By U. Sven. University of Michigan-Flint.
Tere are big diferences in case-fatality are data rates between countries buy linezolid 600mg otc, but some of the vari- ation might be explained by local practices of EU16 countries discharging patients from hospitals purchase 600 mg linezolid overnight delivery, and trans- Denmark 4 generic linezolid 600mg free shipping. Taking that step launched an agenda for Portugal 11 purchase linezolid 600 mg otc. We do not yet know how to ensure that United Kingdom of 12 600 mg linezolid. 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. Te erage and how it can provide answers to guide techniques for measurement have been greatly health policy and practice. Health systems fnancing: the path to universal coverage. Sustainable health fnancing, universal coverage and social health insurance. In: Fifty-eighth World Health Assembly, Geneva, 16−25 May 2005. Geneva, World Health Organization, 2005 (Document WHA58/2005/REC/1). The world health report 2008 − primary health care, now more than ever. United Nations General Assembly Resolution A/RES/67/81. Address at the Conference of Ministers of Finance and Health. Achieving value for money and accountability for health outcomes, Tunis, 4 July 2012. From the Earth Summit to Rio+20: integration of health and sustainable development. Universal health coverage: the third global health transition?
The defined as a subsyndromal form of major depression or the rates of depression in healthy persons are significantly lower symptoms of dysthymia without the 2-year duration order 600mg linezolid overnight delivery, has than those among the medically ill linezolid 600mg with mastercard. The rates of depression been found to be 19% in hospital and 10% in community among medically ill patients range as high as 20% to 40% buy linezolid 600mg line. Depression in the presence of medical illness linezolid 600 mg generic, in comparison with depression in the absence of medical illness buy 600 mg linezolid otc, is associ- ated with more severely impaired physical or cognitive func- DIAGNOSIS OF DEPRESSION IN PATIENTS tion. Untreated, depression can persist for many months WITH MYOCARDIAL INFARCTION OR and may complicate recovery from the medical illness. STROKE Each year, approximately $44 billion is spent in the treat- ment of depression (2). Although depression associated with The problem of diagnosing depression in patients with med- medical illness has been shown to increase mortality (3), ical illness has been a focus of research and a source of the benefits of treating depression on medical morbidity controversy among consultation and liaison psychiatrists for and mortality have not yet been established. Cohen-Cole and Stoudemire (16) reported that we review the relationship between depression and medical four approaches have been used to deal with this problem illness, with cerebrovascular and cardiovascular disease used in the medically ill. In the 'inclusive approach,' depressive as a prototype of medical illness. Rapp and MYOCARDIAL INFARCTION OR STROKE Varna (18) use the 'substitutive approach' of Endicott (19), in which the psychological symptoms of depression are sub- The prevalence of major depression in patients after myocar- stituted for the vegetative symptoms, which tend to be non- dial infarction (MI) has been estimated to be about 20% specific in a physically ill population, and the 'exclusive (3–8). Depressive symptoms following an acute MI have approach' of Bukberg et al. Even in patients removed from the diagnostic criteria if they are not found with only angiographically proven coronary artery disease, to be more frequent in depressed than in nondepressed pa- the prevalence of depression is approximately 18% (11). The prevalence of depression after stroke has been stud- The utility of these methods in the diagnosis of post- ied in numerous countries of the world (12–14). These stroke depression was examined in a study that included studies have found a mean prevalence of major depression 142 patients with acute stroke who were reexamined at 3, of 20% among hospitalized and outpatient victims of stroke, 6, 12, and 24 months after their stroke. Of the 142 patients, and a prevalence of 13% has been found in community 60(42%) reported a depressed mood during their acute hospitalization, and the remaining 82 patients denied a de- pressed mood. Robinson: Department of Psychiatry, University of Iowa, characteristics were found between the depressed and non- Iowa City, Iowa. Ranga Rama Krishnan: Department of Psychiatry and Behavioral depressed groups except that the depressed group was signif- Sciences, Duke University Medical Center, Durham, North Carolina. Thus, the initial diagnoses were based on inclusive criteria during the in-hospital evalu- ation. When this approach was used, 26 patients (18%) met the DSM-IV diagnostic criteria for major depression. The DSM-IV diagnostic criteria were then modified by impos- ing a requirement for five or more specific symptoms (weight loss and early morning awakening were excluded as criteria for major depression because they were not signifi- cantly more frequent in the depressed than in the nonde- pressed patients). Of the 27 patients with major depression, three were excluded in comparison with the diagnosis based FIGURE 81. The percentage of patients found to be depressed after stroke based on the setting in which they were evaluated. The diagnoses based on unmodified Note that hospitalized patients and those in outpatient clinics symptoms had a specificity of 98% and a sensitivity of 100% generally show higher rates of depression than those studied in in comparison with use of the 'exclusive' criteria as the the community. This finding probably reflects the fact that the strokes of patients who seek medical service are more severe than 'gold standard. These studies represent the substitutive approach (i. When this approach was used, none of the original 27 patients in whom major depression had been history of a psychiatric disorder was significantly higher in diagnosed with the inclusive approach was excluded. Throughout the 2 years of At the 3-month follow-up, use of the exclusive approach, follow-up, the depressed patients reported a significantly which requires only specific symptoms (i. The vegetative symptoms that were examined in- depression. When a diagnosis based on specific symptoms cluded anxiety, anxious foreboding, morning depression, was used as the gold standard, the unmodified DSM-IV weight loss, delayed sleep, subjective anergia, early morning criteria and inclusive approach had a sensitivity of 100% awakening, and loss of libido (21). If the substitutive approach, which symptoms that were not more frequent in the depressed requires depression plus four psychological symptoms, had than in the nondepressed group were weight loss and early been used, none of the 12 patients would have been ex- morning awakening at the initial evaluation; weight loss, cluded. Most psychological symptoms were more the unmodified inclusive DSM-IV criteria had a sensitivity frequent in the depressed patients throughout the 2-year of 100% and a specificity of 95%. The psychological symptoms assessed included wor- proach had been used, none of the 15 patients with major rying, brooding, loss of interest, hopelessness, suicidal plans, depression would have been excluded. At the 1-year follow- social withdrawal, self-deprecation, lack of self-confidence, up, when the exclusive approach (i. The only psychological symp- used, 3 of 7 patients no longer met the diagnostic criteria, toms that were not significantly more frequent in the de- and the unmodified inclusive DSM-IV criteria had a sensi- pressed than in the nondepressed group were suicidal plans, tivity of 100% and a specificity of 95%. With use of the simple ideas of reference, and pathologic guilt at 3 months; substitutive approach, none of the 7 patients was excluded. With use of the unmodi- The effect of using each of the proposed alternative diag- fied inclusive DSM-IV criteria, the sensitivity was 100% nostic methods for post-stroke depression based on DSM- and the specificity was 96% in comparison with the exclu- IV criteria was examined (22). The substitutive approach excluded none of the inclusive approach (i. Chapter 81: Depression and the Medically Ill 1181 Although Kathol et al.
The SGAs have a greater affinity than did the typical antipsychotics cheap linezolid 600 mg fast delivery, for 5HT-2A receptors effective 600mg linezolid. They also have a greater affinity for 5HT-2A receptors than for D2 receptors cheap linezolid 600 mg. A most important physiological feature is the interaction between serotonin and dopamine neurons in the basal ganglia generic linezolid 600 mg free shipping. In this region (associated with movement) serotonin neurons inhibit the release of dopamine by dopamine neurons buy linezolid 600mg. Thus, blockade of serotonin will increase the availability of dopamine (thereby, reducing the rate of EPS side-effects). Exceptions abound, however, and amisulpride, generally classed as an SGA has no affinity for serotonin receptors whatsoever. Both FGAs and SGAs are effective in reducing the positive symptoms of schizophrenia (hallucinations, delusions and positive thought disorder). It has been construed that the negative symptoms are composed of two subgroups of symptoms: primary negative symptoms (being part of the illness process), and secondary negative symptoms (being apparent rather than actual symptoms of the disorder, instead, being secondary to drug treatment). Claims are made that the atypicals may produce no secondary negative symptoms, and go some way in relieving primary negative symptoms (Carpenter, 1996). Other symptoms of schizophrenia include cognitive and mood difficulties and reduced quality of life. Evidence suggests that the atypical antipsychotics are helpful in all of these domains (Burton, 2006) than typical agents. Structural brain changes associated with the disease process of schizophrenia have been identified. There is evidence that atypical antipsychotics (but not the typicals) ameliorate these changes. For example, the volumes of the thalamus and cortical grey matter increase with atypical antipsychotic treatment (Scherk & Falkai, 2006). Side-effects of the SGAs Most of the side effects of the FGAs can be encountered with the SGAs, however, they are less frequent and generally less severe. Evidence suggests a decrease in life expectancy in people with schizophrenia of 10-20 years (Laursen et al, 2012). Multiple factors contribute including medication effects, poor general health care, smoking and sedentary life-style. Weight gain is problem in schizophrenia and other mental disorders, in part, because of poor eating habits and lack of exercise. However, the antipsychotics exacerbate this problem and the metabolic syndrome. Weight gain, and metabolic syndrome exists in 10% of drug naïve people with schizophrenia (Mitchell et al, 2013). A meta-analysis (Allison and Casey, 2001) estimated that over a 10 week period the mean increase was as follows: 1) clozapine 4. The prevalence of type 2 diabetes in people with schizophrenia is double that of the general population. Over recent years there has been concern this is a direct result of antipsychotic treatment. As the SGAs are the most effective component in the medical management of psychotic disorders, this question has been soberly examined. An association between schizophrenia and diabetes has been recognized for over a century. Risk factors for diabetes include poor overall health, lifestyle and level of access to heath care. Many SGAs are associated with weight gain, but there is no evidence for an intrinsic role for the antipsychotics in the aetiology of diabetes. Hyperlipidemia (raised cholesterol and triglycerides) appears to be associated with the dibenzodiazepine-derived antipsychotics (clozapine, olanzapine and quetiapine). QTc interval prolongation has been a matter of concern. The average QTc interval in healthy adults is about 400 msec, and a QTc interval of 500 msec or more is a risk factor for torsade de pointes (a ventricular arrhythmia which can lead to syncope, ventricular fibrillation and sudden death). One study found the following prolongations: 1) ziprasidone 20. Recommendations for the monitoring/management of the side effects of the antipsychotics have been provided (Marder et al, 2004). When weight gain is anticipated (clozapine, olanzapine, quetiapine and risperidone) weight, height and BMI, along with abdominal girth at the umbilicus, should be recorded. Nutritional and life style (exercise) advice is recommended. With excessive weight gain a change to another agent may be considered.
Five studies evaluated the use of one or more pharmacological agents with external electrical cardioversion as a primary component of the tested intervention; 1 study compared an AAD drug with a rate-controlling drug (sotalol vs order 600 mg linezolid. Tables F and G summarize the strength of evidence for the evaluated rhythm-control therapies and outcomes proven 600mg linezolid. Details about the specific components of these ratings (risk of bias order linezolid 600mg free shipping, ES-20 consistency discount 600mg linezolid with amex, directness purchase linezolid 600 mg line, and precision) are available in the full report. Across outcomes and comparisons, although the included evidence was from RCTs with an overall low risk of bias and was direct, the findings were often inconsistent or imprecise, limiting our findings. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies Treatment Restoration of Maintenance of Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm Sinus Rhythm AF CV Mortality Hospitaliza- Symptoms/ Mixed Embolic Events tions Control of AF Events, Symptoms Including Stroke) Transcatheter SOE = SOE = High (8 SOE = All-cause: SOE CV: SOE = SOE = SOE = Stroke: SOE = SOE = PVI vs. AADs Insufficient (no studies, 921 Insufficient (no = Insufficient (1 Moderate (2 Insufficient (no Insufficient Insufficient (no Insufficient studies) patients) studies) study, 69 studies, 268 studies) (6 studies, 647 studies) (1 study, 67 OR 6. PVI events in either demonstrated in the PVI or AAD both studies arm AF: SOE = Insufficient (1 study, 67 patients) Transcatheter SOE = SOE = Low (3 SOE = Low (1 SOE = SOE = SOE = SOE = Stroke: SOE = SOE = PVI using Insufficient (no studies, 264 study, 102 Insufficient (no Insufficient (no Insufficient (no Insufficient (no Insufficient (1 Insufficient (no different types studies) patients) patients) studies) studies) studies) studies) study, 82 studies) of ablation No difference No difference patients) catheters between between a different types multipolar Mixed: SOE = of ablation circular ablation Insufficient (no catheters catheter and a studies) point-by-point PVI ablation catheter with an irrigated tip (p = 0. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance of Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm Sinus Rhythm AF CV Mortality Hospitaliza- Symptoms/ Mixed Embolic Events tions Control of AF Events, Symptoms Including Stroke) Transcatheter SOE = SOE = Low (5 SOE = All-cause: SOE SOE = SOE = SOE = SOE = SOE = circumferential Insufficient (1 studies, 500 Insufficient (no = Low (1 study, Insufficient (no Insufficient (no Insufficient (no Insufficient (no Insufficient (no PVI vs. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance of Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm Sinus Rhythm AF CV Mortality Hospitaliza- Symptoms/ Mixed Embolic Events tions Control of AF Events, Symptoms Including Stroke) Transcatheter SOE = SOE = SOE = All-cause: SOE SOE = SOE = SOE = Low (2 Stroke: SOE = SOE = PVI vs. Insufficient (2 Insufficient (15 Insufficient (6 = Insufficient (2 Insufficient (no Insufficient (no studies, 152 Insufficient (2 Insufficient (no transcatheter studies, 384 studies, 1,926 studies, 572 studies, 405 studies) studies) patients) studies, 361 studies) PVI with patients) patients) patients) patients) No significant patients) additional difference ablation sites Cardiac: SOE = between arms in Mixed: SOE = other than CTI Insufficient (no 2 studies Insufficient (no and CFAE and studies) studies) transcatheter PVI involving all 4 PVs vs. Insufficient (no Insufficient (no Insufficient (2 Insufficient (no Insufficient (no Insufficient (no Insufficient (no Insufficient (no Insufficient (no transcatheter studies) studies) studies, 217 studies) studies) studies) studies) studies) studies) PVI plus patients) postablation AF: SOE = Low AADs (1 study, 110 patients) No difference between arms ES-24 Table F. Summary of strength of evidence and effect estimate for KQ 5—procedural rhythm-control therapies (continued) Treatment Restoration of Maintenance of Recurrence of All-Cause and CV/AF Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm Sinus Rhythm AF CV Mortality Hospitaliza- Symptoms/ Mixed Embolic Events tions Control of AF Events, Symptoms Including Stroke) Surgical Maze SOE = SOE = SOE = All-cause: SOE SOE = SOE = SOE = Stroke: SOE = SOE = vs. Summary of strength of evidence and effect estimate for KQ 5—pharmacological rhythm-control therapies Treatment Restoration of Maintenance of Recurrence of All-Cause and AF and CV Heart Failure Quality of Life Stroke (and Bleeding Comparison Sinus Rhythm Sinus Rhythm AF CV Mortality Hospitaliza- Symptoms/ Mixed Embolic Events tions Control of AF Events, Symptoms Including Stroke) Pharmaco- SOE = SOE = SOE = All-cause: SOE SOE = SOE = SOE= Stroke: SOE = SOE = logical therapy Insufficient (no Insufficient (1 Insufficient (4 = Insufficient (1 Insufficient (no Insufficient (no Insufficient (1 Insufficient (1 Insufficient (no in which studies) study, 168 studies, 414 study, 168 studies) studies) study, 144 study, 168 studies) electrical patients) patients) patients) patients) patients) cardioversion is a key Cardiac: SOE = Mixed: SOE = component of Insufficient (no Insufficient (no the treatment studies) studies) Comparison of SOE = SOE = Low (9 SOE = Low (10 All-cause: SOE CV: SOE = Heart failure: SOE = Low (2 Stroke: SOE = SOE = pharmaco- Insufficient (no studies, 2,095 studies, 3,223 = Insufficient (5 Insufficient (no SOE = studies, 1,068 Insufficient (2 Insufficient (no logical agents studies) patients) patients) studies, 2,076 studies) Insufficient (no patients) studies, 1,068 studies) Amiodarone Amiodarone patients) studies) No significant patients) appears to be appears to be AF: SOE = Low difference was better than better than Cardiac: SOE = (1 study, 403 AF symptoms: found in either Mixed: SOE = sotalol but no dronedarone or Low (4 studies, patients) SOE = Low (1 study. Insufficient (no different from sotalol but no 1,664 patients) Rate and mean study, 403 studies) propafenone. Note: AF = atrial fibrillation; CV = cardiovascular; KQ = Key Question; SOE = strength of evidence. Rate- Versus Rhythm-Control Therapies Key points from the Results chapter of the full report are as follows. This finding is based on evidence from four RCTs (two good, two fair quality) involving 1,700 patients (low strength of evidence). A total of 14 RCTs were included in our analysis, 12 that explored a rhythm-control strategy using pharmacological therapy versus a rate-control strategy and 2 that compared a rhythm- control strategy with PVI versus a rate-control strategy that involved AVN ablation and implantation of a pacemaker in one case and rate-controlling medications in the other. Nine studies were of good quality, three were of fair quality, and two were of poor quality. Ten studies were conducted in continental Europe; 1 was conducted in the United States and Canada only; 1 was conducted in Asia only; 1 was conducted in the United States, Canada, South America, and Israel; and 1 study did not report the location. The number of patients included ranged from 41 to 4,060, for a total of 7,556 patients across the 14 studies. The mean age of study participants ranged from 39 years to 72 years. Five studies included only patients with persistent AF, one study included only patients with paroxysmal AF, two studies included both patients with paroxysmal and those with persistent AF, and six studies did not explicitly report type of AF. Four studies included only patients with heart failure. ES-27 Table H summarizes the strength of evidence for the rate- and rhythm-control therapies and evaluated outcomes. Details about the specific components of these ratings (risk of bias, consistency, directness, and precision) are available in the full report. Summary of strength of evidence and effect estimate for KQ 6—rate- versus rhythm- control strategies Outcome Strength of Evidence and Effect Estimate Maintenance of sinus Using AADs for rhythm control: rhythm SOE = High (7 studies, 1,473 patients) OR 0. Since 6 of the 8 studies had ORs that crossed 1 (including 95% of the patients) and given significant heterogeneity, we assessed these studies as demonstrating no difference between rate- and rhythm- control strategies. CV mortality Using AADs for rhythm control: SOE = Moderate (5 studies, 2,405 patients) OR 0. ES-28 Discussion Key Findings In this Comparative Effectiveness Review, we reviewed 148 studies represented by 182 publications and involving 25,524 patients that directly compared rate- and rhythm-control strategies in patients with AF. Although the ultimate goal with any therapy for AF is to improve long-term survival and quality of life, most studies to date have assessed rate control, conversion of AF to sinus rhythm, or maintenance of sinus rhythm. Very few studies focused on final outcomes such as survival, or on the relationship between intermediate outcomes such as ventricular rate or duration of sinus rhythm and final outcomes. For KQ 1, despite strongly held convictions among clinicians about the superiority of individual beta blockers and calcium channel blockers, we found insufficient data to support any of these claims. Based on a limited number of comparative studies, our analysis suggests that either a calcium channel blocker (verapamil or diltiazem) or amiodarone is beneficial compared with digoxin for rate control. Given the widespread use of beta blockers and calcium channel blockers and the population-level impact of even small differences in safety and effectiveness, research comparing individual drugs in different patient populations is needed. For KQ 2, by emphasizing the limitations in the available data and the paucity of data on lenient versus strict rate control, our findings highlight the need for more research in this area. For KQ 3, our findings underscore the need for additional studies to compare rate-control drugs with rate-control procedures in relation to exercise capacity, mortality, cardiovascular events, and quality of life.