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Adiposopathy is “sick fat” a cardiovascular dis- sequences of adipocyte hypertrophy and increased visceral ease? National Institutes of Health-North American Association tion statement on obesity and obesity medicine buy cheap remeron on-line medications ritalin. Exercise ameliorates high- Correlates of fruit and vegetable intake among adoles- fat diet-induced metabolic and vascular dysfunction buy cheap remeron line medicine 10 day 2 times a day chart, and cents cheap 15 mg remeron fast delivery medications interactions. Identifying retail food stores restaurant food consumption with 3-y change in body mass to evaluate the food environment buy cheap remeron 15 mg medicine to reduce swelling. Role of food prepared tional, convenience, and nontraditional types of food stores away from home in the American diet, 1977-78 versus in two rural Texas counties. Night eating and weight change in middle- time in children: a systematic review and meta-analysis of aged men and women. The role of schools systematic review of interventions to improve health pro- in obesity prevention. Availability of a la carte food items Improving health professionals’ management and the in junior and senior high schools: a needs assessment. Lessons Nutritionally complete prepared meal plan to reduce car- from the literature. New York, New York: Oxford University Press; for obesity: effects of matching participants to their treat- 1992. Behavioral theories and the pharmacologic treatment of obesity: A randomized trial. A comparison of weight control behavioral interventions for weight loss: a randomized and weight control plus body image therapy for obese men trial of food provision and monetary incentives. A new predictive equation for resting energy humans: potential pitfalls and health concerns. A new handheld device for measuring resting metabolic rate and oxygen and biosynthesis mediate improved wound repair in refed, consumption. Changing rates of eating disorders: what does ual physical activity by a seven-day recall in a community it mean? Criteria for Evaluating thritis of the knee in the frst national Health and Nutrition Weight-Management Programs. Risk of symptomatic gallstones in women American College of Endocrinology Obesity Task with severe obesity. National Task Force on the Cholelithiasis in patients treated with a very-low-calorie Prevention and Treatment of Obesity, National Institutes diet. Dietary energy density in the treatment of obesity: a analysis of randomized controlled trials. Obesity treatment: can diet weight loss and lifestyle changes on vascular infamma- composition play a role? Mechanisms of increase in plasma tria- of long-term dietary intervention in obese patients: four- cylglycerol concentrations as a result of high carbohydrate year results. Mechanisms for the Prevention, Interdisciplinary Committee for Prevention acute effect of fructose on postprandial lipemia. Changes in risk factors for cardiovascu- ment from the American Heart Association. Diabetes white paper: Defning the update: a report from the American Heart Association. Effects of Guidelines for Clinical Practice for developing a diabetes soft drink consumption on nutrition and health: a system- mellitus comprehensive care plan. Nutrition knowledge, food label use, and sumption and risk of developing cardiometabolic risk fac- food intake patterns among Latinas with and without type tors and the metabolic syndrome in middle-aged adults in 2 diabetes. Meat intake and mortality: a prospective Evidence-based nutrition practice guidelines for diabetes study of over half a million people. The muscle cessed meat consumption and risk of incident coronary protein synthetic response to carbohydrate and protein heart disease, stroke, and diabetes mellitus: a systematic ingestion is not impaired in men with longstanding type 2 review and meta-analysis. Protein in optimal health: heart disease and analysis of prospective cohort studies evaluating the asso- type 2 diabetes. Dietary fat and coronary heart dis- on glycemic control and lipid levels in type 2 diabetes. Effect of a high-protein, low- inadequately controlled by once-daily insulin detemir and carbohydrate diet on blood glucose control in people with oral antidiabetes drugs: the step-wise randomized study. Red meat intake is associ- study of basal-bolus insulin therapy in the inpatient man- ated with metabolic syndrome and the plasma C-reactive agement of patients with type 2 diabetes undergoing gen- protein concentration in women. A dou- and calcium attenuates bone loss over twelve months of ble-blind randomized comparison of meal-related glyce- weight loss and maintenance relative to a conventional mic control by repaglinide and glyburide in well-controlled high-carbohydrate diet in adults. Hypoglycemia in diabetics on dialysis with management of type 2 diabetes: rationale and strategies: a poor glycemic control: hemodialysis versus continuous statement of the American Diabetes Association, the North ambulatory peritoneal dialysis. Carbohydrate issues: type ciated with higher intakes of sugars in two distinct popula- and amount. The effect 1 diabetes using a treat-to-target basal-bolus regimen with of strawberries in a cholesterol-lowering dietary portfolio. Trans undergoing intensive insulin management using lispro fatty acids, insulin resistance and diabetes. Insulin analogs and glycosylated hemoglo- vascular disease risk: should policy decisions be based bin target of less than 7% in type 2 diabetes: a systematic on observational cohort studies, or should we be waiting review of randomized trials. Sugary tes (the Canadian trial of carbohydrates in diabetes): a soda consumption and albuminuria: results from the randomised controlled trial. Comparison of 3 ad libitum diets for weight- subjects improves glucose tolerance, lowers infammatory loss maintenance, risk of cardiovascular disease, and dia- markers, and increases satiety after a subsequent standard- betes: a 6-mo randomized, controlled trial. High-glycemic index carbohydrate increases weight-loss diets with different compositions of fat, pro- nuclear factor-kappaB activation in mononuclear cells of tein, and carbohydrates. Should glycemic index and glycemic load and diet for preventing type 2 diabetes mellitus (Review). Associations between diet and cancer, isch- Kidney Disease Fact Sheet: general information and emic heart disease, and all-cause mortality in non-Hispanic national estimates on chronic kidney disease in the United white California Seventh-day Adventists. The inci- diet and a conventional diabetes diet in the treatment of dence of end-stage renal disease is increasing faster than type 2 diabetes: a randomized, controlled, 74-wk clinical the prevalence of chronic renal insuffciency. Atlas of Chronic Kidney Disease Assessment of the longer-term effects of a dietary portfolio and End-Stage Renal Disease in the United States. Changes in nutrient intake and disease: a statement from the American Heart Association dietary quality among participants with type 2 diabetes Councils on Kidney in Cardiovascular Disease, High Blood following a low-fat vegan diet or a conventional diabetes Pressure Research, Clinical Cardiology, and Epidemiology diet for 22 weeks. Early death in dialysis milk and dairy consumption: an overview of evidence patients: risk factors and impact on incidence and mortal- from cohort studies of vascular diseases, diabetes and can- ity rates. Energy balance guidelines for chronic kidney disease: evaluation, classi- in predialysis patients on a low-protein diet. Factors causing malnutrition in nutritional status and body composition of uremic patients patients with chronic uremia. Prevention of hypertension and its complica- atherosclerosis in chronic renal failure.
As a consequence purchase genuine remeron on-line treatment 3 phases malnourished children, lower total plasma concentrations of some drugs may be required to achieve a therapeutic effect purchase remeron medications in carry on. Bilirubin is a breakdown product of old blood cells which is carried in the blood (by binding to plasma proteins) to the liver where it is chemically modified (by conjugation) and then excreted in the bile into the newborn’s digestive tract generic remeron 30mg online medications available in mexico. Displacement by drugs and the immature conjugating mechanisms of the liver means that unconjugated bilirubin levels can rise and can cross the brain–blood barrier order remeron 30mg amex symptoms 3dp5dt; high levels cause kernicterus (brain damage). Conversely, high circulating bilirubin levels in neonates may displace drugs from proteins. In the first weeks of life, the ability of the liver to metabolize drugs is not fully developed. This all changes in the 1–9-month age group in which the metabolic clearance of drugs is shown to be greater than in adults. This is probably due to the relatively large size of the liver compared with body size and maturation of the enzyme systems. Thus to achieve plasma Routes of administration of drugs 151 concentrations similar to those seen in adults, dosing in this group may need to be higher. Elimination In neonates, the immaturity of the kidneys, particularly glomerular filtration and active tubular secretion and reabsorption of drugs, limits the ability to excrete drugs renally. Below 3–6 months of age, glomerular filtration is less than that of adults, but this may be partially compensated by a relatively greater reduction in tubular reabsorption as tubular function matures at a slower rate. After 8–12 months, renal function is similar to that seen in older children and adults. Oral administration It is not always possible to give tablets or capsules: either the dose required does not exist, or the child cannot swallow tablets or capsules (children under 5 years are unlikely to accept tablets or capsules). Therefore an oral liquid preparation is necessary, either as a ready-made preparation, or one made especially by the pharmacy. Liquid formulations sometimes have the disadvantage of an unpleasant taste which may be disguised by flavouring or by mixing them with, or following them immediately by, favourite foods or drinks. However, mixing the drugs with food may cause dosage problems and affect absorption. It is worth remembering that, to ensure adequate dosing, all of the medicine and food must be taken. Parents and carers should be discouraged from adding medicines to a baby’s bottle. This is because of potential interactions with milk feeds and under dosing if not all the feed is taken. The crushing or opening of slow- release tablets and capsules should also be discouraged; it should only be done on advice from pharmacy. A 5mL medicine spoon or oral syringe should be used and parents or carers may 152 Children and medicines need to be shown how to use these (see the section on oral syringes in Chapter 9 ‘Action and administration of medicines’, page 131). Parenteral administration The parenteral route is the most reliable with regards to obtaining predictable blood levels; giving drugs intravenously is the most commonly used parenteral route. It is now commonplace to use infusion pumps when giving infusions, as opposed to using a paediatric or micro- drop giving set on its own, as pumps are considered to be more accurate and safer. In practice the route is used for concentrated and irritating solutions that may cause local pain if injected subcutaneously and which cannot be given by any other way. Thin infants may be given 1–2mL and bigger children 1–5mL, using needles of appropriate length for the site chosen. However, in neonates, owing to the fragility of the veins, extravasation is relatively common and can cause problems if drugs leak into the tissues. If possible, children should know why they need a medicine and be shown how they can take it. Young children and infants who cannot understand will usually take medicine from someone they know and Practical implications 153 trust – a parent or main carer. So it is important that those who give medicines know about the medicine and how to give it. Occasionally, there may be problems in giving medicines – usually due to taste or difficulty swallowing a tablet or capsule. Parents or carers should not give in to fractious children and not give medicines as then compliance may be a problem; at all stages, the child should be comforted and reassured. They must not be left with the impression that being given medicine is a punishment for being sick. Another problem is that the child may seem better, so parents/carers may not complete treatment, as with antibiotics. The approach depends on the child’s understanding and the circumstances: • Under 2 years: Administration by parents if possible, using an approach which they believe is most likely to succeed. At this age children must have a proper understanding of what is happening and share in the decision making as well as the responsibility. What children and carers need to know • The name of the medicine • The reason for using it • When and how to take it • How to know if it is effective, and what to do if it is not • What to do if one or more doses are missed • How long to continue taking it • The risks of stopping it early • The most likely adverse effects; those unlikely, but important; and what to do if they occur • Whether other medicines can be taken at the same time • Whether other remedies alter the medicine’s effect Nursing staff involved with children need to be aware of medicine and dosage problems in children. Dosing Most doses of medicines have been derived from trials or from clinical experience and are usually given in terms of body weight as milligrams per kilogram of body weight (mg/kg). This assumes that the body weight 154 Children and medicines is appropriate for the child’s age, but this may not always be the case, since children grow at different rates and obesity is becoming more common. Before a dose is decided upon, the appropriateness of the child’s weight for age and height should be assessed. Alternatively, doses may be given for different age ranges as most drugs will have a wide safety margin (i. Using body surface area may be a more accurate method for dosing, as surface area better reflects developmental changes and function. However, determining surface area can be time-consuming and this method of dose calculation is generally reserved for potent drugs where there are small differences between effective and toxic doses (e. Licensing and ‘off-label’ use As stated earlier, many drugs are not tested in children which means that they are not specifically licensed for use in children. So although many Practical implications 155 medicines are licensed, they are often prescribed outside the terms of their Marketing Authorization (or licence) – known as ‘off-label’ prescribing – in relation to age, indication, dose of frequency, route of administration or formulation. Nursing staff should be aware both when an unlicensed medicine is being administered and of their responsibilities. Formulations Appropriate formulations to enable administration of drugs to children are often not available. Children are often unable to swallow tablets or capsules, so liquid medicines are preferred. However, this is not always possible and crushing of tablets or manipulation of solid dosage forms into suspensions or powders is often required. The strength of these products may mean that it is difficult to measure small doses for children and may lead to errors. Some commercially available medicines may contain excipients that may cause adverse effects or be inappropriate to use in some children. Liquid preparations may contain excipients such as alcohol, sorbitol, propylene glycol or E-numbers; sugar-free medicines should be dispensed whenever possible. Parenteral products may contain benzyl alcohol or propylene glycol which can also cause adverse effects such as metabolic acidosis.
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This could be particularly helpful for maintaining intra- regional arrangements buy cheap remeron 15mg 247 medications, especially between developing countries buy cheap remeron 30 mg treatment 001 - b. Other exceptions may include discount remeron online mastercard keratin treatment, for instance remeron 15 mg for sale medicine 79, concerns on culture, minority groups and land. As noted already, these exceptions somehow offset the limits that the pre-establishment model imposes upon States. This may partially modify or nullify the basic treaty by means of importation of provisions from a third party treaty and may also create a sense of uniformity of standards when real variations in scope, content and intent exist for very good policy reasons. The core matter is that States should be able to have what they wish when entering into their commitments. Within this possibility of broad and unrestricted interpretations, different options arise. This option requires that States do not have any objections to “treaty shopping” and any of the effects this might bring about. In the latter case, it is the lack of clarity and precision that facilitates expansionist interpretations. It may also be difficult for the State to know with certainty the commitments it made in the past together with their possible interpretation. Thus, States may wish to exclude all prior treaties as to preserve the integrity of the negotiated entry regime. Moreover, States may also wish to exclude future treaties as well, with the aim of not extending without reaping something in return the benefits granted to other treaty partners, although in doing so the State may also lose the benefits granted to third treaty partners by its counterpart. Alternatively, countries may provide that the benefits conferred by future liberalization or special arrangements would be subject to further negotiation with the aim of incorporating such benefits into the basic treaty (see for instance box 18). In any case, it is advisable to exclude all previous treaties as well as future treaties dealing with certain sectors regulated under reciprocity grounds such as aviation, fisheries and maritime matters including salvage (see for instance box 16). Therefore, States could consider excluding all treaties, past and future, for post- establishment purposes. This of course allows States to negotiate different content in the context of different negotiations and circumstances. The obligation referred to in paragraph 1 above shall not apply to treatment accorded under all treaties, whether bilateral or multilateral, in force or signed prior to or after the date of entry into force of this Agreement. For greater certainty, the obligation referred to in paragraph 1 above shall not apply to treatment accorded under all treaties, whether bilateral or multilateral, in force or signed prior to or after the date of entry into force of this Agreement. This approach is also helpful when States do not want to disrupt the manner in which other treaties may be interpreted. Option 1: Specifying the activities to which treatment applies One variation in this approach is to link the “treatment” owed to investors/investments to a specific set of activities. Option 2: Specifying the nature of “treatment” Another variation is to use more focused wording for what is treatment as it relates to measures taken by the State. This could be done by specifically referring to laws, regulations, administrative practices etc. For greater certainty, the obligation referred to in paragraph 1 above shall apply with respect to treatment accorded by a Contracting Party through the application of measures. Their description however can provide a guidance to arbitral tribunals as to what elements and criteria should be looked at to assess non-conformity or violation of these provisions. Measures that have to be taken for reasons of public security and order, public health or morality shall not be deemed ‘treatment less favourable’ within the meaning of this Article. But an explicit reference would remind arbitral tribunals that there has to be a comparative context when assessing an alleged breach. Comparing what it is reasonably comparable is fundamental so as to serve the object and purpose of guaranteeing competitive equality. Hence a tribunal would be prevented from importing third content or substituting basic content. The exclusion of certain or all provisions of the treaty may be accomplished through the use of formulas such as the following, where Option 1 refers to specific provisions whereas Option 2 ensures that the basic content remains intact. For greater certainty, the obligation referred to in paragraph 1 above shall not apply to [articles/section] of this Agreement. For greater certainty, the obligation referred to in paragraph 1 above shall apply without prejudice to the provisions set forth in this Agreement. Also, the risks of treaty shopping may be effectively mitigated through limits to the scope of application, exclusion of third treaties or specific qualifications, as the preceding subsections have already noted. The use of joint interpretations may be preferable, though the impact of an interpretative note may not be so great if this possibility was not foreseen in the treaty. Some treaties, however, set forth that any interpretation by the contracting parties of a provision of the treaty shall be binding on any tribunal. But the parties to a treaty do not really need a provision of that sort in order to issue an interpretation with legal effects. The general rule of interpretation of the Vienna Convention on the Law of Treaties takes into account “any subsequent agreement between the parties regarding the interpretation of the treaty or the application of its provisions” (Article 31. Likewise, “a special meaning shall be given to a term if it is established that the parties so intended” (Article 31. Unilateral statements have an interpretative value, especially when they have been rendered outside a litigation context. They have limits, however – they cannot change the text of the treaty and have to be part of a broader interpretative exercise. For instance, some treaties, when sent to the approval of the internal legislative body, come with implementation statements or supportive documentation of an often informative character. Other options include, amongst others, participation in the deliberations of international organizations, formal positions and specific objections upon certain issues. Such voices may have a legal effect which would constitute part of the context that arbitrators may need to consider when ascertaining the true intent behind the treaty. However, a danger in such a process is that States may adopt opportunistic statements of interpretation as a hedge against future or pending litigation. The work of the International Law Commission can also play a role in this context. This may be achieved through cautious and well- informed negotiations based on clear, balanced and well-defined definitions, concepts, rules and standards, as well as the proper use of exceptions, reservations, qualifications and/or carve-outs as to meet the particular needs of each contracting party. In all matters subject to this Agreement, this treatment shall be no less favourable than that extended by each Party to the investments made in its territory by investors of a third country. From Apology to Utopia: The Structure of International Legal Argument (Helsinki: University of Helsinki). International Investment Arbitration: Substantive Principles (Oxford: University Press). Weiler, Investment Treaty Arbitration and International Law (New York: Juris Publishing), Chapter 10. Recent developments in the interpretation of most favored nation clauses”, Journal of International Arbitration, Vol.
Thus buy cheap remeron 15mg online symptoms nerve damage, the patient should be instructed to come for Patch testing with 10% abacavir revealed a speciﬁcity of a repeat visit cheap remeron 30 mg online treatment ringworm, if test reactions do develop after 4–7 days generic 15 mg remeron with amex symptoms of breast cancer. The clinical signiﬁcance other chemotherapeutic drugs 15mg remeron mastercard treatment hemorrhoids, experience is limited and test of positive insulin skin test should be conﬁrmed by drug results often negative (low/weak). Insulin additives such as The irritant potential of chemotherapeutic drugs appears protamine have to be considered and tested. For platinum salts, the use of undiluted drugs is scanty on skin test for other therapeutic hormones. Skin prick test up to undiluted macrogol/poly- immediate hypersensitivity reactions. At present, it is existing IgG antibodies to human proteins and complement not possible to recommend optimal skin test concentration activation and manifest as haemolytic anaemia/shock (blood for these additives. There are limited data on skin testing with sera and immuno- Proton pump inhibitors and H2 antihistamines globulins, and deﬁnite recommendations on the value and test concentrations are not possible. Most reported reactions to proton pumps inhibitors and H2 antagonists are immediate hypersensitivity reactions (63). Undiluted and 1/10 parenteral proton pump Adverse reactions to vaccines may be due hypersensitivity to inhibitors appear nonirritant (moderate/weak) (63). Currently, it is not possible to make fever, but not in measles, mumps, rubella or rabies vaccines) speciﬁc recommendations for these drugs (low/weak). Patch and may manifest as acute urticaria, angio-oedema and ana- test with proton pump inhibitors at 10–50% of the drug in phylaxis (58). Although very rare, vaccine components, that petrolatum is nonirritant (moderate/weak). In individuals with a history of serious systemic tests have been described in some case reports. Patch tests reaction to egg and the vaccine needed by the patient is with calcium channels blockers and beta-blockers of 1–30% derived by yolk sac culture (e. Discussion Skin tests have the potential to locally reproduce in vivo an Additives IgE-mediated or T-cell-mediated drug allergy. Interpreted in Several cases of anaphylaxis to additives such as polysorbate the clinical context, skin tests using nonirritant drug concen- 80, carboxymethylcellulose and macrogols/polyethylene gly- trations can conﬁrm or exclude the diagnosis of drug allergy. Although uncommon, hypersensi- In vitro laboratory tests may not be available, restricted in tivity should be considered, if a patient shows reaction to repertoire, not well validated or of research nature. Drug different unrelated drugs containing the same additive (high/ provocation tests are time-consuming, associated with appre- strong). However, we have by 10 mg/ml carboxymethylcellulose have been reported to be consensus been able to agree and recommend test concentra- nonirritant (weak/low). Published by John Wiley & Sons Ltd 709 Skin test concentrations for drugs Brockow et al. Table 4 Drugs for which the value of skin tests has not adequately skin tests, drug allergy cannot be excluded and a drug provo- been demonstrated cation test has to be considered. Hormones, corticosteroids and insulins In addition to standardizing skin test concentration, there Nonbetalactam antibiotics is a need to be able to reproduce test results not only in a Nonplatinum chemotherapeutics single but amongst different centres. Other published techniques and protocols are For many drugs, where the literature is conﬁned to small available in the online Table S1, for example, the multicentre case series, case reports, personal experience or nonexistent, French study on perioperative drugs (34). Studies are in pro- no speciﬁc recommendation is made or should be regarded gress in Europe to validate and further standardize the as tentative until further review. Drug reactions may be due to its establish nonirritant test concentration and determine test metabolites, and testing using drug metabolites should be an sensitivity and speciﬁcity. The recommendations will need Skin prick test is relatively simple to perform and shows regular review and standardization. In specialized centres, we acceptable speciﬁcity for most of the reviewed drugs with the recommend testing all patients with a suggestive history of exception of drugs with irritant or histamine-releasing prop- drug allergy with the concentrations listed in Tables 1–3as erties such as quinolones and opioids (high/strong). Intradermal test has a high sensitiv- ity, but also a higher risk of inducing irritant reactions and Author contributions false-positive results. When nonirritant concentrations are used, skin tests in Additional Supporting Information may be found in the drug hypersensitivity are generally characterized by a rela- online version of this article: tively low sensitivity and a high speciﬁcity (high/strong). Relevant literature data on reported skin test this review, we aimed to select skin test concentrations with concentrations to systemically applied drugs with information the highest possible speciﬁcity (>95%) and thus a high posi- on the test preparation, number of patients and controls, test tive predictive value. Update dures in the diagnosis of drug hypersensitiv- interest group on drug hypersensitivity. Reducing the risk of anaphylaxis dur- Non-immediate reactions to beta-lactams: nol 2011;128:366–373. Management of hypersensitivity reactions to Diagnostic evaluation of a large group of Allergy 2011;66:955–960. Danish anaesthesia allergy centre – tion, diagnosis and management: review of diagnosis of beta-lactam hypersensitivity. J Allergy Clin Immunol quality of evidence and strength of recom- Pharm Des 2006;12:3313–3326. Immediate hypersensitivity to quinol- the patient with a history of local anesthetic Bircher A. Nonir- allergic reactions to dipyrone: value of baso- speciﬁcity for protamine allergy. Anesth ritating concentration for skin testing with phil activation test in the identiﬁcation of Analg 1996;82:386–389. Macias E, Ruiz A, Moreno E, Laffond E, dictive value of skin tests in investigating Diagnosing nonimmediate reactions to ceph- Davila I, Lorente F. J Allergy Clin Immunol mal test and patch test in the diagnosis of Contact Dermatitis 2004;50:359–366. Anaphylaxis to dyes during the peri- of minor determinants of amoxicillin in the oral provocation. Contact allergy and respiratory/muco- ity syndrome: cross-reactivity with tricyclic value of including amoxicillin as a determi- sal complaints from heroin (diacetylmorphine). General- hypersensitivity: ﬂare-up reactions, cross- anic acid can be the component in amoxicil- ized dermatitis due to codeine. Utility of patch testing in patients with Allergy 68 (2013) 702–712 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 711 Skin test concentrations for drugs Brockow et al. Cutaneous project: the diversity of diagnostic proce- corticosteroids in a series of 315 patients: adverse drug reactions caused by delayed dures for drug allergy around Europe. D19380 Access to medicines for multiple sclerosis February 2014 Charles River Associates Table of contents Executive Summary. The symptoms vary from patient to patient but include fatigue, vision problems, difficulties walking or speaking, memory problems and depression. The symptoms often appear periodically – known as relapses – which may last for a few hours, or many months. This looked at available evidence on prevalence, the costs to society and difference in access across European countries and discussed the determinants of patient access.