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By C. Jaroll. University of Denver.

Licorice increases the risk of hypokalemia with furosemide and other loop diuretics and halves the bioavailability of nitrofurantoin cheap 40 mg propranolol otc coronary heart disease quality of life. It is contraindicated in persons with cholestasis cheap 80 mg propranolol mastercard coronary heart problem, cirrhosis buy propranolol 80mg with visa heart disease quiz nursing final exam, hypertension cheap propranolol 80 mg overnight delivery cardiovascular system and muscle contraction, or hypokalemia. An individual consuming a lot of licorice who has increased blood pres- sure and edema should be evaluated for an acquired form of apparent min- eralocorticoid excess syndrome. Shibata S: A drug over the millennia: pharmacognosy, chemistry, and pharmacology of licorice, Yakugaku Zasshi 120:849-62, 2000. Ploeger B, Mensinga T, Sips A, et al: The pharmacokinetics of glycyrrhizic acid evaluated by physiologically based pharmacokinetic modeling, Drug Metab Rev 33:125-47, 2001. Fujisawa Y, Sakamoto M, Matsushita M, et al: Glycyrrhizin inhibits the lytic pathway of complement—possible mechanism of its anti-inflammatory effect on liver cells in viral hepatitis, Microbiol Immunol 44:799-804, 2000. Haraguchi H, Yoshida N, Ishikawa H, et al: Protection of mitochondrial functions against oxidative stresses by isoflavans from Glycyrrhiza glabra, J Pharm Pharmacol 52:219-23, 2000. Tamir S, Eizenberg M, Somjen D, et al: Estrogen-like activity of glabrene and other constituents isolated from licorice root, J Steroid Biochem Mol Biol 78:291-8, 2001. Tamir S, Eizenberg M, Somjen D, et al: Estrogenic and antiproliferative properties of glabridin from licorice in human breast cancer cells, Cancer Res 60:5704-9, 2000. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Olukoga A, Donaldson D: Liquorice and its health implications, J R Soc Health 120:83-9, 2000. Magnesium, an important intracellular cation, is present in numerous enzy- matic systems and is crucial for adenosine triphosphate metabolism. It influ- ences neuromuscular, cardiovascular, immunologic, and hormonal function. Magnesium is a smooth muscle relaxant; it dilates coronary arteries and peripheral vessels, exerts antiarrhythmic effects, may have a permissive effect on catecholamine actions, and can play a role in various thrombogenic conditions. It plays an important role in intracellular homeo- stasis, including activation of thiamine and, consequently, an array of crucial body functions. As an essential cofactor for adenosine 5′-phosphate produc- tion, magnesium plays a pivotal role in the breakdown of glycogen, the oxi- dation of fat, and the synthesis of protein. It influences various cellular functions including transport of potassium and calcium ions, cell prolifera- tion, signal transduction, and energy metabolism. It is required for the metabolism of a number of minerals including calcium, potassium, phos- phorus, zinc, copper, iron, sodium, lead, and cadmium and for the produc- tion of gastric hydrochloric acid, acetylcholine, and nitric oxide. A half a cup of cooked spinach supplies 78 mg of magnesium, one fifth of the daily requirement. Absorption of magnesium is reduced on a 591 592 Part Three / Dietary Supplements high-fat or high-fiber diet, because it is bound in the intestine by phytates and oxalates. Supplementation is usually in the range of 300 to 1000 mg, with a ther- apeutic dose range of 1000 to 1500 mg/day. Physiologic studies suggest that women with no clini- cal evidence of magnesium deficiency may not respond to short-term sup- plementation with any increases in the mass of the exchangeable magnesium body pool or in magnesium turnover rates. In magnesium-depleted patients, both refractory hypocalcemia and hypo- kalemia respond to magnesium replacement. Furthermore, animal experi- ments have shown that magnesium supplementation, although reducing apparent calcium absorption, promotes bone formation, prevents bone resorption, and increases the dynamic strength of bone. Magnesium (200 mg) in combination with vitamin B6 (50 mg) may marginally reduce anxiety-related premenstrual symptoms. Oral administration of magnesium, 500 mg/day, has been reported to relieve exercise-induced muscle spasms within a few days,7 but conflicting trial results for magnesium in the treatment of fibromyalgia have been reported. Magnesium counteracts vasospasm; inhibits platelet aggregation; stabilizes cell membranes; and affects serotonin recep- Chapter 79 / Magnesium (Mg) 593 tors, nitric oxide, and eicosanoid synthesis and release. Randomized clinical trials are urgently needed to determine whether magnesium supplementation will alter the natural his- tory of chronic cardiovascular diseases and whether any benefits detected are limited to patients with magnesium deficiency. Magnesium has been used in the treatment of preeclampsia and eclamp- sia, certain types of ventricular tachycardia, and acute asthma in certain patients. Magnesium deficiency has been postulated to be associated with disor- ders as diverse as cardiac disease; hypertension; preeclampsia; diabetes mel- litus; depressed immunity; premenstrual syndrome; osteoporosis; mood swings; and peroxynitrite damage presenting as migraine, multiple sclerosis, glaucoma, or Alzheimer’s disease. When magnesium supplements are taken, an appropriate regimen includes calcium, with the ratio of calcium to magnesium being 2:1. A review of pathophysiological, clinical and therapeutical aspects, Panminerva Med 43:177-209, 2001. Brighthope I: Nutritional medicine tables, J Aust Coll Nutr Env Med 17:20-5, 1998. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Toba Y, Kajita Y, Masuyama R, et al: Dietary magnesium supplementation affects bone metabolism and dynamic strength of bone in ovariectomized rats, J Nutr 130:216-20, 2000. Manuel y Keenoy B, Moorkens G, et al: Magnesium status and parameters of the oxidant-antioxidant balance in patients with chronic fatigue: effects of supplementation with magnesium, J Am Coll Nutr 19:374-82, 2000. Gawaz M: Antithrombocytic effectiveness of magnesium, Fortschr Med 114: 329-32, 1996. Fox C, Ramsoomair D, Carter C: Magnesium: its proven and potential clinical significance, South Med J 94:1195-201, 2001. Eray O, Akca S, Pekdemir M, et al: Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation, Eur J Emerg Med 7:287-90, 2000. An update on physiological, clinical and analytical aspects, Clin Chim Acta 294:1-26, 2000. Johnson S: The multifaceted and widespread pathology of magnesium deficiency, Med Hypotheses 56:163-70, 2001. Taylor M: Nutritional management of an elderly patient—the importance of magnesium, J Aust Coll Nutr Env Med 18:21, 1999. Manganese is an important trace element that facilitates synthesis of mucopolysaccharides, lipids, and thyroxine. It is an antioxidative transition metal and helps prevent tissue damage caused by lipid oxidation. As part of the enzyme superoxide dismutase, manganese reduces the risk of exposure to free radi- cals. As a constituent of pyruvate carboxylase, it generates oxaloacetate, a substrate in the tricarboxylic acid (Krebs) cycle, and may play a role in glu- cose homeostasis. It also activates enzymes involved in cartilage synthesis; facilitates formation of urea; and activates various kinases, decarboxylases, transferases, and hydroxylases. The recom- mended intake ranges from 2 to 5 mg daily; however, this may be excessive because some consider a manganese intake of more than 10 mg per day from food or 4. As a component of superoxide dismutase, manganese may be used as a marker to help define therapeutic strategies in the clinical management of glioblastoma. Patients with glioblastomas and high levels of manganese superoxide dismutase show a median survival time of 6. Fatigue, weakness, anorexia, apathy, depression, and disturbed sleep have all been reported. Irritability, hallucinations, and poor coordination have been reported in persons with severe manganism. Aberrant manganese metabolism may be found in certain cases of multiple sclerosis and amy- otrophic lateral sclerosis. Brighthope I: Nutritional medicine tables, J Aust Coll Nutr Env Med 17:20-5, 1998. Ria F, Landriscina M, Remiddi F, et al: The level of manganese superoxide dismutase content is an independent prognostic factor for glioblastoma. Aschner M: Manganese: brain transport and emerging research needs, Environ Health Perspect 108(suppl 3):429-32, 2000.

Hypothermia is a common cause of death at sea purchase propranolol 40 mg with visa 3 arteries blocked, especially if one is tossed to sea during an emergency cheap 40mg propranolol overnight delivery cardiovascular disease who. Always have appropriate cold weather gear easily accessible propranolol 80 mg heart disease congestive heart failure, and in adequate supply for the entire crew discount propranolol 80mg amex coronary artery elasticity. The shipboard setting poses some particular risks and is often a more demanding physical environment than being on land. Any kind of impairment of your mental and physical functioning can put one at higher risk overall on shipboard. Over-the-counter medications that make one drowsy or sleepy such as antihistamines for allergies, 6-17 sleeping pills, and cough medications can adversely affect judgment and physical functioning. Always maintain an ongoing awareness of physical and mental capabilities and take that into account when you plan work and non-work activities each day. The primary responsibility to yourself and those around you is not to take risks when under the influence of alcohol or other drugs or medications. These last points are particularly important on board ship where sun exposure can occur for many hours of the day and in relatively unprotected situations. When on liberty, always wear seat belts: everyone in the moving vehicle, driver and passengers, front seat and back, should always wear seat belts. Personal Hygiene Personal hygiene protects the health of each individual and the entire crew. The health of a seaman depends, in part, on his own efforts to maintain habits of cleanliness and neatness. To prevent disease spread by fecal contamination, hands must always be washed immediately after urinating or defecating. A little petroleum jelly, cold cream, or hand lotion rubbed into the skin after washing may help to prevent chapping and resulting skin infections. Personal cleanliness includes good care of the skin, hair, nails, mouth and teeth, and proper maintenance of clothing, towel, and other personal gear. A daily bath or shower, particularly in hot weather or after working in hot compartments, is conducive to good health and lessens the possibility for infection. Care of the mouth and teeth including toothbrushing after meals and daily use of dental floss, are essential to prevent gum disease, infection, and tooth decay. Before brushing natural teeth, any partial dentures should be removed and carefully cleaned with a brush and mild soap or special denture cleanser. Full artificial dentures should be cleaned regularly after meals, and particularly at bedtime, to remove food residue, which can cause moth odor and encourage infection. Short hair can be easier to maintain and can be safer working around equipment with moving parts. Cleanliness aboard ship can 6-18 be encouraged by providing sufficient hot water in convenient wash places to facilitate cleansing. Installation of a laundry and drying room for washing clothes also contributes to cleanliness. Each member of the crew should use their own towel and be responsible for their personal cleanliness. Dirty towels should be laundered as soon as possible and not allowed to accumulate. Single-use paper towels are satisfactory only if waste receptacles are provided and used. The only sure way to prevent sexually transmitted diseases is not to have sexual contact. The risk can be reduced (but not eliminated) by having only one partner and using condoms. Be sure you know the proper way to use condoms – unprotected penetration and the exchange of any sexual fluids can transmit disease. If you always wake up after only five or six hours and find it impossible to drop off again, do not worry; this is probably as much sleep as you need. There is generally no cause for concern if you usually wake up briefly once or twice during the night. However, seven to eight hours of sleep is the average needed to sustain maximal mental and physical performance indefinitely. Needing an alarm to awaken, morning sleepiness, and afternoon tiredness and drop in performance may be signs of insufficient sleep. If you have trouble falling asleep, remember that coffee, tea, colas, chocolate, many cold medicines and pain relievers, and diet aids contain caffeine or related stimulants, which can keep you awake and prevent restful sleep. Many people drink alcohol at night to help them sleep though this may not be a restful sleep. Lie down to sleep at the same time every night and rise at the same time in the morning. Studies have shown that people who work variously changing shifts are not as well rested as those on regular daily schedules. Sleep during daytime hours is often disrupted by noise, light or by natural circadian (day-night) cycles. When standing watch at night, be aware that in more risky situations or undertaking more difficult physical activities, extra concentration is needed. An individual is more likely to fall asleep in a boring or non– stimulating environment and while performing a monotonous task. If an emergency suddenly develops at sea, immediately gaining peak performance can be difficult. Tasks that are likely to be very sensitive to sleep impairment include monitoring data displays for critical levels, monitoring for quality control purposes, and sentry or patrol duties. It can be difficult for the individual to accurately assess his/her limitations when sleep impaired and may be unable to do the complex task of objectively judging one’s own performance. Increasingly, the periodic checkup is being used not so much for the detection of disease as for the opportunity to counsel about health habits, so that we can do a better job of personal disease prevention. The periodic screening tests in several specific areas are important, as recommended by the U. Women over age 20, have a cervical Pap smear taken every year or two; after three normal tests, have a Pap smear every 3 years from then on. Mammography is a yearly screening procedure recommended for women after age 40 (with high risk) or age 50. After age 50, tests for colorectal cancer (digital rectal exam and occult blood test) are advisable on an annual basis. In addition, sigmoidoscopy every 5 years or colonoscopy every 10 years is recommended. Serum cholesterol and triglycerides should be measured at intervals of five years, and more frequently if total cholesterol is elevated. Fasting blood glucose (diabetes screening) should be checked every 3 years; earlier in those with a strong family history. Immunizations have had far greater impact on health than all other health services put together. Thechniques for estimating your future health risk, termed health risk appraisal or health assessment, have been developed. Responses are entered into a computer to estimate the likelihood of developing medical problems such as heart disease and cancer. Remember that the results are estimates and the predictions are only averages: some people will do better than the estimates predict, and others worse.

With an estimated 33 million users discount 40mg propranolol overnight delivery capillaries in fingers, the use of regularly order propranolol 40 mg fast delivery capillaries uk, tend to be polydrug users propranolol 80 mg line cardiovascular disease games,1 best propranolol 40 mg arteries in the arm, 2 meaning that they opiates and prescription opioids may not be as widespread use more than one substance concurrently or sequentially, as the use of cannabis, but opioids remain major drugs of usually with the intention of enhancing, potentiating or potential harm and health consequences. Note: Estimated percentage of adults (ages 15-64) who used drugs in the past year. Con- and problem drug use refect the best available information tinuing to use a drug is considered a conditioned response in 2014, and changes compared with previous years largely refect information updated by 20 countries, mostly in North to the positive reinforcement that the person receives as a result of using the drug. The concept of problem ence, which is characterized by, among other things, the drug use has been used in prior editions of the World Drug desire and compulsion to use drugs despite evidence of Report as a proxy for estimating the number of people with drug use disorders. In 2014, the estimated number of problem harmful consequences, the development of tolerance — drug users increased by 2 million over the previous year, which by increasing the quantity of the drug or drugs to achieve refects an increase in the estimated number of opiate users the same effects and a state of withdrawal — and the nega- in North America and Western and Central Europe, as well tive consequences experienced when the person stops using as in the total number of users of cocaine, amphetamines 9 the drug or drugs. Drugs taken together can have a cumulative or synergistic effect, which increases the overall psychoactive experience; the distinction between users of a particular drug, present- that is one way in which drug users may address the devel- ing an interlinked or cyclical epidemic of drug use and opment of tolerance. Additionally, tolerance” — the pharmacological ability of one drug to such a pattern of drug use presents challenges to health have generally the same effect on the nervous system as professionals responding to emergencies related to drug another drug. The phenomenon of cross-tolerance explains use, as well as to those treating people with disorders in part the frequent substitution of drugs that have a similar related to the use of multiple drugs. Examples of such patterns of drug use include the use of alcohol with benzodiazepines, cannabis or cocaine; Recent trends in polydrug use and concurrent use of heroin, benzodiazepines and antihista- substitution between drugs mines; the use of alcohol or other opioids (methadone, Polydrug use encompasses wide variations in patterns of fentanyl etc. One stimulants such as cocaine and amphetamines is fairly such pattern is “speedballing” — when cocaine is injected common and has been widely reported. Findings from a cohort of regular heroin and methampheta- mine injectors in Melbourne, Australia”, International Journal of 12 Charles P. Bicket, “Poly drug use in heroin 13 Vanderplasschen and others, “Poly substance use and mental health” addicts: a behavioral economic analysis”, Addiction, vol. Landry, Understanding Drugs of Abuse: The Processes of 15 Francesco Leri, Jule Bruneau and Jane Stewart, “Understanding Addiction, Treatment and Recovery (Arlington, Virginia, American polydrug use: review of heroin and cocaine co-use” Addiction, vol. Note: The information presented in the map is for 2014 or the latest year since 2010 for which the information is available. The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). For example, a study showed that an the high prevalence and associated morbidity and mortal- increase in the price of heroin resulted in an increase in 20 ity of the non-medical use of prescription opioids have benzodiazepine and cocaine purchases. In another study, 22 become a major public health issue, a recent increase in cross-price elasticity analysis showed that in the case of heroin use has triggered a sharp increase in heroin-related heroin there was significant substitution with prescription 23, 24 overdose deaths. Several aspects have driven this 16 Jenny Chalmers, Deborah Bradford and Craig Jones, “The effect of 21 Chalmers and others, “The effect of methamphetamine and heroin methamphetamine and heroin price on polydrug use: a behavioural price on poly drug use” (see footnote 16). Bald- win, “Relationship between nonmedical prescription-opioid use 17 Horyniak and others, “How do drug market changes affect charac- and heroin use”, New England Journal of Medicine, vol. The Cannabis use in the past yearCocaine use in the past year highest rate of past-year heroin use was among cocaine users (91. Nine Cocaine use in the past yearNon-medical use of opioid painkillers in out of 10 people who used heroin self-reported co-use of Cannabis use in the past yearNon-medical use of opioid painkillers inthe past year heroin with at least one other drug, and most used heroin Non-medical use of opioid painkillers inthe past yearNon-medical use of other prescription Cocaine use in the past yearthe past yearNon-medical use of other prescriptiondrugs in the past year 25 Ibid. Non-medical use of other prescriptiondrugs in the past year Source: Christopher M. Jones and others, “Vital signs: demo- 26 Compton and others, “Relationship between nonmedical prescrip- graphic and substance use trends among heroin users – UnitedNon-medical use of opioid painkillers indrugs in the past year tion” (see footnote 22). Non-medical use of other prescription extent of heroin use and are an underestimation. Nevertheless, in drugs in the past year the absence of other trend data, this is used to inform the trends in with at least three other drugs. Jones and others, “Vital signs: demographic and the country (United States, Drug Enforcement Administration, substance use trends among heroin users – United States, 2002- National Drug Threat Assessment Summary (October 2015). Ever injected heroin Ever injected opioid pain relievers In Hungary, in the period 2009-2012 a shortage of heroin and an increase in local availability of synthetic cathinones Source: Christopher M. Those reporting non-medical use of prescription opioids for over 100 days in the past year were 40 nearly eight times more likely to report dependence on heroin than those who reported less frequent non-medical 20 use of prescription opioids. Nevertheless, given the large number Amphetamine of non-medical users of prescription opioids, even a small Heroin proportion who switch to heroin use has translated into a Source: Anna Péterfi and others, “Changes in patterns of injecting much higher number of people using heroin. Analysis suggests that the problem of opioid use is not substance-specific and requires holistic approaches to 34 Compton and others, “Relationship between nonmedical address the interconnected epidemic through prevention prescription opioids use” (see footnote 22). Findings from a cohort of regular In Australia, the heroin market changed considerably after heroin and methamphetamine injectors in Melbourne, Australia”, 2000; heroin went from being highly accessible (cheap, International Journal of Drug Policy, vol. The change resulted in a decrease between November 2008 and March 2010, examined the in the prevalence and frequency of injecting heroin, as well impact that the changing market dynamics might have had as a decline in adverse health consequences related to 42 39 on drug use patterns. Also, a combination of heroin and 38 Horyniak and others, “How do drug market changes affect charac- methamphetamine was more commonly used by current teristics of injecting initiation and subsequent patterns of drug use? This practice has been reported particularly nature, as well as a latent indicator, of trends in drug use among marginalized migrant subpopulations of persons resulting in severe health consequences. In 2013, almost 71 per cent of clients in treat- Opioids stand out as a major drug of concern in North ment reported having used more than one substance, with America, Europe (particularly Eastern and South-Eastern polydrug use being more common among cocaine (80 per Europe) and Asia. Misuse of prescrip- nearly three out of every four people in treatment for drug tion drugs and use of cannabis and cocaine were most use disorders are treated for opioid use. The number of frequently reported among users of opioids, while primary people in treatment for cocaine use disorders remains quite cocaine users more frequently reported use of cannabis high in Latin America and the Caribbean, where nearly and opioids. Treatment related to cannabis use users in the Islamic Republic of Iran disorders is more prominent in Africa and Oceania than in other regions. This may be related to the limited treat- In the Islamic Republic of Iran, where opiates remain the ment options for users of other drugs in Africa, where main drug consumed by problem drug users, metham- nearly half of all admissions to treatment for drug use dis- phetamine use has emerged as another drug of concern in orders are for the use of non-specified substances, which recent years. Methamphetamine use has also been masks the true extent of the use of drugs of concern other described as a new form of polydrug use among opiate than cannabis. For example, a for disorders related to the use of amphetamines has been study at an opioid substitution treatment clinic in Zahedan increasing in Asia, half of the people in treatment for drug Province showed that methamphetamine use among use in the region are treated for opioid use disorders. At the global level, the proportion of 48 Zahra Alam-Mehrjerdi, Azarakhsh Mokri and Kate Dolan, “Methamphetamine use and treatment in Iran: a systematic review amphetamine-using cohort and correlates of methamphetamine from the most populated Persian Gulf country”, Asian Journal of dependence”, Journal of Substance Use, vol. Barr and Alireza Noroozi, “Meth- Iran”, International Journal of Drug Policy, vol. Mehrjerdi, “Crystal in Iran: methamphetamine or heroin Malaysia”, Journal of Food and Drug Analysis, vol. For each region, the number of people in100,000 4,000 treatment for the use of different drugs in the region is weighted by the total number of people treated in a country. Member States in Oceania (inFirst time in treatment particular, Australia and New Zealand) do not provide information on the proportion of people in treatment for the first time, and therefore informa-2,000 0 0 tion for Oceania is not reflected in the figures. Note: Data used for each point in time are based on reporting from countries in each region for the year cited or the latest year for which data are available. In Asia,CannabisCannabis OpioidsOpioids CocaineCocaine Amphetamine-type stimulantsAmphetamine-type stimulantsment for cannabis use disorders has increased in all regionsOther drugsOther drugs among those being treated for disorders related to the use since 2003, it has done so to a much greater extent in the of amphetamines, nearly 60 per cent are reported to be in Americas, Western and Central Europe and Oceania. At treatment for the first time; in Europe and Latin America, the same time, in the Americas, the proportion of people nearly 40 per cent of those being treated for cocaine use in treatment for cocaine use has decreased over the past disorders are reported to be in treatment for the first time. In Eastern and South-Eastern Europe, treat- treatment for disorders related to the use of other drugs, ment for opioid use disorders has been a matter of concern including those seeking such treatment for the first time. This reflects increasing trends in the use of cannabis and The increase in treatment demand related to cannabis use amphetamines and the resulting increase in people seeking in some regions warrants special attention. Treatment at or cocaine use disorders; however, they are typically in present consists of behavioural or psychosocial interven- their thirties and, in many subregions, reflect an ageing 52 tions that may vary from a one-time online contact, or a cohort of users in treatment and show an overall decrease brief intervention in an outpatient setting, to a more com- in the proportion of treatment demand. Budney and others, “Marijuana dependence and its treat- cohort”, Drug and Alcohol Dependence, vol. However, lower risk does not in awareness of potential problems associated with can- mean no risk: there are harmful health effects associated nabis use; and changes in the availability of treatment for with a higher frequency of cannabis use and initiation at cannabis.

We know from Frankel and Romer (1999) and Alcalá and Ciccone (2004) that a country’s exposure to international markets has a strong causal effect on the productivity of its firms purchase 40 mg propranolol with visa blood vessels genital area. It is therefore conceivable that a significant loss of market shares by Italian firms might have produced the productivity slowdown 40 mg propranolol amex capillaries with a complete lining. A second (related) shock is the increased need for flexibility of the labor force cheap propranolol 40mg with mastercard cardiovascular system multiple choice questions, induced by a combination of technology and globalization (Dorn and Hanson effective propranolol 80mg arteries kidneys, 2015). While Italy has long been known to lag behind other developed countries in terms of the quality of its institutions, some observers (see Gros 2011) have noted that, starting from the mid-1990s, Italy experienced a sharp decline in government quality as measured by the World Bank’s Worldwide Governance Indicators. This decline might have caused Italy to fall further behind on the technological frontier. We also find no evidence of the labor misallocation hypothesis: Productivity in sectors where labor turnover has been disproportionately large in the United States (which has some of the laxest labor regulations among developed countries) did not grow disproportionately less in countries with less flexible labor markets. Similarly, sectors that are more government-dependent do not exhibit disproportionately lower productivity growth in countries, like Italy, that experienced deterioration on indicators of quality of government. We find this effect to be economically and statistically indistinguishable from zero. Consistent with Garicano and Heaton (2010), we find that more meritocratic firms exploit computing power more effectively. All these findings raise a further question: Why does Italy lag behind in the adoption of meritocratic management practices? The main advantage of a loyalty-based management is its ability to function in environments where legal enforcement is either inefficient or unavailable. Among developed countries, Italy stands out both for its inefficient legal system and for the diffusion of tax evasion and bribes. We look at three major sources of external constraints: access to finance, labor market regulation, and bureaucracy. We find that, while in our sample meritocratic firms are less likely to experience any of these constraints, this effect is significantly weaker for Italian firms. Thus, it appears that in Italy, loyalty-based management has a relative advantage in overcoming financial and bureaucratic constraints. Consistent 4 with this hypothesis, they find that between 2001 and 2003 the productivity growth of Italian firms correlated negatively with the share of temporary workers employed. In our seven-country sample of manufacturing firms (2001–07), we find that these findings do not generalize. Controlling for the share of temporary workers in our specification does not change any of our results. Milana and Zeli (2004) were the first to correlate these delays with sluggish aggregate productivity growth in the years 1996–99. In our analysis, while we confirm that lower investment is part of the problem, we show that the reduced productivity of such investments is indeed even more important. Schivardi and Schmitz (2017) build on our findings to construct a model that explains productivity differences between Germany and Italy. In section 2 we explore the possible structural causes for the lack of productivity growth using sector-level data. In section 4, we provide suggestive evidence of why, in Italy, loyalty prevails over merit in the selection and rewarding of managers. This level of disaggregation makes it possible to focus on inter- sectoral variations in productivity growth, by controlling for country-level determinants with country fixed effects. It also allows us to study the interaction between country-specific factors and industry-specific factors. We end our sample in 2007 to avoid mixing the structural problems of Italy before the two crises with the effect of the two crises. Capital formation and growth accounting series are unavailable for 11 countries for the main period of interest (1995–2006). We use this data at the finest sectorial decomposition for which growth accounting series are made available, with the following three exceptions: 1) we aggregate 5 sectors 50 to 52 (wholesale and retail trade) in order to merge to the dataset some explanatory variables that are available at industry level; 2) we use the aggregate sector 70t74 instead of 70 (real estate) and 71t74 (other business services) because Italian data presents some specific issues regarding the attribution of real 1 estate assets between sectors 70 and 71t74 ; and 3) we drop, as customary, public sector and compulsory social services (sectors 75-99) from the analysis altogether, due to the well-known issues related to the 2 measurement of public sector productivity. Apart from growth accounting series, we also use sector-level price deflators for output, intermediate inputs, and labor, as well as capital compensation and real capital stock indices. We use the March 2011 update of this dataset because it covers all sectors, it offers the largest sample size in terms of country/sector/year and has a sector definition that is compatible with trade and layoff series, allowing us to merge the series. In the appendix, we also use an earlier release of the dataset (using the same sector definition) for robustness. B Country-level variables To construct a proxy variable for meritocratic management at the country level, we use a measure of the extent to which firms select, promote, and reward people based on merit, starting from the Global Competitiveness Report Expert Opinion Surveys (2012). We compute the variable Country Meritocracy as the average numerical answer to the following three questions: 1) “In your country, who holds senior management positions? It is important to note that these indicators are standardized within years: they do not, therefore, carry cardinal meaning, but only ordinal meaning. Also, we use different variables based on hard data, and expressed in levels, to perform robustness tests in our appendix. This index is constructed by combining country-level data on mobile network coverage, the number of secure internet servers, internet bandwidth, and electricity production. Finally, we also use, as a control variable, the size of the shadow economy as a percentage of the total economy, as computed by Schneider (2012). C Sectoral exposure to shocks We measure how much each sector is dependent on the government, by counting news in major economics and financial news outlets from the Factiva News Search database over the period 2000–2012. Government dependence is defined, for each sector, as the ratio of total news having “government” as topic (see table 1 for details) to total news for that sector. We identify government-related news using the subject tags in the Factiva news search engine. The dataset covers 14,000 manufacturing firms from seven European countries (Austria, France, Germany, Hungary, Italy, Spain, and the United Kingdom). In addition to balance sheet information obtained from the Amadeus-BvD databank, this dataset contains response data from a survey undertaken in 2010 that covers a wide range of topics related to the firms’ operations. In particular, this survey contains questions about managerial practices that allow us to compute a measure of firm-level meritocracy. Specifically, the questions are: 1) “Can managers make autonomous decisions in some business areas? We construct our meritocracy index by summing the number of affirmative answers to the above questions. The survey also provides information on the constraints faced by firms by asking managers which of the following (non-mutually exclusive) factors prevent the growth of their firms: 1) financial constraints, 2) labor market regulation, 3) legislative or bureaucratic restrictions, 4) lack of management and/or organizational resources, 5) lack of demand, and 6) other. To measure these constraints, we create three dummy variables that represent, respectively, whether the firm chooses the first, second, or third option. We transform this information into a choice of whether the share of managers related to the controlling family is above or equal to 50% because the resulting percentagesanswers are highly clustered around this threshold. If the 0%, 50% and 100% valuespercentage of managers affiliated with the controlling family is not reported, we use 1 minus the percentage of managers not affiliated with the controlling family (if this is reported). If this is also missing, but the absolute levels are reported, we compute the percentage ourselves from the absolute figures. We use the percentage of the firm’s workforce that has a college degree, as well as the percentage that, in 2008, was 7 employed on a fixed-term contract. A Decomposing output growth The first basic fact we want to pin down is that the Italian growth problem is fundamentally a productivity one. The first term on the right-hand side is the labor productivity growth, the second is the growth in the number of hours worked per employee (intensive margin), and the last one is the growth in the employment ratio (extensive margin). This decomposition shows that Italy lags behind in labor productivity growth (only 7.

In 1992 the World Health Organization • Vertical; from mother to baby transmission has been recommended that all children worldwide should observed globally discount propranolol 80mg without prescription blood vessels in legs, but the risk is considered to be less receive Hepatitis B vaccination effective propranolol 40 mg cardiovascular jobs. Existing Risk factors data indicates a wide variation in prevalence rates • Recipients of unscreened blood cheap propranolol 80 mg free shipping coronary heart 6 acupuncture, blood products from region to region generic propranolol 80mg mastercard cardiovascular zone weight loss, with some countries in and organ transplants Africa, Eastern Mediterranean, South-East Asia and • Intravenous drug users Western Pacific having high prevalence rates. It should • Healthcare workers be noted that seroprevelance studies taken from each • Those undergoing any invasive procedure such country may involve different population groups and as skin piercing and tattooing may not be entirely representative. Patients should be advised to see a doctor or attend a health Prevention of spread facility every 6–12 months so that their liver Patients should be informed and advised regarding function can be monitored. Patients should be advised not to share to cirrhosis are also less likely to respond to household items such as razors or toothbrushes. Patients suitable for therapy • Those with chronic infection It is recommended that screening should be • When liver biopsy shows evidence of fibrosis and accompanied by pre and post test counselling. The low risk of sexual and Risk factors more likely to be associated with household transmission should be discussed. Advice and • A high viral load information should be realistic and appropriate to • Male the individual. For patients who go on to develop liver cancer, the outlook is poor, but chemotherapy may prolong life for a few years. An understanding of modes of transmission can allow individuals to reduce their risk of contracting infection. Statement for the World Conference of obstacles to healthy development, World Health Ministers Responsible for Youth, Lisbon, http:// Organization report on infectious diseases, http:// www/unaids. Weekly Epidemiological Record, Hepatitis C - Global World Health Organization (1998). Aims of care: promote optimal respiratory function, alleviate cough, maintain adequate oxygenation. Possible interventions • Assess respiratory function and vital signs – findings should be recorded as a baseline assessment and 4 hourly thereafter. Changes in bowel habits Symptoms: diarrhoea related to opportunistic infection Possible causes: Cryptosporidosis, Kaposi’s sarcoma in G. The patient’s weight should be taken daily and an accurate record of fluid intake and output maintained. Gently pat the skin dry with a soft cloth or towel rather than wiping it to prevent fragile skin from tearing. Aims of care: prevent dehydration, alleviate distress, restore normal dietary habits. The patient’s weight should be recorded daily and an accurate record of fluid intake and output should be maintained. If the patient is very weak or unconscious it may be necessary for the nurse to provide oral care using gauze soaked in mouthwash or fresh water, and using the index finger, gently cleanse the mouth, applying petroleum jelly to lips to prevent cracking. Possible interventions • Assessment of vital signs and body temperature should be recorded 4 hourly. Aims of care: Alleviate pain Possible Interventions • Assess the location, type, intensity and persistence of the pain. Aims of care: minimise the effects of neurological dysfunction, maintain a safe environment. Possible Interventions • Assess baseline mental status, including the patient’s ability to understand. Speak in a calm and relaxed manner, give one instruction at a time, and repeat information as necessary. Aims of care: keep the patient well nourished, prevent further weight loss, attain normal body weight Possible interventions • Assess previous dietary patterns including food likes and dislikes and any known allergies. Aims of care: establish a trusting/therapeutic relationship, improve motivation and self esteem, reduce the risk of self harm. Aims of care: establish a relationship in which the patient feels able to discuss their concerns, reduce/alleviate anxiety. Possible interventions • Set time aside to spend with the patient and encourage them to express their worry by asking open-ended questions. Weakness and fatigue Possible causes: Weakness and fatigue are common during acute and in chronic end-stage liver disease. Aims of care: to ensure personal hygiene needs are met, to ensure patient comfort, to ensure adequate rest is achieved, to promote self care when appropriate. Possible interventions • Assist the patient with washing or bathing according to their needs and wishes • Assist the patient with toileting as the patient requires • Assist the patient in achieving a comfortable position to promote rest and sleep, whilst preventing risk of pressure sore development • Promote self care and independence when appropriate, assessing and reviewing the patients needs continuously. Aims of care: Ensure adequate intake of nutritional needs Possible interventions • Patients with nausea and vomiting may require intravenous fluids of glucose and saline. This may be necessary due to the increased protein catabolism that occurs with acute liver disease and it can promote liver tissue repair. Jaundice Impaired liver function inhibits the body’s ability to excrete bile salts normally. Excess bile salts are excreted and deposited in the skin resulting in jaundice and generalized itching. Possible interventions • Administer antipruritics as prescribed (often not very effective). Possible complications due to cirrhosis Ascities Damage to liver cells can cause disturbance in the bodies excretory system, causing fluid to accumulate in the abdominal cavity. Possible interventions • Observe all patients with hepatitis B for possible accumulation of fluid in the abdomen. This may progress in terminal illness to incontinence of urine and faeces and coma. Possible Interventions • Observe the patient for early signs of altered mental functioning and report any changes promptly. Risk of haemorrhage The liver may be unable to metabolise Vitamin K, in order to produce prothrombin (clotting factor), therefore the patient is potentially at risk of haemorrhage. Aims of care: to minimize risk of hæmorrhage Possible interventions • Observe for symptoms of anxiety, epigastric fullness, restlessness and weakness, which may indicate bleeding. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals Updated December 2017 I. Roles and Responsibilities of Authors, Contributors, ical Journal Reviewers, Editors, Publishers, and Owners 1. Publishing and Editorial Issues Related to Publication porting of research and other material published in medical in Medical Journals journals, and to help authors, editors, and others involved A. Corrections, Retractions, Republications, and Ver- in peer review and biomedical publishing create and dis- sion Control tribute accurate, clear, reproducible, unbiased medical journal B. The recommendations may also provide useful in- and Retraction sights into the medical editing and publishing process for the C. Duplicate and Prior Publication These recommendations are intended primarily for use 3. Acceptable Secondary Publication by authors who might submit their work for publication to 4. Supplements, Theme Issues, and Special Series no authority to monitor or enforce it. Sponsorship of Partnerships should use these recommendations along with individual I. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals Journals that follow these recommendations are en- that qualify an individual for authorship.

All swimming pools must be filtered buy 80mg propranolol free shipping through arteries zip, treated 40 mg propranolol visa cardiovascular endurance test, tested effective 40mg propranolol cardiovascular blood vessels quiz, and water quality records maintained: 1 propranolol 40 mg low price coronary artery purpose. Water quality records must be maintained daily and should include date/time, disinfectant level, pH, and temperature. Unlike swimming pools that are treated to prevent disease transmission, wading pools are typically filled with tap water and may or may not be emptied and disinfected on a daily basis. Thus, many enteric pathogens (germs from the stool) can be easily spread by contaminated wading pool water that children may accidentally swallow while playing in the pool. Spread of these infections can occur even under the care of the most diligent and thoughtful childcare providers, since these infections can be spread even when the child only has mild symptoms. Children who are ill with vomiting or diarrhea should not play in a swimming or wading pool. Consumer Product Safety Commission warns that young children can drown in small amounts of water, as little as two inches deep. Submersion incidents involving children usually happen in familiar surroundings and can happen quickly (even in the time it takes to answer the phone). In a comprehensive study of drowning and submersion incidents involving children under 5 years old, 77% of the victims had been missing from sight for 5 minutes or less. The Commission notes that toddlers, in particular, often do something unexpected because their capabilities change daily. Child drowning is a silent death, since there is no splashing to alert anyone that the child is in trouble. As an alternative to wading pools, sprinklers provide water play opportunities that are not potential hazards for drowning or disease transmission. Water toys such as water guns should be washed, rinsed, sanitized, and air dried after each use. Influenza (flu), pneumococcal (pneumonia), and pertussis (whooping cough) vaccines can prevent some serious respiratory illnesses. When you are at the clinic or hospital: Cover your cough or sneeze with a tissue and dispose of the used tissue in the waste basket. Follow procedures outlined in the childcare or school’s Bloodborne Pathogen Exposure Plan. They suck their fingers and/or thumbs, put things in their mouths, and rub their eyes. These habits can spread disease, but good handwashing can help reduce infection due to these habits. Caregivers who teach and model good handwashing techniques can reduce illness in childcare settings and schools. Recommendations for hand hygiene products Liquid soap - Recommended in childcare and schools since used bar soap can harbor bacteria. If hands were visibly soiled, hands must be washed with soap and warm running water as soon as it is available, because the alcohol-based hand rubs are not effective in the presence of dirt and soil. Use the nailbrush after diapering or assisting with the toilet activities, before and after food preparation, and whenever nails are soiled. They can break off into food and have been implicated in disease outbreaks in hospital nurseries. Check with the local licensing agency regarding any food codes that may restrict staff from wearing artificial nails when handling and preparing food. Ways for staff to keep hands healthy Cover open cuts and abrasions less than 24 hours old with a dressing (e. They need to wash their hands after going to the bathroom, after the diapering process, after helping a child with toileting, before preparing food, after handling raw meat, before a change of activities, before eating, after playing out of doors, and after nose blowing. After drying their hands, children and caregivers need to turn off the faucets with a paper towel. Key concepts of prevention and control: Handwashing (see pgs 57-60) – the single most effective way to prevent the spread of germs. The purpose of using barriers is to reduce the spread of germs to staff and children from known/unknown sources of infections and prevent a person with open cuts, sores, or cracked skin (non-intact skin) and their eyes, nose, or mouth (mucous membranes) from having contact with another person’s blood or body fluids. Examples of barriers that might be used for childcare and school settings include: - Gloves (preferably non-latex) when hands are likely to be soiled with blood or body fluids. This prevents the escape of bodily fluids rather than protecting from fluids that have escaped. Other examples that most likely would not be needed in the childcare or school setting are: - Eye protection and face mask when the face is likely to be splattered with another’s blood or body fluid. Proper use of safety needle/sharp devices and proper disposal of used needles and sharps are also part of standard precautions. Possible blood exposure Participation in sports may result in injuries in which bleeding occurs. The following recommendations have been made for sports in which direct body contact occurs or in which an athlete’s blood or other body fluids visibly tinged with blood may contaminate the skin or mucous membranes of other participants or staff: Have athletes cover existing cuts, abrasions, wounds, or other areas of broken skin with an occlusive dressing (one that covers the wound and contains drainage) before and during practice and/or competition. Caregivers should cover their own non-intact skin to prevent spread of infection to or from an injured athlete. Hands should be thoroughly cleaned with soap and water or an alcohol-based hand rub as soon as possible after gloves are removed. Wounds must be covered with an occlusive dressing that remains intact during further play before athletes return to competition. The disinfected area should be in contact with the bleach solution for at least 1 minute. If the caregiver does not have the appropriate protective equipment, a towel may be used to cover the wound until an off-the-field location is reached where gloves can be used during the medical examination and treatment. Everyone (childcare staff, teachers, school nurses, parents/guardians, healthcare providers, and the community) has a role in preventing antibiotic misuse. Viruses and bacteria are two kinds of germs that can cause infections and make people sick. Antibiotics are powerful medicines that are mostly used to treat infections caused by bacteria. These drugs cannot fight viruses; there is a special class of medicines called antivirals that specifically fight infections caused by viruses. There are many classes of antibiotics, each designed to be effective against specific types of bacteria. When an antibiotic is needed to fight a bacterial infection, the correct antibiotic is needed to kill the disease- producing bacteria. Anti-bacterial drugs are needed when your child has an infection caused by bacteria. The symptoms of viral infections are often the same as those caused by bacterial infections. Sometimes diagnostic tests are needed, but it is important that your doctor or healthcare provider decide if a virus or bacteria is causing the infection. You need lots of extra rest, plenty of fluids (water and juice), and healthy foods. Some over-the- counter medications, like acetaminophen (follow package directions or your healthcare providers’ instructions for dosage) or saline nose drops may help while your body is fighting the virus. Viral infections (like chest colds, acute bronchitis, and most sore throats) resolve on their own but symptoms can last several days or as long as a couple weeks. When Antibiotics Are Needed Are antibiotics needed to treat a runny nose with green or yellow drainage? Color changes in nasal mucous are a good sign that your body is fighting the virus. If a runny nose is not getting better after 10 to 14 days or if other symptoms develop, call your healthcare provider. Most cases of acute bronchitis (another name for a chest cold) are caused by viruses, and antibiotics will not help. Children with chronic lung disease are more susceptible to bacterial infections and sometimes they need antibiotics.

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