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It is advised that the nurse/midwife refers to the medical practitioner who has prescribed the medication if there are questions regarding the indications for its use for the patient/service-user order nolvadex 10 mg free shipping pregnancy magazines. Additional information and support may also be available by contacting the pharmacist buy 10 mg nolvadex visa pregnancy kidney pain. The medication management policies of health service providers should address the topic of unauthorised/unlicensed medication use, including "off label" use. If a health service provider does not have such a policy in effect, it is recommended that one be considered. The input of the pharmacy department, drugs and therapeutic committee (if established), nursing and medical management and risk management is critical in the multidisciplinary effort to develop and implement safe practices involving these medications. Consequently, if a nurse or midwife decides that a change in the form of the drug is necessary for its safe administration, she/he should consult with the medical practitioner and pharmacist to discuss alternative preparations or forms of administration for the patient/service-user. Development of a policy to support the practice of crushing oral medications, inclusive of guidelines and decision-making rationale for individual events, should also be considered. Considerations for safe practice for crushing include preparing a list of medications which should not be crushed or chewed that is placed in a readily accessible location (e. This list should be updated regularly by the pharmacist and whenever a new product which requires specific instructions becomes available. Continuous quality improvement processes should review whether such practices are effective. Occupational health and safety issues regarding the handling, administration and disposal of waste of certain altered dose medications (e. Nurses and midwives are key health professionals involved in providing immunisations to the patient/service-user and communities in the promotion of public health and prevention of infectious disease. Examples include childhood immunisation programmes, influenza and hepatitis vaccinations and travel vaccinations. Standard Nurses and midwives involved in immunisation programmes (including vaccination administration) should maintain their competency and current knowledge with all aspects of this practice. This encompasses: • Obtaining consent • Vaccine handling and delivery • Storage and stock control • Proper technique of administration • Recognition and intervention with side effects, adverse events and/or complications post immunisation. Supporting Guidance The nurse/midwife should possess the ability to manage adverse reactions and anaphylaxis as first line providers in these emergency situations. Health service providers should have an organisational policy on immunisation/ vaccination addressing these areas to support best practice by nurses and midwives. Available resources on this subject are the Immunisation Guidelines for Ireland (Royal College of Physicians of Ireland, 2002) and the Health Service Executive website http://www. As part of their every day care of patients/service-users, nurses and midwives are in prime positions to observe and report on suspected adverse reactions. Standard Reporting of suspected adverse reactions is critical for safe medication management and patient/service user care. Supporting Guidance The reporting and monitoring of adverse reactions has significant implications for patient/service-user safety. It is not necessary to determine a causal relationship between a drug and subsequent event prior to reporting suspected adverse reactions. Nursing/midwifery staff should liaise with the prescriber about the submission of the report as appropriate. The health service provider’s medication management policies should include information and direction for health care professionals in reporting suspected adverse reactions. Haemovigilance is defined as: "A set of surveillance procedures, from the collection of blood and its components to the follow-up of recipients, to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent their occurrence or recurrence. Nurses and midwives are referred to the Guidelines for the Administration of Blood and Blood Components issued by the National Blood Users Group and the Irish Blood Transfusion Service (2004) for specific information and guidance on the subject of blood administration, monitoring and reporting of adverse events and reactions. These events are usually captured in the hospital quality/risk management systems. Policies should be in place to support the identification, investigation and, where possible, prevention of adverse reactions. Standard As nurses and midwives are often front line users of medical devices and in-vitro diagnostic medical devices, they are key individuals to identify and report any adverse incidents involving medical devices.

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Acarbose for prevention of type 2 Comparison of clinical outcomes and adverse tors nolvadex 20mg visa womens health garcinia cambogia scam. Alogliptin after acute phonylureas or insulin compared with conven- Management of hyperglycemia in type 2 diabetes 10 mg nolvadex free shipping women's health big book of exercises uk, coronary syndrome in patients with type 2 di- tional treatment and risk of complications in 2015: a patient-centered approach: update to a abetes. Diabetes Care 2015;38:140–149 for achieving glycaemic goals using a once-daily Group. Randomized clinical trial of quick-release Comparative effectiveness and safety of medi- Safety, effectiveness, and cost of long-acting bromocriptine among patients with type 2 cations for type 2 diabetes: an update including versus intermediate-acting insulin for type 1 di- diabetes on overall safety and cardiovascu- new drugs and 2-drug combinations. Expenditures and prices prehensive, Consistent Drug Pricing Resource Revised Warnings for Certain Patients With of antihyperglycemic medications in the [Internet], 2016. Accessed 29 July 2016 Diabetes Care Volume 40, Supplement 1, January 2017 S75 American Diabetes Association 9. In all patients with diabetes, cardiovascular risk factors should be systematically assessed at least annually. These risk factors include hypertension, dyslipidemia, smoking, a family history of premature coronary disease, and the presence of albuminuria. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day. B Goals c Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of ,140 mmHg and a diastolic blood pressure goal of ,90 mmHg. A c Lower systolic and diastolic blood pressure targets, such as 130/80 mmHg, may be appropriate for individuals at high risk of cardiovascular disease, if they can be achieved without undue treatment burden. C c In pregnant patients with diabetes and chronic hypertension, blood pres- sure targets of 120–160/80–105 mmHg are suggested in the interest of optimizing long-term maternal health and minimizing impaired fetal growth. Cardiovascular disease and risk manage- c Patients with confirmed office-based blood pressure. Postural changes in blood pressure pressure control in patients with type 2 calcium channel blockers). Additional studies, such as the drug therapy is generally required to neuropathy and therefore require adjust- Systolic Blood Pressure Intervention Trial achieve blood pressure targets (but ment of blood pressure targets. However, most of the evidence of nine (A)or30–299 mg/g creatinine 130–140 mmHg (13). If one class is not tolerated, the find a benefit in the primary end point people with diabetes is based on office other should be substituted. A lifestyle therapy plan should be showntoimprovecardiovascularout- vascular benefit with more intensive developed in collaboration with the pa- comes (19). Smaller blocker amlodipine versus benazepril no benefitidentified that clearly out- trials also suggest reduction in composite and thiazide-like diuretic hydrochloro- weighs potential risks of therapy (40). If needed to achieve A 2014 Cochrane systematic review of gression of advanced nephropathy blood pressure targets, amlodipine antihypertensive therapy for mild to (29–31). If estimated glomerular women did not find any conclusive ev- 2 idence for or against blood pressure tensive agents for prevention of filtration rate is ,30 mL/min/1. In particular, a recent blood pressure medications should be on perinatal outcomes such as preterm meta-analysis suggests that thiazide- made in a timely fashion to overcome birth, small-for-gestational-age in- type diuretics or dihydropyridine calcium clinical inertia in achieving blood pres- fants, or fetal death (41). Consider administering one or lower blood pressure targets to avoid of the following statements: In patients more antihypertensive medications at progression of these conditions during with type 1 diabetes with hypertension bedtime (39). Antihypertensive patients with type 2 diabetes, hyper- blood pressure treatment goals (21). Glycemic control may also benefi- at an initial medical evaluation, and and lifestyle therapy. B cially modify plasma lipid levels, particularly every 5 years thereafter, or more c For patients with diabetes aged in patients with very high triglycerides and frequently if indicated. Multiple clinical trials have dem- tion of saturated fat, trans fat, and response to medication (e. Subgroup analyses of pa- and increased physical activity moderate-intensity statin therapy tients with diabetes in larger trials should be recommended to im- has been shown to provide addi- (46–50) and trials in patients with dia- prove the lipid profile in patients tional cardiovascular benefit com- betes (51,52) showed significant pri- with diabetes.

The estimates will be opiate users by the average heroin consumption per updated periodically as new drug use data is provided by capita per year order nolvadex 20 mg online womens health 092013. At the end of March In order to compare the market values between regions 2011 generic 10mg nolvadex with mastercard breast cancer youngest age, the national average price for one kilogram of dry and countries, all prices were adjusted for purity. The current farm-gate To calculate the amount of opiate flows through a coun- price is the highest price reported since November 2004. A long-term this is that the impact on the final price of price changes comparison of the trader price of opium in Afghanistan at the source is only cumulative, rather than propor- with heroin prices in Europe shows that, despite a tional, resulting in a non-discernible effect at the much marked hike in opium prices between early 2000 and higher order of magnitude of retail prices. The value of the world heroin market tends to Afghanistan was grown in the provinces of southern increase according to the number of international bor- Afghanistan where anti-government elements are active. That is, heroin is generally Although the Afghan Taliban’s role in drug trafficking is cheaper in Afghanistan, a production country, than in not clear, opium poppy farmers, drug traffickers and West and Central Europe, where the drugs have been heroin lab owners paid the group up to 10% of the value transported by various means across long distances and of their opiate shipments as ‘tax’ or protection fees. The major- West and Central ity of the profits went to Iranian criminal groups and, to Europe, 13, 19% Russian a lesser extent, foreign drug traffickers based in the Federation, 18, country. Turkish, Kurdish and Balkan-based organized crime Beneficiaries groups benefited from this trade. Indeed, ben- Dutch and Turkish organized crime groups, and, to a eficiaries in Afghanistan, for example, earned signifi- lesser extent, South Asian groups. In 2009, many international borders became more transparent In 2009, Russian criminal networks made an estimated due to international trade agreements. Based on drug-related are likely to exploit this situation and make connections arrests, the Russian drug market is dominated by Rus- with other criminal networks to facilitate the smooth sian citizens, followed by Tajiks as the most active for- movement of heroin. Drug trafficking in East Europe is most likely conducted by local groups; however, the picture Given the ongoing removal of trade barriers globally, regarding criminal activity in this region is not very traditional methods of border control may become clear. In 2009, only Chinese and other local organized crime groups control a tiny fraction of the more than 400 million containers the South-East Asian heroin market at both retail and that were shipped worldwide were inspected. The heroin trade in Indonesia is pre- just 6% of global heroin seizures made by customs dominantly controlled and directed by West Africans, departments occurred at seaports. In 2009, Africa emerged as a cost-effective heroin traf- In 2009, Africa’s drug trafficking market was worth an ficking route to Europe, North America and Oceania. Nigerian groups likely Africans – particularly West African networks – are dominate the African drug trade and are active in many increasingly transporting Afghan heroin from Pakistan countries around the world, including destination coun- into East Africa for onward shipment to Europe and tries in Europe. The emergence of Africa as a heroin traffick- involves both African networks, including Nigerians and ing hub is likely due to corruption, limited law enforce- Tanzanians, as well as foreign networks, including Chi- ment capacity and increased pressure on ‘traditional’ nese and Pakistanis. East Africa’s minimal law The United States of America dominated regional enforcement at ports of entry has encouraged drug traf- demand for heroin, with a heroin market worth an esti- fickers to transit heroin through that region. North America-based flows of heroin to Africa have also led to increases in organized crime groups (such as Mexican drug cartels) drug use across the continent. Anecdotal information points to and alter trafficking routes to exploit international paths a shortage in some countries, but not in all, suggesting of least resistance. Numerous global vulnerabilities that increased law enforcement efforts and decreased remain and some new areas are emerging. Global seizures of Most indicators and research suggest that cocaine is – cocaine have been generally stable over the period 2006- after heroin – the second most problematic drug world- 2009. Since 2006, seizures have shifted towards the wide in terms of negative health consequences and source areas in South America and away from the con- probably the most problematic drug in terms of traffick- sumer markets in North America and West and Central ing-related violence. Some secondary distribution countries in South America seem to have acquired increasing importance as The overall prevalence and number of cocaine users cocaine trafficking transit countries. There are regional differ- West Africa continues to be significant, in spite of a ences in recent trends, however, with significant decreases reduction of seizures since 2007 (from 25% of European reported in North America, stable trends in West and cocaine seizures that transited countries of West and Central Europe and increases in Africa and Asia. The area estimated consumption of cocaine in terms of the quan- remains vulnerable to a resurgence. Some countries in tities consumed appears to have declined, mainly due to the Asia-Pacific - with large potential consumer markets a decrease in the United States and low levels of per - have registered increasing cocaine seizures in 2008 and capita use in the emerging markets. While demand in the and, more recently, in South America and beyond, high- United States was more than four times as high as in lights the need to treat cocaine as a global problem, and Europe in 1998, just over a decade later, the volume and to develop strategies on the scale of the threat. Member Member Percent Percent Percent States States Use Use Use use use use Region providing perception problem problem problem problem problem problem perception response increased* stable decreased* increased stable decreased data rate Africa 8 15% 4 50% 2 25% 2 25% Americas 15 43% 5 33% 7 47% 3 20% Asia 13 29% 7 54% 3 23% 3 23% Europe 27 60% 14 52% 13 48% 0 0% Oceania 1 7% 0 Global 64 33% 30 47% 26 41% 8 13% * Identifies increases/ decreases ranging from either some to strong, unweighted by population. The information on the extent of cocaine use in South or main difference from previous years is the widening of Central Asia.

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No prisoner of war may be convicted without having had an opportunity to present his defence and the assistance of a qualified advocate or counsel nolvadex 10mg line menstrual odor causes. The death sentence cannot be pronounced on a prisoner of war unless the attention of the court has generic 10mg nolvadex with visa women's health center san bernardino, in accordance with Article 87, second paragraph, been particularly called to the fact that since the accused is not a national of the Detaining Power, he is not bound to it by any duty of allegiance, and that he is in its power as the result of circumstances independent of his own will. A prisoner of war shall from not be confined while awaiting trial unless a member of the armed sentence, forces of the Detaining Power would be so confined if he were treatment) accused of a similar offence, or if it is essential to do so in the interests of national security. Any period spent by a prisoner of war in confinement awaiting trial shall be deducted from any sentence of imprisonment passed upon him and taken into account in fixing any penalty. The provisions of Articles 97 and 98 of this Chapter shall apply to a prisoner of war whilst in confinement awaiting trial. This period of three weeks shall run as from the day on which such notification reaches the Protecting Power at the address previously indicated by the latter to the Detaining Power. The said notification shall contain the following information: 1) surname and first names of the prisoner of war, his rank, his army, regimental, personal or serial number, his date of birth, and his profession or trade, if any; 2) place of internment or confinement; 3) specification of the charge or charges on which the prisoner of war is to be arraigned, giving the legal provisions applicable; 4) designation of the court which will try the case, likewise the date and place fixed for the opening of the trial. The same communication shall be made by the Detaining Power to the prisoners’ representative. If no evidence is submitted, at the opening of a trial, that the notification referred to above was received by the Protecting Power, by the prisoner of war and by the prisoners’ representative concerned, at least three weeks before the opening of the trial, then the latter cannot take place and must be adjourned. Failing a choice by the prisoner of war, the Protecting Power shall find him an advocate or counsel, and shall have at least one week at its disposal for the purpose. The Detaining Power shall deliver to the said Power, on request, a list of persons qualified to present the defence. Failing a choice of an advocate or counsel by the prisoner of war or the Protecting Power, the Detaining Power shall appoint a competent advocate or counsel to conduct the defence. The advocate or counsel conducting the defence on behalf of the prisoner of war shall have at his disposal a period of two weeks at least before the opening of the trial, as well as the necessary facilities to prepare the defence of the accused. He may also confer with any witnesses for the defence, including prisoners of war. He shall have the benefit of these facilities until the term of appeal or petition has expired. Particulars of the charge or charges on which the prisoner of war is to be arraigned, as well as the documents which are generally communicated to the accused by virtue of the laws in force in the armed forces of the Detaining Power, shall be communicated to the accused prisoner of war in a language which he understands, and in good time before the opening of the trial. The same communication in the same circumstances shall be made to the advocate or counsel conducting the defence on behalf of the prisoner of war. The representatives of the Protecting Power shall be entitled to attend the trial of the case, unless, exceptionally, this is held in camera in the interest of State security. He shall be fully informed of his right to appeal or petition and of the time limit within which he may do so. This communication shall likewise be sent to the prisoners’ representative concerned. The Detaining Power shall also immediately communicate to the Protecting Power the decision of the prisoner of war to use or to waive his right of appeal. Furthermore, if a prisoner of war is finally convicted or if a sentence pronounced on a prisoner of war in the first instance is a death sentence, the Detaining Power shall as soon as possible address to the Protecting Power a detailed communication containing: 1) the precise wording of the finding and sentence; 2) a summarized report of any preliminary investigation and of the trial, emphasizing in particular the elements of the prosecution and the defence; 3) notification, where applicable, of the establishment where the sentence will be served. The communications provided for in the foregoing sub- paragraphs shall be sent to the Protecting Power at the address previously made known to the Detaining Power. These conditions shall in all cases conform to the requirements of health and humanity. A woman prisoner of war on whom such a sentence has been pronounced shall be confined in separate quarters and shall be under the supervision of women. In any case, prisoners of war sentenced to a penalty depriving them of their liberty shall retain the benefit of the provisions of Articles 78 and 126 of the present Convention. Furthermore, they shall be entitled to receive and despatch correspondence, to receive at least one relief parcel monthly, to take regular exercise in the open air,to have the medical care required by their state of health,and the spiritual assistance they may desire. Penalties to which they may be subjected shall be in accordance with the provisions of Article 87, third paragraph. Throughout the duration of hostilities, Parties to the conflict shall endeavour, with the co-operation of the neutral Powers concerned, to make arrangements for the accommodation in neutral countries of the sick and wounded prisoners of war referred to in the second paragraph of the following Article. They may, in addition, conclude agreements with a view to the direct repatriation or internment in a neutral country of able- bodied prisoners of war who have undergone a long period of captivity.

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