By S. Randall. Southern Utah University.

However buy cardura 1 mg lowest price, the absence thereof does not mean that the contracting parties to such treaties intended that the standard be applied without a proper comparison cheap cardura 1mg overnight delivery. As mentioned above buy cardura 1 mg line, this treatment covers the life-cycle of the investment as regulated by the host State’s laws and regulations order 1mg cardura with amex. This list of investment activities includes pre- or post- establishment activities purchase cardura 2mg mastercard. Pre-establishment activities typically include the “establishment, acquisition and expansion” of investments, whereas post-establishment activities include the “management, maintenance, conduct, operation, use, enjoyment, sell, disposal or disposition” of investments. Expansion of investment that is subject to prior approval or other authorization may be considered part of the post-establishment activities by some countries. There are considerable variations in treaty language, resulting from the negotiation of each individual treaty, mostly based on a model agreement used from time to time by the parties. For the avoidance of doubt it is confirmed that the treatment provided for in paragraphs (1) and (2) above shall apply to the provisions of Articles 1 to 11 [investor-State disputes] of this Agreement. The tribunal rejected the investor’s claim as it assumed “the validity of its own reading of the relevant clauses of the treaties with Albania and Estonia”. In its view, the investor did not document the existence, in current international law, of such “autonomous standards”, or assuming their hypothetical existence, that “United States measures 4 were reasonably characterized as in breach of such standards”. Some awards have used provisions in third party treaties to clarify the meaning of words used in the basic treaty. The claimants had been denied the required planning licences to develop an investment in property development, although they had received authorization by the Chilean investment authority at the central level. It should be noted that this was a decision on jurisdiction and that the finding was only a prima facie finding. It concluded that this should be the Pakistan-Switzerland treaty (1995) on the ground that it was concluded later in time (i. These are determining factors for their acceptance of the Agreement, as they are directly linked to the identification of the substantive protection regime applicable to the foreign investor and, particularly, to the general (national or international) legal context within which such regime operates, as well as to the access of the foreign investor to the substantive provisions of such regime. Their application cannot therefore be impaired by 12 the principle contained in the most favored nation clause. It should be noted in this context that the tribunal in this case implied that some provisions are specifically negotiated whereas others are not. The tribunal followed the respondent’s main objections, based strongly on the Tecmed v. The tribunal found that the investor had made an investment under the basic treaty, but in any case rejected the proposed alternative: “Each treaty defines what it considers a protected investment and who is entitled to that protection, and definitions can change from treaty to treaty. Eliminating provisions of the basic treaty Other cases have dealt with a different scenario where the claimant seeks to eliminate a non-beneficial provision of the basic treaty on grounds that it is not contained in a third party treaty. The absence of such a clause would, in the claimant’s view, make the conditions of the third party treaty more favourable. Argentina the claimant sought to avoid the application of the emergency exception clause contained in the basic treaty between the United States and Argentina. In the case where foreign investors were competing for the same public procurement project the tribunal compared not only two investors in the same economic sector but also the characteristics of their respective project proposals. Pakistan (merits) the tribunal established that the similarity and hence the comparability between the foreign investors had to be examined at the level of the contractual terms and circumstances. It held that they have similar conditions of application and basically afford indirect advantages to their beneficiaries, namely a treatment no less favourable than the one granted to third parties. It then elaborated on the basis of comparison that had to be met: “Discrimination is to be ascertained by looking at the circumstances of the individual cases. Discrimination involves either issues of law, such as legislation affording different treatments in function of citizenship, or issues of fact where a State unduly treats differently investors who are in similar circumstances. An objective justification may justify differentiated treatments of similar cases. It would be necessary, in each case, to evaluate the exact circumstances and the context. Even though the relevant comparators were engaged in similar activities (they were competitors for the same project), the tribunal concluded that the relevant investors were in different circumstances, in particular because their offers and proposed projects had different characteristics. Pakistan the claimant alleged that it was expelled both to save costs and for reasons of local favouritism, considering in particular that far more favourable timetables had been accorded to Pakistani nationals associated with foreign contractors and that these other contractors had not been expelled even though they were far more behind in the schedule of completion.

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To determine the blood volume required and the rate of transfusion generic cardura 1mg line, see next page cardura 4 mg visa. If there is no possibility of screening generic cardura 1mg, it is up to the physician to weigh the transfusion risk with the life or death risk of not transfusing the patient cardura 1 mg without prescription. Adults Determine the volume of whole blood to be Example: haemoglobin required = 7 g/dl transfused: patient’s haemoglobin = 4 g/dl V = (haemoglobin required minus patient’s patient’s weight = 60 kg haemoglobin) multiplied by 6 multiplied by Volume in ml = (7 – 4) x 6 x 60 = 1080 ml patient’s weight Determine the transfusion rate: Example: 1080 ml to be administered over 3 hours (1 ml of whole blood = 15 drops) 1080 (ml) ÷ 180 (minutes) = 6 ml/minute 6 (ml) x 15 (drops) = 90 drops/minute Children Newborns and children under 1 year: Example: a malnourished child weighing 25 kg 15 ml/kg over 3 to 4 hours 10 (ml) x 25 (kg) = 250 ml over 3 hours Children over 1 year: 250 (ml) ÷ 180 (minutes) = 1 proven 1mg cardura. It is most often caused by both quantitative (number of kilocalories/day) and qualitative (vitamins and minerals, etc. Children over 6 months of age The two principal forms of severe malnutrition are: – Marasmus: significant loss of muscle mass and subcutaneous fat, resulting in a skeletal appearance. In addition to these characteristic signs, severe acute malnutrition is accompanied by significant physiopathological disorders (metabolic disturbances, anaemia, compromised immunity, leading to susceptibility to infections often difficult to diagnose, etc. Usual discharge (cure) criteria are: W/H > – 2 Za and absence of bilateral oedema (2 consecutive assessments, one week apart) and absence of acute medical problems. Treatment 1) Nutritional treatment Nutritional treatment is based on the use of therapeutic foods enriched with vitamins and minerals: – Therapeutic milks (for use exclusively in hospitalised patients): • F-75 therapeutic milk, low in protein, sodium and calories (0. Furthermore, it is important to give drinking water, in addition to meals, especially if the ambient temperature is high or the child has a fever. Therapeutic foods facilitate the recovery of gastrointestinal mucosa and restore the production of gastric acid, digestive enzymes and bile. Amoxicillin, administered as part of routine treatment, is effective in reducing bacterial load. Watery diarrhoea is sometimes related to another pathology (otitis, pneumonia, malaria, etc. However, if the child has no profuse diarrhoea, give plain water (not ReSoMal) after each loose stool. The diagnosis is made on the basis of a history of watery diarrhoea of recent onset accompanied by weight loss, corresponding to fluid losses since the onset of diarrhoea. In the event of dehydration: – In there is no hypovolaemic shock, rehydration is made by the oral route (if necessary using a nasogastric tube), with specific oral rehydration solution (ReSoMal) , containing less sodiumd and more potassium than standard solutions. ReSoMal is administered under medical supervision (clinical evaluation and weight every hour). The dose is 20 ml/kg/hour for the first 2 hours, then 10 ml/kg/hour until the weight loss (known or estimated) has been corrected. In practice, it is useful to determine the target weight before starting rehydration. If the child is improving and showing no signs of fluid overload, rehydration is continued until the previous weight is attained. Regardless of the target weight, rehydration should be stopped if signs of fluid overload appear. Bacterial infections Lower respiratory infections, otitis, skin and urinary infections are common, but sometimes difficult to identify (absence of fever and specific symptoms). Severe infection should be suspected in the event of shock, hypothermia or hypoglycaemia. Since the infectious focus may be difficult to determine, a broad spectrum antibiotic therapy (cloxacilline + ceftriaxone) is recommended. Prevention measures include keeping the child close to the mother ’s body (kangaroo method) and provision of blankets. In case of hypothermia, warm the child as above, monitor the temperature, treat hypoglycaemia. Oral candidiasis Look routinely for oral candidiadis as it interferes with feeding; see treatment Chapter 3, Stomatitis. As in children, any malnourished patient presenting with significant complications should initially be hospitalised, regardless of the anthropometric criteria above. Adults: weight gain of 10-15% over admission weight and oedema below Grade 2 and good general condition. Nutritional treatment follows the same principles as in children, but the calorie intake in relation to body weight is lower. Routine treatment is similar to that in children, with the following exceptions: – Measles vaccine is only administered to adolescents (up to age 15).

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Breaking the silence and isolation around such issues is crucial generic cardura 4 mg free shipping, so that individuals and families confronting substance misuse and its consequences know that they are not alone and can openly seek treatment cheap 2mg cardura with mastercard. As with other chronic illnesses buy cheap cardura 1 mg online, the earlier treatment begins buy cardura 2mg line, the better the outcomes are likely to be proven 1mg cardura. Recognizing that substance use disorders are medical conditions and not moral failings can help remove negative attitudes and promote open and healthy discussion between individuals with substance use disorders and their loved ones, as well as with their health care professionals. Overcoming the powerful drive to continue substance use can be difcult, and making the lifestyle changes necessary for successful treatment—such as changing relationships, jobs, or living environments—can be daunting. This can be challenging for partners, parents, siblings, and other loved ones of people with substance use disorders; many of the behaviors associated with substance misuse can be damaging to relationships. Love and support can be offered while maintaining the boundaries that are important for your health and the health of everyone around you. As a community, we typically show empathy when someone we know is ill, and we celebrate when people we know overcome an illness. Extending these kindnesses to people with substance use disorders and those in recovery can provide added encouragement to help them realize and maintain their recovery. As discussed throughout this Report, many challenges need to be addressed to support a public health- based approach to substance misuse and related disorders. Everyone can play an important role in advocating for their needs, the needs of their loved ones, and the needs of their community. It is important that all voices are heard as we come together to address these challenges. Parents have more infuence over their children’s behavior, including substance use, than they often think. For instance, according to one study, young adults who reported that their parents monitored their behavior and showed concern about them were less likely to report misusing substances. Become informed, from reliable sources, about substances to which your children could be exposed, and about substance use disorders, and talk openly with your children about the risks. Some tips to keep in mind: $ Be a good listener; $ Set clear expectations about alcohol and drug use, including real consequences for not following family rules; $ Help your child deal with peer pressure; $ Get to know your child’s friends and their parents; $ Talk to your child early and often; and $ Support your school district’s efforts to implement evidence-based prevention interventions and treatment and recovery support. Educators and Academic Institutions Implement evidence-based prevention interventions. Schools represent one of the most effective channels for infuencing youth substance use. Many highly effective evidence-based programs are available that provide a strong return on investment, both in the well-being of the children they reach and in reducing long-term societal costs. Prevention programs for adolescents should target improving academic as well as social and emotional learning to address risk factors for substance misuse, such as early aggression, academic failure, and school dropout. Interventions that target youth who have already initiated use of alcohol or drugs should also be implemented to prevent escalation of use. For students with substance use problems, schools—ranging from primary school through university—can provide an entry into treatment and support for ongoing recovery. School counselors and school health care programs can provide enrolled students with screening, brief counseling, and referral to more comprehensive treatment services. Many institutions of higher learning incorporate collegiate recovery programs that can make a profound difference for young people trying to maintain recovery in an environment with high rates of substance misuse. Teach accurate, up-to-date scientific information about alcohol and drugs and about substance use disorders as medical conditions. Teachers, professors, and school counselors play an obvious and central role as youth infuencers, teaching students about the health consequences of substance use and misuse and about substance use disorders as medical conditions, as well as facilitating open dialogue. They can also play an active role in educating parents and community members on these topics and the role they can play in preventing youth substance use. For example, they can educate businesses near schools about the positive impact of strong enforcement of underage drinking laws and about the potential harms of synthetic drugs (such as K2 and bath salts), to discourage their sale. They can also promote non-shaming language that underscores the medical nature of addiction—for instance avoiding terms like “abuser” or “addict” when describing people with substance use disorders. As substance use treatment becomes more integrated with the health care delivery system, there is a need for advanced education and training for providers in all health care roles and disciplines, including primary care doctors, nurses, specialty treatment providers, and prevention and recovery specialists.

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Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects 4mg cardura for sale. Common cognitive distortions that are identifed and addressed in the course of treatment include: “I can’t sleep without medication quality cardura 2 mg,” “I have a chemical imbalance best cardura 4 mg,” “If I can’t sleep I should stay in bed and rest cardura 1mg generic,” “My life will be ruined if I can’t sleep generic cardura 1 mg without a prescription. Many therapists use some form of multimodal approach in treating chronic insomnia. Sleep restriction (Guideline) initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive. As sleep drive increases and the window of oppor- tunity for sleep remains restricted with daytime napping prohibited, sleep becomes more consolidated. When sleep continuity substantially improves, time in bed is gradually increased, to provide suffcient sleep time for the patient to feel rested during the day, while preserving the newly acquired sleep consolidation. In addition, the approach is consistent with stimulus control goals in that it minimizes the amount of time spent in bed awake helping to restore the association between bed and sleeping. Paradoxical intention (Guideline) is a specifc cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. Biofeedback therapy (Guideline) trains the patient to control some physiologic variable through visual or auditory feedback. Sleep hygiene therapy (No recommendation) involves teaching patients about healthy lifestyle practices that improve sleep. It should be used in conjunction with stimulus control, relaxation training, sleep restriction or cognitive therapy. Instructions include, but are not limited to, keeping a regular schedule, having a healthy diet and regular daytime exercise, having a quiet sleep environment, and avoiding napping, caffeine, other stimulants, nicotine, alcohol, excessive fuids, or stimulating activities before bedtime. Evidence be prescribed a drug with a longer half-life; a patient who com- for their effcacy when used alone is relatively weak38-42 and no plains of residual sedation might be prescribed a shorter-acting specifc agent within this group is recommended as preferable drug. Benzodiazepines not spe- cifc side effect profle, cost, and pharmacokinetic profle may cifcally approved for insomnia (e. For example, trazodone might also be considered if the duration of action is appropriate has little or no anticholinergic activity relative to doxepin and for the patient’s presentation or if the patient has a comorbid amitriptyline, and mirtazapine is associated with weight gain. However, the effcacy of low-dose trazodone treatment failures, sedating low-dose antidepressants may next as a sleep aid in conjunction with another full-dose antidepres- Journal of Clinical Sleep Medicine, Vol. These medications have been associated with reports of disruptive sleep related behaviors including sleepwalking, eating, driving, and sexual behavior. General comments about sedatives/hypnotics: • Administration on an empty stomach is advised to maximize effectiveness. Certain antidepressants (amitriptyline, doxepin, mirtazapine, paroxetine, trazodone) are employed in lower than antidepressant therapeutic dos- ages for the treatment of insomnia. These studies, of varying with their comorbid conditions and concurrent medications. It is unclear to what pharmacological Treatment Failure extent these fndings can be generalized to other presentations of insomnia. As but a wealth of clinical experience with the co-administration recommended, alternative trials or combinations may be useful; of these drugs suggests the general safety and effcacy of this however, clinicians should note that if multiple medication tri- combination. A combination of medications from two different als have proven ultimately ineffective, cognitive behavioral ap- classes may improve effcacy by targeting multiple sleep-wake proaches should be pursued in lieu of or as an adjunct to further mechanisms while minimizing the toxicity that could occur pharmacological trials. Other prescription drugs: Examples include gabapentin, Mode of Administration/Treatment tiagabine, quetiapine, and olanzapine. Evidence of effcacy for these drugs for the treatment of chronic primary insomnia is in- Frequency of administration of hypnotics depends on the suffcient. Avoidance of off-label administration of these drugs specifc clinical presentation; empirical data support both is warranted given the weak level of evidence supporting their nightly and intermittent (2-5 times per week) administration. Prescription drugs- Not recommended: Although clinical practice is true “as needed” dosing when the patients chloral hydrate, barbiturates, and “non-barbiturate non-benzo- awakens from sleep. Over-the-counter agents: Antihistamines and antihis- Duration of treatment also depends on specifc clinical char- tamine-analgesic combinations are widely used self-remedies acteristics and patient preferences. Evidence for their effcacy and safety is very notics prior to 2005 implicitly recommended short treatment limited, with very few available studies from the past 10 years duration; since 2005, hypnotic labeling does not address dura- using contemporary study designs and outcomes. Antidepressants and other drugs commonly mines have the potential for serious side effects arising from used off-label for treatment of insomnia also carry no specifc their concurrent anticholinergic properties. In clinical practice, most common insomnia self-treatment, is not recommended be- hypnotic medications are often used over durations of one to cause of its short duration of action, adverse effects on sleep, twelve months without dosage escalation,52-55 but the empiri- exacerbation of obstructive sleep apnea, and potential for abuse cal data base for long-term treatment remains small.

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