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In the event of termination doctor's advice on erectile dysfunction discount kamagra oral jelly 100mg line, City shall be liable only for the payment of all unpaid charges erectile dysfunction exercise video purchase kamagra oral jelly 100 mg, determined in accordance with the provisions of this Agreement, for Work properly performed prior to the effective date of termination. If any circumstance of Force Majeure remains in effect for sixty(60) days, either party may terminate this Agreement. Engineer is duly registered and licensed to do business in the State of Florida and is in good standing under the laws of Florida, and is duly qualified and authorized to carry on the functions and operations set forth in this Agreement. The undersigned representative of Engineer has the power, authority, and legal right to execute and deliver this Agreement on behalf of Engineer. The indemnity provisions set forth in this Paragraph 35 shall survive termination of this Agreement. For this Agreement only, construction sites include places of manufacture for materials incorporated into the construction work, and construction contractors include manufacturers of materials incorporated into the construction work. Engineer is not responsible for any errors or omissions in the information from others that is incorporated into the record drawings. No principal (which includes officers, directors, or executive) or individual holding a professional license and performing work under this Agreement is presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in any architecture, landscape i. The undersigned is authorized to execute this Agreement on behalf of the Engineer and said signature shall bind the Engineer to this Agreement. Austin, Administrative Assistant Through: Michael Cantaloupe, Chief of Police Requested Action: Council Approve a Multi-Year Contract with the Bancorp Bank/dba/Mears Motor Leasing and authorize the City Manager to negotiate, sign and execute the agreement and authorize the Police Department to enter into a purchase order for the negotiated amount. Bancorp has agreed to the early-term the existing lease for one vehicle and lease two new vehicles to the City at the lower cost. The early-term will allow the City to lease two vehicles for twelve months and save approximately $3200. However, the Master Lease is being reviewed by the City Attorney and may need to be amended or replaced in conjunction with this request. The Bancorp has agreed to early-term one lease, effective January 2017 and the other on March 31, 2017. The new multi-year lease agreement will be effective upon completion of the lease documents with the approval of the City Manager and City Attorney and delivery of each vehicle. In consideration of the mutual covenants and upon the terms and conditions contained in this Agreement, Lessor leases to time to time to this Agreement (each, a "Vehicle ") on the terms and conditions in the Schedule and as hereinafter set forth below. It shall commence on the date the Vehicle is Lessee and Lessee hires from Lessor each motor vehicle described in one or more Schedules signed by Lessee and added from 3. The first calendar month of the Term of this Lease shall be deemed to be (i) the calendar month in which the Commencement Date occurs, if the 5. Commencement Date occurs on or before the 15th day of the month, or (ii) the calendar month following the Commencement Date, if the Commencement Date occurs after the 15th day of the month. Lessee shall, during the term of this Lease, use, maintain, operate and service the Vehicle so as fully to comply with the following standards: i) a) Lessee shall be solely responsible, at its own expense, for maintaining and servicing the Vehicle, during the term of this Lease, as provided in Section 6 below. Lessor shall have the right to inspect the, Vehicle upon request at any reasonable time. The Vehicle shall be used in accordance with the monthly mileage allowance listed in the Schedule. Lessee shall pay for any loss in value to the Vehicle caused by misuse, negligence or accident and for all damages to the Vehicle. Lessee shall pay all costs of restoring the Vehicle to good condition for resale, including (but not limited to) replacement or repair of missing or damaged parts and equipment, broken glass or lights, worn tires, cracked engine block, 7. Lessee agrees to return the Vehicle to Lessor at the end of the term of the Lease. Lessee agrees to return the Vehicle in good operating condition and working order, free from physical or mechanical damage, except for reasonable wear and tear. Lessee agrees to return with the Vehicle all license plates, the Vehicle registration and all other documents related to ownership or possession of the Vehicle. Lessee further agrees to accurately report to Lessor the correct mileage accumulated on the Vehicle. Lessee shall pay to Lessor all sums then due under the Lease, including but not limited to all sums due under Section 6 above. Prior to the date each Monthly Payment is due except for the first Monthly Payment, Lessor shall render to Lessee a single statement of the Monthly Payment payable for that calendar month.

Rahe muse erectile dysfunction wiki kamagra oral jelly 100 mg cheap, "The Social Readjustment Rating Scale impotence at 19 cheap kamagra oral jelly 100 mg otc," Journal of Psychosomatic Research, 1967, Table 3, p. To obtain your score, add the numbers associated with each event you experienced in the past year. The problems occur not when you are crowded but when you feel crowded (Taylor, 1991). Jonathan Freedman (1975) has concluded that the effects of crowding depend on the situation. If the situation is pleasant, crowding makes people feel better; if the situation is unpleasant, crowding makes them feel worse. Life Changes and Stress Major life changes-marriage, serious illness, a new job, moving away, and a death in the family-are important sources of stress. Common to most of these events is the separation of an individual from familiar friends, Chapter 15 / Stress and Health 417 relations, or colleagues. Even marriage-a positive change-may involve breaking free from many longstanding ties. In what ways the foremost life-change researchers are would your scale be different? Rahe (1967), who developed a scale to measure the Procedure effects of 43 common events, ranging from 1. First, develop a list of life events that you deem stressful to teenagers and rank them the death of a spouse to going on a vacation. Assign each event a value based on population to rate each of these events on a how much adjustment the event requires. Provide a copy of your list to several friends value of 50, on the basis of how much adjustand ask them to circle the events that they ment the event required. Marriage, for example, may be accomrelationship between stressful events panied by a change in financial status, a change in living that teenagers face and illnesses they conditions, and a change in residence-collectively much experience? Some of the items, such as marriage, are joyful events that are not related to illness (Taylor, 1991). Several studies suggest there is only a small relationship between stressful life events and illness (Brett et al. The scale also fails to measure stress caused by ongoing situations such as racism and poverty. Hassles In addition to the impact that major stressful events such as a divorce or a death in the family can have, psychologists have studied the effects that relatively minor, day-to-day stressors have on health. Examples of hassles include losing your car keys, being caught in a crowded elevator with a smoker, or being late for work or school because you were stuck in traffic (see Figure 15. It has also been suggested that small, positive events, called uplifts, can · Household duties (cleaning, cooking, shopping) protect against stress. Up· Concerns about health lifts are things that make a · Time pressures (not enough time to get something done) · Environmental hassles (noise, pollution, crime) person feel good, such as · Financial hassles (paying bills, saving for the future) winning a tough chess · Worries about your job match, going out to lunch · Concerns about your future with a good friend, or doing · Inner hassles (feelings of low self-esteem or well on a semester exam. Every one of us faces many daily hassles-traffic, arguments, car trouble, and so on. Could it be that the primary effects of stress are the accumulation of little things that just constantly seem to hassle us (Weinberger, Hiner, & Tierney, 1987)? Seventy-five married couples recorded their everyday hassles, and it turned out that those with more hassles had significantly more health problems such as sore throats and headaches, which they experienced later (DeLongis, Folkman, & Lazarus, 1988). Visualize the Main Idea Use a chart similar to the one below to list examples of the different conflict situations. Application Activity Select a day and keep a log of your daily hassles and uplifts. Briefly outline a strategy by which you pay more attention to uplifts and brighten your mood. I remember vividly when he spit across the room at the 100 percent papers posted on the wall. Vocabulary anxiety anger fear social support · · · · Objectives · Give examples of the psychological, physical, and behavioral reactions to stress. There is a wide variety of stress reactions, and their effects range from beneficial to harmful.

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Based on the results of wellcontrolled studies erectile dysfunction doctors rochester ny purchase kamagra oral jelly 100mg line, 40-58% of patients with cervical dystonia would be expected to have a significant improvement in their symptoms erectile dysfunction from adderall generic kamagra oral jelly 100 mg line. In a double-blind, vehicle-controlled parallel study, 51 patients with idiopathic cervical dystonia (spasmodic torticollis) were evaluated. There was also a significant decrease in strength and size of the contralateral sternocleidomastoid and trapezii. Vehicle-treated patients showed a mean decrease of only 0 to 4 degrees (0% to 6%) of head rotation at rest, and had no change in muscle strength or size. The difference in head rotation between treatment groups was statistically significant. Improvement was reported by 8%, 8% and 17% of vehicle-treated subjects at the same time points, respectively. The Physician Global Assessment showed parallel statistically significant improvements. Improvements in wrist, elbow and finger flexor muscle tone were reported at the highest dose in each study at various timepoints. The Physician Global Assessment also showed significant benefit at doses ranging from 75 to 360 units at various timepoints. Equinus foot In a three-month, double-blind, placebo-controlled, parallel study, 145 ambulatory children with cerebral palsy, 2 to 16 years of age, were evaluated. Patients exhibited muscle spasticity of the lower extremity(ies) associated with an equinovalgus foot position during gait. No significant changes in electromyography were seen in the placebo-treated patients. In a long-term, open-label study, 207 patients were evaluated for up to three years. A total of 1,384 chronic migraine adults who had either never received or were not using any concurrent headache prophylaxis, had > 15 headache days, with 50% being migraine/probable migraine, and > 4 headache episodes during a 28-day baseline phase were studied in 2 phase 3 clinical trials. Each secondary variable could only indicate significance if the primary variable and each secondary variable ranked ahead of it indicated statistical significance. The treatment effect appeared smaller in the subgroup of male patients (N=188) than in the whole study population. Neurogenic Detrusor Overactivity associated with a neurologic condition Two double-blind, placebo-controlled, randomized, multi-center Phase 3 clinical studies were conducted in patients with urinary incontinence due to neurogenic detrusor overactivity who were either spontaneously voiding or using catheterization. A total of 691 spinal cord injury or multiple sclerosis patients, not adequately managed with at least one anticholinergic agent, were enrolled. Significant improvements in urodynamic parameters including increase in maximum cystometric capacity and decreases in peak detrusor pressure during the first involuntary detrusor contraction were 40 observed. These primary and secondary endpoints are shown in Tables 8 and 9, and Figures 1 and 2. Retreatment criteria were: patient request, at least 12 weeks since previous treatment, and < 50% reduction (Study 1) or < 30% reduction (Study 2) from baseline in urinary incontinence episodes. In the pivotal studies, none of the 475 neurogenic detrusor overactivity patients with analyzed specimens developed the presence of neutralizing antibodies. Significant improvements compared to placebo were also observed for the daily frequency of micturition, urgency, and nocturia episodes. For all efficacy endpoints, patients experienced consistent response with re-treatments. Retreatment criteria for all phase 3 studies were: patient request, at least 12 weeks since previous treatment, and at least 2 urinary incontinence episodes in 3 days. In the pivotal studies, none of the 615 (0%) patients with analyzed specimens developed the presence of neutralizing antibodies. The proportions achieving at least a 75% and 50% reduction from baseline in urinary incontinence episodes were 46. The proportions achieving at least a 75% and 50% reduction from baseline in urinary incontinence episodes were 44.

While some are comfortable being out about being trans-men and transwomen and while some can easily "pass erectile dysfunction uptodate order kamagra oral jelly 100 mg fast delivery," others just want to live their lives authentically without undue notice erectile dysfunction medication prices cheap kamagra oral jelly 100 mg fast delivery, and for some this is quite difficult due to their physical characteristics. In some cases procedures such as electrolysis, facial feminization or thyroid chondroplasty reduction are perhaps as necessary as breast augmentation, breast reduction or whatever form of genital affirmation surgery are needed. These procedures are perhaps more vital for older transgender individuals who are just now able to attend to their needs. As we know, the younger an individual the more success at mitigating cross-gender characteristics antagonistic the gender confirmation. Not only can the lack of ability to have these procedures performed affect the psychology of the individual, but it can prevent social stigmas, either internal or external, and, despite laws and platitudes to the contrary, can make it more difficult for people to secure gainful employment or to be able to function well in society. Therefore, I ask that the consideration be made within these rulings that such procedures, when deemed necessary by one or more qualified professionals, will be allowed. If the reason for having such rules and regulations is to protect the patient and to prevent abuse (either by the patient, providers or anyone else) then it is imperative that patients are given the best opportunity for the full benefit from the treatments that they are receiving. Comment 10: Gentlepersons, Thank you for the work you have done to improve the policy regarding surgery for transgender patients. For example: Some genital reconstruction procedures, eg phalloplasty, are outside of usual ob/gyn training and usually require additional training; however, hysterectomy and removal of tubes and/or ovaries is a routine part of ob/gyn training and no additional training would be required (and are not "genital reconstruction" per se). Nobody want any surgeons to practice outside of their expertise, but that would be a matter of hospital/ambulatory surgical center privileging - not something for Medicaid to get in the weeds of. I would propose, instead: "The surgeon must have competence in the requested surgery/ies. Thank you for your consideration, and I would be happy to discuss any of this with you. Comment 11: To whom it may concern, I agree that transgender youth should have access to medical coverage. I disagree with the continuing exclusion of Facial Feminization Surgery, Electrolysis and Laser hair reduction. Facial features, hair on the face and body are unmistakably masculine identifiers that humans use to identify gender in the blink of an eye. Without this coverage many trans women are routinely misgendered, othered, ridiculed, stigmatized and subject to violence at the hands of the public. This has been my lived experience along with personally funding electrolysis and laser hair reduction on my face and body. The Transgender community has advanced in my lifetime, written standards of care and coverage for example. Thank you for this opportunity to comment on the proposed Medicaid rule changes concerning transgender coverage. Children cannot give informed consent to permanent sterilization, lifelong medical patienthood, sexual dysfunction, and a host of psycho-sexual difficulties that will increase their risk of mental illness and suicide, as well as making the possibility of dating and or finding a life partner very slim. If you are looking at the small body of existing transgender youth studies, note that they are categorized as "poor quality" by medical researchers. I have spent 3 years researching this topic because I have a transgender-identified child myself. When she is 21 (preferably 25, as that is the age now recognized as the end of "adolescence" and brain maturity) she can make her own informed choices. At 14, socially isolated, depressed, and heavily influenced by youtube videos about transition, my child was very distressed about her breasts. My daughter is an A student and a thriving political activist who still struggles a bit socially and with emotions and has some occasional anxiety, but is doing much better now than she was at 14. I am convinced that the discomforts of puberty, social expectations of "femininity", internalized sexism and homophobia may have influenced her sudden identification as "male". I expect that she will most likely end up identifying as androgynous, gender queer, bisexual or lesbian instead of "trans". If I had rushed her to a gender clinic at 14 and followed the advice of activists and so-called "progressives (note that I am a registered democrat and a second wave feminist), she would have been put on hormones, binding, or even had her breasts removed by now. Give kids time to explore their identity sexuality(this is the role of adolescence! We are failing these children by pathologizing and medicalizing their gender non-conformity and nonheterosexuality!

References:

• https://www.shrewsburyobgyn.com/Guide_to_Vaginal_Estrogens_and_Lubricants.pdf
• https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-019-6393-1.pdf
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/2016-HAC-Report.pdf
• https://sexualityresources.com/sites/default/files/documents/PR%20Booklet%20longform%2018.pdf