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Ranjiv Mathews, MD, FAAP

  • Associate Professor of Pediatric Urology,
  • The Johns Hopkins School of Medicine,
  • Baltimore, Maryland

And so I thank you so much virus upper respiratory discount 1000mg tinidazole overnight delivery, as our Federal Government and our Federal Representatives antibiotics for sinus infection augmentin buy discount tinidazole line, for listening to us infection 7 weeks after abortion buy cheap tinidazole 1000mg on-line, inviting us here today virus 1980 imdb order tinidazole overnight delivery, and I look forward to continuing this conversation antibiotics for dogs clavamox purchase tinidazole 1000mg without prescription. My name is Katherine Fernandez Rundle and I am the State Attorney for Miami Dade County Florida (which encompasses 35 municipalities) virus upload buy 500 mg tinidazole fast delivery. Our experience is that human trafficking does not limit itself to the stereotypes depicted in the movies. It affects every one of our communities, rich and poor; every ethnicity, every race, every gender, and most importantly our very own; local boys and girls, our children and our youth. Not surprisingly, the victims typically are the most vulnerable, primarily our children and our youth. Thirty-four percent (34%) of our cases involved victims under the age of eighteen! The remaining sixty-six percent (66%), were mostly between the ages of 18-24; 92% are female. Human Trafficking is a public health and mental health threat to our children and youth. Rescuing human trafficking victims, requires much more than locating them and physically removing them from their predators. Most have no safe home to return to , no clothing other than that which they are wearing, and many have not eaten or slept in days. Many have been beaten; drugged; raped; isolated; branded; threatened with retaliation; stripped of all their dignity and identity. Their mental, physical, and emotional injuries are often so profound, many are unable to heal and rebound without substantial and sustainable assistance. When proper services are not provided, many victims end up back on the streets where traffickers are waiting to "save" them and restart the sexual exploitation and violent abuse cycle. History has taught us that to successfully prosecute our cases we must ensure services are provided from day one and continue to be provided throughout the duration of the prosecution. Otherwise, our survivors will end up as victims again, in the hands of new traffickers, and our cases will fall apart. We have also had to develop new methods of investigation and prosecution and developed a network of victim services. Our human trafficking prosecutions have become victim focused, not reliant on the victim. We have created in our community a safety net of partnerships that will assist with housing, physical and mental health needs, and reintegration into society. Our building houses prosecutors, law enforcement, victim services, and soon will also house the Department of Children and Families. We would not have become a national model, without all our community service providers, and law enforcement partners, local, state and federal. While we have been preparing for the serge this may bring, we could use more help. We fear that traffickers will be coming to our city to make money during Super Bowl. Although I cannot verify numbers for you, I have read that worldwide it may be a $150 Billion industry and a $32 Billion industry in the U. Although conjecture on my part, I believe that these traffickers have found a safer and more profitable crime in selling children for sex than selling illegal narcotics. We have also had to create adequate reporting methods, and have rapid response teams ready, which include medical professionals on standby, prosecutors on call, housing, food, clothing, and a whole host of other services. The goal is upon receiving a call, a rapid response team (depending on the circumstances) will be dispatched to investigate and rescue the victim. Hopefully, we can serve as a demonstration to other communities on how to attack this crime, especially during a potential "surge". Resources will be needed to address the additional rescues and cases developed prior to Super Bowl 54. Resources will also be needed to continue rescuing victims and developing cases for the human trafficking that occurs 365 days a year, beyond Super Bowl. So how can you help us as one of the leading counties in the country in our anti human trafficking efforts resolve this growing epidemic? In Florida, our needs are much higher than the needs of neighboring states who many not be as affected by this horrific crime. Third: the Federal government could support the development of proper information sharing mechanisms. We have learned traffickers are constantly transporting victims to different cities and states. They perpetrate these crimes from one city to the next, routinely leaving law enforcement one step behind. I have supplemented this testimony with materials highlighting the infrastructure my office and my community have put in place to fight human trafficking. In those same materials you will also see highlights of cases we successfully prosecuted, and collaborations with our national partners. While we know the victim-centered approach we have developed is still in its infancy, I can wholeheartedly tell you it is a must in our fight against human trafficking. Good morning, Madam Chair, Chairman Hastings, Chairman McGovern, committee members, your amazing staff, thank you for the opportunity to speak to you today. I am a professor of clinical obstetrics, gynecology, and reproductive sciences, pediatrics, and nursing at the University of Miami in Miami, Florida. We were able to build models of care that helped these vulnerable populations live healthy lives, and what we learned in Miami spread to clinics across the country. Six years ago, I was contacted by local law enforcement and members of the Human Trafficking Task Force in Miami to provide medical care for victims that they had identified. I realized these survivors, often taken as young children, had experienced years of abuse and medical neglect and had tremendous healthcare and mental health needs. Their healthcare needs were, frankly, beyond the scope of anything that we had in place. I am here to speak with you today because, since then, we have established a comprehensive model of healthcare for survivors of human trafficking. At the University of Miami, along with our partners at Jackson Health System, we developed one of the first clinics in the Nation to help survivors access healthcare and mental health services. We provide medical, primary, and specialty care, mental health and behavioral care services to address the very unique needs of this population, who are deeply impacted by poverty, housing insecurity, food insecurity, and illiteracy. They have all suffered from trauma, from being held captive in one way or another. Our healthcare model is designed on the basic principles we developed listening to the survivors. We employ navigators, usually survivors who have reentered the workforce who chaperone the patient through every visit. Having their name called out to come to the desk in a public place is very frightening for them. Our patients cannot negotiate multiple medical appointments in multiple facilities, but most of the care they need comes from specialists. So the physicians and nurses at Jackson Health System and the University of Miami come to the same familiar clinic room every time to see the patients. So we take a medical history only once and ask all the providers to review it before they see the patient. All of our patients, every one of them has posttraumatic stress with all of the classic symptoms: flashbacks, nightmares, anxiety, depression, suicide attempts. What these survivors need most is mental healthcare, and there are simply not enough available. We are collaborating and sharing best practices with a program in Texas and Atlanta. So, in closing, I just want to reiterate what my colleagues have already said and what you already know. I urge you to support funding to establish medical demonstration projects designed to evaluate the most effective model of medical and mental health aftercare for survivors of human trafficking. I am a Professor of Clinical Obstetrics, Gynecology and Reproductive Sciences, Pediatrics and Nursing at the University of Miami in Miami, Florida. Through this experience, I learned that taking care of these patients meant more than just providing medication. I learned to listen to my patients, to understand the fear, abandonment, and stigma they faced. They also taught me about resilience and the incredible strength of the human spirit. We successfully built a comprehensive care model that not only provided medical treatment but also addressed these other important factors. We have helped countless members of this vulnerable population live healthy lives, and the model we developed in Miami has been implemented in clinics across the country. Six years ago, I was contacted by local law enforcement and members of the Human Trafficking Task Force in Miami to provide medical care for human trafficking victims. I realized these survivors, often taken as young children, had experienced years of abuse and medical neglect, and had tremendous health care and mental health needs. I am here today to share with you the comprehensive model of health care that we have developed for survivors of human trafficking. At the University of Miami, along with our partners at Jackson Health System, we developed one of the first health clinics in the nation to help survivors of human trafficking access health care and mental health services. We provide medical and mental health care to address the unique needs of this population, who are also deeply impacted by poverty, housing insecurity, food insecurity, and illiteracy. Our health care model is designed on basic principles we developed listening to survivors. For example, every practitioner knows they must ask before touching a patient in any way every time. We employ Navigators - usually survivors who have re-entered the workforce - who chaperone the patient through every visit. Our patients cannot negotiate multiple medical facilities, but most need care from multiple specialists. Physicians and nurses come to the same familiar clinic every time to see our patients. Repeating their history re-traumatizes our patients, so we take a medical history only once and ask every doctor to review it before they meet the patient. Our patients have physical injuries and illnesses that have been untreated for years. All of our patients, every one of them, has post-traumatic stress with all of the classic symptoms: flashbacks, nightmares, and anxiety, depression and suicide attempts. What these survivors need most is mental health care, and there is simply not enough available. Our clinic has been replicated in another Florida community, and we are collaborating and sharing best practices with programs in Texas and Atlanta to replicate our model there. Human trafficking exists in every state in our nation, and as a country we are in great need of research and resources to eliminate this horrific practice and provide appropriate care and treatment for these survivors. I urge you to support funding to establish demonstration projects designed to evaluate the most effective model of medical and mental health aftercare for survivors of human trafficking. Thank you for an opportunity to testify today and I look forward to your questions. It is, indeed, a privilege to be here, sitting next to these highly respected experts in the field of human trafficking, and quite humbling. I started my career almost 20 years ago as a Fairfax County police officer, first working as a patrol officer, then graduating to a detective assigned to work in the gang investigations unit. My experience was similar to so many other law enforcement officers when they encounter their first case. As I became aware of what I would later learn was human trafficking, my initial belief was that it was just prostitution. I had never received any training or education surrounding the issue of human trafficking. Those words had not been a part of my academy instruction, and so the concept was quite foreign, much like I believed something such as human trafficking was simply a foreign problem. Sadly, this lack of training for law enforcement is still a problem today, with some estimating less than 5 percent of law enforcement in the United States have received adequate identification and response training. That reality: Human trafficking is exploiting men, women and children alike, yes, in foreign lands, but, more disturbingly, right here in the United States. The land of the free has become one of the top three countries of origin for modern day slaves. Human trafficking is not just a threat to the most urban areas of our country, but is impacting some of the most remotest areas as well. Traffickers are exploiting technology to gain access to potential victims right in their own communities, their own schools, and even their own homes. I have had the honor of working alongside more than 200 victims of human trafficking during the course of my career as a law enforcement officer, alongside victim services professionals, and in my capacity as the executive director of the Just Ask Trafficking Prevention Foundation. They have been exploited by boyfriends or girlfriends, those that have used the guise of love to manipulate them into this lifestyle. They have been exploited by gangs, who have learned that human trafficking is more profitable and less risky than other crimes. They have been exploited by lures of employment and even in some cases by their own family members. I would like to recognize my friend and a member of the Just Ask board of directors, Barbara Wilson, who is with us here today.

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This would indicate that most comfortable note for the participants became higher across the intervention time antibiotics for dog acne safe 1000mg tinidazole. While the median of the fundamental frequency increased systemic antibiotics for acne vulgaris cheap 1000mg tinidazole fast delivery, this number was still within normal values bacteria multiplying discount tinidazole 500 mg visa. Half of the participants saw increases in their fundamental frequency; however bacteria science projects buy 1000mg tinidazole fast delivery, these numbers were not significant antibiotic heat rash discount tinidazole online american express. It is important to note that Participant #4 (Daniel) and Participant #6 (Josh) were amongst the three participants who saw decreases in their median fundamental frequency virus in the heart order tinidazole with mastercard. As discussed above, it is possible that the more advanced the impairment, the more improvement one will see from the intervention. Mean intensity (dB) scores showed increases from pre to post-intervention testing. The act of singing requires greater use of the abdominal muscles to maintain the phonatory intensity necessary to maintain phonation (Garcia-Lуpez & Gavilаn Bouzas, 2009). The use of singing interventions can help to improve vocal intensity through the training of the muscles necessary for respiration (Stegemцller et al. The current study found similar results; however, these improvements were not statistically significant. These findings further support the suggestion that signing-based interventions can assist in improving vocal intensity through respiratory muscle strengthening. While some of the results were promising, the lack of statistical significance was expected based on the small sample size and relative intensity of the intervention. Furthermore, 61 some of the results were more promising for the patients with greater observed impairment than those who maintained relatively normal functionality in their vocal mechanisms. This may suggest that results may be more significant for those with greater impairment; however, earlier applicability of the intervention exercises may help to maintain vocal functionality as the disease progresses. According to the scores by the rater naпve to the identities of the study participants, there were statistically significant decreases in breathiness, pitch, loudness, and overall severity of voice. The intervention of the present study had exercises focused on improving pitch and breath control. Increased awareness of the respiratory system and control over the respiratory muscle could have contributed to these improved ratings. When clients were tested pre-intervention, the majority had no previous knowledge of singing and breath control. Singing requires use and control of both the respiratory and phonatory muscles (Garcia-Lуpez & Gavilаn Bouzas, 2009). Prolonged use and practice using these muscles can help to improve the overall efficiency of the vocal mechanism. As shown by Garcia-Lуpez and Gavilаn Bouzas (2009), singing requires greater muscular coordination than speaking. As the participants practiced these techniques in session, their control over this musculature could have improved. Three participants had increased (worsening) scores for strain from pre-intervention to post-intervention measures. While these results were unexpected, the increased scores could have been contributed to response bias as the participants strained their voices to make their voices sound different or more improved. The lead researcher also administered the final measurements, which may have impacted the way the participants responded to the directions given. Additional research with both a rater naпve to the identities of the study participants, and a researcher naпve to the identities of the study participants may help to remove any bias associated with the results. This would indicate that the participants perceived their vocal impairment as having less of an impact on their quality of life. Limitations While this research did not yield results revealing many variables with statistically significant differences pre-intervention to post-intervention, it is important to acknowledge the limitations and possible biases that may have impacted the results. While none of the participants had received music therapy previously, they were familiar with the treatment method from previous presentations within the group. In addition to this limitation, there was not a control group with which to compare the results. The subjects were asked to complete questionnaires within a short time frame and may have adjusted their answers to best fit the aims of the present study. Measurement bias may have also occurred from the principal researcher also taking final measurements and therefore could not be blinded during this assessment. The participants and the researcher built a therapeutic relationship during the course of the study, and the participants may have adjusted their performance during testing to best fit the aims of the study leading to a response bias. There needs to be further research with increased experimental group size and healthy controls. Furthermore, additional measures need to be taken post-intervention to determine if the effects of the treatment will remain long term. Additionally, future studies must include measurements from speech language pathology and encourage the collaboration between these two disciplines. The treatment requires multiple weekly sessions with added at-home exercises nightly. This treatment strategy may require too much time for participants to commit fully. A combined treatment option that encourages social interaction and vocal improvement through singing interventions may provide a unique opportunity for beneficial change. Collaborative research with large sample sizes, control groups, and trained raters naпve to the identities of the study participants is necessary to find the most benefit for the patients. While some positive changes were apparent from the current study, the researcher found no statistical significance for the acoustic and selfreport measures. Clinically, this finding is relevant because increases the likelihood of the participants future implementation of the techniques in their daily lives. Singing interventions utilize training and coordination of phonatory and respiratory muscles. The effectiveness of singing or playing a wind instrument in improving respiratory function in patients with long-term neurological conditions: A systematic review. Singing exercises for speech and vocal abilities in individual with hypokinetic dysarthria: A feasibility study. Phonatory and articulatory changes associated with increased vocal intensity in Parkinson disease: A case study. Acoustic analysis of the tremulous voice: Assessing the utility of the correlation dimension and perturbation parameter. A pilot study into the effect of vocal exercises and singing on dysarthric speech. This study will be conducted by a board-certified music therapist with further certification in neurologic music therapy techniques specifically designed to work with voice disorders. You will be asked to take part in weekly one-hour music therapy sessions for 8-weeks, as well as to continue practicing the techniques at home. You will also be asked to undergo acoustic measurements of your vocal functioning. To the best of our knowledge, the risk of harm for participating in this research study is no more than you would experience in everyday life. You will not be paid for completing this study, and there is no cost to you for the music therapy session. All participants will be assigned a random identification number and any documentation will be coded with this number to ensure anonymity. Once the study is completed, aggregate data from the study will be analyzed using this unique identification number. All personalized information will be stored on a password protected encrypted device. The people conducting this study will be available to answer any questions concerning this research, now or in the future. You may contact the Principal Investigator, Sarah Swann Solberg, at (828) 231-2562 or through email at swannsl@appstate. If you have questions about your rights as someone taking part in research, contact the Appalachian Institutional Review Board Administrator at (828) 262-2692 or through email at irb@appstate. Currently receiving speech-language pathology or music therapy to address voice disorders 76 Do I have to participate? If you choose not to volunteer, there will be no penalty and you will not lose any benefits or rights you would normally have. If you decide to take part in the study, you still have the right to decide at any time that you no longer want to continue. There will be no penalty and no loss of benefits or rights if you decide at any time to stop participating in the study. You may request a copy of this consent information by contacting the Principal Investigator, Sarah Swann Solberg, at (828) 231-2562 or through email at swannsl@appstate. The measurements(s) will take place at the Communication Disorders Clinic at Leon Levine Hall on Appalachian State Campus. Treatment will take place in a private room once per week at University Hall at Appalachian State University. Treatment will be for 8-weeks and each treatment session will be approximately 60 minutes. I understand that there are no foreseeable risks associated with my participation. I understand that the audio recordings of my measurement session may be stored on an encrypted, password protected computer and may be used for presentations or published data if I sign the authorization below. I understand that de-identified information or quotations from audio recordings or transcripts will be published. I understand that the participation is voluntary and there are no consequences if I choose not to participate. I also understand that I do not have to answer any questions and can end the treatment at any time with no consequences. If I have questions about this research project, I can call the researcher at (828) 231-2562 or the Appalachian Institutional Review Board Administrator at 828-262-2692(days), through email at irb@appstate. I request that my name not be used in connection with tapes, transcripts, photographs or publications resulting from this interview. I request that my name be used in connection with tapes, transcripts, photographs or publications resulting from this interview. Please indicate whether or not you agree to having photos or videos used in research presentations by reviewing the authorization below and signing if you agree. Authorization I hereby release, discharge and agree to save harmless Appalachian State University, its successors, assigns, officers, employees or agents, any person(s) or corporation(s) for whom it might be acting, and any firm publishing and/or distributing any photograph or video footage produced as part of this research, in whole or in part, as a finished product, from and against any liability as a result of any distortion, blurring, alteration, visual or auditory illusion, or use in composite form, either intentionally or otherwise, that may occur or be produced in the recording, processing, reproduction, publication or distribution of any photograph, videotape, or interview, even should the same subject me to ridicule, scandal, reproach, scorn or indignity. I hereby agree that the photographs and video footage may be used under the conditions stated herein without blurring my identifying characteristics. In December 2013, she began her Master of Music in vocal performance at Appalachian State University and graduated in December 2015. She began the combined Equivalency and Master of Music Therapy program at Appalachian State University in the summer of 2015. Solberg completed her music therapy internship at Park Nicollet Health Services in January 2018. Solberg currently works as a hospice music therapist for Medi Home Health and Hospice in Boone, North Carolina, and works for Medi Home Health and Hospice as a hospice music therapist. She currently resides with her loving husband, two amazing dogs, and one sweet bunny in Vilas, North Carolina. Selected Causes of Secondary Acute Gastroenteritis Algal Bacterial Prototheca species Campylobacter species Clostridia species Escherichia coli Neorickettsia helminthoeca Salmonella species Antibiotics Cyclosporine Glucocorticoids Mycophenolate Nonsteroidal anti-inflammatory drugs Ancylostoma caninum Ollulanus tricuspis Physaloptera species Strongyloides species Toxoascaris leonina Toxocara canis Cryptosporidium parvum Giardia species Isospora canis Bacterial cholecystitis Gallbladder mucocele Gastric dilatation and volvulus Hepatic disease Hypoadrenocorticism Pancreatitis Pyometra Renal disease Sepsis Septic peritonitis Splenic torsion Chocolate Lead Mushrooms Organophosphates Xylitol Zinc Canine coronavirus Canine parvovirus Feline immunodeficiency virus Feline leukemia virus Feline parvovirus (panleucopenia virus) Drugs Acutegastroenteritisisatermusedtodescribea syndromecharacterizedbythesuddenonsetof vomitingand/ordiarrheacausedbygastrointestinal mucosalinflammation. Benefitsinclude: Improvedpatientcomfort Decreasedongoingfluidandelectrolytelosses Earlierreintroductionofenteralnutrition Reducedriskofesophagitisandesophageal strictureformation. Theefficacyofsomeprobioticsfortreatmentof chronicdiarrheaindogsandcatshasbeenevaluated but,toourknowledge,therehaveonlybeen2studies evaluatingtheefficacyofprobioticsindogswith acutediarrhea;bothfoundthatprobioticsdecreased thedurationofdiarrheaindogswithacuteidiopathic diarrhea. However,wereserveantimicrobialtherapy forpatientswith: Moredefinitiveevidenceoftranslocation,suchas leukocytosis,elevatedimmaturewhitebloodcell count,andpyrexia Leukopeniaorthosethatareimmunosuppressed Aspecificbacterialenteropathogen(eg, campylobacteriosis) Chronicdiarrhea(asatherapeutictrialtoruleout dysbiosis). Whiletheoptimalamountandtypeofdietary fiberfortreatmentofdogsandcatswithacute gastroenteritisarenotknown,thereisgeneral agreementthat,indogsandcats: Dietaryfermentable fiberenhancesnormalcolonic functionbyprovidingafuelsourceforcolonocytes Dietarynonfermentable fiberincreasesfecalbulk, whichpromotesnormalizedcolonicmotor functionanddefecation. His clinical and research interests include small animal hepatology and gastroenterology. R1 1 Novel speech signal processing algorithms for high-accuracy classification of Parkinsons disease Athanasios Tsanas*, Max A. Then, we select four parsimonious subsets of these dysphonia measures using four feature selection algorithms, and map these feature subsets to a binary classification response using two statistical classifiers: random forests and support vector machines. We use an existing database consisting of 263 samples from 43 subjects, and demonstrate that these new dysphonia measures can outperform state of the art results, reaching almost 99% overall classification accuracy using only 10 dysphonia features. We find that some of the recently proposed dysphonia measures Manuscript received July 18, 2011; revised 31 October 2011; accepted 26 December 2011. This paper has supplementary downloadable material available at ieeexplore. R1 strong evidence linking speech to average Parkinsons disease symptom severity [5], [10-13]. Collectively, these findings reinforce the notion that speech may reflect disease status, after appropriate processing of the recorded speech signals. The range of symptoms present in speech includes reduced loudness, increased vocal tremor, and breathiness (noise). The extent of vocal impairment is typically assessed using sustained vowel phonations, or running speech. Although it can be argued that some of the vocal deficiencies in running speech (such as combinations of consonants and vowels) might not be captured by the use of sustained vowels, the analysis of running speech is more complex due to articulatory and other linguistic confounds [15], [16].

This mutation causes the Fyb antigen to not form on red blood cells bacteria unicellular tinidazole 1000mg sale, but it is still present on other tissues in the body antibiotics and period purchase 300 mg tinidazole free shipping. In these patients infection 86 buy discount tinidazole, although their red blood cells lack the Fy b antigen infection under armpit buy discount tinidazole 500mg on-line, they cannot form the antibody infection 6 weeks after surgery buy tinidazole 300mg low price. Kidd Blood Group System Anti-Jka is an IgG and IgM antibody directed against the Jka antigen in the Kidd blood group system bacteria in water purchase tinidazole with mastercard. Anti-Jka is implicated in Hemolytic Transfusion Reactions, especially Delayed Hemolytic Transfusion Reactions due to its tendency to drop below detectable levels in plasma. Anti-Jkb is an IgG and IgM antibody directed against the Jkb antigen in the Kidd blood group system. Anti-Jkb is implicated in Hemolytic Transfusion Reactions, especially Delayed Hemolytic Transfusion Reactions due to its tendency to drop below detectable levels in plasma. Anti-S is implicated in Hemolytic Transfusion Reactions and Hemolytic Disease of the Fetus and Newborn. Anti-s is implicated in Hemolytic Transfusion Reactions and Hemolytic Disease of the Fetus and Newborn. Approximately 2% of African Americans lack the high prevalence U antigen and can form an anti-U. Anti-U is implicated in severe Hemolytic Transfusion Reactions and Hemolytic Disease of the Fetus and Newborn. Lewis Blood Group System Anti-Lea is an IgM antibody directed against the Lea antigen in the Lewis blood group system. Anti-Lea is generally not considered clinically significant and antigen negative blood is not necessary. Anti-Leb is an IgM antibody directed against the Leb antigen in the Lewis blood group system. Anti-Leb is not considered clinically significant and antigen negative blood is not necessary. There is no risk to the fetus or newborn when a Lewis antibody is present in the mother. Lutheran Blood Group System Anti-Lua is an IgG antibody directed against the Lua antigen in the Lutheran blood group system. Anti-Lub is an IgG antibody directed against the Lub antigen in the Lutheran blood group system. Anti-Lub has generally been implicated in mild, delayed hemolytic transfusion reactions, therefore, in emergent situations Lu(b-) units do not have to be used. Vel Blood Group System Anti-Vel is an IgG and IgM antibody directed against the Vel antigen in the Vel blood group system. P Blood Group System Anti-P1 is an IgM antibody directed against the P1 antigen in the P blood group system. It is generally not considered clinically significant and antigen negative blood is not necessary. Alloanti-P is antibody directed against the P antigen in the P blood group system. It is a naturally occurring antibody and is implicated in Hemolytic Transfusion Reactions. It is an IgG biphasic hemolysin that binds red cells in cold temperatures and then causes intravascular hemolysis at body temperature. Due to the rarity of this phenotype blood for transfusion is not readily available and will require days to obtain. Colton Antibodies Anti-Cob is an IgG antibody to the Cob antigen in the Colton blood group system. Anti- Cob has been implicated in Hemolytic Transfusion Reactions and mild Hemolytic Disease of the Fetus and Newborn. Diego Antibodies Anti-Dia is an IgG antibody directed against the Dia antigen in the Diego blood group system. Anti-Dia has been implicated in Hemolytic Transfusion Reactions and Hemolytic Disease of the Fetus and Newborn. Anti-Wra is an IgG and IgM antibody directed against the Wra antigen in the Diego blood group system. Anti-Wra has been implicated in Hemolytic Transfusion Reactions and Hemolytic Disease of the Fetus and Newborn. Lan Antibody Anti-Lan is an IgG antibody directed against the high incidence antigen Lan. Anti-Lan has been implicated in Hemolytic Transfusion Reactions and mild Hemolytic Disease of the Fetus and Newborn. Chido Antibodies Anti-Ch is directed against an antigen in the Chido/Rogers blood group system. Anti-Ch is not clinically significant and does not require antigen negative blood. Knops Antibodies Anti-Sla is an antibody directed against an antigen in the Knops blood group system. The Sla antigen is present in approximately 98% of the Caucasian population and 50-60% of the black population. These antibodies are not clinically significant and do not require antigen negative blood. Sarika Singh School of Studies in Zoology Jiwaji University the antigen-antibody interaction involves noncovalent interaction between epitope of antigen and hypervariable region of antibody, which are highly complementary to each other. Interactions include hydrogen bonds, ionic bonds, hydrophobic interactions and van der Walls interactions. Non covalent forces in antigen- antibody interaction the strength of noncovalent interaction between single antigen binding site of antibody and single epitope is called antibody affinity. Antigen (Ag) + Antibody (Ab) k1 Ag-Ab k-1 Where k1 is association rate constant and k-1 is dissociation constant k1/k-1=ka, is equilibrium constant and measure of affinity. Ka= molar concentration of bound Ag-Ab/ molar concentration of unbound Ag and Ab 1/ka= kd, is equilibrium constant for dissociation, a quantitative indicator of stability of Ag-Ab complex the strength between multiple binding site of antibody and multiple epitopes is called antibody avidity. Cross reactivity: Ag-Ab interactions are highly specific but sometimes antibody obtained by one antigen, can cross-react with an unrelated antigen. The cross reactivity occurs when two antigen share an identical epitope or if antibodies which are specific for one epitope, bind with unrelated epitope. Precipitation Reactions In aqueous solution, antibody interact with soluble antigen and form a visible precipitate. For this reaction antibody should be bivalent and antigen must be bivalent or polyvalent. Precipitation reaction in fluid: To observe the precipitation in fluid, a constant amount of antibody placed in a series of tubes and add antigen in increasing amount. Then centrifuge the tubes, collect the pellet and measure the amount of precipitate and plot the amount of precipitate against the concentration of antigen (precipitation curve). The maximum precipitation is occurred when the ratio of antibody to antigen is optimal called equivalence zone. Precipitation reaction in gel (immunodiffusion) Antigen and antibody diffuse together in agar gel and formed a visible line of precipitate. Types of immunodiffusion (1) Radial immunodiffusion (Mancini method) (2) Double immunodiffusion (Ouchterlony method) Radial immunodiffusion An antigen sample is placed in a well and allowed to diffuse in antiserum containing gel and finally a precipitation ring is formed around the well. Double immunodiffusion Antigen and antibody placed separately in well and diffuse toward each other. Immunoelectrophoresis this is a combination of electrophoresis and double immunodiffusion. An antigen mixture is separate by electrophoresis into its component on the basis of charge. Antigen and antibody then diffuse toward each other and produce a precipitation line. Agglutination reactions the interaction of antigen and antibody in the formation of clumping is known as agglutination. Bacterial agglutination In the response of bacterial infection, serum antibodies are formed. Serum from the infected person is serially diluted in a series of tubes and bacteria is added. Both type of antigen compete for binding and with increasing concentration of unlabeled antigen displaced the labeled antigen. An enzyme (conjugated with an antibody) reacts with a substrate (chromogenic substrate) and generate a colored product. Protein bands are transferred to nitrocellulose membrane by electrophoresis and protein bands are recognized by flooding the membrane with radiolabeled/ enzyme linked antibody. Immunofluorescence In this technique the location of an antigen in tissue is determined by reaction with an antibody labelled with a fluorescent dye (fluorochrome). Fluorescent molecule absorb light of one wavelength (excitation) and emit light of another wavelength. Indirect staining: Unlabeled primary antibody is detected by additional fluorochrome labeled reagent. Menetralkan Ag Kompleks Ag-Ab menetralkan toksin, mencegah ikatan Ag dengan sel tubuh 2. Mengaktifkan Complement: Kompleks Ag-Ab mengaktivasi komplemen lisis sel; khemotaksis; inflamasi rekrutmen leukosit 3. Precipitating Antigens Ag mengikat Ag bebas cross linkpresipitasi fagosit Ag bakteri cross link aglutinasi fagosit 4. Facilitating Phagocytosis Kompleks Ag-Ab memberi sinyal untuk fagositosis Kompleks Ag-Ab peda permukaan makrofag memfasilitasi fagositosis 5. Hapten Suatu substansia yang hanya mempunyai satu determinan antigenik namun tidak mampu merangsang respon imunitas bila tidak digabung dengan protein karier. Dihubungkan oleh ikatan disulfida ikatan kovalen antara atom sulfur dalam asam amino huruf Y arm, stem, hinge region. Aktivasi Komplemen Sistem komplemen dapat diaktifkan melalui dua jalur yaitu jalur klasik dan alternatif. Protein yang terlibat dalam alur klasik Terdapat 9 protein disebut C dengan nomor yang sesuai dengan urutan peranan dan aktivasinya. Komplemen Protein Antimikroba Diproduksi oleh hati, beredar dl darah, tdp pada membran sel Aktivasi oleh antibodi atau antigen kaskade reksi kimia Efek langsung: lisis mikroorganisme dengan menghancurkan membran sel Efek tidak langsung: - kemotaksis, - opsonisasi, - Inflamasi: rekrutmen sel fagosit, Limfosit B & T. Able to define: Antigen (Ag), Epitope or Antigenic Determinant and antigenicity Immunogen, immunogenicity. Able to compare between superantigen normal antigen Antigen (Ag): Is a foreign substances usually protein and sometimes polysaccharide, Generates a specific immune response and induces the formation of a specific antibody or T cells response or both. Immunogenicity: the ability to induce a humoral or cell mediated immune response. Antibody (Ab): A specific protein that is produced in response to an immunogen and reacts with an antigen Hapten A substance that is non-immunogenic But it can react with the products of a specific immune response with no Antibodies formation. Foreignness Size Chemical Composition Physical Form ­ Particulate > Soluble ­ Denatured > Native 5. Adjuvants: Substances that enhance an immune response to an Ag Chemical Nature of Immunogens Proteins Polysaccharides Nucleic Acids Lipids Types of Antigens 1. T-independent antigen T-independent antigens are antigens which can directly stimulate the B cells to produce antibody without the requirement for T cell help In general, polysaccharides are T-independent antigens. T-Independent and T dependent antigen By the end you will be able to answer these questions Defines different terminologies related to antigen? Vorteile schnelle und aussagekrдftige Ergebnisse nach 15 min ­ anschlieЯend Befundbesprechung ohne Folgetermin preiswerte und mobile Tests kцnnen ьberall durchgefьhrt werden Sensitivitдt: 97,10 % (positive Testung) Spezifitдt: 99,76 % (negative Testung) Entnahme von Nasen- oder Rachenabstrich kein Analysegerдt und kein Labor erforderlich Test Kit enthдlt alle erforderlichen Verbrauchsmaterialien fьr die Auswertung Test fьr den professionellen Gebrauch gelistet beim Bundesinstitut fьr Arzneimittel und Medizinprodukte (BfArM) nach §1 Satz 1 vom 15. Probebehandlung 3x Die Probenahme erfolgt mit Hilfe eines sterilen Abstrichtupfers. Rachenabstrich: Kopf leicht neigen, Mund offen halten und (Tupfer beinhaltet) "ah"sagen. Nasenabstrich: Tupfer aus Nasenrachen langsam entfernen (Tupfer separat und dabei den Boden des Nasenkanals bestellen) abstreichen. Der sterile Abstrichtupfer wird nach der Probenahme unterhalb des Flьssigkeitsspiegels des Probenahmerohres eingeweicht, 3-mal gedreht und gedrьckt. Das Probenahmerohr wird zusammengedrьckt, die Flьssigkeit abgestriffen wдhrend der Tupfer herausgenommen wird. Covid-19 Ag 4-5 Tropfen in die Testkassette (Raumtemperatur von 10-30°C) geben und Ergebnis innerhalb von 15-30 Minuten ablesen. Sistem imun harus mampu mengeliminasi mikroba dengan pertahanan awal melalui sistem imun innate/ non spesifik 2. Sistem imun innate memberikan sinyal ke sistem imun adaptive / spesifik melalui mediator biologis (cth. Sel pada sistem imun adaptive/ spesifik mengenali secara spesifik Antigen (ikatan spesifik ligan dan reseptornya) 4. Pengenalan spesifik ini (ikatan Ag-Ab) bertujuan akhir untuk eliminasi mikroba yang masuk 5. Antigen eksogen: konfigurasi yang disajikan kepada tubuh dari luar cth: Mikroorganisme, pollen, obat, dsb 2. Antigen endogen: konfigurasi yang terdapat dalam tubuh host atau individu Hasil dari metabolisme normal sel cth: antigen pada permukaan eritrosit (gol darah) 3. Foreignness atau faktor keterasingan: substansi yang tidak pernah kontak dengan sistem imun dari ketika embriogenesis Faktor fisik dan kimia antigen Ukuran Molekul (>10kD), tidak terlarut semakin imunogenik Komposisi kimia dan strukutur protein yang menyusun antigen > semakin rumit struktur kimia, maka antigen tersebut dpt tergolong imunogen yg poten > Gugus as amino aromatik (tirosin), derajat imunogen >> Cara pemaparan antigen: intravena, subcutan, perm tubuh, dsb Degradibility: kemampuan dipecah2 oleh sistem imun Sensitivitas metode yang digunakan untuk mengukur respons imun sensitivitas immunoassay Faktor internal Host; genetik, jenis kelamin, umur, Kondisi sistem imun host Dosis paparan antigen 12 c. IgE Isotipe atau klas Antibodi satu dengan lain di berbeda dalam ukuran, fungsi, susunan asam amino dan karbohidrat Perbedaan struktur antar isotipe terletak pada susunan molekul pd rantai berat/heavy chain 8/13/2014 20 Tipe dari rantai berat akan menentukan klas dan subklas dari antibodi Masing-masing isotipe Ig memiliki 2 fungsi yang sama (kecuali Ig D), yaitu: 1. Melakukan pembunuhan atau pemusnahan kompleks imun yang terbentuk melalui mekanisme aktivasi efektor. Aglutinasi: Antibodi dapat menyebabkan antigen (mikroba) menggumpal bersama sama 2. Opsonisasi: Antigen (mikroba) dilapisi oleh Ab yang dapat meningkatkan penelanan mikroba dan pelisisan oleh sel fagosit 3. Netralisasi: IgG menginaktifkan virus dengan cara mengikat permukaannya dan menetralkan toksin melalui blocking sisi aktifnya 8/13/2014 34 4. Organisme target di lapisi dengan antibodi dan di bombardir dengan komponen kimia dari sistem imun nonspesifik (mediator biologis) 5.

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In this situation treatment for dogs flaky skin generic tinidazole 1000 mg mastercard, metformin is the first-line pharmacologic therapy infection 5 weeks after c-section buy discount tinidazole 500mg online, if tolerated and not contraindicated antibiotics for sinus infection types buy discount tinidazole 1000 mg on-line. The use of metformin to treat insulin resistance alone (without prediabetes or diabetes) is theoretically useful antibiotics for acne and probiotics buy tinidazole with a visa, but not supported by studies evaluating clinical outcomes bacteria helicobacter pylori sintomas cheap 1000 mg tinidazole with visa. Thiazolidinediones have been shown to slow the progression of prediabetes to diabetes bacteria urine test results tinidazole 1000 mg without prescription, but cost, safety concerns, and possible adverse fetal effects limit their use. Multiple metabolic issues have been identified, including early diabetes, obesity, high blood pressure, dyslipidemia, and fatty liver. Results from studies addressing the risk of developing these complications are summarized in Table 4. This is particularly important in women with another risk factor for diabetes or body mass index >30. Recent studies have suggested that statins may inhibit theca cell growth and decrease ovarian testosterone production. Other relatively benign treatments such as fish oil or psyllium fiber may also be useful in some patients. Interestingly, a small study in polycystic ovary syndrome women treated with 4 g/day omega-3 fatty acids demonstrated improvement in triglycerides, blood pressure, and hepatic fat content on imaging. These include irregular menses, lack of progesterone, unopposed estrogen exposure, obesity, insulin resistance, and diabetes. Women with polycystic ovary syndrome appear to have an almost threefold increased risk for endometrial cancer (2. In thin women with polycystic ovary syndrome, 10% have impaired glucose tolerance and 1. Previously, prevalence rates of obesity were estimated based on populations of women with polycystic ovary syndrome seeking care. A recent study comparing patients presenting for care in a polycystic ovary syndrome clinic with an unselected population evaluated during a pre-employment physical suggests that obesity and overweight may not be more common in polycystic ovary syndrome. Polycystic ovary syndrome symptoms, including hyperandrogenism and oligoovulation are exacerbated by obesity. Data have been conflicting, but a large Kaiser Permanente study demonstrated that hypertension or elevated blood pressure was more than twice as common in women with polycystic ovary syndrome (27% vs 12%). Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis have recently been recognized as a potential complication in women with polycystic ovary syndrome. Individuals that may be at higher risk of nonalcoholic fatty liver disease including nonalcoholic steatohepatitis include those with metabolic syndrome, insulin resistance, and possibly hyperandrogenemia. Many studies demonstrate abnormal surrogate markers of cardiovascular disease in women with polycystic ovary syndrome. However, data about cardiovascular disease risk are conflicting with some studies suggesting an increased risk in women with polycystic ovary syndrome, whereas other studies have not found this difference in cardiovascular risk. While it is important to recognize and treat cardiovascular risk factors in this population, further research of cardiovascular risk and complications is still needed to clarify the long-term risk. The first-line approach is with hormonal contraceptives, the risks and benefits of which are discussed below ("Cosmetic" section). Because metformin increases ovulation rate,26 it can be considered second-line treatment for cycle control. However, whether the improved ovulation rate is adequate to prevent endometrial hyperplasia is unknown. Psychosocial Although studies evaluating psychosocial issues are small, women with polycystic ovary syndrome appear to have a prevalence of depressive disorders that is about 3 times higher than seen in controls (35% vs 11%, respectively, P <. Patients can be effectively screened for depression by asking 2 simple questions about mood and anhedonia (see Table 529). In our experience, many women with polycystic ovary syndrome describe experiences with providers in which they did not feel their diagnosis and its associated symptoms were viewed as important medical issues. Therefore, providing nonjudgmental support, focusing on positive messages about healthy behaviors and self care, and validating that polycystic ovary syndrome and its associated complications are important to diagnose and treat, are important aspects of the clinic visit. Setji and Brown Polycystic Ovary Syndrome Review 917 permanent hair reduction, but still often require periodic maintenance treatments. Laser relies on the contrast between skin color and hair pigment for effectiveness, and thus works well on light-skinned women with dark terminal hair growth. Darker-skinned patients and those who are heavily tanned require higher-energy pulses, increasing the risk of burns, and therefore are treated with specialized lasers that have cooling devices and adjusted energy levels. Electrolysis requires insertion of an electrode into individual hair follicles to destroy them and may be an option for patients that have a limited area to treat. In addition, topical agents for treating acne, retinoids, antibacterials, benzoyl peroxidase, and salicylic acid can be useful. Cosmetic Hirsutism occurs in up to 75% of American women with polycystic ovary syndrome. Using formulations with lower doses of ethinyl estradiol may minimize adverse estrogen effects. Some newer progestins (including desogestrel, norgestimate gestodene, drospirenone) provide the advantage of lower androgenic activity compared with the older progestin levonorgestrel. However, they are also associated with an increased (although still low) risk of venous thromboembolism. This population may already be at higher risk of venous thromboembolism than unaffected women. They are potentially teratogenic and could result in pseudohermaphroditism in male fetuses. At doses of 50-200 mg daily, it blocks the androgen receptor at the hair follicle. Other treatments of hirsutism include laser, electrolysis, manual removal (waxing, shaving, threading), bleaching, and depilatory creams. Laser and electrolysis both induce Ovulation and Fertility There are few published data about the spontaneous ovulation rate in women with polycystic ovary syndrome. However, in the placebo arm of a relatively large randomized clinical trial of women with polycystic ovary syndrome, spontaneous ovulation occurred in 32% of cycles. If fertility is desired, ways to increase ovulation frequency should be discussed. Although there are no long-term, controlled trials of the effects of weight loss on pregnancy and live birth rates, several small studies in women with polycystic ovary syndrome report improvement in menstrual cycles and ovulation with weight loss. Thus, given the other benefits of diet, exercise, and weight loss in overweight and obese individuals, healthy lifestyle changes are recommended. The anti-estrogen action blocks negative feedback of endogenous estrogens in the hypothalamus and pituitary. This results in an increase of follicle-stimulating hormone and ultimately, ovulation. Ovulation occurs in 60%-85%, with a pregnancy rate of 30%-50% after 6 ovulatory cycles. Over the last 2 weeks, how often have you been bothered with feeling down, depressed, or hopeless? Metformin Metformin improves ovulation rate in women with polycystic ovary syndrome. Compared with placebo, metformin alone does not appear to affect miscarriage rates (odds ratio 0. Women with polycystic ovary syndrome have a higher risk of gestational diabetes, pregnancy-induced hypertension, preeclampsia, and preterm birth. Recognition offers the chance for providers and patients to engage in discussions about prevention and early treatment of metabolic derangements. It leads to discussions about cycle control both for convenience and to prevent endometrial hyperplasia, and opens the door to conversations about mood, eating, and body image, as well as cosmetic concerns, fertility, and sleep. Each of these is critically important to the health and well-being of patients with this common condition. The relationship of serum anti-Mullerian hormone and polycystic ovarian morphology and polycystic ovary syndrome: a prospective cohort study. Relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. Referral bias in defining the phenotype and prevalence of obesity in polycystic ovary syndrome. Sleep Apnea Obstructive sleep apnea is associated with insulin resistance and type 2 diabetes as well as polycystic ovary syndrome. Treatment with at least 4 hours per night of continuous positive airway pressure improves insulin sensitivity, decreases norepinephrine levels and diastolic blood pressure, and lowers cardiac sympathetic activity. Adherence to continuous positive airway pressure treatment may improve metabolic parameters in these patients. Women with polycystic ovary syndrome are often depressed or anxiousea case control study. The prevalence and features of the polycystic ovary syndrome in an unselected population. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. Risk of venous thromboembolism in women with polycystic ovary syndrome: a populationbased matched cohort analysis. Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial. Troglitazone improves ovulation and hirsutism in the polycystic ovary syndrome: a multicenter, double blind, placebo-controlled trial. Pregnancy outcomes and the effect of metformin treatment in women with polycystic ovary syndrome: an overview. Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: Role of insulin resistance. Treatment of obstructive sleep apnea improves cardiometabolic function in young obese women with polycystic ovary syndrome. Incidence and treatment of metabolic syndrome in newly referred women with confirmed polycystic ovarian syndrome. Epidemiology and adverse cardiovascular risk profile of diagnosed polycystic ovary syndrome. Nonalcoholic steatohepatitis and nonalcoholic fatty liver disease in young women with polycystic ovary syndrome. Prevalence of nonalcoholic fatty liver disease in women with polycystic ovary syndrome. Assessment of glucose metabolism in polycystic ovary syndrome: HbAc or fasting glucose compared with the oral glucose tolerance test as a screening method. Effects of exercise on lipoprotein particles in women with polycystic ovary syndrome. Omega-3 fatty acid supplementation decreases liver fat content in polycystic ovary syndrome: A randomized controlled trial employing proton magnetic resonance spectroscopy. Polycystic ovary syndrome and the risk of gynaecological cancer: a systematic review. Diagnosis and treatment of polycystic ovary syndrome: an endocrine society clinical practice guideline. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligoamenorrhea, and subfertility. Polycystic ovary syndrome (Pcos) InsIde: the symptoms explained Your treatment options Coping emotionally with infertility Part of the Pathways to Parenthood booklet series AbouT this bookleT this series of booklets has been developed and written with the support of leading fertility clinics across australia, and accessaustralia ­ a national organisation that provides numerous services for people having difficulty conceiving. We also acknowledge the many people who spoke openly about their own experiences with assisted conception in order to help others experiencing a similar journey. Important notice: the information provided in this booklet does not replace any of the information or advice provided by a medical practitioner and other members of your healthcare team. Use all medications strictly as directed by your doctor and raise any questions or concerns with them before, during or after using prescribed medicines. Full information regarding the medicines listed in this booklet, including how they are taken and side effects, is available from the consumer medicine information (cmi) sheets. With the assistance of your healthcare team, Pcos can be effectively treated and managed, allowing you to live a full and healthy life. There are many ways to help with the symptoms you might have, and the medications and procedures available to assist you in becoming pregnant are well-established and effective. Polycystic ovary (ovarian) syndrome (Pcos) is a common hormonal disorder affecting many women between puberty and menopause. Usually the diagnosis of Pcos requires the presence of at least two polycystic ovaries. Where required, your doctor will exclude other, rare conditions that may present as Pcos. High levels of insulin can also increase the production of male hormones, including testosterone, from the ovary, which contributes to such symptoms as excessive hair growth and acne. But you can work together with your doctor to treat the various symptoms and manage your lifestyle so that you can have a healthy life. When the cycle is running smoothly, the pituitary gland at the base of the brain produces a hormone called follicle stimulating hormone (FsH) to prepare an egg for release. FsH stimulates a fluid-filled sac surrounding the egg to grow into a follicle about 2 cm wide. When the egg is ready (about two weeks before your period), the pituitary gland produces another hormone called luteinising hormone (lH). While this is happening, the ovaries are secreting other hormones such as oestrogen and progesterone to thicken the lining (endometrium) of the uterus and prepare it for pregnancy.

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Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis holistic antibiotics for sinus infection purchase tinidazole 1000 mg. As a result of ongoing research anti virus cheap tinidazole amex, practice guidelines may from time to time change antibiotics iud 500mg tinidazole with visa. The authors of these guidelines have made all attempts to ensure the accuracy based on current information antibiotics for uti that are safe during pregnancy best purchase tinidazole, however bacteria discovery order 1000 mg tinidazole with visa, due to ongoing research antibiotics for sinus infection in babies purchase tinidazole master card, users of these guidelines are strongly encouraged to confirm the information through an independent source. Donna Shalala, a Representative in Congress from the State of Florida and Member of the Subcommittee on Legislative and Budget Process. Rob Woodall, a Representative in Congress from the State of Georgia and Ranking Member of the Subcommittee on Legislative and Budget Process. Alcee Hastings, a Representative in Congress from the State of Florida and Chairman of the Subcommittee on Legislative and Budget Process. Bill Woolf, Executive Director, Just Ask Prevention & Director, National Human Trafficking Intelligence Center. Additional Material Submitted for the Record: Statement from Congresswoman Wasserman Schultz dated December 11, 2019. Curriculum Vitae and Truth in Testimony Forms for Witnesses Testifying Before the Committee. Present: Representatives Hastings, Morelle, Scanlon, Shalala, McGovern, Woodall, and Burgess. The Subcommittee on Legislative and Budget Process of the committee on rules will come to order. I also want to thank my colleague and friend Alcee Hastings from Florida, the distinguished chair of the subcommittee, for his leadership, as well as the chair of the full committee, Mr. I apologize in advance if I have to leave the room before we adjourn as I am managing a rule on the floor this afternoon. With the help of this expert panel, we will learn about the issue of human trafficking. Human trafficking is a worldwide issue, with millions of men, women, and children forced into labor, the sex trade, drug smuggling, and other forms of exploitation. Large sporting events that draw huge audiences of out-of-town visitors often serve as magnets for human trafficking, fueling a multibillion dollar criminal industry. As this vile industry grows, municipalities, counties, States and countries around the world have expanded their efforts to combat human trafficking by focusing on these events. Sometimes dubbed the largest human trafficking event in the United States, the Super Bowl presents an opportunity to begin a conversation on human trafficking and highlight the efforts of Miami-Dade County and other communities across the Nation to eliminate this epidemic. The Super Bowl happens one day a year, but we must be vigilant about combating human trafficking every day. We need to examine the resources available in the effort to combat human trafficking in every community year-round. Today, we will learn about the complexities of combating human trafficking, the ways the Federal Government is assisting local law enforcement, and the additional resources that are needed for prevention. I look forward to exploring these questions and learning from you as we seek to develop effective solutions. And the kind of collaboration that came together in my home State is something that I am just incredibly proud of. And I know we can always do better, and so I am very pleased that we have got such a distinguished panel to talk about that. Our folks who testify in the Rules Committee are the chairman who is bringing legislation and the ranking member who is either collaborating on that legislation or vehemently opposed to that legislation. I am so looking forward today to a nonpartisan issue, something that we are all invested in. We may come to it from a different perspective, but we all have the same goal in mind. And that is certainly the way that Secretary Shalala has led in her time here on this committee, and I look forward to that leadership today. When it comes time to introduce our witnesses, I brought one of our very best from Atlanta, a gentleman who leads an absolutely fabulous organization that has a tremendous record of partnership. And I want to thank both Chairman Hastings and Representative Shalala for bringing us together today on this very important issue. Chairman Hastings has been a leader in this fight against human trafficking for much of his career, using his other chairmanship at the Helsinki Commission to make a difference on an issue as difficult, complex, horrifying and important as this one, and I want to thank him for his leadership. I serve as the co-chair of the Tom Lantos Human Rights Commission with my colleague from New Jersey, Congressman Chris Smith. And for that chairmanship and, believe it or not, this chairmanship too, I work every day to promote these goals: That every person must be free, free of persecution, free from manipulation and free from coercion, and every person deserves dignity, respect, and autonomy to achieve the destiny of their choosing. And all of us, every single one of us plays a role in achieving a freer, fairer world. And so to our witnesses, I want to thank you for the work that you do to end human trafficking and to help survivors reclaim and reengineer their lives. When any major event like the Super Bowl comes to town, Federal attention and resources flow into the community. And it is important for Congress to understand the role our Federal agencies play, how Federal resources are assisting local communities and how we can do more together to stop human trafficking. It is also important that we understand that human trafficking is a 365-day-a-year problem that requires a 365-day-a-year solution. As we here in Congress work to find solutions, we would be wellserved to ask ourselves how our silos might inhibit our thinking about how to direct resources to help communities address trafficking. And so, again, this is an incredibly important topic, and I think we are all grateful that you have come here to give us your expertise and advice. When I see the person I call Donna all the time, I think of all the titles that she has, president and Secretary and now Congress people and whatever. It is sort of like at one point I was a judge and I was a lawyer and I had letters of doctorate, and people would ask me, say, what do you want to call me? We are here today to address human trafficking around major events like the Super Bowl. I have been at parties for the Super Bowl a week in advance and got hung over and was a week later as well. The need for Congress to prioritize fighting this heinous form of modern day slavery is urgently clear. The United States has one of the highest rates of human trafficking in the world, but this is a local, not just a global problem. There have been incidents of trafficking identified in all 50 States and Washington, D. I am painfully aware that my home State of Florida is facing this epidemic on a daily basis and have long fought to boost both awareness and prevention efforts for this very reason. And the State attorney of Miami has done some forward-leaning things that I am sure she is going to tell us about at the instance of working with attorney general of the State of Florida. However, there is still much to do to address this epidemic in Florida and across our Nation. As presentations for the Super Bowl continue in Miami, it is imperative that we do everything we can to better understand how we can protect our communities and our children from the horrors and trauma of human trafficking. And, Madam Chair, with your permission, I would like to introduce into the record a statement of our colleague Debbie Wasserman Schultz and also her statement in support of the effort that she has made, states hundreds of trafficking cases last year, she says, and south Florida is one of the worst epicenters for this heinous crime. The Congresswoman is currently working on legislation which mandates trafficking awareness and intervention training to hotel employees. We need to pay attention to other places where this activity flourishes, particularly around bars. Most importantly, it will include a provision of enforcement so that hotels will be held accountable or have an opportunity to amend their wrongdoing. Thank you for holding this hearing and for the opportunit} to submit this statement on the devastating effect of Human Trafficking in Florida and throughout the U. Human trafficking is an abhorrent scourge and the United States government must do cve,ything in its power to rescue its victims. That is why I have dedicated so much of my time as a legislator to addressing this issue. Many Americans assume human trafficking is something that occurs only in developing countries. Human trafficking as an industry generates $150 billion in illegal profits each year. Those who are most likely to be targeted are low-income women, foster youth, younger females, and girls and women with a history of abuse and estrangement from their families. Unfortunately, South Florida has become a hotbed for this heinous criminal activity. National reports have placed South Florida as the area with the third-highest rate of human trafficking in the entire na! These statistics were the key driver to one of my signature legislative victorie, during my time in the Florida Senate. I thank my colleagues here today for recognizing the sense of urgency in addressing trafficking at the federal level. We canno1 stand idly by and allow this to happen to countless victims in our communities I was proud to join with Chairman Hastings to introduce the Human Trafficking nnd Explmtation Prevention Training Act of2019, which will require school curricula to include training for s! I applaud him for his unwavering ctl~,rts to provide the necessary tools to our students, and I urge the House to take up this legislation immediately. Accordmg 10 an Arizona Stale University study on human trafficking and the 2014 Superbowl, the Super Bowl provides a significanl concentration of people in a relatively confined urban space, and therefore becomes a more desirable location for a trafficker to bring their victims. This legislation will support not only our efforts during 1he Superbowl but will provide the hotel industry and others with the tools to recognize and stop human trafficking in its tracks. The statistics remain alarming and make crystal clear that we must lack le trafficking head-on, with a clear sense of purpose. I look forward to working with my colleagues on the most effective ways lo combat this scourge. I am going to have to go to another meeting, but I did want to-and I will submit these questions in writing, but I want to just speak to them just if I could to give you some context and background. And some of the most compelling testimony that I heard was one morning when we had two witnesses from Central America, who were speaking through translators, and they had been brought to this country and trafficked and used for the worst purposes, but they were trafficked by family members. But I think even just an awareness that this could happen and a patient where they are not allowed to speak for themselves. Some of these things ought to be red flags and ought to be conveyed, whether it is through our professional organizations or medical schools, but this is, unfortunately, something that all of us could see during a typical practice time. I mean, these were ladies who were trafficked by transnational gangs, but then their family members were involved in their trafficking. Chairman, and my colleague Representative Shalala as well as Chairman McGovern for organizing this. I know that in New York, when I was a State legislator, we took a number of steps at the State level to provide resources for victims and also to strengthen State laws. This is clearly a Federal and international problem and deserves a Federal response. So I just appreciate the witnesses being here, and I am looking forward to their testimony. In this role, she leads the Human Trafficking Task Force, a cooperative multiagency law enforcement effort. She has built a comprehensive model of healthcare for survivors of human trafficking. Bill Woolf is executive director of Just Ask Prevention and director of the National Human Trafficking Intelligence Center. Chairman McGovern, Secretary Shalala, Ranking Member Woodall, Congressman Hastings, committee members and staff, thank you for the opportunity to discuss the need to address human trafficking in the United States. I am an immigration attorney by training, with 20 years of experience in addressing violence and exploitation, including human trafficking, within the United States. Our members include survivors themselves as well as former prosecutors, civil and criminal attorneys, and social service providers, who work with over 2,000 trafficking survivors each year. I have provided detailed recommendations in my written statement, but I will summarize those briefly now. The unfortunate truth is that no jurisdiction in the United States is successfully and comprehensively addressing human trafficking, which includes compelled work in a wide variety of industries, both legal and illicit. While it is important to note that there has been an increased understanding of sex trafficking across the United States, labor trafficking, especially child labor trafficking, continues to be mostly ignored. Immigrants are most often victims of labor trafficking with, for example, predominantly women exploited in domestic work and men in agriculture. However, our understanding of the full complexities of victim populations is incomplete, and some of our policy efforts are unintentionally exacerbating this problem. The focus on child sex trafficking, while laudable and important, has, unfortunately, created a dangerous feedback loop. The Preventing Sex Trafficking and Strengthening Families Act of 2014, for example, specifically requires the identification and reporting of child sex trafficking only in the child welfare system. This demonstrates how important it is to design approaches and solutions that both focus on the most prominent problems without ignoring or excluding any victims. While the Super Bowl brings us here today, it is not the cause of human trafficking, and trafficking will not end when the players leave the field or Mr. It is happening in our homes, our stores, our restaurants, our fields and factories and on our streets all across America. We can, however, use the energy and attention of sporting events to bring attention and resources to this issue, but we must do so responsibly, focusing on the true facts before us. Investigations and prosecutions are up, with State laws allowing for more jurisdictions to bring cases. However, services continue to be insufficient and focus on shortterm services instead of long-term recovery. Prosecutions of labor trafficking are stagnant at best, and too often law enforcement resources designated for sex trafficking are squandered on arresting sex workers and buyers without identifying a single trafficking victim or the high-level traffickers who remain in operation. Survivors continue to be arrested for the crimes they commit that their traffickers have forced them to commit, only to then be trapped in a cycle of dependency and poverty by those criminal records while they are denied legal relief from these charges. We have also failed to address primary prevention in a comprehensive way to change the factors that are putting people at high risk of human trafficking.

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