It is also part of the Lisbon number of ‘indirect’ methods have been developed to Consensus on core epidemiological demand indicators provide estimates for this group of drug users cheap 200mg prometrium with visa, including which has been endorsed by the Commission on Nar- benchmark and multiplier methods (benchmark data cotic Drugs purchase prometrium 100 mg with visa. Drug consumption among the youth population countries where there was evidence that the primary (prevalence and incidence); ‘problem drug’ was opiates, and an indirect estimate existed for ‘problem drug use’ or injecting drug use, this 3. High-risk drug use (number of injecting drug users was preferred over household survey estimates of heroin and the proportion engaged in high-risk behaviour, use. Utilization of services for drug problems; alence data found by means of household surveys. Drug-related mortality (deaths directly attributable to Extrapolation methods used drug consumption). Adjustment for differences in age groups Efforts have been made to present the drug situation from countries and regions based on these key epide- Member States are increasingly using the 15-64 age miological indicators. Where the age groups reported by Member States did not differ The use of annual prevalence is a compromise between significantly from 15-64, they were presented as lifetime prevalence data (drug use at least once in a life- reported, and the age group specified. Where studies time) and data on current use (drug use at least once were based on significantly different age groups, results over the past month). A number of countries reported ally shown as a percentage of the youth and adult popu- prevalence rates for the age groups 15+ or 18+. The definitions of the age groups vary, however, cases, it was generally assumed that there was no signifi- from country to country. The number of drug bution of drug use among the different age cohorts in users based on the population age 15+ (or age 18+) was most countries, differences in the age groups can lead to thus shown as a proportion of the population aged substantially diverging results. Applying different methodologies may also yield diverg- Extrapolation of results from lifetime prevalence to ing results for the same country. In such cases, the annual prevalence sources were analysed in-depth and priority was given to the most recent data and to the methodological Some countries have conducted surveys in recent years approaches that are considered to produce the best without asking the question whether drug consumption 258 Methodology took place over the last year. For for a country with a lifetime prevalence of cocaine use of example, country X in West and Central Europe reported 2% would decline to 0. Therefore, data the higher the lifetime prevalence, the higher the annual from countries in the same subregion with similar pat- prevalence and vice versa. Based on the resulting regres- terns in drug use were used, wherever possible, for sion curve (y = annual prevalence and x = lifetime prev- extrapolation purposes. Almost the same result is obtained by calculating interval among those aged 15-64 years in the given the ratio of the unweighted annual prevalence rates of country. The greater the range, the larger the level of the West and Central European countries and the uncertainty around the estimates. Extrapolations based on school surveys A similar approach was used to calculate the overall ratio by averaging the annual/lifetime ratios, calculated for Analysis of countries which have conducted both school each country. Multiplying the resulting average ratio surveys and national household surveys shows that there (0. There is a close correlation The correlation, however, is weaker than that of lifetime observed between lifetime and annual prevalence (and and annual prevalence or current use and annual preva- an even stronger correlation between annual prevalence lence among the general population. In 0 such cases, other countries in the region with a similar socio-economic structure were identified, which reported Life-time prevalence in % of population age 15-64 annual prevalence and treatment data. A ratio of people Data points treated per 1,000 drug users was calculated for each Regression curve country. The results from different countries were then 259 World Drug Report 2011 averaged and the resulting ratio was used to extrapolate possible. One exception was South Asia’s subregional the likely number of drug users from the number of opiate and cannabis estimates. Instead of using all prevalence estimates number of people who use drugs and the for Asia (that is, estimates from the Near and Middle health consequences East to East Asia) to determine India’s contribution to the subregional uncertainty, it was determined that For this purpose, the estimated prevalence rates of coun- India’s contribution was best reflected by its neighboring tries were applied to the population aged 15-64, as countries. Ranges (not absolutes) are provided for dramatic effect on regional and global figures (since estimated numbers and prevalence rates in the Report. Countries with one published estimate (typically those Two ranges were produced, and the lowest and highest countries with a representative household survey, or an estimate of each the approaches were taken to estimate indirect prevalence estimate that did not report ranges) the lower and upper ranges, respectively, of the total did not have uncertainty estimated. The two approaches were as follows: lished estimate, the 10th and 90th percentile in the range of direct estimates was used to produce a lower Approach 1. For example, there are three coun- The global estimates of the number of people using each tries in the North Africa subregion with past year preva- of the five drug groups in the past year were added up. The size of this adjustment was the remaining three countries without prevalence data, made based upon household surveys conducted in the namely the Libyan Arab Jamahiriya, Sudan and Tunisia. Across these the remaining three countries without prevalence data studies, the extent to which adding each population of for a subregional total lower and upper estimate. The average proportion was obtained from house- estimate for populations in subregions with no pub- hold surveys conducted in the same countries as for lished estimate, all of the countries throughout the Approach 1 Across all of these studies, the median pro- region were considered using the 10th and 90th percen- portion of total drug users that comprised cannabis users tile of the regional distribution. The range of cannabis users at the global level combined with those subregions where an estimate was was therefore divided by 0. Estimates of the number of drug-related deaths The number of problem drug users is typically estimated Drug-related deaths include those directly or indirectly with the number of dependent drug users. Sometimes, caused by the intake of illicit drugs, but it may also an alternative approach is used.

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The presence of abnormal discharge should be confirmed by performing a clinical examination safe prometrium 200mg. Furthermore cheap prometrium 100mg visa, specifically check for urethral discharge in patients complaining of painful or difficult urination (dysuria). Treatment of the partner The sexual partner receives the same treatment as the patient, whether or not symptoms are present. Abnormal discharge is often associated with vulvar pruritus or pain with intercourse (dyspareunia), or painful or difficult urination (dysuria) or lower abdominal pain. Routinely check for abnormal vaginal discharge in women presenting with these symptoms. Abnormal vaginal discharge may be a sign of infection of the vagina (vaginitis) and/or the cervix (cervicitis) or upper genital tract infection. The presence of abnormal discharge must be confirmed by performing a clinical examination: inspection of the vulva, speculum exam (checking for cervical/vaginal inflammation or discharge). Abdominal and bimanual pelvic examinations should be performed routinely in all women presenting with vaginal discharge to rule out upper genital tract infection (lower abdominal pain and cervical motion tenderness). The principal causative organisms are: – In vaginitis: Gardnerella vaginalis and other bacteria (bacterial vaginosis), Trichomonas vaginalis (trichomoniasis) and Candida albicans (candidiasis). Laboratory 9 – Tests usually available in the field can only identify causes of vaginitis, and thus are of limited usefulness. Miconazole cream may complement, but does not replace, treatment with clotrimazole. Treatment of the partner When the patient is treated for vaginitis or cervicitis, the sexual partner receives the same treatment as the patient, whether or not symptoms are present. In the case of vulvovaginal candidiasis, the partner is treated only if symptomatic (itching and redness of the glans/prepuce): miconazole 2%, 2 applications daily for 7 days. The principal causative organisms are Treponema pallidum (syphilis), Haemophilus ducreyi (chancroid) and Herpes simplex (genital herpes). Chlamydia trachomatis (lymphogranuloma venereum) and Calymmatobacterium granulomatis (donovanosis)a are less frequent. Case management Patient complains of genital sore or ulcer Take history and examine Look for another i genital disorder. Donovanosis is endemic in South Africa, Papua New Guinea, India, Brazil and the Caribbean. Administer a single dose for early syphilis (less than 2 years); one injection per week for 3 weeks for late syphilis (more than 2 years) or if the duration of infection is unknown. Treatment of the partner The sexual partner receives the same treatment as the patient, whether or not symptoms are present, except in the case of genital herpes (the partner is treated only if symptomatic). Gynaecological examination should be routinely performed: – Inspection of the vulva, speculum examination: check for purulent discharge or inflammation, and – Abdominal exam and bimanual pelvic exam: check for pain on mobilising the cervix. If peritonitis or pelvic abscess is suspected, request a surgical opinion while initiating antibiotic therapy. Clinical features Sexually transmitted infections Diagnosis may be difficult, as clinical presentation is variable. Infections after childbirth or abortion – Most cases present with a typical clinical picture, developing within 2 to 10 days after delivery (caesarean section or vaginal delivery) or abortion (spontaneous or induced): • Fever, generally high • Abdominal or pelvic pain • Malodorous or purulent lochia • Enlarged, soft and/or tender uterus – Check for retained placenta. Treatment – Criteria for hospitalisation include: • Clinical suspicion of severe or complicated infection (e. They should be reassessed routinely on the third day of treatment to evaluate clinical improvement (decrease in pain, absence of fever). If it is difficult to organise routine follow-up, advise patients to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening. Infections after childbirth or abortion – Antibiotic therapy: treatment must cover the most frequent causative organisms: anaerobes, Gram negatives and streptococci. Depending on the formulation of co- amoxiclav available: Ratio 8:1: 3000 mg/day = 2 tablets of 500/62. Stop antibiotic therapy 48 hours after resolution of fever and improvement in pain. In penicillin-allergic patients, use clindamycin (2700 mg/day in 3 divided doses or injections) + gentamicin (6 mg/kg once daily). Clinical features – Venereal warts are soft, raised, painless growths, sometimes clustered (cauliflower- like appearance) or macules (flat warts), which are more difficult to discern. Speculum exam may reveal a friable, fungating tumour on the cervix, suggestive of cancer associated with papilloma virus. Explain the procedure to the patient: apply the solution to the warts using an applicator or cotton bud, sparing the surrounding healthy skin, allow to air dry. On vaginal warts, the solution should be allowed to dry before the speculum is withdrawn. Podophyllum preparations are contra-indicated in pregnantc or breastfeeding women.

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The simplest formula is the familiar Laspeyres index cheap 200mg prometrium visa, which is usually written: L I 0 cheap prometrium 100 mg amex,1= [Σi Pi,1 Qi,0/ Σi Pi,0 Qi,0 ] (1) where 0 and 1 denote two periods in time, a base and current period, respectively, and i indexes goods that are sold in both periods. The Laspeyres tracks the cost of buying the Qi,0 basket at period 0 prices with the cost of buying it at period 1 prices. The index can also be written as a weighted average of price change: L I 0,1 = Σi wi,0 Pi,1 / Pi,0 (2) where the weights, wi,0, are the base period expenditure shares and the price relatives, Pi,1 / Pi,0 measure the price changes for individual drugs. The weights, or shares, are often called “relative importances” and have been the focus of much of the work in the literature. Written this way, it is easy to see that products in the base period market basket are only included in the index if they are sold in both periods (i. That is, the index does not include price change for new goods— 8 goods that entered the market between the two periods—or for goods that exited the market after the base period. Moreover, for goods that were sold in both periods, the Laspeyres fixes the relative importance of these goods at the base period levels and therefore does not reflect any changes in the composition of goods sold over time. A Fisher Ideal index provides relative importances that are more closely aligned with the composition of goods sold over time. It is normally written as: F 1/2 I 0,1 = { [Σi Pi,1 Qi,0/ Σi Pi,0 Qi,0 ] [Σi Pi,1 Qi,1/Σi Pi,0 Qi,1 ] } (3) It is an average (a geometric average) of the Laspeyres index—the first term—and the 3 Paasche index—the second term. The Paasche index is similar to the Laspeyres except that it uses a different market basket to measure price change—it compares the actual cost of buying the bundle in period 1 (Σi Pi,1 Qi,1) to what it would have cost to buy that bundle at period 0 prices (Σi Pi,0 Qi,0). The Fisher index may also be written as a ratio of weighted averages: F 1/2 I 0,1 = { Σi wi,0 Pi,1 / Pi,0 ] / [Σi wi,0 Pi,0 / Pi,1] } (4) with the Laspeyres in the numerator and the inverse of a Paasche in the denominator. Here it is easy to see that, unlike the Laspeyres, the Fisher uses expenditure shares from both periods. So, as market shares change over time, the Fisher places a higher weight on goods that are gaining market share whereas the Laspeyres does not. Just like the Laspeyres, however, this index ignores the entry of new goods and the exit of older goods. In a dynamic industry such as pharmaceuticals, the omission of new and exiting drugs can have important empirical implications. For drugs, the evidence is that pricing for new drugs can be very different from that of older, more established drugs, indicating that an index that includes new drugs will likely show different price growth than one that does not (Berndt 2002). One way to better incorporate any price change for new drugs is to construct indexes over shorter spans of time and to cumulate, or chain, the resulting price indexes. One could construct two Fisher price indexes, one for price change from F F 2003 to 2004 (I 2003,2004 ) and another for price change from 2004 to 2005 (I 2004,2005). While the only new drugs included in (4) are those introduced in 2003, the chained F index includes drugs introduced in 2004 in the I 2004,2005 index. Chained indexes thus provide a way of folding in new goods more quickly and so the index more closely tracks prices for the goods actually sold in the market. However, as discussed earlier, it is widely understood that the applicability of this theory in the health care setting is tenuous at best. Fortunately, there are other criteria that one can use to compare the relative merits of these formulas. In his “axiomatic approach,” Diewert (1992) considers about 20 properties that one would like to see in a price index. For example, one property is a time-reversal test which requires that if the prices and quantities in the two periods being compared are interchanged the resulting price index is the reciprocal of the original price index. Diewert showed that the Fisher index formula met this and other criteria better than other available formulas. Empirical results An important contribution of the empirical literature was to demonstrate that the choice of formula and chaining method matters. The Fisher formula takes into account any changes in the relative importance of drugs over time, whereas the Laspeyres formula does not. For example, in their study of drugs sold by four companies making up about 25% of the market, Berndt, 10 Griliches and Rosett (1993) found that price growth in chained indexes was slower than that in fixed-based indexes. But, in their study of antidepressant drugs, Berndt, Cockburn and Griliches (1996) found the opposite—chained Laspeyres tended to show faster price growth than the unchained counterparts. Which way it goes depends on how fast prices for new goods grow relative to established goods, and how the composition of drugs in the market is changing over time. This says that folding in new goods into the index more quickly yields indexes that grow slower and suggests that, in our sample, prices of new drugs grow slower than those of older drugs. First, the chained price indexes show faster (not slower) price growth than the unchained ones. This reflects the fact that prices for new molecules grow faster than those of older molecules that include generics: as molecules lose patent protection, the diffusion of the less expensive generics pushes down the price of the molecule. Hence, folding in new molecules faster—as the chained indexes do—yields an index that includes molecules with faster price growth and so the chained index grows faster. The unchained Laspeyres—the dotted line in chart 2—grows until mid- 2004 and then exhibits a declining trend through the last quarter in our data. This contour is driven entirely by the influx of generics into the market over this period. The pattern we see in the price index is mirrored in the number of generic prescriptions as a share of total: the rise in prices in the earlier period is associated with a decline in the generic share and the subsequent decline in the price index coincides with sustained increases in 11 the generic share.

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