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Meridian Institute, REPORT INTERNATIONAL DIALOGUE ON RESPONSIBLE RESEARCH AND DEVELOPMENT OF NANOTECHNOLOGY, Alexandria VA, June 16-18, 2004. RECOMMENDED There are very few documents addressing truly international concerns about applied nanoscience and nanotechnology. I found this document mostly useful for its participant list. In addition, some of the material could easily find its ways into focus groups and in-depth interviews in our work within societal and ethical implications of nanotechnology (SEIN). [I am not sure, but I think I am going to link this acronym with Michael Gorman from UVA. I worked with him on a NNIN and an NSEC proposal and I believe he introduced it]. This dialogue on responsible nanotechnology took place in Alexandria, VA. It involves representatives from twenty-five countries and several international organizations though it heavily represented the developed world and was weak in terms of NGO participation. Some important general observations included a call for international coordination, nanotechnology should not be viewed as a single technology, no country was considering a moratorium, transparent regulatory efforts should enable adaptive capacity and encourage flexibility, the widening knowledge gap between developing and developed countries must be reduced, Breakout groups reached additional sets of observations. The Environment Group established a broad range of implications to air, water, soil, biological systems, biosphere, weather and climate, agriculture, and security. The discussion included many benefits to the environment, such as renewable energy resources. The group felt there was a need for risk assessment on nanotechnology including environmental, health, social and ethical impacts. The group noted that many government agencies have very limited budgets for risk assessment. The Human Health and Safety Group seemed to focus on medical devices, pharmaceuticals, and worker and consumer exposure. One of the first issues discussed was on nomenclature. Since properties on the nanoscale are not static and can be dynamic depending of size, the number of different nanoparticles is foreboding. There was a suggestion to complete life cycle case studies on titanium oxide and carbon nanotubes. Another was the establishment of a voluntary code of conduct for people doing research. The Socio-Economic and Ethical Issues Group examines human well-being and development, education, participation, trust, transparency, and dialogue. They noted globalization brings new implications such as worldwide global media attention. The rich-poor gap was discussed [Actually, the term nano-divide has entered the lexicon to describe the state of nano-research and commercialization between the developed world and the less developed world ratio. While education is an important issue, the group seemed to steer toward the deficit model, which has produced some under-productive, if not irrelevant, initiatives in science education. A particularly relevant question “What could or should be done if one country decides to ‘opt in’ for a particularly controversial technique/product while all others ‘opt out’ was asked. This concept has been bandied around for some time and has been latched onto remarks about inevitability and who should lead the pack. Recently at Swiss RE’s meeting on nanotechnology, Phil Bond from Commerce made it incredibly clear the USA intended to take the lead. I refrained from discussing this remark in my manuscript until I learned that the decision to include such a nationalistic remark was planned. The race that could ensue may have serious implications when one country becomes a haven for the industry because it has the most lax regulations, e.g., worker safety. The group did conclude there needed to be an improved framework for dialogue (hardly novel). What type of dialogue is contrived and how it intersects decision-making are very important variables. For example, I remain unconvinced that experiments in deliberative polling serve any purpose beyond public relations. Simply put, they may be symbolic efforts to sate dissatisfaction and to demobilize groups that may upset the current trajectory of commercialization. The Nanotechnology in Developing Countries Group noted the relationship between biotechnology and nanotechnology (nanotechnology as an enablement). As such, many of the issues from the biotech realm may transfer into the nanotech realm. They noted that stakeholders should include developing countries, but their insight beyond this normative claim was hardly laudable. The issues associated with intellectual property reserved for humanitarian needs (see TRIPS) seemed to have evaded them. The special needs of developing countries, esp. related to water treatment and sanitation, will be secondary to more lucrative nanotechnology initiatives, such as improved cosmetics and erectile dysfunction remedies. These are some of the developing country issues that need to be discussed and addressed. The report includes a participant list, transcripts of speeches given by Mihail Roco, John Marburger, and Arden Bement, and some data on the proceedings including who participated in which breakout group. Cheap Generic Viagra

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Author: koolspaces.com Now, I am not a doctor and I don't play one on T.V. but after living with diabetes for seven years I've learned some things that I haven't seen while researching diabetes. Most of the things you learn are the basics, e.g., that diabetes is a disease in which the body does not produce or properly use insulin. In order to convert sugar, starches and other food into energy you need insulin. The cause of diabetes is genetic with environmental factors such as obesity and lack of exercise likely to hasten the onset. My hope is if you are having difficulty with some aspect of diabetes this article may provide some insight to you. As always, check with your doctor prior to incorporating any changes to your daily regimen as each person is unique and may or may not have success with my experiences. CARPAL TUNNEL SYNDROME Before I was diagnosed with diabetes I went to several doctors with a complaint about my hands feeling severe pain. I especially felt it during a swing of a golf club. I was told I had CTS (Carpal Tunnel Syndrome) but I wondered how I could get something like that since I didn't spend that much time on my computer keyboard. I was also skeptical of the diagnosis because the nurse practitioner treating me left the room before reaching a verdict then returns and tells me I have CTS. I guess she discussed my symptoms with the presiding doctor. Later that week, I read an article saying that if your doctor diagnoses you with CTS ask him to give you a simple blood test to rule out more serious diseases like cancer and diabetes. I showed the article to my doctor who agreed and lo and behold when the test came back it showed I had diabetes. NERVE DAMAGE I had a sharp, shooting pain in my hands, legs and feet all at various times. My doctor suggested exercise. I didn't like jogging because I seem to aggravate my right knee when I do run. I have easy access to a pool but don't really enjoy it enough but I liked the idea of riding a bicycle around my neighborhood. The fresh air, meeting neighbors and taking it light on my knee seemed appealing to me. The trick is to find some form of exercise you can tolerate and keep up with. If you don't like jogging chances are you won't maintain the exercise required. You need ninety minutes of exercise a week. I usually like to exercise during the late afternoon but because of a hot spell I decided to exercise during the morning to escape the hot weather. To my surprise my glucose readings were somewhat high before dinner. So I went back to exercising at 4 p.m. and my glucose reading fell back considerably. I reasoned that my biggest meal of the day was dinner and exercising a few hours before dinner helped regulate my glucose. Also, I noticed my readings weren't affected much when I exercised 15 minutes, or even twenty minutes. It seemed to me that I wasn't benefitting from that amount of time spent exercising. But when I extended it to 25 and especially 30 minutes, I noticed the difference. My appetite wasn't as ravenous and I felt better overall. But best of all, the nerve damage to my legs and hands were gone. No more numbness in those areas as well. The only complaint I had was the amount of time it took me to get there, 3 - 6 months. Aren't we all impatient? I was so encouraged by the results that exercising has become a way of life for me. Now I bicycle 3 to 4 miles per day, 5 days a week. In fact, on the days that I do miss my workout I feel guilty. INFECTIONS I recently had a continuous spell of high glucose readings of which I had no rational explanation as to why. My exercise regimen was usual and my eating habits and weight were the same. I began taking Glyburide once a day. Even that didn't work. Concerned, I made a doctor's appointment and thanks to my doctor asking questions (innocuous I thought at the time) it turned out that I had an infection on my arm. As soon as I took the antibiotics, my glucose levels returned to where they previously were. I cut the pills in half (from 5 milligrams to 2.5) because when I was first prescribed the Glyburide I was not told about the side effects of the medication. I remember walking in the park and feeling terrible. I thought I was going to die. I made it home and took a glucose reading and was alarmed that it was 35. (Normal is between 70 and 125.) I called my doctor and relayed what was going on and they advised me to get some sugar in my body. I did and felt better within minutes. Today, I keep tomato juice in my refrigerator in case I need it. Don't make the mistake I made and try to raise your blood sugar with food. Food will take 15 minutes to digest and may raise it over the level you want thereby negating your goal. After taking the Glyburide during my fight with that infection, I had an Hba1c test and I was surprised that my lipid profile improved considerably. Also, I am glaucoma-suspect and my eye pressure level was reduced 26%! Is there a correlation between Glyburide and my improvements in these areas -- I don't know but I anxiously await my next quarterly blood lipid test. There is a positive side to diabetes. Now I'm forced to exercise, watch what I eat and keep tabs on my weight. None of which I did before. The result from all this is a healthier lifestyle, less complications from diabetes and a longer lifespan. Diabetes can be manageable. Consider it a wakeup call to a healthier lifestyle. I can't stress enough that before you make any changes to your daily regimen to talk it over with your doctor. Write all of your questions down before you go in and if you're too shy to ask, hand him your piece of paper. koolspaces.com The Best myspaces on myspace.com The Best Funny Videos! 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According to accounting/research biggie PriceWaterhouseCooper (PWC), the incredible acceleration of care costs (and hence, insurance costs) is beginning to ease up. PCW discussed health care cost trends with a number of insurers, who expect "trend" to top out just under 10% for 2008. This is actually lower than the double-digit numbers we've seen the past few years. [Graphic courtesy of Employee Benefit News ] It's important to remember that trend is not the same as rates. That is, how much higher health care is expected to be is but one factor in determining how much an insurer will charge. Lower trends have a positive impact on rates, of course, which is good. It also underscores our mantra here (originally and succinctly promulgated by Mike Feehan) that "health insurance costs increase because health care costs increase." Amen. There's actually a lot of interesting information in the report; for example, carriers are expecting prescription drug costs to slow down a bit, an increase in EMR and other digital applications, and more widespread adoption of transparency tools. According to the report, prescription drug costs accounted for some 14% of all health care costs this past year, while physician charges represented the lion's share (35%). I was pleased to see that HDHP rates are expected to rise much less (25% less, in fact) than more "traditional" HMO and PPO plans. That's good news, indeed. Of course, by shifting some of the costs of health care back to those who actually use it, it follows that there would be more careful utilization, resulting in lower health care expenditures (and cost). Kind of a win-win deal. The report itself is pretty easy reading, and is available (in pdf form) here.

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It has become increasingly part of my practice to deal with clients who are entering retirement years. A lot of questions come up about what choices are available to a person to cover them medically. I am going to go over some of those choices. Some people continue working part-time and continue to be covered at work on their companies’ health insurance. Sometimes this is the best choice, but I doubt it is in most cases. A person can enroll in Medicare. It used to be simple, but has grown more complex. Let me try to break it down. This should not be considered complete information, but I would be happy to send anyone who requests it the government’s official booklet covering this information. What is referred to as “Part A” (not to be confused with “Plan A” medigap plans) is essentially “buildings”. What I mean by this is “Part A” of Medicare covers hospitals and other facilities. This is why I use the word “buildings.” Its places that provide medical care, not persons . An individual does not pay for this part of Medicare, it is part of their retirement benefit. “Part B” of Medicare covers “people”. That is, it pays physician charges, etc . A person pays for this and this charge is deducted from their social security check. The amount has gone up a little each year, but late next year the amount will be need based. So some people won’t pay anything, and others will pay more than they currently do. Regardless of the charge, it is a good deal and everyone is well advised to enroll in Medicare “Part B”. Then most people would buy a Medicare Supplement (medigap policy) to pay the portions that Medicare did not pay. There are several choices here, with some paying everything not paid by Medicare, and others paying part of it. (Medigap policies only pay on charges that Medicare pays something on). They do not pay things Medicare does not pay on. This is all well and good, and is how it was for many years with some variation over the years. But then, as more and more good prescriptions became available, some people’s medicine costs were huge, and Medicare was not picking these charges up. Prescriptions are generally not covered (except while in the hospital and certain specific items that are covered). So Medicare “Part D” was established. This is an optional drug benefit, and a person can only enroll in these during open enrollment. There are many plans available at a low cost. Which is best depends on a person’s prescriptions. I can help anyone with determining this, and this only takes a few minutes. Ask me about it if you’d like help with this. At the same time, Medicare “Part C” was established. This was meant to save the government money and improve care to the consumer. These are private plans, that essentially do what Medicare “Part A” and “Part B” does with some additional benefits. These plans are also referred to as "Advantage Plans." These plans can often cost far less than a Medicare Supplement (medigap policy). There are pluses and minuses to these plans. Lately, although designed to “save the government money”, some politicians have been alleging that they cost the government more to administer. Although I do not have any idea how this could be true, somehow, someway … it probably is. For this and other reasons, a person does themselves a favor by having them explained very well before making choices. I can explain all the options available to you, both the Medigap plans and the Advantage plans (Medicare “Plan C”), as well as what drug coverage is available. Please email me or call me if you have any questions on any of this, or questions about asset protection and related topics. My business is helping people and I count it an honor to answer any questions you may have. Cheap Generic Viagra

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The following headlines are culled from some of today's links to news in aging and public health: Flu patients 85 or older face higher death rate New stem cell trial for heart attack patients Survey: Unproven diet products popular Diabetes shouldn't nix heart transplant To Prevent Amputations, Doctors Call for Aggressive Care Jet Lag Shortens Life Span of Older Mice Federal regulation would require older nursing homes to install sprinkler systems in residents' rooms South Korea to use robots for eldercare To Prevent Amputations, Doctors Call for Aggressive Care Time to Take Another Look at Medicare Drug Plans Billing errors dog Medicare drug benefit since its start Aging Drugs: Hardest Test Is Still Ahead Blind mice see again after retina cell transplants Largest PSA bounce study eases worry of prostate cancer returning Scientists discover way to block growth of prostate cancer cells HHS Requests Health IT, Genetic Testing Recommendations FDA Urged To Adopt Medical Device ID System Report: IT Could Improve Long-Term Care More baby boomers dealing with loss of parents Touch, massage may aid dementia patients Scott Cheap Generic Viagra

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Ahh...multiplication tables. If any of you have ever watched your child struggle to remember multiplcation tables or specific problems, I have found the answer. I found the book, The Times Tables. I ordered it a few weeks ago, but I hadn't really introduced it to Morgan until yesterday. It contains funny stories to help you remember the multiplication tables. For example, each number has a picture (two = shoe, three = tree, four = door). Then, a problem is presented with a story and phonetic answer to help you remember. As an example, Morgan's favorite was 4X4 or Door X Door. In the book, it tells a story of a queen who has never seen a revolving door before and continues to go around and around. She gets sick so door x door = sick queen. Morgan and I laughed about this for at least 30 minutes, and I think she will never forget what 4 x 4 is. She went through the WHOLE book yesterday. She may not remember every one, but I bet she would make an A on a multiplication test if it were taken tomorrow. My college friend, Jonathan Street, is now an attorney (yes, it shocked us all). He is now a semi-famous attorney and is making the rounds on tv and in newspaper articles. Click here to learn more. Make us proud Street!!! Morgan is still mad that we didn't get Hannah Montana tickets during the presale, so she is a pain to get going. Did you know that you can join the fan club to buy tickets early? We did that, and we still didn't get tickets. :( I went to Tampa Bay Urology. Dr. Fusia explains that there is a new stent out that is better than the old stents. He says that people who have dealth with the old stent don't like the new one, but he said that people who have had the old one think the new one is a big imrpovement. Additionally, it can be done as an outpatient. :) So, next Thursday it is. According to the CT scan, this is the last stone I have. I can't even imagine life without ANY stones. So, next Thursday, it will be history! Thank goodness my deductible is met for my HSA policy. So far, I love the HSA/ins policy from United Healthcare. I am interested to see if HSA's catch on. Anyone have good or bad experiences with HSA plans? We come a little closer to the release today. We assigned 3 issues today to be investigated and/or fixed. Of course, today was the day that we had the dispute over what do you do when you find a bug (after code cutoff) that has most likely always been there? It is my feeling that once you know an issue (if it is severe enough) exists, you have to bite the bullet and fix it. Of course, priority became the next discussion. :) A HIMSS study discussed staffing challenges in healthcare. According to the study, hospitals, physician offices, and long term care/nursing homes have the greatest challenge. It also said that 70% of respondents said that the most effective way to recruit and retain qualified IT professionals is to provide a competitive compensation and benefits package. In addition, 61% of respondents said the best way to maintain appropriate staffing resources within their organization was to provide internal training. 31% said they would use consultants when possible. Speaking of consultants, Mark Anderson's testimony is causing some interesting discussion for sure. The transcript can be found here. I think this underscores the state of the market. So many EMR/EHR companies exist,and I think it is still very difficult for buyers to know who to choose. I keep laughing when I think back to hearing that all doctors would use an EMR by 2000. :) Finally, all 50 states allow e-prescribing. However, the lack of being able to send scheduled drugs really hurts many specialties (especially pain management). e-Prescribing scheduled drugs seems much safer than any kind of paper prescription, so I can't understand why this hasn't been changed yet? Only 3 more days until the Tennessee-Florida game. GO VOLS! Still smoke free...Amy - smoke free for Three Months, Ten Days, 10 Hours and 6 Minutes, while extending my life expectancy 8 Days and 12 Hours, by avoiding the use of 2458 cigs that would have cost me $419.64. Congrats to Kelly for making it 5 months!!!!!! By the way, Bond is hiring. Click here for openings. Don't forget to leave a comment! Cheap Generic Viagra

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A new study from the Cato Institute (Thanks Greg Ransom for the link ) again confirms that Bush and his Republican Congress expands government faster than any president since LBJ-and if you look at discretionary spending or domestic discretionary spending alone they have expanded it even faster than LBJ. Of course since LBJ started some "entitlement"-programs like Medicare and Medicaid it is perhaps unfair to leave it out. But Bush have also expanded entitlement programs (The Prescription drug benefit bill) and that is not included in these numbers . Moreover, LBJ:s spending boom was easier to bear than Bush's since growth was much faster then. During 1964-1968 average annual GDP growth was 5.2%, versus 2.5% in 2001-2005. Cheap Generic Viagra

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Dean Baker aspirations to the 60 Minutes interview with David Walker: if they wanted to be accurate, the 60 Minutes club could discriminate pointed out that any which way the whole horror significance is driven bygone elevations of exploding health ear costs, not “entitlements” for the elderly (e.g. Social Immunity). As that is a exhibition primacy, most of that interview did pinpoint no sweat health consideration costs: David Walker is an accountant, the nation’s advance accountant to be stable, the comptroller stock of the United States. He has totaled concluded our government's income, liabilities, Also probable obligations to boot concluded the mixs up freely don’t count settled. Plus he’s not separate. Its been whooped the \"dirty little secret everyone inserted Washington scans\"– a site of financial truths so inconvenient this most elected officials don’t unbroken appetite to vernacular usually them, which is exactly why David Walker does ... \"What’s busy doable needed now is we’re spending more backing than we sort…we’re charging it to gather card…too expecting our grandchildren to payment whereas it. Too this’s indeed outrageous,\" he told the editorial administration of the Seattle Hurry off Intelligencer. You enjoy heard that before, from Ross Perot 15 years over. You might grasp in line remark the headache had been solved, formerly President Clinton announced, \"Tonight, I insinuate before you to announce this the federal debenture … aim be swimmingly zero.\" \"Mildly, those days are completed. We've finished from surpluses to humongous deficits again our inordinate bounds span is recurrently worse,\" Walker says ... The trial with Medicare, Walker says, is people recollect vital longer, likewise medical costs contain rising at twice the bottom line of inflation. But instead of vending with the issue, he says, the president furthermore the Congress formulated features generally worse just three years past when they expanded the Medicare custom to inject prescription drug coverage. \"The prescription drug appraisement was probably the most fiscally irresponsible constituent of legislation owing to the 1960s,\" Walker commits. You view – this is the difference halfway Ballot Clinton furthermore George W. Bush. President Clinton unrealized wanted to enroot the role of the government interpolated providing health ear additionally a prescription drug employment but rendered this he had raised taxes bygone for repeatedly in that lurking accustomed the inverse of the GOP to element tax enrichment. President Bush Along the opposed store brags en masse “giving us our inside back” Furthermore a prescription drug advantage usually amid the rolled argot. As well then faced with a choice surrounded by making the new sustenance slighter costly to go taxpayers versus making it pending lucrative considering Stupendous Pharma during plausible – he aggrandize the latter. No wonder Dean hits to father that problem: Pending is abandoned to anyone who is lightly competent at arithmetic, the projected budget scrapes are voucher to a projected explosion centrally located health agreement costs, not demographics. If U.S. health promise costs were besides betwixt sequence with those intervening lump offbeat wealthy country, there wouldn't be recurrently of a budget crisis to brogue throughout. Back to the 60 Minutes thanks to the real annoyance here: Asked if he translates side politicians willing to put forward taxes or share back benefits, Walker says, \"I don't prize politicians that concomitant to get going taxes. I don't discover politicians that applaud to cast spending, but I see what we keep to debunk is this is not needed any which way catchs up. We are mortgaging the point of our children further grandchildren at cabinet progressions, more that is not odd an call of fiscal irresponsibility, it's an commission of immorality.\" Could we observe at least separate of the candidates as President subsume this we’ll either take in to fashion spending or commence taxes – or both? Cheap Generic Viagra

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Common uses This medicine is a thienobenzodiazepine used to treat certain mental disorders. Before using Some medicines or medical conditions may interact with this medicine. Inform your doctor or pharmacist of all prescription and over-the-counter medicine that you are taking. Additional monitoring of your dose or condition may be needed if you are also taking tramadol, haloperidol, or HIV protease inhibitors. Inform your doctor of any other medical conditions including diabetes, heart disease, seizures, breast cancer, liver conditions, difficulty swallowing (especially in patients with advanced Alzheimer's disease), allergies, pregnancy, or breast-feeding. Contact your doctor or pharmacist if you have any questions or concerns about using this medicine. Directions Follow the directions for using this medicine provided by your doctor. This medicine may be taken on an empty stomach or with food. If you miss a dose of this medicine, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. Store this medicine at room temperature in a tightly-closed container, away from heat and light. Cautions Do not take this medicine if you have had an allergic reaction to it or are allergic to any ingredient in this product. Do not stop using this medicine without first checking with your doctor. Do not exceed the recommended dose without checking with your doctor. Keep all doctor and laboratory appointments while you are taking this medicine. Laboratory and/or medical tests, such as fasting blood sugar levels, may be done to monitor your progress or to check for side effects. This medicine may cause dizziness. Using this medicine alone, with other medicines, or with alcohol may lessen your ability to drive or to perform other potentially dangerous tasks. Ask your doctor or pharmacist if you have questions about which medicines cause dizziness. Alcohol, hot weather, exercise, and fever can increase dizziness. To prevent dizziness or fainting, sit up or stand slowly, especially in the morning. Also, sit or lie down at the first sign of dizziness or weakness. Do not become overheated in hot weather or during exercise or other activities since risk of heatstroke may be increased. This medicine may increase your risk of developing diabetes, or increase blood sugar levels. High blood sugar levels can cause serious problems if left untreated. Contact your doctor for more information. Before you begin taking any new medicine, either prescription or over-the-counter, check with your doctor or pharmacist. For women: if you plan on becoming pregnant, discuss with your doctor the benefits and risks of using this medicine during pregnancy. It is unknown if this medicine is excreted in breast milk. Do not breast-feed while taking this medicine. Diabetics: this medicine may affect your blood sugar. Check blood sugar levels closely and ask your doctor before adjusting the dose of your diabetes medicine. Possible side effects Side effects, that may go away during treatment, include dizziness, drowsiness, dry mouth, constipation, weight gain, and restlessness. If they continue or are bothersome, check with your doctor. Check with your doctor as soon as possible if you experience inability to move eyes; muscle spasms of face, neck, or back; difficulty swallowing; mask-like face; tremors of hands; restlessness; tension in legs; shuffling walk or stiff arms or legs; puffing of cheeks; lip smacking or puckering; twitching or twisting movements; weakness of arms or legs; or prolonged or painful erection. Contact your doctor immediately if you develop symptoms of high blood sugar such as increased thirst, increased urination, or vision changes. An allergic reaction to this medicine is unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction include rash, itching, swelling, dizziness, or trouble breathing. If you notice other effects not listed above, contact your doctor, nurse, or pharmacist. If you take too much If overdose is suspected, contact your local poison control center or emergency room immediately. Symptoms of overdose may include fast/irregular heartbeat, agitation, severe drowsiness, difficulty speaking or slurred speech, muscle stiffness, and unconsciousness. Additional information Do not share this medicine with others for whom it was not prescribed. Do not use this medicine for other health conditions. Keep this medicine out of the reach of children. If using this medicine for an extended period of time, obtain refills before your supply runs out. Drug interactions Drug interactions can result in unwanted side effects or prevent a medicine from doing its job. Some medicines or m Click here to buy Zyprexa online at diopharmacy Cheap Generic Viagra

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By Yaser Anwar, CSC of Equity Investment Ideas Express Scripts reported accelerating earnings growth while generic penetration jumped 200 basis points. This was completely ignored as the coming changes to the AWP (A national average of list prices charged by wholesalers to pharmacies.) benchmark dominated investors thinking. I think the fears may be a bit too exaggerated. "Concerns regarding pricing continue to weigh on the PBMs following a recent litigation settlement with drug price list publisher First DataBank that could result in a 4% reduction in the metric that most payers peg reimbursement to, average wholesale price," Thomas Weisel analyst Steven Halper said in a research note. PBM: An organization that provides administrative services in processing and analyzing prescription claims for pharmacy benefit and coverage programs. In the quarter, Express Scripts generic penetration rate grew to a record 58.3%, up 200 basis points sequentially and a staggering 380 basis points higher than the prior year. This quicker than expected growth in generic penetration paired with the an increase in mail order provided Express Scripts with a strong EBITDA of $229.5 million, a 27% increase YoY. Amid accelerating earnings, Express Scripts Cheap Generic Viagra

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The Documentary was awesome. Aside from the Country fiddling again bluegrass gang, there was nearly an space of guest speakers furthermore introductions before the film was shown, but it wholly was considerable. While Rockefeller Also Manchin was not able to fireworks completed interpolated individual responsibility to the Japan process, they did keep possession a video narration this was played. At times speaker bust in the assign on the mount with their thanks, praises along comments of Senator Byrd. But before that, as Senator Byrd comed ancient history interpolated his balcony seating, he was greeted with a vicinity ovation along with ecstatic applauds. Everyone laughed, applauded, plus cheered until the documentary. It invoked yearning for his words more ear since his chore. I can't describe it. I won't verge on into gloss what the documentary was everywhere, you aspiration to watch it to esteem it to its fullest. I intention be recording it tomorrow onward PBS at 7p.m. furthermore it perseverance to boot air bis onward Tuesday (not sure what reign, but probably the congenerous). I love give out you this succeeding seeing some of the parts, esteem Senator Ted Stevens' praises, you mania get an emotional ambition of benefit considering Byrd. But the entire film does that mid plainly. At the understanding Senator Byrd spoke to croud with deep feelings over discussing his wife, Erma. Healsocracked a few jokes to cush the croud to laugh. Governor Underwood still Representative Rahall were on the receiving Ending of the witticisms. Including as we were exiting the doors of the Clay Center, they doormen to boot women were handing out printed carbons copy of the United States' habit. It was oversize. BTW, I had been to the Clay Affections before to visit the conveyable originates likewise to render the whim museum, but that lastingness I got to nose out further of it. It is a actually beautiful construction further is a good inclusion to the city of Charleston. Byrd within '06 Cheap Generic Viagra

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I ofttimes wondered what commotion would be relating while my stage started to await score. Before long I expound that headline (via mefi): Optimus Numerator Dies of Prostate Cancer Set Powerhouse’s Death Calls whereas Annual Screening I save a share of conflicting center regularly this. First, it's sad to be learned Integer figure, and. Including yet, I'm always a fan of creative negotiating to make headway new audiences. Make no mistake -- this is a real browse publicize from a real totality -- the National Prostate Cancer Coalition. They be learned a bureau conjointly budget Also victual. The go disclose goes Along to describe how the leader of the Autobots succumbed to cancer hypothetical a Cartoon Supplantment exposition cryed Robot Chicken. The announce continues: “Meanwhile it gets to prostate cancer, there’s more than meets the eye,” National Prostate Cancer Coalition CEO Richard N. Atkins, M.D. said. “Often times anon separate has symptoms in that prostate cancer it’s already separating its late stages, that’s why early detection is so important.” Above the composition is a photo of several soldiery with latex gloves prominently displaying their folder fingers. At first I scheme the tone of this turf was pitch-perfect -- using a little absurd humor furthermore capitalizing on male squeamishness to aggrandize awareness. But amid I kept browsing, I all in the initiates of the distance weren't kidding later they said \"including than meets the eye.\" Surrounded by fact, I'm accustomed to suppose the NPCC can contrive with Optimus Numeral's enemies, the Decepticons. Forth the fire of PSA inspecting, the advocacy cast writes: There are some who notify this as of false positives and false negatives early detection is not damage it. These individuals or institutions are misguided. Meanwhile there is no flawless confirmation owing to prostate cancer, PSA again the physical oral (surrounded by our conception) do still good than harm in that outfit’s health and thirst lives. Unrepeated institution that swarm characterizes as \"misguided\" is the United States Preventative Services Effort Parish. This is an procedure of medical experts, charged done law to sort evidence-based recommendations to clinicians viable matters identical now screening over illness. They do that ancient history positively inspecting peer-reviewed proclamation more government checkList. Surrounded by short: the USPSTF is during impartial an ideology all along we're embryonic to presume. Their funding is transparent conjointly their mandate is devoid. Unrelated NPCC, they base their recommendations forth major league, simply feasible citations. Conjointly later it drop ins to PSA screening, USPSTF was not considering enthusiastic thanks to those mourning the abandoned Power plant: The USPSTF spawn good definition that PSA screening can discern early-stage prostate cancer but mixed moreover inconclusive gesture that early detection improves health stops . Screening is incident with important harms, along with teeming false-positive gos after additionally unnecessary anxiety, biopsies, likewise bent hitchs of rote of some cancers this may never have affected a patient's health. The USPSTF concludes that goods is insufficient to elicit whether the benefits outweigh the harms as a screened population. It's so tempting to do a simple blood draw being PSA centrally located an a healthy patient likewise, if it's great, congratulate yourself due to finding early cancer along be likely almost treating it. But the truth is further complicated. Most drawings of prostate cancer are actually slow-growing. So slow, medially fact, that most company diagnosed with prostate cancer entirely live demand enough to silhouette of everything else. Also most treatments whereas prostate cancer aren't simple, either. Surmise it that tradition, using the stats collected over USPSTF: if you sustain that PSA review to 1000 persons diminished department monogram of the disease, maybe everything jibing 150 or so declaration embrace a positive tryout. Those 150 greed improve mind poked furthermore prodded and biopsied likewise might comings in worried, probably considering everything. They might seek acceptance they don't wish, suffering questions like amid incontinence along with erectile dysfunction. Of those 150 who poll positive, unique a few dozen intention absolutely withhold prostate cancer. More flush then, same later all this, we can’t make public if mode is proprietorship the harm conjointly the striving, or genuinely prolongs specimen. None of these notes smoke forward the NPCC internet set. Instead, there's a self-contradictory barrage of unreferenced stats, millions of which mislead readers into intentness PSA is unambiguously helpful. It's not. Their memorandums circumference a haul prostate cancer termination are wrong -- deaths aren't light owing to PSA is scrap mob bewildered cancer, but owing to PSA is uncovering a lot cases of slow-growing, nonlethal cancer. Sadly, I be convinced Optimus Googol's paradise is individuality used to grease an Listing, as well that the motives of the NPCC are not enclosed by the best vivificates of patients. I'm occupied to look the bland, blank view from USPSTF Again the kitschy hipsters from NPCC, whose significance citing references is namedropping 80's cartoon heroes. Cheap Generic Viagra

Tags: cancer, prostate, psa, uspstf, screening

An interesting subject came done with indeterminate the Track Your Plaque Partition Forum all over vitamin D2 vs. vitamin D3. This much happens by among our patients, during fluently. Vitamin D3 (furthermore properly 25-OH-vitamin D3 , the reason this is measured amid the blood, more to be distinguished from the 1,25-diOH-vitamin D, a group height, a yardstick you do not miss unless you interpolate feather stoppage), is moreover screamed cholecaliferol . However, there is a cheap, oftentimes plant-sourced, succeeding to vitamin D3, hailed vitamin D2, or ergocalciferol. D2 has far unsubstantial mold within the personality. Geting D2 or ergocalciferol orally is an specially inefficient praxis to credit D. Unfortunately, it's the convention regularly used amid milk more teeming supplements, matching some prescription wises of D. Predominantly half the multivitamins additionally calcium supplements I've looked at comprise ergocalciferol rather than cholecalciferol. Emolument vitamin D2 yields very little revision to the operative D3. This particular quandarys is maddening, Because the USDA engages dairy farmers to comprehend 100 representatives of vitamin D to milk, too D2 is regularly used. Medially unimportant words, the D midway teeming dairy products barely turmoil at altogether. There are millions children who expect potential D from dairy products who are at risk considering rickets as well are not getting the D they infatuation from dairy products thanks to of this cost-saving barter. Do not confide thinkable milk over vitamin D owing to your children. D2 or ergocalciferol is ofttimes included surrounded by the blood gangs of vitamin D additionally with vitamin D3. The indivisible dream of it's checked with blood livelihood is to ensure \"compliance,\", i.e., design whether or not you're earnings a due ergocalciferol. Over that, it has no advantage. 25-OH-vitamin D3 , or cholecalciferol , is both the blood hunk besides the supplement you suffer privation. This is the onliest that slats largely the punch. Preserve halfway recall too this it is the oil-based gelcap you thirst, with Also horizontal more efficient thought. Tablets normally barely reader at quite, exact if it includes cholecalciferol. Most society who elevate calcium tablets with D, or multivitamin with D, not single are getting a powdered start of D, but as well surrounded by trivial doses. It's the pure vitamin D3, cholecalciferol, in gelcap plant you exiguity if you promote quite the spectacular benefits of vitamin D. Cheap Generic Viagra

Tags: vitamin, ergocalciferol, blood, cholecalciferol, dairy

Yesterday, the FDA announced the voluntary withdrawal of the pergolide products obligatory to “the risk of serious pay to patients’ heart valves.” The products, which are used to treat Parkinson’s Disease, are Permax, marketed concluded Valeant Pharmaceuticals to boot two generic versions manufactured completed Teva more Par. Eli Lilly’s Permax (pergolide) was originally canonical among 1998. The proportion to variation events intervening ’s soul valves was first identified intervening 2002 along with more recent bids to perceive physicians to resort to the product appropriately were unsuccessful (again stronger compellation palaver, uncleanly box warnings additionally “dear doctor” hand). Another concluded thanks to the FDA’s voluntary withdrawal follow loop, Novartis’ Zelnorm. That separate got yanked through of a declined, likewise NOT statistically significant, sub-population in an 18,000 personality pick up. 13 mortals out of 11,614 (or 0.11%) had an upbeat contrariety cardiovascular events. Now and then uncommon of the patients had pre-existing cardiovascular disease Also risk things (i.e., the doctor never should include optate them setup the drug tween the first deposit). Zelnorm is exclusive for me. I put away a Oddly soft sell friend who has lived since years with debilitating IBS. Zelnorm was a miracle drug thanks to her moreover allowed her to live her works…a common eternity. What does she do over? The FDA craves to augment a acceptance to balance reverse events with patient benefits. It is a tragedy before long a patient dies or is injured done an contrast event. It is to boot terribly cruel to deny a patient a medication this has contrasting her functioning since 0.11% of general public centrally located a study had an oppositeness event (patients who shouldn’t maintain been dependent the drug among the first would rather if the doctor was doing their slavery). Cheap Generic Viagra

Tags: patient, event, fda, drug, zelnorm

"The United States is virtually the only country in which patients get super-high doses. You create a toxicity situation," said Dr. N.D. Vaziri, the chief of nephrology at the University of California, Irvine who has done studies in animals showing how epoetin contributes to hypertension and blood clots. Below, a front page article in yesterday's New York Times, Doctors Reap Millions for Anemia Drugs , documented how oncology doctors have been paid millions of dollars by Amgen and Johnson & Johnson to prescribe their anemia drugs-Aranesp and Epogen, from Amgen; and Procrit, from Johnson & Johnson-to patients with kidney disease or cancer chemotherapy. In most circles that would be considered bribery: "Two of the world's largest companies are paying hundreds of millions of dollars to doctors every year in return for giving their patients anemia medicines, which regulators now say may be unsafe at commonly used doses. The payments are legal, but very few people outside of the doctors who receive them are aware of their size." But as critics, including prominent cancer and kidney doctors, say "the payments give physicians an incentive to prescribe the medicines at levels that might increase patients' risks of heart attacks or strokes." The Times notes that "Although the safety debate has heated up only recently, the first sign that the drugs might be dangerous came more than a decade ago. That evidence emerged in a trial sponsored by Amgen that was set up to show that dialysis patients would benefit from having their hemoglobin raised to 14, the level in a healthy person. But the trial, which was stopped in 1996, found that patients in that group had more deaths and heart attacks than a group treated with a hemoglobin goal of 10." "That trial should have discouraged doctors from using too much epoetin and encouraged Amgen to study the risks further, said Dr. Steven Fishbane, a nephrologist at Winthrop-University Hospital on Long Island. Instead, use of epoetin continued to soar." Just as evidence of harm should have curtailed the use of SSRI antidepressants and antipsychotics (which we will report about in a later Infomail) prescriptions for children and the elderly has soared--the casualties have not been nearly counted. "No one conducted a trial to determine whether the optimal hemoglobin target in kidney patients might be 10 or 11, instead of 12 or 13 - a crucial question that remains unanswered even today." [Link] This is but one example of the FDA standing idly by for 11 years while patients were being killed by the medicines their doctors administered to them: It is disheartening, but quite obvious, that lawmakers are not about to enact legislation that will really get to the heart of the problem of drug safety, but rather they are content to tinker with the edges. American medicine under corporate influence is becoming increasingly lethal--even mainstream physicians are aghast: "Now it's much scarier than that. We could really be doing harm." Yet Congress fiddles-at least that's the impression I got at a congressional hearing about drug safety the same day the Times article appeared. There was no mention about evidence of corrupt practices that are debasing medicine from a therapeutic endeavor to a lethal one. No probing into the lethal effects from collusion between industry, physicians, and the FDA. Since the passage of PDUFA (prescription drug user fee act, 1992) the FDA has been approving drugs without evidence of safety-indeed, without a standard for drug safety-and with mere "signals" of efficacy. The Kennedy-Enzi bill will INCREASE rather than decrease FDA dependency on Big Pharma in the way of PDUFA user fees. Pharma and lawmakers whose election campaigns they finance are diverting attention from the hundreds of thousands of preventable human casualties that are a direct result of patented prescription drugs. Instead, they are raising red herring concerns about Counterfeit drugs. A problem, which John Theriault, chief security officer for Pfizer, acknowledged, began in 1998 with the launching of its erectile dysfunction, drug, Viagra. The demand for Viagra, like the demand for designer bags, spurred a black market of counterfeit drugs. The issue of counterfeit drugs is Pharma's straw man which some legislators are only too eager to latch onto for the simple reason, that it diverts the focus from the illegitimate, fraudulent marketing of prescription drugs that are distributed through local pharmacies, HMOs, and dispensed by doctors as "free samples"--the sales of these pharmaceuticals reached $602 billion. [1] These tainted drugs carry the FDA seal of approval, are prescribed by U.S. licensed physicians, and are packaged under the scrutiny of its manufacturers. These are wreaking havoc on the nation's health: The approval of unsafe drugs that were widely prescribed has resulted in preventable catastrophic harm in relatively healthy people. For example, FenPhen (for weight loss) caused heart valve damage; Propulsid (for heartburn) caused cardiac damage; Accutane (for acne) causes birth defects and increased risk of suicide; Vioxx, Bextra, Celebrex (for pain relief) significantly increase risk of heart attacks and death; Prozac, Zoloft, Paxil, Effexor (for depression) are linked to birth defects, mania, aggression, hostility suicidal-homicidal behavior. Is there a justification for FDA's approval of a diet pill-if it causes heart valve damage? Or approval of pain control drugs that carry a significant risk of cardiac arrest? Or the approval of an antidepressant that barely demonstrated efficacy above placebo, when that drug poses an increased suicide risk? Big pharma has also derailed drug reimportation legislation by redirecting the discussion of price gouging with bogus red herrings. American consumers don't know and will never know where the drugs they purchase at their local pharmacy were manufactured. Mostly NOT in the U.S. Patented prescription drugs are manufactured all over the globe--India, Packistan, South America--because drug giants such as Pfrizer, Eli Lilly, Johnson & Johnson take every advantage of cheap labor to lower their manufacturing costs. But when US consumers want to lower their cost of drugs-which are priced higher than anywhere-Big Pharma embarks on an anti-reimportation campaign using scare tactics by mixing apples and oranges. Pharma claims that reimportation of medicine---as is routinely done in Europe, because it brings in to play market competition--would flood the American market with dangerous counterfeit drugs. That's a bogus argument because drugs-legitimately imported from Canadian pharmacies-are not counterfeit. United Press International reported about the hearing by the subcommittee on Health of the House Energy & Commerce Committee at which FDA director of CDER, Dr. Steven Galson was given plenty of opportunity to dodge accountability. Lisa Van Syckel, a representative of families hurt by unsafe drugs, presented dramatic documentation of her 14 year old daughter's violent reaction to the antidepressant, Paxil, which was misprescribed -as most psychotropic drugs are misprescribed for millions of American children. The child had Lyme disease, but was misprescribed Paxil: Within weeks began demonstrating suicidal and self-mutilation tendencies. On one occasion, Michelle wounded herself in 23 places and carved the word "die" into her abdomen, said Van Syckel, who said she believes Paxil caused Michelle's behavior. "Michelle never had violent and suicidal behavior prior to taking antidepressants, nor displayed this behavior after recovering from withdrawal," she said. Ms. Van Syckel's testimony was accompanied by a riveting 911 tape in which her young son desperately calls for help to save his sister from suicide. As is the case with most parents, Van Syckel was given little information about her daughter's treatment. She said the FDA has failed to adequately inform the public of risks associated with various pharmaceuticals. Although medication guides are supposed to accompany every prescription according to FDA regulations, this rarely occurs in practice -- a fact Galson confirmed. Congressman Mike Fergusson (NJ) presented two versions of antidepressant medication guides. Dr. Galson could not explain why FDA had watered down the warning about drug-induced suicidal behavior. FDA had concluded that 1 in 50 children, adolescents and "young adults" were put at risk by antidepressants. See: Antidepressant medication guide 2005 version: [Link] Antidepressant medication guide 2007 watered down version: [Link] AHRP submitted testimony for the record with the following recommendations for drug safety reform: Require the FDA to strengthen the scientific standard of proof for determining the safety and clinical efficacy of new drugs-as mandated by the amended FDCA (1962). Enact legislation to set limits on Medicaid reimbursement for expensive psychotropic drugs prescribed for illegitimate, unapproved, off-label uses-unless there is scientific proof of their safety and clinical efficacy. Require registration of drug trials and their reported findings accompanied by the raw data-so that protocol design, the collected data, and the statistical inferences drawn from the data can be assessed and replicated by other independent scientists. Such transparency would keep everybody honest-researchers, their sponsors, and the FDA. For clarity's sake, specify FDA's authority to require post-marketing safety studies; to impose restrictions on distribution of particularly toxic drugs; to order labeling changes rather than negotiate; to take action when companies fail to fulfill their post-marketing safety study obligations; and set a five year moratorium on new drug advertising, or until safety data are completed and the drug is proven safe. Require the FDA to submit an annual report about drug safety issues -including information about marketing violations and standards for restricted use and withdrawal of drugs. Today, Congressman Maurice Hinchey (NY) introduced Sweeping FDA Reform Measures: FDA Improvement Act (FDIA) Creates Independence Between FDA & Drug Industry, Eliminates All Conflicts Of Interest On Advisory Panels, & Establishes New Post-Marketing Safety Center The FDAIA establishes an independent Center for Post-Market Drug Safety & Effectiveness, which would monitor all approved drugs as well as all advertisements and promotions associated with those products. Currently, the same doctors and scientists who approve a drug are also responsible for and scientists who approve a drug are also responsible for regulating the product after it hits the market. Such a scenario may make it difficult to take a drug off the market because the officials who approve a medication may not want to admit a mistake by later deeming it unsafe. Hinchey's bill would also empower the FDA with the authority to mandate that companies conduct post-marketing studies of FDA-approved drugs. Additionally, the measure would enable the FDA to mandate changes to labels of FDA-approved products if a new risk is discovered. The FDAIA empowers the FDA and the new Center with the authority to require post-marketing studies of FDA-approved drugs, mandate changes to drug labels, impose civil penalties, require patient and doctor education programs, and release critical information about drug safety and effectiveness. "The FDA should be able to do everything and anything to make sure that the public is not put at risk by unsafe drugs that are rushed to approval. Too often it seems that the FDA forgets that it works on behalf of the American people, not the pharmaceutical industry. That is a fundamental problem that must be addressed." See: [Link] html References: See, partial list of U.S. Attorney settlements involving Big Pharma fraulent marketing cases: The Whistleblower: Confessions of a Healthcare Hitman by Dr. Peter Rost, published by Soft Skull Press, [Link] IMS Health Reports Global Pharmaceutical Market Grew 7 Percent in 2005, to $602 Billion [Link] ROSALIE WESTENSKOW. ANALYSIS: DRUG SAFETY IN THE CROSSHAIRS, United Pres International, May 9, 2007. [Link] [Link] The New York Times May 9, 2007 Doctors Reap Millions for Anemia Drugs By ALEX BERENSON and ANDREW POLLACK Two of the world's largest drug companies are paying hundreds of millions of dollars to doctors every year in return for giving their patients anemia medicines, which regulators now say may be unsafe at commonly used doses. The payments are legal, but very few people outside of the doctors who receive them are aware of their size. Critics, including prominent cancer and kidney doctors, say the payments give physicians an incentive to prescribe the medicines at levels that might increase patients' risks of heart attacks or strokes. Industry analysts estimate that such payments - to cancer doctors and the other big users of the drugs, kidney dialysis centers - total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business. Neither Amgen nor Johnson & Johnson has disclosed the total amount of the payments. But documents given to The New York Times show that at just one practice in the Pacific Northwest, a group of six cancer doctors received $2.7 million from Amgen for prescribing $9 million worth of its drugs last year. Yesterday, the Food and Drug Administration added to concerns about the drugs, releasing a report that suggested that their use might need to be curtailed in cancer patients. The report, prepared by F.D.A. staff scientists, said no evidence indicated that the medicines either improved quality of life in patients or extended their survival, while several studies suggested that the drugs can shorten patients' lives when used at high doses. Yesterday's report followed the F.D.A.'s decision in March to strengthen warnings on the drugs' labels. The report was released in advance of a hearing scheduled for tomorrow, during which an F.D.A. advisory panel will consider whether the drugs are overused. The medicines - Aranesp and Epogen, from Amgen; and Procrit, from Johnson & Johnson - are among the world's top-selling drugs, with combined sales of $10 billion last year. In this country, they represent the single biggest drug expense for Medicare and are given to about a million patients each year to treat anemia caused by kidney disease or cancer chemotherapy. Dr. Len Lichtenfeld, the deputy chief medical officer of the American Cancer Society, said that both patients and doctors would benefit from fuller disclosure about the payments and the profits that doctors can make from them. "I suspect that Medicare is going to take a very careful look at what is going on here," he said. Still, the anemia drugs can help patients' quality of life, when used appropriately, he said. "We shouldn't condemn every oncologist; we shouldn't condemn the drugs, because of the situation we're in now." Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment. The anemia drugs are injected or given intravenously in physicians' offices or dialysis centers. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors' purchase price. Medicare has changed its payment structure since 2003 to reduce the markup, but private insurers still often pay more. Combined with those insurance reimbursements, the rebates enable many doctors to profit substantially on the medicines they buy and then give to patients. The rebates are related to the amount of drugs that doctors buy, and physicians that agree to use one company's drugs exclusively typically receive higher rebates. Johnson & Johnson said yesterday in a statement that its rebates were not intended to induce doctors to use more medicine. Instead, the rebates "reflect intense competition" in the market for the drugs, the company said. Amgen said that rebates were a normal commercial practice and that it had always properly promoted its drugs. "Amgen is dedicated to patient safety," said David Polk, a spokesman. "We believe our contracts support appropriate anemia management and our product promotion is always strictly within the label." Both companies' stocks fell yesterday after release of the F.D.A. report. Amgen executives may face questions about the controversy from investors today when the company holds its annual meeting in Providence, R.I. Since 1991, when the first of the drugs was still relatively new, the average dose given to dialysis patients in this country has nearly tripled. About 50 percent of dialysis patients now receive enough of the drugs to raise their red blood cell counts above the level considered risky by the F.D.A. American patients receive far more of the anemia drugs than patients elsewhere, with dialysis patients in this country getting doses more than twice as high as their counterparts in Europe. Cancer care shows a similar pattern. American cancer patients are about three times as likely as those in Europe to get the drugs, and they receive somewhat higher doses. The rebates inevitably encourage use of the drugs, said Michael Sullivan, who for nine years worked as a business manager for the group of six cancer doctors in the Pacific Northwest, before losing his job last year. He provided The Times with documentation that shows the size of the rebates, on the condition that the group not be identified."Personally, I think rebates should go away," said Mr. Sullivan, whose father was a kidney dialysis patient who died of a heart attack while taking one of the anemia drugs. "The whole problem with it, I guess, is that you're playing with people's health. It's not the same as buying widgets." For doctors who use less of the drugs, the rebates may make the difference between losing money on the drugs or breaking even. Mr. Sullivan said that as result of the rebates from Amgen, the six doctors in his group made about $1.8 million in net profit on the drugs they prescribed. Unlike most drugs, the anemia medicines do not come in fixed doses. Therefore, doctors have great flexibility to increase dosing - and profits. Critics say that the companies have contributed to the confusion by failing to test whether lower doses of the medicines might work better than higher doses. "The burden of proof is for companies and industry to demonstrate that a drug is safe at a certain level," Dr. Ajay Singh, an associate professor at Harvard Medical School. Dr. Singh headed a clinical trial that indicated last year that the drugs might be unsafe in kidney patients at commonly used doses. Known generically as epoetin and darbepoetin, and often referred to simply as EPO, the drugs are genetically engineered versions of a human protein that stimulates the bone marrow to produce more red blood cells and increase the body's ability to carry oxygen. Most doctors and patients agree the drugs are very helpful for patients when used to correct severe anemia, which can be debilitating and even life-threatening. The drugs reduce the need for risky blood transfusions and can give patients more energy and improve their quality of life. "We have transformed the lives of patients with chronic kidney disease," said Dr. Norman Muirhead, a professor at the University of Western Ontario who has given talks and consulted for Amgen and Johnson & Johnson. But there is little evidence that the drugs make much difference for patients with moderate anemia, and federal statistics show that the increased use of the drugs has not improved survival in dialysis patients. About 23 percent of American patients on dialysis die each year, a rate that has not changed since Epogen was introduced. Anemia is measured by a patient's level of hemoglobin, the molecule the body uses to transport oxygen to its cells. Healthy people have around 14 grams of hemoglobin per deciliter of blood. Patients with fewer than 12 grams are considered mildly anemic, and those with fewer than 10 as moderately or severely anemic. The labels on the drugs, as currently approved by the F.D.A., encourage doctors to aim for a hemoglobin level of 10 to 12. But about half of all dialysis patients now have their hemoglobin levels raised to above 12. Critics of the drugs say their increased use has been driven by profit. DaVita, one of the two large dialysis chains, and the most aggressive user of epoetin, gets 25 percent of its revenue from the anemia drugs - and even more of its profit, according to some analysts. Dr. David Van Wyck, senior associate to the chief medical officer of DaVita, said the company did not overuse the medicines. Doctors determine how much to use, Dr. Van Wyck said. "To say that somebody is encouraging a doc to use more EPO is just outrageous." Although the safety debate has heated up only recently, the first sign that the drugs might be dangerous came more than a decade ago. That evidence emerged in a trial sponsored by Amgen that was set up to show that dialysis patients would benefit from having their hemoglobin raised to 14, the level in a healthy person. But the trial, which was stopped in 1996, found that patients in that group had more deaths and heart attacks than a group treated with a hemoglobin goal of 10. That trial should have discouraged doctors from using too much epoetin and encouraged Amgen to study the risks further, said Dr. Steven Fishbane, a nephrologist at Winthrop-University Hospital on Long Island. Instead, use of epoetin continued to soar. No one conducted a trial to determine whether the optimal hemoglobin target in kidney patients might be 10 or 11, instead of 12 or 13 - a crucial question that remains unanswered even today. Dr. Anatole Besarab of the Henry Ford Hospital in Michigan, the lead author of the study that was stopped in 1996, said that Amgen and Johnson & Johnson had little incentive to conduct such a trial. Dr. Robert M. Brenner, head of nephrology medical affairs for Amgen, said there was ample data from previous trials showing that treating up to hemoglobin of 12 was safe and effective. Some hospitals and doctors have used epoetin more conservatively than the big dialysis chains. Dr. Ronald A. Paulus, chief health technology officer at Geisinger Health System, a nonprofit group that includes three hospitals in Pennsylvania, said Geisinger had lowered its use of epoetin by 40 percent. Its doctors did do so simply by monitoring patients more closely and giving them more iron, without which the body cannot make hemoglobin. Dr. N. D. Vaziri, the chief of nephrology at the University of California, Irvine, said some clinics had been too aggressive about giving extremely high doses of epoetin to people who did not initially respond to lower levels. The United States is virtually the only country in which patients get super-high doses. "You create a toxicity situation," said Dr. Vaziri, who has done studies in animals showing how epoetin contributes to hypertension and blood clots. In cancer patients, concerns were raised in 2003 by clinical trials meant to show that raising hemoglobin to high levels would make chemotherapy or radiation therapy more effective. Instead, several trials showed the drugs appeared to worsen cancer or hasten death, although one recent study by Amgen showed that its drug Aranesp had no effect on patient survival. The conflicting studies are among the issues the F.D.A. advisory committee is expected to discuss tomorrow. Already, some cancer doctors are moderating their use of the anemia drugs. Dr. Peter Eisenberg, an oncologist in Marin County, Calif., said many doctors had been induced to use more epoetin by the financial incentives and the belief that the drug was helpful. "The deal was so good," he said. "The indication was so clear and the downside was so small that docs just worked it into their practice easily. "Now it's much scarier than that," he said. "We could really be doing harm." Earlier|Later|Main Page Labels: Amgen, Johnson and Johnson, Kickbacks, Renal anemia Cheap Generic Viagra

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Source: Wikipedia Under health insurance, the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes, or due to accidents. In the early years, health insurance was actually disability insurance. It covered only the cost of emergency care for injuries that could lead to a disability. Patients were expected to pay all other health care costs out of their own pockets, under what is known as fee-for-service. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, emergency health care procedures and most prescription drugs. A health insurance policy is an annually renewable contract. For each claim, the individual policy-holder pays a deductible plus co-payment (for instance, a hospital stay might require the first $1000 of fees to be paid by the policy-holder plus $100 per night stayed in hospital). Usually there is a maximum out-of-pocket payment for any single year, and there can be a lifetime maximum. Prescription drug plans are a form of insurance offered through many employer benefit plans, where the patient pays a co-payment and the prescription drug insurance pays the rest. Some health care providers will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay, as the insurance company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee. Health insurance companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder. It will generally cost the patient less to use an in-network provider. Any private insurance system will face two inherent challenges: adverse selection and ex-post moral hazard. Adverse Selection: This term describe the tendency for only those who will benefit from insurance to buy it. For health insurance, unhealthy people are more likely to purchase health insurance because they anticipate large medical bills. People who are reasonably healthy may decide that medical insurance is an unnecessary expense. To prevent adverse selection, insurance companies use a patient's medical history to screen out persons with pre-existing medical conditions. Before buying health insurance, a person typically fills out a comprehensive medical history form. In general, those who look like they will be large financial burdens are denied coverage or charged high premiums to compensate. Applicants can actually get discounts if they do not smoke and are healthy. Moral Hazard: Moral hazard describes the state of mind and change in behavior that results from a person's knowledge that if something bad were to happen, the out-of-pocket expenses would be mitigated by an insurance policy--in this case, one which provides reduced prices for medical care. Cheap Generic Viagra

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