Topamax

Joseph F. Golob MD

• Resident in Surgery, Case Western Reserve University School of Medicine,
• Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio

The Service believes allowing activities to occur earlier could be advantageous medicine and technology buy topamax 100 mg line, as it will increase the likelihood that Industry will be able to meet its annual goals and reduce pressure to achieve those goals as November 30 draws closer top medicine discount topamax 100 mg without prescription. Because any such variance medicine for constipation topamax 200 mg order free shipping, or other action treatment 6th february topamax 100 mg order with visa, requires a real-time assessment of walrus densities, weather conditions, and potential changes in conditions, which in turn, are based on actual ice dynamics, the Service does not believe a list of potential exceptions will be beneficial to the regulated public. Comment 37: the proposed rule imposes a 3,000-ft height restriction on helicopters within 1 mile of walrus groups observed on land. Response: this mitigation measure has been in effect for the last 3 years, but was not described in the previous rule. This mitigation measure is necessary to protect coastal haulouts, and text has been added to this final regulation to further explain this measure. For example, a Service law enforcement agent, wildlife biologist, or regulatory specialist may be designated to monitor a situation depending upon the circumstances. Given the significant expense, logistics, and technology required to conduct oil and gas exploration in the Chukchi Sea, the Service fails to see how the additional presence of a monitor will be burdensome. Comment 42: In light of the knowledge gained in the past 5 years, the Service should reconsider which mitigation measures and monitoring requirements are absolutely necessary. Response: the Service evaluated the request for this rule based on the best available scientific evidence. The Service utilized knowledge gained in the last 5 years, as well as that gained well beyond the past five years. The standard by which the Service must make a determination is not ``which mitigation measures and monitoring requirements are absolutely necessary,' as stated by the commenter. As new information is developed, through monitoring, reporting, or research, the regulations may be modified, in whole or part, after notice and opportunity for public review. Response: the Service considered the availability and feasibility (economic and technological) of equipment, methods, and manner of conducting proposed activities or other means of effecting the least practicable adverse impact upon the affected species or stocks, their habitat, and on their availability for subsistence uses. It is a potentially useful technology, but has not yet been widely adopted in the Chukchi Sea due to technical limitations. Comment 44: the Service should reconsider the requirement to monitor for aggregations of walruses within 160 dB isopleth because it requires very large observation zones that are both highly questionable given a sciencebased risk assessment and impractical to implement with confidence. Response: We agree; however, the intent of this mitigation measure is to detect animals before they venture into the 180 dB isopleth where temporary or permanent threshold shifts may occur. This approach does not reflect the best available science, and the choice of threshold is not sufficiently conservative. Response: There are no sound pressure level studies specific to walruses of which we are aware. However, data are available for three arctic seal species, and our use of thresholds is consistent with that data. Comment 46: the Service cannot rationally defend its conclusion that proposed seismic surveys will harm no more than small numbers of marine mammals and will have no more than negligible impacts on those species or stocks. The Service should consider an alternative that examines whether takes occur at sound thresholds lower than 160 dB. Response: the 160 dB threshold is the only acoustic threshold that has been described for pinnipeds, predominantly for seals, and our use of these thresholds for walruses is consistent with that data. Damage to hearing has not been demonstrated at 160 dB, and the 160 dB isopleth defines the area in which operators must begin to take measures (ramp down, shut down) to avoid hearing loss in walruses (which presumably occurs at 180 dB) similar to other pinnipeds. Comment 47: Pre-booming requirements for fuel transfer during seismic survey operations is not possible and should be removed as a requirement. Response: the Service acknowledges that pre-booming for moving vessels, such as during a seismic survey operation, is not possible. In addition, they should not have others duties on the vessel that may create a conflict of interest. This is a stipulation from a different Federal agency that could potentially benefit our trust species by minimizing impacts in the environment. Comment 48: the Service needs to provide a template in regards to the raw data requirement for collecting and transmitting marine mammal data. Response: the Service worked with Industry to create such a template, and this template is already in use by several operators and their consultants in the Chukchi Sea. If new types of data are collected, the Service will work with Industry to develop an appropriate updated template. Comment 49: the Service should more precisely (spatially and temporally) tailor coastal exclusion zones to protect subsistence activities where and when they occur.

These types of encounters will most likely be associated with support activities in the coastal environments near walrus coastal haulouts medicine and technology order 200 mg topamax free shipping. Disturbance events could result in trampling injuries or cow-calf separations medicine zantac topamax 100 mg buy overnight delivery, both of which are potentially fatal medications 2016 buy topamax 200 mg overnight delivery. Calves and young animals at the perimeter of the herds appear particularly vulnerable to trampling injuries medicine woman strain topamax 100 mg buy otc. Mortalities from trampling are most severe when large numbers of walruses resting on land are disturbed and flee en masse to the ocean. In 2007, more than 3,000 calves died along the Chukotka coast due to stampedes caused by humans and polar bears. Since then, mortalities in the Russian Federation and the United States have been fewer than 700 per year. Areas where and when walrus coastal haulouts form in the United States will be protected with additional mitigation measures, such as activity exclusion zones, airspace restrictions, and close monitoring. The effect of Industry activities on benthic invertebrates most likely would be from oil discharged into the environment. Oil has the potential to impact walrus prey species in a variety of ways including, but not limited to , mortality due to smothering or toxicity, perturbations in the composition of the benthic community, and altered metabolic and growth rates. The low likelihood of an oil spill large enough to affect prey populations (see analysis in the section titled Potential Impacts of Waste Product Discharge and Oil Spills on Pacific Walruses and Polar Bears, Pacific Walrus subsection) indicates that Industry activities will likely have limited effects on walruses through effects on prey species. Evaluation of Anticipated Effects on Walruses Based on our review of the activities; existing operating conditions and mitigation measures; information on the biology, ecology, and habitat use patterns of walruses in the Chukchi Sea; information on potential effects of oil and gas activities on walruses; and the results of previous monitoring efforts associated with Industry activity in the Chukchi as well as the Beaufort Sea, we conclude that, while the incidental take (by harassment) of walruses is reasonably likely to or reasonably expected to occur as a result of the activities, the anticipated takes will be limited to minor behavioral modifications due to temporary, nonlethal disturbances. Our review of the nature and scope of the activities, when considered in light of the observed impacts of past exploration activities by Industry, indicates that it is unlikely that there will be any lethal take of walruses associated with these activities or any impacts on survival or reproduction. Polar Bears In the Chukchi Sea, polar bears will have a limited presence during the open-water season associated with Industry operations. This is because most bears move with the ice to the northern portion of the Chukchi Sea and distribute along the pack ice during this time, which is outside of the geographic region of the final regulations. Additionally, they are found more frequently along the Chukotka coastline in the Russian Federation. This limits the probability of major impacts on polar bears from offshore Industry activities in the Alaskan portion of the Chukchi Sea. Although polar bears have been observed in open water, miles from the ice edge or ice floes, this has been a relatively rare occurrence. Polar bears will be present in the region of activity in limited numbers and, therefore, oil and gas activities could affect polar bears in various ways during both offshore and onshore activities, through: (1) Impacts from offshore activities; (2) impacts from onshore activities; (3) impacts from human encounters; (4) effects on prey species; and (5) effects on polar bear habitat are described below. Offshore Activities In the open-water season, Industry activities will be limited to vessel-based exploration activities, such as exploratory drilling and seismic surveys. These activities avoid ice floes and the multi-year ice edge; however, they could contact a limited number of bears in open water and on ice floes. Seismic ships, icebreakers, or the drilling rig may become physical obstructions to polar bear movements, although these impacts will be short-term and localized. Likewise, noise, sights, and smells produced by exploration activities could disrupt their natural behavior by repelling or attracting bears to human activities. If bears are present, noise produced by offshore activities could elicit several different responses in individual polar bears. Noise may act as a deterrent to bears entering the area of operation, or the noise could potentially attract curious bears. In general, little is known about the potential for seismic survey sounds to cause auditory impairment or other physical effects in polar bears. Researchers have studied the hearing sensitivity of polar bears to understand how noise can affect polar bears, but additional research is necessary to understand the potential negative effects of noise (Nachtigall et al. Available data suggest that such effects, if they occur at all, would be limited to short distances from the sound source and probably to projects involving large airgun arrays. Polar bears swim predominantly with their heads above the surface, where underwater noises are weak or undetectable, and this behavior may naturally limit noise exposure to polar bears. There is no evidence that airgun pulses can cause serious injury or death to bears, even in the case of large airgun arrays. Additionally, the planned monitoring and mitigation measures include shutdowns of the airguns, which would reduce any such effects that might otherwise occur if polar bears are observed in the ensonification zones.

It can also be used with other keys for special functions treatment 3rd degree burns buy topamax 100 mg line, please check Windows Help medicine 44175 topamax 200 mg order otc. As you slide your finger across the touchpad medicine technology cheap topamax 200 mg buy on-line, the cursor will follow this movement treatment skin cancer topamax 100 mg buy overnight delivery. Many applications support precision touchpad gestures that use one or more fingers, however, some gestures may not be supported by the specific application or program you are using. Touchpad gestures Single-finger slide Slide a finger across the touchpad to move the cursor. Two-finger slide Swiftly scroll through web pages, documents and playlists by placing two fingers on the touchpad and moving both in any direction. Two-finger pinch Zoom in and out of photos, maps and documents with a simple finger-and-thumb gesture. Using the Precision Touchpad - 17 Three-finger press Lightly tap the touchpad with three fingers to open Cortana (if your computer supports Cortana) or open the Search Windows (if your computer does not support Cortana). Move the cursor over a window and tap the touchpad to select that window, or swipe downwards to exit Task View. Four-finger press Lightly tap the touchpad with four fingers to open the Action Center. The precision touchpad includes added technology features that help recognize and prevent unintentional gestures such as accidental taps, gestures, and pointer movement. Note the touchpad is sensitive to finger movement; the lighter the touch, the better the response. In the icon tray in the lower right-hand corner of the screen, select the Notifications icon to open the Notifications pane. If you cannot access Acer Care Center, click Settings in the Start menu, select Update & Security and then click Recovery. Important We recommend that you create a Factory Default Backup as soon as possible. Creating a factory default backup Recovery Management allows you to quickly and easily back up your operating system, installed apps and data. Select the Backup tab and click Get Started for Create Factory Default Backup to open the Recovery Drive window. After creating the recovery backup, you can choose to delete the recovery information on your computer. Recovery - 23 Restoring your computer Recovery Management allows you to quickly and easily restore your computer back to its default status. This process will reinstall your operating system and Recovery - 25 remove all of your personal files, apps, and settings. Warning Selecting "Remove files and clean the drive" will remove all of your personal files and accounts, along with pre-existing drivers that may affect your Windows installation. Bluetoothenabled devices include computers, cell phones, tablets, wireless headsets, and keyboards. Enabling and disabling Bluetooth the Bluetooth adapter must be enabled on both devices. After that, simply turning on the Bluetooth adapter of both devices will connect them. Press the Windows key or select the Windows Start button > Settings > Devices > Bluetooth & other devices, and click the toggle under Bluetooth to enable/disable it. Click on Add Bluetooth or other device then select the device that you want to add. Your computer will automatically start searching for devices, as well as make itself visible to other devices. After pairing, if there is a code displaying on the screen, enter that code on the device to proceed the connection. In the case of one of the devices not having any inputs (as in a headset), the passcode is hardcoded into the device (usually "0000" or "1234").

Lack of comparability in any of these epidemiologic study designs may lead to one or another form of bias symptoms 4 dpo topamax 100 mg purchase overnight delivery, which in turn may minimize or invalidate any information contained in the data from the study treatment models buy cheap topamax 100 mg. Three common and potentially serious forms of bias are selection bias medicine park cabins buy 200 mg topamax with amex, when enrollment into a study is dependent on both radiation exposure and disease status; information bias medications mothers milk thomas hale generic topamax 200 mg buy on-line, when information on disease or on radiation exposure is obtained differentially from exposed or from diseased persons; and confounding bias, when a third factor exists that is related to both radiation exposure and disease effects. Selection bias is generally a minor issue in clinical trials and cohort studies, including retrospective cohort studies. In a prospective cohort study, disease has not yet occurred, so there is little possibility of selecting exposed persons on the basis of their future disease status. Exceptions are rare and limited to situations in which some preclinical sign or symptom affects selection-for example, when persons volunteer for one or another intervention because they know that they are at special risk. By contrast, selection bias can be a major issue in casecontrol studies, because both exposure and disease already have occurred when the study subjects are enrolled; there is the danger that persons who are both exposed and diseased will be overselected to participate in the study. If this occurs, the data contain invalid information on the true relation between exposure and disease. Self-selection (volunteering) for a nonexperimental study can be a particularly potent source of bias. An example of selection bias occurred in a study of leukemia among workers at the Portsmouth, New Hampshire, Naval Shipyard (Najarian and Colton 1978). In an initial case-control study, persons with leukemia who had been occupationally exposed to radiation were widely known and hence more likely to be located and enrolled than were unexposed workers with leukemia, and a positive association between radiation and leukemia was reported. Subsequently, after an extensive follow-up of all members of the workforce, no association between radiation exposure and leukemia was found (Greenberg and others 1985). The initial preferential selection of diseased workers who were exposed to radiation led to an erroneous appearance of a positive association between radiation and leukemia. Information bias may occur in a clinical trial or a cohort study if knowledge of exposure is available when information on disease is being obtained; there is the possibility that of the study subjects and therefore be less reliable than reliance on contemporary records. There may be differential recall of exposure to radiation depending on case or control status, which leads to a lack of comparability in the information available. It is rare to be able to quantify the amount of past exposure in a case-control study. However, in some situations related to radiation exposure, only data from casecontrol studies are available. The critical differences between a retrospective cohort study and a case-control study are that subjects in the former are selected on the basis of exposure category at the start of the follow-up period and exposure measures are concurrent with the actual exposure. Conversely, in a case-control study, subjects and controls are selected on the basis of disease outcome, and past exposures must be reconstructed. On occasion in epidemiology, a hybrid study is performed: the "nested" case-control study. A cohort study is conducted, and subsequently, additional information on exposure is collected for persons with disease and for a sample of persons without disease. For example, radiation exposure among persons with a second cancer may be compared to that among a sample of those without a second cancer. Nested case-control studies are best thought of as a form of retrospective cohort study, in that the study population is initially defined on the basis of exposure rather than of disease. In evaluation of the possible health effects of exposure to ionizing radiation, many of the informative case-control studies have been nested within cohorts. Exposure measures in these studies are generally not based on interview data, but rather on review of available records, sometimes supplemented by extensive modeling and calculations. In some nested studies, the objective is to obtain information on dose or other factors that would be too expensive to obtain for the entire cohort. Examples are a case-control study of selected cancers in women irradiated for cervical cancer to obtain individual dose estimates (Boice and others 1985); a breast cancer study of A-bomb survivors to obtain data on reproductive factors through interview (Land and others 1994b); and a study of lung cancer in Hanford workers to extract smoking histories from medical records (Petersen and others 1990). Comparability in Study Design the design of an epidemiologic study must assume comparability in the selection of study participants, comparability in the collection of exposure and disease information relevant to each study subject, and comparability of the basic characteristics of the study subjects. Any lack of comparability may undermine inferences about an association between exposure and disease, so that interpretation is ambiguous or impossible. Comparability in a clinical trial ordinarily is straightforward, because study subjects are assigned randomly to the Copyright National Academy of Sciences. For this reason, in obtaining information on disease among participants, information on exposure is kept hidden (blinded), so that any error in disease ascertainment occurs equally among exposed and unexposed persons.

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