Loading

Super P-Force

Some examples of notes are: To indicate that an article being cited had a subsequent notice of erratum or retraction published order super p-force in united states online, enter the phrase "Erratum in:" or "Retraction in:" followed by information on the article containing the erratum or retraction order super p-force 160 mg without prescription. Part of a weekly series of stories about the sociology and psychology behind news events cheap super p-force online master card. Newspaper article with other type of note Examples of Citations to Newspaper Articles 1. Standard newspaper article with optional volume and issue numbers Taking steps back to normal after novel rabies therapy. Newspaper article in a language other than English Se retractan cientificos sudcoreanos; admiten mentiras sobre la clonacion. Newspaper article in a language other than English with optional translated title Se retractan cientificos sudcoreanos; admiten mentiras sobre la clonacion [South Korean scientists retract themselves; they admit lies on cloning]. Tchernobyl, 20 ans apres: le vrai impact en France [Chernobly, 20 years after: the real impact on France]. Newspaper title with both a city added and an edition UnitedHealth-PacifiCare deal hailed, deplored. La "gripe del pollo" vuela can las aves silvestres [The "bird flu" flies with the wild birds]. Newspaper article with optional inclusion of letter with page number (omitting section) Krasner J. Newspaper article in a microform A year later, efforts are on to avoid another botched transplant. Newspaper article with a dateline Taking steps back to normal after novel rabies therapy. Maps 489 Citation Rules with Examples for Maps Components/elements are listed in the order they should appear in a reference. Author (cartographer) (R) | Author Affiliation (O) | Title (R) | Map Type (R) | Type of Medium (R) | Edition (R) | Editor and other Secondary Authors (O) | Place of Publication (R) | Publisher (R) | Date of Publication (R) | Pagination (O) | Physical Description (O) | Series (O) | Language (R) | Notes (O) Author (cartographer) for Maps (required) General Rules for Author List names in the order they appear in the text Enter surname (family or last name) first for each author Capitalize surnames and enter spaces within surnames as they appear in the document cited on the assumption that the author approved the form used. Airborne radioactivity survey of the Tabernacle Buttes area, Sublette and Fremont Counties, Wyoming [remote-sensing map]. Rossiiskoe Respiratornoe Obshchestvo [Russian Respiratory Society] Translate names of organizations in character-based languages such as Chinese and Japanese. Map with no author (cartographer) provided Author Affiliation for Maps (optional) General Rules for Author Affiliation Enter the affiliation of all authors or only the first author Begin with the department and name of the institution, followed by city and state/Canadian province/country Use commas to separate parts of the address Place the affiliation in parentheses. Box 11 Organizational names for affiliations not in English Give the affiliation of all cartographers or only the first cartographer. Box 12 Names for cities and countries not in English Use the English form for names of cities and countries whenever possible. Madrid: Comunidad de Madrid, Consejeria de Sanidad, Direccion General Planificacion Sanitaria; 2000. Beijing Shi ji ben yi liao bao xian ding dian yi liao ji gou ding dian ling shou yao dian zhi nan tu [map]. Beijing Shi ji ben yi liao bao xian ding dian yi liao ji gou ding dian ling shou yao dian zhi nan tu [Local medical facilities and retail pharmacies in Beijing covered by basic medical insurance] [map]. Box 16 Titles in more than one language If a map title is written in several languages, give the title in the first language found on the map and indicate all languages of publication after the pagination. Carte de Montreal: communaute urbaine de Montreal = Montreal city plan: urban community [map]. Box 18 No title can be found If a map has no formal title, construct a title using the name of the area covered by the map as the title Place the area name in square brackets Example: [World] [demographic map]. Map in a microform Edition for Maps (required) General Rules for Edition Indicate the edition/version being cited when a map is published in more than one edition or version Abbreviate common words if desired (see Abbreviation rules for editions) Maps 501 Capitalize only the first word of the edition statement, proper nouns, and proper adjectives Express numbers representing editions in arabic ordinals. Example: or becomes c Do not convert numbers or words for numbers to arabic ordinals as is the practice for English language publications. Box 22 First editions If a map does not carry any statement of edition, assume it is the first or only edition Use 1st ed. Map with an edition Editor and other Secondary Authors for Maps (optional) General Rules for Editor and other Secondary Authors A secondary author modifies the work of the author. Box 25 Non-English names for secondary authors Translate the word found for editor, translator, or other secondary author into English if possible to assist the reader. Use the city of the first organization found on the map as the place of publication. Arkansas population distribution, with shaded relief features of the physical landscape [map]. Map with unknown place of publication Maps 509 Publisher for Maps (required) General Rules for Publisher Record the name of the publisher as it appears in the map, using whatever capitalization and punctuation is found there Abbreviate well-known publisher names with caution to avoid confusion. For example: Louisiana State University, Department of Geography and Anthropology. Aarhus (Denmark): Aarhus-Universitetsforlag [Aarhus University Press]; If the name of a division of other part of an organization is included in the publisher information, give the names in hierarchical order from highest to lowest Valencia (Spain): Universidade de Valencia, Instituto de Ciencia y Documentacion Lopez Pinero; As an option, translate all publisher names not in English. Designate the agency that issued the map as the publisher and include distributor information as a note, preceded by "Available from:". Box 35 Multiple publishers If more than one publisher is found on a map, use the first one given or the one set in the largest type or bold type An alternative is to use the publisher likely to be most familiar to the audience of the reference list. For those maps with joint or co-publishers, use the name given first as the publisher and include the name of the second as a note if desired. Box 36 No publisher can be found If no publisher can be found, use [publisher unknown]. Recent unexplained mass mortality of marine fauna: a look at ocean nuclear waste dumps as possible sources of stress [Northeast Atlantic Ocean] [map]. Map with unknown publisher Date of Publication for Maps (required) General Rules for Date of Publication Always give the year of publication Convert roman numerals to arabic numbers. Maps 513 1999 Oct-2000 Mar 2002 Dec-2003 Jan Separate multiple months of publication by a hyphen 2005 Jan-Feb 1999 Dec-2000 Jan Separate multiple seasons by a hyphen; for example, Fall-Winter. Box 38 Non-English names for months Translate names of months into English Abbreviate them using the first three letters Capitalize them Examples: mayo = May luty = Feb brezen = Mar Box 39 Date of publication and date of copyright Some maps have both a date of publication and a date of copyright. Box 40 No date of publication, but a date of copyright A copyright date is identified by the symbol, the letter "c", or the word copyright preceding the date. Map with unknown date of publication Pagination for Maps (optional) General Rules for Pagination Provide the total number of sheets on which the map appears Follow the sheet total with a space and the word sheet or sheets End pagination information with a colon and a space, unless no Physical Description is provided, then use a period Maps 515 Specific Rules for Pagination More than one map on a sheet or more than one sheet per map Box 42 More than one map on a sheet or more than one sheet per map If more than one map appears on a sheet, include this information with the pagination. Map pagination and physical description Physical Description for Maps (optional) General Rules for Physical Description Begin with the scale of the map, followed by a semicolon and a space. For example: 1:250,000; Enter the size of the map in centimeters, followed by a semicolon and a space. Specific Rules for Physical Description Language for describing map characteristics Language for describing microform characteristics Box 43 Language for describing map characteristics Describe map characteristics using the features listed below Give each feature as it is found on the map Abbreviate measures used if desired centimeters = cm. If more than one map is found on a sheet and they differ in size, include all sizes: 2 maps on 1 sheet: 52 x 76 cm. Typical words used include: color Maps 517 black & white positive negative 4 x 6 in. Map in a microform Series for Maps (optional) General Rules for Series Begin with the name of the series Capitalize only the first word and proper nouns Follow the name with any numbers provided. Map in a series Language for Maps (required) General Rules for Language Give the language of publication if other than English Capitalize the language name Follow the language name with a period Specific Rules for Language Maps appearing in more than one language 518 Citing Medicine Box 45 Maps appearing in more than one language If the text of a map is written in several languages, give the title in the first language found on the map and indicate all languages of publication after the pagination.

Pulmonary function tests in a 19-year-old man with acute severe asthma The patterns of the expiratory curve and inspiratory loop should be examined buy 160 mg super p-force free shipping. Obstruction on expiration produces a scooping-out pattern or one that is concave upward in appearance (Fig buy generic super p-force on-line. The expiratory flow tracing (upper quadrant) shows a reduced peak flow proven 160 mg super p-force, reduced forced vital capacity, and flattened expiratory curve consistent with obstruction. There should not be any major limitation of inspiratory flow in uncomplicated asthma, although it is recognized on the flow-volume loop that peak inspiratory flow rates are typically less than expiratory flow rates. There may be modest decreases of inspiratory flow in some patients with asthma, but not to the extent seen if a patient has a respiratory muscle myopathy that accompanies prolonged high-dose systemic corticosteroid use or systemic corticosteroid combined with muscle relaxants in previously mechanically ventilated patients. If there is a flattened inspiratory loop, causes of extrathoracic obstruction should be considered unless the patient has a restrictive disorder. Such patients may also have self-induced arterial hypoxemia from breath-holding or self-induced reductions in their tidal breathing ( 13). The patient reported acute wheezing after an upper respiratory infection and felt that inhaled fluticasone into the airways helped reduce the cough. The current tracing demonstrates a flattened inspiratory curve ( lower quadrant) and one adequate expiratory tracing in the upper quadrant. Notice the dip in the expiratory tracing when the patient did not complete the forced vital capacity maneuver without stopping. She may have a component of asthma as well based on the history of wheezing in the setting of an upper respiratory infection and response to fluticasone. Full pulmonary function tests are required and demonstrate the key finding of reduced total lung capacity (6). Good effort during inspiration and expiration must be ensured, but some patients with asthma also have causes of restriction such as obesity or parenchymal pulmonary disease. The tracing of the expiratory flow curve is helpful in characterizing the defect further. Although asthma is characterized by responsiveness to bronchodilators, patients with acute severe asthma may not respond to albuterol, as in the case in Table 32. There was no bronchodilator effect of inhaled albuterol; in fact, a modest decrease occurred, consistent with bronchial hypersensitivity, even to a metered-dose inhaler treatment. The patient received prednisone daily for a week, then on alternate days, in addition to an inhaled corticosteroid and albuterol. There was no bronchodilator effect, however, because the bronchi were now fully patent. Total lung capacity increases during acute severe asthma as the lung elastic recoil properties decrease ( 14), somewhat analogous to the recoil of the lung changing from that of a normal slinky toy to a broken one. The loss of lung elastic recoil is accompanied with increased outward recoil of the chest wall ( 14). Inspiratory pressures increase as the dyspneic patient applies additional radial traction to bronchi to maintain airway patency. This negative pressure generated by inspiratory muscles, however, is associated with airway collapsibility on expiration, so that air enters on inspiration but is trapped in the lung during expiration. Pulsus Paradoxus Pulsus paradoxus is present in some patients with acute severe asthma and is identified by use of the sphygmomanometer with measurements during inspiration. There are different methods for detection of pulsus paradoxus, and many relate to the setting of cardiac tamponade, in which there is little tachypnea or dyspnea. When the patient with acute severe asthma is assessed, the measurement can be carried out as follows: inflate the sphygmomanometer slightly above the level of systolic pressure at which point no Korotkoff sounds are heard. Then note during inspiration whether the Korotkoff sounds disappear as the systolic pressure reading is decreased quickly by 10 mm Hg. If there are no Korotkoff sounds heard during that new lower systolic blood pressure, a pulsus paradoxus is present. It will not be possible to have the patient inspire slowly as during cardiac tamponade. Thus, a patient with asthma may have a 10-mm Hg inspiratory fall at the systolic blood pressure and then at successively lower systolic pressures until there is no disappearance of Korotkoff sounds with inspiration. Some patients with acute asthma have pulsus paradoxus of 50 to 60 mm Hg because at each level of systolic blood pressure from 150 to between 90 and 100 mm Hg, there was a separate disappearance of Korotkoff sounds during inspiration over each 10-mm Hg drop. Experimentally, normal volunteers were asked to breathe through a resistance circuit in an attempt to produce pulsus paradoxus (16). It took the combination of increased lung volumes and marked airway obstruction to generate pulsus paradoxus. Arterial Blood Gases and Ventilation-Perfusion Inequalities Four stages of arterial blood gas patterns are presented in Table 22. The primary physiologic explanation for arterial hypoxemia in acute asthma is ventilation-perfusion ( / ) inequality (17). There is continued perfusion of very poorly ventilated alveoli resulting in low / ratios. It was determined that on average, 27% of pulmonary blood flow perfused very low / units, whereas in normal subjects, such very low / units do not even exist (17). Only two patients had evidence of perfusion of very high / units, and these patients also had 21% and 46% of their pulmonary perfusion using low / units (17). Diffusing Capacity In patients with status asthmaticus, after treatment to the point at which pulmonary function tests can be performed, diffusing capacity is preserved or even increased (17,18). In patients with asthma without status asthmaticus, the diffusing capacity should not be decreased either. There remains controversy as to what level of reduction of spirometry is needed ( 19). The spirometry returns to baseline within 60 minutes in nearly all cases and is not associated with a late bronchoconstrictive response. Nonspecific bronchial hyperresponsiveness does not accompany isolated exercise-induced asthma. This observation is one reason for the controversy about the definition of exercise-induced asthma ( 19). If the patient repeats the exercise within 40 minutes of the first episode of bronchoconstriction, there will be a reduced bronchoconstrictive response to exercise ( 20). Exercise-induced asthma can also be produced by hyperventilation with frigid cold air ( 23). The mechanism of exercise-induced asthma is that of hyperventilation from exercise causing a heat flux of airway cooling followed by rewarming ( 23). The local hyperemia and airway wall vascular leakage participate in airways obstruction. In patients who have anxiety or who hyperperceive their sensation of dyspnea, use of home peak flowmeters may be of value to the patient and physician. Airway Hyperresponsiveness Patients with asthma have airway hyperresponsiveness to a variety of stimuli, such as histamine, methacholine, and leukotriene D4 ( 26). The recommended times to withhold asthma medications have been published by the American Thoracic Society, such as 48 hours for salmeterol and formoterol and 8 hours for albuterol ( 28). The classic challenge protocol uses five breaths to total lung capacity from a dosimeter and nebulizer system ( 28,29).

order 160mg super p-force mastercard

Only traditional medicines registered as drugs are permitted to make therapeutic claims buy discount super p-force 160 mg on-line. Without preexisting approval order super p-force in united states online, the new approval process is extensive and similar to the approval process of pharmaceuticals generic 160 mg super p-force with amex. Approval requires submission of pre-clinical and clinical study data, and approved medicines are then subject to up to five years of additional post-market surveillance. For example, traditional medicines are also required to adhere to information in the pharmacopoeia and in 105 relevant monographs. If herbal products are used as ingredients in food and do not make specific health 107 claims, then there is no registration requirement as a drug. Traditional medicines in food which claim health effects (these are general health claims, but not specific therapeutic claims) undergo special 108 regulation as health foods. Health foods must have raw materials and final products that comply with food hygiene requirements and that do not cause human harm, animal or human studies to demonstrate a health effect, and a formulation and dosage based on 109 scientific evidence. Traditional medicines that would qualify as health foods, but that are not indigenous to China, have separate regulations as novel health foods. Modern regulations on traditional medicine began with the Drugs and Cosmetics Act of 1940, which contained a separate chapter and rules for Ayurveda, Siddha 110 and Unani drugs. The Act, amended in 2000, requires government licensing of manufacturers and sellers of traditional medicines. It contains regulations for misbranded and adulterated drugs, prohibits the manufacture and sale of certain drugs, and stipulates penalties for regulatory violations. The central government is also empowered to inspect and analyze traditional medicines. Manufacturers of traditional medicines are now required to adhere to good manufacturing practices, as well as requirements related to factory premises and heavy metal contents. Heavy metals are sometimes considered active ingredients of traditional Indian medicines rather than contaminants, but heavy metal testing is now mandatory. In addition, heavy metals may not be present above permissible limits, and labeling must note 111 the presence of heavy metals. Traditional medicine manufacturers are also required to adhere to information contained in national pharmacopoeias and monographs. Safety requirements for traditional medicines are less strict than those applied to pharmaceuticals, and there is generally no submission requirement for clinical trials demonstrating safety and 112 efficacy. These guidelines establish the core components of traditional medicine regulation such as proper botanical identification of medicines, basic quality standards and the need to ensure safety and efficacy. In addition, several complementary guidelines named Resolues Especficas contain additional regulations and relevant information. Medical claims are only permitted for traditional medicines registered as herbal drugs. For a traditional medicine to be approved as an herbal drug it must contain only herbal ingredients and it must meet similar quality, safety and efficacy criteria as required for pharmaceuticals. More than 600 herbal medicines have been registered 116 from around 150 medicinal plant species, only 16% of which are of South American origin. For chemical entities based on plant compounds, documentation of efficacy, safety and quality measures are required for registration, which may include clinical trials. Existing scientific documentation may be submitted, instead of newly performed clinical trials or animal tests, if such documentation already exists for the proposed preparation. Pharmaceutical requirements for data on safety and efficacy are waived in the case of herbal medicines with documented safe traditional use. A post marketing surveillance system for traditional medicines was established in 2001. Producers may prefer to register traditional medicines as foods or cosmetics because quality and safety requirements are simpler. Traditional medicines registered as foods cannot present therapeutic claims, but can be registered in a special food category with the ability to make functional or health claims. Claims should be supported by strong scientific 117 evidence, and references to curing or preventing disease are not permitted. Traditional medicines that have not been traditionally used in Brazil are classified as new foods, and require strong scientific evidence to make functional or health claims. Dried plants with pharmacological effects used to make tea have separate registration procedures. Like foods, traditional medicines registered as cosmetics are not permitted to make therapeutic claims. These products must be for external personal use, and have no specific regulations beyond those that generally apply to cosmetics. Finally, some traditional medicines can also be registered as dinamizados (homeopathic, anthroposophical and 118 antihomotoxic medicines). These are medicines used in homeopathic medicine, and may or may not have exclusively plant based ingredients. In North American societies, traditional Native American healers possess the ability to make medicine bundles. These contain a variety of materials such as animal skins and 121 talismans that are important for communal and personal activities. Indigenous cultures have not historically made the same sorts of property/non-property distinctions supported by current law; however, traditional restrictions on the possession and 124 use of knowledge are common. Social restrictions may govern who, if anyone, can use certain knowledge, and under what conditions. Knowledge may be considered secret or sacred, and making it publicly available would disregard traditional cultural prohibitions. Alternately, some knowledge may be held collectively by a community or considered an integral part of the natural environment. A patent grants a set of exclusive rights to an inventor for a limited time that prevents others from commercially using the patented invention without permission. Patents allow their right holders to prevent third parties from making, using, selling, offering for sale or importing for these purposes a patented invention. In return, an inventor must submit a patent application to the national government which discloses how to replicate the invention by a person skilled in the art. Furthermore, inventions must generally be new, inventive and industrially applicable. Once a patent is expired, third parties may use the claimed invention without the consent of the patent owner. Trademarks protect words, phrases, symbols and designs that identify a source of goods. This helps consumers identify products with preferred characteristics, such as a specific brand of herbal medicine.

discount super p-force

It is the responsibility they will violate the terms of the resident contract and of the training program to have well-publicized processes to disappoint their own family cheap 160mg super p-force amex. It is essential that these processes ensure that no be diffcult; enlisting the help of the attending surgeon generic super p-force 160mg without a prescription, harm to the resident s career follows from the disclosure of who has the primary fduciary responsibility in this case; or unacceptable conduct on the part of others cheap super p-force line. There are times when one s responsibility ate training and continues throughout professional life. It is to patients must take precedence over family needs or a process of socialization during which individuals begin as contractual obligations. Compromise is certainly accept- uninitiated members of the lay public and gradually acquire able on occasion, and for good reason. This happens in parallel frst becomes a pattern of behaviour, the health of the with the transformation from non-expert to expert clinician. This issue In recognition of this, there are different expectations for phy- must be addressed openly during training. As stu- fact that limits must be placed on the expectations of all dents and residents accept increasing levels of responsibility parties to the social contract. Expectations and obligations: situations that arise, and that they can make the often diffcult professionalism and medicine s social contract with society. Training programs bear a heavy responsibility in ensuring that unreasonable demands are not chronically imposed upon residents, and that tensions concerning professional versus personal priorities are discussed openly throughout a resident s training. Behavioural patterns that are detrimental to a healthy lifestyle are often set during residency training. On a more positive note, being aware of the tensions that inevitably arise in practice, and having an opportunity to refect on them in a supportive environment, can help to establish patterns of behaviour that both preserve the professionalism of medicine and lead to healthy patterns of living. The impact of long duty hours Working around the clock can be socially, physically and psy- Case chologically challenging. Long duty hours can lead to isolation A frst-year resident feels life is like a runaway train. Extensive time at work can tax one s energy and procedures, test results, assignments and call). They can t re- around the clock are a risk factor for weight gain, immune dys- member their last workout. The resident is starting duty hours such as years of shiftwork involving night shifts to fnd patients and their complaints annoying. When they and sleep loss have been equated with smoking a pack of ciga- observe their supervisor they are working with today, the rettes per day. Working outside of regular business hours, as in resident notices the supervisor looks just as tired. The doing call or shiftwork, disrupts the circadian rhythms critical resident wonders if they are cut out for medicine. Introduction That medical practice is characterized by intense and long Work hours and fatigue work hours is an understatement. Patients do not choose the Traditionally, fatigue was thought to be a simple equation: fa- hour they become ill, and twenty-frst century medicine is a tigue = hours of work. Physician shortages, an aging population, fatigues one person one day might not have the same impact and diffculties accessing health care mean that the patients on someone else, or even on the same person in other circum- physicians see have increasingly complex needs and are sicker. Fatigue is perhaps better thought of as a function of The exponential growth in medical knowledge and technology an interaction of different factors (see textbox): the individual also place greater demands on physicians, and physicians-in- (e. Sixty-one percent of physicians also reported work- burnout, and exit from practice. Physicians-in-training, with Strategies to cope with long work hours a few short years to prepare for practice, typically spend 60, 80 What can a physician do to mitigate the effects of long work or more hours on duty every week, depending on the specialty hours? These long hours of duty put physicians numbers of physicians, and cures for diseases, medicine will at risk for a number of negative consequences. Maintaining physiological, social and of medical ability, and not only allows a physician to be more psychological rhythms is key to preventing fatigue, illness and productive but also assists with the ability to balance profes- burnout. Circadian rhythms have a profound impact on our sional and personal needs and demands. Similarly, it is important viduals is often overlooked in discussions about physician work for physicians to maintain their social and psychological hours. It is important that, individually and as a profession, we rhythms, including time with family and friends. Finally, a regular exercise routine not aware of the nature of medical work to ensure that health care only enhances physical ftness but also promotes quality sleep, polices and resource allocations promote sustainable practices cognitive function and stress tolerance. Renewal and revitalization are a fnal essential teracting fatigue, the most important by far is to sleep when ingredient. All professionals need time to de-stress and refect on their career and priorities, to renew their energies, and to focus Manage time effectively. These strategies deal about time management during medical education and are essential to preventing burnout and ensuring success and training, few programs take this issue seriously enough to make longevity. The good news is that a wealth of advice is available for those who Case resolution seriously want to acquire good time management techniques. The resident decides to talk to a staff member they respect The key competencies are knowing oneself, prioritizing and about this fatigue. Becoming personally effective requires insight the weekend off medicine, spend some quality time with into one s priorities, strengths, weaknesses and values. The resident will then can one set priorities in alignment with one s fundamental also take some time to refect on how they organize their goals. Techniques to assist prioritizing include values clarif- week to see if they can work smarter. Techniques in this domain include set- ting personal and professional goals (short-, medium- and Key references long-term) and using a personal organizer (e. Shiftwork, fatigue, and safety in emergency career trajectory are examples of roadmaps to success. Patient Safety in Emergency the most out of these priorities, a well-organized work space Medicine. Dealing with intimidation and harassment Case For intimidation and harassment to be tackled effectively, it is Your residency program is under accreditation next year. In some cases, it is faculty who may you will institute as a faculty administrator to prepare for be more concerned about the repercussions of reporting for this event? In many cases, individuals who intimidate and/or harass ably existed as long as the institution of medicine, but have others need education in effective communication as teachers started to be addressed by medical faculties only within the last and administrators, rather than disciplinary action. At a fundamental level, intimidation and harass- cal schools have now adopted directors or deans of equity to ment are defned not only by the behaviour and motivations deal with confict issues between faculty and trainees. Many of the perpetrator, but by the response of the individual who of these individuals directly report to the dean of medicine or is targeted. It should be seen as causing a negative effect on to high-level faculty committees with the ability to institute the victim (e. They focus on the content, psychological issues and or harassment is ever appropriate, such acts must be persistent procedures surrounding the issue of confict. Program directors, faculty members and importance of reporting such events, not only so that medical residents must be aware of these resources and deem them trainees can protect themselves, but also to help prevent their to be effective in dealing with such concerns.

Importantly super p-force 160mg fast delivery, the Index is also a book of eradicated discount super p-force 160mg on-line, as is guinea worm; more than 45% of potential solutions purchase generic super p-force pills. Which means important vaccines for malaria and dengue fever there is plenty companies can achieve without are being implemented. But at the same time, our going back to the drawing board by expanding models for providing healthcare are leaving people good company practices to more products, coun- behind. The challenge is the medicine they need, most of whom live hand to ensure this knowledge benefts those with the to mouth. Pharmaceutical companies, as the innovators There is a social contract between pharmaceutical and producers of life-saving medicine, act early companies and the people who need their prod- in the value chain. Our research suggests that many people in the impact on access can be huge with signif- the industry are committed to fulflling this con- cant savings for healthcare budgets, and of course, tract. But progress is slower than many of us in terms of improving human life and wellbeing. At the Access to Medicine Foundation, we have been tracking the world s largest research-based pharmaceutical companies for ten years now, look- ing at how they bring medicine within reach of people in low- and middle-income countries. Iyer held their top spots over the years by asking the Executive Director right questions, reviewing their paths and challeng- Access to Medicine Foundation ing themselves to keep improving, against a chang- ing backdrop of stakeholder expectations and competing priorities. For and diagnostics more accessible in low- and mid- the 2016 Index, the weight of the performance pillar was increased to dle-income countries. This process ensures that Index metrics express what Methodology Framework stakeholders expect from pharmaceutical companies. Once data is sub- 10 Market In uence & Compliance mitted by the companies in scope, it is verifed, cross-checked and sup- plemented by the Foundation s research team using public databases, 20 Research & Development sources and supporting documentation. The research team scores each company s performance per indicator, before analysing industry progress in key areas. For example, in pricing, the Index examines whether com- 10 Capacity Building panies price products fairly in the countries with the greatest need for those specifc products. In R&D, it looks at whether companies are 10 Product Donations developing products that are urgently needed, yet ofer little commer- cial incentive. They include best and the industry has performed across pricing, licensing and donations; Performance and Innovation. It sets out the Governance & Compliance, and analysis of the company s portfo- drivers behind changes in ranking; how closer integration of these lio and pipeline for high-burden the reasons why companies place policy areas can beneft access to diseases. ThisTo ensure afordability, companies needsocio-economic factors Product Donations 1 (2014). Thisaccounts for 39% of its relevant portfo-41 products with equitable pricing strat- factors. The 2014 Index identifed eightdepends on multiple socio-economicsocio-economic factors that companies Ranking by technical areaManagement4. Together, the strategies target 35%of the priority countries for the diseases the Index analysed which companiestake these eight factors into account,consider when setting prices. Together, strategies for these products products, accounting for 49% of its rel-evant portfolio. Together, the strategiestarget 31% of the priority countries for fed during methodology development. It has seven mar-keted products with equitable pricing marketed products), AstraZeneca is thecompanies (those with fewer than 50the diseases in question. Companies on higherrankings tend to engage in more struc- 43 96Johnson & JohnsonEisai Co. It considersthe following factors most frequently: tured donation programmes, of abroader scale and scope. True needs-based pricing is limited a greater level of responsibility withof donation programmes. It leads in product donations and in applyingprojects that target independently identifed, high-priority diseases. Sales in emerging markets accountogy, immuno-infammation, respiratory and rarefor approximately 25% of total sales. More products have equitable pricing ered for multiple population segments of afordability in these markets. Such strategies arethese still respresent a third of all 850 products on the market, and their use come countries), Only 44 (5%) products out of 850 have a strategy thatmeet the key criteria looked at by the Index and applies in even one prior-ity country*. Its lead-ership is refected in many areas: it has clearly committed to equitable pricing strategies, and is a leader in voluntary licens-ing and capacity building. More products than in 2014Pharmaceutical companies report 850products on the market for high-burden within a country). As in 2014, approx-imately a third of products with equi-table pricing have intra-country strate- analysis will continue to shape priceadjustments for respiratory and car-diovascular disease products in these particularly important where inequality is high (e. Many products have multiple strategies, gies, despite their being seen as particu-larly important for increasing afordabil- markets. Programmes for communica-programmes being expanded and 1415 1117 Gilead Sciences Inc. It has a wide range Its diverse pipeline targets all four disease cat-egories in scope. The diseases with the mostequitably priced products are: ischaemic lack of universal health coverage. This isity where there is high socio-economicinequality, limited public fnancing and a to maximise patient access and aforda-bility. One of its key roles is to integrateExcellence, which has a regional team cifc target groups and on adapting to asingle country context. Change by thesethe 2016 Index used tougher meas- processes for ensuring compli-ance. All sevengency relief and through structuredad hocfor emer- and has put standardised procedureshas increased the scale and scope ofits structured donation programmes, to further foster innovation in this area, and tosystems. Together these cover all disease categories, with part-ners including Fiocruz, Johnson & Johnson and Monash University. Pipeline by stage of development Innovative medicines and vaccines and/or as frst-line treatments: e. For example, they invest inR&D for urgently needed products,even where commercial incentives (albeit those considered key forwork applies to few products10th place. Its solid access frame- and rose from 20th place, andlaunched a new access strategytal. Johnson & Johnson runs the largesttured donation programme that works tracking the reception of donated prod-ucts and requiring regular reports frompartners on results and outcomes of the There are seven companies in theing and auditing requirementsMiddle group lacks stringent monitor- dle-income countries, depending on the local(distributors, wholesalers, etc. Roche has been included in the Index as it can also improve access in areas**Roche declined to provide data to the 2016 Access to Medicine Index. It referred to thefact that oncology, which is not in the Index scope, is its main focus for improving access ucts target just three priority countries. Opportunities missed as there is no equitable pricing strategy(all products and diseases) period of analysis. Eisai has commit to ensuring donation activities Publish information about products registra-tion status. Critically, these yet have room to deepen engage- and withstood closer scrutiny: advances in other measures, with companies show needs-orienta- ment in access to medicine.

By V. Sigmor. University of Scranton.

Jaga