Cymbalta

By M. Chenor. Northwestern College, Iowa.

Treatment guidelines have the potential to inﬂuence The treatment strategy most likely to succeed usually com- the health care of many patients buy cheap cymbalta 60 mg, and therefore the guide- bines the most effective speciﬁc interventions with a strong lines and the process used in their development should be therapeutic relationship and a mutual expectation of and open to public scrutiny cheap cymbalta 30 mg without prescription. Such factors, which are com- scientiﬁc justiﬁcation for a guideline violates a basic prin- mon to most treatment situations, can be powerful deter- ciple of science, which requires open scrutiny and debate. Good guidelines allow for Without the disclosure of adequate scientiﬁc information, ﬂexibility in treatment selection so as to maximize the guidelines are mere expressions of opinion. This document is organized on the basis of two related The judgment of health care professionals, although always dimensions for the evaluation of guidelines. The ﬁrst di- needed, is particularly important in the treatment of condi- mension is treatment efﬁcacy, the systematic and scientiﬁc tions for which research data are limited. The second di- should take these factors into consideration and particularly mension is clinical utility, the applicability, feasibility, and should avoid encouraging an overly mechanistic approach usefulness of the intervention in the local or speciﬁc setting that could undermine the treatment relationship. This dimension also includes It is often assumed that the use of treatment guidelines determination of the generalizability of an intervention will signiﬁcantly reduce the cost of services. It is possible that guideline implementa- countability, criteria for evaluating the process of guideline tion may cause some services to be discontinued because of production are also provided. Treatment Efﬁcacy However, it is also possible that the adoption of guidelines will lead to a shift toward more effective but not necessar- This dimension asks the question, How well does the ily less costly services. The term treatment efﬁ- treatment via guidelines will always be beneﬁcial because cacy refers to a valid ascertainment of the effects of a given it reduces practice variation. However, variation in clinical intervention as compared with an alternative intervention practice is often based on the needs of individual patients or with no treatment, in a controlled clinical context. When the appli- fundamental question in evaluating efﬁcacy is whether a cation of guidelines results in a rigid system that eliminates beneﬁcial effect of treatment can be demonstrated the ability to respond to individual needs of the patient and scientiﬁcally. For inherently either beneﬁcial or detrimental, and the docu- some treatments, the most accessible source of information ment is not intended either to encourage or to discourage on treatment efﬁcacy may be the judgment of health care their development. However, the burden of proof remains professionals and patients who have experience with the on the makers of each guideline and those responsible for treatments. It is important to distinguish between the con- its implementation to establish that the application of the text of discovery of an intervention and the context of guideline is indeed beneﬁcial and does not impair patient veriﬁcation of its clinical efﬁcacy. These criteria are intended to provide ventions have beneﬁcial effects is best answered using structure and guidance for those individuals or groups that research methodologies that have been reﬁned over many evaluate the quality and appropriateness of treatment years to reduce the uncertainties inherent in subjective guidelines. Each criterion describes an important issue that judgment alone and to increase conﬁdence in the strength December 2002 ● American Psychologist 1053 of the intervention. These clinical observations may then form the basis research strategies also promotes the welfare of patients. Appropriate methodolo- Without evidence of efﬁcacy, health care profession- gies may include systematized clinical case studies and als are forced to rely exclusively on their direct experience clinical replication series, in which the clinical efﬁcacy of of the effects of different interventions—an approach that an intervention is examined with a series of diverse patients risks erroneous conclusions. Some medical phisticated empirical methodologies, including quasi and psychological practices that initially appeared helpful experiments and randomized controlled experiments or and became widely accepted were subsequently found in- their logical equivalents. One purpose of this document is volve randomization but include other controls that are to provide a strategy for evaluating the level of conﬁdence designed to rule out some threats to the internal validity of to be placed in judgments about the relative efﬁcacy of inferences regarding treatment efﬁcacy. Randomized con- trolled experiments represent a more stringent way to eval- Criterion 1. Individual studies should be reduces the likelihood that the groups differ before treat- evaluated on the logic of their experimental design. Ade- ment with respect to characteristics that could inﬂuence quate studies may be compiled using qualitative ap- subsequent status. The advantage of randomized clinical proaches or quantitative methods such as meta-analysis. How- When guidelines are based in part on compilations of ever, they are potentially subject to several threats to their studies, both the analyses and the individual studies on external and construct validity, some of which are de- which they are based should be examined carefully, and scribed later in this document. Guidelines should take into consideration infor- which are listed in ascending order as to their contribution mation from the sources identiﬁed in Criteria 2. Comparing a treatment with non- of interventions included in treatment guidelines can be treatment allows the determination not only of whether an supported by multiple observations by trained, knowledge- intervention has any efﬁcacy at all but also of whether it able, and experienced individuals. This determination is often an impor- mean agreement among recognized experts in a particular tant part of the treatment evaluation process. For very infrequent due to such factors as the quality of the treatment relation- behaviors and rare conditions, clinical consensus on appro- ship and the health care professional’s ability to create a priate treatment may be the only available data. Simi- servation has two advantages: (a) The intervention is gen- larly, the provision of a placebo in a test of the efﬁcacy of erally applied in a naturalistic practice setting and (b) the a pharmacological agent duplicates all the aspects of the evaluation typically includes examination of qualitative medication regime except the medication itself. Both these 1054 December 2002 ● American Psychologist strategies have their strengths and weaknesses, and the sonal control. Patients’ sub- tervention’s results are better than the results of other jective evaluation of treatment and its results is important interventions. The strongest recommendations are based in evaluating treatment outcome, even though it may not be on demonstrations that the treatment under consideration is strongly correlated with clinical improvement. Iatrogenic negative effects or side effects of treat- or believed to be effective.

Cardiovascular outcome in white-coat versus sustained mild hypertension: a 10-year follow-up study cymbalta 40mg mastercard. Cardiovascular outcome in treated hypertensive patients with responder generic cymbalta 30 mg free shipping, masked, false resistant, and true resistant hypertension. Masked hypertension in diabetes mellitus: treatment implications for clinical practice. Long-term risk of mortality associated with selective and combined elevation in offce, home, and ambulatory blood pressure. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Untreated Masked Hypertension and Subclinical Cardiac Damage: A Systematic Review and Meta-analysis. Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. Medical Research Council trial of treatment of hypertension in older adults: principal results. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Immediate and late benefts of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial. The Society of Obstetric Medicine of Australia and New Zealand Guideline for the Management of Hypertensive Disorders of Pregnancy. Visit-to-Visit Variability of Blood Pressure and Cardiovascular Disease and All- Cause Mortality: A Systematic Review and Meta-Analysis. Blood pressure variability in relation to outcome in the International Database of Ambulatory blood pressure in relation to Cardiovascular Outcome. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Effects of beta-blocker selectivity on blood pressure variability and stroke: a systematic review. Clinical features of 8295 patients with resistant hypertension classifed on the basis of ambulatory blood pressure monitoring. Prevalence, predictors, and outcomes in treatment-resistant hypertension in patients with coronary disease. National Heart Foundation of Australia Guideline for the diagnosis and management of hypertension in adults 2016 71 203. Predictors and outcomes of resistant hypertension among patients with coronary artery disease and hypertension. Adjusted Drug Treatment Is Superior to Renal Sympathetic Denervation in Patients with True Treatment-Resistant Hypertension. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea. Impact of continuous positive airway pressure therapy on blood pressure in patients with obstructive sleep apnea hypopnea: a meta-analysis of randomized controlled trials. The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials. Predicting blood pressure outcomes using single-item physician-administered measures: a retrospective pooled analysis of observational studies in Belgium. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. Antithrombotic Trialists’ Collaboration, Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Randomised equivalence trial comparing three month and six month follow up of patients with hypertension by family practitioners. Long term monitoring in patients receiving treatment to lower blood pressure: analysis of data from placebo controlled randomised controlled trial. Blood pressure re-screening for healthy adults: what is the best measure and interval?

Primaquine clears submicroscopic Plasmodium falciparum gametocytes that persist after treatment with sulphadoxine-pyrimethamine and artesunate purchase 20 mg cymbalta with visa. Single dose primaquine for clearance of Plasmodium falciparum gametocytes in children with uncomplicated malaria in Uganda: a randomised discount cymbalta 20 mg with amex, controlled, double-blind, dose-ranging trial. Effectiveness of fve artemisinin combination regimens with or without primaquine in uncomplicated falciparum malaria: an open-label randomised trial. Assessment of therapeutic responses to gametocytocidal drugs in Plasmodium falciparum malaria. The reservoir of Plasmodium falciparum malaria in a holoendemic area of western Kenya. Predicting mosquito infection from Plasmodium falciparum gametocyte density and estimating the reservoir of infection. Substantial contribution of submicroscopical Plasmodium falciparum gametocyte carriage to the infectious reservoir in an area of seasonal transmission. Features of recrudescent chloroquine-resistant Plasmodium falciparum infections confer a survival advantage on parasites, and have implications for disease control. Host heterogeneity is a determinant of competitive exclusion or coexistence in genetically diverse malaria infections. Association of house spraying with suppressed levels of drug resistance in Zimbabwe. Malaria cannot be diagnosed accurately with any one set of clinical criteria, as the signs and symptoms (fever, chills, headache and anorexia) are non-specifc and are common to many diseases and conditions. The appropriateness of particular clinical diagnostic criteria varies from area to area according to the intensity of transmission, the prevalent species of malaria parasite and other prevailing causes of fever (3). The concurrent incidence of other diseases with malaria may also affect its presentation. A Detailed weighting and scoring systems for clinical signs and symptoms of malaria 3 may improve the accuracy of clinical diagnosis but still result in low sensitivity and specifcity (studies in The Gambia achieved a sensitivity of 70–88% and a specifcity of 63–82%). These methods may be too complicated to implement and supervise under operational conditions, and many of the key symptoms and signs of malaria in one area may not be applicable elsewhere (5, 6). A review of 10 studies indicated that use of the more restrictive criteria in clinical algorithms resulted in only trivial savings in drug costs in comparison with the use of a fever-based diagnosis, and, in areas of high prevalence, greatly increased the probability of missing malaria infections (7). Light microscopy Microscopy not only provides a highly sensitive, specifc diagnosis of malaria when performed well but also allows quantifcation of malaria parasites and identifcation of the infecting species. Light microscopy involves relatively high costs for training and supervision, and the accuracy of diagnosis is strongly dependent on the competence of the microscopist. Microscopy technicians may also contribute to the diagnosis of non-malarial diseases. Although nucleic acid amplifcation-based tests are more sensitive, light microscopy is still considered the “feld standard” against which the sensitivity and specifcity of other methods must be assessed. A skilled microscopist can detect asexual parasites at a density of < 10 per µL of blood, but under typical feld conditions, the limit of sensitivity is approximately 100 parasites per µL (8). This limit of detection approximates the lower end of the pyrogenic density range. Thus, microscopy provides good specifcity for diagnosing malaria as the cause of a presenting febrile illness. More sensitive methods allow detection of an increasing proportion of cases of incidental parasitaemia in endemic areas, thus reducing the specifcity of a positive test. Good performance of microscopy can be diffcult to maintain, because of the requirements for adequate training and supervision of laboratory staff to ensure competence in malaria diagnosis, electricity, good quality slides and stains, provision and maintenance of good microscopes and maintenance of quality assurance and control of laboratory services. Numerous attempts have been made to improve malaria microscopy, but none has proven to be superior to the classical method of Giemsa staining and oil-immersion microscopy for performance in typical health care settings (9). Cassettes and cards are easier to use in diffcult conditions outside health facilities. The tests have many potential advantages, including: • rapid provision of results and extension of diagnostic services to the lowest-level health facilities and communities; 138 • fewer requirements for training and skilled personnel (for instance, a general health worker can be trained in 1 day); and • reinforcement of patient confdence in the diagnosis and in the health service in general. Severe malaria on Not a Yes Microscopy admission alone can also show Follow-up of parasite density. Health workers Microscopy in the community requires and at health Yes No a reliable posts electricity supply. Although providers of care may be willing to perform diagnostic tests, they do not, however, always respond appropriately to the results. It is therefore important to ensure the accuracy of parasite- based diagnosis and also to demonstrate this to users and to provide them with the resources to manage both positive and negative results adequately (16). Immunodiagnosis and nucleic acid amplifcation test methods Detection of antibodies to parasites, which may be useful for epidemiological studies, is neither sensitive nor specifc enough to be of use in the management of patients suspected of having malaria (17). They are also useful for studies of drug resistance and other specialized epidemiological investigations (18); however, they are not generally available for large-scale feld use in malaria- endemic areas, nor are they appropriate for routine diagnosis in endemic areas where a large proportion of the population may have low-density parasitaemia.