By I. Brenton. University of Southern Mississippi. 2019.
If consensus was not evident after the second ciation with comorbid disorders or other sleep disorder catego- vote generic kamagra chewable 100 mg with mastercard, the process was repeated until consensus was attained to ries order 100mg kamagra chewable free shipping, such as sleep related breathing disorders cheap 100 mg kamagra chewable otc, circadian rhythm include or exclude a recommendation generic kamagra chewable 100mg line. Clinical guidelines provide clinicians with a prevalence of insomnia varies according to the stringency of the working overview for disease or disorder evaluation and man- defnition used. These guidelines include practice parameter papers to 50% of the adult population; insomnia symptoms with dis- and also include areas with limited evidence in order to provide tress or impairment (i. They should not, however, be comorbid (medical, psychiatric, sleep, and substance use) disor- considered exhaustive, inclusive of all available methods of ders, shift work, and possibly unemployment and lower socio- care, or exclusive of other methods of care reasonably expected economic status. The ultimate judgment regarding conditions are at particularly increased risk, with psychiatric and appropriateness of any specifc therapy must be made by the chronic pain disorders having insomnia rates as high as 50% to clinician and patient in light of the individual circumstances 75%. Although details of current models are beyond the scope Pre-Sleep Conditions: of this practice guideline, general model concepts are critical Pre-bedtime activities for identifying biopsychosocial predisposing factors (such as Bedroom environment hyperarousal, increased sleep-reactivity, or increased stress Evening physical and mental status response), precipitating factors, and perpetuating factors such Sleep-Wake Schedule (average, variability): as (1) conditioned physical and mental arousal and (2) learned Bedtime: negative sleep behaviors and cognitive distortions. In particu- Time to fall asleep lar, identifcation of perpetuating negative behaviors and cog- • Factors prolonging sleep onset nitive processes often provides the clinician with invaluable • Factors shortening sleep Awakenings information for diagnosis as well as for treatment strategies. Evaluation continues to rest on a Final awakening versus Time out of bed careful patient history and examination that addresses sleep and Amount of sleep obtained waking function (Table 4), as well as common medical, psychi- Nocturnal Symptoms: atric, and medication/substance-related comorbidities (Tables Respiratory 5, 6, and 7). The Primary Complaint: Patients with insomnia may Other medical Behavioral and psychological complain of diffculty falling asleep, frequent awakenings, dif- Daytime Activities and Function: fculty returning to sleep, awakening too early in the morning, Identify sleepiness versus fatigue or sleep that does not feel restful, refreshing, or restorative. Al- Napping though patients may complain of only one type of symptom, it Work is common for multiple types of symptoms to co-occur, and for Lifestyle the specifc presentation to vary over time. Although no specifc quan- Neurological Stroke, dementia, Parkinson disease, seizure titative sleep parameters defne insomnia disorder, common disorders, headache disorders, traumatic complaints for insomnia patients are an average sleep latency brain injury, peripheral neuropathy, chronic >30 minutes, wake after sleep onset >30 minutes, sleep eff- pain disorders, neuromuscular disorders ciency <85%, and/or total sleep time <6. Patterns of sleep at unusual times may colitis, irritable bowel syndrome assist in identifying Circadian Rhythm Disorders such as Ad- Genitourinary Incontinence, benign prostatic hypertrophy, vanced Sleep Phase Type or Delayed Sleep Phase Type. Assess- nocturia, enuresis, interstitial cystitis ing whether the fnal awakening occurs spontaneously or with Endocrine Hypothyroidism, hyperthyroidism, diabetes an alarm adds insight into the patient’s sleep needs and natural mellitus sleep and wake rhythm. Finally, the clinician must ascertain Musculoskeletal Rheumatoid arthritis, osteoarthritis, whether the individual’s sleep and daytime complaints occur fbromyalgia, Sjögren syndrome, kyphosis despite adequate time available for sleep, in order to distinguish Reproductive Pregnancy, menopause, menstrual cycle insomnia from behaviorally induced insuffcient sleep. Nocturnal Symptoms: Patient and bed partner reports apnea, restless legs syndrome, periodic limb may also help to identify nocturnal signs, symptoms and behav- movement disorder, circadian rhythm sleep iors associated with breathing-related sleep disorders (snoring, disorders, parasomnias gasping, coughing), sleep related movement disorders (kick- Other Allergies, rhinitis, sinusitis, bruxism, ing, restlessness), parasomnias (behaviors or vocalization), and alcohol and other substance use/dependence/ comorbid medical/neurological disorders (refux, palpitations, withdrawal seizures, headaches). Pre-Sleep Conditions: Patients with insomnia may de- ety, frustration, sadness) may contribute to insomnia and should velop behaviors that have the unintended consequence of per- also be evaluated. Daytime Activities and Daytime Function: Daytime strategies to combat the sleep problem, such as spending more activities and behaviors may provide clues to potential causes time in bed in an effort to “catch up” on sleep. Napping (frequency/day, in bed or in the bedroom that are incompatible with sleep may times, voluntary/involuntary), work (work times, work type include talking on the telephone, watching television, computer such as driving or with dangerous consequences, disabled, use, exercising, eating, smoking, or “clock watching. Sleep-Wake Schedule: In evaluating sleep-related sleepiness should prompt a search for other potential sleep symptoms, the clinician must consider not only the patient’s disorders. The number, duration, and timing of naps should “usual” symptoms, but also their range, day-to-day variability, be thoroughly investigated, as both a consequence of in- and evolution over time. Table 6—Common Comorbid Psychiatric Disorders and Symptoms Category Examples Mood disorders Major depressive disorder, bipolar mood disorder, dysthymia Anxiety disorders Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive compulsive disorder Psychotic disorders Schizophrenia, schizoaffective disorder Amnestic disorders Alzheimer disease, other dementias Disorders usually seen in childhood and adolescence Attention defcit disorder Other disorders and symptoms Adjustment disorders, personality disorders, bereavement, stress Journal of Clinical Sleep Medicine, Vol. Conditions often comorbid with insomnia, such as venlafaxine, duloxetine, monoamine oxi- mood and anxiety disorders, may also have familial or genetic dase inhibitors components. Social and occupational histories may indicate not Stimulants Caffeine, methylphenidate, amphetamine only the effects of insomnia on the individual, but also possible derivatives, ephedrine and derivatives, co- contributing factors. Occupational assessment should specif- caine cally include work around dangerous machinery, driving duties, Decongestants Pseudoephedrine, phenylephrine, phenyl- regular or irregular shift-work and transmeridian travel. However, these exams may Pulmonary Theophylline, albuterol provide important information regarding comorbid conditions Alcohol and differential diagnosis. A physical exam should specifcally evaluate risk factors for sleep apnea (obesity, increased neck • Mood disturbances and cognitive diffculties. Complaints circumference, upper airway restrictions) and comorbid medi- of irritability, loss of interest, mild depression and anxi- cal conditions that include but are not limited to disorders of ety are common among insomnia patients. Patients with pulmonary, cardiac, rheumatologic, neurological, endocrine chronic insomnia often complain of mental ineffciency, (such as thyroid), and gastrointestinal systems. The mental sta- diffculty remembering, diffculty focusing attention, and tus exam should focus on mood, anxiety, memory, concentra- diffculty with complex mental tasks. Conversely, in- sis is further aided by the use of sleep logs, questionnaires for terpersonal diffculties may be an important contributor to sleep quality, sleepiness, psychological assessment and quality insomnia problems for some individuals. The daytime activities and exercise may in turn contribute to choice of assessment tools should be based on the patient’s pre- insomnia. Likewise, (1) A general medical/psychiatric/medication questionnaire poor sleep may exacerbate symptomatology of comorbid (to identify comorbid disorders and medication use) conditions. Sleep complaints may herald the onset of mood (2) The Epworth Sleepiness Scale or other sleepiness assess- disorders or exacerbation of comorbid conditions. Other History: A complete insomnia history also in- (3) A two-week sleep log to identify sleep-wake times, gen- cludes medical, psychiatric, medication/substance, and family/ eral patterns, and day-to-day variability. Primary baseline measures obtained from a sleep and potentially on family, friends, coworkers and caretakers. Self medication with times 100) alcohol, over-the-counter medications, prescription medica- • Nap times (frequency, times, durations) tions, and melatonin account for millions of dollars annual- Sleep logs may also include reports of sleep quality, daytime ly. Genetics: With the exception of fatal familial insomnia, a Objective Assessment Tools: Laboratory testing, polysom- rare disorder, no specifc genetic associations have been identi- nography and actigraphy are not routinely indicated in the eval- fed for insomnia. A familial tendency for insomnia has been uation of insomnia, but may be appropriate in individuals who observed, but the relative contributions of genetic trait vulner- present with specifc symptoms or signs of comorbid medical ability and learned maladaptive behaviors are unknown. For example, changing to a less stimulating antidepres- rhythm sleep disorders; sant or changing the timing of a medication may improve sleep Insomnia due to medical or psychiatric disorders or to or daytime symptoms. It should be Before consideration of treatment choices, the patient and noted that comorbid insomnias and multiple insomnia diagno- physician should discuss primary and secondary treatment goals ses may coexist and require separate identifcation and treat- based on the primary complaint and baseline measures such as ment. After discussing treatment options tailored to address the primary complaint, a specifc follow-up Indications for Treatment plan and time frame should be outlined with the patient, regard- less of the treatment choice. Treatment is recommended when the chronic insomnia has Quantifying sleep quality, daytime function, and improve- a signifcant negative impact on the patient’s sleep quality, ment in comorbid conditions requires more involved assess- health, comorbid conditions, or daytime function. It is essential ment, often using specifc questionnaires for specifc insomnia to recognize and treat comorbid conditions that commonly oc- problems (Table 8). If the clinician is unfamiliar with these tests, cur with insomnia, and to identify and modify behaviors and administration and monitoring of these measures may require medications or substances that impair sleep. By defnition, and behavioral interventions show short and long term effcacy Journal of Clinical Sleep Medicine, Vol. When using this diagram, the clinician should be aware that the presence of one diagnosis does not exclude other diagnoses in the same or another tier, as multiple diagnoses may coexist. Acute Adjustment Insomnia, not a chronic insomnia, is included in the chronic insomnia algorithm in order to highlight that the clinician should be aware that extrinsic stressors may trigger, perpetuate, or exacerbate the chronic insomnia. Psychological and behavioral interventions and phar- with psychological and behavioral therapies. Treatments which macological interventions may be used alone or in combination address these core components play an important role in the man- (Figure 2). Regardless of treatment choice, frequent outcome agement of both primary and comorbid insomnias. In addition, periodic clinical reassessment following While most effcacy studies have focused on primary insomnia completion of treatment is recommended as the relapse rate for patients, more recent data demonstrate comparable outcomes in chronic insomnia is high. In co- psychological and Behavioral Therapies morbid insomnias, treatment begins by addressing the comorbid condition. This may include treatment of major depressive dis- Current models suggest that physiological and cognitive hy- order, optimal management of pain or other medical conditions, perarousal contribute to the evolution and chronicity of insom- elimination of activating medications or dopaminergic therapy nia. In addition, patients typically develop problematic behaviors for movement disorder. In the past, it was widely assumed that such as remaining in bed awake for long periods of time, often treatment of these comorbid disorders would eliminate the in- resulting in increased efforts to sleep, heightened frustration and somnia. However, it has become increasingly apparent that over anxiety about not sleeping, further wakefulness and negative the course of these disorders, numerous psychological and be- expectations, and distorted beliefs and attitudes concerning the havioral factors develop which perpetuate the insomnia problem. Negative learned responses may These perpetuating factors commonly include worry about in- Journal of Clinical Sleep Medicine, Vol. The sleep disturbance has a relatively short duration (days-weeks) and is expected to resolve when the stressor resolves. Psychophysiological Insomnia The essential features of this disorder are heightened arousal and learned sleep-preventing as- sociations. Arousal may be physiological, cognitive, or emotional, and characterized by muscle tension, “racing thoughts,” or heightened awareness of the environment.
These rapidly acting drugs order kamagra chewable 100 mg online, if used alone buy discount kamagra chewable 100 mg on-line, can lead to development of parasite resistance buy 100 mg kamagra chewable free shipping. If a slide result is obtained later 100 mg kamagra chewable for sale, the treatment should be adjusted according to species. The algorithm for diagnosis and treatment is as follows: Where microscopy result is available within 24 hours Clinically suspected malaria case Take slide for microscopy P. Microscopic evidence may be negative for asexual parasites in patients with severe infections due to sequestration and partial treatment. However, if the symptoms clearly point to severe malaria and there is no alternative explanation, such a case should be treated accordingly. Loading dose of 20 mg/kg should not be given, if the patient has already received quinine. If parenteral quinine therapy needs to be continued beyond 48 hours, dose should be reduced to 7 mg/kg 8 hourly. Note: • Once the patient can take oral therapy, the further follow-up treatment should be as below: n Patients receiving parenteral quinine should be treated with oral quinine 10 mg/kg three times a day to complete a course of 7 days, along with doxycycline 3 mg/kg per day for 7 days. However, if quinine is not available, artemisinin derivatives may be given to save the life of mother. In recent years, increased attention has been drawn to severe malaria caused by P. Some cases have been reported in India, and there is reason to fear that this problem will become more common in the coming years. Chemoprophylaxis Chemoprophylaxis is recommended for travellers, migrant labourers and military personnel exposed to malaria in highly endemic areas. Use of personal protection measures like insecticide-treated bednets should be encouraged for pregnant women and other vulnerable populations. The drug should be started 2 days before travel and continued for 4 weeks after leaving the malarious area. Note: Doxycycline is contraindicated in pregnant women and children less than 8 years. Note: Mefloquine is contraindicated in cases with history of convulsions, neuropsychiatric problems and cardiac conditions. Recommended reading Malaria in India and guidelines for its control including case management Website of National Vector Borne Disease Control Programme http://www. Anup Anvikar, Scientist D National Institute of Malaria Research, Delhi e-mail: anvikar@rediffmail. Usha Arora, Deputy Director National Vector Borne Disease Control Programme, Delhi e-mail: uarora2006@yahoo. Dhillon, Director National Vector Borne Disease Control Programme, Delhi e-mail: drgpsdhillon@hotmail. Dua, Officer-in-Charge National Institute of Malaria Research, Delhi e-mail: vkdua51@gmail. Sanjib Mohanty, Joint Director Ispat General Hospital, Rourkela e-mail: sanjibmalaria@rediffmail. Sonal, Joint Director National Vector Borne Disease Control Programme, Delhi e-mail: gssnvbdcp@gmail. Neena Valecha, Scientist F National Institute of Malaria Research, Delhi e-mail: neenavalecha@gmail. Neena Valecha Scientist F National Institute of Malaria Research Sector 8, Dwarka New Delhi – 110 077 E-mail: neenavalecha@gmail. Children under five years of age and pregnant women are at risk of serious illness, but malaria affects all levels of society. The Ministry of Health (MoH) is absolutely dedicated to ensuring that this disease is addressed at all levels and on all fronts. The MoH approach to ensure maximum impact on malaria focuses on the integration of the most effective prevention and treatment tools. The importance attached to the management of malaria at the community level, availability of the most effective medicines at all levels of the health system, and use of the newest diagnostic tools including rapid diagnostic tests to ensure proper diagnosis at lower health facilities and at the community level are all key approaches to ensure the highest possible quality of case management. With this combination of approaches, the MoH aims to have a dramatic impact on the level of malaria in the country. It is with this background that I sincerely welcome the revisions made in the Guidelines for the Diagnosis and Treatment of Malaria in Zambia to reflect the updated policy recommendations. These fourth edition guidelines are intended to provide useful updated information to all health Guidelines for the Diagnosis and Treatment of Malaria in Zambia ii workers on the diagnosis and management of malaria at all levels of the health care system. It also contains additional information such as a chapter on malaria prophylaxis for special populations. I hope that these guidelines will continue to serve as an important source of reference material for general malaria management. I equally want to take this opportunity to thank all the organizations and individuals that have provided both technical and financial support to ensure a successful revision of the guidelines. We also acknowledge comments and suggestions made by partners through the Malaria Case Management Technical Working Group. It is transmitted through the bite of an infected female mosquito belonging to the genus Anopheles (An. Malaria is generally endemic throughout the country although the country is stratified by high (hyper-endemic), moderate (meso-endemic), and low (hypo-endemic) areas. The most common species that is clinically significant and causes the most lethal form of malaria is P. Tremendous efforts have been made to reduce the burden of malaria in the country; the national incidence rate is now 373 cases per 1,000 people (Ministry of Health [MoH] (a), 2012). The malaria parasite prevalence of infection in children under five years of age has decreased from 22. The National Malaria Control Centre estimates that there are fewer than 4,000 deaths per year due to malaria (MoH (a), 2012). Malaria also has an impact on pregnant women, contributing significantly to maternal deaths, maternal anaemia, premature delivery, and low-birth-weight infants. Hospital admissions due to malaria and fatality rates have also increased during the same period. This Guidelines document presents revised treatment recommendations based on the latest available evidence. Alternative first-line choice for uncomplicated malaria is dihydroartemisin-piperaquine. In case of failure of the first-line medicine in all age groups, quinine is the medicine of choice. Injectable artesunate is the drug of choice in adults and children with severe malaria. The appropriate single dose of artesunate suppositories should be administered rectally as soon as the presumptive diagnosis of malaria is made. In the event that an artesunate suppository is expelled from the rectum within 30 minutes of insertion, a second suppository should be inserted and, especially in young children, the buttocks should be held together, or taped together, for 10 minutes to ensure retention of the rectal dose of artesunate. Dose should be given once and followed as soon as possible by definitive therapy for malaria. In this respect: o Microscopy will be deployed in the public health sector according to the current national laboratory policy. However, priority will be given to facilities where deployment of microscopy may not be possible. However, practical experience and operational evidence will continue to be carefully monitored and evaluated. Once inside the body, the parasite moves to the liver, where it enters a hepatocyte and develops. From the liver it enters the blood stream and multiplies inside the red blood cells. This complex life cycle of development of the Plasmodium parasite gives way to the different clinical symptoms in the human host (see Figure 1). Guidelines for the Diagnosis and Treatment of Malaria in Zambia 7 Figure 1: Life cycle of the malaria parasite Guidelines for the Diagnosis and Treatment of Malaria in Zambia 8 Guidelines for the Diagnosis and Treatment of Malaria in Zambia 9 Source: Centers for Disease Control and Prevention, 2013 The invasion, alteration, and destruction of red blood cells by the malaria parasites, local and systemic circulatory changes, and the related metabolic abnormalities are all important in the pathophysiology of malaria. It is owing to these factors that malaria infection that is predominantly due to P. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 10 Chapter 2: Clinical Features 2. The first attacks are usually more severe and may persist for weeks, if untreated. Malaria infection is a serious condition that can lead to severe malaria or death if treatment is delayed.
Returning to the acetaminophen example buy discount kamagra chewable 100 mg, if the patient states that the medication is for him and that he needs it for pain generic kamagra chewable 100 mg free shipping, you will need to ask a few more questions buy 100mg kamagra chewable with visa. Additionally kamagra chewable 100mg with visa, you are also responsible for understanding the disease process of the symptom and what pertinent positives and negatives you need to assess. For example, if the patient states that his pain is in his head, you need to know the questions to ask to either rule in or rule out a headache due to a migraine. Appropriate questions in this situation could include, but are not limited to, “Do you have any sensitivity to light? Keep in mind that collecting information for all of these factors is not neces- sary for every patient or every complaint; however, one has to have the knowledge to determine which factors are pertinent to collect in each specific situation. The first part of the mne-11 monic, Qu, stands for “quickly and accurately assessing the patient. The mnemonic stands for symptoms, characteristics, history, onset, loca- tion, aggravating factors, and remitting factors. For example, if a patient has asthma and is complaining of a cold that is causing shortness of breath, you should establish that this patient is a candidate for self-care. Such education will include the self-care strategy, including both nonpharmacologic and pharmacologic agents; the appropri- ate dose, frequency, and maximum duration of the drug regimen; how to administer and store the drug; adverse effects and what to do in case they occur; when and how much relief can be expected; and finally, what the patient should do if the condition worsens or does not improve. Similar to other patient encounters, the patient’s under- standing of the instructions should be assessed and questions from the patient should be solicited and answered. Therefore, your role in the patient interview process as well as the patient’s condition will determine how you will be able to conduct the interview and on which elements you will focus. In the acute care setting, it is important to tailor the interview based on its purpose. There- fore, you will need to focus on learning all the medications that the patient has taken by asking the patient and/or caregiver or family member about the patient’s medications as well as by looking at a list of medications that the patient may have brought with him or her or calling the pharmacy to obtain this information. Depending on the situ- ation, the exact strengths, dosing, and adherence may not be as important if the patient is in critical condition; however, once the patient has stabilized and is either being sent home or to another part of the hospital, it may be necessary to complete a thorough medication history to ensure that medication errors do not occur. Adherence in this case is important because it enables you to assess the possible causes of the asthma exacerba- tion, including the lack of adherence or improper use of an inhaler. However, once the patient’s chest pain has been addressed and treated, assessments and counseling about tobacco use and medication adherence should occur. If the patient is in the intensive care unit, you may need to obtain a complete medication history to ensure that all of the patient’s medical conditions are being addressed. However, after the initial comprehensive medication history, which may be obtained from either a family member or caregiver or by calling the pharmacy, your interactions with the patient may be more focused on specific patient care mea- sures. For example, if the patient is being given pain medication and is conscious and alert, your interview may focus on further exploring how the patient’s pain is being managed and what symptoms he or she is experiencing that are related to the pain and the pain medication. If the patient is on the general floor of the hospital, your interview will be different based on the day of hospitalization and your role in the patient’s care. For example, on the first day the patient is admitted to the hospital, the medical team will have conducted a comprehensive health history, and it may be your role to complete a comprehensive 34 chapter 1 / the patient interview medication history. On subsequent days, you may be interacting with your patient to discuss ongoing treatments and to address any current complaints. Even if a medication history is not conducted on the first day of admittance, it is vital that a comprehensive medication history is obtained and documented at some point during the hospital stay. The learning and appli- cation of communication skills and techniques will allow for a patient encounter that is characterized by respect as well as offer you the opportunity to learn about patient- specific problems, thereby making your assessment, plan, and approach uniquely patient-centered. Additionally, use of a structured approach and framework to obtain all the pertinent information from the patient enables you to rely on a set foundation even as you direct the conversation according to the unique nuances of each particular patient. Awareness of the setting in which you are conducting the patient interview and knowing the purpose of the interview will enable you to gather the information you need to make an accurate assessment and plan, which is essential to providing high-quality, patient-centered care. Simultaneously, actively listening during the patient interview will give you the opportunity to learn about patient-specific problems. It is necessary to modify your approach to the patient interview in order to provide appropriate patient care in any setting. Describe the differences between conducting a medication history for a patient in the emergency room versus the patient in an intensive care unit versus the patient on a general medicine floor. Medication therapy and patient care: Organiza- tion and delivery of services-statements. Current methods used to teach the med- ication history interview to doctor of pharmacy students. A patient’s view of the Yellow Card Scheme 12 What happens when quality or safety 13 concerns arise? Dealing with faulty medicines 14 Responding to concerns about devices 16 How device reporting makes a difference 17 Is it safe to order medicines and devices off 18 the internet? It does this by making sure that and medical devices and equipment used in medicines and medical devices―from painkillers healthcare and the investigation of harmful to pacemakers―work properly and are acceptably incidents. No product is completely services, healthcare providers, and other relevant free of risk but sound evidence underpins all the organisations to improve blood quality and safety. No product is 100 per cent condition being treated, the • Does the medicine do safe, because all products age and sex of the patient, the most good for the have side effects. These and other treatments least harm for most may be very minor, but they which the patient may be people who will be may also be serious. For example, cancer • Are the side effects treatments may make Medicines are very acceptable? They thousands of people may be acceptable for a can also make patients and must meet rigorous medicine used to treat a feel very unwell and standards before they life threatening illness, for increase the chances of are licensed. Aspirin reduces more generally by a wider used for a common minor infammation and fever. Thalidomide was prescribed during the late 1950s and early 1960s to relieve morning sickness in the frst few months of pregnancy, but caused unpredicted serious birth defects. In a bid to prevent a similar occurrence, the Committee on Safety of Drugs was set up in 1963. Many of the provisions of the Act have now been superseded by regulations implementing European legislation on medicines. The Agency has the power to withdraw a product from the market, and in the case of medicines, to suspend production. The Agency can also prosecute a manufacturer or distributor if the law has been broken. The regulations need to be robust enough to protect the public’s health, and this costs money. Licences for medicines are granted only when a product meets high standards of safety and quality and works for the purpose intended. The regulatory system also imposes rigorous standards on medicines manufacturers and wholesale dealers who trade in them. The licensing system guarantees accountability The authorisation process for devices differs for all those involved and ensures that processes, from that applied to medicines. However, once supplies, and quality can be thoroughly marketed, safety and performance of medicines monitored and swift corrective action taken and medical devices are monitored and where necessary. The breast cancer safe, it is given a marketing authorisation or treatment Herceptin and the antiviral medicine product licence. The black triangle a close watch on side effects prescribing manuals, product may also be assigned to a that may be associated with information, and advertising medicine that has already newly marketed products. This means everything from artifcial hips to wound dressings, incubators to insulin injectors • Traditional herbal medicines sold over and scanners to scalpels. Manufacturers should be able to support their • Applications on humanitarian grounds performance claims for the device. On average, the Agency refuses one in fve such requests on the grounds of patient safety or health policy restrictions. Herbal medicines and homeopathic remedies The Traditional Herbal these are currently exempt Medicines Registration from the need for a licence. Details of any herbal product Registered manufacturers found to contain potentially are also legally obliged to harmful ingredients, or which monitor the safety of their interacts with conventional products once they are on medicines, are posted on the market. A medicine may work well in the laboratory, but a clinical trial will fnd out if it also works well in people and is safe to use. Phase 1 trials usually involve healthy people, and are designed to fnd out Around 5,000 licences how the medicine works in the body, and are granted to whether side effects increase at higher medicines, doses. Phase 2 trials look at whether the medicine works in patients with a particular condition or disease and identify common short term side effects.
The anti‐infective component in Ophthalmic Ointment Neodecadron is included to provide action against specific organisms susceptible to it generic kamagra chewable 100mg on-line. Neomycin sulfate is active In Vitro against susceptible strains of the following microorganisms: Staphylococcus Aureus discount 100mg kamagra chewable amex, Escherichia Coli order kamagra chewable 100mg mastercard, Haemophilus Influenzae discount 100mg kamagra chewable with mastercard, Klebsiella/Enterobacter species, and Neisseria species. The product does not provide adequate coverage against: Pseudomonas Aeruginosa, Serratia Marcescens, and streptococci, including Streptococcus Pneumoniae. Usage: For steroid‐responsive inflammatory ocular conditions for which a corticosteroid is indicated and where bacterial infection or a risk of bacterial ocular infection exists. Ocular steroids are indicated in inflammatory conditions of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe where the inherent risk of steroid use in certain infective conjunctivitis is accepted to obtain a diminution in edema and inflammation. They are also indicated in chronic anterior uveitis and corneal injury from chemical, radiation, or thermal burns, or penetration of foreign bodies. The use of a combination drug with an anti‐ infective component is indicated where the risk of infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye. The particular anti‐infective drug in this product is active against the following common bacterial eye pathogens: • Staphylococcus Aureus • Escherichia Coli • Haemophilus Influenzae • Klebsiella/Enterobacter species • Neisseria species • The product does not provide adequate coverage against: • Pseudomonas Aeruginosa • Serratia Marcescens • Streptococci, including Streptococcus Pneumoniae Dosage and Administration: The duration of treatment will vary with the type of lesion and may extend from a few days to several weeks, according to therapeutic response. Apply a thin coating of Ophthalmic Ointment Neodecadron three or four times a day. When a favorable response is observed, reduce the number of daily applications to two, and later to one a day as maintenance dose if this is sufficient to control symptoms. SoluMedrol (Methylprednisolone) Description: Solu‐Medrol Sterile Powder contains methylprednisolone sodium succinate as the active ingredient. It is very soluble in water and in alcohol; it is insoluble in chloroform and is very slightly soluble in acetone. Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt‐retaining properties, are used as replacement therapy in adrenocortical deficiency states. Their synthetic analogs are primarily used for their potent anti‐inflammatory effects in disorders of many organ systems. Methylprednisolone is a potent anti‐inflammatory steroid synthesized in the Research Laboratories of The Upjohn Company. It has a greater anti‐ inflammatory potency than prednisolone and even less tendency than prednisolone to induce sodium and water retention. Methylprednisolone sodium succinate has the same metabolic and anti‐inflammatory actions as methylprednisolone. When given parenterally and in equimolar quantities, the two compounds are equivalent in biologic activity. The relative potency of Solu‐Medrol Sterile Powder and hydrocortisone sodium succinate, as indicated by depression of eosinophil count, following intravenous administration, is at least four to one. This is in good agreement with the relative oral potency of methylprednisolone and hydrocortisone. Note that convulsions have been reported with concurrent use of methylprednisolone and cyclosporin. Drugs that induce hepatic enzymes such as phenobarbital, phenytoin and rifampin may increase the clearance of methylprednisolone and may require increases in methylprednisolone dose to achieve the desired response. Drugs such as troleandomycin and ketoconazole may inhibit the metabolism of methylprednisolone and thus decrease its clearance. Therefore, the dose of methylprednisolone should be titrated to avoid steroid toxicity. This could lead to decreased salicylate serum levels or increase the risk of salicylate toxicity when methylprednisolone is withdrawn. Aspirin should be used cautiously in conjunction with corticosteroids in patients suffering from hypoprothrombinemia. There are reports of enhanced as well as diminished effects of anticoagulant when given concurrently with corticosteroids. Therefore, coagulation indices should be monitored to maintain the desired anticoagulant effect. Dosage and Administration: When high dose therapy is desired, the recommended dose of Solu‐Medrol Sterile Powder is 30 mg/kg administered intravenously over at least 30 minutes. Although adverse effects associated with high dose short‐term corticoid therapy are uncommon, peptic ulceration may occur. In other indications initial dosage will vary from 10 to 40 mg of methylprednisolone depending on the clinical problem being treated. The larger doses may be required for short‐term management of severe, acute conditions. The initial dose usually should be given intravenously over a period of several minutes. Dosage may be reduced for infants and children but should be governed more by the severity of the condition and response of the patient than by age or size. Dosage must be decreased or discontinued gradually when the drug has been administered for more than a few days. If a period of spontaneous remission occurs in a chronic condition, treatment should be discontinued. Routine laboratory studies, such as urinalysis, two‐hour postprandial blood sugar, determination of blood pressure and body weight, and a chest X‐ray should be made at regular intervals during prolonged therapy. Solu‐Medrol may be administered by intravenous or intramuscular injection or by intravenous infusion, the preferred method for initial emergency use being intravenous injection. To administer by intravenous (or intramuscular) injection, prepare solution as directed. Heparin is a heterogeneous group of straight‐chain anionic mucopolysaccharides called glycosaminoglycans having anticoagulant properties, that is preventing blood clotting. Full‐dose heparin therapy usually is administered by continuous intravenous infusion. The risk of recurrence of thromboembolism is greater in patients who do not achieve this level of anticoagulation within the first 24 hours. Subcutaneous administration of heparin can be used for the long‐term management of patients in whom warfarin is contraindicated (e. Low‐dose heparin therapy sometimes is used prophylactically to prevent deep venous thrombosis and thromboembolism in susceptible patients, e. A suggested regimen for such treatment is 5000 U of heparin given subcutaneously every 8 to 12 hours. Dosage and Administration: Dosage is 2 units / ml saline We usually use the 1,000 units/ml concentration. Protamine Description: Protamines are simple proteins of low molecular weight, rich in arginine and strongly basic. This strongly basic nature accounts for their antiheparin effect which makes it a useful antidote to heparin overdose. Antidiarrheal Compounds Lomotil Description: Lomotil (Searle & Co) is an antidiarrheal compound. Replacement Fluids Lactated Ringer’s Solution Description: Polyionic, isotonic solution for fluid therapy. For the monkey the water loss in terms of body weight is (1) Respiratory/cutaneous losses 15ml/kg, (2) Fecal 10 ml/kg, and (3) Urinary 20 ml/kg per day, with total loss of approx. A water‐ deprived animal should be given replacement fluids along with maintenance fluids. Usage: In all surgeries for maintaining the monkey’s fluid requirements during the operative period. During surgery water is also lost from the surgical site, from the vascular effects of anesthetic agents, and from sequestration of interstitial fluids from surgical trauma. Drops per minute (dpm) are computed based on: dpm = (Drp/ml)*(ml/kg/hr)*Weight/60 Dosage and Administration: 3‐15 ml/kg/hr. Box 4404 Nydalen N-0403 Oslo Norway Telephone: (47) 21078160 Telefax: (47) 21078146 E-mail: whocc@fhi. They describe particular issues, which have been discussed and resolved by consensus of the Working Group. Their study of drug consumption in six European countries during the period 1966-1967 showed great differences in drug utilization between population groups. It was agreed at this symposium that an internationally accepted classification system for drug consumption studies was needed. In order to measure drug use, it is important to have both a classification system and a unit of measurement. In connection with this, and to make the methodology more widely used, there was a need for a central body responsible for coordinating the use of the methodology. From January 2002 the Centre has been located at the Norwegian Institute of Public Health.
Individual clinical and centres in Mozambique 100mg kamagra chewable, two-year retention service settings should immediately rates climbed to 98% (35) cheap kamagra chewable 100 mg on-line. Instead of monitoring specifc process and outcome centralized treatment delivery points that indicators and using fndings to enhance ofen require people to travel long distances service quality and impact order kamagra chewable 100mg with amex. In countries incentives to use innovation to enhance with generalized epidemics kamagra chewable 100 mg low price, men are linkage, retention and adherence, such as substantially less likely than women to get communication technology (36). In large measure, this Ensure equity appears to refect diferences in care-seeking Equitable access is not only right; it is also behaviour among men and women. Key actions Ensure meaningful access for women and Strengthen the capacity of key populations girls. Countries should mitigates the deterrent efect of stigma and strengthen or establish systems to track people discrimination. Countries should use, where are mobilized to increase the responsiveness possible, modern communication and sensitivity of mainstream health systems, technologies, including mobile phones, to consideration should be given, where gather information. Immediate steps are needed to should swifly be forged on essential metrics to eliminate the gap in children’s treatment characterize and measure the treatment access. Communities should be fully engaged in the Additional eforts are needed to ensure process of developing the rapid response universal access to paediatric antiretroviral system and in monitoring the results and formulations. In recent years, Africa has taken important steps to preserve future access to affordable medicines. In 2007, the African Union adopted the Pharmaceutical Manufacturing Plan for Africa to boost the regional drug manufacturing capacity and to reduce Africa’s dependence on external suppliers. Steps are also underway to harmonize regulatory systems across the region to avoid needless delays in access to medical products (33). Building regional capacity to manufacture and deliver essential medicines will not only enhance the reliability of drug supplies but also have other public health and economic benefits. All efforts should be made to combat the distribution and use of counterfeit or substandard medicines. Countries should establish and adhere to • Legal and policy frameworks should be clear, ambitious national targets for scaling reviewed and, where indicated, reformed up. Countries informed national dialogue to reform that already have targets in place should measures that impede rapid scaling up immediately review these to ensure that they towards universal access to treatment. In are sufciently ambitious and refect the particular, countries should ensure that urgency of the Treatment 2015 agenda. Tese targets should provide for reviews of legal frameworks, where expedited progress towards equitable reforms are needed. Drawing on the best address bottlenecks to expediting available evidence, including the input of scale-up. Tis advantages, countries should develop body should not have a formal mandate multifaceted partnerships that unite and should complement and support, diverse stakeholders in the common aim rather than replace, existing institutional of expedited progress towards universal arrangements. However, since strategic information is essential to formulating sound policies and programmes, population-specific tracking generates critical information that can inform resource allocation, drive the creation of tailored delivery models and support advocacy to close gaps in access. In all A focus on countries: international settings, some populations are more afected than support to reach the Treatment 2015 others. Te strength of local health systems also target ofen varies within countries, which contributes to subnational diferences in service coverage. South–South cooperation analyse and use strategic information on treatment and timely access to focused, high-quality gaps to improve health outcomes. Treatment 2015 target will demand focused action in areas in which the need and opportunities for Systems should be in place to permit the scale-up are greatest. In addition, specifc countries will accelerate progress towards the 2015 geographical areas (districts or counties) with a target. Treatment 2015: a worldwide imperative To accelerate progress towards the 2015 target by enhancing strategic focus, Treatment 2015 calls for particular efforts to expedite scale-up in 30 priority countries. However, the focus on these 30 countries is not intended to suggest that accelerating the scaling up of treatment is a lesser priority in other countries. On the contrary, every country, regardless of region, is urged to embrace the approach recommended here to ensure the fastest possible scale-up, and the international community should do everything possible to assist all countries in putting the needed policies and programmes in place. For example, in the Middle East and North Africa, regional efforts should focus on countries with the greatest treatment gaps, such as Djibouti, the Islamic Republic of Iran, Somalia and Sudan. Treatment education: a critical component of eforts to ensure universal access to prevention, treatment and care. All potential conflicts of interest are listed at the strategies and diagnostic recommendations also are discussed. To answer these questions clinical circumstances of each person in the context of local disease and synthesize new information available since publication of prevalence. The outcome of the literature review informed development of background Corresponding preparer: Kimberly A. Each key question was discussed, and pertinent in sexual behaviors and use of recommended prevention publications were reviewed in terms of strengths, weaknesses, services; and relevance. As part of the clinical encounter, health and clinical experts reviewed the draft recommendations. More any new sex partners you’ve had since your last visit,” and comprehensive, annotated discussions of such evidence “What has your experience with using condoms been like? For infections with more a sexual history is one strategy for eliciting information than one recommended regimen, listed regimens have similar concerning five key areas of interest (Box 1). For additional efficacy and similar rates of intolerance or toxicity unless information about gaining cultural competency when working otherwise specified. Partners prevention section and sections on chlamydia, gonorrhea, • “Do you have sex with men, women, or both? Prevention of pregnancy which can be resource intensive, is directed at a person’s risk, • “What are you doing to prevent pregnancy? Other approaches use motivational interviewing to move • “Is there anything else about your sexual practices that clients toward achievable risk-reduction goals. A recent federal guideline mutually monogamous relationship with a partner known to recommends that clinical and nonclinical providers assess be uninfected. Rates of breakage and • Ensure adequate lubrication during vaginal and anal sex, slippage may be slightly higher during anal intercourse (33,34). Users should check the firmly against the base of the penis during withdrawal, expiration or manufacture date on the box or individual and withdraw while the penis is still erect. Latex condoms should not be used beyond their Additional information about male condoms is available at expiration date or more than 5 years after the manufacturing http://www. Male condoms made of materials other than latex are Female Condoms available in the United States and can be classified in two general categories: 1) polyurethane and other synthetic and Several condoms for females are globally available, including 2) natural membrane. The effectiveness of other synthetic prevention method, and the newer versions may be acceptable male condoms to prevent sexually transmitted infections to both men and women. Additional Natural membrane condoms (frequently called “natural skin” information about the female condom is available at http:// condoms or [incorrectly] “lambskin” condoms) are made from www. Spermicides containing N-9 might • Carefully handle the condom to avoid damaging it with disrupt genital or rectal epithelium and have been associated fingernails, teeth, or other sharp objects. Condoms with N-9 • Put the condom on after the penis is erect and before any are no more effective than condoms without N-9; therefore, genital, oral, or anal contact with the partner. N-9 use has also been associated with an AquaLube, and glycerin) with latex condoms. Oil-based increased risk for bacterial urinary tract infections in women lubricants (e. Sexually be available to families that desire it, as the benefits of the active women who use hormonal contraception (i. Studies examining the association potential benefit of male circumcision for this population (62). Three randomized, controlled through advance prescription or supply from providers trials performed in regions of sub-Saharan Africa where (64,65). It is also Retesting several months after diagnosis of chlamydia, recommended that health departments provide partner services gonorrhea, or trichomoniasis can detect repeat infection for persons who might have cephalosporin-resistant gonorrhea. Clinicians should positive for trichomonas, should be rescreened 3 months familiarize themselves with public health practices in their after treatment. Any person who receives a syphilis diagnosis area, but in most instances, providers should understand should undergo follow-up serologic syphilis testing per current that responsibility for ensuring the treatment of partners of recommendations (see Syphilis). Clinical evaluation, counseling, diagnostic testing, and treatment providers are unlikely to participate directly in internet partner designed to increase the number of infected persons brought notification. Internet sites allowing patients to send anonymous to treatment and to disrupt transmission networks. The term via the internet is considered better than no notification at all “public health partner services” refers to efforts by public and might be an option in some instances.
Care coordination Specialty pharmacy staff provide patients with all necessary supplies generic kamagra chewable 100mg with visa, specialty drug administration training generic 100 mg kamagra chewable mastercard, and support generic 100 mg kamagra chewable with amex. Adherence management Specialty pharmacy staff contact patients before each scheduled fll to arrange the dispensing of their next dose buy kamagra chewable 100 mg lowest price, identify potential adherence barriers, and manage treatment effects. Ancillary supplies Patients are provided with all necessary supplies needed to administer their medications. Counseling Pharmacists provide patients with relevant information regarding their specialty drug and disease state. Specialty medication Specialty pharmacies ensure that specialty medications are stocked and readily fulfllment accessible for patient dispensing as soon as requested. Cold chain management Specialty pharmacies have detailed cold chain management procedures that include thorough tracking requirements. Specialty clinical protocols Pharmacists closely follow all disease state and drug-specifc clinical protocols for dispensing, monitoring, and patient follow-up processes. Patient assistance Patients have access to fnancial assistance programs provided through drug programs manufacturers, foundations, and other organizations. Patient education Specialty pharmacies ensure multiple languages and methods of education are available to patients. This in turn makes therapies more affordable and will accelerate in the coming years, adding to the arsenal accessible for all patients and preserves plans’ ability to of cures and benefcial treatments for a wide range of cover new, more costly medications. New cholesterol drugs pack huge price Generating Savings for Plan Sponsors and Consumers. Improved Access to Medicines: Biosimilars and Interchangeable 8 Biologic Products. New cholesterol drugs pack huge price Price Competition and Innovation Act of 2007. Specialty pharmacy company-pcsk9-meds-praluent-repatha-both-nab-coverage-top- trends and strategies: 2015. Health Policy Brief: Specialty Generating Savings for Plan Sponsors and Consumers. Managing Specialty Medication Services Through a Specialty Pharmacy Program: The Case of Oral Renal Transplant Immunosuppressant Medications. Specialty drugs—1 including those used to treat conditions such as cancer and hepatitis C—represent a signifcant portion of this spending. The high cost of these novel therapies, which often ofer advancements in patient care, raises afordability concerns for health plans, patients, and consumers. The Pew Charitable Trusts defnes specialty drugs as medications with high costs for a course of treatment or a year of therapy. Some health plans also categorize drugs as specialty if they are novel therapies; require special handling, monitoring, or administration; or are used to treat rare conditions. In general, elevated costs are a distinguishing characteristic of specialty drugs. A recent survey found that 85 percent of health plans consider high cost a determining factor in identifying specialty drugs. Patients are often required to pay co-insurance in order to access these medications. Research shows that requiring patients to pay more out of pocket reduces their use of prescription drugs. Step therapy: When multiple treatment options are available for a patient’s condition, plans sometimes require patients to try, and fail, treatment with a cheaper, traditional drug before letting them access a specialty drug. Patients with rheumatoid arthritis, for example, are sometimes required to attempt therapy with traditional oral medications before they can use specialty biologics. Under most prior authorization criteria, clinical information is necessary to verify that a specialty drug is medically appropriate for a patient before coverage is granted. Looking forward Many specialty drugs ofer meaningful therapeutic advances over existing treatments. Pew is focused on identifying and evaluating policy options that balance the need to control overall health care spending with ensuring patient access to appropriate medications. Schulman, “The Impact of Specialty Pharmaceuticals as Drivers of Health Care Costs,” Health Afairs 33, no. However, the various authors do note that drug price or cost is used as part of their respective defnitions of specialty. Joyce, and Yuhui Zheng, “Prescription Drug Cost Sharing: Associations With Medication and Medical Utilization and Spending and Health,” Journal of the American Medical Association 298, no. Pew applies a rigorous, analytical approach to improve public policy, inform the public, and invigorate civic life. Ofcial Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings. Te information in this booklet describes the Medicare program at the time this booklet was printed. Paid for by the Department of Health & Human Services Table of Contents Section 1: The Basics 7 Medicare prescription drug coverage adds to your Medicare health coverage. Medicare drug plans are ofered by insurance companies and other private companies approved by Medicare. You must also live in the service area of the Medicare health plan or drug plan you want to join. All Medicare drug plans must give at least a standard level of coverage set by Medicare. Medicare drug plans may difer in the prescription drugs they cover, how much you have to pay, and which pharmacies you can use. If you decide to join a Medicare drug plan, compare plans in your Words in area and choose one that meets your needs. If you don’t join a red are Medicare drug plan when you’re frst eligible for Medicare, and defned you don’t have drug coverage that’s expected to pay, on average, on pages at least as much as standard Medicare prescription drug coverage 83–86. Te penalty is in addition to your premium each month for as long as you have a Medicare drug plan. If you don’t use a lot of prescription drugs now, you still may want to think about joining a Medicare drug plan to help lower your drug costs now and help protect against higher costs in the future. If you’re new to Medicare and already have other drug coverage, you have new options to think about. If you aren’t new to Medicare, you may want to look at your options to fnd drug coverage that meets your needs. You can join or switch Medicare drug plans between October 15– December 7 each year, with your coverage beginning January 1 of the following year. Te drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options. If you have (or are eligible for) other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefts administrator, insurer, or plan provider before you make any changes to your current coverage. Doctor samples, discount cards, free clinics, or drug discount websites aren’t drug coverage. For details about how Medicare drug coverage may afect other coverage, see Section 4. All plans must cover the same categories of drugs, but generally plans can choose which specifc drugs are covered in each drug category. If you have limited income and resources, you may qualify for Extra Help from Medicare with paying your drug plan costs. Convenience Check with the plan to make sure the pharmacies in the plan are convenient to you. If you spend part of the year in another state, see if the plan will cover you there. You’ll need to join a prescription drug plan to get Medicare coverage for drugs for most chronic conditions, like high blood pressure. Part B covers certain drugs, like injections you get in a doctor’s ofce, certain oral cancer drugs, and drugs used with some types of durable medical equipment—like a nebulizer or external infusion pump. Under very limited circumstances, Part B covers certain drugs you get in a hospital outpatient setting. Generally, Medicare drug plans cover other vaccines, like the shingles vaccine, needed to prevent illness. Note: Medicare Part A (Hospital Insurance) or Part B generally doesn’t cover self-administered drugs you get in an outpatient setting like in an emergency room, observation unit, surgery center, or pain clinic.