By M. Masil. Salve Regina University. 2019.

Traditional medicines in the Pacific | 271 Finally it discusses some of the work that has been carried out more recently to separate the folk law elements of traditional medicine usage from the more evidence-based practice of contemporary western society and shows that order viagra plus 400 mg, surprisingly order viagra plus 400 mg online, there may be considerable commonality between the two purchase cheapest viagra plus and viagra plus. The setting Australia Australia (similar to New Zealand) is often considered as an enclave of European culture and traditions, thousands of miles away from the source of its traditions. This culture is, however, of fairly recent origin, a matter of only a few hundred years. Before the arrival of European adventurers and settlers, the two countries enjoyed the traditions of their own indigenous peoples. Australasia, although sometimes considered to consist of just Australia and New Zealand, does in fact encompass many other neigh- bouring islands in the South Pacific ocean, many of which share similar traditions, including those associated with the recognition and treatment of illness. Its climate too is extreme, scorching hot and dry in the centre, hot and humid in its northern regions, and almost temperate in its coastal southern parts. Its native people, the Aborigines, have lived in its land for thousands of years, living in tribal units in a nomadic lifestyle, not cultivating land or crops as a rule but moving from one area to another as availability of food sources dictated. The tribes spoke in many different languages or dialects and had no formal written means of transmitting information from one group to another or from one generation to the next. Although some pictorial means were used, most information was passed on by word of mouth. When someone became sick, an elder in the tribe, a traditional healer (ngangkari), would be called in to identify the problem, specifically the evil spirit respon- sible for the sickness. This spirit would be driven away by ritualistic dancing and chanting by the revered elder who would dress in distinctive garb for the occasion. To aid the driving away of the evil spirit, the ill person could also be treated with a concoction of herbs and herbal extracts considered effective for the purpose. Both were settled by their indigenous Melanesian or Polynesian people about 3000–4000 years ago and each became the focus of western attention in the mid-nineteenth century when the British and others became aware of the richness of the vegetation of the islands and their potential for trade. Fiji Fiji became a British colony in 1874, after which time the population mix of the country was altered by the influx of Indians who were brought in by the British as contract labourers. Fiji’s many islands are now home to about 900 000 people, about half of whom are Melanesian–Fijian and most of the remainder Indo-Fijian. Samoa Samoa was also settled by British as well as German and American entre- preneurs, although Britain ceded its territory to Germany in the early twen- tieth century in exchange for the right to retain control over Fiji. New Zealand took over from Germany after 1918 and controlled it until Samoan independence in 1962. At this time, the name Samoa was accepted by the United Nations as the official name of the two largest, western islands of the country. The customs and practices of the 180 000 or so mainly Polynesian people of the islands are very similar, however, as is their approach to medicine. It is made up of a number of islands, the major ones being known as North Island and South Island, respectively. Its native population, the Maoris, arrived about 1000 years ago and its European (British) settlers in the mid-nineteenth century (although it had been visited first by Dutch explorers in the mid-seventeenth century). It is currently also home to a number of other immigrant groups, notably Polynesian and Asians, mainly from south-east Asia. Europeans are the predominant ethnic group now, totalling about 78% at the last (2006) census, while Maoris make up 10%, Asians 9% and Polynesian Pacific Islanders 6%. Traditional treatment of ill-health thus generally took the form of a variety of approaches: physical manipulation, herbal medicine and oversight by a spiritual healer. Specific information about such treatments has been difficult to obtain, largely because of the lack of a written language in each country before the arrival of European colonists and other visitors. Accounts of treatments before this time were largely penned by tempo- rary visitors such as explorers, missionaries and whalers who were not necessarily aware of the complexities of the societies that they were observing nor of course the subtleties of languages with which they were not at all familiar. This changed after these countries were settled by the colonists, who spent more time with the native populations, learning their languages and observing their customs, including their methods of treating illnesses. Although these early settlers brought with them the means – mainly herbal extracts – of treating illness then available in Europe, they also began to experiment with local flora to extend their armamentarium of possibly medi- cinally active plants. They also planted seeds of European plants, either delib- erately or accidentally, and used them where applicable. At the same time, the local populations observed the customs of the settlers, including their methods of treating European sicknesses. When they in turn became infected with the diseases brought in by the settlers, they too began to adopt Euro- pean methods of treating themselves using the herbal medicines of their own country and those introduced by the settlers. As a consequence, when infor- mation about traditional medicines was later recorded in written documents there was often some confusion between those that were originally used and those developed only after colonisation. Australia Before the influx of Europeans in the late eighteenth century, it seems prob- able that Aborigines enjoyed relatively good health, despite the rigours of the Australian climate and the scarcity of some food sources. The ill-health that they experienced was largely brought about by living in close proximity to each other, leading to many skin problems and respiratory disorders. Their diet was necessarily poor and they would frequently encounter sharp objects in their wanderings in the form of either plants stumbled over or objects wielded by other people. They did not, as far as we can ascertain, suffer from most of the infectious diseases of the west, diseases such as smallpox, 274 | Traditional medicine cholera, tuberculosis, sexually transmitted infections, mumps and measles. They were therefore quite unprepared for the devastating impact of foreign microorgan- isms which killed them in their thousands, and they were also not prepared for the equally devastating impact of western society on their own, less structured way of life. Traditional remedies There are many uncertainties about the use of herbal medicines pre-Euro- pean times. Not only were there no written records, but there was also little clarity about the botanical identification of plants used, the specific part to be used and how this part was to be applied. Those Europeans who tried to find out more about the plants used in earlier times were sometimes misinformed through Aboriginal willingness to please. Aboriginals are sometimes so very willing to give names of plants to the traveller that, rather than disappoint him, they will prepare a few for the occasion. The nineteenth century settlers noted that Aborigines were well acquainted with these conditions and employed a number of plants to remedy them. The gummy exudates (known collectively as kino) from various species of eucalyptus, notably Eucalyptus siderophloia and other trees or bushes, were regularly chewed to slow down or stop diarrhoea. Many of these kino exudates have since been shown to contain tannins or other astringent compounds that inhibit secretions of the gastrointestinal tract. The wood of this tree has what is described as a ‘nauseating odour’ but its resinous exudates, when placed in tooth cavities, did relieve the pain of toothache. Many other plants, including several species of acacia, were used as painkillers for both internal and external sources of pain. A number of these also had sedative properties, especially those in the Solanaceae and Lobeli- aceae families, the best known of which is the plant known as ‘pituri’ (Duboisia hopwoodii). The leaves of pituri were chewed in much the same manner as is tobacco and produced a number of similar effects, initially stimulation of activity, followed by lethargy and fatigue. The plant grows in many parts of Australia and its use by Aborigines was so well known that it was considered to be like:.

In a healthy patient the sympathetic and parasympathetic nervous systems counter- balance each other to maintain homeostasis order discount viagra plus on-line. Upper Respiratory Tract Disorders Respiratory disorders are divided into two groups: upper respiratory tract disorders and lower respiratory tract disorders order cheapest viagra plus. These include the common cold buy viagra plus 400 mg visa, acute rhinitis (not the same as allergic rhinitis), sinusitis, acute tonsillitis, and acute laryngitis. The rhinovirus is frequently accompanied by acute inflammation of the mucous membranes of the nose and increased nasal secretions. The rhinovirus is seasonable: 50% of the infections occur in the winter and 25% dur- ing the summer. Although no one has directly died from the common cold, it does create both physical and mental discomfort for the person and leads to a loss of work and school. During this time, the rhinovirus can be transmitted by touching contaminated surfaces and from contact with droplets from an infected patient who sneezes and coughs. After the incubation period, the patient experiences a watery nasal discharge called rhinorrhea, nasal congestion, cough, and an increasing amount of mucosal secretions. Many patients try home remedies to battle the rhinovirus, however these don’t affect the virus. Home remedies include rest, vitamin C, mega doses of other vitamins, and, of course, chicken soup. Vitamin C and mega doses of other vitamins have not been proven effective against the common cold. When home remedies fail, patients turn to both prescription and over-the- counter medication. Charts throughout these pages provide information about specific drugs in each group. Antihistamines (H blocker) 1 Many cold symptoms are caused by the body’s overproduction of histamines. Histamines are potent vasodilators that react to a foreign substance in the body such as the rhinovirus. H2 receptors cause an increase in gastric secretions and are not involved in this response. This is referred to as nasal con- gestion and is caused when the nasal mucous membranes swell in response to the rhinovirus. A decongestant is a drug that stimulates the alpha-adrenergic receptors to tell the brain to constrict the capillaries within the nasal mucosa. The result is that the nasal mucous membranes shrink, reducing the amount of fluid that is secreted from the nose. Decongestants are available in nasal spray, drops, tablets, capsules, or in liq- uid form. These are nasal decongestants that provide quick relief to the patient; systemic decongestants that provide a longer lasting relief from congestion; and intranasal glucocorticoids that are used to treat seasonal and perennial rhinitis. Cough Preparations A cough is a common symptom of a cold brought about by the body’s effort to remove nasal mucous that might drain into the respiratory tract. Antitussives are the ingredients used in cough medicine to suppress the cough center in the medulla. Although the cough reflex is useful to clear the air passages, suppres- sion of the cough reflex can provide some rest for the patient. Expectorants When an individual has a cold or other respiratory infection, it is common to have rather thick mucous that is difficult to expectorate. Expectorants are med- ications that loosen the secretions making it easier for the patient to cough up and expel the mucous. They work by increasing the fluid output of the respira- tory tract and decrease the adhesiveness and surface tension to promote removal of viscous mucus. A list of drugs utilized in the treatment of upper respiratory tract disorders is provided in the Appendix. Patients may take systemic or nasal decongestants to reduce the congestion that frequently accompanies sinusitis. Patients are told to drink plenty of fluids, to rest, and to take acetaminophen (Tylenol) or ibupro- fen for discomfort. In some cases, antibiotics are prescribed if the condition is severe or long lasting and an infection is suspected. Pharyngitis is caused by a virus (viral pharyngitis) or by bacteria (bacteria pharyngitis) such as the beta-hemolytic streptococci. Sometimes patients experience acute pharyngitis along with other upper respiratory tract disease such as a cold, rhinitis, or acute sinusitis. Patients who have a viral pharyngitis are given medications that treat the symptoms rather than attacking the underlying virus. Acetaminophen or ibupro- fen is given to reduce the patient’s temperature and discomfort. Saline gargles, lozenges, and increased fluid are usually helpful to soothe the sore throat. Patients who have bacterial pharyngitis are given antibiotics to destroy the beta-hemolytic streptococci bacteria. However, antibiotics are only prescribed if the result of the throat culture is positive for bacteria. Patients are also given the same treatments for viral pharyngitis to address the symptoms of pharyngitis. Patients who come down with acute tonsillitis experi- ence a sore throat, chills, fever, aching muscles, and pain when they swallow. A throat culture is taken to determine the cause of the infection before an appropriate antibiotic is prescribed to the patient. The patient is also given acet- aminophen or ibuprofen to reduce the fever and the aches and pains associated with acute tonsillitis. The patient is also encouraged to use saline gargles, lozenges, and increased fluid to soothe the soreness brought on by infected ton- sils. Other times it is caused by stress or overuse of the vocal cords—a common occurrence for fans whose team wins the Super Bowl. Refraining from speaking and avoiding exposure to substances that can irritate the vocal cords, such as smoking, is the preferred treatment for acute laryngitis. The result is an impairment of oxygen reach- ing lung tissues that can in some cases irreversibly damage lung tissues. The airway obstruction occurs when the bronchioles constrict (bronchospasm) and mucous secretions increase causing the patient to experience difficulty breathing (dyspnea). Symptoms include fever, chills, cough, rapid breathing, wheezing and/or grunting respirations, labored breathing, vomiting, chest pain, abdominal pain, loss of appetite, decreased activity, and, in extreme cases, signs of hypoxia (low oxygen levels) or cyanosis such as a bluish tint around the mouth or fingernails.

order 400mg viagra plus overnight delivery

Rasayana This is a specialised branch of clinical medicine in ayurveda meant for slowing the effect of ageing and to improve intelligence purchase viagra plus with mastercard, memory buy viagra plus 400 mg lowest price, complexion buy viagra plus 400mg mastercard, and sensory and motor functions. Numerous single and compound rasayana drugs possessing diversified actions, such as immuno- enhancement, free-radical scavenging, adaptogenic or anti-stress and nutri- tive effects, are described in ayurveda literature for their use in health promotion and management of diseases with improvement in the quality of life. Safety Safety of administered medicines Intrinsic toxicity13 The following examples illustrate the toxicity problems of certain tradi- tional Indian medicines. Khat (Catha edulis) Khat, pronounced ‘cot’, and also known as qat, gat, chat and miraa, is a herbal product consisting of the leaves and shoots of the shrub Catha edulis. There are many different varieties of Catha edulis depending upon the area in which it is 210 | Traditional medicine cultivated. The active principles are the two alkaloids, norpseudoephedrine (cathinine) and cathi- none. Although users say that the herb is not addictive, withdrawal has been known to cause lethargy and nightmares. In 1980 the World Health Organization classified khat as a drug of abuse that can produce mild-to-moderate psychological dependence, and the plant has been targeted by anti-drug organisations. However, use of khat was not without detrimental effects and should be discouraged. Fresh leaves of khat contain the alkaloid stimulants cathinone (S- ( )-a-aminopropiophenone) and cathine (S,S-( )-norpseudoephedrine) in addition to more than 40 alkaloids, glycosides, tannins and terpenoids. Although this offence has been identified there have been no successful prosecutions to date. Betel (Piper betle) Use of betel is discouraged in western countries because of its alleged carcinogenic and perceived dysaesthetic properties; nevertheless, betel is widely available in the west. Warning signs include ulcers that do not heal within 3 weeks, red and white patches in the mouth, and unusual swellings or changes in the mouth and neck. A betel quid comprises tobacco, Areca catechu, saffron and lime wrapped in a leaf from the plant Piper betle. An Indian ayurvedic medicine | 211 associated practice involves chewing betel nuts, with a mixture of areca nut, lime (calcium hydroxide) and tobacco – known as paan in south-east Asia, where the practice is most common. The nut produces mild psychoactive and cholinergic effects, including a copious production of a blood-red saliva that users spit out. Lead is regarded as an aphrodisiac, and has been used to counteract impotence in men with diabetes. The following are other examples: • The product al kohl is applied as an eye cosmetic; its main ingredient is lead sulphide. The authors recommend that these patients should be screened for lead exposure and strongly encouraged to discontinue metal- containing remedies. Following a systematic strategy to identify all stores 20 miles or less from Boston City Hall that sold ayurvedic products, Dr Robert Saper and colleagues at Harvard Medical School estimated that one of five ayurvedic products produced in south Asia and available in the area under study contained potentially harmful levels of lead, mercury and/or arsenic. Identification of medicines A number of problems that pharmacists and other healthcare providers may experience in identifying ingredients and assessing their potential toxicity in Asian remedies have been identified:24 • Typographical errors on the label • Inaccurate phonetic transliteration • Changes in nomenclature • Absence of generic names on the label • Undeclared ingredients and adulterants • Assessing the literature and finding information. Trease and Evans’ Pharmacognosy,13 to which frequent references are made in this chapter, provides an excellent and readily available source of information for traditional medicine practices. Potential interactions There is a substantial risk that patients will receive simultaneous western and traditional treatments. Patients seldom volunteer information concerning any traditional medicines being taken. A case has been reported in which a woman receiving chemotherapy for Hodgkin’s disease supple- mented her treatment with at least nine different ayurvedic medicines. Pharmacists can provide an extremely valuable function in this respect by intervening with advice whenever they consider it to be appropriate. An interaction between the fruit karela (Momordica charantia), an ingredient of curries, and chlorpropamide has been reported. There are a number of other close relatives of this plant that are also used by hakims to treat diabetes, including crushed seed kernels of the marrow (Curcubita pepo) and the honeydew melon (Cucumis melo). There is a danger that some patients may be treating their diabetes with both allopathic and traditional remedies without realising the risk of interaction. Indian ayurvedic medicine | 213 Betel nut (see above) is prescribed by hakims either alone or in mixtures. There may be a risk of interactions between this herbal medicine and orthodox drugs. Safety of surgical and manipulative procedures The inclusion of surgical techniques adds another potential danger from non-sterile instruments and consulting environments, and incompetent procedures. There is also a risk from undue pressure or incorrect manipulation by inexperienced practitioners. Evidence There are difficulties in applying western methods to proving the effective- ness of traditional therapies. Data from both animal and human trials suggesting efficacy of ayurvedic interventions in managing diabetes have been published. There are some encouraging results for its effectiveness in treating various ailments, including chronic disorders associated with the ageing process. Pilot studies have also been conducted on depression, anxiety, sleep disorders, hypertension, Parkinson’s disease and Alzheimer’s disease. This group contains experts in pharmacognosy, toxicology, pharma- cology and clinical pharmacology, as well as clinicians and experts in standardisation and quality control. All trials are comparative, controlled, randomised and double blind unless there is a reason for carrying out a single-blind study. The trials are planned by the whole group but carried out at the centres of allopathic medicine with established investigators. There are over 20 clinical trial centres throughout the country for carrying out the multicentre studies. Using this network the council has shown the efficacy of several traditional medicines, including Picrorhiza kurroa in hepatitis and Pterocarpus marsupium in diabetes. The Central Council of India’s systems of medicine oversee research insti- tutes, which evaluate treatments. The government is adding 10 traditional medicines into its family welfare programme, funded by the World Bank and the Indian government. These medicines are for anaemia, oedema during pregnancy, postpartum problems such as pain, uterine and abdominal com- plications, difficulties with lactation, nutritional deficiencies and childhood diarrhoea. The regulations outline requirements for infrastructure, labour, quality control and authenticity of raw materials, and absence of contamina- tion. Of the 9000 licensed manufacturers of traditional medicines, those who qualify can immediately seek certification for good manufacturing practice. The remainders have 2 years to comply with the regulations and to obtain certification. The government has also established 10 new drug-testing laboratories for Indian systems of medicine and is upgrading existing laboratories to provide high-quality evidence to the licensing authorities of the safety and quality of herbal medicines. Randomised controlled clinical trials of selected prescriptions for Indian systems of medicine have been initiated. These will document the safety and efficacy of the prescriptions and provide the basis for their international licensing as medicines rather than simply as food supplements.

It is the marketing team that data are intended to be promoted to ensure that the is the keeper of the strategy cheapest generic viagra plus uk, aware of the compe- trial is designed to ultimately allow for those titive environment (both current and future compe- promotional messages purchase viagra plus with amex. It is especially important Effective collaboration between clinical develop- when entering a very competitive buy discount viagra plus 400 mg on-line, highly devel- ment and marketing teams in the context of phase oped market place (e. It is also important for new classes when there will be a within-class competi- The clinical–legal interface tor launching within a short timeframe. If, on the one years to have drugs within the same class have hand, the sudden exposure of large numbers of similar labeling verbiage (i. Furthermore, sometimes, when such a signal is observed, a retrospective trawl through the preclinical and 10. International Conference on Harmonization Draft Guidance E2E: Pharmacovigilance planning. To some degree, the location where clinical trials are conducted, its location of the study is dictated by the complexity purpose is to produce clean, reproducible clinical of the protocol, the types of procedures required data in a timely and safe manner. But there ates these data by performing the study protocol can be other factors at play that determine where a on human subjects that it recruits. In other regions, such as This chapter describes different kinds of inves- the United States, there are many public and private tigative sites around the globe and makes the case clinical trial options. Data suggest that in the that operating a successful site requires an infra- United States, approximately 35% of studies take structure that enables the generation of good qual- place at academic medical centers (Figure 11. The infrastructure must include critical The rest occur at a combination of public and business functions such as budgeting, patient re- private, dedicated and part-time investigative sites. Substantial investment in staff and equipment is required to conduct these studies • Phase I site as the phase I site often houses inpatients, and Figure 11. They offer community-based, required in Europe, as it was and continues to be in actual use settings, a feature that sponsors find the United States. Europe’s then more lenient reg- attractive (Zisson, 2002), and can be profitable ulatory environment attracted business (Neuer, because they tend to require less infrastructure 2000), but with the advent of the European Direc- than their dedicated site counterparts. With research studies becoming more pharmaceutical sponsors seek to limit costs and complex and entailing more procedures per subject risk by weeding out weak drug candidates earlier, (Figure 11. Data suggest that phase I spending is rising it takes to perform good-quality clinical research more rapidly than other sectors of the clinical in a timely, ethical and fiscally responsible manner. The clinical investigator is ultimately responsible To complicate matters further, there is a high rate for clinical research conducted at the site. The reasons cited are that clin- accomplished through activities such as obtaining ical research interferes too much with other informed consent, administering study drug, main- responsibilities such as private practice medicine taining and storing medical records and reporting or academic obligations, or they lack the infra- adverse and serious adverse events. The Tufts Center research mostly because it is scientifically reward- study reveals that the number of investigators in ing, but they are also attracted to the financial many regions of the world is actually rising. In rewards and the opportunities to improve patient addition, there are now certification programs for care (Lamberti, 2005). With clinical trials number- investigators, so it is possible that those who invest ing in the tens of thousands, there is industry-wide in preparing for and receiving certification by concern that there may be a 15% shortfall in the examination may be less likely to drop out. The examinations test knowl- patient recruitment activities edge in study conduct, regulations and ethical issues. Because of transmitting study data the ever growing number of details that comprise clinical studies, coordinators can easily become scheduling patient visits bogged down and, ultimately, very frustrated. This situation can lead to a decline in work quality meeting with principal investigators or a high level of employee turnover. According to a recent survey, 53% of study coordinators have meeting with study monitors been in their jobs for three years or less (Borfitz, 2004). This includes offering good closing out the study compensation and benefits, offering ongoing train- ing and making decisions to hire more full- or part- participating in preparing proposals for solicit- time coordinators if the workload expands beyond ing new studies the capacity of the existing staff complement. He is the individual who interfaces with sponsors, investigators, study coordinators collecting metrics. Clinical trials cannot operate without regulatory Attention to detail will also serve to improve the oversight. As part of that chain, to and that the clinical data are properly collected, investigative sites share the responsibility for con- recorded and forwarded (Miskin and Neuer, 2002). Estimates vary as to the percentage • Master charts of electronic solutions used to collect and submit • Source documents clinical data, but they are generally in the range of 15–20% of clinical trials (Borfitz, 2004). Data tify creating a position for a full-time regulatory that are missing, placed in the wrong field or out of manager, but once the number of studies con- range are immediately spotted, thereby reducing ducted annually approaches eight or more, a full- the number of queries. And, to facilitate the more or part-time regulatory affairs position needs to be rapid sending of electronic data to sponsors or created. Records critical to safety evaluations should be may be retained for even longer periods if required reported to the sponsor according to the reporting requirements and within the by applicable regulatory requirements or if time periods specified by the sponsor in required by the sponsor. In particular, a visiting study monitor will expect to have direct access to trial documents, requiring suspected serious unexpected adverse so having them readily available is important. Complying with these reporting requirements work, but the essence of clinical research is defined can be greatly facilitated if they are done electro- by specific tasks such as nically. Second, to enable sponsors to conform to the growing number of electronic submission patient recruitment and retention requirements, the clinical trial data that are col- lected from dozens of sites across the globe are budgeting more easily compiled and analyzed if the sites use standardized electronic formats. Data suggest that in All advertisements for trial subjects should be included in the submission for approval by the North America, for example, more than 90% of ethics committee. The review by the ethics clinical trials must extend the enrollment period committee might also include the procedures to beyond established timelines because of incom- take care of subjects responding to the advertisement. Patient recruitment and enrollment target goals The advertisement might contain information on the are set by the sponsor but become the responsibility following points: of the selected investigative sites once they commit 1. The investigator clinically/scientifically Oftentimes, a site expects to fill its enrollment responsible for the trial, if possible or if quota from its own internal patient database, but required by local regulations 5. The person, name, address, organization, statistics suggests that most of the time, this to contact for information approach is less than successful. That the subject responding will be chances for recruitment success, site managers registered 7. The procedure to contact the interested need to determine how to go about recruiting and subjects enrolling patients if the database falls short. That a response on the part of a potential subject only signifies interest to obtain United States, attempt to boost enrollment through further information active patient education and recruitment cam- paigns, including advertising the study in electro- Figure 11. Other Format and Documentation to be Submitted in an Appli- locales have been more conservative, generally cation for an Ethics Committee Opinion, April 2004] relying on practitioners to inform patients of appro- priate clinical trial opportunities. That approach is starting to change, however, as more countries are and continues by making them feel valued at every allowing patient recruitment activities in their reg- step of the process, essentially treating them like ulatory guidelines. Although thousands of clinical trials are be included in advertisements (Figure 11. Proper treatment starts from the beginning, from the minute volun- the number and cost of procedures, that is teers enter the site, extends to follow-up reminder physical examinations, chest X-rays, electrocar- telephone calls or postcards about upcoming visits diograms, stress tests and blood draws, including 11.

400 mg viagra plus free shipping