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By: Rodney B. Turner, PharmD, BCPS

  • Assistant Professor, School of Pharmacy, Pacific University, Hillsboro
  • Infectious Diseases Clinical Specialist, Legacy Health, Portland, Oregon


While there are many systematic reviews on mobile apps for diabetes self-management spasms right side of stomach purchase 500 mg robaxin free shipping, patients may have a difficult time using evidence from systematic reviews to muscle relaxant no drowsiness discount 500mg robaxin with visa decide whether and which app to muscle relaxant methocarbamol addiction purchase robaxin 500mg without a prescription use in care muscle relaxant for alcoholism buy generic robaxin 500mg online. There was also agreement about the types of outcomes to examine, with HbA1c, blood glucose, weight loss, improved nutrition, and level of activity most often discussed. First, several discussed the importance of examining patient preferences and degree of engagement with apps. Specifically, the effectiveness of an app may depend on whether patients have a high or low comfort level with technology, and whether the app continually engages them. Often, apps are touted as a silver bullet for diabetes prevention and selfmanagement. In reality, however, they are adjunctive tools that must be combined with other efforts to improve outcomes. For example, tracking steps via a pedometer may not affect diabetes-related outcomes unless tracking helps motivate patients to walk more. We excluded children, adolescents, pregnant women with diabetes, and patients with gestational diabetes. Interventions (types of technologies): We included studies of commercially available apps or Web sites delivered through mobile devices. To be included, apps had to provide at least one of the following five features: (1) education; (2) data tracking; (3) communication between participants and providers or coaches; (4) social support or social media; and (5) reminders (except for text message-based appointment reminders because these were not close enough to our conceptualization of diabetes selfmanagement). Though not a requirement for inclusion, we considered the dosage, which we defined as the number of times patients used features of the app. We excluded studies using patients with an artificial pancreas because these are more intensive interventions that require additional safety and regulatory considerations. We also excluded studies of medical devices that do not connect to an app, such as blood glucose meters alone. Comparators: We included studies that had comparators of usual care or another mobile or nonmobile program for diabetes self-management. The most important factor in our determination of inclusion/exclusion was whether the control group received some form of care. Outcomes: We included all patient-related outcomes, including but not limited to participant satisfaction; self-efficacy; participant assessments of usability of apps; costs; clinical outcomes such as HbA1c, blood pressure, weight loss, physical activity; quality of life; functionality; incidence of hypoglycemic and hyperglycemic episodes; harms and adverse events; and all-cause death. We excluded provider outcomes, health system outcomes, and technology performance outcomes such as malfunctions and crash statistics. We included articles published in 2008 or later, as this was the first year that mobile apps were available to consumers through Apple and Google Play (formerly Android Market) app stores. We only evaluated the statistical significance of changes in outcomes at the end of the intervention, and did not consider intermediate or follow-up time points. We included registry studies to provide information on harms that may not have been reported in other included studies. We anticipated that this would result in excluding pilot and feasibility studies that contain detailed information on the usability of apps; however, in order to evaluate the clinical efficacy of apps, we focused on comparators that are realistic options for clinical practice. Search Strategies While this was a rapid review, we took steps to ensure that we captured as many studies as possible that evaluated the desired outcomes for commercially available apps for selfmanagement of diabetes. We posted a Federal Register notice about our protocol, to seek additional data and unpublished materials. For all included apps, we contacted app developers or original study authors and requested any additional information they would like to provide. For apps that required a payment, subscription, access code, or password, we requested a free trial so we could adequately describe app features and assess usability. Study Selection One reviewer screened titles and abstracts of systematic reviews and technology assessments then examined full text articles for eligibility. Five systematic reviews addressed our guiding questions and met three additional criteria: (1) searched one or more citation databases; (2) applied prespecified inclusion and exclusion criteria; and (3) assessed the quality or risk of bias of identified studies. For primary studies identified from systematic reviews and additional searches, we applied the inclusion and exclusion criteria described in Appendix B. Study-Level Data Extraction One investigator extracted details about the study design, population, setting, interventions, comparator, and results.

Patients with panic disorder also report more stressful events in the month preceding panic onset spasms from sciatica discount robaxin 500 mg without a prescription, compared with control participants (7) muscle spasms 2 weeks purchase 500mg robaxin visa. Delineating the features of panic disorder that are present in a given patient is also important in establishing a diagnosis of panic disorder and developing a plan of treatment muscle relaxant adverse effects cheap robaxin 500 mg. The essential features of panic disorder are recurrent panic attacks and persistent concern about these attacks (or change in behavior as a result of the attacks) infantile spasms 2 month old generic 500 mg robaxin visa. Panic attacks are discrete periods of intense fear or discomfort that have abrupt onset and usually reach a peak within 10 minutes. These attacks are characterized by distressing physical and psychological symptoms and often by a sense of imminent danger and an urge to escape. Persistent concern about panic attacks can manifest in several ways: worry about having additional attacks, worry about the implications or consequences of the attacks, or changes in behavior that are intended to prevent attacks or cope with an attack should one occur. Fear and avoidance of situations and places such as driving, restaurants, shopping malls, and elevators commonly occur in individuals with panic disorder; this avoidance is referred to as agoraphobia. Patients with concurrent agoraphobia fear and/or avoid situations in which escaping or obtaining help may be difficult or embarrassing if they have panic symptoms. In any evaluation of panic disorder, it is crucial to determine if agoraphobia is present and to establish the extent of situational fear and avoidance. In addition to a full assessment of the features of panic disorder and agoraphobia, a comprehensive psychiatric assessment is essential to identify other anxiety disorders, mood disorders, substance use disorders, personality disorders, and other disorders that often co-occur with panic disorder (9­33). Co-occurring psychiatric disorders require particular attention as some of them affect the course, treatment response, and prognosis of panic disorder (34). Establishing the context in which panic attacks occur is important for accurate diagnosis. Panic attacks frequently occur in other disorders, and in only a subset of individuals is panic disorder an appropriate diagnosis. First, it must be determined that panic attacks do not occur solely as a result of a general medical condition. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia. With most of these conditions, definitive causal relationships between the general medical condition and panic disorder have not been established. Although there appears to be an increased co-occurrence of mitral valve prolapse and panic disorder (36­39), mitral valve prolapse is typically an incidental finding in a patient with panic disorder and does not usually change the treatment plan. B provides further discussion of the impact of cooccurring medical conditions on treatment planning for panic disorder. The Panic Attacks are not due to the direct physiological effects of a substance. Reprinted from Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: 1. Prescription or over-the-counter medications, including decongestants (pseudoephedrine, phenylpropanolamine), stimulants, dopaminergic agents, and agents to treat asthma (beta-adrenergic agonist inhalers, theophylline, steroids) may also induce or worsen panic attacks. Reduction or elimination of intake of such medications and substances may lead to a marked decrease or cessation of panic episodes. Psychiatrists also should consider other psychiatric disorders for which panic attacks can be an associated feature. A diagnosis of panic disorder requires the presence of at least some unexpected attacks during the course of illness that are not triggered by a specific stimulus. Psychiatrists should consider other disorders when panic attacks appear to be exclusively associated with the following: Exposure to a specific feared situation or stimulus (specific phobia) Exposure to situations in which the patient fears negative evaluation (social phobia) Exposure to the focus of an obsession or a situation in which the patient was prevented from performing a compulsive behavior (obsessive-compulsive disorder) Exposure to a reminder of a traumatic experience or to a situation in which the patient feels that safety is threatened (posttraumatic stress disorder) Intense bouts of worrying (generalized anxiety disorder) Exposure to separation from home or an attachment figure in children or adolescents (separation anxiety disorder) Copyright 2010, American Psychiatric Association. If a patient reports panic attacks without associated worry or behavioral change, the psychiatrist should consider whether panic attacks are an associated feature of another disorder or represent a subthreshold panic disorder. Although subthreshold panic disorder is associated with a lesser degree of symptoms, comorbidity, and functional impairment than full panic disorder (40), subthreshold panic disorder is often distressing for the patient, can interfere with functioning, and may progress to full panic disorder in some individuals (41). Standard treatments for panic disorder are generally indicated for patients presenting with subthreshold symptoms, although education or a briefer course of treatment may be sufficient as a first treatment step if symptoms are mild. Panic attacks that occur in the absence of worry about the attacks or behavior change in response to the attacks also may be conceptualized as associated features of other disorders. For instance, it is fairly common for patients with mood disorders to report occasional unexpected panic attacks; however, if persistent concerns about the attacks and behavioral changes in response to the attacks are both absent, then the panic attacks should be conceptualized as an associated feature of the mood disorder.

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This is extremely important in that the public health importance of tetanus on a global scale is attributable largely to muscle relaxant toxicity cheap robaxin 500 mg with visa neonatal disease infantile spasms 7 month old purchase robaxin 500mg free shipping. In 1989 spasms hip cheap 500mg robaxin mastercard, the World Health Assembly declared an initiative to muscle relaxant options purchase robaxin 500 mg on line eliminate neonatal tetanus by 1995 (2). The debate has been notable for its partisan fervor and confusing for its shifting focus to and from different types of herd immunity induction by different types of polio vaccines (12-14,98). The ecology and herd immunity characteristics of polioviruses are heavily dependent upon levels of hygiene. Serologic surveys carried out in the past among unvaccinated populations revealed that the average age at infection ranged from less than 2 years in nonhygienic environments in developing countries to more than 10 years in developed countries (99-101). Interpretation of such values in the context of equations 8, 12, and 13 suggests that the basic reproduction rate ranges from 5 to 30, and that the herd immunity threshold ranges from 80 to 97 percent depending on the level of hygiene. The polio herd immunity controversy has been part of a broader argument concerning the relative advantages of killed, inactivated polio vaccine versus live oral polio vaccine. Among the arguments favoring the live vaccines has been the claim that they provide much greater herd immunity than do inactivated polio vaccines (12, 14). The first is that live vaccines impart greater intestinal (local, immunoglobulin A-mediated) immunity, and, hence, impart greater protection against infection than do the killed vaccines (which induce protection more directly against tissue invasion and disease). To the extent that this is so, then recipients of killed vaccines may be protected effectively against disease but still be susceptible to enteric wild poliovirus infection, and thus provide little or Herd Immunity 291 no indirect protection to their unvaccinated neighbors. If this were so in the extreme, then herd immunity thresholds would be invalid for such vaccines, and only 100 percent inactivated polio vaccine coverage of a population would suffice to protect it from disease. Though there is evidence that prior live oral polio vaccine recipients excrete less virus in their feces than do prior recipients of inactivated polio vaccine, after subsequent challenge with live polio vaccine virus strains, it has also been demonstrated that fecal and oropharyngeal virus excretion is reduced among prior inactivated polio vaccine recipients compared with unvaccinated individuals (102, 103). Thus, inactivated polio vaccines do provide some protection against infection transmission. The greater propensity of inactivated polio vaccine to reduce oropharyngeal excretion of virus might be particularly important in populations with high levels of sanitation, in which respiratory transmission of poliovirus is more important than in areas with poor sanitation conditions, where transmission is overwhelmingly by the fecal-oral route (14). The second argument for greater herd immunity induction by live oral rather than inactivated polio vaccine is based upon the fact that live polio vaccine virus is excreted in the feces and the oropharynx in sufficient quantities for it to be transmitted to contacts. This unique attribute of live oral polio vaccine provides a special mechanism for indirect protection of nonvaccinees, in effect by vaccinating them surreptitiously. The frequency of such live oral polio vaccine spread is dependent on hygiene behavior and intimacy of contact, and varies greatly between populations. Studies carried out in the 1950s in Louisiana and in the Seattle, Washington, virus watch program, showed that oral polio vaccine virus was transmitted to 35-80 percent of child contacts of live oral polio vaccine recipients within low socioeconomic group households, though less frequently within better-off households, and that considerable transmission also occurred beyond the confines of households (104, 105). This means that the proportion immunized in a population receiving live oral polio vaccine is a function of three factors: vaccine uptake, vaccine efficacy, and vaccine virus transmission. The advantage inherent in this unique attribute of the live polio vaccines is tempered only by the fact that the live oral polio vaccine virus may rarely undergo reversion to virulence, and, hence, a small proportion of the contacts of vaccine virus may actually contract paralytic disease (this risk has been estimated to be of the order of one such case per million vaccine doses administered) (106). It appears that wild polio viruses ceased to circulate in most of the United States by 1970, at which time only some 65 percent of children were receiving a complete course of live oral polio vaccine (14). However, given the complex history of previous inactivated polio vaccine and then live oral polio vaccine programs in the country, and the propensity of live oral polio vaccine viruses to circulate in the community, the overall level of immunity in the population is unknown. Given the evidence for disappearance of wild polio viruses from the United States (107), it is probable that the prevalence (or subpopulation-specific prevalences) of immunity was (were) considerably above whatever herd immunity threshold^) might have been in force. In addition to the virologic evidence for reduced fecal excretion of virus in inactivated polio vaccine recipients, there is epidemiologic evidence for indirect protection by killed polio virus vaccines. An analysis of surveillance data from the United States suggested that polio incidence fell by a greater degree during the years 1955-1961 (when only killed vaccines were in use) than could be explained by the direct protection of vaccinees alone (108, but see also 14). An outbreak of 10 cases in Finland in 1984- 292 Fine 1985 was attributed to a type 3 virus different from that included in the vaccine (110). Outbreaks in the Netherlands have been restricted almost entirely to a religious community which refuses vaccination altogether, with no evidence of transmission in the population at large despite the presence of at least 400,000 individuals who have never been vaccinated at all (98, 111). Current efforts at global eradication of polio highlight the importance of herd immunity. Given the low case-to-infection ratio of polio (probably less than 1 percent of infections are recognizable clinically) and the potential of poliovirus to spread through sewage, water, and foodstuffs, case finding and outbreak containment will be less efficient in controlling poliovirus spread than they were against smallpox and might be against measles. There will thus be a greater reliance upon high levels of herd immunity in the strategy for eradication of polio than for these other diseases. This has been recognized in the use of mass live oral polio vaccine campaigns, first in Cuba, then in Brazil, and more recently throughout Latin America (112).

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Participants in the control group did not have regular scheduled communication with providers muscle relaxant chlorzoxazone generic robaxin 500 mg, but were encouraged to spasms posterior knee purchase 500 mg robaxin visa contact providers as needed spasms 1982 buy robaxin 500mg line. The intervention was shown to spasms near anus order robaxin 500mg overnight delivery statistically reduce HbA1c (difference-in-difference = 0. This study was low quality due to inconsistent reporting of outcomes as well as lack of information on randomization and allocation concealment. In addition, providers contacted participants in the intervention group using the app every 7 to 14 days, while the control group did not have regularly scheduled contact with providers. Therefore, the results of this study are applicable when Diabetes Manager is used in addition to scheduled contact with providers every 7 to 14 days. If this additional support affected some outcomes, then the effects of Diabetes Manager by itself are less certain. The Apple app was last updated in 2012, so it is unknown if this function will be fixed in the near future. Users must first create an account online and enter basic information about their diabetes before they are able to use the mobile app. Once users log into the app, they can track their blood glucose, meals and 15 carbohydrates, medication, physical activity, and weight. A privacy policy is available on the Dbees Web site, and there are no clear data security issues. We were only able to evaluate the Android app due to the graphical error on the Apple app. Our "marginal" usability score is consistent with Android marketplace ratings of the app. Participants had a mean duration of diabetes of nearly 17 years and two-thirds (66 percent) were on an insulin pump. Participants had important comorbidities including retinopathy (25 percent) and neuropathy (19 percent). The intervention group used the Dbees app and personal Web portal that allowed manual entry of participant self-care data, including blood glucose, carbohydrate intake, medication, and physical exercise. The study did not demonstrate significant changes in HbA1c, quality of life, or diabetes emotional distress. This study was moderate quality due to a lack of clarity on randomization and insufficient detail about the difference in planned interactions with research staff between the group that used the app and the control group. Like the Diabetes Manager app, this app has a generic food database that allows users to select their meals and automatically import carbohydrate and other nutrition information. This app has a privacy policy that discusses data security and how information will be used, and while there are no clear red flags, this app will request access to photos and Bluetooth connections. The intervention group used the Diabetes Diary with the Diastat feedback module for blood glucose management, while the control group used the Diabetes Diary app without the Diastat feedback module. Out-of-range blood glucose events, defined as blood glucose outside range 72270 mg/dL, were found to be significantly reduced in the Diastat intervention groups (median out-of-range events over 2 weeks: -14. We could not determine the effect of Diastat on HbA1c because the between-group difference-in-differences was not provided. This study was low quality based on incomplete information about randomization and lack of information about allocation concealment. In addition, there were insufficient details about the difference in planned interactions between the research staff and intervention and control groups. Because the app was unavailable to download in the United States, we were unable to provide a usability score. Participants had a mean duration of diabetes more than 8 years and nearly one-fifth (19 percent) of both intervention and control groups were on an insulin pump. Participants with all other insulin regimens, including insulin pumps, were excluded. Participants had a mean duration of diabetes of more than 16 years in the intervention group compared with 15 years in the control group. This study used the same intervention as in the 2010 study described above, and the control group received standard education.


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