The first refers to the benefits or privileges granted by a State by virtue of free trade agreements buy clomiphene 100 mg with visa women's health clinic east maitland, customs unions purchase generic clomiphene pills menstruation 6 days late, 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. An objective justification may justify differentiated treatments of similar cases. It would be necessary, in each case, to evaluate the exact circumstances and the context. Even though the relevant comparators were engaged in similar activities (they were competitors for the same project), the tribunal concluded that the relevant investors were in different circumstances, in particular because their offers and proposed projects had different characteristics. Pakistan the claimant alleged that it was expelled both to save costs and for reasons of local favouritism, considering in particular that far more favourable timetables had been accorded to Pakistani nationals associated with foreign contractors and that these other contractors had not been expelled even though they were far more behind in the schedule of completion. As to the first point, the tribunal established that the similarity had to be examined at the level of the contractual terms and circumstances, but found itself in no position to proceed to any meaningful comparison given the absence of data on the terms and the performance of the different contracts involved.

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Anhydrous ammonia is supplied in pressurised tanks and requires similar dosing equipment to that used for chlorine gas chlorination buy clomiphene 50 mg otc women's health clinic dc. Anhydrous ammonia is fed to the process using an ammoniator buy 50 mg clomiphene free shipping the women's health big book of yoga download; a self contained unit with pressure regulating valve, gas flow meter feed rate control valve and piping to control the flow of ammonia to the process. Anti-siphon or check valves should be used to prevent the backflow of water to the ammoniator. Similarly the dosing of liquid ammonia chemicals used installation similar to the dosing of sodium hypochlorite. Structurally robust fibre reinforced plastic and stainless steel tanks are compatible materials for storage tanks with good mixing downstream of ammonia addition vital to prevent the formation of dichloramine and trichloroamine. Dosing pumps should be diaphragm metering pumps fitted with pulsation dampers and pressure relief valve and back pressure valves at the dosing points. Like chlorine, residual doses of monochloramines leaving a treatment plant depend on the size of the distribution network with dosage rates typically less than 2 mg/l. Monochloramine residuals persist in distribution systems for longer than free chlorine residuals. There are no circumstances where the dose of monochloramine should be substantially greater than the existing free chlorine concentration. It is inevitable that chloraminated and chlorinated water will mix when chloramination is introduced. It is not possible to negate the effect of such mixing, and tastes and odours may occur. It is important that all customers, and the customer service department, are informed of the change so that customer complaints/queries can be minimised and dealt with efficiently. One example, is where fish keepers may remove free chlorine by allowing water to stand and fish deaths result after a changeover to the longer lasting chloramine. Health authorities would need to be informed because of the possible implications for kidney dialysis water treatment systems. It should be borne in mind that a greater contact time with the carbon is required for chloramine. Good practice would be to introduce additional monitoring in the weeks before, during and after chloramination is implemented. Such monitoring will assist detection of possible problems as well as highlighting benefits. As chloramine displaces chlorinated water, during initial implementation, any booster chlorination stations will need to be turned off. This needs to coincide with the arrival of water that contains sufficient chloramine to ensure that the system is not without disinfectant for an unacceptable period. In the most basic system the ratio between chlorine dose (or residual) and ammonia is automatically controlled to a set-point. For greater security, particularly in systems that use a solution of ammonia salt, additional downstream monitoring of ammonia is used to trim the dose. Systems should therefore be designed to provide a ratio of 5:1 but it is recommended that the system is started up at a ratio of 4. There are good reasons for operating below the 5:1 ratio, as the presence of a small amount of free ammonia is found to increase the stability of the monochloramine. The free ammonia and free chlorine should be measured and the ammonia dose adjusted to provide a trace (approximately 0. The chemistry of chloramination is not straightforward, as it is for chlorination. The process for generating chloramine requires accurate control at the treatment works to ensure that the desired product (monochloramine) is formed and not dichloramine or trichloramine. Overall experience is that this risk is very small for control systems that are well designed and operated. Water Treatment Manual Disinfection There is also a risk in networks which are not single source and where chloraminated and chlorinated water can blend in unsuitable proportions. There is a risk that the disinfection residual will be reduced and/or dichloramine may be formed which has a strong chlorine taste. Nitrification due to excess ammonia in the distribution network Chloramination is achieved through a controlled reaction between chlorine and ammonia. Under ideal conditions all of the ammonia can react but it is more usual that small concentrations of ammonia are present after chloramination. Whilst free ammonia is subject to regulation, the main concern relates to nitrite, which is subject to tighter regulation. Ammonia can be converted to nitrite by naturally occurring bacteria that are harmless to human health. This process is known as nitrification, and in extreme cases can lead to marked depletion of oxygen, but generally the issue is the concentration of nitrite. Originally exceedance of the regulatory limit for nitrite was one of the major barriers to wider application of chloramination. A past revision of the Water Quality Regulations increased the allowable concentration of nitrite at the tap from 0. It is a more effective bactericide and virucide than chlorine; effective against Giardia; and the most effective of all the chemical disinfectants used in water treatment against Cryptosporidium. It decays more rapidly than other disinfectants, so does not maintain a persistent residual. Ozone can only be used as a primary disinfectant and should be coupled with a secondary disinfectant for a complete disinfection system for generation of a verifiable residual in distribution networks. Ozone is a toxic, bluish, unstable, potentially explosive gas and is a hazard to plants and animals (Braker and Mossman, 1980). Ozone leak detectors should be installed to give audible/visible warnings and shut down the generators in the event of a leak. The gas is highly corrosive in the presence of moisture; hence piping and other equipment must be constructed of resistant materials. At low pH levels, precursor destruction is quite effective; above some critical pH, ozone is less effective, and sometimes increases the amount of chlorination by-product precursors. This is because alkalinity scavenges any hydroxyl free radicals formed during ozonation, leaving molecular ozone as the sole oxidant, which has a lower oxidation potential than the hydroxyl free radical. It is important when considering ozonation that the objectives for doing so are clear, because the optimum dose and contact time, and the most appropriate location in the treatment train and contactor configuration, all depend on the treatment objective. Parallel reactions will occur, so a single ozonation stage may achieve more than one treatment objective, but problems may arise if inappropriate combinations of objectives are attempted. This occurs due to a decrease in the efficiency of transfer of ozone into water as temperature increases. Dissolved ozone can react directly or indirectly with the water into which it is dosed.

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Secondary post-partum haemorrhage is defined as excessive vaginal bleeding occurring from twenty-four hours to six weeks after delivery buy cheap clomiphene online pregnancy zumba dvd. The bleeding may occur with the placenta retained or after its expulsion from the uterus cheap clomiphene express menopause books. Provided the uterus is curetted gently and no damage is done the blood loss usually ceases soon afterwards and the patient may be discharged • If such a haemorrhage occurs in association with the placenta retained in the uterus, the following should be the course of action: • Rub up a contraction by manual pressure on the uterine fundus • Pass a urethral catheter to empty the bladder • Attempt removal of the placenta by controlled cord traction as soon as a contraction is felt. If not successful await the next contraction and repeat the procedure • If the placenta cannot be expelled in this fashion, manual removal under anaesthesia is indicated • If the facilities for manual removal under anaesthesia are not immediately available refer to hospital. Give at least 2000 ml in first hour • Aim to replace 2-3x the volume of estimated blood loss. Note Avoid dextrans; they interfere with grouping and cross matching as well as with coagulation of blood • If the uterus is poorly contracted (atonic) and the placenta is out and complete, • Misoprostol, oral/sublingual, 600 micrograms • Prostaglandin F2 alpha (if available) should be administered directly into the myometrium. In the first stage of labour the uterine contractions are painful and patients may therefore require analgesia. In the second stage of labour analgesia is required for instrumental delivery and when an episiotomy is given. It is therefore best not to give it when delivery is anticipated within 4 hours i. Inhalational • Nitrous Oxide 50% / Oxygen 50% This is used in the late first stage when delivery is expected within 1 hour. Epidural This procedure administered by an anaesthetist is a very effective way of reducing labour pains. When it is given in the first stage its use extends through the second stage of labour. During the second stage of labour Local Anaesthetics (for episiotomy and pudendal block anaesthesia to facilitate instrumental delivery). The immature foetus is at risk of cerebral haemorrhage because the fragile cranial bones provide insufficient protection for the brain and there is increased susceptibility to infection and impaired clotting mechanisms. The two types are pre-term (before 37 completed weeks) and term (before 37 weeks, but >1 hour before onset of labour). It may be primary or secondary indicating the absence or presence, respectively, of an identifiable underlying cause. It may be spontaneous (threatened, inevitable, incomplete, complete or missed) or induced (therapeutic, criminal or septic). After appropriate treatment and discharge from hospital, it is recommended that patients report back to hospital if there is lower abdominal pain, fever, vaginal bleeding and malodorous discharge. This helps to minimise the haemorrhage but it may be uncomfortable or painful to the patient. Do gentle digital curettage followed by the instrumental curettage under general anaesthesia within 6 hours of initiation of antibiotic therapy. Extreme care is needed in order not to perforate the uterus (if it has not been perforated already). Careful evacuation of the uterus must be done as risk of uterine perforation is high. The procedure must be covered adequately with oxytocics, as haemorrhage can be a problem • Hysterotomy may be indicated where induction fails or is contraindicated. Missed abortion 800 microgram vaginally 3 hourly Give 2 doses and leave to work (0-12 weeks) Or for 1-2 weeks (unless heavy 600 microgram sublingually bleeding or infection) 3 hourly Incomplete abortion 600 microgram orally stat Leave to work for 2 weeks (0-12 weeks) (unless heavy bleeding or infection). Induced abortion 400 microgram vaginally 3 hourly Use 200 microgram only in (13-24 weeks) (maximum 5 doses) women with caesarean scar. Intrauterine fetal 13-17 weeks: 200 microgram 6 with previous caesarean death (>24 weeks) hourly section 18-26 weeks: 100 microgram 6 hourly 27-43 weeks: 25-50 microgram 4 hourly Induction of 25 microgram vaginally 4 hourly Do not use if previous labour Or caesarean section. Note Oxytocin used together with misoprostol must be done with extreme caution as risk for uterine rupture is great. Termination of pregnancy is requested for and done for reasons permissible by law either through a surgical procedure or by pharmacological means. Under the current provisions for Ghana, an induced abortion may be carried out legally only under the following conditions: • In case of rape, defilement or incest • Threat to the physical and mental health of the mother • Presence of foetal abnormality • Mental retardation of the mother Patients given a pharmacological option for abortion will need to be monitored closely for completeness of the abortion process. They should be informed to report back immediately in cases of profuse or heavy vaginal bleeding, fever, offensive vaginal discharge. Abnormal menstrual patterns and bleeding are common in young adolescents and women within the ages of 45-50 years. No cause may be found on investigation as it is mostly due to immaturity of the ovaries and its pituitary controls. Postmenopausal bleeding is said to occur when a woman who has stopped having menstruation for 6-12 or more months begins to bleed per vaginam. Note If heavy menses return, the tablets can be continued for as long as necessary. Atrophic vaginitis responds to vaginal oestrogen cream treatment such as conjugated oestrogen cream. Note Patients taking clomifene (clomiphene) citrate need careful supervision best done by a specialist. A woman is considered to be menopausal if there is no menstruation for a period of at least 6-12 months in the absence of pregnancy. It is associated with physical, emotional and psychological upheaval of varying intensity in the affected individual. The flushes may be associated with • Palpitations • Faintness • Dizziness • Fatigue • Weakness • Emotional and psychological problems include: • Mood changes • Depression • Anxiety • Nervousness • Irritability • Loss of libido • Atrophic changes in the genital tract may give rise to the following: • Increased frequency of micturition and dysuria. Current evidence suggests that hormone replacement therapy in the menopause does not prevent coronary heart disease or strokes. Mechanisms for the glomerular damage may be immune-mediated through deposition of immune complexes or localisation of antibodies. Patients with other causes such as lupus nephritis or systemic vasculitis, who need more intensive investigations, including renal biopsy, should be referred to a physician specialist or a nephrologist. These criteria should be applied in the context of the clinical presentation and following adequate fluid resuscitation where applicable. Women are affected 10 times more than men due to the shortness of their urethra compared to that of men. Potassium citrate, oral, 10 ml 8 hourly if urine is acidic (pH of 6 or below) To reduce bladder pain and dysuria. Bacterial prostatitis may present as an acute condition which may either be sexually transmitted or result from urethral reflux of infected urine into the prostatic ducts, spread from the rectum or spread from the bloodstream. The two main aetiological or risk factors are aging and the presence of testosterone. Depending on the severity of symptoms, treatment may be pharmacological (drug therapy) or surgical. Their use will cause shrinkage of the prostate and relief of the attendant obstruction.

By Z. Konrad. Shasta Bible College.