphasia is rare after right hemisphere strokes, there can be linguistic impairments. These include a deficit in comprehending tone and voice, producing similar emotional tone, and understanding metaphors and jokes. We once examined a male adult patient who had undergone a complete left hemispherectomy. The supramarginal gyrus and the angular gyrus of the parietal lobes are also important to integrating verbal aspects of language with the visual symbolic components involved in reading. Subcortical neural connections, including portions of the basal ganglia and the thalamus, also play a role in language. It may impair the power to speak, write, read, gesture, or to comprehend spoken, written, or gestured language.
Nevertheless erectile dysfunction causes heart order tadapox 80 mg online, preparations for Case Griin (that is erectile dysfunction and diabetes type 1 buy 80mg tadapox mastercard, the plan against Czechoslovakia) will have to be carried out energetically; they will have to be newly prepared on the basis of the changed strategic position because of the annexation of ~ u s t r i a erectile dysfunction shots order 80 mg tadapox with visa. On 28 May 1938 Hitler ordered that preparations should be made for military action against Czechoslovakia by the 2nd October erectile dysfunction doctors in maine quality tadapox 80 mg, and from then onwards the plan to invade Czechoslovakia was constantly under review. On 30 May 1938 a directive signed by Hitler declared his "unalterable decision to smash Czechoslovakia by military action in the near future". Special agents were to be trained beforehand to prevent sabotage, and these agents were to be notified "before the attack in due time. At the beginni~g, guerrilla or partisan warfare is to be expected, therefore weapons are necessary. The plan provided for the temporary division of the country into larger and smaller territorial units, and considered various "suggestions", as they were termed, for t h. The final "suggestion" included the whole country, together with Slovakia and Carpathian Russia, with a population of nearly 15 millions. The plan was modified in some respects in September after the Munich Conference, but the fact the plan existed in such exact detail and was couched in such war-like language indicated a calculated design to resort to force. On 31 August 1938 Hitler approved a memorandum by Jodl dated 24 August 1938, concerning the timing of the order for the invasion of Czechoslovakia and the question of defense measures. In the month of September 1938 the conferences and talks with military leaders continued. I n view of the extraordinarily critical situation which had arisen, the British Prime Minister, Mr. The "piece of paper" which the British Prime Minister brought back to London, signed by himself and Hitler, expressed the hope that for the future Britain and Germany might live without war. On 21 October 1938 a directive was issued by Hitler, and countersigned by the Defendant Keitel, to the Armed Forces on their future tasks, which stated: "Liquidation of the remainder of Czechoslovakia. It must be possible to smash a t any time the remainder of Czechoslovakia if her policy should become hostile towards Germany. The proposal was made to Hacha that if he would sign a n agreement consenting to the incorporation of the Czech people in the German Reich a t once, Bohemia and Moravia would be saved from destruction. He was informed that German troops had already received orders to march and that any resistance would be broken with physical force. The Defendant Goring added the threat that he would destroy Prague completdy from the air. Faced by this dreadful alternative, Hacha and his Foreign Minister put their signatures to the necessary agreement a t 4:30 in the morning, and Hitler and Ribbentrop signed on behalf of Germany. On 15 March German troops occupied Bohemia and Moravia, and on 16 March the German decree was issued incorporating Bohemia and Moravia into the Reich as a protectorate, and this decree was signed by the Defendants Von Ribbentrop and Frick. The time had now come for the German leaders to consider further acts of aggression, made more possible of "attainment because of that accomplishment. Hitler announced his decision to attack Poland and gave his reasons, and discussed the effect the decision might have on other countries. I n point of time, this was the second of the important meetings to which reference has already been made, and in order to appreciate the full significance of what was said and done, it is necessary to state shortly some of the main events in the history of German-Polish relations. As long ago as the year 1925 a n Arbitration Treaty between Germany and Poland had been made at Locarno, providing for the settlement of all disputes between the two countries. On 26 January 1934, a ~ e r m a n - p o l i s h declaration of non-aggression was made, signed on behalf of the German Government by the Defendant Von Neurath. On 30 January 1934, and again on 30 January 1937 Hitler made speeches in the Reichstag in which he expressed his view that Poland and Germany could work together in harmony and peace. On- 20 February 1938 Hitler made a third speech in the Reichstag in the course of which he said with regard to Poland. Relying on her friendships, Germany will not leave a stone unturned to save that ideal which provides the foundation for the task which is ahead of us - peace. Preparations are also to be made to enable the Free State 01Danzig to be occupied by German, troops by surprise. I t is interesting to note in this connection, that one of the arguments frequently presented by the Defense in the present case is that the Defendants were induced-to think that their conduct was not in breach of international law by the acquiescence of other Powers. The declarations of Great Britain and France showed, at least, that this view could be held no longer. The aim is then to destroy Polish military strength, and to create in the East a situation which satisfies the requirements of defense. The Free State of Danzig will be incorporated into Germany a t the outbre,ak of the conflict a t the latest. Policy aims a t limiting the war to Poland, and this is considered possible in view of the internal crisis in France, and British restraint as a result of this. The intention to attack on the part of Germany which was merely invented by the international press. The purpose of the meeting was to enable Hitler to inform the heads of the Armed Forces and their staffs of his views on the political situation and his future aims. After analyzing the political situation and reviewing the course of events since 1933, Hitler announced his decision to attack Poland. He admitted that the quarrel with Poland over Danzig was not the reason for this attack, but the necessity for Germany to enlarge her living space and secure,her food supplies. This is impossible without invasion of foreign States or attacks upon foreign property. If, therefore, the isolation of Poland could not be achieved, Hitler was of the opinion that Germany should attack Great Britain and France first, or at any rate should concentrate primarily on the war in the West, in order to defeat Great Britain and France quickly, 03at least to destroy their effectiveness. Nevertheless, Hitler stressed that war with England and France would be a life and death struggle, which might last a long time, and that preparations must be made accordingly. During the weeks which followed this conference, other meetings were held and directives wpre issued in preparation for the war. The Defendant Von Ribbentrop was sent to Moscow to negotiate a non-aggression pact with the Soviet Union. On 22 August 1939 there took place the important meeting of that day, to which reference has already been made. The Prosecution have put in evidence two unsigned captured documents which appear to be records made of this meeting by persons who were present. I had already made this decision in the spring, but I thought that I would first turn against the West in a few years, and only afterwards against the East. I wanted to establish an acceptable relationship with Poland in order to fight first against the West. But this plan, which was agreeable to me, could not be- executed since essential points have changed. It became clear to me that Poland would attack us in case of a conflict with the West. I am only afraid that at the last moment some Schweinehund will make a proposal for mediation. This latter document consists of a summary of the same speech, compiled on the day it was made, by one Admiral Boehm, from notes he had taken during. It also contains a statement by Hitler that an appropriate propaganda reason for invading Poland would be given, the truth or falsehood of whi& was unimportant, since "the Right lies in Victory". The second unsigned document put in evidence by the Prosecution is headed: "Second Speech by the Fiihrer on 22 August 1939", and is in the form of notes of the main points made by Hitler. Some of these are as follows: "Everybody shall have to make a point of it that we were determined from the beginning to fight the Western Powers. Even if war should break out in the West, the destruction of Poland shall be the primary objective. I shall give a propagandist cause for starting the war never mind whether it be plausible or not. They also show that although he hoped to be able to avoid having to fight Great Britain and France as well, he fully realized there was a risk of this happening, but it was a risk which he was determined to take. On 22 August 1939, the same day as the speech just referred to , the British Prime Minister wrote a letter to Hitler, in which he said: "Having thus made our position perfectly clear, I wish to repeat to you my conviction that war between our two peoples would be the greatest calamity that could occur. Only after a change of spirit on the part of the responsible Powers can there be any real change in the relationship between England and Germany. These were from President Roosevelt on 24 and 25 August; from his Holiness the Pope on 24 and 31 August; and from M.
As much as possible popular erectile dysfunction drugs buy 80 mg tadapox amex, all children with disabilities are to be educated in the regular education environment erectile dysfunction treatment options articles purchase 80 mg tadapox free shipping. In order to remain eligible for federal funds erectile dysfunction pills not working generic tadapox 80 mg, states must ensure that children with disabilities receive a complete individual evaluation and assessment of their specific needs erectile dysfunction 5k order 80mg tadapox with visa. Those receiving special education have the right to receive the related services, which may include transportation, speech pathology and audiology, psychological services, physical and occupational therapy, recreation (including therapeutic recreation), rehabilitation counseling, and medical services for diagnostic or evaluation purposes. Parents have the right to participate in all decisions related to identification, evaluation and placement of their child with a disability. Early intervention is an effective way to help children with disabilities and those who are experiencing developmental delays catch up or address specific developmental concerns as soon as possible in their lives. If you believe your infant or toddler can benefit from early intervention services, you can make a referral yourself or have your hospital or doctor refer your young child. The state is responsible for implementing early intervention programs for infants and toddlers. Call your state agency and explain that you want to find out about early intervention services for your child. Ask for the name of the office, a contact person, and the phone number in your area where you can find out more about the program and have your child screened for a disability or delay. Even though you know that your child has paralysis, he or she will still need to be screened so that necessary services will be identified. Services for Preschoolers with Disabilities: Ages 3 through 5 Services for preschool children (ages 3 through 5) are provided free of charge through the public school system. If your child was receiving Early Intervention services and is still eligible, he or she will transition over to services for preschool, ages 3-5. Another way for very young children to become identified is through the local Child Find office; each state must have comprehensive systems to identify, locate, and evaluate children with disabilities residing in the state and who are in need of special education and related services. Your pediatrician or rehabilitation hospital may suggest that you contact the appropriate agency to have your child screened and/or evaluated to determine if he or she qualifies for services. The school system has 60 days to complete the assessments-the quicker you make a referral, the faster your child can return to school. If your child qualifies for services, an Individualized Education Program will be drafted and the specific services, goals, objectives and accommodations will be outlined. For many students with disabilities, the key to success in the classroom lies in having appropriate adaptations, accommodations, and modifications made to the instruction and other classroom activities. Examples of related services are: physical and occupational therapy, school health services, and rehabilitation counseling. Supplementary aids and services might include an aide, a note taker, or other assistive technology. By planning the transition process, your teen will be prepared to move onto the next phase of their life with supports in place. Practically every school district and postsecondary school in the United States is subject to one or both of these laws. Some of the requirements that apply through high school are different from those that apply beyond high school. Unlike high school, however, a postsecondary school is not required to provide free services. Rather, a postsecondary school is required to provide appropriate academic adjustments as necessary to ensure that it does not discriminate on the basis of disability. If a postsecondary school provides housing to nondisabled students, it must provide comparable, convenient, and accessible housing to students with disabilities at the same cost. If you want a postsecondary school to provide an academic adjustment, you must identify yourself as having a disability; your postsecondary school is not required to identify you as having a disability or to assess your needs. Academic adjustments may include auxiliary aids and services, as well as modifications to academic requirements as necessary to ensure equal educational opportunity. A postsecondary school does not have to provide personal attendants, individually prescribed devices, readers for personal use or study, or other devices or services of a personal nature, such as tutoring and typing. You may contact that person for information about how to address any concerns about discrimination. To learn more about the complaint process, call toll-free 1-800-421-3481 or see It develops and disseminates fact sheets, website directories, newsletters, and resource materials. We also mourn our own losses: We feel isolated; we have no personal time; we feel exhausted, overwhelmed. A caregiver must deal with medical concerns, hygiene, transportation, financial planning, advocacy, and end-of-life issues. Being an effective caregiver means gaining some sense of control over the situation. One way this is done is through information, and by sharing experiences or solving problems with other caregivers. Please know that you are not alone, that you are extremely valuable, and that you and your family can lead active, fulfilling lives despite the challenges of paralysis. Caregiving can be a satisfying experience; it demonstrates fulfillment of a commitment to a loved one. It seems to choose us, emerging from events and circumstances outside our expectations, beyond our control. Family members provide the vast majority of care for people who are chronically ill or disabled. According to the Caregiver Action Network, family caregivers underpin our healthcare system in a profound way. Paralysis Resource Guide 340 10 Caregiving is a job that cannot be skirted and cannot always be delegated. While caring for loved ones can be enormously satisfying, there are days, to be sure, that offer little reward. Caregivers suffer far more depression, stress and anxiety than the general population. Surveys show that up to 70 percent of caregivers report depression, 51 percent sleeplessness, and 41 percent back problems. Nearly three quarters of family caregivers do not go to the doctor as often as they should, and 55 percent say they skip doctor appointments; 63 percent of caregivers report having poor eating habits. Caregivers feel isolated; they often report that their lives are not "normal" and that no one else can possibly understand what they are going through. Families helping a person with a disability in daily living activities spend more than twice as much on out-of-pocket medical expenses than families without a disabled person. Frequently the caregiver must make sacrifices at work to attend to duties at home. You learn to deal with the frustration while learning how to best get the job done. The lessons are often learned the hard way-for the most part, caregivers learn by trial and error how to manage daily routines for food preparation, hygiene, transportation and other activities at home. Here are a few caregiving tips compiled by Paralysis Resource Center Information Specialists: Rule number one for all caregivers is to take care of yourself. Providing care while holding down a job, running a household, or parenting can burn anyone out. A person who is exhausted or sick is more likely to make bad decisions or take out frustrations inappropriately. The more you keep your own well-being in balance, the more you will enhance your coping skills and stamina. By taking care of yourself, you will be better able, both physically and emotionally, to provide care for your loved one. Share and learn and benefit from the collective wisdom of the caregiver community. It is important that caregivers connect with one another to gain strength and to know that they are not alone. For many, the isolation that comes with the job is eased by attending support group meetings with others in similar situations. Support groups provide emotional support and caregiving tips, as well as information on community resources.
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Syndromes
Results from the higher dosage group are representative of the results expected with the recommended dosage [see Dosage and Administration (2 b12 injections erectile dysfunction purchase tadapox 80mg on-line. There are limitations to the interpretability of the placebo data due to the small sample size erectile dysfunction pills new tadapox 80 mg line. Note: Patients with missing values at Week 52 or who were randomized to receive reinduction or maintenance treatment due to disease flare were considered non-responders for Week 52 endpoints erectile dysfunction medicine with no side effects discount tadapox 80 mg with mastercard. A total of 347 stable responders participated in a withdrawal and retreatment evaluation in an open-label extension study erectile dysfunction drug stores buy cheap tadapox 80mg line. During the withdrawal period, no subject experienced transformation to either pustular or erythrodermic psoriasis. All patients received a standardized dose of prednisone 60 mg/day at study entry followed by a mandatory taper schedule, with complete corticosteroid discontinuation by Week 15. Patients subsequently underwent a mandatory taper schedule, with complete corticosteroid discontinuation by Week 19. Patients received either placebo or 20 mg adalimumab (if < 30 kg) or 40 mg adalimumab (if 30 kg) every other week in combination with a dose of methotrexate. Concomitant dosages of corticosteroids were permitted at study entry followed by a mandatory reduction in topical corticosteroids within 3 months. The criteria determining treatment failure were worsening or sustained non-improvement in ocular inflammation, or worsening of ocular co-morbidities. Each dose tray consists of a single-dose pen, containing a 1 mL prefilled glass syringe with a fixed Ѕ inch needle, providing 40 mg/0. Each dose tray consists of a single-dose pen, containing a 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 80 mg/0. Each dose tray consists of a single-dose pen, containing a 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 40 mg/0. One dose tray consists of a single-dose pen, containing a 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 80 mg/0. The other two dose trays each consist of a single-dose pen, containing a 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 40 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 40 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed Ѕ inch needle, providing 20 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 20 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed Ѕ inch needle, providing 10 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 10 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 80 mg/0. Each dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed Ѕ inch needle, providing 40 mg/0. One dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 80 mg/0. The other dose tray consists of a single-dose, 1 mL prefilled glass syringe with a fixed thin wall, Ѕ inch needle, providing 40 mg/0. Instruct patients of the importance of contacting their doctor if they develop any symptoms of infection, including tuberculosis, invasive fungal infections, and reactivation of hepatitis B virus infections [see Warnings and Precautions (5. Other Medical Conditions Advise patients to report any signs of new or worsening medical conditions such as congestive heart failure, neurological disease, autoimmune disorders, or cytopenias. Advise patients to report any symptoms suggestive of a cytopenia such as bruising, bleeding, or persistent fever [see Warnings and Precautions (5. Instructions on Injection Technique Inform patients that the first injection is to be performed under the supervision of a qualified health care professional. Instruct patients not to dispose of loose needles and syringes or Pen in their household trash. Instruct patients that when their sharps disposal container is almost full, they will need to follow their community guidelines for the correct way to dispose of their sharps disposal container. Instruct patients that there may be state or local laws regarding disposal of used needles and syringes. Instruct patients not to dispose of their used sharps disposal container in their household trash unless their community guidelines permit this. This Medication Guide does not take the place of talking with your doctor about your medical condition or treatment. Ask your doctor if you do not know if you have lived in an area where these infections are common. Tell your doctor about all the medicines you take, including prescription and over-thecounter medicines, vitamins, and herbal supplements. Keep a list of your medicines with you to show your doctor and pharmacist each time you get a new medicine. Tell your doctor if you have any of the following symptoms of a possible hepatitis B infection: muscle aches clay-colored bowel movements feel very tired fever dark urine chills skin or eyes look yellow stomach discomfort little or no appetite skin rash vomiting Allergic reactions. Call your doctor or get medical help right away if you have any of these symptoms of a serious allergic reaction: o hives swelling of your face, eyes, lips or mouth o trouble breathing Nervous system problems. Signs and symptoms of a nervous system problem include: numbness or tingling, problems with your vision, weakness in your arms or legs, and dizziness. Your body may not make enough of the blood cells that help fight infections or help to stop bleeding. Symptoms include a fever that does not go away, bruising or bleeding very easily, or looking very pale. Symptoms include chest discomfort or pain that does not go away, shortness of breath, joint pain, or a rash on your cheeks or arms that gets worse in the sun. Call your doctor right away if you have any of these symptoms: o feel very tired o skin or eyes look yellow o poor appetite or vomiting o pain on the right side of your stomach (abdomen) Psoriasis. Tell your doctor if you develop red scaly patches or raised bumps that are filled with pus. Call your doctor or get medical care right away if you develop any of the above symptoms. Call your doctor right away if you have pain, redness or swelling around the injection site that does not go away within a few days or gets worse. Tell your doctor if you have any side effect that bothers you or that does not go away. Do not remove the gray cap (Cap #1) or the plumcolored cap (Cap #2) until right before your injection. Do not remove the gray cap (Cap #1) or the plum-colored cap (Cap #2) while allowing it to reach room temperature. Make sure the amount of liquid in the Pen is at the fill line or close to the fill line seen through the window. Check the solution through the windows on the side of the Pen to make sure the liquid is clear and colorless. Choose an injection site on: · the front of your thighs or · your lower abdomen (belly). If you choose your abdomen, do not use the area 2 inches around your belly button (navel). Do not remove the gray cap (Cap # 1) or the plum-colored cap (Cap # 2) until right before your injection. Hold the middle of the Pen (gray body) with one hand so that you are not touching the gray cap (Cap # 1) or the plum-colored cap (Cap # 2). With your other hand, pull the gray cap (Cap # 1) straight off (do not twist the cap). Make sure the small needle cover of the syringe has come off with the gray cap (Cap # 1). Remove the plum-colored cap (Cap # 2) from the bottom of the Pen by pulling it straight off (do not twist the cap). The plum-colored activator button: · Turn the Pen so the plum-colored activator button is pointed up. Pressing the plum-colored activator button will release the medicine from the Pen. Position the Pen: · Squeeze the area of the cleaned skin and hold it firmly until the injection is complete.