By O. Lukjan. Teikyo Marycrest University. 2019.

Value the mutual support that arises from collegial relation- Chicago: American Medical Association zantac 300 mg mastercard. Learn strategies such as relaxation techniques to help build the emotional resilience that will be needed in times of stress cheap zantac 150 mg without prescription. Tools for cognitive well-being include strategies that use the intellect to stimulate thinking, and hence one s outlook, in positive ways. Writing down your feelings can help you to slow down and refect on your life and practice. Learning to set limits on your time and to use time wisely is a cognitive strategy to deliberately attend to self-care. What is central to stress management is the atten- This chapter will tion we give ourselves in the present moment. Do we pay attention to each bite of our breakfast, or do we hurry it down with gulps of coffee while scanning our emails, half-listening to the radio in the background? Case Do we carefully listen to our patient s complaints, or are we A third-year resident has suffered from anxiety throughout mostly focused on getting through the patient list in time their medical training. But competent than their peers has made the anxiety particularly mindfulness is not something foreign; it s a capacity we often acute. It is both the ability to focus on this text as we read it, and purging as a way to cope with stress. The resident hides the aspect of mind that notices when our attention has drifted this behaviour from others, as they consider the anxiety away. Mindfulness is not thinking: it s more like the awareness and bulimia a further sign of inadequacy. Deepening our resident does enter an introductory six-week mindfulness mindfulness through practise is a way of inoculating ourselves program offered by the medical school. Introduction The relaxation response The road to independent medical practice is long, demanding We can t avoid stress: stress is triggered by change, and life and fraught with stress. When residents eventually largely determines how much they enjoy this period of their fnish their training, new challenges will come. Many manage the inevitable stress of their residency can prepare for an exam by studying, we can prepare for years by focusing on the light at the end of the tunnel, thus the inevitable presence of stress by practising being present. A considerable body of ceptance the workload increases: Oh well, it will be different research demonstrates that mindfulness techniques produces in residency; I ll be making money and can fnally focus on my a relaxation response that has the opposite effect of the stress real vocation. Postponing certain choices today for the promises of tomor- row often makes sense. If we don t crack the books until the Refection: Practising mindfulness in daily life week before our fellowship exams, well, we know how that Allow yourself a few mindful breaths in the will turn out. But, while planning for the future is helpful, liv- morning before you get out of bed. Planning for the Try preparing and eating your breakfast quietly, future means orienting our actions so that they contribute to a without distraction, once a week. Managing stress with mindfulness Let the world wake you up: when you notice a This habit of living for tomorrow is a fawed coping strategy: it phone ring, a door slam, and so on, take a is based on the false premise that tomorrow is more real than moment to sense where you are and how you today. Cultivating mindful- weeks to delay, and eventually eliminate, the binging ness through regular formal practise extends the habit of episodes. The resident also begins to question these nega- being present into our daily activities. Try this for the next tive self-judgments and seeks counselling for the eating few breaths. The resident discloses abdomen moving in and out with each breath and stay with these challenges and fears to a close friend and feels less that sensation. Before long your mind will likely drift off into isolated and less anxious about life in general. The resident thoughts about this experience, or about something completely plans to continue with regular meditation. When you notice that your mind has drifted into thinking, let go of the thoughts and come back to the sense of breathing. It s simple and yet Self-acceptance diffcult to stay present: it takes discipline to train our minds As we become mindful of uncomfortable feelings and the to simply be in the moment when our tendency is to want to habitual patterns they trigger, we may become self-critical: control it. Such activities might take the edge off ing of our quirks and foibles, we also naturally become more our anxiety momentarily, but when anxiety has the upper hand accepting of others. In medical practice there is no greater in our lives the activities that are motivated by anxiety become kindness we can offer our patients than our attention and deeply entrenched habits. Key references In a state of mindfulness we allow ourselves to feel whatever Hassed C, de Lisle S, Sullivan G, Pier C. Whether we are feeling overwhelmed by anger the health of medical students: outcomes of an integrated or lost in boredom we simply allow ourselves to be aware of mindfulness and lifestyle program. Wherever You Go, There You Are: Mindfulness of thoughts and feelings may food through us, our patience Meditation in Everyday Life. New York: Oxford can learn to stay present with our feelings and let go of the University Press.

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Novo Nordisk has one on-go- for Least Developed Countries purchase 150mg zantac amex, there are other exceptions to intellectual property rights in ing structured donation programme cheap 150 mg zantac overnight delivery, with com- barriers along the distribution chain that can extraordinary circumstances. It is ducts a formal bi-annual internal audit on pric- Previous leader, now outperformed. Novo currently funded until the end of 2020, is imple- ing and pricing structures in all mid-sized and Nordisk fell six places, losing its leading position. Five more countries were slated larly in capacity building outside the pharmaceu- to be enrolled in 2016. These require adher- However, in practice, the company has fled to ilance systems. Novo Nordisk has a very strong approach programme, Novo Nordisk works with partners access to relevant products). The majority of to philanthropy, including targeting local needs, to ensure donated products are monitored and these products were launched over 10 years ago. As part of the company discloses a number of relevant initia- programme, each country has a system in place Consistent recall guidelines and public dis- tives for building locally-needed capacities out- for monitoring whether the donated insulin is closure of recalls. Novo Nordisk has consist- side the pharmaceutical value chain, focusing on administered to the intended users. University of Medical Sciences), and China (with ucts during the 2014-2015 Ebola epidemic and the Chinese Academy of Sciences). Limited brochure & packaging adaptation for nerships are long-term, but it is not clear how rational use. It indicates where the patent has been granted, Average performance in strengthening phar- whether extension has been applied for, and the macovigilance systems. Novo ship with the Bangladesh Ministry of Health to Nordisk has published a commitment not to improve capacity of the National Drug Control fle for or enforce patents in Least Developed Laboratory. Novo Nordisk does not engage in non-exclusive voluntary Manufacturing capacity building receives least licensing of its patented products, and has made attention. It improves modestly across all areas, but no disease-specifc commitment to registering new products is outperformed by peers. It is among the leaders in Market in countries in scope, nor does it use intra-country equitable Infuence & Compliance, with no settlements relating to pricing for products in scope. Eisai drops in pricing, however, as it makes chain, albeit through a relatively low number of activities. Eisai can build on its experience with Eisai can expand its collaborative R&D activities of-pocket spending (e. Eisai can expand its pro-ac- ing with partners to understand and target local health stakeholders. Eisai Eisai can do this by publishing its approach to can set disease-level registration targets for Expand access approach to mental health prod- voluntary licensing and its use as a mechanism low- and middle-income countries. To comple- help ensure people in those countries gain early ing access to mental health products that are ment this approach, Eisai can publicly disclose access to high-need products. The company can needed in low and middle income countries the status of its patents, clearly showing where also register existing products in more countries (e. The compa- 0 ny s focus areas are oncology and neuroscience, 2011* 2012* 2013* 2014 2015 including neurodegenerative and neurological Rest of world China Japan Europe disorders. Americas *Due to a change in company reporting practices, numbers from 2011, 2012, 2013 and 2014 are incomparable. It also has projects target- The majority of Eisai s relevant medicines target ing infuenza. These are target high-priority product gaps with low com- 10 mainly mental health conditions and neurological mercial incentive. Communicable Non-communicable disorders: anxiety disorder; bipolar afective dis- Neglected tropical order; epilepsy; migraine; and unipolar depres- sive disorders. Eisai s medicines target non-communicable dis- eases, mainly mental health conditions and neuro- logical disorders, specifcally epilepsy. This project involves multiple access temisinin-based therapy with the potential to cure in a single dose. It improves in all areas, and it does not disclose marketing activities in rele- has a best-practice stakeholder engagement vant countries, nor is it a signatory of the United No overarching policy for including access pro- programme. Eisai s Eisai has a section on its website dedicated to included in its research partnerships. The company does not provide informa- peers, the company is conducting the highest approach as an opportunity to enter emerging tion on its confict of interest policy. Transparent on performance toward access the subject of any settlements for criminal, targets. Paper is a non-fnancial incentive: employees are ofered the opportunity to write a paper pro- R&D commitments linked to public health. Eisai Modest increase in equitable pricing, but from moting access to medicine and to improve gen- is committed to treating diseases that impact low base.

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Some have a compara- pounds are treated equally if they meet the tively narrow disease focus cheap zantac 150 mg online. Some have a com- Companies also often have individual ways of inclusion criteria zantac 300mg generic, regardless of their mechanism paratively narrow scope of country operations. However, for the The Index uses various methods to correct for ferent pricing strategies are referred to. In frst time, the Index has used various methods these variations between companies. In several order to minimise the variability of informa- to correct for variations between products and indicators that measure quantitative elements tion sourced from companies, all companies countries within the scope of the Index. In addition to this, a clarifcation round and fling for registration, only priority countries company revenue for 2014 and 2015. Data availability innovations Companies are sometimes unwilling or unable to disclose commercially sensitive data, or, if they do, may do so only partially. Occasionally, where sensitive data could supporting the pharmaceutical industry to Previously, this was limited only to Innovation be analysed, complete results could not be pub- achieving greater access to medicine. Similarly, in business models, within General Access to lished due to legal constraints related to public recognising those companies trialling or scaling Medicine Management. In other cases, col- up innovative unique-in-industry policies or ini- defnition, cannot be considered innovations. To determine which of the company s practices try-level collection, was not always possible. For innovative activities, special note sible to provide a complete picture of the area expectations are. It can also be described as a was taken of activities submitted by compa- of analysis due to external constraints on the benchmark. The team met twice during the scoring which occurred an where in the world were following criteria: and analysis period to agree which practices to counted when evaluating companies in the Sustainability, defne as best or innovative. Best practices and areas of ethical marketing, corruption and Replicability, innovations were tested with members of the anti-competitive behaviour. Some breaches Alignment with external standards/stake- Technical Sub-Committees where relevant. Even holder expectations, given this expanded scope, it is not possible to Proven efectiveness. Sources of data collection include Lexis-Nexis, In diferent areas of analysis (for exam- the websites of government departments such ple, in Research & Development vs. A best practice might be an example of a gold Even given the signifcantly expanded scope of standard of practice; a best-in-class policy; or investigation, we acknowledge that breaches a strategy, programme, product initiative or may have occurred which were not captured. Innovations have been defned in successive iterations of the Access to Medicine Index as: Measuring Outcomes and Impacts a novel activity/business/model/policy/strat- The study as currently designed is not intended egy being piloted/trialled by companies, which to measure the direct impact of companies (where relevant) has evidence of fnancial or access initiatives on patients and other groups. Alternative measures are used as proxies exception to the requirement for uniqueness is for patient access or considerations of impact. For 2016, the def- Distribution, disclosure of the volume of sales nition of Innovation was expanded to include achieved to diferent sectors within a country is scaling up. Therefore, a practice which was being taken as a proxy measure of the success of an newly trialled/piloted in the previous Index cycle, equitable pricing strategy in being implemented. The company sets objectives to improve access to medicine, and 0 The company does not disclose publicly or via the Index informa- aligns its access-to-medicine strategy with its core business. The company has a performance management system to moni- 0 The company does not have an access-to-medicine strategy and tor and measure the outcomes of its access-to-medicine activities does not set objectives for improving access to medicine. However, there is cial incentives for relevant performance of employees in general, limited evidence of their fnancial sustainability. The company has a system in place to incorporate external and local perspectives on access-to-medicine needs in the development and A. The company has developed innovative (unique in the sector) 5 The company has a structured system in place to incorporate approaches to its access governance, its performance management local stakeholder perspectives into the development and imple- systems and/or its stakeholder engagement. The company uses the same pro- approaches to governance and/or performance management cesses for its subsidiaries or provides evidence of how subsidiar- systems and/or stakeholder engagement and supports this with ies engage with relevant stakeholders. The company publicly discloses information regarding global 0 The company meets none of the above criteria. This includes breaches of national access to medicine in countries within the scope of the Index. In some breaches and/or settlements reached during the period addition, it discloses to or via the Index its political fnancial con- of analysis. The company also discloses policies for responsible The company has not been the subject of settled cases for cor- engagement and management of conficts of interest. The Index scope (such as payments to or promotional activities directed company provides evidence of follow-up action taken to mitigate the at healthcare professionals and opinion leaders).

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Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 41 Knowledge Network of Disease and its derived taxonomy may be expected to impact disease treatment and to contribute to improved health outcomes for patients buy zantac 300 mg overnight delivery. As many of the examples already discussed illustrate buy 300 mg zantac fast delivery, finer grained diagnoses often are the key to choosing optimal treatments. In some instances, a molecularly informed disease classification offers improved options for disease prevention or management even when different disease sub-types are treated identically (see Box 3. A Knowledge Network that integrates data from multiple levels of disease determinants will also facilitate the development of new therapies by identifying new therapeutic targets and may suggest off-label use of existing drugs. In other cases, the identification of links between environmental factors or lifestyle choices and disease incidence may make it possible to reduce disease incidence by lifestyle interventions. Importantly, as discussed below, the Committee believes the Knowledge Network and its underlying Information Commons would enable the discovery of improved treatments by providing a powerful new research resource that would bring together researchers with diverse skills and integrate knowledge about disease processes in an unprecedented way. Indeed, it is quite possible that the transition to a modernized discovery model in which disease data generated during the course of normal healthcare and analyzed by a diverse set of researchers would ultimately prove to be a Knowledge Network of Disease s greatest legacy for biomedical research. Consequently, patients and physicians must currently make decisions about whether to undertake more intensive cancer surveillance (for example, by breast magnetic resonance imaging or vaginal ultrasound) without being able clearly to assess the risks and benefits of such increased screening and the anxiety and potential morbidity that arises from inevitable false positives. Furthermore, some patients elect to undergo prophylactic mastectomies or oophorectomies without definitive information about the extent to which these drastic procedures actually would reduce their cancer risk. Studies attempting to quantify these risks have largely focused on particular ethnic groups in which a limited set of mutations occur at high enough frequencies to allow reliable conclusions from analyses carried out on a practical scale. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 42 individual patients, health-care providers, and payers, by making it possible to avoid unnecessary screening and treatment while reducing cancer incidence and promoting early detection. Molecular similarities amongst seemingly unrelated diseases would also be of direct relevance to drug discovery as it would lead to targeted investigation of disease-relevant pathways that are shared between molecularly related diseases. In addition, ongoing access to molecular profiles and health histories of large numbers of patients taking already-approved drugs would undoubtedly lead to improved drug safety by allowing identification of individuals at higher-than-normal risk of adverse drug reactions. Indeed, our limited understanding of and lack of a robust system for studying rare adverse reactions is a major barrier to the introduction of new drugs in our increasingly risk-aversive and litigious society. Major disparities in the health profiles of different racial, ethnic, and socio-economic groups within our diverse society have proven discouragingly refractory to amelioration. As discussed above, it is quite likely that key contributors to these disparities can be most effectively addressed through public-health measures and other public policies that have little to do with the molecular basis of disease, at least as we presently understand it. However, the Committee regards the Information Commons and Knowledge Network of Disease, as potentially powerful tools for understanding and addressing health disparities because they would be informed by data on the environmental and social factors that influence the health of individual patients,. Researchers and policy makers would then be better able to sort out the full diversity of possible reasons for observed individual and group differences in health and to devise effective strategies to prevent and combat them. A Hierarchy of Large Datasets Would Be the Foundation of the Knowledge Network of Disease and Its Practical Applications The establishment of a Knowledge Network, and its research and clinical applications, would depend on the availability of a hierarchy of large, well-integrated datasets describing what we know about human disease. These datasets would establish the foundation for the New Taxonomy and many other basic and applied activities throughout the health-care system. The Information Commons would contain the raw information about individual patients from which meaningful links and relationships could be derived. Such an information platform would need to be accessible by users across the entire spectrum of research and clinical care, including payers. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 43 community and extracted directly from the medical records of participating patients. At the center of a comprehensive biomedical information network is an Information Commons which contains current disease information linked to individual patients and is continuously updated by a wide set of new data emerging though observational studies during the course of normal health care. The data in the Information Commons and Knowledge Network serve three purposes: 1) they provide the basis to generate a dynamic, adaptive system which informs taxonomic classification of disease; 2) they provide the foundation for novel clinical approaches (diagnostics, treatments strategies) and 3) they provide a resource for basic discovery. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 44 disease classification) and treatment. The fine-grained nature of the taxonomic classification w in clinical decision making by more accurately defining disease. The Information Commons should register all measurements with respect to individuals so that the multitude of influences on pathophysiological states can be viewed at scales that span all the way from the molecular to the social level. Only in this way could, for example, individual environmental exposures be matched to individual changes in molecular profiles. These data would need to be stored in an escrowed, encrypted depository that allows graded release of data depending on the questions asked, the access level of the individual making the inquiry, and other parameters that would undoubtedly emerge in the course of pilot studies. The Committee realizes that this is a radical approach and intense public education and outreach about the value of the Information Commons to the progress of medicine would be essential to harness informed volunteerism, the support of disease-specific advocacy groups, and the engagement of other stakeholders. The Committee regards careful handling of policies to ensure privacy as the central issue in its entire vision of the Information Commons, the Knowledge Network of Disease, and the New Taxonomy. The Knowledge Network of Disease, created by integrating data in the Information Commons with fundamental biological knowledge, drawn from the biomedical literature and existing community databases such as Genbank, would be the centerpiece of the informational resources underlying the New Taxonomy. The links could be one-to-one but most commonly would be many-to-one, and one-to-many (e. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 45 layers could be characterized through a variety of representations that attempt to extract meaning from the Information Commons. Meanwhile, different types of lymphomas, defined by transcriptome analysis, may have distinct metabolomic profiles.