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Sympathy is when you feel sorry for the patient but do not feel the same emotions or are not in the same situation buy lady era 100 mg amex menstrual while breastfeeding, whereas empathy is when you place yourself in your patient’s situation and respond based on either similar personal experiences or through vicarious understanding order lady era 100 mg with amex breast cancer0rg. When you express empathy, it allows your patient to feel as though you understand his or her unique experience and that you are applying your expertise to the patient as an individual. Empathy can be shown in several ways, and each way will depend upon the partic- ular patient as well as the situation. For example, nodding your head, making a state- ment, or asking a follow-up question can show empathy. For example, saying to your patient who has been communication skills 5 diagnosed with cancer, “I know just how you are feeling. At first, he was just so overwhelmed and upset” may make the patient feel like you are not truly listening to her, but rather assuming that she will respond like anyone else with a cancer diagnosis. It may be better to say, “I know from some personal experiences that finding out about cancer can be very overwhelming. Building a good rapport sets the tone for the interview and allows the patient to feel comfortable with you, thereby making the lines of communication more open and honest. Patients may sometimes withhold information if they feel uncomfortable or anxious about sharing their complaints because of a lack of feeling respected, feeling as though their words are not being heard, or quite simply not knowing who you are and what your role is in their care. Therefore, starting the interview by greeting the patient by name, making sure you are pronouncing the patient’s name correctly, asking how he or she prefers to be addressed, and adding a title to his or her name, if preferred, will indicate your interest in the patient and show that you care. You should also give your name and title and then briefly describe the purpose of the interview. I am the pharmacist who is part of your medical team, and I am here to ask you a few questions about what brought you to the hospital and discuss the medications you have been taking at home. Is it okay for me to speak to you with your family/friends in the room or would you prefer to be alone while we talk? In general, open-ended questioning is the preferred technique to use during patient interviews to compel the patient to provide more in-depth and insightful responses. Because open- ended questions do not limit the patient to responding with a yes or no, they encour- age the patient to disclose more information. For example, you can start the interview by asking an open-ended question, such as “How are you feeling today? For example, if you ask the patient a closed-ended question such as, “Do you take your medications as directed by your physician? Instead, if you ask the patient an open- ended question, such as “How are you taking this medication? By gathering more information with open-ended questioning, you may learn that there are dis- crepancies between how the patient is actually taking the medication and how it has been prescribed. Oftentimes, a patient answers, “Yes, I am taking it as directed,” but you then discover that this is not the case, perhaps as a result of dishonesty but more likely because the patient believes that he or she is taking the medication correctly. The use of open-ended questions enables you to gather more information from the patient and to be more complete and accurate in your assessment; this, in turn, leads to appropriate patient-specific care. Closed-ended questions do play a role in communicating with a patient; however, the use of close-ended questions should be specific to the information you want to col- lect. For example, if you would like to know whether the patient took his or her blood pressure medication in the morning to more accurately assess his or her blood pressure reading, you might ask, “Did you take your blood pressure medications this morning? For example, after asking an open-ended question such as “What symptoms communication skills 7 are you currently experiencing? These questions lead a patient to provide a response that he or she perceives to be the answer that the inter- viewer wants to hear. An example of a leading question is “You do not miss any doses of your medication, do you? Therefore, to obtain an accurate response to your questions, leading questions should be avoided. By allowing moments of silence after asking a question, the patient is able to reflect upon your question and provide a more thoughtful and accurate response. However, silence may also indicate that the patient has not understood your question. You can use nonver- bal cues to gauge each patient independently to determine the appropriate length of time to be silent and/or when to break the silence. In general, the silence should be long enough to provide the patient a chance to gather his or her thoughts but not so long as to make the patient feel uncomfortable.

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Defenders of the status quo often adopt dogmatic and entrenched moral positions cheap lady era 100mg on line women's health clinic surrey bc, portraying regulatory legal alternatives as immoral 100 mg lady era amex breast cancer nail designs, 6 extreme, ‘pro-drug’, radical, or even heretical. The clear implication is that debating such alternatives is a political ‘no-go’ zone. Until relatively recently, the climate of fear thus created had pushed the law reform position to the margins of mainstream political discourse. To the rational public health or social policy pragmatist, exploring and seeking out policy options that will deliver the best policy outcomes—an optimum point along this drug policy continuum—the idea that such an arbitrary barrier to policy research and development exists is diffcult to justify. This is especially true given that the vast majority of markets for goods and services, particularly ones that involve risk or poten- tial harm (including many hundreds of medical and non-medical psychoactive drugs), are both legally available and regulated by governments. Legal regulation of potentially risky A wide range of evidence based regulatory mecha- goods and activities is nisms and related enforcement/oversight agencies demonstrably not only are deployed to control and manage producers, the norm; it is one of suppliers, environments, products and consumers. For even the exploration of any such regulatory options to be forbidden in one, relatively narrow, feld of human behaviour does not sit well with the wider commitment of the United Nations to ‘promote social progress and better standards of life 7 in larger freedom’. Activities that take place beyond the parame- ters of a given regulatory framework remain prohibited and subject to legal sanctions. With the possible exception of some very low risk products such as coffee or coca tea, such models are not appropriate for drugs, because they forgo the potential for most forms of responsible state intervention in market regulation and control. In this, they are handing control of drug markets to exploit- ative profteers just as surely as prohibition. Legal commercial actors—whose primary concern is proft maximisation—would be free to aggressively promote consumption through marketing and advertising. The potential for such an approach to create unacceptable public health costs has been all too clearly demonstrated with the example of the free markets for tobacco in much of the developed world during the frst 60 years of the 20th century, and to a greater extent in large parts of the developing world today (see: 5. Nadelmann ‘Thinking Seriously About Alternatives to Drug Prohibition’, Daedalus, 1992, 121: pages 87–132. We describe them below, starting with the most restrictive and moving to the most open. Variants on these models already exist and function across the world, supporting the entirely legal distribution of a range of medical, quasi-medical and non-medical psychoactive drugs. Of course, the precise nature of the respective regulatory frameworks and enforcement infrastructure varies from country to country. This leads to a certain amount of generalisation, but also helps emphasise that such models will inevitably operate differently in different locations. We have also made some basic suggestions as to how to adapt these basic models to cater for the challenges of non-medical drug supply in the future. Under this model, drugs are prescribed to a named user by a qualified and licensed medical practitioner. They are dispensed by a licensed practitioner or pharmacist from a licensed pharmacy or other designated outlet. These guide, oversee and police the prescribing doctors and dispensing pharmacists. They also help determine which drugs are available, in what form, where, and under what criteria. It is limited to medical necessity, which restricts its actual or poten- tial use to the problematic/chronic dependent end of the drug use 9 spectrum. Most commonly, it supports maintenance prescribing as part of a treatment regimen or harm reduction programme. As such it will only ever involve a small fraction of the total drug using population, although it should be noted that this user group is disproportionately associated with the greatest personal and 10 societal harms (especially under prohibition ). Prescribed injectable heroin (diamorphine) also has a long history, and established evidence 11 base. Less common, although not unknown, is the prescription of stimulants, including amphetamines and cocaine. They provide a useful, if limited, demonstration of how legal regulation of drugs can help people become prescribed, rather than street, users; a clear example of the benefts of decriminalisation of drug use and regularisation of their supply route. It is hard to know how such services would develop if managed with the latitude afforded to other, less controversial areas of patient care such as, for example, diabetes or mental health. Witton, ‘Thematic review—heroin prescribing’, Drug and Alcohol Findings, 2003, issue 9, page 16. These include requirements for consumption to be supervised in a specifc venue, for very specifc qualifying criteria to be met, or for the prescribing doctor to obtain a special licence. Prescribing is often time limited, administered in progressively reduced dosage, or made conditional on the patient meeting specifc rehabilitation milestones.

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It is quite another thing to replace a procedure specifically negotiated by parties 49 with an entirely different mechanism generic lady era 100 mg on-line menopause questions for doctor. Such a chaotic situation—actually counterproductive to harmonization—cannot be the presumed 50 intent of Contracting Parties cheap lady era 100 mg fast delivery menstruation leave. Having rejected the claim, the tribunal “wholeheartedly” endorsed the statement of principle made by the tribunal in Plama v. Bulgaria case in the sense that an “agreement to arbitrate should not be reached by incorporation by reference”. For the reasons developed above, it should be evident that this Tribunal cannot accept that standpoint. It saw it as merely generic and of little or no guidance as to determine the intention of the parties to the treaty. Although the defending State had recalled that “every single tribunal that has considered the question of expanding international tribunals’ jurisdiction on the basis of a most-favoured- nation clause has rejected the Claimant’s position […]”. Quite the contrary, it could be argued that, if it applies to substantive protection, then it should apply even more to ‘only’ procedural protection. It also rejected the “invidious” proposition, as some commentators have called it, to assume that investment tribunals were superior to domestic courts and that therefore investors seeking to have their claim assessed by a neutral international forum was based on a rational concern. The tribunal asserted that there was no textual basis or legal rule to say that treatment does not encompass the host State’s acceptance of international arbitration. Examining these arguments lead to a decision by the tribunal in favour of the investor. The discussion then turned to the question whether dispute settlement was an inherent part of the “fair and equitable treatment” standard. This in the majority view relates to normative standards and does not extend to either (i) availability of international as opposed to national fora or (ii) “more” rather than “less” arbitration”(as the separate opinion 68 puts it). To counter these arguments and preserve the integrity of the basic treaty, defendants have argued that the intent of the parties can be deducted from reasonable interpretation and that there is a need for a clear and unambiguous consent. They also claimed that there is no evidence of "less favourable" treatment enshrined in the basic treaty as opposed to a third treaty. Spain, Siemens, Allowed, except months waiting period Gas Natural, Camuzzi, Suez, for Wintershall before local courts National Grid, Wintershall v. Czech Republic Allowed of compensation for expropriation Compare treatment Bayindir v. This footnote would be deleted in the final text of the Agreement: “The Parties note the recent decision of the arbitral tribunal in the Maffezini (Arg. Kingdom of Spain, which found an unusually broad most favored nation clause in an Argentina- Spain agreement to encompass international dispute resolution procedures. By contrast, the Most-Favored-Nation Article of this Agreement is expressly limited in its scope to matters “with respect to the establishment, acquisition, expansion, management, conduct, operation, and sale or other disposition of investments. It is understood that the treatment referred to in paragraph 1 does not include treatment accorded to investors of a non-Party and their investments by provisions concerning the settlement of investment disputes between a Party and the non-Party that are provided for in other international agreements. The Czech Republic therefore is obligated to provide no less than “fair market value” to Claimant in respect of its investment, should (in contrast to this Tribunal’s opinion) “just compensation” representing the “genuine value” be interpreted to be less than “fair market value” [para. The Annulment Committee did not overturn the tribunal on this issue: Annulment Proceeding 21 March 2007, para. The Russian Federation, Arbitration Institute of the Stockholm Chamber of Commerce, Case. Countries pursuing these strategies seek to steer foreign investors into those activities they consider particularly important for their economic development. There is evidence that such a policy can contribute to an acceleration and deepening of the process of industrial development in particular. This approach requires the identification of activities in which a country can reasonably expect to acquire a comparative advantage and the promotion of production in such areas. The countries concerned would thus grant market access or other special privileges only to investors from these countries. Such a strategy assumes that one or several countries with strategic advantages over other potential partners could be identified (and that granting the same conditions to investors from other countries would undermine this strategic partnership).

Common clindamycin toxicities include fever buy lady era 100 mg with mastercard womens health 9 diet, rash buy lady era 100mg on-line womens health weight loss, nausea, diarrhea (including pseudomembranous colitis or diarrhea related to Clostridium difficile toxin), and hepatotoxicity. Common atovaquone toxicities include nausea, vomiting, diarrhea, rash, headache, hepatotoxicity, and fever. Drug interactions between anticonvulsants and antiretroviral agents should be evaluated carefully; if necessary, doses should be adjusted or alternative anticonvulsants should be used. In patients who adhere to their regimens, disease recurrence is unusual in the setting of chronic maintenance therapy after an initial clinical and radiographic response. Although sulfadiazine is routinely dosed as a four-times-a-day regimen, a pharmacokinetic study suggests bioequivalence for the same total daily dose when given either twice or four times a day,69 and limited clinical experience suggests that twice-daily dosing is effective. Toxoplasmosis diagnostic considerations are the same in pregnant women as in non-pregnant women. With respect to congential toxoplasmosis, the risk of transmission is highest in the setting of an acute maternal infection as compared to reactivation. While the risk of transmission increases with advancing gestational age, the severity of fetal sequelae is more pronounced the earlier in gestation the fetus is affected. The value of routine toxoplasmosis screening programs is debated in the United States but generally accepted in other countries. In countries such as France where pregnant women are universally screened and treated, infected offspring are reported to have primarily mild disease and rarely severe disease. Studies published since 2007 support treatment of toxoplasmosis during pregnancy in an effort to decrease vertical transmission and reduce the severity of clinical signs in the offspring. Spiramcyn is not teratogenic, does not treat infection in the fetus and is primarily indicated for fetal prophylaxis. Pyrimethamine should not be used in the first trimester because of teratogenicity concerns. The infant’s care provider should be notified of maternal sulfa use in late pregnancy. While there are limited data on atovaquone safety in humans, preclinical studies have not demonstrated toxicity. Maintenance therapy should be provided, using the same indications as for non-pregnant women. Outbreak of central-nervous-system toxoplasmosis in western Europe and North America. Central-nervous-system toxoplasmosis in homosexual men and parenteral drug abusers. Use of a clinical laboratory database to estimate Toxoplasma seroprevalence among human immunodeficiency virus-infected patients. Toxoplasma gondii infection in the United States, 1999 2004, decline from the prior decade. Incidence and risk factors for toxoplasmic encephalitis in human immunodeficiency virus-infected patients before and during the highly active antiretroviral therapy era. Pyrimethamine for primary prophylaxis of toxoplasmic encephalitis in patients with human immunodeficiency virus infection: a double-blind, randomized trial. Risk factors for Toxoplasma gondii infection in mothers of infants with congenital toxoplasmosis: Implications for prenatal management and screening. Use of the peroxidase-antiperoxidase method to demonstrate toxoplasma in formalin fixed, paraffin embedded tissue sections. A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. Treatment of central nervous system toxoplasmosis with pyrimethamine/ sulfadiazine combination in 35 patients with the acquired immunodeficiency syndrome. Folinic acid supplements to pyrimethamine-sulfadiazine for Toxoplasma encephalitis are associated with better outcome.

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