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The sodium that escapes this recycling stays in the filtrate and eventually leaves the body in the excreted urine buy imodium 2 mg overnight delivery. Specialized tubule cells called the macula densa (from the Latin for “dense spot”) monitor the concentration of sodium in the filtrate that has passed through the glomeruli generic imodium 2mg mastercard. When the amount of sodium falls below a certain level discount imodium 2 mg with amex, the macula densa cells send a message to generic 2mg imodium visa other nearby cells, called juxtaglomerular cells, located in the walls of the blood vessels heading toward the glomeruli. The juxtaglomerular cells release into the bloodstream the first effector chemical of the - 431 - Principles of Autonomic Medicine v. The variables that are kept within bounds are the pressure in the blood vessels approaching the glomeruli and the concentration of sodium in the glomerular filtrate. Relationships of components of the renin-angiotensin aldosterone system to the “volustat” and “barostat” Stretch receptors in two other places outside the kidneys also contribute to regulation of release of renin. When the amount of blood filling the heart falls, such as by a fall in blood volume, or when the blood pressure in the carotid arteries falls, such as from relaxation of - 432 - Principles of Autonomic Medicine v. Conceptually, the homeostat that regulates renin release to maintain blood volume as monitored by the low-pressure baroreceptors can be called the “volustat,” and the homeostat that regulates renin release to maintain blood pressure as monitored by the high-pressure baroreceptors can be called the “barostat. Thus, the renin-angiotensin-aldosterone system is a key effector for two homeostatic systems, the barostat and the volustat. First, stimulation of the sympathetic noradrenergic system increases renin secretion. The total peripheral resistance is the amount of resistance to blood flow in the circulation as a whole. To get a grasp of cardiac output and total peripheral resistance, think of the pressure in a garden hose. Turning on the faucet increases both the flow of water and the pressure in the hose. If you turned down the faucet, this would decrease the pressure - 434 - Principles of Autonomic Medicine v. You could bring the pressure back up by tightening the nozzle, but the flow would decrease further. If the nozzle remained tightened, turning the faucet up would increase the flow, but now the pressure in the hose would be high. In most people with chronic hypertension, the cardiac output is normal or even decreased. This means that in hypertension, the high blood pressure is usually from high total peripheral resistance. Concept diagram showing negative feedback regulation of blood volume and blood pressure by several effectors Just as two variables determine blood pressure, two variables determine cardiac output. The sympathetic noradrenergic system and the renin-angiotensin-aldosterone system are two of the most important effectors in blood pressure regulation. The vagus nerve, the tenth cranial nerve, contributes to blood pressure regulation especially by modulation of heart rate. The sympathetic adrenergic system plays a major role in the high blood pressure commonly found in emergency situations. In addition to the barostat, a volustat regulates blood volume and - 435 - Principles of Autonomic Medicine v. Although the diagram of negative feedback regulation of blood pressure seems very complex, what is depicted actually is a relatively simple model compared to models hypertension researchers have developed. One may ask, if the body has available so many negative feedback loops and effectors to control blood pressure, why does hypertension even exist What goes wrong with the negative feedback regulation, such that the blood pressure becomes persistently high Somehow the complex interplay of the blood vessels, heart, kidneys, and the central nervous system goes awry. A guess—and it’s only a guess—is that the effectors that regulate blood pressure evolved to maintain homeostasis of other internal variables and not blood pressure per se. Throughout human evolution, systems evolved to counter infection, to endure emergencies, to maintain the core temperature of the body, to distribute blood flows to body organs appropriately in different circumstances, to convert ingested food to energy and get rid of waste, to have correct levels of several electrolytes such as sodium, and to conserve water. The side effect of increased blood pressure may have had relatively little significance. In modern society, these needs no longer are pressing, but the homeostatic systems may still operate in a manner that biases toward high intake of fat, sugar, salt, and water, with attendant increased blood pressure. Findings from recent studies about carotid sinus stimulation have forced reconsideration of this dismissal of the arterial baroreflex as a determinant of long-term blood pressure regulation. Modern day carotid sinus stimulation is a descendant of the “Baropacer,” which was an external pacemaker developed in the 1960s. The electrodes of the Baropacer were wrapped around the Modern implanted carotid sinus stimulators are descendants of “baropacer” devices of the 1960s. I was allowed to use a “Baropacer” from the Branch’s animal lab for an experiment - 437 - Principles of Autonomic Medicine v. The experiment was a failure, mainly because of the inability to maintain the integrity of the nerve over time. Carotid sinus stimulation is currently undergoing clinical trials to treat refractory hypertension. It has several other potential uses (that was funny), including treatment for heart failure, some arrhythmias, and metabolic syndrome, all based on inhibition of sympathetic noradrenergic outflows by stimulating baroreflex afferent traffic. Similar technology might be developed to treat supine hypertension in patients with neurogenic orthostatic hypotension from chronic autonomic failure—a very difficult condition for which no drug is effective. Renal Nerve Ablation Another technology undergoing testing to treat refractory hypertension is based on destroying the sympathetic nerves supplying the kidneys.

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Anaesthesiologica Scandinavica buy generic imodium 2mg line, 45(9) discount imodium 2mg fast delivery, 1108– Thalamic hemorrhage: A prospective study of 100 patients best imodium 2 mg. Amitriptyline in clinical cheap 2mg imodium with amex, magnetic resonance imaging, and somatosensory the prophylaxis of central poststroke pain. Amitriptyline for neuropathic pain and dynamic mechanical allodynia and dysesthesia in patients bromyalgia in adults. Motor cortex stimulation for neuropathic pain (Re stimulation for post stroke neuropathic pain. American Journal of Managed Care, stroke pain: Neurological symptoms and pain characteris 12(9 Suppl), S256–S262. Deep brain stroke pain in a lateral medullary infarction: Two case stimulation for the alleviation of post stroke neuropathic reports and literature review. A beta-ber mediated activation of the treatment of central post-stroke pain: A retrospective cingulate cortex as correlate of central post-stroke pain. Risk effects of lamotrigine on pain, sleep, and mood in refractory factors for stroke-related pain 1 year after rst-ever stroke. Analgesia in conjunction (central post-stroke pain) in a patient presenting with right with normalization of thermal sensation following upper limb pain: A case report. Rapid relief of thalamic pain syndrome Sensory abnormalities in consecutive, unselected pa induced by vestibular caloric stimulation. Treatment of central post central post-stroke pain with associated dizziness and stroke pain with oral ketamine. New England stroke and the inuence of long-term pain on everyday Journal of Medicine, 348, 1223–1232. Lamotrigine and diffusion tensor imaging in a case of central poststroke for acute and chronic pain. Lamotrigine for acute and the complexities of pain after stroke: A review with a focus chronic pain. Antiepileptic drugs for central post Journal of Clinical Neurophysiology, 14(1), 2–31. Understanding central post-stroke Central poststroke pain and reduced opioid receptor binding pain. Pharmacological classication of central post-stroke pain model using global cerebral ischaemic mice. Journal of pain: Comparison with the results of chronic motor cortex Pharmacy and Pharmacology, 65(4), 615–620. Cerebrovascu cacy of motor cortex stimulation for intractable central lar Disease, 16(1), 27–30. A history and physical exami nation should place patients into one of several categories: (1) nonspecifc low back pain; (2) back pain associated with radiculopathy or spinal stenosis; (3) back pain referred from a nonspinal source; or (4) back pain associated with another specifc spinal cause. For patients who have back pain associated with radiculopathy, spinal stenosis, or another specifc spinal cause, magnetic resonance imaging or computed tomography may establish the diagnosis and guide management. Because evidence of improved outcomes is lacking, lumbar spine radiog raphy should be delayed for at least one to two months in patients with nonspecifc pain. Acet aminophen and nonsteroidal anti-infammatory drugs are frst-line medications for chronic low back pain. Tramadol, opioids, and other adjunctive medications may beneft some patients who do not respond to nonsteroidal anti-infammatory drugs. Acupuncture, exercise therapy, multidisciplinary rehabilitation programs, massage, behavior therapy, and spinal manipula tion are effective in certain clinical situations. Patients with radicular symptoms may beneft from epidural steroid injections, but studies have produced mixed results. A surgical evaluation may be considered for select patients with functional disabilities or refractory pain despite multiple nonsurgical treatments. Acute episodes of back (3) back pain referred from a nonspinal source; able at. Patients with or (4) back pain associated with another spe org/afp/20090615/1067 persistent or fuctuating pain that lasts lon cifc spinal cause2 (Table 13). Review of systems should focus on of work productivity, treatment costs, and unexplained fevers, weight loss, morning disability payments. Estimates of these costs stiffness, gynecologic symptoms, and uri range from $12. The physical examination should include Evaluation the straight leg raise and a focused neuro the initial evaluation, including a history and muscular examination. A positive straight physical examination, of patients with chronic leg raise test (pain with the leg fully extended low back pain should attempt to place patients at the knee and fexed at the hip between June 15, 2009 Volume 79, Number 12 Differential Diagnosis of Chronic Low Back Pain Nonspecifc or Referred pain Nonmechanical idiopathic (2 percent) (1 percent) (70 percent) Aortic aneurysm Neoplasia rapidly progressive disease (Table 25,6) Lumbar sprain or strain Diseases of the Multiple myeloma or radicular symptoms that do not spon Mechanical pelvic organs Metastatic carcinoma taneously resolve after six weeks. Because (27 percent) Prostatitis Lymphoma and leukemia evidence of improved outcomes is lacking, Degenerative processes Endometriosis Spinal cord tumors imaging, such as lumbar spine radiogra of disks and facets Chronic pelvic Retroperitoneal tumors phy, should be delayed at least one to two Herniated disk infammatory Primary vertebral tumors months in patients with nonspecifc pain Osteoporotic fracture* disease 6 Infammatory arthritis, often without red fags for serious disease. Spinal stenosis Gastrointestinal associated with human disease Psychosocial issues play an important Traumatic fracture* leukocyte antigen-B27 Pancreatitis role in guiding the treatment of patients Congenital disease Ankylosing spondylitis Cholecystitis with chronic low back pain. One study Severe kyphosis Psoriatic spondylitis Penetrating found that patients with chronic low back Severe scoliosis Reiter syndrome ulcer pain who have a reduced sense of life con Transitional vertebrae Infammatory bowel disease Renal disease trol, disturbed mood, negative self-effcacy, Spondylosis Infection* Nephrolithiasis high anxiety levels, and mental health dis Internal disk disruption Osteomyelitis or discogenic pain Pyelonephritis* orders, and who engage in catastrophiz Septic diskitis Presumed instability Perinephric ing tend to not respond well to treatments Paraspinous abscess 8 abscess* such as epidural steroid injections. Evaluation of Scheuermann disease psychosocial problems and “yellow fags” (osteochondrosis) are useful in identifying patients with a Paget disease of bone 8,9 poor prognosis.

Labile hypertension: In this condition the blood pressure fuctuates far more than usual during the day discount 2 mg imodium mastercard. In many instances these fuctuations are asymptomatic but may be associated with headaches purchase imodium 2 mg line. A relationship between blood pressure elevation and stress or emotional distress is usually present discount 2 mg imodium. Paroxysmal hypertension: Patients exhibit sudden elevation of blood pressure (which can be greater than 200/110 mm Hg) associated with an abrupt onset of distressful physical symptoms cheap imodium 2 mg amex, such as headache, chest pain, dizziness, nausea, palpitations, fushing, and sweating. Episodes can last from 10 minutes to several hours and may occur once every few months to once or twice daily. Patients generally cannot identify obvious psychological factors that cause the paroxysms. Medical conditions that can also cause such blood pressure swings need to be excluded. The choice of specifc systemic therapy is infuenced by the patient’s prior treatment with chemotherapeutic agents and the general approach to preserve the efected organs. Supportive care includes the prevention of infection due to severe bone marrow suppression and the maintenance of adequate nutrition. Terapeutic options include treatment with a single agent and combination regimens with conventional cytotoxic chemotherapy and/or molecularly targeted agents, combined with optimal supportive care. Chemotherapy is given in cycles, alternating between periods of treatment and rest. A Web site that lists all the chemotherapeutic agents and their side efects is at. Chemotherapy for the treatment of head and neck cancers is usually given at the same time as radiation therapy and is known as chemoradiation. Neoadjuvant chemotherapy is administered before surgery to Lowered resistance to infecton shrink the size of the tumor thus making it easier to remove. Chemotherapy administered prior to chemoradiation treatment is Chemotherapy can temporarily reduce the production of white blood known as induction chemotherapy. This efect may begin about seven days following treatment and the decline in resistance to infection is maximal usually about 10–14 days Side efects of chemotherapy afer chemotherapy has ended. At that point the blood cells generally begin to increase steadily and return to normal before the next cycle of The kind and type of possible side efects of chemotherapy depend on chemotherapy is administered. Prior to resuming Many individuals do not experience side efects until the end of their chemotherapy blood test are performed to ensure that the recovery treatments; for many individuals these side efects do not last long. Further administration of Chemotherapy can, however, cause several temporary side efects. Tese occur because chemotherapy drugs work by killing all actively growing Bruising or bleeding cells. Tese include cells of the digestive tract, hair follicles, and bone marrow (which makes red and white blood cells), as well as the cancer Chemotherapy can promote bruising or bleeding because the agents cells. The more common side efects are nausea, vomiting, diarrhea, sores Nosebleeds, blood spots or rashes on the skin, and bleeding gums can (mucositis) in the mouth (resulting in problems with swallowing and be a sign that this had occurred. Severe anemia can be The most common side efects include: treated by blood transfusions or medications that promote red cells production. Drugs such as vincristine, vinblastine, and cisplatin ofen Some chemotherapy agents cause hair loss. Rest, energy conservation, and correcting the above contributing Sore mouth and small mouth ulcers factors may ameliorate the fatigue. Some chemotherapy agents cause sore mouth (mucositis) which can interfere with mastication and swallowing, oral bleeding, difculty in More information can be found at the National Cancer Institute swallowing (dysphagia), dehydration, heartburn, vomiting, nausea, Web site at: and sensitivity to salty, spicy, and hot/cold foods. Accordingly, it is important to supplement one’s diet with nutritious drinks or soups. The cytotoxic agents most ofen associated with oral, pharyngeal, and esophageal symptoms of swallowing difculty (dysphagia) are the antimetabolites such as methotrexate and fuorouracil. The radiosensitizer chemotherapies, designed to heighten the efects of radiation therapy, also increase the side efects of the radiation mucositis. Some people are able to lead a normal life during their treatment, while others may fnd they become very weak and tired (fatigue) and have to take things more slowly. Lymphedema is a localized lymphatic fuid retention and tissue swelling caused by a compromised lymphatic system. Lymphedema, a common complication of radiation and surgery for head and neck cancer, is an abnormal accumulation of protein-rich fuid in the space between cells which causes chronic infammation and reactive fbrosis of the afected tissues. When the surgeons remove these glands, they also take away the drainage system for the lymphatics and cut some of the sensory nerves. Like fooding afer a heavy rain when the drainage system is broken, the surgery creates a backup of lymphatic fuid that cannot drain adequately, as well as numbness of the areas supplied by the severed nerves (usually in the neck, chin, and behind the ears). As a result, some of the lymphatic fuid cannot re-enter the systemic circulation and accumulates in the tissues. Lymphedema generally starts slowly and is progressive, rarely painful, causes discomfort in the form of a sensation of heaviness and • Emotional issues (depression, frustration and embarrassment) achiness, and may lead to skin changes. Fortunately over time the lymphatics fnd new ways of drainage Lymphedema has several stages: and the swelling generally goes down. Specialists in reducing edema (usually physical therapists) can assist the patient in enhancing the Stage 0: Latency stage – No visible/palpable edema drainage and shortening the time for the swelling to decrease. This intervention can also prevent the area from becoming permanently Stage 1: Accumulation of protein-rich edema, presence of swollen and from developing fbrosis.

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Because an accurate his tory of past and current treatments and responses to cheap imodium 2mg with visa them is a key ingredient to buy discount imodium 2mg on-line treatment planning purchase 2 mg imodium with visa, excellent documentation is paramount order imodium 2mg without a prescription. Especially critical, for example, is informa tion about prior medication trials, including doses, length of time at specific doses, side effects, and clinical response. Despite the importance of an accurate history, studies of the adequacy of documentation (39) and clinical experience illustrate the extraordinary difficulty encountered in efforts to piece together a coherent story from the medical records of most patients with schizophrenia. Although actual chart documentation is the responsibility of the individual practitioner, it is typically the employing or contracting organization that is in the best position to facilitate good documentation and to effect periodic overviews of treatment. Appropriate documentation of assessment of competency, informed consent for treatment, and release of information also deserve careful attention by the clinician and the treatment organization. Treatment of Patients With Schizophrenia 21 Copyright 2010, American Psychiatric Association. Within the organization there are at least two major issues in information management. From the standpoint of information collection, the organization and its practitioners need to agree on the critical elements of information to obtain and the frequency with which they should be obtained. Recording of information may occur contemporaneously with collection or immediately thereafter. Labor-saving forms (paper or computer-based) may help in prompt ing data collection and easing its recording. Once information is collected, the ability to gain access to the information is essential. Thus, the organization will want to develop plans so that medical records will be available whenever and wherever the patient is seen. In addition, if the patient’s care is transferred from one practitioner to another. Release of a patient’s information will generally require the patient’s consent and should conform to applicable regulations and policies. It is especially important to address the anxiety, fear, and dysphoria commonly associated with an acute episode. Efforts to engage and collaborate with family members and other natural care givers are often successful during the crisis of an acute psychotic episode, whether it is the first episode or a relapse. Also, family members and other caregivers are often needed to provide sup port to the patient while he or she is recovering from an acute episode. The main therapeutic challenge for the clinician is to select and “titrate” the doses of both pharmacological and psy chosocial interventions in accordance with the symptoms and sociobehavioral functioning of the patient (41). It is important to emphasize that acute-phase treatment is often but no longer necessarily associated with hospitalization. With the growth of managed care restricting the use of hospitalization and the development of alternative community-based programs, acute-phase treatment frequently occurs outside of the hospital. Assessment in the acute phase A thorough initial workup, including complete psychiatric and general medical histories and physical and mental status examinations, is recommended for all patients, as allowed by the pa tient’s clinical status. Interviews of family members or other persons knowledgeable about the patient should be conducted routinely unless the patient refuses to grant permission, especially since many patients are unable to provide a reliable history at the first interview. In emergency circumstances, as when a patient’s safety is at risk, it may be necessary and permissible to speak with others without the patient’s consent. When a patient is in an acute psychotic state, acutely agitated, or both, it may be impossible to perform an adequate evaluation at the time of the initial contact. With the patient’s consent, the psychiatrist may begin treatment with an appropriate medication and perform the neces sary evaluations as the patient’s condition improves and permits. For acutely psychotic or agi tated patients who lack the capacity or are unwilling to agree to receive medication, state regulations on involuntary treatment should be followed. Some of the most common contributors to symptom relapse are antipsychotic medication nonadherence, substance use, and stressful life events (42–47). Attention needs to be given to potential drug-drug interactions that may affect blood levels and hence toxicity and adherence. Useful guides for determining potential adverse drug interactions related to the cytochrome P450 enzyme system are now available (48, 49). The reason for nonadher ence should also be evaluated and considered in the treatment plan. General medical health as well as medical conditions that could contribute to symptom ex acerbation can be evaluated by medical history; physical and neurological examination; and ap propriate laboratory, electrophysiological, and radiological assessments. Substance use should be routinely evaluated as part of the medical history and with a urine toxicology screen. It is important to realize that many drugs of abuse, including most designer drugs and hallucino gens, are not detected by urine toxicology screens; if use of such substances is suspected, a blood toxicology screen can detect some of them. Withdrawal from alcohol or some other substances can present as worsening psychosis, and the possibility of withdrawal should be evaluated by medical history and vital sign monitoring in all patients with acute exacerbation of symptoms. Table 1 delineates suggested laboratory tests for evaluating health status, including studies that may be indicated when the clinical picture is unclear or when there are abnormal findings on routine examination, as well as suggested methods to monitor for side effects of treatment. These tests may detect occult disease that is contributing to psychosis and also determine if there are comorbid medical conditions that might affect medication selection, such as impaired liver or renal function. Tests to assess other general medical needs of patients should also be considered. Preventive Services Task Force has reviewed the evidence of effectiveness and developed recommendations for clinical preventive services.

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However cheap imodium 2 mg visa, these particularities will be taken into in the real implementation of the call for tender phases order imodium 2mg visa. Overall discount 2mg imodium free shipping, the validation of unmet needs at buyer’s group level cheap 2 mg imodium with visa, with interviews, co-creation workshop and expert meetings defining needs for the call for tender, were well evaluated by the industry during the open market consultation phase. In addition, the updated eHealth market review has served as to reinforce the priority areas of intervention identified in the validation of user’s needs. Paying special attention to requirements that go beyond the current market situation: medical validation of contents, more engagement of patients, real interaction between patients and clinicians, including an holistic approach of pain self-management, deeply monitoring of pain evolution, among others. The market review update revealed that although there are different solutions that are focused on the management of diseases, there is no current solution that cover and integrate successfully all our needs mentioned. No similar solution in the market covers all the identified needs, according to the industry. There should be special focus on a holistic approach of chronic pain self management (multimodal approach), clinical validation of contents, interoperability with different Healthcare systems and security. The suppliers stress the need to involve the healthcare professionals and patients in the phases so as to co-design the development of the solutions, ensuring success. They also stressed the need to establish the level of interoperability and commented that no tender focused on chronic pain was promoted before. Finally, a reallocation of month’s duration especially in Phase B, which was considered too short, will be necessary so as to ensure the correct implementation of each phase. A robust communication strategy will be implemented to ensure the correct execution of the phases and the relationship between the monitoring team and the suppliers. Appendix I Results from the interviews with health care providers Characteristics of responders and their settings for chronic pain treatment Number of respondents: A total of 39 responders from France (n=6), Spain (n=13) and Sweden (n=20). Although the number of responders is low to draw any statistical significant conclusions, the purpose of our interviews was to extract from the key stakeholders of different hospital’s realities in France, Spain and Sweden so as to facilitate the understanding for the heterogeneous landscape of pain treatment. For this topic there was a considerable difference between countries: 80 % of French responders, 31 % of Spanish and 55 % of Swedish responders were pain specialists. Physicians from other specialists (n=19), nurses (n=6), and psychologists(n=5), were also frequent responders. Table 3: occupation among responders to the health care provider’s questionnaire this may reflect the fact that most responders were pain specialist at specialized pain clinics at predominantly pain specialist settings in urban areas. Collaborations with nurse (76%), psychologist (68%) and physiotherapist (62%) were also common. Collaborations with occupational therapist were also common (44 %) but this was mainly because of high availability in Sweden (70 %). Possible interpretation: the differences between countries may reflect the diversity D3. Multimodal rehabilitation (65%), invasive pain treatment (65 %) and neuromodulation (71%) were offered. For multimodal rehabilitation there was a considerable difference between countries and 90% of the Swedish responders reported availability compared to France (33%) and Spain (25%). Figure 46: Offered treatment at the sites, differences between countries the data most certainly reflects differences in treatment traditions and organizational structure between the three countries. Central neuropathic (79%), chronic headache (76%), osteoarthritis (62%) and rheumatoid arthritis (62%) were also frequently reported kinds of chronic pain. All responders reported that their clinic for chronic pain treatment included treatment for adults. More than 2000 chronic pain patients per year were reported from 27 % of responders while 27 % of responders reported between 200 and 1000 chronic pain patients a year. Most responders worked at pain services treating more than 200 chronic pain patients a year. It would be very valuable to have social status and past medical history filled in before the first consultation. Responders would find it very valuable to have social status and past medical history filled in before the first consultation. Responders would find it valuable to have validated diagnostic questionnaires filled in before first visit. Below are summarized some of them: Examples of medical history of value: Personal relationship and social support Profession, age, height length. Responders would find it valuable if the eHealth solution included a built in decision support. Among Spanish and Swedish responders there were 38% and 35% reporting very valuable. There were a significant proportion of responders who did not find an included alert system valuable. It is possible that some responders perceived connecting to caregiver in a negative, to intrusive, way. The mean value of the respondents were among the lowest in the survey, average 3,71 (Max. Despite that, 52% of responders reported that it would be valuable or very valuable. The relatively low average score could be due to that a considerable proportion of caregivers are somewhat skeptical about the value. Functionality for video consultation could be of value if it is selectable for the caregiver. Functionality for progressive goal setting, planning and evaluation would be of value. Possible interpretation: Functionality for patient access to treatment progress would be of value. Low numbers of responders is the most probable cause of the low rating from French settings. Responders would find it valuable if the eHealth solution included a possibility for patients to report outcome data.

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