By K. Khabir.
It does not publish its in capacity building outside the pharmaceutical Transparent on outcome measures generic 100 mg kamagra gold fast delivery erectile dysfunction treatment natural food. For countries in Leader in building capacity outside the value from its partner organisations cheap 100 mg kamagra gold amex impotence workup. Novartis takes a very strong approach gets are captured in its Access to Healthcare itors the prices charged by its distributors and to philanthropy, primarily through its Novartis Table, which is publicly available on the Novartis works actively with them in an efort to ensure Foundation: it targets local health needs, aims corporate website. This is annually updated and compliance with agreed upon price ceilings, in for sustainability, and includes impact measure- published with the Novartis Annual Report and order to enhance patient afordability. Novartis adapts its Novartis provided antibiotics for humanitar- brochures and packaging materials to address Strong in strengthening pharmacovigilance sys- ian aid programmes. The company has a number to facilitate the product s rational use at vari- of diverse activities to build local pharmacovigi- ous levels of the health system. Novartis ranks in the middle of for Life public-private partnership uses mobile the pack. Novartis takes an innovative, Novartis has not published the status of its research-based capacity building strategy in patents. In partnership with local stakeholders, the company is testing new Public commitment not to enforce patents. However, it still applies equitable pricing to only Sustainable Development Goals, and clearly holds third par- a small portion of its products. It has one of the most trans- ties to the same ethical standards as its own employees. It has fled to register a high pro- building, with a range of initiatives, including a long-term pro- portion of its newest products in high-burden countries and it ject for identifying falsifed medicines. The Health in Developing Countries charters, which with the availability of alternative products in company can ensure its capacity building activ- focus on intellectual property rights and pric- specifc countries. The company can sions in place for its in-house (non-collaborative) also evaluate impact and publish its fndings. Expand equitable pricing strategy to more Ensure access to mental health products on products. It can take It can assess access barriers for these condi- account of more socio-economic factors in its tions and ensure the availability and afordability inter-country equitable pricing strategies. Over half of dle-income countries has been on medicines and the company s projects target high-priority prod- Communicable Non-communicable diagnostics. Improvements in ethical marketing result in Overtaken by peers, drops four places. Its access to its employees on topics related to marketing, are conducted ethically. The Some transparency on access-related out- Achieving a degree of transparency in lobby- company upholds high standards of clinical trial comes. The does not make fnancial contributions to hold- provided to scientifc researchers upon request company publishes on its website its commit- ers of or candidates for political ofce, political via the company s own portal. Requests are pro- ments and objectives, but does not disclose parties or related organisations. It discloses its cessed by an internal committee and denied complete information and updates on overall memberships of industry associations, but does applications are sent for review by a panel performance. Nevertheless, it does not provide informa- duct four times during the period of analysis. All Combating Antimicrobial Resistance in January tion on how its subsidiaries manage their local cases related to unethical marketing practices in 2016, thereby committing to investing in R&D stakeholder engagement activities. The audit programme eral partners, including the Drug for Neglected Innovation: scale up of pilot initiative. The project aims to increase anti-bribery, labour standards and environmen- access to quality healthcare products at an tal regulations. For infectious diseases, the implementation of pricing strategies) and per- company commits to addressing unmet needs forms well in fling to register products where in developing countries, according to defned they are needed. At Best practice: building capacity to help marketed products for high-burden diseases the time of analysis there was no record of an detect suspected falsifed medicines. In 2012, the company renewed its Index and demonstrates key strengths in build- commitment, pledging to increase the number Consistent recall guidelines. The com- of annually donated tablets of praziquantel globally consistent guidelines for issuing drug pany has several best practices, and targets local (Cesol ) to 250 million tablets. This comprises 90% of countries within third-party plant managers through its Virtual the Index scope. It has a strong approach relevant pipeline than the industry average, only a small pro- to access management and is among the most transpar- portion of which targets high-priority product gaps. It expands its engagement in licens- table pricing strategies take limited account of socio-eco- ing, including on access-oriented terms. In Capacity Building, nomic factors, and it performs relatively poorly in terms of its its strengths are in supply chain management and in areas accountability for its sales agents pricing practices. However, it drops in R&D, with a smaller eforts to eliminate lymphatic flariasis and onchocerciasis. It can also assess the need for ucts for non-communicable diseases will be elbasvir/grazoprevir (Zepatier ) in countries accessible. It has *Due to a change in company reporting practices, the numbers from 2011 and 2012 are incomparable with following reporting years. Once again, its over- Mixed performance on transparency of lob- cal trials are conducted ethically. Its policies are all performance is good, with strengths across all bying activities. The company does not pro- access to patient-level data via the company s strategy is aligned with the company s busi- vide any information about its confict of inter- own portal. When the validity of a request is ness strategy: the ability to compete in all mar- est policy. Subject of two settlements relating to unethi- cal behaviour (not in countries of scope). Merck Innovation: signing on to combat antimi- Integrated, company-wide performance man- & Co. These settlements Biotechnology and Diagnostics Industries on measures progress toward its annual goals. The are related to unethical marketing activities and Combating Antimicrobial Resistance in January system tracks each employees progress toward one case of corruption. Merck & have been taken for non-compliance with corpo- tracts, focusing on product R&D for neglected Co. It per- designed to make use of the skills and talents forms relatively poorly when it comes to pro- of Merck & Co. With the Merck Afya Program, low-income countries, though it does not pro- approach to philanthropy: it targets local needs, Merck & Co. It publishes its criteria for aims for sustainable health system improve- icating rabies globally. Rabies is not included in deciding where to register its products, and ments and includes monitoring and evaluation. The London Declaration on Neglected Tropical some data on where its products are regis- The company builds capacities outside the phar- Diseases.
This is true both of 5 H u m a n b o d i e s : d o n a t i o n f o r m e d i c i n e a n d r e s e a r c h trust in individual professionals buy kamagra gold in india erectile dysfunction 27, for example that they will exercise a duty of care towards donors and respect their confidentiality; and of trust in systems discount kamagra gold 100 mg with mastercard impotence kidney disease, that they are the subject of good and responsible governance. In the remainder of this report, we consider the demand for various forms of bodily material from two perspectives. Both reflect on the kind of society we would wish to see and on the manner in which persons flourish. We suggest that an Intervention Ladder would similarly provide a useful tool to help those considering what, if any, forms of additional encouragement should be offered to potential donors to increase the supply of bodily materials or healthy volunteers, whether for treatment or research. Thus, action in accordance with the higher rungs may only be ethical in particular circumstances or contexts. Finally, we emphasise that such a tool clearly cannot capture every consideration of ethical relevance, but rather serves to highlight some of the most common ethical concerns that are likely to arise. We do not consider that refunding expenses involved in donation or providing minor tokens as a spur to donation involve ethical compromises in a way that information campaigns or letters of thanks do not. Indeed, if there is evidence that people who would like to be able to donate are prevented from doing so by cost (for example if a person who wishes to donate a kidney to a family member cannot afford the time off work involved), then it would seem only just to ensure that they are as well able to donate as someone who is sufficiently wealthy not to be affected by such considerations. Public policy has to find a way forward in the light of such competing views: key areas of common ground lie in consideration of the potential harms that might arise from such interventions, to the person donating, to others closely concerned, and to wider social values and relationships. Given that one of the key concerns around any form of non-altruistic-focused intervention is the risk of material being mis- valued, we distinguish between these two approaches through rungs 5 and 6 on the Intervention Ladder. In such cases the benefit in kind is clearly situated within the domain of what has been donated. Non-associated benefits in kind (for example high-value vouchers) fall within rung 6, in that their primary purpose is to offer a straightforward financial benefit. In relation to rung 6, then, the key question is what may constitute ethical payment, and in what circumstances. We endorse the current position, that no payment, over and above the direct reimbursement of costs incurred in being a donor, should be made to living organ donors. We also conclude that systems assigning priority to those who have earlier expressed a willingness to donate are inappropriate, given the wide range of circumstances in which people are held to be ineligible to donate different forms of bodily material. We do, however, endorse the current guidance by the Department of Health that the costs incurred by living organ donors (including actual lost earnings) should be fully reimbursed by their local Primary Care Trusts. Possible ways of achieving this would include through legally binding Directions or through the Code of Practice issued under the Human Tissue Act. Such an incentive might seem sufficiently strong to encourage people to register as donors simply to spare their relatives the financial burden of a funeral and hence constitute rung 6 of our Intervention Ladder: however, such a decision would still include an altruistic component, in the aim to benefit others (the donors relatives). As these arguments demonstrate, when decisions are made in the context of families, the Intervention Ladder will only be one factor to take into account. We consider that payment of funeral expenses in these circumstances could be ethically justified. Under such a scheme, donors could not be physically harmed; those close to the donor might benefit directly; and relatives would also clearly have the option of declining the offer of expenses if they preferred not to accept them. While there is no direct evidence as to how effective or popular such an incentive would be, the similar system in place for those who donate their bodies to medical schools for educational purposes appears to be regarded by both professionals and families as an appropriate acknowledgment of the persons gift. This suggests that the extension of such a scheme to organ donors would not be detrimental either to professional values or the common good. In these circumstances, there is at least a risk that some degree of trust in the system may be lost. If an opt-out system is introduced in Wales we recommend that this is accompanied by robust research, both on the role of relatives in determining whether organs may be donated, and on the effect that the legislative change (as opposed to any confounding factors such as system changes) has had on the numbers of organs donated. Other possible changes with respect to consent defaults include the introduction of mandated choice or prompted choice systems of consent, where individuals are either required or prompted at points during their lifetime to register their views with respect to deceased organ donation. A pilot version of a prompted choice system linked with driver registration is due to begin during 2011. We conclude that, in principle, both mandated choice and prompted choice systems present ethical options for seeking authorisation in advance to deceased organ donation. Difficult issues arise in connection with the amount of information needed for a legally valid consent; and the possibility of signing up to the Organ Donor Register on the basis of very little information about the process of donation has been raised as a matter of concern. We note again the ethical distinction we have drawn between consent for interventions on the body for the purposes of donation during life and authorisation of interventions on the body for the purposes of donation after death, which we consider could well provide a helpful framework for distinguishing between the informational requirements in two very different sets of circumstances. Others, by contrast, may wish to have detailed information about the process of organ retrieval, treatment and transplantation. We conclude that information must be available to those considering donation and it must always be clear that more information is available if people desire it. Current attitudes and policies towards the donation of gametes are strikingly different from those applied to blood and organs. In contrast to the well-funded nationally organised networks promoting and facilitating blood and organ donation, only very limited support is available to raise general awareness of the need for donor gametes. Advertising for gamete donors therefore mainly takes place in the form of ad hoc campaigns by individual clinics, and there is little cooperation between clinics. While travel and other out-of-pocket expenses incurred by gamete donors are reimbursed in full, lost earnings are capped at 250 per cycle of donation. Egg donors, in particular, may therefore potentially be out-of-pocket as a result of their donation. Until such interventions have been tried and evaluated, we consider it highly premature to conclude that a system based primarily on altruism has been shown to fail. In particular, we highlight here the absence of organisational systems necessary for its success, such as the creation of a national infrastructure for egg and sperm donation, on the lines of the structures currently in place for organ donation. Moving to rung 3 of the Intervention Ladder, we see no reason why gamete donors should suffer financial disadvantage as a result of their donation. We consider that the welfare of the potential donor, especially with respect to egg donors, is central in determining what constitutes acceptable practice in this area. However, where egg donation is considered for essentially financial reasons, women may be more likely to consider repeat donations, and may be more likely to continue donating despite potential risks to their health. The lack of good-quality data on the long-term risks of repeat egg donation is a matter of concern here. In addition we recommend, as a matter of urgency, that action is taken by licensed clinics to start collecting data on a systematic basis (if possible retrospectively, as well as through the new registers) to track the long-term health effects of repeat egg donations. Good-quality evidence on these effects is essential in order for proper concern to be given to the welfare of egg donors in any future policy. We note that women who become egg donors through egg-sharing arrangements do not undergo any additional physical risks in the procedure itself; and that current data suggest that their chance of becoming pregnant after the transfer of fresh embryos is on a par with non-egg-sharers, although their cumulative pregnancy rate will be lower because they will have fewer frozen embryos for subsequent transfers after their initial treatment. We also note that, in circumstances where would-be egg-sharers do not in fact produce enough eggs for their own treatment and that of another woman, they should be entitled to use all the eggs for their own treatment, while still receiving the promised rebate on their treatment fees. We consider that the most relevant comparison here, across all the different forms of donation and volunteering noted in this report, is with first-in-human trial volunteers. In contrast with circumstances where eggs are donated for treatment purposes, there is no direct recipient of the donated material and no possibility of a child being born as a result of the donation.
It affects the kidneys in 90% of cases buy discount kamagra gold 100 mg on line erectile dysfunction caused by anabolic steroids, manifesting as Churg Strauss syndrome oliguria purchase 100mg kamagra gold overnight delivery erectile dysfunction gnc, haematuria and uraemia. Macroscopy/microscopy An inammatory small vessel arteritis with predom- Pleural effusion, pneumothorax, inantly mononuclear inltrates. Pleural effusion Investigations Denition 1 Full blood count: anaemia of chronic disease, neu- A pleural effusion is dened as an accumulation of uid trophilia. Decreased Hypoalbuminaemia, 8 Renal biopsy to assess the pattern and severity of oncotic e. Miscellaneous Hypothyroidism Meigs syndrome Management (usually a Cyclophosphamide and high-dose steroids to induce re- right-sided effusion and a benign mission. Inpulmonaryhaemorrhageorsevere Exudate (>30 g/L Infections Bacterial including acute renal failure, plasma exchange may be used. Initially the pleural space is lled with a thin watery uid Signsofaneffusion are only present when >500 mL of containing pus cells (purulent effusion). There is then uid is present and include reduced chest expansion on laying down of brin between the parietal and visceral the affected side, stony dull percussion note, reduced or pleura, which may become organised to form a thick absent breath sounds and vocal resonance. Investigations Clinical features 1 Chest X-ray: visible when there is >300 mL, ranges Patients present with similar features to a pleural effu- from blunting of the costophrenic angles to dense ho- sion: dullness to percussion, absence of breath sounds. Medi- They often appear generally unwell with tachycardia, astinal shift occurs with massive effusion. Needle r Microbiology if the aspirate is turbid and to search aspiration is used to obtain uid for microscopy, culture for an infective course. Management r Cytology to detect neoplastic cells, and distinguish The aim of therapy is to drain the uid and expand the acute from chronic inammation on the basis of lungs whilst treating the infection with appropriate em- the cellular inltrate. Antibiotics are tailored ac- 3 Pleural biopsy if needed: particularly for suspected cording to microbiology results from the uid. Is aimed at the underlying cause thus identication is of r In some patients, videoscopic assisted thorascopic primary importance. Recurrent malignant effusions can be treated with chemical or surgical pleuradhesis. Pneumothorax Empyema Denition Dened as air in the pleural space which may be trau- Denition matic or spontaneous. Themostcommoncauseofempyemaispneumoniawith spread of infection to an associated effusion. Exogenous Clinical features infection may be from a penetrating injury or be iatro- Sudden onset of unilateral pleuritic pain and/or increas- genic, e. Large Endogenous infection may be from perforated oesoph- pneumothoraces produce breathlessness, pallor, tachy- agus or spread from a subphrenic abscess. Pleural malignancy Cystic brosis Pneumonia Aetiology Sarcoidosis The most common cause of pleurisy is infection, related Traumatic Penetrating chest wounds to an underlying bacterial or viral pneumonia. Pleurisy Rib fractures canalsobeafeatureofpulmonaryembolism,pulmonary Oesophageal rupture Iatrogenic Subclavian cannulation infarction, malignancy and connective tissue diseases Positive pressure ventilation such as rheumatoid arthritis. Pleural aspiration Oesophageal perforation during endoscopy Clinical features Lung biopsy Sharp, well-localised pain, worse on inspiration or coughing,andapleuralrubheardonauscultation. Investigations Chest X-ray shows the visceral pleura as a thin line with Macroscopy absent lung markings beyond. Fibrinous exudate is seen over the pleural surfaces and there is variable exudation of uid. Aimed at identication and treatment of the underlying r If the pneumothorax is >20%, particularly if the pa- cause. Nonsteroidalanti-inammatorydrugsandparac- tient has underlying lung disease or is signicantly etamol are used for analgesia. If after a few days disease and embolism the drain continues to bubble and the pneumothorax persists this indicates a bronchopleural stula, i. Denition r Pleurectomy is indicated in recurrent pneumotho- Respiratory failure is dened as a fall in the arterial oxy- racesorfor bronchopleural stulae that fail to close gen tension below 8 kPa. Aetiology/pathophysiology The opposition of lung to the raw area on the chest r Type I failure, sometimes called acute hypoxaemic wall causes the surfaces to adhere to one another. Other signs include required, preferably before patients are completely ex- the use of accessory muscles of respiration, tachypnoea, hausted (see Table 3. With time the arteries undergo a and <8kPa when stable with polycythaemia, nocturnal proliferative change leading to irreversible pulmonary hypoxaemia, peripheral oedema or pulmonary hyper- circulationchanges. Patients increase in blood viscosity and predisposes to must have stopped smoking (for safety reasons), and an thrombosis. Investigations Prognosis Blood gas monitoring is the most important initial in- Fifty per cent of patients with severe chronic breathless- vestigation to establish the type of failure and will dictate ness die within 5 years, but in all stopping smoking is the the mode of oxygen therapy. Pulmonary embolism Pathophysiology Following a pulmonary embolus there is a reduction in Denition the perfusion of the lung supplied by the blocked vessel. Thrombus within the pulmonary arteries causing lack Ventilation perfusion mismatch occurs, leading to hy- of lung perfusion. Production of surfactant also stops if perfu- or uncommonly from the heart embolises to the lungs. Infarct is rare (only occurring in around Prevalence 10% of cases) as the lung is also supplied by the bronchial Common. Aetiology The causes of thrombosis can be considered according Clinical features to Virkhow s triad: The result of a pulmonary embolism depends on the size r Disruptioninbloodowparticularlystasis:Prolonged and number of the emboli. Pleural inam- 1 In massive pulmonary embolism, there is haemody- mationresultsinapleuralfrictionrubandalow-grade namic compromise which may require resuscitative pyrexia. With large emboli, thrombolysis or surgical Clinical signs of a deep vein thrombosis may also be thrombectomy with cardiac bypass may be life-saving. For small or moderate Blood enters the pulmonary vasculature and thus there emboli subcutaneous low molecular weight heparin is is congestion proximal to the blockage. Therapy is converted to warfarin after 48 hours (for 3 Repair results in the formation of a white scar. Lifelong war- farin may be indicated depending on the underlying Microscopy cause, or in recurrent embolism. Typical features include haemorrhage (due to extravasa- 3 If anti-coagulants are unsuccessful or contraindicated tion of blood), loss of cell architecture, cellular inltra- a lter may be inserted into the inferior vena cava to tion and occasionally necrosis. Atelectasis and areas of hypoperfusion may be seen, and large emboli may cause Pulmonary hypertension an elevated hemidiaphragm and enlarged proximal pul- Denition monary arteries. A ventilation perfusion (V/Q) scan is Aetiology usually diagnostic, but is less helpful if the chest X-ray Pulmonary hypertension may be secondary to a variety is abnormal. This in turn raises r Right ventricular strain pattern T wave inversion the pulmonary capillary and arterial pressures (left in leads V1 V4. A similar syndrome is associated with Management sytemic lupus erythematosus, scleroderma and Ray- Treatment is aimed at the underlying cause. The result is a de- disease may benet from oxygen therapy to reduce crease in the lumen of the vessels and hence an increased the vasoconstrictor effect of hypoxia. Progressive fail- r Long-term intravenous infusion of epoprostenol ure of the right side of the heart occurs which is called (prostacyclin) improves the outcome of patients with cor pulmonale.
A study of the incidence of post-herpetic neuralgia in 1982 revealed a gure of 40 per 100 000 (12) buy cheap kamagra gold 100 mg on-line for erectile dysfunction which doctor to consult. Further information from Bowsher (13) indicated that the number of individuals with post-herpetic neuralgia increases with age so that 40% of people over 80 years of age who acquire acute herpes zoster will suffer from chronic post- herpetic neuralgia purchase discount kamagra gold on-line erectile dysfunction pills philippines. In populations in which ever greater numbers are living to 80 years and more, there is likely to be a signicant increase in individuals suffering from post-herpetic neuralgia. One third of patients with multiple sclerosis develop neuropathic pain states, of whom trigeminal neuralgia occurs in 5%, and another one third develop other forms of chronic pain (3). There is an increase in the incidence of trigeminal neuralgia in patients with cancer and other diseases that impair the immunological systems. It is signicant that one third of cancer patients have a neuropathic component to their pain as do a similar proportion of patients with prolonged low back pain (14). It should be noted that stump pain arises from a severed nerve in the limb and may be caused by a local neuroma or by tethering of the severed nerve to local tissues. In contrast, phantom limb pain is central neuropathic pain and more difcult to treat. Central stroke pain is dened as neuropathic pain that follows an unequivocal episode of stroke. For most patients the pain develops gradually during the rst month but delays of many months have been recorded. The pain is incapacitating, distressing and often even more so than other symptoms. In part, this is the result of nerve injury which presents as acute neuro- pathic pain in 1 3% of patients. The majority of such patients experience persistent pain one year after the causative event, indicating that acute neuropathic pain is a very denite risk factor for chronic pain. Hernia repair is followed by moderate to severe pain in 12% of patients one year postoperatively and is of the somatic or neuropathic type (17 ). Breast surgery of various types gives rise to the experience of phantom breast and pain with or without a phantom. The nature of the pain, which is often neuropathic in type, means that the sufferer has a disabling condition that in time may be primarily the result of pain, which is difcult to relieve. As such, it poses a signicant health problem in terms of its personal, social and economic consequences. This diagnostic category is not fully accepted among clinicians because many continue to believe that pain must be a symptom of an ongoing disease or injury. Current research reveals, however, that the pathophysiological changes mentioned persist when signs of the original cause for pain have disappeared. The signs and symptoms of chronic pain, once it has evolved into a disease, are listed in Box 3. The combination of these features of the condition reveal the potential for physical impairment, disability and handicap which collectively form the basis of signicant degrees of burden for both the patient and the family. Therefore many doctors, nurses and others dealing with patients in pain enter their professional careers inadequately equipped to deal with the most common symptom and cause of considerable suf- fering worldwide. Politicoeconomic barriers The availability of drugs for the treatment of pain is a problem in over 150 countries. A treatment gap In many countries, therefore, there is a treatment gap, meaning that there is a difference between what could be done to relieve pain and what is being done. That gap exists in a number of devel- oped countries, primarily because of poor pain education and the often limited and patchy nature of specialized facilities for pain treatment. Additionally, in developing countries these problems are far greater and the gap is far wider because of the lack of education, access to appropriate drugs for pain relief and facilities for pain management. The treatment gap can be reduced worldwide by improving pain education, increasing facilities for pain treatment and access to pain-relieving drugs. In the case of opioid analgesics, an increase in their availability and the employment of correct protocols is a matter of urgency. Also, no stricter measures should be enacted than those requested by the international drug conventions and international recommendations (20) on the use of opioid medicines. Management of pain of neurological origin The range of treatments available for pain directly caused by diseases of the nervous system includes pharmacological, physical, interventional (nerve blocks, etc. Treatments for pain are used in association with other forms of treatment for the primary condi- tion, unless of course pain is itself the primary disorder. There are many studies of the medical treatment of peripheral neuropathic pain (21). There are far fewer studies published on the treatment of central neuropathic pain, for example post-stroke pain. Neuropathic pain does not respond well to non-opioid analgesics such as paracetamol, ace- tylsalicylic acid and ibuprofen a non-steroidal anti-inammatory drug. Opioids have been shown to have some efcacy in neuropathic pain but there are specic contraindications for their use. Topical agents may give local relief with relatively little toxicity; they include lidocaine and, to a lesser extent, capsaicin cream, particularly in the treatment of post-herpetic neuralgia. In selected cases, electrical stimulation techniques such as transcutaneous electrical stimulation or dorsal column stimulation may be used, but the latter in particular is expensive which clearly limits its use. However, the latter route requires administra- tion by a trained specialist and therefore is unlikely to be freely available in developing countries. In relation to that, prejudice has the opioids that could provide such relief have been cat- developed consisting of an unjustied fear of psychological egorized as controlled substances. They are therefore dependence of patients on opioid medication and an unjus- subject to stringent international control and rendered tied fear of death caused by opioids. They ac- for by many international bodies (the International Narcot- count for about 80% of the world population. Nearly one billion of the people living today The programme, as proposed, will focus on regulatory will encounter this problem sooner or later. Most of them barriers, the functioning of the estimate system for import- are pain patients. These causes stem essentially from an imbalance and law enforcers will exchange their views and the prob- between the prevention of abuse of controlled substanc- lems they encounter. It will train civil servants responsible es and the use of such substances for legitimate medical for submitting estimates and, in doing so, train health-care purposes. Furthermore, it will For almost 50 years the focus was on the prevention of develop other activities, including advocacy. Research reveals that such therapies are effective in the reduction of chronic pain and absenteeism from work (22). Relaxation techniques, hydrotherapy and exercise are helpful in the management of painful conditions that have a musculoskeletal com- ponent. There is good evidence that multimodal treatment and rehabilitation programmes are effective in the treatment of chronic pain (23, 24). All health-care workers who treat pain, especially chronic pain, whatever its cause, can expect about 20% of patients to develop symptoms of a depressive disorder. Among patients attending pain clinics, 18% have moderate to severe depression when pain is chronic and persistent. It is known that the presence of depression is associated with an increased experience of pain whatever its origin and also reduced tolerance for pain.