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There are several excellent urine testing kits that have been developed in the last few years that can be used at home and can save you an amazing amount of time and money purchase cefixime 100mg fast delivery treatment for vre uti. Now you can perform many of the same urine tests at home that your doctor performs in hia office order cefixime 200mg amex treatment for dogs eyes. Also buy cheap cefixime 100 mg online antibiotic resistance evolves in bacteria when quizlet, these tests are particularly helpful when using urine therapy because you can monitor your own health progress easily and inexpensively buy cefixime 100mg otc antibiotic resistance diagram. The booklet also explains how to interpret your urine color and appearance which are important additional indicators of health conditions. Many of the research tests on urine recycling have been undertaken with animals, and vetermarians have used urine therapy for treatment by catherizing the arumal and administering oral urine drops with reportedly good results. Urine home test strips are available to test for these conditions and many others: o Kidney and Urinary Tract Infections o Diabetes o Blood in the urine o Pregnancy o Ovulation 208 o Liver Function You can purchase these strips in drug- stores or they are available by catalog Summary Remember to begin your treatment slowly with a few oral drops and increase the amount to a well-tolerated dosage. Do not use the therapy while ingesting heavy amounts of nicotine, caffeine or while using recreational drugs or therapeutic drugs than small amounts. If you do decide to use it, however, use only very small amounts (3-5 drops 1x day. Drink as much water as you feel thirsty for, and keep weli-hydrated, but do not force-drink large amounts oi fluid during the therapy. Daily maintenance doses vary from a few drops to one to two ounces of morning urine, depending on your sensitivity and preference. Start with small amounts and work up to larger amounts gradually for internal use. Do Not combine urine therapy with a starvation diet (or fasting) unless you have been using the therapy for at least two months. Beginning in 1983, the school moved in-stages to the new branch campus in Kubang Kerian, Kelantan. The Health Campus is fully equipped with up-to-date teaching, research and patient care facilities. One of the unique features of the School of Medical Sciences is its integrated organ-system and problem-based curriculum. The course aims to produce dedicated medical practitioners who will be able to provide leadership in the health care team at all levels as well as excel in continuing medical education. More specifically, the student upon graduation, should be able to:- (a) Understand the scientific basis of medicine and its application to patient care. This ‘spiral’ concept enables the school to implement the philosophy of both horizontal and vertical integration of subjects/disciplines. The Medical School in formulating the new curriculum, studied the various problems in established medical faculties parri passu with new developments in medical education. The study of behavioural sciences and exposure to the clinical environment are also incorporated. Clinical work and hospital attachments account for a high percentage of the student’s time in these two years. Emphasis is given to problem - solving, and clinical reasoning rather than didactic teaching. Apart from this clinical exposure, the student is also orientated to health care delivery services within the teaching hospital and the network of supporting hospitals and health centres in the region. The aim is to inculcate a sense of professional responsibility and adaptability so that the student will function effectively when posted later to the various health care centres in the country. The teaching strategy implemented in this phase reflects these approaches:- 28 (i) Discipline - based (ii) Multi-diciplinary integration (iii) Problem - based and problem-solving (iv) Community-orientated (v) Clinical apprenticeship A. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of cell, tissue and embryology will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins 2. Snell, Clinical Anatomy, 7th Ed, (2003), Lippincott Williams and Wilkins Physiology 1. Kumar et al, Robbin and Cotran: Pathology Basis of Disease, 8th ed (2010), SaundersElsevier. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of molecular biology and pharmacology will be evaluated through continuous assessment using formative and summative approaches. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill,. Lectures and learning activities outside the lecture hall such as hospital placement with other health care workers and community projects will be used to help students understand and appreciate the importance, and practice basic medical ethics and communication. Lectures and practical basic first aid will be given to provide early exposure to students on patient care. Basic knowledge and understanding of the key principles of first aid and medical ethics will be evaluated through continuous assessment using formative and summative approaches. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of immunology, microbiology and pathology will be evaluated through continuous assessment using formative and summative approaches. Medical Microbiology, 25 edition (2010), McGraw-Hill Medical Publishing Division Immunology 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of respiratory system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2. Jawetz, Melnick&Adelberg’s, Medical Microbiology, 25 edition (2010): McGraw-Hill Medical Publishing Division th 2. Markell and Voge’sMedical Parasitology, 9 edition (2009), Saunder’s Elsevier Publishing Immunology th 1. Goodman and Gilman, The pharmacological basis of therapeutics 12th ed (2011), New York: McGraw-Hill Medicine 1. These objectives will be achieved through multiple methods of teaching and learning such as lectures, guided self-learning and practical sessions. Basic knowledge and understanding of the key principles of haemopoietic and lymphoid system will be evaluated through continuous assessment using formative and summative approaches. Aqur, Clinically Oriented Anatomy, 6th Ed, (2009), Lippincott Williams and Wilkins th 2.

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She was also starting to use many more botanical therapies - herbs and some of the local plants - she wasn’t yet convinced how effective they were - but she had been pleasantly surprised on several occasions order cefixime cheap online antibiotic resistance in humans. There was no such thing as "single use" purchase 100mg cefixime mastercard antibiotics for mild uti, if they could clean it and/or resharpen it - it was used again - 203 - Survival and Austere Medicine: An Introduction So ten years on purchase line cefixime antibiotic resistance finder, things were vastly different - but human nature being what it was they had adapted buy cefixime online antibiotic quality premium. Back to an agricultural society - but a hybrid society with a knowledge of technology but only a limited ability to deliver it - but with high hopes for the future. The blacksmith – he had been an auto mechanic who shoed horses on the side – but he was the blacksmith now. His son was rapidly picking up the skills, in some ways more adaptable and innovative than his father, but essentially he was the Blacksmiths apprentice. She was greeted by the earnest looking 11-year-old son of one of the farmers up the top of the valley. Since the petrol had corrupted several years ago, the few bikes the village had were now worth their weight in gold. She wasn’t as fast on her bike as he was on his horse and his frustration was starting to show. It was only 8 km’s to the top of the valley, but the Hanson farm was near the top. It was a ride she usually enjoyed, but on this occasion she could feel her anxiety levels rising. Any time she attended an emergency or one was bought to the clinic she had the same feeling of anxiety. It was the one she had had all of her working life - but now the anxiety was amplified by the knowledge that even though she had developed the skills to work without the fancy diagnostic tests and she prided herself on her diagnostic accuracy - the right diagnosis meant little, without the supplies to manage the problem. After what seemed like an eternity to her, but what was in reality only 15 minutes, she reached the farm. It was much like the others that were in the valley away from the main settlement: A pre-crash farmhouse – but now with reinforced fences and barricades and heavy window shutters. There had only been a few attacks in the valley and none against the main settlement – but there was the constant awareness that there were still the occasional loner or small gang that survived by robbery. However for the most part the travelling bandits had burnt themselves out and were now either dead or had found that community farming was the only sustainable long-term option. They had heard stories of several hostile settlements, which, were based around some the early roving bands – and that while they had settled down they were still unpleasant neighbours to have, not thinking twice about stealing crops and livestock. But by virtue of the nature of the catastrophe the population was fortunately widely spread and overtime there was little competition for resources and there had been plenty of supplies to forage from. Access to the valley from the high end was very difficult and they had destroyed the single road access making it almost impossible, except for the very determined person on foot – and even then the almost invisible paths and steep hillsides and cliffs made passage very difficult. The main access was at the bottom of the valley and was across a bridge over the confluence of three rivers from neighbouring valleys and there own, which was deep and fast moving. So while early on there had been several attacks by small groups on foot, they had never had to deal with the motorized attacks they had heard about from some of the other nearby communities. She was shown into the house by Ralph Hanson; it only took a look from the bedroom door to tell that Sue was pretty sick. Alex turned back to the boy and told him to go back down to the village and get someone to bring up a cart. She knelt by the bed and simultaneously began both reassuring the sick woman and taking a history. The blocks rapidly fell into place - Sue had missed her period 2 weeks ago and had just been building up the courage to tell her husband and boys. She had developed colicky abdominal pain yesterday and this morning it had got much worse. Her hands felt cold to touch and she had a rapid thready pulse at 125, the lower half of her belly was rigid and extremely tender. She didn’t really know where to start, Sue needed surgery, and that wasn’t an option. She drew a iv cannula from her bag - it wasn’t actually a cannula - it was the needle from an old cannula - bleached, boiled and sharpened - as sterile as possible - gone where the plastic cannulas - she was back to leaving the metal needles in veins. Sue was lean and muscular and despite her blood loss, several veins popped up as she applied the tourniquet and Alex easily cannulated her. She reached into her bag and pulled out a small jar of coarse brown crystals, a bottle of sterile water, a 10 ml glass syringe, and needles and began the process of making up some heroin. She had a basic idea of the process from her university chemistry and combined with a bit of street knowledge - she had had a go. She had been at medical school at the time, and she remembered talking in clinical chemistry about how they had been extracting the heroin - it was amazingly easy. So now she had a small jar a granular black powder - it probably wasn’t that pure – mostly heroin – but with a small mix of the assorted other opiates and alkaloids found in the poppy. On the few occasions she had used it, it had been very effective - a little trial and error with the dosing - but effective. The main problem now was sterility and removing all the insoluble rubbish - she had adopted - 205 - Survival and Austere Medicine: An Introduction basically the same techniques the addicts had used – but hopefully slightly more sterile - dissolve it in distilled water, filter it as best she could – she had a small supply of cigarette filter paper she had salvaged for the purpose and then heated it to sterilize it. Not perfect by any means, but like everything else in her world now – near enough frequently had to be good enough. But over the next few minutes, her moaning settled and she seemed more comfortable. There was some down in the clinic, but they were too cumbersome to cart around in her medical backpack. The boy reappeared, in a surprisingly short period of time, with one of the farmers from the village and his horse and cart (really a cut down car with a removed engine and a substituted horse) and they half carried and half walked Sue to the back bed of the cart. They moved off slowly down the valley in the cart, with Sue moaning softly as they moved over the broken tar sealed road, Alex again was trying to think what to do next. Always she arrived at the same conclusion – that while setting fractures and perhaps performing an amputation might be possible, she wasn’t ever going to be able to perform open abdominal surgery – and anyone who needed it was going to die. But now faced with Sue Hanson, lying there in front of her, it didn’t seem so black and white anymore. The first 500mls of normal saline had nearly run through, and Sue’s heart rate had come down and the volume of her pulse seemed stronger. Although this didn’t bother her overly, while Sue was still bleeding from her ruptured ectopic she didn’t want to push her blood pressure up anyway – it would just pop what clot might have formed and encourage more bleeding – more the moment, as long as she had a radial pulse and was awake – that was enough – she didn’t need litres of fluid – she needed an operation. The problem had been how to manufacture it and keep it sterile using a pretty rudimentary set-up. Despite the devastating nature - 206 - Survival and Austere Medicine: An Introduction of the “strike”, they hadn’t been completely driven back to the Stone Age, and while she didn’t have access to proper laboratory equipment, early on in there foraging they had striped the county school of much of its science equipment. This had meant that she had a good number of flasks, beakers, test tubes, and bungs and a small glass condensing coil – most useful of all was an old-style hanging scale, with weights for 1-100gms. This motley collection of equipment had enabled her to produce the heroin and also produce small batches of intravenous fluids. Alex had enlisted Tom, the community brewer – he had over the years established a successful little beer brewery and also a still for making various spirits – on which he also made her high proof medical alcohol.

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Their overall conclusion is that was that the threat of arrest and harsh punishment the removal of criminal penalties quality 100 mg cefixime antibiotics for uti azithromycin, combined with the use would deter people from using drugs purchase cefixime without prescription treatment for dogs with demodex mites. In practice buy generic cefixime on-line antibiotics for acne brand names, of alternative therapeutic responses to people struggling this hypothesis has been disproved – many countries with drug dependence 200mg cefixime fast delivery antibiotics for urine/kidney infection, has reduced the burden of drug law that have enacted harsh laws and implemented enforcement on the criminal justice system and the overall widespread arrest and imprisonment of drug users and level of problematic drug use. The researchers wished to examine whether the more repressive policy environment of San Francisco deterred citizens from smoking cannabis or delayed the onset of use. They found that it did not, concluding that: “Our fndings do not support claims that criminalization reduces cannabis use and that decriminalization increases cannabis use. With the exception of higher drug use in San Francisco, we found strong similarities across both cities. We found no evidence to support claims that criminalization reduces use or that decriminalization increases use. Of course, this does not necessarily mean that a period when the use of cannabis was in general decline sanctions should be removed altogether – many drug across the country. However, the researchers found that users will also commit other crimes for which they need this downward trend was the same in Western Australia, to be held responsible – but the primary reaction to drug which had replaced criminal sanctions for the use or possession and use should be the offer of appropriate possession of cannabis with administrative penalties, advice, treatment and health services to individuals who typically the receipt of a police warning called a ‘notice need them, rather than expensive and counterproductive of infringement’. Encourage experimentation by governments unlike the predictions of those public commentators with models of legal regulation of drugs (with who were critical of the scheme, cannabis use in cannabis, for example) that are designed to Western Australia appears to have continued to decline undermine the power of organized crime and despite the introduction of the Cannabis Infringement safeguard the health and security of their citizens. In the 2008 Report of policies and programs that minimize health and social the Cannabis Commission convened by the Beckley harms, and maximize individual and national security. Foundation, the authors reviewed research that had been It is unhelpful to ignore those who argue for a taxed and undertaken to compare cannabis prevalence in those regulated market for currently illicit drugs. This is a states that had decriminalized with those that maintained policy option that should be explored with the same criminal punishments for possession. The current schedules, designed to represent the relative risks and harms of various drugs, were set in place 50 years ago when there was little scientifc evidence on which to base these decisions. This has resulted in some obvious anomalies – cannabis and coca leaf, in particular, now seem to be incorrectly scheduled and this needs to be addressed. Heroin While these are crude assessments, they clearly Cocaine show that the categories of seriousness ascribed to various substances in international treaties need to be Barbiturates reviewed in the light of current scientifc knowledge. The current system of measuring success in the drug policy feld is fundamentally fawed. We simply criminals (that take years to plan and implement) have cannot treat them all as criminals. Similarly, To some extent, policymakers’ reluctance to eradication of opium, cannabis or coca crops merely acknowledge this complexity is rooted in their displaces illicit cultivation to other areas. Many ordinary citizens do have genuine fears about the A new set of indicators is needed to truly show the negative impacts of illegal drug markets, or the behavior outcomes of drug policies, according to their harms or of people dependent on, or under the infuence of, benefts for individuals and communities – for example, illicit drugs. These fears are grounded in some general the number of victims of drug market-related violence assumptions about people who use drugs and drug and intimidation; the level of corruption generated markets, that government and civil society experts need by drug markets; the level of petty crime committed to address by increasing awareness of some established by dependent users; levels of social and economic (but largely unrecognized) facts. For example: development in communities where drug production, selling or consumption are concentrated; the level of • The majority of people who use drugs do not ft the drug dependence in communities; the level of overdose stereotype of the ‘amoral and pitiful addict’. Policymakers can and should Nations estimates that less than 10 percent can be articulate and measure the outcome of these objectives. In the current opportunities are better investments than destroying circumstances in most countries, this would mean their only available means of survival. Profting from weak governance, endemic poverty, A more mature and balanced political and media discourse instability and ill-equipped police and judicial institutions, can help to increase public awareness and understanding. Corruption and money use and dependence can help to counter myths and laundering, driven by the drug trade, pervert local politics misunderstandings. Countries that continue to invest mostly in a law A dangerous scenario is emerging as narco-traffc threatens enforcement approach (despite the evidence) should to metastasize into broader political and security challenges. New evidence44 suggests that criminal networks are expanding operations and strengthening their positions The resources of law enforcement agencies can be much through new alliances, notably with armed groups. Current more effectively targeted at battling the organized crime responses need to be urgently scaled up and coordinated groups that have expanded their power and reach on the under West African leadership, with international fnancial back of drug market profts. Responses should integrate the violence, intimidation and corruption perpetrated law enforcement and judicial approaches with social, by these groups is a signifcant threat to individual and development and confict prevention policies – and they national security and to democratic institutions, so efforts should involve governments and civil society alike. There is a plausible theory put forward by MacCoun and Reuter43 that suggests that supply reduction efforts are most effective in a new and undeveloped market, where the sources of supply are controlled by a small number of traffcking organizations. Where these conditions exist, appropriately designed and targeted law enforcement operations have the potential to stife the emergence of new markets. On the other hand, where drug markets are diverse and well-established, preventing drug use by stopping supply is not a realistic objective. Similarly, the demand for drugs from those increased law enforcement on drug market violence, dependent on some substances (for example, heroin) 91 percent concluded that increased law enforcement can be met through medical prescription programs that actually increased drug market violence. Instead, the existing evidence suggests that practices can actually increase the level of violence, drug-related violence and high homicide rates are likely intimidation and corruption associated with drug a natural consequence of drug prohibition and that markets. Law enforcement agencies and drug traffcking increasingly sophisticated and well-resourced methods of organizations can become embroiled in a kind of ‘arms disrupting drug distribution networks may unintentionally race’, in which greater enforcement efforts lead to a similar increase violence. Promote alternative sentences for small-scale and rates of drug use through mass prevention campaigns frst-time drug dealers. While the presentation of good (and credible) information on While the idea of decriminalization has mainly been the risks of drug use is worthwhile, the experience of discussed in terms of its application to people who use universal prevention (such as media campaigns, or drugs or who are struggling with drug dependence, school-based drug prevention programs) has been we propose that the same approach be considered mixed. Simplistic ‘just say no’ messages do not seem for those at the bottom of the drug selling chain. There have been some carefully planned and targeted They are young people who are exploited to do the prevention programs, however, that focus on social skills risky work of street selling, dependent drug users trying and peer infuences that have had a positive impact on to raise money for their own supply, or couriers coerced the age of initiation or the harms associated with drug or intimidated into taking drugs across borders. The energy, creativity and expertise of civil society people are generally prosecuted under the same legal and community groups are of particular importance provisions as the violent and organized criminals who in the design and delivery of these programs. Young control the market, resulting in the indiscriminate people are less likely to trust prevention messages application of severe penalties. Around the world, the vast majority of arrests are of Successful models of prevention have tended to target these nonviolent and low-ranking ‘little fsh’ in the drug particular groups at risk – gang members, children in market. They are most visible and easy to catch, and do care, or in trouble at school or with the police – with not have the means to pay their way out of trouble. Implemented to a and with no impact on the scale or proftability of suffcient scale, these programs have the potential the market. Offer a wide and easily accessible range of options fghting the drug war, many countries implement laws for treatment and care for drug dependence, and punishments that are out of proportion to the including substitution and heroin-assisted treatment, seriousness of the crime, and that still do not have a with special attention to those most at risk, including signifcant deterrent effect. Invest more resources in evidence-based prevention, a tragic loss of potential for the individual involved, with a special focus on youth. Clearly, the most valuable investment would be in activities that stop young people from using drugs in Preventing and treating drug dependence is therefore the frst place, and that prevent experimental users a key responsibility of governments – and a valuable from becoming problematic or dependent users. In the – have been implemented and proven in a range of face of growing evidence of the failure of these strategies, socio-economic and cultural settings. Governments should ensure that their drug dependence There are a number of ways to make progress on this treatment facilities are evidence-based and comply with objective. We therefore welcome the change of tone millions of citizens are sent to prison unnecessarily, emerging from the current administration50 – with millions more suffer from the drug dependence of President Obama himself acknowledging the futility loved ones who cannot access health and social care of a ‘war on drugs’ and the validity of a debate on services, and hundreds of thousands of people die from alternatives.

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Prevention  All children by the age of 15 months must be vaccinated against mumps or have an exemption for childcare enrollment cheap cefixime 100mg with visa antibiotic resistance results from. An additional dose of mumps is highly recommended for kindergarten or two doses by eighth grade enrollment buy discount cefixime online antibiotics for acne depression. When a mumps outbreak is identified generic 200 mg cefixime antimicrobial herbs, exemptions in childcare centers or schools will not be allowed order cefixime 200mg amex natural antibiotics for acne infection. Students who refuse immunization should be excluded until at least 26 days after the onset of parotitis in the last person with mumps in the affected school or childcare center. Norovirus is often incorrectly called the “stomach flu”, although it is not caused by the influenza virus. In addition, fever, headache, muscle aches, fatigue, and stomach cramps can occur. The illness can be mild to moderately severe with symptoms usually lasting 24 to 48 hours. Spread can occur when people do not wash their hands after using the toilet or changing diapers. People can also get sick by eating food items contaminated during preparation or serving. Person-to-person spread often occurs within families, schools, nursing homes, cruise ships, in childcare settings, and communities. No one with vomiting and/or diarrhea should use pools, swimming beaches, recreational water parks, spas, or hot tubs for 2 weeks after diarrhea and/or vomiting symptoms have stopped. Staff must avoid food preparation when diarrhea and vomiting are present and for at least 3 days after diarrhea and/or vomiting have stopped. Wash hands thoroughly with soap and warm running water after using the toilet and changing diapers and before preparing or eating food. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. If you think your child Symptoms has Norovirus: Your child may have watery diarrhea, vomiting, and  Tell your childcare fever. Other symptoms may include headache, stomach provider or call the cramps, and tiredness. Childcare and School: Spread Yes, until the child has been free of diarrhea and vomiting for at least - By eating or drinking contaminated food or beverages. Prevention  Wash hands after using the toilet and changing diapers and before preparing food or eating. The cough may occur in sudden, uncontrollable bursts, sometimes ending with high-pitched whooping sounds and/or vomiting. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth. Preventive treatment may be considered for close contacts who are at a higher risk for more severe disease, including infants and immuno- compromised persons. If you think your child has Symptoms Parapertussis: Your child may have a runny nose, sneezing, or mild  Tell your childcare coughing. If your child has been infected, it takes 6 to 21 days (usually 7 to 10 days) for symptoms to start. Childcare and School: No, if the child is healthy Spread enough for routine activities. Contagious Period Unknown, but likely to be most contagious at the time of early cold-like symptoms. Call your Healthcare Provider ♦ If anyone in your home is coughing for more than 7 days. Pertussis (also known as whooping cough) can be a serious illness, especially in young, unvaccinated children. Adults and older children with pertussis may be the source of infection for infants and young children. This is a concern because in recent years, more adults, adolescents, and school-aged children have been contracting pertussis. After a week or two, a persistent cough develops, which may occur in explosive bursts (paroxysmal coughing), sometimes ending in a high-pitched whoop and vomiting. A whoop may be absent in older children, adults, and infants younger than 6 months. The coughing attacks usually increase during the first two weeks of illness and then remain the same for two or three more weeks before gradually decreasing. Older children and adults may have a less typical cough; however, it is usually persistent and may lead to vomiting or a whoop. Although the disease may be less severe in adults and older children, they can unknowingly infect infants and preschoolers who are at risk for serious illness. Persons remain contagious until three weeks after explosive bursts of coughing begin. Those treated with antibiotics are contagious until 5 days of treatment are completed. If not treated with 5 days of antibiotics, exclusion should be for 21 days after cough onset. If there is a high index of suspicion that the person has pertussis, exclude until the individual has been evaluated by a medical provider and deemed no longer infectious by the local health department, 5 days of antibiotics are completed or until the laboratory test comes back negative. Some lab tests (pertussis cultures) are less accurate after antibiotics are given or if significant time has passed since the onset of symptoms. Antibiotics are usually not given to people who have had a cough for more than 21 days because they will no longer be helpful. Adolescents ages 11 through 18: Adolescents aged 11 or 12 should receive a single dose of tetanus, diphtheria, and pertussis (Tdap) in place of tetanus and diphtheria (Td). Adolescents aged 13 through 18 who have not received Tdap should receive a single dose of Tdap instead of Td for booster immunization Adults Ages 19 through 64: One dose of Tdap vaccine is recommended in place of the next booster of Td. Tdap is recommended for adults having close contact with infants less than 12 months of age, providing the interval of the most recent Td was two years or more. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth. If you think your child Symptoms has Pertussis: Your child may first have a runny nose, sneezing, mild cough, and possibly fever. Childcare and School: If your child has been infected, it may take 5 to 21 days (usually 7 to 10 days) for symptoms to start. If staff or children are not Contagious Period treated, they need to stay From the time of the first cold-like symptoms until 21 home until 21 days after days after coughing begin. Call your Healthcare Provider If someone in your home has: ♦ had a cough 7 or more days. Antibiotics will reduce the contagious period, but may do little to relieve your child’s cough. Also, if public health has recommended that antibiotics are needed because of an exposure. Age appropriate pertussis vaccine should be administered in the absence of documented laboratory confirmed disease.

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The so-called “talk test” (exercising at Evidence of the health benefts of physical activity is long- an intensity that permits simple conversation with an exercis- standing purchase cefixime 100mg without prescription bacteria on the tongue, incontrovertible and ever-increasing buy 200mg cefixime otc antibiotics for acne bacteria. Regular par- ing partner or friend) is a remarkably accurate indicator of a ticipation in physical activity greatly decreases the likelihood level of activity that optimizes cardio-respiratory function and of chronic disease and premature mortality discount cefixime 200 mg fast delivery antimicrobial vinyl flooring. How does the busy practitioner despite this knowledge cefixime 200mg without prescription antibiotics for sinus infection contagious, physicians appear to be no more active protect suffcient time for physical exercise? And, sadly, although medical integrate physical activity into one’s personal and professional students are typically active on a regular basis, it is too often the lifestyle? How do we normalize such activity within the profes- case that as they embark upon their careers they give less time sional community? Activities that are te- likelihood that regular physical activity will be part of a physi- dious, uncomfortable or intimidating are not likely to form the cian’s lifestyle. At the same time, many medical practitioners basis of a lifetime of healthy physical activity. Find something bring to exercise the same achievement-oriented, goal-driven you enjoy and look forward to the release it offers from the approach that is in part responsible for their success as stu- pressures of a busy professional life. However, while an athletic model of physical activity may be motivating and rewarding for some, it Feasible. It is reassuring to know that the health ized facilities or signifcant travel are diffcult to integrate into benefts of physical activity accrue with as little as thirty min- daily life. A lunchtime walk, an evening jog, or a regular swim utes of moderate-intensity exercise most days of the week. Biking to work and taking the stairs whenever pos- important, health-enhancing properties of an active lifestyle. Physical activity that frequently involves family and friends has a further motivation built in. Encouraging Case resolution the whole family to engage in regular physical activity can allow Deciding to make one’s personal health a priority is an you to pass on your exercise “values” to your children, opti- important step in making time for physical activity. Skiing, biking, sledding, will always be rounds to attend and journals to read, and hiking—he choices are limitless. Establishing time, recognizing the realities of an on-call schedule, favourite physical activities early in a career helps to ensure and discussing these issues with resident colleagues, this that enjoyable, anticipated and active periods will be integrated resident is able to incorporate regular physical activity into into weekly rhythms for the long term. The resident no longer takes elevators unless of exercise intensity will help prevent injury and increase the absolutely necessary (there’s a “Stairway to Health” pro- likelihood of enjoyable physical recreation over a lifetime. As benefts to physical health, physical activity allows private, chief resident, they also encourage younger colleagues to personal time for refection and recreation. Family vacations for physicians to integrate physical activity into their personal are now chosen with physical activities in mind: camping lifestyles in ways that are both practical and, most importantly, and canoeing in the summer. By demonstrating to friends and colleagues that physi- Key references cal activity is important to one’s well-being, the resident Frank E, Breyan J, Elon L. Physician disclosure of ensures understanding and support as they optimize time healthy personal behaviors improves credibility and ability to for personal health. Physical inactiv- portive advice on the importance of personal health and ity among physicians. The resident’s bicycle helmet serves as a reminder to colleagues, hospital and attending staff that personal health and physical activity are important, central components of a contemporary practitioner’s lifestyle. The resident’s example and leadership result in the hospital providing bike racks and shower facilities for staff. And it is a • introduce a model of considering the role of spirituality in practice that requires ongoing self-refection and attention. We tend to forget to care Case for ourselves when we are single-mindedly committed to the A frst-year resident is feeling disillusioned with medicine. Compassion that does not include The resident entered medicine because their father died oneself is incomplete. Now feeling frustrated by the inevitable deaths of too many of Burnout is distressingly common in medicine, as in other their patients the resident is thinking of taking a year off occupations where time is spent supporting others. The what might be regarded as a spiritual illness: if engagement wisdom and compassion that this engenders does not make us with one’s life is a sign of spiritual health, burnout is the oppo- more expert; it makes us more human. Physicians who were once wholeheartedly committed to to do; spirituality, how to be. As physicians, we can beneft from medicine begin to avoid work, become less interested in their practising both. Courses on spirituality have begun to appear in medical school Not surprisingly, burnout can lead to depression, addiction and curricula. Spirituality is primar- ideals, long hours, tensions between personal and work obliga- ily an inner, subjective matter, whereas Western medicine is tions, and historical insensitivity of the medical profession to based on objective, empirical science. Whether or not spiritual the health of its members all contribute to the psychological matters belong in our medical curricula, surveys suggest that and emotional vulnerability of physicians. This vulnerability most medical practitioners do consider spiritual questions is intensifed in residency by the lack of a sense of personal and values personally relevant. Given that burnout is an principle central to all spiritual traditions, is embedded in the occupational risk for physicians, how can they lessen it? Interestingly, there is now some important way is to develop spiritual resilience. Perhaps Immunizing ourselves against the inevitable stresses of our this is because the scientifc and pragmatic knowledge acquired profession requires us to regularly nourish the spirit. One during training, together with the stresses of medical training, essential means of doing this is to deepen self-awareness by result in an “objectifcation” of patients which may make us consciously paying attention to our own selves. Diet, exercise, to say, caring as empathetic concern is gradually replaced by relationships, study, play, work—these all need to be integrated caring as a means to an end: freedom from disease. But who decides on the relative weight two aspects of caring, the spiritual and the material, are not we place on each aspect of this whole, and how do we know mutually exclusive. From the spiritual perspective, one could say that caring is Balance doesn’t derive from a checklist, nor can it be con- not so much a means to an end as an end in itself. It comes from connecting is fundamentally about a sense of connection to someone with ourselves and nurturing a sense of groundedness. Perhaps we are feeling completely frustrated From a spiritual perspective, openness to life in all of its expres- with the cardiac patient we’ve been called to see for the fourth sions, painful or otherwise, is the path. Perhaps we’d rather ignore the pager altogether, or controlling every outcome, or curing every disease, lie many unload on the clerk who keeps paging us. Instead, just stop- spiritual opportunities: to be touched by the unspeakable raw- ping for a few moments and letting ourselves honestly feel our ness of a mother’s grief over her lost child; to be humbled by frustration and fatigue may be what we really need. We may prefer to avoid or ignore such experiences when they arise and run off When we notice diffcult feelings and still accept ourselves, to write our notes in the chart. Yet, medicine is a challenging without self-criticism or denial, we are developing compassion profession in large part because it directly exposes us to the en- for ourselves.

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