In rare cases antimicrobial therapy publisher generic zithromax 500 mg on-line, the left ventricle and in particular the apex may also be involved antibiotic home remedies buy 500mg zithromax overnight delivery. It is an inherited progressive disease which may eventually lead to heart failure antibiotic spray cheap zithromax 250 mg mastercard. However bacteria 3 in urine buy 500mg zithromax fast delivery, lethal arrhythmias are quite often the first clinical manifestation of the disease. Myocardial ischaemia secondary to an exaggeration of the sharp angle in the aberrant origin occurring with exercise, especially as the artery traverses an expanded aorta and pulmonary arterial trunk, may lead to anginal chest pain, syncope or pre-syncope. Various non-invasive stress tests are available to detect exercise-related myocardial ischaemia. Coronary angiography is the gold standard for evaluation of the coronary arteries including their origin and course, but it is only used in athletes if a diagnosis has been made and therapeutic measures are considered. So-called channelopathies, inherited arrhythmia syndromes due to mutations in genes coding for ion-channels within the conduction system, are of increasing importance. Arrhythmic events (mostly polymorphic ventricular tachycardia) occur more commonly at night than during the day and more commonly during sleep than while awake. Commotio cordis occurs as a result of a blunt, non-penetrating blow to the chest. It is most common in children and adolescents (mean age 13), since these age groups characteristically have compliant chest walls that appear to facilitate the transmission of the energy from the chest blow to the myocardium. Animal experiments attempting to replicate commotio cordis have shown that a blow must hit the chest wall directly over the heart and occur within 15 to 30 milliseconds before the T-wave peak (about 1% of the duration of the cardiac cycle) which represents the vulnerable phase during repolarisation. Prevention Football Medicine Manual 107 ideally identify any unknown risk in a player. However, as mentioned previously, there is no consensus on the ideal pre-participation medical assessment for every athlete in all sports. For example, medical history (including personal and family history) and a focused clinical examination are widely accepted as the basis and cornerstone of every such assessment. It has been suggested that a proper medical history alone may identify up to 75% of problems that affect athletes. Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Depending on resources, competition level and objectives, as well as in pilot studies to obtain specific data, the use of echocardiography might well be indicated. Exercise stress tests are not recommended as a primary diagnostic tool in pre-competition medical assessment, but may provide further information on specific clinical questions (see. In an ideal world, screening by medical assessment should start at the beginning of competitive player activity. The screening should then be repeated on a regular basis every one to two years for the timely identification of diseases which are only detectable after progression over time. Once a significant pathology has been identified, adequate risk assessment and therapy have to be implemented and recommendations for physical activity following established guidelines. However, the organisational, logistical, legal and not least financial issues and conditions in football worldwide might in fact not be in favour of pursuing this ideal strategy in all countries, and football has to investigate alternative feasible ways to protect players globally as much as possible. At the same time, any declaration of ineligibility for football may represent a personal disaster for a talented or ambitious player. The higher the level of competition and the more parties and interests involved, the more complex decisions on eligibility become. Careful decision-making based on official and widely accepted recommendations developed by consensus groups is therefore indispensable. Besides the predisposing anomalies that have been discussed in detail in this chapter, other cardiovascular findings such as rhythm and conduction abnormalities, hypertension, congenital and rheumatic heart diseases, and peri-/myocarditis may also lead to non-eligibility for competitive sports. However, recent findings show that football players, though less often than athletes in other sports, are also dieting and suffering from eating disorders, menstrual dysfunction and stress fractures. Therefore, team physicians should have a basic knowledge of how to prevent the triad and be aware of the warning signs. Each of the components in itself causes considerable morbidity, but all three together have a synergistic negative effect on health. Elite players and those girls and women who train particularly hard are at the highest risk. Pathogenesis Pressure to reduce weight is a common explanation for the frequent eating disorders among athletes. A significantly lower percentage of football players compared to handball and endurance athletes reported eating disorders (Table 2. Prevention Football Medicine Manual weight-cycling, early start of sport-specific training, personality factors, injury, a sudden increase in training volume and certain coaching behaviours. However, losing weight does not necessarily lead to improved performance but to unfavourable energy deficits. It has to be stressed that prolonged energy deficits cannot be sustained without harm to health and performance. The body has no automatic mechanism for matching energy intake to activity-induced energy expenditure. Inadvertent energy deficits may sometimes occur without an eating disorder or even without any dietary restriction. Most athletes with energy deficits, however, consciously reduce dietary energy intake without reducing their energy expenditure on exercise, while others increase energy expenditure on exercise without increasing their energy intake. The susceptibility of the reproductive axis to exerciseand diet-related stresses varies considerably among individuals. Irregular menstrual bleeding and amenorrhea due to suppressed levels of oestrogen can be a consequence of intense exercise and low energy intake and/or high psychological and physical stress. In the long run, irreversible damage to the reproductive system is to be expected. Any factor that contributes to menstrual dysfunction can have a direct or indirect influence on bone density. Symptoms and signs Disordered eating behaviour is characterised by disturbances in eating patterns, body image, emotions and relations. Some athletes practise abnormal eating behaviours including fasting, vomiting, diet pills, laxatives, diuretics and enemas. Anorexia nervosa is the extreme of restrictive eating where individuals continue to starve themselves when far below an ideal body weight. Bulimia refers to a cycle of food restriction or fasting followed by excessive eating, self-induced vomiting and use of laxatives. As opposed to anorectic patients, bulimic patients are more often of normal weight or might be even overweight. Undernourishment and eating disorders may cause serious medical problems and can even be fatal. Low energy intake may delay recovery from exercise, impair adaptation to training stimulus and compromise the immune system and reproductive function. The loss of fluids and electrolytes during purging can lead to dehydration, acidbase abnormalities and cardiac rhythm disturbances. Menstruation disorders range from irregularities to missed periods and amenorrhea. Influence on performance In football, the relationship between carbohydrate intake and the ability to maintain high intensity work, especially in the second half of the match, is well known. Low carbohydrate availability reduces performance and can lead to reduced skill and judgement, leading to more errors during the match. Therefore, it is important to maximise glycogen storage before and during the match. Prolonged energy deficits leading to menstrual dysfunction may cause muscle weakness, reduced performance and stress fractures. Dehydration and electrolyte abnormalities decrease coordination, balance and muscle function. Prophylaxis the team physician should continuously educate players on the importance of a diversified diet providing sufficient energy for match play, training and other activities.
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The hypoglycem ic ef fects of repaglinide may be increased and prolonged if taken with gemfibrozil antibiotic xi generic zithromax 250 mg on line. These drugs include atorvastatin bacterial vaginosis discount 100 mg zithromax with amex, fluvastatin antibiotics ointment buy zithromax 250 mg cheap, lovastatin infection x girl generic zithromax 500mg free shipping, pravastatin, rosuva statin, a nd simva statin. With the exception of pravastatin, a ll are highly bound to pla sma proteins and undergo extensive first -pass metabolism. Drug interactions Taking a sta tin drug with amiodarone, clarithromycin, cyclosporine, erythrom ycin, fluconazole, gem fibrozil, itraconazole, ketoconazole, or niacin increases the risk of myopathy or rhabdomyolysis (a potentially fatal brea kdown of skeletal muscle, causing renal failure). Lovastatin, rosuvastatin and simvastatin may increase the risk of bleeding when administered with warfarin. All of these drugs should be a dministered 1 hour before or 4 hours after the administration of bile-sequestering drugs (cholestyramine, colesevelam, and colestipol). Myalgia is the m ost common musculoskeleta l effect, although arthralgia and muscle cramps may also occur. Myopathy and rhabdomyolysis are rare, but potentia lly severe, reactions tha t may occur with these drugs. The drug undergoes rapid meta bolism by the liver to a ctive and ina ctive metabolites. Pharmacodynamics the mechanism of a ction by which nicotinic acid lowers triglyceride and a polipoprotein levels is unknown. However, it may work by inhibiting hepatic synthesis of lipoproteins that conta in apolipoprotein B -100, promoting lipoprotein lipase activity, reducing f ree fatty a cid m obilization f rom adipose tissue, and increasing f ecal elimination of sterols. Nicotinic a cid is contra indicated in patients who are hypersensitive to nicotinic acid and in those with hepatic dysfunction, active peptic ulcer disease, or arterial bleeding. Adverse reactions to nicotinic acid High doses of nicotinic acid ma y produce vasodilation and cause f lushing. Extendedrelease forms tend to produce less severe vasodilation than immedia terelease forms do. To help minimize flushing, administer aspirin 30 m inutes before nicotinic acid, or give the extendedrelea se f orm at night. Nicotinic a cid can cause hepatotoxicity; the risk of this adverse reaction is greater with extended -release forms. Other adverse rea ctions include nausea, vom iting, dia rrhea, and epigastric or substernal pain. Bile-sequestering drugs (cholestyra mine, colesevela m, and colestipol) ca n bind with nicotinic acid and decrease its effectiveness. Pharmacokinetics Ezetimibe is rapidly a nd extensively absorbed f ollowing oral administration. Pharmacodynamics Ezetimibe reduces blood cholesterol levels by inhibiting the absorption of cholesterol by the small intestine. This leads to a decrease in delivery of intestinal cholesterol to the liver, reducing hepatic cholesterol stores a nd increa sing clearance from the blood. Pharmacotherapeutics Ezetimibe m ay be administered alone or with dietary changes to treat primary hypercholesterolemia and homozygous sitosterolemia (heredita ry hyperabsorption of cholesterol a nd pla nt sterols). Adverse reactions to cholesterol absorption inhibitors the most com mon adverse reactions include: fatigue abdominal pa in and diarrhea pharyngitis and sinusitis arthralgia back pa in cough. Drug interactions Ezetimibe a dministered with cholestyra mine may lea d to decreased effectiveness of ezetimibe. Ezetimibe a dministered with cyclosporine, f enofibrate, or gemf ibrozil leads to increased levels of ezetimibe. Coagulation studies 3 A patient dia gnosed with hypertension is m ost likely to be prescribed which cla ss of drugs first? Angiotensin -converting enzyme inhibitor 4 Nitrates a re the drug of choice f or relieving acute angina. Types of drugs used to treat disorders of the hematologic system include: hematinic anticoagulant thrombolytic. They do so by increasing hemoglobin, the necessary element for oxygen transportation. Iron preparations discussed in this section include f errous f umarate, f errous gluconate, ferrous sulfate, iron dextran, a nd sodium f erric gluconate complex. Pharmacokinetics (how drugs circulate) Iron is absorbed primarily from the duodenum and upper jejunum of the intestine. On the other hand, when total iron stores a re la rge, the body a bsorbs only a bout 5% to 10% of the iron available. Hemoglobin has it Iron is transported by the blood and bound to tra nsferrin, its carrier plasma protein. About 30% of the iron is stored primarily as hemosiderin or ferritin in the reticuloendothelial cells of the liver, spleen, a nd bone m arrow. Excess iron is excreted in urine, stool, sweat, and through intestinal cell -sloughing. Pharmacodynamics (how drugs act) Although iron ha s other roles, its most importa nt role is the production of hemoglobin. Pharmacotherapeutics (how drugs are used) Oral iron therapy is the preferred route for preventing or treating iron deficiency anemia. Pregnant women may need iron supplements to replace the iron used by the developing fetus. Adverse reactions to iron therapy the most com mon adverse reactions to iron thera py a re ga stric irritation and constipation. Iron preparations also darken stool, a nd liquid preparations ca n stain the teeth. The most serious reaction is anaphylaxis, which may occur after administration of parenteral iron. To guard a gainst such a reaction, administer an initial test dose bef ore giving a f ull-dose inf usion. Pa tients with end -stage rena l disease who are receiving hemodia lysis may a lso receive parenteral iron therapy at the end of their dialysis session. Iron preparations a vailable for parenteral administration are iron dextra n (given by I. Other drug interactions involving iron include: Absorption of tetracyclines (demeclocycline, doxycycline, minocycline, oxytetracycline, a nd tetra cycline), methyldopa, quinolones (ciprof loxacin, levofloxacin, lomef loxacin, moxifloxacin, norf loxacin, ofloxacin, and spa rfloxacin), levothyroxine, a nd penicillamine m ay be reduced when taken with oral iron preparations. To test for drug sensitivity and prevent serious reactions, always give a test dose of iron dextran before beginning thera py. To trea t anaphylaxis, keep epinephrine a nd standa rd emergency equipment readily a vailable. Pharmacokinetics Vitamin B 12 is available in pa renteral, ora l, and intranasal forms. For the body to a bsorb oral forms of vita min B 12, the gastric m ucosa must secrete a substance called intrinsic factor. People who have a def iciency of intrinsic factor develop a specia l type of anemia known a s vitamin B 12 -deficiency pernicious anemia. Although hydroxocobalamin is absorbed m ore slowly from the injection site, its uptake in the liver ma y be greater tha n that of cya nocobalamin. Most gets lost With either drug, the liver slowly releases vitamin B 12 as needed by the body. About 3 to 8 mcg of vitamin B 12 are excreted in bile each day and then reabsorbed in the ileum. Within 48 hours after a vitamin B 12 injection, 50% to 95% of the dose is excreted unchanged in urine. Pharmacodynamics When vitamin B 12 is administered, it replaces vita min B 12 that the body would norma lly absorb from the diet. This vita min is essentia l for cell growth a nd replica tion a nd f or the maintenance of m yelin (nerve coverings) throughout the nervous system. Pharmacotherapeutics Cyanocobalamin and hydroxocobalamin a re used to treat pernicious anemia, a megaloblastic a nemia characterized by decrea sed gastric production of hydrochloric a cid and intrinsic f actor deficiency. Intrinsic factor, a substance normally secreted by the parietal cells of the ga stric mucosa, is essentia l f or vitamin B 12 absorption.
Attention- deficit/hyperactivity disorder in relation to addictive behaviors: A moderated-mediation analysis of personality risk factors and sex antibiotic 5 day pack purchase zithromax 100 mg online. Self-esteem in adolescent patients with attention-deficit/hyperactivity disorder during open-label atomoxetine treatment: psychometric evaluation of the Rosenberg Self-Esteem Scale and clinical findings antibiotics for acne list cheap zithromax 250mg visa. Caloric and nutrient intake in children with attention deficit hyperactivity disorder treated with extended-release methylphenidate: analysis of a crosssectional nutrition survey virus facebook cheap zithromax 500 mg otc. Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings virus que causa el herpes purchase 250 mg zithromax mastercard. Atomoxetine response in the inattentive and combined subtypes of attention deficit hyperactivity disorder: a retrospective chart review. Clinical and cognitive response to extended-release methylphenidate (Medikinet) in attention deficit/hyperactivity disorder: efficacy evaluation. A long-term open-label safety and effectiveness trial of lisdexamfetamine dimesylate in adolescents with attention-deficit/hyperactivity disorder. Effectiveness, safety, and tolerability of lisdexamfetamine dimesylate in children with attention-deficit/hyperactivity disorder: an openlabel, dose-optimization study. A 6-month, open-label, extension study of the tolerability and effectiveness of the methylphenidate transdermal system in adolescents diagnosed with attention-deficit/hyperactivity disorder. Time course and predictors of health-related quality of life improvement and medication satisfaction in children diagnosed with attentiondeficit/hyperactivity disorder treated with the methylphenidate transdermal system. Mediators of methylphenidate effects on math performance in children with attention-deficit hyperactivity disorder. Long-term quality-of-life and functioning comparison of atomoxetine versus other standard treatment in pediatric attention-deficit/hyperactivity disorder. Methylphenidate treatment in children with attention deficit hyperactivity disorder and comorbid social phobia. Switching from immediate release to sustained release methylphenidate in the treatment of children and adolescents with attention deficit/hyperactivity disorder. Atomoxetine in children with attention-deficit hyperactivity disorder with prior stimulant therapy: a prospective open-label study. Do stimulants reduce the risk for cigarette smoking in youth with attention-deficit hyperactivity disorder? Long-term treatment with atomoxetine for attention-deficit/hyperactivity disorder symptoms in children and adolescents with autism spectrum disorder: an open-label extension study. Treatment of attention deficit hyperactivity disorder with monoamine amino acid precursors and organic caution transporter assay interpretation. Developmental progression to early adult binge drinking and marijuana use from worsening versus stable trajectories of adolescent attention deficit/hyperactivity disorder and delinquency. Neuroimaging-Aided Prediction of the Effect of Methylphenidate in Children with Attention-Deficit Hyperactivity Disorder: A Randomized Controlled Trial. Equine-Assisted Activities and Therapy for Treating Children with Attention-Deficit/Hyperactivity Disorder. Methylphenidate-risperidone combination in child psychiatry: A retrospective analysis of 44 cases. Clinical outcomes from an open-label study of edivoxetine use in pediatric patients with attention-deficit/hyperactivity disorder. Predicting methylphenidate response in attention deficit hyperactivity disorder: a preliminary study. Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants. Adverse reactions of Methylphenidate in children with attention deficit-hyperactivity disorder: Report from a referral center. Ritalin((R))) in Children and Adolescents with Attention Deficit Hyperactivity Disorder: A Double-Blind, Randomized Clinical Trial. The relationship between symptomatic and functional changes of Korean children and adolescents with attention-deficit/hyperactivity disorder treated with osmotic-controlled release oral delivery system-methylphenidate. Changes of Heart Rate Variability during Methylphenidate Treatment in Attention-Deficit Hyperactivity Disorder Children: A 12-Week Prospective Study. Effect of methylphenidate on height and weight in Korean children and adolescents with attention-deficit/hyperactivity disorder: a retrospective chart review. Baduk (the game of go) improved cognitive function and brain activity in children with attention deficit hyperactivity disorder. Effects of methylphenidate on working memory functioning in children with attention deficit/hyperactivity disorder. A Survival Analysis of Psychostimulant Prescriptions in New South Wales from 1990 to 2010. A brain-computer interface based attention training program for treating attention deficit hyperactivity disorder. The effect of methylphenidate on sustained attention among adolescents with attention-deficit hyperactivity disorder. Parent training in reduction of attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms in children. Injury prevention by medication among children with attention-deficit/hyperactivity disorder: a case-only study. Long-term effects of short-acting methylphenidate on growth rates of children with attention deficit hyperactivity disorder at Queen Sirikit National Institute of Child Health. Effect of osmotic-release oral system methylphenidate on learning skills in adolescents with attention-deficit/hyperactivity disorder: an open-label study. Stimulant medication effects on growth and bone age in children with attention-deficit/hyperactivity disorder: a prospective cohort study. Growth and pubertal development of adolescent boys on stimulant medication for attention deficit hyperactivity disorder. Effect of methylphenidate treatment on appetite and levels of leptin, ghrelin, adiponectin, and brain-derived neurotrophic factor in children and adolescents with attention deficit and hyperactivity disorder. Factors associated with atomoxetine efficacy for treatment of attention-deficit/hyperactivity disorder in children and adolescents. Reading outcomes of children and adolescents with attention-deficit/hyperactivity disorder and dyslexia following atomoxetine treatment. Remission Rate and Functional Outcomes during a 6-Month Treatment with Osmotic-Release Oral-System Methylphenidate in Children with AttentionDeficit/Hyperactivity Disorder. Does placebo response differ between objective and subjective measures in children with attention-deficit/hyperactivity disorder. Tolerability of atomoxetine for treatment of pediatric attention-deficit/hyperactivity disorder in the context of epilepsy. Predictors of pharmacological treatment outcomes with atomoxetine or methylphenidate in patients with attention-deficit/hyperactivity disorder from China, Egypt, Lebanon, Russian Federation, Taiwan, and United Arab Emirates. Long-term effects of stimulants on neurocognitive performance of Taiwanese children with attention-deficit/hyperactivity disorder. Executive function deficits in children with attentiondeficit/hyperactivity disorder and improvement with lisdexamfetamine dimesylate in an openlabel study. Naturalistic exploration of the effect of osmotic release oral system-methylphenidate on remission rate and functional improvement in Taiwanese children with attention-deficit-hyperactivity disorder. Efficacy of Strattera in children and adolescents with attention deficit hyperactivity disorder. Treatment of Attention Deficit/Hyperactivity Disorder among Children with Special Health Care Needs. No elevated genomic damage in children and adolescents with attention deficit/hyperactivity disorder after methylphenidate therapy. Gender Differences in the Behavioral Symptoms and Neuropsychological Performance of Patients with Attention-Deficit/Hyperactivity Disorder Treated with Methylphenidate: A Two-Year Follow-up Study. Neurocognitive performance and behavioral symptoms in patients with attention-deficit/hyperactivity disorder during twenty-four months of treatment with methylphenidate. Clinical symptoms and performance on the Continuous Performance Test in children with attention deficit hyperactivity disorder between subtypes: a natural follow-up study for 6 months. Salivary neurosteroid levels and behavioural profiles of children with attention-deficit/hyperactivity disorder during six months of methylphenidate treatment.
However antibiotics for uti in breastfeeding discount 100mg zithromax otc, they often remain under the radar due to unofficial migration bacteria make gold trusted zithromax 100 mg, which can mean they have little access to legal aid or help from Nepali authorities antibiotic beginning with c order zithromax 250mg otc. The government continued to report on a steady number of deaths of migrant workers in the Middle East and Southeast Asia virus map discount 500mg zithromax otc, many of whom labor under harsh conditions and without access to proper health care. An August report by the Ministry of Labour, Employment and Social Security stated that, on average, two migrant workers have died every day during the last seven years, primarily, but not exclusively, in the Gulf states. Although the government has provided some restitution to families of migrant workers who died or suffered severe injury, it has failed to implement its stated policy of providing legal aid to workers accused of crime in host countries. Failure to properly combat the exorbitant fees charged by migration agencies means that many Nepalis remain in debt. Most victims survived through several monsoons and winters without any proper shelter. New Criminal Code the government replaced the outdated national legal code, known as the Muluki Ain, with a new criminal code that came into effect in August, although implementation laws still must be passed to bring it fully into effect. Activists and journalists were concerned that certain regressive provisions in the new law criminalize normal news-gathering activities, such as reporting on public figures, including through satire. Himal Southasian, a monthly magazine, was forced to relocate its headquarters from Nepal to Sri Lanka in 2018 following threats from the government to shut it down. Although the constitution recognizes sexual orientation and gender identity as protected through fundamental rights, the criminal code failed to repeat the protection clause, which contradicts the constitution. Additionally, although Nepal has in many ways been at the forefront of protecting the rights of sexual minorities-including by legally recognizing a third gender category based solely on self-identification-the new law only recognizes marriage rights as being between a man and woman. Disability Rights Many children with mental and physical disabilities study in separate schools or classrooms and do not receive quality inclusive education because schools lack physical accessibility, teachers trained in inclusive education, accessible educational materials, and other supports. In 2017, Nepal adopted the Disability Rights Act and an Inclusive Education Policy, which calls for children with disabilities to study without discrimination in their communities. In 2016, the government launched a national strategy to end child marriage by 2030, but action on operationalizing and implementing the plan has since stalled. A crackdown by national police and armed progovernment groups in 2018 left 300 dead, over 2,000 injured, and hundreds arbitrarily arrested and prosecuted. Stacked with his supporters, the Electoral Council barred political parties and removed opposition lawmakers. The Supreme Court of Justice has upheld Electoral Council decisions undermining political rights and allowed Ortega to circumvent a constitutional prohibition on re-election and run for a second term. His party secured a 79 percent majority in Congress in 2016, enabling it to fast-track institutional reforms that gave the president direct personal control over the police and army, allowed him to legislate by decree, and run for indefinite re-election. Key International Actors the Nepal government continued talks with India to renegotiate trade and border treaties to prevent blockade on essential goods. In April, China offered infrastructure and development assistance under its One Belt, One Road initiative, including a railway link from Lhasa in Tibet all the way through Nepal to the border with India. While the railway could offer significant opportunities, many in civil society voiced concerns over the impact on communities that would be displaced as a result, and its lack of key human rights safeguards. Restrictions on free assembly and expression rights for the Tibetan community continued under sustained political pressure from China. Crackdown on Dissent In April, massive anti-government protests broke out countrywide. Police, in coordination with armed pro-government groups, brutally repressed them, killing hundreds, and injuring several thousand. Government forces were responsible for most of the 324 people killed as of September, a figure that included 23 children, and for most of the over 2,000 injured. Public hospitals under the purview of the Ministry of Health denied or obstructed medical care for wounded protesters. In some cases, the whereabouts of detainees were not confirmed for up to two weeks, constituting enforced disappearances during the time they were missing. National Police subjected protesters to abuses that at times amounted to torture, including beatings, waterboarding, electric shocks, and rape. As the crackdown intensified, some individuals responded violently and 22 police officers died between April and September, according to official statistics. High level officials repeatedly accused protesters of being "terrorists" or "attempting to overthrow the government. Among these were 136 people accused of terrorism-related offenses, some under the new counterterrorism law that the legislature enacted in July. Public officials repeatedly made stigmatizing statements to undermine the credibility of defenders. In July, during a public address, Ortega referred to prominent Catholic bishops who have denounced government abuses as "assassins" and "coup-plotters. In August, for example, police detained Emilia Mello, a Brazilian-American documentary filmmaker in Carazo, confiscated her equipment, interrogated her for several hours, and deported her the next day. Political Discrimination During the crackdown, the Nicaraguan Health Ministry authorities fired at least 135 doctors, nurses, and other health workers from several public hospitals in apparent retaliation for participating in protests or otherwise expressing disagreement with government policy. As of November, another 11,383 people had been given an appointment to seek asylum. The 2006 total abortion ban penalizes women and girls who have abortions with prison terms of up to two years. The penalties for medical professionals range from one to six years in prison for providing abortions. A 2008 legal challenge submitted to the Supreme Court argued that the ban was unconstitutional. The court never ruled on this case, nor on a similar one regarding the 2014 constitution. The abortion ban remains in place and forces women and girls facing unwanted pregnancies to have clandestine abortions, at great risk to their health and lives. Numerous other states, including Australia, Costa Rica and Iceland, raised similar concerns during their statements in their individual capacity. Abductions, suicide bombings, and attacks on civilian targets by Boko Haram persisted. At least 1,200 people died and nearly 200,000 were displaced in the northeast in 2018. In June, at least 84 people were killed in double suicide bomb attacks attributed to Boko Haram at a mosque in Mubi, Adamawa State. Decades old communal conflict between nomadic herdsmen and farmers in the Middle Belt intensified in 2018 and further exacerbated the security situation in the country. At least 1,600 people were killed and another 300,000 displaced as a result of the violence. In February, insurgents abducted 110 schoolgirls from Dapchi, Yobe State, in a style reminiscent of the 2014 abduction of 276 Chibok school girls. One hundred and four of the Dapchi girls were released two weeks later after negotiations with the government. Five of the remaining girls reportedly died in captivity and one girl, Leah Sharibu, continues to be held hostage allegedly for refusing to deny her Christian faith. Over 35,000 internally displaced people returned to northeast communities despite security concerns and lack of basic necessities, including food and shelter. Between October 2017 and July 2018, authorities conducted three rounds of trials of over 1,500 Boko Haram suspects in a military base in Kainji Niger State. Some defendants had been in detention since 2009 and the majority faced charges of material and non-violent support to Boko Haram. The trials were fraught with irregularities, including lack of interpreters, inadequate legal defense, lack of prosecutable evidence or witnesses and non-participation of victims. Inter-Communal Violence Recurring violence between herdsmen and farmers, as well as related cattle theft and banditry in many northern states, including Zamafara and Kaduna, posed serious threats to peace and security. Although the violence is increasingly described in religious terms, competing claims to land and other resources are at its core. In June, a typical reprisal attack began after farmers allegedly killed five herdsmen for allegedly trespassing on farms in Plateau state. In apparent retaliation, herdsmen attacked villages in the area, killing 86 and injuring hundreds, including women and children. In September, suspected herdsmen killed 51 people and abducted about 24 others in Numan, Adamawa State.
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