By T. Rendell. Salem College. 2018.
A clinical No eligible economic psychotherapy trial for adolescent depression comparing cognitive cheap lopressor 100 mg otc, family and supportive outcomes therapy generic 50 mg lopressor free shipping. Arch Gen Psychiatry 1997;54:877–85 Britto MT generic 25mg lopressor visa, Vockell AL buy 12.5mg lopressor fast delivery, Munafo JK, Schoettker PJ, Wimberg JA, Pruett R, et al. Improving Absent/ineligible comparator outcomes for underserved adolescents with asthma. Pediatrics 2014;133:e418–27 Broquet Ducret C, Verga ME, Stoky-Hess A, Verga J, Gehri M. Randomized trial of a comprehensive No eligible health outcomes asthma education program after an emergency department visit. Ann Allergy Asthma Immunol 2006;97:44–51 Bruzzese JM, Markman LB, Appel D, Webber M. An evaluation of open airways for schools: Absent/ineligible comparator using college students as instructors. J Asthma 2001;38:337–42 Bruzzese JM, Evans D, Wiesemann S, Pinkett-Heller M, Levison MJ, Du YL, et al. J Sch Health 2006;76:307–12 Bruzzese JM, Unikel L, Gallagher R, Evans D, Colland V. Feasibility and impact of No eligible economic a school-based intervention for families of urban adolescents with asthma: results from a outcomes randomized pilot trial. Fam Process 2008;47:95–113 Buchner DA, Butt LT, De Stefano A, Edgren B, Suarez A, Evans RM. Effects of an asthma No comparator; adult/child management program on the asthmatic member: patient-centered results of a 2-year study mixed data in a managed care organization. Am J Manag Care 1998;4:1288–97 Buelow JM, Johnson CS, Perkins SM, Austin JK, Dunn DW. Creating Avenues for Parent No eligible economic Partnership (CAPP): an intervention for parents of children with epilepsy and learning outcomes problems. Epilepsy Behav 2013;27:64–9 Butz AM, Malveaux FJ, Eggleston P, Thompson L, Schneider S, Weeks K, et al. Use of Absent/ineligible comparator community health workers with inner-city children who have asthma. Clin Pediatr 1994;33:135–41 Bynum A, Hopkins D, Thomas A, Copeland N, Irwin C. The effect of telepharmacy No eligible economic counseling on metered-dose inhaler technique among adolescents with asthma in rural outcomes Arkansas. Telemed J E Health 2001;7:207–17 Bywater T, Hutchings J, Linck P, Whitaker C, Daley D, Yeo ST, et al. Incredible Years parent Population training support for foster carers in Wales: a multi-centre feasibility study. Child Care Health Dev 2011;37:233–43 Cabral ALB, Carvalho WAF, Chinen M, Barbiroto RM, Boueri FMV, Martins MA. Are Study design International Asthma Guidelines effective for low-income Brazilian children with asthma? Eur Respir J 1998;12:35–40 Catov JM, Marsh GM, Youk AO, Huffman VY. Asthma home teaching: two evaluation No eligible health outcomes approaches. Dis Manag 2005;8:178–87 Charlton I, Charlton G, Broomfield J, Mullee MA. Audit of the effect of a nurse run asthma No eligible health outcomes clinic on workload and patient morbidity in a general practice. Br J Gen Pract 1991;41:227–31 Chase HP, Crews KR, Garg S, Crews MJ, Cruickshanks KJ, Klingensmith G, et al. Clin Pediatr 1992;31:450–6 Chen SH, Yeh KW, Chen SH, Yen DC, Yin TJ, Huang JL. The development and establishment No eligible health outcomes of a care map in children with asthma in Taiwan. J Asthma 2004;41:855–61 104 NIHR Journals Library www. Interactive support interventions for caregivers of No eligible health outcomes asthmatic children.
NMDA receptors are gated by mem- The inhibition of NMDA receptor function by ethanol brane potential and the simultaneous binding of both has direct neuroprotective consequences (20) 12.5 mg lopressor fast delivery. Ethanol at concentrations as tagonist effects of ethanol may influence its modulation of low as 5 mM (20 mg%) inhibits ion flux through the the release of other neurotransmitters (21 lopressor 50mg fast delivery,22) buy lopressor 25mg visa, perhaps re- NMDA receptor-gated ion channels lopressor 50 mg cheap, making NMDA re- flecting the capacity of low-dose NMDA antagonism to ceptors one of the highest affinity ethanol targets in the preferentially attenuate the activation of local inhibitory cir- brain (Fig. The subjective effects of ethanol are tested in animals by Ethanol effects on the NMDA receptor function are de- measuring their ability to discriminate the effects of ethanol pendent on the concentration of glycine and the phosphory- and other drugs. NMDA antagonists substitute for ethanol lation status of the receptor. In cultured cerebellar granule in these experiments, where they resemble the effects of cells, ethanol lowered the NMDA receptor affinity for gly- higher doses of ethanol than ethanol doses that are most cine, and ethanol effects were partially reversed by raising similar to the effects of -aminobutyric acid (GABA) ago- glycine levels (16). Supporting the importance of the NMDA site, phosphorylation event may gate the effects of ethanol on WSP (withdrawal seizure prone) and WSR (withdrawal sei- glycine affinity at the NMDA receptor (16). Other protein zure resistant) mice differ in their NMDA receptor density kinases (e. Regional variations in NMDA receptor subunit compo- sition contribute to distinctions in ethanol effects on NMDA Receptor Adaptations with Ethanol Tolerance NMDA receptor function across brain regions (see ref. Functional NMDA receptors are composed of Multiple lines of evidence implicate NMDA receptor up- an NR1 subunit, with at least eight splice variants, and one regulation as a mechanism contributing to acute ethanol NR2 subunit from among the four known subtypes (NR2 withdrawal. Chronic ethanol administration up-regulates Chapter 100: Ethanol Abuse, Dependence, and Withdrawal 1427 NMDA receptor number, particularly in the cerebral cortex 0. Ketamine did not stimulate ethanol craving in and hippocampus (27). During acute ethanol withdrawal, patients, although craving was associated with the ethanol- NMDA receptor increases are associated with tremors, anxi- like effects of another NMDA antagonist dextromethor- ety, ataxia, and convulsions (27). Additionally, NMDA antago- antagonist component of ethanol effects in the brain. The nists given during withdrawal suppress withdrawal seizures NMDA antagonist-induced euphoria does not yet appear (28). Lastly coadministration of the ganglioside GM1 and dopamine dependent. For example, the euphoric properties ethanol prevents NMDA receptor up-regulation and the of ketamine are not blocked by haloperidol pretreatment display of withdrawal seizures (29). These findings parallel clinical findings describing the tured cells and whole animals, chronic ethanol administra- lack of interaction of ethanol and amphetamine (39). In tion increases the levels of the NR2A and NR2B protein contrast, the euphoric effects of ketamine (40), like ethanol subunits and their subunit messenger RNA (mRNA) levels (41), are attenuated by pretreatment with the opiate re- (30). Some, but not all, studies also suggest that NR1 sub- ceptor antagonist naltrexone. Ethanol may possess actions unit protein level increases may be accompanied by increases at other brain targets that attenuate the dysphoric properties in NR1 mRNA levels (31). In cultured cells, the increases arising from its blockade of NMDA receptors including the in NMDA receptor subunit proteins are associated with facilitation of GABAA receptor function (42) or blockade increased NMDA receptor function (32). The consequences of NMDA receptor up-regulation during dependence are compounded by increases in gluta- Glutamatergic Dysregulation in Ethanol Dependent Pa- mate release associated with the initiation of abstinence tients: Relationship to the Familial Riskto Develop Alco- (33). Perhaps as a result, ethanol withdrawal is associated holism. Postmortem studies of brain tissue from ethanol- with seizures and neurotoxicity (see ref. In vivo, ethanol withdrawal increases cere- Glutamate and the Complex Discriminative Stimulus Ef- brospinal fluid (CSF) glutamate levels. With repeated episodes of the preclinical studies (24), both the intensity and the degree withdrawal, patients show increased seizure risk (48) and of similarity of the ethanol-like effects of ketamine were hyperreflexia (49). Similarity of the effects of placebo (open circles), ketamine 0. Values are expressed as mean standard error of the mean (SEM). Ketamine effects were significantly more similar to ethanol than both marijuana and cocaine by post-hoc contrast (F1 6. NMDA antagonist component of ethanol response from The similarity between the behavioral effects of GABA ago- dysphoria to euphoria, promoting further alcohol use. Re- nists and ethanol is dose-dependent, with the greatest simi- cently detoxified ethanol-dependent patients show reduc- larity between these drug classes observed with relatively tions in their sensitivity to the perceptual, mood, and cogni- low training doses of ethanol (15).
As a general rule discount lopressor 100 mg overnight delivery, the countries that make the Median Interquartile range greatest progress in maternal and child health are Source: Demographic and Health Surveys or Multiple Indicator those that successfully narrow the gap between Cluster Surveys in 46 low- and middle-income countries lopressor 100 mg lowest price. Tis is a form of “progressive universalism” in which the health order 100mg lopressor visa, for aspects of prevention and health pro- poorest individuals gain at least as much as the motion lopressor 25 mg low cost, and for patient safety and patient experi- richest on the way to universal coverage (61). Te risk is measured as the proportion of people who die within 30 quality as well as quantity days of admission (Fig. As with many It is not just the quantity of health services pro- measures of quantity, national statistics on the vided that is important, but also the quality of quality of care are ofen not precisely compara- them. In this instance, case-fatality rates should on the quality of care, the Organisation for ideally be based on individual patients, but Economic Co-operation and Development some national databases do not track patients in (OECD) has developed measures of quality for and out of hospitals, between hospitals or even selected interventions: for cancer and mental within the same hospital, because they do not 20 Chapter 1 The role of research for universal health coverage Fig. Case-fatality rates following use unique patient identifers. Tere are big diferences in case-fatality are data rates between countries, but some of the vari- ation might be explained by local practices of EU16 countries discharging patients from hospitals, and trans- Denmark 4. Taking that step launched an agenda for Portugal 11. We do not yet know how to ensure that United Kingdom of 12. Crude rates In this chapter research questions of two Age and sex standardized rates kinds have been identifed. Te frst and most 95% conﬁdence interval important set of questions is about choosing the health services needed, improving the coverage EU, European Union. Te Organisation for Economic Co-operation and second set of questions concerns measurement Development (65). Te health services that are necessary and the people who need them should be defned with 21 Research for universal health coverage respect to the causes of ill-health, the technolo- enhanced by tracking progress towards the gies and instruments for intervention, and the MDGs, especially in low- and middle-income cost. Te services required vary from one setting countries (50). However, beyond the MDGs there to another, as does the capacity to pay for them. Similarly, while there are evidence on this issue is mixed. A comparative some standard indicators of the quality of health study of 22 low- and middle-income countries services, of equity of access, and of fnancial risk found that interventions to support universal protection, there is much scope for refning the health coverage usually improve access to health methods of data collection and measurement. Te study also found, less convincingly, that Universal health coverage is seen as a means such interventions can have a positive efect on of both improving health and promoting human fnancial risk protection and, in some instances, development. Tis puts research for universal a positive impact on health (68). Another conclu- coverage in the wider context of research for sion of the review was that the efects of inter- development. Research will play a role not only ventions varied according to the context, design in meeting the MDGs but also in supporting and process of implementation. For exam- is illustrated further in Chapter 3 of this report. Just as the necessary health services vary An additional and complementary challenge to between settings, so too must the combination that of increasing universal health coverage is to of indicators for measuring the coverage of ser- develop research that can enhance understand- vices. Because it is not possible to measure the ing of how intersectoral policies can improve coverage of all services, a set of tracer inter- health and advance development. Research needs could be selected to exemplify major types of researchers with skill and integrity, who are diseases or health problems such as acute infec- funded to work in well-equipped institutions. Universal coverage is achieved when results that lead to improvements in health, each intervention is accessible to all who need it, mechanisms are needed to translate evidence and when it has the intended efects. To defne such a set of indicators is worldwide; these provide the basis on which to another task for research. Chapter 3 shows, Tere are already numerous indicators of by example, how research can address a wide health-service coverage that have been standard- range of questions about universal health cov- ized and validated, and they are widely used.
In addition buy lopressor 50mg low price, symptoms alone have 307 recently been shown to underestimate postablation AF burden buy lopressor 25 mg with amex. Furthermore buy 12.5mg lopressor mastercard, recurrent episodes of AF may be of varying lengths of time from seconds to months purchase 100mg lopressor with visa. This wide variation in duration may have very different effects on the development of other clinically important outcomes such as exacerbation of heart failure or development of stroke. Our study was limited to English-language publications. It was the opinion of the investigators and the Technical Expert Panel (TEP) that the resources required to translate non-English articles would not be justified by the low potential likelihood of identifying relevant data unavailable from English-language sources. We do note, 125 however, that many of our included studies were conducted in Europe and there is the possibility that negative studies from such geographic locations might not have been translated into English, resulting in publication bias. We also limited our analysis to RCTs except for specific key questions (KQ 2 and KQ 5, focusing on cardiac resynchronization therapy). Although the inclusion of observational studies would have expanded the evidence base for our review, it was the opinion of the investigators and the TEP that the resources needed to include the potential observational studies would not be justified given the number of RCTs available and the potential risk for bias intrinsic in the observational evidence. These studies, however, may have provided additional useful information on safety and effectiveness data in patients with comorbidities and adverse events. Finally, as a comparative effectiveness study, we restricted our analysis to studies that compared two active therapies for AF and did not include placebo-controlled trials. Inclusion of such placebo-controlled trials may have allowed additional quantitative analyses to be performed used mixed treatment meta-analyses. Research Gaps AF is one of the most common arrhythmias and is associated with increased morbidity, increased mortality, and high health-related costs. There are several established treatments for both rate control and rhythm control, as well as newer pharmacological and procedural treatments for both. In our analyses, we found research gaps related to patient-centered outcomes for both established as well as newer therapies. We used the framework recommended by 308 Robinson et al. This approach considers PICOTS (Populations, Interventions, Comparators, Outcomes, Timings, and Settings of interest) to identify gaps and classifies gaps as due to (a) insufficient or imprecise information; (b) biased information; (c) inconsistency or unknown consistency; and (d) not the right information. Research Gaps: Rate-Control Drugs Evidence gaps in the comparative effectiveness of rate-control drugs specifically included: • What are the comparative safety and effectiveness of pharmacological agents used for ventricular rate control in patients with AF in terms of their impact on long-term outcomes of all-cause mortality, cardiovascular mortality, or other cardiovascular-related outcomes? No comparator studies included evaluated long-term outcomes of all-cause mortality, cardiovascular mortality, or other cardiovascular-related outcomes. Based on our analyses, more RCTs are needed comparing different rate-control agents among general patients with AF, as well as in patients with AF and heart failure. We identified only one study comparing the effectiveness of different beta blockers. Given that beta blockers are some of the most commonly used drugs for rate control, additional comparative studies are needed. Of particular interest would likely be the comparison between the beta blockers metoprolol and carvedilol, both of which are commonly used but which have different properties that could make them more suitable for certain subgroups of patients (e. An additional area of future research would be the exploration of beta blockers and calcium channel blockers used together. Patients in these studies should be followed long term to determine long-term outcomes. Research Gaps: Strict Versus Lenient Rate-Control Strategies Evidence gaps in the comparative effectiveness of strict versus lenient rate-control strategies include: • What are the comparative safety and effectiveness of a strict rate-control strategy versus a more lenient rate-control strategy in patients with AF? Unfortunately very few studies, and only one RCT, examined the comparative effectiveness of a strict rate-control strategy versus a more lenient rate-control strategy in patients with AF. In addition, no clear subgroups of interest were examined in the single RCT included in this analysis. This RCT was, however, of good quality and found no significant difference in outcomes among patients treated with strict or lenient rate control except for stroke risk, which favored lenient rate control. However, further studies are needed that are adequately powered to evaluate clinically meaningful outcomes, including stroke risk, and these studies should also be carried out among general patients with AF but also among subgroups of patients, such as those with heart failure. In order to better compare future studies, achieving consensus on standardized definitions of strict and lenient rate control is needed.