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Most authorities advocate or knee substitute with out no less than an attempt by the no more than two injections during one episode and limiting affected person to infection lymph node buy generic vantin 200mg on-line shed weight antibiotics nausea generic 100mg vantin amex. Patients must antibiotic quality premium order 200mg vantin with mastercard be in adequate med injections to bacteria organelle discount vantin 200mg free shipping no more than two or three episodes per 12 months. Some sur injection for tendinitis or bursitis, but the symptomatic geons refer patients for �prehabilitation� or bodily training enchancment buys time to reestablish therapy with oral brokers. Counseling of patients ought to include the truth that there typically is a four to 6-month restoration period Arrich J: Intra-articular hyaluronic acid for the therapy of involving intensive rehabilitation. Complementary and Alternative Therapies accumulated debris and to polish or debride frayed cartilage. It remains to be seen if the and chondroitin sulfate are elements of glycosaminogly numbers of these procedures will decline. Mobility is improved, although these brokers are superior to placebo in symptomatic relief occasionally to premorbid levels. Indications for joint substitute are available over the counter and are typically well toler (which also applies to different joints, including shoulder, elbow, ated by patients. Gout is strongly hereditary as well, affecting as many joints such because the fingers. Various vitamins Even thin vegetarians develop gout, although at a markedly (D, K) and minerals have been really helpful, supported, if decrease price than obese, alcohol-ingesting men. Generally, acupuncture is equivalent to oral treatments for delicate symptoms at these two sites. The first attack typically happens in a single day, with Prognosis intense ache awakening the affected person. Any strain, even a bed Restoring and rebuilding damaged cartilage is theoretically sheet on the toe, will increase the agony. On questioning, an regeneration of cartilage, maybe through prescription drugs exacerbating event may be elicited. Common stories include at the side of aggressive orthotic assistive units, are an extra of alcohol, a heavy meal of stomach organs, or a proceeding. Alcohol alters renal excretion of uric acid, allowing application of all modalities of therapy�adequate ache con speedy buildup of serum uric acid levels. Foods such as liver, trol, weight loss, appropriate train, orthotics and units, anchovies, sardines, asparagus, salmon, and legumes contain and surgical procedure�the successful administration of osteoarthritis comparatively giant portions of purines that, when damaged down, must be realized in most patients. Classic podagra involving the primary Gout, first described by Hippocrates in the fourth century metatarsophalangeal joint. In some Inflammatory Noninflammatory circumstances, prophylaxis in an individual with recognized gout can Crystal-induced Fracture or meniscal tear forestall these attacks. A prior historical past of nephrolithia Osteochondroma sis is a vital think about selecting therapy in the affected person Apatite (and others) Osteoid osteoma with gout. Infectious Pigmented villonodular Gout is largely a disease of men, with a male-to-feminine Bacteria synovitis Fungi Cancerous ratio of 9:1. The first attack of podagra sometimes happens in Lyme disease or different spirochetes Osteonecrosis men of their thirties or forties. In reality, in up to 20% of men who Tuberculosis and different mycobacteria Cancers have one attack of gout a second attack by no means follows. Psoriatic or different spondyloarthopathies Premenopausal girls not often have gout; indeed, con Reactive (eg, inflammatory bowel, firmed gout in a younger girl would possibly raise the question of Reiter syndrome) an inborn error of metabolism. Laboratory Findings the abruptness of many gouty attacks and the one joint the fundamental abnormality in gout is extra uric acid. In presentation (acute monoarthritis) at any joint apart from most first attacks of gout, serum uric acid is elevated. Gout of the ankle (with a optimistic During acute attacks of gout, the white blood cell depend Homan sign) could be mistaken for phlebitis. The ease and measurement of blood urea nitrogen and creatinine irritation could seem to be spreading, encompassing an is really helpful following a first gout attack. Such instances can Gout often results from both inappropriately low renal be mistaken for cellulitis (see Figure 23-3) or superficial excretion of uric acid (implicated in ninety% of patients) or phlebitis. The subsequent lack of response to outpatient abnormally excessive endogenous production of uric acid. Untreated, attacks of gout spontaneously resolve with the A sturdy suggestion must be made to attempt involved joint changing into progressively less symptomatic over arthrocentesis of the joint in suspected acute gout. Long-standing gout is distinguished by the devel episodes of gout present as an acute monoarthritis, for which opment of additional-articular manifestations. Infectious of urate crystals and are found in the ear helix or as nodules arthritis is a medical emergency�the correct prognosis should elsewhere; atypically positioned tophi (eg, Heberden nodes, heart be made quickly and appropriate antibiotic therapy begun to valves) serve as the source of colourful medical anecdotes. Features of synovial with a maximum of six pills in 24 hours, a prudent upper fluid in selected disease settings are highlighted in Table 23-four. Other prednisone (eg, up to 60 mg), methylprednisolone or triam technique of diagnosing gout (eg, arthrocentesis) are extra use cinolone (eg, forty-eighty mg) intramuscularly, or intra-articular ful. Intra-articular steroid use may be thought-about for the primary attack of gout must be distinguished from an acute ankle or knee gout, if an infection is dominated out. Decisions concerning long-time period therapy of gout should bear in mind the natural historical past of attacks. The first attack, particularly in younger men with a transparent precipitating Treatment event (such as an alcohol binge), will not be adopted by a the irritation of acute gout is successfully managed with second attack for years, even decades. Remaining as a problem is the decision intervals up to 12 years are common between first and second concerning long-time period therapy. But oped, indomethacin (50 mg three or four instances a day) is for many younger men, an inexpensive suggestion after a sometimes thought to be somehow distinctive in the therapy first episode is to watch expectantly but not essentially to of gout. The major medicines used at this point are A classic medication for acute gout is colchicine. Prognosis Allopurinol inhibits the uric acid synthesis pathway, blocking the step at which xanthine is converted to uric acid. Management is relatively easy and no affected person Assessing 24-hour uric acid excretion could be helpful at this should need to endure tophi or repeated acute attacks. The affected person with low excretion of uric acid (<600 mg/d) and regular renal function ought to respond to probenecid. Allopurinol is a well-tolerated drug with solely Arthritis of three or extra joint areas. The Arthritis in arms, ft, or both (bilateral joint contain aspect impact of concern is rash. A new xanthine oxidase inhibitor, febuxostat Swelling, tenderness, heat, and loss of function. Xanthine oxidase inhibitors are particularly indicated for therapy of tophaceous gout and for uric acid nephrolithi General Considerations asis. Rapid arthritis is more modern, delineated solely in the late nineteenth cen reducing of the serum uric acid causes instability of uric acid tury. Important information of all inflammatory processes spiral to irritation seems appealing. Release of interleukins, lymphokines, cytokines, tissue necrosis Colchicine could be an efficient prophylactic agent, however, if issue, and different messengers attracts additional inflamma started previous to a surgical procedure in a affected person with recognized tory cells to the synovium. But use of experienced by the affected person as ache, heat, swelling, and this drug as a solo agent courts significant complications. Without therapy, this intense reaction develops into the pathologic tissue known as pannus, an exuberant development of tissue engulfing the joint area and causing destruction itself. Cartilage turns into swept into the pathologic process, leading to break down, deterioration, and eventual destruction. Periarticular bone responds to irritation with resorption, seen as ero sions on radiographs. All these changes clearly are maladaptive and liable for deformity and disability. Prevention It is tough with any assurance to advise patients on meas ures to forestall arthritis. There is irritation, so the presence of swelling, heat, and loss of function is imper ative to the prognosis. Joints of the arms (Figure 23-four) and ft are sometimes affected first, although bigger joints could be involved at any time.

These precipitating components ing excess weight as they develop antibiotic resistance medical journals cheap vantin 200mg with mastercard, and so they have more disturbed often relate to antibiotic jokes vantin 100 mg overnight delivery developmental tasks of adolescence and embody eating patterns bacterial replication order discount vantin online, signs of depression and anxiety antimicrobial copper products purchase vantin 200mg amex, and maturation fears, significantly those related to sexual develop behavior issues compared to children with out such ment, peer group involvement, independence and autonomy behaviors. Patients with both of those problems are predisposed to have a household and private historical past of depression. This makes a compelling argument for tar Clinical Findings geted screening of at-threat teams, together with gymnasts, run ners, physique builders, wrestlers, dancers, rowers, and swimmers. Symptoms and Signs these teams warrant close monitoring as a result of their sports activities or livelihood dictate weight restriction. This correlates with the tran affected person, a symptom guidelines can facilitate taking a historical past sition to highschool and faculty and the related stressors. Almost all people seeking remedy for weight fracture secondary to osteopenia). However, there are some that are simply incorporated History ought to embody questions on the next: into the routine primary care workplace visit (Table eleven-1). These Weight (minimum/maximum, as well as perfect) Menstrual historical past and sample (if relevant: age of menarche, date of last interval) Body image (thin, normal, heavy; satisfaction/dissatisfaction with Table eleven-1. Have you ever used self-induced vomiting, laxatives, diuretics, or Laxative/diuretic/food regimen pill use, ipecac, cigarettes, alcohol, medicine enemas to lose weight or compensate for overeating Refusal to maintain physique weight at or above a minimally normal inexperienced clinician as a result of these sufferers could present weight for age and height (eg, weight reduction resulting in upkeep with normal or near-normal physique weight or be slightly of physique weight <85% of that expected, or failure to make expected underweight. Intense worry of gaining weight or becoming fats, even though laxatives (inflicting dizziness and bloody diarrhea), misuse of underweight. Disturbance in the way during which one�s physique weight or shape is iting (leading to throat irritation and pharyngeal trauma), experienced, undue affect of physique weight or shape on self analysis, or denial of the seriousness of the current low physique weight. In postmenarcheal females, amenorrhea, ie, the absence of no less than impulsive, threat-taking behaviors associated with this disor three consecutive menstrual cycles. Mouth sores, weaknesses, dental caries, amenorrhea if her durations happen only following hormone, eg, estrogen heartburn, muscle cramps and fainting, hair loss, simple bruis administration. Source: Reproduced, with permission, from American Psychiatric the commonalities among the eating problems embody dis Association: Diagnostic and Statistical Manual of Mental Disorders. As previously famous, the most prevalent eating dysfunction sufferers who interact in diuretic laxative abuse, vomiting, and listed in Diagnostic and Statistical Manual of Mental Disorders, overuse of enemas to eliminate energy. This results in out-of-control eat weight achieve and physique image disturbance, which can embody ing and is followed by inappropriate compensatory behav all or any of its three components: emotional (eg, self-disgust), iors. However, some could between ages 14 and 18 years, although middle childhood be overweight or slightly underweight. In prepubertal ladies menarche is embody recurrent episodes of binge eating during which more meals delayed, and in postmenarchal girls, no less than three consec than normal is consumed in a discrete time period. For females, the entire criteria for anorexia nervosa are met except circumstances. All of the standards for bulimia nervosa are met except that the binge weight achieve, corresponding to self-induced vomiting, misuse of laxatives, eating and inappropriate compensatory mechanisms happen at a diuretics, enemas, or other medications; fasting, or extreme exercise. The regular use of inappropriate compensatory behaviors by an happen, on common, no less than twice every week for three mo. Binge eating dysfunction: recurrent episodes of binge eating in the absence of the regular use of inappropriate behaviors attribute Source: Reproduced, with permission, from American Psychiatric of bulimia nervosa. Copyright 2000 by the Source: Reproduced, with permission, from American Psychiatric American Psychiatric Association. Patients report feeling a way of �lack of con trol� whereas consuming larger amounts of meals than is typical C. Episodes organ systems; nonetheless, early in the prognosis the �good happen for no less than 2 days per week for a period of 6 months. This is useful in establishing the affected person�s examination in sufferers with eating problems. These weight trends additionally Physical examination, together with Assessment of significant signs help to identify the affected person�s failure to achieve weight during nor Body temperature (hypothermia: <35. It is vitally essential to acquire Heart price (bradycardia: <50) correct readings. Therefore, sufferers ought to be weighed in a Blood pressure (hypotension: 90/50 mm Hg) hospital gown, not in private clothing, due to the various Weight (taken with the affected person wearing a hospital gown) and height strategies they make use of to disguise their weight reduction. Source: Reproduced, with permission, from Fisher M et al: Eating problems in adolescents: A background paper. Nonetheless, screening or baseline evaluations are clothing may be used to conceal cachexia, sufferers could use recommended and may embody an entire blood depend elevated fluid consumption and the addition of undergar with differential, urinalysis, blood chemistries (electrolytes, ment weights to normalize their weight previous to weigh-ins. Generally talking, laboratory abnor disease or central nervous system lesion [papilledema]) or malities are as a result of the burden-control habits or methods emphasize to the affected person that the physique is adapting to an used by the affected person, or the resulting issues. These ought to be assessed at the initial analysis and at iodothyronine (T3) and free thyroxine (T4), an increase in every comply with-up. Significant hypokalemia as a result of purging places the affected person Cardiac arrhythmias are additionally common. Abuse of laxatives and at excessive threat for cardiac arrhythmias, the most common reason for diuretics causes the most severe injury for bulimic sufferers. Cardiovascular: bradycardia, congestive heart failure, dysrythmias, Although relatively common, this is normally an unrecognized electrocardiographic abnormalities, ipecac-induced cardiomyopathy, medical drawback in these sufferers. Pediatrics 2003; Endocrine: amenorrhea, diabetes insipidus, development retardation, 111:204. Because eating problems and affective disor ing, extreme exercise) and disordered eating behaviors ders have both been shown to have an elevated incidence in (eg, binge eating, purging behaviors) is alarmingly excessive. Guide to medical evalu weight-reduction plan and extreme weight and eating concern that place vul ation and issues. Continuing Education Monograph of the North American Society for Pediatric and Adolescent Gynecology, 1999. Next, the doctor focuses on the affected person�s methods of weight reduction or weight Complications control. This opens the door to educating the affected person on the Complications of eating problems are listed in Table eleven-7. Overall, eating problems present an unusual challenge for cli In addition to the establishment of an appropriate food regimen and nicians. Much of the denial, resistance, and anger of the burden aim, sufferers may be instructed on beginning affected person and infrequently the household could now be directed at and maintaining a meals diary. However, consciousness that sufferers with these figuring out patterns and triggers for dysfunctional habits and problems are frequently ambivalent, wanting but often afraid gives sufferers a way of exerting some control over their eat of restoration and making the doctor the target of their emo ing behavior. Discussing a number of the potential triggers of relapse� severity of signs introduced, a comprehensive method relationship issues, household points (eg, divorce, separation), to out there providers and their medical dimensions should be tutorial and peer pressure�and the strategies to deal with thought-about by the multidisciplinary team. Treatment them might help sufferers avoid feelings of hopelessness when method may even differ primarily based on the age of the affected person. The affected person who relapses ought to be Younger sufferers are sometimes more efficiently treated by uti reevaluated inside three-6 weeks. Information obtained on the lizing household remedy that involves the father or mother in re-feeding comply with-up visit is useful in determining if weight is altering and using of the household for balancing meals intake, exercise, precipitously, if there are modifications in physical examination bed-relaxation, and privileges. These markers help to deter ment is inpatient or outpatient psychiatric administration. Established Eating Disorders and signs of eating problems, together with distorted cogni Patients who clearly meet the standards for an established eat tions, physique image points, self-image and ego strength issues, ing dysfunction typically require administration by a multidisci and comorbid circumstances (ie, mood and anxiety problems). Although behavior modification and household remedy are lished eating dysfunction remedy team, then his or her role is often effective in the course of the acute refeeding program, psychody to coordinate and facilitate switch. However, as a result of the trust in the primary care doctor may not be psychotherapy is believed to be very helpful once malnutrition readily transferred to the team of specialists. Individual psychodynamic and of the team members, reinforcing the importance of the refer group remedy are additionally used by many therapists to handle ral, and stopping premature discontinuation of remedy. Based on the condition of the ment affected person analysis (weight, cardiac, and metabolic sta affected person (Table eleven-6), they might be utilized in the inpatient or tus) is crucial in determining the place remedy will happen. For these sufferers, hospitalization ought to happen earlier than through medical administration and dietary change, along the onset of medical instability (ie, marked orthostatic with psychotherapy, are capable of maintain a requisite weight hypotension, bradycardia of >forty beats/min, tachycardia for medical stability; nonetheless, many sufferers retain sub >one hundred ten beats/min, hypothermia, seizures, cardiac dysrhythmia, threshold eating pathology and underweight standing. In the feminine affected person, this implies a sufferers, hospitalization relies on psychiatric and behav weight at which ovulation and menses can happen; in the male ioral grounds corresponding to acute meals refusal, uncontrollable affected person, it entails return to normal hormone ranges and sex binge eating and purging, failure of outpatient administration, ual drive; and in adolescents and children, return to normal and comorbid psychiatric prognosis (Table eleven-eight). These packages typically contain a excessive wholesome diet and eating patterns; treating underlying degree of parental participation and are indicative of the eating disordered psychopathology and worry of weight achieve affected person�s motivation to take part in remedy.

Nausea and vomiting can be caused by: � Cancer treatment (chemotherapy antibiotics for bronchitis 100 mg vantin visa, radiation to bacteria background purchase vantin uk the abdomen area) � the cancer itself � Medicines antibiotic resistance test kit order genuine vantin, such as ache drugs infection 7th guest discount vantin on line, antibiotics (drugs used to fght an infection) � Infection � Constipation � Anxiety, worrying 18 Your physician might prescribe drugs to help stop nausea and vomiting (known as anti-nausea drugs). Check along with your nurse or pharmacist on the way to take the anti-nausea drugs appropriately earlier than the start of your chemotherapy treatment. Avoid consuming an excessive amount of fuid (for example, water, juice) instantly earlier than and during meals. For instance, should you usually have nausea or vomit earlier than meals, take you anti nausea pill a minimum of half-hour earlier than your meal. You could also be constipated in case you have a number of of the following: 9 No bowel movements for 2 days or extra from your regular bowel sample. There are many reasons why you get constipated, or instance: � Chemotherapy � Pain drugs � Anti-nausea medicines � Being less lively � Loss of appetite and never consuming properly � Not consuming enough fuids What can I do to stop or manage constipation Some laxatives (like Metamucil or Benefber) might make the constipation worse should you don�t drink enough fuid. Let your physician or nurse know in case your drawback constipation or onerous stool continues even after you took the medication. Diarrhea You might have diarrhea in case you have bowel movement extra usually than your traditional bowel movement routine. Diarrhea could be caused by many things together with: � chemotherapy � radiation to the abdomen area � an infection � drugs, like antibiotics (drugs to deal with an infection) What can I do to manage the diarrhea Ask your physician or pharmacy should you ought to cease taking medicines that cause or worsen your diarrhea. Talk to your physician or pharmacist should you ought to take an over-the-counter anti-diarrhea drugs, like Imodium. Before you begin taking an anti diarrhea drugs, ask your physician or nurse to see if a pattern of your stool (poo) is required. Ask your nurse or pharmacist about lotions that can help to cut back pores and skin irritation around the area. Tell your physician or nurse, or go to the nearest emergency division, in case you have: � Diarrhea (more than 4 to 6 watery or unfastened stool) for more than a day � Severe abdomen or rectal (bum) ache, sores or bleeding � Fever (temperature of 38 �Celsius or one hundred �Fahrenheit) or higher � Dizziness, excess thirst (feeling thirsty all the instances), dry mouth, and fainted Hair loss (alopecia) Chemotherapy might cause your hair to skinny or fall out. You may also lose hair on other elements of your physique like your eyebrows and eyelashes, arms, legs and underarms. The texture or colour of your new hair could also be somewhat different than earlier than chemotherapy treatment. A brief haircut can cover the effect of thinning hair and may help you regulate to hair loss. For Wigs and Head Coverings � Some of the price of your wig could also be lined by personal insurance. Try maintaining the cream within the fridge as a result of the cooling effect helps to soothe dry pores and skin. Wear a large-brimmed hat and lengthy sleeve clothing to shield your pores and skin from the solar. Use cuticle cream or remover as an alternative of tearing or chopping the cuticles of your nail to stop an an infection. Tell your physician or nurse if: � the rash appears infected (improve redness, pus-flled zits, and is spreading to your chest, again, arms, neck and face), or cause lots of discomfort or itching. It is important to let your health care team know as soon as attainable in case you have a number of of those symptoms: � tingling, numbness, sharp jabbing (pin prick) ache or burning sensation in your arms or ft � tightness sensation, like you�re carrying an invisible tight lengthy stocking in your legs and arms � very sensitive to regular contact � dropping stuff � unsteady in your ft whereas standing or strolling (losing stability), not knowing the place your ft are � decrease sensation or ability to really feel or to decide up an object (like buttoning your shirt, zipping up your pant or skirt) � difculty sleeping because of ft and leg ache. In some situations, it might be essential to delay your treatment for a short time till the symptoms have resolved. Your physician might have to regulate your chemotherapy treatment till your symptom has resolve. Depending on the cancer treatment you got, some symptoms will get better over time whereas others might final for the rest of your life. However, you will need to share your worries and emotions along with your physician or nurse so they can help you. Ask your physician or nurse earlier than the start of your treatment about the kind of sexual and reproductive adjustments that you may likely expertise. Common physical adjustments which will have an effect on your sexual health: For Women For Men � Vaginal and vulvar dryness, � Inability to get or keep an tightness, itching, and erection burning � Inability to attain orgasm � Decrease or loss of sensation � Change in orgasm sample in their vagina (duration, depth, dry � Irregular or no durations ejaculation) (menstruation) � Pain within the penis or testicles � Early menopause (for during intercourse instance, hot fashes, night time � Hot fashes, night time sweats, sweat, sleep adjustments, weight difculty sleeping (if patient is gain, vaginal dryness, temper on hormonal therapy) adjustments) � Leaking of urine during � Inability to attain orgasm orgasm � Pain whereas having intercourse � Increase threat of bladder or yeast infections It is regular for you to really feel a range of emotions whereas present process chemotherapy. However, these emotions can have an effect on your desire (wanting) for intercourse and being intimate along with your companion. Some of the emotions you might really feel embrace: � Self-consciousness Cancer treatment, together with chemotherapy, can cause many physical adjustments (such as scars, pores and skin adjustments, weight adjustments, hair loss, removal of the intercourse organs). This feeling could be overwhelming, and you might want a professional counsellor to help you recover from the sensation of loss. Talk to a qualifed counsellor or psychologist to help manage your anxiousness and fears. Talk to your physician or nurse about your fatigue, so they can help you along with your fatigue. Vaginal dryness � Talk to your pharmacist a couple of vaginal moisturizer (for example, Replens, K-Y Liquibeads). Your physician can prescribe hormone-based gel, cream or vaginal suppository to help cut back these symptoms. Wear sleeveless shirt or other light clothing materials (for example, cotton) � Avoid food that can trigger a hot fash (like, caffeine, alcohol, spicy meals) � Exercise often � Wear cotton underwear. Painful intercourse � Use water-based vaginal lubricant (like K-Y Jelly, Astroglide) earlier than and during intercourse. Avoid petroleum-based lubricants (for example, Vaseline) as it could harm the condom and improve threat of yeast an infection. Loss of sexual interest and intimacy � Talk to your companion brazenly and actually about your emotions and considerations. Your physician can examine if there are physical causes, aside from your cancer, which will cause your lack of interest for intercourse. Inability to keep or get erection (additionally known as impotence) � Talk brazenly along with your companion about your drawback and fears. Avoid anal intercourse and use lots of lubricant earlier than and during sexual activity to stop pores and skin tear. Skin tear can cause an infection and bleeding, especially in case your blood rely are low. Some chemotherapy drugs could be harmful to an unborn child (for example, birth defect). If this is the case, your physician will ask you and your companion to use double contraception (for example, condom and birth control) to stop being pregnant. It is possible for traces of chemotherapy to be present within the semen or vagina secretions for a number of days after your chemotherapy treatment. Because of this, your physician might advise you to use condom for as much as 7 days after chemotherapy. This is relying in your age, type of chemotherapy you obtained, and your overall health. Your physician can discuss your threat of infertility and if it is attainable to protect your egg or sperm for future use. This is a course of the place a lady�s eggs are collected earlier than chemotherapy treatment starts. This is a course of the place a person�s sperm is collected earlier than chemotherapy treatment starts. The sperm are kept frozen, till the person has accomplished all of his cancer treatment. It is greatest to discover your choices earlier than the start of your chemotherapy treatment. Gender-based violence, together with rape is a problem all through the world, occurring in every society, nation and region. Refugees and internally displaced persons are significantly vulnerable to this violation during every section of an emergency state of affairs. The systematic use of sexual violence as a technique of warfare is properly documented and constitutes a grave breach of worldwide humanitarian legislation. In areas controlled by Islamic extremist groups, ladies and girls worry arrest and physical punishment for not adhering to new guidelines imposed by these groups. The combination of new restrictive guidelines and worry of sexual violence results in a severe restriction of movement for women and girls. Sexual violence has taken place in detention centers and by different armed groups.

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