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Zimmerman DL buy super p-force oral jelly discount, Ruzicka M effective 160mg super p-force oral jelly, Hebert P buy 160 mg super p-force oral jelly, Fergusson D, Touyz RM, Burns KD. Short daily versus conventional hemodialysis for hypertensive patients: a randomized cross-over study. Ineligible participants (N = 3) Keane DF, Lindley E. Use of hand-to-hand measurements for body composition monitoring in patients with inaccessible or amputated feet. Hung SC, Kuo KL, Peng CH, Wu CH, Lien YC, Wang YC, Tarng DC. Volume overload correlates with cardiovascular risk factors in patients with chronic kidney disease. Tsai YC, Tsai JC, Chiu YW, Kuo HT, Chen SC, Hwang SJ, et al. Is fluid overload more important than diabetes in renal progression in late chronic kidney disease? Ineligible outcomes (N = 8) Broers NJH, Usvyat LA, Marcelli D, Bayh I, Scatizzi L, Canaud B, et al. Season affects body composition and estimation of fluid overload in haemodialysis patients: variations in body composition; a survey from the European MONDO database. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 111 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. APPENDIX 6 Ferrario M, Moissl U, Garzotto F, Signorini MG, Cruz D, Tetta C, et al. Study of the autonomic response in hemodialysis patients with different fluid overload levels. Ann Int Conf IEEE Eng Med Biol Soc 2010;2010:3796–9. Gracia-Iguacel C, Gonzalez-Parra E, Perez-Gomez MV, Mahillo I, Egido J, Ortiz A, Carrero JJ. Prevalence of protein-energy wasting syndrome and its association with mortality in haemodialysis patients in a centre in Spain. Ronco C, Verger C, Crepaldi C, Pham J, De Los Rios T, Gauly A, et al. Baseline hydration status in incident peritoneal dialysis patients: the initiative of patient outcomes in dialysis (IPOD-PD study). Santos PR, Monteiro DL, de Paula PH, Monte Neto VL, Coelho ML, Arcanjo CC, et al. Volaemic status and dyspepsia in end-stage renal disease patients. Schwermer K, Hoppe K, Radziszewska D, Klysz P, Sawatiuk P, Nealis J, et al. N-terminal pro-B-type natriuretic peptide as a marker of hypervolemia and predictor of increased mortality in patients on hemodialysis. Siriopol D, Voroneanu L, Hogas S, Apetrii M, Gramaticu A, Dumea R, et al. Bioimpedance analysis versus lung ultrasonography for optimal risk prediction in hemodialysis patients. Yuste C, Abad S, Vega A, Barraca D, Bucalo L, Pérez-de José A, López-Gómez JM. Assessment of nutritional status in haemodialysis patients. Non-English language and unable to obtain translation (N = 2) Castellano-Gasch S, Palomares-Sancho I, Molina-Nunez M, Ramos-Sanchez R, Merello-Godino JI, Maduell F. Diez GR, Del Valle E, Negri AL, Crucelegui S, Luxardo R, Zambrano L, et al. Hypovitaminosis D in patients on hemodialysis (HD): related factors and influence on muscle strength. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 113 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. S d yd et a il a r ic ip a nt c ha r a c t er i ic s I nt er vent io n c ha r a c t er i ic s im s a nd o c o m es R s ( A stu g rou p; ontrolg rou p; tota l b oth g rou ps) l irst author, y ar: uan- S h ng, nroll PD T W wasad juste ac c ord ing to im s T od te rm ine i th algorithm f or l S e c ond aryre ports no R and om is b ioim pe anc e spe c trosc opy( B S M IS ) ad justing PD T W withB IS is l Language nglish nalys algorithm b e ne f ic ialon th hospitalisation rate l Pub lic ation type f ullte xt ge ( y ars m e an ( S D y ars llth param e te rsre lvant tof lui and oth r pivotalc linic aloutc om e sin l N um b e r of c e ntre s six we re re v al toth prim aryc are patints l S e tting: ialysisc e ntre s S e x ( m al staf f and th yad juste PD T W O utc om e s inc i nc e of intrad ialysis l ountry T aiwan ac c ord ing toth s ata hypote nsion wassignif ic antlylowe r in l S tart/ e nd ate s O c tob e r 2 to iab e te sm e llitus th stu ygroup l PD T W wasad juste ac c ord ing to S e pte m b e r 2 T h inc i nc e of O or C V- re late l c linic alsym ptom sand signsb yone or Prospe c tiv / re trospe c tiv ata Inc lusion c rite ria: patintsage v ntswe re lowe r in th stu ygroup c ollc tion: prospe c tiv y arsand witha d ialysisvintage of twof ixe xpe rinc e ialysisstaf f in and lowe r am ong non- d iab e te sm e llitus l ac hc e ntre S tu yd sign: R C T m onths patintsin th stu ygroup l R and om isation m e thod using a xc lusion c rite ria: c oronaryste ntsor T h ata ab out f lui we re not PD T W wasac hiv in of c om pute r- ge ne rate s q u nc e pac e m ake r im plantation; m e tallic vic e s isc los toprim aryc are staf f m onthsin whic had justm e nt of PD T W l L ngthof f ollow- up: m onths in b od y suc hasartif ic ialjointsor pins re q u nc yof m e asure m e nt: othgroups wasin th sam e ire c tion asth l S ourc e of f und ing: N phroC are sia c ontralate ralor b ilate ralam putations re c e iv m onthlym e asure m e ntsb e f ore re sults Pac if ic , T aiwan ivision ( grant pre gnanc y th ir m i - we kd ialysiss ssions num b e r 1 l T ype of vic e us th IS l irst author, y ar: ur, nroll f lui ov rload inf orm ation was im s wh th r or not ob jc tiv l S e c ond aryre ports no R and om is provi totre ating physic iansand us m e asure m e nt of f lui ov rload with l Language nglish nalys toad justf lui re m oval uring d ialysis b ioim pe anc e spe c trosc opyish lpf ulin l Pub lic ation type f ullte xt ge ( y ars m e an ( S D lui ov rload wasass ss twic e m onthly optim ising f lui status l N um b e r of c e ntre s two f lui ov rload inf orm ation wasnot O utc om e s LVM I( g/ m c re as l S e tting: ialysisc e ntre s( ope rate b y S e x ( m al provi totre ating physic iansand f lui signif ic antlyin th inte rv ntion group F re s niusM ic alC are re m ovald uring ialysiswasad juste and had nostatistic alsignif ic ant c hange l ountry T urke y iab e te sm e llitus ac c ord ing tousualc linic alprac tic e in th c ontrolgroup l S tart/ e nd ate s N R rywe ight wasass ss b yroutine T h LVM Id c re as in th inte rv ntion l Prospe c tiv / re trospe c tiv ata Inc lusion c rite ria: patintswhowe re c linic alprac tic e c hoc ard iography group wassignif ic antlyhigh r than in c ollc tion: prospe c tiv willing topartic ipate in th stu ywith - hour am b ulatoryB P m e asure m e nt and th c ontrolgroup l S tu yd sign: R C T writte n inf orm e c ons nt, age puls wav analysiswe re pe rf orm e at l R and om isation m e thod N R y ars and on th rapy b as line and m onths l L ngthof f ollow- up: m onths sc h ul thric e we kly( 1 hours l S ourc e of f und ing: unre stric te grant we kly f or m onthswe re inc lu f rom th urope an N phrologyand D ialysisInstitute S d yd et a il a r ic ip a nt c ha r a c t er i ic s I nt er vent io n c ha r a c t er i ic s im s a nd o c o m es l T ype of vic e us xc lusion c rite ria: pre s nc e of a re q u nc yof inte rv ntion: f or th stu y U rine output: signif ic ant inc re as in pac e m ake r or d f ib rillator, artif ic ialjoints group, f lui ov rload wasass ss twic e proportion of anuric patintsand or pins am putation, pe rm ane nt or m onthly f or th c ontrolgroup, thiswas signif ic ant d c re as in urine output in te m poraryc ath te rs b e ing sc h ul ass ss v ry3 m onthsb e f ore th non- anuric patintsat1 m onthsin th f or living d onor kine ytransplantation, m i or e nd - we kH s ssion b ioim pe anc e ass ssm e ntgroup. N o pre s nce o s riousli - lim iting com orb i c hange in th proportion of anuric situations( e. I Parhon U niv rsity S e x ( m al in th f orm of a stric t targe t inte rval unad juste and m ultivariate ad juste H ospitald ialysisc e ntre p ( b ioim pe anc e - re c om m e nd rywe ight wassignif ic antlylowe r in th l ountry R om ania iab e te sm e llitus kg) tob e ac hiv uring th ne xt b ioim pe anc e ass ssm e nt group than l S tart/ e nd ate s July2 to m onth T hus in th b ioim pe anc e in th c linic alm e thod sgroup D c e m b e r 2 Inc lusion c rite ria: allad ult patints( age ass ssm e nt arm , allpatints ith r und r- Proportion of patintsm aintaine l Prospe c tiv / re trospe c tiv ata y ars f rom th r C. I Parhon or ov rhy rate we re b rought toth within kg of th b ioim pe anc e c ollc tion: prospe c tiv U niv rsityH ospitald ialysisc e ntre alre ad y b ioim pe anc e - re c om m e nd rywe ight, re c om m e nd rywe ight was l S tu yd sign: R C T on th rapyf or m onths with2 - g we ight ad justm e ntspe r statistic allysignif ic antlyhigh r in th l R and om isation m e thod b loc k xc lusion c rite ria: patintswithlim b ialysiss ssion b ioim pe anc e ass ssm e nt group than rand om isation te c hniq u am putations m e tallic joint prosth s s rywe ight wasd te rm ine / ad juste in in th c linic alm e thod sgroup at around l L ngthof f ollow- up: m onths ab s nc e of a pe rm ane nt vasc ular ac c e ss th c linic alm e thod sgroup b yc linic al hal of th q uarte rlyass ssm e nts l S ourc e of f und ing: part of thisstu y c om pe nsate c irrhosis pre gnanc y re re nc e c rite ria ( B P valu pre s nc e wasf und b yth U niv rsityof or a c ard iac ste nt or pac e m ake r we re of oe m a, intrad ialytic hypote nsion, M ic ine and Pharm ac yIa igrant xc lu f rom th stu yb e c aus c ram ps tc. I Parhon re q u nc yof m e asure m e nt: population, patintsc onsi re l S tart- e nd ate s ay2 to unit m e asure m e nt wasus b e f ore ialysis ov rhy rate had a signif ic antly D c e m b e r 2 xc lusion c rite ria: b ioim pe anc e wasnot ialysiswaspe rf orm e thre tim e s inc re as riskf or all- c aus m ortalityin l Prospe c tiv / re trospe c tiv ata pe rf orm e in patintswithm e tallic joint pe r we k b othunivariate and m ultivariate ox c ollc tion: prospe c tiv prosth s s( c ard iac pac e m ake rs survivalanalys s l S tu yd sign: c ohort stu ywith c om pe nsate c irrhosis( T h num b e r of V v ntswas f ollow- up and lim b am putations( O th r signif ic antlyhigh r in ov rhy rate l R and om isation m e thod N xc lusion c rite ria we re re f usaltotake patintsin b othunivariate and l L ngthof f ollow- up: m e ian part in th stu y age y ars ac tiv m ultivariate ox re gre ssion analys s ( 4 m onths syste m ic inf e c tionsand te rm inal l S ourc e of f und ing: U niv rsityof illne ss s( M ic ine and Pharm ac y G r. Popa Iasigrant num b e r 1 and u f isc d ii ipc e grant num b e r PN - II- I - PC l T ype of vic e l irst author, y ar: nalys b e low m e ian tim e Looke at th re lationship b e twe n im s tod te rm ine i O isan S anthakum aran, av rage hy ration status( O W hy ration param e te rsand PD - re late ind pe nd nt riskf ac tor f or pe ritonitis l S e c ond aryre ports no b ov m e ian tim e - av rage pe ritonitisaswe llasth variab lslike lyto O utc om e s O wasa pre ic tor of l Language nglish hy ration status( O W im pac t pe ritonitisrate s pe ritonitis - f re survivalf rom nte ric l Pub lic ation type f ullte xt ge ( y ars m e an ( S D b e low m e ian om pare pe ritonitisrate sof patints organism son univariate analysis l N um b e r of c e ntre s one O W ab ov withab ov or b e low th m e ian tim e T hism ayb e partlyc aus b yth high l S e tting: N R m e ian O W av rage hy ration param e te r ( O W c om orb iityof patints( whohad an l ountry U K p total re q u nc yof m e asure m e nt: N R ad vanc e age and iab e te sm e llitus l S tart/ e nd ate s January2 to S e x ( m al b e low m e ian, O nlyinc lusion of nutritionalparam e te rs 1 O c tob e r 2 ab ov m e ian, total re uc e thisassoc iation l Prospe c tiv / re trospe c tiv ata iab e te sm e llitus( % b e low m e ian, c ollc tion: prospe c tiv ab ov m e ian, l S tu yd sign: c ohort stu ywith p total f ollow- up S d yd et a il a r ic ip a nt c ha r a c t er i ic s I nt er vent io n c ha r a c t er i ic s im s a nd o c o m es l R and om isation m e thod N Inc lusion c rite ria: sam e c ohort of patints l L ngthof f ollow- up: m onths asin O Lone b ut witha slightly l S ourc e of f und ing: re s arc hgrants longe r re c ruitm e nt pe riod and xtra f rom re s niusm e ic alc om panyand partic ipants c onsisting of allC PD and B axte r H althc are PD patintswhohad at last one l T ype of vic e c onte m porane ousB m e asure m e nt l xc lusion c rite ria: allpatintswith am putations c ard iac pac e m ake rsor d f ib rillatorswe re xc lu aswe we re unab l tope rf orm IS m e asure m e nts l irst author, y ar: W ize m ann, nalys hype rhy rate asure m e ntstake n onc e only b e f ore im s toinv stigate how th l S e c ond aryre ports no norm ohy rate total ialysis and patintsd ivi into m agnitu of th pre vailing O l Language nglish ge ( y ars m e an ( S D hype rhy rate hype rhy rate ( re lativ hy ration of inf lu nc e slong- te rm survivalin patints l Pub lic ation type f ullte xt norm ohy rate or norm ohy rate groups whic h re c e iving l N um b e r of c e ntre s thre total we re th n c om pare on hy ration O utc om e s signif ic ant pre ic torsof l S e tting: ialysisc e ntre S e x ( m al N R param e te rsand m ortality m ortality age S B P, iab e te sm e llitus l ountry urope iab e te sm e llitus( % hype rhy rate re q u nc yof m e asure m e nt: thre tim e s pe riph ralvasc ular d is as re lativ l S tart/ e nd ate s to norm ohy rate total pe r we k, b e f ore th start of hy ration statuspre ialysis 1 January2 Inc lusion c rite ria: allpatintswho tre atm e nt l Prospe c tiv / re trospe c tiv ata re c e iv tre atm e nt in th thre stu y c ollc tion: prospe c tiv c e ntre sin l S tu yd sign: c ohort stu ywith xc lusion c rite ria: th patintswith f ollow- up pac e m ake rs/ im plante f ib rillatorsor l R and om isation m e thod N am putation of a m ajor lim b l L ngthof f ollow- up: m onths we re xc lu l S ourc e of f und ing: N R l T ype of vic e A O ac ute f lui ov rload T , antihype rte nsiv PD autom ate PD IS , - b ioim pe anc e spe c trosc opy I b ioim pe anc e analysis IS , b ioim pe anc e spe c trosc opy P, b lood pre ssure PD c ontinuousam b ulatoryPD O R , re lativ f lui ov rload I R , inte rq uartil range L VG , long- d ialysisvintage group; m ainte nanc e N not applic ab l N O G , non- ov rhy rate group; N R , not re porte N R S , non- rand om is stu y O G , ov rhy rate group; O ov rhy ration; S D VG , short- d ialysisvintage group. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 125 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. S d y: fi a u ho a nd yea r o fp b lic a t io n C a s ella no o p p e e t a l im e t a l im e t a l eie t a l o ne no f ies c u a nt ha ku m a r a n izem a nn ReB c r ier ia e t a l e t a l e t a l e t a l e t a l R e pre s ntativ sam pl Inc lusion/ e xc lusion c rite ria c larly d f ine Partic ipantsat a sim ilar point in d is as progre ssion C ons c utiv s lc tion of partic ipants Prospe c tiv ata c ollc tion C larlyd f ine inte rv ntion Inte rv ntion liv re b y e xpe rinc e pe rson Inte rv ntion liv re in appropriate s tting Im portant outc om e sc onsi re O b jc tiv outc om e m e asure B lind ass ssm e nt of m ain outc om e s Long noughf ollow- up Inf orm ation on non- re spond nts d ropouts W ith rawalslike lytointrod uc e b ias Im portant prognostic f ac tors i ntif i DOI: 10. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 127 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. P es ence o f D ia s o lic left V M er ia ls iffnes I nd ica t o r gr o u p ( m m H g) , ( m m H g) , vent icu la r ( g/ m 2 V ( m / b s o l e Rela t ive a s es ed o s p ia lia t io n m ed ica t io n m ea n ( S m ea n ( S hyp er o p hy m ea n ( S m ea n hyd r a t io n s a t hyd r a t io n a t H a n- S heng e t a l Ind icator Inci nce IR ratioand R ( pe r Pre ialysisS B P O and O post f or all O R f or allpatints patint- y ar) f or alld iab e te s patints f or patints f or patintswith m e llitusand non- d iab e te s withinitialF O of initialF O of l m e llituspatints I land f or and f or patints patintswithinitial withinitialF O of F O of lchange lchange with withb as line b as line T otal S tu y O v rall v nts IR ll O ll O ll ( S D ( b ioim pe ance I0 to0 of l ( S D O post O of l d iab e te sm e llitus v nts O of ( S D ( S D p IR I0 to l p O of O of l 0 non- d iab e te sm e llitus p l O ( S D 4 v nts IR I ( S D p p 0 to0 O post ( S D 1 p O of l O ( S D p F O post ( S D p C ontrol O v rall v nts ll ll O ll O R : inci nce O of l ( S D O post ( SD O of ( 9 I0 to0 ( S D O l O R IR I0 O of l of l O ( SD O of to1 R ( S D O post l ( 9 I0 to1 ( S D ( SD p l iab e te sm e llitus p O of e v nts inci nce l O ( 9 I0 to0 ( S D p IR I0 to O post 1 R I ( S D 0 to2 l N on- d iab e te sm e llitus e v nts inci nce ( 9 I0 to0 IR I0 to 1 R I 0 to2 P es ence o f D ia s o lic left V M er ia ls iffnes I nd ica t o r gr o u p ( m m H g) , ( m m H g) , vent icu la r ( g/ m 2 V ( m / b s o l e Rela t ive a s es ed o s p ia lia t io n m ed ica t io n m ea n ( S m ea n ( S hyp er o p hy m ea n ( S m ea n hyd r a t io n s a t hyd r a t io n a t L o e t a l Ind icator T otal aily O W / I W d f ine os m e an ( SD at 1 we ks T otal( B ioim pe ance ( S D ( S D ( p change p change p change p change withb as line and withb as line withb as line withb as line b e twe n groups C ontrol ( S D ( S D ( p change p change p change p change withb as line and withb as line withb as line and withb as line b e twe n groups b e twe n groups H e t a l Ind icator ospitalisation rate Pre and post Pre and post p- valu p- valu O pre and O post 1 patints ialysis p- valu ialysis p- valu change f rom change change withb as line change f rom change f rom b as line f rom b as line b as line b as line T otala S tu y ospitalis Pre ialysis Pre dialysis: 73 O pre ( SD ( b ioim pe ance hospitalisation rate p p p O post patint- y ar, post d ialysis post d ialysis p ( SD p ( 1 p p change withb as line F O pre ( SD F O post ( SD C ontrol ospitalisation, Pre ialysis Pre ialysis O pre ( SD hospitalisation rate p p post p p i re nce b e twe n O post patint- y ar: p N S , post d ialysis ialysis groups ( SD change d i re nce b e twe n groups p p I to O pre ( SD – p O post ( SD B twe n- group O pre I change s to ( 9 I p O post – I to p P es ence o f D ia s o lic left V M er ia ls iffnes I nd ica t o r gr o u p ( m m H g) , ( m m H g) , vent icu la r ( g/ m 2 V ( m / b s o l e Rela t ive a s es ed o s p ia lia t io n m ed ica t io n m ea n ( S m ea n ( S hyp er o p hy m ea n ( S m ea n hyd r a t io n s a t hyd r a t io n a t O no fr ies cu e t a l d id no t ep o r Ind icator patints hange with R F O ( S D not tre ate b as line change within withA T groups( 9 I m e ication, within- group change B ioim pe ance p I to – to p p C ontrol N R ; p N S I to4 – to2 p p B twe n- group twe n- group nd of inte rv ntion: change s m e an i re nce ( e nd of p change inte rv ntion) : f rom b as line to 1 I nd of inte rv ntion: – to8 to p b e twe n- p group m e an d i re nce ( change f rom b as line toe nd of inte rv ntion) : – I – to2 p P es ence o f D ia s o lic left V M er ia ls iffnes I nd ica t o r gr o u p ( m m H g) , ( m m H g) , vent icu la r ( g/ m 2 V ( m / b s o l e Rela t ive a s es ed o s p ia lia t io n m ed ica t io n m ea n ( S m ea n ( S hyp er o p hy m ea n ( S m ea n hyd r a t io n s a t hyd r a t io n a t P o nce e t a l Ind icator ospitalis at last once Pre and post Pre and post O ( l ( S D R O ( S D d ialytic ialytic com pare with com pare with b as line b as line T otal S tu y Pre ialytic S B P: Pre ialytic P: ( b ioim pe ance p p N S post- d ialytic S B P: post- d ialytic 1 P: C ontrol Pre ialytic S B P: Pre ialytic P: an O 1 p p N S post- d ialytic S B P: post- d ialytic 1 P: B twe n- group I p N S d i re nce to0 p A T , antihype rte nsiv P, b lood pre ssure P, iastolic b lood pre ssure O f lui ov rload O R , re lativ f lui ov rload IR , inc i nc e rate N S , not signif ic ant; O ov rhy ration; R F O re lativ f lui ov rload a T e n patintshospitalis asa re sult of ne w V v ntsd uring th stu ype riod DOI: 10. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 133 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. APPENDIX 10 Study details Participant characteristics Aims and outcomes (> 160/100 mmHg despite AHT unstable angina, amputation, CV medications); severe heart failure revascularisation; parameters (NYHA functional classification III measured by BCM or IV) l Intervention model: parallel assignment l Study title: Bioimpedance l Estimated enrolment: 516 l Aims: to test whether or not Spectroscopy to Maintain Renal l Inclusion criteria: adults aged taking regular measurements Output (BISTRO)94 > 18 years commencing with a bioimpedance device l ClinicalTrials. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 135 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 137 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. EME HS&DR H TA PGfAR PHR Part of the NIHR Journals Library www.

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Half of the respondents judged that their CCG was the most influential in this regard cheap super p-force oral jelly 160 mg line, and NHSE was ranked second order super p-force oral jelly paypal. However order super p-force oral jelly no prescription, nearly half of the respondents did not rate their own CCG as the most influential. NHSE was seen as the next most influential institution in shaping service redesign and the growing importance of collaboration between CCGs is also indicated. However, the fact that nearly half of CCG board members themselves judged that their CCG did not exercise the most influence might be expected to be a potential curb on expectations about the exercise of leadership by CCG clinicians or other CCG players. The data for the assessment of influence split by role holder are shown in Figure 3. Notably, it was the chairpersons of CCGs who were most likely to perceive their CCGs as influential. However, other role holders, most notably finance directors, did not. Less than half of accountable officers perceived their CCG to be the most influential body in shaping services. This is an especially important finding because arguably, among all of the different role holders, one would expect the accountable officers to have the clearest line of sight on the various forces at play. It would suggest that the reality of CCG influence is rather less than was implied by the policy intent as it was described at the outset of this report. Many GPs on CCG boards reported that they were disillusioned with their CCG experience. For example: The CCG is becoming increasingly bureaucratic and much more like a PCT. We are increasingly subject to government directives and with short deadlines. There is no space for creative solutions from the CCG. GP member of governing body We then undertook a different analysis: the perceived relative influence of different bodies was correlated with the ratings of CCGs allocated by NHSE. It may be that the pattern of institutional influence is reflected in 100 90 80 Other Patients 70 Hospitals and other providers 60 My local HWB My CCG in collaboration with 50 some neighbouring CCGs 40 Various regulators NHSE 30 My CCG 20 10 0 FIGURE 3 Relative influence of different bodies as reported by different role holders. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 21 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS 100 90 80 Other 70 Patients Hospitals and other providers 60 My local HWB 50 My CCG in collaboration with some neighbouring CCGs 40 Various regulators 30 NHSE My CCG 20 10 0 Inadequate Requires Good Outstanding improvement FIGURE 4 The relative influence of different bodies (2016) by NHSE headline rating of the CCG. Alternatively, it may be that this pattern suggests the possibility of a self-fulfilling prophesy: those expecting low impact achieved just such; conversely, those assuming that they had influence were able to exercise it. There is an alternative explanation: the low and high performers sensed the state of play and disowned or owned responsibility accordingly. Figure 5 shows comparative data for 2014/16 with regard to perceived influence on the design of services in the local health economy. There certainly seemed to be no sense of a growing influence. The largest group of respondents said that their own CCG was the major player (38% of influence in 2016). However, other bodies were also seen as important, and these included NHSE (14%) and local collaborations of CCGs (18%). There were significant differences in this assessment depending on the role of the respondent with regard to their views about NHSE and NHS Improvement. GP members of the governing bodies were most likely to perceive NHSE and NHS Improvement as influential. Next we looked at ratings of CCGs by perceived importance of collaboration among neighbouring CCGs. And perhaps they did not want to collaborate with others in case this affected their performance ratings. When asked to rate the influence exerted by hospitals and other providers, it tended to be respondents from CCGs rated as inadequate who were more likely to accord the highest influence to these bodies (Figure 7). This may reflect the reality of powerful local hospital trusts or it might reflect a lack of will or capability in tackling these providers. The next section shifts focus from the influence of CGGs to an analysis of relative influence within them. Most especially, there was the contentious issue of whether managers or clinicians were exercising power and, relatedly, what influence, if any, other role holders such as the lay members, the secondary care doctors and the nurses had. Influence within Clinical Commissioning Groups Given that the policy intent, as shown in Chapter 1, was to create commissioning organisations led by clinicians – and most especially by GPs – we wanted to know whether or not these institutions had lived up to that aspiration. We began with a question which asked about the relative influence of different groups on the redesign of services. The four groups were managers, GPs, other clinicians excluding GPs and lay members. In broad terms, managers and GPs were seen to be the most influential by far. In 2014, of the two, GPs were marginally ahead; however, by 2016 the rankings had reversed and managers were marginally ahead in terms of ranked influence. This is especially notable given that the majority of respondents were GPs. Other members of the governing bodies (including the lay members, secondary care doctors and nurses) were rated as far less influential. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 23 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS 45 40 35 30 Year 25 2014 20 2016 15 10 5 0 Managers GPs Other clinicians Lay members excluding GPs FIGURE 8 Influence of managers, GPs, other clinicians and lay members in the redesign of services. Some answers from 2016 were then broken down to show how different kinds of respondents answered this question. It was evident that finance officers tended to see managers as the most influential figures. GP members of governing boards and others (directors of public health and other managers) tended likewise to see managers as influential. Next, we delved deeper into the perceived influence of GPs, as broken down by role of respondent. As the results in Figure 10 show, GP members of the boards were, ironically, the least convinced that they had much influence.

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This was written by a young Christian man who developed schizophrenia and began to believe that Satan had taken control in Heaven buy super p-force oral jelly 160 mg with visa. He had not decided to change his religion buy cheap super p-force oral jelly 160 mg online, that is generic 160 mg super p-force oral jelly, he had not become a devil worshiper, and he was distressed by his new belief. This man despised Satan, and it is unlikely that he would wish to apply the words “but beautiful” to him/her. It is probable that when he thought of heaven, he thought about the attributes of God, and stayed on that line of thinking while writing about Satan. This letter was written by a man with schizophrenia. He had once been a patient of the author, but had not been seen by him for some years. He had been in a psychiatric hospital under the care of Dr Jeff Self. The patient writes that his hallucinations (voices) are worse than being dead or tortured. For years he had experienced visual hallucinations of attractive women. He writes about having sex with his visions which he can “feel” in his pillows. It is very difficult to classify the information that he is having sex with his visions. If it is not possible to have sex with visions, then this is a false belief and could be classified as a delusion. But, was this man having visual hallucinations of himself having sex with the attractive women who appeared in his earlier visions? Insufficient details are available about his experience for firm conclusions to be reached. This patient had difficulty with logical thought, so he was unable to describe things better, even when specifically asked. Last modified: November, 2015 7 By convention, psychotic disorders are those in which there are psychotic symptoms, PLUS significant impairment of the capacity to function effectively in everyday life. It is possible to have a mental disorder, and a psychotic symptom, but not to have a greatly reduced capacity to function in everyday life. Thus, it is possible to have a psychotic symptom without having a fully developed psychotic disorder. Consider a person who has suffered an acute psychotic disorder, who with treatment has returned to work and normal life, but who still hears a voice a few of times a day. Such an individual experiences occasional psychotic symptoms, but the full psychotic disorder is in remission, and he/she would not be described as being psychotic. Consider a person with anorexia nervosa who purposefully restricts food intake and exercises excessively because of a fear of being fat, who is emaciated to a dangerous degree, but who nevertheless believes he/she is overweight. By strict criteria, this person is experiencing something at least very similar to a delusion. Further, when such patients see themselves in a mirror, they frequently “see” themselves as fat, a phenomenon which suggests mistakes of perception. This condition is often disabling (although, some people with anorexia nervosa can perform rewarding work and maintain stable relationships). In spite of apparent “delusions” and mistakes of perception, and some reduction in the ability to conduct a social and working life, by convention, anorexia nervosa is not classified as a psychotic disorder, and patients suffering this condition are not described as psychotic. The symptoms of this disorder include hallucinations, delusions, reduced ability to think logically (thought slippage), behavioural signs such as the holding of bizarre postures, the loss of the ability to experience emotions and spontaneity, social withdrawal, and personal neglect. During acute episodes, hallucinations, delusions and thought slippage are the most prominent symptoms. With treatment or natural remission these symptoms are less prominent and the loss of spontaneity, social withdrawal and personal neglect become more noticeable. Delusional disorder, in contrast, only manifests (one or more) delusions. Usually the delusion is of a paranoid type, and the patient believes he/she is being watched and is in danger from spies, organised crime, etc. The patient may be able to work and appear normal to others. As there is only one symptom and the patient may appear to function reasonably well outside the home. Suspiciousness or frank delusions result in conflict at work and the patient is usually finally placed on some form of pension. The social life is also severely impaired, the patient eventually withdrawing to live behind reinforced doors with an array of locks, in a state of constant apprehension. Last modified: November, 2015 8 Mood disorders The Oxford English Dictionary defines mood as “1, a particular sate of mind or feeling, and 2, a prevailing feeling, spirit or tone”. Thus, feelings are the central issue, and under this heading one might expect to include fear, jealousy or love. Bipolar disorder (once called manic-depressive psychosis) is the most dramatic form - characterised by mood elevated (manic) and lowered (depressed) phases. These phases may last for months or even become chronic. For a given patient, swings may predominantly occur in one direction, alternatively, about equal numbers of swings may occur in each direction. In the mood elevated phase the patient is often over confident, grandiose, irritable and disinhibited, with rapid thoughts, reduced need for sleep and abundant energy. Delusions may occur about possessing exceptional importance or skills; hallucinations (often of being spoken to by God or adoring others) less commonly occur. In depressed phases the mood and energy are low, thinking is slowed and the ability to concentrate is reduced. Sleep is disrupted, the patient often waking in the early hours and unable to return to sleep. There is loss of interest in food, sexual or any other activity, and weight loss is a frequent feature. The patient in a manic phase is clearly acting out of character, and with mood elevation as a springboard, problems arise when patients engage in risky behaviour such as unwise investments, fast driving, ill-advised sexual liaisons or audacious activities. The patient in a depressive phase may also act out of character, becoming inactive and withdrawn. However, not infrequently, the patient thinks about death and regrettably, suicide is more common among significantly depressed individuals than among the healthy population. Major depressive disorder or unipolar depression is the term applied when severe episodes of depression occur, but the individual has never experienced a manic or hypomanic episode. Cyclothymic disorder manifests both depression and elevations, but severity is insufficient for the diagnosis of bipolar disorder. Persistent depressive disorder is a chronic condition of depressed mood; this may indicate a major depressive disorder which has incompletely resolved, or a long term condition which has never reached the diagnostic criteria for major depressive disorder. Last modified: November, 2015 9 Non-psychotic disorders The non-psychotic disorders are, in general, what Freud referred to as the “neuroses”. The symptoms of the psychotic disorders such as hallucinations and delusions are largely unknown to healthy individuals.