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Comparative effcacy of a laser on infammatory process modulation in mice: proand anti-infammatory recombinant feline interferon omega in refractory cases of calicivirus-positive cytokines hypertension vitals cheap 0.1 mg clonidine overnight delivery. Evaluation of low-level laser therapy in the prevention and treatment of radiation-induced mucositis: a double-blind randomized study in head and 19 blood pressure journal free download purchase genuine clonidine. Gobbo M hypertension portal 0.1 mg clonidine amex, Ottaviani G blood pressure chart to record purchase cheap clonidine, Perinetti G, Ciriello F, Beorchia A, Giacca M, et neck cancer patients. Effect of low-level laser therapy on Candida albicans growth in patients with denture stomatitis. The general and local factors that are involved in such deficient healing cases are detailed, in parallel to surgical procedure to enhance ridge preservation or to ‘regenerate’ tissues. The relationships between the orthodontist and periodontist are underlined, because both praticioners assess patient’s risk factors and follow him during this treatment stage. Besides the potential context of early treatment (serial extracesthetic repercussions, these periodontal tions, germectomies), for adolescents with defects also give rise to a clinical problem severe crowding or protrusion/overjet, or with achieving some orthodontic movefor adult patients who have fewer possibiliments, such as complete closure of the ties for expanding the arch. The consequences of this ‘‘simple’’ proEach individual has his own capacity to cedure have not always been accurately heal, that is determined by his biotype and assessed, whereas many mucosal and ossbiological profile, consisting of cytokines 4,5,14,25,29,49,52 eous complications may show up after the and inflammation mediators. Address for correspondence: Nicolas Cohen 1 10, rue Margueritte – 75017 Paris nicolas. The potential for local post-extractional healing and on the healing also depends on acquired facdistinctive characteristics of extractors, and especially by the cause of tions in orthodontics, followed by a the extraction (following trauma, enpresentation of the techniques that dodontic lesion, periodontal lesion or allow for preservation (atraumatic exon the contrary extraction of a tractions) or osteomucosal regenerahealthy tooth for orthodontic purtion (grafts, biomaterials and poses). This creates a platelet aggregation Any surgical procedure disrupts that forms a clot (erythrocytes and tissue homeostasis. The tected by the cells present in the tisplatelets produce growth factors and sues that release inflammatory mediators (cytokines) involved in mediators and that organize a line of angiogenesis, the Platelet-Deriveddefense. This last way of healthe smooth muscles and the mitoing, with ad integrum restoration of genic properties of the fibroblasts. They have been the dental socket is next rapidly widely described histologically but colonized by granulation tissue, conbio-molecular research has advanced sisting of neo-vascular tissues, our macroscopic understanding of inflammatory cells and erythrocytes, the healing process. The next stage is blood platelets come into contact called the provisional matrix, where with collagen connective tissue, the mesenchymal cells are organized 2 N. Inflammation Coagulum Inflammation Epithelialization Proliferation Neovascularization Matrix synthesis Formation Contraction of the lesions Maturation Remodeling Apoptosis Collagen synthesis Lesion 1 10 30 100 Figure 2 Tissue phenomena of cicatrization over time. This allows for mineralization progressively begins, cementogenesis when teeth are prethat resembles the fingerlike formasent and osteogenesis when they tion of immature bone within the are not. This osteogenesis can only matrix, embedded in ‘‘primary take place if the osteoblasts have spongy cell culture‘‘. This immature time to form a bony network and if bone is progressively remodeled into osteogenesis is not inhibited by contrabecular bone and spongy bone tact with the fibroblasts. The need to (trabeculae of mineralized bone, with ‘‘filter’’ the cells that penetrate into secondary osteons, surrounded by the zone of regeneration must not medular spaces rich in vessels, adihowever impede the expression of pocytes, mesenchymal and inflamthe inflammatory factors since they matory cells). Human studies on post-extractional healing have demonstrated that mineralization begins at the end of Mucosal healing nd the first week; between the 2 and the epithelialization of the extraction th 4 week, the bony appearance of site is founded on the migration and dithe clot has disappeared, with the vision of the cells of the basal stratum, proliferation of granulation tissue and starting from the areas bordering the the provisional matrix; and between wound. It begins within 12 hours fol6 and 8 weeks, most of the granulalowing surgery. The healing is distinction tissue has been replaced by tive in the buccal cavity since it is a the provisional matrix (approximately septic and humid site with a very high 60%) and with immature bone (aprate of regeneration. The speed of the proximately 40% along the outer mucosal healing has therefore been walls of the alveolus). The osseous compared to that of the skin, and formation has not been completed seems to be faster, due to certain bio24 weeks after extraction. Given that these the detoxified radicular surfaces, by mediators are expressed differently preventing, with the help of a based on the individual, it is conceimembrane (resorbable or not), the vable that they will be good markers 4 N. The pre-surgical evaluafigure 3 (a to j), the female patient, tion of soft tissues is especially im23 years of age who benefitted from portant, because the periodontal an orthodontic treatment that intypology provides some basis for volved extraction of premolars, preprognosis. Today it is recognized that sented with a vertical fracture of a a fine biotype is a surgical risk factor; permanent first molar, that needed to manipulating soft tissues poses a risk be extracted. The intraoral clinical and their capacity to heal and to reviews at 8 weeks post extraction generate seem to be reduced due to (Fig. In most situations, an extraction Taking into account the prolapsed siinduces bone resorption, that is alnus and the low residual volume, we ways more significant on the buccal decided on a regenerative therapy in2,4,12,25,52 side. Protecting the memHowever, regardless of the surgical brane against the risk of exposure technique used, a loss of volume in was ensured by sutures, ensuring a the transverse and vertical direction closure of the gingival edges without 22,49 excessive traction (Fig. A numbefore regeneration (8 weeks after ber of authors have then suggested extraction) (Fig. In every case, nized and purulant, typically with yelregeneration promoted the preservalow greenish appearance. It was is intense, and must be treated difficult to compare the various techpromptly. The operative technique and Infectious complications surgical instruments used for an osInfectious complications can occur teotomy are also a factor. As a result when the formation of coagulum of the use of drills fitted with an indoes not take place or is altered by ternal cooling system for osteo30 early fibrinolysis. They are caused by tomies, infection complications a bacterial colonization of the clot or appear less frequently. The experiby an inflammatory process entailing ence of the surgeon, the use of a a massive migration of granulocytes. They 27 the the duration of healing, includes concluded that there was enough alveolar osteititis, suppurative osteitiscientific evidence showing that antitis, necrotic osteititis and fibrous biotics administered just before and/ healing. With dry osteititis (or fibrinoor after a surgical procedure reduced lytic or dry socket), the socket apthe risk for infection, pain and dry pears bare, with white greyish and socket after extraction but that the Rev Orthop Dento Faciale 2014;17:304 7 N. For these patients, healing secondary effects (generally brief and can turn out to be very unpredictable. For the case shown in figure 4a, the patient, 50 years of age, presents with type 2 diabetes, and with Complications linked to taking difficulty in controlling plaque, with medications severe maxillary crowding, 23 and 24 All the drugs that are going to practically overlapped each other. He alter one of the physiological phases presented with chronic adult periodof healing are likely to expose patients ontitis with severe localized inflamto some complications (inflammatory mation (Fig. The orthodontic phase and anti-inflammatory treattreatment plan chosen involved the ments, vascular and proliferative phase extraction of 23, that presented with and anti-angiogenic treatments. Healing Corticosteroids for example, admioccurred with invagination of the bucnistered systemically and in strong cal mucosa, even though there was doses, delay healing. This affect no orthodontic movement for closing is basically linked to their anti-inflamthe gap underway (Fig. This dechange in the quality of the inflammalayed healing, with a more random retory phase, a decrease in resistance to generation phase, has been shown in infections as well as the debridement 30 vitro and in vivo. The lack of oxygenation or perfusion of tissues is also one of the Complications related to a main factors responsible for the delay pathological condition in healing. In a hypoxic environment, It is generally recognized that some the deposition of collagen on the mapatient profiles entail difficulties with trix is initially slowed then interrupted healing. They tients who previously had oral radiapresent with the modifications of the tion treatment or anti-angiogenic expression of certain mediators such as treatments are particularly at risk. The bone tissue when exposed to Controlling glycemia appears to be funheavy doses of radiation undergoes damental for normal healing, because irreversible changes with narrowing hyperglycemia alters the leukocyte of the blood vessels, that then functions, decreases phagocytosis and decrease the flow of blood to the chemiotactism, and increases the risk tissues. They were evalucompared the loss of bone support in ated with CbCt before and after a group of patients treated or not treatment, in order to determine the treated with extraction of the premoheight of the alveolar ridge and the 35 lars (n = 12 and n = 10 respectively). The with a decrease in collagen and an inauthors found a decrease in the buccrease in glycoaminoglycanes. Ancal-lingual alveolar dimensions in both other hypothesis concerning the groups, with no significant difference origin of these fissures is that there between them. On the other hand, the is a break in the gingival fibers, folbone loss was significantly greater in lowed by a pathological bone remothe group treated with extractions, in deling with loss of the cortical 42 the extraction site, and the distal region bone. The anatomical configon a site subjected to orthodontic uration of these gingival clefts contrispace closure following extraction is butes to the problem of cleaning the a fairly common occurrence. Their extraction site and predisposes the frequency has been estimated to be area to an increase in the plaque in45,46 35%. Fourteen of the forty patients presented with cleft on one or several of the premolar extraction sites, while no cleft was evident in the premolar zones of the control group of patients i. Some authors suggest that, for Figure 5 the affected sites, the transeptal fithe development of severe gingival fissures on the bers are disorganized and not regen57 mandible in this patient who underwent a planned exerating, since the invagination is traction protocol, in the course of orthodontic leveldeveloping passively by the folding ling. The retraction of the canines has not yet been of the gingival tissues; histological performed, but a lateral frenum seems to extend into studies have demonstrated the prethe area of the gingival cleft. The color of the plaque sence of an epithelial hypoplasia, clearly demonstrates that the patient hasn’t mastered while the connective tissues present good tooth brushing techniques.
High immunization rates arrhythmia kidney disease order 0.1 mg clonidine overnight delivery, in general arterial doppler generic 0.1 mg clonidine visa, have reduced dramatically the incidence of all vaccine-preventable diseases (see Tables 1 arteria y vena esplenica buy 0.1mg clonidine with mastercard. Licensing of new hypertension complications order clonidine australia, improved, and safer vaccines; anticipated arrival of additional combination vaccines; establishment of an adolescent immunization platform; and application of novel vaccine-delivery systems promise a new era of preventive medicine. Identifcation of the rare occurrence of intussusception after administration of the frst licensed oral rhesus rotavirus vaccine confrmed the value of such surveillance systems. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. Additionally, 24-hour contact telephone numbers for medical questions are available in the Physicians’ Desk Reference ( The monograph also provides information about other vaccines recommended for travel in specifc areas and other information for travelers. The hotline is a telephone-based resource available to answer immunization-related questions from health care professionals and members of the public. The schedulers are based on the recommended immunization schedules for children, adolescents, and adults. Parental Concerns About Immunization Health care professionals should anticipate that some parents will question the need for or the safety of immunizations, want to space out vaccines, refuse certain vaccines, or even decide to reject all immunizations for their child. Some parents may have religious or philosophic objections to immunization, which are permitted by some states. One important aspect physicians can control is their relationship with patients and their parents. A nonjudgmental approach is best for parents who question the need for immunizations. Ideally, health care professionals should determine in general terms what parents understand about vaccines their children will be receiving, the nature of their concerns, their health beliefs, and what information they fnd credible. People understand and react to vaccine information on the basis of a variety of factors, including previous experiences, attitudes, health beliefs, personal values, and education. Parents who refuse vaccines should be advised of state laws pertaining to school or child care entry, which can require that unimmunized children not attend school during disease outbreaks. Documentation of such discussions in the patient’s record may help to decrease any potential liability should a vaccine-preventable disease occur in an unimmunized patient. Only then should state agencies be involved to override parental discretion on the basis of medical neglect. Immunization can result in antitoxin, anti-adherence, anti-invasive, or neutralizing activity or other types of protective humoral or cellular responses in the recipient. The immunologic response to vaccination is dependent on the type and dose of antigen, the effect of adjuvants and host factors related to age, preexisting antibody, nutrition, concurrent disease, or drug effect and genetics of the host. The effectiveness of a vaccine is assessed by evidence of protection against the natural disease. Vaccines for some viruses (eg, hepatitis A and hepatitis B, human papillomavirus) and most bacteria are inactivated, component, subunit (purifed components) preparations or inactivated toxins. Some vaccines contain purifed bacterial polysaccharides conjugated chemically to immunobiologically active proteins (eg, tetanus toxoid, nontoxic variant of mutant diphtheria toxin, meningococcal outer membrane protein complex). In the case of conjugate polysaccharide vaccines, the protein linkage between the polysaccharide and the protein enhances vaccine immuno genicity. For example, an injected inactivated viral vaccine may evoke suffcient serum antibody or cell-mediated immunity but evoke only minimal mucosal antibody in the form of secretory immunoglobulin (Ig) A. Major constituents, including cell line derivation or animal derivatives, as relevant, are listed in package inserts. When this is the case, physicians should be aware that such products may have different active and/or inert ingredients. Other vaccines consist of multiple antigens, which can vary substantially in chemical composition and number (eg, acellular pertussis components, Haemophilus infuenzae type b, and pneumococcal and meningococcal products). Standardized forms are available to assist clinicians in screening for allergies and other potential contraindications to immunization ( Vaccines licensed for refrigerator storage should be stored at 35°F–46°F (2°C–8°C). Inactivated vaccines may tolerate limited exposure to elevated temperatures but are damaged rapidly by freezing (cold sensitive). Some vaccines must be protected from light, which can be accomplished by keeping each vial or syringe in its original carton while in recommended storage and until immediate use. Physical appearance is not an appropriate basis for determining vaccine acceptability. Vaccine Management: Recommendations for Handling and Storage of Selected Biologicals. Instead, refrigerator-freezers with separate external doors and well-sealed compartments for refrigeration and freezing should be used. These thermometers are sold with an individually numbered certifcate documenting this testing. The refrigerator temperature should be maintained between 2°C and 8°C (35°F and 46°F) with a target temperature of 40°F, and the freezer temperature should be –15°C (5°F) or colder. Predrawing vaccine increases the possibility of medication errors and causes uncertainty of vaccine stability. Offce personnel should have a written and easily accessible procedure that outlines vaccine packing and transport. After a power outage or mechanical failure, do not assume that vaccine exposed to temperature outside the recommended range is unusable. Gloves are not required when administering vaccines unless the health care professional has open hand lesions or will come into contact with potentially infectious body fuids. Different vaccines should not be mixed in the same syringe unless specifcally licensed and labeled for such use. This recommendation does not preclude administration of vaccines in school-based or other nonclinic settings. Syncope may occur following any immunization, particularly in adolescents and young adults. Personnel should be aware of presyncopal manifestations and take appropriate measures to prevent injuries if weakness, dizziness, or loss of consciousness occurs. The relatively rapid onset of syncope in most cases suggests that health care professionals should consider observing adolescents for 15 minutes after they are immunized. An attached dose-divider clip is removed from the sprayer to administer the second half of the dose into the other nostril. Data do not warrant recommendation of a single preferred site for all injections, and product recommendations of many manufacturers allow fexibility in the site of injection. Recommended routes of administration are included in package inserts of vaccines and are listed in Table 1. To minimize untoward local or systemic effects and ensure optimal effcacy of the immunizing procedure, vaccines should be given by the recommended route. In children younger than 1 year of age (ie, infants), the anterolateral aspect of the thigh provides the largest muscle and is the preferred site. These vaccines should not be administered subcutaneously or intracutaneously, because they can cause local irritation, infammation, granuloma formation, and tissue necrosis. Reported adverse events include broken needles, muscle contracture, nerve injury, bacterial (staphylococcal, streptococcal, and clostridial) abscesses, sterile abscesses, skin pigmentation, hemorrhage, cellulitis, tissue necrosis, gangrene, local atrophy, periostitis, cyst or scar formation, and inadvertent injection into a joint space. Site and Needle Length by Age for Intramuscular Immunization Needle Length, Age Group inches (mm)a Suggested Injection Site Newborns (preterm and term) and 5fi (16)b Anterolateral thigh muscle 8 infants <1 mo of age Term infants, 1–12 mo of age 1 (25) Anterolateral thigh muscle Toddlers and children 5fi –1 (16–25)b Deltoid muscle of the arm 8 1–1fi (25–32) Anterolateral thigh muscle Adults Female and male, weight <60 kg 1 (25)c Deltoid muscle of the arm Female and male, weight 60–70 kg 1 (25) Deltoid muscle of the arm Female, weight 70–90 kg 1 (25)–1fi (38) Deltoid muscle of the arm Male, weight 70–118 kg 1 (25)–1fi (38) Deltoid muscle of the arm Female, weight >90 kg 1fi (38) Deltoid muscle of the arm Male, weight >118 kg 1fi (38) Deltoid muscle of the arm a Assumes that needle is inserted fully. Because of the decreased antigenic mass administered with intradermal injections, attention to technique is essential to ensure that material is not injected subcutaneously. When necessary, 2 or more vaccines can be given in the same limb at a single visit. The distance separating the injections is arbitrary but should be at least 1 inch, if possible, so that local reactions are unlikely to overlap. Multiple vaccines should not be mixed in a single syringe unless specifcally licensed and labeled for administration in 1 syringe. A brief period of bleeding at the injection site is common and usually can be controlled by applying gentle pressure. Parents should be educated about techniques for 1 reducing injection pain or distress. Parents should be advised not to threaten children with injections or use them as a punishment for inappropriate behavior. Older children may be more comfortable sitting on a parent’s lap or examination table edge and hugging their parent chest to chest, while an immunization is administered. A rapid plunge of the needle through the skin without aspirating and rapid injection may decrease discomfort.
Some authors have observed differences in the size of the hooks on the scolices of cysticerci found in humans blood pressure question buy 0.1mg clonidine with amex, swine blood pressure goals buy generic clonidine 0.1 mg on line, cats hypertension vs preeclampsia clonidine 0.1 mg low price, dogs blood pressure beta blocker purchase clonidine canada, and baboons, and proposed the existence of different strains or subspecies. A multilobular cysticercus without a scolex has frequently been observed in human cysticercosis in Mexico; it has been designated Cysticercus racemosus. The gravid proglottids, which can contain more than 100,000 eggs, detach from the strobila one by one; they are motile and often exit actively through the anus. The eggs are either expelled from the proglottid or released when it disintegrates, contaminating the environment. Inside bovines, the viable eggs ingested by grazing cattle develop into cysticerci (still called Cysticercus bovis) in a manner similar to the eggs of T. Cysticerci begin to degenerate in a few weeks, and after nine months, many of them are dead and calcified. Occurrence in Man: It was estimated in 1947 that nearly 39 million people in the world were infected by T. Taeniases are not notifiable diseases, and the available information is based on isolated studies of specific sectors of the population, such as schoolchildren, recruits, and others. Also, since many studies of prevalence are based on the finding of eggs in feces, and the eggs of T. A local report in Poland analyzed 736 cases of cestodiasis diagnosed in 1997: 634 were caused by T. On a college campus in Chile, the 11 cases of taeniasis diagnosed at the species level between 1985 and 1994 were caused by T. In contrast, in Bali, Indonesia, one of every three cases of taeniasis was caused by T. Based on these findings, any prevalence exceeding 1% in the general population should probably be considered very high. Hinz (1991) estimated that there were 900,000 infections in Germany, for a prevalence of 1. The endemic areas are the Caucasus region, the former Soviet republics in south and central Asia, and certain countries on the Mediterranean, such as Lebanon, Syria, and the former Yugoslavia. Up to 65% of the children were found to be infected in parts of the former Yugoslavia. Fan (1997) reported a prevalence of 11% in the mountainous zones of Taiwan, 6% on Cheju Island in the Republic of Korea, and 21% on Samosir Island in Indonesia. But the natives of these areas engage in food and hygiene practices that greatly encourage the spread of parasites between man and swine (Depary and Kossman, 1991). Occurrence in Animals: Animals are resistant to infection with the adult parasites. In clinical cases, the most common symptomatology consists of abdominal pain, nausea, debility, weight loss, flatulence, and diarrhea or constipation. While a patient may have one or several of these symptoms, experience in Chile showed that only about a third of patients have any of these symptoms before becoming aware of the infection. In rare cases, there may be intestinal obstruction and even perforation of the colon (Demiriz et al. Individual reactions to the infection differ and may be influenced by psychogenic factors, since patients often notice symptoms only after they see the proglottids (Pawlowski, 1983). In addition, complications such as appendicitis and cholangitis have not been recorded. The most common signs were movement of proglottids (95% of patients), going on for years in some of them; anal pruritus in 77%; nausea in 46%; abdominal pain in 45%; dizziness in 42%; increased appetite in 42%; and headache in 26%. Source of Infection and Mode of Transmission: In contrast to their role in other zoonotic infections, humans constitute an essential link in the epidemiology of taeniasis. Humans are the exclusive definitive host of the three species of Taenia; their feces contaminate cow pastures and areas where home-bred swine may eat. Taeniae can live for many years in the human small intestine, and can eliminate hundreds of thousands of eggs in a single day in the gravid proglottids. Survival of the eggs in pastures depends on the ambient temperature and humidity; in summer, T. In developing countries, where peasants on poor farms or large ranches often defecate in open fields, both swine and cattle have access to taenia eggs. The use of sewer water for irrigation or of contaminated water from rivers or other sources for watering animals contributes to the spread of cysticercosis. Another factor that has acted to raise the incidence of taeniasis in recent years is the increasing use of detergents that impede the natural destruction of the parasite’s eggs in sewer systems. Taenia eggs can be carried several kilometers by river water, and they may be transported over long distances by gulls and other birds. An important role in the dissemination of taeniae eggs is also attributed to coprophagous insects. The distribution and prevalence rates of the human taeniases vary considerably in different geographic areas of the world. The infection has almost disappeared from the more industrialized countries, where modern intensive swineraising practices do not permit access to human feces. Moreover, since this population group often does not have the benefit of drinking water and sewer systems, the swine have a much higher risk of infection by human feces. Finally, a high percentage of these swine are slaughtered at home for household or local consumption and, therefore, the animals are not subject to veterinary inspection. Human infection is closely related to the habit of eating dishes prepared with raw beef or beef cut into thick pieces that are not thoroughly cooked. The infection can also be contracted by tasting meat dishes during their preparation, before the meat is completely cooked. The risk of contracting the infection is five times greater in a family in which there is a carrier of T. The risk is 14 times greater among workers involved in processing and marketing raw meat, probably due to their access to meat that is not subject to veterinary inspection or that is discarded during inspection. However, as far as the poorer classes are concerned, the systems for supplying potable water, excreta removal, and veterinary inspection of slaughterhouses are often deficient, which facilitates the infection of cattle and, subsequently, of man. There is some question about whether man can contract cysticercosis through regurgitation of distal portions of a T. While the majority of authors used to believe that the regurgitation of gravid proglottids from the jejunum or the ileum would be most unusual, the discovery of the oral expulsion of a T. Thus, there is little opportunity for the eggs to be released in the intestine; parasite eggs are found in the feces of just one quarter of patients. Moreover, the various species of the genus Taenia cannot be distinguished by microscopic examination of the eggs. For these reasons, diagnosis of human intestinal taeniasis is generally made by identifying gravid proglottids in the feces. Proglottids are not eliminated on a daily basis, so the examination must be repeated if results are negative. Control: Human taeniases are not just a threat to public health, but also a factor in economic loss. Almost all actions to control this zoonosis are based on appropriate health education of the at-risk population. Barriga (1997) proposes several control measures that consist of interrupting the epidemiological chain of the parasite at any of the following points of intervention: 1. These are prevented by early diagnosis and effective treatment of infected persons, since man is the only definitive host. This is prevented through an appropriate excreta disposal system, consisting not just of a traditional sewer system, but also well-built and utilized septic tanks and education of the population in their proper use. Unfortunately, the economic and cultural conditions of the rural populations in developing countries often preclude these actions. Also, traditional sewer systems can decrease the viability of taenia eggs up to approximately 8%, but the final solids can still contain significant numbers of viable eggs (Barbier et al. This is avoided by preventing breeding swine and bovines access to food or drink contaminated with human feces. However, poor peasants customarily breed a few swine for their own consumption or sale on the local market and, because of ignorance or lack of the means to implement hygienic breeding standards, the animals have easy access to places that have been contaminated with human feces, and they acquire cysticercosis. This can be prevented by treating the animals—which is too expensive, insufficiently effective, and not preventive of subsequent infections—or by vaccination. Studies of vaccination of the intermediate hosts of cestodiasis are very far advanced; in the case of bovine cysticercosis, there are just a few practical marketing problems to be resolved before its routine use can be initiated (Lightowlers, 1996). Attempts to vaccinate against porcine cysticercosis in Peru fared less well (Evans et al. This can be prevented by good veterinary inspection in slaughterhouses and educating the population against avoidance of inspection.
Another 2016 study examining 4 popular diabetes apps found that there was “wide variability” in the ease 74 of entering blood glucose hypertension 2 nigerian movie order clonidine 0.1mg with visa, one of the easiest tasks to blood pressure 4020 clonidine 0.1 mg without prescription complete of those examined arteria rectal superior purchase clonidine 0.1mg visa. For example heart attack vs angina discount clonidine 0.1mg without a prescription, do apps that require a fee or paid subscription result in larger benefits in outcomesfi Are there specific features of apps that lead to improved health outcomes, and others that do notfi Unfortunately, because we identified relatively few studies on commercially available apps, study quality was variable, and we could not empirically assess the features and usability of several apps, we could not make any judgements about the relationship between cost, features and efficacy. Short Duration of Studies Studies ranged from 2 to 12 months, which is relatively short compared with the lifelong duration of diabetes. It is unclear whether these apps impact long-term outcomes, including microvascular and macrovascular complications. Methodological Issues With Available Evidence Our risk of bias assessments revealed that there is lack of consistency in how researchers are reporting their mHealth studies. Limited information on randomization, allocation, masking, and analysis of drop-outs are common methodological problems in studies of health care interventions. However, other methodological issues specific to mHealth made it difficult to interpret and apply findings. In some cases, this was because the main purpose of the study was to see if both groups had a change from 34 baseline. For example, the study on NexJ was interested in whether a health coaching intervention was efficacious both with and without an app, so pre-post differences for both groups were presented. Still, study authors calculated the difference-in-difference between groups for HbA1c. Study design also made it difficult to determine what effect could be attributed to the app and what was attributable to the additional interactions with study personnel or providers. For several studies, the intervention group had the ability to message providers or study staff and get an immediate response while usual care participants had to go through standard channels like phone calls or monthly appointments. In these cases, the control group did not provide a sufficient degree of attention control so it is not clear whether the app or the extra attention was causing the effect. This makes it difficult to interpret and apply findings across health care contexts where patients may not have as much support. Additional issues that came up in several studies included inconsistent or missing information on how much participants used apps. Most of the systematic reviews we included in this review commented that there is a lack of 15, 21-23 rigorous research on apps for diabetes. These tools attempt to standardize the level of detail included in studies so that the results can be interpreted in a meaningful way; however, it does not appear that these tools have been consistently used even though the checklist was published in 2011, before a majority of the studies were published. Limitations In addition to limitations caused by the variable quality of identified studies, there were three major limitations in this review: limitations created by the type of report, limitations caused by the lack of access to some of the commercially available apps, and limitations in how usability was assessed. Rapid Review Limitations We identified our list of potentially relevant studies from five recently published systematic reviews as well as hand-searching. Also of note, although we took steps to critically assess the potential for bias in these studies, we did not consider every potential area for bias. Specifically, we did not evaluate primary and secondary outcomes as specified by study authors. Limitations From Lack of Access to Apps We focused on commercially available apps accessible by the general public; however, defining “commercially available” became difficult. Of the 13 apps we evaluated, only 10 were available on Apple platforms and 10 available on Android platforms. Of the 10 Apple apps, we were unable to download one because it was only available for download from the French Apple App Store. This means we could not provide first-hand usability scores and consumer details about the app and had to rely on second-hand, potentially biased sources, mainly the developer Web sites. So, while we included the app because it was a commercially available app with evidence, it is unavailable to use in the United States. On the Apple platform we were able to download three apps that we could not subsequently log into. The Android platform had two apps that were unavailable from the United States Google Play Store, and three that we could not log into. There was one app that we were able to download on an Apple device, but it was not in English. For this app, we based our assessment of features on potentially biased information from the developer. Due to limited funding, our evaluation of three paid apps’ characteristics (Diabetes Manager, mDiab, and Glucose Buddy Pro) was only conducted on one platform, an Apple iPad. Therefore, we were unable to report any discrepancies in features and functions across platforms. Finally, it is likely the versions of apps we assessed may have been different from the versions of apps that were studied, as most (7 out of 13) apps had been updated since the studies were published. Because none of our reviewers had diabetes, they may not have represented the experiences and preferences of people with diabetes. In addition, reviewers had limited exposure to the app and were bound by the scope of the questions. This scoring tool consists of only 10 questions, available in Appendix D, and was designed to be a “quick and dirty” evaluation tool to assign a score to a process that is 76 descriptive, nuanced, and subjective in nature. We were also unable to examine all characteristics of apps that are important to patients. Most notably, we did not examine technology performance outcomes such as malfunctions or crash statistics. While reliability is an important consideration for patient decisionmaking, we were unable to address this characteristic in this review. Next Steps Future Research Needs First, there is a need for longer-term studies (more than 1 year) on apps for diabetes. Diabetes is a chronic condition and the risk of serious complications increases over time. These complications can take several months to years to develop, and are some of the most important outcomes for studies to address. Therefore, longer-term studies are necessary to tell whether an app has an impact on the development of these complications. In addition, longer-term studies are important in determining whether patients continue to engage with these apps, or if they eventually lose interest. Longer-term studies could also help determine if the beneficial effects of apps on short-term outcomes hold up over time. It is particularly difficult to assess long-term outcomes in studies of apps, since apps are constantly changing. In longer-term studies, or multiple studies of one app, it is critical to report the app version, timing of updates, and any significant changes to features or content. This helps to determine if the results can be applied to the most recently updated app and current health care context. An example is a cohort study where the outcomes of those who use an app versus those who do not are tracked over several years. Interviews and surveys could be used to ask why patients continue to use an app or not, and how patients’ interest in an app changes over time. Second, researchers should consistently include harms in studies of diabetes apps, particularly hypoglycemic episodes. Ideally, studies would separate hypoglycemic episodes by severity, distinguishing between self-reported mild episodes and those that require medical assistance. It is important to report mild and severe hypoglycemic episodes for both shorter and longer-term studies. This would help ensure that the findings represent the effect of the app, not of the additional support. Future researchers should also consider head-to-head comparisons of multiple apps. This study design would provide adequate 34 attention control, and would be more patient-centered, as many patients know they want to use an app in care but do not know which one is most appropriate for them. Fourth, researchers should consider evaluating the most popular apps from app storesand converselymaking researched apps available to patients. As previously discussed, relatively few commercially available apps are supported by evidence, so patients do not know how these apps will affect their diabetes-related outcomes. Patients and physicians need evidence on the apps that are currently available to them if they are to make informed decisions on which app to use in care. Last, there is a need for a broader research and dissemination agenda on diabetes apps.
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