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Karen R. Burns, PhD * , University of Georgia, Anthropology Department, Baldwin Hall, Athens, GA 30602 After attending this presentation, attendees will find that they look at routine sex determination of skeletal remains from a more critical perspective. This appealing historical case highlights the problem of gender assignment and identification. It alerts the identification scientist to the wide range of sexual presentations confounding easy male female recognition. Attendees will have examples of specific syndromes to consider. This presentation will impact the forensic community and or humanity by demonstrating the problems created by ambiguous genitalia and gender misidentification and the symptoms of congenital adrenal hyperplasia. It is reasonably well known that determination of sex from skeletal remains is population dependent and sometimes ambiguous. But even the seemingly unambiguous cases can be confounded by life styles or congenital anomalies. Casimir Pulaski was a Polish nobleman and an accomplished equestrian, trained in the finest of European military traditions. He was known to be adventurous, reckless, and yet reclusive. In 1768, he began his command of Polish forces in the fight for independence from Russia. After being condemned to death for his efforts, he fled to France where he was recruited for the cause of American independence. Pulaski became the first U.S. Calvary Commander. His troops were brilliantly successful until the Battle of Savannah in 1779. Pulaski was wounded by grapeshot "to the groin, " and died two days later on a hospital ship anchored in the Wilmington River. He was reported to be buried on a nearby plantation. In 1853 the purported remains were exhumed, and examined at the Medical College of Georgia, where they were declared to be those of Pulaski. The skeleton was packed in a metal box and placed within the plinth of the Pulaski Monument in Savannah. In 1996, the monument was dismantled for renovation, and the local coroner decided it was time to validate the 1853 identification. The skeletal analysis was standard. It was obvious by modern osteological methods that the remains were those of a woman, and therefore presumably not those of Pulaski. But the result itself required further validation, and the subsequent investigation exposed a number of ambiguities. Not only were the remains consistent with Pulaski in age, race, and stature, but also in two instances of specific antemortem trauma a broken hand and a battle wound to the face. There was no and
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1. Azzawi, M., Bradley, B., Jeffery, P. K., Frew, A. J., Wardlaw, A. J., Knowles, G., Assoufi, B., Collins, J. V., Durham, S., Kay, A. B. 1990 ; Identification of activated T lymphocytes and eosinophils in bronchial biopsies in stable atopic asthma. Am. Rev. Respir. Dis. 142, 14071413. 2. Corrigan, C. J., Kay, A. B. 1990 ; CD4 T-lymphocyte activation in acute severe asthma. Relationship to disease severity and atopic status. Am. Rev. Respir. Dis. 141, 970 977. Walker, C., Virchow, J. C. J., Iff, T., Bruijnzeel, P. L., Blaser, K. 1991 ; T cells and asthma. I. Lymphocyte subpopulations and activation in allergic and nonallergic asthma. Int. Arch. Allergy Appl. Immunol. 94, 241243. 4. Robinson, D. S., Ying, S., Bentley, A. M., Meng, Q., North, J., Durham, S. R., Kay, A. B., Hamid, Q. 1993 ; Relationships among numbers of bronchoalveolar lavage cells expressing messenger ribonucleic acid for cytokines, asthma symptoms, and airway methacholine responsiveness in atopic asthma. J. Allergy Clin. Immunol. 92, 397 403. Virchow, J. C. J., Walker, C., Hafner, D., Kortsik, C., Werner, P., Matthys, H., Kroegel, C. 1995 ; T cells and cytokines in bronchoalveolar lavage fluid after segmental allergen provocation in atopic asthma. Am. J. Respir. Crit. Care Med. 151, 960 968. Gavett, S. H., Chen, X., Finkelman, F., Wills-Karp, M. 1994 ; Depletion of murine CD4 T lymphocytes prevents antigen-induced airway hyperreactivity and pulmonary eosinophilia. Am. J. Respir. Cell Mol. Biol. 10, 587593. 7. Krinzman, S. J., De Sanctis, G. T., Cernadas, M., Mark, D., Wang, Y., Listman, J., Kobzik, L., Donovan, C., Nassr, K., Katona, I., Christiani, D. C., Perkins, D. L., Finn, P. W. 1996 ; Inhibition of T cell costimulation abrogates airway hyperresponsiveness in a murine model. J. Clin. Invest. 98, 26932699. 8. Wills-Karp, M. 1999 ; Immunologic basis of antigen-induced airway hyperresponsiveness. Annu. Rev. Immunol. 17, 255281. 9. Banchereau, J., Bazan, F., Blanchard, D., Briere, F., Galizzi, J. P., Van Kooten, C., Liu, Y. J., Rousset, F., Saeland, S. 1994 ; The CD40 antigen and its ligand. Annu. Rev. Immunol. 12, 881922. 10. Hollenbaugh, D., Grosmaire, L. S., Kullas, C. D., Chalupny, N. J., Braesch-Andersen, S., Noelle, R. J., Stamenkovic, I., Ledbetter, J. A., Aruffo, A. 1992 ; The human T cell antigen gp39, a member of the TNF gene family, is a ligand for the CD40 receptor: expression of a soluble form of gp39 with B cell co-stimulatory activity. EMBO J. 11, 4313 4321. Caux, C., Massacrier, C., Vanbervliet, B., Dubois, B., Van Kooten, C., Durand, I., Banchereau, J. 1994 ; Activation of human dendritic cells through CD40 cross-linking. J. Exp. Med. 180, 12631272. 12. Rousset, F., Garcia, E., Banchereau, J. 1991 ; Cytokine-induced proliferation and immunoglobulin production of human B lymphocytes triggered through their CD40 antigen. J. Exp. Med. 173, 705710. 13. Zhang, K., Clark, E. A., Saxon, A. 1991 ; CD40 stimulation provides an IFN-gamma-independent and IL-4-dependent differentiation signal directly to human B cells for IgE production. J. Immunol. 146, 1836 1842. Lederman, S., Yellin, M. J., Cleary, A. M., Pernis, A., Inghirami, G., Cohn, L. E., Covey, L. R., Lee, J. J., Rothman, P., Chess, L. 1994 ; T-BAM CD40-L on helper T lymphocytes augments lymphokine-induced B cell Ig isotype switch recombination and rescues B cells from programmed cell death. J. Immunol. 152, 21632171.
Trials were considered to be valid if they met the inclusion criteria and contained sufficient data for further analysis. Trials were excluded at this stage if they were duplicate publications or if the data presented were subsets of data reported elsewhere. All potentially comparable input and outcome data were extracted and recorded in tables by using Minitab software v.10.2, 1994 Minitab Inc., USA ; . These tables formed the basis for our analysis and enabled us to establish clinically meaningful comparisons and methylphenidate.
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Low-dose oral oestrogen preparations result in lower circulating oestrogen levels and less increase in sex hormone binding globulin, with symptom relief comparable to that of higher-dose therapy.21 A new low-dose regimen conjugated equine oestrogen, 0.45 mg; and medroxyprogesterone acetate, 1.5 mg daily ; induces favourable changes in lipids, lipoproteins and haemostatic factors.22 Whether it will also result in lower risk of cardiovascular events and breast cancer remains to be seen.
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Addiction Medicine has been ev olving rapidly ov er the past decade. It is currently in the process of seeking recognition as a medical speciality. A number of significant adv ances hav e been made in the understanding of dependence, and in the capacity to manage this prev alent and concerning disorder as it relates to alcohol, cannabis and other drugs of dependence. Clinical placements, where expenses such as locum f ees, as well as trav el and accommodation costs are reimbursed, are av ailable for NSW medical practitioners, including GP registrars. The placements are funded by the NSW Health's Centre for Drug and Alcohol, and may v ary in length f rom one day to two weeks. The placements are to enable GPs to update their clinical skills and gain competence and conf idence in dealing with addiction and its associated issues. The training is av ailable in public hospitals and drug treatment serv ices throughout NSW, and covers topics such as pain management, cannabis, alcohol, opioid or psy chostimulant abuse as well as drugs in pregnancy. 0K has been set aside f or this purpose in 2006-2007. To enquire about these opportunities or arrange a placement, phone Anne Lawrance at the Centre for Drug and Alcohol on 02 9391 9261 or email: ANLAW doh.health.nsw.gov.au and
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REFERENCES 1. Mann M, Koller E, Murgo A, Malozowski S, Bacsanyi J, Leinung M. Glucocorticoidlike activity of megestrol: a summary of Food and Drug Administration experience and a review of the literature. Arch Intern Med. 1997; 157: 1651-1656. Lundgren S, Helle SI, Lonning PE. Profound suppression of plasma estrogens by megestrol acetate in postmenopausal breast cancer patients. Clin Cancer Res. 1996; 2: 1515-1521. Alexieva-Figusch J, Blankenstein MA, Hop WC, et al. Treatment of metastatic breast cancer patients with different dosages of megestrol acetate: dose relations, metabolic and endocrine effects. Eur J Cancer Clin Oncol. 1984; 20: 33-40. Kontula K, Janne O, Vihko R, de Jager E, de Visser J, Zeelen F. Progesterone-binding proteins: in vitro binding and biological activity of different steroidal ligands. Acta Endocrinol Copenh ; . 1975; 78: 574-592. Camanni F, Massara F, Molinatti GM. The cortisone-like effect of 6-methyl-17-acetoxyprogesterone in the adrenalectomized man. Acta Endocrinol Copenh ; . 1963; 43: 477-483. Kontula K, Paavonen T, Luukkainen T, Andersson LC. Binding of progestins to the glucocorticoid receptor: correlation to their glucocorticoidlike effects on in vitro functions of human mononuclear leukocytes. Biochem Pharmacol. 1983; 32: 1511-1518. Turcotte JG, Haines RF, Brody GL, Meyer TJ, Schwartz SA. Immunosuppression with medroxyprogesterone acetate. Transplantation. 1968; 6: 248260. Steer KA, Kurtz AB, Honour JW. Megestrol-induced Cushing's syndrome. Clin Endocrinol Oxf ; . 1995; 42: 91-93. Siminoski K, Goss P, Drucker DJ. The Cushing syndrome induced by medroxyprogesterone acetate. Ann Intern Med. 1989; 111: 758-760. Willemse PH, van der Ploeg E, Sleijfer DT, Tjabbes T, van Veelen H. A randomized comparison of megestrol acetate MA ; and medroxyprogesterone acetate MPA ; in patients with advanced breast cancer. Eur J Cancer. 1990; 26: 337-343. Loprinzi CL, Schaid DJ, Dose AM, Burnham NL, Jensen MD. Bodycomposition changes in patients who gain weight while receiving megestrol acetate. J Clin Oncol. 1993; 11: 152-154. Koller E, Mann M, Malozowski S, Bacsanyi J, Gibert C. Aseptic necrosis in HIV seropositive patients: a possible etiologic role for megestrol acetate. AIDS Patient Care STDS. 2000; 14: 405-410. Willemse PH, Dikkeschei LD, Tjabbes T, van Veelen H, Sleijfer DT. Adrenal steroids as parameters of the bioavailability of MA and MPA. Eur J Cancer. 1990; 26: 359-362. Briggs MH, Briggs M. Glucocorticoid properties of progestogens. Steroids. 1973; 22: 555-559. Loprinzi CL, Jensen MD, Jiang NS, Schaid DJ. Effect of megestrol acetate on the human pituitary-adrenal axis. Mayo Clin Proc. 1992; 67: 11601162.
1992 inter-office memorandum, Baxter informs its employees how to respond to inquiries concerning AWP increases for Baxter products: If you receive inquiries from customers or payors questioning our rationale on this recent increase in Published AWP for Baxter products please communicate the following message and no more. If any further information is needed please send the inquiry to me directly. A recent review of industry published direct prices and AWPs revealed that Baxter's published AWPs are significantly lower than competitive AWPs. We have therefore adjusted our AWPs to meet competitive levels. Most of Baxter General Healthcare Division's products are sold to distributors at negotiated contract prices that are different from AWPs. We do not have knowledge of or input to the actual prices charged to the provider by our distributors. The contracted prices to our distributors will not be directly affected by this change in AWPs. BAX MDL 0004210 ; Highly Confidential ; . 279. In addition, Baxter's marketing and sales documents, which were prepared and and naproxen and medroxyprogesterone.
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Later revealed a third individual, Harry Carl Sapp, Jr. "Sapp" ; , as the man who had been waiting in the truck at the pharmacy. Officers ultimately retrieved a total of ten sealed containers of controlled substances from the scene -- the same number of pill bottles that the owner of the pharmacy reported missing. included three bottles of 1, 000 of 1, 000 7.5-milligram ten-milligram dosages dosages This of of and nasonex.
Megestrol acetate MA ; and medroxyprogesterone acetate MPA ; are synthetic, orally active derivatives of the naturally occurring hormone progesterone. In several clinical trials, these compounds have been found to improve appetite, caloric intake, and nutritional status.86-90, 96-102 Megestrol has demonstrated a dose-related benefit from dosages ranging from 160 mg 40 mg orally four times daily ; to 1600 mg on appetite, caloric intake, body weight gain mainly fat ; , and sensation of well-being, with an optimal dosage of 800 mg daily.97 Increasing dosages from 160 mg of megestrol to 800 mg per day improves response to a level beyond which no further improvement occurs. It is recommended that a patient be started on the lowest dosage 160 mg day ; and the dose be titrated upwards according to the clinical response.87, 91 Quality of life measures such as the Karnovsky index may or may not be influenced by progesterone agents.89, 91, 102 Medroxyprogesterone has similarly been shown to increase appetite and food intake with stabilization of body weight at a dose of 1000 mg 500 mg twice ; daily.91 Although the drug may be used at 500 to 4000 mg daily, side effects increase above oral doses of 1000 mg daily.86 Medroxyprogesterone can also be given in a depot formulation. Oncologists are increasingly prescribing megestrol or medroxyprogesterone oral suspensions rather than tablets for their patients because of improved compliance and decreased cost.91, 103 There is, at present, considerable evidence of the effect of synthetic progestins on appetite.
Chapman JA, DiSaia PJ, Osann K, Roth PD, Gillotte DL & Berman ML 1996 Estrogen replacement in surgical stage I and II endometrial cancer survivors. American Journal of Obstetrics and Gynecology 175 11951200. Chlebowski RT & McTiernan A 1999 Elements of informed consent for hormone replacement therapy in patients with diagnosed breast cancer. Journal of Clinical Oncology 17 140142. Creasman WT 1999 HRT and women who have had breast or endometrial cancer. Journal of Epidemiology and Biostatistics 4 217225. Creasman WT, Henderson D, Hinshaw W & Clarke-Pearson DL 1986 Estrogen replacement therapy in the patient treated for endometrial cancer. Obstetrics and Gynecology 67 326330. Emons G for the German Society of Senology ; 2002. Hormonsubstitution nach Mammakarzinom. Eine Konsensusempfehlung. Gyna kologe 35 11141116. Emons G & Schulz K-D 1998 Atiologie des Endometriumkarzinoms. In Endometrium und Hormonsubstitution, pp 4754. Eds AO Mueck & T Romer. Stuttgart: Georg Thieme Verlag. Emons G, Fleckenstein G, Hinney B, Huschmand A & Heyl W 2000 Hormonal interactions in endometrial cancer. Endocrine-Related Cancer 7 227242. Emons G, Grundker C & Hanf V 2003 Are estrogens carcinogens? Gynakologe 36 182189. Erkkola R, Kumento U, Lehmuskowski S, Mattila L & Mustonen M 2002 No increased risk of endometrial hyperplasia with fixed long-cycle hormone replacement therapy after two years. Journal of the British Menopause Society 8 155156. Farish E, Barnes JF, O'Donoghue F, Fletcher CD, Ekevall K & Hart DM 2000 The role of megestrol acetate as an alternative to conventional hormone replacement therapy. Climacteric 3 125134. German Society of Endocrinology 1988 Konsensus: Ostrogen- Gestagen-Substitution wahrend und nach den Wechseljahren. Deutsches Arzteblatt 85 B-13221325. German Society of Endocrinology 1996 Konsensus: strogen- Gestagen-Substitution wahrend und nach den Wechseljahren. Endokrinologie-Informationen 20 122125. Glazier MG & Bowman MA 2001 A review of the evidence for the use of phytoestrogens as a replacement for traditional estrogen replacement therapy. Archives of Internal Medicine 161 11611172. Grady D, Gebretsadik T, Kerlikowski K, Ernster V & Petitti D 1995 Hormone replacement therapy and endometrial cancer risk: a meta-analysis. Obstetrics and Gynecology 85 304315. Guttuso T, Kurlan R, McDermott MP & Kieburtz K 2003 Gabapentin's effects on hot flashes in postmenopausal women: a randomised controlled trial. Obstetrics and Gynecology 101 337345. Hill DA, Weiss NS, Beresford SAA, Voigt LF, Daling JR, Stanford JL & Self S 2000 Continuous combined hormone replacement therapy and risk of endometrial cancer. American Journal of Obstetrics and Gynecology 183 14561461. Hillard T 2000 Serving without stimulation. Journal of the British Menopause Society Suppl 2 ; 6 1113. Johnson EB, Muto MG, Yanushpolsky EH & Mutter GL 2001 Phytoestrogen supplementation and endometrial cancer. Obstetrics and Gynecology 98 947950. Kenemans P 2000 Postmenopausal sex hormones and cancer of the endometrium and breast. Journal of the British Menopause Society 6 Suppl 3 ; 49. Kloosterboer HJ & Sands R 2000 Intracinology: the secret of the tissue-specificity of tibolone. Journal of the British Menopause Society 6 Suppl 2 ; 2327. Lauritzen C 1993 Ostrogensubstitution in der Postmenopause vor und nach behandeltem Genital- und Mammakarzinom. In Menopause und Hormonsubstitution heute, pp 7680. Ed C Lauritzen. Basel: Aesopus Verlag. Lee RB, Burke TW & Park RC 1990 Estrogen replacement therapy following treatment for stage I endometrial carcinoma. Gynecologic Oncology 36 189191. Liehr JG 2000 Is estradiol a genotoxic mutagenic carcinogen? Endocrine Reviews 21 4054. Loprinzi CL, Michalek JC, Quella SK, O'Fallon JR, Hatfield AK, Nelimark RA, Dose AM, Fischer T, Johnson C & Klatt NE 1994 Megestrol acetate for the prevention of hot flashes. New England Journal of Medicine 331 247252. Marsden J 2002 Hormone replacement therapy and breast cancer. Lancet Oncology 3 303311. Mikkola TS & Clarkson TB 2002 Estrogen replacement therapy, atherosclerosis, and vascular function. Cardiovascular Research 53 605619. Morrison JC, Martin DC, Blair RA, Anderson GD, Kincheloe BW, Bates GW, Hendrix JW, Rivlin ME, Forman EK, Propst MG & Needham R 1980 The use of medroxyprogesterone acetate for relief of climacteric symptoms. American Journal of Obstetrics and Gynecology 138 99104. Mueck AO & Seeger H 2002 Statins and menopausal health. Journal of the British Menopause Society 8 141146. Mueck AO & Seeger H 2003 Smoking, estradiol metabolism and hormone replacement therapy. Drug Research 1 111. Mueck AO & Stoll K-D 2001 Opipramol bei menopausalem Syndrom als Alternative bei Kontraindikationen gegen Hormonsubstitution. In Opipramol, Sigmaligand und stimmungsaufhellendes Anxiolytikum, pp 137146. Eds WE Muller & HJ Moller. Neu-Isenburg, Germany: LinguaMed Verlag. Mueck AO, Seeger H, Haasis R, Gohlke-Barwolf C, Schieber M, Schuchert A & Meinertz T 1999 Effect of oral vs. transdermal estradiol on cGMP during exercise in women with coronary artery disease--randomized, double-blind, placebo-controlled cross over study. Circulation 100 Suppl 18 ; 1386. Mueck AO, Seeger H & Wallwiener D 2002 Impact of hormone replacement therapy on endogenous estradiol metabolism in postmenopausal women. Maturitas 43 8793. Mueck AO & Wallwiener D 2003 Hormonsubstitution nach Brustkrebs. Medizinische Welt 5156. Natrajan PK, Soumakis K & Gambrell RD 1999 Estrogen replacement therapy in women with previous breast cancer. American Journal of Obstetrics and Gynecology 288295. North American Menopause Society NAMS ; 2000 The role of isoflavones in menopausal health: consensus opinion of the North American Menopause Society. Menopause 7 215229.
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Qualifying IOP, Use of contraindicated medications, Concurrent investigational medication, Noncompliance 56 ; . 3. Efficacy results Of the 594 patients included in the ITT analysis, 293 were male and 301 were female. The mean age of the patients was 63.7 years and the ages ranged from 21 to 91; 274 patients 46% ; were younger than 65 years at the time of the enrolment. The frequencies of patients by race were 488 Caucasian, 63 Black, 4 Asian and 39 other races as follows: 36 Hispanic, 1 Native American, 1 Indian, and 1 Spanish Irish. The diagnoses were distributed as follows: 382 patients were diagnosed with open-angle glaucoma, 196 with ocular hypertension, 14 with pigmentary glaucoma and 2 with pseudoexfoliation glaucoma. There were no statistically significant demographic differences among treatment groups at baseline. Travoprost 0.0015% and 0.004% ; dosed once daily produced IOP reductions that were equal or superior to IOP reductions produced by timolol 0.5% dosed twice daily based on tests of noninferiority. Superiority to timolol 0.5% was demonstrated at 9 of vs. 0.0015% group ; and 10 of 13 vs. 0.004% ; treatment visits. Comparisons of Travoprost vs. timolol travoprost 0.004% vs. Timolol 0.5% and travoprost 0.0015% vs. Timolol 0.5% ; were planned and carried out as tests of non inferiority. The per protocol data set was used for the non inferiority tests and the ITT data set was used for the superiority tests. For all tests, comparisons were made first between travoprost 0.004% and timolol 0.5% then travoprost 0.0015% and timolol, in accordance with the planned sequential testing strategy. The 95% confidence limits in the PP population showed that travoprost 0.004% and travoprost 0.0015% were non inferior to timolol 0.5% at all treatments visits for both the combined and individual visit results. All the upper 95% confidence intervals were less than + 1.5 mmHg, the upper limit of clinical relevance established to demonstrate non inferiority in this study. The largest value for the upper 95% confidence limit was + 0.42 mmHg. Subsequent to the tests of non-inferiority, superiority of travoprost to timolol was demonstrated by greater IOP reductions at 10 of visits for the travoprost 0.004% timolol comparison and at 9 of for travoprost 0.0015% timolol comparison. Travoprost 0.0015% and 0.004% ; dosed once daily produced clinically relevant and statistically significant IOP reductions from baseline. IOP changes were greatest in the travoprost 0.004% group and ranged from -6.6 to -8.0 mmHg when compared to those treated with travoprost 0.0015% -5.9 to -7.5 mmHg ; and timolol -5.2 to -7.1 mmHg ; . The clinical relevance of the IOP reductions was further demonstrated by the percent of patients in each treatment group who responded to treatment. A clinically relevant response was considered if IOP decreased to 17 mmHg or lower, or if their IOP decreased by 30% or more. The percentage of responders was 50.5% for travoprost 0.004%, 45.1% for travoprost 0.0015% and 35.4% for timolol. The IOP reductions produced by both concentrations of travoprost were maintained over the 6-month treatment period. The IOP reductions produced by Travoprost 0.004% were greater than those produced by Travoprost 0.0015% at most treatment visits by up 0.7 mmHg, although these differences were not significant. The by visit analysis demonstrated that the mean IOP produced by travoprost 0.004% was lower than produced by travoprost 0.00015% at 8 of 13 visits. Study C-97-79 1. Description of the study This was a 9-month, randomised, double blind, multicenter, active-controlled, parallel group study to compare the safety and efficacy of 0.0015% and 0.004% once daily travoprost with 0.5% twice daily timolol. This study had the same entry criteria and primary endpoint as study 97-71 except that measurements were taken at 9 a.m. and 11 a.m. rather than 8 a.m. and 10 a.m. Also the same hypotheses as those used in study 97-71 comparing travoprost with timolol were tested.
Overall, epilepsy contributed more than seven million DALYs 0.5% ; to the global burden of disease in 2000 21, 22 ; . Figure 3.2.1 shows the distribution of DALYs or lost years of healthy life attributable to epilepsy, both by age group and by level of economic development. It is apparent that close to 90% of the worldwide burden of epilepsy is to be found in developing regions, with more than half occurring in the 39% of the global population living in countries with the highest levels of premature mortality and lowest levels of income ; . An age gradient is also apparent, with the vast majority of epilepsy-related deaths and disability in childhood and adolescence occurring in developing regions, while later on in the life-course the proportion drops on account of relatively greater survival rates into older age by people living in more economically developed regions.
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