Avana

Andrew R. Banker, DDS, MD

• Assistant Professor
• Department of Oral and Maxillofacial Surgery
• Louisiana State University Health Sciences Center
• Shreveport, Louisiana

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I E C t g du c a t c t i ty N N i v y doctor for erectile dysfunction philippines purchase avana 100 mg without prescription, I y c v/ I U str ct s R e r i v yo 4 o l y. Upper respira diagnosed after 11 September 2001 among tory symptoms and other health effects among rescue and recovery workers: findings from the residents living near the World Trade Center site World Trade Center Health Registry. Characterization and bronchial responsiveness in firefighters at the of the dust/smoke aerosol that settled east of the World Trade Center site. Environmental Medicine: Surveillance for World Trade Center disaster Integrating a Missing Element Into Medical health effects among survivors of collapsed and Education. A national survey of stress reactions after Respiratory symptoms & physiologic assessment the September 11, 2001 terrorist attacks. Nationwide longitudinal study of the Health Consequences of Smoking: A Report of psychological responses to September 11. Vlahov, D, Galea S, Ahern J, Resnick H, Kilpatrick exposed to World Trade Center dust. Distal airway function in symptomatic subjects stress disorder and other psychological sequelae with normal spirometry following World Trade among World Trade Center clean up and recovery Center dust exposure. Rhinosinusitis: Establishing definitions for clinical Psychological resilience after disaster: New York research and patient care. Nocturnal the aftermath of 9/11: effect of intensity and gastric acidity and acid breakthrough on different recency of trauma on outcome. Exercise treatment for depression: the effects of psychological trauma on drinking efficacy and dose response. For example, there has been an emphasis on new content developed assessing competencies related to geriatric medicine, and prescription drug use and abuse. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Similarly, special acknowledgement is due to Dr Raymond Boudet-Dalbin of the Labora toire de Chimie Therapeutique, University of Paris, France, for drawing the chemical structures. Sincere appreciation is extended to the Nippon Foundation, Japan, which provided funds for the development and publication of this volume. For example, between 1999 and 2001, herbal medicines sales increased by 22% in the Czech Republic, doubled in Turkmenistan, and increased by 170% in Bulgaria. Eu ropean countries are not just importers, but also producers of a large va riety of medicinal plants and herbal medicines. Difficult economic conditions often limit access to the rather expensive conventional medicines that are available, with the result that they seek out less expensive alternative medicines such as herbal products. Many European Union countries already have well-established na tional policies and programmes for regulating and monitoring herbal medicines. However, they often lack technical expertise, skills and knowledge in this area, as well as resources for conducting research and establishing national standards and quality assurance measures for medicinal plants and herbal medicines. Each monograph follows a standard format, with information presented in two parts, followed by a reference list. The rst part presents pharmacopoeial summaries for quality assurance, while the second part includes sections on medicinal uses, pharmacology, safety issues and dos age forms. Use of the monographs the monographs may serve as an authoritative source of information for national drug regulatory authorities, since they have been fully involved in the development of the monographs. They merely represent the systematic collection of scienti c information available at the time of preparation, for the purpose of information exchange. The De nition provides the Latin binomial name, the most impor tant criterion in quality assurance. Latin binomial synonyms and ver nacular names, listed in Synonyms and Selected vernacular names re spectively, are names used in commerce or by local consumers. The monographs place outdated botanical nomenclature in the synonyms category, based on the International Code of Botanical Nomenclature. The vernacular names comprise an alphabetical list of selected names from individual countries worldwide, in particular from areas where the medicinal plant is in common use. They refer to the medicinal plant it self not the medicinal plant part, which is identical to the monograph name. While every effort has been made to delete names referring to the medicinal plant part, the relevant section of each monograph may still include these. Geographical distribution is not normally found in official compendia, but is included here to provide additional quality assurance information. The detailed botanical description under Description is intended for qual 5 General technical notices ity assurance at the stages of production and collection; the description of the crude drug material under Plant material of interest is for the same purpose at the manufacturing and commerce stages. General identity tests, Purity tests and Chemical assays are all normal compendial components included under those headings in these mono graphs. Where purity tests do not specify accepted limits, those limits should be set in accordance with national requirements by the appropri ate authorities of Member States. Each medicinal plant and the speci c plant part used as crude drug material contain active or major chemical constituents with a character istic pro le that can be used for chemical quality control and quality assurance. They merely represent the systematic collection of scienti c information available at the time of preparation, for information exchange. The rst category, Uses supported by clinical data, includes medical indications that are well established in some countries and have been vali dated by clinical studies documented in the scienti c literature. Clinical trials may be controlled, randomized, double-blind studies, open trials, cohort studies or well documented observations on therapeutic applica tions. The second category, Uses described in pharmacopoeias and well estab lished documents, includes medicinal uses that are well established in many countries and are included in official pharmacopoeias or govern mental monographs. Uses having a pharmacologically plausible basis are also included, as well as information resulting from clinical studies that clearly need to be repeated because of con icting results. The third category, Uses described in traditional medicine, refers to indications described in unofficial pharmacopoeias and other literature, and to traditional uses. Their appropriateness could not be assessed, be cause sufficient data to support the claims could not be found in the lit erature. Other published experimental data that are not associated with the medicinal uses have not been included, to avoid confusion. The details included in the References have been checked against the original sources wherever possible. For references in languages other than English, except for those in Chinese and Japanese, the title is given in the original language, except in cases where an English summary is available. The underground portion consists of a compound bulb with numerous brous rootlets; the bulb gives rise above ground to a number of narrow, keeled, grasslike leaves. In orescences are umbellate; scape smooth, round, solid, and coiled at rst, subtended by membraneous, long-beaked spathe, splitting on one side and remaining attached to umbel. Small bulbils are produced in in orescences; owers are variable in number and some times absent, seldom open and may wither in bud. Plant material of interest: fresh or dried bulbs General appearance Bulbus Allii Sativi consists of several outer layers of thin sheathing pro tective leaves which surround an inner sheath. Organoleptic properties Odour strong, characteristic alliaceous (1, 6, 8); taste very persistently pungent and acrid (1, 6, 8). Dry scales consist of 2 or 3 layers of rectangular cells having end walls with a broadly angular slant. The upper epidermal cells next to the dry scale layer consist of a single layer of rectangular to cubical cells next to which are several layers of large parenchymatous cells. Among these cells are interspaced many vascular bundles, each of which consists of xylem and phloem arranged alternately. Lower epidermis consists of cubical cells which are much smaller than the upper epidermal cells. The same arrange ment of tissues is met within different bulblets, 2 or 3 of which are ar ranged concentrically (1, 6). Powdered plant material Pale buff to greyish or purplish white, with characteristic aromatic allia ceous odour and taste. It is characterized by the presence of sclereids of the epidermis of protective leaves, thin epidermis of storage cells, latex tubes, swollen parenchyma cells with granular contents, and ligni ed nar row spiral and annular vessels (1). General identity tests Macroscopic and microscopic examinations and microchemical analysis are used to identify organic sulfur compounds (1), thin-layer chromato graphic analysis to determine the presence of alliin (14). Normally, the maximum residue limit of aldrin and dieldrin for Bulbus Allii Sativi is not more than 0. Other purity tests Chemical tests and tests for foreign organic matter to be established in accordance with national requirements. Chemical assays Qualitative and quantitative assay for sulfur constituents (alliin, allicin etc. Major chemical constituents the most important chemical constituents reported from Bulbus Allii Sa tivi are the sulfur compounds (7, 9, 24, 25). Rather, they are degra dation products from the naturally occurring cysteine sulfoxide, alliin [1]. When the garlic bulb is crushed, minced, or otherwise processed, alliin is released from compartments and interacts with the enzyme alliinase in adjacent vacuoles. Hydrolysis and immediate condensation of the reac tive intermediate (allylsulfenic acid) forms allicin [2]. Allicin itself is an unstable product and will undergo additional reactions to form oth er derivatives. The content of alliin was also affected by processing treatment: whole garlic cloves (fresh) contained 0. On prolonged storage or during germination, these peptides are acted on by glutamyl transpeptidase to form thiosul nates (25). Alliin and allicin decom pose rapidly, and those products must be used promptly (18). Dried Bulbus Allii Sativi products should be stored in well-closed containers, protected from light, moisture, and elevated temperature. Uses described in folk medicine, not supported by experimental or clinical data As an aphrodisiac, antipyretic, diuretic, emmenagogue, expectorant, and sed ative, to treat asthma and bronchitis, and to promote hair growth (6, 9, 13). Pharmacology Experimental pharmacology Bulbus Allii Sativi has a broad range of antibacterial and antifungal activ ity (13). Its antimicrobial activity has been attributed to allicin, one of the active constituents of the drug (41). However, allicin is a relatively un stable and highly reactive compound (37, 42) and may not have antibacte rial activity in vivo. Ajoene and diallyl trisul de also have antibacterial and antifungal activities (43). Garlic has been used in the treatment of roundworm (Ascaris strongyloides) and hookworm (Ancylostoma cani num and Necator americanus) (44, 45). Allicin appears to be the active anthelminthic constituent, and diallyl disul de was not effective (46). Oral administration of allicin to rats during a 2-month period lowered serum and liver levels of total lipids, phospholipids, triglycerides, and total cholesterol (65). Total plasma lipids and cholesterol in rats were reduced after intraperitoneal 14 Bulbus Allii Sativi injection of a mixture of diallyl disul de and diallyl trisul de (66). Because both allicin and ajoene are converted to allyl mercaptan in the blood and never reach the liver to af fect cholesterol biosynthesis, this mechanism may not be applicable in vivo. In addition to allicin and ajoene, allyl mercaptan (50 mmol/l) and diallyl disul de (5 mmol/l) enhanced palmitate-induced inhibition of cholesterol biosynthesis in vitro (50). The drug appeared to decrease vascular re sistance by directly relaxing smooth muscle (74). The drug appears to change the physical state functions of the membrane potentials of vascu lar smooth muscle cells.

Some regions may experience little if any reduction in the length of the heating season erectile dysfunction doctor near me buy avana online from canada. Source: Federal Service for Hydrometeorology and Environmental Monitoring (Roshydromet) impotence because of diabetes order avana on line amex, Assessment Report on Climate Change and its Consequences in Russian Federation (Moscow erectile dysfunction venous leak treatment avana 100 mg overnight delivery, 2008) erectile dysfunction kits buy avana american express. In areas that experience this change impotence venous leakage ligation purchase avana uk, residents and workers may experience greater indoor comfort erectile dysfunction doctor in houston buy discount avana online, as heating systems and building envelopes will be better able to cope with the heating load. For those regions that do experience a reduction, the extent of the related energy savings is a matter of some debate, even in official Russian government projections. According to analysis presented in 2005 and 2008 by the Russian Federal Service on Hydrometeorology (Roshydromet), the reduction in heating days resulting from a warmer climate may not translate into saved fuel. Even if there are fewer total heating days, they may stretch out over the same period of the lxi lxii year or even longer because of increased temperature variability. According to the Fourth National Communication, the reduction in heating requirements by 2025 will result in a net fuel savings of 5-10 percent nationwide (and greenhouse gas emissions lxiii reduction of 2 percent). If the latter projection proves accurate, the saved fuel could provide a significant economic benefit, and potentially a significant balance-of-payments benefit, provided that the saved fuel was exported instead of being consumed domestically. Just as a changing climate is expected to affect energy demand in Russia, so too will it affect energy supply. On the supply side of the ledger, the changing climate may affect hydroelectric power production, electricity transmission and distribution systems, and petroleum production and transportation systems. Hydroelectric power production will realize some benefit, and some negative impacts, associated with the increase in flows of rivers that are used for hydroelectric production. As is true with the question of the length of the heating season, the net benefit or cost in 2020 remains ambiguous. Many of the major Russian rivers will experience increased water flows due to glacial melt and selective regional precipitation changes. For the most part, this change will offer opportunities for increased power production. According to Roshydromet, the Volga-Kamsk Cascade will experience a net increase of 10-20 percent in water flows. The reservoirs throughout the Northwest Federal District will experience a 5-10 percent increase, and the massive Siberian power dams along the Angarsk-Yenisey, Vilyu, Kolyma, and Zeya will experience increases ranging as high as 15 percent. In addition, certain hydro-electric reservoirs in the southern part of the country will experience reductions in productivity due to reduced water flow. Nonetheless, operating regimes for all power dams will require review in light of anticipated climate change, according to Roshydromet. In addition, there will be increased challenges related to managing head and tail waters in the face of increased flows, and particularly in relation to increased lxiv incidence of extreme downpours. Another energy supply-related impact from climate change to 2030 will relate to electricity transmission systems. One form of the heightened risk to power transmission will come from permafrost melt and the resulting creation of thermokarst and other unstable soil conditions. High voltage power lines will be one of the many kinds of structures that will be susceptible to damage as upper soil layers thaw and re-freeze. One particularly vulnerable transmission system will be the lines serving the Bilibino nuclear power plant on the Arctic coast and running from the town of Chersk to Pevek. Another heightened risk for power transmission systems will be increased wind load on power stanchions, as on other large structures. Power lines in the North Caucasus, as well as in the regions of Murmansk, Arkhangelsk, Leningrad, portions of Sakha (Yakutia), Irkutsk, Magadan, Khantiy-Mansiysk, and Evenkia will be exposed to 20 percent increases in wind force and may lxv need to be reconstructed or reinforced as a consequence. Climate change by 2030 appears unlikely to sufficiently affect the Russian electric power sector as to lead to significant national security implications for the Russians. However, major power system failures could lead to serious human hardship and could therefore conceivably fuel political dissatisfaction in Russia. If the hydropower and power transmission industries face challenges as climate change intensifies, even greater challenges face the petroleum industry, with likely greater significance for the Russian economy and state. Together they represent on the order of 60 percent of total exports and lxvi one-third or more of state revenues. Russia learned, starting in late 2008, that its economy was therefore at risk of significant volatility in case of a downturn in global energy prices, and diversifying the economy away from extractive industries is a stated goal of the Russian government. Many areas that are currently the focus of exploration and production activity will be more difficult to exploit. Pipeline and rail transportation systems that cross major rivers and permafrost will be subjected to unprecedented stresses and strains, many of which were not anticipated when initial design parameters were established. Critical new upstream development areas, such as the Yamal Peninsula, will be more complicated to reach by land and harder to develop in the face of thawing permafrost and shorter winter seasons. The Russian petroleum industry has traditionally centered in West Siberia and the Volga region, with transportation links extending to European portions of Russia and then to western and central European markets. At present, in addition to thousands of producing oil and gas wells, Russia has roughly 50,000 kilometers of oil pipelines and roughly 150,000 kilometers of gas pipelines, most of which were constructed in the 1980s under Soviet rule. The thousands of river crossings did not provide margins of error to accommodate the increased water flow that will result from climate change by 2030. They were not constructed using horizontal directional drilling techniques that allow deeper and more secure passage under riverbeds. In addition to climate-related risks for river crossings, oil and gas pipelines and other facilities are at risk in permafrost regions. In these areas, pipelines and other structures are typically constructed above ground to allow thermal insulation to avoid thawing the soil. In the period to 2030, however, these regions will experience deeper seasonal thawing, resulting in structural subsidence and weakened integrity of pipelines and other petroleum-industry installations. The permafrost zones are also exceptionally important for the future development of oil and especially gas production. Maintaining Russian gas exports is therefore a matter of highest national priority. New production is crucial for Gazprom to realize its production targets and satisfy both domestic requirements and export lxxi consumers in coming years. Three of the key areas that the Russians expect to produce new gas will keenly feel the effects of a changing climate by 2030. First, the Yamal peninsula is an Arctic region that is a vast wealth of untapped gas prospects. According to some Gazprom projections, it could account for as much as 200 billion cubic meters (bcm) of gas production per year lxxii by 2020, and 360 bcm per year by 2030. However, developing Yamal will be significantly complicated by a changing climate. Supplies that will need to be brought in by land will require the construction of new roads and rail links, which will be tricky with the growth of thermokarst. Previous techniques, like the use of seasonal ice roads will be more problematic due to the shorter cold season. New above-ground pipelines and other elevated installations will have to be constructed using deeper foundations to avoid structural damage from subsidence. Here, one massive new field called Shtokman is to be developed some 550 kilometers north of the Kola lxxiii Peninsula, with a projected annual production of around 90 bcm of gas. This hugely challenging technical undertaking, which will require the construction of ice-capable production platforms in more than 300 meters of water, is especially difficult because it is so far offshore that it is beyond the range of helicopters, yet it is vulnerable to seasonal pack ice and vicious storms. In the face of a rapidly changing Arctic climate, vessels traveling to Shtokman will have to navigate increasingly severe waters and endure bitter winter storms. A third key projected area for the Russian gas industry is Eastern Siberia and the Russian Far East. As mentioned above, the Russian gas industry has traditionally been oriented toward customers within Russia and in neighboring European countries. However, in the past decade, Gazprom and the Russian government have identified the goal of moving to the East and developing gas resources that can feed to the Pacific Rim. The official Eastern Gas Program released in lxxiv August 2007 projects total extraction of 100 bcm/year by 2030. Other prospects are being pursued as far west as the area to the north of Lake Baikal. All of these projects will require major new construction with countless major and minor river crossings and a significant number of permafrost operations. This development will therefore be vulnerable to the same kinds of challenges from climate impacts as have been discussed above. Food Production and Drinking Water Supply Russia will experience a mix of positive and negative impacts on food and water supply in the period to 2030. The net impacts in these important areas will depend heavily on the extent to which adaptation measures can be implemented in an affordable and timely manner, but doing so will be difficult. Experts project that Russia will experience an increase in total water supply in the period to 2030. According to Roshydromet, in the aggregate Russia will experience an 8-10 percent increase in water volume by 2015 the equivalent of a 12-14 percent increase per capita with these trends expected to continue in the years that follow. That said, different regions will experience significantly different changes in their respective water supply. The northern and northwestern portions of European Russia, as well as the central Volga, many of the non-Chernozem lands, the Urals, and the Russian Far East will experience increasing water availability. In the dams along the Volga Kamsk Cascade, water flows are projected to increase by 10-20 percent by 2015, as mentioned above. In the Northwest federal district, dams will see a 5-10 percent increase over the same period. And some of the key Siberian rivers systems the Angarsk Yenisey, the Vilyu, the Kolyma, and the Zeya will experience flow increases by up to lxxv 15 percent. On the other hand, many other parts of Russia will experience worsening water shortages, including densely populated industrial regions that are projected to experience increases lxxvi in water demand of 5-25 percent. In the Chernozem lands, these water-poor areas will include the Belgorod, Voronezh, Kursk, Lipetsk, Orel, and Tambov regions. In the south, Kalmykia, Krasnodar, Stavropol, and Rostov regions will face increasingly challenging lxxvii water situations, with reductions in water supply on the order of 5-15 percent. In southwestern Siberia, the list will include Altay, Kemerovo, Novosibirsk, Omsk, and Tomsk. Across a key southern belt, a whole host of Russian regions will face mounting, and serious, water problems. Included in this list will be both certain key agricultural lands (more on food supply below), and also a number of key industrial regions. Even the capital and the Moscow Oblastwill face particularly acute water supply lxxviii problems. Regarding food supply, the longstanding popular presumption in Russia has been that a warmer global climate would translate into a significantly more hospitable Russian environment for agricultural production. Indeed, there are several respects in which climate change by 2030 will reduce longstanding challenges for Russian agriculture. First and foremost, growing seasons have already become longer and are predicted to lxxix become longer still. Accompanying this change will be a reduction in the frequency of winter temperatures that are sufficiently bitter to damage winter plantings. More sensitive varieties of winter plantings will be possible in much of Russia by 2030, and it will be possible to plant lxxx existing varieties farther north than would have been the case in the past. For example, it will be possible to plant longer-ripening grains and late-ripening sugar beets lxxxi as far north as Moscow. Interestingly, the longer growing seasons will not be accompanied by an increased frost-free period except in the Northwestern, Central, and lxxxii Volga federal districts. Based on temperature ranges expected by 2030, it will also be possible to introduce entirely new crops that are not widely grown in Russia today. For example, the projected temperature of the north Caucasus and the lower Volga will be well suited to intensive agriculture for crops that are typically found in Central Asia and the south Caucasus at lxxxiii present crops such as cotton, grapes, tea, citrus, and other fruits and vegetables. A key question, however, is whether the longer growing seasons and the warmer Russian agricultural lands will result in increased yields. Warmer average temperatures will produce better grain yields in some parts of the country that have not traditionally served as the heartland for grain production. Regions such as the Northwest and Central federal districts and the Volga-Vyatsk region are expected to see a 10-15 percent increment in grain yields. Nationwide, according to lxxxiv Roshydromet, grain yields could shrink by more than 11 percent by 2020. Plant diseases and pests will become a more serious challenge in many parts of Russia. In the southern part of European Russia and in western Siberia, locusts are expected to be increasingly common.

Individual training programs have the authority to add any medication used locally by paramedic impotence and diabetes generic 200mg avana otc. Thiamine Page 88 of 385 Airway Management impotence age 45 buy cheap avana line, Respiration erectile dysfunction treatment doctors in bangalore discount avana amex, and Artificial Ventilation Airway Management Paramedic Education Standard Integrates complex knowledge of anatomy best herbal erectile dysfunction pills order avana line, physiology erectile dysfunction just before intercourse cheap 50mg avana, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of assuring a patent airway erectile dysfunction treatment austin tx purchase avana 50mg visa, adequate mechanical ventilation, and respiration for patients of all ages. Cell and tissue beds and disruptions of membrane integrity, enzyme systems and acid-base balance. Review of the physiologic differences between normal and positive pressure ventilation C. Paramedics should not enter a scene or approach a patient if the threat of violence exits. A variety of specialized protective equipment and gear is available for specialized situations. Based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any healthcare delivery setting c. Primary assessment: unstable Page 105 of 385 Patient Assessment History Taking Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. Chest pain a) Onset b) Duration c) Quality d) Provocation e) Palliation f) Palpitations g) Orthopnea h) Edema i) past cardiac evaluation and tests i. Requires use of knowledge of anatomy, physiology and pathophysiology to direct the questioning a. Results of questioning may allow you to think about associated problems and body systems c. Clinical reasoning requires integrating the history with the physical assessment findings 2. Test differential diagnosis list with questions and assessments relating to systems with similar types of signs and symptoms c. Patients may use this to collect their thoughts, remember details or decide whether or not they trust you b. Do not attempt to have the patient lower their voice or stop cursing; this may aggravate them H. Sensory issues (hearing and vision) may require paramedic to interview at eye level so patient can read lips 2. Activities of daily living Page 116 of 385 Patient Assessment Secondary Assessment Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. This includes developing a list of differential diagnoses through clinical reasoning to modify the assessment and formulate a treatment plan. Place special emphasis on areas suggested by the present illness and chief complaint 4. Maintain professionalism throughout the physical exam while displaying compassion towards your patient C. Female see Special Populations; Obstetrical and Medical Emergencies; Gynecological 2. Secondary trauma assessment order (see Trauma) Page 129 of 385 Patient Assessment Monitoring Devices Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. State regulatory processes may elect to expand, delete or modify from the monitor devices in this section Page 131 of 385 Patient Assessment Reassessment Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. May not be appropriate to perform a complete secondary assessment on all medical patients 2. Realize the differential diagnosis may change as the patient condition changes or additional information becomes available Page 136 of 385 Medicine Neurology Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Page 140 of 385 Medicine Abdominal and Gastrointestinal Disorders Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Specific Injuries/ illness: causes, assessment findings and management for each condition A. Introduction-Pathophysiology, incidence, risk factors, methods of transmission, complications 2. Pathophysiology, incidence, causes, risk factors, methods of transmission, complications for gastroenteritis caused by an infectious agent a. General assessment findings and symptoms for patients with gastroenteritis caused by an infectious agent 3. General management for a patient with gastroenteritis caused by an infectious agent 4. Pathophysiology, incidence, causes, risk factors, methods of transmission, complications for a patient with a drug resistant bacterial condition 2. Progressive worsening of neurologic signs is characteristic of rabies and should be considered as a positive indicator for rabies Page 158 of 385 7. Patient and family teaching regarding communicable or infectious diseases and their spread. Pathophysiology, causes, Incidence, morbidity, and mortality, assessment findings, management for endocrine conditions A. Pharmacodynamics of prescribed medications for behavioral/psychiatric disorders 1. Ejection - Initial, shorter, rapid ejection followed by longer phase of reduced ejection i. Typical sudden onset of discomfort, usually of brief duration, lasting three to five minutes, maybe 5 to 15 minutes; never 30 minutes to 2 hours b. Defined as impaired diastolic filling of the heart caused by increased intrapericardiac pressure B. Victims of blunt trauma in arrest whose presenting rhythm is asystole, or who develop asystole while on scene Page 194 of 385 2. Apply pathophysiological principles to the assessment of a patient with cardiovascular disease B. Quality assurance Page 201 of 385 Medicine Toxicology Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Introduction-Pathophysiology, incidence, toxic agents, risk factors, methods of transmission, complications B. Common causative agents pesticides (organophosphates, carbamates) and nerve agents (Sarin, Soman) 2. Management for a patient with exposure to/use of Barbiturates/sedatives/ hypnotics a. Assessment findings and symptoms for patients with exposure to/use of Huffing agents a. Management for a patient with exposure to/use of with acute and chronic alcohol abuse and withdrawal a. Assessment findings and symptoms for patients with poisoning/exposure to household poisons E. Pulmonary complaints may be associated with exposure to a wide variety of toxins, including carbon monoxide, toxic products of combustion, or environments that have deficient ambient oxygen (such as silos, enclosed storage spaces etc. Specific illness/injuries: causes, assessment findings and management for each condition A. Page 215 of 385 Medicine Hematology Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. Definitions, Pathophysiology, epidemiology, mortality and morbidity, and complications B. Patient education and prevention Page 224 of 385 Medicine Gynecology Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. General Management for a patient with a common or major non-traumatic musculoskeletal disorder. Joint abnormalities (including Arthritis (Septic, Gout, Rheumatoid, Osteoarthrosis) and slipped capital femoral epiphysis) 1. Patient education and prevention Page 231 of 385 Shock and Resuscitation Shock and Resuscitation Paramedic Education Standard Integrates comprehensive knowledge of causes and pathophysiology into the management of cardiac arrest and peri-arrest states. Integrates a comprehensive knowledge of the causes and pathophysiology into the management of shock, respiratory failure or arrest with an emphasis on early intervention to prevent arrest. Generally speaking, the heart pumps blood out of the left ventricle, around the circulatory system and back to the right side of the heart. The negative intrathoracic pressure created by normal ventilation assists venous return. When the airway is open, air rushes from the higher-pressure zone outside the body into the low-pressure zone inside the chest. Since patients in cardiac arrest are not breathing, they do not produce negative inspiratory pressure to assist the circulatory system. Then with the next compression, a greater amount will be forced to the lungs and other vital organs. When practical, log roll the supine patient on their side to allow for an appropriate assessment of the posterior body. Location of normal bronchovesicular and bronchial breath sounds in the chest and the meaning of abnomal locations. Transfer of patients to the most appropriate hospital Page 246 of 385 Trauma Bleeding Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Unable to maintain +90% investigate cause (tension pneumothorax) Page 251 of 385 4. Fluid choice a) Types of fluid (Refer to American College of Surgeons guidelines) i) Advantages ii) Disadvantages iii) Role of hydrostatic pressure iv) Role of colloid oncotic pressure b) Blood substitute products c) Blood administration in the field c. Review knowledge from previous levels Page 253 of 385 Trauma Chest Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. With large holes air enters both the trachea and the hole rapidly collapsing the lung g. Internal venous bleeding may be more severe because arterial bleeds can occlude the lumen of the artery. Large amounts of intra-abdominal bleeding may occur without much external evidence 8. Traction control hemorrhage by apply pressure on internal bleeding within muscles wrapped by muscle sheaths. Le Fort I Fracture separates hard palate and lower maxilla from remainder of skill Page 278 of 385 b. Many toxins cause the patients cells to release bradykinins, histamines, and serotonin c. May cause head trauma, cardiac damage, burns, extremity vasospasm, paresis or parethesias. Looking a trauma scene and attempting to determine what injuries might have resulted 2. Typically a patient considered to have multi-trauma has more than one major system or organ involved a. Multi-trauma treatment will involve a team of physicians to treat the patient such as neurosurgeons, thoracic surgeons, and orthopedic surgeons 4. The definitive care for multi-system trauma is surgery which can not be done in the field b. Newly licensed paramedics who have not seen many multi-system trauma patients need to stick with the basics of life saving techniques b. Be suspicious at trauma scenes, sometimes an obvious injury is not the critical cause one the potential for harm. Multi-casualty care Page 301 of 385 Special Patient Population Obstetrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Postpartum Complications: pathophysiology, assessment, complications, management 1. Post partum depression Page 306 of 385 Special Patient Population Neonatal Care Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Neonatal mortality risk can be determined via graphs based on birth weight and gestational age b. Resuscitation is required for about 80% of the 30,000 babies who weigh less than 1500 grams at birth 3. Complete airway obstruction a) Atelectasis b) right-to-left shunt across the foramen ovale ii.

In fact erectile dysfunction va disability rating cheap avana 100 mg mastercard, there are boats that can be single-handed by people with no hand function whatsoever erectile dysfunction caused by lipitor buy avana with amex. These were originally designed to be quad friendly erectile dysfunction fast treatment discount avana 50 mg with visa, with inspiration from Sam Sullivan erectile dysfunction dr mercola generic avana 200 mg on-line, a high-quad sailor from British Columbia (former mayor of Vancouver) erectile dysfunction lisinopril avana 200mg discount. Paralysis Resource Guide 196 4 There are also many disabled-only races erectile dysfunction 21 years old buy avana 100 mg cheap, including the Paralympic Games. For information on racing: the United States Sailing Association, 1-800-877-2451; And for those with limitations of mobility, underwater sports offer an exhilarating aquatic equality unsurpassed on land. With training and some assistance getting in and out of equipment, even high-quads can enjoy scuba diving, and perhaps the clear, 85-degree water of the beautiful reefs of the Caribbean. There are dive programs all over the United States that specialize in getting disabled divers trained and certified. Level A divers are certified to dive with one other person; a Level B diver must dive with two other nondisabled divers. Team Reeve runners get coaching and personalized training advice, fundraising assistance and most of all, tremendous satisfaction both for themselves, and for helping the Foundation. At the highest end of the tech scale is the mono-ski, best for those with good upper body strength Hall of fame mono-ski racer Sarah Will, in 2002 and trunk balance. The skier sits in a molded shell mounted to a frame above a single ski with a shock absorber linking the frame to the ski. The bi-ski, a bucket seating system similar to the mono ski, sits atop two heavily shaped skis and can be balanced with attached or hand-held outriggers. Bi-skis are used by individuals who have more significant physical limitations and are tethered or skied from behind by an instructor. The sit-ski, akin to a toboggan, works for people with even more significant limitations. Those with some hand function can steer the sit-ski with short ski poles and by leaning. Among the largest is the National Sports Center for the Disabled, which runs recreation programs year-round, at Winter Park in Colorado. A full-scale California program can be found at Alpine Meadows, in the Tahoe region: The Adaptive Sports Foundation at Windham Mountain runs a large program on the East Coast: Cross country sit skis have molded or canvas seats mounted on frames that are simple and light weight, creating more independence. The frames are attached to two cross country skis for snow skiing or a mountain-board for summer trails. The skier propels along the course using cross country ski poles that have straps to support any limited hand function. Paralysis Resource Guide 200 4 Patrick Ivison was 14 months old when a car backed over him and injured his spinal cord. Jesse Billauer, a quad after a surfing accident, started Life Rolls On to raise awareness about quality of life and spinal cord injury. Jesse, of course, got back on his board, riding huge waves on his stomach, with help from some stand-up surfers to get in and out. To share the joy, he started They Will Surf Again, a program that gets people in wheelchairs out riding the waves, on surfboards, at beaches across the United States. Decent wheelchair players can actively compete against stand-up players, making this one of the best activities to share with friends and family. Learning mobility on the Paralysis Resource Guide 202 4 court is exciting and challenging, and it helps build strength and cardiovascular fitness. The 2016 Summer Paralympics debuted the triathlon event with the Olympic distance of swimming, biking and running. Sit-down athletes use a handcycle for the bike and a racing wheelchair for the run portions of the Triathlon. It takes a bit of practice to become skillful with their accessible devices, but if a gamer is motivated, this popular activity is still wide open to them Organizations such as the Game Accessibility Project have taken up the torch addressing concerns of disabled gamers about the availability of accessible video games by providing resources for developers, publishers, and researchers with the goal to increase accessibility in games. If skiers get good at it and have the urge to compete, there are various water ski meets around the United States. The towropes have a modified handle so individuals with hand disabilities can hook up to a boat and thrill to the speed and wake-crashing fun of water skiing. Skis are available commer cially; many have been added to recreation programs in many communities across the country. Water ski tournaments for skiers with mobility limitations include slalom, tricks and jumping events. The activity has clear benefits for fitness but lifting has also emerged as a very competitive activity at the international level. Contact the National Wheelchair Basketball Association, telephone 719-266-4082; There are dozens of competitive teams in the United States; each team utilizes four players, mostly quads (players must have all four limbs affected by disability). The player with the ball must pass or dribble every ten seconds or a turnover is awarded. Players are seated on sleds, which are affixed to two hockey skate blades under the seat. The sleds are about three inches off the ice and are anywhere from two to four feet long, depending on the size of the player. The best chance for action occurs at an annual tournament sponsored by the National Wheelchair Softball Association, where thirty or so teams show up to compete. The game is much the same as slow-pitch softball, using a sixteen-inch slow-pitch ball, with base paths shortened to fifty feet. The net is about three feet high and the court is smaller than a standard volleyball setup. Activities include winter skiing, water sports, summer and winter competitions, fitness and special sports events. Participants include those with visual impairments, amputations, spinal cord injury, dwarfism, multiple sclerosis, head injury, cerebral palsy and other neuromuscular and orthopedic conditions. With minor exceptions, services provided to disabled athletes are comparable to those provided to nondisabled Olympic athletes. The Paralympics are open to elite athletes who meet the rigid qualifying standards of their sport. Athletes are categorized by a combination of functional and medical determinations. The Paralympic Games have been contested since 1960 and now feature competi tion in twenty sports. The organization sponsors opportunities for paralyzed people of all shapes, sizes and ages to camp, fish, sail, scuba dive, hunt, water ski or take pictures from a pontoon boat in the scenic swamps of East Texas. Sports brings individuals with and without disabilities together in unique athletic events (mountain climbing, white water rafting, biking, rides around the world, rides through Vietnam, etc. The program promotes diversity and increased awareness, acceptance and integration of those with disabilities. The worlds of creative endeavor and artistic expression are inclusive; there are no limitations on imagination. There are only a few restrictions on accessing the tools of art; musical instruments, paint brushes, pencils or video cameras are fairly adaptable. Because art is infinite and unconditional, people with disabilities are free to express themselves without physical, social, or attitudinal barriers. The arts are not recreation, per se, but they can be uplifting, refreshing and socially involving. The arts provide unlimited possibilities for personal, academic, and professional success. By engaging in the arts, people with disabilities are able to greatly contribute to their communities, help extinguish old stereotypes regarding disability, and create a culture truly representative of all people. Ruben was a painter and a member of the prestigious Association of Foot and Mouth Painting Artists. It takes anywhere from 20 to 60 hours to complete a piece from beginning to end with this method. My art has been the biggest thing in my life that has kept me goal oriented and not just stagnant. Unless you have an unusually high threshold for the unpredictable, the best travel plan is to have a plan. But planning is especially important for people who use adaptive gear or need to get around with reduced mobility. No plan is bulletproof, of course, especially when it comes to transportation, lodging, scheduling, weather, and all the unforeseen tribulations that remind you that travel is an art, not a science. Travel professionals know how to get you where you want to go and pretty much what to expect once you get there, matching your level of adventure with your need for creature comfort. This would include, among many other places, San Diego, Las Vegas, Disney World in Orlando, New York, and Washington, D. As a whole, the cruise business does a good job anticipating the needs of travelers with disabilities, especially on the most modern sailing vessels. Your expert friend or travel agent should know a few basic tricks (see a list of tips from veteran wheelchair travelers, including those who use mechanical ventilation, page 221). If the plane has fewer than sixty seats, powerchair users may also be required to give a two-day notice.

Renal Trauma Renal trauma occurs more frequently in male patients and can occur in up to 10% of abdominal traumas erectile dysfunction caused by vyvanse order genuine avana on-line. It is important to differentiate between penetrating and blunt renal traumas erectile dysfunction age range order avana in united states online, as a mechanism of injury can determine the severity and management of the injury erectile dysfunction alcohol buy avana with american express. Blunt traumas occur in the setting of motor vehicle accidents erectile dysfunction first time buy avana visa, motorcycle accidents erectile dysfunction over 75 avana 200 mg mastercard, falls erectile dysfunction organic cheap 50mg avana visa, and some sports. In the adult patient population, imaging for possible renal trauma should be performed in the setting of gross hematuria, or if microscopic hematuria is present with a systolic blood pressure less than 90 mmHg. Delayed phase imaging is critical, to evaluate for collecting system or ureteral injury. Conservative management can certainly include blood transfusion, though ongoing requirements for blood products should be a trigger to consider an active intervention. If the patient is hemodynamically unstable despite resuscitation, and intervention should be performed. There are 2 categories of intervention, including angioembolization and surgical management. This is performed by administering to milliliters per kilogram of intravenous contrast with a plain film performed 10 to 15 minutes later. This can be considered a very reasonable tool for patients who are hemodynamically stable, but have continued to demonstrate evidence of ongoing bleeding. On occasion, patient with urinary extravasation may have worsening flank pain, low-grade fevers, or a rising creatinine. These patients may require ureteral stenting, and if this fails nephrostomy tube placement. The exception to active surveillance of the patient with urinary extravasation is one who has a ureteropelvic junction or renal pelvis laceration. Figure 5 demonstrates a large urinoma in a patient with urinary 53 extravasation from a renal injury. Ureteral Trauma Ureteral trauma can occur from external trauma and during urologic and non-urologic surgery (iatrogenic injury). External ureteral trauma is most often associated with penetrating trauma, though blunt trauma can also result in avulsion of the ureter at the level of the ureteropelvic junction. Similar to renal trauma, appropriate imaging with delayed films is critical to detect an injury. In the setting of external penetrating trauma, if the patient is taken directly for exploratory laparotomy, the ureter should be evaluated for viability and vascular supply. A high suspicion for ureteral injury should be maintained based on the trajectory of the injury. Nonviable ureteral tissue should be debrided with care to preserve as much vascularity as possible. If the patient does not require laparotomy, an attempt at ureteral stenting in the setting of a partial ureteral injury is a reasonable approach. If a stent cannot be placed, options include a nephrostomy tube with delayed repair, or in some cases immediate exploration if the injury occurred recently. There are a number of options to repair the ureter based on the location of the injury. Injuries distal to the iliac vessels should be repaired with a primary reimplantation if feasible. Other maneuvers to allow ureteral implantation into the bladder include a Boari flap and a psoas hitch. Midureteral injuries can be repaired with a ureteroureterostomy if there is adequate length to create a tension-free anastomosis. In the acute setting, bowel interposition (also called an ileal ureter) should not be performed but remains an option in the delayed setting. Testis Trauma Testicular trauma is relatively rare, and like bladder and renal trauma, can occur due to penetrating and blunt injury. The imaging modality of choice in the setting of a suspected testis trauma is a scrotal ultrasound. Severe injury to the testis can result in impairments in both spermatogenesis and hormone production. Ultrasound findings of a large hematocele (blood around the testis) can indicate an injury to the testis or the structures surrounding the testis. Ultrasound may also demonstrate disruption of the tunica albuginea, and this requires surgical exploration and 53 repair. Figure 7 demonstrates the cutaneous findings that can be seen in the setting of scrotal and testis trauma. A high index of suspicion as well as a thorough history and physical exam and judicious use of lab studies and imaging are critical to the timely diagnosis and treatment of urologic emergencies. An evidence-based approach to emergency department management of acute urinary retention. Management of urinary retention: rapid versus gradual decompression and risk of complications. Manual bladder washouts for urinary clot retention: A survey of knowledge among healthcare workers. Clot Retention: Our experiences with a simple new technique of evacuation with a thoracic catheter. Prevalence of priapism in individuals with sickle cell disease and implications on male sexual function. Priapism as a result of chronic myeloid leukemia: case report, pathology, and review of the literature. Colour Doppler ultrasound hemodynamic characteristics of patients with priapism before and after therapeutic interventions. Intracavernous papaverine/phentolamine induced priapism can be accurately predicted with color Doppler ultrasonography. Diagnostic and therapeutic options for the management of ischemic and nonischemic priapism. Hemodynamic patterns of pharmacologically induced erection: evaluation by color Doppler sonography. High-flow priapism treated with superselective transcatheter embolization using polyvinyl alcohol particles. Intralesional injection of collagenase Clostridium histolyticum may increase the risk of late-onset penile fracture. Surgical management of traumatic penile amputation: a case report and review of the world literature. Glans penis necrosis following paraphimosis: A rare case with brief literature review. Bladder perforation after augmentation cystoplasty: determining the best management option. Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank. Part I: Introduction, history, anatomy, pathology, assessment, and emergency management. Effect of early realignment on length and delayed repair of post-pelvic fracture urethral injury. The effectiveness of early primary realignment in children with posterior urethral injury. The obstructed calyces of the kidney are unable to drain infected urine, leading to sepsis or abscess. Noticed the right hydronephrosis, cortical thinning from long-term obstruction, and a crossing vessel (red arrow) which is the likely source of the obstruction. Emergent decompression is indicated if the patient has a concurrent urinary tract infection. It would be very reasonable to consider bladder cancer in the differential diagnosis for a mass like this with associated hydronephrosis. Cystoscopy would help determine whether this mass is an enlarged prostate or a bladder neoplasm. Emmanuel Njeuhmeli, Marelize Gorgens, Elizabeth Gold, Rachel Sanders, Jackson Lija, Alice Christensen, Francis Ndwiga Benson, Elizabeth Mziray, Kim Seifert Ahanda, Deborah Kaliel, Tin Tin Sint, Chewe Luo Glob Health Sci Pract. Mbaraka Amuri, Georgina Msemo, Marya Plotkin, Alice Christensen, Dorica Boyee, Hally Mahler, Semakaleng Phafoli, Mustafa Njozi, Augustino Hellar, Erick Mlanga, Aisha Yansaneh, Emmanuel Njeuhmeli, Jackson Lija Glob Health Sci Pract. Webster Mavhu, Natasha Larke, Karin Hatzold, Getrude Ncube, Helen A Weiss, Collin Mangenah, Prosper Chonzi, Owen Mugurungi, Juliet Mufuka, Christopher A Samkange, Gerald Gwinji, Frances M Cowan, Ismail Ticklay Glob Health Sci Pract. Webster Mavhu, Karin Hatzold, Getrude Ncube, Shamiso Fernando, Collin Mangenah, Kumbirai Chatora, Owen Mugurungi, Ismail Ticklay, Frances M Cowan Glob Health Sci Pract. Collin Mangenah, Webster Mavhu, Karin Hatzold, Andrea K Biddle, Getrude Ncube, Owen Mugurungi, Ismail Ticklay, Frances M Cowan, Harsha Thirumurthy Glob Health Sci Pract. Laura Fitzgerald, Wendy Benzerga, Munamato Mirira, Tigistu Adamu, Tracey Shissler, Raymond Bitchong, Mandla Malaza, Makhosini Mamba, Paul Mangara, Kelly Curran, Thembisile Khumalo, Phumzile Mlambo, Emmanuel Njeuhmeli, Vusi Maziya Glob Health Sci Pract. Virgile Kikaya, Rajab Kakaire, Elizabeth Thompson, Mareitumetse Ramokhele, Tigistu Adamu, Kelly Curran, Emmanuel Njeuhmeli Glob Health Sci Pract. Mortality prevention approach and a component of combi depending on in newborns from all causes currently accounts for nation prevention packages. This supplement whether a country 44% of all deaths among children less than 5 years provides country experiences on scaling up as introduces and of age. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, the quality of health care for women and new Puren A. Male ages 15 years and older), young adolescents (boys ages circumcision has historically been performed in infancy, 10 to 14 years), and young infants (boys ages 0 to adolescence, and adulthood in various regions of Africa 2 60 days). Njeuhmeli and colleagues estimated that for religious and cultural reasons or for ethnic identity. This is the catch-up phase to reach the reduction in vaginal infections and cancer of the cervix 3,4 majority of males who may be currently sexually active. It also carries addi making through operations and implementation tional child health benefits, including reduced research. Donor-funded ments that strengthen service delivery platforms programs and services face challenges at the include infrastructure support, including for end of the funding period and are often hard to surgical procedures; training, supervision, and sustain nationwide. For complications, a system adverse events if performed in a supportive of referral should be in place suited to the local 24 1 environment. Governments and from 2010 found few reported severe complica stakeholders must ensure that parents/guardians tions, but mild or moderate complications have are fully informed before they provide consent. Manual for early provision, including situational analysis of the infant male circumcision under local anaesthesia. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, once adult programs have reached high coverage. Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, realized immediately, the routine offering of et al. Risks from circumcision during the rst human immunode ciency virus prevention: knowledge and month of life compared with those for uncircumcised boys. Poster trends in child mortality report 2014: estimates developed by the available from: pag. Early infant male circumcision: report of a global partners meeting, Johannesburg, 32. Convention on the Rights of the Child, New York, 20 November integration of early infant male circumcision services into 1989, United Nations Treaty Series, Vol. Feasibility facility assessment in preparation of introduction of early infant male circumcision 35. Available from: prevention programming: guidance for decision-makers on dec. Toward a systematic approach to generating Medline demand for voluntary medical male circumcision: insights and 25. In some countries, progress has been and no longer expanding and the response is constantly uneven, and certain age groups and certain districts are adapting to the evolution of the epidemic to maintain 2 reaching saturation before others. The Global Fund has just released a policy paper on sustainability, Sustaining the status quo is not a prerequisite. In addition, ensuring engagement regular data collection is needed to monitor from civil society and the private sector as the progress of programming. Data should program planners, implementers, and moni include specific surveys and surveillance, ex tors is key, with the assurance that all penditures, and performance measures. Data stakeholders have access to information in a should be made available in a timely manner transparent manner that allows for holding so they can be used to better inform and target each other accountable for results. Depending on the context and desires of the local For long-term success, high-quality and government, it may make sense to focus on responsive service delivery is also key to different populations as there is near-saturation meeting the demand of clients and should of the 15 to 49 age range during or after scale-up be assessed. In the scale-up phase, the country Strategic investment, efficiencies, and circumcises males across the entire target age sustainable financing: Shifts in the source group, requiring a large number of annual or level of financing may have implications for circumcisions. After the target coverage is the type and level of services to be delivered achieved, males are circumcised only as they and their sustainability. Planning transitions move into the focus age group to maintain the necessarily involves understanding the cur target coverage level. These focus population rent and future financial landscape, including groups are: the possibility of assigning public resources Adolescents: the country continues to cir for specific priority services, and the opportu nities for diversified funding through resource cumcise adolescents ages 10 to 14 to maintain mobilization and innovative financing from target coverage. The longer necessary to continue circumcising potential for integrating services should be adolescents, and the country can focus entirely considered. The 15 ele of individuals to be circumcised is not much lower To plan for a ments are: than in other scenarios. The mixed-focus Expenditure data strategy is the most expensive for drugs and Performance data supplies.

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