Cloning and the human embryo Cloning and reproduction buy discount super levitra 80mg, especially cloning the human embryo order 80 mg super levitra amex, made the headlines after the report at one of the American Fertility Society meetings generic super levitra 80 mg with visa, in 1994 purchase super levitra overnight, of an experiment describing embryo-splitting. The principle of the creation of identical human beings is thus not a new subject, but the method described by Wilmut and colleagues certainly is (Wilmut et al. Jonas has also stated that the two most awesome kinds of responsibility we may ever face are those of politicians towards society and of parents to their children. This arguably may be extended to future or planned children, the matter Ethical issues in embryo interventions and cloning 155 which concerns us in assisted reproduction. It is indeed because we are responsible, or moral subjects, that we wish to analyse rationally the argu- ments for and against cloning for reproductive purposes. Interestingly, the introduction of the report by the group of advisers to the European Union (European Commission, 1997) states, ‘As there is no dis- crimination against twins per se, it follows that there is no per se objection to genetically identical human beings’. This makes it clear that one must Wnd other arguments than the noumenon (‘thing in itself’) of cloning (its ‘real existence’) in order to counter arguments in favour of human reproductive cloning. The argument of dignity is underlined, using the Kantian categorical precept – ‘to treat each and everyone as an end to themselves and not merely as a means to an end’. Of course we know that a clone obtained by somatic cell nuclear transfer would not be totally identical to the adult donor of the nucleus, because of the recipient cytoplasm bearing the maternal mitochondria; but more im- portantly, the same argument can be used against reproductive cloning by embryo-splitting and transfer to diVerent surrogate mothers at diVerent times. To quote the report: It would be absurd to consider that an adult and his clonal duplicate who must necessarily be born much later, and is bound to have a diVerent life history, could be to any degree presented as two copies of a single and identical person. To believe such a thing would be to fall victim to the reductive illusion which is born of the dismal confusion between identity in the physical sense of sameness (idem) and in the moral sense of selfness (ipse). The report continues: [N]evertheless, although to possess the same genome in no way leads two individuals to own the same psyche, reproductive cloning would still inaugurate a fundamental upheaval of the relationship between genetic identity and personal identity in its 156 F. The uniqueness of each human being, which upholds human autonomy and dignity, is immediately expressed by the unique appearance of body and countenance which is the result of the singularity of each genome. The autonomous human being (who may be deWned as one who is ‘submitted to his or her own laws’) may allegedly be threatened in this very quality by facing his or her relatively identical clones. Can we not argue instead that the best way to counteract discrimination is to accept diVerence as a valuable addition to the rich tapestry of life rather than fear its conse- quences? Indeed if dignity has to be deWned in any essential manner, as it must be if enshrined in international declarations, it is the unique quality of all human beings, also recognized in their diVerences, even if there is a degree of sameness, which gives us dignity. This is obviously absurd, and we have therefore to conclude that even if normal sexual reproduction were a necessary condition for human liberty, it is far from being a suYcient one. It seems reasonable to suppose that the constraints im- posed by the father’s sexual identity would somehow aVect the cloned child; would this be a reduction of the child’s liberty? Ethical issues in embryo interventions and cloning 157 Perhaps feminist psychoanalytical arguments can help us understand the problem of identity – for example, the work of Julia Kristeva (1991) and Luce Irigaray (see Whitford, 1991). Kristeva argues that we cannot respect and accept strangers if we have not accepted our own portion of strangeness, in other words, the stranger within ourselves (Kristeva, 1991). The implication for cloning is that the parent(s) seeking reproductive cloning cannot accept that strangeness carried in the matrix of the gestating mother. In the same analytical vein, one could argue that the fantasy of immortality, or the desire for genetic perpetuation at any cost by those who cannot procreate, seems a more narcissistic venture than the often unconscious choice of a reproductive partner. In a similarly psychoanalytical fashion, Irigaray begins from the Lacanian account of the mirror stage in identity development, but adds a feminist twist. For men, ego formation depends on coming to see the world as a mirror, on which the male projects his own ego; women are part of the mirror, so that they never see reXections of themselves (Whitford, 1991: p. The implication for cloning, after the manner of both Kristeva and Irigaray, is that deeper psychoanalytical forces are at work in popular revulsion at the idea. Because the identity of the subject is shaky, and subjectivity itself something to be constructed rather than a given, cloning poses a threat to our personal identity which we Wnd diYcult to tolerate. Another psychoanalytical question concerns the child thus conceived, rather than the parent – how will the child cope with building his or her sexual identity? Therapeutic cloning (or other applications of cloning technology which do not involve the creation of genetically identical individuals) has led to much less dismay. The European Commission Group of Advisors on the Ethical Implications of Biotechnology (1997) report reiterates in its summary that: As far as the human applications are concerned, it distinguishes between reproductive and non-reproductive (research), and also nuclear and replacement and embryo splitting limited to the in vitro phase, i. The European report stresses that therapeutic cloning should aim either to throw light on the causes of human disease or to contribute to the alleviation of suVering. All raise questions about what respect is owed to the embryo, its moral status, as well as about human rights, including the right to reproduce and the right to a family life. Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Bioethics Convention. Currently only 1 in 50 women of child-bearing age becomes pregnant following a renal transplant, and it may be that many more would welcome the chance of biological parenthood if their fertility problems could be overcome. However, some reviews (Sturgiss and Davison, 1992; Davison, 1994) have suggested that pregnancy in the graft recipient, unlike the rare pregnancy in patients undergoing dialysis, is usually likely to lead to a live birth, and that pregnancy may have little or no adverse eVect on either renal function or blood pressure in the transplant recipient. The current medical consensus is that if, prior to conception, renal function is well preserved, and if the patient does not develop high blood pressure, only a minority of transplant recipients will experience a deterioration of their renal function attributable to pregnancy (Lindheimer and Katz, 1992). It is inevitable that the rapid return to good health enjoyed by the majority of women following successful renal transplantation should encourage them to consider conception. Lockwood was due to severe, recurrent pre-eclampsia, a potentially life-threatening condition of late pregnancy causing raised blood pressure and renal compli- cations, which can progress to cause Wts and cerebro-vascular accidents (strokes). Sterilization by tubal ligation was offered and accepted under these circumstances, in view of the anticipated further deterioration of her renal function with any subsequent pregnancy. There was a signiﬁcant further ad- vance of her renal disease, necessitating the initiation of haemodialysis (a kidney machine) two years later, and a living, related donor renal transplant (from her mother) was subsequently performed. After the transplant, Mrs A remained well and maintained good kidney function on a combination of anti-rejection drugs, steroids and blood pressure tablets. At age 26, a reversal- of-sterilization operation was performed because she had become so distressed by her childlessness, but hysterosalpingography (a test to check for fallopian tubal patency) two years later, when pregnancy had not occurred, showed that both tubes had once again become blocked. Mrs A’s pregnancy test was positive 13 days after embryo transfer, and an ultrasound scan performed at eight weeks’ gestation showed a viable twin pregnancy. Throughout the treatment cycle and during pregnancy, the patient’s anti- rejection drugs (azathioprine and prednisolone) were continued at mainte- nance doses. The pregnancy was complicated at 20 weeks’ gestation by a right deep vein thrombosis, affecting the femoral and external iliac veins, and anti-coagulation with heparin and warfarin was required. Spontaneous rupture of the mem- branes, leading to premature delivery, occurred at 29 weeks’ gestation; the twins were delivered vaginallyand in good condition three hours later. After delivery of her babies, Mrs A remained well and her renal graft continued to function normally, with no change in immunosuppressive or antihypertensive (blood pressure) medication required. Risks to the mother, the fetus and the neonate Severe pre-eclampsia and eclampsia can result in irreversible damage to the maternal kidney, particularly due to acute renal cortical necrosis. Women who have recurrent pre-eclampsia in several pregnancies or blood pressures that remain elevated in the period following delivery (the puerperium), especially if they have pre-existing renal disease and/or hypertension, have a higher incidence of later cardiovascular disorders and a reduced life expect- ancy (Chesley, Annitto and Cosgrove, 1989). Pregnancy is recognized to be a privileged immunological state, and therefore episodes of rejection during pregnancy might be expected to be lower than for non-pregnant transplant recipients. Nevertheless, rejection episodes occur in nine per cent of pregnant women, occasionally in women who have had years of stable renal function- ing prior to conception. More rarely, rejection episodes occur in the puer- perium, when they may represent a rebound eVect from the altered im- munosuppressiveness of pregancy. Immunosuppressive (anti-rejection) drugs are theoretically toxic to the developing fetus; however, maternal health and graft function require im- munosuppression to be maintained. A large French study of women with pre-existing renal damage reported a prematurity rate of 17 per cent and a spontaneous abortion rate (miscarriage) of 20 per cent, as compared to 164 G. Severe pre-eclampsia can present as a progressive condition, tending to occur with greater virulence in successive pregnancies (Campbell and MacGillivrey, 1985). This, after all, had been the rationale behind the original decision to sterilize the patient after the death of her second baby, precipitated by pre-eclampsia and extreme prematurity. The successfully functioning trans- planted kidney had been donated by the patient’s mother and therefore, as an organ, was 30 years older than the patient herself. An editorial review (Davison and Redman, 1997) reported that 35 per cent of all conceptions in renal transplant patients failed to progress beyond the Wrst trimester because of therapeutic (approximately 20 per cent) and spon- taneous (approximately 14 per cent) abortions. Problems occur some time after delivery in 11 per cent of all women with transplants, unless the pregnancy was complicated prior to 28 weeks’ gestation, in which case remote problems can occur in 24 per cent of pregnancies. However, of the conceptions that continue beyond the Wrst trimester, 94 per cent end success- fully, in spite of a 30 per cent chance of developing hypertension, pre-eclampsia, or both.
The taxpayer tab for government 11 spending on the consequences of risky substance significant behavioral characteristics that 12 use and addiction alone totals $467 order super levitra 80mg overnight delivery. Our continued failure to prevent and treat the disease The Largest Share of Costs Falls to the is inconsistent with ethical standards and the Health Care System goals of medical practice order 80mg super levitra with amex. The largest share of spending on the consequences of risky substance use and 18 addiction is in health care buy super levitra 80mg low price. Persons with addictive diseases are among the highest-cost 19 health care users in America: they have higher utilization rates purchase super levitra now, more frequent hospital admissions, longer hospital stays and require 20 more expensive health care services. Treatment The health care costs associated with addiction also stem from the impact that addiction has on There are no national data available on total the ability to treat other diseases. Addiction health care spending for screening or ** 34 affects the body in ways that complicate health intervention services; therefore, data on cost care, for example, by weakening the immune savings from these services and from addiction 23 treatment come from individual studies rather system. The cost estimates for treating diabetes, cancer and heart * Including medical, mental health and direct conditions were inflated to 2010 dollars using the treatment costs. According to a 1999 study, the cost Cost-benefit studies of screening and brief * † of providing managed, comprehensive interventions for tobacco and alcohol use among addiction treatment benefits with low co- adults and pregnant women have demonstrated a ‡ 43 payments and no annual limits was $5. Adding managed, studies have demonstrated that medical costs for unlimited addiction treatment benefits to a plan patients with addiction increase significantly as that previously did not offer addiction treatment 44 these patients age, implying that the greatest § benefits would increase costs only by an cost savings can be achieved by early ** 40 §§ 45 estimated 0. In the health Congressional Budget Office estimated that care field, treatment costs of up to $50,000 for mandating parity for mental health and addiction each year of life saved are considered to be a treatment benefits would increase group health worthwhile investment in health (i. Smoking cessation programs yield parity in Federal Employee Health Benefit Plans positive health outcomes at the low cost of have concluded that total plan spending per *** 47 $5,000 per healthy year gained compared to $56,200 per year for Aspirin and statin therapy * Benefits carved out and provided by a large ‡‡ managed behavioral health care organization. Research is presented related to screening and † Including outpatient, intensive outpatient, inpatient interventions for smoking and risky alcohol use. A study of primary especially cost effective, given that the smoking- care screening and brief physician intervention attributable medical care needed by infants for adult risky drinkers yielded a net benefit of 56 whose mothers smoked while pregnant is an $947 per person. A one- percent reduction in the prevalence of smoking The use of screening and brief interventions in in the U. A study of screening and brief § low-birth weight births by 2,000, resulting in interventions for risky alcohol use among adults $21 million in avoided direct medical costs. In The American Legacy Foundation projected that total, the implementation of a hospital-based a reduction in Medicaid costs of nearly one alcohol screening and brief intervention program ** billion dollars could be achieved by preventing for risky alcohol use was estimated to reduce †† the current cohort of 24-year-olds from health care costs by $3. Brief interventions with adolescents were successful in motivating all Medicaid ages 18 and 19 who were admitted to a trauma recipients who smoke to quit, states’ Medicaid center for alcohol-related injuries also have been expenditures would be, on average, 5. An alcohol intervention program costing For 45-year old men with a 10-year risk for $50,000 that could successfully prevent at least coronary heart disease of 7. Consisting of two doctor visits and two nurse † Costs include individually-tailored diet and exercise follow-up calls. Significant declines were seen in hospital stays, generating billions of dollars areas such as the number of inpatient 61 hospital days and emergency department in largely avoidable health care charges. Some research suggests that treatment alcohol or drugs other than nicotine who “pays for itself,” often on the day it is delivered were enrolled in an outpatient treatment † and the total cost savings from addiction program with a control group found that 63 treatment continue to accrue over time. The study 64 are greater than the cost of treatment, also found that treatment can cut health care administrators and policymakers too often costs associated with addiction by about one disregard benefits of treatment that accrue quarter, primarily by reducing the number of beyond the narrow silo of each individual annual hospital stays and the likelihood of 67 government program. The one exception was opioid associated with an annual $2,500 reduction ** maintenance therapy which paid for itself in in medical expenses among adult patients health care savings. Adults who met criteria for addiction involving alcohol or other drugs but did not receive treatment. Most of the reductions in medical examples of the nature of the treatment provided. Following the implementation of Medicaid- covered pharmaceutical therapy for addiction A performance audit of the costs and involving nicotine, Massachusetts had a 46 savings to the Colorado Medicaid Program-- percent annual decrease in hospitalizations for which in 2006, implemented a benefit to heart attacks and a 49 percent annual decrease in †† 74 provide outpatient addiction treatment for cases of coronary atherosclerosis. Those in the control group depending on the modality of treatment were more likely to have an alcohol-related visit (with long-term residential treatment to the emergency department during the study yielding the greatest reduction in recidivism, compared to patients taking naltrexone (15 72 76 roughly 27 to 34 percent). One study Measured as receiving a clinical diagnosis of alcohol or other drug dependence or psychosis, examined the cost effectiveness of providing receiving detoxification services or having been referred for alcohol or other drug assessment by the state division of alcohol and substance abuse. There were, however, no significant changes in ‡ Analysis based on available Medicaid claims data, rates of hospital admissions for respiratory conditions not a controlled longitudinal study. Recently-enacted federal and state parity laws An examination of health care and pharmacy have expanded coverage for addiction treatment costs for patients with addiction involving where offered, and the Patient Protection and opioids in a large U. Another study projected Federal and state parity laws require private that methadone maintenance therapy costs ‡ 80 insurers that provide mental health and addiction $5,915 for every year of life gained. In general, restrictions placed capacity for heroin users is cost effective, at on addiction services (e. Applies to plan years beginning on or after July 1, ‡ Assuming annual treatment costs of $5,250. Employers including addiction benefits in 97% 97% * most popular plan This includes traditional and benchmark/benchmark Employers placing equivalent managed care plans. Even if they are married, in school or eligible to † Including new small fully-insured or self-insured enroll in their employer’s plan. These services Impede Comprehensive Addiction Care were reimbursed only when reasonable and 112 necessary to diagnose or treat illness or injury. Recent developments in Medicare would provide coverage in primary § Medicare and Medicaid reimbursement have care settings for preventive annual alcohol ** begun to remove some of the cost barriers that screening of all patients and up to four brief, health professionals faced in routinely screening face-to-face interventions for Medicare their patients for risky use of addictive beneficiaries who screen positive for risky substances and conducting early interventions alcohol use but who do not meet clinical criteria 106 113 when necessary. Although there are no specific 107 Medicare codes for general tobacco use effective. The Medicaid codes cover these services related to alcohol and other drugs screening, questions about tobacco use are 108 considered part of the medical history to be (excluding nicotine). These codes are available for health care providers in individual collected, for example, during the Initial states to use but there is no requirement for Preventive Physical Examination for those new 115 providers to use the codes. As of August 2010, Medicare determine which services are reimbursed and, to does cover preventive tobacco cessation be operational, states have to enable the billing counseling for smokers who do not present with * 109 signs or symptoms of tobacco-related disease. With regard to smoking, the only screening The benefit includes two individual tobacco services that states explicitly are required to cessation counseling attempts per year, with 116 provide are those that fall under the Early and each attempt consisting of up to four sessions. Medicare allows providers to choose any screening tool that is alcohol and other drugs (excluding nicotine) for appropriate for their clinical population and setting. A similar legal provision of individuals covered under Medicaid and allows many states to deny disability payments * 122 commercial insurance, but also allows states or workers’ compensation to individuals harmed facing budget deficits to scale back eligibility while under the influence of alcohol or while † 123 under certain circumstances. Because of participating in an illegal act, such as driving 130 economic constraints, states appear to be cutting under the influence. Current coverage of addiction treatment is not designed to prevent An additional resource problem that stands in and treat the disease effectively. States are counseling and/or psychotherapy, and free to choose whether or not to include tobacco 143 diagnosis, treatment, assessment and cessation benefits for other enrollees. Eight states covered group counseling for all Medicaid Outpatient rehabilitation services, including enrollees, five covered group counseling only diagnostic and treatment services. States for enrollees in some programs (fee for service providing optional benefits under Medicaid or managed care) and five states covered group often choose this option since it does not counseling for pregnant women only. As of require services to be provided under the 2009, 34 states covered the nicotine patch for all direction of a physician and instead permits Medicaid enrollees, 33 covered bupropion, 32 the delivery of services including mutual covered nicotine gum, 32 covered varenicline, support by community paraprofessionals and 28 covered nicotine nasal spray, 27 covered 138 nicotine inhalers and 25 covered nicotine peers; 144 lozenges. As of 2011, six state Medicaid 139 programs provide comprehensive coverage for Clinic services; and smoking cessation treatments for all Medicaid 140 enrollees, while five state Medicaid programs Case management services. Last, states may provide addiction treatment services as part of a Medicaid managed care † 141 Medicare. Medicare covers the their eligibility requirements and benefits, following services, when medically necessary: individuals have substantially different access to care depending on the state in which they live. States Tobacco cessation counseling from a that opt simply to expand their Medicaid qualified physician or practitioner for all * programs are required to follow the rules and smokers and tobacco cessation medications 157 151 requirements of Medicaid. States also may use a benefits package that is † Annual limits are caps that insurers place on the actuarially equivalent to one of the benchmark plans, benefits an enrollee is entitled to each year. Limits an already existing state-funded plan or any other can apply to particular services (e. Lifetime limits are caps on results in a cost increase of greater than two percent expenditures, on specific services or both during an in the first plan year and greater than one percent in individual’s lifetime. For some of those allowed visits or length of stay, however, does who were successful in becoming insured, co- not accord with best practices for treating cases insurance and co-payments rendered treatment 164 169 of addiction that are chronic and relapsing. Furthermore, coverage for for addiction treatment benefits were 170 mental health and addiction services varies unaffected. Yet arise from its passage, many limitations remain rather than defining what these services must both in policy and practice. As a result, individual market (“grandfathered”) health 173 care may transition toward outpatient plans. Supreme insurance through individual mandates to 168 * purchase insurance and government subsidies.
Megumi1 clusion: Muscle force of (A) upper limb demonstrates 39% decrease 1 short time after stroke buy super levitra 80mg. Man shows more signifcant decrease than Kagoshima University purchase super levitra 80 mg visa, Department of Rehabilitation and Physical women (40% vs 35%) discount 80mg super levitra fast delivery. Grant of Kagoshima University Hospital buy 80 mg super levitra fast delivery, Department of Rehabilitation, Medical University of Lodz, Poland 502-03/5-127-05/502-54-173. Material and Methods: Two raters Medicine and Rehabilitation, Makassar, Indonesia, 3Hasanuddin (A and B) tested 38 post-stroke patients. For the intra-rater reliabil- Hospital, Physical Medicine and Rehabilitation, Makassar, Indo- ity investigation, rater A tested the participants on three separate test nesia occasions (days 1, 2, and 3) at the same time of day. For the inter- rater reliability investigation, raters A and B independently tested Introduction/Background: Cerebrovascular incident or stroke is the participants on the same test occasion (day 3). The classifcation will stratify the stroke survivor into vegetative, non-vegetative total dependency, minimally independ- ency, moderate independency, independent supervised, vocational 458 limitation, vocational supervised, and normal respectively. He was referred to speech pathologist, A barium swallow was outpatient clinic and inpatient ward of Akademis Jaury Hospital in carried out to assess the swallowing and swallowing therapy was Makassar, Indonesia. WalkAide is single channeled with transcu- Saga University, Rehabilitation Medicine, Saga, Japan taneous electrodes with the wireless control of stimulation through Introduction/Background: The purpose of this study was to deter- a tilt sensor. Twenty individuals who had experienced stroke ≥6 months tients with spastic upper limb hemiparesis. Material and Methods: previously and had a functional ambulation classifcation score of The study subjects were 12 post-stroke outpatients with spastic up- ≥5 took part in the 4-week intervention, and were followed up for per limb hemiparesis (age: 52 to 73 years, males: 10). WalkAide assisted gait training, and physi- injected into the spastic muscles and orthotic treatment was done cal therapy was combined during interventions. It has been reported that most of stroke patients recover mind is a motor neuron disease. Mate- factors which affect swallowing abnormalities, but these studies in- rial and Methods: Case description: We report a case of 70 years cluded all stroke types. Therefore, it is still unclear what factor af- old gentleman with sudden onset of dysphagia and posing a di- fect prognosis of dysphagia in supratentorial stroke. The individual was brought to our clinic with focused thalamic hemorrhage patients who received rehabilitation in 03 weeks history of dysphagia and no associated motor or sensory a post-acute rehabilitation hospital and examined relationships be- weakness. There was history of hypertension but not diabetes mel- tween clinical evaluations and severity of dysphagia to clarify fac- litus. Material and Methods: Subjects were 91 patient has no neurological defecit except for dysphagia, his cranial patients (34 females and 57 males, mean age 68. Seon-duck 1National Rehabilitation Center Research Institute, Clinical Re- presenting with Acute Stroke. It search for Rehabilitation, Seoul, Republic of Korea, 2National Re- is known that these changes are likely to represent the confuence habilitation Hospital, Health Promotion Center for the Disabled, of micro-infarcts. It might then be expected that these changes Seoul, Republic of Korea could represent a signifcant risk for vascular dementia. We Introduction/Background: It has been previously shown that stroke wanted to fnd out whether those patients who developed cognitive survivors did very little physical activities after the onset of stroke. Was the stroke simply a sentinel event in nearly two-thirds of the time they were inactive. And could social inactivity is likely to cause the physical and psychological we use the Fazekas (a measure of the extent of deep white mat- problems. Material and Methods: Participants training program that included resistance, aerobic, balance, fexibility were recruited upon admission to our Acute Stroke Unit. We tested 92 patients (48 men, 44 women) with Introduction/Background: The objectives of this study were to as- stroke (median age 72, range 54–82). Results: There was signifcant difference at QoL be- ischemic stroke (>3 months) were enrolled in our study. The func- 1Fujita Health University, Rehabilitation Medicine, Toyoake, Ja- tional statue was assessed according to the Barthel index, the New pan, 2Fujita Health University Hospital, Department of Rehabilita- Functional Ambulation Classifcation and the «Timed up and go tion, Toyoake, Japan test». Results: The participants’ median age was 58 years, Introduction/Background: Previous papers reported that patients 30 men (60%) and 20 women (40%). The dominant side was affected in Methods: We selected 86 cerebral infarction patients who admitted 64% of cases. Depressive profle and poor mental QoL were both associated the average length of stay, the proportion of home discharge, and with functional impairment as assessed by the Barthel Index. The period from the onset of cerebral infarction to re- depression were prevalent in ischemic stroke patients. Conclusion: Early starting to inpatient rehabilitation is 468 critical for reducing post-stroke disability. Material and Methods: A prospective study comparing two rehabilitation protocols was conducted over a period cal School, Department of Physical and Rehabilitation Medicine, of 3 months. Results: An improvement 10Sungkyunkwan University School of Medicine, Department of of balance and gait parameters, of the upper limb function and of Physical and Rehabilitation Medicine, Seoul, Republic of Korea functional status (Barthel Index), was obtained in both groups. It is also effca- pare functional recovery in the frst-ever stroke patients according cious on postural control (sitting and standing balance). Other rand- tive cohort study for all acute frst-ever stroke patients admitted to omized controlled trials with a larger number of patients, and a more participating hospitals in nine distinct areas of Korea. Saitoh1 patients were reviewed excluding stroke patients who didn’t agree J Rehabil Med Suppl 55 Poster Abstracts 139 this study. The patient who were transferred to rehabilitation were sudden death, vasospasm, re-bleeding; long term complications in- 1,482 persons (18. There were signifcant difference between clude epilepsy, neurological symptoms, cognitive impairment, anxi- 2 groups in educational year, weighted index of comorbidity, com- ety, depression or post-traumatic stress disorder. Only a ffth of the bined condition and age-related score, etiology of stroke, initial patients have no residual symptoms. The patient underwent en- bilitation department were different from those of not transferred dovascular neurosurgery (coiling technique). Although the level of severity of stroke in transferred group tions were minimal - right Abducens nerve paralysis, slight motor was much higher than that in not transferred group, the former defcit on the right arm and leg with minimum reduction of muscle showed signifcant time effect and time cross group interaction to strength. After 10 days of intensive medical treatment, the patient recover their physiologic function. Thus, early transfer to rehabili- started the rehabilitation program in the neurosurgery unit, and after tation department for post-stroke rehabilitation is very important 3 weeks, he was transferred to the rehabilitation department. The re- not only to improve stroke patient’s functional recovery but also to habilitation protocol included psychological support, dietary regime show a positive interaction including time effect. Maeshima1 lowing brain injury include physical limitations and diffculties with 1 thinking and memory. Recovery and prognosis are highly variable Fujita Health University Nanakuri Memorial Hospital, Rehabili- and largely dependent on the severity of the initial status. Results: Before treatment, experimental group and control group the balance function scores were no signifcant difference (p>0. Popa” University of Medicine and Pharmacy Iais- Roma- nia, Medical Rehabilitation, Iasi, Romania, 2Clinic Emmergency Hospital “ Prof. We started using it as a wearable patient moni- rating scale was used to assess the paralyzed Shoulder joint move- tor to screen our stroke patients during their post-acute rehabilita- ment function in the patients with stroke, before and after treatment. The Fugl-Meyer movement function out between Oct 2013, and Jul 2015, with 56 positive and 12 nega- score in the treatment group was obviously higher than the control tive results. Conclusion: Peripheral magnetic stimulation com- patients were confrmed by the detailed investigation of the Sleep bined with routine rehabilitation reduces or prevents shoulder joint Centre. The higher rate of the positive results is explained by our double or triple 475 selection criteria. Material and Methods: 23 healthy cal therapy in a patient with cerebrovascular disease who showed subjects walked on treadmill at 0. Mirror therapy is a technique that uses visual feedback about motor performance to 480 improve rehabilitation outcomes. Gomez Diaz10 group underwent 20 minutes of mirror therapy consisting of wrist 1 Complejo Hospitalario Universitario De Ourense, Neurological and fnger fexion and extension movements, while the control 2 group performed sham therapy with similar duration, 5 days a week Rehabilitation, Ourense, Spain, Complejo Hospitalario Universi- tario De A Coruna, Epidemiology Unit, A Coruna, Spain, 3Centro for 4 weeks. After treatment both groups showed statisti- Augusti, Intensive Care, Lugo, Spain, 8Complejo Hospitalario cally signifcant improvement in all outcome measures.
Type B reactions are un- listed in the local prescribing information cheap super levitra 80mg with visa,in an predictable idiosyncratic reactions which are usu- effort to inform patients and prescribers of any ally infrequent but can be very serious or fatal purchase super levitra 80 mg without a prescription. It is the responsibility of Monitoring the safety of medicines is a shared re- the manufacturer to try to obtain as much relevant sponsibility involving super levitra 80mg without prescription,among others purchase super levitra line,the pharma- information as possible so that they can be clinic- ceutical industry,physicians,and regulatory ally assessed,particularly those that are serious. The primary responsibility must belong to the individual pharmaceutical company,which knows the most about the drugs and has the Sample Size greatest interest in the proper and safe use of the drugs and in maximizing the usefulness of their Clinical trials designed to prove the safety and products to patients. While the group had identified during controlled clinical trials,due to no official authority,it was hoped that the members the exclusion of patients taking concomitant medi- would influence their respective government cations,which are not allowed to be taken during agencies to enact regulations which would improve a study. Any report drug interaction was found to be due to inhibition of serious,unexpected adverse drug reactions was of cytochrome P-450 by ketoconazole or erythro- to be submitted to regulators within 15 working mycin,leading to the build-up of native terfena- days of receipt by the company. The benefits of the A document prepared by the pharmaceutical subject drug are described,compared to alternative manufacturer,containing [among other things] all therapies (medical and surgical) and no treatment relevant safety information,such as adverse drug at all. Similarly,after discussing the new safety reactions,which the manufacturer requires to be listed for the drug in all countries where the drug is issue,the risks are compared between the subject marketed. As there were questions pertain- cluding the quality and qantity of any subsequent ing to what information should be included in a evidence that would influence the decision. Conference on Harmonization 1994; Worden 1995) to provide a forum for discussions regarding differences in technical requirements for product Benefit±Risk Evaluation registration,to identify where technical modifica- tions or mutual acceptance of research and devel- The comparative evaluation or balancing of risks opment procedures could lead to more economical and benefits of pharmaceutical products is inevit- use of resources,and to make recommendations on able,although there are no standard,widely practical ways to achieve greater harmonization. A serious adverse adverse events are considered possibly drug-related event (or experience,or reaction) was defined as by the reporter,even if the motivation is only an any untoward medical occurrence that at any inquiry into the possibility that the subject drug dose results in death,is life-threatening,requires could be associated with the event in a particular inpatient hospitalization or prolongation of patient. Occasionally a case report,even from a existing hospitalization,results in persistent or sig- patient,will describe fully his/her adverse event, nificant disability/incapacity,or is a congenital including positive rechallenge,and this is very im- anomaly/birth defect. Does it provide reassurance,when reviewed as a whole set, matter,though,to the patient or prescriber to that no reports for drug x causing event y have know the incidence more specifically,e. For spontaneous case reports in general, The spontaneous case report database cannot be the specific incidence is less important than diligent used to give an accurate incidence rate of even the open-minded review of the data,looking for pat- Type B adverse reactions,as not all cases are terns. Nor do spontaneous case reports lend them- It is often difficult to assess causality,both for selves to meaningful comparisons between differ- individual patients and in relation to the drug itself. There were broad differences in The main advantage of spontaneous case reports interpretation of causality of adverse events,repre- is that they can provide important signals when senting the difficulties in assessing causality of indi- reviewed collectively. Nevertheless,routine review of individual known to occur with other drugs in the same class cases by responsible,experienced reviewers is the or with similar structure? Postmarketing Product labeling describes currently known rele- safety surveillance may be the only way new signals vant information about a drug and is intended to can be detected in this population. Cohort Disease studies investigate non-randomized groups(s) on a specific drug,followed through time to see if a Oral contraceptives and gall bladder disease posed specific event occurs. Case-control studies investi- a difficult problem,since early studies inconsist- gate non-randomized groups of subjects with ently demonstrated the association between the and without an adverse event,reviewed retrospect- drug and the event. A case-control study would have It is unlikely that the association of thalidomide been a possibility if the specific gall bladder dis- taken by the pregnant female and phocomelia in order could have been specified,but it is not imme- the fetus would have been detected via the spontan- diately obvious what would have constituted an eous reporting system,because they were unsus- unbiased control group (Castle and Cooke ). With the in- women taking thalidomide would not have been creased use of technology,paper reporting of indi- helpful,since the background incidence of birth vidual case reports will be replaced by electronic defects is relatively high,and therefore the size of reporting via transmission of selected data fields. Whichever route is chosen,a company should mation if it is known that these messages do not decide on is own set of requirements for a database, reach prescribing physicians. It is also presumably the responsibility of the regulatory authorities to identify and counsel any prescriber who they identify may have mispre- Downsizing scribed a drug to the detriment of a patient. These mistakes are not deliberate,but in view of the Many pharmaceutical companies are experiencing volume of literature received by busy physicians, strains on resources due to budget constraints it is essential that important information concern- and resource reallocation (or downsizing). In the future, professionals need to process more cases and in less the medical history of a patient could be added to time,due to changing regulatory reporting time- a card which could be used by a pharmacist to lines. The physician would then be alerted to any contraindications,warnings or precautions Licensing In and Licensing Out that may be relevant to individual patients if pre- scribed the drug. Agreements should quantifying adverse drug reactions in children: opportunities include wording describing how individual reports and obstacles for the manufacturer. Defining how much newly laid patio may be, someone always manages management, by whom and whose disease, are to tripupat the point where two slabs abutÐthe just some of the further considerations. Partly from entire process along the pathway of the disease, a lack of understanding, partly political interfer- focused around the needs of the patient. It ever, implementation of the recommendations con- has far-reaching consequences for the health ser- tained in Information for Health is part of a 7-year vices and its employees and for the politicians programme. There should be no Pharmaceutical companies have tried modest ex- dogmatic belief that the private sector should do everything or that the public sector should periments, but have not seen many of their efforts do everything. In brief, Despite the obvious answers to the concerns ex- the guidance highlighted the following areas of con- pressed in Government guidance, few companies cern: or health service units appeared to have had the enthusiasm to take on the inevitable obstacles and 1. Where long-term arrangements with pharma- Most citizens in developed European nations feel partners mean an assured market, the pharma- that their health services are world beating. The report called patient there is still the anxiety, waits for test for the concentration of professional excellence in results, trips to hospital and visits to the surgery. As the progress into this model is not time- Take, for example, the management of diabetes staged, for the foreseeable future, there is likely to be mellitus. Whoever weight loss, pronounced thirst, or excessive urin- commissions healthcare will be beset with the trad- ation, perhaps abdominal pain and recurrent infec- itional problems of juggling demand and resources, tions or unexplained tiredness. Penalties for poor perform- The pharma-component in general is a small part ance, such as unplanned admission to hospital or of the overall costs of providing treatment. The difficult future faced by pharma- the major costs were for the supervision and hospi- companies is well known and recognized by most talization of the minority of the seriously ill. First, it is not the profits and dividends, the complexity of modern best use of its time for a health service to focus on product development, the costs of research, and cutting expenditure on the drugs budget, since this the obstacles of managed entry into the system is a tiny proportion of the cost. Some of the mergers have been marriages of con- Why should a pharma-company making pills for venience, others appear to have been far more of a the management of diabetes restrict itself to the shot-gun affair. The investment cash, earmarked some instrument for the calculation and evaluation for development, is too small to catch up from the of outcomes, including distribution of savings, very low starting base. The mysterious world of founded on the simple expectation that public the medic is revealed and power shifts to the health measures and medical technology provide payer. This formance, opportunities for improvement, failures may have been the case in dealing with acute ill- and foul-ups at zero investment for the commis- nesses that are largely curable. Each of these prototypes used valid science to The cost savings are not recorded but can be as- develop clinical practice protocols, test the proto- sumed! Agreed case management must be based on what most other large-scale industries have protocol-driven care, with staff committed foundÐthat solutions to increased profitability in and trained in related care such as patient edu- a changing market are not to be found in merely cation. The motivation for the com- tailored to the needs of particular patient groups pany to be involved is likely to be based on a desire can exclude patients who have those diseases but to acquire a monopoly in the market. In short, the judge said that guidelines could be the pharmaceutical industry has no track record ignored where a responsible body of professional of managing healthcare delivery. Meta- unhelpful budget boundaries by purchasing disease analysis of randomized controlled trials, large- management services from publicly-owned pro- sample randomized control trials, small-sample viders, or franchizing services. In healthcare systems struggling for budget, However, if healthcare is to ignore service it does seem obvious commonsense that preventing boundaries and the needs of residents, patients, more people from getting sick or becoming more and clients are seen as a horizontal continuum, ill is one way of making available resources the flow of money has to produce a high tide of go furtherÐin other words, demand management. However, it is in Scotland, where the model care, for some chronic conditions, by provid- is different, and where that the best possibility for ing lifestyle advice and health maintenance wellness management exists. At the forefront of this work is the Dir- enjoyed liberated much of their thinking but, argu- ector of Public Health for the Glasgow Health ably, produced an operational isolation. The key issue is the facility to take the whole Treating some conditions effectively requires disease area budget and focus it on preven- demolition of the operational boundaries that tion as well as cureÐin other words, wellness man- exist, as patients track their path through the agement. In England, Health Improvement system from department to department, from pri- Programmes are the tool; managers, clinicians, mary to secondary care, and often back againÐ and others will use to focus on local disease crossing supplier boundaries that created interface and public health problems and address them. If the approach sionÐhealth, social services, local authorities, and has a weakness, it is that it depends on good quality the voluntary sectorÐhave a voice. It is his unique experience that provides nity budgets can now be merged with primary care an interesting perspective on how to set up a service budgets. Hitherto, the administration of an expen- that might cross the boundaries and budgets of sive drug in primary care that kept a patient out of primary and secondary care. This is a useful starting point as There was no mechanism to share the cost or to the approach has implications for many other ser- redistribute the savings. The new arrangements create others may need oral or injected insulin replace- the possibility of a win±win situation for both ment; some may have stable disease; and others sectors and in the end the patient becomes the may be brittle, requiring much closer monitoring. Identification of the limits of care, the calculations include: cost-benefit analysis; cost- numbers and types of patients to be included, the effectiveness analysis; cost-minimization analysis; treatment protocols, and the outcome or success the cost of illness, e. Emergency arrangements for risk-sharing, if support of the medical profession, whose cooper- the number of patients referred exceeds the ation is required, can be a way around the lack of number contracted for.