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Essential medicines are intended to be available within the context of functioning health systems at all times in adequate quantities buy proscar 5 mg without a prescription prostate cancer foods to eat, in the appropriate dosage forms generic 5mg proscar visa prostate quotes, with assured quality and adequate information order line proscar prostate picture, and at a price the individual and the community can afford. It incorporates the need to regularly update medicines selections to: » reflect new therapeutic options and changing therapeutic needs; » the need to ensure medicine quality; and » the need for continued development of better medicines, medicines for emerging diseases, and medicines to meet changing resistance patterns. Effective health care requires a judicious balance between preventive and curative services. A crucial and often deficient element in curative services is an adequate supply of appropriate medicines. In the health objectives of the National Drug Policy, the government of South Africa clearly outlines its commitment to ensuring availability and accessibility of medicines for all people. These are as follows: » To ensure the availability and accessibility of essential medicines to all citizens. The private sector is encouraged to use these guidelines and drug list wherever appropriate. Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations. It remains a national responsibility to determine which medicines are regarded as essential. A medicine is included or removed from the list using an evidence based medicine review of safety and effectiveness, followed by consideration of cost and other relevant practice factors. These therapeutic classes have been designated where none of the members of the class offer any significant benefit over the other registered members of the class. It is anticipated that by limiting the listing to a class there is increased competition and hence an improved chance of obtaining the best possible price in the tender process. In circumstances where you encounter such a class always consult the local formulary to identify the example that has been approved for use in your facility. The perspective adopted is that of a competent prescriber practicing in a public sector facility. A brief description and diagnostic criteria are included to assist the medical xix officer to make a diagnosis. These guidelines also make provision for referral of patients with more complex and uncommon conditions to facilities with the resources for further investigation and management. The dosing regimens provide the recommended doses used in usual circumstances however the final dose should take into consideration capacity to eliminate the medicine, interactions and co-morbid states. It is important to remember that the recommended treatments provided in this book are guidelines only and are based on the assumption that prescribers are competent to handle patients’ health conditions presented at their facilities. Adopting a more flexible approach promotes better utilisation of resources with healthcare provided that is more convenient for patients. Conditions and medicines are cross referenced in two separate indexes of the book. The section on Patient Education in Chronic Conditions aims to assist health workers to improve patient adherence and health. These systems should not only support the regulatory pharmacovigilance plan but should also provide pharmacoepidemiology data that will be required to inform future essential medicines decisions as well as local interventions that may be required to improve safety. To facilitate reporting, a copy of the Adverse Drug Reaction form and guidance on its use has been provided at the back of the book. Feedback Comments that aim to improve these treatment guidelines will be appreciated. The submission form and guidelines for completing the form are included in the book. Paediatric Dose Calculation Paediatric doses are mostly provided in the form of weight-band dosing tables according to age. In particular, do not use age bands if the child appears small for his/her age or is malnourished. These standardised paediatric weight- band dosing tables for specific conditions are contained in an appendix. Prescription Writing Medicines should be prescribed only when they are necessary for treatments following clear diagnosis. In certain conditions simple advice and general and supportive measures may be more suitable. In all cases carefully consider the expected benefit of a prescribed medication against potential risks. This is important during pregnancy where the risk to both mother and foetus must be considered. All prescriptions should: » be written legibly in ink by the prescriber with the full name and address of the patient, and signed with the date on the prescription form; » specify the age and, in the case of children, weight of the patient; xxi » have contact details of the prescriber e. In all prescription writing the following should be noted: » The name of the medicine or preparation should be written in full using the generic name. A zero should be written in front of the decimal point where there is no other figure, e. Avoid Greek and Roman frequency abbreviations that cause considerable confusion – qid, qod, tds, tid, etc. Consider whether the number of items is too great to be practical for the patient, and check that there are no redundant items or potentially important drug interactions. Check that the script is dated and that the patient’s name and identification number are on the prescription form. Only then should the prescriber sign the script, and as well as provide some other way for the pharmacy staff to identify the signature if there are problems (print your name, use a stamp, or use a prescriber number from your institution’s pharmacy). Patient Adherence Adherence is the extent to which a person’s behaviour – taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider. Poor adherence results in less than optimal management and control of the illness and is often the primary reason for suboptimal clinical benefit. It can result in medical and psychosocial complications of disease, reduced quality of life of patients, and wasted health care resources. Poor adherence can fall into one of the following patterns where the patient: » takes the medication very rarely (once a week or once a month); » alternates between long periods of taking and not taking their medication e. Although there is no gold standard, the current consensus is that a multi method approach that includes self report be adopted such as that below. Social and economic » May lack support at home or in » Encourage participation in the community treatment support programs. Healthcare team related » Little or no time during the visit to » Encourage patient to ask provide information. Treatment related » Complex medication regimens » If possible reduce treatment (multiple medications and doses) complexity can be hard to follow. Although many of these recommendations require longer consultation time, this investment is rewarded many times over during the subsequent years of management. For a patient to consistently adhere to long term pharmacotherapy requires integration of the regimen into his or her daily life style. The successful integration of the regimen is informed by the extent to which the regimen differs from his or her established daily routine. Where the pharmacological proprieties of the medication permits it, the pharmacotherapy dosing regimen should be adapted to the patient’s daily routine.

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It is related to Ebola virus and a parent type belongs to Viral Hemorrhagic fevers of Filoviridae family safe proscar 5mg mens health hair loss. Mode of transmission How the animal host first transmits Marburg virus to humans is unknown buy cheap proscar 5mg line androgen hormone meaning. However discount proscar 5mg without a prescription prostate 5xl free shipping, humans who become ill with Marburg hemorrhagic fever virus may spread virus to other people. For example, persons who have handled infected monkeys and have come in direct contact with their fluids or cell cultures have become infected. Spread of the virus between humans has occurred in a setting of close contact, often in a hospital. Droplets of body fluids, or direct contact with persons, equipment, or other objects contaminated with infectious blood or tissues are all highly suspect as sources of disease. Transmission through infected semen can occur up to seven weeks after clinical recovery. Signs and symptoms are into two phases: Phase One: Sudden onset of fever, chills, headache and myalgia. Phase Two: Maculopapular rashes, Trunk rash, Nausea, Vomiting, Sore throat, Abdominal pain, Diarrhea, Jaundice, Pancreas inflammation, Severe weight loss Liver failure, Massive hemorrhage (all orifices), Multi-organ dysfunction, Delirium, Shock, and Death. These include: 353 | P a g e o Fluid and Electrolyte balancing o Maintaining oxygen status o Blood transfusion and clotting factors o Treat for any complicating infections. Transmission to human is mainly through direct or indirect contact with blood or organs of infected animals. The virus can be transmitted to human through the handling of animal tissue during slaughtering or butchering, assisting with animal births, conducting veterinary procedures. Human become viraemic; capable of infecting mosquitoes shortly before onset of fever and for the first 3–5 days of illness. Signs and symptoms are Influenza like illnesses: sudden onset of fevers, headache, myalgia, backache neck stiffness photophobia and vomiting. Most human cases are relatively mild small proportion develop a much more severe disease. Symptoms last from 4-7 days after which the immune response to infection becomes detectable with appearance of IgM and IgG. Most of human cases are relatively mild and of short duration so will not require any specific treatment. Though many cases of yellow fever are mild and self-limiting, the disease can also be a life threatening causing hemorrhagic fever and hepatitis. It is endemic in equatorial Africa and South America, with estimated 200,000 cases and 30,000 deaths annually. Overall case-fatality rate in Africa 23% Incubation period of 2-6 days and human become viremic - capable of infecting mosquitoes, shortly before onset of fever and for the first 3–5 days of illness. Once infected, mosquitoes remain so for life Treatment, prevention and control No specific anti-viral treatment, supportive therapies are recommended. Prevention and Control involve mosquito control and provision of yellow fever vaccine. Indication for Yellow fever vaccine: • persons ≥ 9 months of age – Planning travel to or residence in an endemic area – Planning travel to a country with an entry requirement • Needs to be given ≥ 10 days prior to arrival in endemic area • Revaccination at 10 year intervals 6. Table 2: The schedule for immunization for children is as follow: Age Vaccine Type of vaccine/state Disease Remarks (dose, Protection prevented site and route) Birth 1. Pentavalent Liquid Hepatitis B (Left thigh) Haemophilus influenza type b infections 3 Months 1. Pentavalent Liquid (Left thigh) Full dose 10 years 9 Months Measles Live attenuated / Freeze Measles 0. Onset of kala-azar is shown by low grade fever, splenomegaly, enlarged liver and lymphadenopathy. In the cutaneous form, single or multiple lesions are found on exposed parts, from where Leishmania Donovan bodies can be demonstrated. If parasites persist, treatment may be repeated, two to three times with a ten day interval in between. Since an immediate hypotensive reaction may occur, patients should lie down during the injection and adrenaline should be at hand. Further, due to possible nephrotoxicity, urine must be examined for albumin and/or casts. Treatment Medicine of choice Suramin is the medicine of choice for the early stages of African trypanosomiasis (T. V as a test dose then if there is no reaction give 20mg/kg body weight single dose, freshly prepared (maximum 1 g) every 5 – 7 days. The patient is then rested for 5-7 days and then the above regime of melarsoprol is repeated. This is done once again after a further rest of 5-7 days, thus completing 3 courses of melarsoprol. However, man is infected directly through contact with infected hides or inhalation of spores in the lungs or ingestion of infected meat. The main clinical features are itching, a malignant pustule, pyrexia and rarely pulmonary and gastrointestinal signs. V every 6 hours until local oedema subsides then continue with A: Phenoxymethylpenicillin 250 mg 6 hourly for 7 days. Children Premature infant and neonate A: Benzylpenicillin 6mg/kg body weight every 6 hours until local oedema subsides then continues with A: Phenoxymethylpenicillin 62. Infants (1-12 months) A: Benzylpenicillin 75 mg/kg body weight daily 8 hourly until local oedema subsides then continue with A: Phenoxymethylpenicillin62. Children (1-12 years) A: Benzylpenicillin 100 mg/kg body weight daily 6 hourly until 1 local oedema subsides. Then give A: Phenoxymethylpencillin125-250mg6 hourly for 7 days Second choice A: Erythromycin (O) 500 mg 8 hourly orally for 10 days Children:10 mg/kg body weight 8 hourly for 10 days 2. The common causative organisms of the disease are either staphylococcus or streptococcal bacteria. Clinical features of a breast abscess are tenderness, swelling, red, warm, fever and painful lymph nodes. Instruct the patient to apply hot compresses and a constriction bandage to relieve pain in the affected breast, and to express milk if applicable to reduce engorgement. The main disease forms are bubonic, septicaemic and pneumonic with the former being the commonest. The incubation period is within 7 days and case fatality rate may exceed 50 to 60% in untreated bubonic plague and approaches 100% in untreated pneumonic or septicaemic plague. Treatment When preliminary diagnosis of human plague is made on clinical and epidemiological grounds:  Subject the patient to appropriate antimicrobial therapy without waiting for definitive results from the laboratory. Each febrile episode ends with a sequence of symptoms collectively known as a "crisis. This phase is followed by the "flush phase", characterized by drenching sweats and a rapid decrease in body temperature.

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A individuals remain asymptomatic buy proscar 5 mg with amex mens health 15 minute workout dvd, they serve as total of 27 drugs are included in the current version the reservoir for the pathogen buy generic proscar 5 mg on line mens health quizzes, making control of of the database best proscar 5mg prostate quebec. All the mice in the drug-treated mainly in infections involving aerobic, Gram- groups survived whereas the control mice died within 30 days. Synergistic among the aminoglycosides it has not been widely effects with the aminoglycosides and beta lactams used clinically to treat tuberculosis probably due have resulted in use of this combination treatment to a combination of drug costs and toxicity. Di Perri G, Bonora S (2004) Which agents should we use Human drug drug interactions: Concurrent use of for the treatment of multidrug-resistant Mycobacterium other aminoglycosides and gentamycin, tobramycin, tuberculosis? J Antimicrob should not be used with potent diuretics (ethacrynic Chemother 40, 27 32. Stability: Stable in aqueous solution at pH 4 8; unstable in strongly acidic or strongly basic solutions [Merck Index]. Interestingly, many tuberculosis demonstrated the up-regulation of bacteria lack tlyA and may be naturally resistant to several ribosomal proteins (e. In addition it is associated with but its use is limited due to renal and auditory renal effects due to kidney tubulopathy leading to al- toxicities. Most patients have eosinophilia • Human: Not bioavailable via oral administration. Heifets L, Lindholm-Levy P (1989) Comparison of bacte- for the treatment of multidrug-resistant Mycobacterium ricidal activities of streptomycin, amikacin, kanamycin, tuberculosis? Antimicrob clinical isolates of Mycobacterium tuberculosis and Agents Chemother 37, 2344 7. After constitution, each 5 ml of Biaxin suspension contains 125 mg or 250 mg of clarithromycin. Human adverse reactions: Reactions are generally Good tissue penetration with 5 times more drug in mild and the drug is well tolerated especially with lung compared with plasma and penetration into slow-release tablets of Biaxin. Andini N, Nash K (2006) Intrinsic macrolide resistance 184 mg/kg and 227 mg/kg in two separate studies. Nash K (2003) Intrinsic macrolide resistance in Mycobacterium smegmatis is conferred by a novel those obtained following administration to mice by erm gene, erm(38). Antimicrob Agents Chemother corneal opacity and lymphoid depletion were all 33, 591 2. Concomitant dosing of astemizole is not of Mycobacterium tuberculosis to clarithromycin is recommended for similar reasons and because of effectively reversed by subinhibitory concentrations of cell wall inhibitors. Di Perri G, Bonora S (2004) Which agents should we use when three antimicrobial agents are combined against for the treatment of multidrug-resistant Mycobacterium Mycobacterium tuberculosis. Clofazimine was first synthesized in 1954 as an anti-tuberculosis lichen-derived compound. The drug was thought to be ineffective against tuberculosis but in 1959 Chang demonstrated its effectiveness against leprosy. Brand names: Lampren(e) (Novartis) Derivatives: Riminophenazine analogs B4154 and B 4157. No organisms were endothelial components following oral treatment recovered from lungs although spleens still showed of 20 mg/kg for several months;21 other tissues had signs of infection. In the same model some efficacy relatively low drug levels (range 3 114 mg/g of wet was observed with once and twice weekly dosing. Liposome-encapsulated drugs tend to accumulate • Human: 45 62% oral absorption rate. The average in macrophages and are released at slower rates serum concentrations in leprosy patients treated than the free counterpart (reviewed in Adams et al. Lamprene higher tolerable doses in the same animal (compare passes into breast milk. Three metabolites have been identified but Controversy about drug carry-over in animal models it is unclear if metabolites are pharmacologically clouds simple interpretation of some of the reported active. Absorption varies 98 Clofazimine from 45% to 62% following oral administration in teratogenicity was found in these infants. The skin and fatty tissue 75 100% of the patients within a few weeks of of offspring became discolored approximately 3 days treatment; ichthyosis and dryness (8 28%); rash and after birth, which was attributed to the presence of pruritus (1 5%). Abdominal pain, diarrhoea, nausea, vomiting or Antimicrob Agents Chemother 36, 2729 35. Ames test Mycobacterium tuberculosis to inhibitors of metabolism: reveals no evidence of carcinogenicity risk but long- novel insights into drug mechanisms of action. The skin of infants born to women who comparative intracellular activities against the virulent had received the drug during pregnancy was found H37Rv strain in human macrophages. Multidrug therapy against acid and clofazimine against Mycobacterium tuberculosis. Chromosome nanosuspension for intravenous use and evaluation of analysis in bone marrow and spermatocytes. Gangadharam P, Reddy M (1995) Carryover of clofazimine clofazimine, an antileprosy drug, in mice in vivo. Aqueous solutions buffered to pH 10 with sodium carbonate can be stored without loss for one week at +4ºC [Merck Index]. It is most often used in combination with d-alanine:d-alanine ligase (Ddl) which synthesizes up to 5 drugs to treat M. Di Perri G, Bonora S (2004) Which agents should we use Human metabolic pathway: Excretion is primarily for the treatment of multidrug-resistant Mycobacterium renal, with 50% excreted unchanged within 12 hours, tuberculosis? In-vivo efficacy in animal model: In vivo in mouse (drug given orally 15 days post i. Minor abnormalities of reversible although irreversible blindness has been the cervical vertebra were seen in the newborn of reported. Other gave birth to two foetuses with monophthalmia, side effects that have been observed are pruritus, one with a shortened right forearm accompanied joint pain, gastrointestinal upset, abdominal pain, by bilateral wrist-joint contracture and one with malaise, headache, dizziness, mental confusion, dis- hare lip and cleft palate. Degenerative and treatment was discontinued; the authors suggest changes in the central nervous system, apparently close monitoring of liver toxicity when these two drugs are used together for prophylaxis. Focal interstitial carditis was also noted in of ethambutol binding to Mycobacterium smegmatis. Irreversible blindness has been comparative intracellular activities against the virulent H37Rv strain in human macrophages. Kaur D, Khuller G (2001) In vitro, ex-vivo and in vivo color blindness, and/or visual defect. These events activities of ethambutol and sparfloxacin alone and have also been reported in the absence of a diagnosis in combination against mycobacteria. An exploration in niazid, pyrazinamide, and ethambutol pharmacokinetics murine tuberculosis. Cynamon M, Sklaney M (2003) Gatifloxacin and and sensitivity in multidrug-resistant Mycobacterium ethionamide as the foundation for therapy of tuberculosis. Di Perri G, Bonora S (2004) Which agents should we use Agents Chemother 37, 2344 7. Brand names: Tequin (Bristol-Myers Squibb); Zymar (Allergan) Derivatives: Gatifloxacin is a quinolone/fluoroquinolone antibiotic related to ciprofloxacin, enoxacin, fleroxacin, gemifloxacin, grepafloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, pefloxacin, prulifloxacin, rufloxacin, sparfloxacin, temafloxacin, trovafloxacin and sitafloxacin Solubility: 60 mg/ml at pH 4 [DrugBank] Polarity: Log P 1.

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Th e followingquestionsto clarify compliance were asked:�H ave B oth questionsasked 58 al discount proscar 5mg with mastercard prostate oncology pharmacy. F inally additionalquestionsand also analyzed accordingto th e repliesto th e oth er inntional order 5 mg proscar mastercard prostate herbal remedies. G ood compliance = neverorrarely ch anged oromitd medicationwith outconsultingaph ysician generic proscar 5 mg free shipping mens health initiative. Inntional 95 L ah denpera patientswere ch angingth eirmedicationaccordingsymptomsby th emselves. R eference N umberof M eth od formeasuringcompliance A spectofnon- C omp- h ypernsive compliance mainly liance patients measured (% ) Toyosh ima 6289 1. Inntional 80 compliance relad to exnsionofth e medication-takinginrvals, reductionofdosage,stoppingand resumingofmedicationand comple discontinuationofmedication. M emory problems, 74 with aquestionrelad to th e frequency offorgettingto take medicine. R eference N umberof M eth od formeasuringcompliance A spectofnon- C omp- h ypernsive compliance mainly liance patients measured (% ) W allenius 623 Inth e questionnaire itwasasked wh eth erth e patientssometimesorofn Inntional 64 etal. A llaspects 56 and Snow h ad collecd 80% ofantih ypernsive medicinesprescribed to h im/h er. M emory problems, 42 ofpillsmissed orth e numberofextrapillstakenperweek onanaverage. Effective inrventions in long-rm care were complex and included differencombinations of more conveniencare, information, counselling, reminders for appointments and missed drug refills, self-monitoring of medication-taking and blood pressure, supporto compliance, family therapy and other forms of extra supervision or atntion. Even the mosffective inrventions did nolead to a substantial improvemenof compliance. There are only a handful of rigorous compliance inrvention studies among the thousands of studies on compliance (Haynes eal 1996). Since compliance is a problem in all treatmenregimens in which medications are to be taken by patients, an improvemenin basic and applied compliance research would be profitable. The application of new knowledge of how to effectively improve compliance would have a much grear effecon health than any existing treatmen(Haynes eal 1996). In a more recensysmatic review of randomized controlled trials aiming to increase compliance with antihypernsive medication, iwas found thareduction of the number of daily doses seems to be the mospromising method (Schroeder eal 2004). However, skipping a single dose means an approximaly 48-hour inrval between doses in a once a day regimen, while the corresponding inrval is approximaly 24 hours in a twice a day regimen (Waeber 2004). The study also showed thapatienducation alone was noa successful method (Schroeder eal 2004). However, some motivational and complex methods are promising, bubecause of insufficienvidence, they cannobe recommended based on our currenknowledge level. Furthermore, the wrirs commenthaven the besmethods for improving compliance and treatmenoutcomes have nobeen very effective. The following sections presendifferenfactors associad with compliance, and these factors are shown summarized in Table 2. Hypernsion and its Health care sysm and Patientreatmenpersonnel - certain groups of - reasonable costs - understanding the benefits antihypernsive drugs - effectiveness of treatmenof treatmen- dosage once a day - the way the benefits of - no memory problems - morning dosage treatmenare presend - no incorrecdisease- - shorr duration of - trusin physicians relad beliefs medication - certain cultural and - no adverse drug effects attitudinal factors or their - symptoms of disease absence - previous hospitalizations - older age because of cardiovascular - device for measuring disease blood pressure ahome - regular living habits The type of antihypernsive drug A study in the Unid Stas on nearly 22. Another study from the Unid Stas followed originally 7211 patients on monotherapy for hypernsion during 12 months based on the Medicaid database (Rizzo and Simons 1997). One dose a day was associad with betr compliance than doses taken twice a day or more ofn. Timing of dosages Iseems thathere are differences in compliance depending on the timing of dosage. A Japanese study of hypernsive patients showed compliance to be beswith a morning dose, second beswith an evening dose and worswith a daytime dose (Fujii and Seki 1985). Furthermore, a French 4-week study followed hypernsive patients who had been advised to take their medications between seven and nine o�clock in the morning (Mallion eal 1996). By measuring compliance with an electronic pill box, iwas found thathere were more delayed doses aweek-ends. Number of antihypernsive medications A study in the Unid Stas on 98 hypernsive patients did nofind an association between compliance and the number of antihypernsive medications (Shaw eal. A Finnish study on 623 patients with antihypernsive medication similarly did nofind an association between compliance and the number of cardiovascular medications (Wallenius eal. However, a Canadian study on 367 cardiovascular patients did find an association between non-compliance and fewer medications (Shalansky and Levy 2002). These findings are also suppord by a large study from the Unid Stas concerning 7211 hypernsive patients (Rizzo and Simons 1997). Experience of adverse drug effects and symptoms in patients with high blood pressure Several studies have repord thaperceived adverse drug effects are common. A Finnish study in 30 health centres with 3520 medically tread hypernsive patients showed tha10% of patients repord symptoms relad to antihypernsive medication spontaneously and 20% did so when asked abousymptoms by the physician (Kumpusalo eal 1997b). In a detailed symptom inquiry, 80% of patients repord aleasone symptom and an average of four symptoms. A Norwegian study of 2586 medically tread hypernsive patients also showed the prevalence of adverse drug effects to be dependanon the method of measuremen(Olsen eal 1999). Wallenius eal (1995) found perceived adverse drug effects to be associad with inntional non-compliance. In several other studies patients have also repord adverse effects as the reason for their non-compliance (Cooper eal. In this respecthe results of a randomized controlled trial where patients received an antihypernsive drug (n = 1105) or a placebo (n = 187) are noworthy (Preston eal 32 2000). Unbearable adverse drug effects, which led to discontinuation of medication, were repord by 13% of the patients in the placebo group and 12% of the patients in the antihypernsive drug group. Sometimes iis difficulto distinguish the real adverse effects of antihypernsive treatmenfrom the symptoms of hypernsion (Flack eal. Whether the adverse drug effects are real or not, health care professionals need to take the patient�s experiences seriously to ensure successful treatmenof hypernsion. Hypernsive patients have also repord symptoms relad to high blood pressure or rise of blood pressure including e. Iis also good to think whether the patient�s symptoms could be due to something else, e. Other factors Patients have also repord as reasons for their non-compliance feeling well withoudrugs or feeling worse than before medication and lack of symptoms of hypernsion (Balazovjech and Hnilica 1993, Svensson eal. Furthermore, a lower prevalence of previous hospitalizations because of cardiovascular disease has been associad with discontinuation of antihypernsive medication (Degli Esposti eal 2002). Some patients have also repord attribud their non-compliance to the claim thathey cannoafford to buy medicine (Cooper eal. The office visito a physician or a nurse may produce costs, as will transportation to differenhealth care facilities.

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