睿学教育Wisdome Education

Jacquelyn L. Bainbridge, PharmD, FCCP

• Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado

http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/A-G/Pages/BainbridgeJacciPharmD.aspx

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A common approach to dealing with the non- ideality of flow in disinfection systems is to consider tx heart attack jack ps baby purchase 6.25 mg coreg visa, defined as the time in which the fastest flowing x% of liquid passes through the tank prehypertension 135 buy generic coreg online. Conversely pulse pressure 63 generic 12.5 mg coreg otc, tx is the minimum residence time of the remaining (100-x)% of the liquid. A step change in the dosing of the tracer is started at time 0, and continued until the outlet concentration has increased to equal the inlet concentration. The outlet concentration is simply plotted against time, and the time at which the outlet concentration equals x% of the inlet concentration is tx. Such tests are ideal where a suitable chemical (chlorine, phosphate, fluoride) is already being used. The tracer is dosed as a single slug at time 0, and the outlet is monitored for a suitable period. Provided chlorine demand is stable over the duration of the test and the rate of chlorine decay is not excessive (no ammonia, good quality treated water), chlorine can be used as a tracer by monitoring chlorine residual at the tank outlet after a step change in dose. However, if the water already has a naturally high conductivity, the amount of salt required could be excessive in relation to compliance with water quality standards. Other options include fluoride and phosphate, where these are being dosed for fluoridation or plumbosolvency control. Tracers that can be detected at low concentrations are preferred, because high concentrations can result in density currents influencing the hydraulics. The use of chlorine or fluoride would provide the most practical option for tracer tests. The actual duration should be sufficient to achieve a target minimum recovery of applied tracer. For a spike test this effectively requires continuing sampling until measured tracer concentration has dropped to the background level. In the absence of tracer test data, an initial estimate of non-ideality can be made by consideration of the tank design, in particular provision of baffling. Poor baffling arrangements in contact tank Water Treatment Manual Disinfection For a poorly baffled tank, the contact time used for calculation of Ct using the t10 value would be less that one-third of that derived from dividing the tank volume by flowrate. A good contact tank will have structures in place that: Prevent jetting at the inlet; Distribute the flow across the full width and depth in the direction of flow; Prevent streaming at the outlet. Features to be avoided include: Submerged pipe inlet with no break plate or other means of preventing jetting; Outlet weirs or launders that are not full width; Bell-mouth outlets in the main body of the contact tank. The incorporation of structures within a tank to promote even flow distribution carries a capital cost. However, the design of the service reservoirs often gives little consideration to the flow patterns formed within the tank, other than using top water inlets to limit loss from the reservoirs in the event of pumped main leakage and placing inlet and outlet at opposite sides of the reservoir. As a consequence, these storage assets can be hydraulically very inefficient, with large areas of tanks containing very slow moving or stagnant water making them unsuitable for use as contact tanks. However, if there is a dedicated main to the service reservoir without any consumer connections, this would provide effective contact time to be taken into account in the Ct calculations. In smaller schemes the practice of burying lengths coiled small diameter pipes downstream of dosing points is sometimes employed to provide contact time. Increased length to width ratios and the inclusion of baffle walls in the design of such reservoirs can increase their efficacy for chlorination contact. In addition, changes in operation which affect the ratio of inflows, outflows and operating levels can significantly change the flow profile through the tank. The shape of the diurnal curve of water demand can vary significantly between different supply areas because of differences in water use and local economies. These differences should be taken account of in determining the impact of such daily usage patterns on the effectiveness of service reservoirs for chlorine contact. The prompt provision of additional contact tankage by Water Service Authorities can also often be compromised or delayed by existing site constraints and the need for further land acquisition. The rectification of obvious deficiencies in chemical dosing locations together with the achievement of proper disinfectant mixing using mechanical mixers, correct pH control and improving residual monitoring will all help to mitigate the risk to human health posed by insufficient chlorine contact. Three approaches can in principle be used for defining the value for C: the concentration can be estimated from the area under the chlorine decay curve in the tank; an average oxidant concentration can be derived from the arithmetic mean of the initial dose and the residual concentration; the outlet residual can be used to provide a conservative estimate of concentration.

Syndromes

• Blood tests to check electrolyte levels
• Diseases such as reactive arthritis and lichen sclerosis et atrophicus
• Over-activity of the gastrin-producing cells in the stomach (G-cell hyperplasia)
• Oxygen
• Bleeding
• Mental status changes such as confusion or hypomania

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Treatment related adverse cardiovascular outcome or all-cause mortality by treating events were signifcantly increased in the intensively to lower (<130/80 mmHg) compared to standard (<140/90 treated patients with more frequent hypotension arrhythmia vs atrial fibrillation buy coreg 25 mg otc, mmHg) targets in patients with hypertension pulse pressure range normal purchase coreg canada, across 95 heart attack x ray coreg 6.25 mg buy with visa, 96 syncopal episodes, acute kidney injury and electrolyte a range of co-morbidities. Accordingly, this guideline recommends that all those • Aiming for a systolic blood pressure target of 120 mmHg may requiring antihypertensive drugs should be treated to a be inherently diffcult in patients with high baseline pressures target of <140/90 mmHg. In those at high risk in whom and where attaining 140 mmHg is already presenting a it is deemed safe on clinical grounds and in whom challenge. There is general support for diastolic This recommendation is subject to review as more blood pressure to be <90 mmHg. This blood pressure measurement technique generally yields lower blood pressure readings than those obtained by conventional clinic blood pressure and is more akin to out of offce measurements. Findings from circumstances, at least two antihypertensive drugs from the Ongoing Telmisartan Alone and in Combination with different classes are required to control blood pressure. The recommendations in this guideline are based on evidence of two or more of these agents was associated with for drug classes, rather than individual drugs. Product increased incidence of adverse outcomes and no information sheets should always be checked. A large number of randomised controlled trials and A 2015 meta-analysis involving 55 blood pressure subsequent systematic reviews demonstrate that the lowering randomised controlled trials and 195,267 benefcial effects of antihypertensive drugs are due patients comparing drug classes with placebo, showed to blood pressure lowering per se and are largely that blood pressure lowering is accompanied by independent of drug class and mechanism of action. In head-to-head trials, they In patients with hypertension without co-morbidities, two are equally effective in blood pressure reduction and key systematic reviews support the fndings that all drug prevention of cardiovascular events overall,112 however classes are equally effective in the reduction of blood may have important differences in their effcacy in some pressure, but differ in their effcacy in preventing certain clinical conditions, such that they are not necessarily outcomes. There was no signifcant difference in the demonstrated to better prevent kidney failure in people effect of any of the 10 drug pair-wise comparisons on with advanced diabetic nephropathy115–117 but inferior in cardiovascular mortality. Calcium channel blockers were the prevention of coronary heart disease in patients with shown to reduce all-cause mortality and the incidence of hypertension. Once decided to treat, patients with uncomplicated hypertension should be Strong I treated to a target of <140/90 mmHg or lower if tolerated. The balance between effcacy and safety is less favourable for beta-blockers than other frst-line antihypertensive drugs. Thus beta-blockers should not be offered as Strong I a frst-line drug therapy for patients with hypertension not complicated by other conditions. Starting drug treatment* Start with low–moderate recommended dose of a frst-line drug. If not well tolerated, change to a different drug class, again starting with a low– moderate recommended dose. If target not reached after 3 months* Add a second drug from a different pharmacological class at a low–moderate dose, rather than increasing the dose of the frst drug. If target not reached after 3 months* If both antihypertensive drugs have been well tolerated, increase the dose of one drug (excluding thiazide diuretics) incrementally to the maximal recommended dose before increasing the dose of the other drug. If target not reached after 3 months* If, despite maximal doses of at least two drugs, a third drug class may be started at a low–moderate dose. It is advisable to reassess for non-adherence, secondary hypertension and hypertensive effects of other drugs, treatment resistant state due to sleep apnoea, undisclosed use of alcohol or recreational drugs or high salt intake. If blood pressure remains elevated, consider seeking specialist advice *Maximum effect of drug likely to be seen in 4–6 weeks. If baseline blood pressure is severely elevated earlier reviews may be considered. If more antihypertensive drugs, start with low to moderate doses information is required, refer to the approved Product and gradually increase where required. Information and Consumer Medicines Information available from the National Prescribing Service at www. Listening carefully to patients and confrming of all suspected adverse reactions to prescription drugs. Fosinopril 10–40 mg once daily Selected adverse effects: Lisinopril 5–40 mg once daily Perindopril arginine 5–10 mg once daily Cough Perindopril erbumine 4–8 mg once daily Hyperkalaemia (risk increased by renal Quinapril 5–40 mg daily in one or two doses impairment) Ramipril 2. Lercanidipine 10–20 mg once daily Long-acting (once daily) products are preferred. If Reduce heart rate and depress cardiac >240 mg give in two doses contractility (verapamil more than diltiazem). Thiazide-like diuretics* Note: loop diuretics not recommended as an antihypertensive unless volume overload is present. Effects on electrolytes, lipids and Hydrochlorothiazide 25 mg once daily blood glucose are dose dependent, start with a low dose and increase slowly. Selected adverse effects: Postural hypotension, dizziness, hypokalaemia, hyponatraemia, hyperuricaemia, hyperglycaemia 40 Guideline for the diagnosis and management of hypertension in adults 2016 National Heart Foundation of Australia Antihypertensive Usual dose range Comments Beta-blockers Note: Beta-blockers vary in pharmacological/physicochemical properties which can affect tolerability.

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The field Sleep disorders can be divided into those pro- of sleep disorders medicine has become increasingly ducing insomnia arrhythmia atrial tachycardia discount 25 mg coreg overnight delivery, those causing daytime sleepi- complex with more than 90 disorders of sleep described prehypertension education discount coreg 25 mg on-line, ness blood pressure 150 90 12.5 mg coreg buy fast delivery, and those disrupting sleep. Transient insom- nia is extremely common, afflicting up to 80% of each with clear diagnostic criteria. Chronic insomnia affects 15% of of diseases produces mental or physical discomfort affect- the population. Two newer benzodiazepine-like agents, zolpidem and zaleplon, have fewer side sleep), (2) those with a primary complaint of daytime effects, yet good efficacy. Other agents for insom- sleepiness, and (3) those associated with disruptive be- nia include sedating antidepressants and over-the- haviors during sleep—the disorders of arousal. Medications, including Sedatives and Hypnotics amphetamines, may be used to induce daytime alertness. Chronic medical ill- insomnia (< 2 weeks in duration) affects up to 80% of the nesses can become symptomatic during specific population on a yearly basis. In the 1990s in the United States, stages and can thus cause sleep disorders or 2. The comparative restless legs syndrome and periodic limb move- frequency of the more common diagnoses resulting in ment disorder may be treated with dopamine ago- 5 chronic insomnia is presented graphically in Figure 1. An understanding of the disorders of sleep Historically, sedative/hypnotics have been some of the and the effects of medications is required for the appropriate use of medications affecting sleep. Chloral hydrate was (Primary Care Companion J Clin Psychiatry 2001;3:118–125) the original “Mickey Finn” slipped into the drinks of un- suspecting marks for the purposes of criminal activity. In the years of Family Practice, University of Colorado School of Medicine, the Sleep Disorders Center of Southern Colorado and Penrose/St. Francis Sleep leading up to the 1960s, barbiturates were commonly uti- Laboratory, and Parkview Neurological Institute (Dr. Unfortunately, these medi- Department of Family Medicine and Division of Geriatrics, Department of Medicine, University of Colorado Health Sciences Center (Dr. Pagel has received grant/research support Morrison, among others, were celebrities who died during from Sepacor and has served on the speakers/advisory board for Cephalon, Wyeth-Ayerst, and Searle. Diagnoses Resulting in Chronic Insom nia result in a dependence on that agent to induce sleep. Idio- Inadequate Sleep Hygiene syncratic reactions of persistent daytime somnolence and/ Other Substance or memory loss have been reported in some patients. Abuse Tachyphylaxis is unusual, and thus they can be used on a Anxiety Psychopathologic Insomnia long-term basis. Clinical comparison of these Respiratory agents suggests that zolpidem may have greater sleep- Mood Disorder Sleep Disorders inducing efficacy and zaleplon, fewer side effects. Disorder This decrease most likely reflects the public’s and the aMeta-analysis data from Sateia et al. Nonpharmacologic behavioral methods, such as sleep hy- In the 1970s benzodiazepines became available for the giene, hypnosis, relaxation training, sleep restriction, and treatment of insomnia. Insomnia is com- viewed therapeutically based on their pharmacodynamics monly a symptom of nocturnal discomfort, whether psy- (Table 1). Rapid onset of action is characteristic of flur- chological, physical, or environmental. Medications, in azepam and triazolam, indicating that both of these agents general, can be safely utilized on a short-term basis for the have excellent sleep-inducing effects. Therefore, the underlying reasons and diseases fect in the elderly has been associated with increased auto resulting in chronic insomnia should be addressed. For patients in this category syndrome of insomnia followed by persistent anxiety that and those with idiopathic insomnia (persistent lifelong in- may extend beyond the half-life of the agent. In patients with chronic insomnia, 22% report as triazolam, this rebound occurs during the same night in using ethanol as a hypnotic. Temazepam and estazolam have half-lives used in excess with other sedative/hypnotic agents, over- compatible with an 8-hour night of sleep.

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Supporting Guidance The nurse/midwife should possess the ability to manage adverse reactions and anaphylaxis as first line providers in these emergency situations blood pressure medication anxiety generic coreg 25 mg on line. Health service providers should have an organisational policy on immunisation/ vaccination addressing these areas to support best practice by nurses and midwives blood pressure practice purchase coreg with a visa. Available resources on this subject are the Immunisation Guidelines for Ireland (Royal College of Physicians of Ireland pulse pressure with cardiac tamponade buy generic coreg 25 mg online, 2002) and the Health Service Executive website http://www. As part of their every day care of patients/service-users, nurses and midwives are in prime positions to observe and report on suspected adverse reactions. Standard Reporting of suspected adverse reactions is critical for safe medication management and patient/service user care. Supporting Guidance The reporting and monitoring of adverse reactions has significant implications for patient/service-user safety. It is not necessary to determine a causal relationship between a drug and subsequent event prior to reporting suspected adverse reactions. Nursing/midwifery staff should liaise with the prescriber about the submission of the report as appropriate. The health service provider’s medication management policies should include information and direction for health care professionals in reporting suspected adverse reactions. Haemovigilance is defined as: "A set of surveillance procedures, from the collection of blood and its components to the follow-up of recipients, to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent their occurrence or recurrence. Nurses and midwives are referred to the Guidelines for the Administration of Blood and Blood Components issued by the National Blood Users Group and the Irish Blood Transfusion Service (2004) for specific information and guidance on the subject of blood administration, monitoring and reporting of adverse events and reactions. These events are usually captured in the hospital quality/risk management systems. Policies should be in place to support the identification, investigation and, where possible, prevention of adverse reactions. Standard As nurses and midwives are often front line users of medical devices and in-vitro diagnostic medical devices, they are key individuals to identify and report any adverse incidents involving medical devices. There is no mandatory reporting system for users; however, users are encouraged to report serious incidents. The administration of sedation should be seen as a continuum of stages, as patients/service-users may make the transition from one level to another in a rapid and unpredictable manner, dependent upon the dosage of medication, sensitivities, physical status of the patient/service-user and absence of recovery period stimulation (Somerson, Husted and Sicilia, 1995). The levels of sedation commonly described in the literature are: • Minimal sedation - a medication-induced state in which a patient/service-user is able to respond normally to verbal commands • Moderate sedation/analgesia, commonly known as "conscious sedation" – a medication-induced state in which the patient’s/service-user’s consciousness is depressed but she/he is able to respond to verbal commands singularly or accompanied by light tactile/physical stimulation. No assistance is needed by the patient/service-user to maintain her/his airway and there is adequate spontaneous ventilation. Cardiovascular function is normally maintained • Deep sedation/analgesia – a medication-induced state of depressed consciousness in which the patient/service-user cannot easily be aroused, although she/he responds purposefully as a result of repeated or painful stimulation. The patient/service-user may have difficulty independently maintaining ventilatory function and assistance may be needed to maintain a patent airway. Cardiovascular function is usually preserved • General anaesthesia – a medication-induced loss of consciousness. The patient/service-user is not purposefully responsive to verbal or painful stimulation. Standard Conscious sedation requires continual monitoring and assessment of the patient/service-user and requires the nurse/midwife to respond immediately to any adverse events/reactions or complications. The nurse/midwife should be able to demonstrate competency in assessment of the patient/service-user involving complete care requirements before, during and after the administration of conscious sedation, including the recovery period. Supporting Guidance The nurse/midwife should consider evidence-based practice guidelines devised by professional organisations with clinical expertise in the administration of medications used for sedation/anaesthesia, as well as advanced airway management and cardiovascular support. The health service provider should have a written policy for conscious sedation, detailing health care staff responsibilities and involvement in caring for patients/service- users receiving conscious sedation. Multidisciplinary input from nursing, medicine, anaesthesia and pharmacy members should be sought for the development, regular review and audit of this policy and standards of practice for conscious sedation. The health service provider should have in place an educational/competency validation mechanism that includes a process for evaluating and documenting the nurse’s/midwife’s demonstration of the knowledge, skills and abilities related to the management of patients receiving minimal and moderate sedation/analgesia. A medication protocol involves the authorisation of the nurse/midwife to supply and administer a medication to groups of patients in a defined situation meeting specific criteria and who may not be individually identified before presentation for treatment. An individually named prescription is not required for the supply and administration of medication when a medication protocol is in effect. Care (involving medications), for the most part, should be founded and provided on an individual explicit basis for the patient/service-user.

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Blood pressure In the pharmacy-based study arrhythmia or anxiety discount 12.5 mg coreg with amex, iwas nopossible to dermine how many patients really had a personal blood pressure card and how many actually based their answers on memory blood pressure chart who coreg 25 mg buy without prescription. However heart attack brain damage order cheap coreg, according to the results of a study where patients checked and repord their blood pressures, iseems thathe patienis a reliable source of blood pressure readings, aleaswhen memory problems do noconfuse the results (Cheng eal 2002). Thus, possible memory problems may have caused inaccuracy in the blood pressure readings. In the pharmacy-based study, the limifor poor blood pressure was older (160/90 mmHg or more), i. In the primary health care based study, the accuracy of blood pressure measurements depends on the trained health nurses measuring the blood pressure. The differenskills of each nurse can cause variability in the blood pressure readings. Furthermore, the inaccuracy of the device, the circumstances of measurement, the lack of resbefore measuremenand many other factors may cause errors the blood pressure measuremen(Beevers eal. In fact, when an adequa number of questions were asked, practically every hypernsive patienseemed to have experienced these problems. Furthermore, our finding aboufive problems per patienalso indicas the large prevalence of these problems, and iseems obvious thathe treatmenof hypernsion is today far from optimal. Perceived problems relad to the health care sysm and personnel This study showed thanine ouof 10 hypernsive patients had perceived health care sysm relad problems. The high prevalence of lack of follow-up by the health centre shows one major aspecof antihypernsive treatmentharequires more atntion. The majority of these patients repord thatheir visits to a nurse or a doctor because of hypernsion had remained under their own discretion. Thus, our presensysm of health care needs to be improved by involving all hypernsive patients in regular follow-up. There should be a functional sysm of reminders in appointment-making or control visits for possible drop-outs. Appropria information and reinforcemencould prevenmany other problems in the treatmenof hypernsion, buwe lack a clear agreemenon the responsibilities between the differenprofessional groups in health care. Watkins eal (1987) repord thaan information bookleabouhypernsion, which was mailed to the patients, was continued to be in regular use by one-fifth of the patients afr a year. Howard eal (1999) repord thaover three- quarrs of the patients ranked 15 of the 22 information ims aboumedicines as importanin the inrview. However, when information is provided to hypernsive patients, the quality of information is very important. In two-thirds of the leaflets, hypernsion was noxplained in the conxof the overall cardiovascular risk. The importance of continued monitoring was noxplained in over half of the leaflets. We need to ensure thathe patienhas absorbed the new information and to educa health care professionals to know how to do that. Lack of supporby health care personnel suggests thamany hypernsive patients are rejecd and alone with their hypernsion treatment. In a study where family members were educad to supporthe patient, hypernsive patients showed higher levels of appointment-keeping behaviour and weighand blood pressure control than the ordinary care group (Morisky eal 1985). Ihas also been shown thameasures of social network did nopredicthe incidence of hypernsion, budid predicthe 15-year mortality hazard (Vogal 1992). Every fifth of our patients had problems with the practical aspects of hypernsion care and the scheduling of blood pressure measurements. This raises the question of how the health care sysm could offer suitable services for all hypernsive patients as well as for other patients with chronic disease, especially for the working-aged population. Self- monitoring of blood pressure may be an option for some patients, buthawill nolimina the need to provide more flexible hypernsion services for the patients. In Finland, ihas been possible to decrease out-of-hours consultations by adopting a sysm where general practitioners have a lisof defined patients (Vehvilainen and Takala 1996). Ihas been suggesd thathe costs of antihypernsive treatmenmay be an obstacle to blood pressure control in certain subgroups of the population (Shulman eal 1986).

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Most commonly pulse pressure def discount coreg, it supports maintenance prescribing as part of a treatment regimen or harm reduction programme blood pressure ranges too low coreg 6.25 mg order with amex. As such it will only ever involve a small fraction of the total drug using population arteria world discount 6.25 mg coreg mastercard, although it should be noted that this user group is disproportionately associated with the greatest personal and 10 societal harms (especially under prohibition ). Prescribed injectable heroin (diamorphine) also has a long history, and established evidence 11 base. Less common, although not unknown, is the prescription of stimulants, including amphetamines and cocaine. They provide a useful, if limited, demonstration of how legal regulation of drugs can help people become prescribed, rather than street, users; a clear example of the benefts of decriminalisation of drug use and regularisation of their supply route. It is hard to know how such services would develop if managed with the latitude afforded to other, less controversial areas of patient care such as, for example, diabetes or mental health. Witton, ‘Thematic review—heroin prescribing’, Drug and Alcohol Findings, 2003, issue 9, page 16. These include requirements for consumption to be supervised in a specifc venue, for very specifc qualifying criteria to be met, or for the prescribing doctor to obtain a special licence. Prescribing is often time limited, administered in progressively reduced dosage, or made conditional on the patient meeting specifc rehabilitation milestones. It raises some diffcult questions for practitioners, as it exposes the grey areas between medical, quasi-medical and non-medical use. There are ongoing controversies and conficts between the clear need to reduce harms associated with problematic illicit drug use and a reluctance to dispense drugs that are being used in any way non-medically. From a medical point of view, these are particularly helpful to those injecting, who are at high risk of contracting blood borne diseases. These benefts are sometimes undermined if practitioners are accused of supporting drug use for pleasure or recreation, while simultaneously ‘failing to treat’—or even ‘endorsing’—dependence. Specialist training, a specifc qualifcation/licence, or a new specialist prescribing-practitioner professional niche could be put in place. These would be supported 22 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices by a strictly ethical code of conduct, and clearly defned general guidance. They would potentially be overseen by a new regulatory agency, or equivalent sub-group. Users were registered and managed in Iran until 1953, and then again in the early 1970s (similar programmes are now being cautiously re-introduced); comparable systems also existed in Pakistan and India—where remnants still function—and in Bangladesh, Indonesia, Thailand and elsewhere. Pharmacists are trained and licensed to dispense prescriptions, although they cannot write them. They can also sell certain generally lower risk medical drugs from behind the counter. These include restrictions according to buyer age, level of intoxication, quantity requested, or case-specifc concerns relating to potential misuse. In addition, pharmacists are trained to offer basic medical advice, support and information. However, it could easily be adapted and developed into an effective way of managing the avail- ability of currently illicit drugs for such purposes. Licensed and trained professionals could serve as gatekeepers for a range of such drugs. They would be legally required to restrict sales according to the kind of strict criteria defned above, and would also act as a source of realistic, well informed and practical advice and support. This new role would be subject to a similar code of practice to that of more conventional pharmacists, but with additional access control criteria. These specialist pharmacists would also be required to offer advice about harm reduction, safer use, and treatment services and referrals to help users quit, where appropriate. Such advice would be supported by necessary addi- tional training or experience in drug counselling. They could either operate alongside existing pharmacies (subject to appropriate licensing conditions) or from separate licensed outlets. Such a system would put various combi- nations of regulatory controls in place to manage the vendor, the 24 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices supply outlet, the product and the purchaser, as appropriate.

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One can draw the following conclusions from this table:  some cancer treatments can be provided at relatively low cost 5 purchase 25 mg coreg amex;  prices of single-source products are significantly higher than multi- source products and not affordable for low- and middle-income countries blood pressure medication kinds coreg 12.5 mg purchase;  prices of the same treatments can differ widely pulse pressure 55 mmhg cheap coreg 25 mg buy online. The table shows that the lowest/highest price ratio for certain products varies from 1 to 33. While patents can explain the high prices of 2 out of the 15 products in the table, patents are not the reason for the price discrepancies seen for the same product. For example tamoxifen, which has the highest low/high price ratio is not patented anymore and available from multiple sources. These discrepancies indicate that greater price transparency can help procurement officials to make better choices. Officials can use the global market pricing information to select the best value for money and increase access to treatment for more eligible patients. Cases of specific cancer drugs In this section we will describe some of the cancer medications that have been the subject of controversy, mostly because of high pricing. We have selected proven effective treatments and a mix of older and more recent products: dasatinib, docetaxel, erlotinib, imatinib, letrozole and trastuzumab. Of these, only imatinib is included in the National List of Essential Medicines of India. Three of the six medicines, docetaxel, letrozole, and trastuzumab are medicines used in the treatment of breast cancer. Breast cancer is the fastest growing cancer in India, and worldwide the most common cancer in women. The difference between generic and originator prices is significant and shows that access to generic supply is key to lowering the cost of treatment. These price differences indicate that South Africa could create savings through price negotiations and better procurement. Trastuzumab - Roche (breast cancer) Trastuzumab is a biotechnology product (monoclonal antibody) indicated for the treatment of specific types of breast cancer. Trastuzumab is either prescribed as a monotherapy or as a combined/adjuvant therapy with other chemotherapeutic agents (cisplatin or docetaxel or paclitaxel). Trastuzumab was developed and patented by Genentech and is currently 60 marketed by Roche as Herceptin. This patent was not granted in India because the product was developed before 1995 when India did not grant patents for pharmaceutical products. In 2007, a secondary patent was granted in India to Genentech (the original developer, later acquired by Roche) on a composition of the drug. Roche did this after the Kolkata patent office had revoked patents related to 61,62 trastuzumab. Roche has entered into an agreement with the Indian generic manufacturer Emcure Pharmaceuticals Ltd. Technically Emcure’s product is not a biosimilar because it simply repackages the product produced by Roche. Roche has attempted to challenge the marketing of biosimilar trastuzumab quoting misrepresentation as ‘biosimilar Trastuzumab’ and ‘biosimilar version of Herceptin’ without following the ‘due process in accordance with the 66 guidelines for similar biologics’ for getting approvals in India. On 26 November Biocon and Mylan received marketing authorization in India for their biosimilar trastuzumab products which they each market under 67 separate brand names. In their application they point out that one possible supplier of trastuzumab suggested the drug could be manufactured for $31 per gram, or $242 per year, roughly 1 percent of the lowest Roche price. The current Roche prices range from $3,000 to 68 $9,000 per gram (1 gram of gold costs $42 – 4 November 2013). The Expert Committee considered the applications in detail and noted the high quality evidence showing relevant clinical benefits in support of both imatinib and trastuzumab but deferred the final specifications of the medicines and their inclusion until 69 the review of the section of cytotoxics is completed. In 2013, an estimated 232,340 women were diagnosed as having breast cancer in the United States, and an estimated 39,620 women died from breast cancer. A number of factors have been found to be associated with breast cancer, including family history, nulliparity (no pregnancies), early menarche (menstruation), advanced age, and personal history. Breast cancer can be suspected when a lump is found in the breast, when the breast has changed sizes, when there is discoloration of the skin of the 17 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. Diagnosis begins with a professional medical history and physical examination, including breast examination.

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The tasks to be carried out at this level include: • Recognize the symptom of fever and danger signs (see Chapter 2) and promptly seek appropriate care blood pressure zoloft buy generic coreg pills. Tasks at this level include: • Carrying out diagnoses according to their training and recognizing danger signs pulse pressure exercise 12.5 mg coreg sale. In addition prehypertension systolic coreg 25 mg free shipping, measures to reduce body temperature should be recommended, such as tepid sponging, fanning, and giving paracetamol. Follow-up should be conducted with patients, particularly children below five years and pregnant women. Referred patients should be accompanied to the health facility or a referral letter sent with the patient indicating treatment given and when. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 44 Criteria for referral to a health facility (Appendix A1): • All pregnant women with fever. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 45 Chapter 6: Management of Severe Malaria P. Delay in diagnosis and appropriate treatment may lead to serious complications and even death. The key features of effective case management of severe malaria are early recognition, assessment by a qualified health worker, referral to a higher facility where necessary, and appropriate antimalarial and supportive therapy. The following laboratory investigations should be done whenever severe malaria is suspected and laboratory capacity is available at the health facility level. Measuring creatinine and electrolytes is most valuable when acute renal failure threatens or develops. None of these investigations should delay treatment in a Guidelines for the Diagnosis and Treatment of Malaria in Zambia 47 patient who is suspected of having severe malaria! All life-threatening conditions and the presence of any danger sign in a patient with fever and parasitological evidence of malaria should be considered as possible severe malaria and referred to a facility or admitted to hospital without delay for appropriate management. Weigh patient (particularly children), if possible, and calculate dosage per body weight. Make rapid clinical assessment and look for signs of meningitis and other conditions. Start treatment for hypoglycaemia, meningitis and other conditions where indicated. Plan first 8 hours of intravenous fluids, including diluents for antimalarial medicine, glucose therapy, and blood transfusion, if necessary. Children with metabolic acidosis may benefit from a Guidelines for the Diagnosis and Treatment of Malaria in Zambia 49 resuscitation bolus of fluid, preferably a plasma expander such as normal saline. The most common indication for blood transfusion is severe anaemia (Hb less than 5 g/dl). The decision whether to transfuse should not rely only on the haematocrit and/or Hb level but should also be based on assessment of the patient’s overall medical condition. A central venous pressure line may be necessary if pulmonary oedema is suspected and may be useful in a patient with shock or impending renal failure. For patients in coma or respiratory distress, the need for intubation and mechanical ventilation may be considered. Dilute with 5 ml of 5% dextrose solution or water for injection or normal saline (0. Withdraw into syringe and inject intravenously over 5 Guidelines for the Diagnosis and Treatment of Malaria in Zambia 51 minutes. Each vial of injectable artesunate must be reconstituted with 1 ml of sodium bicarbonate, which is supplied together with the vial of artesunate. Shake for 2 to 3 minutes until the powder is completely dissolved and the solution is clear. Dilute with 2 ml of 5% dextrose solution or water for injection or normal saline (0. After initial parenteral treatment for a minimum of 24 hours, once the patient regains consciousness and can take medications orally, discontinue parenteral therapy and commence full course of artemether-lumefantrine.

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Participants had 4-5 individual 90-minute consultations in the frst 6 weeks of sickness leave blood pressure medication with hydrochlorothiazide 6.25 mg coreg fast delivery, plus a booster session in the frst 3 months after the return to work blood pressure 7050 purchase coreg with visa. At the 12-month follow up heart attack 50 years 25 mg coreg purchase otc, all participants had returned to work; however, sickness leave was shorter in the intervention group than in the control group. The intervention, which consisted of psychoeducation, cognitive therapy, coping skills training, problem solving, activity scheduling, and relaxation was conducted in seven 60- to 75-minute group sessions over 4 weeks. There was no evidence of a signifcant change in the pattern of coping strategies used by the treatment group compared to controls. They were also provided with audiotapes to facilitate home practice of the techniques learned. However, non-randomised and controlled clinical trials were also included due to the limited number of evidence-based studies on older adults. There is little evidence supporting the effcacy of behavioural intervention in treating advanced sleep-phase disorder, however, due to the low risk, cost and lack of alternative approaches, behavioural interventions are recommended. To meet criteria as an evidenced-based treatment, studies had to report signifcant between-group treatment effects and between-group effect sizes of at least. An additional treatment, stimulus control, partially met criteria for an evidence-based treatment but was without corroborating investigations. In the other 3 studies there were no statistical differences between treatment and control conditions. Effect sizes for the groups compared to waitlist control were calculated separately from effect sizes for groups with face-to-face control. Although based on a very small number of studies, face-to-face treatment was not signifcantly superior to self-help treatment. Participants attended 15 weekly 90-minute group sessions during the treatment period and 4 six-weekly sessions during the frst 6 months of the 12-month follow up. There were no signifcant differences between the treatment groups with all participants improving to a similar degree. Those in the self-help group were provided with assistance by telephone in 6, bi-weekly, 15 minute calls. Both treatments resulted in an increase in intercourse, a decrease in fear of coitus, and an enhancement of non-coital penetration behaviour, compared to no treatment. Two thirds of the participants in the treatment groups made clinical gains and one third no longer flled diagnostic criteria. Manuals, when included in treatment, were associated with the largest effect sizes. Treatment duration was three months, with 3- and 12-month follow up after termination. Psychoeducation, cognitive therapy, and pharmacotherapy (if needed) were also included. The therapist responded to emails within a week and timing and frequency were left up to the participant and therapist. Psychoeducation title of PaPer The PsychoedPlusMed approach to erectile dysfunction treatment: The impact of combining a psychoeducational intervention with sildenafl authors and journal Phelps, J. The brief intervention, PsychoedPlusMed, consisted of a single, 60-90 minute didactic workshop delivered to groups of 6-8 men, plus self-help materials. They also reported greater satisfaction with how quickly the treatment worked and higher confdence levels in their ability to engage in sexual intercourse. Other less methodologically-rigorous studies also reported positive effects on pain and quality of life. However, the meta-analysis did not show a statistical effect of the intervention on pain intensity. The exposure treatment consisted of behavioural analysis, psychoeducation and graded in vivo exposure. The multidisciplinary treatment involved medical treatment administered individually and a program of 14 weekly 1-hour group sessions over 4 months. In the current study, participant data were divided into two groups: recovered or non-recovered, depending on their posttreatment fatigue severity score. Treatment courses were 3-4 weeks in duration, and consisted of group sessions for fve days per week, each lasting 6. The acceptance measure showed a particularly large improvement with treatment, and was directly related to improvements in overall functioning. Two participants experienced little beneft from treatment, four experienced a relatively large amount of change across outcome measures, and the remainder experienced substantial gains in one or two domains and moderate gains in the other domains.

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Saliva is also critical for rention of and comforin wearing dentures since the adhesion blood pressure grapefruit order coreg line, cohesion and surface nsion are inrrelad and they all depend on the presence of saliva [1 arterial insufficiency discount coreg 6.25 mg buy,2 arteriography 12.5 mg coreg visa,15]. Saliva can be measured from each major gland or from a mixed sample of the oral fuids, rmed whole saliva. To assess salivary gland secretion and oral dryness a variety of methods have been used, from self�repord questionnaires (e. Ihas been shown thamucosal wetness measured by micro-moisture mer Periotron � is a reliable measure of oral dryness and had a positive correlation with unstimulad whole saliva [23]. However, sialometry is the mosobjective method to assess salivary function and to dermine the quantity of both resting and stimulad whole saliva. During sialometry, saliva can be collecd by several methods including draining, spiting, suction, and absorben(swab) method and measured. Whichever chnique is cho- sen for saliva collection, iis critical to use a well-defned, standardized, and clearly documend procedure [20,24]. Large variability in salivary fow ras within and between individuals has been repord, which has impaired the establishmenof standard values. Iusually leads to the subjective com- plainof oral dryness which is rmed xerostomia. The rm xerostomia comes from the Greek word xeros (dry) and stoma (mouth), which means dry mouth. Dry mouth is one of the moscommon and mosunpleasansymptoms for which patients ofen seek help from a dentisor physician [18]. Xerostomia is noa synonym for hyposalivation since imay also occur with the changes in the quality of saliva, while the amounof saliva stay unchanged. This is the reason thapeople sometimes complain of dry mouth buhave proper salivation [3]. Therefore, a pa- tiencomplaining of dry mouth cannoautomatically be assumed to have salivary dysfunction, while oral dryness may have many causes [20]. Any individual may experience xerostomia with or withouhyposalivation, experience hyposalivation with or withouxerostomia or may have an average salivary fow and normal sen- sation [17]. Oral dryness is one of the moscommon and mosunpleasanoral symptom which adversely afects all oral functions and compromise oral health in any afec- d person. Ileads to numerous oral sequelae including mucosal dryness, difculty in chewing, swallowing and speaking, burning and pain of oral mucosa, propensity to damage of oral mucosa and infection, increased fungal infection, demineraliza- tion of eth and increase in caries, dysgeusia, halitosis and difculty in wearing dentures. Therefore, for the maintaining good oral and general health, saliva should be secred in an adequa quantity and quality [27]. However, the prevalence reaches almos100% in patients with Sjogren�s syn- drome and those who are receiving radiation therapy for head and neck cancer [29]. Ihas been shown thathe prevalence increases with age and thaxerostomia is more prevalenin postmenopausal women compared to men [16,30]. Iis estimad thaabou30% of the population older than 65 sufer from xerostomia [29]. Altho- ugh previous opinion thasalivary function declines with aging process, iis now accepd thasalivary fow as well as salivary constituens are both age-stable in the 72 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Mravak-Stipetic: Xerostomia - diagnostics and treatmenabsence of major medical problems and medications. Since there is no evidence thaxerostomia is likely to resulfrom the aging pro- cess alone ican be concluded thathe condition is a side-efecof various diseases and the drugs used to treathese diseases [29,33]. In general, causes may be gro- uped into two cagories [34]: a) primary or direccauses comprise conditions thadirectly afecsalivary glands and cause decreased salivary production [35]. The prevalence of Sjogren�s syndrome is 1% to 4% in older adults and is more common in postmenopausal women [36]. Authors conclu- de thathese observations are relevanfor identifying patients who would moslikely beneffrom inrvention treatment. When an autoimmune disease is suspecd, a minimally invasive chnique of minor salivary gland biopsy of the lower lip should be made with the dermination of serum antibodies [38]. In Sjogren�s syndrome the progressive lymphocytic infltration gradually de- stroys the secretory acini of the major and minor salivary glands which results in hyposalivation and fnally in xerostomia.

Keldron, 53 years: See the chart on page 34 for a list of some of the letters that confrm you qualify for Extra Help.

Dolok, 65 years: Signature of physician 353 Appendix 3 Medical certificate for a child I, the undersigned.

Sancho, 35 years: Slowly eliminated drugs, such as mefoquine (terminal elimination half-life (t½ẞ), 2–3 weeks), piperaquine (t½ẞ 4 weeks) and chloroquine (t½ẞ 1–2 months), persist in the blood and provide a selective flter for weeks or months after drug administration has ceased.

Dennis, 30 years: I express my gratitude to professor Ilkka Kantola and professor Timo Pitkajarvi for being the reviewers of this work.

Zapotek, 43 years: Our review of the lirature on with duration of symptoms ranging from one to 60 cervical radiculopathy from degenerative disorders months.

Mortis, 21 years: The right dosage: • Considering if the dosage is appropriate based on age, size, vital signs or other variables • If it is necessary to measure the dose (e.

Raid, 41 years: The ingly common use of improved breeds, indoor cultiva- level in the Netherlands increased from 20% to almost tion and the use of sophisticated techniques.

Elber, 25 years: Ankylostomiasea • During larval penetration/migration albendazole as a single dose (as for Ancylostoma duodenale Cutaneous signs (pruritic papulo-vesicular rash at the site of penetration, usually the feet) ascariasis) is much more effective Necator americanus and pulmonary symptoms (similar to ascariasis).

Leon, 54 years: In particular, risk assessment is made more diffcult by the wide variation in physiological and psychological makeup of individual drug users.

Mamuk, 40 years: Avery T, Barber N, Ghaleb M, Dean Franklin B, Armstrong S, Crowe S, Dhillon S, Freyer A, Howard R, Pezzoles C, Serumaga B, Swanwick G and Talab O.

Kayor, 22 years: Unfavorable effect of atropinediphenoxylate (Lomotil) therapy in lincomycin-caused diarrhea.

Peer, 61 years: Intravaginal clindamycin the same medication for early treatment failure of bacterial vaginosis.

Yokian, 56 years: Refer to a dentist, where available orthodontics or endodontic specialist depending on the need of advanced treatment Note: Referral to oral and maxillofacial surgeon is done to patients with complicated maxillofacial injuries.

Ronar, 48 years: Both groups showed the same patrn of pain relief in arm pain aall examination times withoustatically significandifference (P=0.

Pyran, 33 years: Systems and measures need to be put in place to minimize distractions and disruptions during the medication administration process.

Bufford, 42 years: If the appellate court fails to issue its ruling at the conclusion of the hearing, the petition is deemed to have been granted and the consent requirement is waived.

References

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• Zerr KJ, Furnary AP, Grunkemeier GL, et al: Glucose control lowers the risk of wound infection in diabetics after open heart operations, Ann Thorac Surg 63:356, 1997.
• Pritchard J, Brown J, Shafford E, et al. Cisplatin, doxorubicin, and delayed surgery for childhood hepatoblastoma: a successful approachoresults of the first prospective study of the International Society of Pediatric Oncology. J Clin Oncol. 2000;18(22): 3819-3828.
• Poon D, Cheung YB, Tay MH, et al. Adrenal insuffi ciency in intestinal obstruction from carcinomatosis peritoneioa factor of potential importance in symptom palliation. J Pain Symptom Manage. 2005;29:411-418.
• Richardson SE, Khan I, Rawstron A, et al. Risk-stratified adoptive cellular therapy following allogeneic hematopoietic stem cell transplantation for advanced chronic lymphocytic leukaemia. Br J Haematol 2013;160(5):640-648.