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By P. Hamil. Florida International University. 2019.

Or is equity in learning opportunities provided only when all citizens share the same kind of learning environment? This battle of equity versus equality in the access to institutional care cheap 100 mg modafinil overnight delivery, already being waged in education generic modafinil 200mg online, is now shaping up in the medical field. The per capita expenditure on health care, even for the poorest sector within the United States population, indicates that the base line at which such care turns iatrogenic has long since been passed. In rich countries, the total budget of services for the poor, if used for that which reinforces self-care, is more than ample. More access, even though restricted to those who now receive less, would only equalize the delivery of professional illusions and torts. Above all, health designates the range of autonomy within which a person exercises control over his own biological states and over the conditions of his immediate environment. Primarily the law ought to guarantee the equitable distribution of health as freedom, which, in turn, depends on environmental conditions that only organized political efforts can achieve. Beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom. Implicit in this concept is a preferred position of inalienable freedoms to do certain things, and here civil liberty must be distinguished from civil rights. The liberty to act without restraint from government has a wider scope than the civil rights the state may enact to guarantee that people will have equal powers to obtain certain goods or services. Civil liberties ordinarily do not force others to carry out my wishes; a person may publish his or her opinion freely as far as the government is concerned, but this does not imply a duty for any one newspaper to print that opinion. A person may need to drink wine in his kind of worship, but no mosque has to welcome him to do so within its walls. At the same time, the state as a guarantor of liberties can enact laws that protect equal rights without which its members would not enjoy their freedoms. One sure way to extinguish freedom to speak, to learn, or to heal is to delimit them by transmogrifying civil rights into civic duties. The freedoms of the self-taught will be abridged in an overeducated society just as the freedom to health care can be smothered by overmedicalization. Any sector of the economy can be so expanded that for the sake of more costly levels of equality, freedoms are extinguished. We are concerned here with movements that try to remedy the effects of socially iatrogenic medicine through political and legal control of the management, allocation, and organization of medical activities. Insofar as medicine is a public utility, however, no reform can be effective unless it gives priority to two sets of limits. The first relates to the volume of institutional treatment any individual can claim: no person is to receive services so extensive that his treatment deprives others of an opportunity for considerably less costly care per capita if, in their judgment (and not just in the opinion of an expert), they make a request of comparable urgency for the same public resources. Here the idea of health-as-freedom has to restrict the total output of health services within subiatrogenic limits that maximize the synergy of autonomous and heteronomous modes of health production. In democratic societies, such limitations are probably unachievable without guarantees of equity without equal access. In that sense, the politics of equity is probably an essential element of an effective program for health. Conversely, if concern with equity is not linked to constraints on total production, and if it is not used as a countervailing force to the expansion of institutional medical care, it will be futile. Like consumer advocacy and legislation of access, this attempt to impose lay control on the medical organization has inevitable health- denying effects when it is changed from an ad hoc tactic into a general strategy. Four and a half million men and women in two hundred occupations are employed in the production and delivery of medically approved health services in the United States. As the number of patient relationships outgrows the elements in the total population, the occupations dealing with medical information, insurance, and patient defense multiply unchecked. Of course, physicians lord it over these fiefs and determine what work these pseudo- professions shall do. But with the recognition of some autonomy many of these specialized groups of medical pages, ushers, footmen, and squires have also gained some power to evaluate how well they do their own work. By gaining the right to self-evaluation according to special criteria that fit its own view of reality, each new specialty generates for society at large a new impediment to evaluating what its work actually contributes to the health of patients. Organized medicine has practically ceased to be the art of healing the curable, and consoling the hopeless has turned into a grotesque priesthood concerned with salvation and has become a law unto itself. The policies that promise the public some control over the medical endeavor tend to overlook the fact that to achieve their purpose they must control a church, not an industry. Dozens of concrete strategies are now being discussed and proposed to make the health industry more health-serving and less self-serving: decentralization of delivery; universal public insurance; group practice by specialists; health- maintenance programs rather than sick-care; payment of a fixed amount per patient per year (capitation) rather than fee-for-service; elimination of present restrictions on the use of health manpower; more rational organization and utilization of the hospital system; replacement of the licensing of individuals by the licensing of institutions held to performance standards; and the organization of patient cooperatives to balance or support a professional medical power. To increase efficiency by upward mobility of personnel and downward assignment of responsibility could not but tighten the integration of the medical-care industry and with it social polarization. As the training of middle-level professionals becomes more expensive, nursing personnel in the lower ranks is becoming scarce. The hospital only reflects the labor economy of a high-technology society: transnational specialization on the top, bureaucracies in the middle, and at the bottom, a new subproletariat made up of migrants and the professionalized client. But if it became the model for over-all health care, it would be equivalent to the creation of a medical Ma Bell.

It requires technical expertise to obtain images Two dimensional is useful for evaluating the anatomical and clinical expertise to interpret the results appropri- features buy discount modafinil 200 mg on line. The following features are typically assessed: r Left parasternal: With the transducer rotated appro- r Anatomical features such as cardiac chamber size order modafinil 200 mg fast delivery, my- priately through a window in the third or fourth inter- ocardial wall thickness and valve structure or lesions. Ventricular aneurysms or defects such as atrial or ven- r Apical: This is a view upwards from the position of tricular septal defects can be seen. When generate 2-D images with simultaneous imaging of ow awaveencounters an interface of differing echogenic- direction and velocity. Any Common indications for echocardiography: reected waves (echoes) that reach the transducer are r Suspected valvular heart disease, including infective sensed and processed into an image. Tissues or interfaces that reect the waves look for any valve lesions or regurgitation, and any strongly such as bone/tissue or air/tissue will appear evidence of a cardiomyopathy. Fluid is anechoic, so tions, such as ventricular septal rupture or papillary appearsblack. It will also identify areas of ischaemic alise the heart because they cast acoustic shadows. A transducer probe is mounted on the tip of a exible tube that is passed into the oesophagus. The patient needs to be nil by mouth prior to the proce- Ischaemic heart disease dure, local anaesthetic spray is used on the pharynx, and intravenous sedation may be required for the procedure Denition to be tolerated. In the normal heart there is a balance between the oxy- There are three types of echocardiography: two di- gen supply and demand of the myocardium. The predomi- Chronic stable angina nant cause of cardiac ischaemia is reduction or inter- Denition ruption of coronary blood ow, which in turn is due to Chest pain occurring during periods of increased my- atherosclerosis+/thrombosiscausingcoronaryartery ocardial work because of reduced coronary perfusion. Incidence Incidence Ischaemic heart disease results in 30% of all male deaths Angina is common reecting the incidence of ischaemic and 23% of all female deaths in the Western world. Geography Geography More common in the Western world where it is the com- Predominantly a disease of the Western world, but this monest cause of death. Aetiology/pathophysiology Risk factors can be divided into those that are xed and those that are modiable: Aetiology r Fixed: Age, sex, positive family history. Rarelycardiacischaemiamayre- sult from hypotension (reduced perfusion pressure), se- Pathophysiology vere anaemia, carboxyhaemoglobinaemia or myocardial The pathology of stable angina is the presence of high- hypertrophy. The underlying mechanism r Chronic stable angina results from the presence of is atheroma, which affects large and medium-sized ar- atherosclerotic plaques within the coronary arteries teries. The true pathogenesis of atheroma is not fully reducing the vessel lumen and limiting the blood ow. This suggests that the initiation of fatty Concentric lipid rich: 28% of plaques streak may not be due to the risk factors for atheroscle- Eccentric lipid rich: 12% of plaques rosis. They contain varying amounts of free lipid, collagen tains free lipid as well as foam cells with an overlying and foam cells. A grading system exists based on (dobutamine) may show abnormal ventricular wall the level of activity provoking pain (see Table 2. Risk factor modication is crucial, in particularstoppingsmoking,treatmentofhypertension, Grade I Pain as a result of strenuous physical activity only improving diabetic control and lowering cholesterol. The gure shows a cardiac cycle from each lead taken at rest (left) and during exercise (right). Symptomatic treatment may involve one or a combi- careinconjunctionwith-blockersorinpatientswith nation of the following: heart failure. They are particularly useful after a my- If symptoms cannot be controlled by medication, the ocardial infarction to reduce the risk of a subsequent main choices for coronary intervention are between cardiac event. In patients with triple vessel disease or verapamil also reduce the heart rate and the force of left main stem coronary artery disease, surgery im- ventricular contraction resulting in a decreased my- proves outcome. A bal- plaques with a lipid-rich morphology are at greatest risk loon is inated in the coronary artery to reduce the of ssuring. It includes the follow- or is provoked more easily, persists for longer and often ing: fails to respond to medical treatment. Patients require r Unstable angina describes clinical states between sta- emergency assessment and investigation to allow rapid ble angina and acute myocardial infarction. Pathophysiology As with stable angina, the underlying pathological lesion Clinical features istheatheromatousplaque. There may also be signs of r High-risk patients may benet from a glycoprotein hypertrophy or previous infarction (Q waves). If the level is normal patients venousheparininplaceoflow-molecular-weighthep- are dened as having unstable angina. Artery occluded Pattern of infarction r 24 72 hours: Cellular inammation visible. If the atrioventricu- Acute myocardial infarction is caused by the occlusion lar node is involved bradyarrhythmias are common, of a coronary artery, usually as the result of rupture of although any arrhythmia is possible. The myocardium supplied by that artery eas of infarction, which cause contractile dysfunction. Myocardial infarctions due to extensive myocardial damage, rupture of the occur more commonly in the early morning possibly ventricular septum or papillary muscle leading to mi- due to increased coronary artery tone, increased platelet tral regurgitation. The latter present with worsening aggregatability and decreased brinolytic activity.

Patients who have urticaria or angioedema as skin manifestations tend to have a better prognosis; they are more likely to have no cardiac or neurologic manifestations (36) order 200 mg modafinil mastercard. Biopsy specimens of the papular and nodular lesions are characterized by perivascular infiltrates of eosinophils cheap modafinil 200 mg without a prescription, neutrophils, and mononuclear cells without evidence of vasculitis ( 36). Neurologic involvement occurs in 54% of cases and has three forms: thromboembolic disease resulting from thrombotic cardiac disease, primary central nervous system dysfunction (36), and peripheral neuropathy. Clinically, patients who present with thromboembolic events have had strokes or transient ischemic attacks. Visual symptoms, occurring in 23% of patients, are also attributed to microemboli or possibly local thrombi. Central nervous system dysfunction is manifested as gait disturbances, behavioral changes, memory loss, or upper motor neuron signs such as increased muscle tone. Peripheral neuropathy may be expressed as mononeuritis multiplex with symmetric or asymmetric sensory deficits or painful paresthesias, or as motor neuropathies. Pulmonary involvement is believed to occur as a secondary manifestation of congestive heart failure or of embolic events originating from right ventricular thrombi or by primary infiltration of the lung by eosinophils. Thus, chest radiographs may show evidence of congestive heart failure, pleural effusions, or infiltrates. Treatment begins with corticosteroids (usually prednisone, 1 mg/kg/day for several weeks and then on alternate days). Hydroxyurea (1 to 2 g/day) ( 37) is used for patients who do not respond adequately to corticosteroids. Interferon-a administered subcutaneously in several dosage regimens has also been reported to be effective ( 38,40). The syndrome is characterized by a necrotizing vasculitis in patients with asthma and eosinophilia. Diagnostic criteria formulated by the American College of Rheumatology, yielding a sensitivity of 85% and a specificity of 99. Because it is relatively rare and therefore not readily recognized, the diagnosis may be missed. The mean age of onset is 38 years; men are affected slightly more frequently than women ( 47). Typically, asthma or rhinitis precedes the development of the other manifestations by a mean of 8. Virtually all patients have pulmonary involvement as asthma or bilateral migratory pulmonary infiltrates (48). The most common gastrointestinal symptoms are abdominal pain, nausea or vomiting, diarrhea, and hematochezia. Myalgias and arthralgias are the most common musculoskeletal symptoms; however, true arthritis is rare (3,47). Distribution of clinical manifestations in Churg-Strauss syndrome Laboratory studies are most notable for fluctuating peripheral blood eosinophilia, with peaks ranging from 20% to 90% of the differential white blood cell count. Perinuclear antineutrophil cytoplasmic antibodies directed against myeloperoxidase occur in 50% to 70% of patients ( 48,49). Biopsy of involved tissues is characterized by necrotizing vasculitis of the small arteries and veins, eosinophils, and extravascular granulomas. Without treatment, the prognosis is poor with 50% dying within 3 months of the onset of vasculitis ( 49). Some investigators believe that the early use of cyclophosphamide (Cytoxan) prevents irreversible organ damage ( 47). Eosinophilic Pneumonias The eosinophilic pneumonias are a group of disorders characterized by blood or tissue eosinophilia and pulmonary infiltrates. This term was intended to describe the more inclusive category of pulmonary diseases characterized by eosinophilic infiltrates with or without peripheral blood eosinophilia. Later, other related syndromes, such as acute eosinophilic pneumonia, were described. There are four eosinophilic pneumonias not discussed earlier: tropical pulmonary eosinophilia, Lffler syndrome, and chronic and acute eosinophilic pneumonia. Excellent reviews ( 45,49) provide further details and a description of several others for which space does not allow inclusion here. Most patients with Lffler syndrome have either a parasitic infection or drug reaction, although no cause can be found in about one third of cases. Patients are generally at least 30 years of age ( 6,54), and many have a history of atopy. Blood eosinophilia is present in about 90%, but its absence does not exclude the diagnosis (55). The chest radiograph reveals progressive peripheral dense infiltrates, which resemble a photographic negative of pulmonary edema (53,55,56). High-resolution computed tomography scans of the chest may identify peripheral infiltrates not evident on the radiograph and may also reveal mediastinal adenopathy. Pulmonary function tests may present a restrictive or normal pattern of lung volumes ( 45).

Boehringer Ingelheim falls four not publish its stakeholder engagement pro- ing codes of conduct that applies to all employ- places from 14th: its equitable pricing behav- cesses modafinil 200mg, activities and related outcomes buy cheap modafinil 200 mg online. PreCare is a in disciplinary action, including termination of not provide any price or volume-of-sales infor- holistic stroke care package for reaching low-in- employment or discontinuation of services. Boehringer coupon-based loyalty program, also for stroke Audit system extends to third parties. The com- Ingelheim has equitable pricing strategies for the and which targets both patients and healthcare pany has an auditing system that is co-managed same products as in 2014: these are focused on professionals. These oversee regular audits within the However, only a few (6%) of the company s rele- for adhering to protocols and patient tracking. The system covers vant products have pricing strategies that target all countries in which the company has opera- priority countries (disease-specifc sub-sets Best Practice: Making More Health. Together, these target work together to develop, support and scale up just a few (6%) priority countries. Boehringer innovative business models that address global Ingelheim is the only company without a spe- health challenges, focusing on prevention, diag- cifc commitment to applying equitable pricing in nosis and treatment. Boehringer Ingelheim s ad hoc donations commit to the core Ingelheim fell 13 places. It demonstrated less principles of international guidelines for dona- Consistent recall guidelines. Ingelheim is one of the few companies undertak- ing regular audits and requiring regular reporting Limited brochure & packaging adaptation for Above average performance in R&D capac- from recipients on donations. Boehringer Ingelheim s strongest dence of adapting brochures and packaging capacity building area is R&D: it has a number of Involved in humanitarian assistance. Boehringer materials to address language needs, but does partnerships with local research organisations Ingelheim typically donates ad hoc donations to not consider literacy, demographic, environmen- to support R&D expertise in countries. All of its long-term partners AmeriCares, Direct Relief tal or cultural needs in countries in scope. Boehringer Ingelheim updates safety labels in countries in scope but did not volun- Consistent performer. Boehringer Ingelheim is tarily share other safety information with rele- a consistent performer in Patents & Licensing, vant authorities. In 2016, it improves its behav- ity: with authorities in the Middle East (including iour by expanding the geographic scope of its Egypt and Iraq). This is the broadest non-en- but did not commit to timely reporting of sus- forcement agreement noted by the Index, and pected cases. Local capacity-building needs for health-re- lated skills and infrastructure outside the value No transparency on patent status. Boehringer Ingelheim does not publish the status of its Ingelheim does not demonstrate a strategic, patents. The company undertakes capacity building activities Absence of competition-related breaches. The governance of its approach to product than in 2014, and now has three donation pro- access has signifcantly improved: its new Going Beyond grammes. However, it has the smallest pipeline relevant to the Medicines Alone strategy combines its several initiatives Index. It has improved substantially in Market Infuence the period of analysis, it was judged to have breached com- & Compliance, with a more transparent approach to ethi- petition law in Mexico. Eli Lilly shows innovation in capacity cal marketing and lobbying, and a broad, risk-based approach building but does not clearly demonstrate that all its capacity to auditing. It uses equitable pricing strategies for one more building activities consistently target local needs. Eli Lilly R&D activities fll key product gaps by drawing Set registration targets for key diseases. This helps to ensure early these by drawing upon its diverse expertise Lilly China Research and Development Centre. As new products move into late stages of devel- company can also register existing products in Plus, given that non-communicable diseases opment, Eli Lilly can make plans for products to more countries with high burdens of disease. Given the large numbers of people in Strengthen and expand capacity building low- and middle-income countries living with Mitigate mark-ups in low- and middle-income eforts. Eli Lilly can draw on its experience in livestock and other animals, Eli Lilly can leverage countries. For example, it can expand Consider local needs and access during prod- its eforts to build manufacturing capacity, work- uct development. Eli Lilly can ensure more of its ing with local partners to identify shared goals.