Use Of Available Options Research Articles

The role of primary pharmacological therapy in acromegaly

Background and objectivesPrimary pharmacological therapy may be the only viable treatment option for many patients with acromegaly, especially those presenting with advanced disease with large inoperable tumors. Long-acting somatostatin analogs are currently the first-line treatment of choice in this setting, where they provide biochemical control and reduce tumor size in a significant proportion of patients. We herein present a brief overview of the role of primary pharmacological therapy in the treatment of acromegaly within the context of Latin America and support this with a representative case study.Case descriptionA 20 year old male presented with clinical and biochemical evidence of acromegaly. The glucose-suppressed growth hormone (GH) was 5.3 μg/L, his insulin-like growth factor-1(IGF-1) was 3.5 times the ULN and serum prolactin greater than 4,000 μg/L. Pituitary MRI revealed a large and invasive mass, extending superiorly into the optic chiasm and laterally into the left cavernous sinus. He was treated with a combination of octreotide and cabergoline with remarkable clinical improvement, normalization of GH and IGF-1 values and striking shrinkage of the adenoma.ConclusionThis case illustrates how effective the pharmacological therapy of acromegaly can be and yet at the same time, raises several important issues such as the need for life-long treatment with costly medications such as the somatostatin analogs. Access to these agents may be limited in regions where resources are restricted and clinicians face challenges in order to make the most efficient use of available options.

MANAGEMENT OF PATIENTS WITH MILD COGNITIVE IMPAIRMENT AND MILD TO MODERATE DEMENTIA

Click to increase image sizeClick to decrease image sizeKeywords: MCIdementiacholinesterase-inhibitorsmanagement of MCI

Role of chemotherapy in breast cancer

Breast cancer represents a major health problem, with more than a million new cases and 370,000 deaths worldwide yearly. Options and understanding of how to use cytotoxic chemotherapy in both advanced and early stage breast cancer have made substantial progress in the past 10 years, with numerous landmark studies identifying clear survival benefits for newer approaches. Despite this research, the optimal approach for any individual patient cannot be determined from a literature review or decision-making algorithm alone. Treatment choices are still predominantly based on practice determined by individual or collective experience and the historic development of treatment within a locality. In many situations treatment decisions cannot be divorced from economic considerations. Blanket application of international, national or local guidelines is usually impractical or inappropriate and careful consideration of the detailed circumstances of each patient is required to make optimal use of available options. Recent research has allowed us to refine breast cancers further into prognostic groups based on a gene expression profile. Clinical trials to prove the value of this approach are currently being designed. This review discusses the evidence for various chemotherapy regimens in the adjuvant and metastatic settings, and examines the current evidence for the timing of radiotherapy in the adjuvant setting.

Access to health care for youth leaving foster care: Medicaid and SCHIP

Purpose To examine how Medicaid and the State Children’s Health Insurance Program (SCHIP) could improve health care access for youth aging out of foster care, a vulnerable population with multiple health concerns. Methods On the basis of an analysis of state and federal laws, state plans and amendments, and a telephone survey of state officials, this article identifies options in Medicaid and SCHIP for states to provide health insurance coverage for these youth, examines states’ use of available options, and highlights other relevant federal health care programs. Results Numerous Medicaid and SCHIP eligibility categories could provide coverage for older adolescents leaving foster care. The federal Foster Care Independence Act of 1999 (FCIA) created a new Medicaid expansion option for this group and other opportunities for states to address their health care needs. Numerous other federal programs also finance health care that could serve this population. Conclusions The potential exists through Medicaid or SCHIP to ensure that nearly all former foster youth have health insurance as they leave state custody, but Medicaid and SCHIP cannot alone meet all health care needs of these youth. Financing available through other public programs is essential. A few states have adopted the new FCIA Medicaid expansion option for former foster youth, and a larger number have implemented other relevant Medicaid options. Additional states have used other innovative approaches to facilitate health care access. Most states could do much more. A major challenge is to find approaches that can be implemented during times of severe budgetary limitations.