Conclusions: In conclusion obesity promotes a pro-tumor microenvironment, that can be corrected through surgically induced weight loss. Of note, other recent reports also showed that increased Y/T activity enables resistant cells to proliferate when other oncogenic pathways. Garcia Marrufo2, Mariana Moncada-Madrazo1, Analy Gomez-Picos1, Cynthia VillarrealGarza1 and Dione Aguilar2. Orteronel is a novel, oral, selective, nonsteroidal inhibitor of 17, 20-lyase, a key enzyme in androgen biosynthesis under evaluation as a potential therapeutic strategy in hormone-sensitive cancers. Cobleigh, Matthew Najor, Satnam Brar, Sanja Turturro, Liam Portt, Timothy Yung and Abde M Abukhdeir. We also tested multiple combinations of these drugs and observed benefits from several combinations that exceeded single agent use. Treatment with single agent vincristine or zoledronic acid for 19 days resulted in statistically-significant decreases of 37. Our results provide the first evidence that vincristine in combination with zoledronic acid may be efficacious in treating breast cancers. MammaPrint is a 70-gene microarray-based assay that classifies each breast cancer patient as low or high risk to develop metastases within 10 years after diagnosis. Patients had a clinical tumor classification of T2-T4 with 0-3 positive lymph nodes. Patients were required to have adequate bone marrow reserves, renal function and hepatic function, as determined by standard blood and serum measurements. Patients under 18 years of age or those with confirmed metastatic disease, inflammatory breast cancer, any serious uncontrolled intercurrent infections, or other serious uncontrolled concomitant disease were excluded. Patients with any prior chemotherapy, radiotherapy, or endocrine therapy for the treatment of breast cancer were also excluded. Tumor samples were collected via incisional or core needle biopsy and shipped to Agendia for processing of the MammaPrint and BluePrint gene panels, as well as whole human genome expression microarrays. Additional studies to evaluate the prognostic and/or predictive values of additional gene panels from the whole human genome microarrays are underway. To keep the study homogenous, only studies evaluating invasive ductal carcinoma were included and studies evaluating ductal carcinoma in-situ and lobular ductal carcinoma were excluded. An overestimation was defined as imaging tumor size more than 10 mm larger than its pathological counterpart. Results: Twenty-five studies with 3,562 patients were included in the final analysis. However, it is highly likely to overestimate tumor size and can result in unnecessary mastectomies. Nomogram was validated externally with the prospective cohorts of 167 patients from 2016 to 2018 of Cancer Hospital of Chinese Academy of Medical Sciences and 75 patients from 2018 to 2019 of Beijing Tiantan hospital. Isabelle JoyceLima Silva-Fernandes, Clarissa Gondim Picanco-Albuquerque, Maria Claudia dos Santos Luciano, Deysi Viviana Tenazoa Wong, Maria Julia Barbosa Bezerra, Flavio Silveira Bitencourt, Francisca Fernanda Barbosa Oliveira, Paulo Goberlanio de Barros Silva, Rosane Oliveira Sant The patients had their age at diagnosis ranged from 25 to 65 years, with an average of 41 years. Treatment choices have been taken mainly based on safety according to guidelines which aim hierarchically categorize the clinical benefits of any clinical decision. Considering the magnitude of benefit, neo/adjuvant breast cancer treatment is positioned at medium/high levels. It was considered the period from June 2018 to June 2020 to analyze the total cycles prescribed/month. For safety assessment, it was considered the demand for medical care at emergency unit. The impact of treatment modifications should be monitored to minimize unfavorable outcomes. Demographic, clinicopathological, laboratory and treatment characteristics were collected from electronic medical records. Of these, 60% were Non-Hispanic, 40% were Hispanic, 46% were Black, 19% were Caucasian and 6% were Asian. Premenopausal and postmenopausal status was identified in 21% and 75% of patients, respectively.
People must be healthy in order to work, and consistent access to health insurance is vital to being healthy enough to work. Making Medicaid more difficult to access could have the exact opposite effect on employment that supporters of work requirements claim to be pursuing. Proposals to Take Health Coverage Away from Individuals Who Do Not Meet New Work Requirements Grow Government Bureaucracy and Increase Red Tape Taking away health coverage from Medicaid enrollees who do not meet new work requirements would add new red tape and bureaucracy to the program and only serve as a barrier to health care for enrollees. One of the key lessons of the Work Support Strategies initiative is that every time that a client needs to bring in a verification or report a change adds to the administrative burden on caseworkers and increases the likelihood that clients will lose benefits due to failure to meet one of the requirements. In many cases, clients remain eligible and will reapply, which is costly to families who lose benefits as well as to the agencies that must process additional applications. For example, seasonal workers may have a period of time each year when they are not working enough hours to meet a work requirement and as a result will churn on and off the program during that time of year. Or, some may have a reduction in their work hours at the last minute and therefore not meet the minimum numbers of hours needed to retain Medicaid. Many low-wage jobs are subject to last-minute scheduling, meaning that workers do not have advance notice of how many hours they will be able to work. If you are constantly at the whim of random scheduling at your primary job, you will never know when you will be available to work at a second job. As people are disenrolled from Medicaid for not meeting work requirements, possibly because their hours get cut one week or they have primarily seasonal employment (like construction work), they will cycle back on Medicaid as their hours increase or the seasons change. People may be most likely to seek to re-enroll once they need healthcare and be less likely to receive preventive care if they are not continuously enrolled in Medicaid. Disenrollment and lock out would lead to worse health outcomes, higher costs Medicaid enrollees must meet the work requirement for four months out of every six-month period in order to maintain coverage. Enrollees who lose exempt or employment status and are no longer complaint with the requirement at least four months of the six-month period will have their benefits suspended. These benefits will remain suspended untul the Medicaid enrollee demonstrates compliance with the requirement for one month. Once suspended from Medicaid coverage, beneficiaries will likely become uninsured. Needed medical services and prescription drugs, including those needed to maintain positive health outcomes, may be deferred or skipped. Because people without health coverage are less likely to have regular care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health. This will only lead to poorer health outcomes and higher uncompensated costs for providers. In a 2003 analysis, researchers from the Urban Institute found that people who are uninsured for less than 6 months are less likely to have a usual source of care that is not an emergency room, more likely to lack confidence in their ability to get care and more likely to have unmet medical or prescription drug needs. A 2008 analysis of Medicaid enrollees in California found that interruptions in Medicaid coverage were associated with a higher risk of hospitalization for conditions such as heart failure, diabetes, and chronic obstructive disorders. In addition to the poorer health outcomes for patients, these avoidable hospitalizations are also costly for the state. Studies repeatedly show that the uninsured are less likely than the insured to get preventive care and services for major chronic conditions. Support services will be inadequate Child care is a significant barrier to employment for low-income parents. Many low-income jobs have variable hours from week to week and evening and weekend hours, creating additional challenges to finding affordable and safe child care. Finding affordable and safe child care for children is difficult and a barrier to employment. Requiring employment in order to maintain health care, but not providing adequate support services such as child care, sets a family up for a no-win situation. Even with the recent increase in federal child care funding, Tennessee does not have enough funding to ensure all eligible families can access child care assistance. Although Tennessee proposes to exempt individuals who are disabled or designated as physically or mentally unfit to work, in reality many people who are not able to work due to disability or unfitness are likely to not receive an exemption due to the complexity of paperwork. Additionally, those with disabilities may have a difficult time navigating the increased red tape and bureaucracy put in place to administer a work requirement, including proving they are exempt. The end result is that many people with disabilities will in fact be subject to the work requirement and be at risk of losing health coverage. The proposal does not provide any estimate of the number of people who are expected to become disenrolled from Medicaid. This lack of information is unacceptable and Tennessee should provide details about the anticipated change in enrollment in the state.
| Comparative prices of Avodart | ||
| # | Retailer | Average price |
| 1 | SonyStyle | 316 |
| 2 | OfficeMax | 923 |
| 3 | Nordstrom | 659 |
| 4 | Ace Hardware | 693 |
| 5 | Barnes & Noble | 348 |
Areas were selected for the evidence-based data available to direct provider decision-making and the potential for improving patient selection and care by eliminating inappropriate testing. Specific recommendations were drafted for each subject area, accompanied by peer-reviewed literature citations. Developing an action plan for patient radiation safety in adult cardiovascular medicine: proceedings from the Duke University Clinical Research Institute/American College of Cardiology Foundation/American Heart Association Think Tank held on February 28, 2011. Although fluoroquinolones are efficacious in three-day regimens, they have a higher risk of ecological adverse events, such as increasing multidrug resistant organisms. The initial evaluation of an uncomplicated patient presenting with symptoms should include history, physical examination and urinalysis. In some cases, urine culture, post-void residual urine assessment and bladder diaries may be helpful. More invasive testing should be reserved for complex patients, patients who have failed initial therapies. Nonsurgical treatment options for pelvic organ prolapse include pessaries, which are removable devices that are placed into the vagina to support the prolapsed organs. Exceptions include women with an active vaginal infection and those who would be noncompliant with follow-up. Posterior vaginal repair of rectocele is performed for women with symptoms of a posterior vaginal wall bulge or difficulty with defecation. The addition of synthetic or biologic grafts to this repair does not improve patient outcomes. Avoid removing ovaries at hysterectomy in pre-menopausal women with normal cancer risk. There is evidence from observational studies that surgical menopause may negatively impact cardiovascular health and all-cause mortality. Ovarian conservation before menopause is particularly important in patients with a personal or strong family history of cardiovascular disease or stroke. By consensus, the Clinical Practice Committee selected the top five most overused tests within specified parameters. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Porcine subintestinal submucosal graft augmentation forrectocele repair: a randomized controlled trial. Prophylactic and riskreducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. American Urological Association Fifteen Physicians and Patients Should Question A routine bone scan is unnecessary in men with very low-risk or low-risk prostate cancer. Very low-risk or low-risk patients (defined by using commonly accepted categories such as American Urological Association guidelines) are unlikely to have disease identified by bone scan. Progression to the bone is much more common in advanced local disease or in high-grade disease that is characterized by fast and aggressive growth into surrounding areas such as bones or lymph nodes. While testosterone treatment is shown to increase sexual interest, there appears to be no significant influence on erectile function, at least not in men with normal testosterone levels. Such patients are unlikely to experience significant health problems in the future due to their condition and can be seen again if necessary. Ultrasound has been found to have poor diagnostic performance in the localization of testes that cannot be felt through physical examination. Studies have shown that the probability of locating testes was small when using ultrasound, and there was still a significant chance that testes were present even after a negative ultrasound result. Additionally, ultrasound results are complicated by the presence of surrounding tissue and bowel gas present in the abdomen. Antibiotics in the absence of signs and symptoms (which may include fever; altered mental status or malaise with no other cause; flank or pelvic pain; flank or suprapubic tenderness; hematuria; dysuria, urinary urgency or frequency; and, in spinal cord injury patients, increased spasticity, autonomic dysreflexia or sense of unease) is not efficacious and risks inducing resistance to antimicrobials. Additionally, initial placement of a suprapubic tube requires a skin puncture or incision and therefore antibiotics should be considered. Magnetic resonance imaging of the pelvis may be useful in some men considering active surveillance. There is no clear benefit to mesh removal in the absence of symptoms, and mesh removal in this circumstance exposes the patient to potential complications such as bladder injury, rectal injury and fistula formation. Shared decision making (between health care provider and patient and, in some cases, family members) is an excellent strategy for making health care decisions when there is more than one medically reasonable option.
In 29 out of 76 samples, concentrations far exceeded federal health and safety standards, sometimes by several orders of magnitude. Further, high levels of pollutants were detected at distances exceeding legal setback distances from wellheads to homes. Highly elevated levels of formaldehyde, for example, were found up to a half-mile from a wellhead. In Arkansas, seven air samples contained formaldehyde at levels up to 60 times the level known to raise the risk for cancer. Influence of oil and gas emissions on ambient atmospheric non-methane hydrocarbons in residential areas of Northeastern Colorado. Air concentrations of volatile compounds near oil and gas production: a community-based exploratory study. Air monitors showed 32 different hydrocarbon-based air pollutants, including the carcinogens naphthalene and benzo[a]pyrene. The researchers found that drilling and fracking emit prodigious amounts of volatile organic air pollutants, including benzene, toluene, and methane, all of which are precursors for ground-level ozone (smog). Multiple pieces of equipment on and off the well pad, including condensate tanks, compressors, dehydrators, and pumps, served as the sources of these emissions. This research shows that drilling and fracking activities are the cause of the extraordinarily high levels of winter smog in the remote Uintah basin-which regularly exceed air quality standards and rival that of downtown Los Angeles. According to the study, the consequences for public health are "as yet unrecognized. Volatile organic compound emissions from the oil and natural gas industry in the Uintah Basin, Utah: oil and gas well pad emissions compared to ambient air composition. Leakage of vaporous organic compounds during the necessary removal of hydrogen sulfide gas, along with the venting of gas both during drilling and during the process of making the well ready for production, were major contributors. Even in the best case, wind and nuclear power are still preferable (by factors of 3. The results showed a large number of compounds detected above the Method Reporting Limit (the minimum quantity of the compound that can be confidently determined by the laboratory). Air sampling found three known/suspected carcinogens, and a number of other compounds associated with significant health effects. Benzene results from Denton, Dish, and Fort Worth are particularly alarming since they exceeded the long-term ambient air limits set by the Texas Commission on Environmental Quality, and benzene is a known carcinogen. Further, the company responsible operated with no permit, underreported its emissions and provided faulty data to regulators. Captured by indoor air monitors, the spikes tend to occur at night when stable atmospheric conditions hold particulate matter low to the ground. They found that exposures may be underestimated by an order of magnitude, mixtures of chemicals are not taken into account, and local weather conditions and vulnerable populations are ignored. Their observations "reveal a strong causal link between oil and gas emissions, accumulation of air toxics, and significant production of ozone in the atmospheric surface layer. Crystalline silica was also discussed, including as a concern for people living near well pads and production staging areas. Understanding exposure from natural gas drilling puts current air standards to the test. Planning for fracking on the Barnett shale: Urban air pollution, improving health based regulation, and the role of local governments. Air pollution and hydraulic fracturing: Better monitoring, planning and tracking of health effects needed in Texas. Highly elevated atmospheric levels of volatile organic compounds in the Uintah Basin, Utah [Abstract]. Air impacts of increased natural gas acquisition, processing, and use: A critical review. They found that most areas had "atmospheric methane concentrations considerably higher than reported urban background concentrations," and many toxic chemicals were "strongly associated" with compressor stations. Wheeling-Ohio County Health Department Administrator Howard Gamble stated, "The levels of benzene really pop out.
Patients with life expectancies of less than 10 years are unlikely to live long enough to derive the distant benefit from screening. Furthermore, these patients are more likely to experience the harms since patients with limited life expectancy are more likely to be frail and more susceptible to complications of testing and treatments. Therefore the balance of potential benefits and harms does not favor cancer screening in patients with life expectancies of less than 10 years. Members of the ad hoc committee were then solicited to determine possible topics for consideration. The topics chosen were selected to meet the goals of the Choosing Wisely campaign, utilizing the unique clinical perspective of members of the Society in ambulatory general medicine as well as hospital-based practice. The final topics were selected by a vote of committee members based on the strength of the existing evidence, the unique standing members of the Society have in addressing the clinical topics selected, as well as contributions the recommendations would make in terms of patient safety, quality and economic impact. Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes. Cost-effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. Guide to clinical preventative services: an assessment of the effectiveness of 169 interventions. What is the value of routinely testing full blood count, electrolytes and urea, and pulmonary function tests before elective surgery in patients with no apparent clinical indication and in subgroups of patients with common comorbidities: a systematic review of the clinical and cost-effective literature. Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. Cancer screening in elderly patients: a framework for individualized decision making. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the "Idle central venous catheter". As leading teachers of the next generation of physicians, we are committed to moving the practice of medicine to a more evidencebased approach. We are deeply committed to using science to improve our knowledge-base so that our patients can receive the best treatments, the optimal prevention care and the highest quality of life. We believe that the Choosing Wisely campaign mirrors these same commitments to the evidencebased practice of medicine for the benefit of our patients. False positive results of either test can lead to unnecessary procedures, which have risks of complication. Pap testing of the top of the vagina in women treated for endometrial cancer does not improve detection of local recurrence. False positive Pap smears in this group can lead to unnecessary procedures such as colposcopy and biopsy. Colposcopy for low-grade abnormalities in this group does not detect recurrence unless there is a visible lesion and is not cost effective. Avoid routine imaging for cancer surveillance in women with gynecologic cancer, specifically ovarian, endometrial, cervical, vulvar and vaginal cancer. Imaging in the absence of symptoms or rising tumor markers has shown low yield in detecting recurrence or impacting overall survival. There is now an evidence-based consensus among physicians who care for cancer patients that palliative care improves symptom burden and quality of life. Palliative care empowers patients and physicians to work together to set appropriate goals for care and outcomes. Palliative care can and should be delivered in parallel with cancer directed therapies in appropriate patients.
Syndromes
Antiepilepsy drugs should not be abruptly discontinued in patients in whom the drug is administered to prevent major seizures because of the strong possibility of precipitating status epilepticus with attendant hypoxia and threat to life. In epileptic patients previously receiving Depakene (valproic acid) therapy, Depakote tablets should be initiated at the same daily dose and dosing schedule. After the patient is stabilized on Depakote tablets, a dosing schedule of two or three times a day may be elected in selected patients. In the clinical trials, there was no evidence that higher doses led to greater efficacy. Dosage should be increased more slowly and with regular monitoring for fluid and nutritional intake, dehydration, somnolence, and other adverse reactions. Dose reductions or discontinuation of valproate should be considered in patients with decreased food or fluid intake and in patients with excessive somnolence. The ultimate therapeutic dose should be achieved on the basis of both tolerability and clinical response [see Warnings and Precautions (5. The probability of thrombocytopenia appears to increase significantly at total valproate concentrations of 110 mcg/mL (females) or 135 mcg/mL (males) [see Warnings and Precautions (5. The benefit of improved therapeutic effect with higher doses should be weighed against the possibility of a greater incidence of adverse reactions. Depakote is contraindicated in patients with known hypersensitivity to the drug [see Warnings and Precautions (5. Depakote is contraindicated in patients with known urea cycle disorders [see Warnings and Precautions (5. Serious or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise, weakness, lethargy, facial edema, anorexia, and vomiting. Liver function tests should be performed prior to therapy and at frequent intervals thereafter, especially during the first six months. However, healthcare providers should not rely totally on serum biochemistry since these tests may not be abnormal in all instances, but should also consider the results of careful interim medical history and physical examination. Caution should be observed when administering valproate products to patients with a prior history of hepatic disease. Patients on multiple anticonvulsants, children, those with congenital metabolic disorders, those with severe seizure disorders accompanied by mental retardation, and those with organic brain disease may be at particular risk. Experience has indicated that children under the age of two years are at a considerably increased risk of developing fatal hepatotoxicity, especially those with the aforementioned conditions. When Depakote is used in this patient group, it should be used with extreme caution and as a sole agent. Above this age group, experience in epilepsy has indicated that the incidence of fatal hepatotoxicity decreases considerably in progressively older patient groups. The drug should be discontinued immediately in the presence of significant hepatic dysfunction, suspected or apparent. In some cases, hepatic dysfunction has progressed in spite of discontinuation of drug [see Boxed Warning and Contraindications (4)]. This is especially important when valproate use is considered for a condition not usually associated with permanent injury or death. Women who are planning a pregnancy should be counseled regarding the relative risks and benefits of valproate use during pregnancy, and alternative therapeutic options should be considered for these patients [see Boxed Warning and Use in Specific Populations (8. To prevent major seizures, Depakote should not be discontinued abruptly, as this can precipitate status epilepticus with resulting maternal and fetal hypoxia and threat to life. Pregnancy registry data show that maternal valproate use can cause neural tube defects and other structural abnormalities. Evidence suggests that folic acid supplementation prior to conception and during the first trimester of pregnancy decreases the risk for congenital neural tube defects in the general population. Several published epidemiological studies have indicated that children exposed to valproate in utero have lower cognitive test scores than children exposed to either another antiepileptic drug in utero or to no antiepileptic drugs in utero. The largest of these studies is a prospective cohort study conducted in the United States and United Kingdom that found that children with prenatal exposure to valproate had lower Differential Ability Scale (D. Although all of the available studies have methodological limitations, the weight of the evidence supports the conclusion that valproate exposure in utero causes subsequent adverse effects on cognitive development. In animal studies, valproate-exposed offspring had malformations similar to those seen in humans and demonstrated behavioral deficits [see Use in Specific Populations (8. Some of the cases have been described as hemorrhagic with rapid progression from initial symptoms to death. Some cases have occurred shortly after initial use as well as after several years of use.
Oral antibiotics may have significant adverse effects and do not provide demonstrable benefit after tonsillectomy. History, physical examination and allergy testing are the cornerstones of diagnosis of allergic rhinitis. The six topics were selected based on their supporting evidence (for example, clinical practice guidelines), committee support, and the current use (frequency) of the test or procedure. Committees were asked to provide their support for any of the proposed topics, reasons why a topic should not be included, as well as identifying any additional topics for consideration along with supporting evidence. Topical ofloxacin versus systemic amoxicillin/clavulanate in purulent otorrhea in children with tympanostomy tubes. Medical disorders in this specialty are among the most common affecting patients, young and old. Five Things Physicians and Patients Should Question Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis and bronchiolitis). Although overall antibiotic prescription rates for children have fallen, they still remain alarmingly high. Unnecessary medication use for viral respiratory illnesses can lead to antibiotic resistance and contributes to higher health care costs and the risks of adverse events. Research has shown these products offer little benefit to young children and can have potentially serious side effects. Many cough and cold products for children have more than one ingredient, increasing the chance of accidental overdose if combined with another product. The literature does not support the use of skull films in the evaluation of a child with a febrile seizure. High doses also have been associated with numerous short- and long-term adverse outcomes, including neurodevelopmental impairment. Ordering screening panels (IgE tests) that test for a variety of food allergens without previous consideration of the medical history is not recommended. For example, about 8% of the population tests positive to peanuts but only approximately 1% are truly allergic and exhibit symptoms upon ingestion. When symptoms suggest a food allergy, tests should be selected based upon a careful medical history. There is no evidence that surveillance urine cultures or treatment of asymptomatic bacteriuria is beneficial. Surveillance cultures are costly and produce both false positive and false negative results. Treatment of asymptomatic bacteriuria is harmful and increases exposure to antibiotics, which is a risk factor for subsequent infections with a resistant organism. This also results in the overall use of antibiotics in the community and may lead to unnecessary imaging. The second stage involved expert review and evaluation of the management groups that oversee the functions of the committees, councils and sections. Based on a set of criteria (evidence to document unproven clinical benefit, potential to cause harm, over-prescribed and utilized, and within the purview of pediatrics) a list of more than 100 topics was narrowed down to five. Clinical practice guideline for the diagnosis, management, and prevention of bronchiolitis. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. Antimicrobial resistance and antimicrobial stewardship: appropriate and judicious use of antimicrobial agents. Efficacy, abuse, and toxicity of over-the-counter cough and cold medications in the pediatric population. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Identification of children at very low-risk of clinically-important brain injuries after head trauma: A prospective cohort study. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Febrile Seizures: Guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure.
Such improvements would include the use of optimized rations, enzymes and artificial amino acids. Further savings in the grain bill could come from the use of advanced animal genotypes. While research into technological advances for commercial and industrial livestock production have been largely left to the private sector, the public sector needs to assume a proactive role in research and technology development with regard to natural resource management, and in reducing market barriers for small producers. Reducingtheenvironmentalandsocialimpacts ofintensiveproduction As described in Chapter 1, an estimated 80 percent of total livestock sector growth comes from industrial production systems. The environmental problems created by industrial systems do not derive from their large scale or their production intensity, but from their geographical location and concentration. In extreme cases, size may be a problem: sometimes units are so large (a few hundred thousand pigs, for example) that waste disposal will always be a problem, no matter where these units are put. Industrial systems are often located in a way that prevents sustainable waste management. Crop production and livestock activities are being increasingly separated, so that sufficient land to safely dispose of waste is not available nearby. So far, environmental concerns have not often been a factor shaping the regional distribution of livestock production. Easy access to input and product markets, and relative costs of land and labour have so far been the major deter- 278 Summary and conclusions mining factors. For developing countries, the concentration of industrial units in peri-urban environments is typical because of infrastructure constraints. In developed countries, there is certainly a move towards rural environments but this often seems to be motivated by an attempt to hide these places away, rather than addressing the fundamental environmental concerns. What is required therefore is to bring waste generated into line with capacity of accessible land to absorb that waste. Suitable policy options include zoning and licensing, mandatory nutrient management plans, and facilitation of contractual agreements between livestock producers and crop farmers. Only a spatially decentralized livestock sector will create sufficient opportunities and incentives for recycling livestock waste on land. For the medium-term future, the preferred option is the reintegration of crop and livestock activities. Policies need to drive the decentralization of industrial and intensive livestock away from consumption centres and ports, towards rural areas with nutrient demand. Regulations are needed to deal with heavy metal and drug residue issues at the feed and waste levels, and with other public health aspects such as food-borne pathogens. Spatially decentralized livestock activities can also offer substantial social benefits for rural development, particularly in areas with limited alternative employment and growth opportunities. Incentives need to accompany these regula- tions, such as lower taxes for establishment of commercial production units in nutrient deficit areas, eventually subsidies for relocation of large scale enterprises. Where decentralization cannot be achieved, industrial systems need to have systems of zero-emission in place, such as in industrial parks with full waste treatment, including biogas digestion and processing of manure for use as fertilizer. With current technology these systems will be costly and energy-intensive, but bio-gas, where technology is improving fast, might be an attractive option. In parallel, there is a need to address the environmental impacts associated with production of grain, oil and protein feed. Feed is usually produced in intensive agriculture, and the principles and instruments that have been developed to control environmental issues there need to be widely applied. They include integrated pest management, and soil management and fertilization plans. In parallel, to reduce pressure on marine capture fisheries, the sector needs to develop alternatives to the use of fishmeal as feed, for example by using synthetic amino acids. The shift to intensive production systems is accompanied by increasing size of operation, driven by economies of scale. Despite an overall growth of the sector, this is only achieved at the cost of pushing numerous small- and middle-scale producers and other agents out of business. Diversification within and outside the agricultural sector and social safety nets are some of the policies developed to address these issues.
Caution should be exercised so as to open areas only when there are functioning authorities to control access, land titling, area protection and law enforcement. Public research and extension can help in driving land use towards more productive and sustainable forms, by developing technical packages focusing on intensification, including improved pasture, intensified dairy or beef production and the inclusion of forests and silvo-pastoral land use on farms. Research (Murgueitio, 2004; Olea, Lopez-Bellido and Poblaciones, 2004) has shown that such forms of land use are profitable, particularly for small farms with a relative abundance of labour, and can generate significant environmental benefits. A large part of tropical pastures (estimates range up to 50 percent) are seriously degraded, caused by unsuitable terrain (slopes), and high rainfall. Deforestation and the spontaneous establishment of pastures without any protective measures or improvements, leaves the soil exposed and subject to erosion. The ensuing degradation can be addressed by forms of silvo-pastoral land use that mimic the original vegetation to a certain extent (see Box 6. The most immediate option lies in payment for water services, as benefits in improved water flows and quality would directly benefit local communities downstream. Silvo-pastoral systems, in combination with other measures of water protection, considerably reduce runoff and sedimentation of reservoirs. About 200 farmers in six watersheds in three countries (Colombia, Costa Rica and Nicaragua) participate in this scheme. A total of about 2 000 hectares were established with improved, deeperrooting pastures and more trees, more than 850 km of living fence were established, which significantly improved the connectivity of the different habitats, and about 100 hectares in slopes were left in fallow to regenerate to secondary forest. In Costa Rica, the government decided to include agroforestry (and this scheme) in its forest environmental service payment scheme, which is funded through fuel taxes and water charges. In Colombia the National Livestock Federation is negotiating international and national funding sources to up-scale this pilot operation. In some cases, new opportunities for payment schemes are arising, such as for Costa Rica, where part of the fuel tax is used for such purposes. Payments for biodiversity protection are, at present, mainly in the form of tourism revenues. As described in Chapter 2, when introducing the concept of the livestock transition, pasture expansion has reached its peak in most parts of the world, occupying areas that are, at best, marginally productive, which are, in many ways, unsuitable for sustained production. Growing demands for environmental services are starting to compete with traditional forms of low-output livestock production, leading to progressive abandonment of marginal pastures. Degradation of rangeland, on both communal and private lands, is a pressing issue in many countries, including developed countries. Degradation of rangeland has important negative consequences for water resources and biodiversity and is an important source of greenhouse gases. These problems are particularly pronounced in areas where the livelihoods of many poor people depend on livestock, and on the common pasture that sustains them, and where alternative livelihood options (such as urban employment) are absent. These conditions are widespread in arid and semi-arid zones of sub-Saharan Africa, and parts of the Near East, South Asia and Central Asia (see Map 26, Annex 1). Under common property regimes, overgrazing of common property resources is often caused by mobility restrictions. These arise from the expansion of rainfed cropping in key dry-season grazing areas for mobile systems, land privatization, fencing and establishment of irrigation schemes. A key characteristic of the dry areas is the extreme variability of the rainfall, and hence bio-mass production. Fixing livestock numbers under such extreme variability is, therefore, counterproductive.
Evidence is insufficient to detect differences by medication dose, duration of treatment, long term effectiveness and harms. With notable exceptions, the majority of surgical studies did not follow patients beyond the postoperative period. Therefore, many studies did not report patient-specific, or symptom related outcomes such as change in fibroid-related pain or bleeding. Many of the studies with surgical or procedural interventions reported intermediate outcomes only, such as technical success, hospital length of stay, or estimates of blood loss related to the surgery. For the complete assessment of strength of evidence, including risk of bias, study limitations, reporting bias, precision, consistency and directness of results, see the summaries presented in the full report. It is likely that much fewer than half of women will choose subsequent treatment in the near-term after an initial intervention. However, we can also speculate that the priorities which led women to participate in the initial trials reflected the intensity of treatments they were most interested in pursuing so it is not surprising surgeries were most followed by other procedures promptly (within 6 months) by those were not satisfied with initial results while those who enrolled in medication trials were less likely to pursue more aggressive options. Because of the limited roster of studies that followed women for 6, 12, or 24 months, this analysis does not substitute for study of treatment trajectories in which all initial treatments can be followed by all possible combinations of next treatments. Influence of Patient/Fibroid Characteristics on Effectiveness Overall, data are inadequate to assist women in choosing one intervention over another based on her individual characteristics or the characteristics of her fibroids. Too few studies were adequately powered to determine within arms if one subgroup or another has superior outcomes within a treatment. Such information is required as a first step towards using individual characteristics to inform treatment choice. Risk of Leiomyosarcoma When Mass Thought To Be a Fibroid Overall, from 160 studies, we conclude that in every 10,000 who have surgery for fibroids, between 0 to 13 women, may be found to have a leiomyosarcoma. One advantage to prospective studies is that they employ standardized approaches for inclusion and data collection and apply quality controls for histopathology. Participants in prospective studies were somewhat younger than those in retrospective studies (mean age 38. Among prospective studies 57 percent focused on myomectomy findings; 36 percent on hysterectomy, and 6 percent included both types of surgery. Among retrospective studies 32 percent focused on myomectomy; 49 percent hysterectomy, and 19 percent both. Because leiomyosarcoma risk increases with age 25,26, differences in age distribution and potentially in surgery type would be expected to result in a lower prevalence estimated by our models. The literature investing the prevalence of leiomyosarcoma in presumed fibroids has grown rapidly and this continues to inform risk estimates. Unfortunately, the published literature does not contain enough detail to stratify risks by age, menopausal status, or surgical approach. Similarly, the literature lacks information on individual or fibroid characteristics that could discriminate those at high risk from those with lower risk. Thus the available data produces wide confidence intervals for broad groups of women when estimating rare outcomes. Factors Affecting Leiomyosarcoma Survival At this time, definitive data that power morcellation is associated with poor long-term outcomes in the presence of unsuspected leiomyosarcoma is limited. In our meta-analysis of 24 studies that provide data about use of morcellation in three categories: none, scalpel, or power; we find that power morcellation may be a determinant of death from leiomyosarcoma. As noted above, we cannot discern from the available literature any patient or fibroid characteristics that predict survival. Applicability Overall, our findings are widely applicable to the general population of women seeking treatment for uterine fibroids. We excluded studies in pregnant women, and restricted our synthesis to treatments currently available in the United States. Although the outcomes collected may differ by country and by healthcare setting, the interventions were selected to be comparable so that the results reported in this review are expected to apply to women with fibroids in the United States. This population is not an ideal substitute as participants in the trials presumably hoped to receive active treatment and may report their status differently than women willing to be randomized to watchful waiting. This could restrict applicability but since the majority of studies included a plausible level of participant masking, they would be unlikely to know if they were on an active agent. Surgical studies evaluated hysterectomy, myomectomy, and endometrial ablation in over 3,000 women.
References:
