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The small raised number 5 next to the 10 is known as the power or exponent – it tells you how many of the same number are being multiplied together buy discount strattera 40mg on-line treatment laryngitis. Now consider this: 1 1 1 1 1 1 × 10 10 10 10 10 10 10 10 10 10 Powers or exponentials 37 Here we are repeatedly dividing by 10 discount strattera 18 mg fast delivery medicine cabinets with lights. For short you can write: –5 1 10 instead of 10 10 10 10 10 In this case, you will notice that there is a minus sign next to the power or exponent. In conclusion: • A positive power or exponent means multiply the base number by itself the number of times of the power or exponent; • A negative power or exponent means divide the base number by itself the number of times of the power or exponent. You will probably come across powers used in the following way: 3×103 or5×10–2 This is known as the standard index form. It is a combination of a power of 10 and a number with one unit in front of a decimal point, e. This type of notation is seen on a scientific calculator when you are working with very large or very small numbers. It is a common and convenient way of describing numbers without having to write a lot of zeros. The manual or instructions that came with your calculator will tell you how to do this. See the section on ‘Powers and calculators’ for an explanation of how your calculator displays very large and small numbers. If you don’t know how to use your calculator properly, then there is always the potential for errors. The estimating process is quite simple: numbers are either rounded up or down in terms of tens, hundreds or thousands to give numbers that can be calculated more easily. Single-digit numbers should be left as they are (although 8 and 9 could be rounded up to 10). Estimating answers 43 Once the numbers have been rounded up or down, it’s possible to do a simple calculation, and the result is close enough to act as an estimate. No set rules for estimating can be given to cover all the possibilities that may be encountered. Add those numbers: 3,459 + 11,723 + 7,895 + 789 4 + 7 + + 7 = 2 6 Then add two noughts (to convert back to a number in the hundreds): 2600 (2,600) Round up or down to a number in the thousands (i. In this case 5 zeros were ignored, so add them to the end of the answer from Step Two: 15 00000 = 1,500,000 The estimated answer is 1,500,000. In this case 2 zeros were ignored, so add them to the end of the answer from Step Two: 21 00 = 2,100 The estimated answer is 2,100. If there is a zero in the divisor (the number you are dividing by), then this must be cancelled out with a zero from the dividend (the number you are dividing). This may, at first, appear confusing, but the following may make it clearer: 36,000/ ÷50/ Cancel out 1 zero from each side of the division sign (÷) to give 3,600 ÷ 5. If there were two zeros in the divisor, then two zeros would have to be cancelled from the dividend, i. In this case two zeros were ignored, so add them to the end of the answer from Step Three: 700=700 The estimated answer is 700. If you round up numbers, the estimated answer will be more than the actual answer. If you round down numbers, the estimated answer will be less than the actual answer. You obviously cannot round down to zero, as this would not give a proper answer – multiplying anything by zero gives an answer of zero. You simply convert the number to a fraction (see the section on ‘Converting decimals to fractions’ on page 34). If there is more than one number after the decimal point, then round up or down to one decimal place. Estimating answers 47 Once the decimal has been converted to a fraction, calculate the sum as if you are multiplying or dividing by fractions (see the sections on ‘Multiplying fractions and ‘Dividing fractions’ earlier).
As the trading opportunities in other sectors become exhausted buy strattera 25 mg free shipping symptoms just before giving birth, as experience within services trade generally expands strattera 40 mg otc medicine advertisements, and as the financial climate stabilises, countries will increasingly look to the opportunities that international trade in services has to offer. For exporting services, this will centre on technology transfer, skill enhancements and foreign income. At present, medical tourism is driven by commercial interests lying outside of organised and state-run health policy-making and delivery. Are there possibilities to bring it more within the remit of domestic policy competency, involving for example third-party payers sending patients overseas? Given the heavily ‗politicized‘ nature of health care in all countries (even those with substantial private health care sectors), there will also be concerns about the threats this poses, including aspects related to brain drain, quality of care and equity. If an agreement is achieved to send patients abroad on a more bi-lateral basis, then this may open channels for other agreements such as these, which can then combine international recruitment with training and work experience programmes to address brain drain issues in the importing country. If such a route were taken, this would effectively be a form of outsourcing, with such agreement typically following the well-worn tracks of medical tourist mobility. Countries continue to evaluate their positions on trade liberalization in health, as part of wider bi- lateral, regional and multilateral trade agreements. The latter especially has been the focus of debate, centred on the World Trade Organization‘s General Agreement on Trade in Services (Blouin et al. However, there is widespread recognition that the trade agenda (in services generally, and health specifically) is increasingly pursued at the regional or bi-lateral levels (Smith et al. Could this development be broadened to include medical tourist exchanges with countries where travel distance are longer, culture and language less familiar, but where cost savings to the public purse are more apparent? This is an important shift in the dialogue, as greater bi-lateral and regional trade may reduce many of the concerns expressed over health services trade, and offer greater benefits. For instance, it may result in greater quality assurance, as well as better litigation procedures. However, much of the research evidence, anecdote and opinion on trade in health services remain focussed on this multi-lateral perspective. It is important, therefore, to explore bi-lateral trade in more detail, and to assess how it compares to multi-lateral trade. Such a focus would move discussion from the level of global medical tourism to more specific bilateral exchanges – for particular treatments, under specific quality-assured conditions (Smith et al. Beyond the national level, medical tourism raises questions for trans-national and global structures and processes. How, indeed if at all, should the medical tourism industry be best regulated, and where is intervention most likely to be effective? There is currently a lack of agreed international standards for assessing and ensuring quality and safety of medical tourism providers and health professionals, and no obligation for them to ensure quality and safety other than an ethical one. Currently, there is no universal ―official agency/group‖, such as the United Nations, the World Health Organization, the World Tourism Organization or the World Trade Organization, engaged in either the delivery of accreditation, the co- ordination of delivery of accreditation, or licensing or studying the existing schemes that deliver accreditation. There is a range of possible solutions (both national and transnational) ranging from interventions that provide more information (although by whom and at what points is not clear); those that restrict choice of potential consumers (either directly prohibited or through discouragement); or attempts to restrict supply (whether approving or licensing providers or intermediaries). There are also interventions that may aim to offer consumer protection around poor-quality treatments which could involve encouraging independent holistic accreditation by recognised schemes, advising that clinicians responsible for delivering services take out personal medical indemnity which would compensate their patients in the event of problems occurring as a consequence of their seeking healthcare, or requiring medical tourists to take out insurance coverage (Cohen, 2010). Source health systems may attempt to shift risk onto individual medical tourists, for example with disclaimers to prevent medical tourists from seeking to rectify poor outcomes at cost to the public purse. What are the programme priorities surrounding medical tourism for both source and destination countries? As outlined, medical tourist choice may lead to externalities at the system and programme level. Costs may result from overseas cosmetic surgery or dental work that requires subsequent treatment within home countries. There are few case reports or studies of these aspects and the scale of any problem is not clear. Large numbers of medical tourists will also impact on the source country‘s own health system, because outflows reduce both revenue and support for local services. Patients who circumvent waiting times make access and equity for the wider population more problematic. Opportunities for financial benefit from medical tourism include potentially exerting competitive pressure on systems importing health care and may help drive down the costs and prices offered in domestic systems, or relaxing legal restictions in order to stimulate domestic provision of treatments. Most countries that engage in delivering care to medical tourists do so to increase their level of direct foreign exchange earnings. Some countries may promote health services in order to develop facilities 42 to better serve local patients, although the possibility of resources being diverted from the domestic population and invested into private hospitals and away from rural areas remains a potential dysfunctional outcome.
Polypharmacy was deﬁned as at least nine medications strattera 25 mg lowest price treatment 3rd stage breast cancer, a higher threshold compared with other studies in ambulatory or hospitalized settings generic strattera 40 mg on line symptoms xanax is prescribed for. However, one study of 2014 residents, the majority of whom were 85 years or older, in 193 assisted living facilities reported a mean of 5. They reported that 57% of patients were taking at least one unnecessary medication. Hanlon and colleagues25 reported similar ﬁndings; lack of indication was the most common reason for unnecessary medications in a study of 397 hospitalized elderly veterans. Common unnecessary medications include gastrointesti- nal, central nervous system, and therapeutic nutrient/mineral agents. A study of ambulatory Medi- care patients revealed that the most common drug classes prescribed in a 1-year period were cardiovascular agents, antibiotics, diuretics, analgesics, antihyperlipi- demics, and gastrointestinal agents. The most common nonprescription medications consumed by older adults were analge- sics (aspirin, acetaminophen, and ibuprofen), cough and cold medications (diphen- hydramine and pseudoephedrine), vitamins and minerals (multivitamins, vitamins E and C, calcium), and herbal products (ginseng, Ginkgo biloba extract). Aside from increased direct drug costs, patients are at higher risk for adverse drug reactions, drug interactions, nonadherence, diminished functional status, and various geriatric syndromes. In a prospective, randomized controlled longitudinal multicenter European study of 1601 community-dwelling elderly adults, 46% of patients had a potential drug-drug interaction. The risk of drug-disease interactions has been shown to increase as the number of drugs as well as the number of comorbidities increase. The prevalence rates should be interpreted cautiously, because they may be overestimated due to how interactions and their clinical importance are deﬁned. These interactions are signiﬁcant because they may decrease the efﬁcacy or increase the risk of toxicity of a drug. As a result, the prescriber may change the dose or add more medications, further increasing the risk for other interactions and side effects. Nonadherence Complex medication regimens related to polypharmacy can lead to nonadherence in the elderly. The number of medications has been shown to be a stronger predictor of nonadherence than advancing age, with higher rates of nonadherence as the number of medications increases. Increased Health Service Utilization and Resources The use of multiple medications leads to increased costs for both the patient and the health system as a whole. Whereas the proper use of medications may lead to decreased hospital and emergency room admissions, the use of inappropriate medications may not only increase patients’ drug costs but cause them to use more health care services. A retrospective population study in Ireland concluded that approximately 9% of the total drug-related expenditures were on potentially inappro- priate medications. A retrospective cohort study of elderly Japanese patients reported that patients with polypharmacy were at risk of having a potentially inappropriate medication, which then increased the risk for hospitalization and outpatient visits and resulted in a 33% increase in medical costs. In a review of 42 cohorts of medical inpatients composed of mostly older adults, the rate of delirium ranged from 11% to 42%. Another study of 156 hospitalized older adults found that the number of medications was an independent risk factor for delirium. Similarly, drug classes that can exacerbate dementia are benzodiazepines, anticonvulsants, and anticholinergic drugs such as tricyclic antidepressants. A cohort study of 294 Finnish elders reported that those with polypharmacy were found to have a decrease of 1. Twenty-two percent of patients with no polypharmacy were found to have impaired cognition as opposed to 33% and 54% with polypharmacy and excessive polypharmacy, respectively. A cross-sectional study in older outpatients found that the number of prescribed medications was signiﬁcantly associated with the risk of falls. Z a r w iz et a l Ou a t ien t m a n a ged ca r e ( ﬁr in t er ven t i n ) lin ica lp ha r m a ci eview ed T he r a t e o fp ly ha r m a cyr educed b y 2 eco n d dr ug r egim en s educa t ed a ft er ﬁr in t er ven t i n , fr m in t er ven t i n ) hyicia n s a n d p a t ien t n even t a t ien t p ly ha r m a cy a n d w o ked ft er he s eco n d in t er ven t i n , he w ih p hyicia n s educe ly ha r m a cyr a t e w a s educed b y p ly ha r m a cy fr m even t 1 a t ien t Scha m der et a l I n p a t ien t a n d o u a t ien t I n p a t ien t a n d o u a t ien t er ia t ic eva lua t i n a n d m a n a gem en t 2 fr a ilelder lyvet er a n s ger ia t ic eva lua t i n a n d educed t he n um b er fun n eces a r y m a n a gem en t co n s i in g o f a n d in a p ia t e dr ugs in ger ia t icia n , n u e, cia l in p a t ien t b u n o in w o ker a n d p ha r m a ci u a t ien t H a n l n et a l Ou a t ien t vet er a n s lin ica lp ha r m a ci eview ed Us in g t he M edica t i n ia t en es 1 egim en s a n d co m m un ica t ed I n dex, in a p ia t e p es cr ib in g r eco m m en da t i n s in w r iin g ign iﬁca n t lydecr ea s ed in he a n d ver b a llyt im a r y in t er ven t i n gr u co m p a r ed w ih p hyicia n. G a l Ou a t ien t vet er a n s Pha r m a ci ha r m a co her a p y educed a ver a ge n um b er f co n s ul es cr i i n s er a t ien t F illi et a l Ou a t ien t edica r e u veyed, lder lyM edica r e b en eﬁcia r ies Oft he 1 a t ien t w ho cheduled a 1 b en eﬁcia r ies a t ik fo ly ha r m a cy m edica t i n eview , ep ed r es n ded, w er e s en t let er b ym a n a ged ha vin g a m edica t i n dico n t in ued. Phyicia n s vided w ih guidelin es n ly ha r m a cy F ick et a l edica r e a n d C ho ice hyicia n s Phyicia n s w er e m a iled a li in g fp en t ia llyin a p ia t e 2 u hea s er n m a n a ged fp a t ien t w ho w er e t a kin g m edica t i n s w er e dico n t in ued. T he ca r e o ga n iza t i n en t ia llyin a p ia t e m o co m m o n dico n t in ued p im a r yca r e p hyicia n s m edica t i n s a s deﬁn ed b y m edica t i n s w er e a n t ihi a m in es a n d p a t ien t he B eer cr ier ia , a s w ella s a n a lges ics a n d m u cle r ela xa n t a ler n a t ive r eco m m en da t i n s p vided b ym uli le in dep en den t ha r m a ci a n d ger ia t icia n s 180 Shah & Hajjar Use of certain medications is also of concern when considering risk factors for falls in older adults. Psychotropic and cardiovascular medications are of particular concern because of their association with increased risk of falls.
There are primarily 2 companies that market product files to pharmacy claims processors: First DataBank (First DataBank buy generic strattera 25mg symptoms 9 days past iui, Inc generic strattera 40 mg overnight delivery treatment wetlands. Federal Food, Drug, and evaluating the safety and effectiveness of medical devices? Medical device regulation: an introduction for the practicing Accessed December 1, 2010. Report to the Ranking ProductsandMedicalProcedures/DeviceApprovalsandClearances/ Member, Committee on Finance, U. Pharmacy entails a realize this mistake once they have returned home health science specialty which embodies the and have taken the first dose. Latent errors can be knowledge of pharmacology, toxicology, described as “accidents waiting to happen “ The pharmacokinetics and therapeutics for the care of causes of these types of errors are usually patients. Health care is nearly 10 years behind other identifiable and can be corrected before the error industries in its efforts to reduce the errors. According to studies cited in the institute of Medicine report, “to Err is Human; Building a Safer Health? Incomplete patient information (not knowing System” 44,000 to 98,000 Americans die each year about patients’ allergies, other medicines as a result of medical errors. Medication error may they are taking , previous diagnoses, and lab be nobody’s baby, but when it happens, it could results for example) well turn out to be everyone’s worry and the reasons given for medication error range from silly to the? Miscommunication of drugs orders, which can economically inefficient use of pharmaceuticals is involve poor handwriting , confusion between commonly observed in the health care system drugs with similar names, misuse of zeroes throughout the world especially in the developing and decimal points, confusion of metric and countries. Some of the errors though are serious other dosing units, and inappropriate and require attention. Lack of appropriate labeling as a drug is hospital stays, additional treatment, and prepared and repackaged into smaller units malpractice litigation. Environmental factors, such as lighting, heat, noise, and interruptions that can distract health “A medication error is an preventable event professionals from their medical tasks. Such events may be related to prescription and inaccurate calculation of doses *Adapted with gratefulness from The Pharma Review, August 2005 ** Indraprastha Apollo Hospital, New Delhi 60 especially in children. Workplace environmental problems increasing drug or dose) and those of omission (failure to the job stress. Access to drugs by non-pharmacy personnel with ineligible prescriptions or verbal medication orders and errors are likely. Lack of patient information perceived the following as causative factors for medication errors-? Overload/ unusually busy day (59%) symbols that occur practically are given in Table 1:? No time to counsel (29%) that they observe, the denominator is called “opportunities for errors” and includes all the doses? Failed communication: handwriting and oral communications, especially over the telephone, drugs with similar names, missing or misplaced zeroes and decimal points, confusion between metric and apothecary systems of measure, use of nonstandard abbreviations (table-1) ambiguous or incomplete orders 61 Ta. D/C Discharge, also discontinue Patients’ medications have been prematurely discontinued when “D/C” was intended to mean “discharge” versus discontinue”! Failure to “shake well”: The failure to with its drug distribution system and a deficiency should “shake” a drug product that is labeled “shake be written. This will almost always lead to an Medication errors due to failure to follow under dose or over dose depending on the label instruction suspending abilities of the diluent’s and the elapsed time since the last “shake “. Also included under this category is the failure to 62 “roll” insulin suspensions. Insulin suspensions purpose can help further assure that the should not be shaken, they should be “rolled” proper medication is dispensed and creates in order to mix the insulin particles with the an extra safety check in the process of diluents without creating air bubbles. Crushing medications: Crushing tablets or Independent double-check systems can capsules that the label states “do not crush”. When this procedure is properly carried out, the likelihood that two individuals would make? Medications taken with food or antacids: the same error with the same medication for The administration of medications without food the same patient is quite low. Forcing functions and constraints they allow medication in order to prevent Gl irritation. Examples include software programs and whereas, some of the medication is with “forcing functions “ that require the entry administered in empty stomach or before of additional pertinent patient information taking food for better pharmacological & before the order is completed and the therapeutical action. Sublingual tablets which should not be and tasks can lessen human fallibility by swallowed: Swallowing a sublingual tablet limiting reliance on memory.