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Individuals with chronic health concerns also reported that their medical decisions are more frequently affected by information found online order 40mg celexa schedule 8 medicines. Fox and Jones (2009) reported on a 2008 Pew Research Center study related to patient autonomy in seeking health information from various sources purchase 40 mg celexa medicine while pregnant. The study found that 61% of adults use the Internet to search for health information celexa 40 mg lowest price symptoms jaw cancer, and over half of online health queries are made on behalf of someone other than the Internet user buy generic celexa pills silent treatment. Therefore, in order to establish effective doctor-patient relationships, physicians need to take patient autonomy and outside sources into consideration. In addition to consulting professionals, a majority of adults consult friends or family members, books, and other reference material for medical assistance. Significant percentages of those interviewed claimed that information found online affected health-related decisions they made for themselves or someone in their care (Fox & Jones, 2009). These results underscore the importance of online information for individuals with chronic illness, suggesting that doctors treating such patients should be particularly aware of and sensitive to patient autonomy and knowledge. As noted above, traditional doctor-patient relationships have tended to marginalize women by virtue of social perceptions of the female role. In addition to 49 being placed in a position of inferiority due to doctors’ medical expertise, female patients in the care of male physicians may conform to traditional, submissive feminine roles (Chrisler, 2001). This undermines female patients’ autonomy and makes doctor-patient collaboration unlikely. Thus, it is important for women to feel that their feminine status does not affect the quality of the care they receive. Despite theoretical and empirical evidence that a more collaborative, less doctor- centered model of healthcare promotes positive healthcare outcomes (Houle et al. Factors that contribute to the persistence of the traditional model include sexism in healthcare, the medical education system, economics, the culture of the medical profession, and women’s communication patterns. Sexism in Health Care Abundant research and theoretical literature indicates that sexism exists in the medical profession and results in a number of problems, including under-treatment and misdiagnosis of women’s medical issues. According to Secker (1999), male-dominated philosophical, theological, literary, and scientific traditions have characterized women (as opposed to men) as emotional, irrational, pathological, unintelligent, incompetent, dishonest, passive, and childlike (p. Applying these traditions in the medical profession has resulted in a diagnostic bias whereby women’s health complaints tend to be viewed as psychosomatic in origin (Hamberg et al. According to Cheney and Ashcraft (2007), in the medical profession, there is “a tendency to privilege the rational over the emotional” (p. Empirical research supports these theoretical arguments, indicating that physicians tend to interpret men’s symptoms as biological and women’s as psychosomatic (Hamberg et al. When women report pain, they are less likely than are men to be taken seriously and less likely to receive adequate treatment (Miaskowski, 1999). Additionally, research has shown that, for patients with diffuse symptoms, doctors give advice regarding lifestyle more often to women than they do to men, and that they prescribe sedatives more often to women than to men (Hamberg et al. The same study indicated that male physicians prescribe sedatives to women more often than female physicians do, indicating that traditional gender roles continue to play a part in doctor-patient relationships. Munch (2004) performed a meta-analysis of the literature on physicians’ diagnosing of women’s medical complaints. The analysis revealed that physicians tend to misdiagnose women’s complaints as psychosomatic or non-serious due to gender bias. This is particularly true in cases when the physiological cause of the condition is unknown. Munch’s analysis also revealed that doctors are less aggressive in treating 51 coronary disease in women than in men, and that hospitalized women receive fewer therapeutic and diagnostic procedures than men. In a study of patients with chest pain, Elderkin-Thompson and Waitzkin (1999) found that men were more likely than women to be admitted to the hospital. However, women who were not hospitalized were less likely to have received a stress test at follow-up. This could indicate that the nature of sexism in healthcare requires women to prove that their complaints are as valid as those of their male counterparts. The necessity for women to prove the validity of their complaints is particularly striking in light of evidence reported by Addis and Mahalik (2003) indicating that, compared to women, men are less likely to seek care for nearly all mental and physical health problems. The authors noted that traditional masculine gender socialization plays a role in discouraging men from seeking treatment. According to the social constructionist perspective, men are traditionally constructed as better able to cope physically and emotionally with health problems than women. In the past decade, significant progress has been made in the understanding of sex differences in health and illness (Verdonk, 2009). In 2004, the American Heart Association published evidence-based guidelines for the prevention of heart disease in women. Nevertheless, gender bias in the diagnosis and treatment of illness remains 52 ingrained in the medical field as a result of the biomedical focus in medical training (Celik, Lagro-Janssen, van der Weijden, & Widdershoven, 2009). The authors suggested that in order to successfully address the problem of gender bias in medicine, gender sensitive issues should become a fundamental part of medical education. Medical Education The biomedical focus in medical training contributes to the perpetuation of traditional doctor-patient relationships (Celik et al. In the Western medical profession, health-care practitioners are taught that diagnostic and treatment decisions should be based on objective evidence of disease, such as blood tests (Hoffmann & Tarzian, 2001). This system encourages practitioners to disregard patients’ subjective illness experiences, making them unlikely to treat patients as equals in a collaborative relationship (Hoffmann & Tarzian, 2001; McGuire et al. Patients’ preferences, concerns, and emotions are likewise not taken into account (Haidet et al. Dyche (2007) asserted that although interpersonal communication skills are recognized as important by some educators, they have received much less attention than task oriented, verbal aspects of communication. During the first two years of medical school, courses in communication typically utilize actors who are trained to act like patients. However, during the third and fourth years of medical school when students have contact with real patients, the focus of 53 training shifts from communication skills to diagnostic skills and patient management (Levinson, Lesser, & Epstein, 2010). Various medical societies have recognized that effective doctor-patient collaboration requires relational versatility, or the ability of doctors to match their interpersonal approach to the communication needs of their patients (Houle et al. Research into how people categorize other people into groups (social categorization theory) has indicated that practicing physicians and medical students tend to categorize patients as an “out group,” or similar to one another, but different from medical professionals (with whom doctors consider themselves as an “in group”). However, in a study by Clucas (2011), doctors who received communication skills training viewed patients at an “intergroup” level, or dissimilar to one another and medical professionals. In other words, doctors who received communication skills training viewed their patients in a more personal manner. Personalization of care, in turn, leads to collaboration, greater patient satisfaction and adherence to treatment, and fewer malpractice lawsuits (Clucas, 2011; Firth-Cozens, 2008b). Garden (2008) and Halpern (2007) have stressed the importance of empathy and humility in medical training related to doctor-patient relationships. However, 54 emotionally engaged physicians communicate more effectively, suggesting a need for increased training in empathy and emotion. This suggests that the structure of medical education encourages the development of these attitudes even when they did not previously exist. Garden (2008) hypothesized that factors contributing to this issue include long work hours and sleep deprivation among medical students, as well as stress and burnout in medical professionals.

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Be certain to protect the patient from fainting and falling during the assessment of postural vital signs to prevent injury discount celexa 20 mg with amex treatment of shingles. After having the patient lie flat on his back for one minute generic celexa 10 mg with amex symptoms to pregnancy, measure the blood pressure and pulse in that position order celexa now medicine used for uti. Next buy celexa on line amex treatment room, have the patient sit up to a 90-degree angle with the legs hanging down in a dependent position. Finally, have the patient stand upright in a vertical position and after waiting one minute again, obtain the blood pressure and pulse in the changed position. Postural vital signs change (from lying to sitting or standing) that result in a decreased systolic blood pressure of 20 mm Hg or more, or an increased pulse rate of 20 beats/minute. The patient may experience weakness, dizziness, visual disturbance or even fainting during the test. These symptoms are usually eliminated by having the patient lie down again and by rehydration. Such a response to changes in position should be considered a symptomatically positive test. Treatment of Dehydration Once a patient has become dehydrated the two available routes of fluid replacement are oral and intravenous. There are objectives of treatment: Rehydration and prevention of further dehydration Specific treatment of the underlying cause Symptomatic treatment to decrease discomfort Oral replacement should attempt to replace both fluids and electrolytes lost in the dehydration process. Sodium and glucose transport are coupled in the small intestines because the presence of glucose stimulates the intestinal absorption of water and solutes. A reasonable approximation of this can be made by adding 1 ½ tablespoons of sugar, ½ teaspoon of table salt, 3/4 teaspoon of baking soda and 1/4 teaspoon of salt substitute to a liter or quart of water. The resulting solution can be seasoned to taste by adding lemon juice, punch concentrate or dissolved flavored gelatin mix. Starting with starchy water in which rice, potatoes or pasta have been boiled adds sugar polymers to the electrolyte solution to speed the absorption of water and solutes. Rehydration fluids are to be given to the otherwise healthy patient until: the patient can maintain normal urine output levels of 50-100 ml/hour for an adult. Oral maintenance solutions are similar to rehydration solutions, but the amount of sodium chloride can be cut in half. Mixed with crushed ice to form a slushy drink, this solution will replace fluid and electrolyte losses if taken in good quantity by people working in hot environments. This same maintenance solution can be used after rehydrating a patient to avoid further depletion of fluid and solutes. If possible, the underlying cause of fluid and electrolyte loss should be identified and treated. Diarrhea with blood or white blood cells in it may require specific antibiotic therapy. Fluid replacement by itself will greatly reduce the discomfort level for the patient and relieve the dizziness experienced when standing. Early communication with medical specialists ashore is critical in taking care of a markedly dehydrated patient at sea. Also, have current vital signs including postural measures of pulse and blood pressure in lying, sitting and standing positions. The on shore medical consultant will also want to know about current symptoms and response to treatment provided. If possible, measure and record urine output and be prepared to provide information on how much urine the patient is producing per hour. With awareness of the serious nature of dehydration and early recognition, treatment and rehydration can frequently be conducted without need of highly sophisticated medical care facilities. The sea-goer must dress appropriately for the conditions, be vigilant and respond to changing weather and seas. This includes outfitting the vessel with all recommended safety gear and appropriately using it, a 1-16 complete first aid kit including blankets, knowing how to get medical assistance, eating nutritious foods, drinking adequate non-dehydrating fluids, avoiding alcohol and minimizing caffeine, and maintaining good overall health. The conversion between Fahrenheit and Centigrade is: °C = 5/9 (°F - 32) and °F = 9/5°C + 32. However, every person is different and there is a range within which the temperature may still be considered normal. The superficial zone is the temperature of the skin and is influenced by the air temperature. When assessing an individual’s temperature that is either rising or falling to dangerous levels, one should rely strictly on the core temperature. In addition to exposure to the elements, some causes of hypothermia or hyperthermia are endocrine conditions, such as abnormalities of the thyroid gland; brain lesions such as tumors, or strokes; spinal cord injuries; alcohol consumption; infection; drugs; anesthesia; and inadequate fluid or nutrition. Survival depends upon the body’s core temperature, the length of time the sea-goer remains in the abnormal state of temperature regulation, how the body responds, and treatment interventions. As body temperatures rise or fall to dangerous levels, medical assistance should be sought and the advice thoroughly followed. It is a serious condition and can endanger the life of a person, if left untreated. People at sea can become hypothermic when they get wet and cold, and when they are in cool or windy places without proper clothing or protection. The elderly and those individuals who are intoxicated may not demonstrate symptoms or signs reliably. Keeping this exception in mind, the stages are as follows: o o o o The first stage is mild hypothermia (32. Common signs and symptoms will include uncontrolled shivering mental changes, poor judgment, confusion, poor coordination, difficulty walking, clumsy use of hands, difficulty talking, and drowsiness. Common signs and symptoms include irregular heart beat, a slowed heart beat (about ½ of normal) and metabolism (about ½ of normal). Pupils frequently do not react to light, shivering stops, and probable loss of consciousness may follow. Common signs and symptoms in this stage include the absence of reflexes, breathing may cease and the heart may stop. At these temperatures, there are documented cases of survival, even with no heart beat or breathing. It is important to remember that a cold or hypothermic patient should not be pronounced dead until they have been warmed. If no low reading thermometer is available, it is wise to consider the patient to be in severe hypothermia if the following signs and symptoms are present: no shivering in spite of being very cold mental changes such as drowsiness, confusion or unconsciousness abnormal coordination, trouble walking or using the hands, and difficulty talking. The skin will feel cold, the body stiff, and a severe illness or injury that may have contributed to the low body temperature may be present. Treatment: It is important to treat the hypothermic patient very gently to prevent abnormal heart rhythms. Do not begin chest compressions if the patient has any heart beat or pulse, even if it is very slow. Dry the patient and replace with dry warm coverings over and under the patient and around the head. The degree of exposure to cold and the length of time will be helpful information.

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A figure about 27 per cent higher Europe purchase celexa in united states online medications emts can administer, North Africa and the Near and Middle than in 1998 celexa 10 mg with visa treatment uterine cancer, this reflects the growth in the global popu- East remain the main markets for cannabis resin lation over the period 1998-2014 buy celexa online now symptoms 8 days post 5 day transfer. Given the large margin of error buy 20mg celexa free shipping medicine to stop diarrhea, caution needs to be applied when considering this The subregion in which the largest amount of cannabis figure; however, analysis of the perception of changes in resin was seized in 2014 was again Western and Central use, as reported by Member States, shows a similar pat- Europe, accounting for 40 per cent of the global seizures tern, indicating that the use of cannabis increased until of cannabis resin (Spain alone accounted for 26 per cent 2009, only to grow less rapidly thereafter. The proportion of global quantities of seized following a twofold increase from the early 1990s onwards, cannabis resin accounted for by Europe declined from 77 a temporary decline in cannabis use was seen after 2009, per cent of the world total in 1998 to 48 per cent in 2009 until cannabis use increased again in 2013 and 2014, and 43 per cent in 2014, which reflects the decrease in the returning to the level reported in 2009. In the 250 1,000 Near East, cannabis resin produced in Lebanon is used to 800 supply other markets in the subregion. For more details of perception indices, see the online methodol- Other subregions ogy section of the present report. Near and Middle East North Africa Eastern and South-Eastern Europe 174 The Eurobarometer survey also shows a slight increase in the use of cannabis between 2011 and 2014 among young people in the Euro- Western and Central Europe pean Union (past-month use increased from 6. In order to develop and enforce regulations for the legal cannabis industry, each state has appointed a regulatory agency. The resulting regulatory details vary United States: prevalence among the populaton aged 12 and older depending on the jurisdiction, including limits on the European Union: prevalence among the quantities that can be possessed or purchased, and market populaton aged 15-64 structure (for the regulatory details in each jurisdiction, Australia: prevalence among the populaton see table on page xxv in the annex of the present report). Uruguay Uruguay announced in mid-2012 that it would permit is still significantly less prevalent in that country now than the production and distribution of cannabis for recre- in the late 1970s. Increased cannabis use has also been ational use by adult residents (persons aged 18 and older). In the past four years, four jurisdictions in the United States and Uruguay have passed laws to allow the production, The circumstances of legalization in Uruguay were quite distribution and sale of cannabis for non-medical purposes different from the developments in the United States in (i. Boidi and others, “Marijuana legalization in Uruguay and beyond” (Miami, United States, Florida International University, While each of the jurisdictions legalizing cannabis had Latin American and Caribbean Centre, Latin American Marijuana previously approved medical cannabis laws, only Colo- Research Initiative, 2015). Pacula and others, “Assessing the effects of medical mari- 182 Uruguay, Junta Nacional de Drogas, “Regulación controlada del juana laws on marijuana use: the devil is in the details”, Journal of mercado de marihuana: una alternativa al control penal y a la crimi- Policy Analysis and Management, vol. Individuals are allowed to access only United States, including selected areas, one mode of supply, which they must declare upon regis- and Uruguay, 2000-2014 tering with the cannabis registry. In October 2015, only two private firms were issued 10 10 licences to cultivate cannabis, and to date no cannabis has been sold in pharmacies. Officials estimate that cannabis from the first harvest will not be ready for sale until mid- 5 5 2016. By February 2016, about 4,300 people had regis- tered to grow cannabis at home, and 21 cannabis clubs had been licensed. Recent surveys reveal that 40 per cent 0 0 of the cannabis users in the country are hesitant to register with the system to obtain cannabis,183 while the rest have indicated that they intend to register and obtain the drug through pharmacies. Some may play out in the longer term, especially as the regulations evolve and the Source: United States, Department of Health and Human Services, markets mature. Currently, the best data on the among young adults in the United States, outcomes of cannabis legalization come from Colorado including selected areas, 2000-2014 and Washington, the states that adopted cannabis legislation early. That cannot be said of the other 35 jurisdictions in the United States (Alaska, Oregon and 30 Washington, D. However, in the jurisdictions that 0 legalized recreational cannabis, where the prevalence of past-month cannabis use has historically been higher, past- month prevalence increased more rapidly than past-month Alaska (persons aged 18-25) prevalence at the national level during this period. Cruz, “Marijuana consumption patterns among frequent consumers in Montevi- Oregon (persons aged 18-25) deo”, paper presented at the ninth Conference of the International Washington (persons aged 18-25) Society for the Study of Drug Policy, Ghent, Belgium, 19-22 May 2015. Available at http:// Source: United States, Department of Health and Human Services, esiglesia. Further- young adults (persons aged 18-25), which is more pro- more, monthly medical cannabis sales have not exhibited nounced in Colorado, where the prevalence of past-month a downward trend in the two years since legalization. In Uruguay, the prevalence of can- ical cannabis identification cards, the impact of legalization nabis use is much lower, but household surveys suggest on the medical cannabis market may take much longer to that there was an increasing trend even before the legal- become apparent in jurisdictions with both medical and ization of cannabis use. In Colorado, and currently in Oregon, cannabis stores have been allowed to operate simultaneously as recre- Medical cannabis markets after legalization in ational and medical cannabis stores, but in the long run the United States it is unclear whether those systems will be separate or inter- twined or whether one system will fold into the other, as It is unclear whether the legalization of cannabis for rec- in the State of Washington. The original purpose of med- Products and potency ical cannabis laws was to provide access to cannabis for those with a qualifying medical need. Since the legalization Cannabis potency in the United States has been increasing of recreational cannabis use, individuals can now obtain over the past three decades, particularly in jurisdictions that have allowed medical dispensaries. However, the recreational cannabis markets in most jurisdictions are currently higher priced recreational cannabis herb sold in the states of Washington (after taxes) and often have fewer retail outlets than the and Colorado is nearly 17 per cent, with some samples existing medical cannabis market. Data on cannabis potency are ifying patients, the introduction of regulated recreational scarce in Uruguay, as authorities in that country only recently began to analyse seized cannabis,188 but the Gov- cannabis markets may not present an additional incentive to forego the benefits of their medical status. Accord- After the legalization of the non-medical use of cannabis, ing to the authorities, this limit has been set with a view the number of patients in Colorado’s mandatory medical to reducing health risks caused by cannabis use. In 2014, such products accounted for an estimated 35,000,00035,000,00035,000,000 114,000 114,000 35,000,000 114,000 35 per cent of retail sales of recreational cannabis in Col- 30,000,00030,000,00030,000,000 114,000 30,000,000 112,000 112,000112,000 orado. Pacula and Paul Heaton, “The effects of medical marijuana laws on potency”, International Journal of Drug Policy, vol. Source: Colorado Department of Public Health and Environment and Colorado Department of Revenue. Saloga, “The effect of legalized retail marijuana on the dosage: an assessment of physical and pharmacokinetic relationships demand for medical marijuana in Colorado”, paper prepared for the in marijuana production and consumption in Colorado” (Boulder, ninth Conference of the International Society for the Study of Drug Colorado, Marijuana Policy Group, University of Colorado Boul- Policy, Ghent, Belgium, 19-22 May 2015. Legalization of the use of recreational cannabis may have also increased the number of accidents or injuries Public safety associated with cannabis use or intoxication. In 2014, The increased availability of cannabis for recreational use is likely to increase the number of users driving while 190 Mark A. Kleiman, “Legal commercial cannabis sales in Colorado and Washington: what can we learn? Mello, “Half-baked: the retail lateral control with and without alcohol”, Drug and Alcohol Depend- promotion of marijuana edibles”, New England Journal of Medicine, ence, vol. However, this may have oped a unique tax scheme for legal cannabis (see table on resulted from increased law enforcement scrutiny. The recrea- tional cannabis markets in Colorado and Washington have Cannabis markets grown considerably since such schemes were put in place. In Colorado, recreational cannabis market profits reached Despite the legalization of recreational cannabis use, the nearly $600 million in 2015, compared with $313 million illicit cannabis market has not been entirely displaced in in 2014. The state collected $56 million in recreational the states of Colorado and Washington. In Washington, cannabis tax revenues in 2014 and over $114 million in the medical, recreational and illicit cannabis markets each 2015. While these figures are large, they represent only a accounts for approximately one third of the state’s canna- very small portion of the state’s total revenues, which bis sales,200 while in Colorado the illicit cannabis market totalled nearly $11 billion in the fiscal year 2014. Smith, Washington State Liquor and Cannabis Board, “Data on supply, higher taxation and regulatory burden. Addi- In Oregon, data on initial sales or tax revenues are not yet tional revenues are distributed primarily to the Marijuana available, although the Oregon Liquor Control Commis- Enforcement Division and to public health programmes sion has indicated that recreational cannabis sales tax rev- such as substance abuse intervention and prevention pro- enue after regulatory costs will be distributed as follows: grammes and educational campaigns. Just the Oregon Health Authority for alcohol and drug use eight months into the fiscal year 2016, sales have already prevention. Wash- ington collected $65 million in tax receipts in the fiscal In Uruguay, taxation on cannabis sale has been deferred, year 2015 (accounting for 0.