By Y. Sancho. Southern Methodist University. 2018.
In contrast to the positive claims from open trials generic mildronate 500 mg free shipping, ditive benefit to an established treatment program buy 500 mg mildronate mastercard. Few fol- results from double-blind trials have been limited, for the low-up studies have examined whether medication treat- most part. Double-blind studies, at most, report marginal ment produces lasting benefit. A new generation of studies success in treatment of specific problems such as improving has begun to focus on whether medication can prevent re- the rate of weight gain during refeeding, and disturbed atti- lapse after patients leave to a structured treatment setting. Use of Antidepressants in AN One problem with determining the efficacy of pharma- cotherapy in AN is that often medications have been given There has been controversy as to whether AN and major in association with other therapies. Thus, it may be unclear depressive disorders share a common diathesis; however, whether it was the medication or therapy that resulted in critical examination of clinical phenomenology, family his- improvement. Furthermore, the primary criterion for im- tory, antidepressant response, biological correlates, course provement has often been weight gain, not a normalization and outcome, and epidemiology yield limited support for of thinking and reduction in fears of being fat. Still, the high frequency of mood tant to emphasize that treatment in structured settings, such disturbances associated with this disorder resulted in trials as inpatient units, even without medication, succeeds in of drugs such as amitriptyline (41–43), and lithium (44). Thus, it may be difficult to prove that an active medi- compared with the effects of placebo. However, relapse within For more that 50 years (45), investigators have suggested 1 year after successful inpatient weight restoration is very that AN shares similarities with obsessive-compulsive disor- common (25). In fact, patients with AN have a high prevalence ported that only 23% of the patients had a good outcome of obsessive-compulsive symptoms or disorders (46–48), as at 1 year after discharge despite intensive outpatient individ- well other anxiety disorders (49). Controlled trials of the neuroleptics pimozide (27) and Individuals with a past history of AN display evidence of sulpiride (28) have suggested limited effects in accelerating increased serotonin (51) activity that persists after long-term weight gain or altering anorectic attitudes for some patients weight recovery. In addition, women who recover from AN for part of the study, but overall drug effect was marginal. Similarly (10), personality characteris- a good outcome on placebo (P. Aside tics associated with AN, such as introversion, self-denial, from improved outcome, fluoxetine administration was as- limited spontaneity, and a stereotyped thinking style, may sociated with a significant reduction in obsessions and com- also persist after weight recovery. Studies in humans and pulsions and a trend toward a reduction in depression. Together, these data raise the possibility in some patients with AN. Women plicated in OCD (52) and only serotonin-specific medica- with AN, when malnourished and underweight, have re- tion has been found to be useful in treating OCD. In addition, low estrogen values during the malnour- patients with AN. Initial reports on cyproheptadine, a drug ished state may reduce serotonin activity by effects on gene that is thought to act on the serotonergic and histaminergic expression for serotonin receptors (64) or the serotonin system (53), indicated that it might have beneficial effects transporter (65). SSRIs are dependent on neuronal release on weight gain, mood, and attitude in some patients (54, of serotonin for their action. Cyproheptadine data from comparison trials with ami- compromised release of serotonin from presynaptic neu- triptyline and placebo found cyproheptadine to significantly ronal storage sites and reduced synaptic serotonin concen- improve weight gain in the restricting subtype of AN, trations, then a clinically meaningful response to an SSRI whereas amitriptyline was more effective in those patients might not occur (66). The possibility that fluoxetine is only with bulimic behavior (56). For example, CSF 5-HIAA levels are low might help patients with AN gain and/or maintain a healthy in underweight anorexics, normal in short-term weight-re- body weight. Recently, the Pittsburgh group reported a dou- stored anorexics, and elevated in long-term weight-restored ble-blind placebo-controlled trial of fluoxetine in 35 pa- anorexics (67). If CSF 5-HIAA levels accurately reflect CNS tients with restrictor-type AN (59). Subjects were started serotonin activity, then these data imply that a substantial on fluoxetine after they achieved weight restoration (approx- increase in serotonin activity occurs after weight gain. The use of serotonin-specific medications in the treat- Patients were randomly assigned to fluoxetine (N 16) ment of AN is promising but many questions remain. First, or placebo (N 19) after inpatient weight-restoration and only one double-blind placebo-controlled study has been then were followed as outpatients for 1 year. After 1 year completed in a relatively small number of restrictor-type of outpatient follow-up, 10 of 16 (63%) subjects had a good patients.
These effects were consistent across risk groups buy discount mildronate 500 mg line, and increased with predicted risk level best 250mg mildronate. Table 18 shows, following adjustment for length of time in each phase and all other significant covariates, an increase in the proportion of participants who attended the ED in the intervention phase compared with the control phase. The number of ED attendances per participant was also higher in the intervention phase. These data are also highly skewed, with most participants (> 80%) not experiencing any attendances, but a few attending on multiple occasions. Analysis using log-transformed data is therefore appropriate, and shows an increase of 3% in emergency admissions per participant per year at risk in the intervention phase. These effects were consistent across risk groups, and increased with predicted risk level. Following adjustment for length of time in each phase and all other significant covariates, we found a decrease in the proportion of participants with GP event-days recorded in the intervention phase compared with the control phase, an effect that was consistent across risk groups. However, the number of days when GP activity was recorded per participant per year at risk was higher in the intervention phase. Although these data are less skewed, with most participants (> 80%) experiencing event-days, the rate of events is still heavily weighted to the smaller numbers at highest predicted risk of emergency admission to hospital. Analysis using log-transformed data is, again, therefore, appropriate, and shows an increase of 1% in days on which GP activity was recorded per participant per year at risk in the intervention phase. This effect was reversed among the two highest risk groups. Following adjustment for length of time in each phase and all other significant covariates, we found overall no difference in the proportion of participants with outpatient visits in the intervention phase compared with the control phase, with varying effects across the risk groups. Analysis using log-transformed data shows an increase of 5% in outpatient attendances per participant per year at risk in the intervention phase, an effect related to an increase in the two lowest risk groups. Table 21 shows, following adjustment for length of time in each phase and all other significant covariates, no effect in mean bed-days per patient per year at risk. However, these data are highly skewed, with most participants (> 90%) not experiencing any hospital stays, but a few attending on multiple occasions and some with very long lengths of stay. Analysis using log-transformed data is therefore appropriate, and shows an increase of 3% in mean bed-days per participant per year at risk in the intervention phase. This effect was consistent across risk groups, and increased with predicted risk level. We have not carried out full, adjusted analyses for this variable as this was not a formally set outcome; however, we present this as a background check of safety and have found no clear effect associated with trial phase. Table 23 illustrates that there was not a large variation in the profile of PRISM scores between clusters of practices (mean range between 5. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend ( p b g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend ( p c g e atstudy day 1 g ender( p W score ( p PR I S M score; and days atri sk d g e atstudy day 1 PR I S M score; days atri sk and seasonali ty ( p e g e atstudy day 1 p PR I S M score; and days atri sk f g e atstudy day 1 g ender W score; PR I S M score; days atri sk and seasonali ty. T S ec o n da r y o utc o m e: even t- da ys a n a lysis b y tea tm en ta llo c a ted da te P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te Proporti on ofparti ci pants lla OR p to 0 to 0 w i th one ormore G P b ev ent- days: proporti on ( % R i sk g roup 1 OR p to 0 R i sk g roup 2 c OR p to 0 R i sk g roup 3 d OR p to 0 R i sk g roup 4 e OR p to 0 N umberofG Pev ent- days llf [ ] [ ] p to 0 to 0 perparti ci pant mean ( S D g [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 h [ ] [ ] p to 0 R i sk g roup 3 [ ] [ ] p to 0 j R i sk g roup 4 [ ] [ ] p to 0 N umbers ofG Pev ent- days ll [ ] [ ] p to 0 to 0 perparti ci pantperyearat l ri sk mean ( S D [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 m [ ] [ ] p to 0 R i sk g roup 3 n [ ] [ ] p to 3 R i sk g roup 4 o [ ] [ ] p to 0 c T S ec o n da r y o utc o m e: even t- da ys a n a lysis b y tea tm en ta llo c a ted da te P ha se ( un co ected f ha se dur a ti O utco e up ter ven ti t l djusted co a r is sti a te p L og - transformed numbers ll [ ] [ ] p to 0 to 0 ofG Pev ent- days per q parti ci pantperyearatri sk R i sk g roup 1 [ ] [ ] to 0 mean ( S D [ ] ( p R i sk g roup 2 r [ ] [ ] to 0 L ( p R i sk g roup 3 s [ ] [ ] to 0 L ( p R i sk g roup 4 t [ ] [ ] to 0 L ( p S D standard dev i ati on. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; W h ealth component PR I S M score; days atri sk seasonali ty; and trend. T S ec o n da r y o utc o m e: o ut a tien ts visits a n a lysis b y tea tm en ta llo c a ted da te P ha se O utco e up ter ven ti t l djusted co a r is sti a te Proporti on ofparti ci pants lla OR p to 1 to 0 w i th one ormore b outpati entv i si ts: proporti on R i sk g roup 1 OR p to 1 ( % c R i sk g roup 2 OR p to 0 R i sk g roup 3 d OR p to 0 R i sk g roup 4 e OR p to 1 N umberofoutpati entv i si ts llf [ ] [ ] p to 1 to 0 perparti ci pant mean ( S D g [ ] R i sk g roup 1 [ ] [ ] p to 1 R i sk g roup 2 h [ ] [ ] p to 0 R i sk g roup 3 [ ] [ ] p to 0 j R i sk g roup 4 [ ] [ ] p to 1 N umbers ofoutpati ent ll [ ] [ ] p to 0 to 0 v i si ts perparti ci pantper l yearatri sk mean ( S D [ ] R i sk g roup 1 [ ] [ ] p to 0 R i sk g roup 2 m [ ] [ ] p to 0 R i sk g roup 3 n [ ] [ ] p to 0 R i sk g roup 4 o [ ] [ ] p to 4 c T S ec o n da r y o utc o m e: o ut a tien ts visits a n a lysis b y tea tm en ta llo c a ted da te P ha se O utco e up ter ven ti t l djusted co a r is sti a te p L og - transformed numbers ll [ ] [ ] p to 0 to 0 ofoutpati entv i si ts per q parti ci pantperyearatri sk R i sk g roup 1 [ ] [ ] p to 0 mean ( S D [ ] r R i sk g roup 2 [ ] [ ] p to 0 R i sk g roup 3 s [ ] [ ] p to 0 L R i sk g roup 4 t [ ] [ ] p to 0 L S D standard dev i ati on. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender W score; PR I S M score; days atri sk seasonali ty; and trend. S i g ni fi cantcov ari ates and factors ( p unless oth erw i se stated) are: a g e atstudy day 1 g ender( p W score; PR I S M score; and seasonali ty. As questionnaires were sent to a sample deliberately skewed towards those with higher PRISM scores, we separately summarise characteristics of respondents in Table 24. Table 25 shows no difference in Mental Health Component scores but higher (improved) Physical Health Component scores in respondents in the intervention phase, with a trend towards greater improvement in those in the higher-risk groups. However, no differences were evident when questionnaire responses were summarised by an overall SF-6D. Satisfaction scores were slightly lower overall in the intervention phase, although there was no clear pattern across risk groups. The earliest PRISM score within this extended window is dated 2 September 2012 and is available for 96,314 out of the 230,999 participants. Just over half (n = 51,570) of these 96,314 participants were still in the control phase on 31 July 2013 and this subsample of 51,570 participants is the basis of the analysis in this section.
Reproduced discount 250mg mildronate mastercard, by permission of the publisher cheap mildronate 250mg amex, from Pena-Rosas et al. The strength of inference that can be made from research studies is dependent partly on the study design, rang- ing from observational studies (weaker), through cross-sectional, case−control and cohort studies, to randomized controlled trials (stronger) (14). To apply the results of a research study in another setting requires causes and effects to be linked in the same way; this is not a matter of study design. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system assesses the quality of evidence and the strength of recommendations on the basis of the evidence. It is a transparent and systematic mechanism for judging whether the results of research are robust enough to inform policy (15, 16). At present, GRADE is an effective tool for assessing the value of an intervention studied by a clinical trial, but is less well suited to judging, for example, how easily an intervention can be implemented in a health system, or its suitability with respect to health equity. GRADE has had to be fine-tuned to deal with issues specific to immunization, such as the population-level effects of vaccines, and to the use of data from surveillance systems (17). Furthermore, the outputs of GRADE need to be presented in a manner that is accessible to policy-makers. Initiatives such as DECIDE (Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence, http:// www. Creativity everywhere behind the development of both products and procedures in private companies of all sizes (23). Tis report takes a more positive working assumption in this report is that new view. Tere are undoubtedly many problems that ideas will throw up potential solutions to health are hard to solve en route to universal health cov- problems, and that innovators will turn some of erage – such as improving the efciency of health these proposed solutions into practical applica- care through the dense network of connections tions if they are permitted and encouraged to do that make up health services. Some of these practical innovations will be wherever we look in the world, we fnd people shown by research to be worthy of large-scale proposing ingenious solutions to difcult ques- implementation. Creativity is a In the next section we show that the research leitmotif in this report. While creative solutions needed to harness these new ideas is on the rise. New ideas are pervasive, Te landmark 1990 report from the Commission as revealed in a 10-country survey of R&D car- on Health Research for Development had a last- ried out for the 2010 African Innovation Outlook. Problems, ideas, solutions Innovation in action: mobile phone software developed to monitor fetal movements and heartbeats Zeinou Abdelyamin from Algeria has been worried that the widespread use of insecticides and rodenticides leaves chemical residues that are harmful to people and domestic animals. In 2012, he won an African Prize for Innovation for carrying out research to formulate nonchemical pesticides that leave no trace in the environment (19). In the same year, Aaron Tushabe and fellow students at Makerere University, Uganda, wanted to find ways to make pregnancy safer for women who do not have easy access to hospitals (20). They invented a portable scanner to detect anomalies in gestation, such as ectopic pregnancies and abnormal fetal heart beats (see photograph). Cheaper than ultrasound, their hand-held scanner is a funnel-like horn that gives a read-out on the screen of a mobile phone. Meanwhile in Tamil Nadu, India, Dr V Mohan has created the “self-expanding diabetes clinic” to provide diagnosis and care to people in remote rural areas of India (21). His mobile clinic, housed in a van carrying satellite equip- ment, visits some of the remotest parts of Tamil Nadu, linking urban doctors to rural patients via community health workers. The van has telemedicine technology to carry out diagnostic tests, such as retinal scans, and transmit the results within seconds to Chennai, even from areas too remote for Internet connectivity. The wider application of these innovations needs to be guided by health technology assessments (22). The key point, however, is that examples of creativity and innovation can be found everywhere. Milestones in research for health 1990 Report of the independent Commission on Health Research for Development (1) This report exposed the mismatch between investment in health research in developing countries (5% of all funds) and the burden of disease in these countries, measured as years of life lost through preventable deaths (93%). The mismatch was later characterized by the Global Forum for Health Research as the “10/90 gap” (less than 10% of global spending on research devoted to diseases and conditions that account for 90% of the burden of ill-health) (24). The report recommended that all countries undertake and support essential national health research; that more financial support for research should be obtained through international partnerships; and that an international mechanism should be established to monitor progress. They called for the establishment of a Global Health Research Fund to support research in areas that primarily affect developing countries, focusing on basic scientific research in health and biomedicine. They drew attention to the science that is needed to improve health systems, and urged greater efforts to bridge the gap between scientific potential and health improvement. In parallel, WHO launched the World report on knowledge for better health (28).
The decision to combine data across these different conditions was a methodological one buy 500mg mildronate with visa, justified on the basis that this provided a reasonable number of studies for meta-analysis and permitted a broad cumulative assessment of the effects of self-care support interventions for mental health order 500mg mildronate otc. A finer-grained analysis of the effects of self-care support on the different patient experiences and utilisation pathways that these conditions may precipitate demands the acquisition of a much bigger evidence base. The generation of new evidence should adopt clear and consistent standards of data reporting, including comprehensive reporting of patient outcomes, utilisation and costs Our review adopted a comprehensive and rigorous approach to study eligibility judgements and data synthesis. Our ability to conduct some of our analyses has been hampered by poor reporting of outcome data in primary studies. Although our typology of self-care support interventions was relatively simple, its application was complicated by variation in the amount of the detail provided, including lack of transparency regarding intervention personnel and the amount and nature of the support that they provided. More comprehensive, consistent and theory-led reporting of intervention content and processes would facilitate much more effective analyses of specific intervention ingredients. We identified a notable number of studies (n = 19) that met our review inclusion criteria but failed to provide data amenable to meta-analysis. Deficiencies in outcome reporting are common and are not specific to our review, although the requirement that primary studies reported both QoL and utilisation outcomes meant that the impact of these deficiencies was inevitably more acute. More consistent and comprehensive reporting of data would enable more effective syntheses. Our primary objective was to assess the ability of self-care support to reduce costs without compromising outcomes for children and young people. This objective does not map neatly onto conventional economic analyses, which focus on incremental cost-effectiveness ratios (ICERs) and associated net mean benefit statistics. Traditionally, interventions that increase costs, but provide significant health benefits for children, might attract support from decision-makers, who would then face decisions about which other interventions (with less attractive cost-effectiveness profiles) might be replaced. The current research aimed to establish whether or not cost savings could be made without comprising patient health. The primary analysis identified in our protocol was on total costs. We applied liberal inclusion criteria to the cost outcomes included in our forest and permutation plots, and included data where it represented a composite measure of health service costs. However, inconsistencies in data reporting meant that not all studies included all sources of health service or intervention delivery costs. As such, some outcomes may have fallen short of what would conventionally be considered a comprehensive assessment of NHS costs. No clear relationship between patient outcomes and costs was evident in the permutation plot, although only a small number of comparisons was available for meta-analysis and variability across studies was high. Lack of data availability meant that we could not accurately assess the robustness of our secondary analyses, which we based on partial costs. Our protocol stipulated that our secondary analyses would, where data allowed, sequentially explore the effect of self-care support on inpatient, outpatient, primary care and community care resources. Lack of consistent measurement and ambiguity in the data available meant that these analyses could not be carried out. From the patient perspective, any positive effect of self-care support on QoL is likely to be appraised and interpreted in the context of other gains and losses, including the costs incurred in engaging in self-care behaviours. Future studies should thus seek to establish which models of self-care support, if any, are associated with reduced service utilisation and explore, through the collection of comprehensive cost data, potential patterns of cost shifting between services and patients. This finding is based on the short-term follow-up data reported by the primary studies in our review. Where multiple follow-up assessments were conducted, we extracted data closest to a 12-month assessment. Self-care support for children and young people may have an early and valuable part to play in developing self-efficacy, empowering patients and promoting positive health behaviours for LTC management. Insights into the processes underlying utilisation can be derived from adult studies, which suggest that reductions in health service use may be facilitated by shifting conceptions of reliance on traditional services and translating the acquisition of skills and practices into everyday routines. Further research may usefully establish if, and if so, which models of self-care support for children and young people have had longer-term effects on QoL and health utilisation.
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