By A. Potros. Whittier College.

As for changes of the level of urea in blood downward buy quetiapine 100mg low price, this trend should be considered as positive in terms of activation of nitrogen-releasing renal function cheap quetiapine 100 mg amex. In the same animals cheap quetiapine 100 mg otc, hydrochlorothiazide caused no significant changes in creatinine, urea and total protein content in the blood compared with untreated control. In experimental rats, intragastric administration of enalapril caused a tendency to increase the content of creatinine, urea and a statistically significant increase in total protein content in the blood. Experimentally hypertensive rats developed disorders of fluid and electrolyte homeostasis, which was reflected in increasing of serum creatinine and total protein levels. Mechanisms for implementation of antihypertensive response of hynokarb are based on activation of nitrogen-releasing renal function. Parasitic diseases, caused by helminthes, one-celled and arthropods, are a wide group of illnesses, that largely determine the state of health of the population. The share of parasitic diseases account for 14 million deaths per year, representing 25% of the total Earth mortality – every fourth death. The aim of the study was to investigate the distribution of the most important parasitic disease of people in Ukraine. A big variety of intestinal forms of the single – celled are the most spread protozoonoses in Ukraine. Giardiasis, Amoebiasis are dominant among them, and cystic protists and Toxoplasma are the most dangerous ones. However, the most topical disease, which is caused by the single-celled, is malaria. From 300 to 500 million of people suffer from malaria every year, at that time from 1. Intestinal helminthoses take the 3d place in the world among all 27 infectious diseases. According to the statistics, every third inhabiotant of Europe is affected by at least one helminth. From 400 to 600 thousands patients with different helminthoses are officially registered every year. Enterobiosis and ascariasis are the most spread representatives of Nematodosis among the inhabitants of Ukraine. Opisthorchiasis is the most spread representative among all trematodosis, which were identified. The second largest focus of opistorchiasis among the countries of the former Soviet Union is situated in Ukraine. It is the basin of the Dniper with its tributaries (Psyol, Sula, Seym, Vorskla etc). The highest level of the infection is observed in Poltava, Chernihiv and Sumy regions where the percent of disease is accordingly 10%, 15% and 70-80% in Sumy region. Human toxocariasis is caused by the migrating larve of the canine nematodes – Toxocara canis, which provoke the disease «syndrome of the migrating larve – syndrome larva migrans». In recent years human toxocariasis has acquired the global dissemination and stay one of the most topical parasitic problems. The number of people, which were infected by toxocariasis, varies widely in the world. According to the Central Sanitary Epidemiological Station of the Ministry of Health of Ukraine the number of toxcariasis cases among people in our country annually increase from 1 in 1998 to 154 in 2007 and more than 2. Analysis of the literature has revealed widespread human zoonosis in the world and particular in Ukraine. Parasitic diseases are a major reason of the significant mortality of people, in addition they contribute to morbidity by other infectious diseases, causing the deterioration of immunity of the human body. The study of the spread of parasitic diseases is a topical problem nowadays, that needs its solution. As one of the most effective analgesics and antipyretics, paracetamol is nevertheless a potential hepatotoxic agent. Not only overdose of paracetamol, but even its long-term use contributes to the development of drug hepatitis, especially for people with hepatitis of various etiologies or patients with diabetes mellitus. The liver synthesizes, concentrates, and secretes bile acids and excretes other toxicants, such as bilirubin. Cholestasis, in turn, causes intrahepatic accumulation of toxic bile acids and excretion products, which promotes further hepatic injury. Efficiency of researched extracts is 20% higher on average than the efficiency of the reference drug silibor in the intensity, of the hepatoprotective action. Conducted research testifies the advisability of further preclinical lime leaves extracts studies to create new domestic plant hepatoprotector on their basis. The Department of therapy internship, Semey State Medical University, The Republic of Kazakhstan Sholpan. The cardiovascular disease is one of the first places among causes of death and disability In Kazakhstan. Therefore, a priority for the development of medicine is to improve the prevention of cardiovascular diseases, in particular cardiovascular diseases, especially coronary heart disease. Аtherothrombosis is a trigger the development of such threatening cardiac events and myocardial infarction. In is based on genetic disorders that cause an individual predisposition to develop the disease, against which manifest impact of environmental factors. Most of these genetic disorders is represented by point mutations (single nucleotide polymorphism) unextended or deletions. Rate of occurrence frequency of polymorphisms Leu33Pro, Thr145Met, C786T, H1/H2 in patients with coronary heart disease, a mutation that determines the increased risk of thrombosis. In the presence of mutant alleles H1/H2 differences between groups of patients with 2 coronary artery disease and healthy individuals were highly significant (χ =30. We always expect not only improve the appearance but also to solve certain problems from cosmetics, especially from the "medical cosmetics. Medical cosmetics produced in the same forms as cosmetics traditional, cream, lotion, balm, emulsion, gel, shampoos, lipsticks, pencils and so on. Unlike conventional cosmetics, medical cosmetics destroys the protective sheath retains fluid and mineral balance of the skin covering its surface with a thin protective film protects the skin from harmful environmental influences. Since cosmeceuticals designed with properties for sensitive or diseased skin, it contains a minimal amount of preservatives and fragrances. Today cosmeceuticals considered the main source of growth of pharmaceutical market in Ukraine, as it has a wide demand among the population. The aim of the study was to analyze the composition of some health care cosmetics foreign and domestic production. Identify active ingredients of cosmetics with therapeutic effect and to identify their impact. The study was conducted in the form of a survey of women of all ages who use cosmetics at least 1 time per week. Based on the analysis the medical cosmetics include amino acids, unsaturated fatty acids, micro- and macronutrients, vitamins, providing full power skin, zinc oxide, Panthenol, calcium gluconate, hyaluronic acid, collagen, urea, plant extracts, thermal water, as well as special components, patented.

Psychic derangements may appear when corticosteroids are used 200mg quetiapine with mastercard, ranging from euphoria discount quetiapine 300 mg mastercard, insomnia purchase quetiapine 100 mg with visa, mood swings, personality changes, and severe depression to frank psychotic manifestations. Also, existing emotional instability or psychotic tendencies may be aggravated by corticosteroids. Drugs that induce hepatic enzymes such as phenobarbital, phenytoin and rifampin may increase the clearance of corticosteroids and may require increases in corticosteroid dose to achieve the desired response. Dermatologic: Impaired wound healing; thin fragile skin; petechiae and ecchymoses; facial erythema; increased sweating; may suppress reactions to skin tests. Neurological: Convulsions; increased intracranial pressure with papilloedema (pseudotumour cerebri) usually after treatment; vertigo; headache. Endocrine: Menstrual irregularities; development of Cushingoid state; suppression of growth in children; secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness; decreased carbohydrate tolerance; manifestations of latent diabetes mellitus; increased requirements for insulin or oral hypoglycaemic agents in diabetics. As a quaternary ammonium derivative, hyoscine-N- butylbromide does not enter the central nervous system. Therefore, anticholinergic side effects at the central nervous system do not occur. Peripheral anticholinergic effects result from a ganglion-blocking action within the visceral wall as well as from anti- muscarinic activity. Concomitant treatment with dopamine antagonists such as metoclopramide may result in diminution of the effects of both drugs on the gastrointestinal tract. Reduction of respiratory tract and oral secretions (particularly in the palliative setting). Note, for this indication, hyoscine butylbromide is preferred by the palliative care team. The syndrome of nasal polyps, angioedema, and bronchospastic reactivity to aspirin or other nonsteroidal anti-inflammatory agents. Bleeding Risk: Ibuprofen, like other nonsteroidal anti-inflammatory agents, can inhibit platelet aggregation but the effect is quantitatively less and of shorter duration than that seen with aspirin. Ibuprofen has been shown to prolong bleeding time (but within the normal range) in normal subjects. Because this prolonged bleeding effect may be exaggerated in patients with underlying haemostatic defects, ibuprofen should be used with caution in persons with intrinsic coagulation defects and those on anticoagulant therapy. Renal Effects: As with other nonsteroidal anti-inflammatory drugs, long-term administration of ibuprofen to animals has resulted in renal papillary necrosis and other abnormal renal pathology. In humans, there have been reports of acute interstitial nephritis with haematuria, proteinuria, and occasionally nephrotic syndrome. A second form of renal toxicity has been seen in patients with prerenal conditions leading to a reduction in renal blood flow or blood volume, where the renal prostaglandins have a supportive role in the maintenance of renal perfusion. In these patients administration of a nonsteroidal anti-inflammatory drug may cause a dose dependent reduction in prostaglandin formation and may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and the elderly. These abnormalities may progress, may remain essentially unchanged, or may be transient with continued therapy. Severe hepatic reactions, including jaundice and cases of fatal hepatitis, have been reported with ibuprofen as with other nonsteroidal anti-inflammatory drugs. Although such reactions are rare, if abnormal liver tests persist or worsen, if clinical signs and symptoms consistent with liver disease develop, or if systemic manifestations occur (e. Aseptic Meningitis Aseptic meningitis with fever and coma has been observed on rare occasions in patients on ibuprofen therapy. Although it is probably more likely to occur in patients with systemic lupus erythematosus and related connective tissue diseases, it has been reported in patients who do not have an underlying chronic disease. During concomitant therapy with ibuprofen, the patient should be observed closely for signs of renal failure, as well as to assure diuretic efficacy. Lithium: Ibuprofen produces an elevation of plasma lithium levels and a reduction in renal lithium clearance in patients on concomitant therapy. Right ventricular failure with pulmonary artery hypertension after separation from cardiopulmonary bypass and failure to improve with standard therapy. Initially reduce frequency of administration (rather than dose) to titrate to effect. A response to iloprost is indicated by an increase in cardiac output or mixed venous oxygen saturation, often with reduction in central venous pressure. There may be minimal or no change in pulmonary artery pressure (even though pulmonary vascular resistance has fallen). After inhalation, it causes direct vasodilatation of the pulmonary arterial bed with subsequent decrease in pulmonary vascular resistance & increase in cardiac output and mixed venous oxygen saturation. The risk of rebound pulmonary artery hypertension seen with inhaled nitric oxide does not appear to be present with iloprost. The initial dosing frequency should be decreased with intervals of 3-4 hours between nebulisers. Use with caution in patients with severe asthma or chronic obstructive pulmonary disease. Paediatric Use Iloprost should not be administered to children or adolescents under 18 years of age. Iloprost inhibits platelet function so its use with anticoagulants (heparin, warfarin) or other inhibitors of platelet aggregation may increase the risk of bleeding. Agitate the contained until the solution is clear Infuse doses of 500mg over 20 minutes. The bactericidal activity of imipenem results from the inhibition of cell wall synthesis. It is a potent inhibitor of betalactamases from certain gram-negative bacteria which are inherently resistant to most beta-lactam antibiotics, e. Imipenem has in vitro activity against a wide range of gram-positive and gram-negative organisms. In vitro tests show imipenem to act synergistically with aminoglycoside antibiotics against some isolates of Pseudomonas aeruginosa. Imipenem has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections. Escherichia coli Gardnerella vaginalis Haemophilus influenzae Haemophilus parainfluenzae Klebsiella spp. Therefore, it is important to consider this diagnosis in patients who present with diarrhoea subsequent to the administration of antibacterial agents. These drugs should not be used concomitantly unless the potential benefits outweigh the risks. Gastrointestinal: Pseudomembranous colitis, diarrhoea, nausea, vomiting, haemorrhagic colitis, hepatitis (including fulminant hepatitis), jaundice, gastroenteritis, abdominal pain, glossitis, tongue papillar hypertrophy, staining of the teeth and/or tongue, heartburn, pharyngeal pain, increased salivation. Haematologic: Pancytopaenia, bone marrow depression, thrombocytopaenia, neutropaenia, leukopaenia, haemolytic anaemia. Skin: Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, angioneurotic edema, flushing, cyanosis, hyperhidrosis, skin texture changes, candidiasis, pruritus vulvae.

Anogenital warts are usually transmited by sexual contact; they should always be treated buy 50 mg quetiapine with amex, although they frequently recur generic 200mg quetiapine visa, because of the increased risk of cervical cancer order quetiapine 50mg fast delivery. Podo- phyllum resin, a caustc antmitotc agent, may be applied to small external lesions. The risk of extensive local necrosis and of systemic toxicity excludes the use of podophyllum resin on larger surfaces. Where podophyllum is contraindicated or inefectve surgical removal, electrocautery, cryosurgery and laser therapy are possible optons. Topical applicaton of 5-fuorouracil has been reported to be of value in resistant cases but the treatment is expensive and efcacy is stll under investgaton. Coaltar* Pregnancy Category-C Indicatons Chronic psoriasis, either alone or in combinaton with exposure to ultraviolet light; eczema. Dose Psoriasis: apply 1 to 4 tmes daily, preferably startng with lower strength preparaton. Adverse Efects Irritaton; photosensitvity reactons; rarely, hypersensitvity, skin; hair and fabrics discoloured; stnging. Contraindicatons Hypersensitvity; avoid use on face; acute eruptons; excessively infamed areas. Precautons Irritant-avoid contact with eyes and healthy skin; not to be used in acute psoriasis; pregnancy (Appendix 7c). Adverse Efects Local irritaton; discontnue use if excessive erythema or spread of lesions; conjunctvits following contact with eyes; staining of skin; hair; and fabrics; stains skin. Dose Actnic keratosis, genital warts: apply thinly 1 to 2 tmes daily untl marked infammatory response occurs (usually 3 to 4 weeks); healing may require further 2 months afer completon of treatment. Adverse Efects Local infammatory and allergic reactons; rarely, erythema multforme; photosensitvity reactons during and for up to 2 months afer treatment; eye irritaton. For injecton: store protected from light in a single dose container at a temperature not exceeding 30⁰C. Isotretnoin Pregnancy Category-X Indicatons Resistant and severe nodulocystc acne, dry scaly surface, motling, wrinkles, rough and leathery texture, acute promyelocytc leukemia, actnic keratoses. Duraton of treatment: 15-20 week; may be discontnued if number of cysts is reduced by >70% (whichever is sooner). Patents with very severe acne or acne evident on the body instead of face: max dose of 2 mg/kg daily. Adverse Efects Dryness of skin and mucous membranes, pruritus, epistaxis, cheilits, erythema, sometmes Stevens-Johnson syndrome, paresthesias, anxiety, conjunctvits, paronychia, rise in serum lipids, pancreatts, hypervitaminosis (however it is less than that of tretnoin), edema, hair thinning and intracranial tension leading to nausea and vomitng, hearing impairment, hepatotoxicity, visual impairment. Psychiatric side efects such as depression, suicidal tendencies and psychotc symptoms can occur frequently in adolescents and young adults. Dose Hyperkeratotc skin disorders: apply once daily, startng with lower strength preparatons; gradually increase strength untl satsfactory response obtained. Precautons Diabetes mellitus or if peripheral blood circulaton impaired; avoid contact with eyes; mouth; and mucous membranes; avoid applicaton to large areas; iritated; loose/ infected skin; pregnancy (Appendix 7c). Urea Pregnancy Category-D Indicatons Hydratng agent and keratolytc for dry, scaling and itching skin conditons. Precautons Avoid applicaton to face or broken skin; avoid contact with eyes; pregnancy (Appendix 7c). Adverse Efects Transient stnging and local irritaton; irritaton to eyes; skin and respiratory tract. It is readily transmited from person to person; therefore the entre household must be treated at the same tme to prevent reinfecton. It is not necessary to take a bath before treatment with an acaricide, but all clothing and bedding should be washed to prevent reinfecton. It must be applied to all skin surfaces, from the scalp to the soles of the feet, avoiding contact with the eyes; it is too irritant for use on chil- dren. Permethrin is less irritant and more efectve than benzyl benzoate, but also more expensive; it may be used on children. Young infants can be treated with a cream containing precipi- tated sulphur 6-10% applied once daily for one week. Pediculosis: Pediculosis of the head and body is caused by Pediculus humanus capits and Pediculus humanus corporis respectvely; pubic lice (crab lice) infestatons are caused by Pthirus pubis, which may also afect the eye lashes and brows. All are trans- mited by person to person contact, and may also contaminate clothing and bedding. All members of the afected household (and sexual contacts) must be treated at the same tme, and clothing and bedding should be washed or exposed to the air; in head lice infestatons, hair brushes and combs should also be disinfected. Head and body lice are readily treated with permethrin; malathion is efectve against pubic lice. Dose Adult- Scabies: apply from neck down at night for 2 nights; on each occasion wash of afer at least 24 h. Pediculosis: apply to afected area and wash of 24 h later; further applicatons possibly needed afer 7 and 14 days. Gamma Benzene Hexachloride Pregnancy Category-B Indicatons Pediculosis (but use for head lice is restricted by resistance), scabies. Dose For pediculosis: As 1% preparaton, apply to scalp and hair (taking care not to enter eyes), it should be massaged for 4 minutes and rinsed thoroughly. For scabies: Take a proper bath and dry your skin then apply loton in a thin layer below the neck upto the sole of feet. Contraindicatons Seizure; hypersensitvity; skin infammaton; broken skin; premature infants; lactaton; pregnancy (Appendix 7c). Precautons Seizure disorder; open wound or sores; neonates, infants below 2 years; avoid contact with face, eyes; mucus membranes urethral meatus, psoriasis, elderly. Adverse efects Insomnia; paresthesia; giddiness, agranulocytosis, aplastc anaemia, skin irritaton, contact dermatts; ataxia; alopecia; severe neurologic toxicites; symptoms of acute poisoning include nausea, vomitng, tremors, coma, convulsions and respiratory failure. Dose Intradermal injecton Adult and Child- 5 to 10 units (1 unit may be used in hypersensitve patents or if tuberculosis is suspected). Contraindicatons Should not be used within 3 weeks of receiving a live viral vaccine. Adverse Efects Occasionally nausea, headache, malaise, rash; immediate local reactons (more common in atopic patents); rarely, vesicular or ulceratng local reactons, regional adenopathy and fever; necrosis, prurits, pain. Tropicamide is a short-actng relatvely weak mydriatc that dilates the pupil and paralyses the ciliary muscle. Fluorescein* Pregnancy Category-B Indicatons Detecton of lesions and foreign bodies in the eye. Dose Ocular instllaton Adult and Child- Detecton of lesions and foreign bodies in eye: instll sufcient soluton dropwise to stain damaged area. Precautons History of allergy or bronchial asthma; lactaton; pregnancy (Appendix 7c). Adverse efects Gastrointestnal distress; hypotension; syncope; cardiac arrest; thrombophlebits.

The comparison of the United States and Germany specifcally order quetiapine 200mg overnight delivery, and the United States and Europe more generally that is developed in this chapter illuminates tensions associated with consumer-driven regulation that are shaping the competitive landscape for pharmaceutical product development and sales buy quetiapine 100 mg with amex. It is striking that just as patient and disease-based activists have taken on certain regulatory functions traditionally associated with the state or peak medical associations 50 mg quetiapine for sale, a greater consumer and market orientation in medical care has increasingly put the onus on patients to independently seek out information about pharmaceuticals and to treat prescription drugs like other goods they purchase. However, little scholarship to date has connected these developments with the industry’s economic performance or business strategy. Though in part speculative at this point, the data and analysis presented here are an initial step toward deepening the understanding of interrelationships among government regulation, patients’ mobilization both as regulators and consumers, and the functioning of the pharmaceutical industry. First, I present summary data and brief analysis of the pharmaceutical sector in its national contexts. Some critics of the industry have argued that by chasing global markets and by moving research and manufacturing facilities to countries with lower labor costs, frms were able to shop for weaker national regulatory systems and exert deregulatory pressure. Instead, it appears that the pharmaceutical industry has remained largely concentrated in the United States and Europe, which historically set high barriers to drug approvals. Second, the chapter seeks to connect academic literature in the history and economics of innovation with studies of regulation. Both areas have seen interesting work in recent years, but little has been done to integrate perspectives from the two areas. Dukes, “The Regulation of Drugs: Worlds of Difference” International Journal of Technology Assessment in Health Care. The data suggests a puzzle of why frms headquartered in the United States have had notably better results since the early 1980s than their competitors in Germany, and to a lesser extent other European countries. A regulatory approach defned around protecting “patients” in Europe, and the complexities of shared authority among the medical profession, other peak associations, and the state in Germany may have unwittingly contributed to a weaker domestic pharmaceutical industry. The conclusion argues that understanding the relationship of innovation to regulation in different countries is critical to moving beyond current crises in regulatory policy to the beneft of patients for whom medicines are intended. Locating Pharmaceutical Production and Consumption In the late 1970s and early 1980s, a series of studies by the U. Yet some thirty years later, a set of similar measures presented here suggests that the U. New York: United Nations, 1979; National Academy of Engineering, The Competitive Status of the U. Thomas, “Estimating the Effects of Regulation on Innovation: An International Comparative Analysis of the Pharmaceutical Industry,” Journal of Law and Economics 21 (1978), 133-163; for a review of the drug lag, see: Arthur Daemmrich, “Invisible Monuments and the Costs of Pharmaceutical Regulation: Twenty-Five Years of Drug Lag Debate,” Pharmacy in History 45 (2003), 3-17. Additional measures, including the size of the national pharmaceutical market and the attractiveness of a country for clinical research, help to deepen this analysis and connect to the discussion of regulatory approaches in the face of a new disease, societal pressures for compassionate use programs, and attention to biomarkers as a component of a personalized approach to medicine that follows in the next section. In a striking development considering the industry’s origins in Germany, France, and Switzerland, in the past ffteen years have witnessed a signifcant shift in the center of power of the pharmaceutical industry: of the ffteen largest global frms in 005, nine were headquartered in the United States, whereas one was in France, two in Switzerland, and the sole German frm to make the group came in the fourteenth position. Through the mid-1980s, the balance was rather more evenly distributed: even though only three of the top ffteen frms were based in Germany, two of them – Hoechst and Bayer – held the top two positions. All of the leading frms expanded international markets in this three-decade period, however, sales fgures correlate well with new product innovation and frms headquartered in the United States moved from the bottom half toward the top of the list between 1974 and the present. Table 1: Top 15 Pharmaceutical Firms by Sales, 19749 Rank Company Name Location Pharmaceutical Sales ($ millions) 1 Roche Switzerland 1,386 2 Merck U. In addition to this shift in position for frms based on their headquarters location, another striking feature of these tables is the phenomenal growth in sales for top frms between 1988 and 2005, compared to more modest growth during the 1970s and early 1980s. For many of the top frms, this growth was achieved through mergers and heavy marketing of new products. Yet at least half of the top ffteen companies did not achieve growth through mergers and instead expanded sales signifcantly based on new product introductions alone. More generally, the nearly ten-fold sales growth between 1988 and 2005 indicates the degree to which pharmaceuticals have become high-demand consumer products. In the mid-1970s, European pharmaceutical frms (including those in the United Kingdom) accelerated spending from $966 million to $2. Or does the evidence suggest a shift in new product innovation from Europe to the United States? In the two decades between 1961 and 1980, frms based on the European continent invented and brought to market over sixty percent of new therapeutic molecules. Pharmaceutical Industry (1984); Pharma Marketletter, various years; Arthur Hass, et al. Germany’s relative ranking slipped further after 001, as Hoechst frst merged with Rhone-Poulenc into Aventis in 1999 and then disappeared further with the Sanof-Aventis merger of 004. Mergers that created GlaxoSmithKline and Novartis have propelled these companies into the upper echelon of the industry, but from a sector perspective, Europe’s pharmaceutical industry, most notably Germany’s, dropped out of nearly all rankings of top frms by the mid- 000s. Duplicate medicines and additional dosage forms were removed from the analysis, leaving just new chemical and biological drugs. Companies were then coded for their national headquarters at the time of the approval. Figure 2: New Drug Approvals in the European Union, 1997-2007 The graphs in Figures 1 and 2 underscore a longer-term outcome of the shifts in sales and R&D spending since the early 1980s. Overall, prescription drug sales remain strongly concentrated in the United States, Europe, and Japan. Even with a larger population, Europe’s share of global pharmaceutical consumption was nearly ffteen percent less than that of the United States (see Table 5, below). Clinical trials offer a further indication of where the pharmaceutical industry is orienting its activities. While press attention has focused on the outsourcing of clinical trials to developing countries, as of spring 2008 the vast majority of trials underway were in North America or Europe. Yet with over twice as many clinical trials going on in the United States as in the European Union, frms appear to be running trials in their home countries, creating a virtuous cycle from R&D investment to testing to market approval for frms in the United States. Measured by the patient pool, costs, regulatory conditions, availability of expertise, and infrastructure, Germany’s high costs, modest 279 Arthur Daemmrich patient populations, and challenges of recruiting participation in clinical research put it below the Czech Republic, the United Kingdom, Poland, and Hungary. In February of 006, the Bundestag passed legislation lowering the “reference price” – the amount that insurers must cover – to the bottom third of existing prices. Patients are responsible for making up the difference for drugs priced above the limit. As a commentary in Nature Biotechnology noted, however, “In theory, innovative drugs should be excluded from the mechanism, but in the past, more and more patent-protected drugs were included as they were dubbed ‘pseudo-innovative’ by the system’s oversight bodies. Quoting an expert from the trade magazine 15 Wynn Bailey, Carol Cruickshank and Nikhil Sharma, “Clinical Trial Offshoring: Country Attractiveness Index”. Ketcham, “Reference Pricing of Pharmaceuticals for Medicare: Evidence from Germany, the Netherlands, and New Zealand,” in David M. Richard Wang, “The Quantity and Quality of Worldwide New Drug Introductions, 198 - 00 ,” Health Affairs 25 (2006), 452-460. There are 80 million ‘consumers’ here, and the older they get, the more medicine they’re going to need. American patients are thus benefting with “access to cutting-edge medicines before they are available in Europe. The Bain report further argued that European countries will suffer delayed access to drugs and poorer health outcomes. Quantifying results, Bain estimates that Germany lost nearly $5 billion in health value from lowered access to innovative drugs and thousands of “high value added” jobs that were created instead in the United States. Firms may be motivated to open sales branches in countries with higher margins, but this does not explain the relative decline of the German and French pharmaceutical industry.

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