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However arrhythmia back pain buy digoxin 0.25 mg fast delivery, standard neuroimaging does not enable comprehensive quantitative assessment of the brain injury blood pressure medication green pill digoxin 0.25mg, so a substantial discrepancy between the degree of clinical impairment and the degree of injury is often seen on neuroimaging what is pulse pressure yahoo buy digoxin cheap. Unfortunately these proteins lack either the necessary sensitivity or brain specificity or both to be used effectively alone (Pineda blood pressure yahoo digoxin 0.25mg with amex, Wang, and Hayes. Clinical signs and symptoms can occur alone or in combinations and might result in functional impairment. These signs and symptoms appear to be independent of pre-existing conditions except in cases of exacerbation of pre-existing conditions. They usually can be defined by one or more of the three following categories: 15 Physical: headache, nausea, vomiting, dizziness, blurred vision, sleep disturbance, weakness, paralysis, sensory loss, spasticity, disorders of speech or language, swallowing disorders, balance disorders, disorders of coordination, seizure disorder; Cognitive: attention, concentration, memory, speed of processing, new learning, planning, reasoning, judgment, executive control, self-awareness, language, abstract thinking; Behavioral/emotional: depression, anxiety, agitation, irritability, impulsivity, aggression and violence, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired self-awareness, inability to take responsibility or accept criticism, or alcohol or drug abuse/addiction. The signs and symptoms listed above are typical of each category but are not an exhaustive list of all possible signs and symptoms. If a patient meets criteria in more than one severity category, the higher severity level of severity is assigned. If not clinically possible to determine the brain injury level of severity because of medical complications. For example, one or more of the following may be useful: imaging studies; monitoring intracranial pressure; electroencephalography that may demonstrate absence of electrical brain activity; and, transcranial doppler that may detect the absence of blood flow in the brain. In the acute stage, the primary aim is to stabilize the patient and to prevent secondary injuries (U. Rehabilitation is the primary treatment for the sub-acute and chronic stages of recovery (U. These guidelines relied on extrapolated data from civilian trauma settings and recognized that tactical operations might alter the care that is provided in the combat setting. A decision-tree included in the document gives frontline providers triage decision-making assistance. Acute care for conditions such as intracranial pressure management, nutrition, and general critical care are consistent with civilian best practices (Bullock and Povlishock, 2007). These guidelines focus on the management of those with sub-acute to chronic injury and include an educational component regarding the natural history of concussion and the expectation of recovery. Surgical interventions, such as those for subdural and epidural hematomas, are effective (Bullock et al. Additionally, heterogeneity in neuropathology occurs from person to person (Jennett, Adams, Murray, and Graham, 2001; Adams, Graham, and Jennett, 2001; Maxwell et al. Numerous explanations for explaining this discordance exist, but the heterogeneity of the patient population is one of the most noteworthy contributing factors (Narayan et al. Therefore, nearly all of the treatment guidelines are based on smaller studies and case reports, including medical and surgical interventions to attenuate some types of acute neurotraumatic injuries. A neurosurgical intervention to reduce intracranial pressure, decompressive craniectomy, is one example, although this procedure also remains controversial (Bullock et al. Large-scale comparative effectiveness research that leverages the variability in practice patterns also has been proposed as a means of identifying those treatments associated with better outcome (Maas et al. Long-Term Care Improving continuity of quality care and service delivery along with inter-service, interagency, intergovernmental, and public and private collaboration for care are all critical to the success of long-term care. In addition, management, transition, and associated training, tracking, and accountability for this care are essential for administering such programs. Vet Centers offer an alternative to traditional mental health care that helps many combat veterans overcome the stigma and fear related to accessing professional assistance for military-related problems. Eligibility for Vet Center services is based on military service in a combat theater and does not require a veteran to complete the enrollment process. Of this total, more than 205,481 veterans were provided outreach services, and 63,506 were provided clinical readjustment services by mental health providers in Vet Centers such as individual and group counseling for veterans and their families, substance abuse assessment and referral, and screening and referral for medical issues. The mission of the Polytrauma System of Care is to provide the highest quality of medical, rehabilitation, and support services for veterans and active duty service members injured in the service. The polytrauma system of care is composed of four component layers as described below and shown on this map. Provision of rehabilitation services for patients who are minimally conscious or 25 minimally responsive is based on expert opinion rather than scientific evidence. Cornerstones of treatment for patients with severe disorders of consciousness include aggressive medical care to treat potential reversible causes of impaired consciousness (infection, sedation, hormone imbalance); prevention of complications (contracture, pressure sores, malnutrition); family support and education. Additional interventions often include structured sensory stimulation and trials with medications to increase responsiveness. These networks are intended to help eligible entities coordinate innovative approaches, collaborative networks, and virtual linkages to increase the delivery of mental health and other healthcare services to meet the needs of veterans of Operation Iraqi Freedom and Operation Enduring Freedom that reside in remote rural areas. In addition to record review, clinician-to-clinician communication occurs to allow additional transfer of information and resolution of any outstanding questions. Psychosocial support for families of injured service members is paramount as decisions are made to transition from the acute care setting of a military treatment facility to a rehabilitation setting. This encompasses psychological support, education about rehabilitation, the next setting of care, and information about benefits and military processes and procedures. Follow-up appointments are made before discharge, and the transferring practitioners are readily available for personal contact with the receiving provider to ensure full communication. After rehabilitation, 64% were discharged to home or military bases, 27% to other inpatient service or military treatment facilities, 6% to residential day programs, and 3% to nursing homes. These patients might be unconscious on arrival and require stabilization, mechanical ventilation, and intensive care services. In addition, management of co-occuring injuries and meticulous medical care is required to prevent deterioration and the many potential complications, such as infections, acute respiratory distress syndrome, disseminated intravascular coagulation, brain swelling, and multi organ failure. Monitoring of intracranial pressure is common, and algorithms are in use for lowering raised intracranial pressure to preserve cerebral blood flow and prevent pressure-related distortion of the brain (herniation syndromes). Focus is usually on identifying those who are at risk for deterioration, usually caused by post-traumatic intracranial hemorrhage. Certain states also have enacted legislation requiring student athletes who sustain a concussion to be seen by a medical expert before they can return to play (National Conference of State Legislatures, 2013). Only limited interventions have demonstrated effectiveness in improving 30 outcomes for patients in rigorous controlled studies (Vanderploeg et al. In the absence of strong evidence, and faced with pressing clinical needs, providers have adopted practices based upon consensus and clinical experience (Fadyl and McPherson, 2009; Lane-Brown and Tate, 2009; Cicerone et al. Patients might partially or completely improve after spending weeks, months, or years in states devoid of purposeful behavior; patients might recover their ability to speak, walk, and make new memories. Moreover, what prompts recovery and the speed, duration, and extent of recovery is not well understood. The majority of scientific investigations of recovery after brain injury focus on focal brain injury, especially stroke. This is further complicated in persons with comorbidities, such as depression, personality disorder, or substance abuse, which can cause some of the symptoms seen in post-concussive syndrome. The most important factor appears to be the severity of the injury (Schretlen and Shapiro, 2003). Return to work is considered an important metric of recovery, although it is inadequate for children and retired adults and it is important to recognize that many adults with disabilities successfully participate in the workplace. Persons who sustain more severe injuries have worse outcomes, with only 20% making a good recovery, as assessed by the Glasgow Outcome Scale (Thornhill et al. Further complicating this picture are animal studies that have demonstrated better recovery in females (Stein, 2004). Penetrating injuries have worse outcomes than closed injuries (Wertheimer, Hanks, and Hasenau, 2008). The majority of experimental preclinical investigations of recovery after brain injury use models of focal brain injury. A second hypothesis is that persistent metabolic alterations in injured, but not lethally injured, brain cells result in neuronal dysfunction and subsequent behavioral impairments (Marcoux et al. For example, that metabolic alterations in grey matter are caused by reduced neuronal activity secondary to a loss of connectivity from diffuse axonal injury might be possible. These neuropsychiatric and emotional disorders might create the most serious challenges to returning to work or other pre-injury activities and to community reintegration.

Targeted treatment of pyo Blau syndrome does not result in excess interleukin-1 activity blood pressure urgency generic 0.25mg digoxin free shipping. Pediatr Dermatol 2005; Hematopoietic stem cell transplantation rescues the immunologic phenotype and 22:262-5 blood pressure cuff amazon cheap digoxin online visa. Peridis S arrhythmia electrolyte imbalance buy cheap digoxin 0.25 mg, Pilgrim G atrial fibrillation cheap 0.25mg digoxin with amex, Koudoumnakis E, Athanasopoulos I, Houlakis M, Parpounas muscular atrophy, microcytic anemia, and panniculitis-associated lipodystrophy. Proc Natl Acad odystrophy and elevated temperature with evidence of genetic and phenotypic Sci U S A 2011;108:7148-53. Ramot Y, Sayama K, Sheffer R, Doviner V, Hiller N, Kaufmann-Yehezkely M, Curr Allergy Asthma Rep 2002;2:379-84. Familial atypical cold urticaria: ical hemolytic uremic syndrome, microhematuria, hypertension and chronic renal description of a new hereditary disease. Clin J Am Soc Nephrol 2013; Distinct cutaneous manifestations and cold-induced leukocyte activation associ 8:407-15. Mutant Antibody mediated rejection associated with complement factor h-related protein adenosine deaminase 2 in a polyarteritis nodosa vasculopathy. Strobel S, Abarrategui-Garrido C, Fariza-Requejo E, Seeberger H, Sanchez complement components in systemic lupus erythematosus. Mannan-binding lectin insuf ciency in children with recurrent infections autoantibodies. J Immunol ital H colin de ciency in premature infants with severe necrotising enterocolitis. Familial clustering of non-nuclear autoantibodies and C3 and C4 Hematol 2012;95:102-6. We know how important it is for you to have an accurate understanding of your diagnosis, treatment and support options. An important part of our mission is bringing you the latest information about advances in treatment for Hodgkin lymphoma, so you can work with your healthcare team to determine the best options for the best outcomes. Our vision is that one day the great majority of people who have been diagnosed with Hodgkin lymphoma will be cured or will be able to manage their disease with a good quality of life. We hope that the information in this publication will help you along your journey. Our commitment to pioneering science has contributed to an unprecedented rise in survival rates for people with many diferent blood cancers. Hodgkin Lymphoma I page 1 Introduction Lymphoma is a general name for a group of cancers that afect the lymphatic system. In the United States in 2013, about 9,290 persons were expected to be diagnosed with Hodgkin lymphoma. Brief descriptions of normal blood and marrow and the lymphatic system are provided for background (see page 26). Hodgkin Lymphoma also contains information about important considerations before and after treatment to help provide greater quality of life for survivors. Some of the medical terms used throughout this publication may be synonyms for other words or phrases used by healthcare professionals. Check with your doctor if you have questions about how the terms used in this publication apply to you. Here to Help this publication will be helpful when you talk to your doctor about the tests and treatment you need. We encourage you to take the lead in asking questions and discussing your fears and concerns. This will help your healthcare team answer your questions, extend emotional support and provide any needed referrals. Denial, depression, hopelessness and fear are some of the reactions people may have. Keep in mind that {{Many people are better able to cope once their treatment plan is established and they can look forward to recovery. New approaches to therapy are being studied in clinical trials for patients of all ages and at every stage of treatment. During and after treatment, you may want to have friends, family members or caregivers help you get information. They provide accurate, up-to-date disease and treatment information and are available to speak with callers Monday through Friday, 9 a. Our Information Specialists help patients work with their doctors to fnd out about specifc clinical trials. Information Specialists conduct clinical trial searches for patients, family members and healthcare professionals. This program ofers assistance for fnancially eligible patients with certain blood cancer diagnoses to help pay for private or public health insurance premiums and/or co-pay costs for prescription medications. Free language services are available when you speak with an Information Specialist. Let your doctor know if you want a professional healthcare interpreter who speaks your native language or uses sign language to be present during your visit. Your chapter can arrange for peer-to-peer support through the Patti Robinson Kaufmann First Connection Program. The Patient Financial Aid program ofers a limited amount of fnancial aid for qualifed patients. Suggestions From Other People Living With Cancer {{Get information about choosing a cancer specialist or treatment center. Veterans with certain blood cancers who were exposed to Agent Orange while serving in Vietnam may be able to get help from the United States Department of Veterans Afairs. For more information call the Department of Veterans Afairs at (800) 749-8387 or visit People who were involved in the aftermath of the attacks of September 11, 2001 may be eligible for help from the World Trade Center Health Program. For more information, call the World Trade Center Health Program at (888) 982-4748 or visit Hodgkin described several cases of people with symptoms of a cancer involving the lymph nodes. The accumulation of the cancerous lymphocytes results in the tumor masses that are found in the lymph nodes and other sites in the body (see Signs and Symptoms on page 8). Reed-Sternberg cells are usually B cells and have diferences and variations to them. It is less common in middle age but becomes more common again after age 65 (see Figure 1). The vertical axis shows the frequency of new cases of Hodgkin lymphoma per 100,000 people, by age-group. Hodgkin Lymphoma and the Lymphatic System Lymph nodes are located throughout the body Spleen Marrow the lymphatic system is part of the immune system. I Lymph nodes and other lymphoid tissues that are commonly involved in lymphoma are those around the ears and jaw, in the tonsils and adenoids, in the front and back of the neck, above and below the collar bone, in the armpit, near the elbow, in the chest, in the abdomen, in the pelvis and in the groin. The spleen contains many clusters of lymphocytes that can become malignant and grow, leading to the enlargement of the spleen. The gut-associated (intestinal) lymph tissue may also be the site of lymphoma development. Tumor masses can also occur outside the lymph nodes in lung, bone or other body tissue.

The large cerebral blood flow requirement makes children with head injuries extremely susceptible to hypoxia; hypoxia and hypotension in a child with a head injury can cause ongoing damage as bad as the initial injury itself b arrhythmia associates of south texas cheap digoxin 0.25mg with mastercard. Since the weaker neck supports a relatively heavier head and therefore flexes more easily with trauma arterial nephrosclerosis order digoxin 0.25mg line, cervical spine injuries sustained are usually higher (C1-3) f blood pressure units buy cheap digoxin online. Infants of this age whose crying is responded to timely by parents have been shown to cry less at 1 year and have decreased aggression at 2 d blood pressure healthy vs unhealthy purchase digoxin 0.25 mg on line. Though infants sleep a lot, they should be arousable; inability to arouse a baby should be considered an emergency iii. Be diligent about keeping babies warm and dry to limit hypothermia Page 330 of 385 iv. Infants do not develop head control until closer to 6 months, so when handling a baby, make sure to support the head and neck well v. This is a particularly stressful time for parents adjusting to the eating, sleeping, and crying cycle; sometimes this is complicated by post-partum depression, too, which can be a risk factor for abuse. Infants do not typically roll until around 3-4 months; a history of an infant less than that rolling himself off of a bed or table and sustaining major injuries may indicate abuse iii. Infants of this age begin to identify and respond to facial expressions; approach them with a smile or funny face and a happy, soft spoken voice iv. With the increased mobility of crawling and walking comes exposure to physical dangers B. The front teeth come in before the molars, which means that children may bite off large pieces of food and then not be able to grind them up before swallowing, increasing the risk of food aspiration; do not give children exam gloves to play with iii. Allow a child to hold objects of importance to them like a blanket, stuffed animal or doll Page 333 of 385 viii. With the head beginning to grow at a slower rate than the body, children begin no longer requiring shoulder rolls limiting flexion of the neck when bag-valve-mask ventilating or intubating ix. Do not waste time trying to use logic to convince preschoolers; they are concrete thinkers,; avoid frightening or misleading comments vii. Children with chronic illness or disabilities begin to be very self-conscious iii. With patients loosing baby teeth and getting adult teeth, one must be particularly careful when intubating ii. School aged children can understand simple explanations for illness and treatments iii. Reassure children that everything is going to be all right, if appropriate, and that they are not going to die vi. Relationships generally transition from mostly same sex ones to those with the opposite sex d. Recurrent respiratory infections and exercise induced bronchospasm are complications c. Oral and intramuscular medications (prednisolone, dexamethasone)Corticosteroids vi. History (fever, vomiting, diarrhea, urine output, fluid intake, blood loss, allergic symptoms, burns, accidental ingestion) b. Physical findings (heart rate, blood pressure, capillary refill, color, petechiae, mental status, mucous membranes, skin turgor, face/lip/tongue swelling) 4. Anaphylactic: subcutaneous epinephrine, intravenous anti histamines (diphenhydramine, ranitidine), and intravenous steroids d. History (age, fever, vomiting, photophobia, headache, prior seizures, extremity shaking, staring episodes, trauma, ataxia, ingestions, oral intake, bloody stool, urine output, baseline developmental level) b. History (polyuria, polydipsia, weight loss, visual changes, poor feeding, abnormal odors, growth delays) b. Physical findings (all vital signs, lung sounds, extremity tenderness, signs of active bleeding, bruises, joint swelling, lympadenopathy, capillary refill) c. History (blood or bile in emesis, diarrhea, age, gender, constipation, fever, medications, tolerance of gastrostomy tube feeds, prematurity, blood type incompatibility, epistaxis, liver disease) Page 341 of 385 b. Role of the Prehospital Professional (scene assessment, assessment of the caregiver, communication with the caregiver, documentation, reporting suspected abuse/neglect, safely transporting one or more injured children) 2. Normal changes associated with aging primarily occur due to deterioration of organ systems; B. Reduction in renal function due to decreased blood flow and tubule degeneration 2. May present with only dyspnea, acute confusion (delirium), syncope, weakness or nausea and vomiting B. Presentation can include dyspnea, congestion, altered mental status, or abdominal pain. Delirium a sudden change in behavior, consciousness, or cognitive processes generally due to a reversible physical ailment. Evaluation of pathophysiology through history, possible risk factors, and current medications a. Venous access care should be taken to avoid use of indwelling fistulas or shunt unless necessary in cardiac events. Blood pressures, lying, sitting, and standing noting any change of 10 mm/Hg or more lower as the patient moves to an upright position d. Pulses, lying, sitting, and standing noting any change of 10 beats per minute more higher as the patient moves to an upright position. Medications that damage the kidneys: antibiotics, nonsteroidal anti-inflammatory drugs, anticancer drugs 2. Evaluation of patient treatment through reassessment of disease Page 354 of 385 S. Diabetes Mellitus an inability of the pancreas to produce a sufficient amount of insulin causing hyperglycemia. Hypothyroidism-is destruction of the thyroid tissue over time that causes an insufficient amount of thyroid hormone in the blood. Myxedema coma is a premorbid consequence of hypothyroidism in the elderly caused by a recent history of surgery, hypothermia, infection, hypoglycemia, and sedative use. Oxygen with adjuncts appropriate to patient condition; may necessitate aggressive management iii. Type I osteoporosis is seen in post menopausal women due to the decline in estrogen and most commonly causes radial and hip fractures. Rheumatoid Arthritis is an autoimmune disorder that affects the joints of the body. These infections compounded by an inability, due to ageing of the hypothalamus, may not produce a fever in the face of an immunological insult such as a viral, bacterial, or occult infection. Prevention strategies will likely be absent, increasing the probability of disease D. It is estimated that 41 million Americans and one-third of people living in poverty have no health insurance, and insurance coverage held by many others would not carry them through a catastrophic illness F. Financial challenges for health care can quickly result from loss of a job and depletion of savings G. In addition, poor health is closely associated with homelessness, where rates of chronic or acute health problems are extremely high I. Free (or near-free) health care services are available through local, state, and federally-funded organizations 3. Accommodations that may be necessary when providing patient care include allowing adequate time for obtaining a history, performing assessment and patient management procedures, and preparing the patient for transport E.

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To examine potential interaction effects more closely pulse pressure amplification purchase genuine digoxin on line, we present coalitions arrhythmia breathing order digoxin no prescription, you have to make a choice of when you will be predicted probabilities and marginal effects plots in app 18 generic 0.25mg digoxin fast delivery. Partisanship can translate into in uence without embeddedness is high hypertension care plan order digoxin overnight delivery, as well as some dampening embeddedness effects question, as long as you are partisan with the right party. Coalition Age is positive and health policy eld is both large (in terms of the number of signi cant in models 2 and 4 but not in models 1 and 3. Coalition Issue Is Controversial is viant from coalitions in other policy domains. Indeed, a negative and signi cant in models 1 and 3 but not in models recent study by Crosson and Heaney (2014) documents this 2and4. They interviewed lobbyists working for 124 Among the endogenous variables, the coef cient on In randomly selected groups from any area of public policy. They then followed up with resulting from the fact that certain groups are more likely to be a second round of interviews with leaders of 84 coalitions recognized as making leadership contributions to coalitions randomly selected from this set. For example, the American Medical these coalitions (40%) dealt in some way with health. Also, the Edges variable, which accounts for the founding year, based on a similar data collection strategy. This variable is analogous to the constant in a stan behavior inside health policy coalitions as representative of dard regression model and, thus, should not be given a sub behavior inside coalitions focused on other policy domains. This result holds up in boxplots), then the model captures the network properties of every model we estimate. Thus, we have a very high degree the observed leadership graph well and does not suffer from of con dence in hypothesis 1a. Second, the coef cient on omitted-variable bias with regard to endogenous depen Diversity # Embeddedness is insigni cant in every model in dencies (Hunter, Goodreau, and Handcock 2012). Thus, we nd no support for exception of coalition mode k-stars, the models twellin either hypothesis 3a or 3b. It includes the same covariates but uses a different restriction for founders of the coalition. A k-star is a con guration of k nodes that each has one connection in the model, they are xed as structural zeros. These models are estimated to account for same covariates but places no restrictions on the analysis in the fact that there is not a unique way to measure embed terms of structural zeros or ones. The use of these alternative measures does not lead to how the way we set up the network analysis affects our con different conclusions about our hypotheses. This difference in the speci cation does not affect ysis is robust to multiple alternative measures of embedded conclusions about our hypotheses. For example, a pro-life group beddedness, Interest Group Mode Two-Stars, and Edges. In this minimal model, Partisan difference is that models 7 and 8 use an alternative measure Diversity has a coef cient that is positive and signi cant. Similarly, models 9 and 10 use an alternative tion on model 13 with the addition of Number of Coalition measure of Network Embeddedness that relies on intracoali Memberships. In this model, the coef cients on Partisan tion communication rather than coalition comembership. Diversity and Network Embeddedness are both positive and We did not use this measure in the main models because signi cant. Comparison of models 13 and 14 reveals that the of a likely endogenous relationship between the presence of leadership in a coalition and the likelihood that coalition 5. We examined predicted probabilities and marginal effects plots (see members are in communication. Volume 80 Number 2 April 2018 / 507 signi cance of Network Embeddedness is conditional on Goodness-of t plots for all models discussed in this including Number of Coalition Memberships in the speci section are included in appendix section 6. We suspect that this condition may hold because all models and robustness checks is provided in appendix groups that are in a greater number of coalitions may be section 10. Model measure the recognized leadership contributions of all 15 is a variation on model 1 that considers other measures of groups within a coalition using a single informant for each diversity within a coalition in addition to Partisan Diversity. Doing so requires this variation ascertains whether partisan diversity is crucial the assumption that the informants are not systematically or whether other kinds of diversity may have similar effects biased in favor of or against particular groups in their coa on coalitions. These alternative measures of diversity quire us to estimate statistical models containing 73 dummy do not enter model 15 with statistically signi cant coef variables (for each of N 2 1 coalitions). Further, these speci cations do not eralized linear model, or linear mixed-effects model frame affect conclusions about our hypotheses. Hence, future research should evaluate how possible and signi cance for Partisan Diversity is nearly identical in respondent biases might in uence estimates about the effects models 1 and 15, none of the other diversity measures seem of coalition composition. An alternative approach would be to moderate or mediate the effect of partisan diversity on to turn to multiple informants per coalition, although such a leadership contributions. In other words, the the relevance of diversity is increased when coalitions receive partisan diversity effect on recognition of contributions may greater attention from the public. A way around this limitation would be to observe that differ from model 1, thus allaying concerns that the group contributions to coalitions directly (rather than rely impact of diversity may be a function of the visibility or ing on informants). Mode Two-Stars in addition to Interest Group Mode Two Third, we measure contributions by groups dichotomously. This alternative speci cation examines the effect of Either groups are recognized for contributing leadership or controlling for network dependence in the second mode, they are not. This approach would allow common recognition of leadership contributions by several the comparison of leadership to other types of contributions, coalition members induces nonindependence of observa such as nancial or staff contributions. The results reveal no signi cant this study yields new insights about how interest group network dependence in the coalition mode and do not alter collaboration is related to the composition of lobbying co the conclusions with respect to our other hypotheses. The results strongly support the hypothesis that partisan diversity is positively associated 6. Coalitions that cross the partisan divide tend 508 / Contributions by Interest Groups to Lobbying Coalitions Michael T. Heaney and Philip Leifeld to operate differently from coalitions cloistered within one That is, there are likely greater bene ts to transcending party. This nding reveals that partisan polarization corre partisanship when it is a major factor that divides the po sponds to not only the decision making of legislators but also litical system than when it is not. Alternatively, if the political the behavior of ancillary political actors (see also Heaney and system is divided by another factor, such as a region, then Rojas 2015). Thus, it would be tions is positively associated with how connected their potentially productive to consider the effects of different members are through other coalitions, reinforcing the idea types of coalition heterogeneity over time and space. Observing the effects of network embeddedness, how search demonstrates that prior studies of coalitions, which ever, is associated with the number of coalition memberships focused exclusively on the interest group level of analysis, that an interest group has. This contingency may hold be were insuf cient to understand the nature of interest group cause groups with more coalition memberships are less likely contributions to lobbying coalitions. That is, embedded sential to incorporate analysis of coalitions themselves, es ness matters more for groups that are more selective about pecially their membership composition in terms of partisan which coalitions they join. This analysis, which In evaluating the importance of these ndings, it is nec views coalitions as relational teams, demonstrates the crucial essary to consider the scope of conditions under which they role of advocacy networks in linking interest groups and are likely to hold. We anticipate Hadden, Mark Hansen, Marie Hojnacki, Greg Huber, Kevin that our ndings about network embeddedness apply broadly Hula,LorienJasny,GeoffLorenz,JohnPadgett,JenVictor,and across political institutions and periods of time, as the em the anonymous reviewers. The second author carried out parts beddedness nding has already been demonstrated widely of this work at the Swiss Federal Institute of Aquatic Science across the social sciences. We expect, however, that the effects and Technology (Eawag); the University of Bern, Institute of of partisan diversity are likely to be more contingent on the Political Science; and the University of Konstanz. Executive agencies, for example, vary in the degree to which they are responsive to electoral pressures.

The illegal trade involved 67 countries/territories during the period under review blood pressure medication kidney order digoxin 0.25 mg with amex, and non-range countries played a considerable role in international pangolin trafcking blood pressure medication ending in pine discount digoxin 0.25mg with visa. However arrhythmia emedicine order digoxin canada, the countries or territories most commonly involved in international trafcking were largely within Asia iglesias heart attack best order for digoxin, with the exception of several African countries. Asian countries or territories were mostly implicated as origin and destination countries or territories, while African countries were mostly implicated only as origin countries. It is possible that some of the commonly used trade routes, which have stopped being used in consecutive years, were impacted by improved law enforcement. Shifing trade routes, which have led to a highly mobile trade network are evidenced by the detection of an average of 27 new trade routes emerging per year. It should be noted that the analysis was focussed on a country-by-country basis, therefore the number of individual trade routes would obviously be higher if the analysis had been focussed on specifc locations (or ports) within a given country. Europe was identifed as a major transit region, mostly for African pangolins being transported to Asia, but also as a destination in the case of the Netherlands and Switzerland. The Netherlands was also the only European destination country for large-quantity shipments of body parts and scales from Uganda and China respectively. Europe has previously been identifed as a transit hub, and also as a major destination for a large variety of wildlife species and their products (Engler and Parry-Jones, 2007; Challender and Hywood, 2012; Auliya et al. The European transit countries that were found to be involved in the highest number of incidents were Germany and Belgium, both of which also happen to be among the countries that directly supplied seizure data for this analysis. It is acknowledged that some countries or territories may be over-represented relative to others that did not provide data, however, this does not change the fact that pangolin trade is occurring in non-range countries. Tese countries are also in a geographically convenient position, and have well connected transport infrastructure, for the trafcking of African pangolins to Asia and could potentially represent another current (or future) transit hub. China appears to be an endpoint for much of the illegal trade, supporting the fndings of the existing literature (see. Not only was China the most commonly involved country, but it was also the main destination for large-quantity shipments of scales and whole animals. This can most likely be attributed to an ongoing demand for pangolin meat and scales, which is believed to be increasing (Xu et al. It has been suggested that urban consumption of meat might be tied to increasing afuence (Challender 2011), while the use of pangolins for medicinal and tonic food purposes in China dates back to the 16th century and is deeply rooted culturally (Coggins 2003; Ellis 2005; Zhang 2009). Tere also remains a legal market in China for pangolin scales, for which scales must be certifed, but uncertifed scales are still sold illegally within the country (Vallianos 2016; Xu et al. It should be noted, that across the three commodity categories, quantities are not comparable. The thresholds were chosen diferently, based on the distribution of the data within the three commodity categories, and 100 body parts cannot be compared to 1000 kg of scales for example. This is particularly important as high frequency, but comparably low volume shipments, will require a diferent type of law enforcement response, compared to a large multi-tonne shipment. The level of organization required for high volume transactions is fundamentally diferent, which will be refected in the individual players involved in this trade. The proportion of incidents involving trafcked scales appears to be increasing through time, as does the proportion of trade involving African pangolins, and scales were more likely to be of African origin. Trade in Asian species on the other hand appears to be decreasing, as does the trade in body parts, which was the commodity category that Asian species were most likely to be trafcked in. This trend may be an indicator of declining Asian pangolins throughout their ranges (although further studies are required to support this) and an increase in trade of African species, a shif which has already been inferred in other studies (Challender and Hywood 2012; Gomez et al. It remains to be tested if this holds true for traded quantities of African and Asian species as well, as this was not explored in detail in the current analysis. However, it was found that 55% of all large-quantity shipments of scales (involving 1000 kg or more of scales) originated in Africa, and large-quantity shipments of scales were also increasing through time, as was the weight of these shipments. Furthermore, the 10 shipments involving 1000 kg scales or more accounted for 60% of all scales (by weight) traded during the study period, highlighting the immense signifcance of these shipments from Africa. The theory of a proportional market shif to African pangolins is further supported by the increasing number of African countries involved in the international pangolin trafcking network through time. Increasing research is already being conducted into the identifcation of diferent species and their geographic origins using forensic methods (Wasser et al. It is suggested that these techniques should be used in future pangolin seizures as well, in order to assess better the threats to the diferent individual species of pangolins, particularly because of a potentially increasing threat to African pangolin species. It is important to note that country and territory rankings may change if the analyses focussed on the whole dataset of seizures, not only international incidents. Domestic incidents were not included, as this report aimed to focus on international trafcking routes. Due to missing trade route information in many reported seizure incidents, some countries may appear less involved than they likely are in reality, or may not be mentioned in this report at all. Future analyses need to focus on confrming the identity of these countries, as well as the role they play in pangolin trafcking. Tere are many biases inherent to seizure data, which will ultimately infuence the results of any seizure analysis. Tere are diferent levels of law enforcement within each country, as well as the level of reporting. In the seizure data there is also a language bias, meaning in most cases the received datasets were largely based on English-language media reports, while it has been shown that vernacular language reports will provide additional information pertaining to particular non-Anglophone countries and news reports (Nijman 2015). In the available datasets, some of the incidents were reported in languages other than English (mostly in Indonesian, Malay, Tai and Chinese), but newspaper articles in other languages were not specifcally searched. Destination countries or territories may represent the true fnal destination, or may just be a transit country or territory, if the true fnal destination (fnal importer) was not reported in the incident. An origin country or territory may also be a transit country or territory, if the true origin country or territory (frst exporter) was not reported in the incident. Hence, origin and destination countries or territories were defned as the frst and last known point in any trade route, respectively. Regardless of whether countries or territories were the intended true fnal destination in a trade route, they were still an importer of illegally traded pangolin products. It is now also a well-established fact that China is a major destination country for pangolin products (Pantel and Chin 2009; Nijman et al. Future accurate reporting of potential destination countries is important for identifying other major demand countries. Further analysis of these data will require careful consideration of the potential seizure and reporting biases. The reporting of seizures of pangolins specifcally has been made a requirement through Notifcation No. Parties have been asked to report on information including pangolin seizures, prosecution efort, forensics analysis, stockpile management, and inventories of captive populations, to enable a more thorough assessment on the conservation of African and Asian pangolin species. European countries served as transit points, with the exception of the Netherlands (and potentially Switzerland), which was primarily a destination for pangolins and their products. The involvement of African countries (and African pangolin species) in terms of number of incidents increased through time. African countries also emerged as the major origin countries for large-quantity shipments of scales. However, most trafcking occurred within Asia during the study period, both in terms of number of incidents, but also quantities. Further studies into the quantities and commodities of pangolins and their derivatives being trafcked, and the role of non-range countries are imperative to present a more holistic solution to the problem of illicit trade. However, the countries that most need to enhance their law enforcement eforts are those with low numbers of seizures, but at the same time implicated in the routes of many trafcking incidents. Several European countries, especially, Germany, France, and Belgium are also implicated as they have been identifed as important transit hubs, especially for African pangolins. Furthermore, analysis of the type of product, and the quantities seized, may be useful in determining the type of criminal activities and/or networks behind the shipments, and the enforcement response required. This will be imperative to ensure an increase in successful conviction rates, and stronger penalties, which serve as meaningful deterrents. Co-operation from transportation and logistics companies involved in movement (however unwittingly) of shipments along trade routes is also necessary; these companies are encouraged to share information on methods of concealment or trafcking, specifc routes used, and other notable information to enable efective law enforcement investigations. This would provide further insights into the targeted behaviour change initiatives required based on motivational variations amongst consumers. This will greatly assist in identifying the role of non-Asian countries as centres of demand for international pangolin trafcking. Trade in live reptiles, its impact on wild populations, and the role of the European market.