Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

The association of allergies and attention deficit hyperactivity disorder in children

To investigate the association between allergies and attention deficit hyperactivity disorder (ADHD), a case-control study was conducted using the National Longitudinal Survey of Youth population. Cases were between the ages of 4 and 11 years and were classified either by a maternal-reported diagnosis or by the Behavior Problems Index Hyperactivity Scale. Controls were chosen from the same age group but had a score of less than 14 on the overall Behavior Problems Index. A history of allergies was considered positive if any of the following conditions were reported as requiring treatment by a doctor or other health professional: asthma, allergic conditions, or food allergies. A strong association was observed between allergies and a maternal-reported diagnosis while controlling for demographic, socioeconomic, perinatal, and environmental factors (adjusted odds ratio = 2.85 (95% CI = 1.49-5.42)). Other risk factors found to be important risk factors for a diagnosis of ADHD were gender (male), gestational age ($<$36 weeks), and maternal education ($\leq$high school). No association between allergies and cases classified as ADHD based on the hyperactivity symptom scale was observed. This study confirms other studies that reported an allergy/ADHD association in diagnoses populations. Further investigation confirming the association and explanation of the reasons and underlying mechanisms of the observed association is warranted. These studies should use validated diagnostic criteria for the diagnosis of ADHD symptoms and allergies, adequate sample sizes, and control for confounding. ^

Attention-deficit hyperactivity disorder symptoms and lead exposure in children: A systematic review of literature

Blood lead levels > 10 µg/dL are known to affect various areas of the brain that influence behavior and cause many other health problems in children. As a result, the Centers for Disease Control and Prevention (CDC) set the blood lead action level at 10 µg/dL. However, recent research provides evidence that blood lead levels <10 µg/dL also may lead to behavioral problems in children. With the recent increase in diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD) in children in the U.S. it is important to determine possible environmental toxins such as lead that may play a role in causing ADHD symptoms. The aim of this systematic review of the literature was to identify recent published studies that examine an association between blood lead levels < 10 µg/dL and ADHD symptoms in children in order to summarize their findings and describe major gaps in the literature. Although available research is limited, the articles reviewed indicate that blood lead at levels much below the CDC action level of 10 µg/dL may affect a child's level of attention, hyperactivity, impulsivity and ADHD diagnosis. Additional prospective research is warranted in order to inform the revision of current blood lead action levels as well as better elucidate the relationship between lead and ADHD diagnoses.^

The illness experiences of African Americans residing in an inner city community, Houston, Texas

This dissertation documents health and illness in the context of daily life circumstances and structural conditions faced by African American families living in Clover Heights (pseudonym), an inner city public housing project in the Third Ward, Houston, Texas. Drawing from Kleinman's (1980) model of culturally defined health care systems and using the holistic-content approach to narrative analysis (Lieblich, Tuval- Mashiach, & Zilber, 1998) the purpose of this research was to explore the ways in which social and health policy, economic mobility, the inner city environment, and cultural beliefs intertwined with African American families' health related ideas, behaviors, and practices. I recruited six families using a convenience sampling method (Schensul, Schensul, & LeCompte, 1999) and followed them for fourteen months (2010–2011). Family was defined as a household unit, or those living in the same residence, short or long-term. Single, African American women ranging in age from 29–80 years headed all families. All but one family included children or grandchildren 18 years of age and younger, or children or other relative 18 years of age and older. I also recruited six residents with who I became acquainted over the course of the project. I collected data using traditional ethnographic methods including participant-observation, archive review, field notes, mapping, free-listing, in-depth interviews, and life history interviews. ^ Doing ethnography afforded the families who participated in this project the freedom to construct their own experiences of health and illness. My role centered on listening to, learning from, and interpreting participants' narratives, exploring similarities and differences within and across families' experiences. As the research progressed, a pattern concerning diagnosis and pharmacotherapy for children's behavioral and emotional problems, particularly attention-deficit hyperactivity disorder (ADHD) and pediatric bipolar disorder (PBD), emerged from my formal interactions with participants and my informal interactions with residents. The findings presented in this dissertation document this pattern, focusing on how mothers and families interpreted, organized, and ascribed meaning to their experiences of ADHD and PBD. ^ In the first manuscript presented here, I documented three mothers' narrative constructions of a child's diagnosis with and pharmacotherapy for ADHD or PBD. Using Gergen's (1997) relational perspective I argued that mothers' knowledge and experiences of ADHD and PBD were not individually constructed, but were linguistically and discursively constituted through various social interactions and relationships, including family, spirituality and faith, community norms, and expert systems of knowledge. Mothers' narratives revealed the complexity of children's behavioral and emotional problems, the daily trials of living through these problems, how they coped with adversity and developed survival strategies, and how they interacted with various institutional authorities involved in evaluating, diagnosing, and encouraging pharmaceutical intervention for children's behavior. The findings highlight the ways in which mothers' social interactions and relationships introduced a scientific language and discourse for explaining children's behavior as mental illness, the discordances between expert systems of knowledge and mothers' understandings, and how discordances reflected mothers' ‘microsources of power’ for producing their own stories and experiences. ^ In the second manuscript presented here, I documented the ways in which structural factors, including gender, race/ethnicity, and socioeconomic status, coupled with a unique cultural and social standpoint (Collins, 1990/2009) influenced the strategies this group of African American mothers employed to understand and respond to ADHD or PBD. The most salient themes related to mother-child relationships coalesced around mothers' beliefs about the etiology of ADHD and PBD, ‘conceptualizing responsibility,’ and ‘protection-survival.’ The findings suggest that even though mothers' strategies varied, they were in pursuit of a common goal. Mothers' challenged the status quo, addressing children's behavioral and emotional problems in the ways that made the most sense to them, specifically protecting their children from further marginalization in society more so than believing these were the best options for their children.^

The attention/support to students in the socio-labor transition

In the present paper I intend to put forward some inquiries regarding the socio-labor guidance and transition of the young people in the co-ordinates of contemporary society. The outstanding paradox in which some young people are immersed when trying to get a first, second, third employment is also analyzed: "The job of looking for a job". This is a common experience shared by many young people when they try to find a place in the complex labor panorama. Looking for a job is a recurrent situation in contemporary society, given the high dose of precarious employment in which the productive world moves. Life-long jobs belong to the past and what is normal is that people strive to enter the competitive labor market repeatedly. Moreover, the paper offers the partial results of a larger research project that approaches tutorship, decision taking and expectations before the academic-labor future of the studentship in the last years of secondary school. Finally, I suggest some insights in the line that it is not longer feasible to work with old-fashioned guidance, trying to channel people's vocation and offering them information so that they get a job that provides them with the happiness of "doing what you like". Behind these ideas lay the normal biographies, the predictable itineraries. Labor market complexity makes the transition to working life very difficult. Once immersed in it, biographies and labor itineraries are constructed and reconstructed at the rhythm of the changing fortunes of times.

The attention/support to students in the socio-labor transition

In the present paper I intend to put forward some inquiries regarding the socio-labor guidance and transition of the young people in the co-ordinates of contemporary society. The outstanding paradox in which some young people are immersed when trying to get a first, second, third employment is also analyzed: "The job of looking for a job". This is a common experience shared by many young people when they try to find a place in the complex labor panorama. Looking for a job is a recurrent situation in contemporary society, given the high dose of precarious employment in which the productive world moves. Life-long jobs belong to the past and what is normal is that people strive to enter the competitive labor market repeatedly. Moreover, the paper offers the partial results of a larger research project that approaches tutorship, decision taking and expectations before the academic-labor future of the studentship in the last years of secondary school. Finally, I suggest some insights in the line that it is not longer feasible to work with old-fashioned guidance, trying to channel people's vocation and offering them information so that they get a job that provides them with the happiness of "doing what you like". Behind these ideas lay the normal biographies, the predictable itineraries. Labor market complexity makes the transition to working life very difficult. Once immersed in it, biographies and labor itineraries are constructed and reconstructed at the rhythm of the changing fortunes of times.

The attention/support to students in the socio-labor transition

In the present paper I intend to put forward some inquiries regarding the socio-labor guidance and transition of the young people in the co-ordinates of contemporary society. The outstanding paradox in which some young people are immersed when trying to get a first, second, third employment is also analyzed: "The job of looking for a job". This is a common experience shared by many young people when they try to find a place in the complex labor panorama. Looking for a job is a recurrent situation in contemporary society, given the high dose of precarious employment in which the productive world moves. Life-long jobs belong to the past and what is normal is that people strive to enter the competitive labor market repeatedly. Moreover, the paper offers the partial results of a larger research project that approaches tutorship, decision taking and expectations before the academic-labor future of the studentship in the last years of secondary school. Finally, I suggest some insights in the line that it is not longer feasible to work with old-fashioned guidance, trying to channel people's vocation and offering them information so that they get a job that provides them with the happiness of "doing what you like". Behind these ideas lay the normal biographies, the predictable itineraries. Labor market complexity makes the transition to working life very difficult. Once immersed in it, biographies and labor itineraries are constructed and reconstructed at the rhythm of the changing fortunes of times.

Inferring the Effects of Vertical Integration from Entry Games : An Analysis of the Generic Pharmaceutical Industry

This paper introduces a novel method for examining the effects of vertical integration. The basic idea is to estimate the parameters of a vertical entry game. By carefully specifying firms' payoff equations and constructing appropriate tests, it is possible to use estimates on rival profit effects to make inferences about the existence of vertical foreclosure. I estimate the vertical entry model using data from the US generic pharmaceutical industry. The estimates indicate that vertical integration is unlikely to generate anticompetitive foreclosure effects. On the other hand, significant efficiency effects are found to arise from vertical integration. I use the parameter estimates to simulate a policy that bans vertically integrated entry. The simulation results suggest that such a ban is counterproductive; it is likely to reduce entry into smaller markets.

Determination of Dipyrone in pharmaceutical preparations based on the chemiluminescent reaction of the quinolinic hydrazide-H2O2-vanadium (IV) system and flow injection analysis

A rapid, economic and sensitive chemiluminescent method involving flow-injection analysis was developed for the determination of dipyrone in pharmaceutical preparations. The method is based on the chemiluminescent reaction between quinolinic hydrazide and hydrogen peroxide in a strongly alkaline medium, in which vanadium(IV) acts as a catalyst. Principal chemical and physical variables involved in the flow-injection system were optimized using a modified simplex method. The variations in the quantum yield observed when dipyrone was present in the reaction medium were used to determine the concentration of this compound. The proposed method requires no preconcentration steps and reliably quantifies dipyrone over the linear range 1–50 µg/mL. In addition, a sample throughput of 85 samples/h is possible. Copyright © 2011 John Wiley & Sons, Ltd.

Effects of binaural stimulation in attention and EEG

When two pure tones of slightly different frequency are presented separately to each ear, the listener perceives a third single tone with amplitude variations at a frequency that equals the difference between the two tones, this perceptual illusion is known as binaural auditory beat. There are anecdotal reports that suggest that the binaural beat can entrain EEG activity and may affect the arousal levels, although few studies have been published. There is a need for double-blind, well-designed studies in order to establish a solid foundation for these sounds, as most of the documented benefits come from self-reported cases that could be affected by placebo effect. As BB’s are a cheap technology (it even exists a free open source programmable bin aural-beat generator on the internet named Gnaural), any achievement in this area could be of public interest. The aim in our research was to explore the potential of BB’s in a particular field: tasks that require focus and concentration. In order to detect changes in the brain waves that could relate to any particular improvement, EEG recordings of a small sample of individuals were also obtained. In this study we compare the effect of different binaural stimulation in 7 EEG frequency ranges, 78 participants were exposed to 20 min binaural beat stimulation. The effects were obtained both qualitative with cognitive test and quantitative with EEG analysis. Results suggest no significant statistical improvement in 20 min stimulation.

Effect of binaural stimulation on attention and EEG

When two pure tones of slightly different frequency are presented separately to each ear, the listener perceives a third single tone with amplitude variations at a frequency that equals the difference between the two tones; this perceptual illusion is known as the binaural auditory beat (BB). There are anecdotal reports that suggest that the binaural beat can entrain EEG activity and may affect the arousal levels, although few studies have been published. There is a need for double-blind, well-designed studies in order to establish a solid foundation for these sounds, as most of the documented benefits come from self-reported cases that could be affected by placebo effect. As BBs are a cheap technology (it even exists a free open source programmable binaural- beat generator on the Internet named Gnaural), any achievement in this area could be of public interest. The aim in our research was to explore the potential of BBs in a particular field: tasks that require focus and concentration. In order to detect changes in the brain waves that could relate to any particular improvement, EEG recordings of a small sample of individuals were also obtained. In this study we compare the effect of different binaural stimulation in 7 EEG frequency ranges. 78 participants were exposed to 20-min binaural beat stimulation. The effects were obtained both quali- tative with cognitive test and quantitative with EEG analysis. Results suggest no significant statistical improvement in 20-min stimulation.

Monitoring visual attention on a neurorehabilitation environment based on interactive video

The use of new technologies in neurorehabilitation has led to higher intensity rehabilitation processes, extending therapies in an economically sustainable way. Interactive Video (IV) technology allows therapists to work with virtual environments that reproduce real situations. In this way, patients deal with Activities of the Daily Living (ADL) immersed within enhanced environments [1]. These rehabilitation exercises, which focus in re-learning lost functions, will try to modulate the neural plasticity processes [2]. This research presents a system where a neurorehabilitation IV-based environment has been integrated with an eye-tracker device in order to monitor and to interact using visual attention. While patients are interacting with the neurorehabilitation environment, their visual behavior is closely related with their cognitive state, which in turn mirrors the brain damage condition suffered by them [3] [4]. Patients’ gaze data can provide knowledge on their attention focus and their cognitive state, as well as on the validity of the rehabilitation tasks proposed [5].

Background noise and its influence on the brain waves related to attention

In this work, we present a study whose objective is to prove the influence of background noise produced inside university facilities on the brain waves related to attention processes. Recordings of background noise were carried out in study areas inside university facilities. Volunteers were asked to perform an attention test without any background noise but also while being exposed to the sound recordings, and their cerebral activity was recorded through electroencephalography (EEG). After the application of the test in both conditions, changes in the frequency bands related to attention processes (beta 13-30 Hz and theta 4-7 Hz) were studied. The results of this study show that when the students were performing the test while being exposed to background noise, both beta and theta frequency bands decreased statistically significantly. Because attentional improvement is related to increases of the beta and theta waves, we believe that those decreases are directly related to a lack of attention caused by the exposure to background noise. Nevertheless, the results do not allow us to conclude that background noise produced inside university facilities has an influence on the attentional processes.

A journey through Spain in the years 1786 and 1787 : with particular attention to the agriculture, manufactures, commerce, population, taxes and revenue of that country and remarks in passing through a part of France

Sign.: A4, B-Z8, Aa-Bb8, Cc4

A journey through Spain in the years 1786 and 1787 : with particular attention to the agriculture, manufactures, commerce, population, taxes, and revenue of that country and remarks in passing through a part of France

Contiene: "Appendix" con las equivalencias entre la moneda castellana y la inglesa y un indice de nombres geograficos