A. Flint. Belmont University.

This was a large Level I study performed at 23 different emergency departments across the United States buy caverta 100mg fast delivery. The goal of the NEXUS study was to assess the validity of four predetermined clinical criteria for cervical spine injury (Table 17 purchase caverta 50mg line. These criteria were (1) altered neurologic function generic caverta 50 mg on line, (2) intoxication order 100mg caverta with visa, (3) midline posterior bony cervical spine tender- ness, and (4) distracting injury. The NEXUS investigators prospectively enrolled over 34,000 patients who underwent radiography of the cervical spine following blunt trauma. Canadian Cervical Spine Prediction Rule A second level I clinical prediction rule, the Canadian C-spine rule for radi- ography (25) was published subsequent to the NEXUS trial, but with a similar objective: to derive a clinical decision rule that is highly sensitive for detecting acute cervical spine injury. The Canadian C-spine rule was a prospective cohort study of 8924 subjects from 10 community and univer- sity hospitals in Canada. Excluded were patients who had neurologic impairment, decreased mental status, or penetrating trauma. Like the NEXUS study, the Canadian C-Spine Study was an observational study performed without informed patient consent. However, patients who were eligible for the study but did not undergo radiography were followed up with a structured telephone interview 14 days following their discharge from the emergency department (ED). Thus, any patients who had not undergone radiography, and who had missed fracture would potentially be discovered during the investigation. The Canadian study investigated the predictive ability of 20 factors, and based on the reliability and pre- dictive properties of these factors, developed a prediction rule consisting of three questions. The Canadian C-spine rule was validated using a prospective cohort study of 8283 patients presenting at the same 10 Canadian community and academic hospitals as the original study (32). Diagnostic performance Potential decrease Test (reference) Sensitivity Specificity in radiography C-spine prediction rules NEXUS (29) 99. It was noted during the course of this study that physicians failed to evaluate neck range of motion, as required by the Canadian C-spine rule, in 10. While virtually all of this group of incompletely evaluated patients underwent cervical spine imaging (98. The data supporting the adoption of one cervical spine prediction rule over the other is limited. Two studies, the validation study for the Canadian C-spine rule and a retrospective analysis of the Canadian C-spine derivation cohort have attempted to compare the NEXUS and Canadian rules (32,33). However, both cohorts excluded those with altered levels of consciousness, effectively eliminating one of the NEXUS criteria. In addi- tion, others have voiced concerns regarding physician familiarity with the various rules, side-by-side comparison, and the definitions of the NEXUS criteria used in these trials (34,35). The choice of clinical prediction rule in a broader clinical context is also unclear, as no trial has examined the impact of implementing these prediction rules outside of the research setting. Applicability to Children Evidence for who should undergo imaging is less complete in children than in adults. Determination of clinical predictors of injury in pediatric patients is complicated by the decreased incidence of injury in children, requiring a larger sample size for adequate study (36,37). In addition, chil- dren may sustain serious cervical cord injuries that are not radiographi- cally apparent (37,38). Among the level I studies, the Canadian clinical prediction rule development study excluded children (31). The NEXUS trial included children, but there were only 30 injuries in patients under age 18, and only four in patients under age 9 (36). Although no pediatric injuries were missed in the NEXUS study, sample size was too small to adequately assess the sensitivity of the prediction rule in this group. Therefore, no adequate evidence exists regarding appropriate criteria for imaging in children.

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Patterning—The guiding of movements over and over to allow the brain to develop repeated functions; underlies many of the physical therapies used in MS management order caverta 100mg with mastercard. Peripheral nervous system—Consists of numerous nerves in the body that serve the function of carrying the stimuli and informa- tion into the brain and spinal cord and order caverta 50 mg free shipping, from there 100 mg caverta free shipping, back into the different parts of the body order caverta 50 mg amex. Physiatrist—A physician who specialize in physical medicine and rehabilitation; may be involved in the management of MS. Placebo—An inactive substance given to group of patients in a drug study to compare with the active substance; any inactive substance given instead of an active one. Plasmapheresis—The removal of plasma (the fluid of blood), with replacement by an approriate fluid; removes impurities in the plasma. Prevalence—The algebraic product of incidence and duration (how many cases per unit of population at any one time). Protein—A class of chemicals naturally occurring in plants and ani- mals composed of nitrogen and amino acids. Ranvier’s nodes—Constrictions in the myelin sheath that allow for extremely rapid electrical transmission. Rectum—The lowest part of the bowel, the part that follows the colon, which pushes the stool out during elimination. Reflex—An immediate response of a certain part of the human body to a brief stimulus, which usually does not require processing of the stimulus through the conscious mind. An example is the jerk- ing of the leg upon striking it or withdrawal from fire before con- scious awareness. Relaxation technique—A technique designed to calm, including biofeedback, meditation, or yoga. Remission—A lessening in the severity of symptoms or their tem- porary disappearance during the course of the illness. Retrobulbar neuritis—Swelling or irritation of the optic nerve behind the eye secondary to inflammation. Romberg’s sign—An inability to maintain the body balance with the eyes shut and the feet close together. Semen—The thick secretion from the urethra (penis) emitted at the climax of sexual excitement. Sexuality—Related to the total sexual life of a person—whether including the sexual organs themselves or not. It is often manifested by extreme stiffness of the muscles, which results in difficulties with active and passive movements of the extremities. Sphincter—A circular band of muscle fibers that tightens or closes a natural opening of the body, such as the external anal sphincter, which closes the anus, and the internal and external urinary sphincters, which close the urinary canal. Spinal cord—The part of the CNS that connects the brain and its related structures to the peripheral nervous system. Steroids—Chemicals that either mimic or are from various endocrine organs of the body (usually the adrenal gland); they are potent antiinflammatory (antiswelling) and immune-suppressing agents and often used in the management of MS. Suppressor T cells—A type of lymphocyte that suppresses the pro- duction of antibody-forming cells from B lymphocytes. Suprapubic catheter—A tube placed in the bladder through the skin just above the pelvic bone (pubic bone). Sympathetic nervous system—That part of the autonomic (auto- matic) nervous system partially responsible for many automatic functions, such as sweating, heart beating, sexual activity, bowel/bladder function; centered in the chest and low back region. T cell—A type of white blood cell formed in the thymus, tonsils, and other organs involved in the immunologic reaction; believed to be substantially involved in the MS process. Transcutaneous nerve stimulation (TNS)—The placing of an elec- trical stimulation along an area to stimulate the nerve in the same region—used for pain control. Transverse myelitis—An acute attack of inflammatory demyelina- tion in which the spinal cord loses its ability to transmit nerve impulses up and down. Paralysis and numbness are experienced in the legs and trunk below the level of the inflammation. Tremors—Various involuntary movements involving arms, legs, or head, occurring in numerous illnesses and conditions and greatly varying in type and severity. Trigeminal neuralgia—Severe pain in the face due to irritation of a nerve from the brain stem.

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Baby boomers 50mg caverta sale, armed with information from the Internet purchase 50mg caverta free shipping, influenced the shift away from the dependent patient to an aggressive consumer patient demanding a role in the therapeutic process discount caverta 50 mg fast delivery. The changes that have taken place in healthcare over the last two decades or so have been numerous and dramatic proven caverta 100mg. These changes have served 66 arketing Health Services to transform the healthcare industry of the early 1980s into a quite dif- ferent creature. Lack of space in this book does not allow a review of all of the changes that occurred during the last decade and a half, but some of the more important ones are listed below, along with their signif- icance for healthcare marketing. Providers Faced Growing Competition During the 1980s healthcare providers were exposed to unprecedented competition on a number of fronts. For the first time healthcare providers were forced to profile their customers and be able to determine their needs. They also had to understand their competition and develop a level of mar- ket intelligence never dreamed of in the past. Most observers would agree that the emergence of competition has been a major driver of healthcare marketing. Emphasis Shifted from Inpatient to Outpatient Care Until the last decade or so, medical care was synonymous with inpatient care. Hospitalization was often a prerequisite for the activation of insurance coverage. By the 1980s, almost every industry force was discouraging the use of inpatient care. Hospitals had to rapidly understand the changing mar- ket conditions and position themselves to capture the growing outpatient market. Hospitals had to think in terms of a different approach to market- ing as the traditional patterns of physician referral for inpatient care were de- emphasized and consumerism emerged as a factor in the system. Emphasis Shifted from Specialty to Primary Care Hospitals have historically relied on the medical specialists on their staffs to admit patients and generate their revenue. By the late 1980s, industry forces were encouraging the use of primary care physicians rather than spe- cialists. Hospital systems had to examine their referral patterns and revise their thinking with regard to primary care physicians. For the first time, hospitals had to actively court family practitioners, internists, and pedia- tricians and marketers had to develop means for showcasing their primary care capabilities to both consumers and health plans. Employers Emerged as Major Players in the Industry After World War II, employers began offering health insurance to their employees and passively footed the bill for their medical expenses. By the mid-1980s, however, employers were taking a more active role in the man- agement of their employees’ health benefits. Suddenly, healthcare providers The Evolving Societal and Healthcare Context 67 found they had a new customer with a different set of needs from their tra- ditional customers. Business coalitions emerged to negotiate with health- care providers from a position of strength. The Industry Became Increasingly Market Driven Until the healthcare industry became market driven in the 1980s the opin- ions of patients were seldom considered important. Suddenly, healthcare providers needed to know what the patient liked and did not like about the services provided. Patient satisfaction surveys became common, and providers and health plans started being graded with report cards on their performance. Marketers were called on not only to identify the wants and needs of the market but also to assist in maintaining a high level of customer satisfaction. Managed Care Emerged as a Dominant Force The emergence of managed care as a major force essentially changed the ground rules for healthcare providers. Instead of searching for sick patients who would require health services, the marketer was directed to identify healthy persons who would not consume many services. Healthcare providers participating in managed care plans (particularly capitated plans) had to shift their focus from treat- ment and cure to health maintenance.

In fact in a Report issued in February 2002 caverta 50mg visa, NICE indicated that it did not believe that there was sufficient evidence at present to prescribe beta-interferons on the NHS order caverta 50 mg on line. In other words their judgement was that prescription by the NHS was not currently cost effective order caverta 100mg mastercard. However cheap caverta 50mg without prescription, it indicated that people who had already been prescribed beta- interferons, before its judgement, could continue to receive them. It also indicated that efforts were being made to find ways for the drugs to be supplied on a more cost-effective basis. In fact on the same day as the NICE announcement, it was also announced that what was called a ‘risk-sharing agreement’ had been reached with the relevant drug companies and the NHS to provide beta- interferons through neurologists in MS clinics for approximately 9000 people with MS (about 15% of those with the disease) on very specific criteria as follows: Relapsing-remitting MS People with MS must fulfil the following four criteria: • be able to walk independently • have had at least two clinically significant relapses in the last 2 years • be 18 years old or older • have no contraindications. Secondary progressive MS Beta-interferon is only prescribed for people with relapsing secondary MEDICAL MANAGEMENT OF MS 19 progressive MS. People must fulfil the following criteria: • be able to walk at least 10 metres with or without assistance • have had at least two disabling relapses in the last 2 years • have had minimal increase in disability due to slow progression over the last 2 years • be 18 years old or older In relation to the agreement, a group of people with MS taking the drug will be evaluated over a period of 10 years, and the relationship of any benefits to the costs will be assessed. If the equation between costs and benefits is then considered as positive, the drugs will then be allowed to be prescribed on the NHS. Compared to some other countries the proportion of those with MS being prescribed beta-interferons is still relatively low, although it should be said that, in addition to issue of cost, there is still substantial debate amongst neurologists as to the frequency and extent of benefits from the beta-interferons. Glatiramer acetate (Copaxone) and the management of MS Glatiramer acetate is a synthetic compound made of four amino acids (the building blocks of proteins) that are found in myelin. It has been shown in clinical trials that glatiramer acetate reduces the number and severity of relapses and appears to slow the onset of disability in some people with MS. While the mode of action of glatiramer acetate is not completely understood, it is different from that of the interferons. Over the past 15 years, there have been many clinical trials to investi- gate the efficacy and safety of glatiramer acetate in people with MS. The best results were seen in people with MS who had the lowest levels of neurological disability. Studies have shown that at the end of 2 years there were about 25% fewer relapses in people taking glatiramer acetate compared with those not taking the drug, and more people on the drug tended to improve. Administering glatiramer acetate The drug is injected subcutaneously (under the skin) every day. People with MS or family members who first receive proper training in aseptic 20 MANAGING YOUR MULTIPLE SCLEROSIS injection techniques can perform the injections without medical supervision. Side effects of the drug The drug is generally well tolerated and does not cause any of the ‘flu-like symptoms or increase in depression sometimes associated with the inter- feron drugs. The most common side effects are injection site reactions, pain upon injection, and a postinjection reaction involving shortness of breath, flushing, palpitations, anxiety and chest pain. This reaction, which occurs in about one in seven people at one time or another resolves itself within 15–20 minutes and does not appear to have any long-term consequences. Prescribing glatiramer acetate (Copaxone) As the effect of glatiramer acetate and its process of development have been broadly similar to that of the interferons, it has also been subject to the same process of assessment by NICE as the interferons (see above). The same judgement was also made in relation to glatiramer acetate, as were also the same risk-sharing arrangements with the company manufacturing the drug. Thus the drug is also available for prescription by neurologists in MS clinics using slightly different criteria. To be prescribed the drug, people must fulfil the following criteria: • be able to walk at least 100 metres without assistance • have had at least two clinically significant relapses in the last 2 years • be 18 years old or older. The future of DMTs (disease-modifying therapies) in MS It is undoubtedly true that we are in a very exciting phase of development of DMTs. Although we cannot yet talk about a cure, we can now consider seriously the possibility of slowing down the course of the disease and not just ameliorating the symptoms of relapses. However, the results of research so far seem to suggest that the earlier the current DMTs (the interferons and glatiramer acetate) are given in the course of the disease, the more effect they are likely to have. Some believe that MEDICAL MANAGEMENT OF MS 21 they should be given at the very earliest sign of MS, others that these drugs should wait upon a full and clear diagnosis on more comprehensive criteria.

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