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Since the mid 90's, payers have been utilizing the specialty pharmacy provider SPP ; to help them manage their ever-growing member base requiring these high cost injectable products. With this trend continuing to grow, it is certain that the specialty pharmacy sector will continue to be a key component of the healthcare services machine for many years to come. This being a certainty, the need to understand the capabilities of this sector is a must. To start this inquiry, the first and most obvious question is "what exactly is specialty pharmacy and what makes it so special"? To answer this and to gain a better understanding of their service capabilities as a whole, lets start at the beginning. The specialty pharmacy companies of today trace their roots back to the home intravenous pharmacy service model founded in the late 70's. The home IV model grew out of a need to provide a more convenient, lower cost alternative to hospital delivered parental nutrition and IV antibiotics. As it is often the case in new industries, growth and expansion consolidates, slows and eventually turns south. The homecare market was no exception. The rapid home IV pharmacy industry growth came at a price. As more companies entered the market vying for preferred "fee for service" payer contracts, profit margins began to erode and fairly fast at that. By the mid 90's, aggressive contracting drove down profitability almost four-fold. Home IV companies, with their comprehensive and costly clinical services could no longer afford to provide their standard service offerings. Financial survivability for many home IV companies meant streamlining their operations through centralizing distribution and spinning off or closing profit-draining services such as nursing and social works. Additionally, companies turned their service focus away from operationally intensive intravenous products, to a select group of expensive, self-injected therapies. Thus, beginning around 1995, evolving out of the home IV pharmacy market, a cost effective, "high touch" service model emerged as a means to help support the special therapy needs associated with the chronic injectable product. This model, referred today as "Specialty Pharmacy, " continues to be a primary means by which many payers and manufacturers chose to distribute specialty injectable products to their members or patients. Today, the national specialty pharmacy providers SPP ; are comprised of a mixture of independent "stand alones, " PBM, and or retail chain owned organizations. This represents a major shift from what had been an "inde. Do not fall, buy avapro of morecomplex than 16 hours and baycol. Tablite supplements are special formulations by solaray, inc to be fast-acting, easy to swa.
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Two of the Group's leading products were jointly developed with BMS: the anti-hypertensive agent irbesartan Aprovel Avaro Karvea ; and the atherothrombosis treatment clopidogrel Plavix Iscover ; . Sanofi-Synthlabo is paid, as inventor of the two molecules, a royalty on all sales generated by these products. This royalty is recorded as a reduction in cost of goods sold. As co-developers of the products, Sanofi-Synthlabo and BMS each receive equal development royalties from their two licensees, which have been responsible, since 1997, for marketing the products using their local distribution network, composed of the affiliates of both groups. These licensees operate in two separate territories: i ; Europe, Africa and Asia, under the operational management of Sanofi-Synthlabo; and ii ; other countries excluding Japan ; , under the operational management of BMS. In Japan, Sanofi-Synthlabo has granted a license for irbesartan to BMS and Shionogi, a Japanese pharmaceutical company. The alliance agreement does not cover the distribution of Plavix in Japan. The products are marketed in different ways in different countries. Co-promotion consists of a pooling of sales resources under a single brand name. Co-promotion is preferably achieved through contracts or through appropriate tax-transparent legal entities. Each partner records directly its share of taxable income. Co-marketing consists of separate marketing of the products by each local affiliate using its own name and resources under different brand names for the product. In certain countries of Eastern Europe, Africa, Asia, Latin America and the Middle East, the products are marketed on an exclusive basis, either by Sanofi-Synthlabo or by BMS. In the territory managed by Sanofi-Synthlabo, operations are recognized by the Group as follows: i ; In most countries of Western Europe and Asia for clopidogrel Plavix Iscover ; excluding Japan ; , co-promotion is used for both products. The legal entities used are partnerships "socits en participation" ; or other tax-transparent entities, which are majority-owned by and under the operational management of the Group. Sanofi-Synthlabo recognizes all the revenue associated with the sale of the drugs, as well as the corresponding expenses. The share of net income reverting to BMS subsidiaries is recorded in "Other operating income expense ; , net.

The medical management of unruptured EP, after adequate patient selectiion, in the majority of cases renders any surgical intervention unnecessary and preserves fertility potential. In both, the conservative management with MTX and the salpingostomy techniques, tubal patency and future fertility performance, seem to be similar. Repeated administration of MTX leads to regression of the EP in up 95% of the treated cases. However, not rarely 20% ; this is accompanied by unpleasant side effects, due to systemic distribution of the drug, which can be avoided with a single dose. This is even more advantageous when the drug can be administered intra-amniotically, under ultrasound guidance. Medical management of EP, has very rarely been employed, when the gestational mass was beyond 35 mm, and or the cardiac activity visible. In the limited number of cases that this was reported, the success rate was low and this could be attributed to the inadequate amount of MTX given 50mg ; . The above, generally accepted limitations of this treatment, have been based mostly on logical assumptions and hence, they are rather arbitrary. We found that, in the unruptured early ET 56 days from the LMP ; , the local administration of 100mg MTX, under laparoscopic or sonographic guidance, seems to be effective, regardless of the pretreatment - HCG levels, the size of the gestational sac or the presence of cardiac activity, and with no significant side effects. In view of the high initial dose 100mg ; , repeat MTX is not recommended. Instead, cases with persistently high -hCG levels, should be managed by laparoscopic salpingostomy or, if the fetal heart activity is visible, by intracardiac injection of 10% KCL or other embryotoxic agent. Although in the laparoscopic linear salpingostomy, the resolution period is more predictable and shorter , local injection of MTX could be the first choice in unruptured EP, avoiding a comparatively prolonged and more complicated laparoscopic salpingostomy. Hence, the recently reported view that operative laparoscopy should remain the gold standard for treating early EP, does not seem justified, however it might be appreciated that the technique chosen , often depends on the skills of the gynaecologist. FM3.03.03 LAPAROSCOPIC MANAGEMENT OF ECTOPIC PREGNANCY. Per Lundorff, Viborg-Kjellerup Sygehus, Viborg, Germany The benefits of laparoscopic surgery were evaluated in a randomized trial and compared with atraumatic surgical treatment by laparotomy. Consecutive analysis of human chorionic gonadotropin hCG ; in serum was used for prediction and detection of persistent trophoblast. The pelvic status could be evaluated both at EP surgery and at second-look laparoscopy. Impairments or improvements of adhesions between laparotomy and laparoscopy were evaluated. Fertility outcome was assessed by questionnaires to all patients, and the impact of adhesion formation and adhesiolysis was rated with respect to the fertility outcome. Results: For the laparoscopy group the mean postoperative stay at hospital was 2.2 days and 5.4 days for the laparotomy group. The mean sick leave for the laparoscopy group was 10.9 days and 24.1 days for the laparotomy group. Thirteen patients 12% ; developed complications because of persistent trophoblastic activity. There was no statistical significans between the groups. After the laparoscopic approach, the impairment of the adhesion status was considerably less than after laparotomy. HCG levels of 3000 IU L was a valuable limit for detecting persistent trophoblast. Yet, intrauterine pregnancy rate after laparoscopic surgery did not differ from the laparotomy group. Conclusions: Pre and postoperative hCG determinations are valuable for the prediction and detection of subsequent complications. The fertility outcome of patients treated by laparoscopy or laparotomy is equal, although adhesion formation is more extensive after laparotomy. Table align ’ center’ border ’ 0′ cellpadding ’ 1′ cellspacing ’ 0′ width ’ 100%’ avapro without a prescription avapro florida buy avapro diet pillniagara cheap avapro cod falls order avapro usually recommended by the drug is and cefzil!

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