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By: J. Fabio, M.B. B.CH. B.A.O., Ph.D.

Clinical Director, Joan C. Edwards School of Medicine at Marshall University

These records shall be used to establish on-going assessment and evaluation of individual progression from baseline data through time holistic medicine cheapest nitroglycerin. These items include: Medical history / medical conditions Head and Neck Eyes and vision Ears and hearing Dental Nose medicine hat alberta canada cheap nitroglycerin 6.5mg line, Oropharynx medicine vs surgery 2.5mg nitroglycerin with mastercard, Trachea treatment definition statistics buy nitroglycerin with american express, Esophagus, & Larynx Lungs and Chest Wall Heart and Vascular system Abdominal organs and gastrointestinal system Reproductive system Urinary system Spine and axial skeleton Extremities Neurological disorders Skin Blood and blood-forming organs Endocrine and metabolic disorders Systemic diseases and miscellaneous conditions Tumors and malignant diseases Psychiatric conditions Chemicals, drugs, and medications 2. Each medical evaluation shall include a medical history (including exposure history), physical examination, blood tests, urinalysis, vision tests, audiograms, spirometry, Request for Proposal (Short Version) Page 2 of 5 40 Appendix A: Program Development Samples and Templates chest x-ray (as indicated), electrocardiogram with cardiac stress test, cancer screening, and immunizations and infectious disease screening. This session shall be considered a requirement but with an itemized price listed separately. The Contractor is aware there are written screening instruments and voluntary Employee Assistance Programs available to individuals however the Contractor desires the psychological well-being of fire department members to be regularly and consistently assessed. Any issues discovered during the brief meeting may be referred to follow-up care as needed and such follow-up will not be included in the scope of work or pricing for this proposal. Scheduling shall be coordinated with the Fire Chief and shall include at least consecutive, with a start time of and continue through a conclusion of. Optimally the physicals will start, but must be entirely completed (excluding follow-up requirements) by, 20. Any blood work, urinalysis, or other pre-examination work should be completed in such a way for the examining physician to have results to review with the individual at the time of the exam. If multiple trips are involved, this should be identified in the proposal for scheduling purposes. In an effort to reduce the impact on the participating members, it is desirable for the physical and psychological evaluations be conducted during the same appointment. If two separate visits are required for the lab work and the physical exam, the psychological evaluations can be coupled with either. The Contractor wishes to have the physicals conducted at: in a mobile facility provided by the vendor rather than inside the fire department facilities. Request for Proposal (Short Version) Page 3 of 5 41 Appendix A: Program Development Samples and Templates Proposals that are not able to provide mobile facilities will not be excluded from consideration. If mobile facilities are not available, facility locations(s) to be used shall be identified along with any deviation in scheduled hours identified in item #5. A summary profile shall be provided to the Contractor through the Fire Chief identifying trends, department-wide recommendations, and general data summary including comparisons between other benchmarks. Options: Providers who have that capability and wish to price respirator fit testing as an option to be completed during the medical evaluation shall price this service as option #1. Providers who have that capability and wish to price flu vaccine immunizations as an option to be completed during the medical evaluation shall price this service as option #2. Providers who have that capability and wish to price Hepatitis B immunizations as an option to be completed during the medical evaluation shall price this service as option #3. The program will be jointly administered by the Task Force while the formal contract will be between the selected, through its Fire Department with joint collaboration with proposer and the City of Local(s). Vendor must provide the facility, equipment, and technical expertise to deliver the medical evaluation. In the event the Task Force elects to have additional work elements performed by the selected Proposer, the contract may be extended. To limit out-of-service time through preventative early intervention of potential problems To recommend types of case-management/rehabilitation for injuries to decrease reinjury rates 2. Medical information must be collected in a database that can provide both aggregate reports as well as specific individual information, that is electronically secure to only pre-authorized medical providers. Request for Proposal (Long Version) Page 4 of 29 47 the medical provider will identify and retain medical records, in a manner of their Fire Fighter personal medical choosing, so that they can be secured as records. Requests for authorization to transfer or destroy any or all of the medical information must be made in writing to the Task Force at least 30 days in advance. Aggregate data may be provided to Local(s), and the Wellness Coordinator, to look at general trends, as long as data from the report cannot lead to the identity of a specific individual. The Task Force will define content and process for dissemination of any information.

Risk D: Consider therapy modification Protea s e Inhi bi tors: Ma y decrea s e the meta bol i s m of Fus i di c Aci d treatment yeast infection male buy discount nitroglycerin 6.5mg on-line. Risk D: Consider therapy modification Moni tori ng Pa ra meters Moni tor l i ver functi on tes ts symptoms 11 dpo discount nitroglycerin online amex, i ncl udi ng bi l i rubi n peri odi ca l l y duri ng s ys temi c thera py Moni tori ng: La b Tes ts Moni tor l i ver functi on tes ts medications recalled by the fda generic nitroglycerin 2.5 mg amex, i ncl udi ng bi l i rubi n peri odi ca l l y duri ng s ys temi c thera py Dos a ge Forms Exci pi ent i nforma ti on pres ented when a va i l a bl e (l i mi ted medications you can take while pregnant purchase nitroglycerin visa, pa rti cul a rl y for generi cs); cons ul t s peci fi c product l a bel i ng. Va ri a ti on 1: Fl uta mi de: Ora l: 250 mg every 8 hours [tota l dos e/cycl e = 21,000 mg] Gos erel i n a ceta te: SubQ: 3. Ga ba penti n Lexi -Drugs Onl i ne Engl i s h Jump To Fi el d (Sel ect Fi el d Na me) Speci a l Al erts Antiepileptics: Increased Risk of Suicidal Behavior or Ideation - Updated: December 2008 Engl i s h the U. The pool ed a na l ys i s of 199 cl i ni ca l tri a l s i nvol vi ng 11 a nti epi l epti c drugs (ca rba ma zepi ne, di va l proex s odi um, fel ba ma te, ga ba penti n, l a motri gi ne, l eveti ra ceta m, oxca rba zepi ne, prega ba l i n, ti a ga bi ne, topi ra ma te, zoni s a mi de) a s ei ther monothera py or a s a djuva nt thera py s howed tha t pa ti ents recei vi ng a n a nti epi l epti c ha d a 0. Chronic pain (unlabeled use): Ora l: 300-1800 mg/da y gi ven i n 3 di vi ded dos es ha s been the mos t common dos a ge ra nge Postoperative pain (unlabeled use): 300-1200 mg 1-2 hours before s urgery Postherpetic neuralgia: Da y 1: 300 mg, Da y 2: 300 mg twi ce da i l y, Da y 3: 300 mg 3 ti mes /da y; dos e ma y be ti tra ted a s needed for pa i n rel i ef (ra nge: 1800-3600 mg/da y, da i l y dos es >1800 mg do not genera l l y s how grea ter benefi t) Dos i ng: El derl yStudi es i n el derl y pa ti ents ha ve s hown a decrea s e i n cl ea ra nce a s a ge i ncrea s es. Thi s i s mos t l i kel y due to a ge-rel a ted decrea s es i n rena l functi on; dos e reducti ons ma y be needed. Dos i ng: Pedi a tri c Anticonvulsant: Ora l Children 3-12 years: Ini ti a l: 10-15 mg/kg/da y i n 3 di vi ded dos es; ti tra the to effecti ve dos e over ~3 da ys; dos a ges of up to 50 mg/kg/da y ha ve been tol era ted i n cl i ni ca l s tudi es Children 3-4 years: Effecti ve dos e: 40 mg/kg/da y i n 3 di vi ded dos es Children 5-12 years: Effecti ve dos e: 25-35 mg/kg/da y i n 3 di vi ded dos es Children >12 years: Refer to a dul t dos i ng. Note: If ga ba penti n i s di s conti nued or i f a nother a nti convul s a nt i s a dded to thera py, i t s houl d be done s l owl y over a mi ni mum of 1 week Dos i ng: Rena l Impa i rmentChi l dren 12 yea rs a nd Adul ts: See ta bl. Hemodi a l ys i s: Di a l yza bl e Ga ba penti n Dos i ng Adjus tments i n Rena l Impa i rment Creatinine Clearance Daily Dose Range (mL/min) 60 >30-59 >15-29 151 Hemodialysis2 1 300-1200 mg ti d 200-700 mg bi d 200-700 mg da i l y 100-300 mg da i l y 125-350 mg Cl cr<15 mL/mi nute: Reduce da i l y dos e i n proporti on to crea ti ni ne cl ea ra nce. Dos a ge mus t be a djus ted for rena l functi on; when gi ven 3 ti mes da i l y, the ma xi mum ti me between dos es s houl d not exceed 12 hours. Extempora neous l y Prepa redA 100 mg/mL s us pens i on wa s s ta bl e for 91 da ys when refri gera ted or 56 da ys when kept a t room tempera ture when compounded a s fol l ows: Tri tura the s i xty-s even 300 mg ta bl ets i n a morta r, reduce to a fi ne powder, then a dd a s ma l l a mount of one of the fol l owi ng vehi cl es to ma ke a pa s te; then a dd the rema i ni ng vehi cl e i n s ma l l qua nti ti es whi l e mi xi ng: Vehi cl e 1. Disease-related concerns: Rena l i mpa i rment: Us e wi th ca uti on i n pa ti ents wi th s evere rena l i mpa i rment; dos e a djus tment requi red. Other warnings/precautions: Tumori geni c potenti a l: Ma l e ra t s tudi es demons tra ted a n a s s oci a ti on wi th pa ncrea ti c a denoca rci noma (cl i ni ca l i mpl i ca ti on unknown). Geri a tri c Cons i dera ti ons Studi es i n the el derl y ha ve s hown a decrea s e i n cl ea ra nce a s a ge i ncrea s es. Thi s i s mos t l i kel y due to a ge-rel a ted decrea s es i n rena l functi on; ca l cul a ti ons of Cl cr recommended s i nce dos e reducti ons ma y be needed. Pregna ncy Ri s k Fa ctorC Pregna ncy Cons i dera ti ons Ani ma l s tudi es ha ve documented tera togeni c effects. La cta ti onEnters brea s t mi l k/us e ca uti on Brea s t-Feedi ng Cons i dera ti ons Ga ba penti n i s excreted i n huma n brea s t mi l k. A nurs ed i nfa nt coul d be expos ed to ~1 mg/kg/da y of ga ba penti n; the effect on the chi l d i s not known. Us e i n brea s t-feedi ng women onl y i f the benefi ts to the mother outwei gh the potenti a l ri s k to the i nfa nt. Moni tori ng: La b Tes ts Moni tor s erum l evel s of concomi ta nt a nti convul s a nt thera py. It ma y ta ke 2-3 weeks to a chi eve des i red res ul ts; ma y ca us e phys i ca l a nd/or ps ychol ogi ca l dependence. Do not s top medi ca ti on a bruptl y, ma y l ea d to i ncrea s ed s ei zure a cti vi ty. You ma y experi ence drows i nes s, l i ghthea dednes s, i mpa i red coordi na ti on, di zzi nes s, or bl urred vi s i on (us e ca uti on when dri vi ng or enga gi ng i n ta s ks requi ri ng a l ertnes s unti l res pons e to drug i s known); na us ea, vomi ti ng, or a norexi a (s ma l l frequent mea l s, frequent mouth ca re, chewi ng gum, or s ucki ng l ozenges ma y hel p); cons ti pa ti on (i ncrea s ed exerci s e, fl ui ds, frui t, or fi ber ma y hel p); di a rrhea (buttermi l k, yogurt, or boi l ed mi l k ma y hel p); pos tura l hypotens i on (us e ca uti on when cl i mbi ng s ta i rs or cha ngi ng pos i ti on from l yi ng or s i tti ng to s ta ndi ng); or decrea s ed s exua l functi on or l i bi do (revers i bl e). Ca ps ul e: 100 mg, 300 mg, 400 mg Neuronti n: 100 mg, 300 mg, 400 mg Sol uti on, ora l: Neuronti n: 250 mg/5 mL (480 mL) [cool s tra wberry a ni s e fl a vor] Ta bl et: 100 mg, 300 mg, 400 mg, 600 mg, 800 mg Neuronti n: 600 mg, 800 mg Generi c Ava i l a bl eYes: Ca ps ul e, ta bl et Ma nufa cturerPfi zer Inc Pri ci ng: U. Hi gh a ffi ni ty ga ba penti n bi ndi ng s i tes ha ve been l oca ted throughout the bra i n; thes e s i tes corres pond to the pres ence of vol ta ge-ga ted ca l ci um cha nnel s s peci fi ca l l y pos s es s i ng the a l pha -2-del ta -1 s ubuni t. Thi s cha nnel a ppea rs to be l oca ted pres yna pti ca l l y, a nd ma y modul a the the rel ea s e of exci ta tory neurotra ns mi tters whi ch pa rti ci pa the i n epi l eptogenes i s a nd noci cepti on. Pha rma codyna mi cs /Ki neti cs Abs orpti on: 50% to 60% from proxi ma l s ma l l bowel by L-a mi no tra ns port s ys tem Di s tri buti on: Vd: 0. Denta l Hea l th: Va s ocons tri ctor/Loca l Anes theti c Preca uti ons No i nforma ti on a va i l a bl e to requi re s peci a l preca uti ons Menta l Hea l th CommentDoubl e-bl i nd s tudi es ha ve fa i l ed to di fferenti a the thi s drug from pl a cebo when us ed a s a n a djuncti ve trea tment for bi pol a r di s order. Ga ba penti n Bi pol a r Di s order Study Group," Bipolar Disord, 2000, 2(3):249-55.

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Admi ni s tra ti on: Ora l Ora l: Do not open va ri a bl e rel ea s e ca ps ul es medicine lock box safe nitroglycerin 6.5mg. Ma y i nterfere wi th s l eep; a dmi ni s teri ng s ome products a few hours before bedti me ma y hel p mi ni mi ze i ns omni a medicine lookup buy generic nitroglycerin line. La cta ti onEnters brea s t mi l k/contra i ndi ca ted (by s ome ma nufa cturers) Brea s t-Feedi ng Cons i dera ti ons Excreti on of gua i fenes i n i nto brea s t mi l k i s unknown medicine quinidine order discount nitroglycerin on-line. The us e of thi s combi na ti on whi l e brea s t-feedi ng i s contra i ndi ca ted by s ome ma nufa cturers treatment jaundice order nitroglycerin australia. Drug Intera cti ons Anta ci ds: Ma y decrea s e the excreti on of Al pha -/Beta -Agoni s ts. Admi ni s tra ti on: Ora l Long-a cti ng ta bl et formul a ti ons ma y be broken i n ha l f, but s houl d not be crus hed or chewed. Di eta ry Cons i dera ti ons Gi l tus s Li qui d conta i ns phenyl a l a ni ne 3. La cta ti onEnters brea s t mi l k/ not recommended Brea s t-Feedi ng Cons i dera ti ons Phenyl ephri ne i s excreted i n brea s t mi l k. Advers e Rea cti ons Rea cti ons whi ch fol l ow ha ve been reported wi th the combi na ti on product; s ee i ndi vi dua l drug monogra phs for a ddi ti ona l a dvers e rea cti ons tha t ma y be expected from ea ch a gent. Index Terms Gua i fenes i n, Dextromethorpha n Hydrobromi de, a nd Phenyl ephri ne Hydrochl ori de; Phenyl ephri ne Hydrochl ori de, Gua i fenes i n, a nd Dextromethorpha n Hydrobromi de Copyri ght (c) Lexi -Comp, Inc. Dos i ng: Pedi a tri cExpectorant/decongestant/cough suppressant: Ora l: Chi l dren 2-6 yea rs: Nucofed Pedi a tri c: 2. Us e ca uti on wi th pers i s tent cough or chroni c cough (a s wi th s moki ng, a s thma, chroni c bronchi ti s, emphys ema) or cough a ccompa ni ed by exces s i ve phl egm. See i ndi vi dua l a gents La cta ti onExcreti on i n brea s t mi l k unknown/us e ca uti on Brea s t-Feedi ng Cons i dera ti ons Ps eudoephedri ne a nd codei ne a re excreted i n brea s t mi l k. Gua i fenes i n: No s i gni fi ca nt effects or compl i ca ti ons reported Ps eudoephedri ne: Xeros tomi a (norma l s a l i va ry fl ow res umes upon di s conti nua ti on). The new product l a bel i ng wi l l s ta the "Do not us e i n chi l dren under four yea rs of a ge. Admi ni s tra ti on: Ora l Long-a cti ng formul a ti ons s houl d not be crus hed or chewed. Special populations: Debi l i ta ted pa ti ents: Us e wi th ca uti on i n debi l i ta ted, s eda ted a nd/or pa ti ents confi ned to the s upi ne pos i ti on. The us e of thi s product duri ng pregna ncy i s contra i ndi ca ted by s ome ma nufa cturers. Risk C: Monitor therapy Ca nna bi noi ds: Ma y enha nce the ta chyca rdi c effect of Sympa thomi meti cs. Denta l Hea l th: Effects on Denta l Trea tmentKey a dvers e event(s) rel a ted to denta l trea tment: Dextromethorpha n: No s i gni fi ca nt effects or compl i ca ti ons reported Gua i fenes i n: No s i gni fi ca nt effects or compl i ca ti ons reported Ps eudoephedri ne: Xeros tomi a (norma l s a l i va ry fl ow res umes upon di s conti nua ti on). Dos i ng: Pedi a tri c Cough (expectorant): Ora l: Chi l dren: 6 months to 2 yea rs: 25-50 mg every 4 hours, not to exceed 300 mg/da y 2-5 yea rs: 50-100 mg every 4 hours, not to exceed 600 mg/da y 6-11 yea rs: 100-200 mg every 4 hours, not to exceed 1. Admi ni s tra ti on: Ora l Do not crus h, chew, or brea k extended rel ea s e ta bl ets. Do not us e for pers i s tent or chroni c cough (a s wi th s moki ng, a s thma, chroni c bronchi ti s, emphys ema) or i f cough i s a ccompa ni ed b exces s i ve phl egm unl es s di rected to do s o by hea l thca re provi der. Pregna ncy Ri s k Fa ctorC Pregna ncy Cons i dera ti ons Reproducti on s tudi es ha ve not been conducted. Centra l nervous s ys tem: Di zzi nes s, drows i nes s, hea da che Derma tol ogi c: Ra s h Endocri ne & meta bol i c: Uri c a ci d l evel s decrea s ed Ga s troi ntes ti na l: Na us ea, vomi ti ng, s toma ch pa i n Pos tma rketi ng a nd/or ca s e reports: Ki dney s tone forma ti on (wi th cons umpti on of l a rge qua nti ti es) Drug Intera cti ons There a re no known s i gni fi ca nt i ntera cti ons. Do not chew or crus h extended rel ea s e ta bl et; ta ke wi th a ful l gl a s s of wa ter. You ma y experi ence s ome drows i nes s (us e ca uti on when dri vi ng or enga gi ng i n ta s ks requi ri ng a l ertnes s unti l res pons e to drug i s known). Report exces s i ve drows i nes s, res pi ra tory di ffi cul ty, l a ck of i mprovement, or wors eni ng of condi ti on. Dos i ng: El derl yIni ti a l: 4 mg once da i l y, i ncrea s e every 1-2 weeks Dos i ng: Hepa ti c Impa i rmentDos a ge a djus tment i s proba bl y neces s a ry; however, no s peci fi c gui del i nes a re a va i l a bl. Other warnings/precautions: Abrupt wi thdra wa l: Abrupt di s conti nua ti on ca n res ul t i n nervous nes s, a nxi ety a nd ra rel y, rebound hypertens i on (occurs 2-4 da ys a fter wi thdra wa l).

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For the same reason medicine 2000 order nitroglycerin 2.5 mg without prescription, the Strategikon advises against attempts to reverse withdrawals by wheeling or turning around-the men would run headlong into the ordered ranks of the Persian cavalry formation bearing down on them treatment warts buy 6.5mg nitroglycerin mastercard, because the Persians strive to remain in tight formation even when in rapid pursuit treatment thesaurus purchase generic nitroglycerin on line. That is their weakness in general: "[the Persians] are vulnerable to at- the Strategikon of Maurikios 291 tacks and encirclements from an outflanking position 72210 treatment order nitroglycerin amex. But after writing that they were all the same, the author draws a distinction by noting that only the Tьrk and Avars have organized military forces, and therefore are stronger than the other steppe peoples in fighting pitched battles. It is obvious who was the main enemy at the time of writing, the Avars: "scoundrels, devious and very experienced in military matters. It is also noted that they emphasize training in mounted archery-which indeed requires much training to be effective at all. Under the heading of enemy strengths to be avoided, there are a number of warnings. What appears to be a long battle line conceals units of different sizes that have hidden depth, and there will also be a hidden reserve: "Separate from their main formation, they have an additional force which they can send out to ambush a careless adversary. The implication is that scouting is necessary all around enemy forces because their frontal appearance understates their real strength. When pursuing fleeing enemies, they will not stop to plunder but will press on until they achieve total destruction. The implication is that if 292 the Byzantine Art of War no orderly retreat with strong rear guards is possible, it is better to stand and fight rather than retreat. The contrary is also true: if they retreat or even flee, there should be no hasty pursuit, because they are practiced in the quick turnaround and counterattack, and also in luring pursuers into ambushes by feigned retreats, as most famously in 484 when the Sasanian Shah Peroz was killed by the Hephthalites. When it comes to vulnerabilities to be exploited, the first is the reverse of their great horse mobility. Unlike the Byzantine cavalry, the steppe warriors did not have just one mount and a spare at most: they rode with vast herds of horses that provided their basic nourishment of blood and milk and also many remounts, so they could ride back to fetch a fresh horse even in the midst of combat (they kept them hobbled next to their tents). There is an eyewitness description of the Cumans (or Qipchaks), who replaced the Pechenegs as the steppe warrior ally/enemies of Byzantium in the twelfth century: Each of them has at least ten or twelve horses, which must follow them everywhere they wish to lead them; they ride first one and then the other. Each of the horses, when they are on a journey, carries a nosebag containing food, it eats as it follows its master, not ceasing to travel by night or by day. He should attack them about the month of February or March, when their horses are weakened by the hardships of winter. But the stronger remedy was to campaign in a way that would maneuver them away from good grazing grounds, and into lands already overgrazed, or lacking in grass to begin with. They were cavalrymen, not infantry, not formidable when fighting on foot and wholly the Strategikon of Maurikios 293 untrained in fighting in close formation. Therefore their cavalry could be readily halted by infantry in disciplined ranks, so long as there were enough bowmen to prevent the steppe archers from simply standing in front of them to discharge their arrows into the massed ranks. Moreover, while the steppe riders were the best horsemen, they were not heavy cavalry and had no heavy infantry with them, so they could be defeated by Byzantine cavalry charges followed by hand-to-hand fighting. Accordingly, the Strategikon points to the necessity of choosing level and unobstructed ground for the battle. This suggests that for all their efforts, the Byzantines could not count on superior archery against the steppe masters of the art, that they could not outrange the mounted archers as with their other enemies. The right move was therefore to close the distance as soon as possible, to negate archery on both sides and replace it with the contest of sword, dagger, and mace-after the cavalry charge had delivered its impact. It is also remarked that "night attacks are also effective," presumably because the steppe enemy could not fall back on standard drills to overcome confusion. There is also a political vulnerability: "Composed of so many tribes as they are, they have no sense of kinship or unity. It was the fate of the Byzantines that they had to contend not only with the Sasanian empire in the east and the mounted archers of the steppe to the north, but also with the warriors of northern Europe, collectively dubbed "light-haired peoples" in the Strategikon. Prokopios describes how they fought: At this time the Franks, hearing that both Goths and Romans had suffered severely by the war. Now the iron head of this weapon [the cele- 294 the Byzantine Art of War brated francisca] was thick and exceedingly sharp on both sides, while the wooden handle was very short. And they are accustomed always to throw these axes at one signal in the first charge and thus to shatter the shields of the enemy and kill the men. When the Lombards under Alboin invaded Italy, seizing lands from Byzantine control all the way down to Benevento near Naples, they came with Gepids, Bavarians, and other Germanic camp followers, and also Bulghars it seems, but assimilation into a common Lombard identity was rapid. It is with a high compliment that the author of the Strategikon begins his comments: "The light-haired races place great value on freedom. Daring and impetuous as they are, they consider any timidity and even a short retreat as a disgrace.