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The main risk is in the increased tendency towards thrombosis seen in smokers treatment whiplash purchase ropinirole 1mg visa, which can lead to medicine 014 generic ropinirole 1 mg online myocardial infarction treatment arthritis order genuine ropinirole. Smoking also increases the levels of carbon monoxide in the body medications used to treat schizophrenia buy ropinirole 0.25 mg amex, which binds to haemoglobin, reducing the amount of oxygen reaching body tissues. The number of daily smokers worldwide is thought to be around 1 billion men and 250 million women. All of these factors can increase the risk of atherosclerosis and thrombolytic embolism. Type I diabetes is also known as insulin dependent diabetes and is caused by the body not producing any 22. High blood pressure affects the heart by causing it to thicken and stiffen as it has to work harder to pump blood; this can lead to heart attacks. The effect on the vascular system is one of pressure on vasculature walls, leading to aneurisms and stroke. Cholesterol levels have on the whole been rising globally37 and are expected to continue rising in predictions up to 2030 (although interestingly, North America and Western Europe are expected to have a drop in cholesterol levels). This risk is inextricably tied in with several other risk factors such as diet, physical activity and levels of obesity. Physical activity can reduce cholesterol levels, decrease obesity and cause the heart and muscles to work harder in pumping blood around the body. The number of cases of diabetes is also likely to increase dramatically over the same timescale. Although both of these statistics are tempered by a predicted rise in world population, there is still a real increase in smokers and diabetes cases predicted to 2030 (Table 2). At least 155 million school-age children worldwide are overweight or obese, according to the latest estimates from the “International Obesity TaskForce”. Around 3045 million within that figure are classified as obese accounting for 2-3% of the world’s children aged 5-17. The development of the lipid hypothesis of atherosclerosis in Russia in the early 1900s provided the basis for research into cholesterol and the clinical relief of atherosclerosis through angioplasty (including catheterisation with balloons, and stents). Drug treatments have developed rapidly over the 20th Century, in particular the use of aspirin to prevent heart attacks and stroke in the 1970s, and the continuing advance of thrombolytic therapeutic drugs such as streptokinase (discovered in 1945). Since many advances in surgery are applicable across these types of procedures it is sensible to group surgical advances together. For each of these areas we will discuss the types of research that fall into them, with some advances used as illustrative examples. For example, advances in drug therapy to prevent rejection of transplanted tissue are an obvious area where surgery cannot advance without advances in areas such as the quality of drug therapy or effective genotyping of transplant donors. Electrics research now comprises projects looking at a variety of problems in cardiology that can be treated with electrical devices. One such area is the miniaturisation of implantable pacemakers, so that they do not need unwieldy battery packs. Another would be the use of implanted defibrillators to both monitor and restart the heart rhythm in any case of fibrillation. Advances in cardiology electrics are now very much dependent on developments in electrical engineering and computing technology. Firstly, research continues into heart surgery, concentrating on heart valve replacements and work on beating hearts. Secondly, research on surgery to other parts of the cardiovascular system is a major area of research. These include breakthroughs in angioplasty54 and implantation of electrical devices during surgical procedures. In this document we use mechanics to mean those interventions that mechanically alter the cardiovascular system. For example, stents are wire mesh tubes that are used to physically hold open the arteries. Stents are often used to keep arteries open after angioplasty so that the artery can heal without contracting and reducing blood flow. Stents are now also able to be covered in slow release drug coatings that inhibit closure (sclerosis) of the artery after surgery. These are called “drug eluting stents” and are becoming the common choice of cardiovascular surgeons. If using a catheter, then it is often necessary to have a stent that is initially smaller in diameter than the artery it is designed to hold open (in order to allow the stent to be put in place. When in position in the artery, the balloon is inflated, increasing the diameter of the stent and pushing the stent into position. Once open and holding the artery, the balloon is deflated and removed with the catheter, leaving the stent in place. More complex forms of catheterisation can remove atherosclerotic plaques; this is the process of atherectomy. There are a number of atherectomy methods that include shaving the plaque, sucking away parts of the plaque, using a rotational device that wears down the plaque (as a rotational sander would), and even laser atherectomy using adapted catheters. This has been criticised in the past as it biases against applied clinical research, since clinical researchers have different citation patterns to basic researchers. As part of the initial work in Project Retrosight, there will be a bibliometric analysis of the cardiovascular research field, identifying research from the case study countries in particular. Work by the Wellcome Trust in 1998 looked at publications in biomedical science and their distributions. In 2005, “The Scientist” magazine published a bibliometric analysis of the top papers (based on citations) published in all science over three periods – 2003-2005; 1995-2005; and all time. Number of global clinical trials published in Medline in selected biomedical subjects 2. However, Lenfant suggests that it is the follow up to decoding the human genome, identifying the make up of the human proteome that is going to be key in understanding pathological processes at the cellular level. Imaging is also mentioned, but in a more 60 Ross (1999) “Atherosclerosis An inflammatory disease”, New England Journal of Medicine, 340(2), 115126; and Shepherd et al (1995) “Prevention of coronary heart-disease with pravastatin in men with Hypercholesterolemia”, New England Journal of Medicine, 333(20), 1301-1307 61 Braunwald (1997) “Shattuck Lecture – Cardiovascular medicine at the turn of the Millennium: Triumphs, concerns and opportunities”, New England Journal of Medicine, 337(19), 1360-1369 62 Lenfant (2001) “Cardiovascular research: A look into tomorrow”, Circulation Research, 88, 253-255 63 the human proteome is the protein equivalent of the human genome, i. These research themes are echoed in Lefkowitz and Willerson’s 2001 “Prospects for Cardiovascular Research”. An example of this is the use of molecular biology advances to understand the molecular basis of plaque formation in athersclerosis. However, these research agendas are very much researcher led, rather than disease led. For example, they predict that by 2020, a vaccine may have been developed which switches of nicotine receptors (cutting the physical addictiveness of cigarettes). They also predict that by 2020 screening for heart disease will use an array of genetic markers; that xenotransplantation (transplantation of animal organs into humans) will be possible due to improved understanding of tissue rejection; and that nano-technology will allow intra-artery repair of atherosclerosis. Heart failure: preventing disease and death worldwide © European Society of Cardiology 2014. The views expressed in this publication are not necessarily those of the sponsor or publisher. Save where permitted under applicable copyright laws, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electrical, mechanical, photocopying, recording or otherwise, without prior written permission from the copyright owner. The commission of any unauthorized act in relation to this publication may lead to civil or criminal actions. The global burden of heart failure 4 Heart failure survival rates remain poor across the globe Heart failure is common, and patient numbers are increasing Heart failure exacts severe economic, social and personal costs 2. Identifying and treating patients at risk of developing heart failure Preventing heart failure in the elderly and socioeconomically disadvantaged: unique challenges 3. Improving public awareness of heart failure 14 Public awareness of heart failure symptoms is dangerously low A healthy lifestyle reduces the risk of heart failure 4. The need to apply best practice 16 Guidelines worldwide agree on the key stages in heart failure care Best practice in heart failure care involves compliance with guidelines Encouraging compliance: measuring and improving quality of care 5. Future directions in care: urgent unmet needs 24 Diagnosis: improved tools for medical decision-making in heart failure Treatment: new options are needed for many patients with heart failure Long-term management: innovation could save lives and money References 30 Acknowledgements 35 ii Executive summary Executive summary Heart failure is a life-threatening disease and addressing it should be considered a global health priority. At present, approximately 26 million people worldwide are living with heart failure. The outlook for such patients is poor, with survival rates worse than those for bowel, breast or prostate cancer. Furthermore, heart failure places great stresses on patients, caregivers and healthcare systems. Demands on healthcare services, in particular, are predicted to increase dramatically over the next decade as patient numbers rise owing to ageing populations, detrimental lifestyle changes and improved survival of those who go on to develop heart failure as the final stage of another disease.

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Among generic manufacturers medicine for depression order on line ropinirole, Hetero and Natco have obtained marketing authorization in India symptoms meningitis 0.5 mg ropinirole visa, Incepta in Bangladesh medications 1 gram generic ropinirole 0.25mg online, and Pharma 5 in Morocco symptoms flu order genuine ropinirole on line. Data protection is waived, and licensees are authorized to sell outside the licensed territory, so as long as they do not use the technology transferred from the originator company, and do not infringe patents. So far, seven companies have signed the licensing agreement with the Medicines Patent Pool (Aurobindo, Cipla, Emcure, Hetero, Laurus, Natco and Zydus Cadila). Two of them, Hetero and Natco, are reported to be manufacturing daclatasvir and marketing it at least in India. Several companies are making daclatasvir available outside of the licensing agreement in countries where there are no patents as in Bangladesh, Egypt and Morocco. Prices of generic daclatasvir 60 mg, per 28-day supply, reported from Bangladesh, Egypt, India and Morocco Local market Export Manufacturers Marketing companies/distributors Country Public Private Public Private Incepta Pharmaceuticals Ltd. Signifcant reductions in cost of generic production of sofosbuvir and daclatasvir for hepatitis C treatment in lowand middle-income countries. European Association for the Study of the Liver, International Liver Congress 2016, Barcelona, Spain, 13–17 April 2016. For subtype 1b, use for 12 weeks without ribavirin (no cirrhosis) or with ribavirin (compensated cirrhosis). Alternative regimen: for genotype 4 infection (without dasabuvir); use with ribavirin for 12 weeks (no cirrhosis) or 24 weeks (compensated cirrhosis). The fact that the treatment combines three different molecules with different patents fled for each molecule makes it more challenging for generic companies to circumvent patents where granted. For the triple combination (ombitasvir/paritaprevir/ ritonavir plus dasabuvir), it was approved in Albania, Azerbaijan, Bosnia and Herzegovina, Brazil, Colombia, Costa Rica, Egypt, Malaysia, Mexico, Serbia and Tunisia, and fled in Belarus, Dominican Republic, Ecuador, Jamaica, Panama and Thailand. The originator company of ombitasvir/paritaprevir/ritonavir plus dasabuvir has not developed a comprehensive medicines access programme or entered into a license agreement. It uses a case-by-case “access pricing” approach for Africa and other lowand lower–middle-income 42 countries. Price negotiations are under way in Algeria, Moldova, Morocco, South Africa, Tunisia and Ukraine. The company grants compassionate use and/or early access on a case-by-case basis, based on therapeutic need and eligibility. Through its early access programme, the company is currently providing treatment on a named patient basis in Mongolia, Tunisia, Ukraine and Viet Nam. In the absence of license agreements and because of patent protection around all three components of the treatment, and due to the complexity of the combination, there are no generic versions approved in any country so far. None of the generic manufacturers surveyed indicated that it intends to develop a generic version. Simeprevir is registered in a few middle-income countries, including Brazil, Bulgaria, Colombia, Egypt, El Salvador, Guatemala, Lebanon, Mexico, Moldova, Nicaragua, Peru, Romania, Thailand and Ukraine, and in one low-income country (Rwanda). The company has not entered into a license agreement, despite the fact that simeprevir has already been on the market for nearly three years. It will evaluate requests for compassionate use from any country where simeprevir is not available. There is no generic production of simeprevir at this time, but two generic manufacturers (Incepta in Bangladesh and Hetero in India) reportedly plan to develop a generic version. The patents cover the compound, the prodrug, crystalline forms, formulations and combinations. The primary patents that claim the compound and the prodrug have not been fled in certain countries or regions (see. Secondary patents have been fled more widely and thus require screening as to what extent they are relevant to local production or importation of generic versions. Most of these countries are also included in the territory of the license agreement. Information about the registration status of sofosbuvir is available online (77, 95). The innovator company announced that it endeavours to register its hepatitis products in all countries included in its access programme (101 countries) using the royalties of the license agreements to fnance this activity. None of the generic formulations produced by the different companies has been prequalifed or approved by a stringent regulatory authority. Status of registration of generic sofosbuvir 400 mg, reported by generic companies Company Approved Submitted Dossier in preparation Hetero Algeria, Bangladesh, Democratic Kenya, Benin, Myanmar, 19, including Ukraine Republic of the Congo, Egypt, India, Viet Nam Nepal Natco Kyrgyzstan, Nepal 36 countries Strides 20 countries including Egypt, Nigeria, South Africa Pharco Azerbaijan, Egypt, Kyrgyzstan and Ukraine Cadila India Pharma 5 Cote d’Ivoire, Guinea, Morocco Incepta 24 countries Richmond Argentina Getz Pharma Pakistan Pricing and access. Since then, the price has declined through negotiations with medicines distributors and public sector agencies such as the U. The high price has led public and private payers in high-income countries to institute non-evidence-based access restrictions – including for those with a history of current or past injection drug use. Prices in highincome countries remain high and put serious pressure on health systems (see Chapter 3). In countries that are not included in the voluntary license agreement and in high-income countries, the innovator company, Gilead Sciences, negotiates prices on a country-by-country basis without disclosing the negotiated price publicly. The innovator company has signed agreements with 11 generics manufacturers in India, two generics manufacturers in Egypt and one manufacturer in Pakistan. The latter agreements allow them to import or manufacture and sell sofosbuvir in their national markets; see Chapter 3 for more detail. Countries where no patents are in force can, however, buy sofosbuvir or sofosbuvir/ ledipasvir from manufacturers that have not signed the license agreement with Gilead Sciences. The 101 countries in the territory include all low-income and many but not all middle-income countries. To access the reduced prices offered by Gilead Sciences and its licensees, countries must implement Gilead Sciences’ anti-diversion measures; so far, this has been documented in Egypt, Georgia, Pakistan, Romania and Rwanda. It is important that such programmes do not compromise patient autonomy, confdentiality, the patient–medical provider relationship, and do not logistically complicate procurement and delay treatment scale up (see Chapter 4, Box 4. Prices of generic sofosbuvir 400 mg, per 28-day supply, reported from Bangladesh Egypt, India (64), Morocco and Pakistan Marketing companies/ Local market Export Manufacturers Country Distributors Public Private Public Private Incepta Incepta Pharmaceuticals Ltd. Pharco* Pharco* Egypt $51 $70 $70–85 N/A Natco Pharma Ltd N/A $149 N/A $199 Emcure Pharmaceuticals Ltd N/A $154 N/A N/A Mylan Ltd N/A $163 N/A N/A Natco Pharma Ltd. Strides Shansun N/A $108 N/A $300 Zydus Heptiza (division N/A $185 N/A N/A of Cadila Healthcare Ltd) India Hetero Labs N/A $185 N/A $250–$300 Abbott India Ltd N/A $192 N/A N/A Biocon N/A $215 N/A N/A Hetero Labs Cipla Ltd N/A $169 N/A $233 Dr Reddy’s N/A $215 N/A N/A Ranbaxy N/A $154 N/A N/A Sun Pharmaceuticals Ltd N/A $180 N/A N/A Pharma 5 Pharma 5 Morocco N/A $300 N/A N/A Getz Pharma Getz Pharma Pakistan N/A $15–42 N/A N/A *26 other manufacturers or distributors are currently producing or marketing generic sofosbuvir in Egypt. Hetero N/A India Dr Reddy’s Hetero N/A India Emcure Natco N/A India Pharma 5 Pharma 5 N/A Morocco Getz Pharma Getz Pharma N/A Pakistan 1 Hetero and Natco market sofosbuvir under their own name, but also sell fnished formulation to other companies. Most of the countries where the primary patent has not been fled or granted are included in the territory of the license agreement, for example, the Philippines, but there are also some countries outside the license agreement, for example, Georgia, Iran, Jordan and Malaysia. Information about the registration status of sofosbuvir/ledipasvir of the originator company is available online (77). The company announced that it endeavours to register its hepatitis products in all countries included in its access programme (101 countries) using the royalties of the license agreements to fnance this activity. For the time being, none of the generic formulations available from different companies has undergone approval by a stringent regulatory authority or prequalifcation. Sofosbuvir/ledipasvir is covered by the same voluntary licensing agreement as sofosbuvir (see Chapter 3 for details). Companies that produce or market sofosbuvir/ledipasvir 400 mg/90 mg Manufacturer of the Type of license Distributor Country of origin fnished formulation agreement Companies selling or producing fnished formulations of sofosbuvir/ledipasvir with a license from Gilead Sciences (101 countries/territories) Hetero1 Hetero International India Cipla N/A International India Sun Pharma Hetero International India Natco1 Natco International India Cadila Hetero International India Mylan N/A International India Companies selling or producing fnished formulations with a national license None reported Companies selling or producing fnished formulations of sofosbuvir/ledipasvir without a Gilead license Incepta Incepta None Bangladesh Beximco Beximco None Bangladesh Pharmed Health Care, Future Pharmaceutical Industries, Marcyrl co. Wide variation in estimates of global prevalence and burden of chronic hepatitis B and C infection cited in published literature. Hepatitis C virus maintains infectivity for weeks after drying on inanimate surfaces at room temperature: implications for risks of transmission. Vertically acquired hepatitis C virus infection: correlates of transmission and disease progression. Pathology of chronic hepatitis C in children: liver biopsy fndings in the Peds-C Trial. Evaluating progression of liver disease from repeat liver biopsies in children with chronic hepatitis C: a retrospective study. A prospective study of the rate of progression in compensated, histologically advanced chronic hepatitis C. Manual for the development and assessment of national viral hepatitis plans: a provisional document. Patent situation of key products for treatment of daclatasvir, ledipasvir, simeprevir, sofosbuvir, ombitasvir/paritaprevir/dasabuvir (updated June 2016).

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Udi Aloni treatment strep throat order ropinirole 2mg otc, 97 min 92507 treatment code discount ropinirole online master card, in English) On April 9 symptoms ketoacidosis buy ropinirole 0.5 mg otc, 1948 medicine werx purchase genuine ropinirole on line, a Jewish militia entered the Palestinian village of Deir Yassin and killed over 100 villagers. A legend says that to this day, the survivors have been communicating with the ghosts of the village. Through the voices of Israeli and Palestinian citizens of diverse backgrounds, it reveals their hopes and fears and explores the issues that divide them. It also describes in a compelling way a broad common ground of yearning for peace, pointing the way toward a resolution of this tragic conflict that would meet the deepest needs of both societies. But when the Israeli government ordered the evacuation of Gaza in August 2005 as part of its disengagement plan, the decision resulted in massive political and social turmoil. Storm of Emotions documents the historic moment of this evacuation, one of the most complex and provocative missions to ever be undertaken by Israel’s police forces. The film focuses on the police forces as it accompanies police crews during the disengagement process and follows participants including a religious policeman, a policewoman, senior officers, and more. Hany Abu-Assad, 90 min, Arabic with English subtitles) On a typical day in the West Bank city of Nablus, where daily life grinds on amidst crushing poverty and the occasional rocket blast, we meet two childhood best friends, Said (Kais Nashef) and Khaled (Ali Suliman), who pass time drinking tea, smoking a hookah, and working dead-end menial jobs as auto mechanics. From their spirited interaction, it is apparent that there is a budding romance growing between them. But then Said is approached by middle-aged Jamal (Amer Hlehel), a point man for an unnamed Palestinian organization who informs Said that he and Khaled have been chosen to carry out a strike in Tel Aviv. They were chosen for this mission as a team, because each had expressed a wish that if either is to die a martyr, the other would want to die alongside his best friend. Rashid Masharawi, 90 min, in Arabic with English subtitles) Ahmad, a film director, tells people he is leaving home to settle abroad far from Palestine. Reluctantly, he accepts one last job: to audition actors for the new National Palestinian Theatre, a dream project still under construction with unreliable funding. Humor comes with a dash of irony, like when a straight-faced Bissan delivers a rapid series of optimistic news cliches about their region for a sound check. Everywhere, they are greeted by long lines of camp residents: the would-be actors hope that the chosen ones will get to return to Palestine. One young woman claims to have been an extra in a crowd that marched down the street shouting “Free Palestine! Ahmed directs them to perform a familiar action, one at the heart of their lives: to wait. Tawfik Abu Wael, 100 min, Arabic with English subtitles) It has been ten years since Abu Shukri and his family, have settled in a valley, in the middle of nowhere, far away from their hometown. The father goes to the village to sell the charcoal whereas the son runs off to the village school. Abu Shukri, the father, brought them to this place against their will and they know that the reason why they left the village is also the reason why they can never return. The second film produced in 2002 won first place at the 2003 International Student Film Festival. Though the children live only 20 minutes apart, they exist in completely separate worlds; the physical, historical, and emotional obstacles between them run deep. Promises explores the nature of these boundaries and tells the story of a few children who dared to cross the lines to meet their neighbors. Rather than focusing on political events, the seven children featured in Promises offer a refreshing, human and sometimes humorous portrait of the Palestinian-Israeli conflict. This series includes two episodes recounting the rebuilding of the Nasrallah family’s house, the family that Rachel Corrie sought to protect when she was killed. Elia Suleiman, 88 min, in Arabic, Hebrew, French & English with English subtitles) Like a meditative Jacques Tati, Elia Suleiman plays the protagonist E. But his journey becomes a search for roots by a man whose culture has been uprooted. The film explores the effects of ghettoization and marginalization on the Palestinian psyche. He begins to inquire into his sense of belonging, his role as the insider/outsider. The complex Israeli social and political fabric is captured in a Tel Aviv pub owned by a middle aged woman who, along with her patrons, is looking for love. Artistically shot in black-and-white, the story details the intertwining lives of those who frequent a small coffee-house/bar. Arab and Jewish teens work with counterparts from around the country to create original dramas about coexistence. The plays, in Arabic and Hebrew, are performed for family, friends and the public at-large. Innocent Abroad: An Intimate Account of American Peace Diplomacy in the Middle East. The book emphasizes Clintons initial strategic focus on Syrian-Israeli relations, and the authors discussion of Syria runs parallel to his central narrative about the Israel-Palestine conflict, which traces the tumultuous eight years from the hopeful handshake between Yitzhak Rabin and Yasser Arafat in 1993 through the beginning of the second intifada. The author achieves an impressive balance of scale, packing a tremendous amount of anecdotal information throughout, creating a portrait of diplomacy that reveals the influence of countless small details, from ceremonial gifts to friendly kisses, on world affairs. At the same time, the book surveys the enduring challenges that plagued the Clinton team’s efforts to bring peace to the region, making insightful connections between the history in which the author participated and the present state of the region. Drawing from his extensive experience and 160 interviews with presidents, advisers and negotiators, he apportions censure and praise with an even hand, sparing not even his failures or those of his colleagues. Miller evinces genuine compassion for both sides in the conflict (stressing that Americans cannot fully understand the life-and-death stakes in the struggle between Israelis and Palestinians), while maintaining a detachment that allows him to draw hard conclusions. Miller says that though the two sides hold ultimate responsibility for their shared fate, American involvement is imperative and calls for the tough-love approach of Kissinger and Carter, arguing compellingly that such engagement is now more vital to our national interests, and to our security, than at any time since the late 1940s. Lasensky provide a peerless example of sound public-policy analysis, in which American national interests are the paramount value pursued. Practitioners, scholars and students are unlikely to see anything like it in literature on the Arab-Israeli conflict. This is not a patient, soft-spoken, diplomatic treatise on the niceties of how to negotiate peace treaties. Rather, it is closer to an indictment of how a great country like the United States, with all its resources and strengths, cannot match its power with sophisticated leadership necessary to bring all parties of the Arab-Israeli conflict to an agreement. To be sure the reader does not miss the point, the authors use the word failure and its synonyms over 172 times throughout the text. In "Restoring the Balance," experts from the Saban Center at the Brookings Institution and from the Council on Foreign Relations propose a new, nonpartisan strategy drawing on the lessons of past failures to address both the short-term and long-term challenges to U. A World of Trouble: the White House and the Middle East-from the Cold War to the War on Terror. Tyler makes the issues and relationships clear without resorting to oversimplification or ideological grandstanding, and his journalistic instincts steer him toward direct quotation and telling anecdotes rather than generalization. The Palestine Mandate and the Creation of Israel, 1920-1949 (The Making of the Middle East). An engineer of the 1978 Camp David Accords and 2002 recipient of the Nobel Peace Prize, Carter would seem to be a perfect emissary in the Middle East, an impartial and uniting diplomatic force in a fractured land. In hard-hitting essays the contributors debate the two justifying and rationalizing constructions, laying bare the conflict’s roots and the distorted prisms that fuel it. Israeli and Palestinian Narratives of Conflict is an invaluable resource for anyone seeking to make sense of today’s headlines. Occupied by Memory: the Intifada Generation and the Palestinian State of Emergency. Based on extensive interviews with members of the "intifada generation," those who were between 10 and 18 years old when the intifada began in 1987, the book provides a detailed look at the intifada memories of ordinary Palestinians. The stories are presented as part of a complex and politically charged discursive field through which young Palestinians are invested with meaning by scholars, politicians, journalists, and other observers. What emerges from their memories is a sense of a generation caught between a past that is simultaneously traumatic, empowering, and exciting—and a future that is perpetually uncertain. The book will be of interest not only to scholars of the Middle East but also to those interested in nationalism, discourse analysis, social movements, and oral history. Offering a balanced history of both Israeli and Arab goals, Palestine and the Arab-Israeli Conflict covers the history of Palestine before Israeli independence in 1948 and brings the story forward to the breakthrough Arab-Israeli Accord of 1993 and its troubled aftermath. Helena Cobban reviews the history of negotiations between Israel and Syria during the 1990s and provides insider information about the negotiating dynamics, patterns, personalities, and changes between these two mid-eastern nations.

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The Massachusetts OxyContin and Heroin Commission of the state legislature made a similar recommendation in its 2009 report treatment urinary tract infection purchase 2 mg ropinirole mastercard, suggesting that school education programs be updated to treatment for scabies order ropinirole without prescription include illicit drugs and prescription drug abuse treatment refractory buy ropinirole with a mastercard, and that a statewide program should be required throughout the continuum of education symptoms yeast infection order genuine ropinirole on line, including in elementary schools. Advocates should also assess the extent to which viral hepatitis education is provided or could be integrated into youth substance use disorder prevention programs (such as recovery schools and youth intervention programs), regional centers for healthy communities, and town-based community partnerships on youth substance use disorder prevention. A statewide campaign could include signs on subways and buses, public service announcements, and social media efforts that build upon the consistent messaging strategies used by “Know More Hepatitis. This education campaign must also include creation and promotion of culturally sensitive materials. Advocates could approach pharmaceutical companies and the American Liver Foundation for funding and sponsorship to support these initiatives. However, advocates at Tapestry note that reimbursement for the rapid test by MassHealth is far below the actual cost of administration. Still others worry that having an independent line item may make hepatitis funding more vulnerable to cuts. Advocates will need to make a decision about which strategy will be most effective. By teaching pediatricians and primary care providers to perform a short questionnaire accompanied by a brief intervention, providers can identify and refer more individuals in need of substance use disorder support. As will be discussed in the next section, more research is needed to identify how best to coordinate and fund models of care and treatment that incorporate both medical and community-based supports for individuals with co-occurring disorders. One treatment provider indicated that while the funding disappeared, there is still a continued need to support clients dealing with hepatitis C. More research is needed to identify how best to coordinate and fund models of care and treatment that incorporate both medical and community-based support for individuals with co-occurring disorders. In many ways, Massachusetts is far ahead of the rest of the country in its provision of health insurance for almost all of its residents. At the same time, even for insured individuals in Massachusetts, there are still barriers to care and treatment as well as opportunities for improvement. In particular, many people reported that the cost of copays for individuals with private insurance can act as a major barrier, with some copays for those undergoing treatment in the thousands of dollars. For example, in Provincetown as with many summer tourist communities, residents’ income can vary widely from the summer (when tourists are in town) to the winter months when they may be largely unemployed. Further, individuals with mental health and substance use disorders may be disproportionately impacted by complicated and burdensome administrative procedures and other barriers to enrollment that can lead to lack of coverage. Pursuant to the new laws, prescription drug companies may now provide assistance in the form of copay cards and coupons for any drugs that do not have generic equivalents,389 which could include the new protease inhibitors. While in many ways Massachusetts was the model for federal reform, under the new laws there will also be changes to the Massachusetts system. This could reduce churning for some individuals who move back and forth between CommCare and MassHealth (for example, long-term unemployed individuals). Benefts for these newly eligible individuals are expected to be similar to those currently offered in CommCare Type 1 plans (through which many of these individuals may currently be receiving insurance). To the extent that benefts in the new Basic Health Plan may differ from those currently offered in various MassHealth plans, this could potentially lead to lesser benefts and slightly increased cost sharing for some consumers. At the same time, advocates are currently working with the Offce of Medicaid to explore ways to create safeguards that would ensure that these populations continue to maintain access to the same levels of benefts and cost sharing. By implementing the Basic Health Plan, state offcials hope to reduce the number of persons who experience gaps in coverage by creating greater continuity between plans offered on MassHealth and those offered through Basic. Unlike CommCare for example, the new Basic Health Plan will be administered by the Offce of Medicaid (which also administers MassHealth). Because people would receive these new tax credits prospectively, they could be subject to a reconciliation process where they would have to return a portion of their tax credit should their expected income change. By contrast, under the Basic Health Plan option, Massachusetts would receive the tax credits rather than the subsidies going directly to the individual, eliminating the problem of potential reconciliation for people in this income bracket. Finally, the Basic Health Plan option might also allow Massachusetts to provide greater subsidization for this population, as the subsidies offered through federal tax credits will be lower than the current level of subsidization for individuals in this income bracket on CommCare. Unfortunately, the state has recently indicated that it may no longer be able to utilize the Basic Health Plan option due to a lack of federal guidance, as no federal regulations concerning state implementation of this option have been released. Advocates should push for federal guidance and state implementation of the Basic Health Plan. Although the state has indicated that it will work to cover the gaps in cost to some degree, it is not clear yet whether these individuals will receive the same level of subsidization as is currently available through CommCare. Such changes will also require expansive outreach and enrollment efforts to help explain the evolving system, as many individuals may be transitioning from one program to another (for example, CommCare to the Basic Health Plan). Many of the individuals served through these programs may be homeless, battling addiction, and/or low income, and some people never make it back to the test sites to receive and discuss their results. If clients cannot afford phones, counselors may receive test results but be unable to reach the affected individuals for follow-up. For example, the average wait time in Hampden County for internal medicine was 99 days, and for gastroenterologists it was 67 days. All of these factors can lead to instances where an individual may be lost to follow-up. In other areas such as Fall River and Fitchburg, public transportation is available only during working hours. These individuals may be frequenting the same community-based sites for harm reduction but never actually see a medical provider. For example, in a study done at Charlestown Community Health Center, loss to follow-up was the most common barrier to treatment among adults ages 40 and older (23%), and even more common among younger adults, ages 20 to 39 (40%), who had received a positive test result but not treatment. Particularly for the Latino community in western Massachusetts, advocates identifed a lack of providers with linguistic and cultural competence, which may also affect a patient’s understanding of a test result. Fear of Treatment/Diffculty of Treatment Fear of the side effects of interferon-based treatment was another challenge identifed by community advocates. More than one individual who had been through treatment said it was one of the hardest things basic training in they have ever done, and described constant fatigue, the army. Further, each individual responds differently to treatment, and for some, the process may not be nearly as onerous. For both these reasons, it is important for individuals to have all the most recent information prior to making an informed decision with their doctor about whether to pursue treatment. A minority of people (10-25%) clear the virus spontaneously and never develop chronic illness. This means that even when individuals have access to medical care, there can be additional medical or structural barriers to actually receiving treatment. For example, patients who are actively injecting drugs may develop fungal and/or bacterial infections, and antiviral medications can decrease their body’s ability to respond to the infection. Patients also make choices about whether to engage in treatment, regardless of a provider’s recommendation. However, several community members expressed concern that there are not enough substance use disorder treatment programs in Massachusetts, particularly for youth. For example, Massachusetts ranked among the highest states (top ten) for individuals needing but not receiving treatment for illicit drug use in the past year among youth aged 12-17 years and young adults aged 18-25 years. The plans should aim to create a network within the community so that individuals who are dealing with viral hepatitis will know where to go, and support providers will know where to refer them. Further, as previously discussed, communities may have coalitions and even strategic plans to address substance use disorder, and these plans should be revisited to incorporate viral hepatitis education and prevention. Using rapid tests signifcantly alleviates the problem of clients not returning to receive test results, and allows immediate referral to other resources when necessary. As a result, counselors report an increase in the number of people they are able to effectively counsel and refer. Increasingly, young adults are presenting at clinics suffering from overdoses and other substance use problems. They are also building relationships with other primary care providers (including pediatricians), who may not be aware of the risk factors for substance use disorder and/or hepatitis. Third, Charlestown has begun offering hepatitis testing to all patients in its suboxone clinic. With the help of a staff member, every week providers at the center are alerted if a suboxone patient is coming in who should be referred for hepatitis testing.

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