Wednesday, July 18, 2018

Stress And Glucose Levels

The underlying mechanism proposed to explain the association between stress and glucose levels involves interference with carbohydrate metabolism following various stressors potentially leading to insulin resistance3. Identify sources of stress.

Stress can be a major barrier to effective glucose control.

Stress and glucose levels. If you look specifically at mental stressors they can cause an increase in blood glucose levels for people with type 2 diabetes but they can have a more variable response either increasing or decreasing blood glucose levels for people with type 1. In turn elevated stress can raise glucose levels putting many in an unpleasant vicious cycle. Under stress your body goes into fight-or-flight mode raising blood sugar levels to prepare you for action says Richard Surwit PhD.

Managing your stress and relaxing more will help you and your baby stay as healthy as possible. This is true not only in people living with diabetes type 2 but also others with normal blood sugar control 12. Can Stress Cause Diabetes.

Listening to your body and the way it feels can be the first sign of a. Namely stress can both contribute to and be a consequence of diabetes. Although this is of adaptive importance in a healthy organism in diabetes as a result of the relative or absolute lack of insulin stress-induced increases in glucose cannot be metabolized properly.

Having diabetes to manage on top of lifes normal ups and downs can itself be a cause of stress. Stress hormones in your body may directly affect glucose levels. The impact on blood sugar caused by stress is so significant that some researchers feel it serves as a trigger for diabetes in people already predisposed to developing it.

In short stress will generally cause your blood sugar to rise. One study recommended rating your perceived stress try a scale of 1 to 10 with 10 being the most stressed and recording your blood sugar level. It also triggers your blood glucose levels to skyrocket.

Stress doesnt cause diabetes but it can affect your blood sugar levels and how you look after your condition. How stress affects your blood sugar. For people with diabetes this can be particularly problematic as they find it harder than non-diabetics to regain normal blood glucose levels after a bout of stress.

Stress stimulates the release of various hormones which can result in elevated blood glucose levels. Stress can increase your blood glucose levels. Another way that chronic stress directly increases blood sugars is.

When the body is under stress the adrenal glands trigger the release of glucose stored in various organs which often leads to elevated levels of glucose in the bloodstream. Everyones stress and diabetes response can be a little different. Physical stress can increase blood sugar in people with type 1 and type 2 diabetes.

Chronic or sustained stress can cause a persistent rise in our blood sugars. Its not always easy to live with and this can also feel harder when many people dont understand it. For example a person may feel that their stress levels rise when having to plan meals and measure their blood sugar.

The mental vicious circle. You cant avoid stressful situations but. The stress can push us to overeat which raises our glucose levels which leads to us to suffer from notable fatigue and low energy levels.

It will also be difficult to bring it down because of the insulin resistance created by stress hormones and the production of glucose from your livers response to adrenaline. Stress can also cause you to turn to unhealthful behaviors such as overeating eating unhealthful foods or smoking. All kinds of stress mental physical and emotional can cause glucose levels to skyrocket and can be dangerous.

If youre experiencing stress or. The problem is sustained or chronic stress. 4 After a few weeks of this you may be able to notice a trend in your stress and blood sugar.

Tuesday, July 17, 2018

Pch Grant Program

PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties. You Never Have to Pay to Receive a Legitimate PCH Win.

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Graduate nurses are eligible and must provide approval from the respective regulatory college to.

Pch grant program. 7-1-4-8-7 -3 Email Ticket Number. Amounts exclude transfers to other government departmentsorganizations. The truth is you never ever have to pay to receive a sweepstakes prize from Publishers Clearing House or any other company.

PCH GRANT is a Federal Assistant program offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties. Economists concluded that CoronaVirus was one of the most effective measures deployed to blunt the. PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties.

Evaluation of the Partnership for Community Health Grant Program ICH was the evaluator for the Partnership for Community Health PCH grant program an initiative of Neighborhood Health Plan and Partners HealthCare in partnership with the Massachusetts League of Community Health Centers. Our continued success in todays new digital publishing environment is built on PCHs unique free-to-play chance-to-win value. Publisher Clearing House PCH COVID-19 Census Grant.

Scammers extort money from you in exchange for a promise of a prize that never materializes. There are more to PCH scams than just friend requests on social media. The eligibility criteria for the PCH Grant are as follows.

PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties. Remember at Publishers Clearing House the winning is ALWAYS FREE and there are NEVER any fees to. The Publisher Clearing House PCH established 1953 by the Harold Mertz and now supported by the AMERICA GOVERNMENT with the objective of human growth educational and community development.

Publishers Clearing House Grant Award 382 Channel Drive Port Washington New York 11050. Order Winning Numbers. 32 rows PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering.

PCH funding programs under 5M Unless specified otherwise figures reflect planned spending figures for FY2019-2020 per the 2019-20 Departmental Plan adjusted for in-year top-ups through Budget Implementation Votes and Supplementary Estimates. PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties. After you are assured that you completed everything properly and your chances to get the grant are high you submit the application form along with a 199 fee.

FL 6542975 Dear Beneficiary These specific DonationsGrants will be awarded to 105 lucky international recipients worldwide in different categories. Nurses RNs RPNs or LPNs with an active practice license. A really easy way to spot a PCH scam is if you are asked to pay or wire money to claim a prize.

PCH GRANT is a Federal Assistant program leading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties. The grant is available only today so you really have to get the ball rolling ASAP. You download the form and might even call the phone number listed for more information.

This is being offered in the form of a Personal Care Home PCH Grant. PCHGRANT is a Federal Assistant programleading direct-to-consumer company offering a unique blend of curated multi-channel shopping and free-to-play chance to win digital entertainment across a network of web and app-based entertainment properties.

Monday, July 16, 2018

Cdc Air Purifiers

When used along with other best practices recommended by the Centers for Disease Control and Prevention operating an air. US CDC abruptly pulls COVID-19 guidelines on airborne spread The retracted guidelines encouraged people to use air purifiers to limit exposure to germs.

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Cdc air purifiers. Although the CDC reports that coronavirus is primarily spread through person-to-person contact or contact with contaminated surfaces and. Airborne droplets expelled from the mouth or nose of someone infected with. Here the clean volumetric air flow rate Q is.

Clean other surfaces in your home when they are visibly dirty or as needed. Congregation of people in cleaner air shelters and cleaner air spaces can potentially provide a route for the transmission of SARS CoV-2 the virus that causes COVID-19 among individuals using the facilities staff and volunteers. Air purifiers do not prevent the spread of coronavirus.

The updated guidance posted on the CDCs website on Friday also recommended that people use air purifiers to reduce airborne germs indoors. The use of cleaner air shelters and cleaner air spaces can result in congregating of groups of people including older adults and those with heart or lung conditions. Focus on high-touch surfaces such as doorknobs tables handles light switches and countertops.

Clean them more frequently if people in your household are more likely to get very sick from COVID-19. When used properly air purifiers can help reduce airborne contaminants including viruses in a home or confined space. Free Shipping on Qualified Orders.

Ad Everyday Low Prices and Amazing Selection. Central furnace or HVAC filters are designed to filter air throughout a home. Air purifiers with HEPA or HEPA-like filters will trap most airborne particles including pet dander and pollen.

You might also choose to disinfect. Improve central air filtration. Based on CRs lab tests of air purifiers we recommend looking for a model with a CADR over 240 which can perform roughly five air exchanges per hour in its suggested room size.

1 Properly fitted FFR and half facepiece reusable elastomeric respirators are expected to reduce exposures to one-tenth of the concentration that is in the air based on OSHAs APF of 10 for these respirator types. Consider using natural ventilation ie opening windows if possible and safe to do so to increase outdoor air dilution of indoor air when environmental conditions and building requirements allow. Portable air cleaners and HVAC filters can reduce.

ACH Q x 60 room volume 200 cfm x 60 12 x 10 x 10 120001200 10 ACH. The addition of the HEPA filter device provides additional clean air to the room. The CDC says air purifiers can help reduce airborne contaminants including viruses in a home or confined space The EPA Environmental Protection Agency adds that air purifiers are helpful.

The CDC maintains that when used properly air purifiers can help reduce airborne contaminants including viruses in a home or confined space The CDC also warns that air purifiers and other ventilation-improving products are not enough to protect yourself and your family from COVID-19 and suggests following other official prevention guidelines. CDC Director Dr Robert Redfield recently. So a CADR of 400 will bring 400 cubic feet of clean air into a room every minute.

Disable demand-control ventilation DCV controls that reduce air supply based on temperature or occupancy. Ad Everyday Low Prices and Amazing Selection. Will an air cleaner or air purifier help protect me and my family from COVID-19 in my home.

Q Q e Q hepa 80 cfm 120 cfm 200 cfm. CDC has published recommendations for HCP respiratory protection and of commonly used NIOSH-approved FDA-cleared single-use filtering facepiece N95 surgical respirators. The CFM rates how much air the purifier will process in a minute.

However by itself a portable air cleaner is not enough to protect people from COVID-19. This number is then multiplied by the efficiency to get the CADR or clean air delivery rate roughly analogous to replacing the air in a room with fresh air. Portable air cleaners also known as air purifiers or air sanitizers are designed to filter the air in a single room or area.

Sunday, July 15, 2018

What Is A Good Glucose Level

A woman with a fasting blood glucose level of 100 to 125 mgdL may have a condition known as impaired fasting glucose or prediabetes which can increase your risk of developing type 2 diabetes. Normal blood sugar levels for diabetics before eating fasting range from 80 mgdL to 130 mgdL while the high range starts at 180 mgdL.

Chart Of Normal Blood Sugar Levels For Adults With Diabetes

Target blood sugar levels for people with diabetes.

What is a good glucose level. The target levels can also vary if you have diabetes. Mean nighttime glucose of 81-102 mgdl. For generally healthy individuals without diabetes who havent eaten for eight hours or more a normal blood sugar level is between 70-99 mgdL.

12 hours after the start of a meal. This simple chart shows target blood sugar levels for adults before and after meals after fasting before exercise and at bedtime as well as an A1c target. Tips to manage and prevent low or high blood sugar levels you can be used while eating fasting and after eating.

You can also try the best fat-burning foods to lose weight quickly. It depends on your diet lifestyle and overall health. A normal fasting no food for eight hours blood sugar level is between 70 and 99 mgdL A normal blood sugar level two hours after eating is less than 140 mgdL Diabetes is diagnosed by any one of the following.

A blood glucose test is a blood test that screens for diabetes by measuring the level of glucose sugar in a persons blood. People without diabetes typically have between 72140 milligrams of glucose per 1 deciliter of. Mean daytime glucose of 83-106 mgdl.

Your blood sugar level range can be low or normal or even high. Glucose levels between 70-120 mgdl for approximately 90 of the day and to rarely ever go above 140 mgdl or below 60 mgdl 24-hour mean glucose levels of around 89-104 mgdl. Target glucose ranges vary from person to person but in general its ideal for blood sugar levels to be between 126 mgdL and 180 mgdL before starting exercise.

For people with diabetes blood sugar level targets are as follows. Two consecutive fasting blood glucose tests that are equal to or greater than 126 mgdL. 7099 mgdl 3955 mmolL Official ADA recommendation for someone with diabetes.

4 to 7 mmolL for people with type 1 or type 2 diabetes. Fasting normal blood sugar Normal for person without diabetes. Glucose is a form of natural sugar and that is why it is present in food.

What is a normal blood sugar level. Under 9 mmolL for people with type 1 diabetes and under 85mmolL for people with type 2 diabetes. For example if you are diabetic and are monitoring your blood sugar you might get a reading of 65 mgdl.

If you test your blood glucose and its lower than 126 mgdL here are the steps to take depending on the exact reading you get. More on this later. Target blood sugar levels for people without diabetes.

Blood glucose levels vary depending on a persons health status and whether they have eaten. That is considered to be mild hypoglycemia and you would be wise to eat 15 grams of fast-acting carbohydrates and retest your blood sugar in 15 minutes. Normal blood glucose level while fasting range within 70 to.

When youve eaten in the past two hours it should. The answer to the question what is a normal blood sugar level is as follows. The American Diabetes Association ADA delineates certain levels as normal blood sugar levels but the ADAs normal may not mean optimal Whats more measuring blood glucose isnt the only or even the best way to assess metabolic health ideal levels of blood sugar triglycerides high-density lipoprotein HDL cholesterol blood pressure and waist circumference.

But in case of 2 hours after of meal 70mgdl is considered lower than the standard level. 80130 mgdl 4472 mmolL Normal blood sugar 2 hours after meals. A fasting blood glucose level of 126 mgdL or greater may indicate that you have diabetes.

The normal blood sugar glucose level for a healthy adult without diabetes should be less than 126 mgdL milligrams per deciliter or 6 mmolL millimole per litre before fasting and meals and below 200mgdL or 11 mmolL two hours after meals. According to the standard chart 70-99mgdl is referred to as a normal blood glucose level in the case of fasting. Less than 100 mgdl.

Mean post-meal glucose peaks ranging from 992 105 to 1372 211 mgdl. After an overnight fast a normal blood sugar level is less than 100 milligrams per deciliter mgdL according to the American Diabetes Association ADA.

Saturday, July 14, 2018

Collagenase Santyl For Wrinkles

Collagenase SANTYL Ointment is used to remove damaged tissue from chronic skin ulcers and severely burned areas. Collagenase is an enzyme that breaks down collagen in damaged tissues within the skin and helps the body generate new healthy tissue.

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Cleaning solutions such as hydrogen peroxide normal saline or.

Collagenase santyl for wrinkles. Collagen is a type of protein that connects and supports fibers in body tissues such as skin tendons muscles and bone. The optimal pH range of collagenase is 6 to 8. Collagenase SANTYL Ointment is used to remove damaged tissue from chronic skin ulcers and severely burned areas.

Collagenase topical for the skin is applied to severe burns or skin ulcers to help remove dead skin tissue and aid. You may apply Santyl directly to the wound or apply it to a sterile gauze pad and then to the wound. You may need to apply it more often if the wound area becomes soiled.

Gently cleanse the wound with sterile saline or as directed by your healthcare professional. Do not use if you have shown hypersensitivity to collagenase. Clean the area as directed by your doctor.

It is usually applied once daily or as directed by your doctor. How to apply Collagenase SANTYL. Is Santyl Smith Nephew.

The enzyme collagenase is derived from the fermentation by Clostridium histolyticum. What is collagenase topical Santyl. As you age your body produces less and less collagen which results in the inevitable formation of fine lines wrinkles -- and stretch marks.

If the dressing becomes soiled collagenase may be applied more frequentlyTo apply wash hands first. Occasional slight redness may occur if SANTYL Ointment is placed outside the wound area. It has been reported that collagenase cleaves the amino acid bond of collagen and breaks down the collagen and elastin which possibly leads to the prolonged skin damage or wrinkle formation.

You may need to apply it more often if the wound area becomes soiled. Apply SANTYL Ointment directly to the wound source once a day at a 2 mm thickness or about the thickness of a nickel. Try not to get any ointment on the healthy skin around the wound.

Naturally plant phenolic compounds have been known to inhibit the collagenase activity. 100 Natural Antiseptic Healing Cream. Santyl is a collagenase based ointment 250 Ug which is.

Santyl is usually applied once daily. Santyl ointment Generic Names. Higher or lower pH conditions will decrease the enzymes activity and.

Do not use if you have shown hypersensitivity to collagenase. Xia ex is. Topically applied for enzymatic wound debridement 8586.

Two new studies published Skin Pharmacology and Physiology find a daily regimen of a new type of collagen supplement improves skin elasticity and reduces wrinkles around the eyes by. Collagenase SANTYL Ointment SANTYL is indicated for debriding chronic dermal ulcers and severely burned areas. The only product available in the US.

You may apply collagenase topical directly to the wound or apply it to a sterile gauze pad and then to the wound. Clostridium collagenase is the active enzyme used in Collagenase SANTYL Ointment which selectively degrades non-viable collagen fibers while conserving living collagen tissue 98. 27 To prevent the skin from aging or wrinkles natural collagenase inhibitors from plant is desirable.

SANTYL is contraindicated in patients who have shown local or systemic hypersensitivity to collagenase. Recommended 5X Faster Healing Wounds Infected Skin Bed Sores Diabetic Ulcers Neuropathy Burns Eczema Psoriasis Itchy Skin Shingles Res Q Ointment. The enzyme collagenase is derived from the fermentation by Clostridium histolyticum.

The reason for this has to do with collagen a protein that functions to hold or bind skin cells together and which serves to keep skin supple. Collagenase is a biologic ointment that breaks down collagen within the contaminated wound bed with enzymatic debridement action. Before applying Santyl rinse the skin area several times with normal saline solution or other cleanser recommended by your doctor.

Collagenase topical is usually applied once daily. 42 out of 5 stars. Occasional slight redness may occur if SANTYL Ointment is placed outside the wound area.

Collagenase Santyl Ointment is a sterile enzymatic debriding ointment which contains 250 collagenase units per gram of white petrolatum USP. As it is a biologic product and prescription item collagenase can be expensive and cost-prohibitive for some patients.

African American Maternal Mortality

And maternal age and health status the. According to the CDC black mothers in.

Maternal Mortality Rates In The U S Are Shockingly High Especially For Black Women Children S Institute

PTSD associated with womens experiences of racism impacts perinatal outcomes.

African american maternal mortality. Studies found persistent negative outcomes in African-American maternal mortality even when participants were controlled for significant educational and socioeconomic differences. Black women in the United States are more likely to die from pregnancy or childbirth than women in any other racial group. 94 of our deliveries are minority mothers and minor furor is maternal mortality rate of point 01.

Disparities Across the Nation. Maternal Mortality among African American Women in the State of Georgia Causes Policy and Ethical Considerations. As a result of pregnancy or its complications.

M Hsia J. The impact of the pandemic among African-Americans could further worsen the racial disparities in maternal mortality MM and severe maternal morbidity SMM. Too many Black women are dying in pregnancy and childbirth.

14 In the United States pregnancy-related mortality is three to four times higher among Black women than among White women. African American mothers are three times. Prior to the COVID-19 pandemic African-American mothers were three times as likely to die from pregnancy-related causes compared to white mothers.

In a statement the hospital spokesperson saying. Black American Indian and Alaska Native AIAN women are two to three times more likely to die from pregnancy-related causes than white women and this disparity increases with age researchers from the Centers for Disease Control and Prevention CDC report today in the Morbidity and Mortality Weekly Report MMWR. Posted Mar 06 2020 The United States has the highest maternal and infant mortality.

Research demonstrates the link between racism and post-traumatic stress disorder PTSD which may be one mechanism through which gendered racism contributes to black womens increased risk of maternal mortality as PTSD is associated with cardiovascular disease and earlier mortality from any cause 27. Black mothers die at a rate thats 33 times greater than whites and Native American or Alaskan Native women die at a rate 25 times greater than whites according to. They are up to five times more likely according to the Centers for Disease Control and Prevention CDC Petersen et al 2019.

In recent years as high rates of maternal mortality in the US. The purpose of this review is to explore the causes policy and ethical contextual factors contributing to increased maternal mortality rates among African American women in the State of Georgia. One of the most disturbing considerations for the disproportionate incidence of maternal mortality among African-American women is the chronic stress presented by the discrimination that black women experience in the rest of their livesthe double whammy of race and genderthat may ultimately be the most significant factor in poor maternal outcomes 10 Such.

For example a comparative analysis of African-American n60 and Caucasian n47 females presented a 307 to 1 ratio of pregnancy-related death between the two demographics respectively. American IndianAlaska Native and Black women are 2 to 3 times as likely to die from a pregnancy-related cause than white women. Reducing maternal mortality is one of the significant challenges facing the health system in the United States especially in the State of Georgia which has one of the highest MMR in the nation.

Black maternal health disparities. About 700 women die each year in the US. Yet between 2000 and 2013 high Black maternal death rates placed the United States second worst in maternal mortality among 31 Organisation for Economic Co-operation and Development nations.

Indeed one study showed that aer controlling for income. Have alarmed researchers one statistic has been especially concerning. Black women in the United States are more likely to die from pregnancy or childbirth than women in any other race group.

African American women remain at higher risk for maternal and infant mortality.

Friday, July 13, 2018

Sustainability Plan Example

It focuses on implementation and organizational infrastructure and processes as well as the fiscal strategies and resources for sustainability. Several years ago together with my friend Antonia Kuyumji I prepared a plan for a fast-growing company with a goal of improving its sustainability.

Developing A Sustainability Plan In A Project Proposal Proposalforngos

The following chart provides a hypothetical example of a sustainability plan for an evidence-informed innovation.

Sustainability plan example. Assemble a planning team 2. Review the programs mission and purpose 3. Incorporate the resources and time required to execute the Sustainability Management Plan in the project budget and schedule.

The sustainability plan is basically a document that describes how your project will be sustained in the long term. Ensure healthy lives and promote wellbeing for all at all ages Goal 4. View Sample Sustainability Plans.

Plan ComponentMethod Action Steps Timeline Develop Vision Mission Case for Support Create internal staff team to guide planning process. Sample Sustainability Section In the past year Philanthropy by Design PBD has approached several new grantmakers for support and we are pleased to report that PBD has received grants from the San Francisco Foundation for technical assistance and capacity building the True North Foundation the van Loben Sels Foundation and GATX Capital Corporation. This theme of UWE s Sustainability Plan contributes to meeting the following Sustainable Development Goals Goal 1.

Develop distribute and implement this Sustainability Management Plan. Fore example you may describe your needs as wanting to continue your current work while phasing in a slow expansion of efforts in some key areas eg the network may be planning to phase in support of a set of regional networks so that the network will be well. For example the UNs sustainable development goals encompass a broad spectrum of environmental goals such as clean energy and climate action as well as goals for economic growth hunger poverty health education equality peace and justice.

The sustainability plan has become more and more important because donors would like to fund projects that have the. We recommend you do at least a 12-months plan and preferable a 3-year plan. And why it is needed.

Company Sustainability Plan Template. End hunger achieve food security and improved nutrition and promote sustainable agriculture Goal 3. Companies often categorize sustainability into three pillars.

This document focuses on community sustainability financial sustainability and organizational sustainability. A less common variation is organisations that plan to set up a private company which would then donate to the program. 2 Adapted and modified from the Finance Project Framework.

Environment Social and Economic. DEVELOP A SUSTAINABILITY ACTION PLAN. Review the Program Sustainability Assessment Tool results 4.

End poverty in all its forms everywhere Goal 2. Download Action Planning Template 1. A sustainability plan provides a means of bringing everything together under a set of goals and metrics and provides a vision for the future development of the jurisdiction.

The Project Manager shall. Assessing your program to inform planning and document results. For example setting up an import business and using the profits to fund an early learning program.

A sustainability plan works best when it is used and reviewed on a continual basis. Prioritize the key areas of sustainability capacity to address first 6. Develop and update the P5 Impact Analysis P5IA with the support of the Project Team and include it in the project plan.

Sustainability Action Plan The following sample plan shows action steps you can take during the first year. Sustainability planning should be done throughout the life of an initiative. Determine which program elementsactivities should be maintained eliminated or adapted 5.

The following is a partial example. Download Action Planning Template 2. Based on a plausible but fictitious scenario the innovation targets anger management issues in youth who have been.

We hope these samples can give you some direction as you write your own plan. A good sustainability plan is a roadmap that will help all stakeholders successfully reach their goals2. Reassess sustainability capacity annually.

If your project falls into this category then the sustainability section should look more like a business plan. Implement the Sustainability Action Plan. This often covers quality of education affordability efficiency infrastructure school culture organizational excellence student experience employee satisfaction leadership development research sustainability and community and alumni engagement.

Sample Sustainability Action Plans We have developed examples of action plans for the Program Evaluation Partnerships and Communications domains. Creating a framework for long-term sustainability is the end goal of developing a sustainabil-.

Can Iud Cause Back Pain

Immediate Side Effects After Having a Mirena Inserted. Up to 52 percent of women may experience uterine cramps and vaginal bleeding may occ...