That Which We Call a Rose
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What’s in a name? Sometimes nothing much. Sometimes a shift in paradigm.

The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS). The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As the EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order. To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology. Is it EMR or is it EHR? Is it just semantics? Would an EMR by any other name smell as sweet (bitter)?

In a recent ONC blog, Peter Garrett and Joshua Seidman argue that there is a significant difference between EMR and EHR. The former is just “a digital version of the paper charts” and “not much better than a paper record”, while the latter is “designed to be accessed by all people involved in the patients care”, including patients, and generally “represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual”. This dramatic difference stems from replacing the word “Medical”, which implies disease, with the word “Health” which is “the general condition of the body”. Note that the word “Patient” is still absent. However, Health is supposedly from cradle to grave, while Medical is episodic in nature. Since, no matter what you call it, clinicians are the primary users of this software, would we say that doctors provide Medical Care or Health Care?

When we say that cost of Health Care is sky-rocketing, we don’t usually include costs for clean air, clean water, car seatbelts and gym memberships, and although we all know that an apple a day keeps the viagra cialis online pharmacy pharmacy away, the cost of apples is not included in our Health Care expenditures. To be sure, Medicine, “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease”, does include costs for direct prevention of specific diseases (immunizations) and efforts for early diagnosis of others (screenings). Historically, doctors, nurses and their less formally educated predecessors have been tending to the very sick. It is with this goal in mind that Dr. Plummer’s collaborative Medical record was created, and it is for this purpose that the American Academy of Pediatrics advocated for a Medical home for sick children, and it is Medical care for the sick which the EMR attempted to facilitate, one patient at a time. The EHR represents quite a different philosophy and places new and expanded responsibilities on the Medical profession.

The EHR is intended to serve the healthy as well as the sick, and the President’s vision is that every American should have one, whether that particular American is healthy or not. The ONC vision, shared by many innovators in the field, is that “EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care”. That broader view will presumably include lifestyle habits, diet and exercise and everything one may wish to record which pertains to one’s general health status. If and when a person becomes ill and is transformed into a patient, the various clinicians and care providers will contribute their documentation to the EHR, and since EHRs are easily shareable, all Medical care will be coordinated through the EHR and collaboration will flourish, as it should. This sounds almost exactly the same as what a Personal Health Record (PHR) is supposed to be. Is an EHR really a PHR?

No. EHRs include one feature that is not possible in a PHR: the ability to aggregate individual patients into populations. When physicians write introspectively about their work, you usually find stories about this or that particular patient, pondering whether they did too much for the 90-year-old Alzheimer’s victim, or too little for the misdiagnosed 40-year-old ovarian cancer patient. They talk about emotions, or lack thereof, about small victories and exasperatingly “non-compliant” middle aged executives who should know better. Each story has a patient with a name, physical details and most often character description. For those inclined to self-assessment, the day-in and day-out tally of these personal episodes is the decisive yardstick. When people recommend a doctor to a friend, they usually talk about “nobody could figure out what was wrong with Katie; he took one look at her and knew right away” or “you can get in today or tomorrow and she is so nice and patient ; always takes my phone calls and you know I can be a pain (giggle)” or “when Adam had that knee problem, he fixed it like magic and he did surgery on cousin Joe’s shoulder; as good as new, and I think he takes care of the Cardinals too; he is definitely the best in town”.

This unscientific, anecdotal method of both performing and assessing one’s work will be replaced by the broader view of EHR enabled population indicators and considerations. Instead of dealing with Mr. Wilson’s gout and Mrs. Wilson’s incontinence, you are now the keeper of the Health of Populations. The EHR can tell you that half of your under 40 patients are obese and doing absolutely nothing about it. You, or your team, will need to intervene because an ounce of prevention today will lead to healthier lives for this population, and lower costs for society. While managing Mrs. Wilson’s neuropathy is important (especially to Mrs. Wilson), having your population of 300 diabetics controlled within acceptable cost effective parameters will become the main focus of your practice. EHRs will provide you with the intelligence (information) to manage your numbers and with ongoing measurements to assess your performance against goals, and EHRs will continuously collect data for ground-breaking research and more effective recommendations.

EHRs, as imperfect, ineffective and downright primitive, as they are today may be our first glimpse of a future where curing or treating disease is largely a thing of the past. If populations are proactively managed and everybody gets their shots and recommended genetic therapy, or whatever they will come up with next, Medical care will be limited to trauma and exotic ailments that have not been researched just yet. While our generation will not be crossing the River into the Promised Land of perpetual Health, it is up to us to manage this transition so human dignity is preserved and collateral damage is minimized in the process of industrializing medicine, a process which starts with changing the M in EMR to the H in EHR.

ED -- Erectile Dysfunction
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Viagra Viagra Professional


By Lane Jordan

Erectile Dysfunction (also know as impotence) is the failure to gain and maintain an erection. ED should not be confused with other sexual disorders such as lack of sex drive, ejaculation, and orgasm problems. It strictly deals with the ability to get an erection.

Most experts believe Erectile online pharmacy affects well over 30 million men in the US. Typically, ED is caused by a physical occurrence such as an injury, disease, or substance use. Anything that prevents the necessary level of blood flow the penis can result in ED. Although, ED is not an inevitable effect of aging, it is estimated that 5% of men experience it at the age of 40 and 15 to 25 percent of men over 60 experiences ED.

Erectile Dysfunction can be caused by damage to arteries, muscles, and tissues, often as a result of disease. Diseases can include diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease. All of the these diseases combined account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience impotence.

A Patients medical history can give insight as to the cause of ED, as well as diseases that lead to ED. Ones sexual history can also help discover the cause of ED. Also, history of prescription and illegal drug use can help discover the cause of ED. Thus, cutting down and/or stopping certain medications or illegal drug use can alleviate ED.

If you believe you may have erectile dysfunction, you should see your doctor for an examination. There are several relatively simple tests, which can be administered by a doctor to diagnose ED. Again, impotence affects millions of American men and there is no shame in being diagnosed with ED; its very common and there are many treatments for it. In my opinion, the most shame would come from knowing you have a sexual problem, and suffering through it without seeking help. ED has been treatable with great success. So if you’re sexuality is not right due to inability to get and/or maintain an erection, seek help from you’re doctor, they will be able to diagnose and treat the problem.

Andropause and Bio-T Blood screening
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As many of my friends are over the age of 45, I find myself concerned about their sexual health as they enter this phase of their lives. Natural production of testosterone declines after a certain age, and there are symptoms associated with it. I found a very nice Canadian website called andropause.ca that not only helps men understand what it is and what the treatment options are, but it addresses the issue that most doctors are not familiar with this condition, including your family doctor. There is a list (by province) of doctors who specialize in andropause.



I mentioned andropause to a few clients (over age 65) who have complained about weak erections and lowered libido, a few symptoms of the condition. They mentioned it to their (female) doctor, who discounted the possibility without doing a blood test that measures the bio-available testosterone in the sample. I felt sad and compelled to provide an outside source of information and a list of sympathetic doctors (at least to my Canadian friends).



Men that I know who are on supplemental testosterone have more energy, more life, and enjoy more their visits with me. When sex hormones are balanced these guys feel better than normal, and fatigue never seems to get to them like it did before supplementation. They don't accumulate body fat as fast as before, and their dicks get as hard as a rock like it did before. Erection drugs like Viagra and online pharmacy work better, and that aspect makes sexual activity less worrisome.



Worrying about getting erections remove the mental energy that is needed for letting go and having fun. But with preparation and participation in adjusting to the natural changes that occur to everyone that ages, sex can get better than you remember because of the appreciation factor.



You can fully appreciate something when it is gone, and when you get it back after some effort, you will never let it slip away again. Sex is something joyful that we must never lose touch with. But when sex does leave a person's life, people around you can tell. You should witness the subtle transformation my friends undergo when they leave my apartment. Simply put, it's a good feeling for everyone!

Men's Health All Terrain Race - June 15, 2008 (part 2)
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Men's Health All Terrain Race - June 15, 2008 (part 2)

Race started at 7:00AM for the 12k Trail Running. Not much runners compared to the fun runs held in Fort Bonifacio as it's quite far from Makati area and since it just offers a 12k route, it eliminates a lot of people just looking to do shorter runs (hint, hint).

At the beginning of the race, there were already a lot of uphill climbs, which prompted a lot of people (myself included) to walk instead of run in an effort to save on energy. But organizers made up for the hard start by having a lot of downhill running at last leg of the race. Course was a mix of concrete ground and pebbled (and some muddy) trails.

When I had a hard time getting a skin tan at the beaches of Boracay, here it was very easy as my skin got dark just from running for more than an hour. It was that hot! Automatic darker skin for all of us! Good thing there were enough water stations here to sate our thirsts.

It took me a very long time of 1 hour and 23 minutes to finish this 12km course but had already come up with a list of excuses to make up for it:

1. It was my first 12k Trail running race so regardless of how slow I am compared to my regular 10km races, it is still a personal record for my one and only 12k Trail running record. Clearly, this excuse is a one-time thing only.


2. I wore heavier but safer trail running shoes so not used to its weight and feel. But glad to have worn this old pair as it got dirty from the mud and saved me from a lot of potential ankle sprains had I worn my regular running shoes.


3. There were some open but inclined areas where I was thinking of running instead of walking but with the very hot weather, I didn’t want to run and risk a heat stroke. Yes, it really was that hot! Besides, none of the runners around me were running so figured they must all know what they were doing.


4. My performance here is still better than the Mens’ Health 8KM All-Terrain Race I joined exactly two years ago when I finished it at about 1 hour and 10 minutes. And this race is 50% longer than that one.

The bike race followed at about 9:00AM. We didn’t stay anymore for the awarding of prizes or Father’s Day Festival, as both would happen after the bike race, which would take another hour of waiting under the scorching sun.

Definitely a nice place to run given the change of familiarization in area, course and grounds but it is still something I have to think twice of doing a third time because of the long distance travel from my house.





Me and Gigay with Awarding/Announcing Stage at Background




All happy that we finished it regardless of our time. The word is SURVIVAL!






Group shot with Annlee, Wawie, me and Gigay




Start of 20KM Bike Race





Report: medical care denied to UK immigration detainees with HIV/Aids
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Source: Medical Justice



Most HIV+ immigration detainees helped by Medical Justice have been denied life-saving online pharmacy in detention according to our new research.



'Detained and Denied', based on the first ever comprehensive analysis of treatment of HIV+ immigration detainees in the UK draws on medical evidence from eight independent clinicians who assessed the detainees. Many of the 35 men, women and children studied are torture survivors from countries where rape is used as a weapon of war.



As a result of denial of medication some detainees have developed drug resistance, necessitating more complex drug combinations which are inaccessible to many in the country they are being deported to.  Without these drugs they may die within a few years, leaving their children orphans in a country some of them have never been to before.



More than three-quarters of the people in our study who were deported, had little or no medication. The UK Border Agency (UKBA) tried to deport an HIV+ pregnant mother who had been given less than a month's medication even though it is critical that treatment is not interrupted during pregnancy, to avoid a newborn child becoming infected.



Medical Justice has been granted permission by the Court of Appeal to intervene in the case of three HIV-positive (ex)detainees it has assisted who seek to have their detention ruled unlawful because of failure to treat them properly.  The 'Detained and Denied' report will form part of Medical Justice’s evidence that will be submitted.



Medical Justice calls for UK Border Agency to immediately stop detaining people who are HIV+ for immigration purposes.



"The UK Border Agency claims that healthcare in its centres is equivalent to that in the NHS, but the report shows that being in detention leads to a situation in which these patients cannot access proper medical care. In the case of HIV, this is a threat to the patients' lives. HIV-positive people should therefore be released and properly cared for."

Dr Indrajit Ghosh, a GP and HIV specialist who visited a number of detainees included in the study


“NAT welcomes the important report from Medical Justice, 'Detained and Denied', on the treatment of people with HIV in immigration detention, and deplores the continuing failures in care.  The NAT/BHIVA best practice Advice is there to assist those responsible to provide equivalent high quality care to that available in the community - not to do so is inexcusable.”

Deborah Jack, Chief Executive of the National AIDS Trust (NAT)


"Terrence Higgins Trust has supported many people with HIV whose health, physical and mental, has suffered while in detention. Given the clarity and quality of the BHIVA/NAT guidelines, there can be no excuse for this."

Lisa Power, Policy Director, Terrence Higgins Trust


“The clinical care in detention centres is currently so poor that it is a dangerous place for someone with HIV. Health and wellbeing is affected and lives are even being shortened.  That is unacceptable.”

Jenny Willott MP


“The research highlights the way people like me are not treated like human beings in detention. ... I was scared that I was going to die in Yarl’s Wood when they refused to give my medication. It was as if they were turning off my life support machine.”

“Mary”, HIV+ ex-detainee (name changed to preserve anonymity)


"We provide primary healthcare facilities in all immigration removal centres which are equivalent to those available in the community.”

Director of detention services, UK Border Agency – 20/03/11


"Nobody is denied access to necessary treatment or medication whilst detained".

Lord Attlee - 2 March 2011


Notes



About the 35 HIV+ detainees’ cases that Medical Justice handled:

  • 28 are women and three are children, mostly from African countries.

  • Five had been detained for over a year, and some for several years – immigration detention in the UK is indefinite

  • 80% discovered their HIV infection after their arrival in the UK



Many have fled their own countries seeking safety and refuge and fear being deported back to face further persecution. Many are unlikely to be able to access treatment in the country they are being deported to and fear they may only live a few years without treatment. Some UK-born children may be orphaned in a country they have never been to and where they have no family.



All of the detainees were being detained indefinitely for immigration purposes, despite not being accused of any crime, yet some were forced to undergo medical examinations while handcuffed to guards, even though UKBA Detention Service Order 08/2008 states “handcuffs should be removed during hospital treatment and if requested by a treating clinician.”



British government treats HIV+ detainees’ health beneath contempt in UK immigration removal centres:

  • 60% suffered disruptions in their medication due to their detention and many developed resistance to their drugs

  • 77% were deported with little or no medication

  • 66% were subjected to harmful practices, so dangerous that they may have led to permanent harm, including:

  • Denial of access to hospital for appointments with HIV specialists

  • A failure to carry out or pass on the results of tests to determine resistance to particular medications

  • Putting detainees at risk of contracting opportunistic infections

  • Despite typical symptoms of HIV infection, a detainee was not given a test for over a year – she is HIV+

  • One detainee was given a significant overdose of her medication by the detention centre’s healthcare staff

  • One woman was given the wrong drugs

  • Detention centre staff failed to respect the confidentiality of detainees

  • Some detainees were forced to undergo consultations whilst handcuffed to escorts

  • Less than half were deported, begging the question why they were locked up in the first place

  • Some detainees attempted suicide due to fear of deportation

The Medical Justice study tracked breaches of the National AIDS Trust and the British HIV Association guidelines.



Guidelines for the treatment of HIV+ detainees have been set out by the National AIDS Trust and the British HIV Association (BHIVA). The BHIVA guidelines simply call for NHS-equivalent for HIV+ detainees, nothing more. UKBA policy is that healthcare in its detention centres is NHS-equivalent all detainees anyway. However, when challenging failures to provide care in line with BHIVA guidelines (i.e. NHS-equivalent), UKBA claims that it is neither willing nor able to enforce the guidelines within detention centres. It’s a classic Catch-22, with potentially lethal consequences.



The British government is willing to deport people who they know will die within a few years as a consequence.



UKBA has deported HIV+ children who are unlikely to have consistent access to treatment where they are deported to. 46% of the detainees were removed, despite in some cases former treating clinicians writing letters explaining, explicitly, that deporting particular detainees would be likely to lead to death. In one case, a judge recommended that the UKBA either find a woman who had been removed with insufficient ARV drugs and bring her back to the UK, or arrange to have three months supply of medication flown out to her. Neither happened.



The British government may have shortened detainee’s lives and prematurely orphaned children.



Through its private company sub-contractors who provide healthcare in detention centres, the government has denied HIV medication to detainees in our study for days, and in some cases - weeks. One person reportedly went without some of the drugs that he was supposed to be taking for nearly 3 months.  Furthermore, the government has denied blood tests to investigate resistance and/or withheld results. Missing just one dose of HIV medication can be serious and increases the propensity to HIV related (and non HIV related) illness. Ultimately, this can be fatal.



The process of detaining people who are HIV positive inherently puts them at risk.



Medical Justice calls for and end to the immigration detention of anyone who is HIV+, not least because our findings indicate that the process of detaining people who are HIV positive inherently puts them at risk and has caused significant harm. Common problems included interruptions to medication and treatment due to the process of arrest, being temporarily held in various places, removal attempts and administrative errors.  Some hospital appointments are missed as another private company providing transportation has set priorities for transport ; hospital appointments are quite far down the priority list. Furthermore, detainees have been put at serious risk of contracting dangerous – potentially fatal – infections or viruses when made to share rooms with people with TB, Swine Flu and chickenpox.



Case-studies of the contemptible treatment of HIV+ detainees:

A husband and wife, both HIV+, were arrested in a dawn raid with their two children. The parents were denied their HIV and other medication for a period of time.  The parents had kept their HIV status secret from their children but the detention centre staff told the children. The family were then separated when the father was put in isolation for a short time. Even though a doctor who had treated the parents prior to detention wrote that without access to continued medication in the country they were being returned to, the life expectancy of both parents was likely to be only a few years, the government tried to deport the family with less than 3 months medication. Describing the effect of detention on his children, the father said; “… they think that they are not human beings anymore, they have no future and they think that we are criminals.”



Failure to treat HIV - Four people exhibited symptoms which could have been indicative of a development of their HIV infection which, according to our records, were not sufficiently investigated. One woman was coughing yellow spit, had signs of TB infection, and was at risk of numerous life-threatening opportunistic infections. Little, however, appeared to have been done to investigate these symptoms. Another woman had lost approximately 20kg in weight, had abdominal pains, and watery diarrhoea; yet she had not seen a HIV specialist in over a month. 



Denial of test results - one man in an unstable medical condition claimed that clinicians in detention refused to give him the results of blood tests and instead would only give them to the UKBA.   



Attempt to deport a baby untested for HIV - There was an attempt to deport an HIV+ mother with her baby despite the fact that the baby was too young to test to ensure he had not been infected with HIV, The baby had not been offered malaria prophylaxis and, given that he was born in the UK, would be extremely vulnerable to this disease.



Discrepancy in medication supplies – The NHS norm is to supply patients with three months’ supply of medication, yet immigration detainees are normally given 28 days supply, even though they are being deported to countries where it is known that access to medication is at best patchy.


About Medical Justice - Medical Justice is a small charity with four staff and acts as a network of volunteer medics, solicitors, barristers, ex-detainees, and detainee visitors who arrange for independent doctors to men, women, children, including torture victims, in 11 immigration removal centres around the UK. In response to medical abuse we have exposed, and with evidence from our case-work, we seek policy changes to secure lasting improvements for immigration detainees.



A meeting on the medical care detainees with HIV/Aids receive while in immigration detention



Monday 9 May, 1-2pm, at the Institute of Race Relations, 2-6 Leeke Street, London WC1X 9HS



Speakers:

  • Theresa Schleicher - Medical Justice

  • Jon Burnett - author of 'Detained and Denied: the clinical care of immigration detainees living with HIV'

This meeting is aimed at lawyers, campaigners, ex-detainees, individuals and organisations interested in how asylum seekers with HIV/Aids are treated in detention. As places are limited it is essential to reserve a seat. Please RSVP to events@irr.org.uk. And note that meetings start promptly at 1 o'clock.



Medical Justice: Detained and denied

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PARP INHIBITORS AND TOPOTECAN
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A phase I combination study of ABT-888 and topotecan hydrochloride in adults with refractory solid tumors and lymphomas

08.04.09
Category: Scientific News

Coadministration of the PARP viagra potentiated the toxic effects of topotecan


Poly (ADP-ribose) polymerase (PARP) is an essential nuclear enzyme important for recognizing DNA damage and facilitating DNA repair. PARP inhibitors may prevent efficient repair of DNA damage induced by topoisomerase 1 inhibitors such as topotecan.

Dr S Kummar from the National Cancer institute, Bethesda, USA presented the study at the 7th International Symposium on Targeted Anticancer Therapies in Amsterdam, the Netherlands, on 23–25 March 2009. The objectives of the trial were to establish the safety, tolerability, and maximum tolerated dose of the combination of the oral PARP cheap cialis ABT-888 with topotecan, to evaluate the pharmacokinetics of each agent alone and in combination, and to determine drug effects on the level of PARP inhibition in peripheral blood mononuclear cells (PBMCs) and tumor samples.

Patients with histologically documented solid tumors and lymphoid malignancies whose disease had progressed following standard therapy were eligible. Treatment consisted of 21-day cycles of ABT-888 po and topotecan iv. PBMCs and optional biopsies were collected, and PARP activity was determined using a validated ELISA assay comparing pre- and post-treatment PAR levels.

Two of 6 patients developed dose-limiting toxicities (DLTs; grade 4 thrombocytopenia and grade 4 neutropenia) at the starting dose; myelosuppression was also observed at level 1. ABT-888 dosing was reduced to 5 days and the dose of topotecan lowered. However, significant myelosuppression was still seen at level 2. Six patients on study had stable disease for ≥ 2 cycles but 5 were removed due to toxicities. One patient with thyroid cancer on level 3 continued on study for > 6 months. PARP activity was inhibited in PBMCs in 14 of 18 patients. In 2 patients for whom paired tumor and PBMC data are available, there was a > 75% decrease in PAR levels 3-7 hours after treatment.

PARP inhibitors are being developed as chemopotentiating agents. However, coadministration of the PARP inhibitor ABT-888 potentiated the toxic effects of topotecan in this trial.

Successful Eating Disorders Coalition Lobby Day!
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Wowed by EDC National Lobby Day, April, 2011

Dear EDC Member Organizations, supporters, advocates and all those who care about the cause of Eating Disorders-

Over 100 advocates from across the country descended on the nation's capitol to advocate for the FREED Act --the Federal Response to Eliminate Eating Disorders (HR 1448, S 481). We had over 50 new advocates join us this year!

The events all began with a Reception and Meet and Greet Social on Monday evening prior to Lobby Day. "The Joy of Recovery: A Story of Inspiration" was shared by long time EDC advocate Eileen Binckley. A light dinner along with refreshments were served as advocates both new and old mingled...finish reading at the Eating Disorders Coalition Blog

New Use for Active Ingredient of Cialis
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The FDA has approved a new use for tadalafil, which is the active ingredient in the erectile dysfunction drug cheap cialis. Tadalafil, sold as Adcirca, is now approved to improve exercise ability in people with pulmonary arterial hypertension, which is a rare, life-threatening lung disorder that causes high blood pressure in the lungs.
Adcirca comes in 40 milligram tablets; patients take one tablet per day.
In 2005, the FDA approved Revatio, a pulmonary arterial hypertension drug made with sildenafil, the active ingredient in the erectile dysfunction drug Viagra. Revatio pills are taken three times daily at 20 milligrams per pill.
Adcirca, which will be available in August, is made by the drug company Lilly, which also makes Cialis. Adcirca will be marketed in the U.S. by United Therapeutics Corporation.
The FDA approved Adcirca based on a clinical trial in which pulmonary arterial hypertension patients either took Adcirca (given as two daily tablets, with each tablet containing 20 milligrams of tadalafil) or a placebo pill for 16 weeks.
At the end of the study, the patients walked for six minutes; during that time, patients taking Adcirca walked 33 meters farther than patients in the placebo group. Patients taking Adcirca also had less clinical worsening of their pulmonary arterial hypertension during the study than patients taking the placebo, according to a news release from United Therapeutics.
The most common side effects during the clinical trial included headache; muscle pain; flushing; colds and other respiratory tract infections; nausea; pain in the arms, legs, or back; upset stomach; and nasal congestion. United Therapeutics states that those side effects were generally brief and mild to moderate in intensity.

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CIALIS ENGLAND 50mg OBAT KUAT VITALITAS
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CIALIS ( tadalafil) 50mg is used for treating erectile men' s erectile dysfuncion ( e, g..Impotence) cheap cialis starts working in 30minutes and lasts for about 36 haurs, while viagra effect lasts up to 5 haurs besides you can take cheap cialis with or without food.




Function :

1.This product make the penis erect quicly, improve sexual intercourse quality, shorten the interval for a second intercourse and reduce fatigue. Remove prematur ejaculation, activate kidney function and increase secretion of testicle cell.

2.It contains many vigor factors required by male, long-term administration can increase spirit, prostate and other similar diseases, usage and dosage : take one pill 10-30 minutes before sexual intercourse.





Administration and dosage: take one pill 10-30 minutes before sexual inter course.



Cialis 50mg adalah obat perangsang untuk peria berbentuk pil atau tablet berfungsi untuk membuat ereksi pada penis.
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Dalam 1box CIALIS 50mg berisi 10tablet.
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