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Sanof does public research organisations in countries in of diseases buy discount donepezil 10 mg online, including diabetes cheap donepezil american express, malaria purchase 5mg donepezil amex, schiz- not publish the status of its patents cheap 5 mg donepezil free shipping. 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. However, it does not disclose fnancial tures or other access-oriented terms are sys- pany s core business strategy: access to health- contributions. Initially launched in Kenya, Healthy Although it states that it has taken disciplinary ducted ethically. Heart Africa aims to reach 10 million hyperten- action following violations of its codes of con- sive patients across Africa by 2025: by estab- duct governing lobbying, corruption and market- Innovation: signing on to combat antimicro- lishing new partnerships; ensuring access to ing, it provides no further details. In January 2016, AstraZeneca afordable anti-hypertensive medicines and ser- signed the Declaration by the Pharmaceutical, vices; and by developing local ownership. AstraZeneca Biotechnology and Diagnostics Industries on has an auditing system that uses a mixture Combating Antimicrobial Resistance, thereby Mature access management structures in place. The scope of each audit is The company also has a dedicated incentive based on a market-specifc risk assessment. AstraZeneca shares intellectual property to sup- to achieve access-related targets. These bodies interest, to resolve allegations that it underpaid to help the Drugs for Neglected Diseases initia- fulfl an advisory role, identifying and discussing rebates owed under the Medicaid Drug Rebate tive develop new leads. AstraZeneca is generally less Biggest riser in Pricing, Manufacturing & Drops three places due to breaches of corrup- active than in 2014: its relevant pipeline has Distribution. AstraZeneca drops from 7th to 10th grown, but with comparatively little movement 19th in 2014 to 8th in 2016. This is due to comparatively stronger and less collaborative R&D based on pro-access its innovative approach to equitable pricing and performances from peers. Its rank also refects changes in perfor- the implementation of this approach to products found in breach of civil laws and codes of con- mance among its peers. The company s focus signifcantly increased the number of its prod- areas include public health initiatives, increasing ucts with equitable pricing strategies, taking New public commitment not to fle patents. However, only a third er-middle income countries and upper-middle (31%) of its products have pricing strategies that income countries that together cover 70% of Best practice: manufacturing capacity build- target some priority countries (disease-specifc countries within the scope of the Index. Rather than training sub-sets of countries with a particular need for individual manufacturers, AstraZeneca provides access to relevant products). New commitment to licensing, with clear funding, training and other support to Tianjin exceptions. Although AstraZeneca has not yet University to fll local manufacturing skills gaps. Registration behaviour lags behind advances in licensed a product, it has now set out the situa- Via the university, the company s expertise can pricing. Its policy be shared more widely, to help improve manu- of disease-specifc registration targets. It does excludes licences for products for non-commu- facturing safety standards at the industry level not publish where its products are registered or nicable diseases in lower-middle income coun- in China. The company has fled to permits supply to Least Developed Countries, Innovation: building capacity through Healthy register some (40%) of its newest products in low-income countries and lower-middle income Heart Africa. In 2014, AstraZeneca launched just a few (6%) priority countries (disease-spe- countries. It acknowledges based training for health-workers, and targeted that countries have the right to determine what supply chain management support. For its Healthy Innovation: scale-up of Young Health Heart Africa programme, in East African mar- Patent status disclosure. AstraZeneca has scaled up its kets, AstraZeneca has developed new artwork lishes the status of all patents it holds for high- Young Health Programme. The programme for felodipine (Plendil ), lisinopril (Zestril ) and need products in the high-burden countries focuses on preventing non-communicable dis- lisinopril/hydrochlorothiazide (Zestoretic ), measured by the Index, including publishing the ease among adolescents. AstraZeneca s intra-country equi- for patents, where it is prepared to license, and table pricing strategy for ticagrelor (Brilinta ) for which products, and gives an indication of Drops four places. This strategy is particularly important AstraZeneca donations are covered within the as ticagrelor is a frst-line therapy in the preven- Active in all areas of capacity building, targets AstraZeneca Global Guidance Procedure and tion of atherothrombotic events, is on patent, local needs. This has shaped its new pricing pliant with its regulations to ensure products are policy and will continue to do so in the future.

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Tachycardia may reflect a primary cardiac problem or may be a marker of disease in another system donepezil 5 mg low cost. Causes Sinus tachycardia: The rhythm is a marker of a disease and not a disease itself discount donepezil online master card. When this fluid collection impairs cardiac filling cheap 10mg donepezil otc, it is considered pericardial tamponade generic 5mg donepezil. Causes Trauma with a hemopericardium Infection (Tuberculosis most common; viruses also can cause) Cancer (often metastatic and often bloody) Renal failure Signs and symptoms Pericardial effusion can mimic symptoms of pericarditis including chest pain (often pleuritic and positional), palpitations, malaise, weakness and shortness of breath. Circumferential effusions causing right atrium and/ or right ventricular collapse during diastole. Must urgently reduce pericardial effusion to allow heart to fill by performing a pericardiocentesis (see Appendix). Recommendations Tuberculosis most important and reversible cause of pericardial effusion in our setting. Hypertensive Emergency Definition Hypertension: A chronic, usually asymptomatic disease defined as persistently elevated blood pressure > 140/90 in adults. Consider formal echo and renal ultrasound if working up secondary causes of hypertension. Be careful of rapid drops in blood pressure with Nifedipine and Hydralazine, as this can cause end organ damage. Infective Endocarditis Definition: Infection of the endocardium (valves and/ or mural endocardium). Risk increased greatly with rheumatic or prosthetic heart valves or with history of congenital heart disease. Management It is impossible to treat endocarditis unless you consider it in your differential diagnosis! Consider in any patient with a fever and either new murmur or signs of thrombotic emboli (gangrene limb, stroke). Treat according the heart failure algorithms (see heart failure chapter) Many patients will require surgical intervention and should be transferred immediately to referral center with cardiology available. Recommendations All patients with suspected endocarditis should be referred to center capable of performing echocardiography and cardiology review. But if the patient is very sick, do not delay antimicrobial therapy Syncope Definition: Syncope is a transient loss of consciousness followed by complete recovery of neurologic function without resuscitative efforts. It is caused by either lack of blood flow to both cerebral hemispheres or to the reticular activating systems. Pre-syncope is transient near loss of consciousness and is treated the same as syncope. Other causes include obstructive lesions (hypertrophic cardiomyopathy, pericardial tamponade, stenotic valve lesions), very large pulmonary embolism. However, given lack of resources to address an identified problem, should not be routinely recommended. The emergency provider must attempt to differentiate a "surgical abdomen" from a non-surgical abdomen. Patients require aggressive, early treatment and often early transfer to referral hospital. Liver disorders are divided into two categories - acute or chronic - depending on the duration of the illness. However, it is appropriate to transfer these patients if there is a possibility for another diagnostic cause of confusion (i. Transfer patients with continued fever, tachycardia, low blood pressure, or other signs of acute illness not getting better with antibiotics. Recommendations Complications from chronic liver disease can be complicated and life- threatening. Providers must recognize gallbladder infections and treat with appropriate antibiotics. Appendicitis Definition: Inflammation or infection of the appendix caused by acute obstruction of appendiceal lumen and eventual ischemia of the bowel wall. Care must be taken to exclude alternative etiologies of abdominal pain, particularly in women of child-bearing age. Imaging: none Management Acute Diarrheal Illness: The goal of management is to provide appropriate fluid resuscitation, determine cause, and initiate specific antimicrobial therapies where appropriate. Pylori treatment o Consider early referral for endoscopy in patients with weight loss, vomiting after eating, dysphagia. Abdominal Mass Definition: Any abnormal collection of tissue in the abdominal region. Cancers that are recognized early have much better prognoses as treatments are more feasible. Testicular torsion is an emergency- surgery can correct the problem and save the testis if done within six hours. Signs and symptoms Timing of onset of pain- if less than six hours, transfer immediately without work up o Torsion: sudden onset scrotal, inguinal, or abdominal pain. If clinical diagnosis is suspicious for torsion and less than 6hr since onset of symptoms, refer immediately for ultrasound and surgical evaluation without delay. Management: The general goal is to decide whether there is a high likelihood of testicular torsion based on exam and history.. If immediate transfer not possible or if arrival to urology will be more than 6hr after onset of pain, attempt manual detorsion. Use an ultrasound, when available, to verify a full bladder and ensure no bowel is present. Patients with clot retention, significant hematuria, sepsis or possible neurologic cause of urinary retention should be transferred on an emergent or urgent basis, depending on vital signs Renal Failure- Acute and Chronic Definition: Decrease of kidney function that can be acute (decline in kidney function over hours to days) or chronic (decline in kidney function over months to years). Typically, patients with acute renal failure have clinical symptoms that require prompt attention while chronic renal failure patients have subacute or chronic symptoms. The goal is to start treatment on each of these conditions while awaiting transfer to referral hospital for dialysis consideration. Typically, insurance will not cover chronic dialysis treatments, but patients can pay out of pocket for treatment. It is also reasonable to transfer any patient anuria, not responding to fluid bolus. Sprinkle granulated sugar on prepuce and glans for osmotic reduction of edema Compressive dressing may be wrapped around penis for a few minutes before manual reduction to help with swelling Manual reduction involves gentle, steady pressure on the glans with the tips of the thumbs while applying gentle traction to the foreskin. Open to tent the skin to ensure proper placement, advance the hemostat to the level of the coronal sulcus and then close it, essentially crushing the foreskin. Leave closed hemostat in place 3-5 min, then remove it and cut the crushed foreskin longitudinally with straight scissors. This is a life-threatening infection that spreads rapidly, causes sepsis and death. There is risk of permanent damage and impotence if left untreated for more than four hours. Serial doses of lmL of dilute solution can be given every 5 minutes up to one hour If phenylephrine not available, dilute O. Causes Calcium oxalate (majority) Infection stones Uric acid Signs and symptoms History o Patients often have rapid onset, excruciating pain (severe pain), typically from the back/flank radiating to the groin/front area. Small surveys in Rwanda suggest very high resistance rates for most commonly available antibiotics. Acute pharyngitis may lead to immediate complications including abscess, cellulitis, epiglottitis. Untreated pharyngitis may lead to a later complication of rheumatic fever, which is a leading cause of structural heart disease later in life. Examine patient for trismus (inability to open mouth), drooling, meningismus, stridor or other signs of severe disease or airway compromise. Severe disease may also present with inability to swallow or lie supine, muffled voice or respiratory distress (use of accessory muscles) o Patients with retropharyngeal abscess may hold the head stiff and complain of neck pain. In adults, often extends into mediastinum o Patients with peritonsillar abscess may lean to one side o Patients with simple pharyngitis will be well appearing, have a clear voice, no difficulty with respirations.

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