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Level 3: The resident continues to advance and demonstrate additional milestones purchase viagra professional 50mg on line; the resident demonstrates the majority of milestones targeted for residency in this sub-competency generic 100mg viagra professional fast delivery. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency viagra professional 100 mg line. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years buy viagra professional 50 mg online. Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www effective viagra professional 100mg. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:  selecting the level of milestones that best describes the resident’s performance in relation to the milestones or  selecting the “Has not Achieved Level 1” response option Selecting a response box in the middle of a Selecting a response box on the line in between levels level implies that milestones in that level and indicates that milestones in lower levels have been in lower levels have been substantially substantially demonstrated as well as some milestones demonstrated. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Knows the different Applies medical knowledge Considers array of drug Selects the appropriate Participates in developing classifications of pharmacologic for selection of therapy for treatment. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Identifies pertinent Performs patient assessment, Determines a backup Performs indicated Teaches procedural anatomy and physiology obtains informed consent and strategy if initial attempts procedures on any patients competency and corrects for a specific procedure ensures monitoring equipment is to perform a procedure are with challenging features mistakes in place in accordance with unsuccessful (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Discusses with the patient Knows the indications, Knows the indications, Performs procedural Develops pain indications, contraindications contraindications, contraindications, potential sedation providing management and possible complications of potential complications complications and appropriate doses effective sedation protocols/care plans local anesthesia and appropriate doses of of medications used for procedural with the least risk of analgesic/sedative sedation complications and Performs local anesthesia using medications minimal recovery time appropriate doses of local Performs patient assessment and through selective anesthetic and appropriate Knows the anatomic discusses with the patient the most dosing, route and technique to provide skin to landmarks, indications, appropriate analgesic/sedative choice of medications sub-dermal anesthesia for contraindications, medication and administers in the procedures potential complications most appropriate dose and route and appropriate doses of local anesthetics used for Performs pre-sedation assessment, regional anesthesia obtains informed consent and orders appropriate choice and dose of medications for procedural sedation Obtains informed consent and correctly performs regional anesthesia Ensures appropriate monitoring of patients during procedural sedation Comments: Suggested Evaluation Methods: Procedural competency forms, checklist assessment of procedure and simulation lab performance, global ratings, patient survey, chart review Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Emergency Medicine. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Prepares a simple wound for Uses medical terminology Performs complex wound Achieves hemostasis in a Performs advanced wound suturing (identify appropriate to clearly describe/classify repairs (deep sutures, bleeding wound using repairs, such as tendon suture material, anesthetize a wound (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Performs a venipuncture Describes the indications, Inserts a central venous Successfully performs 20 Teaches advanced vascular contraindications, anticipated catheter without central venous lines access techniques Places a peripheral undesirable outcomes and ultrasound when intravenous line complications for the various appropriate Routinely gains venous vascular access modalities access in patients with Performs an arterial Places an ultrasound difficult vascular access puncture Inserts an arterial catheter guided deep vein catheter (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Adheres to standards for Routinely uses basic patient Describes patient safety Participates in an Uses analytical tools to maintenance of a safe safety practices, such as time- concepts institutional process assess healthcare quality working environment outs and ‘calls for help’ improvement plan to and safety and reassess Employs processes (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Demonstrates an awareness of and responsiveness to the larger context and system of health care. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes.

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When the diet was high in fat (50 percent of energy) purchase viagra professional 50mg online, the area under the curve for plasma glucose and insulin concentration was lower than when the diet had a low fat content (25 percent of energy) (Yost et al order 100 mg viagra professional with visa. Garg and coworkers (1992b) reported that insulin sensitivity generic viagra professional 50mg mastercard, indicated by insulin-mediated glucose disposal order viagra professional 100 mg, was similar after almost a month of ingestion of either a reduced fat (25 percent of energy) or an increased fat diet (50 percent of energy) discount 100 mg viagra professional with visa. However, favorable effects of substituting a monounsaturated fat diet for a saturated fat diet on insulin sensitivity were seen at a total fat intake of up to 37 percent of energy (Vessby et al. A large, long-term intervention trial in adults showed that reducing total fat intake, in part, reduced the risk of the onset of type 2 diabetes by 58 percent (Tuomilehto et al. Thus, there is no definitive evidence from metabolic and interventional studies that higher fat intakes impair insulin sensitivity in humans as they do in various labora- tory animals. Any suggestive links between fat intake and either insulin secretion or sensitivity may be mediated through confounding factors, such as body-fat content, making it difficult to detect any independent contri- bution of total fat intake to insulin sensitivity. Although high fat diets can induce insulin resistance in rodents, investigations in humans fail to confirm this effect. Risk of Cancer High intakes of dietary fat have been implicated in the development of cancer, especially cancer of the lung, breast, colon, and prostate gland. Early support for this theory comes from laboratory animal and cross- cultural studies. The latter were based largely on international food dis- appearance data and migrant and time trend studies. In recent years, the theory that a diet high in fat predisposes to certain cancers has been weak- ened by additional epidemiological studies. Early cross-cultural and case- control studies reported strong associations between total fat intake and breast cancer (Howe et al. Total fat intake in relation to colon cancer has strong support from animal studies (Reddy, 1992). Howe and colleagues (1997) reported no association between fat intake and risk of colorectal cancer from the combined analysis of 13 case-control studies. Epidemiological studies tend to suggest that dietary fat intake is not associated with prostate cancer (Ramon et al. Giovannucci and coworkers (1993), however, reported a positive association between total fat consumption, primarily animal fat, and risk of advanced prostate cancer. Findings on the association between fat intake and lung cancer have been mixed (De Stefani et al. With increasing intakes of carbohydrate, and there- fore decreasing fat intakes, there is a trend towards reduced consumption of dietary fiber, folate, and vitamin C (Appendix K). With higher fat intakes, it is difficult to create practical high fat menus that do not contain unacceptably high amounts of saturated fatty acids (National Cholesterol Education Program, 2001). Micronutrient inadequacy can occur when sugars intake is very low (less than 4 percent of total energy) (Bolton- Smith and Woodward, 1995) because many foods that are abundant in micronutrients, such as fruits and dairy products, also contain naturally occurring sugars. A wide variety of foods from different food groups are needed to meet nutrient requirements. Because sugars are important for the palatability of foods, the complete omission of sugars from the diet could endanger overall nutrient adequacy by leading to low total energy intake, as well as low micronutrient intakes (Bolton-Smith, 1996). Although reduced nutrient intakes have been reported, adverse affects on health have not. Individuals with fructose intolerance, a condition caused by fructose-1-phosphate aldolase deficiency, strictly avoid foods containing fructose and sucrose and yet remain in good health (Burmeister et al. Conversely, many interventional studies show that when fat intake is high, many individuals consume additional energy, and therefore gain additional weight. Furthermore, these ranges allow for sufficient intakes of essential nutri- ents while keeping the intake of saturated fatty acids at moderate levels. There is no lower limit of intake and no known adverse effects with the chronic consumption of Dietary Fiber or Functional Fiber (Chapter 7). While such trends exist, it is not possible to determine a defined intake level at which inadequate micronutrient intakes occur. Fur- thermore, at very low or very high intakes, unusual eating habits most likely exist that allow for other factors to contribute to low micronutrient intakes. Based on the available data, no more than 25 energy from added sugars should be comsumed by adults.

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Leadership development is a tremendous opportunity to fo- cus on your own resiliency discount 50mg viagra professional visa. The insights gained in leadership development discount 50mg viagra professional overnight delivery, particularly with respect to identifying your core values and beliefs cheap 50 mg viagra professional visa, your interpersonal style and your personality traits generic 100 mg viagra professional visa, are powerful and practical generic 100 mg viagra professional mastercard. When things are stressful and diffcult, and your vulnerabilities become apparent, your lead- ership skills and traits can help you to cope well. In addition, your leadership skills can help promote a system of medicine that promotes the health and well-being of all involved, includ- ing all health professionals as well as the patients and families they serve. However, establishing and maintaining lifestyle habits, this might even motivate their patients to adopt a healthy equilibrium between professional and personal life similarly healthy behaviours. Thus, an argument can be made is not easy, and it is not uncommon for practising physicians that medical education should encourage health professionals and residents to struggle with time management, competing to practise and exhibit healthy lifestyles. Recommendations demands between work and home, and tensions in intimate have been made on the basis of research fndings that spend- relationships. Physicians’ work-life balance is shaped by many ing more personal time with friends and family can decrease factors, including workload, practice specialty and setting, the stress. However, perhaps the strongest determinant must ensure that they have their own family physician, be alert of a healthy work-life balance is the ability to control one’s to colleagues in need of support, and when appropriate initi- schedule and the total number of hours worked. For the professional culture of Canadian surveys have shown that most physicians believe medicine to achieve a healthy balance between work and home their workload is too heavy and that their family and personal life, these concepts must not only be taught, but must also be lives have suffered because of their choice of medicine as a strongly encouraged by individuals in positions of authority at career. A lack of balance between work and home life can lead all levels of medical education. On the job, the consequences may include cynicism, decreased job satisfaction, The following chapters will discuss how to maintain positive poor work performance and absenteeism. These stresses can interpersonal relationships during training and throughout spill over into personal life, straining relationships and leading one’s career. Specifc attention will be paid to physicians’ rela- to family discord and isolation from friends. The Canadian Medical Association’s Policy on Physician Health Key references and Well-being emphasizes that physicians should be aware of Armstrong A, Alvero R, Dunlow S, Nace M, Baker V, Stewart the essential components of well-being, such as rest, exercise, E. They identifed four risk factors for a disrupted quences of work-home interference among medical residents. In addition, • describe some interventions that can improve the personal many doctors are embarrassed to fnd that they need relation- relationships of physicians. They are often “wounded healers” who have already faced stressors that make them vulnerable to mental illness, Case or who have undiagnosed mental health problems (e. Most of the residents in the such problems are likely to be compounded in spousal rela- program have intimate partners, and several have children. Although the One of the residents told the program director that this onset of relationship diffculties can be insidious, physicians resident had not had a chance to spend meaningful time should be alert to the warning signs, such as more frequent with their partner, with the exception of a yearly vacation. Useful strategies that develop and safeguard intimacy in a relationship include: protecting time to communicate with one’s partner; reading Introduction about the dynamics of relationships; attending a marital retreat; Certain traits that seem to go with the territory of medicine attending couples therapy; and taking time to manage one’s can have a detrimental effect on physicians’ personal lives. Refection for educators Warde and colleagues, reported increased marital and parental Get to know the spouses and signifcant others in the lives satisfaction have been closely associated with a decrease in of the residents in your program early on in residency confict between professional and familial roles. Educate residents’ spouses about the physician the confict between the demands training and home-life, and health resources available to their families (e. These individuals are often the frst to in both parental and marital satisfaction. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work–home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians’ relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong’s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one’s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one’s partner, • explore challenges specifc to those relationships.

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The rate at which amino acids contribute to energy generation is fairly constant and does not increase nearly as much as glucose and fatty acid oxidation during periods of physical exertion cheap viagra professional 100 mg. Indeed purchase viagra professional 100mg without a prescription, using amino acids as a major energy source would be wasteful purchase 50mg viagra professional with mastercard, since protein is the most limited energy yielding nutrient purchase viagra professional 50 mg. Beyond the overriding effect of relative exercise intensity cheap 100mg viagra professional with amex, other factors such as exer- cise duration, gender, training status, and dietary history play important, but secondary, roles in determining the pattern of substrate utilization (Brooks et al. Therefore, the same general relationships among relative exercise intensity, duration, and pattern of substrate utilization hold for most persons, including endurance athletes. Intensity of Physical Activity Oxidation of lipid provides most of the energy (~ 60 percent) for non- contracting skeletal muscle and overall for the body at rest in people who have not eaten for 10 to 12 hours (i. During mild exercise, the use of lipid increases, but if the level of effort increases, carbohydrate energy sources are used to a relatively greater extent (Figure 12-7). For exercises intensities greater than 50 percent of Vo2max, the oxidation of free fatty acids declines in muscle, both as a percentage of total energy as well as on an absolute basis. In other words, there is crossover from prevalence of lipid oxidation at rest and during mild exercise to predominance of carbohydrate energy sources during moderate and greater efforts. The main carbohydrate energy source is muscle glycogen, and this is supplemented to some extent by glucose and lactate—glucose mobilized from the liver and lactate produced by muscle glycogen breakdown. If exercise persists beyond 60 to 90 minutes, lipid use will rise as carbohydrate fuel sources become depleted. In this case, the intensity of exercise must drop because of the depletion of muscle glycogen, decreasing levels of blood glucose, and other fatiguing conse- quences of the effort (Graham and Adamo, 1999). Dietary carbohydrate is relatively rapidly assimilated compared to fat and protein, thus raising blood glucose and insulin levels. The increments in blood glucose and insulin in response to carbohydrate intake are less in trained than in untrained individuals (Dela et al. Hence, as shown in Figure 12-7 for fed individuals, crossover to predominant carbohydrate oxidation occurs already during mild (22% Vo2max) exercise, even in trained individuals, if they have recently consumed carbohydrates. Duration of Physical Activity Within seconds after initiation of even mild exercise, muscle glycogen stores are mobilized to provide energy for muscle work. Depending on the person, the change from fat to carbohydrate dependence occurs at different levels of exertion. When labored breathing accompanies exercise, crossover to carbohydrate dependence has generally occurred. In most cases, relationships between activity duration and intensity will be inversely related—harder intensity physical activities will necessarily be of less duration than easier ones. Extreme effort is made possible in part by the use of preformed high-energy bonds in the form of creatine- phosphate, in addition to energy generation by glycogen and glucose catabolism, with very little use of fat, leading to fatigue within seconds or minutes. In contrast, activities of mild to moderate intensity, performed over periods of hours, can result in large increments of energy expenditure with a substantial contribution coming from lipid stores (Brooks et al. Therefore, in order to use physical activity to enhance body fat utilization, sustained activity that causes substantial increases in energy expenditure is more important than the peak rate of substrate oxidation. Even in highly fit athletes, glycogen reserves will become largely depleted after maintaining high rates of exertion for several hours, so that increas- ing amounts of lipid will be oxidized. As a result of such physical activity, increased lipid oxidation will also take place during recovery from exercise (Chad and Quigley, 1991; Kiens and Richter, 1998). Gender In general, metabolic responses of women and men are similar, but women oxidize more lipid than men during exercise and when perform- ing a task at a given level of intensity (Friedlander et al. Paradoxically, women depend more on blood glucose and less on muscle glycogen than do men. The effects of menstrual variations on substrate utilization are under investigation, but the effects are likely to be small, because estrogen and progesterone appear to have antagonistic effects on substrate utilization (Campbell et al. In contrast to the effects of menstrual cycle variations in endogenous ovarian sex steroids, high levels of exogenous synthetic ovarian steroid analogs, such as contained in oral contraceptives, cause a mild insulin resistance and decrease use of blood glucose in women at rest (Yen and Vela, 1968). Consequently, men and women may possibly differ subtly in patterns of substrate utilization during physical activity, but overall patterns of carbohydrate and lipid use are similar. The effect of meno- pause on substrate utilization during exercise has not been studied in sufficient detail to establish if it leads to significant changes in substrate utilization. However, changes in body fat content and distribution after menopause suggest that patterns of activity and energy substrate utiliza- tion change after menopause (Poehlman et al. This age-related decline is associated with the decline in muscle mass and maximal heart rate that decreases approximately 1 beat/min/year (Suominen et al. As a result, fat oxidation during physical activity is decreased and carbohydrate oxidation is increased in elderly adults (Sial et al. Recognizing that Vo2max declines with age, any given task is likely to be accomplished at relatively greater exercise intensity, and consequently greater dependence on carbohydrate-derived energy sources.

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