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By doing so the Contracting Parties substantially ease the commitment given that the investment shall be bound not only by the conditions of entry but also by any new measure issued in the form of a law or regulation by the host State (see box 12) purchase levitra plus pills in toronto erectile dysfunction pills at walmart. Without prejudice to its laws and regulations buy discount levitra plus 400mg erectile dysfunction after stopping zoloft, each Contracting party shall accord to investments and activities with such investments by the investors of the other Contraction Party treatment not less favorable than that accorded to the investments and associated activities by its own investors buy cheap levitra plus 400mg on line impotence 28 years old. Neither Contracting Party shall subject investments and activities associated with such investments by the investors of the other Contracting Party to treatment less favorable than that accorded to the investments and associated activities by the investors of any third State. Examples of general exceptions include: public order and morals, national security, and emergency exceptions and the denial of benefits clause. The first refers to the benefits or privileges granted by a State by virtue of free trade agreements, customs unions, labour integration markets or any other sort of regional economic arrangements. The second exception refers to international agreements that partly or mainly deal with taxation issues. The reason is that under double-taxation treaties, the contracting parties partly renounce, on a mutual basis, their right to tax investors located in their territories in order to avoid double taxation. The treatment granted by this Article does not refer to the advantages that one of the Contracting Parties grants to the investor of a third State as a result of an agreement to avoid the double taxation or other agreements relating to taxation matters. In case there is no such double taxation agreement between the Contracting States, the respective national tax law shall be applicable. The treatment granted under this Article shall also not relate to advantages which either Contracting State accords to investors of third States by virtue of a double taxation agreement or other agreements regarding matters of taxation. The reason is that States may have a number of potentially inconsistent measures as regards entry conditions. These exceptions must be consistent with the domestic framework and reflect existing non-conforming measures. Here, the exceptions do not necessarily reflect domestic law but allows some flexibility that the Contracting Parties wishes to retain with respect to said sectors, sub-sectors or activities. The provisions of Articles 3, 4 and 6 of this Agreement shall not apply to: (a) procurement by a Party or state enterprise; (b) subsidies or grants provided by a Party or a state enterprise, including government-supported loans, guarantees and insurance; 6. The provisions of Article 4 of this Agreement shall not apply to financial services. Canada reserves the right to adopt or maintain any measure that accords differential treatment to a country pursuant to any existing or future bilateral or multilateral agreement relating to: a) aviation; b) fisheries; c) maritime matters, including salvage. If a Party accords more favourable treatment to investors of a non-Party and their investments by concluding or amending a free trade agreement, customs union or similar agreement that provides for substantial liberalisation of investment, it shall not be obliged to accord such treatment to investors of the other Party and their investments. Any such treatment accorded by a Party shall be notified to the other Party without delay and the former Party shall endeavour to accord to investors of the latter Party and their investments treatment no less favourable than that accorded under the concluded or amended agreement. The former Party, upon request by the latter Party, shall enter into negotiations with a view to incorporating into this Agreement treatment no less favourable than that accorded under such concluded or amended agreement. Each Party shall accord to investors of the other Party treatment no less favourable than that it accords, in like circumstances, to investors of any third State with respect to the establishment, acquisition, expansion, management, conduct, operation, and sale or other disposition of investments in its territory. Notwithstanding paragraphs 1 and 2, the Parties reserve the right to adopt or maintain any measure that accords differential treatment: (a) to socially or economically disadvantaged minorities and ethnic groups; or b) involving cultural industries related to the production of books, magazines, periodical publications, or printed or electronic newspapers and music scores. Different treatment is justified if the would-be comparators are in different objective situations. However, the absence thereof does not mean that the contracting parties to such treaties intended that the standard be applied without a proper comparison. As mentioned above, this treatment covers the life-cycle of the investment as regulated by the host State’s laws and regulations. This list of investment activities includes pre- or post- establishment activities. Pre-establishment activities typically include the “establishment, acquisition and expansion” of investments, whereas post-establishment activities include the “management, maintenance, conduct, operation, use, enjoyment, sell, disposal or disposition” of investments. Expansion of investment that is subject to prior approval or other authorization may be considered part of the post-establishment activities by some countries. There are considerable variations in treaty language, resulting from the negotiation of each individual treaty, mostly based on a model agreement used from time to time by the parties. For the avoidance of doubt it is confirmed that the treatment provided for in paragraphs (1) and (2) above shall apply to the provisions of Articles 1 to 11 [investor-State disputes] of this Agreement. The tribunal rejected the investor’s claim as it assumed “the validity of its own reading of the relevant clauses of the treaties with Albania and Estonia”. In its view, the investor did not document the existence, in current international law, of such “autonomous standards”, or assuming their hypothetical existence, that “United States measures 4 were reasonably characterized as in breach of such standards”. Some awards have used provisions in third party treaties to clarify the meaning of words used in the basic treaty. The claimants had been denied the required planning licences to develop an investment in property development, although they had received authorization by the Chilean investment authority at the central level. It should be noted that this was a decision on jurisdiction and that the finding was only a prima facie finding. It concluded that this should be the Pakistan-Switzerland treaty (1995) on the ground that it was concluded later in time (i. These are determining factors for their acceptance of the Agreement, as they are directly linked to the identification of the substantive protection regime applicable to the foreign investor and, particularly, to the general (national or international) legal context within which such regime operates, as well as to the access of the foreign investor to the substantive provisions of such regime. Their application cannot therefore be impaired by 12 the principle contained in the most favored nation clause. It should be noted in this context that the tribunal in this case implied that some provisions are specifically negotiated whereas others are not. The tribunal followed the respondent’s main objections, based strongly on the Tecmed v. The tribunal found that the investor had made an investment under the basic treaty, but in any case rejected the proposed alternative: “Each treaty defines what it considers a protected investment and who is entitled to that protection, and definitions can change from treaty to treaty. Eliminating provisions of the basic treaty Other cases have dealt with a different scenario where the claimant seeks to eliminate a non-beneficial provision of the basic treaty on grounds that it is not contained in a third party treaty. The absence of such a clause would, in the claimant’s view, make the conditions of the third party treaty more favourable. Argentina the claimant sought to avoid the application of the emergency exception clause contained in the basic treaty between the United States and Argentina. In the case where foreign investors were competing for the same public procurement project the tribunal compared not only two investors in the same economic sector but also the characteristics of their respective project proposals. Pakistan (merits) the tribunal established that the similarity and hence the comparability between the foreign investors had to be examined at the level of the contractual terms and circumstances. It held that they have similar conditions of application and basically afford indirect advantages to their beneficiaries, namely a treatment no less favourable than the one granted to third parties. It then elaborated on the basis of comparison that had to be met: “Discrimination is to be ascertained by looking at the circumstances of the individual cases. Discrimination involves either issues of law, such as legislation affording different treatments in function of citizenship, or issues of fact where a State unduly treats differently investors who are in similar circumstances.


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Parents or carers should not give in to fractious children and not give medicines as then compliance may be a problem discount levitra plus 400mg erectile dysfunction urologist; at all stages discount 400mg levitra plus overnight delivery erectile dysfunction doctor sydney, the child should be comforted and reassured generic levitra plus 400mg overnight delivery erectile dysfunction statistics nih. They must not be left with the impression that being given medicine is a punishment for being sick. Another problem is that the child may seem better, so parents/carers may not complete treatment, as with antibiotics. The approach depends on the child’s understanding and the circumstances: • Under 2 years: Administration by parents if possible, using an approach which they believe is most likely to succeed. At this age children must have a proper understanding of what is happening and share in the decision making as well as the responsibility. What children and carers need to know • The name of the medicine • The reason for using it • When and how to take it • How to know if it is effective, and what to do if it is not • What to do if one or more doses are missed • How long to continue taking it • The risks of stopping it early • The most likely adverse effects; those unlikely, but important; and what to do if they occur • Whether other medicines can be taken at the same time • Whether other remedies alter the medicine’s effect Nursing staff involved with children need to be aware of medicine and dosage problems in children. Dosing Most doses of medicines have been derived from trials or from clinical experience and are usually given in terms of body weight as milligrams per kilogram of body weight (mg/kg). This assumes that the body weight 154 Children and medicines is appropriate for the child’s age, but this may not always be the case, since children grow at different rates and obesity is becoming more common. Before a dose is decided upon, the appropriateness of the child’s weight for age and height should be assessed. Alternatively, doses may be given for different age ranges as most drugs will have a wide safety margin (i. Using body surface area may be a more accurate method for dosing, as surface area better reflects developmental changes and function. However, determining surface area can be time-consuming and this method of dose calculation is generally reserved for potent drugs where there are small differences between effective and toxic doses (e. Licensing and ‘off-label’ use As stated earlier, many drugs are not tested in children which means that they are not specifically licensed for use in children. So although many Practical implications 155 medicines are licensed, they are often prescribed outside the terms of their Marketing Authorization (or licence) – known as ‘off-label’ prescribing – in relation to age, indication, dose of frequency, route of administration or formulation. Nursing staff should be aware both when an unlicensed medicine is being administered and of their responsibilities. Formulations Appropriate formulations to enable administration of drugs to children are often not available. Children are often unable to swallow tablets or capsules, so liquid medicines are preferred. However, this is not always possible and crushing of tablets or manipulation of solid dosage forms into suspensions or powders is often required. The strength of these products may mean that it is difficult to measure small doses for children and may lead to errors. Some commercially available medicines may contain excipients that may cause adverse effects or be inappropriate to use in some children. Liquid preparations may contain excipients such as alcohol, sorbitol, propylene glycol or E-numbers; sugar-free medicines should be dispensed whenever possible. Parenteral products may contain benzyl alcohol or propylene glycol which can also cause adverse effects such as metabolic acidosis. In addition, there will be occasions when it will be difficult to give the dose required, because of the lack of an appropriate formulation – for example, to give 33mg when only a 100mg tablet is available. In these instances, it is advisable to contact the pharmacy department to see if a liquid preparation is available or can be prepared. If not, the doctor should be informed so that the dose can be modified, another drug can be prescribed, or another route can be used. Another problem is frequency of dosing; dosing during the day will mean doses may have to be given at school which may not always be easy or possible. Medicines may have to be changed to those that can be given once or twice daily outside school hours. Royal College of Paediatrics and Child Health and Neonatal and Paediatric Pharmacists Group. These values should only be used if a specific dose cannot be found, since they assumes the child is ‘average’. A difference of one place to the left or right could mean a 10-fold change in the dose, which could be fatal in some cases. But even so, care must be taken with the number of noughts; a wrong dose can be fatal. Drug Handling and Drug Response • Drug handling (pharmacokinetics) and drug response (pharmacodynamics) may change. General Principles • A full medication history (including over-the-counter drugs) – this should highlight any previous adverse reaction, potential interactions and any compliance issues. Various compliance aids are available, but it is important to establish that the patient can use them. This group receives 52 per cent of all prescriptions and often take a variety of drugs for several conditions. Of those aged over 75 years, 36 per cent are taking four or more drugs (polypharmacy). As a person grows older, it is almost inevitable that drug treatment will be needed. A part of the ageing process will mean that physiological changes will occur that will affect how the elderly person handles and responds to drugs. Absorption There is a reduction in gastric acid output and delay in gastric emptying with ageing. These changes do not significantly affect the absorption of the majority of drugs. Although the absorption of some drugs such as digoxin may be slower, the overall absorption is similar to that in the young. Metabolism A reduction in liver blood flow and in liver mass occurs as part of the ageing process; as a consequence, hepatic metabolism of some drugs may be altered. For those drugs eliminated primarily by liver metabolism, the capacity of the liver is reduced significantly by up to 60 per cent; resulting in decreased hepatic metabolism, increased plasma concentrations and longer half-lives, e. The nutritional status of a person can also have a marked influence on the rate of drug metabolism. In frail elderly people, drug metabolism can be reduced to a greater extent than in elderly people with normal body weight. Distribution In older people, total body mass, lean body mass and total body water decrease, but total body fat increases. The effect of these changes on drug distribution depends on whether a dug is lipid- or water-soluble. A water- soluble drug is distributed mainly in the body water and lean body tissue. Because the elderly person has relatively less water and lean tissue, more of a water-soluble drug stays in the blood, which leads to increased blood concentration levels. Drug handling in the elderly 161 Since the elderly person has a higher proportion of body fat, more of a fat-soluble drug is distributed in the body fat. This can produce misleadingly low blood levels and may cause dosage to be incorrectly increased. The fatty tissue slowly releases stored drug into the bloodstream, and this explains why a fat-soluble sedative may produce a hangover effect.

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Insulin administration specifc competence is required for administering subcutaneous insulin order generic levitra plus line impotence in xala. Right to refuse Right indication 3 Re-check the medicine order and medicine prior to Right documentation administering (not required for unit dose packs) levitra plus 400 mg without a prescription erectile dysfunction freedom book. Name and photograph of Medicine buy levitra plus 400 mg on line impotence drugs over counter, Allergy or Duplicate resident checked against Visually dose, route, Medicine hypersensitivity name resident name on medicine inspect time last dose stickers stickers being administered given Think Registered nurses: Be aware Be cognisant of cultural Pre-administration 5 Rs + 3 of individual resident safety considerations. Right to refuse 3 Re-check the medicine order and medicine (under some circumstances) after preparation but before administering. Give medicine and observe Right reason that it has been Right documentation swallowed safely Perform hand hygiene Continued over page Medicines Care Guides for Residential Aged Care 5 Medicines Administration Safety (Continued) 1. Explain why the medicine is prescribed and offer medicine again Document the episode in the clinical fle and medicines administration record. Resident education and information Document the education and/or information provided to the resident or their representative regarding medicines in the resident’s clinical fle. Resident’s response to medicines Document the effect of medicines on the resident in their clinical fle, including all adverse medicine reactions. Common errors include: Referrals Wrong resident Maintain a copy of referrals to other health Wrong medicine professionals related to a resident’s medicines Similar sounding medicine names management in their clinical fle. Wrong dose/strength/duplication Misinterpretation of units Incident reporting (eg, grams, milligrams, micrograms) • Record all medicine errors on an incident form. Photos Date photos used to identify residents and ensure they resemble their current appearance. Medicines Care Guides for Residential Aged Care 7 Documentation, Incident Reporting and Quality Activities (Continued) Quality and risk activities • Encourage a quality improvement approach. Legal considerations These include: • professional accountability • complete documentation of events. Any suspected adverse reactions should be reported to the Centre for Adverse Reactions Monitoring. Medicines Care Guides for Residential Aged Care 9 Adverse Medicine Reactions – Contributing factors to adverse reactions Inform the prescriber immediately with pharmacist notifcation of potential interactions or adverse reactions. Increased sensitivity to the Cell mediator receptors and target organs have reduced ability effects of medicines with age to compensate. Reduced ability to The liver, lungs and kidneys become less able to metabolise metabolise medicines medicines with age. This may refect a woman’s relatively smaller size for given Female gender medicine doses. Many adverse effects are dose related, and identifying the Dose right dose can be made more diffcult due to weight and body composition in older adults. The incidence of adverse effects tends to increase with the Polypharmacy number of medicines taken. A history of signifcant adverse effects to medicines increases History the risk of further adverse reactions. Hereditary factors can determine the relative defciency of Genetic factors enzyme(s) involved in the metabolism of some medicines, which can increase the risk for adverse reactions. Poor adherence may be unintentional, or intentional due to Not taking medicines as resident confusion, complex medicine regimens, side-effects, prescribed adverse medicine reactions or medicine costs. Antibiotics, anti-infammatories and antihypertensives are the most common causes of adverse medicine reactions in older adults. Rest home For those residents who have recently started a Controlled drugs can only be provided by controlled drug, skilled assessment of treatment individual named prescription and must be kept effcacy is required and should be carried out by in a controlled drugs cabinet or locked cupboard. Yes No A separate page is to be used for each medicine and strength of the medicine It is recommended Resident requires controlled two staff are on drugs and is unstable or duty to witness requires frequent assessment Quantity Time and controlled drug (eg, residents who are: Resident’s Name of administration in deteriorating, require and dose of date of name prescriber the rest home palliative care, in acute medicine administration pain and/or delirious). Storing • The prescriber’s registration number must be included on all prescription forms. Special and resident-specifc orders • Record the date medicines are opened, such as 12. It is recommended that the prescriber’s • Check monthly for expired, damaged and registration number also be included on the unused medicines. Changing medicine orders, including changing unit dose packs and discharged/deceased residents • Send new medicine orders to the pharmacy to ensure a supply is received within an appropriate timeframe. Resources • Provide access to current medicines information resources for the staff, residents and health professionals. Sharing medicines • Never give medicine to anyone other than the person for whom it is labelled. Bulk supply • Bulk supply is only suitable for facilities with hospital certifcation. Medicines Care Guides for Residential Aged Care 15 Cytotoxic Medicines • Cytotoxic medicines have the ability to kill or slow the growth of living cells and are used to treat conditions such as cancer, rheumatoid arthritis and myeloproliferative disorders. The following cytotoxic medicines are sometimes prescribed for residents in residential aged care: • methotrexate Cytotoxic • hydroxyurea medicines • chlorambucil • cyclophosphamide • azathioprine • fuorouacil. Cytotoxic medicines should be stored in a locked cabinet, in a locked Storage medicine room, separate from other medicines. Medicines Care Guides for Residential Aged Care 17 Residents Self-Medicating There are many reasons why it might be preferable for residents to self-medicate (eg, to maintain autonomy or as part of a rehabilitation programme). As part of the assessment, it may be benefcial to ask the resident what they know about their medicines and conditions, which medicines are actually being taken and how they take them, and any benefcial and/or unwanted effects experiences they have had. Alternative medicines • Include over-the-counter, complementary, homeopathic, naturopathic, traditional and supplementary medicines on the medicines chart as these can sometimes cause side effects, adverse drug reactions and interactions. Monitoring and documentation • Identify on the medicines chart that the resident is self-medicating. Storage • Provide locked storage that is only accessible to the resident and authorised staff. Medicines management for facility leave • Document in the clinical fle who is taking responsibility for medicines management while resident is on leave. Medicines Care Guides for Residential Aged Care 19 Residents Self-Medicating – Factors to considerTher Use the following guide to assess a resident’s ability to self-medicate safely. If their ability is on the blue end of each indicator, they are likely to be able to self-medicate. However, if their ability for any indication is on the red section, the ability to self-medicate is questionable. Self-medication risk Low Medium High Medicine Minimal side effects/adverse effects Some adverse effects – Narrow therapeutic index, potentially not serious serious adverse effects Administration diffculty Topical/oral Subcutaneous/intramuscular/rectal/vaginal Intravenous infusion/pump Functional ability Independent/previous self-medication Some functional dependency Dependent Environment Own home/supported living Rest home/private hospital Hospital ward/intensive care unit Monitoring required Responses easily judged Simple questions/physical, cognitive assessment Complex monitoring and assessment Packaging/regimen complexity Unit dose packaging Simple regimen Moderately complex Complex regimen Medicines not (eg, blister-packed) Few changes regimen Frequent changes pre-packaged 20 Medicines Care Guides for Residential Aged Care Medicines Review Multidisciplinary team medicines review Assessment for Medicines reviews Resident and/or family Resident input Education for staff medicines review to be undertaken education/information Include: • On admission • Direct contact • Disease process Evidence-based practice • Goals of care • Every 3 months between reviewers • Medicines desired regarding medicines • Resident medicines • When health and resident/ effects/benefts used within the facility history status changes representative offers • Potential side including: • Allergies/sensitivities essential advantages. When stopping medicines, consider reducing them gradually as stopping medicines abruptly can cause unwanted effects. Consider stopping medicines that are Consider the appropriateness of medicines potentially inappropriate for the resident in light of: because of: • organ function (eg, renal /hepatic, tissue • development of an adverse effect/drug perfusion, nutritional status) interaction • electrolyte levels/hydration • inconsistency with current goals of therapy (eg, end of life care) • pharmacogenetic factors • the resident’s life expectancy • recent baseline observations, including body mass index and blood pressure • other co-morbidities. Consider starting preventative medicines that are consistent with the resident’s goals.

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