Evenafter the repeal of the Indian Medical Council Act 500mg chloromycetin amex medications held for dialysis, 1956 order chloromycetin once a day medicine dispenser, the rules and regulations made thereunder shall continue to be in force till new rules and regulations are framed by National Medical Council buy generic chloromycetin pills treatment table. Sub-clause (1) of clause 4 provides for the appointment of Chairperson and Members of the Commission. Sub-clause (4) of clause 6 provides for payment of salary and allowances to the Chairpersons and Members, other than ex officio Members. Sub-clause (1) of clause 8 provides for appointment of Secretary of the Commission and sub-clause (5) thereof provides for appointment of officers and other employees of the Commission. Sub-clause (6) of said clause provides for payment of salary and allowances to Secretary, officers and other employees of the Commission. Sub-clause (1) of clause 16 provides for constitution of four Autonomous Boards consisting of a President and two Members each. Clause 18 provides for appointment of President and Members of the Autonomous Boards and sub-clause (2) of clause 19 provides for salary and allowances of the President and Members of the Autonomous Boards. Clause 40 provides for payment of grants to the Commission, after due appropriation made by Parliament by law in this behalf, as the Central Government may think fit. Sub-clause (1) of clause 41 provides for the constitution of Fund to be called the National Medical Commission Fund which shall form part of the public account of India and setting up of the Commission would entail some expenditure from the consolidated Fund of India. All Government grants, fees and charges received by the Commission and its constituent bodies and all sums received by the Commission from such other source as may be decided upon by the Central Government shall be credited to the fund and shall be applied for payment of salaries and allowances and the expenses incurred in carrying out the provisions of the Bill. The expenditure would be largely met from corpus of the existing Medical Council of India and the funds generated by the National Medical Commission. The budgetary support by the Government to the Commission and its constituent bodies is estimated not to exceed the level of the current budgetary support given to the Council. Further, as expenditure would depend on the number of meetings of the Commission, recurring or non-recurring expenditure cannot be anticipated at this stage. Sub-clause (3) of clause 15 of the Bill empowers the Central Government to make the National Licentiate Examination operational from such date, within three years from the date of commencement of this Act, as may be appointed by notification. Sub-clause (1) of clause 16 of the Bill empowers the Central Government, by notification, to constitute the autonomous Boards under the overall supervision of the Commission, to perform the functions assigned to such Boards under this Act. Sub-clause (3) of clause 36 of the Bill empowers the Central Government, on the recommendations of the Commission, and having regard to the objects of this Act, by notifcation, to add to, or, as the case may be, omit from, the Schedule any categories of medical qualifications granted by a statutory or other body in India. Clause 39 of the Bill empowers the Commission to issue an order to direct that any medical qualification granted by a medical institution in a country outside India, after such date as may be specified in that notification, shall be a recognised medical qualification for the purposes of this Act. The matters in respect of which rules may be made are matters of procedure and administrative detail and it is not practicable to provide for them in the Bill itself. A common practice during a tary recalls, business decisions, and natural disasters (U. There are national efforts to prospec- including adverse events and medication errors may occur. Patients may tively monitor drug shortages and increase the number of early also file complaints because of drug shortages. The survey • The survey results describe the ongoing effects of drug shortages focused on 6 different domains: demographics, adverse events, medication on patient care, pharmacy operations, and patient harm caused errors, patient outcomes, patient complaints, and institutional cost. Our results also 193 respondents (response rate 13%) who participated in the survey. The most common types of medication errors reported were omis- effects of drug shortages on patient complaints. Patient complaints were reported ver the last several years, drug shortages have posed a by 38% of respondents. The majority of respondents reported an esti- mated quarterly institutional cost from shortages of less than $100,000, serious challenge for health care institutions to provide and approximately one quarter of respondents reported adding at least 1 Oconsistent, effective, and safe patient care. The majority of participant practice during a drug shortage is to select an alternate agent to comments mentioned the increasing institutional costs attributed to drug continue patient care without disruption. Delayed care and cancelled care Unintended consequences of using alternate agents during have been reported from shortages. Further research is necessary to better a drug shortage include adverse events and medication errors. In some cases, alternate medications may not create barriers to safe and effective medication therapy on a daily exist and may lead to poor patient outcomes. Even when alternate medications are procured, there are patient harm, shortages may also have an effect on the drug unintended consequences, including adverse events and medica- budget of the institution. Furthermore, clinicians may need to tion errors associated with the alternative therapy. To our 7 A medication error was defined as “any error occurring in knowledge, the effects of drug shortages on patient complaints the medication use process. The purpose tabulated as well as the types of medication errors (wrong drug of our survey was to quantify the effect of drug shortages on dispensed/administered, wrong dose dispensed/administered, patient outcomes, clinical pharmacy operations, patient com- wrong administration route, wrong frequency, wrong indica- plaints, and institutional cost. Respondents were also asked about informational gaps from previous surveys as well as to gather the number of category G-I events at their institutions caused contemporary data regarding these patient care issues. The MedAssets Pharmacy Coalition is composed of individuals from several health care Patient Outcomes areas, including acute care, nonacute care, management, and Information was solicited regarding drug shortages and delays industry. An e-mail was then sent to pharmacy directors in the of care or cancellations of care and the total numbers of each MedAssets Pharmacy Group Purchasing Organization mem- of these events. Delayed care was defined as any treatment that could not be provided when it was required. Cancelled care was defined The survey launched on October 2, 2012, and concluded on as any treatment that was abandoned or terminated because October 23, 2012, with 3 e-mails sent to encourage participa- of a drug being unavailable. No personal or institutional identifying information was death, treatment failure, readmission due to treatment failure, collected, and respondents had the option of not respond- increased length of hospitalization, increased patient monitor- ing to questions. This study was approved as exempt by the ing, patient transferral to an institution with a supply of the Northwestern University and Midwestern University institu- needed medication, delay of therapy, suboptimal treatment, tional review boards. The survey focused on 6 different domains: demographics, adverse events, medication errors, patient outcomes, patient Patient Complaints complaints, and institutional cost. Survey respondents were Respondents were asked if their institutions had received any asked to think about the question in the context of the last 2 patient complaints caused by drug shortages and the number years prior to the survey. Demographics Demographic questions included type of institution, location of Institutional Cost institution, number of patients served, and the drug category of Respondents were asked if they were estimating their costs medications that were unavailable. Adverse events were categorized according to the National Participant Comments Cancer Institute Guidelines for Investigators: Adverse Event Respondents were invited to summarize the effect of drug Reporting Requirements. Comments as a case in which the adverse event may be related to the were categorized into 5 different domains: medication error, drug shortage, and “probably related” was defined as a case adverse event, patient outcome, patient complaints, and insti- in which the adverse event is likely related to the shortage. Each comment could be categorized into more than requiring intervention were also listed. Medication Errors Results Of 183 respondents, 53% (n = 97) reported 1 to 10 medication The survey was sent to 1,516 directors of pharmacy in the errors, and 2. Serious errors were reported responded with 193 respondents (response rate 13%) agree- by 5 respondents (2. The majority of the respondents were permanent harm); 9 respondents (5%), with 1 to 5 category from acute care institutions that serve less than 100 patients, H (required intervention to sustain life); and 2 respondents and the location of the respondents was divided evenly among (1. The most common types of medication errors reported common categories of medications that respondents reported were omission (n = 86, 55.

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The Liapunov derivative is V˙ =[βεs − (γ + d + q)(ε + d + q)]i ≤ 0 250mg chloromycetin with amex medicine 0027 v, since βε ≤ (γ + d + q)(ε + d + q) purchase chloromycetin in india symptoms enlarged prostate. The set where V˙ = 0 is the face of D with i = 0 buy chloromycetin 250mg fast delivery 7mm kidney stone treatment, but di/dt = εe on this face, so that I moves off the face unless e = 0. Because the origin is the only positively invariant subset of the set with V˙ = 0, all paths in D approach the origin by the Liapunov–Lasalle theorem [92, p. Thus if R0 ≤ 1, then the disease-free equilibrium is globally asymptotically stable in D. The characteristic equation corresponding to the Jacobian at the endemic equi- librium is a fourth-degree polynomial. Using a symbolic algebra program, it can be shown that the Routh–Hurwitz criteria are satisfied if R0 > 1, so that the endemic equilibrium (3. ThusifR0 > 1, then the disease-free equilibrium is unstable and the endemic equilibrium is locally asymptotically stable. Then we have the usual behavior for an endemic model, in the sense that the disease dies out below the threshold, and the disease goes to a unique endemic equilibrium above the threshold. Before formulating the age-structured epidemi- ological models, we present the underlying demographic models, which describe the changing size and age structure of a population over time. These demographic mod- els are a standard partial differential equations model with continuous age and an analogous ordinary differential equations model with age groups. The demographic model consists of an initial-boundary value problem with a partial differential equation for age-dependent population growth [114]. Let U(a, t) be the age distribution of the total population, so that the number of individuals at time t in the age interval [a1,a2]isthe integral of U(a, t) from a1 to a2. Note that the partial derivative combination occurs because the derivative of U(a(t),t) with respect to t is ∂U da + ∂U , and da =1. We briefly sketch the proof ideas for analyzing the asymptotic behavior of U(a, t) when d(a) and f(a) are reasonably smooth [114, 123]. Solving along characteristics − a d(v)dv with slope 1, we find U(a, t)=B(t − a)e 0 for t ≥ a and U(a, t)=u0(a − a − a−t d(v)dv t)e for t0, the age distribution is (d + q)e−(d+q)a, because the increasing inflow of newborns gives a constantly increasing young population, so that the age distribution decreases with age faster than de−da, corresponding to q =0. In this case, d(a) is zero until age L and infinite after age L, so that D(a) is zero until age L and is infinite after age L. Of course, the best approximation for any country is found by using death rate information for that country to estimate d(a). The factor w(a)=e−D(a) gives the fraction of a birth cohort surviving until age a, so it is called the survival function. The rate of death is −w (a), so that the expected ∞ ∞ age a of dying is E[a]= a[−w (a)]da = wda. When the death rate coefficient 0 0 d(a) is constant, then w(a)=e−da and the mean lifetime L is 1/d. This demographic model with age groups has been developed from the initial boundary value problem in the previous section for use in age-structured epidemiologic models for pertussis [105]. It consists of a system of n ordinary differential equations for the sizes of the n age groups defined by the age intervals [ai−1,ai], where 0 = a0 1. The second method is to do a local stability analysis of the disease-free equi- librium and to interpret the threshold condition at which this equilibrium switches from asymptotic stability to instability as R0 > 1. Here we use the appearance of an endemic steady state age distribution to identify expressions for the basic reproduction number R0, and then show that the disease-free steady state is globally asymptotically stable if and only if R0 ≤ 1. The age distributions of the numbers in the classes are denoted by M(a, t), S(a, t), E(a, t), I(a, t), and R(a, t), where a is age and t is time, so that, for example, the number of susceptible individuals at time t in the age interval [a1,a2] is the integral of S(a, t) from a1 to a2. Because informa- tion on age-related fertilities and death rates is available for most countries and because mixing is generally heterogeneous, epidemiology models with age groups are now used frequently when analyzing specific diseases. However, special cases with homogeneous mixing and asymptotic age distributions that are a negative ex- ponential or a step function are considered in sections 5. For example, the negative exponential age distribution is used for measles in Niger in section 7. Here it is assumed that the contact rate be- tween people of age a and age a˜ is separable in the form b(a)˜b(˜a), so that the force of infection λ is the integral over all ages of the contact rate times the infectious ∞ fraction I(˜a, t)/ 0 U(˜a, t)da˜ at time t. The division by the total population size ∞ 0 U(a, t)da makes the contact rate λ(a, t) independent of the population size, so the contact number is independent of the population size [57, 97, 102, 159]. One example of separable mixing is proportionate mixing, in which the contacts of a person of age a are distributed over those of other ages in proportion to the ac- tivity levels of the other ages [103, 174]. If l(a) is the average number of people contacted by a person of age a per unit time, u(a) is the steady state age distribu- ∞ tion for the population, and D = 0 l(a)u(a)da is the total number of contacts per unit time of all people, then b(a)=l(a)/D1/2 and b(˜a)=l(˜a)/D1/2. An- other example of separable mixing is age-independent mixing given by b(a)=1and ˜b(˜a)=β. Thus the boundary conditions at age 0 are ∞ M(0,t)= f(a)[M + E + I + R]da, 0 ∞ S(0,t)= f(a)Sda, 0 while the other distributions at age 0 are zero.

D. Jensgar. Saint Andrews Presbyterian College.