Three Sisters Poem
Three Sisters Poem
Thevar Peravai Thiruvadanai
Showing posts with label When. Show all posts
Showing posts with label When. Show all posts
Saturday, 15 April 2017
Friday, 14 April 2017
WHEN YOU LOSE WEIGHT WHERE DOES THE FAT GO
Despite a worldwide obsession with diets and fitness regimes, many health professionals cannot correctly answer the question of where body fat goes when people lose weight, a UNSW Australia study shows.
The most common misconception among doctors, dieticians and personal trainers is that the missing mass has been converted into energy or heat.
"There is surprising ignorance and confusion about the metabolic process of weight loss," says Professor Andrew Brown, head of the UNSW School of Biotechnology and Biomolecular Sciences.
"The correct answer is that most of the mass is breathed out as carbon dioxide. It goes into thin air," says the study's lead author, Ruben Meerman, a physicist and Australian TV science presenter.
In their paper, published in the British Medical Journal today, the authors show that losing 10 kilograms of fat requires 29 kilograms of oxygen to be inhaled and that this metabolic process produces 28 kilograms of carbon dioxide and 11 kilograms of water.
Mr Meerman became interested in the biochemistry of weight loss through personal experience.
"I lost 15 kilograms in 2013 and simply wanted to know where those kilograms were going. After a self-directed, crash course in biochemistry, I stumbled onto this amazing result," he says.
"With a worldwide obesity crisis occurring, we should all know the answer to the simple question of where the fat goes. The fact that almost nobody could answer it took me by surprise, but it was only when I showed Andrew my calculations that we both realised how poorly this topic is being taught."
The authors met when Mr Meerman interviewed Professor Brown in a story about the science of weight loss for the Catalyst science program on ABC TV in March this year.
"Ruben's novel approach to the biochemistry of weight loss was to trace every atom in the fat being lost and, as far as I am aware, his results are completely new to the field," says Professor Brown.
"He has also exposed a completely unexpected black hole in the understanding of weight loss amongst the general public and health professionals alike."
If you follow the atoms in 10 kilograms of fat as they are 'lost', 8.4 of those kilograms are exhaled as carbon dioxide through the lungs. The remaining 1.6 kilograms becomes water, which may be excreted in urine, faeces, sweat, breath, tears and other bodily fluids, the authors report.
"None of this is obvious to people because the carbon dioxide gas we exhale is invisible," says Mr Meerman.
More than 50 per cent of the 150 doctors, dieticians and personal trainers who were surveyed thought the fat was converted to energy or heat.
"This violates the Law of Conservation of Mass. We suspect this misconception is caused by the energy in/energy out mantra surrounding weight loss," says Mr Meerman.
Some respondents thought the metabolites of fat were excreted in faeces or converted to muscle.
"The misconceptions we have encountered reveal surprising unfamiliarity about basic aspects of how the human body works," the authors say.
One of the most frequently asked questions the authors have encountered is whether simply breathing more can cause weight loss. The answer is no. Breathing more than required by a person's metabolic rate leads to hyperventilation, which can result in dizziness, palpitations and loss of consciousness.
The second most frequently asked question is whether weight loss can cause global warming.
"This reveals troubling misconceptions about global warming which is caused by unlocking the ancient carbon atoms trapped underground in fossilised organisms. The carbon atoms human beings exhale are returning to the atmosphere after just a few months or years trapped in food that was made by a plant," says Mr Meerman, who also presents the science of climate change in high schools around Australia.
Mr Meerman and Professor Brown recommend that these basic concepts be included in secondary school curricula and university biochemistry courses to correct widespread misconceptions about weight loss among lay people and health professionals.
Friday, 7 April 2017
Walkasins May Restore Balance When Walking
Today's post from pr.com (see link below) talks about an interesting development in prosthetics to help improve balance while walking, for people living with neuropathy. As almost all of you with neuropathy problems in the feet will know, balance is a serious issue; leading to unexpected trips and falls and quite often injury. It's immensely frustrating and often alarming to realise that you can't trust or place your feet in the environment in which you move. Numbness, tingling, burning, pain or a combination of all of the above, lead to wrong signals and misplacement and you're constantly watching the ground and your feet to avoid accident. Any technological development such as these Walkasins is therefore extremely interesting. They do initially look a bit 'clunky' and remind you of ankle tracking technology used for criminals but hey...wear long trousers! Reading the article, it seems that the trials were small and the technology is not yet widely available on the market but it's comforting to know that companies are seriously investing in this area and it's been a long time coming.
Minneapolis, MN, May 10, 2017 --(PR.com)
“I put them on, and it was like a miracle,” says neuropathy sufferer and study subject, Mr. Tim Kelley. Walkasins work by restoring sensory signals that are not functioning normally in patients with neuropathy. This immediate restoration of sensory function also impressed Dr. Diane Wrisley of Wingate University. “His brain learned to use the Walkasins immediately," says Wrisley. "He put them on and it was like, ‘Wow! I know where I am in space.’ His improvement is phenomenal.”
RxFunction, manufacturer of Walkasins® - the first Wearable Sensory Prosthesis to help improve balance, announced exciting results from an ongoing research study at Wingate University on the long-term benefits of Walkasins use. Walkasins help improve gait and balance in patients who have peripheral neuropathy, a condition that significantly increases the risk of falling due to loss of balance. The Foundation for Peripheral Neuropathy reports an estimated 40 Million Americans have some form of peripheral neuropathy, most commonly due to diabetes or chemotherapy.
Over 40% of diabetic patients develop neuropathy, which negatively affects quality of life and confidence to walk without falling.
“These exciting results have exceeded our expectations and illustrate how Walkasins can significantly improve the lives of millions of patients who experience gait and balance problems due to peripheral neuropathy,” says Dr. Lars Oddsson, co-inventor of the technology and President of RxFunction. “This is a game-changer that can improve health and quality of life and help decrease healthcare costs,” says Dr. Oddsson.
With neuropathy, “you don’t know where your feet are in space,” says Dr. Diane Wrisley, Principal Investigator of the study and Director of Post-Professional Programs for Wingate University’s Department of Physical Therapy. “It’s like you’re walking with bricks on your legs.”
Tim Kelley, a volunteer participant in the research study at Wingate developed diabetes three years ago. Kelley lost his truck driving license, his career of 31 years, as he became unable to drive due to his peripheral neuropathy. Over the next three years, Mr. Kelley lost confidence in his ability to walk and move safely, gained 30 lbs and even used a wheelchair for getting around. He attended physical therapy in the months leading up to the study but had noticed limited improvements.
Mr. Kelley has shown dramatic changes following his participation in the Walkasins study at Wingate University. “I put them on, and it was like a miracle,” Kelley says. Walkasins work by restoring sensory signals that are not functioning normally in patients with neuropathy. This immediate restoration of sensory function also impressed Dr. Wrisley; “His brain learned to use the Walkasins immediately. He put them on and it was like, ‘Wow! I know where I am in space.’ His improvement is phenomenal,” Wrisley says.
Dr. Wrisley has tracked Mr. Kelley’s improvement in gait and balance using standardized measurement tools, the Functional Gait Assessment (FGA) and the Mini Balance Evaluation Systems Test (Mini-BEST). After a month of daily Walkasins use, these measures have continued to improve even further. “We may be maxing out the FGA and Mini-BEST. He almost has perfect scores in them,” Dr. Wrisley said. What this means for Mr. Kelly is that he has gone from using a wheel chair to get around to now where he can walk 2-3 miles with confidence.
Dr. Wrisley has seen Mr. Kelley’s self-confidence improve immensely with Walkasins use as measured by the Activities Specific Balance Confidence scale (validated clinical outcomes measure). Patients with a confidence score below 67% are predictive to have an 84% chance of falling. Mr. Kelley has changed from 24% to 74% (on a zero to 100% scale).
Another measurement of improvement is Mr. Kelley’s increased walking speed which has improved more than 0.5m/s since using Walkasins. Walking speed is an important indicator of overall health and has been termed “the Sixth Vital Sign”; it’s a simple measure that can predict future health status, physical decline, adverse events and even death. Studies have associated increments of 0.1 m/s of walking speed improvements with improved health status, less physical disability, fewer hospitalization days, and a one-year reduction in medical costs of $1,188.
“We’re thrilled to be able to report these results during Peripheral Neuropathy Awareness Week,” says Dan Leach, CEO of RxFunction. “We’re energized by the exuberance shown by our trial patients and are looking forward to helping millions of people who have peripheral neuropathy with the release of Walkasins later this year.”
Interview with Mr. Kelley (trial patient at Wingate University, NC): youtu.be/MEq-nRnsAVU
Once on the market, Walkasins will be available by prescription following an assessment for neuropathy, clinical need, and physical benefit.
About RxFunction Inc.
RxFunction Inc. is a wearable technology company with an initial focus on developing and leading a new business segment within the U.S. medical grade assistive technology marketplace. The Company’s vision is to improve physical ability for social participation and quality of life. Privately held and headquartered in Minneapolis, MN, RxFunction has taken assignment of patented technology developed by Co-founder, Dr. Lars Oddsson, as a research professor at Boston University’s Neuromuscular Research Center, and funded by Edina, MN Investment Bank, Cedar Point Capital, and the NIH’s National Institute on Aging (SBIR Grant AG040865). Walkasins have not been submitted to the FDA for review, and are not available for sale at this time.
Additional information about RxFunction is available at www.rxfunction.com
Press Contact: Dan Leach, dleach@rxfunction.com
http://www.pr.com/press-release/715825
Tuesday, 4 April 2017
Do You Feel Believed When Youre In Pain
Today's post from the ever reliable pain-topics.org (see link below) looks critically at how other people's (and thus patients') pain is judged. Neuropathy sufferers will be well aware of how this can work and how you can feel disbelieved by both doctors and those around you. There is no sensation like neuropathy pain, tingling or numbness and unless the other person understands that, it can be difficult convincing them that your suffering is genuine. Doctors are just as guilty of making judgements based on body language, especially if the patient tries just a little too hard to convince them that what they're feeling is real. People with neuropathy need to find ways of describing their symptoms in a way that is relevant to the listener (the 'walking with a sock full of wet sand' is a good one for the numbness; or 'like walking on bare bones' for neuropathic aching; or 'like being connected to the mains' for the tingling. The actual pain you feel is more difficult but if you feel you are being doubted by a doctor, ask him or her directly then at least you'll know if you still have work to do. Most doctors will hear the story and symptoms of a neuropathy patient and immediately know what's going on - the symptoms are pretty unique - but friends, family and colleagues may take a bit more persuading. Don't give up; you have the right to be taken seriously.
Posted bySB. Leavitt, MA, PhD Tuesday, December 11, 2012
Many chronic pain sufferers often feel that their maladies are misunderstood, disbelieved, or unaccepted by others. New research confirms that if there is no clear and convincing biomedical cause identified to satisfactorily explain the pain other people tend to discount it and have little sympathy toward the patient.
Researchers at Ghent University in Belgium conducted a pair of studies to investigate the impact of medical and psychosocial information on estimations of another person’s pain, along with observers’ emotional responses and their behavioral tendencies toward the person with pain [De Ruddere et al. 2012]. Study participants were recruited from the community: Study 1: N = 29 women, 10 men; Study 2: N = 29 women, 12 men.
Participants variously viewed photographs of 4 alleged patients (2 men, 2 women; ages 44 to 57 years) described as having shoulder pain conditions. With each photograph there was a written brief vignette describing 2 of 4 different circumstances: either the presence or absence of a medical explanation for the pain, along with either the presence or absence of psychosocial influences attributed to the pain experience.
For example, pain was medically explained as associated with either “a little fracture,” “an inflammation,” or a “muscle strain”; in the no-cause condition the vignette simply stated that “based upon medical examination there appeared to be no injury to the shoulder.”
Psychosocial influences were described in Study 1 vignettes from the patients’ perspectives: eg, “[Fictitious patient name] reports having more pain when experiencing job stress” or “…more stress at home.” In Study 2, these influences were more authoritatively attributed to medical opinion: eg, “…the doctor decided that psychosocial factors have an impact upon the pain, in particular job stress and feelings of anxiety” or “…in particular relationship problems and a depressive mood.”
If psychosocial influences did not exist, in Study 1 they simply were not mentioned. In Study 2, however, there was a more explicit declaration that “…the doctor decided that psychosocial factors do not have an impact upon the pain.” Thus Study 1 and 2 were similar, except for a much stronger attribution of psychosocial factors, or lack thereof, in the second study.
After examining each vignette/photo, study participants were shown a brief video segment (8 seconds) displaying the respective patient having his/her shoulder examined and expressing facial signs of moderate pain. Then, on 4 different 100mm visual analog scales (VAS), participants rated each patient’s pain, their own distress upon viewing the patient in pain as well as their sympathy toward the patient, and their inclination to help the patient.
Writing in the December 2012 edition of the Journal of Pain, the researchers report that, in both Studies 1 and 2, results indicated significantly lower ratings on all measures when medical evidence for pain was absent. That is, when a medical explanation for a patient’s pain was missing, participants rated the pain as lower and their own distress at viewing the patient as lower, as well as less sympathy toward the patient and less willingness to help.
Surprisingly, there was no overall effect found on any of the 4 outcome measures due to claimed psychosocial influences on patients’ pain. The one small exception was in Study 2, in which participants indicated feeling less personal distress when psychosocial factors were explicitly indicated (ie, noted by examining physicians as having an impact).
The researchers conclude that the findings suggest pain is taken less seriously when there is no medical evidence to help explain it, and psychosocial influences on the patient — eg, stress at work or home, anxiety, relationship issues — are not considered as important contributors to pain. This line of investigation is important, the researchers note, for better understanding how patients’ pain for which there is no clear medical explanation is interpreted and judged by other persons.
COMMENTARY: Research in the social psychology field is often most interesting when it confirms — more or less scientifically — what most people already think they intuitively know. This present study confirms what many patients already have expressed in prior comments to various UPDATES articles; that is, when chronic pain is unexplained by a diagnosis of some severe biopathology patients often face significant obstacles to being taken seriously by their families, friends, and healthcare providers.
In the study by De Ruddere et al. it was somewhat puzzling that psychosocial factors appeared to have so little influence on participants’ perceptions. It seemed that medical evidence for the pain superseded all other information when judging the genuineness of pain and consequent feelings of sympathy or helpfulness toward the patient.
As often is the case in the pain management field, more research is needed before leaping to any firm conclusions. For one thing, patients in the video segments displayed what had been determined as representing moderate pain; expressions of more severe pain might have had much greater impact on assessments — evoking higher ratings of pain (whether or not medically explained) and greater empathy by study participants.
Another important limitation was that participants had no personal relationships or direct interactions with the fictitious patients; completely unlike what would be the case in clinical settings or among family/friends. Essentially, the researchers attempted to create a laboratory setting for assessing human variables that are far more complex in everyday life or clinical practice.
Participant-group sizes — Group 1, N= 39; Group 2, N=41 — were probably adequate to provide reasonable statistical power for detecting significant differences, avoiding Type II (false negative) findings. [Readers should note that numbers of participants indicated in the study abstract and the article text itself are grossly discordant; we are using numbers from the text.]
However, composition of the participant groups must be considered: overall, the two groups were unequally balanced toward women, average participant age was significantly lower than the test patients (roughly 28 vs 51 years), and approximately half of participants were college students. So, generalizing the findings at this time to how older persons, healthcare providers, or family/friends might react could be erroneous.
Therefore, there are still unanswered questions about how the qualities of patients and those interacting with them, as well as available information about patient medical condition and/or psychosocial influences, affect judgments when it comes to pain assessment, sympathy, and helping behavior. The researchers, themselves, acknowledge most of these limitations; yet, this study is an important step toward a better understanding of several factors that might significantly bias perceptions of patients’ pain and impact the care that they receive in medical settings and at home.
REFERENCE: De Ruddere L, Goubert L, Vervoort T, et al. We Discount the Pain of Others When Pain Has No Medical Explanation. J Pain. 2012(Dec);13(12):1198-1205
http://updates.pain-topics.org/2012/12/pain-doubted-if-medical-basis-is-missing.html
Wednesday, 15 March 2017
When Pain Relief Fails
Today's post from the always excellent pain-topics.org (see link below) looks at a study by leading pain specialists which shows that pain medication should be fitted to the individual patient rather than to the disease or cause. This is because of the relative high failure rate of analgesics amongst people with the same problems. Usually, if a medication hasn't worked to the patient's realistic requirements within 2 to 4 weeks, it never will and another option should be considered. Neuropathy patients are experts in this scenario but may find their doctors less than willing to change treatment until the right one is found. This is because medications are more frequently tailored to traditional treatment paths, the disease and parameters the drug companies lay down, than to the individual patient who knows best if something is working or not. This article takes a little reading but is definitely worth the effort.
Expect Analgesic Failure, But Seek Success
Posted by SB. Leavitt, MA, PhD Thursday, July 11, 2013
A better understanding of potentially high therapeutic failure rates in pain management may be a first step toward doing better with currently available treatments. Clinically, this means expecting analgesic failure, assessing pain, and considering options for stopping and switching therapies. This also requires casting aside a reliance on what works for “average” patients, and asking what works best, for whom, in what circumstances.
Most analgesic medications work well, but in only a relatively small percentage of people, according to Andrew Moore from Oxford University and colleagues writing in the British Medical Journal[Moore et al. 2013]. They propose a transformation in thinking about how analgesic efficacy and harm should be assessed, and suggest several practical implications of a better understanding and appreciation of therapeutic failure rates:
“No single drug will treat successfully more than a minority of patients with a painful condition.
Successful pain relief is also likely to improve sleep, depression, fatigue, quality of life, function, and ability to work.
Experience (and some evidence) suggests that failure with one drug does not necessarily mean failure with others, even within a class.
We do not know the best order in which to use drugs, in terms of efficacy, harm, or cost.
Success or failure can be determined within 2-4 weeks, and success, when achieved, tends to be long lasting.
Because success rates are low, a wide range of drugs is needed to do the best for most patients, especially in complex chronic conditions.”
Measuring Success
Individual patient responses to any therapy vary greatly, Moore et al. observe. Pain relief measurements delineating successful outcomes typically are not distributed along a normal bell-shaped curve, but are usually bimodal; that is, most patient responses are either very good (above 50% pain relief) or very poor (below 15%). Therefore, the frequency distribution curve is more “U-shaped”; rather than the classic bell curve in which most responses fall toward the center and correspond with the mean (average).
Due to the U-shaped response distribution, research outcomes based on averages are unhelpful and misleading since “average” pain relief is actually experienced by few, if any, patients. The mean score tells us nothing about how many patients will experience clinically useful pain relief; hence, Moore and colleagues suggest that research should be moving toward “responder analyses” — focusing and reporting on the proportion of patients achieving outcomes that patients themselves consider to be worthwhile.
In that regard, the authors observe that patients want large reductions in pain intensity (typically at least 50% relief and ideally no worse than mild pain), with amelioration of associated problems, such as sleep disturbance and depression, but without common adverse events interfering with treatment. Patients who get better (responders) typically do well, experiencing improvements in fatigue, depression, and sleep interference, plus better function and quality of life. Non-responders gain none of those benefits.
From a research perspective, as well as in daily practice, the authors suggest that all persons who discontinue treatment for any reason should be considered as non-responders. Furthermore, the scientific assessment of analgesia and the clinical practice of analgesic delivery could be simplified into 3 guiding principles: A) measure pain in individual patients, B) expect analgesic drugs to fail to provide a good response in most patients, and C) prepare for the next step if and when failure occurs.
Defining Analgesic Failure
In their article, Moore et al. examine some drug-specific success and failure rates for postoperative pain, migraine, and chronic musculoskeletal and neuropathic conditions, using data predominantly from good quality reviews and meta-analyses. In a table, they list outcomes for 44 studies evaluating placebo in comparison with NSAIDs and various other drugs (eg, acetaminophen, triptans, antidepressants, antiepileptics, and others). Only 2 studies of opioid monotherapy were included, both for chronic noncancer pain.
Overall, and with but a few exceptions, less than half of patients achieved at least a 50% reduction in pain intensity (responder definition), and failure rates were highest over the long term in patients with chronic pain conditions. Of the 44 studies, success rates were above 50% for only 4 drugs in acute postoperative pain (acetaminophen + ibuprofen; acetaminphen + oxycodone; etoricoxib; ibuprofen + codeine) and 1 drug for migraine (zolmitriptan). For all other drugs and in all other conditions, fewer than half of patients achieved at least a 50% reduction in pain intensity.
Analgesic failure rates generally ranged from 55% to ≥87%. Data for opioids in chronic noncancer pain were available only for tapentadol and oxycodone in a combined analysis of osteoarthritis and chronic low back pain trials; tapentadol (200-500mg) had a failure rate of 90% and oxycodone (40-100mg) had a failure rate of 100%. Those rates took into account therapeutic responders compared with placebo responders, and it should be noted that in absolute terms, on their own, 30% of tapentadol-group patients and 21% taking oxycodone did experience analgesic success.
As Moore et al. observe, “The magnitude of the failure to achieve good pain relief, especially over the longer term in chronic pain, is sobering.” The high failure rates reported in their paper are a consequence of using patient-centered definitions of benefit combining a significant level of pain relief (>50%) with tolerable adverse events (ie, allowing continuation in therapy), using high standards of evidence, and avoiding major imputation bias (ie, focusing on responders). These higher standards are backed by considerable evidence supporting their validity, but they do portray less favorable outcomes than are often reported in the research literature.
Moving Toward Pragmatic Approaches
The use of responder analyses changes judgments of benefit and risk. In cases of therapeutic failure, patients without benefit should be exposed to no risk because the drug is stopped when they drop out of treatment. The good news is that success is often achieved within the first 2 weeks or so of treatment or not at all, the authors note, and benefits tend to be enduring. Obviously, only successfully effective drugs should continue to be prescribed.
Of some importance regarding chronic pain, Moore et al. observe that typical clinical trials may inadvertently underestimate treatment efficacy if the data are closely examined. Fixed-dose regimens may exacerbate adverse events and discontinuations, resulting in higher failure rates. An alternate approach would be to allow patient-directed drug titration to achieve adequate pain relief with tolerable adverse events; at that point, only subjects with treatment success (responders) would be randomized blindly between continuing therapy and placebo.
Such trial designs would have lower failure rates and more directly mimic what occurs in clinical practice. Additionally, the authors continue, drug therapy is rarely the only treatment used for chronic pain; however, clinical trials designed for regulatory purposes consider only single, or unimodal interventions.
A most essential pragmatic implication of high failure rates is that populations with pain need access to a broad range of analgesics and/or other interventions to have a better chance of success. According to Moore et al., the problem is a dearth of research data to help in devising therapy starting, stopping, and switching rules. In other conditions, like depression, switching medications is often effective; randomized trials have shown that any antidepressant used initially may benefit fewer than half of patients, but the majority can benefit when failures are followed by switching to other medications for depression.
Practical Implications of Therapeutic Failures
Essential practice principles for pain management should include assessing pain, expecting and recognizing analgesic failure, and reacting to it by pursuing analgesic success rather than blindly accepting failure. In any condition, the order in which analgesics should be tried is predicated on efficacy and safety, and adjusted for individual patient characteristics and response, suggest Moore and colleagues.
The authors further observe that guidelines developers often restrict treatment recommendations to 1 or 2 drugs for any pain condition. The developers consider similar drugs to operate as a class, overlooking the fact that there can be important differences in pharmacokinetics or drug interactions across similar medications. Less restrictive guidance recommendations, centered on patient-practitioner interactions — taking into account clinical wisdom as well as available evidence — may do better, Moore et al. affirm.
The authors additionally suggest that regulatory authorities need to recognize that therapeutic failure is the norm and set standards of acceptance based on real-world expectations. For example, Moore et al. note that European regulators have refused to license any drug for fibromyalgia because of inadequate average effect sizes, ignoring the fact that these drugs work well (≥50% reduction in pain intensity) for treating this difficult condition in around 10% of patients. New drugs are unlikely to be much better, the authors suggest, so a change in regulatory attitudes is overdue, would be sensible, and will benefit patients.
Finally, Moore and colleagues acknowledge that chronic pain conditions are complex and associated with considerable comorbidity. Coupled with the nuances of neurobiological pain modulation, central nervous system transformations, and genetic influences, high failure rates with single pharmacologic interventions are unsurprising. “The new game in town is specificity of effect for specific targets, but with only a small percentage of patients benefiting,” they state. “We need to determine how best to use the interventions we have to provide better care for more people at lower cost.”
COMMENTARY:
Assertions about the importance of failure are somewhat unusual in scientific discourse; yet, Moore and colleagues believe that pain medicine has reached a degree of maturity where it can constructively confront, embrace, and learn from better understandings of therapeutic failings. That may or may not be the case; for example, some current arguments against opioid analgesics for chronic noncancer pain seem to demand that either the therapy works well and for all patients or it is unacceptable — there is no middle-ground or acceptance of failure.
The studies examined by Moore et al. in their paper, with the respective analgesic failure rates, are exemplary but not exhaustive of the possibilities — eg, dose/frequency variations and combinations of different agents — when it comes to effective pharmacotherapy for various pain conditions. Nor were the studies critiqued from quality-of-evidence perspectives; yet, there are important lessons to be learned.
Additionally, a soon to be published paper by Moore, as sole author [2013, see ref below], further explores some of the essential principles and is worth examining. Plus, readers with a deeper interest in evidence-based pain management should be following our series on “Making Sense of Pain Research” [see article listing here], which discusses the many factors affecting research quality.
Here is further comment on several of the critical points that emerge from the papers by Moore et al. [2013] and Moore [2013]:
Analgesic failure refers to the clinical reality that any medication (or other intervention) will not work for all patients all of the time. In most cases, as demonstrated by the research evidence provided by Moore et al., the very best analgesics provide ≥50% pain relief in roughly half of treated patients. This amounts to a number-needed-to-treat (NNT) of about 2 compared with placebo; that is, for every 2 patients treated with active drug rather than placebo 1 additional patient will benefit.
For almost any medication, an NNT=2 would be a large and clinically significant effect size; yet it does not begin to approach the 100% response rate that patients and many practitioners may desire or expect. Furthermore, Moore et al. found that NNTs for various analgesics can range widely up to NNT>100, depending on the pain condition; however, even in the worst of cases, a certain percentage of patients (albeit, possibly extremely small) can benefit.
The important message is that therapeutic failure is quite common and in significant proportions of patients, but this should not deter pursuing another analgesic within the same or different class of drug. Oftentimes, expectations need to be lowered to the level of clinical reality; eg, while long-term opioid therapy may not benefit all patients with chronic noncancer pain, it does help a certain proportion of patients and significantly so.
There is no such thing as an “average” patient, even though research trials tend to define outcomes based on average, or mean, scores on efficacy measures. In doing this, research can be misleading, since the greatest proportions of patients either experience successful outcomes (eg, more than 50% pain relief) or very poor results (eg, less than 15% pain relief). Interestingly, mean placebo responses tend to follow the same pattern, which can result in small absolute differences between active therapy and placebo overall (hence increasing NNT values to less significant levels [NNT is calculated by 1 divided by the absolute difference between groups on a measure]).
The most vital question is: what works, for whom, in what circumstances? Along with that, it must be remembered that pain relief is but one measure of therapeutic success that may be meaningful to patients.
In overcoming a slavish reliance on “averages,” Moore et al. appear to be advocating for “per-protocol” analyses in pain research trials that focus on “responders.” That is, subjects who drop out of a study for any reason are considered as therapeutic failures, even if they had achieved some degree of pain relief at the time of their discontinuation. This recognizes that benefits outweigh risks in treatment responders — they achieve desired outcomes with tolerable adverse effects, if any, over an extended period of time.
In contrast, much of the pain research uses “intention-to-treat, or ITT” approaches, whereby outcomes in all subjects are taken into account whether or not they complete the trial. In some cases, the last observation (eg, pain score) prior to discontinuation is carried forward (LOCF) in final analyses, as if it represents an overall therapeutic effect.
Moore and colleagues argue that this approach interjects bias into the analyses, and may be acceptable for statistically determining if an intervention has any analgesic effect, but not for determining clinical effectiveness for individual patients. In other words, if patients cannot continue with a therapy for some reason they will not realize further benefits; the fact that they might have achieved some benefits up to a point in time, but then had to drop out prematurely due to adverse effects, may rescind the value of the therapy.
As much as anything, Moore and Moore et al. are advocating for a pragmatic, patient-centered, practice-oriented approach to understanding therapeutic failure and success in pain management. This might be somewhat of a paradigm shift for how research in the pain field is conducted and how regulatory and other bodies reach decisions on drug approvals and labeling. In essence, an unbiased focus on therapeutic response requires that treatments should be stopped when they do not work to avoid undue exposures to risks; however, those patients who do respond sufficiently, no matter how small in numbers, can experience large benefits to offset against rare but potentially serious harms. A degree of failure should not defeat the pursuit of success when it comes to pain management.
REFERENCES:
> Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ. 2013;346:f2690 [abstract here].
> Moore RA. What works for whom? Determining the efficacy and harm of treatments for pain. PAIN. 2013(Mar); online ahead of print [abstract here].
http://updates.pain-topics.org/2013/07/expect-analgesic-failure-but-seek.html
Posted by SB. Leavitt, MA, PhD Thursday, July 11, 2013
A better understanding of potentially high therapeutic failure rates in pain management may be a first step toward doing better with currently available treatments. Clinically, this means expecting analgesic failure, assessing pain, and considering options for stopping and switching therapies. This also requires casting aside a reliance on what works for “average” patients, and asking what works best, for whom, in what circumstances.
Most analgesic medications work well, but in only a relatively small percentage of people, according to Andrew Moore from Oxford University and colleagues writing in the British Medical Journal[Moore et al. 2013]. They propose a transformation in thinking about how analgesic efficacy and harm should be assessed, and suggest several practical implications of a better understanding and appreciation of therapeutic failure rates:
“No single drug will treat successfully more than a minority of patients with a painful condition.
Successful pain relief is also likely to improve sleep, depression, fatigue, quality of life, function, and ability to work.
Experience (and some evidence) suggests that failure with one drug does not necessarily mean failure with others, even within a class.
We do not know the best order in which to use drugs, in terms of efficacy, harm, or cost.
Success or failure can be determined within 2-4 weeks, and success, when achieved, tends to be long lasting.
Because success rates are low, a wide range of drugs is needed to do the best for most patients, especially in complex chronic conditions.”
Measuring Success
Individual patient responses to any therapy vary greatly, Moore et al. observe. Pain relief measurements delineating successful outcomes typically are not distributed along a normal bell-shaped curve, but are usually bimodal; that is, most patient responses are either very good (above 50% pain relief) or very poor (below 15%). Therefore, the frequency distribution curve is more “U-shaped”; rather than the classic bell curve in which most responses fall toward the center and correspond with the mean (average).
Due to the U-shaped response distribution, research outcomes based on averages are unhelpful and misleading since “average” pain relief is actually experienced by few, if any, patients. The mean score tells us nothing about how many patients will experience clinically useful pain relief; hence, Moore and colleagues suggest that research should be moving toward “responder analyses” — focusing and reporting on the proportion of patients achieving outcomes that patients themselves consider to be worthwhile.
In that regard, the authors observe that patients want large reductions in pain intensity (typically at least 50% relief and ideally no worse than mild pain), with amelioration of associated problems, such as sleep disturbance and depression, but without common adverse events interfering with treatment. Patients who get better (responders) typically do well, experiencing improvements in fatigue, depression, and sleep interference, plus better function and quality of life. Non-responders gain none of those benefits.
From a research perspective, as well as in daily practice, the authors suggest that all persons who discontinue treatment for any reason should be considered as non-responders. Furthermore, the scientific assessment of analgesia and the clinical practice of analgesic delivery could be simplified into 3 guiding principles: A) measure pain in individual patients, B) expect analgesic drugs to fail to provide a good response in most patients, and C) prepare for the next step if and when failure occurs.
Defining Analgesic Failure
In their article, Moore et al. examine some drug-specific success and failure rates for postoperative pain, migraine, and chronic musculoskeletal and neuropathic conditions, using data predominantly from good quality reviews and meta-analyses. In a table, they list outcomes for 44 studies evaluating placebo in comparison with NSAIDs and various other drugs (eg, acetaminophen, triptans, antidepressants, antiepileptics, and others). Only 2 studies of opioid monotherapy were included, both for chronic noncancer pain.
Overall, and with but a few exceptions, less than half of patients achieved at least a 50% reduction in pain intensity (responder definition), and failure rates were highest over the long term in patients with chronic pain conditions. Of the 44 studies, success rates were above 50% for only 4 drugs in acute postoperative pain (acetaminophen + ibuprofen; acetaminphen + oxycodone; etoricoxib; ibuprofen + codeine) and 1 drug for migraine (zolmitriptan). For all other drugs and in all other conditions, fewer than half of patients achieved at least a 50% reduction in pain intensity.
Analgesic failure rates generally ranged from 55% to ≥87%. Data for opioids in chronic noncancer pain were available only for tapentadol and oxycodone in a combined analysis of osteoarthritis and chronic low back pain trials; tapentadol (200-500mg) had a failure rate of 90% and oxycodone (40-100mg) had a failure rate of 100%. Those rates took into account therapeutic responders compared with placebo responders, and it should be noted that in absolute terms, on their own, 30% of tapentadol-group patients and 21% taking oxycodone did experience analgesic success.
As Moore et al. observe, “The magnitude of the failure to achieve good pain relief, especially over the longer term in chronic pain, is sobering.” The high failure rates reported in their paper are a consequence of using patient-centered definitions of benefit combining a significant level of pain relief (>50%) with tolerable adverse events (ie, allowing continuation in therapy), using high standards of evidence, and avoiding major imputation bias (ie, focusing on responders). These higher standards are backed by considerable evidence supporting their validity, but they do portray less favorable outcomes than are often reported in the research literature.
Moving Toward Pragmatic Approaches
The use of responder analyses changes judgments of benefit and risk. In cases of therapeutic failure, patients without benefit should be exposed to no risk because the drug is stopped when they drop out of treatment. The good news is that success is often achieved within the first 2 weeks or so of treatment or not at all, the authors note, and benefits tend to be enduring. Obviously, only successfully effective drugs should continue to be prescribed.
Of some importance regarding chronic pain, Moore et al. observe that typical clinical trials may inadvertently underestimate treatment efficacy if the data are closely examined. Fixed-dose regimens may exacerbate adverse events and discontinuations, resulting in higher failure rates. An alternate approach would be to allow patient-directed drug titration to achieve adequate pain relief with tolerable adverse events; at that point, only subjects with treatment success (responders) would be randomized blindly between continuing therapy and placebo.
Such trial designs would have lower failure rates and more directly mimic what occurs in clinical practice. Additionally, the authors continue, drug therapy is rarely the only treatment used for chronic pain; however, clinical trials designed for regulatory purposes consider only single, or unimodal interventions.
A most essential pragmatic implication of high failure rates is that populations with pain need access to a broad range of analgesics and/or other interventions to have a better chance of success. According to Moore et al., the problem is a dearth of research data to help in devising therapy starting, stopping, and switching rules. In other conditions, like depression, switching medications is often effective; randomized trials have shown that any antidepressant used initially may benefit fewer than half of patients, but the majority can benefit when failures are followed by switching to other medications for depression.
Practical Implications of Therapeutic Failures
Essential practice principles for pain management should include assessing pain, expecting and recognizing analgesic failure, and reacting to it by pursuing analgesic success rather than blindly accepting failure. In any condition, the order in which analgesics should be tried is predicated on efficacy and safety, and adjusted for individual patient characteristics and response, suggest Moore and colleagues.
The authors further observe that guidelines developers often restrict treatment recommendations to 1 or 2 drugs for any pain condition. The developers consider similar drugs to operate as a class, overlooking the fact that there can be important differences in pharmacokinetics or drug interactions across similar medications. Less restrictive guidance recommendations, centered on patient-practitioner interactions — taking into account clinical wisdom as well as available evidence — may do better, Moore et al. affirm.
The authors additionally suggest that regulatory authorities need to recognize that therapeutic failure is the norm and set standards of acceptance based on real-world expectations. For example, Moore et al. note that European regulators have refused to license any drug for fibromyalgia because of inadequate average effect sizes, ignoring the fact that these drugs work well (≥50% reduction in pain intensity) for treating this difficult condition in around 10% of patients. New drugs are unlikely to be much better, the authors suggest, so a change in regulatory attitudes is overdue, would be sensible, and will benefit patients.
Finally, Moore and colleagues acknowledge that chronic pain conditions are complex and associated with considerable comorbidity. Coupled with the nuances of neurobiological pain modulation, central nervous system transformations, and genetic influences, high failure rates with single pharmacologic interventions are unsurprising. “The new game in town is specificity of effect for specific targets, but with only a small percentage of patients benefiting,” they state. “We need to determine how best to use the interventions we have to provide better care for more people at lower cost.”
COMMENTARY:
Assertions about the importance of failure are somewhat unusual in scientific discourse; yet, Moore and colleagues believe that pain medicine has reached a degree of maturity where it can constructively confront, embrace, and learn from better understandings of therapeutic failings. That may or may not be the case; for example, some current arguments against opioid analgesics for chronic noncancer pain seem to demand that either the therapy works well and for all patients or it is unacceptable — there is no middle-ground or acceptance of failure.
The studies examined by Moore et al. in their paper, with the respective analgesic failure rates, are exemplary but not exhaustive of the possibilities — eg, dose/frequency variations and combinations of different agents — when it comes to effective pharmacotherapy for various pain conditions. Nor were the studies critiqued from quality-of-evidence perspectives; yet, there are important lessons to be learned.
Additionally, a soon to be published paper by Moore, as sole author [2013, see ref below], further explores some of the essential principles and is worth examining. Plus, readers with a deeper interest in evidence-based pain management should be following our series on “Making Sense of Pain Research” [see article listing here], which discusses the many factors affecting research quality.
Here is further comment on several of the critical points that emerge from the papers by Moore et al. [2013] and Moore [2013]:
Analgesic failure refers to the clinical reality that any medication (or other intervention) will not work for all patients all of the time. In most cases, as demonstrated by the research evidence provided by Moore et al., the very best analgesics provide ≥50% pain relief in roughly half of treated patients. This amounts to a number-needed-to-treat (NNT) of about 2 compared with placebo; that is, for every 2 patients treated with active drug rather than placebo 1 additional patient will benefit.
For almost any medication, an NNT=2 would be a large and clinically significant effect size; yet it does not begin to approach the 100% response rate that patients and many practitioners may desire or expect. Furthermore, Moore et al. found that NNTs for various analgesics can range widely up to NNT>100, depending on the pain condition; however, even in the worst of cases, a certain percentage of patients (albeit, possibly extremely small) can benefit.
The important message is that therapeutic failure is quite common and in significant proportions of patients, but this should not deter pursuing another analgesic within the same or different class of drug. Oftentimes, expectations need to be lowered to the level of clinical reality; eg, while long-term opioid therapy may not benefit all patients with chronic noncancer pain, it does help a certain proportion of patients and significantly so.
There is no such thing as an “average” patient, even though research trials tend to define outcomes based on average, or mean, scores on efficacy measures. In doing this, research can be misleading, since the greatest proportions of patients either experience successful outcomes (eg, more than 50% pain relief) or very poor results (eg, less than 15% pain relief). Interestingly, mean placebo responses tend to follow the same pattern, which can result in small absolute differences between active therapy and placebo overall (hence increasing NNT values to less significant levels [NNT is calculated by 1 divided by the absolute difference between groups on a measure]).
The most vital question is: what works, for whom, in what circumstances? Along with that, it must be remembered that pain relief is but one measure of therapeutic success that may be meaningful to patients.
In overcoming a slavish reliance on “averages,” Moore et al. appear to be advocating for “per-protocol” analyses in pain research trials that focus on “responders.” That is, subjects who drop out of a study for any reason are considered as therapeutic failures, even if they had achieved some degree of pain relief at the time of their discontinuation. This recognizes that benefits outweigh risks in treatment responders — they achieve desired outcomes with tolerable adverse effects, if any, over an extended period of time.
In contrast, much of the pain research uses “intention-to-treat, or ITT” approaches, whereby outcomes in all subjects are taken into account whether or not they complete the trial. In some cases, the last observation (eg, pain score) prior to discontinuation is carried forward (LOCF) in final analyses, as if it represents an overall therapeutic effect.
Moore and colleagues argue that this approach interjects bias into the analyses, and may be acceptable for statistically determining if an intervention has any analgesic effect, but not for determining clinical effectiveness for individual patients. In other words, if patients cannot continue with a therapy for some reason they will not realize further benefits; the fact that they might have achieved some benefits up to a point in time, but then had to drop out prematurely due to adverse effects, may rescind the value of the therapy.
As much as anything, Moore and Moore et al. are advocating for a pragmatic, patient-centered, practice-oriented approach to understanding therapeutic failure and success in pain management. This might be somewhat of a paradigm shift for how research in the pain field is conducted and how regulatory and other bodies reach decisions on drug approvals and labeling. In essence, an unbiased focus on therapeutic response requires that treatments should be stopped when they do not work to avoid undue exposures to risks; however, those patients who do respond sufficiently, no matter how small in numbers, can experience large benefits to offset against rare but potentially serious harms. A degree of failure should not defeat the pursuit of success when it comes to pain management.
REFERENCES:
> Moore A, Derry S, Eccleston C, Kalso E. Expect analgesic failure; pursue analgesic success. BMJ. 2013;346:f2690 [abstract here].
> Moore RA. What works for whom? Determining the efficacy and harm of treatments for pain. PAIN. 2013(Mar); online ahead of print [abstract here].
http://updates.pain-topics.org/2013/07/expect-analgesic-failure-but-seek.html
Wednesday, 11 January 2017
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Friday, 30 December 2016
PREGNANT WOMEN INVOLVE PARENT IN ABORTION WHEN ANTICIPATING SUPPORT
When an adolescent wants to terminate a pregnancy, how does she decide whether to talk to a parent? A recent study from the Section of Family Planning and Contraceptive Research at the University of Chicago found that pregnant teens will turn to parents and adults who are engaged in their lives and who will offer support, regardless of her pregnancy decision. Young women will avoid talking with parents who are less involved or may try to prevent them from seeking care
The study, published online ahead of print in theAmerican Journal of Public Health, explored the factors young women under age 18 consider when deciding to involve a parent. Researchers conducted interviews with 30 minors seeking abortion in Illinois, prior to implementation of the 2013 parental notification law. Currently, there are 38 states with laws requiring a parent to provide consent or receive notification before a minor can access abortion services.
"There's a commonly accepted idea that teens will try to hide their pregnancy or abortion decision. However, pregnant young women actually do turn to parents in the majority of cases," said Section policy researcher Lee Hasselbacher. "In our study, 70% of the young women involved a parent or guardian. They thought carefully about which parents and adults in their lives they could turn to for help in making their decision."
While each young woman's family circumstance was different, there were several common motivations for involving a parent. Factors favoring telling included close and supportive relationships, need for help with logistics like travel or payment, or experiences that made discovery of the pregnancy seem inevitable.
Minors expressed a range of motivations for not telling a parent about their abortion. Some teens worried that if their parent learned of their decision, it would dramatically change their relationship or feared it would even lead to anger or harm. Young women also discussed the lack of a relationship or presence as a reason they did not want to involve a parent.
One of the strongest findings was that among those young women who did not involve either parent, most were concerned that one or both parents would directly interfere with their decision to get an abortion.
"Policymakers should not force communication at the time of pregnancy; instead they should focus on supporting family communication long before a pregnancy or abortion decision," said Dr. Melissa Gilliam, Section Chief of the Section of Family Planning and Contraceptive Research at the University of Chicago and senior author on the study. "This study reveals teenagers will seek adult help."
Monday, 28 November 2016
When The War On Drugs Hit The Super Bowl
Today's post from statnews.com (see link below) once more focusses on the opioid crisis; an issue that won't go away and has a direct bearing on the lives of many neuropathy sufferers who need strong medications to dampen their pain. This time it's the Super Bowl hitting the spotlight for different reasons than the quality of sport. It was an advertisement trying to elicit sympathy for genuine patients who need opioids to stay sane that caused all the fuss and just goes to show what happens when someone tries to go against the flow of current media opinion. It also shows quite how much issues can be media-driven and that's a dangerous trend, especially when it concerns medical issues that the media has very little understanding of. Whatever the statistics of drug overdose, drug abuse and drug criminality, there is a significant segment of society that needs strong medications to be able to function normally. These people with chronic pain diseases must not be ignored or swept away on a tide of media hysteria. They must be able to have access to the drugs they need - end of story! If there's a problem with criminality and or drug abuse, then tackle that problem but leave the genuine patients alone!
 |
| "Well, that's one opinion!' |
By Rebecca Robbins @rebeccadrobbins February 8, 2016
A Super Bowl ad mixed humor and empathy as it introduced the problem of opioid-induced constipation.
Abuse of prescription painkillers has grabbed center stage in conversations about the nation’s opioid epidemic. Presidential candidates talk openly about their relatives’ struggles with addiction. Officials at the state and federal levels ponder ways to restrict the number and dosage of pills doctors can prescribe.
That’s why it was so striking to see a Super Bowl ad that took a different tack: It aimed to stir empathy for patients who truly need the drugs to manage chronic pain.
The 1-minute spot targeted viewers who “need an opioid to manage chronic pain” — and who suffer from a common side effect of the pain relievers, constipation.
Read more: Obama wants $1.1 billion to fight opioid abuse Striking a balance between humor and gravitas, the ad featured a man suffering from the condition who can’t help noticing that everyone else around him can poop: A dog on the street. A woman with toilet paper stuck to her shoe. Even a sugar shaker dispenses crystals with ease.
The ad drew sharp rebuke from high-profile observers on social media, who saw it as a tone-deaf commercial play amid a devastating public health crisis.
“Big pharma buys #Superbowl ad to warn about the most pressing effect of opiates: constipation. Thanks. For nothing,” tweeted the police department in Burlington, Vt.
Even White House Chief of Staff Denis McDonough weighed in on Twitter: “Next year, how about fewer ads that fuel opioid addiction and more on access to treatment.”
But several advocates for patients with pain saw it differently. They spent months advising drug makers on the ad, and said their goal was simple: to illuminate one of the burdens faced by the patients they represent.
Paul Gileno, president of the US Pain Foundation, was particularly troubled by a coarse tweet from comedian Bill Maher, who joked that the ad seemed to be aimed at “junkies.”
That happens all too often, Gileno said: Patients in persistent, terrible pain are wrongly “labeled as junkies or pill seekers” because they seek relief. Yes, he said, there’s a need to educate people about painkiller abuse. But there’s also a need to remind the public that these drugs have legitimate uses.
“There is a huge need for education on both issues,” Gileno said.
Read more: Opioid crisis drives record overdose deaths
“We definitely see both sides of the issue, and both sides need to be dealt with, but we can’t forsake one of the issues,” said Barby Ingle, president of the International Pain Foundation.
The ad didn’t promote a specific medication. Instead, it urged patients to ask their doctor about prescription treatment options for the condition. It also plugged a website that links to information about Movantik, a drug marketed by the ad’s makers, AstraZeneca and Daiichi Sankyo.
The spot was directed by Lenny Dorfman, a veteran ad maker with Hungry Man Productions who works on commercials for big-name consumer brands like Nike and Coca-Cola.
Super Bowl ads tend to focus on products and issues that have mass appeal. That’s why, for example, you tend not to see the ads for erectile dysfunction that dominate the airwaves during regular season NFL games.
So it was telling that the advertisers deemed prescription opioid users suffering from a particular side effect to be a large enough market to justify a Super Bowl ad. Thirty-second spots during the game sold for up to $5 million.
Abigail Bozarth, an AstraZeneca spokeswoman, said the company’s goal was to “open the door” for patients with opioid-induced constipation to talk with their doctors, “which provides another important touch point to help ensure opioids are being appropriately used.”
In 2014, prescription opioid pain relievers killed about 19,000 people, up more than threefold since 2001.
This story was updated with more information about the response from local and federal officials to the Super Bowl ad.
Rebecca Robbins can be reached at rebecca.robbins@statnews.com
Follow Rebecca on Twitter @rebeccadrobbins
http://www.statnews.com/2016/02/08/opioid-constipation-super-bowl-ad/
Wednesday, 19 October 2016
When Should I Take A Pregnancy Test Calculator
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Friday, 1 July 2016
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Build tests better. We've helped test and certify millions of people in thousands of organizations. By test.com Learn More.TODAY Parents is the premiere destination for parenting news, advice community. Find the latest parenting trends and tips for your kids and family on TODAY.com..What's in a Name? What Every Consumer Should Know About Foods and Flavors; 4 Medication Safety Tips for Older Adults; FDA: Cutting-Edge Technology Sheds Light .Walmart Diabetic Test Strips Treatment Diabetes Alternative Diabetes Treatment Walmart Diabetic Test Strips ::The 3 Step Trick that Reverses Diabetes .Other medical and health news. First study to link antibiotic resistance with exposure to the disinfectant chlorhexidine Telemedicine, in addition to clinical care .What Are Diabetes Blood Test Strips What Are Diabetes Blood Test Strips :: what are the symptoms of diabetes type 2 - The 3 Step Trick that Reverses Diabetes .About: Lilypie tickers are free, update daily and can be used to track how Pregnant, or how far along in your Pregnancy you are. Baby, Toddler and Kid Birthday, as . Tech 2/16/2012 @ 11:02AM 3,063,735 views How Target Figured Out A Teen Girl Was Pregnant Before Her Father Did.Printables, coloring pages, recipes, crafts, and more from your child's favorite Nickelodeon and Nick Jr. shows.. The World Health Organization has declared an international health emergency over the spread of the Zika virus, now known to cause devastating birth .
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