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A fraction is said to have been reduced to its lowest terms when it is no longer possible to divide the numerator and denominator by the same number generic testosterone anadoil 40mg with amex. This process of converting or reducing fractions to their simplest form is called cancellation generic 40mg testosterone anadoil with visa. Remember – reducing or simplifying a fraction to its lowest terms does not change the value of the fraction discount testosterone anadoil 40mg otc. If you have a calculator, then there is no need to reduce fractions to their lowest terms: the calculator does all the hard work for you! Equivalent fractions Consider the following fractions: 1 3 4 12 2 6 8 24 Each of the above fractions has the same value: they are called equivalent fractions. If you reduce them to their simplest forms, you will notice that each is exactly a half. Now consider the following fractions: 1 1 1 3 4 6 If you want to convert them to equivalent fractions with the same denominator, you have to find a common number that is divisible by all the individual denominators. For each fraction, multiply the numbers above and below the line by the common multiple. So for Fractions and decimals 27 the first fraction, multiply the numbers above and below the line by 4; for the second multiply them by 3; and the third multiply them by 2. So the fractions become: 1 4 4 1 3 3 1 2 2 × and and 3 4 12 3 4 12 6 2 12 1 1 1 4 3 2 , and equal , and , respectively. For example: 14 7 4 14 +7 – 4 17 + – = 32 32 32 32 32 To add (or subtract) fractions with the different denominators, first convert them to equivalent fractions with the same denominator, then add (or subtract) the numerators and place the result over the common denominator as before. For example: 1 1 1 3 2 4 3– 2 + 5 – += – + = = 4 6 3 12 12 12 12 12 Multiplying fractions It is quite easy to multiply fractions. You simply multiply all the numbers ‘above the line’ (the numerators) together and then the numbers ‘below the line’ (the denominators). For example: 2 3 2 ×3 6 × = 5 7 ×7 35 However, it may be possible to ‘simplify’ the fraction before multiplying, e. You can sometimes ‘reduce’ both fractions by dividing diagonally by a common number, e. You will probably encounter fractions expressed or written like this: 2 5 2 3 whichisthesameas ÷ 3 5 7 7 In this case, you simply invert the second fraction (or the bottom one) and multiply, i. A decimal number consists of a decimal point and numbers both to the left and right of that decimal point. Multiplying decimals Decimals are multiplied in the same way as whole numbers except there is the decimal point to worry about. If you are not using a calculator, don’t forget to put the decimal point in the correct place in the answer. At first, it looks a bit daunting with the decimal points, but the principles covered earlier with long multiplication also apply here. The decimal point is placed as many places to the left as there are numbers after it in the sum. This is particularly true in infusion rate calculations, as it is impossible to give a part of a drop or a millilitre (mL) when setting an infusion rate. If the number after the decimal point is 5 or more, then add 1 to the whole number, i. Converting decimals to fractions It is unlikely that you would want to convert a decimal to a fraction in any calculation, but this is included here just in case. The value of this multiple of 10 is determined by how many places to the right the decimal point has moved, i. The following table explains the Roman numerals most commonly seen on prescriptions. It doesn’t matter whether they are capital letters or small letters, the value is the same. The position of one letter relative to another is very important and determines the value of the numeral. Consider the following: 10 × 10 × 10 × 10 × 10 Here you are multiplying by 10, five times. Instead of all these 10s, you can write: 105 We say this as ‘10 to the power of 5’ or just ‘10 to the 5’. 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. 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. 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.

Mental Health Issues “We recommend turning our legal problems over to lawyers and our financial or medical problems to professionals discount 40mg testosterone anadoil mastercard. Just as we wouldn’t suggest that an insulin-dependent diabetic addict stop taking their insulin cheap testosterone anadoil 40mg visa, we don’t tell mentally ill addicts to stop taking their prescribed medication order testosterone anadoil 40mg on line. Responsibility rests with the member to be honest about their condition with informed healthcare professionals, and to evaluate their treatment and medication options. For me, the disease of addiction and my mental disorder must be dealt with simultaneously. Although the steps are my best defense against relapse, no amount of step work, prayer, meeting attendance, or calling my sponsor will change the fact that I have mental illness. Ultimately, the decision to take medi- cation or not to take medication is a deeply personal one. For some addicts, this may mean seeking mental health treatment and taking medication as prescribed. Our experience shows 20 We should share honestly with our doctor and sponsor, examine our motives, and decide what course of action is right for us. Members in this situation often find that after a period of time in recovery they are able to stop taking this medication under the supervision of their doctor. We should share honestly with our doctor and sponsor, examine our motives, and decide what course of action is right for us. A mental health professional can assist us in understanding our illness and explain our treatment options. We have found collectively that medicine, religion, and psychiatry alone are not sufficient to treat the disease of addiction. We have found that a meeting may not be the ideal place to share personal details about our diagnosis and treatment. With the freedom to share honestly in meetings comes the responsibility to seek a solution. With the use of any medication, we must be honest with ourselves, our healthcare team, and our sponsor about our feelings and motives. Meetings are a powerful way of carrying our message of recovery to the addict who still suffers. Our first reaction may be apprehension, but it is important that we welcome every addict seeking recovery. Our collective attitude should be one of loving acceptance toward all addicts, regardless of any other problems they may experience. The foundation we have in recovery can be a crucial factor in our decision-making process. If we are able to communicate, we let the professionals treating us know that we are recovering addicts. We accept that we are not in control of the situation and trust the professionals who are treating us. It is helpful to remember that the principles of recovery apply to every area of our life, even in a crisis. I explained my addiction to the doctor and asked if not taking the medication would be life-threatening. When we break a bone, experience a high fever, or cut ourselves, we may require emergency care. Relying on others can help alleviate the fear and irrational thinking that we may experience during a medical emergency. However, in some circumstances, we may be involved in an accident or traumatic injury and be forced to act very quickly. During these times we rely on our Higher Power for guidance and maintain our faith. When we are faced with a medical emergency, we can tap into the spiritual connection we have developed with a Higher Power through the steps. The Basic Text tells us that the power that brought us to the program is still with us and will continue to guide us if we allow it. The presence of people we trust and faith in a Higher Power are both valuable tools. The strength we gain from this support can help us 25 make decisions that will enhance our recovery. Relying on others alleviates the fear and irrational thinking that come with isolation. The spiritual connection we have developed with a Higher Power helps guide our decisions and provides a source of strength. A chronic illness is a persistent, often life-threatening, and incurable condition. Our experience is that chronic illnesses may have periods of remission and recurrence. Regardless of our particular circumstances, we apply the spiritual principles of our program to living with our chronic illness.

In Sjogren�s syndrome the progressive lymphocytic infltration gradually de- stroys the secretory acini of the major and minor salivary glands which results in hyposalivation and fnally in xerostomia generic testosterone anadoil 40 mg on line. Another explanation for the loss of glan- dular function may be relad to an inhibition of nerve stimuli of the glands [39] discount testosterone anadoil 40mg with visa. Mravak-Stipetic: Xerostomia - diagnostics and treatmenThe hypofunction of egzocrine glands causes dryness of mucosal surfaces order 40mg testosterone anadoil amex, mosnoticeable of the mouth and eyes [36]. Irradiation and cytostatic drugs lead to sialoa- denitis which in turn may lead to irreversible damage of acinar cells of major and minor salivary glands and resulin hyposalivation and permanenxerostomia [1]. Long-rm morbidity in patients receiving combined radiation and chemotherapy is signifcanbecause of salivary gland hypofunction, radiation-induced xerostomia, mucositis and severe dysphagia [20]. Although radiotherapy was earlier considered the moscommon cause of sali- vary gland hypofunction and xerostomia, in recenyears medications have emer- ged as the moscommon cause, particularly in elderly people. Ihas been shown thaamong the moscommonly prescribed drugs 80% of them cause xerostomia with more than 500 medications causing an adverse efecof dry mouth [2,16,20,40]. The moscommon medications causing hyposalivation are those with an- ticholinergic activity, sympatomimetics and benzodiazepines [2]. The risk for xerostomia will increase the synergistic efects of xerogenic medications, multiple medications (polypharmacy),higher dose of medication and the time of starting the medication. This is the main reason thathe prevalence of medication-induced xe- rostomia is highesin the elderly. Mravak-Stipetic: Xerostomia - diagnostics and treatmenDehydration of the organism can secondarily afecsalivation, and changes in the quantity of war in the body can afecthe wetness of oral mucosa which may crea a feeling of dry mouth [2,20,29,34]. The feeling of dry mouth can occur also due to the change in cognitive abilities of the central nervous sysm following a cerebral vascular acciden(stroke) (48) and sensory disturbances in the mouth. Al- rations in autonomic innervation of salivary glands with predominansympathetic stimulation, during episodes of acu anxiety or stress, cause changes of salivary composition thacreas sensation of oral dryness. There are also psychological conditions thalead to feeling of oral dryness such as depression and insomnia as well [2, 29, 33, 34, 48]. Drugs associad with dry mouth (2) Drugs thadirectly damage salivary glands Cytotoxic drugs Drugs with anticholinergic activity Anticholinergic agents: atropine, atropinics and hyoscine Antirefux agents: proton-pump inhibitors (e. Mravak-Stipetic: Xerostomia - diagnostics and treatmenquality of life, requireing careful planning of long-rm dental and oral care. Parotid glands exposed to doses of grear than 60 Gy sustain permanendamage with no recovery in salivary hypofunction with time [20]. Frequently seen acu accompanying oral side efects include mucositis, dysphagia, erythema and desquamation of oral mucosa. La complications are resulof cronic injury on exposed tissue; mucosa, vasculature, salivary glands, connective tissue and bone. The type and severity of these changes are relad directly to total dose adminisred, fraction size and duration of the treatmenas well as on volume of irradiad tissue. Qualitative changes in saliva include increased viscosity, increased organic component, alred pH, decreased transparency, and yellowbrown discolo- ration [50]. The assessmenof the severity of xerostomia in patients with head and neck cancers afer radiotherapy and its efecon quality of life (QoL) over a period of 6 months, in a study of Kakoei eal. Iwas also shown when multiple daily treatments are given in small fractionad doses (<1,8-2 Gy) this does noincreae the incidence of xerostomia [20]. Iis obvious thathe quality of life in patients who underwenradiotherapy in the head and neck region is strongly infuenced by xerostomia and all its consequ- ences. Patients usually sufer from dry, vulnerable and painful oral mucosa, have difculties in all oral functions (chewing, swallowing and particularly speech), per- 76 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Mravak-Stipetic: Xerostomia - diagnostics and treatmenception of tas is alred or even partially lost. The risk for dental caries increases secondary to number of factors: shif to cariogenic fora, reduction of salivary pH, and loss of mineralizing components. The reduction in salivary fow may contribu to the risk of fungal infection and osonecrosis of the mandible. All these secon- dary efects of radiation-induced xerostomia contribu to the so-called xerostomia- syndrome [54]. Patients with xerostomia may be asymptomatic withoucomplaints, or more frequently, complain of dry mouth and develop various complications. Pati- ents usually experience difculties while speaking, chewing, swallowing (dyspha- gia) and wearing dentures [1-3,15,20,34]. Oral mucosa is dry and sensitive, prone to injuries, fungal infection and in- fammation, painful with burning sensations, tas is alred and halitosis is pre- sent. In patients with Sjogren�s syndrome in which exocrine glands and the connec- tive tissue is afecd patients complain abouthe dryness of the eyes. These initial changes may precede clinical eviden- ce of mucosal changes or measurable reduction in salivary gland function [36].

Treatment failure may be due to drug resistance buy 40mg testosterone anadoil overnight delivery, poor adherence to treatment 40mg testosterone anadoil free shipping, poor quality of drugs discount testosterone anadoil 40 mg online, unusual pharmacokinetic properties in that individual, or misdiagnosis. The development of malarial symptoms and signs 28 days or more after the initiation of malaria therapy is considered as indicative of a new infection, and requires appropriate investigation. In all patients with suspected severe/complicated malaria with or without fever or history of fever, the use of a confirmatory blood slide is recommended, so that parasitaemia can be quantified. Note that, high parasitaemia is not always present in severe disease and initial blood slide examination may be negative. When effective malaria prevention strategies are in place, the number of children with fever due to malaria may markedly reduce. This information will be used to determine the need for change in national diagnostic guidelines. In patients with non-severe symptoms and signs, anti-malaria treatment may be withheld if the diagnostic test is negative, and the patient carefully observed. In patients with severe symptoms and signs, anti-malaria treatment should be offered if the malaria test results are negative, and repeat blood film examination is recommended to confirm the diagnosis. Although clinicians may treat patients for malaria even if the test results are negative, they must note that, in all cases, fever may have another cause. Apart from preventive measures, early diagnosis and complete treatment are the important modalities that have been adopted to contain the disease. In view of widespread chloroquine resistance in Plasmodium falciparum infection, and other recent developments, the national policy has been revised to meet these challenges. These guidelines are the collaborative effort of National Vector Borne Disease Control Programme, National Institute of Malaria Research and experts from different parts of the country. The aim of this endeavour is to guide the medical professionals on the current methods of diagnosis and treatment based on the national drug policy (2008). This manual deals with the treatment of uncomplicated malaria and specific antimalarials for severe disease. The general management should be carried out according to the clinical condition of the patient and judgement of the treating physician. The warning signs of severe malaria have been listed so as to recognize the condition and give the initial treatment correctly before referring them to a higher facility. It is hoped that these guidelines will be useful for doctors involved in the management of malaria. Prompt and effective treatment is also important for controlling the transmission of malaria. The continued treatment of such cases with chloroquine is probably one of the factors responsible for increased proportion of P. A revised National Drug Policy on Malaria has been adopted by the Ministry of Health and Family Welfare in 2008 and these guidelines have therefore been prepared for clinicians involved in the treatment of malaria. The fever is often accompanied by headache, myalgia, arthralgia, anorexia, nausea and vomiting. The symptoms of malaria can be non-specific and mimic other diseases like viral infections, enteric fever etc. Malaria should be suspected in patients residing in endemic areas and presenting with above symptoms. It should also be suspected in those patients who have recently visited an endemic area. The user’s manual should always be read properly and instructions followed meticulously. It is the responsibility of the clinician or technician doing a rapid test for malaria to ensure that the kit is within its expiry date and has been transported and stored under recommended conditions. Early diagnosis and treatment of cases of malaria aims at: • Complete cure • Prevention of progression of uncomplicated malaria to severe disease • Prevention of deaths • Interruption of transmission • Minimizing risk of selection and spread of drug resistant parasites. Patient should be advised to stop primaquine immediately if he develops symptoms like dark coloured urine, yellow conjunctiva, bluish discolouration of lips, abdominal pain, nausea, vomiting etc. Presently, Artemether + Lumefantrine fixed dose combination and blister pack of artesunate + mefloquine are also available in the country. Artemisinin derivatives must never be administered as monotherapy for uncomplicated malaria. These rapidly acting drugs, if used alone, can lead to development of parasite resistance. If a slide result is obtained later, the treatment should be adjusted according to species. The algorithm for diagnosis and treatment is as follows: Where microscopy result is available within 24 hours Clinically suspected malaria case Take slide for microscopy P.