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Analysing the data An assessment of the clinical effectiveness of a product re- After extracting the relevant data from each of the studies quires a full ‘systematic review’ of the available evidence cheap fluticasone master card asthma symptoms dog dander. A that meet the review inclusion criteria an ‘evidence table’ systematic review involves four steps: is constructed cheap 500 mcg fluticasone otc asthmatic bronchitis diet. In such a table the relevant data for each study are summarised and usually include: • The study’s bibliographic reference generic 100mcg fluticasone otc asthma yellow mucus. It is very common, however, to attempt a quantitative synthesis – or meta-analysis – of Was the study described as randomized? The relevant data are the mean differ- Was the method of double blinding 0/1 ences in outcomes at the end of the study with their 95% described and appropriate? Estimates of the effect size for of the Was there a description of withdrawals 0/1 included studies, and the pooled estimate from all the studies, are often depicted as a ‘forest plot’1; an example and dropouts? Deduct 1 point if the method of randomization 0/À1 This forest plot summarises the results of each of five was described and was inappropriate? In a typical forest plot, there is an abbreviated was described and inappropriate? The point estimate (mean) of the results of each study is represented as a • Study setting (e. There is no generally accepted ap- increase in the frequency of ischaemic stroke) is shown proach to doing this but one of the more common to the right. A score of 5 would indicate and all five ‘squares’ are to the left of the ‘no effect’ (odds that the particular study appeared to avoid both selection ratio ¼ 1) vertical line. A score of 0 would cast consider- fidence interval does not cross the ‘no effect’ line and the able doubt on a study’s internal validity. In the other two studies, the upper boundaries of Qualitative synthesis the 95% confidence interval cross the ‘no effect’ line and would not reach conventional levels of statistical signifi- Almost all systematic reviews include an element of narra- cance (i. The overall tive or ‘qualitative’ synthesis outlining, or expanding on, as- pooled mean effect size, taking account of the results of pects of the included studies. The defining characteristic of a formal narrative synthesis is the use of a textual ap- 1The ‘forest plot’ is so called because (to some – though not to the proach that provides an analysis of the relationships within author’s – eyes) the ‘plot’ resembles a forest! It is a more subjective process patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database of Systematic than meta-analysis and, when used, needs to be rigorous Reviews Issue 3, Art. The manner in which health-care The final step in a systematic review is to discuss its priorities are decided varies between countries, but ration- strengths and weaknesses, and to draw conclusions. Both ing decisions are necessary – explicitly or implicitly – in all strengths and weaknesses will depend in large part on countries because resources are finite and demand is (al- the range and quality of the included studies. In pharma- are statistical techniques that can sometimes be helpful coeconomics this involves trying to estimate the extra in establishing probable publication bias. If a health-care system devotes very large sums the prevention of ischaemic stroke in patients with non- of money to a product that gives only modest benefits, valvular atrial fibrillation. Moreover, the authors were able other people, with other conditions, will be denied cost- to estimate that about 25 strokes and about 12 disabling or effective care. The cost-effectiveness component of a fatal strokes would be prevented yearly for every 1000 pa- health technology assessment thus attempts to provide tients with atrial fibrillation treated with warfarin. In doing so, the assessment has The use of natural units is relatively simple and they can to take account of: be used effectively in comparing the costs and benefits of • The relevant costs. It is for this reason that most economic analyses prefer to use health ‘utilities’ as the measure of 1. The costs of using a particular pharmaceutical will include the acquisition costs of the product, as well as the costs as- Health utilities sociated with its use (such as any special monitoring Utilities are numbers assigned to preferences according to requirements, additional visits to hospital). There are a number of ways by which health utilities rin for the prevention of ischaemic stroke, the costs will can be captured and all are based on an assessment, by therefore have to include the costs of the warfarin itself, each person, of the improvement in their quality of life. The costs will also productofinterestaswellasthoseusingthecompara- have to include the consequences of any adverse effects tor(s). If the study itself did not collect health-related which, in the case of warfarin, would need to encompass quality of life data, there are techniques that allow it to the costs associated with warfarin-induced bleeding. The costs will also have to take account of any savings The most widely used technique for capturing health- from which a health-care system would benefit. It isnot disease-specificand captures patients’ to prevent ischaemic stroke, would include the savings preferences for particular health states. In this case the costs (and cost offsets) from a particular treatment their health state might move would be extended to include any reduction in time off from (say) 0. This is multiplied by the number of years for which resulting from fewer strokes that would reduce the costs as- it is enjoyed to yield the ‘quality-adjusted life years’ sociated with unemployment or disability. If patients could on average expect to enjoy a util- Whether the economic perspective (as economists de- ity gain of 0. It isa political, fiscal (relating to government revenue, especially taxes) and gov- 3. For this reason there is considerable variation between countries as Two types of analysis are possible depending on whether to the economic perspective taken. A societal perspective is the benefits are expressed in natural units or as utilities. Benefits economists must of necessity construct an economic For the purposes of an economic analysis, the benefits of a model. There is a great variety of these, and they vary in health technology can, broadly, be expressed either in ‘nat- their complexity. Other natural units might include the number of addi- incremental cost (£) per incremental gain in some natural tional centimetres of height gained from the use of human unit. Health technology as- used, it is impossible to make comparisons across condi- sessments should provide decision-makers with a sophis- tions. How would a decision-maker make a ‘value for ticated analysis of the available data, together with a money’ comparison between £20 000 per life year gained critical evaluation of the strengths and weaknesses of for treating advanced cancer, with £20 000 per centimetre the assessment as well as the limitations in the economic height gained from the use of growth hormone in a child analyses. One of the most critical issues, in the assessment of the clinical data, is the extent to which the benefits in trials can be extrapolated beyond the data. These are the decisions that decision-makers themselves A health technology assessment may also include eco- must make. A reasonable decision-maker could reasonably nomic evaluations in subgroups of patients, such as those conclude that to stop warfarin treatment after 1. These decisions are ones that require judge- value for money, but when there may be subgroups who ments to be made rather than strict adherence to the tenets might gain greater benefit. Health technology assess- ment plays a crucial role in underpinning evidence-based clinical practice but it does not supplant the place of judgement! Oxford University Handbook for Systematic Reviews Economic Analysis in Health Care. Safety, in relation to its use: evaluation at the point of marketing is provisional in the sense that it is • Present-day requirements.

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In patients with diabetes order fluticasone 100mcg with visa asthma spacer, overnight surges of counter-regulatory hormones–– including cortisol buy fluticasone 100mcg asthma 4939, catecholamines buy fluticasone without prescription asthma 8 month old, and in particular growth hormone–– 1 without adequate insulin release, contribute to fasting hyperglycemia. The differential diagnosis of fasting hyperglycemia includes insufficient dosing of basal insulin, carbohydrate intake at bedtime or during the night, and the dawn phenomenon. Dawn phenomenon is a transient increase in insulin resistance in the early morning hours, likely related to exaggerated response to counter-regulatory hormones, typically with an 1 increase in hepatic glucose output after 4:00 a. With consideration of possible dawn phenomenon, the patient’s basal insulin was changed from glargine to detemir at doses of 30 units in the morning and 50 units in the evening. The pharmacokinetics of detemir vary by dose but can include a more 3 pronounced peak at higher doses than what is observed with glargine. Although it was anticipated that this change in basal insulin would improve her morning control, the evening dose was reduced compared with the previous evening dose of glargine to minimize the risk of hypoglycemia. She tested a few overnight blood glucose values and reported them being in the 150– 160 mg/dL range (8. The dose of detemir was increased to 30 units in the morning and 70 units in the evening. In contrast, the blinded 3-day system functions as a data recorder and is designed to help with therapeutic decision making by collecting continuous data for analysis by the provider. The degree of morning hyperglycemia was related to the postprandial peak after dinner (Fig. Her insulin regimen was modified by increasing the dinnertime lispro from 36 to 42 units and the breakfast lispro from 16 to 26 units. Over the next 2 months the predinner dose of lispro was gradually increased to 52 units and liraglutide to the maximal dose of 1. Additionally, with obese insulin-resistant patients, improving the diet and exercise remain is important and additional pharmacological therapies contribute to improvements in glycemic control. Its use in 5 combination with insulin therapy for type 1 diabetes has been reported. This patient’s final regimen represents off-label use, but it has the potential benefit of weight neutrality and weight loss effects in some patients. Liraglutide as additional treatment to insulin in obese patients with type 1 diabetes mellitus. Endocr Pract 2013;19(6):963– 967 Case 70 Insulin Injections: What You “See” May Not Be What You Get 1 2 Robert J. She was given a vial of insulin and syringe and asked to demonstrate how she gives insulin. She took the syringe, drew back to 50 units, pushed it into the vial sitting on the desk, pushed the air into the vial, and then promptly drew back 50 units of air back into the syringe. Instructed on insulin pen use, glucose levels have been controlled with <20 units premixed insulin twice a day. Missing Pen Needle A 50-year-old woman was discharged from the hospital following total pancreatectomy. She was seen by her primary care physician who asked her to demonstrate her injection technique. She dialed the appropriate dose of insulin and then proceeded to try and inject the insulin without any attached needle. The patient had not received a prescription for pen needles and neither the pharmacy nor the patient questioned this. Covered Pen Needle A 60-year-old woman was discharged from the hospital with a new requirement for insulin. When asked to demonstrate injection technique, she put a new needle on the pen, dialed in the correct insulin dose, and then “injected” herself. Inject Insulin and Count to 10 A 78-year-old woman was referred for “brittle” diabetes. Using pens, she perfectly described how she would dial in the dose, inject, and count to 10. When asked to demonstrate, she dialed in the correct number, inserted the pen needle under her skin, fully pushed the plunger, and immediately pulled the pen needle out, holding the insulin pen at arm’s length while she counted to 10. Discussion When assessing insulin use, medical providers consider the dose and type of insulin, renal function, diet, and exercise. Patients with poor vision may believe they have injected their insulin, with the insulin actually injected onto their skin. Experienced patients may have been taking their insulin appropriately, but with changes in their health and vision, the technique that the patient and providers took for granted became the unknown weak link in their management. Insulin pens generally are thought to be easier to use and to allow for more accurate dosing than 2,3 with insulin syringes, especially when low doses are used. When the response to changes in insulin do not make sense (as with a thin elderly patient needing >200 units/day), consider basic technique problems. Neither the patient, nor pharmacist, nor anyone in the emergency room realized that the pen needles were not present. We previously have reported that problems with writing insulin prescriptions for discharge to home from the 4 hospital can occur. Covered Pen Needle Before being discharged to home, the patient demonstrated that she could use the insulin pen correctly. Once home, the patient had all of her diabetes supplies, but never actually injected her insulin dose as she left the plastic cap that covers the needle in place. This safety cap covers the needle and the patient never actually sees the needle, before or after the injection. Thus, as far as the patient was concerned, having the cap on the needle was normal. Inject Insulin and Count to 10 Although instructed in use of insulin pens, technique was never confirmed. She did not wait several seconds after the injection before withdrawing the pen, but dutifully counted those seconds off, tightly holding the pen while it was in the air. Some of the insulin was injected on the skin and some in the air, but little subcutaneously. Patients with diabetes, even longstanding diabetes and previous diabetes education, may have developed poor habits. Technique needs to be observed for 5 errors, especially if diabetes control remains problematic. Patients should be instructed and demonstrate using all components of the specific insulin delivery device that they will have at home. Patients need printed educational material in their preferred language informing them of all of the components and steps necessary for a successful insulin injection. When ongoing glucose control remains difficult, having the patient demonstrate all aspects of insulin injection technique should be part of the evaluation. This is true even if the patient had mastered the technical aspects of insulin self-administration. Elderly patients may need additional reinforcement of diabetes instruction despite years of diabetes experience.

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Car- cinoid tumors are the most common cheap 100 mcg fluticasone otc new asthma treatment channel 9, accounting for glands and/or signet-ring cells with cellular atypia about 85% of epithelial tumor cheap fluticasone online mastercard asthmatic bronchitis jaw. They can be further Mucin-producing tumors of the appendix may be 25 divided into two major groups purchase fluticasone with visa asthma inhaler brands, including those produ- confined to the appendix, forming a mucocele or cing extracellular mucin that forms mucinous ascites, may manifest as intraperitoneal spread. This can commonly known as ‘‘pseudomyxoma peritonei,’’ and be seen as mucinous ascites, frequently loculated, those not producing extracellular mucin. Signs 22–24 of investigators have proposed systems of classi- of invasion from the solid component of the mucinous fication for mucin-producing tumors based on their ascites to the adjacent organs or structures may a Fig. Note barium filling the lumen of the appendix (arrowhead) and vessels (curved arrow) in the mesoappendix. Surgery showed that it was mucinous tumor of the appendix with low malignant potential. Poorly differentiated adenocarcinoma of the appendix with nodal metastases along the root of the mesentery and omental metastasis in a patient presenting as carcinoma of unknown primary. The other group of appendiceal adenocarcinoma has clinical and pathological features similar to those 1. These have cellular differentiation from well- to mod- In Standring S (ed) Gray’s Anatomy – The Anato- erately and poorly differentiated adenocarcinoma and mical Basis of Clinical Practice, 40th ed. In Standring S (ed) times, large tumors in this region may be difficult to Gray’s Anatomy – The Anatomical Basis of Clin- distinguish, whether they originate from the appendix, ical Practice, 40th ed. Takemura M, Iwamoto K, Goshi S, Osugi H, Hir- oaki K: Primary volvulus of the small intestine in an Disease from the small intestine and appendix com- adult, and review of 15 other cases from the Japa- monly undergoes intraperitoneal spread. Am J the appendix A clinicopathologic study of 184 Gastroenterol 2006; 101:1647–1654. P atterns of S pread of D iseasefrom theL arge Intestine Embryology and Anatomy At the hind end of an early fetus, the caudal end of the primitive hindgut and the allantois join to of the Colon, Rectum, and Anal form a chamber called the cloaca. The mesenchy- mal tissue above the cloaca proliferates and sepa- Canal rates it into the urethra and the anal canal and fuses with the anal membrane to become the uror- The colon and rectum develop from the distal segment 2 ectal septum. As described in the preceding chapter, migration, elongation, and coun- terclockwise rotation of the midgut locate the jejunum Anatomic Consideration in the left side and the ileum and ascending colon in the right side of the abdomen. Outpouching of the intest- The large intestine consists of the cecum, ascending inal tube distal to the intestinal–vitelline duct forms colon, transverse colon, descending colon, sigmoid the cecum and the vermiform appendix. The mesen- colon, and rectum: tery of the distal segment of the midgut fuses with the posterior parietal peritoneum to fix that segment The ascending colon, descending colon, and rec- of the midgut to the extraperitoneum, making it a tum are extraperitoneal organs because the 1,2 ‘‘secondary’’ extraperitoneal organ. Similar to the ascending colon, the des- hepatic flexure is attached to the posterior perito- cending colon is fixed to the left extraperitoneum by neum and the duodenum by a short fibrous the posterior parietal peritoneal lining. In general, the artery ments as compared to dots of the marginal vessels of and vein supplying and draining each segment of the the ascending or descending colon, because they run colon accompany each other in the mesocolon, with more horizontally. The position of the vessels varies the marginal artery and vein forming the arcade along depending upon the position of the transverse colon. These vessels in the mesocolon and the colon does, the marginal vessels can be seen cephalad marginal vessels along the mesocolic side of the colo- to the wall of the colon. However, if the transverse nic wall form the anatomic landmarks to localize the colon suspends or floats up toward the diaphragm as 4 mesocolon. The distal segments of the ileo- but these vessels are all coursing toward the head and colic vessels distribute in the mesentery of the distal body of the pancreas upon which the root of the ileum and mesoappendix and communicate with the transverse mesocolon inserts. The ileocolic and marginal vessels are covered by the posterior The Descending Colon and Mesocolon parietal peritoneal layer. Since the ileocolic vessels are located in relation to The plane of the descending colon and mesocolon is the root of the mesentery, their course is fixed and not similar to the ascending colon and mesocolon. The After crossing the third portion of the duodenum, they vessels can be identified anterior to the left ureter, can be identified anterior to the right ureter and the the gonadal vessels, and the left renal vein. The plane between the inferior mesenteric The transverse colon is suspended in the peritoneal vein and the marginal vessels of the descending cavity by the transverse mesocolon, which is formed colon can be depicted as the plane of the descending by two posterior peritoneal layers. Disease of the Colon and Rectum 295 The Sigmoid Colon and Mesocolon that contains loose areolar tissue with no major vessels providing a bloodless plane for dissection. The sigmoid colon has a mesocolon suspending it The anterior aspect of the mesorectal fascia extends within the peritoneal cavity. The sigmoid mesoco- from the peritoneal recess anterior to the rectum, lon is formed by the two peritoneal layers attached known as the pouch of Douglas, to the plane to the third sacral segment and extending in the behind the seminal vesicles and prostate gland in cephalad direction toward the left external iliac the male and the cervix and vagina in the female. These two leaves the fascia of Denonvillier or the fascia of the recto- of sigmoid mesocolon ascend toward the anterior vaginal septum. Its length and ruffle-like arrangement vary tum, separating it from the pelvic side wall, muscle, depending upon the length and redundancy of the and the branches of hypogastric vessels, nerves, and sigmoid colon. The super- the antero-lateral aspect of the mesorectum ior rectal vessels are plexuses of vessels on both sides of 6,7 through the ‘‘lateral ligament. The marginal vein forms the arcade along the rectal vessels, nerves from the inferior mesenteric mesocolic side of the colon with multiple branches of plexuses, and lymph nodes along these vessels. The primary lymphatic drai- nage is to the node at the saphenofemoral junction and The rectum is continuous with the sigmoid colon it may follow the path of the superior rectal vessels. The proximal Table 12–1 lists vascular anatomic landmarks of the third of the rectum is covered by the peritoneum lining ascending, transverse, descending, and sigmoid meso- forming peritoneal recesses on its lateral and anterior colon, and the mesorectum. The visceral peritoneum covering the sigmoid colon continues downward sur- rounding the rectum to become the mesorectal fascia: Disease of the Colon and Rectum The posterior aspect of the mesorectal fascia is Diverticulitis and Colitis separated from the presacral fascia by the retro- rectal space anterior to the sacrum and coccyx. Diverticulitis: Diverticulosis of the colon is com- The presacral fascia is a dense fibrous tissue cover- mon among people over 45 years of age, affecting 8,9 ing the bone and its vessels such as the middle sacral up to 80% of those over 80. Inflammation devel- artery that can be an anatomic landmark of the ops when food, stool, or fecalith blocks the neck of fascia. The mesorectal fat and vessels and nodes (arrowheads) surrounding the rectum (R) are enclosed within the fascia. The fascia of Denonvillier (white arrowhead) lies between the seminal vesicles and prostate (P) and the rectum (R). Anterior to the sacrum (S) and coccyx, the posterior mesorectal fascia (black arrows) and the presacral fascia (black arrowheads) are separated by the retrorectal space. They may result in local pericolic inflammatory Ischemic colitis: Ischemic colitis commonly affects changes and may perforate and spread into the population over 70 years of age. Similar to the shock, thromboembolic lesion, trauma, iatrogenic small intestine, Crohn’s disease manifests as trans- injury, or post-surgery. In the acute stage, it often mural thickening due to ulceration and granuloma- manifests as edematous wall thickening, due to tous inflammation with ‘‘skip’’ distribution. It is reperfusion of the ‘‘leaky’’ vessels of the ischemic more predominant in the distal ileum and ascend- segment. Fibrotic the organism responsible for pseudomembranous changes and fat replacement in the submucosal colitis. Its toxin causes necrosis and denuded layer may result in the halo sign of the wall of the mucosa with exudates forming pseudomembranes, colon and rectum. Extraluminal extension is rare in transmural inflammation, and pericolic inflamma- ulcerative colitis.