Lasix

Mohan S. Gundeti, MB, MS, DNBE, MCh (Urol), FEBU, FICS, FRCS (Urol), FEAPU

Assistant Professor of Urology in Surgery and Pediatrics,
The University of Chicago and Pritzker School of Medicine
Director, Pediatric Urology, and Chief Pediatric Urologist,
Comer Children? Hospital, the University of Chicago
Medical Center, Chicago, Illinois

Babies who Genital herpes infection can be are at risk should be immunised caught through genital contact with Toxoplasmosis at birth blood pressure treatment guidelines buy lasix visa. This is 90?95% effective an infected person or from oral sex this infection can damage in preventing them from getting with someone who has oral herpes your baby if you catch it during hepatitis B and developing long (cold sores) and can be dangerous pregnancy blood pressure top number low order 100 mg lasix with mastercard, so take precautions term infection pulse pressure waveform cheap lasix 40mg fast delivery. Most women within 24 hours of birth and two causes very painful blisters or have already had the infection more doses are given at one and ulcers on the genitals arteria meningea media discount 100 mg lasix with visa. Less severe before pregnancy and will be two months prehypertension nhs buy cheap lasix on-line, with a booster dose attacks usually occur for some years immune prehypertension ppt lasix 100mg low price. Avoid oral catch toxoplasmosis while you are Your baby will be tested for sex if either of you have cold sores pregnant, you can get treatment. Tell your Any babies who have become doctor or midwife if either you Parvovirus B19 infected should be referred for or your partner have recurring (slapped cheek disease) specialist assessment and follow-up. If you come is infected without using a You may have been into contact with someone who condom infected with hepatitis is infected you should talk to your. In most cases, the baby is not 1991, or blood products prior affected when a pregnant woman You may have already been to 1986 is infected with parvovirus. In women it is found in the intestine and vagina and causes no problem in most pregnancies. In a very small number it infects the baby, usually just before or during labour, leading to serious illness. If you have already had a baby Infections transmitted Sheep who had group B streptococcal infection, you should be offered by animals Lambs and sheep can be a source antibiotics during labour to reduce of an organism called Chlamydia Cats the chances of your new baby psittaci, which is known to cause Cats? faeces can contain miscarriage in ewes. If you experience during the pregnancy, you should no one else can do it, use disposable? Pigs if your labour is premature, your Research is going on to see if pigs waters break early, you have a Avoid close contact with sick cats can be a source of hepatitis E fever during labour or you currently and wear gloves when gardening infection. Your midwife or doctor even if you don?t have a cat in in pregnant women, so avoid will assess whether you need case the soil is contaminated with contact with pigs and pig faeces. Wash your hands and gloves There is no risk of hepatitis E from your baby from being infected. You may be able to have tests early in pregnancy to check whether your baby is at risk or affected (see page 49). Ideally, you should do this before you get pregnant or in the early weeks of pregnancy. Are any you should talk to your doctor, immunisations needed which might midwife, occupational health be harmful to the pregnancy? You can get this from: terms and conditions as your original check conditions with them. If your employer fails to pay you during your suspension, you can bring a claim in an employment tribunal (within three months). Try to water to stay hydrated and do the use your lunch break to eat and rest, recommended calf exercises. If travelling in rush hour is exhausting, ask your employer if you can work slightly different hours for a while. If you are on your own, keep Road accidents are among the housework to a minimum, and most common causes of injury go to bed early if you can. To protect Your rights to antenatal care, yourself and your baby, always leave and bene? You will be offered a series of appointments with a midwife, or sometimes with a doctor (an obstetrician). They will check that you and your baby are well, give you useful information about being pregnant and what to expect as well as answering any questions you may have. Let your midwife know if you have a disability that means you have special requirements for your antenatal appointments or labour. If you don?t speak English, let your midwife know and arrangements will be made for an interpreter. If you are working, you have the right to paid time off for your antenatal care (see page 170). If you have had Your midwife or doctor should a baby before, you should have give you information in writing If you cannot keep an antenatal around seven appointments. You may have lots of things At each appointment you should you want to ask the midwife. Wherever appointments you are likely to possible, the appointments have and when they will happen. The table on pages 42?43 gives a brief guide to what usually happens at each antenatal appointment. Help and support If you have any questions or worries, talk to your midwife or doctor. Booking Your midwife or Your midwife or doctor should: appointment doctor should give you. You may be offered a visit at the hospital for an initial assessment this is so that you are given and perhaps for an ultrasound scan or for special tests. You will If you are going to have your baby in hospital probably want to ask a lot of questions yourself. If this is in your urine, A rise in blood pressure later in about your circumstances that it may mean that you have an pregnancy could be a sign of pre might affect your pregnancy infection that needs to be treated. At the end of your booking this is not a problem, but may appointment, you should make you feel light-headed if you understand the plan of care for get up quickly. Your booking appointment is an opportunity to tell your midwife or doctor if you are in a vulnerable situation or if you need extra support. This could be because of domestic violence, sexual abuse or female genital mutilation. If your pregnancy is and birth As part of your antenatal care, uncomplicated and you are well, you will be offered a number of. Some are offered to all active labour women and some are only offered Your later appointments are usually. To do this, they will Your blood will be tested to check measure the distance from the top your blood group and to see of your uterus to your pubic bone. This means that if she gets pregnant with another rhesus positive baby, the immune response will be quicker and much greater. If you have the virus doctor will need to discuss harmful to the baby as it may result or are infected during pregnancy, it the management of your in a condition called haemolytic may infect your baby (see page 37). Your baby of your baby being infected rhesus disease can start a course of immunisation if you and your baby don?t Anti-D injections prevent at birth to help prevent infection. Tests for hepatitis C are not 28 and 34 weeks as well as usually offered routinely as part of. If you think you may to reduce the risk of infection this is quite safe for both the be at risk (see page 37), talk to your to your baby. If the If you get rubella in early pregnancy, care that reduce the risk of your baby baby is not affected, the it can seriously damage your unborn becoming infected. Your midwife or doctor will negative, the fact that you had the test as part of your antenatal care should negative because the talk to you about what happens not affect your ability to get insurance. For more can be transmitted to your information about rubella, visit baby in this way. Testing is offered if there to decide if any other tests are is a family history of cystic? The information you give Tay-Sachs disease will help your midwife or doctor to offer the correct tests and will also Testing for Tay-Sachs disease should help to give you the correct results be offered if you or your partner of the test. Routine smears are weeks and is sometimes called Indian, Chinese, African or only offered to women over 25. If you are due to have a cervical help to determine when the Healthy people can be carriers of smear (if you have not had one baby is due. The second scan sickle cell or thalassaemia without in the last three years), you will usually takes place between 18 knowing it and can pass it on to probably be told to wait until and 20 weeks and is called the their children. Your Herpes effects on mothers or their midwife or doctor will discuss babies, and may be carried out the implications for your baby. If you, or your partner, have ever for medical need at any stage For further information contact had genital herpes, or you get your of pregnancy. Although scans are which is caused by an abnormal depending on the ultrasound medical procedures, many couples number of chromosomes. Tests can also provide valuable information for your care during Fetal movement the pregnancy. However, no test You will usually start feeling can guarantee that your baby will some movements between 16 be born without an abnormality. Later in pregnancy No test is 100% accurate and some your baby will develop its own abnormalities may remain undetected. Deciding whether to have tests these movements will range You may not want to have a from kicks and jerks to rolls and screening test if you think that you ripples and you should feel them At the scan would continue your pregnancy every day. A full a screening test and it suggests an talk to you about the pattern of bladder pushes your uterus up and increased chance of a chromosomal movements. You then abnormality, you will be offered a reduction in movements, may lie on your back and some jelly is put diagnostic tests, which will give be a warning sign that your on your abdomen. All women should have dating and Screening results More information nuchal translucency scans between Some maternity services give the. A small sample of sure you see the appropriate health and may be a little uncomfortable. They can give you more information or put you in touch with parents If all the chromosomes have to who decided to continue with a pregnancy in which an abnormality be looked at, it can take up to had been detected or those who decided to have a termination. When deciding whether or not to go ahead with this test, try to balance the risk of miscarriage against the value of the result to you. Make sure you get answers to your questions or the opportunity to discuss any worries. You should be asked to keep your maternity notes at home with you 1 2 3 4 5 and to bring them along to all your antenatal appointments. This refers to the length of your pregnancy in weeks from the date of your last menstrual period. These are the results of your urine tests for half of your pregnancy, it may be a sign of pre-eclampsia protein and sugar. Early in pregnancy the top of the uterus, or fundus?, can be felt low down, below your 12 navel. If there is a big difference (more than two weeks), ask your midwife what action is appropriate. Up to about 30 weeks, your baby moves head (or bottom, or feet if they are in the breech position) about a lot. If your baby stays with its bottom downwards, They may say that the head is engaged? this is when this is a breech (?Br?) presentation. Usually it is nothing to worry about, but tell your midwife or doctor if it suddenly gets worse as this may be a sign of pre-eclampsia (see page 67). They want to make you feel provide care for the majority of happy with all aspects of the care women at home or in hospital. The professionals during labour and, if everything is as previous complications in you see should introduce themselves straightforward, will deliver your pregnancy or chronic illness. If any complications develop You can request to see an but if they forget, during your pregnancy or delivery, obstetrician if you have any don?t hesitate to you will also see a doctor. After the of who you doctor who specialises in providing birth, you and your baby will have seen and pain relief and anaesthesia. If you be cared for by midwives and what they have said decide to have an epidural, it will maternity support workers. In many hospitals your midwife can arrange for you to talk to an anaesthetist about analgesia or anaesthesia if you have medical or obstetric problems. Some provide antenatal education and teach antenatal exercises, Research relaxation and breathing, active You may be asked to positions and other ways you. This may be to test a postnatal exercises to tone up your your baby after the birth to new treatment or to? Your midwife can help make sure all is well and will your opinions on an aspect you with these exercises. Health visitors are specially professionals you see will trained nurses who offer help and have students with them. You sonographer will perform your baby and you will be visited can say no, but if you let a your dating and nuchal by a member of the team in the student be present it will help translucency or anomaly scan. You may continue to see add to your experience of at other points in their your health visitor or a member pregnancy and labour. Speak to your community Some classes are for pregnant at around the same time as you. Others will concentrate on certain aspects, such as exercises and relaxation or caring for your baby. Sometimes these changes can cause you discomfort or irritation, and you may be worried about what is happening to you. There is usually nothing to worry about, but you should mention anything that concerns you to your midwife or doctor. If you think that something may be seriously wrong, trust your own judgement and get in touch with your midwife or doctor straight away. This chapter describes some of the minor and more serious health problems and gives advice on how to deal with them and when you should get help. When to get help If your backache is very painful, ask your doctor to refer you to an obstetric physiotherapist at your hospital. Constipation You may become constipated very early in pregnancy because of the hormonal changes taking place in How to ease cramp Feeling hot your body. It usually helps if you pull your During pregnancy you are likely toes hard up towards your ankle to feel warmer than normal. You are also likely to wholegrain cereals, fruit and You may often feel faint when sweat more.

These molecular and clinical manifestations result from an impaired step in the inflammatory process hypertension kidney pain purchase lasix overnight delivery, namely heart attack feat mike mccready money mark lasix 100 mg line, the emigration of leukocytes from the blood vessels to sites of infection hypertension impact factor cheap lasix amex, which requires adhesion of leukocytes to the endothelium prehypertension que es buy lasix 40 mg low cost. In the last 20 years arrhythmia life expectancy order genuine lasix on-line, three distinctive defects in the leucocyte adhesion cascade hypertension benign 4011 purchase 100 mg lasix with visa, involving several precise ordered steps such as rolling, integrin activation and firm adhesion of the leukocytes have been described. Two phenotypes, designated Other causes of leukocytosis should be ruled as severe deficiency and moderate deficiency, out. In vitro studies demonstrated a marked defect in random Management and treatment migration as well as chemotaxis to various the most important focus should be to control chemoattractant substances. Prompt antibiotic therapy should be transmigration through endothelial cells were initiated as early as possible in case of acute found to be severely impaired [16]. Leukocyte-endothelial-cell 3 years, the frequency of infections decreases interactions in leukocyte transmigration and the and children no longer need prophylactic inflammatory response. Lubke T, Marquardt T, Etzioni A, Hartmann E, antigen, the selectin ligand, on leukocytes. Adhesion genetic leukocyte adhesion deficiency in sub assays are not performed in most laboratories second triggering of integrin avidity by and should be carried out only in laboratories endothelial chemokines results in impaired which are specialized in these assays [21]. A novel immunodeficiency from 20 weeks of gestation, cordocentesis can syndrome characterized by dysfunctional beta2 establish the diagnosis [22]. J Allergy Clin Brief report: recurrent severe infections caused Immunol 1998; 102:323. McDowall A, Inwald D, Leitinger B, Jones A, deficiency: molecular basis and functional Liesner R, Klein N, Hogg N. Fischer A, Landais P, Friedrich W, Gerritsen B, Fasth A, Porta F, Vellodi A, Benkerrou M, Jais 13. Gene therapy for deficiency syndrome associated with defective leukocyte adhesion deficiency. The site con tion-based programs six months, there were 79 subscribers from tained background information about the net for birth defects sur 20 states. Today, the listserv has more than work and its committees, links to other state veillance and research 650 subscribers! Cara prevention strategies; the late 1970s, played a pivotal role in es has been the glue? that keeps the Network and to assist families and their providers in tablishing the Network. Each year, the committee picks vices and products, assess our long-term financial and eco a new focus topic for the packet. The next few years will be important as we continue an opportunity to meet with our colleagues from around to grow and evolve as an organization. I encourage you to get the world to discuss the causes and prevention of birth involved and join one of our committees. Prepregnant obesity and risk for structural birth neurology and pediatrics and director of the Division of Pediat defects. Trevathan has conducted epidemiologic studies of child the centers are in the process of geocoding the addresses hood epilepsy and developmental disabilities; has directed mothers reported for the entire pregnancy. Trevathan is board-certified in pediatrics, neu will enable the centers to start studying environmental expo rology with special qualification in child neurology, and clini sures, such as drinking water components. Final changes are cur veillance regional meetings, and a tentative meeting for the rently being made to these materials with the hope of making states in the western U. The workshops report is its first use of the Society for Thoracic Surgeons will be held in June and July. The primary goal of applying this tional Science Education Standards, ensuring that teachers classification system was to use the fewest diagnostic catego across the nation can use them in their classrooms. Lesson ries as possible while still describing the lesions accurately, plans developed are available to all teachers through the Sci with an emphasis on separating cardiac defects by their poten ence Ambassador website ( Details of the use of the system will be described in a contacts to ensure that manuscript to be published later in 2007. In addition, the exclusion ducting formative research with Spanish-speaking Latinas and criteria have been revised for cardiomyopathy, ventricular hy key individuals who work closely with this audience. For those interested in the groups were held with Spanish-speaking women throughout the changes, the full 6-digit code is available as a pdf file from the U. And then, Birth Defects Monitoring in Georgia meeting, which will be again based on the feedback received, a final draft set of mate held in late August. This final set was also tested veillance, epidemiology, clinical, costs, and other aspects of with key individuals in the community who work closely with Down syndrome. This event is always a shin Amy Case has joined Allison James as Co Long-range planning for future meet ing moment for Network Chair of the Annual Meeting Committee, ings by proposing sites 2-5 years in members. Since the Annual Meet Assessing the variability of having It is not too early to start ing, we have met in March and April, evaluat more paid exhibitors. Members interested in joining have recently joined the committee, and would Make a note-to-self! Some this committee are asked to contact Cara Mai at welcome additional participants, especially times great accomplishments cmai@cdc. We done a lot of work to improve this product and the State Leadership are planning to make this a regular yearly keep it current so that we all keep informed on Award acknowledges of outstanding contribution or supplement and your input to its future content current literature. Mem Birth Defects Education & members who have volunteered to make time bers interested in joining this committee are Prevention Award recog to address the critical issue. The committee also continues to lications and Communications, Finance and the request for nominations work on a newborn screening fact sheet to Executive Committees. As you can see from the above, membership ad hoc Awards Committee is provides an opportunity to participate in a vari looking forward to receiving the following are additional strategic plan ety of activities. A panel dis cussion on this topic in San Antonio led to We are also working hard to provide helpful re some helpful insights that will guide our ef sources to birth defect abstractors. We hope you will take makes a difference toward ensuring we reach their PubMed abstracts. The revision of a manuscript currently under review, which the data committee are involved in a number of projects, in examines preterm births and birth defects. Please feel free to con strategies involved in the presentation of birth defects data. We meet trying to define the characteristics of a feasible program once a month via a conference call. Results from cuss the status of our projects and hear news from the March of a survey that was sent out to state contacts are currently Dimes, National Council on Folic Acid, and the Spina Bifida being developed into a manuscript by this work group, Association. We discuss new findings in the literature and oc which is led by Julianne Collins. Russ Kirby ous stages, including: is leading this work group, which should reconvene soon. Please contact Julianne Collins at spina bifida and anencephaly rates have declined or lev julianne@ggc. Jim Robbins is leading this work group and has received some data to analyze from state programs. Interestingly, providers who regularly Membership and Elections women aged 18 to 45 years. Recommendations for phone number and for the use of folic acid to reduce the number of cases of specific pass code spina bifida and other neural tube defects. Their contact information is listed K Green-Raleigh, H Carter, J Mulinare, C Prue, J on page 10. Trends in Folic Acid Awareness and Behav ior in the United States: the Gallup Organization for the March of Dimes Foundation Surveys, 1995?2005. This funding Anencephaly evaluated to consider an increase in the current Congenital Heart Defects ensures that the program can continue to conduct fortification level. These initiatives will bring us Cleft Lip its surveillance activities, which in turn support Cleft Palate closer to the goal of preventing up to 70 percent its work as one of nine Regional Research and Down syndrome of pregnancies affected by neural tube defects. Hydrocephaly Microtia Chapters are working on creating, improving, or Spina Bifida For more information, contact the March of protecting state birth defects surveillance pro Pregnancy Loss Dimes National Office of Government Affairs or grams through legislative (authorization and/or the local March of Dimes Chapter. Visit the Resource tab appropriations bills) or regulatory initiatives as a 2007 state advocacy priority. The list of research initiatives whose aims include assess dardization of analytical practices, generate inclusive over ing the prevalence of human genetic variation, the association views of fields-at-large, facilitate rapid confirmation of find between genetic variants and human diseases, the measurement ings, and avoid duplication of effort. An initial set of guidelines was agreed upon and will be refined over the coming months. Louis, Missouri programs about learning what you Location: Hyatt Regency Hotel need to know now to have a safe Website: Please send comment or questions about this newslet ter to Russel Rickard at russel. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4. No one We encourage elected and appointed health ofcials, had ever attempted to quantify 107 diseases and injuries in researchers, policy-makers, and others to explore the every region of the world. The 2017 study comprises seven papers and a complete edition of the international medical journal The Lancet. The number of collaborators totaled 3,676 from 146 countries and territories; it includes 38 billion estimates of 359 diseases and injuries and 84 risk factors in 195 countries and territories. Our organizations and both of us personally are committed to improving the accuracy, timeliness, and policy-relevance of health data and information. The memorandum of understanding we signed will result in increased awareness and understanding of health problems globally, as well as the evaluation of strategies to address them. Moreover, this agreement highlights our shared commitment to ensure that health policy is based on the most accurate and up-to-date data available. Life expectancy Number of years a person is expected to live based on their present age. Replacement rate The total fertility rate at which a population replaces itself from generation to generation, assuming no migration, or approximately 2. Super-regions Seven world regions whose constituent countries are grouped on the basis of cause of death patterns: Central Europe, Eastern Europe, and Central Asia High-income Latin America and Caribbean North Africa and Middle East South Asia Southeast Asia, East Asia, and Oceania Sub-Saharan Africa Total fertility rate The average number of children a woman would bear if she survived through the end of the reproductive age span (age 10 to 54 years) and experienced at each age a particular set of age-specifc fertility rates observed in the year of interest. Under-5 mortality The probability (expressed as the rate per 1,000 live births) that children born alive will die before reaching the age of 5 years. The 2017 study produced and used a Among age groups, the under-5 age group experienced huge new set of population estimates, which has led to substantial reductions in mortality between 1950 and 2017, while adults changes in mortality estimates in many countries. Life expectancy, 2017* Years *Data shown in the fgure represent life expectancy at birth for both sexes. Life expectancy? by sex globally, and by level of socioeconomic development, 2017 90 Disparities in life expectancy between males and 80 females were greatest in countries at the high-middle 70 and middle levels of development. Global, regional, and national age-sex-specifc mortality and life expectancy, 1950?2017: a systematic analysis for the Global Burden of Disease Study 2017. Despite this, mortality from cardiovascular diseases 200k has increased since 2007 worldwide. Global, regional, and national age-sex-specifc mortality for 282 causes of death in 195 countries and territories, 1980?2017: a systematic analysis for the Global Burden of Disease Study 2017. Nineteen 41% decrease in communicable diseases and new causes were added for a total of 359 causes. The study also neonatal disorders includes a more detailed analysis of healthy life expectancy. Years someone can expect to live in full health in 2017 Tere are large inequalities across countries in healthy life expectancy, which is the number of years a person can expect to live in full health. Healthy life expectancy** at birth, both sexes, 2017 Years of healthy life 45 50 55 60 65 70 74 **Healthy life expectancy is the number of years that a person at a given age can expect to live in full health, taking into account mortality and disability. The disease burden caused by these two risk factors, compared to the burden expected based on the level of socioeconomic development, varied considerably by region. Tose estimates confrm and extend our understanding of key population trends, including those related to health. Tat ensures in a population) that are then converted into single-year valid comparisons between diferent places and times. This conversion requires mathematical steps published and publicly accessible free of charge. Recent population growth has been highest in Africa, Asia, and Latin America Population growth rate, 2010?2017 <-1. The relationship between total fertility rate and population growth in 2017 Countries may continue growing in population even if their total fertility rates are below the replacement rate of 2. This is due to population momentum, in which past growth of birth cohorts leads to more females of childbearing age, which leads to birth rates that, for a time, remain high relative to deaths in the population. Countries plotted by total fertility rate and population growth rate, 2017 Countries with:? Oman Total fertility rate above the replacement rate and increasing population Total fertility rate above the replacement rate and decreasing population? Qatar Total fertility rate below the replacement rate and decreasing population 5. But if less progress is made, life and all-cause and cause-specifc mortality for 250 causes of expectancy could decrease by 0. Change in life expectancy, 2016?2040, both sexes* All countries are likely to experience at least a slight increase in life expectancy by 2040 0 to <1 1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to <8 8 to <10 10 to 12 *Diferences in life expectancy shown are based on what has been observed historically and the future trend based on that observation. It produces estimates for 41 of the 52 health the most countries likely to attain their targets. Note: Population census coverage is not included because of its binary status and because it does not have forecasts. Tese techniques have been developed and used by The Jackson Laboratory for over 75 years. They are safe, reliable, economical, efcient, and ensure that the mouse strains produced are genetically well defned. Due to mutagenesis, transgenic, and gene-targeting technologies, the number of available mouse models is escalating. So are the costs, mouse room space, and related resources needed to accommodate these mice. Due to all these factors, the art and science of managing mouse colonies efciently is more important than ever.

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A recent review of these methods blood pressure regular buy lasix on line amex, however hypertension zinc order lasix online now, reported that they appear equally valid 41 for documenting treatment failure in depressed patients heart attack remix 100mg lasix otc. Consensus Definition of Treatment-Resistant Depression Determining Consensus A consensus can be identified in several ways arrhythmia young adults order genuine lasix on-line. One approach is to have the strongest evidence base identifying the preferred definition prehypertension american heart association purchase generic lasix line. A second way is to have a preponderance of best practice guidelines or consensus statements clearly identify a preferred definition hypertension diagnosis code order lasix 40mg otc. 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. However, the authors explained that because of the absence of evidence indicating a natural distinction between patients with one or two treatment failures and those without, as well as the pejorative nature of the term treatment-resistant depression? for patients, they recommended a model addressing inadequate response by considering sequenced treatment options. Summary of Consensus Findings In summary, the majority of systematic reviews and guidelines or consensus statements reported that the most commonly used definition is patients whose depression does not remit following two or more treatment attempts of an adequate dose and duration. We found no agreement as to whether the treatment attempts require different classes of antidepressants. Similarly, the literature produces no agreement of how to define adequate dose and duration, although minimum duration tends to be cited as 4 weeks. Definitions of treatment-resistant depression and level of consensus by number of treatment failures: Guidelines and consensus statements as source Number of Focus of Specifically Treatment Guideline or Define Define Definition of Treatment Define Current Stated or Most Failures as Consensus Adequate Adequate Consensus? Notes Psychiatry functioning even after two or after 4 weeks that there is no Guidelines for more adequate courses of of treatment clear consensus Unipolar treatment. Unipolar In therapy-resistant depression Not found Not found Not found Not found Yes Proposed a Depression (where pharmacotherapy has definition for when Guideline been administered adequately, psychotherapy Harter et al. Definitions of treatment-resistant depression and level of consensus by number of treatment failures: Guidelines and consensus statements as source (continued) Number of Focus of Specifically Treatment Guideline or Define Define Definition of Treatment Define Current Stated or Most Failures as Consensus Adequate Adequate Consensus? Differ by how structured the assessment is (from standard clinical assessment to highly structured research tool); this factor affects feasibility d. No consensus on or any preferred tool exists for making the diagnosis for various reasons: a. All guidelines and consensus statements described clinical confirmation using diagnostic criteria. The systematic and nonsystematic reviews generally did not describe or did not use formal instruments to clarify treatment 44, 45 resistance, although some reviews recommended using a structured instrument to confirm. In consensus statements or guidelines, clinical confirmation of a current depressive episode was based on standard clinical assessments. Limitations of the current validation studies are small sample sizes, the use of chart review methodology, and the potential nongeneralizability of their findings to less severe or outpatient 44 populations. An effective staging model must be user-friendly for busy clinicians, clear, and able to predict the likelihood of remission in an objective manner. Key Question 3: Success or Failure of Treatment in Clinical Studies of Treatment-Resistant Depression this is a complex question for this chapter. Among the questions are whether experts agree about such measures, whether they are reported by patients or clinicians (typically, physicians), and whether we can document their psychometric properties and find information about minimally significant clinical differences. Also of concern is whether and, if 45 so, how well such measures describe a wide array of clinical, quality-of-life, or behavioral variables. Both patient-reported and clinician-administered measures are available for each category of outcomes; we found no stated preference for one type over the other, although patient-reported tools are more feasible to use. Although we detected no strong consensus on a preferred instrument, experts appear to agree that the preferred outcome is remission (complete recovery as measured by a score below a threshold) using a standardized and validated measure (regardless of the tool). Various functionality scales have been reported, but none is the most commonly used. All depressive-specific measures have been validated and have acceptable psychometric properties. Functional impairment tools have been validated and have acceptable psychometric properties. Experts disagree about which measure is preferred and, for a specific measure, which difference best accounts for a minimum clinically significant change. Detailed Synthesis Tables 8, 9, and 10 show the variety of depressive-specific, general psychiatric, and functioning or quality-of-life measures, respectively, described in our eligible sources. This review is not meant to be comprehensive, and it reflects what reviews generally report about the instruments. For example, we did not assess the evidence base for the range of scores reported on particular instruments. Below, we review the outcomes identified in our search for the three main issues for this question. Several of these have more than one version (typically a traditional long? version and one or more versions with fewer items). Some have a history dating back two decades or more and thus have long histories of use for several purposes but usually not for making a definitive clinical diagnosis. All are suitable for use in trials or nonexperimental studies for the purposes intended (measuring severity, evaluating outcomes). Information describing the scales and their psychometric properties is generally reported in the literature in some detail, although such data are often spread over multiple articles. However this might be measured by a standardized and validated tool, this was the clear preferred outcome. Table 7 provides information on these, although neither can be said to be better? than the other. Functional impairment tends to be broadly defined: enjoyment of or satisfaction with life, impairments in a wide array of daily activities or relationships, several domains of health status (which can be collapsed into self-reports of physical or mental health), or overall levels of 52 disability. Of the five measures available for this task, four are self-reported and one is clinician reported. The four patient-reported measures generally have appropriately strong psychometric properties, and one or more produce scores that are calibrated against scores of other measures (chiefly those for evaluating severity of depression). Examining Minimal Clinically Important Differences Most measures have adequate psychometric properties. All depressive-specific measures have been validated and have acceptable psychometric properties as reflected in measures of internal consistency, convergent validity, test-retest reliability, and correlation with other instruments to assess depressive severity (Table 6). It has evolved as a practical means of giving clinical relevance to changes in 125 standardized instrument scores when no gold standard of meaningful change exists. For example, some users define such a difference as a numerical change in a score reflected by a standardized 126 mean difference. Finally, some report this difference as a percentage 94 change in score, with varying percentages reported as clinically meaningful. General psychiatric measures can also be used as a measure of minimum significant clinical difference (Table 7). The discrete psychometric properties of these instruments have been less studied, because they often are used as the clinical reference standard against which other measures are 122 compared. For functionality and quality-of-life measures, psychometric properties appear adequate (Table 9). Most of the available literature did not address, or apparently achieve consensus about, designs that might minimize placebo effects. A study length of at least 6 weeks? was often recommended; however, experts often noted that longer trials or studies would be preferable. Getting patients to an adequate dose of a given medication may take a few weeks; for that reason, 6 weeks of adequate dosing may require a trial length longer than 6 weeks. Compliance and consideration of prior psychotherapy use are important to assess and control for in analyses. Summary of research design information (continued) Topic; Consensus on Consensus on Study Authors and Research Designs Consensus on Length of Study Design to Design to Minimize Year of Used Antidepressant Trials Minimize Bias Placebo Effect Publication Predictors of Studies of any design Did not address Did not address Did not address response for use. Few publications directly addressed the issue, but we detected a general consensus that a prospective, randomized trial design using certain study components best helped minimize bias. Randomized trials of various types, including in a few cases cluster randomized trials or nonrandomized controlled trials, were the preferred study design by the available systematic 61 31-36, 39-41, 44, 58, 64-66 5, 18, 30, 37, 45, 46 reviews, the nonsystematic reviews, and the guidelines or 19, 21, 23, 38, 42, 67-79 consensus statements. Some investigators or experts extended their inclusion criteria to accept various nonexperimental (observational) designs of reasonable strength, such as prospective cohort studies. A handful included observational studies that could possibly have been subject to bias from confounding factors. About seven sources included systematic reviews as a research design; some also included meta-analyses. Similarly, virtually all sources that commented on a preferred study design to minimize bias reflected a consensus that they preferred randomized designs. A few sources specified a preference for use of meta-analyses, including network. The literature also emphasized other key study design components to minimize the role of bias. Systematic review of staging methods recommended the use of prospective study designs 31, 44 and validated instruments, where possible. Adequate dosage of medication should be at maximum tolerated doses (according to 31, 41 prescription recommendations), further standardizing the definition. In general, systematic 31, 41 18, 30, 44-46 19, 67, 69, 70 reviews, nonsystematic reviews, and guidelines or consensus statements recommended that study duration with adequate dosing should be at least 6 weeks. They also appeared to prefer that remission, operationally defined using a validated instrument, is the 31, 44 preferred outcome. Systematic reviews emphasized that both compliance and consideration 31, 41, 44 of prior psychotherapy use are important to assess and control for in analyses At the same time, these sources clearly appreciated that adding the above components risked 44 the feasibility and applicability of these management strategies in real-world settings. Consensus on Appropriate Trial Length Finally, as reported elsewhere, most sources that addressed the issue of trial length for antidepressant medication studies generally took the stance of trial duration being at least 6 18, 19, 30, 31, 41, 44-46, 67, 69, 70 weeks? of a treatment at an adequate dose. Of note, getting patients to an adequate dose of a given medication may take a few weeks; for that reason, 6 weeks of adequate dosing may produce a trial length longer than 6 weeks. Some groups were comfortable with 4 to 6 weeks? duration for a drug study; some advocated for or advised longer trials. Yet others commented that the trials needed to provide adequate dosages of the medications in question. We sorted each of those categories by whether the publications were systematic reviews, ostensibly providing the highest quality of evidence; nonsystematic reviews; or guideline or consensus statements. Accordingly, within each cell in the tables below, we identify what is reported about predictors for remission and response, respectively. For example, the probability of responding to an antidepressant declines by a factor of approximately 15 percent to 20 percent for each prior failed drug treatment. One guideline noted that the probability of responding to an antidepressant declines by a factor of approximately 15 percent to 20 percent for each prior 67 failed drug treatment. Below we report on patient and study characteristics overall and by treatment-specific categories. We give tables with counts for most subsections below; notable exceptions and trends not captured in tables are presented in the text. Studies were inconsistent about the necessary duration of prior treatment attempts for study entry. Most studies required at least one and often two prior failed treatment attempts of adequate therapy. Several patient characteristics were rarely considered for study entry: duration of depressive symptoms, prior depressive relapses, prior treatment intolerance, prior augmentation or combination therapy, prior psychotherapy, and suicidality. Detailed Synthesis Patient Characteristics Related to Inclusion or Exclusion Age Nearly all studies included participants ages 18 years or older, although four studies (pharmacology only) limited enrollment to participants 60 years or older (Table 16). Forty studies (25%) did not report age criteria; 38 studies (23%) did not report an age limit for inclusion. Most studies excluded patients with psychotic depression; rarely were other specific types of depression considered (Table 17). One trial excluded patients with seasonal affective disorder and depression secondary to a medical condition. Number of Depression Relapses and Time to Relapse Only a single trial considered number of depression relapses, a specific subtype of failed treatment where a patient has a depressive episode that remits only briefly and then returns before full recovery occurs, as an inclusion criterion. No study either considered time to relapse as an inclusion criterion or reported on it. Psychiatric Comorbidities Most studies did not name psychiatric comorbidities as inclusion criteria, although some studies did report on the number of included participants with other psychiatric disease. More frequently, investigators used coexisting psychiatric illnesses as exclusion criteria; substance abuse was the most frequently noted exclusion (Table 18). Many studies named specific disorders for exclusion; some studies more generally excluded any type of psychiatric comorbidity or any other Axis I disorders that were present. Suicidal Ideation and Suicide Attempts Only one trial specifically included patients with acute suicidality. Fifty-eight studies excluded patients with current suicidal ideation, and 11 studies excluded patients with recent suicide attempts. Seven studies reported only the presence of suicidal ideation among participants; 15 studies reported on prior suicide attempts among participants (Table 20).

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References

Han, K.R., Belldegrun, A.S. Third-generation cryosurgery for primary and recurrent prostate cancer. BJU Int 2004;93:14-18.
Mangano MM, Antonioli DA, Schnitt SJ, Wang HH. Nature and significance of cells with irregular nuclear contours in esophageal mucosal biopsies. Mod Pathol 1995;5:191.
Finsterer J. Inherited mitochondrial neuropathies. J Neurol Sci. 2011;304(1-2):9-16.
Hart CL, Hole DJ, Lawlor DA, et al. Effect of conjugal bereavement on mortality of the bereaved spouse in participants of the Renfrew/Paisley Study. J Epidemiol Community Health 2007;61(5):455-60.
Robiony M, Polini F, Costa F, Politi M. Osteogenesis distraction and platelet-rich plasma for bone restoration of the severely atrophic mandible: preliminary results. J Oral Maxillofac Surg 2002;60:630-635.
Wenaweser P, Daemen J, Zwahlen M, et al: Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice: 4-year results from a large 2-institutional cohort study. J Am Coll Cardiol 2008;52:1134-1140.