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Non-pregnant patient Pain characteristics Gynecological ĺ Cyclic Pain perception varies across cultures and it also in- fluences health-seeking behavior conventional medicine quality 100mg topiramate. The duration of pain may be important as sudden onset may suggest բ Non-cyclic acute appendicitis treatment centers purchase topiramate with visa, while a long history before the acute episode may indicate typhoid perforation or intestinal obstruction4 medicinenetcom buy discount topiramate line,7,8. Colicky intermittent pain may be sug- gestive of intestinal obstruction or ureteric colic7,8. Pain of sudden onset can hint at visceral perfora- tion, and is insidious in inflammation, e. The frequency of pain or its cyclic Non-gynecological nature could also be suggestive of dysmenorrhea which typically presents with pain around the men- Figure 1 Classification of acute pelvic pain in the strual period. Ovulation pain (Mittelschmerz) is non-pregnant patient typically felt around the mid cycle6,7. Table 1 Gynecological and non-gynecological causes of acute pelvic pain Gynecological causes Reproductive period/age Adenomyosis; degenerating fibroid; endometriosis; Mittelschmerz, ovarian torsion; pelvic inflammatory disease; ruptured cyst; tubo-ovarian abscess; dysmenorrhea Adolescents Similar to women of reproductive age, with addition of imperforate hymen and transverse vaginal septum Postmenopausal Causes similar to that of the reproductive age group except for ectopic pregnancy and menstruation-related causes like dysmenorrhea, endometriosis etc. Non-gynecological causes Gastrointestinal Appendicitis; bowel obstruction and constipation; diverticulitis; gastroenteritis; inguinal hernia; irritable bowel syndrome; mesenteric venous thrombosis Urinary Cystitis; pyelonephritis; ureterolithiasis Musculoskeletal Strain tendons/muscles; joint infection/inflammation; hernia Others Among the patients of African origin sickle cell crisis could present with acute abdominal– pelvic pain; dissecting aortic aneurysm; lead poisoning; drug abuse; porphyria; somatization disorder 54 Acute Pelvic Pain in Limited-resource Setting Table 2 Common causes of acute pelvic pain Diagnosis Common features Sexually transmitted infec- Lower abdominal pain, cervical excitation tenderness and adnexal tenderness tions and pelvic inflammatory disease (Chapter 17) Tubo-ovarian abscess Minor features include dyspareunia, fever, abnormal discharge (Chapter 11) Tubo-ovarian torsion Acute pain, initially unilateral, often started by rapid turning or twisting movements (e. Pain, often unilateral, may be associated with gastrointestinal symptoms and may resolve spontaneously after the next period or within several cycles Dysmenorrhea (Chapter 7) Cyclic lower abdominal, usually starts before and predominantly during the first 2 days of menses; may be associated with gastrointestinal symptoms such as lower back pain, diarrhea, nausea and vomiting Mittelschmerz Mid-cycle pain usually mild; may be associated with bleeding per vagina, severe symptoms mimic ruptured ectopic or acute appendicitis. Resolves spontaneously Appendicitis Pain starting at epigastric area later settling at right iliac fossa; pain, anorexia, nausea and vomiting. Fever at later stages Endometriosis (Chapter 6) Pelvic pain, dysmenorrhea, dyspareunia, pelvic tenderness, tender sacrouterine ligament. Most of the time it is a chronic disease, but can present with an acute exacerbation Urinary tract infection Dysuria, frequency, lower abdominal pain, urgency, suprapubic tenderness, systemic symptom is slight Pyelonephritis Sudden pain radiating to suprapubic area; systemic symptom is common fever, chills, nausea and vomiting Typhoid perforation General abdominal pain, fever, acute abdomen Although pain quality and severity are non- in acute appendicitis4,7,8. Frequency, dysuria, scald- specific, they may provide some clue about the ing and hematuria are suggestive of urinary tract etiology. Abrupt and severe pain is typically associ- disorder7,9. Presence of fever in association with ated with perforation (ectopic pregnancy), strangu- pelvic pain is suggestive of infection or inflamma- lation (ovarian torsion) or hemorrhage (ovarian tory etiology, such as appendicitis, PID, ovarian cyst). Dysmenorrhea and abortion may be associ- torsion or tubo-ovarian abscess (TOA)4. Colicky pain typifies and syncopal attack could be an associated feature ovarian torsion or nephrolithiasis. Burning or of ruptured ectopic gestation or hemorrhagic aching pain often occurs with inflammatory pro- ovarian cyst. Inflammatory conditions and hemo- cesses such as appendicitis or tubo-ovarian abscess peritoneum can sometimes present with non- and PID4,7. Progressively worsening pain would specific symptoms of nausea, vomiting and suggest visceral inflammation or perforation4. Headache, malaise and fever before on- set of pain are suggestive of typhoid perforation7,8. Associated symptoms Aggravating and alleviating factors Diagnosis is often considered based on the associ- ated symptoms (Table 3). Nausea and vomiting are Changes in pain may occur in relation to menses, associated with acute appendicitis, pyelonephritis coitus, activity, diet, bowel movement or voiding. Anorexia is a common feature These characteristic may help in narrowing the 55 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Table 3 Symptoms associated with acute pelvic pain Symptoms Common causes Cyclic pain Dysmenorrhea, Mittelschmerz, endometriosis, cryptomenorrhea Amenorrhea Ectopic gestation, abortion and other pregnancy-related complications Vaginal bleeding Abortion complications, ectopic gestation, STI Fever STI, appendicitis, pyelonephritis, ovarian torsion Dyspareunia Endometriosis, slow-leaking or unruptured ectopic, STI, ovarian cysts Urinary symptoms UTI, pyelonephritis, STI GI Intestinal obstruction, diverticulitis Previous surgery Intestinal obstruction, ectopic gestation Collapse Ruptured ectopic gestation, hemorrhagic cyst STI, sexually transmitted infection; UTI, urinary tract infection; GI, gastrointestinal differential diagnosis. For instance, dyspareunia Physical examination may be indicative of endometriosis; it could also be Physical examination should commence with a present in PID, ectopic pregnancy and ovarian 4,6,7 general assessment of the patient to assess the sever- cyst. The pulse should be assessed for Obstetrics and gynecological history rate, volume and rhythm. Findings could be sugges- The last menstrual period may indicate the possibi- tive of an infection process or shock, as in ectopic lity of pregnancy complications such as ectopic or hemorrhagic cyst. It also provides one of the gestation or miscarriage.

Diseases

• Craniofacial and osseous defects mental retardation
• Macrocephaly dominant type
• Idaho syndrome
• Cardiomyopathy cataract hip spine disease
• Morillo Cucci Passarge syndrome
• Microcephaly brachydactyly kyphoscoliosis
• Kleeblattschaedel syndrome
• Decompensated phoria
• Larsen syndrome craniosynostosis

W alsh medicine list order 200mg topiramate fast delivery, N o N o N o-unclear N o (48/54 Y es Poor 2000a ifdifferential analyz ed) Insomnia 259 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 8a medicine used to stop contractions order topiramate 200 mg on-line. Q uality assessm entofrandom iz ed controlled trials ofnewerdrugs forinsom nia Post- A uth or medicine 5277 topiramate 100 mg overnight delivery, A dh erence L oss to fu L oss to fu ITT randomiz atio Q uality year reported C ontamination reported? Ph armace 2002 3% placebo, uticals 30% z olpidem W are, N o N o N o N o N o F air L orex 1997 Ph armace uticals W h eatley, N o N o N o U nable to U nable to F air N ot 1985 determine determine reported Z ammit, N o N o N o N o N o F air Sepracor 2004 (303/308 atnigh t1; 293/308 at 1 month ) Z ammit, 2007 Insomnia 260 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 8b. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) A llocation R andomiz ation concealment G roups Inclusion Exclusion O utcome C are meth od meth od similarat criteria criteria assessors provider Patients A ttrition A uth or Y ear described? Berry 2006 M eth od not M eth od not Y es Y es N R N R N R Y es described described F ava 2006 M eth od not M eth od not Y es Y es Y es U nclear, U nclear, U nclear, described described reported as reported reported double blind as double as double blind blind K ryger 2007 M eth od not M eth od not N R N otreported Y es Y es U nclear, U nclear, Y es Y es described described by orderof reported as reported randomiz ati double blind as double on blind K rystal 2008 M eth od not M eth od not Y es Y es Y es U nclear, U nclear, Y es Y es 2008 described described reported as reported double blind as double blind M cC all 2006 M eth od not M eth od not Y es Y es Y es Y es U nclear, U nclear, Y es described described reported reported as double as double blind blind R osenber 2007 M eth od not M eth od not N R N otreported Y es Y es U nclear, U nclear, U nclear, Y es g described described by orderof reported as reported reported randomiz ati double blind as double as double on blind blind R oth 2007 2007 M eth od not M eth od not Y es Y es Y es U nclear, U nclear, U nclear, Y es described described reported as reported reported double blind as double as double blind blind Insomnia 261 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 8b. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) A llocation R andomiz ation concealment G roups Inclusion Exclusion O utcome C are meth od meth od similarat criteria criteria assessors provider Patients A ttrition A uth or Y ear described? Soares 2006 M eth od not M eth od not Y es Y es Y es U nclear, U nclear, U nclear, Y es described described reported as reported reported double blind as double as double blind blind W alsh 2008 M eth od not Y es N o N umberof Y es Y es Y es U nclear, Y es Y es described awakenings reported and sleep as double quality blind h igh erin placebo group (different directions) W alsh 2007 M eth od not M eth od not Y es Y es Y es Y es Y es Y es Y es (esz opiclo described described ne) Insomnia 262 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 8b. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) A llocation R andomiz ation concealment G roups Inclusion Exclusion O utcome C are meth od meth od similarat criteria criteria assessors provider Patients A ttrition A uth or Y ear described? Z ammit 2007 M eth od not Y es N o Differences Y es Y es Y es Y es Y es (ramelteon described inweigh t ) and sexat baseline Insomnia 263 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 8b. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) H andling of Post- carryover randomiz a effects (for L oss to fu tion W ith drawalrate crossover differential ITT exclusions differentialor studies A uth or orh igh? C omment only) F unding Berry N o U nable to N o N o determine F ava Y es 50/545 Y es 543/545 Y es 40 for Y es 172/545 Sepracor (9. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) H andling of Post- carryover randomiz a effects (for L oss to fu tion W ith drawalrate crossover differential ITT exclusions differentialor studies A uth or orh igh? C omment only) F unding Soares N o 4/410 (1% ) Y es Y es 13 for N o 51/410 Sepracor protocol (12. Q uality assessm entofrandom iz ed controlled trials (new forU pdate #2) H andling of Post- carryover randomiz a effects (for L oss to fu tion W ith drawalrate crossover differential ITT exclusions differentialor studies A uth or orh igh? C omment only) F unding Z ammit N o 1/405 N o Y es 6 for N o 34/405 Takeda (ramelteon protocol with drew ) deviation, (8. O bservationalstudies A uth or N Drugs (m ean Durationof Eligibility C riteria Y ear dose);durationof treatm ent C ountry treatm ent A llain,1991 20,513 Z opiclone 7. Insomnia 267 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 9. O bservationalstudies A uth or O th erpopulation Design Datasources Tim e period A dverse events Y ear ch aracteristics of assessm ent C ountry assessm ent A llain,1991 62. O bservationalstudies A uth or R esults F unding Y ear C ountry A llain,1991 N europsych iatricadverse events,no. O bservationalstudies A uth or N Drugs (m ean Durationof Eligibility C riteria Y ear dose);durationof treatm ent C ountry treatm ent A ncoli- 260 Z aleplon5 mg, 1 year Primary insomnia defined by Israel, increased to 10 DSM -IV criteria. Inclusioninth e extensionph ase required completionofth e double-blind ph ase and a run-outperiod of7 days followed by 7 to 28 treatment-free days with out adverse effects,and returnto th e clinicafterth e treatmentfree intervalwith a minimum of five daily sleepquestionnaires to confirm th e need for continued sleepth erapy. Bain,2003 4,752 Z olpidem or N otreported Patients prescribed z olpidem U S (687 z olpidem, temaz epam ortemaz epam inone h ospice 4,065 temaz epam) practice setting. Insomnia 270 of 309 Final Report Update 2 Drug Effectiveness Review Project Evidence Table 9. O bservationalstudies A uth or O th erpopulation Design Datasources Tim e period A dverse events Y ear ch aracteristics of assessm ent C ountry assessm ent A ncoli- M eanage 73. Bain,2003 H ospice patients R etrospective Database from one 6 month s N umberoftimes U S database analysis practice. IC D-9 codes th erapy was ofprescribing associated with each discontinued, patterns treatmentmodality. O bservationalstudies A uth or R esults F unding Y ear C ountry A ncoli- F requency ofcommonTreatment-emergentadverse events (TEA Es) W yeth R esearch Israel, duringopen-labelrun-outph ase,number(% ): and th e 2005 H eadach e-155(27% ) R esearch U S and Infection-73(13% ) Service of Europe Backach e-58(10% ) VeteranA ffairs Bronch itis/ph aryngitis-65(11% ) Diego R h initis-53(9% ) H ealth care Diz z iness-43(7% ) System. Th e TEA Es mostfrequently associated with discontinuation,number(% ): Pain-29(5% ) Somnolence ordiz z iness-23(4% ) G astrointestinalch anges-11(2% ) C ardiovascularch anges-8(1% ) Bain,2003 U se temaz epam orz olpidem,discontinuationdue to adverse events: N otreported U S z olpidem(n=89)vs. A mongdiscontinuationexcept"ch ange indose":adverse drugreaction- 4. 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RCT medicine zyrtec buy topiramate 100mg without a prescription, single-blind Multinational (17) Mometasone DPI (200) No (only for M Fair 48 2000 vs medicine dictionary prescription drugs buy topiramate 100mg free shipping. BUD treatment thesaurus generic 200 mg topiramate mastercard, 730 Age ≥ 12, moderate, on ICS, smokers Mometasone DPI (400) both medium) excluded vs. Characteristics of head-to-head studies comparing inhaled corticosteroids in children and adults Study Design Country N Population Comparison Equivalent Quality Study Duration Setting (total daily dose in mcg) dosing Rating Ciclesonide compared with flunisolide No systematic reviews or head-to-head trials found Ciclesonide compared with fluticasone 63 Bateman 2008 RCT Multinational - Europe, North America, CIC HFA-MDI (640) Yes (high) Fair South Africa vs. Fair Controller medications for asthma 45 of 369 Final Update 1 Report Drug Effectiveness Review Project Table 7. Characteristics of head-to-head studies comparing inhaled corticosteroids in children and adults Study Design Country N Population Comparison Equivalent Quality Study Duration Setting (total daily dose in mcg) dosing Rating vs. Characteristics of head-to-head studies comparing inhaled corticosteroids in children and adults Study Design Country N Population Comparison Equivalent Quality Study Duration Setting (total daily dose in mcg) dosing Rating publication 19% smokers 321 and 332 Multicenter 8 weeks and 6 weeks Flunisolide compared with mometasone No systematic reviews or head-to-head trials found Flunisolide compared with triamcinolone No systematic reviews or head-to-head trials found Fluticasone compared with mometasone 57 Harnest et al. RCT, DB Multinational (20) MF DPI (200) No (only for Fair 52 2001 vs. RCT, DB, triple- dummy US FP MDI (196) + Salmeterol (84) Yes (medium Fair 53 1999 vs. Controller medications for asthma 47 of 369 Final Update 1 Report Drug Effectiveness Review Project Table 7. Characteristics of head-to-head studies comparing inhaled corticosteroids in children and adults Study Design Country N Population Comparison Equivalent Quality Study Duration Setting (total daily dose in mcg) dosing Rating 12 weeks TAA MDI (1200) Multicenter, Pulmonary/allergy medicine clinics (50) Condemi et al. Note: “No difference” in the above results section indicates that there was no statistically significant difference between active treatments with ICSs; results are written in the same order as the drugs are entered in the comparison column for each study. Symbol use: Drug X > Drug Y = statistically significant difference in outcomes favoring Drug X; Drug X > Drug Y trend = point estimate favors Drug X, but the difference is not statistically significant or tests of statistical significance were NR; No difference = no statistically significant difference or tests of statistical significance were not reported and outcomes are similar. Note: “No difference” in the above results section indicates that there was no statistically significant difference between active treatments with ICSs; results are written in the same order as the drugs are entered in the comparison column for each study. Controller medications for asthma 48 of 369 Final Update 1 Report Drug Effectiveness Review Project Table 8. Characteristics of head-to-head studies comparing inhaled corticosteroids that included children Study Design N Comparison Equivalent Quality Study Duration Study Population (total daily dose) dosing Rating Beclomethasone compared with budesonide Adams, N et al. Systematic review with meta- Majority in Europe BDP Yes Good 22 2002 analysis vs. Systematic review with meta- Multinational (most in Europe) FP vs. BDP (33 trials) For some of Good 23 2007 analysis the included Severity ranged from mild to severe FP vs. BUD (37) studies 71 trials (14,602 participants), 59 persistent parallel, 14 cross-over (four had FP vs. BDP/BUD (2) a washout) 38 studies had FP: BDP/BUD Majority of studies (47) were dose ratio of between 6 weeks and 5 months; 1:2; 22 had dose ratio 1:1; 14 were ≤ 4 weeks remainder had multiple dose ratio comparisons or ratio was unclear Lasserson et al. Systematic review with meta- Multinational (most in Europe) FP compared with extrafine HFA Yes Good 24 2010 analysis BDP Severity ranged from mild to severe 9 trials (1265 participants) persistent 3 to 12 weeks 2/9 trials in children De Benedicts et RCT, DB Multinational (7 countries: Holland, FP DPI (400) Yes (medium) Fair 31 al. RCT, DB Multinational (11 worldwide) FP MDI (200) Yes (medium) Fair 34 1993 vs. Characteristics of head-to-head studies comparing inhaled corticosteroids that included children Study Design N Comparison Equivalent Quality Study Duration Study Population (total daily dose) dosing Rating controlled on current meds, smoking 6 weeks status NR Multicenter (32) Budesonide compared with Ciclesonide von Berg et al. RCT, DB, DD Multinational - Australia, Germany, CIC HFA-MDI (160) Yes (low) Fair 62 2007 Hungary, Poland, Portugal, Serbia vs. Systematic review with meta- Multinational (most in Europe) FP vs. BDP (33 trials) For some of Good 23 2007 analysis the included Severity ranged from mild to severe FP vs. BUD (37) studies 71 trials (14,602 participants), 59 persistent parallel, 14 cross-over (four had FP vs. BDP/BUD (2) a washout) 38 studies had FP:BDP/BUD Majority of studies (47) were dose ratio of between 6 weeks and 5 months; 1:2; 22 had dose ratio 1:1; 14 were ≤ 4 weeks remainder had multiple dose ratio comparisons or ratio was unclear Ferguson et al. RCT, DB, DD Multinational (6 countries worldwide) FP DPI (400) Yes (medium) Fair 44 1999 vs. RCT, DB, DD Multinational (4: Netherlands, FP DPI (400) No (medium Fair 46 1996 Sweden, Denmark, Finland) vs.