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It consists of reported medical terms which warrant special attention because of their possible association with serious disease states generic 100 mg viagra flavored impotence in diabetics. There will always be room for medical debate about which terms order viagra flavored 100 mg on-line erectile dysfunction doctor nyc, diagnoses or entire cases should be regarded as clinically serious generic viagra flavored 100mg without a prescription erectile dysfunction medication nhs, or serious from an administrative/regulatory perspective discount 100 mg viagra flavored erectile dysfunction reddit. However, application of recognized medical criteria for establishing diagnoses and descriptions 16 would be advantageous. Recognize, however, that ordinary prescribers or other providers of case reports will not be familiar with or have access to the compendia recommended for use by the industry and regulators. Thus, it is important to remember that the terms and/or diagnoses given by the reporter of a case must also be recorded and included in any case submission to regulators. Clinically consistent patterns of laboratory test abnormalities are of more importance than isolated values. The most significant situation of all is when there is a chronological trend in an abnormality. The ultimate judgment of seriousness is a clinical one, taking all these considerations into account as well as the nature of the pathophysiological disturbance reflected by the particular abnormal test or tests. Harmonizing Adverse Drug Reaction Terminology, Drug Safety, 19(3): 165-172 (1998) and the currently comprehensive Reporting Adverse Drug Reactions: Definitions of Terms and Criteria for Their Use, Edited by Z. It does not refer to what might be anticipated (expected in a different sense) from the known pharmacological properties of the medicine. Nor does it refer to what may occur in the course of the treated disease such as in the case of disease progression and/or lack of drug effect. The relative weight of the criteria for inclusion may also vary during the life cycle of a drug. Investigators of a drug in early development need details concerning animal toxicology, anticipated class effects, kinetics, pharmacodynamics, laboratory data, vital signs, etc. When initiating the first clinical studies (Phase 1), obviously nothing has been previously observed in humans with the medicine. Therefore, none of the reactions that might be predicted from preclinical data or from class effects should be considered expected. However, for adverse reactions that might be anticipated, greater importance is usually given to their detection and monitoring in the safety section of the study protocols. There is also agreement that the safety information used as a reference should differ according to a drug’s regulatory status (development vs marketed) and depends on the nature of the regulatory reporting. For investigational products, the Investigator’s Brochure, if available, is the reference document for expedited reporting and for any pre-approval periodic reporting. For expedited reporting to individual country regulators on marketed drugs, the locally approved product information. The situation becomes more complex when a drug is already on the market in one or more countries but is still under investigational status in others — or if a marketed drug is also under investigational status for new uses (indications, populations) or for a new dosage form. In the absence of standardised guidelines, opinions and decisions on expectedness for a given adverse reaction can differ greatly between and 20 ClinicalSafetyDataManagement:PeriodicSafetyUpdateReportsforMarketedDrugs. Recommendations and Proposals As already mentioned, there are two perspectives to keep in mind when classifying expectedness, one regarding the choice of terms (semantics) and the other the validity of the terms given the clinical evidence on a case. If not, is there a synonym or medically equivalent term that is contained within the coding terminology employed by the organisation When a report is inadequately documented, this ‘‘semantic’’ evaluation may be the only possible recourse for a decision on expectedness. Following the recommendations, several examples of their application are presented. In the absence of sufficient documentation and in the face of uncertainty, a reaction should be regarded as unexpected. Guidelines for Interpreting and Formatting Adverse Experience Information in the United States, Drug Information Journal, 35: 269-284, 2001. The ability generally to assess and characterise a case and particularly to assign expectedness with accuracy and reprodu cibility relies on the quality and completeness of individual reports. Clear, unambiguous wording is required in the Reference Safety 25 Information in which the list of terms is: complete, covering all the drug-induced situations which may be encountered; mutually exclusive, such that each term would cover medical conditions with comparable clinical properties, namely, their nature, severity, specificity or usual outcome; situations with different clinical attributes would be ascribed different terms. One approach to enhance the choice and inclusion of proper terms is to apply standard medical definitions for the terms. In other words, what are 24 Terminology in use by some refer to Type A reactions, viz. Points of view on adverse drug reactions terminology, Therapie, 53: 145-149, 1998. Relevant definitions are needed mostly when there are discrepancies between medical dictionaries, or when the available definitions are not readily applicable in the face of incomplete information. An example of a system-organ class terminology that correlates terms with the newly developed definitions with terms derived 26 from older medical definitions has been published. The examples given below are derived from that survey; details are provided in Appendix 4. Further anatomical specification: o left-sided chest pain is equivalent to chest pain; it should not be assessed as unexpected if chest pain is expected; o if arteritis is expected, temporal arteritis should be considered unexpected due to the associated additional risks and poorer prognosis. Medical judgement should be used in these and other decisions which are based on whether the extra specificity is clinically important. Further specification regarding severity: o fulminant hepatitis should not be considered expected if ‘‘liver injury’’ is mentioned in the reference information; fulminant hepatitis is defined, for example, by time to onset and specific signs of severity, and deserves to be identified as such, owing to the known high incidence of fatal outcome. When a term mentioned in the reference information encompasses situations with distinguishable and recognised levels of severity, a significantly more serious case should be considered unexpected. Petechia associated with labeled thrombocytopenia, or dehydration associated with labeled pseudomembranous colitis, are not unexpected. Melena, a complication of labeled gastrointestinal irritation, is unexpected because gastrointestinal irritation per se does not usually cause bleeding. On the other hand, melena would be expected if the label includes ‘‘gastrointestinal bleeding.
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The middle finger is the point of power generic viagra flavored 100mg with visa erectile dysfunction massage, where all the force from flicking the wrist is transferred into spin on the disc generic viagra flavored 100mg visa erectile dysfunction vyvanse. Some students will feel more control spreading these two fingers apart purchase viagra flavored 100 mg overnight delivery drugs for treating erectile dysfunction, others will like the power they get from putting both of them on the inside rim buy viagra flavored 100 mg line erectile dysfunction uti. They can be curled in toward the palm or extended along the rim; again, whichever is more comfortable. When lining up to their target, students should stand square (torso and hips facing their target). This helps them step around the mark (which will be covered later) and reduces the amount of arm, elbow, and torso they try to put into their throw. Stepping to the side may not come naturally, and students may need to focus on their feet for a couple throws until it becomes more comfortable. Sometimes the forehand is called the flick because of the flicking motion that comes with the wrist snap. Leading with the middle finger, the wrist should snap in the direction of the target. Students can think of the motion as snapping something sticky off of their middle finger. Students should be discouraged from trying to throw the forehand more than ten feet when they are first learning. When students first start throwing a forehand they often use too much arm, elbow, and torso. The forehand motion is not natural for most students, and it could take upward of a hundred throws before they begin to get a sense for how it feels to throw a forehand successfully. Keeping the throwing elbow stable and just snapping the wrist is the best way to maximize accuracy early. When using this method, be sure that the elbow is extended and not tucked next to the torso, in order to practice good habits of extending beyond a mark to throw. Isolating the movement to the wrist makes the disc fly flatter because there will be more spin and the release will be more stable. Releasing the disc so that the outer edge (the edge opposite the grip) is released at a downward angle will also help it flatten out in the air. Grip Student does all four of Student does three of the Student does two of the Student does one or the following: places following: places thumb following: places thumb none of the following: thumb on top, index on top, index finger on top, index finger places thumb on top, finger underneath, underneath, middle underneath, middle index finger underneath, middle finger on the finger on the inside of finger on the inside of middle finger on the inside of the rim, ring and the rim, ring and pinky the rim, ring and pinky inside of the rim, ring and pinky finger on the finger on the outside of finger on the outside of pinky finger on the outside of the rim. Step Student steps with same Student steps with same Student steps with same Student does not step foot as the throwing foot as the throwing foot as the throwing with same foot as the hand, transferring weight hand, transferring weight hand but does not throwing hand. Follow-through and extension are essential to teaching students to throw a flat backhand, and as they advance, to purposefully curve the flight path of the disc. Here are some tips that can help your students flatten out their throws: Wind-up, release and follow-through should be on the same horizontal plane. To make this easier to visualize it is helpful to give students a reference point, such as a target in the near distance. When the throwing motion is completed, the student should be pointing at the target. In fact, sometimes (depending on the direction and strength of the wind) the outer edge of the disc must even point slightly toward the ground. Most students who practice throwing long enough learn how to manipulate the flight of the disc on their own – and that’s part of the fun! Once the students can successfully throw flat backhands with reasonable accuracy, they can experiment with different types of curve. A major indicator for the flight of the disc is the position of the outer edge of the disc (the edge opposite the grip) as it is released. Pointing the outer edge of the disc toward the ground will make the disc cross in front of the thrower’s body, arc up to the right (for a right-handed thrower) and back in to the left to hit a target standing parallel with the thrower shaped curve. Pointing the opposite edge of the disc up will make the disc fly in an make the disc arc up to the left (for a right-handed thrower) and back to the right to hit a target standing parallel with the thrower. Spin Disc spins so that the Disc spins so that the Disc spins but the flight Disc has no spin. Wind-up and Follow Student winds up and Student winds up and Student winds up and Student does not wind Through (for flat throws) follows through follows through follows through up or does not follow (extends elbow) on the (extends elbow), but it is (extends elbow) in through. Angle of Flight Student demonstrates Student demonstrates Student demonstrates Student demonstrates control over the disc’s control over the disc’s control over the disc’s control over the disc’s flight path for 4 out of 4 flight path for 3 out of 4 flight path for 2 out of 4 flight path for 1 out of 4 throws. Day 1: Review Intermediate Backhand Cues: Wind up and follow through at wind up and follow through to point at your target Snap your wrist so you get good spin Control the outer edge of the disc Introduce Basic Forehand Cues: Keep your elbow still Really flick your fingers Step to the side Introduce Lobster Catch Cues: If it is over your waist, fingers on top If it is under your waist, fingers on the bottom Clamp down tight Throwing and Catching in Pairs Description: Students practice throwing both backhands and forehands to a partner and catching using the lobster catch. Allow students to explore different throws and use questions to help them figure out how to throw and catch more consistently. Step to the side All Lobster and Forehand Partner Disc Golf Description: this activity is a variation of disc golf, another popular disc sport. In pairs, students count how many catches and throws it takes to advance the disc to a particular target from a tee-off point. Students may not move their feet when they have the disc, but are allowed to move when it is their turn to catch. The challenge in this activity is to use only forehands (no backhands) and to catch using the lobster catch (no pancakes). For a greater challenge, require students to complete all of their passes before moving onto the next hole. To spice up the course, you can design it so that students must throw around trees, bushes, backstops, cones, or blacktop. Closing Questions: What do you do to help keep your elbow still while throwing a forehand
Low back pain is frequently encountered in general practice In general practice generic viagra flavored 100mg pills to help erectile dysfunction, over one quarter of patients between 18 and 75 years of age have consulted their general practitioner about a problem of low back pain in the last ten years trusted 100 mg viagra flavored impotence yohimbe. In 2004 cheap viagra flavored 100mg on-line erectile dysfunction and prostate cancer, 5% of patients registered with a general practitioner (the "practice population") consulted their doctor about low back pain generic viagra flavored 100mg amex impotence underwear. Compared with other patients, these low back pain patients are more prone to comorbidity, receive three times more prescriptions for anti-inflammatory drugs and have clinical biology tests more often. Around 40,000 classic hospital stays and 46,000 one-day hospital admissions have been recorded for low back pain problems. The most common diagnosis is "displacement of lumbar disc without radiculopathy" (a diagnosis for which discectomy is carried out in two thirds of cases). Considerable regional disparities were recorded, with a higher proportion of admissions and surgical interventions in the north of the country and in Brussels. The limits inherent to these estimates are, on the one hand, the absence of specificity of the nomenclature codes for lumbar pain (especially chronic pain) and, on the other hand, the lack of many other sources of information on costs (such as consultations, hospitalization and other items of expenditure). According to the longitudinal data of the Socialist Mutuality, the approximate annual medical cost connected with the care per patient suffering from chronic low back pain and for whom medical imaging codes have been invoiced is 922. This estimate is also limited by several factors: the method used to select patients suffering from chronic lumbar pain, the absence of data relating to consultations, the lack of accuracy in terms of the anatomical region to which certain procedures are related and the unknown time interval between the diagnosis and a possible intervention. This study concluded that the total direct medical cost of chronic low back pain in Belgium varies from 81 to 167 million euros. The total amount could therefore be prudently estimated at between 270 million and 1. Grave consequences for social security While the indirect costs cannot be accurately estimated, an analysis of the occupational medicine databases shows that the effects of chronic low back pain on society and on industry are harmful indeed. This type of disability is more prevalent among male employees with the status of manual workers who have recently joined the company. As a result, one in every 20 patients is assessed as being permanently unable to return to work. In 15% of cases, the patient can go back to work provided the work is adapted, a fact that highlights the crucial role of the occupational physician when it comes to caring for low back pain. The consequences are staggering: of the workers presenting an acute episode of low back pain connected with occupational accidents 72% were absent from work, and of this total figure 8,2% were absent for three months or more. A total of 62,4% and 95% of workers are temporarily or permanently disabled respectively. The sectors most affected are the timber industry, the construction industry and the metalworking industry. The construction and health/social sectors have the highest figures for permanent disability. Furthermore, the data reveal the geographic disparities, as the number of permanent partial disabilities is higher in Wallonia than in Flanders. Overexertion is the most frequently declared cause of accidents, while falling is the most frequent cause of injuries leading to permanent disability. The primary role of these medical practitioners must be to inform workers: backache is a frequent disorder; certain posts and certain positions involve more risks; acute back pain often resolves itself spontaneously (90% within six weeks); it is important to keep active in spite of the pain. Although the physical constraints involved in work play a role at an etiological level, psychosocial factors (such as stress, anxiety or dissatisfaction with work) affect the seriousness of the ongoing disorder and the likelihood of chronicity. The second role of these physicians is to promote prevention strategies aimed at preventing chronicity. The literature gives evidence in favour of back schools (in the workplace, including an exercise component) and multidimensional or multidisciplinary interventions (see above). A multidisciplinary approach based on a combination of a program of exercises and psychological and/or social care is particularly beneficial. Occupational physicians and advisory physicians therefore bear some responsibility for the care of workers disabled by low back pain, along with family doctors. The physician should ideally reduce the period of disability by advising the patient to pursue his normal activities. In the event of recurrent or constant lumbar pain, an analysis of the "yellow flags" will identify workers at risk of chronicity (psychological problems or depression). In this regard, a return to work program backed up by cooperation between the curative sector and the occupational medicine sector is beneficial as it encourages the worker to return to work and reduces the number of days lost. The first basic step in this care program is to maintain normal activities as much as possible. Furthermore, exercise programs play a positive role in re-education and multidisciplinary care is beneficial. Many noninvasive treatments that are currently applied are based on scanty evidence or do not work at all. Based on the existing studies, we cannot yet define precisely the efficacy or the potential side effects of many invasive techniques (injections). Due to a lack of data in Belgium, it is not possible to evaluate the extent of chronic low back pain with any accuracy. The available databases provided by occupational medical services and by the mutuality sector do not provide a means of systematically identifying these workers/patients or monitoring them in the care circuit. In addition, these databases do not yield any hypotheses on the geographic disparities that are observed. The evaluation of medical costs that we propose in this study is largely underestimated. A proper evaluation would require a data collection program geared specifically to the epidemiology and to the costs connected specifically with that particular pathology. Given that the indirect consequences of the pathology account for the bulk of the cost, occupational physicians and advisory physicians have a crucial role to play when it comes to helping workers get back to work as quickly as possible (in cooperation with the family doctor), bearing in mind that the data demonstrate that prolonged absence can lead to chronicity. In cases of chronic low back pain, it is crucial for the patient to get back to work as quickly as possible. Prescribing useless tests and applying inappropriate treatments maintains the chronicity of the backache and does the patient more harm than good.
Seasonal fruits and vegetables such as figs order viagra flavored 100 mg on-line erectile dysfunction vacuum pump medicare, pomegranates viagra flavored 100mg erectile dysfunction at the age of 30, dates buy 100mg viagra flavored fast delivery erectile dysfunction treatment viagra, onions discount viagra flavored 100mg amex erectile dysfunction drugs reviews, garlic, lentils, vetch, pistachios, and pine nuts en hanced the diet, but the daily fare was dependent upon cereals and the bread made 8 from them (Borowski 2002, 95–96; Borowski 2004, 96–107). The Judahite diet relied so heavily on bread that the Hebrew word for it, lechem, is metanymous with food. Common herd animals, such as sheep and goats, were a major part of the house 9 hold’s economy. The secondary products from the household herds were used in many ways: their fleece was used to weave into clothes, their dung was used for fuel, and their milk was used to make a variety of dairy products such as yogurt, cheese, and curds. The Judahite household rarely ate meat unless it was procured through the hunting of wild game, the household herd needed to be culled, the household needed ready cash, or there was a special occasion such as a wedding, agricultural/religious festival, or as a gesture of hospitality. Ovens found in the archaeological record are usually incomplete so it is difficult to say precisely what they looked like. However, ethnographic studies in the Middle East provide several oven types, some of which may be the modern descendants of ancient ovens. The simplest type of oven wouldn’t be classified as an oven at all; food could be prepared on the embers of a fire or over hot rocks (Isa 44:19). A step beyond the hot rocks would be a saj, which is a rounded metal disk that is placed over the fire or resting on the rocks. Once the dough is made, it is thrown back and forth between the palms of the baker until it is a thin flap of dough and then placed on the saj to quickly bake on either side. While the ancient Judahites would not have baked on a rounded metal disk, the method of baking could indicate how bread was baked on hot rocks (1 Kgs 19:6) or the coals of a fire (Isa 44:19) (Shafer-Elliott 2013, 119). A third type of oven ethnographers observed in the Middle East is a tabun (Arabic plural: tawabin). The term tabun is used anachronistically to describe ovens found in ar chaeological excavations in Israel (Ebeling and Rogel 2015, 328). Although usually incomplete, the ovens we have found resemble more of the tannur type of oven (Arabic plural: tannaneer) used in the Middle East. A modern tannur is a “cylindrical clay oven in which fuel is lit at the bottom and dough is baked on the upper inner walls” (Ebeling and Rogel 2015, 329). The term tannur is found in the Hebrew Bible fifteen times, seven of which refer to an oven used to bake bread (Exod 7:28; Lev 2:4, 7:9; 11:35, 26:26; Hos 7:4, 6–7). A lid is often placed over the top opening of both tawabin and tannaneer to retain heat or allow other items to be placed on top or even inside to cook (Shafer-Elliott 2013, 120–21; Ebeling and Rogel 2015, 330). Excavations of Iron Age houses in Judah and Israel typically find the remains of ovens in two locations. One oven is found inside the house, often in the central long room that was presumably the main living area where multiple household chores were conducted. Ovens in Iron Age houses in the southern Levant were usually located near entryways, which would be consistent with the lack of venti lation in ancient houses (Baadsgaard 2008, 21–22). The form, function, and name of these thermal features have been a matter of much confusion. For a recent and well-informed discussion on ancient thermal features in the archaeology of the southern Levant see Ebeling and Rogel 2015. Meals were prepared in cooking vessels that evolved throughout the Bronze and Iron Ages and were heavily influenced by the arrival of the Philistines. In the Hebrew Bible, words for cooking pots include parur (Num 11:8, Judg 6:19, 1 Sam 2:14), siyr (Exod 16:3; 2 Kgs 4:38–41; Jer 1:13; Ezek 11:3, 7, 11; Mic 3:3; Zech 14:20–21), qallachat (1 Sam 2:14; Mic 3:3), and dud (1 Sam 2:14) (Shafer-Elliott 2013, 220). Generally speaking, cooking vessels can be categorized into three basic forms: the Bronze Age pot or bowl, the Philistine jug, and the hybrid pot. The cooking pots found within Bronze-Age Canaan and later in Israel evolved from a simple and common bowl-shaped vessel. The typical pot of the Bronze Age was a large, handless, open-mouthed pot with an everted rim, round base, and carinated body, which makes it look like a large bowl. The Late Bronze Age pots kept the traditional shape of their Middle Bronze Age predecessors, but with some variations in size and an increasingly carinated shape. Its open mouth, wide shape, and special cooking ware allowed the pot to be used for several types of cooking, including steaming, frying, simmering, and boiling. It served also for cooking larger food items like meat and for serving larger groups of people. Bronze Age pots were placed inside the oven, over its upper opening, or against the stones of the hearth, while those with handles could be suspended over an open fire. This type of pot is familiar in Late Bronze Age Canaan and in Israel, with variations continuing to the end of the Iron Age (Killebrew 1999, 84, 92–95, 106–9). In the Late Bronze and Early Iron I Ages, the Philistines appeared and brought a new type of cooking vessel with them. Generally speaking, the shape of the new vessel was less like a bowl and more like a jug, with a closed mouth, a globular to ovoid shape, and one or two loop handles from the rim to its shoulder. Philistine jugs were typically uniform in size, with a volume of about one-half to three-fourths of a gallon (2–3 liters), a maximum height of ca. The cooking jug nearly replaced the traditional cooking pot at sites desig nated as Philistine on the southern coastal plain and is less commonly found in sites outside of Philistia, hence its designation “Philistine jug. The cooking jug’s primary mode of cooking 288 Cynthia Shafer-Elliott was probably simmering: its thin walls were useful for slow, low-heat cooking of liquid dishes; its flat base allowed it to rest directly on or near the heat source; and its handle allows for easy removal. Soot marks on the sides of the jugs indicate that they were placed directly over an open fire or leaned on a hearth. Its small size also dictated the amount of cereals or vegetables cooked within it, indicating smaller portions and consumption by fewer people (Ben Shlomo et al 2008, 225– 46; Gur-Arieh et al 2011, 349–55; Killebrew 1999, 93–95, 107).
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