Abimbola Aina, M.D.
 https://www.hopkinsmedicine.org/profiles/results/directory/profile/0016460/abimbola-aina In addition gastritis diet eggs discount esomeprazole on line, this led to the performance of a small number of controlled trials on antidepres sants in samples of acute bipolar depressive patients (Baumhackl et al gastritis diet öåíà buy esomeprazole mastercard. Apparently xenadrine gastritis esomeprazole 40mg without a prescription, the sceptical view that antidepressants might not be effective in acute bipolar depression gastritis diet óêð purchase esomeprazole 20mg visa, which seems to be very extreme, or the position that they might not be as effective as in unipolar depression, or that the induced risk of switch into mania and rapid cycling might override the benefits of a good antidepressive response, which were expressed in this very sceptical and maybe over-critical tendency especially in the most recent years, is not supported by empirical evidence. Zornberg and Pope (1993) reviewed seven controlled studies that exam ined the efficacy of tricyclic antidepressants in the treatment of bipolar depression. In general, the data indicate that tricyclic antidepressants are more effective than placebo for patients with bipolar depression. The relative efficacy compared to other antidepressants is not so clearly established. Their efficacy when combined with lithium, or alternatively with other mood stabilizers, has not been systematically studied, although this is the manner in which antidepressants are increasingly used in acute bipolar depression. Two controlled studies have tested monoaminoxidase inhibitors in patients with bipolar depression. Selective serotonin re-uptake inhibitors have not been well studied in a controlled manner in the treatment of acute bipolar depression. One controlled study found that fluoxetine was superior to imipramine and placebo in the treatment of acute bipolar depression (Cohn Antidepressant treatment of bipolar depression 389 et al. Two clinical trials suggested buproprione as effective in the treatment of episodes of bipolar depression (Fogelson et al. All of these studies have methodological limitations: most of them were conducted in only a small number of patients, a placebo control group was rarely used, and the risk and especially differential risk of switch into mania was apparently of greater interest in some of the studies than the proper evaluation of the antidepressive efficacy. Nevertheless, altogether the data appear to support to a certain degree the hypothesis that antidepressants are effective not only in acute unipolar depression but also in acute bipolar depression. It has to be admitted, as already pointed out, that the database from controlled clinical trials is limited. Nevertheless, it gives no hint that antide pressants might not be effective in acute bipolar depression. Under this aspect it seems questionable whether we really need more formal studies on the efficacy of classical or new-generation antidepressants in bipolar disorders, with all the associated risks for the patients, or whether we should continue to believe in the traditional hypothesis that a drug which has shown efficacy in unipolar depression is also effective in bipolar depres sion. Based on the theoretical assumption that most psychoactive drugs are syndrome-orientated in their efficacy, and not cause-related, we suppose the efficacy of antidepressants not only in unipolar as well as in bipolar functional depression but even in organic depression. Especially the broad clinical experience from many years of treatment with antidepressants seems to validate this approach. Therefore, in the following section our own study based on controlled clinical experiences in the routine treatment conditions of a large sample of inpatients, which definitely shows that acute bipolar depressive patients respond as well as acute unipolar depressive patients, will be presented. The results are even more convincing because, given the fact that the sample was an inpatient sample, most of the patients suffered from a severe unipolar or bipolar depression. Thus, we avoided the uncertainty which is a risk when studying antidepressive efficacy in mild or moderate depression, where it has been shown that anxiolytics or other drugs can also turn out as "antidepressants" (Laakman et al. Grunze on the routine documentation in the Psychiatric University Hospital in Munich, which has been performed since the late 1970s, and which includes sociodemographic data, anamnestic data, treatment and psychopathological data. In those patients with multiple hospitalizations only the first stay in our hospital was considered for this study. The cohorts of unipolar and bipolar depressive patients were comparable with respect to psychosocial parameters, the severity of depression at admis sion and treatment regimens. Bipolar patients showed a slightly decreased apathy score at discharge, and a slightly elevated score of the manic syndrome. In addition to the main analysis on the outcome of unipolar and bipolar depressed patients, several additional analyses were performed: 1. Outcome in unipolar and bipolar depressed patients subdivided into four year cohorts (1980?1984, 1985?1988, 1989?1992), reflecting potential changes in treatment regimens. Outcome in unipolar and bipolar depressed patients grouped for different degrees of severity of depression. Outcome in unipolar and bipolar depressed patients with and without neuroleptic treatment as add-on to antidepressant treatment. None of these sub-analyses revealed any significant differences between the response of unipolar or bipolar depressed patients, and especially there was no difference between more or less severely depressed groups of patients. These results seem to reject the hypothesis that antidepressants in the case of this study, predominantly tricyclics may be less effective in the acute treatment of bipolar I depressed patients compared to unipolar depressed patients. This study did not check for differences in unwanted effects, such as switching or rapid cycling, which are commonly attributed to the use of tricyclic antidepressants in bipolar patients. Apparently these unwanted effects, for which data are available from a subgroup of 158 bipolar I depressed patients (Bottlender et al. When all the evidence is taken together, there does not seem to be any question that antidepressants are effective in acute bipolar I depression, and that apparently the efficacy is equal to the response in unipolar depres sion. In this context the general need of antidepressant treatment in bipolar depression, at least in moderate and severe cases, should be emphasized to avoid the risk of suicide, the risk of chronicity, etc. Naturalistic studies show that bipolar depressions are an underestimated treatment challenge, not only with respect to the risk of switch into mania, rapid cycling, etc. Such results should emphasize the need for the best effective treatment of the depressive syndrome. To date there are no data available which show comparable efficacy of drugs other than antidepressants in acute bipolar depressive patients (see below! The opposite is true most of the mood stabilizers have not been investigated in the adequate way, i. Apart from this positive statement for the use of antidepressants in bipolar depression, it should be considered that the use of antidepressants has its special limitations in bipolar depressions in rapid cycling conditions, and also in mixed mania or mixed depression. In the case of rapid cycling, treatment with an antidepressant should be generally terminated as early as possible to avoid the induction of further rapid cycling. In mixed mania/mixed depression, antidepressants have to be avoided because they are contraindicated in the presence of manic symptoms (Calabrese and Woyshville 1995, Sachs 1996). In cases of acute bipolar depression with psychotic symptoms such as delusions, etc. A meta-analysis of 80 publications covering a total of about 4000 patients with bipolar depression or unipolar depression, not showing a bipolar history or feature at the time of the 392 H-J. Peet also differentiated in his analysis between different treatment groups of bipolar depressive patients. In some of the studies mentioned above, the concomitant treatment with a mood stabilizer was not considered, which might lead to an underestima tion of the switch rate under antidepressants. Based on a within-subject analysis between patients who received mood stabilizers and those who received mood stabilizers plus an antidepressant, Boerlin concluded that mood stabilizers may reduce the risk for switching. Patients who were treated with an antidepressant and a mood stabilizer in co-medication had no higher a risk of switch into mania than patients who were treated with a mood stabilizer alone. The protective function of mood stabilizers, in this case lithium, can also be derived from long-term studies on bipolar depression in which patients were treated with imipramine and lithium (Prien et al. In patients specifically diagnosed as bipolar (n = 158), the incidence of maniform states was 51% in 49 patients treated with imipramine alone, 21% in 60 patients treated with lithium alone, 28% in 36 patients treated with lithium and imipramine, and 23% in 13 patients receiving only placebo. Antidepressant treatment of bipolar depression 393 In our switch rate study we collected the data from the records and investigated the switch rate of 158 bipolar I depressive inpatients of the Psychiatric University Hospital, Munich (Bottlender et al. In addition, we used the sociodemographic, anamnestic and psychopathological data from our routine documentation system (see above! Thirty-nine patients (25%) of the sample switched to a maniform state during the treatment period in the hospital. Among that group the phenomenon occurred in 23 patients (15% of the total sample) as a hypomania and in 16 patients (10% of the total sample) as mania. According to the naturalistic data set, mood stabilizers can reduce the risk for switch ing, especially in patients treated with tricyclics; however, the protection does not seem sufficient in all patients, since 59% of the switched patients received mood stabilizers. It is of great interest that apparently the switch into hypomania or mania has no significant influence on the duration of hospital treatment. However, under international perspectives this finding should be related to the long duration of hospital stay of about 60 days, which is not unusual for a German university psychiatric hospital, and which on the one hand demonstrates the quite luxurious treatment condi tions in German psychiatry, and on the other hand gives a hint towards a selection of partially treatment-refractory patients. The following variables were tested and not found to be significantly associated with the risk of switch: gender, age, duration of illness, number of prior episodes of mania, number of prior episodes of depression, depressive syndrome at admission, hallucinatory syndrome at admission. Based on these findings the authors concluded that tricyclics do not increase the risk of switching into mania, and that the so-called switch effect due to tricyclics represents random manifestations of bipolar illness. Syndromes
Among permanent irreversible methods tubal ligation was used by 2% and vasectomy by other 1% gastritis diet vanilla purchase esomeprazole canada. In comparison with that of Nairobi as per the demographic health study of the same year to be implants (12 gastritis diet ðæä buy esomeprazole with american express. Vasectomy reliance as a family planning option tends to have stagnated at 1% which equates to global prevalence gastritis diet ýëåêòðîííàÿ buy 40 mg esomeprazole free shipping. Most of the respondents who used long term and permanent methods have attained secondary school education gastritis blood test purchase esomeprazole 40mg on line. These findings are in line with those of studies in Bulgaria where women who had attained high school education were likely to use long acting methods however they could not rely on sterilization compared to those without high school education. However, in some instances providers end up choosing the method for client or worse still some client insist on a method against the advice provided by contraceptive provider. That was further confirmed during service providers focused group discussion where one participant said; We respect the choices of clients, many seem to know about the methods from internet, relatives and friends and thus come decided on the method. A point further explained by studies from Rwanda, Ghana and Nigeria that partner approval, objection and support towards contraceptive choice influences use of contraception, suggesting the role played by men/spouses and socio cultural perception towards contraception even though merely 15% of the respondent in Westland? That was further identified as a challenge by family planning service providers during the focused group discussion where one participant said; We don?t have ways of making men attend clinic even though we encourage clients to bring their partners only a few come. The study found the commonest myths, misconceptions and beliefs among women 78 who did not use long term and permanent contraceptives to be; implants causes high blood pressure and sudden death (8%),coil hurts husband during intercourse and affects sex styles(7%), women become pregnant with coil (6%). That is in contrast to studies done in Ethiopia which identified myths, beliefs and misconception to be a hindrance to utilization of long acting and permanent methods. However the misconceptions identified are almost similar with the population in Mekelle, Ethiopia misconceiving coil to cause cancer, delay pregnancy, interfere with sexual intercourse and implant affect normal activity and its insertion is very painful (Alemayehu, 2014). That difference in influence could possibly be explained by variation in rural-urban socio economic and demographic characteristics between the two populations in Kenya and Ethiopia, given Westlands is within the Kenyan capital city. Likewise a study carried out in Tigray, Ethiopia 2012 (Alemayehu) found out that a large proportion of women use contraception for child spacing (65%) than permanent limitation for number of children (17%) thus rely on either short or long acting methods. The study findings revealed 37% of the respondents who currently used short term methods would consider long term and permanent methods in future compared to 63% who would continue with the same methods. A further proportion of those using long term methods (15%) would consider reverting to short term methods compared to 85% who would still use them. In addition 15% of the respondents missed the service from the facility due to lateness (5%) and stock out (1%). That information is useful to clients when choosing the method to use or to switch to incase one fails. The usage of long term reversible method was considerably higher (implants, 22%, coil 8%) than permanent irreversible method (tubal ligation, 2. The factors found to be significantly associated with usage of long term and permanent methods at p<0. The later are cost effective in the long run and as well reduces the strain on county health resources (staff, supplies and commodities). Family planning service providers should enquire more from clients about contraceptive method related side effects and satisfactorily manage them to promote method adherence. P healthcare workers to offer all methods other than rely only on partners like Tupange project. A qualitative study to determine how best men can be involved in reproductive health matters especially in family planning ii. The study findings indicated side-effects could be hindering utilization of long acting methods. Therefore a study to assess the prevalence of these side effects and how to minimize their occurrence iii. A study to be carried out to determine why women prefer short term methods of family planning despite their desire to space their children for more than 2 years yet long acting reversible methods are effective for longer periods with high success rate. A more intense qualitative studies especially in the community settings are needed to gain further insight on acceptance of Long term/acting and permanent methods of family planning by women of reproductive age. Pattern of contraceptives choices among the married women attending the family planning clinic of a tertiary health iInstitution, Niger. Factors Associated with Utilization of Long Acting and Permanent Contraceptive Methods Among Married Women of Reproductive Age in Mekelle Town,Tigray Region,North Ethiopia. Transvagenial Ultrasonographic Assessment of the Expulsion Rate of Intrauterine Devices Inserted in the Immediate Intrapartum Period:A Pilot Study. Strategies to Prevent Unintended pregnancy; Increasing Use of Long-acting Reversible contraceptives. Gender, Class and Contraception in Comparative Context; the Perplexing Links between sterilization and Disadvantage. Long Acting and Permanent Contraception;an International Development Service Delivery Perspective. Addressing Unmet Needs for Long Acting Family Planning in Ethiopia; Uptake of Implanon and characteristic of Users. National Family Planning Guidelines for Service Providers;Updated to Reflect the 2009 Medical Eligibility Criteria of the world health organization. Improving Access to Longterm Contraceptive in Rural Guetamala Through the Ministry of Health. Acceptance of Long Term contraceptive Methods and its Related Factors Among the eligible couples in selected Union, Bangladesh. Providing long-acting and Permanent Contraceptives through Outreach in rural Uganda. Promoting Health Spacing Between Pregnancies in India: Need for Differential Education Campaigns. Demand for Long Acting and Permanent Methods of Contraception and Factors for Non-use Among married women of Goba Town, Bale Zone, South East Ethiopia. Reproductive Health journal the United Nation Department of Economic and Social Affairs. Jamaican and Barbadian Health care Providers Knowledge, Attitude and Practices Regarding Emergency contraceptive Pills. The information gathered will be used to improve the provision of the long-term and permanent contraceptive method in this health facility as well as other facilities in Kenya. Procedures to be followed Participation in this study requires I ask you some questions which I will record the answers in the questionnaire. You will receive the same care whether you agree to join the study or not and your decision will not change the care you will receive from the facility today/later or that you will get from any other facility at any other time. Participation is voluntary and you may ask questions related to the study at any time. You may refuse to respond to any question and you may also stop the interview at any time without any consequences to the services you receive from this health facility or any other organization now or in the future. Discomfort and risks Some of the questions you will be asked may make you uncomfortable. The interview may add 91 approximately half an hour to the time you wait before you receive your routine services. Benefits Participation in this study will enable us learn more about the family planning methods effectiveness in enabling users fulfill their reproductive goals. Confidentiality the interview will be conducted in private and your name will not be recorded in the questionnaire. Contact information If you have any questions feel free to contact the principal investigator Justus Muthee on 0725823229, Dr. Harun Kimani on 0725552475 or the Kenyatta University Ethical Review Committee Secretariat on kuerc@ku. I have been given a chance to ask any questions and my questions have been answered to my satisfaction. I understand that my records will be kept private and I can leave the study at any time. I understand that I will receive the same care whether I decide to participate in the study or not and my decision will not change the care I receive from the health facility today or that I will get from any other facility at any other time. Date? Investigators statement I, the undersigned have explained to the volunteer in a language she understands the procedures to be followed in the study and any risks/benefits that my be involved. Purchase esomeprazole in india. GYM Benefits of eating WATERMELON (Tarbooj) | Info by Guru Mann.
Examples include diagnostic tools used in the different diagnostic settings gastritis diet zantrex esomeprazole 40 mg with amex, psychometric properties of measures used to determine efficacy or effectiveness gastritis diet 4 believers purchase genuine esomeprazole, and study designs that have demonstrated effects on definition akute gastritis purchase 40mg esomeprazole free shipping, for example gastritis symptoms shortness of breath purchase esomeprazole now, minimizing bias and placebo effects. Such a majority agreement? can be determined by guidelines or best practices, or consensus statements, or systematic reviews that represent state of the art consideration of the relevant topic, or other ways. Since there is no clearly identified group to formulate such an agreement, we believe that what is presented in consensus statements, clinical practice guidelines, government reports, and the peer-reviewed literature is a legitimate marker for agreement among clinical, research, and policy experts, especially if a majority of those citations appear to agree with each other over time. Because we did not have access to individual patient data, we focused primarily on study-level characteristics. To avoid issues of ecological fallacy, whereby inferences about the nature of individuals are wrongly deduced from inferences for the group to which those individuals belong, we converted patient-level covariates to study-level covariates whenever possible. To ensure consistency, we developed a data codebook and an analysis plan after we selected the covariates. Regression or other statistical analyses focus on interventions for which we have at least 10 63 studies using a similar comparator intervention. We also selected relevant outcome measures, focusing insofar as possible on patient-centered outcomes. We also recalculated the direction of effect, if necessary, so that an odds ratio >1 indicates a beneficial effect and an odds ratio <1 indicates a harmful effect. The impact of the study and patient-level characteristics on treatment effects for each outcome were assessed using random effects meta-regression models. To quantify the impact of a characteristic on the treatment effect, we computed the ratio of odds ratios and associated 95 percent confidence intervals to compare the odds ratio of the intervention effect 11. We began with bivariable analyses, comparing results for one characteristic at a time and then conducted multivariable analyses, including all of the characteristics that were significant in the bivariable analyses for the applicable outcome. Some study and patient-level characteristics were excluded from the analyses owing to lack of variability across studies or high levels of missing data. Furthermore, findings may differ depending on the definition of the primary outcome of interest. As noted in Methods, we present interpretative text and summary tables documenting our findings. It also records the yields from our efforts to identify other sources of information, including handsearching grey and other literature sources. Two moved forward to full text review, resulting in one article added to the included pool of studies for this review. The two most common reasons for exclusion at the full-text level were ineligible population (89 exclusions) and ineligible study design (45 exclusions). Appendix A presents the literature search strategies; Appendix B lists the articles excluded at the full-text stage of review. For our analyses, we used three general categories of publications: systematic reviews, nonsystematic reviews, and guidelines or consensus statements. Relevant records were checked against the database for duplication and 154 relevant records were moved forward to dual full-text review. In addition, 18 publications reported on 13 different guidelines or 19, 21, 23, 38, 42, 67-79 consensus statements. Since 2005, definitions have emphasized failure to achieve remission as the preferred definition of treatment failure. However, the majority of systematic reviews and guidelines or consensus statements reported that the commonly used definitions were based on patients whose depression failed to respond (a decrease in depressive severity of at least half) or did not go into remission (complete 15 recovery as measured by a score on a depressive severity instrument below a threshold) following two or more treatment attempts of an adequate dose and duration. Whether the treatment attempts require different classes of antidepressants is not a settled matter. Experts do not agree on how to define adequate dose and duration, although the minimum duration cited is 4 weeks. Use of one or the other of these basic definitions?and more importantly what specific elements are included in them?has challenged researchers, clinicians, and policymakers for years. These failures can range from a single treatment failure (relating to any drug) to three or more failures using three different classes of antidepressants. Others include whether the failure occurred in the current episode, whether the individual received an adequate dose of the medication, and whether the duration of treatment was considered adequate. Of note, since 2005, a consensus has been developing that the proper definition of failure is the inability to achieve remission (sometimes to remit?). Other agreement among experts 31, 41 appears to be that an adequate trial is, at a minimum, 4 weeks at an adequate dose, although some argue that 6 weeks should be the minimum. Agreement is less clear whether an adequate dose means a minimum effective therapeutic dose or a maximum tolerated dose. Within these four main categories, the various sources are listed in chronological order. The separate rows and citations can include individual studies, systematic reviews, or guidelines and similar documents. The applicability and feasibility of these staging tools in clinical practice are not known. These variables include the duration of the episode, the depression subtype, depressive 31, 44 severity, and psychiatric or medical comorbidity. Staging models for treatment-resistent depression to define the spectrum of illness Predictive Validity and Reliability How Is Failure Tested? Other Comments European Staging Determined by the Poor response to Not found Three general categories: the predictive value has not been Model number of weeks a second systematically assessed, and with treatment (adequate) trial Nonresponder: 6?8 weeks Nonresponder: Nonresponse reliability has not been tested Fekadu et al. Reliability for these indicate a greater Not considered Staging is primarily based on models was not reported. Staging models for treatment-resistent depression to define the spectrum of illness (continued) Predictive Validity and Reliability How Is Failure Tested? Further staging depends on the duration of treatment with adequate medication trials. No studies tested the reliability or predictive utility or reliability of this model. It is a function primarily of the number of prior antidepressant failures (with no 45 hierarchy of antidepressant classes). Higher scores for patients were associated with failure to achieve remission; the model correctly predicted treatment resistance in more than 85 percent of cases. Predictive Validity of Staging Models A recent systematic review compared the predictive utility and reliability of these models. The operationalization criteria improved, and the scoring of different treatment strategies (between/within class switching and augmentation/combination) changed as evidence accumulated. Still, the evidence base is limited, and the superiority of one model over any other model for use in a clinical setting is uncertain. A recent review of these methods, however, reported that they appear equally valid 41 for documenting treatment failure in depressed patients. Consensus Definition of Treatment-Resistant Depression Determining Consensus A consensus can be identified in several ways. One approach is to have the strongest evidence base identifying the preferred definition. A second way is to have a preponderance of best practice guidelines or consensus statements clearly identify a preferred definition. A third way is to indicate the approach most frequently reported in the literature or by the guidelines or consensus statements. By contrast, less invasive interventions, such as medications or psychotherapy, were more likely to use a more stringent cut-off of one or more failures. It involved patients depression who had not achieved remission following two or more adequate 31, 40, 41, 58 antidepressant medication treatments (at least 4 weeks at an adequate dose per authors). The requirement for failure to occur following medication from two different antidepressant classes, as opposed to merely two different antidepressants, varies by systematic review. Details are in Table 6, which is ordered by the number of required treatment failures and then chronologically by source. One considered stages of treatment resistance (rather than a dichotomous definition) based on the number of prior treatment failures. For example, Stage 1 indicates failure to achieve response after one course of adequate treatment, and Stage 2 indicates failure to achieve response after 64 two courses of adequate treatment, and so on. The latter guideline had previously used a dichotomous definition of two or more failures. Diseases
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