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Proximal transection/injury with probable ductal disruption: If duct is spared erectile dysfunction treatment youtube purchase tadapox no prescription, external drainage erectile dysfunction injections australia purchase generic tadapox line. If duct is damaged erectile dysfunction fun facts tadapox 80 mg visa, external drainage and pancreatic duct stenting may be considered. General Often overlooked in the initial evaluation of the multiply injured trauma victim. Urinalysis should be done to document presence or absence of microscopic hematuria. Retrograde Urethrogram Trauma Should be performed in any patient with suspected urethral disruption (before Foley placement). Retrograde Cystogram Should be performed on patients with gross hematuria or a pelvic fracture. Extravasation of contrast into the pouch of Douglas, paracolic gutters, and between loops of intestine is diagnostic for intraperitoneal rupture. Extravasation of contrast into the paravesicular tissue or behind the bladder is indicative of extraperitoneal bladder rupture. Bladder Rupture Thirty percent of patients with rectal injury will have an associated injury to the bladder. Renal Injury Minimizing the time from injury to treatment is important in minimizing morbidity and mortality associated with pancreatic injury. Urologic Injury Scale of the American Association for the Surgery of Trauma Eighty percent of pancreas can be resected without endocrine or exocrine dysfunction. Blood at the urethral meatus is virtually diagnostic for urethral injury and demands early retrograde urethrogram before Foley placement. Maintaining a high urine output together with alkalinization of the urine can help prevent the renal failure by reducing precipitation of myoglobin in the kidney. Shock is defined as inadequate delivery of oxygen and nutrients to maintain normal tissue and cellular function. Pathophysiology and Types of Shock Shock describes a state of imbalance between tissue substrate delivery (supply) and tissue substrate consumption (demand). Shock is classified into different types according to which of these factors are abnormal. The three major types of shock are hypovolemic, distributive (includes septic, anaphylactic, and neurogenic), and cardiogenic. As the condition progresses, they are hypotensive, have decreased pulse pressure, become confused, and have cold, clammy skin due to "clamping down" of peripheral vessels via increased sympathetic tone. Of the vital organs, the first "casualty" of hypovolemic or cardiogenic shock (both "cold shocks") is the kidneys, as blood is shunted away from the constricted renal arteries. An adequate urine output is one of the crucial signs that the treatment is adequate. Manifestations include mild tachycardia, tachypnea, anxiety, orthostatic hypotension, decreased pulse pressure, and oliguria. All of the above plus lethargy, mental status change, severe hypotension, and oliguria or anuria. Failure to respond to fluid resuscitation is usually due to persistent massive hemorrhage, hence requiring emergent surgical procedure. They include septic shock (most common), neurogenic shock, and anaphylactic shock. Factors that suppress the tachycardic response to hypovolemia: Beta blockers Atheletes Damage to autonomic nervous system (as in spinal shock) Never use dextrosecontaining solution for resuscitation. Physical exam findings-fever, tachypnea, warm skin and full peripheral pulses (from vasodilation), normal urine output. Later, delayed physical examination findings include vasoconstriction, poor urinary output, mental status changes, and hypotension. Positive blood cultures (negative about 50% of the time, particularly if drawn after antibiotics are started). Antibiotics: Start broad-spectrum antibiotics early and empirically treat until blood cultures come back!! Activated protein C may have some role in patients with sepsis and dysfunction of two or more organs. Most common gramnegative organisms: Escherichia coli, Klebsiella, Pseudomonas aeruginosa. Top three gram-positive organisms: Staphylococcus aureus, Enterococcus, coagulase-negative Staphylococcus. It is characterized by hypotension and bradycardia (absence of reflex sympathetic tachycardia and vasoconstriction). Remember, type I hypersensitivity reactions are immunoglobulin E (IgE) mediated and require prior exposure. Antiarrythmics, cardiac pacing, or cardioversion for pathologic dysrhythmias or heart block. Cardiac tamponade: Pericardiocentesis for aspiration of fluid or blood; surgical exploration to repair possible heart wound. Left heart failure or biventricular failure: Isolated left ventricular failure: Pressors, and reduce afterload. Congestive heart failure: Diuretics and vasodilators (nitrates) to decrease preload. Classically, the following inotropes can be used: Dobutamine: Used after dopamine to increase cardiac contractility. Amrinone and milrinone (phosphodiesterase inhibitors): Used in patients unresponsive to dopamine or dobutamine. It is threaded via the subclavian or internal jugular into superior vena cava right atrium right ventricle pulmonary artery. Clinical context: If the pump fails, pressures in the left ventricle increase and you will have an increased wedge. Urine output-most useful measure of effective fluid resuscitation (marker of renal perfusion). The "wedge" pressure is obtained by inflating the distal end of the Swan-Ganz and "floating" this "balloon" down the pulmonary artery until it "wedges. Likewise, if you hemorrhage and have no preload, your stroke volume will decrease as well. For example, in addition to stimulating 1 receptors, dobutamine stimulates 2 (which causes vasodilation). Furthermore, remember that virtually any direct stimulation of the heart (1) can cause the side effect of arrhythmias. It reflects the left ventricular pressure, which will be increased with left ventricular failure. Action: Strong stimulation of 1 receptors (ionotropic/chronotropic effects on the heart) and 2 (vasodilation). It dilates the vasculature, but no evidence shows that it is renal protective or improves renal failure.

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Scope Cognitive science is a large field insulin pump erectile dysfunction cheap tadapox 80 mg with mastercard, and covers a wide array of topics on cognition erectile dysfunction pump canada discount tadapox 80mg. However best erectile dysfunction pills uk cheap tadapox 80mg on-line, it should be recognized that cognitive science is not equally concerned with every topic that might bear on the nature and operation of the mind or intelligence. Social and cultural factors, emotion, consciousness, animal cognition, comparative and evolutionary approaches are frequently de-emphasized or excluded outright, often based on key philosophical conflicts. Another important mind-related subject that the cognitive sciences tend to avoid is the existence of qualia, with discussions over this issue being sometimes limited to only mentioning qualia as a philosophically-open matter. Some within the cognitive science community, however, consider these to be vital topics, and advocate the importance of investigating them. This is not an exhaustive list, but is meant to cover the wide range of intelligent behaviors. Computational modeling uses simulations to study how human intelligence may be structured. The former view uses connectionism to study the mind, whereas the latter emphasizes symbolic computations. One way to view the issue is whether it is possible to accurately simulate a human brain on a computer without accurately simulating the neurons that make up the human brain. Cognitive science 104 Attention Attention is the selection of important information. The human mind is bombarded with millions of stimuli and it must have a way of deciding which of this information to process. Attention is sometimes seen as a spotlight, meaning one can only shine the light on a particular set of information. Experiments that support this metaphor include the dichotic listening task (Cherry, 1957) and studies of inattentional blindness (Mack and Rock, 1998). In the dichotic listening task, subjects are bombarded with two different messages, one in each ear, and told to focus on only one of the messages. At the end of the experiment, when asked about the content of the unattended message, subjects cannot report it. Knowledge, and Processing, of Language the ability to learn and understand language is an extremely complex process. Language is acquired within the first few years of life, and all humans under normal circumstances are able to acquire language proficiently. A major driving force in the theoretical linguistic field is discovering the nature that language must have in the abstract in order to be learned in such a fashion. Some of the driving research questions in studying how the brain itself processes language include: (1) To what extent is linguistic knowledge innate or learned? This is one way of representing human language that shows how different components are organized hierarchically. The study of language processing ranges from the investigation of the sound patterns of speech to the meaning of words and whole sentences. Linguistics often divides language processing into orthography, phonology and phonetics, morphology, syntax, semantics, and pragmatics. Many aspects of language can be studied from each of these components and from their interaction. The study of language processing in cognitive science is closely tied to the field of linguistics. Linguistics was traditionally studied as a part of the humanities, including studies of history, art and literature. In the last fifty years or so, more and more researchers have studied knowledge and use of language as a cognitive phenomenon, the main problems being how knowledge of language can be acquired and used, and what precisely it consists of. Linguists have found that, while humans form sentences in ways apparently governed by very complex systems, they are remarkably unaware of the rules that govern their own speech. Thus linguists must resort to indirect methods to determine what those rules might be, if indeed rules as such exist. In any event, if speech is indeed governed by rules, they appear to be opaque to any conscious consideration. Cognitive science 105 Learning and development Learning and development are the processes by which we acquire knowledge and information over time. Infants are born with little or no knowledge (depending on how knowledge is defined), yet they rapidly acquire the ability to use language, walk, and recognize people and objects. Research in learning and development aims to explain the mechanisms by which these processes might take place. A major question in the study of cognitive development is the extent to which certain abilities are innate or learned. The nativist view emphasizes that certain features are innate to an organism and are determined by its genetic endowment. The empiricist view, on the other hand, emphasizes that certain abilities are learned from the environment. Although clearly both genetic and environmental input is needed for a child to develop normally, considerable debate remains about how genetic information might guide cognitive development. They argue that genes determine the architecture of a learning system, but that specific "facts" about how grammar works can only be learned as a result of experience. Long-term memory allows us to store information over prolonged periods (days, weeks, years). Short-term memory allows us to store information over short time scales (seconds or minutes). Declarative memory-grouped into subsets of semantic and episodic forms of memory-refers to our memory for facts and specific knowledge, specific meanings, and specific experiences. Cognitive scientists study memory just as psychologists do, but tend to focus in more on how memory bears on cognitive processes, and the interrelationship between cognition and memory. One example of this could be, what mental processes does a person go through to retrieve a long-lost memory? Or, what differentiates between the cognitive process of recognition (seeing hints of something before remembering it, or memory in context) and recall (retrieving a memory, as in "fill-in-the-blank")? Perception and action Perception is the ability to take in information via the senses, and process it in some way. Vision and hearing are two dominant senses that allow us to perceive the environment. Some questions in the study of visual perception, for example, include: (1) How are we able to recognize objects? One tool for studying visual perception is by looking at how people process optical illusions. The image on the right of a Necker cube is an example of a bistable percept, that is, the cube can be interpreted as being oriented in two different directions.

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A paradoxical increase in seizure frequency may also occur with marked phenytoin toxicity impotence lexapro purchase tadapox 80mg otc. It can accelerate the metabolism of a number of lipid-soluble drugs impotent rage purchase genuine tadapox on line, including carbamazepine erectile dysfunction pills from canada cheap tadapox 80 mg amex, sodium valproate, ethosuximide, anticoagulants, steroids and cyclosporin. Due to its saturable metabolism, phenytoin provides a target for drugs such as allopurinol, amiodarone, cimetidine, imipramine and some sulphonamides. Phenobarbital Phenobarbital is an established treatment for focal and tonic-clonic seizures but is seldom currently used in developed countries due to its potential to cause neurotoxicity. To minimise sedation, a low dose should be started (30 mg in adolescents and adults), which can be increased gradually (15-30 mg incremental steps) according to clinical requirements. The value of measuring its levels is limited, as concentration associated with seizure control varies considerably. The major problem in the clinical use of phenobarbital is its effect on cognition, mood and behaviour. It can produce fatigue, listlessness and tiredness in adults and insomnia, hyperactivity and aggression in children (and sometimes in the elderly). Tolerance develops to the deleterious cognitive effects of the drug but also to its efficacy in some people. Phenobarbital is an enzyme inducer and can accelerate the metabolism of many lipid-soluble drugs and has an impact on bone health. Piracetam Piracetam is only indicated as an adjunctive treatment in refractory myoclonus. Effective doses are usually between 12 and 24 g/day and this bulk is one of the limiting factors of the use of this drug. Primidone Primidone is metabolised to phenobarbital and its efficacy is similar to that of phenobarbital, but it is not as well tolerated. There is therefore nothing to recommend it over phenobarbital for people in whom treatment with a barbiturate is contemplated. It use in women of childbearing potential, however, is problematic in view of its potential teratogenicity. The starting dose of sodium valproate for adults and adolescents should be 500 mg/day for one or two weeks, increasing in most people to 500 mg twice daily. Since the drug can take several weeks to become fully effective, frequent dosage adjustments shortly after initiating therapy may be unwarranted. As valproate does not exhibit a clear-cut concentration-effect-toxicity relationship and the daily variation in the level at a given dose is wide, routine monitoring is not helpful unless used as a check of adherence to therapy. Side effects of sodium valproate include dose-related tremor, weight gain due to appetite stimulation, thinning or loss of hair (usually temporary), and menstrual irregularities including amenorrhoea. Sedation is an uncommon complaint, although stupor and encephalopathy can occur, albeit rarely, possibly as a consequence of underlying carnitine deficiency. Mild hyperammonaemia without hepatic damage is seen in up to 10% of people taking it. This is usually transient, but occasionally can present clinically with confusion, nausea and vomiting and clouding of consciousness. Sodium valproate can inhibit a range of hepatic metabolic processes, including oxidation, conjugation and epoxidation reactions. Aspirin displaces sodium valproate from its binding sites on plasma protein and inhibits its metabolism. Sodium valproate, however, does not interfere with the hormonal components of the oral contraceptive pill. Tiagabine Tiagabine is last resort drug for focal seizures with or without secondary generalisation. The recommended dose is between 30 and 45 mg/day, although higher doses (up to 80 mg/day) have been used. Tiagabine should be started at 10 mg/day in two divided doses, and increased by 5-10 mg/day each week up to 30 mg/day in the first instance. Exacerbations of seizures and cases of non-convulsive status epilepticus have also been reported. Topiramate Topiramate is licensed as a first-line drug for people with focal seizures with or without secondary generalisation and for generalised seizure disorders. Recommended doses are between 75 and 300 mg, although some people may derive benefit from a dose that is outside this range. The recommended starting dose for most people is 25 mg once daily, titrating upwards every two weeks in 25 mg/day increments up to 200 mg/day in two divided doses. After that, the dose can be increased by 50 mg each week until seizure control is achieved or side effects develop. Because of this, topiramate doses may need to be adjusted downwards if people are coming off carbamazepine or phenytoin. These are usually transient and in some people seem to be related to the dose and rate of titration. People starting topiramate should increase their fluid intake to reduce the risk of kidney stones. Initial weight loss is seen in up to 40% of people and is usually not problematic. Topiramate is teratogenic in some animal models and it is not recommended as a first-line option in women of childbearing potential. Vigabatrin Vigabatrin is now a last resort treatment for people with focal seizures. It is, however, still a first-line treatment for infantile spasms, particularly those associated with tuberous sclerosis. The recommended dose is 1000-2000 mg/day, although doses of up to 4000 mg/day in two divided doses can be used if necessary. Treatment should be started with a low dose (250-500 mg/day), and titrated slowly upwards over a period of several weeks until therapeutic response is achieved. Too rapid titration may be associated with an increased incidence of adverse events. Usually this has no clinical significance, but occasionally an increase in phenytoin dose is necessary if seizures increase a few weeks after the introduction of vigabatrin. The corollary of this effect is that plasma phenytoin concentrations rise after the withdrawal of concomitant vigabatrin therapy. Sedation, dizziness and headache are the most commonly reported adverse effects, particularly when doses are being increased. Up to 10% of people taking vigabatrin develop a change in mood, commonly agitation, ill temper and disturbed behaviour, depression or, more rarely, paranoid and psychotic symptoms. Visual field defects have been associated with long-term treatment with vigabatrin in up to 40-50% of people and this limits the use of the drug to those cases in which potential benefit outweighs risk. In chronological order these are: oxcarbazepine, levetiracetam, pregabalin, zonisamide, stiripentol, rufinamide, lacosamide, eslicarbazepine acetate, retigabine, perampanel and brivaracetam.

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Out of the 14 countries with the highest maternal mortality ratio of over 1 erectile dysfunction pills otc buy genuine tadapox online,000 deaths per 100 erectile dysfunction drugs forum order generic tadapox on line,000 live births impotence caused by medications order tadapox 80 mg with mastercard, 13 were in sub-Saharan Africa. SubSaharan Africa and South Asia together accounted for 86 percent of all global maternal deaths in 2005. Nearly 32 maternity homes providing emergency obstetric care facilities were established in remote areas to encourage women to deliver there rather than at home. Improvements in maternal health 10 An International Assessment in Egypt also had positive externalities for neonatal and child morbidity and mortality. As an illustration of this, the under- ve mortality per 1,000 children declined from 85 to 28 between 1992 and 2008. In Pakistan, the use of mobile health care service units bene ted nearly 850,000 patients. Women have received treatment for stula through surgical outreach and family planning campaigns. Initiatives include mid-level health o cers, who provide emergency surgery at rural hospitals in the face of doctor shortages. But two thirds of new infections and a similar rate of those currently infected live in sub-Saharan Africa. A survey of sex workers in Cambodia indicated that condom use more than doubled after the introduction of the 100% Condom Use Programme. Globally, by 2007, over 4 million people in developing countries were receiving them - a 47 percent increase over the 2006 gure. Only 14 percent of women surveyed said they used condoms, even though they had more than one partner in the last 12 months. A signi cant number of husbands often leave to work in the mines, mainly in South Africa. In the meantime, women are left to care for the children, with limited access to income earning opportunities. Reports indicate that, as a coping mechanism, women engage in sex work and transactional sex. About 1 million people die each year from malaria, with 88 percent of the deaths occurring in sub-Saharan Africa, 6 percent in South Asia and 3 percent in Southeast Asia. Kenya also bene ted from the support of the Global Fund, where drugs and nets were distributed free of charge, nanced by a partnership with pharmaceutical companies, where the price of essential drugs was adjusted to re ect local purchasing power. Following the second campaign in 2008, 71 percent of all households in the target group were in possession of a bed net and close to one million children bene ted from parasite treatment. However, at the national level, despite a large distribution of free insecticide-treated bed nets, 45 percent of women and children continue to sleep without nets. However, surveys show that net utilization rate is still low at 27 percent, demonstrating the limitations of isolated disease-speci c interventions. Asia has the highest incidence, with 55 percent of all new cases, followed by sub-Saharan Africa with 31 percent. Since its inception, the programme has initiated more than 11 million patients on treatment, saving more than 2 million additional lives. Globally, the world has failed to reach its targets for stemming the loss of biodiversity by 2010. In Ghana, the area covered by forest fell from 33 percent to 24 percent between 1990 and 2005. Even where it is done legally, trees are not replanted, mainly due to weak capacity to monitor and ensure compliance. Farming methods still involve slash-and- 13 What will it take to achieve the Millennium Development Goals? Together, they contain more than 600 species of coral, 3,000 sh species and the largest mangrove forest region in the world. However, the area continues to be at risk, threatened by over shing, destructive shing practices, population pressures and climate change. Per capita emissions are the highest in developed regions, at about 12 metric tons compared to 3 metric tons for developing regions, with sub-Saharan Africa accounting for 0. Rapid relative growth in emissions is also occurring in fast-growing economies such as India and China. In Fiji, the Marine Protected Areas networks have increased local income by employing women as reef gleaners, who bene t from selling shell sh. Women bene ted from a 35 percent increase in their income in just over three years. In Niger, vulnerability to drought was reduced through large-scale reforestation programmes and the transfer of ownership titles from the State to communities. Women in developing countries spend up to 25 percent of their time carrying rewood and fuel over long distances, at great risk to their health and safety. Rural households largely rely on biomass fuels, which are associated with indoor air pollution, primarily a ecting the health of women and children. However, out of the 884 million people who face water scarcity, three fourths live in rural areas. But the heavy reliance on ground water and poor pumping technologies expose the water to contamination and pollution. In these areas, close to a third of children were infected with one or more intestinal parasites. Improved water supply to schools and enhanced hygienic knowledge contributed to a decline in the incidence of lambliasis by 76 percent in the villages covered by the project. Agricultural activities are a ected due to severe droughts or ooding, impacting on household income and food security. In Nepal, women make up 73 percent of the labour force in agriculture, and natural disasters impact on them disproportionately. Climate shocks can also lead to disease outbreaks; besides malaria, measles, meningitis and Guinea worm cases proliferate due to high temperatures. In the Keta district, farming was severely a ected, cutting maize production by half. When the rivers Pra, Tano and Lake Bosumtwi dry up, the dams also experience a decrease in the water levels, leading to power blackouts, with adverse e ects on households and rms. For instance, tuna canneries and clothing manufacturers often cut output, shorten the workweek, and have to incur the cost of purchasing power generators. Governments buy insurance coverage, which enables them to cope during the post-disaster period. Lucia and the Dominican Republic, during the aftermath of an earthquake that struck the eastern Caribbean. It began in 2007 with high food and fuel prices, which disproportionately a ected the poor. In 2010, it is estimated that an extra 15 million and 19 million people will fall into poverty measured at $1. And in the Zambian mining sector, 6,000 people lost their jobs in November 2008 alone. Due to the crisis, the number of workers engaged in vulnerable employment is likely to stay at 1.

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Most systems have humeral trays with several different offsets and thicknesses causes of erectile dysfunction in 30s purchase online tadapox, which can be combined with polyethylene liners of various thicknesses to erectile dysfunction causes nhs quality 80 mg tadapox optimize the stability of the implant while minimizing impingement erectile dysfunction treatment san francisco purchase 80 mg tadapox. The ability to adjust humeral length and version may be more limited with these Onlay components. For humeral stems that are malpositioned too proximally, the resulting humeral length and deltoid tension created by the thickness of the humeral tray and polyethylene may preclude stem retention. Overtensioning the deltoid can have deleterious consequences as this results in increased load on the glenosphere and scapular spine, which potentially may result in glenoid component loosening and fatigue fractures of the acromion/ scapular spine. While some systems have the capacity to adjust the humeral version to a certain degree by modifying the humeral tray. However, this modest adjustment may not be sufficient in cases of excessive retroversion. If the height or version preclude a simple conversion, the anatomic stem needs to be removed. We prefer to use a flexible osteotome to separate any bony ingrowth between the body of the humeral stem and the proximal humeral metaphysis. Flexible osteotomes are thinner and more maneuverable, ultimately allowing more of the proximal humeral bone stock to be preserved. This step is critical for cemented as well as uncemented components as circumferential separation of the body from the humerus is necessary for safe component removal. Following removal of the modular body, the overall position of the humeral component needs to be assessed prior to preparing the proximal humeral metaphysis for the reverse body component. If the humeral component is malpositioned too proximally, one can address this in one of two ways: additional resection of the proximal humerus or by adjusting the height of the modular body component. One of the unique benefits of the Inlay system is that additional humeral resection can be performed without interfering with the well-fixed stem distally. Even with a convertible platform humeral component system 25% of cases will require removal of the stem due to component position in height and version at the index procedure. Convertible humeral component platform options offer significant advantages in revision surgery when possible. It is for this reason that I always choose a convertible platform system in primary shoulder Arthroplasty procedure when possible. Kany J, Amouyel T, Flamand O, Katz D, Valenti P: A convertible shoulder system: Is it useful in total shoulder arthroplasty revisions? Gohlke F, Rolf O: Revision of failed fracture hemiarthroplasties to reverse total shoulder prosthesis through the transhumeral approach: Method incorporating a pectoralis-major-pedicled bone window. Castagna A, Delcogliano M, de Caro F, et al: Conversion of shoulder arthroplasty to reverse implants: Clinical and radiological results using a modular system. The distribution of the arthroplasty according to aetiology is reported in table 1. Specifically, patients undergoing shoulder arthroplasty have been shown to remain quite active. McCarty et al5 has showed that 64% of patients undergoing shoulder arthroplasty returned to sporting activities. However, the survival rate can be different regarding etiology and type of arthroplasty. A preoperative diagnosis of post-traumatic arthritis was associated with an increased risk of revision during the length of the study. Because of a too small number of patients in other groups, he was not able to analyze other etiologies. We therefore carried out a study with two goals: - to evaluate shoulder arthroplasties after more than 2 years of follow up with survival curves to prosthetic revision, and - to analyze the effects of preoperative aetiology on those outcomes. Our hypothesis is that, both aetiology and type of arthroplasty are the main parameters which influence the revision rate. A reoperation was necessary in 52 cases and a revision in 200 cases (out of 20 had had a reoperation before). Table 3 Survival rate according to type of arthroplasty Table 1 Distribution of arthroplasty according to aetiology. At 5 and 10 years, there is no significant difference regarding the survival rate. For hemi there is a break during the first 3 years and then the curve becomes stable. We have analysed complications, reoperations (without implant exchange excepted insert) and revisions (with implant exchange or removal). Survival curves were established with the Kaplan-Meier technique and with 95 per cent confidence intervals according to Rothman. One endpoint was retained: - implant replacement, whatever the reason Survival curves were segmented according to aetiology or to the type of arthroplasty to seek significant differences. Comparisons of instantaneous survivorship were carried out with the log-rank test. One hundred and sixty-three were lost of follow up or bedridden or have refused to come. Segmentation of the curves according to the aetiology showed a significant difference (Table 4). This is the worst aetiology regarding survival rate and the main cause were, dislocation, infection and humeral loosening. We have been able to analyse all types of aetiologies and all types of arthroplasties with a minimum follow up of 2 years and a mean follow up of 8 years. Aetiology and type of arthroplasty are important factors of the survival of prosthesis in this specific patient population under 60 years old. This rate is higher than in previous studies8, 9 In these studies, the survival rate at 10 years is 100% for Kasten8 and 94. Extreme care must be taken to prevent late glenoid loosening which is the main complication and makes revision difficult. Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up. Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique. A multicentre study of the long-term results of using a flat-back polyethylene glenoid component in shoulder replacement for primary osteoarthritis. Comparison of functional outcomes of reverse shoulder arthroplasty with those of hemiarthroplasty in the treatment of cuff-tear arthropathy: a matched-pair analysis. Trends in the utilization of primary total hip arthroplasty, 1969 through 1990: a population-based study in Olmsted County, Minnesota. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. Patient reported activities after shoulder replacement: total and hemiarthroplasty. Scapular inferior notching was recorded according to the classification of Sirveaux et al.

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Public spending on education in Botswana has been increasing by 4 percent per annum for the last 10 years erectile dysfunction pills generic generic 80 mg tadapox visa. Further investments are also needed in the health sector as recognized by the 2001 African Union Abuja Declaration low testosterone causes erectile dysfunction order tadapox with a mastercard. As shown in gure 4 impotence versus erectile dysfunction purchase generic tadapox on line, however, out of the 46 countries in sub-Saharan Africa, only three of them (Liberia, Rwanda and Tanzania) had achieved health expenditure above the agreed minimum threshold by 2007. Figure 4: Public health expenditure in sub-Saharan Africa (% of government expenditure), 2007 Source: Calculated from World Development Indicators. While external assistance contributes to the development process, at some point developing countries need to graduate to a state of self-reliance. Sustaining these investments requires policies that do not only focus on reallocation of government budgets, but on a meaningful expansion of the scal space to ease the budgetary constraints. In other cases, sales taxes are limited, as most transactions take place among rural and urban small businesses. Domestic resource mobilization in con ict prone countries is constrained by the relatively large size of the informal economy, high poverty levels and weak institutional capacity of revenue authorities. Another source of development nance is the extractive industry, which is the driver of growth in many commodity exporting countries. Measures must be taken to broaden the socio-economic returns from the extractive industry using reasonable rates of royalties and corporate taxes. As a result of trade liberalization, total tax revenues typically decline unless alternative measures are adequately implemented to compensate for the fall in revenues;166 improving the e ciency and equity of the indirect tax system. Regressive outcomes must be avoided given that most developing countries rely on indirect taxes; improving the e ciency of public expenditure. Exemptions are granted for children, the elderly and those below the poverty threshold. Earmarked taxes can create unnecessary complexities in the budget where each tax is assigned to a particular expenditure. However, a case can be made for a temporary earmarked tax that is to be phased out, and mainly designed to nance services with signi cant externalities. Both programmes achieved successes in education due to additional cash incentives for enrolment. In Bangladesh, monetary incentives given to female students, under the Female Secondary School Stipend Programme, are associated with increases in school enrolment. Areas covered under the programme have experienced a 23 percent increase in school enrolment compared to those without the programme. In the health area, access to primary care services and vaccinations were free for all girls and children under ve years. By December 2009, the number of families covered under the Smart Card system had reached 6. Since targeted interventions are by nature exclusive, broad political support is required for scaling up and sustaining them. Programmes can be terminated suddenly, given that the poor do not have the voice to push for their continuation, or the political and external support for the programmes simply vanishes. However, the programme was terminated, mainly due to waning domestic support and heavy reliance on external funding. Finally, programmes need to be institutionalized, thereby gradually moving to universal coverage under a nationwide social protection system. In developed and middle-income countries, social protection and stimulus packages may work well. Failure to provide work within 15 days of application entitles applicants to automatic unemployment bene ts. In July 2008, the Government of Botswana also introduced its public employment programme. As part of its countercyclical policy, the government of Sierra Leone in 2009 implemented a work programme focused on environmental rehabilitation and rural infrastructure development, employing about 14,000 workers. Based on the study of Sierra Leone, projects with the following characteristics would seem to work well:184 they are identi ed and prepared prior to the need for implementing them; they have accounting procedures in place to reduce the likelihood of misuse of funds; they can easily be initiated and quickly terminated, preferably by central governments, in order to avoid delays due to limited administrative capacity of local governments; and wages and salaries are the major components of expenditure, with a low capital component. Irrigation schemes were developed, which enable farmers to grow a dry season rice crop in ooding and drought prone areas. Fossil fuel resources such as oil are costly and lead to a carbon-intensive economy, associated with external dependence and greater costs in the long run. Countries with limited fossil fuel resources may therefore bene t from promoting renewable energy. In particular, the impact of the global nancial and economic crisis represents an ongoing threat to sustainable development, which brought to light the need for accountability and responsibility in order to minimize the risk of such crises unfolding in the future. If other donors contribute concomitantly according to the size of their economies, this level of aid could be surpassed. Enhancing the communication of achievements to date to constituencies in developed countries would go a long way in mobilizing public support for aid increases. At the same time, greater agreement could be sought between bilateral donors on targeting aid allocations for poverty reduction. Ultimately, the domestic allocation of aid should be the budgetary choice of the receiving country and its population, but donor preferences in favour of the social sectors have also been strong. Faster progress should be made under the Rome, Paris and Accra agendas on aid e ectiveness. Half of all technical assistance provided to the country was not coordinated with the Government. Of a total of 541 donor missions to the country in 2005, 17 percent involved more than one donor. About 111 project implementation units existed in parallel to the government structures, and out of a total of 791 annual donor missions, only 10 percent involved donor coordination. Additional sector activities are to be managed through delegated cooperation arrangements. Based on comparative advantage, a lead donor is to manage donor coordination for each sector and act as a focal point for the Government. To support accountability at all levels, partners should publish how they are allocating their aid, and under what conditions (including on allocation policies). In turn, aid recipients - to increase the leverage of the populations for which assistance is being garnered - should publish how they are allocating and spending monies received. For instance, the Global Fund nanced antiretroviral treatment for 770,000 people and basic care and support for 1. In 2009, the Task Force on Innovative International Financing for Health Systems released a report outlining about 24 potential innovative nancing mechanisms, ranging from tobacco taxes and levies on airline tickets, to global premium bonds. Care must be taken so that new funding sources do not translate into new institutions or vehicles that further fragment the aid system and increase overall costs. Further debt relief for many countries is required as a consequence of the global nancial and economic crisis. External debt service payments as a proportion of export revenues in developing countries fell from 13 percent in 2000 to 4 percent in 2007.


  • Limit your intake of sugar, salt (sodium), and alcohol.
  • Hoarseness occurs with drooling, especially in a small child
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  • Genital sores in males
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  • Throbbing headache on one side of the head or the back of the head
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Signs of hypovolemic shock may also be present due to erectile dysfunction medication names order 80mg tadapox mastercard massive retroperitoneal fluid sequestration and dehydration erectile dysfunction drugs in philippines discount tadapox 80mg visa. Elevated amylase: Also found in salivary glands discount erectile dysfunction drugs tadapox 80mg with mastercard, small bowel, ovaries, testes, and skeletal muscle, so is not a specific marker for pancreatitis. Although amylase may be persistently elevated in renal insufficiency, a level three times the upper limit of normal is suggestive of pancreatitis. Demonstrates pseudocysts, phlegmon, abscesses or pancreatic necrosis (see Figure 14-2). The Pancreas High amylase levels are also seen in intestinal disease, perforated ulcer, ruptured ectopic pregnancy, salpingitis, salivary gland disorders, renal failure, and diabetic ketoacidosis. Aggressive hydration with electrolyte monitoring to maintain adequate intravascular volume. Correction of associated biliary tract disease: Gallstone pancreatitis should be treated with early interval cholecystectomy only after acute pancreatic inflammation has resolved. Other (10%): Hyperparathyroidism, hypertriglyceridemia, congenital pancreatic anomalies, hereditary, obstruction. Nonoperative management: Includes control of abdominal pain, endocrine and exocrine insufficiency (insulin and pancreatic enzyme therapy). Ductal decompression procedures: Puestow procedure (longitudinal pancreaticojejunostomy) for segmental ductal dilation. Duval procedure (retrograde drainage with distal resection and end-to-end pancreaticojejunostomy). Ablative procedures (resection of portions of pancreas): Frey procedure (longitudinal pancreaticojejunostomy with partial resection of the pancreatic head). Whipple procedure (pancreaticoduodenectomy with choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy). If after 6 weeks they have not resolved and are > 6 cm in size, internal drainage of the mature cyst is indicated via cyst gastrostomy or Roux-en-Y cyst jejunostomy. Tumors in the head of the pancreas, however, often present earlier because they cause biliary obstruction. Tumors of the head: the only chance for a cure is the Whipple procedure (pancreaticoduodenectomy), and most tumors are not resectable at the time of diagnosis. If unresectable (due to liver/peritoneal metastases, nodal metastases beyond the zone of resection, or tumor invasion of the superior mesenteric artery), palliative procedure considered: Relieve biliary obstruction. The median survival for patients who undergo successful resection is approximately 12­19 months, with a 5-year survival rate of 15­20%. Most are solitary lesions with even distribution in the head, body, and tail of the pancreas. Proinsulin or C-peptide levels should be measured to rule out surreptitious exogenous insulin administration. Diazoxide can improve hypoglycemic symptoms by inhibiting pancreatic insulin release. Ninety percent are located in the "gastrinoma triangle" (Figure 14-4) bordered by: Junction of second and third part of the duodenum. Gastrinoma triangle-the anatomic triangle in which approximately 90% of gastrinomas are found. Secretin stimulation test will cause a paradoxical increase in gastrin in patients with Zollinger-Ellison syndrome (double fasting level or increase of 200 pg/dL over the fasting level). Most are malignant; majority have metastasized to lymph nodes and the liver at time of diagnosis. Signs of hypokalemia-palpitations/arrhythmias, muscle fasiculations/ tetany, paresthesias. Typical scenario: A 57-year-old male presents with a history of severe watery diarrhea characterized by hypokalemia and achlorhydria. Severe dermatitis-often a red psoriatic-like rash with serpiginous borders over trunk and lower limbs. Dysfunction of the thyroid can result in hyper or hypo states of hormone production. Development Persistence of the thyroidpharynx connection may occur via a sinus or cyst, called a thyroglossal duct cyst. These cysts present as midline neck masses that move with swallowing and are usually seen in children or adolescents. The thyroid develops at the base of the tongue between the first pair of pharyngeal pouches, in an area called the foramen cecum. The thyroid gland then descends down the midline to its final location overlying the thyroid cartilage, and develops into a bilobed organ with an isthmus between the two lobes. However, the thyroglossal duct may fail to obliterate and form a thyroglossal cyst or fistula instead. A pyramidal lobe can be seen in 50­80% of the population and represents a remnant of the distal thyroglossal tract. Suspended from larynx, attached to trachea (cricoid cartilage and tracheal rings). Relationships: Anterior: Strap muscles (sternohyoid, sternothyroid, thyrohyoid, omohyoid). Intraglandular lymphatics connect both lobes, explaining the relatively high frequency of multifocal tumors in the thyroid. It can be damaged during a thyroid operation, so the surgeon must know its course well. Damage produces ipsilateral vocal cord paralysis and results in hoarseness or sometimes shortness of breath due to the narrowed airway. Musculoskeletal system: Increased reactivity up to a point, then response is weakened; fine motor tremor. This means that it is important to look for other functioning thyroid tissue prior to removing a lingual thyroid. Persistent sinus tract remnant of developing gland: Thyroglossal duct cyst-may occur anywhere along course as a midline structure with thyroid epithelium, usually between the isthmus and the hyoid bone: Most common congenital anomaly. Incomplete descent: Lingual or subhyoid position (if gland enlarges, patient will have earlier respiratory symptoms). Heat intolerance, palpitations, fatigue, weight loss, dyspnea, weakness, increased appetite, exophthalmos, thyroid bruit (50­90%). Choosing a treatment: Consider: Age, severity, size of gland, surgical risk, treatment side effects, comorbidities. Radioablation is the most common choice in the United States: Indicated for small or medium-sized goiters, if medical therapy has failed, or if other options are contraindicated. Potassium iodide reduces hormone production (via Wolff-Chaikoff effect), used to shrink gland prior to surgical excision. Treatment is surgical since medical therapy and radioablation has a high failure rate. Patient presents with fever, tachycardia, muscle stiffness or tremor, disorientation/altered mental status. Iatrogenic: s/p thyroidectomy, s/p radioablation, secondary to antithyroid medications. Adolescents/adults (particularly when due to autoimmune thyroiditis): Eighty percent female.

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Newly included donation programme focused on chronic myeloid leukaemia enlarged prostate erectile dysfunction treatment discount tadapox 80mg on line, in partnership with the Max Foundation erectile dysfunction nutrition tadapox 80 mg visa. Bristol-Myers Squibb can develop a clear approach to erectile dysfunction drugs in philippines generic 80mg tadapox visa establishing access plans for R&D projects during development that takes into account the specific considerations necessary for each project, especially for its late-stage projects. Applying equitable pricing strategies to this product, to countries where disease burden is high, would help increase affordability for those most in need: for example, Brazil, Indonesia, Pakistan, Afghanistan, Bangladesh and Nigeria. Bristol-Myers Squibb can improve its commitment to ensure responsible sales practices by decoupling sales incentives from sales targets. Removing the emphasis on sales targets is recognised as a mechanism for reducing the impact of unethical marketing on, for example, rational prescribing. Regulatory approvals: 5, for additional indications for nivolumab (Opdivo) in the treatment of five different cancers in scope. This pipeline is almost entirely comprised of projects targeting cancer with two projects for neglected tropical diseases. M&A news: 2016 acquisition of Padlock Therapeutics, a biotechnology company specialising in autoimmune diseases. Presence in emerging markets: In 2018, BristolMyers Squibb reports sales in 13 countries in scope; 24 less than in the 2016 Index. Namely, it has an internal auditing department for the whole company, involving both internal and external resources and applying to all third parties. It does not, however, report fraud-specific risk assessments, nor does it demonstrate evidence of a monitoring system for non-compliance in the workplace, or procedures to segregate duties, to ensure decisions are checked by another party. Bristol-Myers Squibb publicly discloses its policy positions on access-related topics. Bristol-Myers Squibb does not have a clear process in place to develop access plans during R&D. In general, Bristol-Myers Squibb develops access plans for R&D projects late in the development process and close to submission for market approval. To date, Bristol-Myers Squibb does not have any project-specific access provisions in place for its eight late-stage R&D projects. Public policy to ensure post-trial access; commits to registering trialed products. BristolMyers Squibb has a publicly available policy for ensuring post-trial access to treatments for clinical trial participants. Once a product is approved, Bristol-Myers Squibb commits to registering it in all countries where clinical trials for the product have taken place. Bristol-Myers Squibb has an access-to-medicine strategy with a business rationale. The strategy includes measures such as equitable pricing, licensing, philanthropy and capacity building. The highest level of responsibility for access sits with its Worldwide Access Council, at the executive level. BristolMyers Squibb performs strongly in encouraging employees to work towards access-related objectives. These incentives include awards for performance and public recognition by senior company leaders in internal meetings and through internal social media for objectives reached. Bristol-Myers Squibb measures and monitors progress and outcomes of access-to-medicine activities. It also publicly reports on commitments, targets, objectives and performance information. Bristol-Myers Squibb publicly discloses which stakeholder groups it engages with on access issues, but does not publicly share its process for selecting who to engage with, nor its policy for ensuring responsible engagement. The company publicly discloses its membership of patient organisations, including the financial support it provides. It discloses policies for responsible engagement within its Principles of Integrity. It does not publicly disclose its policy approach to payments made to healthcare professionals in countries in scope. Bristol-Myers Squibb does not commit to filing its newest products for registration in countries in scope within one year of first market approval. However, it publicly commits to implement inter-country equitable pricing strategies for a minority of its products for diseases in scope, including for future products. Some new products in scope filed for registration in the majority of priority countries. Bristol-Myers Squibb has filed 10% of its newest products for registration to date in more than half of the relevant priority countries (disease-specific subsets of countries with a particular need for access to relevant products). Bristol-Myers Squibb has publicly committed to R&D for diseases and countries in scope. Its R&D strategy for low- and middle-income countries is informed by an evidence-based public health rationale linked to sources including the United Nations Sustainable Development Goals. Bristol-Myers Squibb has one of the smallest pipelines in the Index with 25 projects. For diseases in scope where priorities exist, Bristol-Myers Squibb is active in two projects; both of these target priority R&D gaps. Most of these strategies apply inter-country pricing; these take into account an average of three socioeconomic factors. Bristol-Myers Squibb also applies an equitable pricing strategy to one further product informed by a public health rationale. Bristol-Myers Squibb has guidelines for drug recalls that apply to all countries in scope. Bristol-Myers Squibb has initiatives that meet inclusion criteria in three areas of capacity building: manufacturing, R&D, and health system strengthening. While its health system strengthening projects have good governance structures in place, some initiatives fall short on setting clear, measurable goals and objectives. Does not provide evidence of reporting substandard or falsified medicines to relevant authorities. Bristol-Myers Squibb has a policy for the prevention and handling of counterfeit medicines. BristolMyers Squibb has non-exclusive voluntary licensing agreements in place for two compounds (for diseases in scope). Bristol-Myers Squibb does not have a public policy available that sets out its approach to filing for or enforcing patents in low- and middle-income countries. The programme is carried out in partnership with the the Max Foundation and has been ongoing since 2016. During the period of analysis Bristol-Myers Squibb also donated products for the treatment of hepatitis C in a demonstration project with several partners. Bristol-Myers Squibb has transition plans in place for its dasatinib (Sprycel) donation programme, to ensure ongoing access for patients once the programme ends. BristolMyers Squibb has eight capacity building initiatives that were included for analysis by the Index: i. Although it holds a comparatively average standard of transparency, it continues to incentivise sales agents against sales targets. With a mid-ranking performance, it lacks a process to develop access plans during R&D, but considers access for a key paediatric product.

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This type of analysis can remove about 80% of the bias that might have gone into treatment selection impotence stress purchase 80 mg tadapox mastercard. The 95% confidence interval encompasses the limit inside which the point estimates is likely to erectile dysfunction psychological treatment techniques buy cheap tadapox lie 95% of the time; this could be for the mean or single estimate erectile dysfunction clinic raleigh tadapox 80mg free shipping. When the trial is negative and one of the subsets shows a positive result, it confirms benefits in that subset because it is a randomized trial. Which of the following statements regarding ventilation during cardiac arrest are correct? For witnessed out-of-hospital cardiac arrest due to ventricular fibrillation, what is the appropriate energy level for defibrillation? In a cardiac arrest situation with no access for drug delivery, what is the preferred access? Which of the following are contraindications for basic life support and advanced cardiopulmonary life support? What dose of amiodarone can be used in fibrillatory arrest after the first dose of epinephrine? The initial drug therapy for hypotensive, bradycardic patient includes which of the following? The Cincinnati prehospital stroke scale components include which of the following? Recombinant tissue plasminogen activator in acute stroke is contraindicated in which of the following situations? Contraindications for nitroglycerin in acute coronary syndrome include which of the following? For eye opening: spontaneous 4, in response to speech 3, in response to pain 2, none 1. For best verbal response: oriented conversation 5, confused conversation 4, inappropriate words 3, incomprehensible sounds 2, none 1. For best motor response: obeys 6, localizes 5, withdraws 4, abnormal flexion 3, abnormal extension 2, none 1. Our principal goal remains to offer to all levels - from junior trainees to experts in the field - a range of practical information with regard to new techniques and ideas. Particular importance should be given to younger shoulder surgeons, enabling them to increase their knowledge. The goal is to offer better treatment to our patients, and, with this in mind, we will propose a scientific program with up to date information concerning long-term results and latest innovations on shoulder prosthetic arthroplasties. This course belongs to you, and these 3 world-class scientific days will be of great benefit to everyone. A large conference area will be set up for debates where experienced specialists will be able to share their knowledge and examples of difficult cases. Importance should be given for technical innovations regarding the pre operative planning of shoulder arthroplasty. Live surgeries with various arthroplasties will be performed by the main experts of the world. And, of course, this event will be, once again, a great occasion to network with your colleagues from all over the world. Brunner (Germany) Tips and Tricks in Complex Fracture Treatment 6/ Tips and Tricks in Complex Fracture Treatment. Clavert (France) New Technology Session 7/ 8/ Virtual Reality: the Future of Surgical Education in Orthopedics and Beyond. Habermeyer (Germany) 22/ Pyrocarbon interposition shoulder arthroplasty: preliminary results from a prospective multicenter study at 2 years of follow-up. Garret (France) 23/ Pyrocarbon Humeral Head in Hemi Shoulder Arthroplasty: Preliminary Results at 2-year Follow-up. Favard (France) 15/ 16/ 17/ Clinical and radiological long term results of anatomical stemless prostheses. Teissier (France) Anatomic metal back versus full polyethylene with more 5 years follow up. Neyton (France) 18/ Mid term clinical and radiological results of an uncemented metal backed glenoid component in total shoulder arthroplasty. Scheibel (Switzerland/Germany) 20/ Why I prefer an On-lay Humeral Tray Component when performing Reverse Shoulder Arthroplasty. Castagna (Italy) Lateralization in Reverse Shoulder Arthroplasty: a descriptive analysis of humeral and glenoid lateralization. Werthel (France) 32/ the Biomechanics of Reverse Shoulder Arthroplasty Polyethylene Insert Constraint. Athwal (Canada) New Trends Video Demonstrations: Pre Op Planification 41/ 42/ Pre-op Planning and Navigation in Total Shoulder Arthroplasty. Collin (France) Presentations What do you prefer 43/ 44/ 45/ Reverse shoulder arthroplasty: technical considerations & outcomes. Favard (France) Reverse Shoulder Arthroplasty in Patients with Preoperative Deltoid Impairment. Agneskirchner (Germany) 50/ Complications of reverse total shoulder arthroplasty - how to manage fractures of the scapula? Neyton (France) 51/ Optimizing humeral stem fixation in revision shoulder arthroplasty with the cement-within-cement technique. Joaquin Sanchez-Sotelo documented a relatively poor observer agreement (1820), and alternative classification systems have not fared much better. This is important for defining the minimal displacement (1-part), as well as the patterns of all displacements for decision making and for future outcome studies. In an attempt to further understand the reasons for poor agreement when using Neer principles for classification and treatment recommendations, in 2005 we published a study that identified a number of issues, including difficulties with identification of fracture planes on plain xrays, different radiographic appearances with changes in position of the arm when xrays were taken, and others. As a result of this study, we now try to first identify what fracture pattern we are dealing with, and then try to predict displacement. The development of this classification resulted from a collaborative research effort between Mayo Clinic and Fundacion Jimenez Diaz. Recent publications have suggested that surgical treatment does not improve the outcome of nonoperative treatment. As a result, the humeral head articular cartilage faces posteriorly and inferiorly, and the shaft is in extension. The more comminution at the posteromedial level, the more unstable the fracture will be after surgical reduction. The main potential adverse outcome with nonoperative treatment with these fractures is malunion resulting in decreased range of motion and loss of function. Valgus impacted fractures (Vl) In these fractures, the plane separating the humeral head is located at the anatomic level as well, but the humeral head is displaced in valgus: comminution is on the lateral side, and the articular surface is oriented in excessive valgus. The majority of the times, the humeral head is facing superiorly or superolaterally, and the greater tuberosity is fractured and displaced medially and posteriorly. Because of the valgus angulation, the tuberosity can be located above the articular surface, resulting in malunion and impingement. Depending on the severity of the disruption at the anatomic neck, the head might remain unstable and result in nonunion.

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Companies are all different in the way they operate impotence definition buy tadapox 80 mg online, where they operate erectile dysfunction treatment in vadodara purchase tadapox cheap online, and in their portfolio of investigational and marketed products sudden erectile dysfunction causes buy genuine tadapox online. Best & innovative practices A summary of all best practices and/or innovative practices identified for the company in any of the Technical Areas for the 2018 Index. It continues to outpace peers by building on a strong foundation of strategies that are applied to both R&D projects and products on the market. Access strategy is clearly linked to business rationale, with incentives for senior management aimed at long-term objectives. Compliance: New to 1st place, it discloses all components of an internal control system looked for by the Index. R&D: Retains top place, by creating an integrated Global Health R&D unit, and the largest number of projects targeting priority R&D gaps. Pricing: Holds top place, with one of the highest proportions of equitable pricing strategies being applied to priority countries. Patents: A new leader, with its voluntary licence for dolutegravir (Tivicay) having the largest geographic spread. Capacity: Leads for the first time with the highest number of initiatives meeting all good practice standards. Maintains strong performance, but falls short compared to the leader in endemic country-coverage. It has also committed to measure impact and share results publicly via Access Observatory for two of its projects. The strategy centres around improving access to medicine and strengthening health systems in countries in scope by developing partnerships focused on access, such as ViiV Healthcare. It is one of 14 companies to have both financial and non-financial incentives in place to motivate employees to perform on access-related issues. These incentives include a variable pay system linked to long-term results, bonuses and rewards. Furthermore, it is one of the companies that is measuring impact by reporting on the progress of its Save the Children partnership. It publicly discloses which stakeholder groups it engages with on access issues, but does not publicly share its process for selecting who to engage with. It has some policies covering responsible interactions with stakeholders, namely to operate with integrity and transparency with local stakeholders, following its standard for interacting with patient organisations. Its R&D strategy for low- and middle-income countries is informed by an evidence-based public health rationale with each commitment developed in response to public health needs in these countries. It has a code of conduct relating to ethical marketing and anti-corruption, and provides annual compliance training for employees. The company provides evidence of having formal processes in place to ensure compliance with standards by third parties. Instead, it rewards other qualities such as technical knowledge and quality of service. It also has a monitoring system in place to track compliance in the workplace; it conducts audits involving both internal and external resources-that also applies to third parties. For example, it has a policy on intellectual property and access to medicine for developing countries. It is one of the few companies in scope to have a policy that prohibits political contributions. It discloses its policies for responsible engagement, including responsible lobbying. Commits publicly to equitable pricing and reports a commitment to file to register new products in scope. It also publicly commits to implement inter-country equitable pricing strategies for the majority of its products for diseases in scope. However, it publicly shares some registration information for the majority of its products. It demonstrates evidence of having equitable pricing strategies for 60% of its products for diseases in scope. The majority of these strategies apply both inter- and intra-country pricing; these take into account an average of four socioeconomic factors. For example, its albendazole (Zentel) donation programme aims to eliminate lymphatic filariasis in 39 countries. It has at least two initiatives in each area which meet all good practice standards. These initiatives typically fall short on having good governance structures in place and processes for mitigating conflicts of interest. Extensive initiative to improve child healthcare A wide range of projects through a global partnership with Save the Children. Dolutegravir (Tivicay) licence has widest geographic potential for improving access the non-exclusive voluntary licence for dolutegravir (Tivicay) covers 95% of low- and middle-income countries in scope. The company has non-exclusive voluntary licensing agreements in place for two compounds (for diseases in scope). Its broadest licence, for dolutegravir (Tivicay), encompasses 102 countries including 71 middle-income countries in scope. Global Health R&D Unit to stimulate collaboration Targeted open innovation incubators and research units with focus on R&D for conditions unique or endemic to low- and middle-income countries. Improved performance compared to peers in its internal controls and transparency, including financial support made to patient groups. R&D: Rises to 3rd place for its new approach to considering access planning for all new medicines. Pricing: Holds 3rd place, with an above-average performance across all pricing metrics but outperformed by leaders. Capacity: Falls 2 places to 3rd, but holds strong against new metrics for good practice, notably in health system strengthening. Donations: Rises two places to 3rd, achieving a comparatively wide geographic coverage for its leprosy programmes which aim to eliminate the disease in 49 countries. Novartis can work to ensure that its Access Principles are successfully applied to establish access plans for all new medicines in late-stage development regardless of disease scope. As the Novartis Access Principles were recently implemented in 2018, early success is critical to proving that access can be considered across the pipeline and successfully executed. While equitable pricing strategies apply in some priority countries, the company could expand its scope to include all countries where need is the highest, including Egypt, Arab Rep. Novartis has developed a new tool, Potential Affordability by Decile, to determine price segmentation in countries in scope. Novartis could apply this tool to address the affordability of products including valsartan (Diovan) for hypertensive heart disease and ischaemic heart disease in low- and middle-income countries.


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