Deep Medicine [Chapter 2]「淺度醫療」的真相：為何我們付出龐大代價卻得不到真正健康？

In Healthcare By Sigrid On

現代醫療正面臨「淺度醫療」的危機 — — 醫師被大量文書與檢查結果淹沒，與病人真正交流的時間極少，導致誤診、過度診斷與不必要的治療。過度篩檢與過度治療不僅浪費醫療資源，也可能傷害病人，許多常規醫療處置缺乏實證支持。數位醫療雖帶來便利，卻使醫病關係更加疏離。

Deep Medicine [Chapter 2]「淺度醫療」的真相：為何我們付出龐大代價卻得不到真正健康？

「如果醫師能在 2 分鐘內獲得所有需要的病人資訊，然後在 15 分鐘的門診時間中，用 13 分鐘與病人對談，而不是花 13 分鐘在查找資料，只剩 2 分鐘與病人交談，這會是什麼景象？」
 — — Lynda Chin

「他跟我說，我需要一個手術來修補我心臟上的破洞，」Robert 是一位 56 歲的公司經理，直到幾年前心臟病發之前，他一直都很健康。所幸他及時接受支架（Stent）治療，心臟並未受到太大的損害。自那時起，他大幅改善生活型態，成功減重並維持減掉了超過 11 公斤的體重，同時保持規律且積極的運動習慣。

然而，某天下午他突然視力出現問題、臉部開始感到麻木，在醫院急診室接受一系列緊急檢查，包括：
– 腦部電腦斷層掃描（Head CT scan）
– 抽血檢查（Blood Tests）
– 胸部 X 光（Chest X-ray）
– 心電圖（Electrocardiogram）

經過一天的觀察，他的視力逐漸恢復正常，臉部麻木感也消退了。醫師告訴他，這是一次「小中風」（Ministroke）或稱為「暫時性腦缺血發作（TIA, Transient Ischemic Attack）」，並建議他繼續服用自心臟病發作以來一直在吃的阿斯匹靈。然而，這種未做任何治療策略改變或新增用藥的處置方式，讓他對未來再次發作的風險感到相當憂心。於是他預約了兩週後的神經內科門診，希望能找出問題的根源。神經內科醫師進行了更多檢查，包括：
– 腦部核磁共振（Brain MRI）
– 頸動脈超音波（Carotid Artery Ultrasound）

然而，這些檢查都未能解釋這次暫時性腦中風的原因，神內醫師便將他轉診給心臟科。心臟科醫師掃心臟超音波（Echocardiogram）時發現了卵圓孔未閉（Patent Foramen Ovale, PFO）：這是個位於心房中隔的小洞，所有胎兒體內（因為胎兒不需要將血液送到肺部進行氣體交換）都有，通常在出生後第一次呼吸時就會關閉，不過約有 15–20% 的成年人仍然存有這個開口。

心臟科醫師興奮地向 Robert 解釋：「就是這個！」他認為血栓可能透過這個心房之間的開口穿過，最後到腦部造成小中風。為了預防未來再次中風，醫師建議他接受一個封堵這個開口的手術，安排在十天後進行。Robert 對這個解釋和手術的必要性產生疑慮，於是去尋求 Dr. Eric（本書作者）的第二意見。Dr. Eric 認為僅憑如此有限的評估就將 PFO 認定為中風的確切根源，這樣的診斷過程令人擔憂，因為：

1. PFO 相當普遍，在進行排除性診斷前，不應輕易將其視為中風的原因
2. 許多同時有 PFO 和中風的病人，兩者之間可能完全沒有因果關係
3. 若 PFO 真的會導致中風，那麼有 PFO 的人（約五分之一的人口）應該會有更高的中風發生率

況且，針對隱源性腦中風（Cryptogenic Stroke，指原因不明的中風）所進行的多項隨機對照試驗顯示，雖然手術確實可以降低後續中風的發生率，但手術本身的併發症風險也不容忽視，使得整體效益相當有限。對 Robert 來說，情況更加複雜，因為他只經歷了小中風，而且目前的評估還不夠完整，無法將其歸類為隱源性腦中風

Dr. Eric 為了找出其他可能的病因，開始進行更深入的檢查。心房顫動（Atrial Fibrillation）是一種常見的心律不整，也是造成小中風的重要原因之一。為了評估這個可能性，Dr. Eric 開立了一個非侵入性的檢查 — — （iRhythm）公司製造的 Zio 心律監測、一種類似 OK 繃的貼片，可以持續配戴 10–14 天，內建晶片能夠記錄配戴期間每一次心跳的心電圖。Robert 配戴了貼片 12 天，檢查結果顯示在這段期間內，Robert 確實出現了數次無症狀的心房顫動。由於發作時心跳速率並不快，且部分發生在睡眠期間，所以他完全沒有感覺到任何不適。

相較於心房中隔的小洞，心房顫動更可能是造成他小中風的原因，因此可以透過使用抗凝血藥物（Blood Thinner）來預防未來可能發生的中風，而不需要進行心房中隔缺損的修補手術。雖然抗凝血劑可能會增加出血的風險，但考慮到預防中風的效益，這個權衡是值得的。當 Dr. Eric 向 Robert 解釋這個診斷結果、治療計畫和預後時，Robert 明顯鬆了一口氣。

Dr. Eric 分享 Robert 的故事，並不是因為他們成功找到了正確的診斷，而是 Robert 的經歷完美展現現今醫療體系的問題。從急診到第一次心臟科門診的整個過程，都反映出 Dr. Eric 所謂的「淺度醫療（Shallow Medicine）」：
– 醫病關係不再是情感連結，而是變成情感斷裂
– 疲憊且沮喪的醫師與失望的病人之間產生疏離
– 診斷過程出現系統性的問題，導致診斷錯誤或過度診斷
– 這些問題造成了巨大的經濟浪費和醫病雙方的傷害

醫病關係的缺陷與醫療現場所發生的錯誤是相互關聯的：與病人淺度地接觸容易導致錯誤的診斷，進而促使醫師反射性開立不必要或不恰當的檢查與治療。根據三項大型研究的綜合分析，在美國每年約有 1,200 萬件重大診斷錯誤案例，原因來自多個面向：
– 未開立適當的檢查
– 誤判檢查結果
– 未建立完整的鑑別診斷
– 忽略異常發現

就 Robert 的案例而言，明顯存在多重錯誤：
– 鑑別診斷不完整（未考慮心房顫動的可能）
– 未開立適當檢查（心律連續監測）
– 過度詮釋檢查結果（將 PFO 視為確定病因）

醫療體系的盲點

在美國，醫療診斷錯誤所導致的問題遠比想像中更加嚴重，錯誤診斷往往會導致不當的治療方式，就像原本要為 Robert 進行一個不必要的心臟手術來封閉心房中隔缺損。近年來，許多研究都指出這類不必要醫療處置有多麽常見，甚至高達三分之一的手術其實都是不必要的。

為了解決這個問題，美國醫界曾經推動過兩個重大計畫：第一個是 2012 年開始的「明智選擇（Choosing Wisely）」運動，美國內科醫學會基金會（ABIMF）與九個專業醫學組織合作，發布了一份「醫師和病人應該質疑的五件事」清單，列出最常被過度使用或不必要的檢查和醫療處置。這個計畫有超過 50 個醫學會參與、共同找出數百項對病人效益低但風險或成本高的醫療處置，且特別指出醫學影像檢查的過度使用問題。

以醫學影像的使用情況為例，每 100 位 65 歲以上的聯邦醫療保險（Medicare）受益人，每年平均接受：
 — 50 次以上的電腦斷層掃描（CT）
 — 50 次以上的超音波檢查
 — 15 次核磁共振造影（MRI）
 — 10 次正子斷層掃描（PET）

據估計，在美國每年進行的 8,000 萬次電腦斷層掃描中，約有 30–50% 是不必要的。然而，儘管「明智選擇」計畫成功讓醫學會承認其最常被濫用的醫療處置，但實際成效卻相當有限。後續的全國性調查顯示，那些被列為低效益的七項醫療處置仍然持續被不當使用，主要原因有二：
1. 「治療幻覺」：賓州大學的大衛．卡薩雷特（David Casarett）醫師指出，醫師普遍高估自己所提供的醫療處置的效益。
2. 確認偏誤：醫師往往因為預期某項檢查或治療會有效果，即使沒有客觀證據支持，也會繼續相信其效益。

很大的問題在於我們缺乏有效的機制來改變醫師的行為模式，雖然「明智選擇」計畫與消費者組織合作，試圖透過教育來改變醫療行為，但成效依然有限。《消費者報導》（Consumer Reports）協助發布相關建議清單，但公眾對這份冗長的建議並不了解，因此也就沒有來自病人端的草根需求，去推動更好、更明智的醫療檢查。此外，美國醫學委員會（ABIMF）也無法追蹤醫師開立檢查的原因和模式，無法獎勵那些減少不必要檢查的醫師，也無法懲處那些過度檢查的醫師。

2017 年，由波士頓勞恩研究所（Lown Institute）主導的國際計畫「明智醫療聯盟」（RightCare Alliance）展開了第二波改革，在《刺胳針》（Lancet）期刊發表一系列重要論文，量化分析了多個國家不必要的醫療處置。研究顯示，美國是最嚴重「過度醫療」國家，高達 60% 的醫療處置可能是不必要的，而針對背痛等症狀的醫學影像檢查又位居首位。

雖然「明智醫療聯盟」也研究了一些適當但使用不足的醫療處置，但相較之下，這個問題的嚴重程度較輕。就像「明智選擇」（Choosing Wisely）計畫一樣，「明智醫療聯盟」希望他們的大量數據能夠被整合到未來的醫療常規中，但目前尚無證據顯示這個目標已經達成。ProPublica 的 David Epstein 在 2017 年發表了一篇精闢的文章：《當證據說不，醫師卻說好》（When Evidence Says No, But Doctors Say Yes），以心臟病患者的動脈支架手術為例：「對於病情穩定的病人來說，支架手術完全無法預防心臟病發作，也絲毫無法延長壽命。」Epstein 的結論不僅適用於支架手術，也適用於許多其他手術，「研究結果並非證明手術完全無用，而是顯示這些手術做在超多不太可能從中受益的病人身上。」

問題的癥結不僅在違背實證醫學的治療方式，更在於我們用來做治療決策的證據本身，在醫學中，我們經常依賴所謂「替代終點」（Surrogate Endpoints）的改變，而非真正重要的終點指標。例如，在心臟病的治療上，我們可能只根據血壓的變化來進行治療，卻沒有證據顯示這樣的治療是否真的能降低心臟病發作、中風或死亡的機率。在糖尿病的治療上，我們可能過度關注糖化血色素（HbA1c）的數值變化，而忽略了預期壽命和普遍認可的生活品質指標。

2019 年時，美國門診的看診時間相當短暫，複診病人平均看診時間為 7 分鐘、初診病人平均看診時間：12 分鐘；南韓三星醫學中心平均看診時間僅有 2 分鐘！這種倉促的診療模式，不僅影響醫療品質，更容易導致誤診，醫師無法深入了解病人的真實狀況，只能在短時間內透過片段的資訊做出醫療決策。這種「一次性」的醫療模式，也讓醫師無法全面掌握病人在真實生活中的健康狀況，包括工作中的身體狀況、睡眠品質、日常生活中的健康指標。

這種系統性的缺陷，不僅影響醫療品質，更可能導致誤診率上升，最終損害病人權益。我們需要重新思考如何在數位化時代，保持醫療的人性化，同時提升醫療效率。

2017 年，美國心臟協會（American Heart Association）與美國心臟病學會（American College of Cardiology）修改了高血壓的診斷標準，導致超過 3,000 萬美國人被新增診斷為高血壓病人，但這項改變卻缺乏紮實的實證醫學支持。大規模的過度診斷不僅造成醫療資源的浪費，更可能導致不必要的治療介入。

數位醫療時代的隱憂：從過度檢查到醫病關係的轉變

現代醫療體系中，醫師與病人之間的互動正面臨許多過去沒有的挑戰，哈佛大學醫師 Russell Phillips 指出：「電子病歷系統（EMR）已經將醫師變成了資料輸入技術員」，醫師被迫將大量時間花在鍵盤上，而非關注病人，美國醫師的工作倦怠率接近 50%、每年有數百名醫師自殺身亡，42,000 名醫師的研究顯示，醫師倦怠會使病人安全事件風險增加一倍。

電子病歷系統存在嚴重的技術性缺陷：
– 80% 的病歷內容只是從前次紀錄 Ditto 複製貼上
– 系統間的互操性極差
– 獨立軟體格式阻礙資訊流通

一位放射科醫師 Saurabh Jha 在 Twitter 上妙喻：「你的提款卡在外蒙古都能用，但你的電子病歷卻無法在這條街對面的醫院使用」。即使是最基本的生理指標如血壓、心率、心律，或是病人的焦慮程度與情緒狀態，我們都無法完整掌握。就算我們真的獲得了這些數據，由於缺乏完整的真實世界數據（Real-world Data）作為參考基準，我們仍然無法做出有意義的比較分析。

這個問題進一步因醫師與病人之間過時的溝通方式而惡化，人們早已時時刻刻運用電子郵件、社群軟體和視訊會議等工具，與世界各地的親朋好友保持緊密聯繫，但超過三分之二的醫療人員仍未善用數位通訊工具來強化與病人的關係（但應該不是每個國情社會文化都鼓勵這種精神）。雖然有人將此歸咎於時間不足、醫療法規顧慮，以及缺乏給付誘因，但也凸顯醫師與病人之間脆弱的連結。現今的醫療環境可以用四個「不足」來形容：

– 資料不足（Insufficient Data）
– 時間不足（Insufficient Time）
– 脈絡不足（Insufficient Context）
– 醫病互動不足（Insufficient Presence）

這就是 Dr. Eric 所說的「淺度醫療」（Shallow Medicine）。

淺度醫療的代價

以美國的醫療篩檢為例，2019 年每年五十多歲女性例行性乳房攝影檢查的總成本超過 100 億美元。然而統計顯示，若追蹤 10,000 名持續進行十年乳房攝影的五十多歲女性，僅有 5 人（0.05%）能避免乳癌死亡，卻有超過 6,000 人（60%）會至少遇到一次偽陽性結果。這些偽陽性不僅帶來不必要的侵入性檢查（如切片、手術）、放射治療或化療，更造成病人極大的恐懼與焦慮。

同樣地，儘管美國泌尿科醫學會（American Urological Association）在 2013 年已建議不要常規進行 PSA 篩檢，但仍被廣泛使用，每年約有 3,000 萬美國男性接受篩檢，其中 600 萬人被發現 PSA 值升高，100 萬人接受前列腺切片檢查。大約 18 萬人（18%）確診為前列腺癌，但同時也有相同數量的男性雖然有前列腺癌，卻在切片檢查中成為漏網之魚；而大多數前列腺癌其實終其一生都不會威脅到病人的生命。雖然目前已有多項研究證實某些基因標記（Genomic Markers）可以預測腫瘤的侵入性和擴散傾向，但仍未被納入臨床實務中。

從數據來看，每篩檢 1,000 名男性，僅能避免 1 例前列腺癌死亡；若要樂觀解讀，這個效益是乳房攝影的兩倍（每 1,000 人 0.5 例）！但從另一個角度來看，一名男性因 PSA 異常而被誤診的機率是救活他的 120–240 倍，接受不必要放射治療或手術的機率是救活他的 40–80 倍。

南韓在 1999 年推出全國性癌症篩檢計畫，為一般民眾提供免費或低額自付的篩檢服務，其中包括甲狀腺超音波檢查。結果在短短十年間，甲狀腺癌的診斷率暴增 15 倍，成為南韓最常見的癌症，超過 4 萬人被診斷出甲狀腺癌。然而，這驚人的發現率增加，卻完全沒有改善病人的預後，甲狀腺癌相關死亡率絲毫未減。

美國 15 年前曾出現「檢查你的頸部」的宣傳活動，標語寫著：「甲狀腺癌不在乎你有多健康。任何人都可能得到，包括你。這就是為什麼它是美國成長最快的癌症。」這個預言最終成真，導致發生率大幅上升，超過 80% 被診斷的病人接受甲狀腺切除手術，並需要終身服用荷爾蒙替代療法；將近一半的病人還接受了頸部放射治療。但就如同南韓的經驗，這種積極的診斷和治療對預後毫無影響，反而可能因不必要的放射治療帶來額外風險。達特茅斯大學（Dartmouth）的研究人員發現，從 1975 年到 2010 年間，常規乳房攝影檢查的推行導致乳癌診斷率上升了 30%，但轉移性乳癌的發生率卻絲毫未減。

這些案例充分說明了「淺度醫療」（Shallow Medicine）的問題，過度篩檢不僅造成醫療資源的浪費，更可能對病人造成不必要的傷害。

貝氏定理在醫療篩檢的應用

許多問題其實可以透過更智慧的方式來避免，如果醫師能夠花時間仔細評估病人是否真的處於疾病風險中，許多不必要的檢查和治療就能避免。一個廣為人知但經常被忽視的重要工具就是貝氏定理（Bayes’ Theorem），這個定理描述如何運用特定條件下的知識來評估某事件發生的機率。

以乳癌為例來說明，雖然我們知道約 12% 的女性一生中會罹患乳癌，但這並不表示每位女性都有相同的 12% 風險。攜帶特定（BRCA）基因突變的女性，以及具有較高基因風險分數的族群，罹患乳癌的風險就明顯較高。目前的篩檢方式存在著明顯的問題，一為忽視詳細的家族病史（往往是因為醫師沒有足夠時間與病人深入討論），二是未進行特定乳癌相關基因變異的篩檢，因此很容易導致偽陽性結果的產生。

同樣的情況也發生在全身性掃描或核磁共振造影（MRI）檢查，在健康人身上進行這些檢查往往會發現大量的「偶然發現」（Incidental Findings），或如以撒．柯漢（Isaac Kohane）所戲稱的「偶然瘤」（Incidentalomas），經常會引發不必要的焦慮和後續檢查。在沒有症狀的健康人身上進行運動壓力測試（Exercise Stress Tests）同樣會產生高比例的異常結果，進而導致更多不必要的檢查和治療。

這些案例都凸顯出，我們需要更精準、更個人化的醫療方式，而不是一味地進行全面性篩檢。醫療決策應該建立在對個別病人風險因子的全面評估基礎上，而不是簡單地套用統計數據。

美國醫療體系中，許多醫療機構正在利用富裕階層對健康的焦慮，打著「及早發現疾病可以救命」的口號，進行不必要的血管攝影等檢查。許多知名診所為企業主管們提供全身健檢，通常包含大量不必要的測試，費用從 3,000 到 10,000 美元不等，但問題是當我們進行越多不必要和缺乏依據的檢查時，出現偽陽性的機率就會相對提高。為了確認這些偽陽性或偶然發現的結果，後續的檢查甚至可能危及病人的性命。

Welch 等研究人員發現，在 Medicare（美國老年醫療保險）的受益人中，有 40% 的人在投保後五年內會接受腹部電腦斷層掃描，這些檢查帶來的非預期風險是病人可能被診斷出腎臟癌而必須接受腎臟切除手術，而有 4% 的病人在手術後 90 天內死亡，而且存活的病人整體癌症存活率也沒有改善。由此可見，醫療檢查不應該毫無節制地進行，而是應該根據個人的風險因素和檢查適當性來決定。

從醫療支出來看，美國 2019 年時每年的醫療支出已超過 3.5 兆美元，醫院支出佔了將近三分之一；醫師支出在過去幾十年來相對穩定，約佔總支出的五分之一，但處方藥的支出正在失控，2015 年已超過 3,200 億美元，而用於治療癌症和罕見疾病的特殊藥物，每年的治療費用從 10 萬美元起跳，最高甚至可達到 100 萬美元。

至於醫師和病人對藥物效果的過度期待，Scripps Research 的 Nicholas Schork 研究指出，許多常用藥物的實際療效遠低於一般認知：

– 精神科藥物 Abilify：每五位病人中只有一位能真正獲益
– 銷售額最高的十種藥物：平均有 75% 的病人無法達到預期效果
– 高價藥物如 Humira、Enbrel、Remicade 等，年銷售額超過 100 億美元，但效益卻相當有限

這個現象並非單純的藥物無效或藥廠牟利的問題，而是反映目前醫療體系的兩個根本問題：
1. 醫師缺乏精準預測病人對特定治療反應的能力
2. 對個別病人的了解不夠深入，無法準確判斷誰會對治療有正向反應

醫療品質的警訊

從整體醫療成效來看，在經濟合作暨發展組織（OECD）的十八個會員國中，美國在三個關鍵指標上都表現不佳：
– 平均壽命
– 嬰幼兒死亡率
– 產婦死亡率

Dr. Eric 認為這並非單純的醫療技術問題，而是反映更深層的社會經濟不平等。例如，非裔美國婦女的產婦死亡率特別高，凸顯出醫療資源分配不均的問題。多年來，醫療經濟學家一直在討論「彎曲曲線」（Bending the Curve）的概念，意指在維持相同或更好的醫療成效下降低成本；然而美國近年來的平均壽命不斷下降，醫療支出卻持續攀升。

目前所實行的「淺度醫療」（Shallow Medicine）正導致三個嚴重問題：
– 醫療資源的巨大浪費
– 並不是最佳化的治療結果
– 不必要的醫療傷害

「淺度醫療」本質上是一種缺乏智慧的醫療模式，在資訊時代，我們已經有能力為每位病人個體產生和處理近乎無限的數據資料，是時候深入探討並充分運用這些健康數據了，每個人的「巨量資料」（Big Data）都蘊含著提升診斷準確性和改善治療效果的潛力。然而，這些數據量實在太過龐大，已經遠遠超出任何人類醫師所能處理的範圍，因此我們必須徹底改變現有的醫療診斷方式，重新思考臨床醫師的基本決策流程。

現代醫療體系正處於關鍵的轉型時期，需要善用科技工具來提升醫療效能，同時我們也需要思考人工智慧在未來醫療發展所能發揮的重要性。未來的投資機會可能在於發展精準醫療技術，以及建立更完善的病人評估系統，而不是一味追求新藥研發。同時，Dr. Eric 也提醒我們需要重新思考目前的醫療資源分配模式，避免不必要的醫療支出。

— –

📒 Compiled by — 台中慈濟醫院復健科 R3 陳佳菁醫師 Sigrid Chen, PM&R Resident Physician at Taichung Tzu Chi Hospital, Taiwan; Former Medical Consultant at ASUS Intelligent Cloud Services.

255 thoughts on “Deep Medicine [Chapter 2]「淺度醫療」的真相：為何我們付出龐大代價卻得不到真正健康？”

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  181. فرم 602 و نحوه ی استفاده از آن، به منظور تسهیل فرآیند ثبت‌نام در مقاطع کارشناسی پیوسته و کاردانی دانشگاه‌های سراسر کشور، پس از کسب رتبه قابل قبول در آزمون سراسری و انتخاب رشته، ارائه مجموعه‌ای از مدارک توسط پذیرفته‌شدگان الزامی است.

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  184. فرم 602 و نحوه ی استفاده از آن، به منظور تسهیل فرآیند ثبت‌نام در مقاطع کارشناسی پیوسته و کاردانی دانشگاه‌های سراسر کشور، پس از کسب رتبه قابل قبول در آزمون سراسری و انتخاب رشته، ارائه مجموعه‌ای از مدارک توسط پذیرفته‌شدگان الزامی است.

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  185. This permits us to achieve perception into how different folks
    expertise Anavar. This gives you a noticeable improve in power, as well as elevated endurance
    and stamina. Anavar doubtless also increases ATP, instantly contributing to more strength and endurance37.
    Hopefully, nobody on the market thinks you probably can take a steroid and then sit again with
    your ft up, eating chocolate cake all day, expecting to transform into Vin Diesel magically.
    As long as you’re keen to work for it, Anavar can and does
    deliver satisfying outcomes in most cases. There are a great number of dangers to long-term health, a few of which we
    might not notice till much later in life. I’m not willing to take that threat anymore, and
    that’s how I got here across what I imagine is the number one legal substitute for Anavar – Anvarol.

    You can go onto Youtube and watch users discuss their first experience and hearken to folks debate
    about what they think and how much they’ve taken and
    for a way lengthy. There’s a bunch of stuff you could
    read about and see how others have responded to taking Anavar and what product they’ve used.
    In latest years nonetheless the value for anavar has dropped as a outcome of
    it’s changing into simpler to pay cash for again. We
    liv in a day and age now where with a little little bit of research you can simply go online and order
    some anavar straight to your home.
    Nonetheless, gynecomastia stays possible as a end result of trenbolone
    elevating progesterone levels. Anavar, regardless of being
    a chopping agent, may be very effective at increasing muscular power.
    We have known a number of elite strongmen who cycle Anavar before a contest.

    Its strength-enhancing attributes could also be because of its unique capacity to shuttle ATP (an essential molecule for energy) inside the
    muscle cells. Girls who take Anavar don’t usually expertise masculinization under our care.
    The period between cycles is supposed to be a time
    where your organs can rest and get well. Fixed use will reduce HDL and increase LDL
    (the dangerous cholesterol), except for this your possibilities
    of cardiovascular disease go up the longer you stay
    on the drug.
    This interval is important to prevent hormonal imbalance and
    scale back the risk of creating undesirable outcomes. With Clenbuterol and Anavar, you’re going to wish to limit your Anavar dosage to
    mg every day. It will help with each weight reduction and helping to lift
    your endurance. Ladies are limited in regard to what
    steroids they’ll use, as many compounds trigger virilization side effects.
    Nonetheless, we have found that masculinization doesn’t happen on HGH, because it doesn’t elevate androgen hormones corresponding to
    free testosterone. Subsequently, women can successfully use HGH to
    burn fats and enhance muscle tone with out forming male traits.

    It is important to talk to your physician before
    taking Anavar, especially in case you have any underlying health situations.
    When combining Anavar with TRT, the dosage, period of use,
    and frequency of administration must be rigorously determined by your healthcare skilled primarily based in your specific wants and
    objectives. The dosage of Anavar may differ relying on elements
    corresponding to gender, earlier experience
    with anabolic steroids, and desired outcomes. Though Oxandrolone and Stanzolol are sometimes thought-about to be related compounds, i.e., ‘cutting’ steroids which
    are nice for recomping and growing strength, they do actually work nicely collectively.

    Most cycles will lengthen testosterone use past the 8 weeks of the Anavar cycle, for a complete of 12 weeks, before starting post-cycle remedy.
    Anavar is by far the most well-tolerated steroid for females, not like Winstrol.
    Oral Winstrol is still considered a relatively mild
    steroid compared to most others. Nonetheless, most women will find that Anavar is extra well-tolerated in relation to
    controlling the side effects. For ladies who wish to use Winstrol,
    the oral form solely is recommended, and doses have to be stored very low to keep away from virilization. Even although Anavar is what
    we contemplate to be a milder steroid in comparability with
    most others, it’s nonetheless an anabolic steroid.
    They won’t be turning into the Hulk (nor would most women want to), however the
    elevated definition is a certainty, and with muscle
    replacing fats weight, any physique weight put on will be lean muscle.

    If you expertise any critical unwanted effects while taking
    Anavar, you want to cease taking the treatment and talk to your healthcare supplier instantly.
    It is essential for women to use Anavar with warning
    because of the potential for virilization,
    which is the development of male-like characteristics.
    If you are understanding two instances per week – we advocate beginning with 50mg of Anavar per
    day. For instance, if you’re figuring out four instances per week
    – we recommend starting with 20mg of Anavar per day.
    If you would possibly be understanding more than thrice per week, we recommend beginning at the lower finish of the dosage vary.
    If you would possibly be figuring out three times per week or less,
    you can begin on the larger end of the dosage range.
    In one research, members reached sleep 36% faster after a single dose of valerian (38).
    In terms of meals choice, principally clear
    meals decisions ought to be consumed, including unrefined carbohydrates and
    unsaturated fat. Healthy meals that are not excessive in sodium will
    inhibit water retention, adding to the dry and defined look that Anavar encourages.
    Calorie intake ought to be tailor-made to a user’s objectives when biking
    Anavar.
    In conclusion, Anavar is often a valuable software for athletes, powerlifters, and endurance athletes
    trying to enhance their performance. By following the recommended
    dosages, monitoring your progress, and taking safety
    precautions, you probably can experience the advantages of Anavar while minimizing the dangers.
    Before starting an Anavar cycle, it’s necessary to seek the assistance of with a healthcare skilled to
    determine the appropriate dosage and to watch your progress all through the cycle.
    This will assist be sure that you’re utilizing the steroid safely and successfully.
    When it involves using Anavar, males ought to strategy the drug with caution as a result of
    its potential unwanted effects.
    A 2004 research involving males aged years old, who maintained
    a 20mg every day Anavar dosage, showed a noticeable
    reduction in body fat over a 12-week period. And 12 weeks after the check subjects stopped utilizing the drug, they retained 83% of
    their reductions in whole, trunk, and extremity fat (3).
    Another examine revealed that men aged years old additionally experienced a big amount of Anavar weight loss (4).

    It could increase the risk of bleeding if taken with blood thinners like warfarin. If mixed with other steroids, the probabilities of unwanted effects,
    together with liver injury, rise significantly. Anavar also can impact
    blood sugar levels, so those with diabetes should exercise caution. At All Times inform your physician about any medicines or dietary supplements you are taking to keep
    away from dangerous interactions.
    Its half-life is about 10 hours, so taking it twice every day preserves a good stage within the bloodstream for a extra constant
    effect. With a duration of eight weeks and 50mg of Anavar per day,
    this is what you could call a regular Anavar cycle for
    men. Like I talked about at the start of this text, the doses and
    cycles could vary. Some bodybuilders might discover that Anavar dosage of 50mg per day is
    too little, so one thing like 80mg every day may be more appropriate.
    Nevertheless, I would at all times advocate that you don’t leap straight to larger doses.
    Some people could possibly see decent outcomes on 50mg a day eight
    weeks cycle. It is actually up to you to resolve how your physique reacts to this anabolic steroid.

    References:

    What does steroid do to the body

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  197. By growing protein synthesis and nitrogen retention,
    Trenbolone helps to advertise lean muscle mass growth.
    This is why Trenbolone is commonly used by bodybuilders in the course of
    the bulking part of their coaching program. Trenbolone, additionally
    regularly referred to as ‘tren’ is well known for its capability to increase
    the production of the insulin-like Progress Issue 1 (IGF-1) hormone, which performs a key
    position in muscle progress.
    This class of 19-nor steroids is called as such because of the truth that these compounds comprise a selected alteration on the 19th carbon on the anabolic steroid’s molecular construction. This alteration, which is the elimination of the 19th carbon,
    isn’t seen in any other anabolic steroid classes.
    Because of this, trenbolone is considered an distinctive cutting steroid, even when it’s
    utilized on its own.
    This is as a outcome of Trenbolone is a strong steroid with a variety of potential side effects.
    Some bodybuilders will take as a lot as 200 mg per day, but it is important to remember
    that the dangers of unwanted effects additionally increase with
    dosage. If you are new to taking steroids, it’s typically beneficial
    to begin with a lower dose and enhance it steadily
    over the course of a number of weeks. The amount
    of Tren you take will depend upon numerous factors, including your experience with steroids, your
    fitness objectives, and your tolerance for side effects.
    However as with any steroid, there are potential legislation and well
    being risks involved with taking it.
    The ester itself doesn’t affect Masteron’s activity because it turns
    into hooked up over time once you’ve administered the steroid, leaving Masteron to take full
    effect. Enanthate is tougher to find, although it comes with the
    profit of fewer common injections because of its longer half-life.
    The worst part about steroids is not only the unwanted side effects, however it’s the dependancy that
    results in your demise.
    TE use means fewer injections but potentially longer-lasting unwanted
    aspect effects. Virtually all Tren cycles will see you including some testosterone into the cycle
    too. It helps to gauge how much tren you probably
    can ‘handle’ rather than hitting it too exhausting.

    Users can train more regularly and at higher intensities without the chance of overtraining.
    Reduced restoration time also minimizes the risk of muscle soreness and
    injury, making it possible to take care of consistent coaching progress.
    This advantage allows athletes to stick to demanding schedules and reach their objectives extra
    quickly, as they will push via rigorous routines with much
    less pressure on their muscular tissues and joints. For these of you looking to construct lean muscle mass, following a cycle
    is very extremely beneficial. Based on existing
    analysis and our patient’s lab results,
    tren should be thought of a harsh and toxic anabolic steroid.

    For best results, your food regimen should be a little above maintenance calories.
    For finest results, mix testosterone at your chosen dose with 400mg of Masteron weekly, cut up
    into two doses per week where both steroids could be mixed and administered together.
    This 12-week beginner cycle permits new users to evaluate the consequences and outcomes of Masteron without interference from or interplay with other,
    stronger steroids. We ought to take a look at dosing Masteron slightly in a special way than bulking steroids, the place you take greater doses to increase mass
    gains (to a certain point). Most Masteron customers will find that mid-range
    doses are sufficient to deliver every little thing this steroid can. Let’s take a glance at
    how it compares to in style compounds like testosterone, Deca, and EQ.

    Metabolite areas have been normalized to creatine and expressed as creatine ratios.
    Group differences on MRS metabolite levels
    had been assessed by linear regression. Inside the AAS-user group,
    the affiliation between MRS measures and lifelong cumulative AAS dose was additionally assessed by linear regression. However, by 1987 trenbolone acetate,
    discontinued as an injectable steroid. When trenbolone acetate became an unique implant pelette and for that matter a non controlled
    substance when bought in that state.
    Remember that the impression of steroids on erectile health can differ from person to person, and
    not everyone will expertise ED as a facet impact.
    Everyones favourite mental disaster in a bottle, grab your popcorn and load
    up your bitcoin. Everyones least favorite compound by week 8+ and their favorite compound once they arent on it, lets see who actually will post pics justifying their tren dosages.
    Such effects, spoken of so much many assume that if you do not experience such effects the trenbolone isn’t actual.

    Ladies who take Tren will nearly actually expertise sturdy side effects, it’s because Trenbolone is highly androgenic, and thus ladies usually suffer from virilization signs.
    Deca might have an effect on a user’s intercourse life
    worse than Tren, with it being notoriously identified for inflicting erectile dysfunction (impotence).

    This is due to Deca decreasing DHT levels, which is a vital hormone for blood move to the
    penis. Anti-estrogens are considered effective in stopping gyno, even from steroids which raise progesterone.
    Nevertheless, anti-estrogens are more doubtless to have a negative effect on blood lipids.
    As A End Result Of Tren could be very androgenic, users will notice the shoulders and traps blow
    up greater than other muscle groups, because of them having more androgen receptors.
    Trenbolone is an even more harsh steroid that can spike blood strain significantly.

    In our experience, trenbolone typically worsens cardiovascular efficiency due to notable
    elevations in blood pressure. As A Result Of blood circulate to the heart and
    dealing muscle tissue is impaired, it can cause customers to turn into out
    of breath more easily, even throughout daily tasks such
    as strolling up the steps. The steroid’s position in supporting rigorous workouts and pushing the boundaries of endurance can result in stronger coronary heart muscles
    and increased cardiovascular capability. Over time, improved health and muscle mass may end up
    in a decrease resting heart fee, indicating good cardiovascular health.

    The chemical modifications described above lead to Trenbolone turning into
    dramatically more potent of an androgen and an anabolic than its progenitor hormone Nandrolone, or even Testosterone.
    As such, we can put Trenbolone’s anabolic and androgenic energy into perspective by comparing
    it to Testosterone. Testosterone possesses an anabolic and
    androgenic score of a hundred each, respectively.
    Trenbolone holds an anabolic and androgenic rating of each 500 each, respectively.

    The modification responsible for making Trenbolone 5 times stronger than Testosterone is its
    two double bonds at carbons 19 and 11.

    References:

    Steroid legality (rosendal-leach-5.blogbright.net)

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  198. سامانه جامع رشد و پرورش سیرت sirat.csdeo.ir، به عنوان یک بستر یکپارچه و آنلاین، توسط سازمان آموزش و پرورش استثنایی جهت تسهیل فرآیند نوبت‌دهی و مدیریت اطلاعات مربوط به سنجش سلامت جسمانی و آمادگی تحصیلی کودکان در آستانه ورود به مقاطع پیش دبستانی و کلاس اول ابتدایی، طراحی و راه‌اندازی شده است.

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  203. دفتر گزارش‌های آماری سامانه سیدا ویژه مدارس، به عنوان یک منبع اطلاعاتی جامع شامل داده‌های کلیدی دانش‌آموزان از جمله مشخصات فردی، آدرس دقیق و پایه تحصیلی آنان، در دسترس مدیران مدارس از طریق سامانه مای مدیو قرار دارد.

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  206. دفتر گزارش‌های آماری سامانه سیدا ویژه مدارس، به عنوان یک منبع اطلاعاتی جامع شامل داده‌های کلیدی دانش‌آموزان از جمله مشخصات فردی، آدرس دقیق و پایه تحصیلی آنان، در دسترس مدیران مدارس از طریق سامانه مای مدیو قرار دارد.

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  227. The half-life of Anavar is around 9 hours, which signifies that it takes around 9 hours for
    half of the drug to be eradicated from the physique.
    It is important to note that the half-life of Anavar can differ depending on various components corresponding to age,
    weight, and overall health. This means that the dosage and timing of Anavar might need to
    be adjusted accordingly to make sure optimal results.
    The half-life of Anavar is roughly 9 hours, which means that after 9
    hours, half of the drug will have been eliminated from
    the body. It is essential that you simply select very properly when it comes to choosing Anavar (Oxandrolone) because it is so broadly faked and underdosed.
    It could be a exhausting steroid to get a maintain of as a result of excessive
    demand so examine along with your supply as to what they have in stock.

    If you do not have any existing kidney problems,
    utilizing low doses and short cycles of Anavar is unlikely to trigger kidney damage.

    Still, should you use excessive doses and long cycles, you will be putting your kidneys
    – and other organs – at great threat of harm. Males on a slicing cycle with Anavar can anticipate an excellent fat loss,
    and it will be fairly fast as a result of Anavar is a quick-acting
    steroid that you’ll only use for eight weeks max.
    As A Result Of Anavar is type of a female-friendly steroid that women can use with minimal or no unwanted facet effects, utilizing it with Ostarine, which also
    comes with a low danger of unwanted facet effects, is the perfect strategy
    for women. Extra experienced users of Anavar often lengthen to the 50-70mg every day dose while sticking
    to an 8-week cycle. A testosterone ester should also be
    included in an intermediate cycle, and once more,
    the dosage will depend upon what you’re making an attempt to realize and whether
    or not it is a hardcore slicing cycle.
    Customers are unlikely to achieve plenty of muscle mass with the addition of Anavar; nevertheless,
    there’ll nonetheless be a noticeable distinction in muscle hypertrophy by the tip
    of a cycle. Anavar is a gentle steroid, hence why it’s successfully utilized in medication for treating women and babies (without damaging
    effects). Winstrol should solely be taken for eight weeks (maximum) as a result
    of its poisonous results on the liver. Contemplating this is a bulking cycle, we can assume users shall
    be eating excessive quantities of energy for maximum gains.
    Testosterone suppression is going to be extreme, so our
    sufferers sometimes take three PCT supplements (Nolvadex, Clomid, and hCG) to convey their testosterone ranges
    again to a normal vary. Testosterone suppression is going to
    be extreme following this cycle, requiring an aggressive post-cycle therapy protocol
    to stop a psychological and physiological crash as well as muscle loss.

    At doses at or above 10mg per day, these dangers increase, with a changing of the voice usually being
    the primary signal. Stopping Tbol at that point can normally reverse the symptoms, but ongoing use will put
    you vulnerable to doubtlessly irreversible changes.
    The major reason Tbol is delicate in its unwanted side effects (similar to Primobolan and Anavar) is the disparity
    between its androgenic and anabolic results and the
    dearth of aromatization into estrogen. That doesn’t
    mean Turinabol is not without its side effect dangers, although.

    Like Turinabol, Trenbolone additionally doesn’t aromatize,
    and the features might be very clear. Tbol is among the
    few steroids that works equally well as a kick-start AAS or one to add to the top of a cycle to finish
    off and sharpen your physique, due to its lack of water retention. Despite its low androgenic activity, Tbol can deliver on virilization at higher doses.

    Any dose above 5mg day by day is extremely more doubtless to end result in the development
    of masculine traits. Women shouldn’t use Turinabol
    for longer than six weeks, however many will discover that even four weeks is effective
    while minimizing the risk of side effects. Turinabol isn’t a
    potent steroid, so diving proper into the next dose may be
    tempting.
    This should be a cycle best suited for including lean mass and/or
    bulking. So earlier than doing a stack with another
    steroids, first take into consideration what you need to achieve, and then use the correct of steroid alongside Anavar for best results.
    Anavar (Oxandrolone) is one of the hottest oral steroids right now, mainly because of being nicely tolerated by men and women. Its extraordinary effects have been proven numerous times, being utilized by
    professional bodybuilders and athletes who compete in various sports activities disciplines.
    Anavar is usually thought-about to be a safer steroid than others, however it
    could still trigger potential side effects.
    Some common side effects of Anavar use embody acne, hair loss, and decreased libido.

    Cardarine is essentially an experimental compound with little analysis
    into its effects. It is known it has triggered severe well
    being risks in lab outcomes, including most cancers, and
    this unpredictability and thriller round its attainable hazards
    make it an enormous danger to use. This is why I strongly suggest trying out Cardarine options as a
    substitute.
    If you are still on the lookout for Delatestryl or generic variations, pay
    shut consideration to the potential for counterfeit merchandise.

    Counterfeiters are well aware of the demand and recognition of
    Testosterone Enanthate, so a fair variety of fakes exist and
    will not be of the standard that you’d get with real pharmaceutical Testosterone Enanthate.
    You know you’re getting the best model if you can find Testosterone Enanthate at a pharmaceutical grade degree.

    Cardarine is very useful to cardio train; that’s
    thought-about its most vital profit. You will notice that the place you beforehand
    received fatigued during cardiovascular coaching, on Cardarine, you probably can push well previous
    your normal limits and hold figuring out. This will lead to more fats burning,
    however you must also notice improved cardio efficiency after finishing a Cardarine cycle, so long
    as you train regularly. The time of day you’re taking Cardarine isn’t so essential, nevertheless it must be taken at the SAME time every
    single day so you keep a consistent degree.
    For maximum outcomes, customers should reduce alcohol
    consumption throughout a cycle. Nevertheless, low quantities of alcohol are unlikely to affect a user’s results considerably.
    Nonetheless, there are studies suggesting clenbuterol has muscle-building results
    in animals (32). Clenbuterol’s anabolic potential remains controversial,
    with our sufferers and many bodybuilders failing to expertise any notable increases in muscle hypertrophy throughout
    practical settings. We discover injectable trenbolone poses
    little risk to the liver in reasonable doses, with it quickly
    coming into the bloodstream as an alternative of passing by
    way of the liver. Nonetheless, methyltrienolone, or oral trenbolone, is severely hepatotoxic and consequently is not utilized in medicine, with research deeming its toxicity
    unacceptable (31).
    Its anabolic properties can lead to increased muscle mass after
    4-6 weeks of utilization and improved power performance. This creates a
    favorable environment for the development of lean muscle
    tissue with out extreme water retention, frequent in lots of anabolic steroids.
    Anavar, also identified as Oxandrolone, is a popular anabolic steroid used by bodybuilders and athletes to boost performance,
    construct lean muscle mass, and shed physique fat.
    Identified for its comparatively mild side effects and versatile performance,
    it’s usually used in both cutting and bulking cycles.

    References:

    Steroids For Runners – Jobseeker.Cloud –

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  238. اسامی پذیرفته‌ شدگان بدون آزمون دانشگاه آزاد، پس از اتمام فرآیند
    ثبت‌ نام و انتخاب رشته برای پذیرش بدون
    کنکور دانشگاه آزاد، اسامی پذیرفته‌ شدگان
    بدون آزمون دانشگاه آزاد از طریق وبگاه رسمی پذیرش این دانشگاه به نشانی azmoon.org منتشر خواهد شد.

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  239. It may be efficient when taken alone but is often stacked with other
    steroids for higher results. Anvarol from Crazy Bulk is one such
    legal different that not only delivers on its promises but in addition trumps Anavar in terms of outcomes.
    It Is comparatively delicate, so it doesn’t come with too many dangers,
    and it could assist you to achieve your objectives quicker than when you were to go on a diet and exercise plan alone.
    Nevertheless, everyone is totally different
    and some people may experience harsher side effects
    than others.
    Bodybuilders use it for slicing cycles because it
    burns fat and builds muscle. It is essential to
    start with a lower dosage vary, similar to 10mg per day, and steadily
    enhance it to 20mg per day if well-tolerated.
    Beginners should carefully monitor their body’s response to the steroid and assess
    any potential unwanted effects. Lastly, Anavar binds to androgen receptors within the body, triggering specific cellular responses.
    This activation can end result in elevated muscle power, improved
    recovery, and enhanced athletic performance overall.
    Anavar is metabolized by cytochrome P450 enzymes, notably CYP3A4,
    which can be inhibited or induced by other medication.
    However, it’s necessary to note that the use of anabolic steroids,
    including Anavar, should be approached with warning
    due to potential side effects and health risks. If you’re excited about injectable steroids, two in style choices are testosterone enanthate and testosterone cypionate.
    These steroids are sometimes utilized in testosterone alternative therapy
    and may help enhance muscle mass and energy. Nonetheless, it is important to notice that these steroids can have potential unwanted aspect effects
    and will only be used beneath the guidance of a healthcare skilled.

    It has gained popularity among girls looking for efficiency enhancement, physique
    recomposition, or athletic improvement. Anavar’s low androgenic properties make it much less prone to cause virilization, a set
    of masculinizing side effects. Men using Anavar
    could expertise several specific unwanted aspect effects related to
    their hormonal stability and reproductive well being.
    One of the main considerations of Anavar for
    males is the suppression of natural testosterone manufacturing.
    Since Anavar is a synthetic form of testosterone, the
    body might reduce or stop its own production of the hormone.

    A 20mg dose of Anavar day by day might help you lose
    four pounds of fats – in 12 weeks. Anabolic steroids often scale back subcutaneous
    fat whereas increasing visceral fats. This article will study Anavar’s advantages and where you can buy
    it. When it comes to buying Anavar (Oxandrolone), it’s
    essential to navigate the market correctly to ensure you obtain a real and high-quality product.
    This table supplies an outline of important suggestions for
    getting Anavar, comparing respected sources, product authenticity
    verification methods, and high quality assurance indicators.
    By following the following tips, you can enhance your possibilities of shopping
    for Anavar safely and acquiring a genuine, high-quality product.

    Anavar has since been utilized by bodybuilders and
    athletes as a method to help them construct muscle and increase strength.

    Nevertheless, some athletes may choose to increase
    their cycle up to 10 weeks. It is important to note that the longer the cycle, the upper
    the danger of unwanted facet effects. Due To This Fact, it is recommended to stick to a shorter cycle to minimize the risk of opposed results.

    Anabolic-androgenic steroids (AAS) are artificial (manufactured) versions of the
    male intercourse hormone testosterone. Anavar is most likely not
    the costliest steroid on the market right now, but it is also not the most affordable.
    So you have to just ensure you are buying legit merchandise
    to keep away from placing your hard-earned money to waste.

    It’s important to note that the particular PCT protocol
    for Anavar use may range relying in your individual wants and targets.
    Elements such as your age, dosage, cycle length, and total health
    ought to be taken into consideration when designing a PCT plan. Consulting with a educated healthcare
    supplier or experienced bodybuilding coach can help make certain that you’re using Anavar safely and effectively.

    Nonetheless, getting a prescription for Anavar 50mg isn’t simple
    as it’s a managed substance. Physicians only prescribe the steroid for medical
    reasons similar to muscle losing situations and osteoporosis.
    Furthermore, most physicians are reluctant to prescribe steroids
    due to their side effects. Concerns about Anavar water retention and Anavar with testosterone also require cautious consideration. Anavar is understood for selling lean muscle mass with out extreme weight achieve.

    Women ought to begin with the bottom potential dose and steadily increase it as wanted.

    A typical cycle size for ladies is 4-6 weeks, but some may lengthen their
    cycle as much as 8 weeks. It is essential to notice that ladies are extra vulnerable to unwanted
    side effects than men, so it is necessary to be cautious when taking
    Anavar. Epicatechin helps in decreasing myostatin levels, additional supporting muscle progress, whereas Osthole boosts power and muscle hardness.
    To see any real features, you will have to use sufficient that
    it knocks out your pure testosterone manufacturing, which means you will definitely need a post-cycle therapy (PCT).
    Anavar is a widely-used anabolic steroid that’s
    favored for its mild nature and important advantages.
    Initially developed to assist patients regain weight after surgical procedure
    or trauma, it has gained in depth use amongst bodybuilders and athletes.

    If you would possibly be utilizing Anavar, it may be very important observe
    a correct PCT protocol to ensure that you maintain the positive aspects you might have made and avoid any negative side effects.
    If you’re considering taking Anavar, you could be wondering how it will
    have an result on your blood check results. Anavar, also called oxandrolone, is an artificial
    anabolic steroid that’s usually used for chopping cycles. It is known for its ability
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    that means only a small percentage of the substance is not absorbed into the
    systemic circulation. Oxandrolone(Anavar) is the one oral anabolic-androgenic steroid(AAS) that’s primarily metabolized by the
    kidneys, and not by the liver. This makes Oxandrolone(Anavar)’s hepatotoxicity
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    of its low androgenic activity. Feminine users usually make the most of doses as low as 5–10 mg day by day to realize a lean, sculpted physique without
    important risk of masculinizing unwanted side effects.

    References:

    side effects of stopping steroids (Zelma)

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  247. اعلام نتایج نهایی انتخاب رشته آزمون سراسری، قابل توجه
    داوطلبان آزمون سراسری که به منظور اطلاع
    از اعلام نتایج نهایی انتخاب رشته آزمون سراسری در زمان مقرر، می‌توانید از طریق پایگاه
    اطلاع‌رسانی سازمان سنجش آموزش کشور اقدام
    فرمایید.

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