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By: Mikayla Spangler, PharmD, BCPS

  • Associate Professor, Creighton University School of Pharmacy and Health Professions
  • Clinical Pharmacist, CHI Health Clinic—Lakeside, Omaha, Nebraska

https://spahp.creighton.edu/faculty-directory-profile/505/mikayla-spangler

Express Scripts struck rebate deals with Novo Nordisk to antiviral shot buy zovirax 400 mg otc conceal the true prices of Levemir and Novolog and profit from the inflated rebates antiviral rx generic zovirax 200mg with amex. But for the Levemir/Novolog Pricing Enterprise’s unlawful fraud antiviral youwatch zovirax 200mg mastercard, Express Scripts would have been incentivized to disclose the deceit by its competitors, thereby obtaining a competitive advantage. By failing to disclose this information, Express Scripts perpetuated the Levemir/Novolog Pricing Enterprise’s scheme, and reaped substantial profits. At all relevant times, OptumRx was aware of Novo Nordisk’s conduct, was a knowing and willing participant in that conduct, and reaped profits from that conduct. OptumRx struck rebate deals with Novo Nordisk to conceal the true prices of Levemir and Novolog and profit from the inflated rebates. But for the Levemir/Novolog Pricing Enterprise’s unlawful fraud, OptumRx would have been incentivized to disclose the deceit by its competitors, thereby obtaining a competitive advantage. By failing to disclose this information, OptumRx perpetuated the Levemir/Novolog Pricing Enterprise’s scheme, and reaped substantial profits. Whether the rebates were intended to benefit health care payers, plan members, and/or the general public. Whether Levemir and Novolog would have been placed in a “preferred” formulary position absent the rebates; and h. The extent to which the rebating scheme would force plan members to incur additional expenses for their Levemir and Novolog prescriptions. The discounts were fictitious: the result of a deliberate scheme to create large rebates without lowering real prices. Without these misrepresentations, the Levemir/Novolog Pricing Enterprise could not have achieved its common purpose. The Levemir/Novolog Pricing Enterprise engaged in and affected interstate commerce because, inter alia, it set the price of drugs that were sold to and utilized by thousands of class members throughout the United States, its territories, the District of Columbia, and the Commonwealth of Puerto Rico. The impacts of the Levemir/Novolog Pricing Enterprise’s scheme are still in place—i. During the class period, Novo Nordisk exerted control over the Levemir/Novolog Pricing Enterprise and participated in the operation or management of the affairs of the Levemir/Novolog Pricing Enterprise, directly or indirectly, in the following ways: a. Novo Nordisk periodically raised the published Levemir and Novolog 67 benchmark prices; c. Mail and interstate wire facilities, promotional and other materials which claimed that rebates (such as those applied to Levemir and Novolog) saved health care payers and consumers like Plaintiffs and class members money on their prescription needs; and f. The scheme had a hierarchical decision-making structure that was headed by Novo Nordisk. Mail and interstate wire facilities, promotional and other materials which claimed that rebates (such as those applied to Levemir and Novolog) saved health care payers and consumers like Plaintiffs and class members money on their prescription needs; and c. Novo Nordisk conducted and participated in the conduct of the affairs of the Levemir/Novolog Pricing Enterprise through a pattern of racketeering activity, including acts that are indictable under 18 U. The pattern of racketeering activity by the Levemir/Novolog Pricing Enterprise likely involved thousands of separate instances of use of the U. Mail or interstate wire facilities in furtherance of the unlawful Levemir and Novolog pricing scheme. Collectively, these violations constitute a “pattern of racketeering activity,” within the meaning of 18 U. Mail and/or interstate wire facilities employed by Novo Nordisk was related, had similar intended purposes, involved similar participants and methods of execution, and had the same results affecting the same victims, including Plaintiffs and members of the class. Novo Nordisk has engaged in the pattern of racketeering activity for the purpose of conducting the ongoing business affairs of its Levemir/Novolog Pricing Enterprise. The pattern of racketeering activity alleged herein and the Levemir/Novolog Pricing Enterprise are separate and distinct from each other. During the class period, the Levemir/Novolog Pricing Enterprise’s unlawful conduct and wrongful practices were carried out by an array of employees, working across state boundaries, who necessarily relied upon frequent transfers of documents, information, products, and funds by the U. Many of the precise dates of the Levemir/Novolog Pricing Enterprise’s uses of the U. Indeed, an essential part of the successful operation of the Enterprise alleged herein depended upon secrecy.

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Chen (College of Chemistry hiv infection during menstruation buy 400 mg zovirax with visa, Nankai University) 11:40 80 Synthesis of Nitrogen-Doped Molybdenum Sulphide and Molybdenum Sulphide/Oxide 16:40 89 Sputtered Iridium Oxide Nanocomposite As Active Materials for Microsupercapacitors Operating in Supercapacitor Electrode – C anti viral labyrinthitis buy zovirax 200 mg lowest price. Hong (Mechanical Engineering hiv infection rates singapore generic 800mg zovirax with visa, (The University of Texas at Dallas) Sungkyukwan University), and T. Pala (Indian Institute of State Hybrid Supercapacitors on Fabric Technology Kanpur), and S. Sabolsky Electrodeposition As High Performance Electrode Material for Supercapacitor Applications – G. Schnabel (National Lithium Ion Anodes 3 – 08:00 – 12:00 Renewable Energy Laboratory), G. Lone Star A1, Dallas Sheraton Convention Center Patwardhan (The University of Shefeld) 08:20 296 Electrochemical Properties of Amorphous Lithium Ion Cathodes 1 – 08:00 – 12:20 Silica As an Anode Material for Li-Ion Chair(s): Yiman Zhang and Xinhua Liang Batteries – V. Vullum-Bruer (Norwegian 08:00 306 Surface Modifcation for Suppressing University of Science and Technology) Interfacial Parasitic Reactions of Nickel-Rich 08:40 297 Tunable Syntheses of Advanced Silicon Lithium-Ion Cathode – J. Chen (Argonne National Laboratory) 09:20 299 Nanocarbon Composites for Energy Storage Applications – L. Ci (Shandong University) 08:20 307 Redox Chemistry in Conventional Layered Lithium Metal Oxide Cathodes – W. Sallis (Lawrence Berkeley 10:00 300 Silicon Nano Wires Anodes for High National Laboratory), B. Lutkenhaus (Texas A&M University) to Accommodate the Fast Charging for 10:40 302 Alleviate Gassing Problem of Li4Ti5O12 Lithium Secondary Batteries – B. Wang (National Kim (Dong-A University) Taiwan University of Science and Technology), 09:20 310 A Discovery of an Unexpected Metal H. Wu (Industrial Technology Research Dissolution of Thin-Coated Cathode Institute), and N. Wu (National Taiwan Particles: Its Theoretical and Experimental University) Explanations – Y. He (Missouri University of 11:00 303 Light-Weight and Flexible Carbon Science and Technology), S. Wang (Florida International O2: Preserving Cathode Structure for Long University) Term Cycling (1000 Cycles) Li-Ion Batteries – H. Battery Model Coupling Macroscopic Li (National Renewable Energy laboratory), and Microscopic Deformations – W. Colclasure (National Energy Laboratory) Renewable Energy Laboratory) 11:00 314 Structural and Electrochemical 16:00 325 Pre-Electrochemical Treatment Efect Characterization of Thin Film Li2MoO3 of Cu Eqcm Electrode on Lithium Cathodes – E. Nishihara (Ochanomizu University) Nanda (Oak Ridge National Laboratory) 16:20 326 Graphene Pliable Pockets Remedying 11:20 315 A Comparison of Electrode Surface Films Nanocrystalline Metal Anode for All Li Formed with Diferent Oxide Cathodes Ion Types Energy Storages Induced By for Lithium-Ion Batteries – E. Erickson Polymer-Triggered Synthesis Process in an (The University of Texas at Austin, Bar-Ilan Expeditious, Scalable and Inexpensive Way University), W. Kang (Korea Advanced University of Texas at Austin) Institute of Science and Technology) 11:40 316 Structure and Electrochemistry of LiV3O8 16:40 327 Morphology Controlled Fabrication of Thin Film Electrode: Efect of Difusion Rate Nanostructured Molybdenum Oxides By and Concentration on Cell Polarization – Y. Monoxide Electrodes during Initial Cycle in Dudney (Oak Ridge National Laboratory) Lithium-Ion Batteries – D. Lee (City University of Hong Kong) Transition Metal Oxide Cathode Electrode – 17:20 329 Efect of Diferent Carbon Precursors on J. Renman (Department of Chemistry Ångström, Uppsala University), Lone Star A2, Dallas Sheraton Convention Center and F. Gupta (Indian 13:40 318 Performance of Si Anodes in Ionic Liquid Institute of Technology Delhi) Electrolytes with Added Carbonates – D. Lone Star A1, Dallas Sheraton Convention Center Svensson (Norwegian University of Science and Technology) Lithium Ion Cathodes 2 – 14:00 – 18:20 14:00 319 Dandelion-like Mesoporous SiOx@C Chair(s): Leon Shaw, Gary Koenig and Dongchang Chen Nanoparticles for High-Capacity and Ultralong Lifespan Lithium-Ion Battery 14:00 331 Characterization of Chemical and Anode – Z. Koenig (University 4 14:20 320 Facile Technique for the Production of Metal of Virginia) Oxide Anodes for Lithium Ion Batteries – 14:20 332 Understanding the Efects of Ultra-Thin E. Al O Coatings Prepared By Atomic Layer 2 3 Karahan (Istanbul Medipol University), and O.

Double-blind hiv infection from blood transfusion buy zovirax 800mg fast delivery, crossover study of Biotene Oralbalance and BioXtra systems as salivary substitutes in patients with post-radiotherapy xerostomia antiviral for herpes buy zovirax 200mg on line. Oral Health Related Quality of Life in Patients of Head and Neck Cancer Attending Cancer Hospital of Bhopal City antiviral for chickenpox discount 400mg zovirax visa, India. Hyperbaric oxygen in the management of late radiation injury to the head and neck. Quality of life, psychological wellbeing and treatment needs of trauma and head and neck cancer patients. Clinico-therapeutic management of osteoradionecrosis: a literature review and update. Common oral complications of head and neck cancer radiation therapy: mucositis, infections, saliva change, fibrosis, sensory dysfunctions, dental caries, periodontal disease, and osteoradionecrosis. Prevention Intervention Possibilities in Radiotherapy and Chemotherapy-induced Oral Mucositis: results of Meta-analyses. Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. Compliance with fluoride custom trays in irradiated head and neck cancer patients. Oral health-related quality of life before hematopoietic stem cell transplantation. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Improving the Transition From Oncology to Primary Care Teams: A Case for Shared Leadership. Infectious diseases in allogeneic haematopoietic stem cell transplantation: prevention and prophylaxis strategy guidelines 2016. Disturbances in dental development and craniofacial growth in children treated with hematopoietic stem cell transplantation. Chlorhexidine treatment for the prevention of dental caries in children and adolescents. Risk factors for and the role of dental extractions in osteoradionecrosis of the jaws: A national-based cohort study. Distress, concerns and unmet needs in survivors of head and neck cancer: a cross-sectional survey. Chemotherapy associated oral sequelae in patients with cancers outside the head and neck region. Potential risks of orthodontic therapy: a critical review and conceptual framework. A prospective study to evaluate a new dental management protocol before hematopoietic stem cell transplantation. Prospective study establishing a management plan for impacted third molar in patients undergoing hematopoietic stem cell transplantation. Systematic review of natural agents for the management of oral mucositis in cancer patients. Ensure all patients have been  For patients with head and neck cancer, patients should be identified for dental seen for a comprehensive assessment at the multidisciplinary meeting and an assessment arranged assessment by a Dental  For all other patients, complete the Oral Health Screening Chart and Referral Surgeon prior to cancer (Appendix 2 and 4) and forward to dental team therapy  Liaise with the dental team to develop and implement an individual care plan 2. Advice on the oral side effects  Provide written information on side effects of treatment (Appendix 5) of treatment  Give support and encouragement  Dietary advice in liaison with the Dietitian 3. Maintenance of oral hygiene  Provide advice and assistance where appropriate  Follow Practical Oral Care (Appendix 3)  the Oral Assessment Guide (Appendix 4) should be completed daily and placed in the patient’s individual care plan; contact the dental team for guidance prior to 2. Inspection of the oral cavity completion if required should be carried out daily  Document findings in the patient’s individual care plan to monitor any changes  Refer to the dental team when indicated 3. Monitor compliance in  Supervise and provide assistance; give instructions to carers where appropriate performing oral care  Give support and encouragement 4. Pain control  Give topical / systemic analgesia, as directed  Give topical / systemic antifungal agents, as prescribed 5. Oral candidal infections  If chlorhexidine gluconate mouthwash and nystatin suspension are prescribed, (Thrush) stagger their use by one hour  Give advice to help with a dry mouth 6. Manage xerostomia  Ensure recommended saliva substitute is prescribed and used when appropriate 67 3. Arrange follow-up visit to the  Arrange an appointment dental team  To ensure follow up occurs when the patient is discharged, an oral care entry should be made in the summary notes / discharge letter 2. Mucositis  Acute inflammation of the  Onset 12-15 days  Onset usually one  Onset usually one week mucosa after treatment week after treatment after treatment  White/yellow fibrinous slough, commenced commencement commencement often with ulceration  Ulceration often severe  Ulceration often severe  Painful to speak/eat/swallow  Portal for microbial entry  Healing complete 2-3 weeks post-completion cancer therapy 2.

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The tumour staging is essential to hiv infection rates louisiana buy zovirax 800mg on-line determine whether only surgery is indicated or whether radiation or chemotherapy may be needed later life cycle of hiv infection zovirax 400mg on-line. The risks and sequels of surgery primarily depend on or develop from the extent of the tumor and its relationship to hiv global infection rates discount 400mg zovirax contiguous oral structures. Sequels may include disorders in speech and swallowing, pain, limitations in oral motor function; infections, enteral nutrition. During resection of oral cancers, teeth and their supporting bone are often removed. In order to achieve functional rehabilitation, it is necessary to replace missing elements. Some patients may require an intraoral prosthesis for obturation of a velopharyngeal deficit or to reshape and augment the contours of a resected hard palate. The work of a speech therapist is crucial in this venture (Vendrell & Ranking, 1999). Radiotherapy is associated with side effects that vary in intensity and duration and are dependent on several factors. Not all patients will experience all possible complications but they should be aware of the potential risks. Acute and chronic complications in the short and long term have been studied by different authors; some complications are described below. Hyposalivation during the 1st week of Oral Squamous Cell Carcinoma Clinical Aspects 35 radiation treatment amounts to 50-60% of the usual saliva flow. Hyposalivation subjective symptom xerostomy implies several other symptoms like dysphagia, dysgeusia, dysosmia and speach difficulties(Jansma et al. Xerostomy brings about a change in oral microflora and, as a result, cariogenic microorganisms streptococos mutans y lactobacilos prevail in the saliva, causing caries and periodontal diseases. The oral mucosa becomes soft, irritable and susceptible of fungal infections (candidiasis) and inflammations (Daly & Drane,1972; Hinds,1971). Recently, preventive measures to decrease the effects of radiation induced xerostomy have been widely studied. To begin with, patients should give up tobacco, alcohol and spicy, too hot, too cold or too hard foods and replace them by soft and moist nutrients. Secondly, they should be advised to be well hydratated and to use saliva substitutes. After three weeks of therapy, it takes 500-8,000 times normal concentrations of taste stimulant to elicit a normal taste response. Taste acuity levels usually return to normal within 2-12 months following completion of therapy, if adequate saliva is available (Jasma et al. Mucositis: Oral mucositis is the inflammation that takes place in the oral epithelium as a result of antineoplastic treatments such as radiotherapy, chemotherapy or bone marrow transplant which are very frequent in these treatments for oncohematologic disease. Not only do the consequences of the inflammation affect the quality of life of the patient but it can also mean a limitation in the application of the treatment, as well as an increase in hospital length of stay and therapeutic costs. Radiation-induced mucositis depends on the absorbed radiation dose, fractioning, delivery modality and soft tissue status. Other influential patient-related variables are age, sex, nutritional condition, oral microbiota, salivary flow and inflammation among others. The study of the degrees of severity of oral mucositis has yielded different results coming from diverse research centers. The lack of a uniform systematic approach adopted for its evaluation by means of oral examination makes it difficult to assess its consequences. The various existing scales to measure mucositis were analyzed by López Castaño et al. Treating infections as soon as they are detected will help to reduce pain, as well as control the spread of infection. In patients undergoing head and neck radiotherapy, Candida colonization tends to increase during the course of the treatment and remains increased if xerostomia occurs (Epstein et al. Candidiasis can cause a burning or scalding sensation, can distort taste and may interfere with swallowing. Its spread to the esophagus or systemic dissemination is a serious consequence (Rankin & Jones, 1999).

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Clinically hiv infection from woman to man cheap zovirax 800 mg without prescription, the early oral lesions are similar to natural antiviral herbs 200 mg zovirax with amex those seen in pseudomembranous candidosis hiv infection no symptoms cheap zovirax 400 mg with amex, but later they are similar to the lesions of chronic hyperplastic (nodular) candidosis. Characteristically, the lesions are generalized, with a predilection for the buccal mucosa, commissures, tongue, palate, and lips, and may extend to the oropharynx and esophagus (Fig. Cutaneous and nail involve ment in varying degrees of severity are associated with the oral lesions (Fig. Fungal Infections Candida-Endocrinopathy Syndrome Oral lesions occur in about 35 to 45% of the cases and are clinically characterized by indurated pain this syndrome is a unique form of chronic ful ulceration or verrucous, nodular, or mucocutaneous candidosis that is accompanied by granulomatous lesions (Fig. The palate, endocrinopathies, such as hypoparathyroidism, tongue, buccal mucosa, gingiva, and lips are the hypoadrenalism, hypothyroidism, or pancreatic preferred sites of localization. Oral candidosis begins lesions appear as the initial presenting manifesta at the age of 4 to 6 years or later, whereas the tion. The differential diagnosis of candidosis includes chemical burns, traumatic lesions, white spongue Laboratory tests. Histopathologic examination of nevus, leukoplakia, hairy leukoplakia, lichen biopsy specimens, direct examination of smears planus, and mucous patches of secondary syphilis. Laboratory test useful in establishing the diagnosis is direct microscopic examination of smears. Ketoconazole and amphotericin B are ture and histopathologic examination may also be effective in the treatment of histoplasmosis. Ketoconazole, North American Blastomycosis amphotericin B, fluconazole, and intraconazole Blastomycosis is a chronic fungal infection caused are used systemically with success in generalized by Blastomyces dermatitidis and usually occurs in forms of the disease. The disease mainly involves the lungs and the skin, rarely the bones, the genital tract, and other organs. Clinically, oral lesion is usually present as an ulcer Histoplasmosis is a systemic fungal disease caused with a slightly verrucous surface and thin borders by the organism Histoplasma capsulatum. Ketoconazole, fluconazole, intra acute primary, chronic cavitary, and progressive conazole, and amphotericin B are effective drugs. The acute primary form, which is more common, is characterized by constitutional symptoms (low-grade fever, malaise, chills, myal gias, etc. The chronic cavitary form is characterized exclusively by pulmonary signs and symptoms. Clinically, it is characterized by constitutional symptoms and hepatosplenomegaly, lymphadenopathy, bone marrow involvement, pulmonary radiologic find ings, gastrointestinal disorders, adrenal insuffi ciency, and oral and pharyngeal manifestations. Fungal Infections Paracoccidioidomycosis form is the most common inasmuch as signs and symptoms from oral, cranial, and facial structures Paracoccidioidomycosis (South American blas account for 40-70 % of all reported cases. The dis grade fever, headache, malaise, sinus pain, bloody ease is particularly restricted to Brazil and other nasal discharge, periorbital or perinasal swelling countries of South and Central America. Three and edema, ptosis of the eyelid, extraocular mus forms of the disease are recognized: pulmonary, cle paresis, and progressive lethargy. Palatal ulceration and terized by weight loss, fever, dyspnea, cough, necrosis are the most characteristic oral lesions. The mucosa surrounding the ulcer is usually Clinical, oral lesions usually present as a thickened. Orbital and intracranial invasion is a chronic irregular ulcer with a granular surface common complication. Perforation of the hard palate associ the differential diagnosis of oral lesions should ated with pain may be seen in severe cases. Computerized axial tomography may be useful to demonstrate the extent of bone destruction. Serologic test by underlying predisposing conditions is also impor immunodiffusion or the complement fixation is tant. Intravenous amphotericin B, keto conazole, and intraconazole are effective drugs. Mucormycosis Mucormycosis (zygomycosis, phycomycosis) is a rare, often fatal, acute opportunistic fungal infec tion which usually involves debilitated individuals. Fungi of the family Mucoraceae, mainly rhizopus and rhizomucor, and rarely other species are the cause of the disease. The most common predispos ing condition is poorly controlled diabetes mellitus with ketoacidosis.

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References:

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