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For some nutrients discount viagra with dapoxetine 100/60 mg, such as saturated fat and cholesterol best buy viagra with dapoxetine, biochemical indicators of adverse effects can occur at very low intakes viagra with dapoxetine 100/60mg fast delivery. Thus, more information is needed to ascer- tain defined levels of intakes at which onset of relevant health risks (e. A state- ment for health professionals from the Nutrition Committee, American Heart Association. This comprehensive effort is being undertaken by the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes of the Food and Nutrition Board, Institute of Medicine, the National Academies, in collaboration with Health Canada. See Appendix B for a description of the overall process, its origins, and other relevant issues that developed as a result of this new process. Establishment of these reference values requires that a criterion of nutritional adequacy be carefully chosen for each nutrient, and that the population for whom these values apply be carefully defined. A requirement is defined as the lowest continuing intake level of a nutrient that, for a specific indicator of adequacy, will maintain a defined level of nutriture in an individual. The median and average would be the same if the distribution of requirements followed a symmetrical distribution and would diverge if a distribution were skewed. This is equivalent to saying that randomly chosen individuals from the population would have a 50:50 chance of having their requirement met at this intake level. The specific approaches, which are provided in Chapters 5 through 10, differ since each nutrient has its own indicator(s) of adequacy, and different amounts and types of data are available for each. That publication uses the term basal requirement to indicate the level of intake needed to prevent pathologically relevant and clinically detectable signs of a dietary inadequacy. The term normative requirement indicates the level of intake sufficient to maintain a desirable body store, or reserve. Its applicability also depends on the accuracy of the form of the requirement distribution and the estimate of the variance of requirements for the nutrient in the population subgroup for which it is developed. For many of the macronutrients, there are few direct data on the requirements of children. Where factorial modeling is used to estimate the distribution of a requirement from the distributions of the individual components of the requirement (maintenance and growth), as was done in the case of protein and amino acid recommendations for children, it is necessary to add (termed convolve) the individual distributions. Examples of defined nutritional states include normal growth, maintenance of normal circulating nutrient values, or other aspects of nutritional well-being or general health. The goal may be differ- ent for infants consuming infant formula for which the bioavailability of a nutrient may be different from that in human milk. In general, the values are intended to cover the needs of nearly all apparently healthy individuals in a life stage group. Qualified health professionals should adapt the recommended intake to cover higher or lower needs. Instead, the term is intended to connote a level of intake that can, with high probability, be tolerated biologically. This indicates the need for caution in consuming amounts greater than the recommended intake; it does not mean that high intake poses no potential risk of adverse effects. In many cases, a continuum of benefits may be ascribed to various levels of intake of the same nutrient. One criterion may be deemed the most appropriate to determine the risk that an individual will become deficient in the nutrient, whereas another may relate to reducing the risk of a chronic degenerative disease, such as certain neurodegenerative dis- eases, cardiovascular disease, cancer, diabetes mellitus, or age-related macular degeneration. Role in Health Unlike other nutrients, energy-yielding macronutrients can be used somewhat interchangeably (up to a point) to meet energy requirements of an individual. However, for the general classes of nutrients and some of their subunits, this was not always possible; the data do not support a specific number, but rather trends between intake and chronic disease identify a range. Given that energy needs vary with individuals, a specific number was not deemed appropriate to serve as the basis for developing diets that would be considered to decrease risk of disease, including chronic diseases, to the fullest extent possible. These are ranges of macronutrient intakes that are associated with reduced risk of chronic disease, while providing recommended intakes of other essential nutrients. Above or below these boundaries there is a potential for increasing the risk of chronic diseases shown to effect long-term health. The macro- nutrients and their role in health are discussed in Chapter 3, as well as in Chapters 5 through 11. The amount consumed may vary substantially from day-to-day without ill effects in most cases. Healthy subgroups of the population often have different requirements, so special attention has been given to the differences due to gender and age, and often separate reference intakes are estimated for specified subgroups. When this is an issue, it is discussed for the specific nutrient in the section “Special Considerations. People with diseases that result in malabsorption syndrome or who are undergoing treatment such as hemo- or peritoneal dialysis may have increased requirements for some nutrients. Special guidance should be provided for those with greatly increased nutrient needs or for those with decreased needs such as energy due to disability or decreased mobility. Life Stage Groups The life stage groups described below were chosen while keeping in mind all the nutrients to be reviewed, not only those included in this report. Infancy Infancy covers the period from birth through 12 months of age and is divided into two 6-month intervals. Except for energy, the first 6-month interval was not subdivided further because intake is relatively constant during this time. That is, as infants grow, they ingest more food; however, on a body-weight basis their intake remains nearly the same. During the second 6 months of life, growth velocity slows, and thus daily nutrient needs on a body-weight basis may be less than those during the first 6 months of life. The extent to which intake of human milk may result in exceeding the actual requirements of the infant is not known, and ethics of human experimentation preclude testing the levels known to be potentially inadequate. It also supports the recommendation that exclusive human-milk feeding is the preferred method of feeding for normal, full-term infants for the first 4 to 6 months of life. In general, for this report, special consideration was not given to pos- sible variations in physiological need during the first month after birth, or to the variations in intake of nutrients from human milk that result from differences in milk volume and nutrient concentration during early lactation. However, where warranted, information discussing specific changes in bioavailability or source of nutrients for use in develop- ing formulations is included in the “Special Considerations” section of each chapter. Because there is variation in both of these measures, the computed value represents the mean. It is assumed that infants will have adequate access to human milk and that they will con- sume increased volumes as needed to meet their requirements for mainte- nance and growth. This is because the amount of energy required on a body-weight basis is significantly lower during the second 6 months of life, due largely to the slower rate of weight gain/kg of body weight. Toddlers: Ages 1 Through 3 Years Two points were primary in dividing early childhood into two groups. First, the greater velocity of growth in height during ages 1 through 3 years compared with ages 4 through 5 years provides a biological basis for divid- ing this period of life.

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We would hope in the majority of cases that students will be able to do their preferred elective choices purchase viagra with dapoxetine 100/60 mg without a prescription. Year 1 Each 10 credit module will last for five weeks with one week at the end for self-study/ assignment writing buy discount viagra with dapoxetine. Year 2 Students will complete the following compulsory courses: 1 Clinical Skills Principles (examination purchase viagra with dapoxetine paypal, communication and Sept–Oct procedures) 2 Acute Medicine and Clinical Decision Making (10 credits) Oct–Dec 2. Some of the modules have a maximum student quota also – please speak to the course organisers for further details about this. Programme timetable A finalised timetable for each term will be published at the start of the term and sent to all enrolled students. The course material for the individual weeks will be made available on the first Monday of the week. Most of this material, including e-lectures and core reading, can be accessed at any time, so they are not included in the timetable. Any scheduled events (usually tutorials) requiring fixed time commitment will be shown on the timetable distributed at the start of each term. We do understand that due to time differences, not all students will be able to attend these tutorials, and they will be archived for future viewing. You are responsible for organising your time and making sure you meet assessment deadlines and any other requirements. Features include:  Case of the Week: we will present new cases every week and these will be explored further in the discussion boards. Content will be divided into modules, and each module lasts for five weeks, with a further week at the end for assessment. Students can explore these further in the literature, interactive resources and tutorials. Students will be encouraged to contribute to the discussion boards where they share their thinking with other students. During most weeks there will be interactive online tutorials (see below) in which students and tutors share information, discuss key issues, identify learning needs and gaps and benefit from the interaction of the group. Online tutorials (Wimba tutorial space) We will also be using the Wimba platform to provide a virtual tutorial environment where students can meet for live lectures/tutorials/group discussions. Wimba allows delivery of face-to-face teaching and encourages a sense of community in the students. Students are strongly encouraged to attend the live tutorial sessions, but they will be archived for future viewing for the benefit of any students unable to attend. There will be an introductory tutorial in Fresher’s Week so that everyone has the opportunity to familiarize themselves with the tutorial platform. We would be grateful if all students could always be present in the tutorial room five minutes before the tutorial is due to start. Online resources and OpenMed In addition to the core teaching material, we will be encouraging use of open- access resources that have been released (usually by other teaching or educational organisations) under creative commons licenses for general teaching use. We have collated these into different clinical specialties and graded them for level of user and quality; they can be accessed through the OpenMed website at openmed. For each specialty area we have grouped resources into a useful learning pathway or curriculum. Many of our tutors will be adding and rating resources in their specialty areas and will point you in the direction of any useful additional resources. Anyone interested in contributing to the website should contact Dr Eleri Williams. Library facilities and e-textbooks Library facilities will be provided electronically through the University of Edinburgh Library Online. Students will also have access to the physical library buildings if they do wish to access these in Edinburgh. The University library will allow access to most journals and online e-textbooks related to the course. Computer requirements Computer and broadband A computer and internet access (preferably broadband) are required to participate in the course. A webcam is very useful for full participation in tutorials but a microphone and headphones will allow ‘voice-only’ participation. Software / computer configurations We will ask you to download some free software and to run configurations to ensure your computer is set up to run some of the e-learning resources (e. You will be given full details of this prior to commencing the course—see below for further details: Flash player Check you have the latest Flash Player (Version 9 or above) How do I know what version of Flash Player I have? Two ways of doing this, either: a) Right-click any flash object in a web browser b) Click on Start> Control Panel >Add/Remove Programs. A dialogue appears that tells you the version of Flash Player currently installed. Wimba Classroom Ensure that your computer is configured to run Wimba (the online tutorial software) before starting the course. Please use the ‘wizard’ to check that your computer and headset are set up for Wimba: edlive. The following are links to demos/videos showing how Wimba Classroom works: Wimba basics: www. Email When you join the University you will get a University of Edinburgh email account and address which will be used for a variety of essential communications. You must access and manage this account regularly as important information from the University will be sent to this address. If you already have a web-based email account and think you are unlikely to check your University email account, it is your responsibility to set up a forward on your University email. Change of details It is vital that you inform Registry Services of any change to details. You are given the opportunity to check and amend your details annually via your Registration Forms, but details can be changed at any time using the online form found here: www. Transkills training Transkills run a range of personal and professional development training courses for students across the University. Course organisers Eleri Williams (Lecturer in Internal Medicine) has responsibility for the day-to- day running of the course, and should be the first point of contact for all students. Associate tutors Associate tutors with specialist expertise will be invited to contribute/run modules in their specialty areas. The programme director is also there to facilitate your orientation and smooth progression through the degree, from initial induction to subsequent course choice, and the transition into the dissertation stage and to the successful completion of the degree. It is your responsibility to inform the programme director immediately of any problems that are interfering with your coursework or progress through the programme, including any religious or medical requirements that might affect your participation in any aspect of the programme. The style of assessment has been chosen to best complement the taught material and learning outcomes. Times New Roman 12pt, Arial 10pt)  With a structure, style and authorial voice consistent with the related literature – i. The thesis will demonstrate the student’s ability to complete a piece of objective research, which may be in the form of an extended clinical audit, a laboratory based project, a systematic review, or similar in any area of internal medicine. The student will be allocated an individual tutor/ supervisor based at the University of Edinburgh, and we would aim to find people with appropriate specialist interest in the areas required. Candidates will however be encouraged to work closely with senior staff in their home institutions, with mutually beneficial fostering of suitable academic links between the University of Edinburgh and medical institutes worldwide.

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For example buy genuine viagra with dapoxetine online, a cobalt therapy unit with an adequate radioactive source is not obsolete 100/60mg viagra with dapoxetine sale, but a mammography unit with a tungsten target and an aluminum filter is generic viagra with dapoxetine 100/60mg with amex, because the image quality that is produced is substandard. Acquiring obsolete equipment may have detrimental effects on the health care system. Availability of operation and service manuals No piece of equipment should be acquired without operation and service manuals. This may be difficult if the language of the original equipment owner was different from that of the intended recipient and the equipment is no longer being manufactured. Availability of accessories and replacement parts When acquiring second hand equipment, it is important to assess whether the original accessories come with the main unit. Examples of potential problems are wedges for cobalt therapy machines, image receptors for mammography units and collimators for gamma cameras. It is essential that replacement parts be available from the original manufacturer or a reputable distributor for the length of the intended use of the equipment. The recipient institution should investigate from the original manufacturer the length of time they can support the equipment and whether local distributors and/or third party maintenance organizations have spare parts and accessories in stock, for how long and at what cost. Equipment which uses some kind of software, especially if it is no longer manufactured, may have old software versions that may be out of date, or if nothing else, awkward to use. Before acquiring any equipment, the availability of software upgrades should be explored from the original manufacturer and budgeted for. Environmental (facility) conditions There are several types of environmental concerns that need to be addressed when installing a piece of equipment in a new facility built to house it. First, the facility needs to comply with local building codes regarding space, accessibility, floor loading capacity, electrical power (voltage, frequency, phase and heat dissipation), water volume, pressure and drainage, etc. If the equipment emits radiation, the structural shielding needs to be calculated and its adequacy tested — preferably before the unit is installed, but certainly before it is put into clinical use — taking into account patient, staff and public dose constraints [3]. If the second hand equipment to be acquired is to be placed in an already existing building, to comply with local regulations may be more difficult, as there may be structural limitations. Furthermore, if open radioactive sources, such as those used in nuclear medicine, are included, there should be a plan for disposal of the radioactive waste that will be generated. Most types of radiological equipment can only function well with a stable power supply. This is particularly true for old computed tomography scanners, which cannot function unless the room temperature is very low. The requirements for both temperature and humidity should be known before the equipment is acquired. Room modifications should be implemented and plans for daily monitoring of the temperature and the humidity established, before the equipment is put into clinical use. Sustainability considerations Prior to equipment acquisition, facilities should ensure, through appropriate budgeting, that there is adequate and properly trained staff for its operation and that the equipment can be maintained during its projected lifetime. If the equipment is technically complex, it may be less expensive to outsource maintenance services than to train local maintenance personnel. Discarding the equipment at the end of its life cycle should also be contemplated and disposal costs budgeted. Obtaining authorization from the regulatory authorities Facilities of countries with radiation protection legislation/regulations need to seek approval of the regulatory authority before acquiring radiological equipment. The authorization process may require registering the equipment or licensing the installation [3]. Most refurbishing companies will not sell any piece of equipment to a foreign country until such documentation is produced. Facilities which plan to introduce new practices will need to produce more documentation than facilities which only replace a unit and usually require permits from other governmental entities such as the ministry of health, which regulates medical practices. In facilities of countries which do not have any radiation safety legislation, it is the responsibility of the facility manager to ensure that the equipment and its use comply with international safety standards. The compliance should be documented in writing and be made available to the staff and to the patients and public, if required. Site preparation Good coordination should exist between equipment acquisition and site preparation. The room in which the equipment is to be housed needs to be ready before the equipment arrives, so that its installation can proceed smoothly. Clearing customs If the equipment comes from a foreign country, import permits are required. The facility manager must ensure that the documentation required in customs clearing processes is ready well before the equipment arrives. Installation Arrangements for installation, including the need for cranes and other heavy machinery, should be made in advance of radiological equipment arrival. Contractors and local staff must be properly protected and monitored if they can be exposed to ionizing radiation during their work, for example when a cobalt source is exchanged. Acceptance testing Acceptance testing is the process of determining whether the unit meets acquisition specifications. Acceptance tests are normally done between a person of the institution (preferably a medical physicist) and an engineer or technical representative of the manufacturer. For second hand equipment, compliance with the original manufacturer’s specifications can be tricky, unless it has been specified in the acquisition agreement. Previous service records should be examined in detail, and repaired or replaced components should be tested very carefully to assess whether they may compromise safety. Adjustment costs may have to be borne by the user, unless clearly indicated in the acquisition agreement that the responsibility is the institution’s or the company’s providing the equipment. Consumables, such as X ray film or printing paper, should be available at acceptance testing, to ensure that the tests can be performed and documented. Commissioning Commissioning is the process in which the necessary clinical data are acquired so that the unit can be used clinically. If so, these data should be consulted and verified before allowing patient examinations or treatments. Verification should be performed by a knowledgeable and competent medical physicist and should be more or less extensive depending on the complexity of the equipment. Establishment of quality control/quality assurance programmes Based on the acceptance testing and on the acquired data during commissioning, it is important to develop a set of tests and establish compliance criteria to check that the unit continues to perform adequately. The institution’s medical physicist should assume responsibility that the unit always functions within the established tolerances. Specific attention was given to: (i) the situation in developing countries, where access to proper imaging must be improved; (ii) the fact that training in diagnostic imaging and radiation protection is part of the safety culture; and (iii) the need to normalize education requirements for radiation, which is a high priority. The areas covered were the need for dose reduction as a result of standardized quality assurance procedures, education and training, and the development and implementation of a sustainable safety culture, research needs to improve the knowledge in individual radiosensitivity of patients, as well as the access to proper imaging techniques and training in diagnostic imaging and radiation protection in developing countries. Integration of radiation protection and safety It is important to include radiation protection and safety plans in management control systems in hospitals. This can best be achieved by involvement of key managers, authority given to radiation protection experts and transparent internal audits. Key challenges within such a process include effective communication within the organization and adoption of a graded approach towards radiation and safety. Dose assessment and national registries It is important to assess effective collective doses from diagnostic X ray and nuclear medicine examinations.

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The role of the austere care nurse differs greatly from that of the modern “traditional” nurse generic viagra with dapoxetine 100/60mg amex. They may be home trained or educated using a village health care worker model buy discount viagra with dapoxetine on-line, or merely thrust into the role without any training beyond life experience generic viagra with dapoxetine 100/60 mg amex. Even if educated in the traditional model of nursing by way of a college, university or hospital-based program one may find themselves thrust by circumstance or design into a role for which all your education and experience have failed to prepare you. You may have to be your own lab technician, physical therapist, nutritionist and beyond. You may have the luxury of working with others or find yourself practicing completely independent of all outside assistance. Protocols and treatment regimens may have to be formulated on the fly depending on available resources and working conditions. Whatever your background you may be expected to provide continuous, ongoing care lasting anywhere from days to weeks, to months or in a very few cases perhaps years. In that respect the care provided is no different from the traditionally accepted nursing model of the day-to-day caregiver. Successful practice of austere nursing may require you to assess, diagnose and treat based upon your own assessments absent the assistance of others educated beyond a basic nursing level. You may find yourself making decisions about what antibiotics to use, whether to close a wound or leave it open to heal by granulation, how to best address the nutritional requirements of your patient(s) and how to best ration scarce resources. The line between nursing care and medical care is a thin one and frequently crossed. Much of what is discussed in other chapters is relevant to nursing care and visa versa. Remember this: by virtue of the circumstances under which you will be providing austere nursing care your decisions must be based upon what is in your patient’s best interests and not governed by medical-legal considerations. If your world were in proper working order there would be little call for austere practices to begin with. There will be no such thing as scheduled shifts, resupply a phone call or fax message away, and possibly no physician or other higher medical authority within travelling distance or in communication. Where regulation leaves off common sense and ethical considerations have to take over. As stated above the rules by which modern medical care is provided have little or no application here. In an austere environment you will find that: The system has broken down entirely either on a local scale or across the board. The system doesn’t apply, such as in backcountry areas of third world, and even some first world nations (examples of the latter: the Alaskan bush country, the Hudson Bay region of Canada, or the Australian Outback). Occasionally circumstance prevents communication with the proper authority either due to physical difficulty or because of severe time constraints. Examples would include: Lack of phone lines, radio-signal dead areas due to terrain or distance, and a lack of all-weather roads, or roadways blocked by physical obstacles (flooded rivers, mudslides, avalanche, and deep snow). The time spent attempting to communicate with the proper authorities would endanger your patient. Assuming one is trained, licensed, and authorized to practice as a nurse or other appropriate health care provider they will have to fall back upon the premise of what any reasonably competent person with equivalent skills and training would do given the same set of circumstances. A modern example would be nurses and other caregivers responding to the World Trade Centre crashes or the Asian tsunami. Emergent and on-going care was provided in both situations without benefit of prior authorization or proper tools, making do with what was available based upon the assessed needs of those requiring care and the given environments. In the absence of formal training a prudent person will identify their skills and the resources available and act within those boundaries. There is a wealth of information contained within the pages of this book that will set you well on your way to providing quality care under difficult circumstances. Tightly linked with that premise is actually knowing what may legitimately constitute harm to begin with. Whatever the situation may be, you are morally if not legally bound to operate within the generally accepted standards of the ethical provision of care that aids in the recovery or comfort of your patient(s) without causing detriment by way of deliberate omission or a willful act of harm. It mirrors the fundamentals of what is required for survival – food/ warmth (shelter)/water/clothing – except when you are looking after patients you must provide these essentials for them. Lack of proper hydration may lead to prolonged healing, decreased ability to fight infection, altered levels of awareness, improper waste elimination, and in severe cases organ failure and eventual death. Food Patients may require varying diets that may differ significantly from what they are used to. For something as simple as a tooth extraction a diet of soft breads, ground meats and mashed vegetables may all they can tolerate due to difficulties chewing. Two recommended books that include dietary information are War Surgery Field Manual and Where There Is No Doctor. Warmth The old adage about treating for shock by keeping a person warm has more than a ring of truth. Not only shock but also any number of ailments as well as injuries may cause a person to lose body heat. Besides covering them with warm blankets think in terms of warming the bed itself. In the austere environment looking to the past for answers may provide answers to issues that otherwise seem insurmountable. Linen Clean linen and lots of it is one of the keys to providing good nursing care – sheets, blankets, washing cloths and towels. Until you have actually provided nursing care to a person it is hard to believe how much linen you can go through in a day. You should give some thought to how you will wash large amounts of linen possibly without access to electricity. During this period we will be concerned with addressing the continuing problems created by the illness or injury. Assuming that we will eventually have access to outside assistance our job of providing for such cases is simply a matter of ensuring that recovery continues or that the patient’s condition at least remains stable. If there is no outside assistance likely in the foreseeable future our task is then to ensure the patient’s eventual recovery to their former state of health. The patient may be suffering the after-effects of an acute illness, or require regular care for healing wounds and/or acute injury. In either situation their care is likely to require regular assessment of vital signs, elimination, pain, and overall function. During this phase of care you may reasonably be expected to administer medications on an ongoing basis, perhaps change dressings and apply various treatments intended to promote healing of wounds and/or injuries, provide some or all of your patient’s basic needs (reference Hotel Care above). You will need the use of various tools that make this phase of care practical, and to know the tricks that make such care practical as far as time and effort. Care Planning Just as important is taking time to step back and assess the overall situation and devise a plan of care to guide your efforts.

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