Combination Products for Glaucoma: An Overview of Treatment Principles

2007 ◽  
Vol 17 (5_suppl) ◽  
pp. 5-8
Author(s):  
C. Traverso
Keyword(s):  
Intraocular Pressure ◽  
Combination Therapy ◽  
Fixed Combination ◽  
Prescribing Patterns ◽  
Current Evidence ◽  
Evidence Based ◽  
Combination Therapies ◽  
Safety And Efficacy ◽  
Evidence Based Guidelines ◽  
Delay Progression

Glaucoma is a leading cause of blindness and visual impairment. Treatments that lower intraocular pressure (IOP) tend to delay progression of the condition. However, the target IOP cannot be achieved with monotherapy in many patients. If monotherapy adequately controls IOP and is well tolerated, it should not be changed, but if the therapy is only partially effective, a combination may be used. Combination therapy is eventually needed in many cases of glaucoma. Combinations may be given as adjunctive or preferably as fixed therapies. The mechanism of action and contraindications of the constituent agents should be taken into account when prescribing combinations, for optimal safety and efficacy. As treatment choice expands, prescribing patterns are changing worldwide. Fixed combination therapies are increasingly prescribed in Europe in particular for the treatment of glaucoma. They should be administered according to the current evidence-based guidelines.

Combination Treatments for Schizophrenia

CNS Spectrums ◽  
2004 ◽  
Vol 9 (S9) ◽  
pp. 19-23 ◽  
Author(s):  
Alexander L. Miller
Keyword(s):  
Electroconvulsive Therapy ◽  
Cognitive Deficits ◽  
Negative Symptoms ◽  
Current Evidence ◽  
Positive Symptoms ◽  
Combination Therapies ◽  
Safety And Efficacy ◽  
Combination Treatments ◽  
Improved Outcomes ◽  
Expert Recommendations

ABSTRACTCombination treatments, especially combinations of antipsychotics, are used frequently for schizophrenia, despite a paucity of evidence regarding their safety and efficacy. Because the literature basis is weak and expert recommendations are largely lacking, providers should be vigilant in documenting improved outcomes for patients thought to benefit from combination treatments. Target symptoms that have been studied include psychosis, cognitive deficits, and negative symptoms. The strongest evidence is for augmentation of clozapine with another antipsychotic or with electroconvulsive therapy for persistent positive symptoms. Combination treatments for cognitive deficits and negative symptoms are being actively investigated, but current evidence is insufficient to recommend available agents for these components of schizophrenia. It is important that appropriate monotherapies be given adequate trials before resorting to combination therapies.

scholarly journals P113: Examining emergency physicians’ self-reported opioid prescribing practices for the treatment of acute pain: A Newfoundland perspective

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S105-S106
Author(s):  
P. Doran ◽  
G. Sheppard ◽  
B. Metcalfe
Keyword(s):  
Emergency Department ◽  
Acute Pain ◽  
Oral Morphine ◽  
Prescribing Patterns ◽  
Evidence Based ◽  
Emergency Physicians ◽  
Prescribing Practices ◽  
Opioid Prescribing ◽  
Ensure Patient Safety ◽  
Evidence Based Guidelines

Introduction: Canadians are the second largest consumers of prescription opioids per capita in the world. Emergency physicians tend to prescribe stronger and larger quantities of opioids, while family physicians write the most opioid prescriptions overall. These practices have been shown to precipitate future dependence, toxicity and the need for hospitalization. Despite this emerging evidence, there is a paucity of research on emergency physicians’ opioid prescribing practices in Canada. The objectives of this study were to describe our local emergency physicians’ opioid prescribing patterns both in the emergency department and upon discharge, and to explore factors that impact their prescribing decisions. Methods: Emergency physicians from two urban, adult emergency departments in St. John's, Newfoundland were anonymously surveyed using a web-based survey tool. All 42 physicians were invited to participate via email during the six-week study period and reminders were sent at weeks two and four. Results: A total of 21 participants responded to the survey. Over half of respondents (57.14%) reported that they “often” prescribe opioids for the treatment of acute pain in the emergency department, and an equal number of respondents reported doing so “sometimes” at discharge. Eighty-five percent of respondents reported most commonly prescribing intravenous morphine for acute pain in the emergency department, and over thirty-five percent reported most commonly prescribing oral morphine upon discharge. Patient age and risk of misuse were the most frequently cited factors that influenced respondents’ prescribing decisions. Only 4 of the 22 respondents reported using evidence-based guidelines to tailor their opioid prescribing practices, while an overwhelming majority (80.95%) believe there is a need for evidence-based opioid prescribing guidelines for the treatment of acute pain. Sixty percent of respondents completed additional training in safe opioid prescribing, yet less than half of respondents (42.86%) felt they could help to mitigate the opioid crisis by prescribing fewer opioids in the emergency department. Conclusion: Emergency physicians frequently prescribe opioids for the treatment of acute pain and new evidence suggests that this practice can lead to significant morbidity. While further research is needed to better understand emergency physicians’ opioid prescribing practices, our findings support the need for evidence-based guidelines for the treatment of acute pain to ensure patient safety.

Meeting Summary

2007 ◽  
Vol 17 (5_suppl) ◽  
pp. 28-30 ◽  
Author(s):  
C. Migdal
Keyword(s):  
Patient Satisfaction ◽  
Intraocular Pressure ◽  
Combination Therapy ◽  
Fixed Combination ◽  
Mechanisms Of Action ◽  
High Patient Satisfaction ◽  
Lowering Effect

Several fixed combination products are now available in glaucoma management. Considerations when selecting combination therapy include safety, finding the best combination of mechanisms of action. Combigan® is one such product that has been shown to be more effective than either of its constituent agents, brimonidine or timolol, used alone. It has at least a similar intraocular pressure (IOP)-lowering effect as the concomitant use of its two constituents, and it produces a significant additional lowering of IOP in patients who switch from other therapies, including Cosopt®. Combigan has high patient satisfaction ratings.

scholarly journals The Pelvic Floor During Pregnancy and after Childbirth, and the Effect of Pelvic Floor Muscle Training on Urinary Incontinence - A Literature Review

2015 ◽  
Vol 11 (1) ◽  
pp. 19-30
Author(s):  
Gunvor Hilde ◽  
Kari Bo
Keyword(s):  
Urinary Incontinence ◽  
Literature Review ◽  
Pelvic Floor ◽  
Vaginal Delivery ◽  
Pelvic Floor Muscle Training ◽  
Pelvic Floor Muscle ◽  
Current Evidence ◽  
Evidence Based ◽  
Muscle Training ◽  
Evidence Based Guidelines

Pregnancy and especially vaginal childbirth are risk factors for pelvic floor dysfunctions such as urinary incontinence (UI). The aim of this literature review was to give an overview of how the pelvic floor may be affected by pregnancy and childbirth, and further state the current evidence on pelvic floor muscle training (PFMT) on UI. Connective tissue, peripheral nerves and muscular structures are already during pregnancy subjected to hormonal, anatomical and morphological changes. During vaginal delivery, the above mentioned structures are forcibly stretched and compressed. This may initiate changed tissue properties, which may contribute to altered pelvic floor function and increased risk of UI. Trained pelvic floor muscles (PFM) may counteract the hormonally mediated increased laxity of the pelvic floor and the increased intra-abdominal pressure during pregnancy. Further, a trained PFM may encompass a greater functional reserve so that childbirth does not cause the sufficient loss of muscle function to develop urinary leakage. Additionally, a trained PFM may recover better after childbirth as the appropriate neuromuscular motor patterns have already been learned. Evidence based guidelines recommend that pregnant women having their first child should be offered supervised PFMT, and likewise for women with persistent UI symptoms after delivery (Grade A recommendations). Conclusion: Several observational studies have demonstrated significantly higher PFM strength in continent women than in women having UI, and further that vaginal delivery weakens the PFM. Current evidence based guidelines state that PFMT can prevent and treat UI, and recommend strength training of the PFM during pregnancy and postpartum.

Evaluating the Effects of an Evidence-Based Hemostasis and Thrombosis Treatment Algorithm Tool on Medical Practitioner and Trainee Clinical Decision Making

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4736-4736
Author(s):  
Joseph Shatzel ◽  
Derrick Tao ◽  
Sven R Olson ◽  
Edward Kim ◽  
Molly Daughety ◽  
...  
Keyword(s):  
Decision Making ◽  
Medical Students ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Mean Difference ◽  
Current Evidence ◽  
Evidence Based ◽  
Clinical Vignettes ◽  
Evidence Based Guidelines ◽  
Attending Physicians

Abstract INTRODUCTION There are many interventions in the disciplines of hemostasis and thrombosis that have been shown to be effective by high quality evidence, leading to the development of evidence-based guidelines by several professional groups. The extent to which providers and medical trainees make use of these guidelines in real-time clinical decision making is not known. Current hemostasis and thrombosis guidelines also lack an easy to navigate algorithmic design such as what is used by the National Comprehensive Cancer Network (NCCN) which may limit their utilization. Using several evidence based guidelines and consensus expert opinion we created an algorithmic tool designed to easily answer clinical questions in thrombosis and hemostasis, and conducted a prospective study assessing provider understanding of current evidence based recommendations and the effects of the algorithmic tool on clinical decision making. METHODS We implemented a prospective survey study of health care providers and medical students from the Oregon Health & Science University during July of 2016. Practitioners who care for patients with thrombotic or hemostatic issues were eligible; including internists, hematologist and oncologists, family medicine practitioners, nurse practitioners & physician assistants, hematology and oncology fellows, internal medicine and family medicine residents, and medical students. The survey included demographic questions, 11 clinical vignettes with multiple-choice questions asking participants for the most evidence-based treatment decision and to rate their confidence in the answer, and post-assessment feedback. Participants were encouraged to use the resources they would typically use in a clinical setting to make these decisions. Included subjects were randomly assigned access to our evidence-based algorithmic tool, (available online at http://tinyurl.com/Hemostasis-ThrombosisGuideline) available as downloadable PDF. The 11 clinical questions were scored, and an unpaired t-test was performed to determine if any significant difference existed in scores between participants with and without the evidence-based algorithmic tool. RESULTS During the study period, 101 individuals participated: 48 medical students, 23 medicine residents, 17 attending physicians, 9 fellows, and 4 NP/PAs. Across all participants, those with access to the algorithms on average answered 3.84 (34%) more questions correctly (95% CI 3.08 - 4.60, P < 0.0001) (Table 1). Participants randomized to receive the algorithm were significantly more confident in their treatment decisions than participants without the algorithm (P < 0.0001). Significantly higher scores were found among individual groups including medical students, (mean difference 4.73, 95% CI 3.64 - 5.82, P < 0.0001), attending physicians (mean difference 2.58, 95% CI 0.63 - 4.53, P = 0.0131), and residents & fellows (mean difference 3.81, 95% CI 2.66 - 4.96, P < 0.0001). There was insufficient data to find a difference in score among NP/PAs who did and did not receive the algorithm. Participant reported confidence in their answers was significantly higher in those who were randomized to receive the algorithm (mean difference of0.95 on a 5-point confidence scale, 95% CI0.50 to 1.39, P < 0.0001). CONCLUSION Our study found that at baseline, there were limitations in provider and trainee understanding of the current evidence based management of clinical issues relevant to hemostasis and thrombosis, and that the use of an easy to navigate algorithmic tool significantly altered treatment decisions in commonly encountered clinical vignettes. Our findings suggest that utilization and decision-making may benefit from a more streamlined, algorithmic display of guidelines. Future prospective studies are needed to determine if such a tool improves management and outcomes in practice. Disclosures No relevant conflicts of interest to declare.

The increasing role of breast cancer lymphedema screening, diagnosis, and management as part of evidence-based breast cancer survivorship.

2016 ◽  
Vol 34 (3_suppl) ◽  
pp. 145-145
Author(s):  
Chirag Shah ◽  
Frank A. Vicini
Keyword(s):  
Breast Cancer ◽  
Cancer Survivorship ◽  
Diagnosis And Treatment ◽  
Detection Methods ◽  
Current Evidence ◽  
Routine Practice ◽  
Evidence Based ◽  
Breast Cancer Survivorship ◽  
Cancer Management ◽  
Evidence Based Guidelines

145 Background: With improved outcomes across all stages, breast cancer survivorship represents an increasingly significant oncologic issue. One major facet of breast cancer survivorship is assessment and management of sequelae of treatment including breast cancer related lymphedema (BCRL) which has an incidence of 5-40% depending on locoregional and systemic treatment. BCRL represents a complication associated with physical changes as well as reduction in quality of life and continues to increase in prevalence with new diagnostics (ex. L-Dex, perometry) increasing the sensitivity for detection. Methods: Review of current evidence based guidelines from the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and the American Cancer Society. Results: Evidence based treatment guidelines for breast cancer have evolved in 2015. For the first time, the NCCN guidelines include a reference to BCRL as part of routine treatment stating “to educate, monitor, and refer for lymphedema management” represents a standard component of breast cancer treatment and survivorship and allows for the early diagnosis and treatment of BCRL. At this time, neither the ASCO Breast Cancer nor ASCO survivorship guidelines incorporate BCRL management into routine practice. At this time, BCRL management is not part of ACS survivorship protocols. Conclusions: At this time, due to increasing data on BCRL diagnosis and treatment, evidence based guidelines are beginning to incorporate BCRL education, diagnosis, and treatment into standard breast cancer management plans. With increasing focus on survivorship, prospective BCRL programs are being developed that begin evaluation prior to treatment with screening in place and early intervention to help prevent progression by using diagnostics with increased sensitivity (ex. L-Dex, perometry).

scholarly journals Is there adequate provision of venous thrombo-embolism prophylaxis following hip arthroplasty? An audit and international survey

2010 ◽  
Vol 92 (8) ◽  
pp. 668-672 ◽  
Author(s):  
BA Rogers ◽  
S Phillips ◽  
J Foote ◽  
KJ Drabu
Keyword(s):  
Patient Satisfaction ◽  
Hip Arthroplasty ◽  
Current Evidence ◽  
Evidence Based ◽  
International Survey ◽  
Duration Of Treatment ◽  
Once Daily ◽  
Vte Prophylaxis ◽  
Published Evidence ◽  
Evidence Based Guidelines

INTRODUCTION The peak incidence of venous thrombo-embolism (VTE) occurs 3 weeks following hip arthroplasty surgery and current guidelines proposing VTE prophylaxis continuing for 4 weeks after surgery. This study first compares the duration of treatment and satisfaction between patients prescribed low molecular weight heparin (LMWH) and rivaroxaban, a new oral Factor Xa inhibitor, following elective hip arthroplasty; and second, surveys the duration of LMWH use in other units. SUBJECTS AND METHODS An international survey detailing the use of LMWH was performed. A prospective audit was performed of 100 hip replacements, with 50 prescribed 40 mg once daily of subcutaneous enoxaparin and subsequently 50 patients prescribed 10 mg once daily of oral rivaroxaban. The duration of treatment, patient satisfaction and complications for both cohorts was quantified and compared against published evidence-based guidelines. RESULTS The survey demonstrated that four out of 39 (10.2%) units that routinely prescribe LMWH do so for at least 4 weeks following surgery. The audit demonstrated that rivaroxaban afforded a superior mean duration of postoperative VTE prophylaxis (35 days vs 5.4 days; P < 0.05) and superior patient satisfaction. There was no difference in the incidence of bleeding, wound infection or thrombotic complications. CONCLUSIONS This study demonstrates that patients are exposed to an increased VTE risk following hip replacement surgery due to the inadequate prescription of LMWH. This is poor clinical practice, contrary to current evidence-based guidelines and has potential medicolegal implications. The prescription of rivaroxaban affords a superior patient compliance compared with subcutaneous LMWH, thus ensuring that patients receive VTE prophylaxis for the current recommend period of time.

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