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The Specialty 5 discount viagra soft 50mg with amex injections for erectile dysfunction video,000 Care unit is focused on: rare diseases generic viagra soft 50mg line erectile dysfunction doctor philippines, mul- 0 tiple sclerosis, oncology and immunology. Its portfo- ority product gaps with low commercial incen- Neglected tropical Multiple categories lio has a strong focus on diabetes and cardiovas- tive. It is most active in infectious diseases, (including in Brazil, Mexico and the Philippines). Sanof rises Retains top ten position, staying frm in 7th transparency and compliance. Sanof retains its position, with a clear gest riser in this area, climbing 13 places into the pipeline than in 2014, and its policies for clinical approach to access management and an inves- top fve. This is due to its above-average trans- trial conduct have improved, as has its openness tigation into the link between climate change parency and comprehensive compliance system. Certifcation system for managing ethical mar- R&D commitments linked to public health Integrated approach to access spanning all keting practices. It has developed eases in scope and has a clear R&D presence in aims to optimise patient outcomes, covering a certifcation system for regularly testing and relevant countries. The com- focus on unmet health needs, informed by the care and disease management. This approach pany discloses general information about its company s teams in relevant countries. The company publishes Sanof discloses its policy positions on several ically included in its research partnerships. Its confict of interest policy is ble information, building formalised dialogue not publicly available. Sanof signed the Declaration nerships for patient support and humanitarian Annual audits of high-risk third parties. Sanof is transparent about its company conducts annual audits in its prior- and Diagnostics Industries on Combating stakeholder engagement activities, but does not ity markets and rotational audits in other coun- Antimicrobial Resistance in January 2016, publish its stakeholder selection process. External experts may be thereby committing to investing in R&D that used on specifc tasks. The project includes a payment Rises four places due to improved equitable sory board, composed of international experts, and invoice management system to track the pricing. Sanof moves from 8th into the top fve, that regularly meets to discuss the topic and expenses of invitees attending promotional due to its improved performance in equitable inform company strategy. Its vant partnerships with local universities or other equitable pricing strategies cover a wide range No transparency on patent status. Sanof does public research organisations in countries in of diseases, including diabetes, malaria, schiz- not publish the status of its patents. Sanof does not Best practice: training to strengthen supply that target priority countries (disease-specifc engage in non-exclusive voluntary licensing, and chains. Sanof developed and piloted a supply sub-sets of countries with a particular need for has not stated whether it would consider doing chain management training programme for access to relevant products). The programme has been rolled out ing strategies, overlooking other socio-economic ject of breaches, fnes or judgements relating to in several countries, including Ghana and Sierra factors. However, it does consider the needs competition law during the period of analysis. During its sales agents: its afliates are responsible for Previously in the leading group, now outper- this Index period, Sanof donated a combined defning the sales practices of regional agents formed in capacity building. It is strong in building capac- pentamidine (Pentacarinat ), and efornithine monthly basis. Sanof monitors the prices set by ities outside the pharmaceutical value chain, (Ornidyl ). Sanof s approach to philanthropy, through fled to register all (100%) of its newest products the Sanof Espoir Foundation, is strong: it works Monitoring is mainly the responsibility of part- in at least some priority countries (disease-spe- toward long-term change based on local needs, ners. Sanof works with international organisa- cifc sub-sets of countries with a particular need and includes impact measurement. These prod- pany builds capacities outside the pharmaceuti- tions conduct regular audits and send the results ucts were frst launched between 1999 to 2016. The organisations are responsible for Sanof has already registered products launched Sant partnership in Cameroon). For structured donation programmes Adapts brochures and packaging to limited Sanof commits to assessing and building capac- Sanof monitors and tracks the reception of extent. Sanof adapts brochures and packaging ity in countries in scope for in-house manufac- donated products. In practice, the company undertakes a rel- tal needs, but does not consider cultural, literacy atively large number of capacity building activ- Involved in numerous emergency relief eforts. In addition, Sanof has provided humanitar- number of activities for building local pharma- ian aid to refugees in multiple countries. For holds a low position in Patents & Licensing, with example, the company supports health workers no indication that it considers engaging in licens- from sub-Saharan African countries with weak ing, and low overall transparency. It has several best and innovative practices: in pricing, including pricing, where it has a new afordability-based patents and capacity building. It has extensively expanded and updated grown, but with comparatively little movement and less col- its access strategy, which it operationalises, e. These belong AstraZeneca can evaluate the impact of its products in its commitment to licensing. AstraZeneca can build tries (disease-specifc sub-sets of countries with and countries/regions. Such part- budesonide (Pulmicort ) can be expanded to nerships can be important for addressing local India, Bangladesh, Nigeria, and China. AstraZeneca of its relevant products while they are still in this could include ticagrelor (Brilinta ), a frst- can apply its new afordability-based pricing the pipeline. This is important for key late-stage line option for preventing atherothrombotic policy to more key products: such as its selec- products, whether developed in-house or via events. This could make AstraZeneca the frst tive beta-2-adrenoreceptor agonists, used in the research partnerships. AstraZeneca Asia/Africa/Australasia Europe Americas has sales in 67 countries in scope. It has gained marketing authorization sis and onchocerciasis, which target high-priority AstraZeneca s portfolio is heavily focused on from the European Medicines Agency for several product gaps with low commercial incentive. Nevertheless, the company s dis- also made specifc commitments to conduct- AstraZeneca the biggest riser. AstraZeneca closure around its marketing programmes and ing R&D in China and Africa, in order to respond is the biggest riser in this area, climbing from related payments only meets minimum legal to the unique needs of people living in those 14th into the top fve. AstraZeneca makes a clear commitment policy positions relating to compulsory licens- to making its intellectual property, compounds Access strategy aligned with corporate strat- ing, intellectual property, product counterfeit- and expertise available for free in a sub-set of egy. However, the com- ing healthcare barriers in low and middle-income try associations and about the board seats it pany has no clear policy for ensuring these fea- countries.

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Because the results of the investigation may lead to recommendations or strategies for preventing similar future outbreaks discount viagra soft 50 mg online discount erectile dysfunction drugs, thereby improving long term disease prevention activities order viagra soft 50 mg fast delivery erectile dysfunction instrumental. For some communicable diseases, a single suspected case might suffice to start the process of investigation. For instance diseases with a potential for massive epidemics or diseases caused by etiologic agents of high virulence need more attention and alertness than others. Such diseases need 13 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia immediate investigation followed by immediate response. The steps to follow are set by the individual investigator depending on the suspected cause of the outbreak. Collect laboratory specimens and obtain laboratory results 14 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia 5. Verify that there is an epidemic Reports about presence of epidemics are not always correct and one of the crucial tasks in epidemic investigation is verifying whether there is really an epidemic or not. This is particularly important when considering the resources that would be expended for an artifactual rise in the number of cases or deaths. Verifying the diagnosis in the index case/s In order to verify the suspected epidemic, one might start by verifying the diagnosis in the index case(s). This is done by reviewing clinical and laboratory findings in index cases to establish diagnosis. Index cases are important because they indicate the possible start of an outbreak; the sooner the index case and other early cases are identified and diagnosed, the higher the chance of arresting the epidemic. However, it should be noted that the notion of index cases might not be valid in case of diseases which normally occur at a predictable regularity and that occasionally occur in excess of their expected frequency. Compare current occurrence with the expected occurrence: The other essential task of verifying an epidemic is to compare the current number of cases with the past levels of disease in that community, considering the seasonal variation in the occurrence of the disease. Rule out artifactual changes in the occurrence of the disease: Even if there seems to be an apparent excess in the number of cases or deaths due to a disease, still potential causes of a false-rise exist and should be looked for. In such situations, the following three considerations should be done in order to declare an epidemic. For example diseases like viral hemorrhagic fever pose a serious threat to the public because of extremely high risk for disease wider transmission in contrast to diseases like neonatal tetanus which pose less threat to the public. The consequence of overlooking a real epidemic of a mild viral skin rash with only minimal sequels might be far more acceptable than overlooking a viral encephalitis with proven fatal cases. For example in an area where there are no vaccines for Mumps, outbreak investigations might not result in proper actions. Prepare to conduct further investigation Once the investigator decides to conduct an outbreak investigation for the verified epidemic, the next logical 18 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia step is to make the necessary preparations to launch further investigation. Search and gather scientific information necessary for the outbreak investigation: No single investigator is fully knowledgeable about all diseases, and health problems which need investigation and appropriate ways of investigating and managing their outbreaks. Each outbreak investigator, therefore, should always update him/her self with the necessary scientific knowledge both about the nature of the disease to be investigated and also about the scientifically proven or sound methods of investigating and managing the outbreaks. This includes collecting sample questionnaires, discussing with experienced people, reading applicable literatures, etc. Make important communications: As is often the case, there are people and units of governmental organizations responsible for investigating and/or managing epidemics. Identify 19 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia these people and communicate with them to plan the investigation and management together. For example, using the already available data and with discussion with responsible persons, decide where to undertake the investigation taking the most affected geographical location as a starting place for the outbreak investigation. Establish an outbreak investigation and management team For a smooth execution of outbreak investigation and management, it is helpful to establish a team with clearly defined roles. In situations where there is epidemic preparedness, there will already be identified team members who will take part in the investigation and management as well. Team members should be well aware of their specific roles in the process of investigating the outbreak. In addition the team should plan and decide how communication among the team members will go during the outbreak investigation. Develop data collection tool for the outbreak investigation The investigation team should develop data collection tool relevant for the health problem under investigation. Make administrative arrangements This part of the preparation should not be neglected, as it is one of the major factors affecting success of outbreak investigations. Beginning from the start of the epidemic investigation, investigators should plan for adequate transportation, personnel, equipment and logistic supplies. Since case definitions used at this initial stage of the outbreak investigation lack specificity, they are labeled as suspected case definitions. Making efforts to find these standard case definitions saves time and prevents bad consequences a poorly constructed case definition. Laboratory investigations usually include: 23 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia A. Through out the outbreak investigation, steady quality assurance together with checkup of congruence between clinical findings and laboratory results should be made. For this, communication between laboratory persons and clinicians is very crucial. However, it should be remembered that for many health facilities laboratory investigation of every case can not be practical for obvious reasons. In 24 Manual on Investigation and Management of Epidemic Prone Diseases in Ethiopia such situations, it might suffice to conduct laboratory tests for the first few cases of the disease. For example, taking serum samples for the first 5 cases is recommended for measles. It has to be also noted that laboratory tests may include environmental investigations, i. In fact it is the result from the findings of the epidemiological investigation that guides the collection and testing of environmental samples. Example: Samples of foods and beverages served at a common meal believed to be the source of an outbreak of gastroenteritis should be investigated after a clue from epidemiologic results. Thus, active search for additional cases is extremely vital if the investigation is to prevent healthy people from contracting the disease. Passive surveillance: This includes: - Searching similar cases in the registers of health facilities where cases have been reported, - Recording each case fulfilling the suspected case definition on the reporting format prepared for the investigation. The case reporting format should include identifying information, socio-demographic information, clinical and lab information, risk factor information. Active surveillance: This includes: Sending out a letter describing the situation and asking for reports. Meanwhile, cases of the disease that are already identified should get the appropriate treatment preferably by following standard case management guidelines.

Eisai has a relatively small amount of part- No registration targets order line viagra soft erectile dysfunction young living, no transparency purchase cheap viagra soft erectile dysfunction treatment himalaya. It does not Fiocruz in Brazil and the University of Khartoum publish where its products are registered or the in Sudan. It is not clear how the company targets criteria it uses to decide when and where to reg- local skills gaps through these partnerships. The company has fled to reg- ister less than half (43%) of its newest products Focus on in-house manufacturing capacity in just a few priority countries (disease-specifc building. Eisai s commitment to assessing needs sub-sets of countries with a particular need for and building capacity in countries in scope is for access to relevant products). The company under- takes a number of capacity building activities Language, literacy and environmental needs across Asia, including with third parties, but considered. Eisai undertakes philanthropic the same product, it uses illustrations to ensure activities but does not disclose a clear philan- information can be understood by populations thropic strategy or relevant initiatives to build of varying literacy levels and addresses environ- capacities outside the pharmaceutical value mental needs by using blister packs. Eisai has risen from Developed Countries, low-income countries, and 9th position to 4th. Eisai does not its donations approach publicly; it also states publish the status of its patents. Eisai builds countries throughout Asia, discussing with gov- capacity in all areas of the pharmaceutical value ernment ofcials as well as other relevant stake- chain, but has a relatively small number of activ- holders the ways in which to contribute to the ities and does not clearly focus on local needs. Engages in ad hoc donation programmes in nat- Stronger in strengthening pharmacovigilance ural disasters. Eisai demon- plies after natural disasters, including the 2014 strates that it updates safety labels for its prod- earthquake in China and cyclone Hudhud in India. Its modest improve- ple, it is comparatively less transparent than in 2014 about its ments are frequently overshadowed by peers. Its equi- some improvements in how it measures progress toward table pricing and product registration performance has not access-related goals, and has time-bound targets tied to its kept pace with peers. Bayer provides limited evidence that R&D commitment to addressing neglected tropical diseases. Bayer is Bayer is comparatively active in strengthening pharmacovigi- engaged in large-scale structured donation programmes for lance systems. Bayer can develop and disclose a public access to these medicines, while ensuring their engagement. Bayer can develop processes for position on the fling for and enforcement of responsible use. Bayer can join global eforts to selecting and engaging with local stakehold- patents. Thirteen other companies in the Index address antimicrobial resistance, for example by ers to help ensure local needs are addressed have already taken this step. This would help signing the Declaration by the Pharmaceutical, through its R&D, capacity building and access give drug procurement agencies and generic Biotechnology and Diagnostics Industries on management approaches. Local stakeholder manufacturers confdence about where Bayer Combating Antimicrobial Resistance. The 6 34 adaptations of nifurtimox have been in clini- Its portfolio consists of 27 medicines and con- cal development since at least 2014 (the previ- traceptives, and seven vector-control products ous Index), and clinical development of emodep- 13 (all pesticides). Communicable Non-communicable all registered for the prevention of malaria and/ Bayer s R&D projects target independently iden- Neglected tropical Multiple categories or dengue. Approximately one third of Bayer s portfolio tar- The company is also active in infectious diseases, gets women s health, mainly via contraceptives. It is also adapting Lampit for Chagas disease, developing a pae- diatric formulation and a shorter treatment regimen (to 60 and 30 days). However, it In addition, Bayer s position supports the protec- does not commit to ensuring access-oriented Maintains position despite limited improve- tion of both the international patent system and terms are systematically included in its research ment. Bayer maintains its position, improving the its own intellectual property worldwide. However, at the local level, its stake- and their budgets in several cities worldwide. Takes measures to ensure clinical trials are holder engagement activities are executed only Bayer does not publish its policy for preventing conducted ethically. Access activities are embedded in business Not transparent about breaches of laws and strategy. Bayer did not provide any information Has system for sharing patient-level data, yet include sustainable and commercially-viable regarding its breaches of codes, regulations and disclosure is incomplete. Bayer s has a policy of strategies, such as equitable pricing, patient-ac- laws and any consequent settlements. Nevertheless, the company does essential part of its long-term licence to operate. Bayer states patient-level data upon request via clinicalstudy- Centralised performance management system that it does not make any donations or contribu- datarequest. Bayer uses a centralised system to col- tions of any kind to political parties, politicians or lect quantitative and qualitative data for tracking candidates for political ofce. This infor- of fnancial contributions made to industry asso- Bayer has a general position to not disclose the mation is only partially disclosed. However, access plans for its emodepside col- Ad-hoc engagement with local stakeholders. Has enforcement processes and actively tracks laboration (for onchocerciasis) have been pub- Bayer has a clear and structured approach to compliance. The company has enforcement pro- lished by its partner, the Drugs for Neglected engaging with stakeholders at a regional and cesses and disciplinary measures in place. However, it does not have a not report whether disciplinary measures have sibility of this product for populations in need specifc approach for engaging with local stake- been taken during the period of analysis. Drops seven places due to relatively poor per- Drops six positions due to lower transparency. This is due to a fall in its per- panies that pledges not to make any political formance in equitable pricing and registration. Looking at Bayer s relevant it has implemented the new diferential pricing pipeline, it is the same size as in 2014, and the framework that it was piloting in 2014. Limited consideration of socio-economic fac- sistent with industry standards, it does not tors when setting prices. Bayer does not publish infor- qualifcation for its adaptation of emodepside to the relevant priority countries (disease-spe- mation about marketing activities in countries treat onchocerciasis in humans by 2023. However, its Measures in place to ensure R&D partnerships inter-country equitable pricing strategies only Some transparency on lobbying activities. Within take afordability and no other socio-economic Bayer discloses its policy positions related to its collaboration with Drugs for Neglected factors into account.

Does aminophylline benefit adults admitted to the hospital for an acute exacerbation of asthma? Aminophylline purchase viagra soft 50 mg without prescription erectile dysfunction icd 9, salbutamol and combined intravenous infusions in acute severe asthma buy genuine viagra soft on-line erectile dysfunction massage techniques. Should we stop using theophylline for the treatment of the hospitalized patient with status asthmaticus. Intravenous magnesium for acute asthma: failure to decrease emergency treatment duration or need for hospitalization. Magnesium bolus or infusion fails to improve expiratory flow in acute asthma exacerbations. A randomized trial of magnesium in the emergency department treatment of children with asthma. Higher-dose intravenous magnesium therapy for children with moderate to severe acute asthma. Intravenous magnesium sulphate in the management of moderate to severe acute asthmatic children nonresponding to conventional therapy. Efficacy of magnesium sulfate in acute adult asthma: a meta-analysis of randomized trials. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. High-dose intravenous magnesium sulfate in the management of life-threatening status asthmaticus. Helium oxygen gas therapy: use and availability for the emergency treatment of inoperable airway obstruction. The effect of heliox on pulsus paradoxus and peak flow in non-intubated patients with severe asthma. Inhaled helium-oxygen revisited: effect of inhaled helium-oxygen during the treatment of status asthmaticus in children. The use of heliox as a vehicle for beta-agonist nebulization in patients with severe asthma [Abstract]. Zafirlukast reduces relapses and treatment failures after an acute asthma episode. Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma. Use of a measurement of pulmonary hyperinflation to control the level of mechanical ventilation in patients with acute severe asthma. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. Detrimental effects of positive end-expiratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: hidden auto-positive end-expiratory pressure. Does bicarbonate improve cardiac or respiratory function during respiratory acidosis and acute severe asthma a prospective randomized study [Abstract]. Sedation of critically ill patients during mechanical ventilation: a comparison of propofol and midazolam. Use of ketamine in asthmatic children to treat respiratory failure refractory to conventional therapy. Metered-dose inhaler versus nebulized albuterol in mechanically ventilated patients. Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis. Safety and possible efficacy of fiberoptic bronchoscopy with lavage in the management of refractory asthma with mucous impaction. The osteomeatal complex comprises the primary functional drainage unit for the anterior paranasal sinuses. Extending from the ostium is an aerated channel called the infundibulum, which is bordered by the inferomedial orbital wall laterally and by the uncinate process medially. The uncinate process arises as an extension from the lateral wall of the nasal cavity behind the nasolacrimal fossa ( Fig. Secretions passing through the infundibulum reach the semilunar hiatus, a region just beyond the tip of the uncinate process and below the ethmoid bulla, which in turn opens into the middle meatus. It receives secretions from the middle ethmoid air cells and itself drains into the semilunar hiatus. The anterior ethmoid air cells have individual ostia that open into the infundibulum. The frontal sinus drains through the frontonasal recess, into the infundibulum and middle meatus. Secretions from the middle meatus drain posteriorly through the posterior nasal choanae into the nasopharynx ( 1,2). The maxillary sinus drains through its ostium ( solid arrow) into the infundibulum (small double arrows). The infundibulum is bordered by the medial orbital floor, the ethmoid bulla ( b), and the uncinate process (open arrow). The segment of bone lateral to this vertical attachment is called the lateral lamella ( L). Within the nasal cavity there are typically three paired sets of bony projections (the superior, middle, and inferior nasal turbinates) that arise from the lateral nasal wall. The middle nasal turbinate has a vertical plate (lamella) that attaches to the cribriform plate, and a lateral lamella, which is a small projection of bone extending lateral to this vertical attachment to the roof of the ethmoid air cells (fovea ethmoidalis). There is also a horizontal attachment of the middle turbinate to the lamina papyracea (medial orbital wall) called the basal lamella. The basal lamella is the bony plate that separates the anterior and middle ethmoid air cells from the posterior ethmoid cells. It receives secretions from the posterior ethmoid cells and the sphenoid sinuses via the sphenoethmoidal recesses ( Fig. This distinct functional region is sometimes called the posterior osteomeatal unit. The posterior ethmoid air cells and the sphenoid sinuses ( S) drain through the sphenoethmoidal recess (small arrow) into the superior meatus. The lamina papyracea (arrowheads) is the thin bony separation that makes up the lateral wall of the ethmoid sinuses and the medial wall of the orbit. Note the close proximity of the superior orbital fissure ( large arrow) to the sphenoid sinus wall. The anterior part of the septum is cartilaginous (quadrangular cartilage), and the bony posterior portion is made up of the vomer inferiorly and the perpendicular plate of the ethmoid bone superiorly. The nasal cavity communicates posteriorly with the nasopharynx via the posterior nasal choanae.

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