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By E. Mine-Boss. Bluffton University. 2018.

Interest rates on secured lated $60 purchase viagra sublingual 100mg overnight delivery,000 in debt (on a personal line of credit) during liabilities such as a car loans are usually higher cheap 100mg viagra sublingual free shipping, ranging from training and has $20 discount 100mg viagra sublingual with mastercard,000 in student loans purchase viagra sublingual 100 mg online. Here, interest rates can vary from 16 to 24 per cent of the balance, depending on the Introduction client’s credit rating. Paying down a credit card balance by using In 2007, the average debt of Canadian medical residents at a personal line of credit can save 11 to 19 per cent of the the end of training was reported as $158,728 (Kondro 2007). Indeed, given rising tuition costs, debt during medical training has become a necessary evil for most residents. However, not Pros and cons of student loan consolidation all debt is the same, and proper debt management can lower All physicians can claim a federal tax credit (15 per cent in overall interest payments and help to speed up repayment. Interest paid are: for any other indebtedness, such as bank loans or lines of • Canada and provincial student loans, credit, are not eligible for this credit. However, residents who are carrying with federal and/or provincial student loan authorities. This a signifcant debt load and are faced with a limited cash fow debt tends to be relatively favourable in terms of after-tax rates may wonder about the relative merits of paying down their and repayment options. Several fnal decision may be a matter of personal preference and of Canadian provinces have therefore pioneered programs to risk tolerance. Learning how different fnancial management defer interest on the provincial portion of medical resident practises can best ft a residents personal level of comfort and loans. The interest rates on federal and provincial student loans may be as high as two or three percentage points above the prime Negotiating with fnancial institutions lending rate. However, the interest paid on these loans has been Residents can save precious time and avoid unnecessary frustra- claimable as a federal tax credit since 1998. Most provinces tion by working with a fnancer who is familiar with physicians’ provide such tax credits as well. In consolidating all debts to the bank, the resi- from terms that are more advantageous than those normally dents will forfeit both federal and provincial tax credits. A fnancial consultant can provide If the student loans stay outside of the loan consolida- their physician clients with some useful advice in preparation tion, the residents will realize an after-tax interest rate of for a meeting with a fnancial institution’s account manager. A credit rating is based mainly on an individual’s history of debt repayment, The fnancial planner gave three alternatives to the resi- his or her current fnancial position (assets and liabilities) and dents on their debt management process. Because banks often place more emphasis on current credit rating than on future income potential, it is Focus on savings: If they both purchase $13,000 of crucial to maintain an excellent credit rating. Because credit ratings are based on a seven-year cycle, any late interest payments or failures to pay bills will have a negative Focus on reducing debt: After four years of practice impact on an individual’s credit rating for some time. A fnancial consultant can provide advice on maintaining a good credit Combine strategies: By combining these strategies, rating. Understanding the pluses and minuses Good debt management involves evaluating all liabili- of consolidating loans, repaying debt, purchasing retire- ties with respect to type of debt, amount, interest and ment savings plans is important for all residents who conditions of repayment. Trainees should be approach their fnancial institutions to consolidate their proactive with their money by negotiating with fnancial loans into a line of credit or term loan. Through appropri- ratings, they can negotiate a line of credit at interest rates ate fnancial planning all residents can secure fnancial as low as the prime lending rate. Tax Tips for the Medical However, caution should be used when considering con- Student, Resident and Fellow. The bank offers the resident and spouse the prime rate of four per cent on a line of credit to consolidate their indebtedness—including their student loans, on which they have been paying prime plus three per cent. The bank’s offer seems to be attractive, but after a closer look, the actual after-tax savings would be approximately 1. Logan C, Director Disability Services, Homewood Employee Health: personal conversation Canadian Medical Association. In Creating a Healthy Culture in Medicine: a Report From the 2004 Quality Worklife—Quality Healthcare Collaborative. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Rich P. Global Business pdf and Economic Roundtable for Mental health College of Family Physicians of Canada, Canadian Medical 1-E. Promoting healthy partnerships in medical Intelligence: Key Readings on the Mayer and Salovey Model.

Female patients of fertile age should routinely be interviewed and tested for pregnancy before treatment discount 100 mg viagra sublingual. It is also necessary to have strict procedures to verify that the patient is not breastfeeding viagra sublingual 100 mg on line. In therapy purchase viagra sublingual 100mg on line, higher activities per patient are handled than for diagnostic purposes and the radionuclides are often different from those used in diagnostic nuclear medicine order 100 mg viagra sublingual free shipping. They are usually β emitters, sometimes low energy electron and α emitters with longer physical and biological half-times and, therefore, constitute a greater radiation protection problem. Therapy radionuclides may require different facilities to radionuclides used for diagnostic procedures, to ensure the safe preparation and administration of the radiopharmaceutical. Local skin doses to the hands of the personnel due to β emitters can reach high values. There are situations where the equivalent dose at the fingertips could considerably exceed the recommended annual limit, which is 500 mSv [12, 13]. Optimized working conditions can, however, keep the doses to staff well below the limits for occupational exposure both for the dose to the extremities (500 mSv/year) 1 and to the eyes (20 mSv/year ) [13]. In both diagnostic and therapeutic nuclear medicine, the patient becomes a source of radiation not only for him/herself but also for staff, caregivers, family members and the general public, and remains so until the radioactive material has decayed or is excreted from the body [14]. On the other hand, the number of therapy patients is much lower than the number of patients undergoing diagnostic investigations [1] and the yearly contribution to the effective dose to most staff members is usually small. However, members of ward nursing staff can easily reach effective doses of a few millisieverts per year. For this group, it is essential that information and education in radiation protection and establishment of routines guarantee that doses to pregnant staff members are such that the dose to the embryo/foetus is kept under 1 mSv [11]. Here also routines are needed to guarantee that the dose to the embryo/foetus is kept below 1 mSv [11]. Individualization is possible, for example, by using quantitative imaging modalities, external counting and blood sampling for pre-therapeutic biokinetics measurements. Here, the standard methods and the expected advances in performing individualized dosimetry are discussed. The administered activity should accumulate selectively in tumour cells and, thus, kill or sterilize the target cells, while avoiding adverse effects to other organs as far as possible. The administered activity for treatment must be properly determined for optimal safety and efficacy of the treatment. This approach is simple, but leads to over- and undertreatment of some patients as individual biokinetics are not considered. This much more complex approach should, if properly performed, avoid over- and undertreatment of patients and should, consequently, be preferred. In the following section, the steps of nuclear medicine dosimetry are presented [1], and advances and challenges are briefly discussed [2]. Quantification of patient specific pharmacokinetics Nowadays, planar gamma camera imaging is performed most frequently, followed by manual region drawing. Although this is a large improvement compared to non-patient specific approaches, the well known limitations of planar imaging cannot easily be overcome [4]. Furthermore, whole body counting and blood or urine sampling can provide additional information on the biokinetics of a given substance. Kinetic model Usually, the measured time points of the patient’s biokinetics were simply fitted by sums of exponentials [6, 7]. To eliminate this dependence on the observer, fit function selection should be performed using an adequate model selection criterion, e. An important quality control is the presentation of the standard errors of the residence times [3, 7]. This can be improved using standard methods based on population kinetics to calculate the optimal sampling schedule [14–16]. This, in turn, will lead to an increased precision of the calculated residence times for a given number of measurements.

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As propylene glycol can dissolve plastic viagra sublingual 100 mg cheap, the drug should preferably be administered using a glass syringe (only if sterilisation is reliable) cheap viagra sublingual 100 mg visa, otherwise inject immediately (but slowly) using a plastic syringe buy generic viagra sublingual 100 mg on-line. Duration – According to clinical response Contra-indications buy 100mg viagra sublingual, adverse effects, precautions – Do not administer in gastric ulcer. Do not freeze – • Expiry date indicated on the label is only valid if stored under refrigeration and protected from light. Exposure to heat and especially light causes the deterioration of the active ingredient and thus loss of efficacy. Contra-indications, adverse effects, precautions – Do not administer to patients with allergy to metronidazole or another nitroimidazole (tinidazole, secnidazole, etc. Contra-indications, adverse effects, precautions – Do not administer to patients with severe respiratory impairment or decompensated hepatic impairment. The child may develop withdrawal symptoms, respiratory depression and drowsiness when the mother receives morphine at the end of the 3rd trimester and during breast-feeding. In these situations, administer with caution, for a short period, at the lowest effective dose, and monitor the child. Contra-indications, adverse effects, precautions – May cause: • tachycardia, fibrillation, hypertension, pulmonary oedema when given postoperatively, due to a sudden reversal of analgesia; • nausea, vomiting; • acute withdrawal syndrome in opioid-dependent patients. Contra-indications, adverse effects, precautions – May cause: headache, diarrhoea, skin rash, nausea, abdominal pain, dizziness. Initially 5 to 8 drops/minute, then increase by 5 to 8 drops/minute every 30 minutes (max. Do not freeze – • Expiry date indicated on the label is only valid if stored under refrigeration and protected from light. Exposure to light and heat causes the deterioration of the active ingredient and thus loss of efficacy. Contra-indications, adverse effects, precautions – Do not administer to patients with severe hepatic impairment. Remarks – For the prophylaxis of pneumocystosis, pentamidine may be used by inhalation of nebulised solution using suitable equipment. If necessary, a second dose of 5 to 10 mg/kg may be administered 15 to 30 minutes after the first dose. Contra-indications, adverse effects, precautions – Do not administer in patients with severe respiratory depression. Do not use oral route in newborns at high risk (preterm neonates, jaundice, neonatal diseases; newborns whose mother is treated with enzyme-inducing drugs). Dosage and duration Dosage depends on the severity of hypokalaemia and the patient’s underlying condition. The infusion may be repeated if severe symptoms persist or if the serum potassium level remains <3mmol/litre. Contra-indications, adverse effects, precautions – Administer with caution to elderly patients. If more than 30 minutes have elapsed since the heparin injection, the dose of protamine to be given should be one half the dose of heparin injected. Contra-indications, adverse effects, precautions – May cause: hypotension, bradycardia and dyspnoea; allergic reactions, notably in diabetics treated by protamine-insulin. Dosage the dosage is expressed in terms of salt; it is the same for quinine dihydrochloride or for quinine formate: – child and adult: • loading dose: 20 mg/kg administered over 4 hours, then keep the vein open with an infusion of 5% glucose over 4 hours • maintenance dose: 8 hours after the start of the loading dose, 10 mg/kg every 8 hours (alternate quinine over 4 hours and 5% glucose over 4 hours) for adults, administer each dose of quinine in 250 ml. Do not administer a loading dose to patients who have received oral quinine, mefloquine or halofantrine within the previous 24 hours: start with maintenance dose. Duration – change to oral treatment as soon as possible with a 3-day course with an artemisinin-based combination (if patient developed neurological signs during the acute phase, do not use the combination artesunate- mefloquine) or oral quinine to complete 7 days of treatment. Contra-indications, adverse effects, precautions – May cause: hypoglycaemia; auditory and visual disturbances, cardiac disorders (especially in the event of overdose), hypersensitivity reactions, cardiac depression if injected undiluted by direct Iv route. If contractions persist, increase the rate by 10 to 20 drops/minute every 30 minutes until uterine contractions cease. Continue for one hour after contractions have ceased, then reduce the rate by half every 6 hours. Duration – 48 hours maximum Contra-indications, adverse effects, precautions – Do not administer to patients with pre-eclampsia, eclampsia, uterine haemorrhage, intra- uterine infection, intra-uterine foetal death, placenta praevia, placental abruption, rupture of membranes, multiple pregnancy, severe cardiopathy.

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When you dry herbs/botanicals the medicinal components are concentrated with the removal of the water discount 100mg viagra sublingual fast delivery. Soaking (tincturing) the dried herb/botanical in alcohol extracts those concentrated medicinal components and makes them available buy viagra sublingual 100 mg without prescription. An additional bonus is that alcohol-based tinctures are medicinally potent for years if stored in dark bottles or jars 100mg viagra sublingual overnight delivery. We tincture most of our herbs and botanicals so they are immediately available for use purchase viagra sublingual 100mg fast delivery, and we can be confident they are potent in an acute situation. We also keep dried herbs available for infant/child usage as teas, and also particular dried herbs available for poultices, and compress, and topical usage. To prepare the tincture you need quart canning jars with lids, dried herbs/botanicals, and at least 90 proof Vodka. Everclear is excellent to use also and in a pinch you could use another grain-based product. You want the alcohol to become saturated with the medicinal components of the herb/botanical, and other alcohol liquors/whiskey have components already saturating the alcohol so it probably won’t be as medicinally potent, but it would still have more potency that other preparation methods. Fill the quart jar about 1/3 full of dried herb/botanical, chopped root, or crushed (not powdered) leaf, fill the jar to the "shoulder" with vodka/Everclear, secure the lid, shake, and put in a dark cool place. In 10-14 days strain the liquid into dark bottles or jars, cap tightly, and label. The commonly accepted tincture dosage is 1-2 eye droppers full, 1 dropper full equals approximately 1/2 teaspoon. Alternatively, you can use the dropper to place the tincture in gelatine capsules. You can buy empty gelatine capsules in health food stores by the capsule or by the bag of 1000. Just pop the capsule apart, fill the larger section with finely crushed (powdered) dried herb, put - 70 - Survival and Austere Medicine: An Introduction back together, and take with water. Poultice: A poultice is warm, mashed, fresh, or finely crushed dried herb applied directly to the skin to relieve inflammation, bites, eruptions, boils, and abscesses. Depending on the size of the area to be treated put enough herbs in a glass dish/pot, cover with enough olive oil, or water, or decoction of the same herb to thoroughly saturate the herb, heat gently until a comfortable temperature to the skin, apply directly to the area to be treated covering it completely, and then cover with a sterile bandage. Bolus/Suppository: These are made using vegetable glycerine or cocoa butter mixed with a dried powdered herb to the consistency of bread dough. This method allows the herb to be in direct contact with the area needing treatment. Syrup: To about a pint of decoction you add enough honey and/or eatable glycerine to thicken slightly. Especially good for children to treat coughs, congestions, and sore throat as it will coat these areas slightly ,and keep the medicinal components in direct contact with the tissues. Specific Herbs and Botanicals We have tried to refine a list of herbs/botanicals, both wildcrafted and home grown, that would be most useful in treating the most common illnesses or diseases that may manifest in a survival situation. From the reading you have been doing in your newly acquired herb information books you now realize the vast amount of information and herbs available for use. Just use this list as a starting point to adjust and personalize according to your needs and medical situations. Wildcrafting: The following 7 herbs and botanicals grow almost universally all over the U. It has a blood cleanser effect (detoxifier) and is nutritive to the liver; also mildly diuretic. Dandelion (Taraxacum officinale): Harvest 2nd year roots in the spring or fall; young leaves in the spring for fresh eating. The root has been used for centuries to treat jaundice as it has a powerful alterative effect on the liver. Echinacea (Echinacea angustifolia): Harvest 2nd and 3rd year roots in early winter after the plant has totally died back (see, you do need your map! Echinacea purpurea: Harvest flower heads with seeds before petals drop in late summer. Tincture, water infusion, oil infusion, decoction, poultice, compress, bolus, syrup, capsule. Using these two varieties together gives increases the potency of your treatments.

The pulmonary thepatientissaidtosufferfromsleepapnoeaifmorethan vasculature responds to hypoxia by vasoconstriction 15 such episodes occur in any 1 hour of sleep buy viagra sublingual 100mg cheap. Hypoxia also increases arrhythmias and there is an increased risk Prevalence of stroke and myocardial infarction order 100 mg viagra sublingual overnight delivery. Investigations A simple sleep study with overnight pulse oximetry to- Sex gether with a history from sleeping companion may be Male preponderance purchase viagra sublingual 100 mg fast delivery. Many require a full sleep study (polysomno- gram) buy viagra sublingual 100 mg overnight delivery, which consists of a pulse oximeter, a tidal volume Aetiology measurement, oronasal flow and electroencephalogra- Risk factors include obesity, smoking, chronic obstruc- phy to record sleep and arousal patterns. Polycythaemia tive pulmonary disease and alcohol or other sedatives (raised haemoglobin and packed cell volume) may occur which exacerbate the problem by causing hypotonia and in advanced cases. Apnoea can be divided into the following: Management 1 Central apnoea when there is depression of the respi- Non-pharmacological treatment includes weight loss, ratory drive, e. Snoring arises because of turbulent airflow around the 2 Surgicaltreatmentmaybedifficultaspatientsareoften soft palate with partial obstruction. Thereisareflex the redundant tissues in the soft palate and lateral increase in respiratory drive, which eventually rouses the pharynx is sometimes performed but its benefit in Chapter 3: Restrictive lung disorders 117 true obstructive sleep apnoea is unproven and it changes and the cysts seen in honeycomb lung. It has been reclassified as usual interstitial pneu- Radiation monia, a form of idiopathic interstitial pneumonia. Extrinsic allergic alveolitis Ankylosing spondylitis and other connective tissue diseases (scleroderma, rheumatoid arthritis, sys- Prevalence temic lupus erythematosus) Uncommon. Sarcoidosis, berylliosis (exposure to this industrial al- loy mimics sarcoidosis) Age Tuberculosis Usually late middle age. Cryptogenic fibrosing alveolitis (idiopathic pul- monary fibrosis) Sex Asbestosis Slightly M > F The other main groups of causes are the pneumoco- nioses, which are occupational lung diseases in response Aetiology to fibrogenic dusts such as coal and silicon, and drug- Unknown, but an indistinguishable disease is seen in induced, such as amiodarone. Pathophysiology Antinuclear factor is positive in one third of patients The lung has limited ability to regenerate following a se- and rheumatoid factor is positive in 50%. Fibrosis may be localised, bilateral of patients are current or former smokers, and smoking or widespread depending on the underlying cause. Patients are at an increased risk of secondary infection and even if the original insult is removed may develop progressive Pathophysiology fibrosis and subsequent respiratory failure. The alveo- There appear to be areas of fibroblast activation, which lar wall fibrosis greatly reduces the pulmonary capillary lay down matrix, and healing of these leads to fibrosis. It network, leading to the development of pulmonary hy- is not clear what causes the acute lung injury or the ab- pertension, right ventricular hypertrophy, with eventual normal healing process, but increased levels of cytokines right heart failure (cor pulmonale). They may present with secondary 118 Chapter 3: Respiratory system bacterial infection. Single-lung transplant and fine end-inspiratory crackles in the mid to lower has been shown to be viable, but most patients have lungs. Microscopy Prognosis Characteristically chronic fibrotic, scarred zones with Median survival of 5 years. Forty per cent die of progres- collapsed alveoli and honeycombing alternate with ar- sive respiratory failure, most of the others from acute in- eas of relatively unaffected lung. Newer injury, there are foci of activated fibroblasts with little anti-fibrotic and immunological therapies are being in- inflammation. Complications The disease is progressive and usually unresponsive to Extrinsic allergic alveolitis treatment, and patients develop respiratory failure, pul- Definition monaryhypertensionandcorpulmonale. Anacuteform An immune reaction within the lung to inhaled organic exists (Hamman–Rich syndrome or acute interstitial dusts. Disease Source Antigens r Lung biopsy is indicated if possible, usually trans- Farmer’s lung Mouldy Micropolyspora bronchial via bronchoscopy. Because of the patchy hay/vegetable faeni, nature of the disease, however, surgical lung biopsy material thermophilic of several sites may be needed. A trial of pred- and feathers nisolone 30 mg is indicated if the diagnosis is not well Malt worker’s Germinating Aspergillus established in case there is a responsive interstitial pneu- lung barley clavatus monitis. Azathioprine and ciclosporin have also been Humidifier fever Contaminated Various bacteria humidifiers and/or tried. On 2 High-dose prednisolone is used to cause regression of examination there may be tachypnoea and cyanosis, the early stages of the disease, later stages where there with widespread fine end-inspiratory crackles and is fibrosis are not amenable to treatment. Farmer’s lung is an occupational disease in the United Kingdom with sufferers being entitled to compensation. Definition An acute form of respiratory failure caused by diffuse Complications pulmonary infiltrates and alveolar damage occurring Diffuse fibrosis and formation of honeycomb lung in hours to days after a pulmonary or systemic insult.

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