By C. Tarok. University of Miami.

The activity levels lj are found from the forces of infection λj and the infective fractions i secnidazole 500 mg line, as explained in Appendix C of [105] generic 500 mg secnidazole with amex. Then b = ˜b = l /D1/2 secnidazole 500 mg generic, where j j j j 32 D = j=1 ljPj is the total number of people contacted per unit time. In the first model each pertussis booster moves the individual back up one vaccinated or removed class, but for those in the second model who have had a sequence of at least four pertussis vaccinations or have had a previous pertussis infection, a pertussis booster raises their immunity back up to the highest level. Thus the second model incorporates a more optimistic view of the effectiveness of pertussis booster vaccinations. Neither of the two methods used to find approximations of R0 for measles in Niger works for the pertussis models. The replacement number R at the pertussis endemic equilibrium depends on the fractions infected in all of the three or four infective classes. For example, in the first pertussis model 32 j=1 λj(sj + r1j + r2j)Pj/(γ + dj) R ∼= , 32 j=1(ij + imj + iwj)Pj where ij, imj, and iwj are the infective prevalences in the full-, mild-, and weak-disease classes I, Im, and Iw. In the computer simulations for both pertussis models, R is 1 at the endemic equilibrium. If the expression for R is modified by changing the factor in parentheses in the numerator to 1, which corresponds to assuming that all contacts are with susceptibles, then we obtain the contact number 32 j=1 λjPj/(γ + dj) σ ∼= , 32 j=1(ij + imj + iwj)Pj which gives the average number of cases due to all infectives. Thus it is not possible to use the estimate of the contact number σ during the computer simulations as an approxima- tion for R0 in the pertussis models. Since the age distribution of the population in the United States is poorly approximated by a negative exponential and the force of infection is not constant, the second method used for measles in Niger also does not work to approximate R0 for pertussis in the United States. The ultimate goal of a pertussis vaccination program is to vaccinate enough people to get the replacement number less than 1, so that pertussis fades away and herd immunity is achieved. Because the mixing for pertussis is not homogeneous and the immunity is not permanent, we cannot use the simple criterion for herd immunity that the fraction with vaccine-induced or infection-induced immunity is greater than 1 − 1/R0. None of the vaccination strategies, including those that give booster vaccinations every five years, has achieved herd immunity in the pertussis computer simulations [105, 106]. The results presented in this paper provide a theoretical background for reviewing some previous results. In this section we do not attempt to cite all papers on infectious disease models with age structure, heterogeneity, and spatial structure, but primarily cite sources that con- sider thresholds and the basic reproduction number R0. The cited papers reflect the author’s interests, but additional references are given in these papers and in the books and survey papers listed in the introduction. We refer the reader to other sources for information on stochastic epidemiology models [18, 20, 56, 59, 66, 81, 128, 167], discrete time models [2, 3], models involving macroparasites [12, 59, 90], genetic het- erogeneity [12, 90], plant disease models [137, 194], and wildlife disease models [90]. Age-structured epidemiology models with either continuous age or age groups are essential for the incorporation of age-related mixing behavior, fertility rates, and death rates, for the estimation of R0 from age-specific data, and for the comparison of vac- cination strategies with age-specific risk groups and age-dependent vaccination rates. Indeed, some of the early epidemiology models incorporated continuous age structure [24, 136]. Modern mathematical analysis of age-structured models appears to have started with Hoppensteadt [114], who formulated epidemiology models with both con- tinuous chronological age and infection class age (time since infection), showed that they were well posed, and found threshold conditions for endemicity. Expressions for R0 for models with both chronological and infection age were obtained by Dietz and Schenzle [68]. In age-structured epidemiology models, proportionate and preferred mixing parameters can be estimated from age-specific force of infection data [103]. Mathematical aspects such as existence and uniqueness of solutions, steady states, stability, and thresholds have now been analyzed for many epidemiology models with age structure; more references are cited in the following papers. Age-structured models have been used in the epidemiology modeling of many dis- eases [12]. Dietz [61, 64], Hethcote [98], Anderson and May [10, 11], and Rouderfer, Becker, and Hethcote [174] used continuous age-structured models for the evaluation of measles and rubella vaccination strategies. Hethcote [99] considered optimal ages of vacci- nation for measles on three continents. Grenfell and Anderson [89] and Hethcote [105, 106] have used age-structured models in evaluating pertussis (whooping cough) vaccination programs. Irregular and biennial oscillations of measles incidences have led to various mathematical analyses including the following seven modeling ex- planations, some of which involve age structure. Schenzle [177] used computer simulations to show that the measles out- break patterns in England and Germany could be explained by the primary school yearly calenders and entry ages. Bolker and Grenfell [27] proposed realistic age-structured models with seasonal forcing and stochastic terms. Ferguson, Nokes, and Anderson [79] proposed finely age-stratified models with stochastic fluctuations that can shift the dynamics between biennial and triennial cycle attractors. For many infectious diseases the transmission occurs in a diverse population, so the epidemiological model must divide the heterogeneous population into subpopula- tions or groups, in which the members have similar characteristics. This division into groups can be based not only on mode of transmission, contact patterns, latent pe- riod, infectious period, genetic susceptibility or resistance, and amount of vaccination or chemotherapy, but also on social, cultural, economic, demographic, or geographic factors. For these models it is useful to find R0 from the threshold conditions for invasion and endemicity and to prove stability of the equilibria. The seminal paper [140] of Lajmanovich and Yorke found this threshold condition and proved the global stability of the disease-free and en- demic equilibria using Liapunov functions. For these models R0 can be shown to be the spectral radius of a next generation matrix that is related to the Jacobian matrix A [103, 110]. For proportionate mixing models with multiple interacting groups, the basic reproduction number R0 is the contact number σ, which is the weighted average of the contact numbers in the groups [103, 110, 113]. The sexual transmission of diseases often occurs in a very heterogeneous population, because people with more sexual partners have more opportunities to be infected and to infect others. The basic reproduction number R0 has been determined for many different models with heterogeneous mixing involving core, social, and sexual mixing groups [113, 129, 131, 138, 139, 184]. It has been shown that estimates of R0, under the false assumption that a heterogeneously mixing population is homoge- neously mixing, are not greater than the actual R0 for the heterogeneous population [1, 103]. Many models with heterogeneity in the form of competing strains of infectious agents have been considered for diseases such as influenza, dengue, and myxomatosis [17, 40, 41, 42, 63, 70, 73, 74, 76, 155, 160]. There is clear evidence that infectious diseases spread geographically and maps with isodate spread contours have been produced [12, 55, 158, 166]. Some estimated speeds of propagation are 30–60 kilometers per year for fox rabies in Europe starting in 1939 [166], 18–24 miles per year for raccoon rabies in the Eastern United States start- ing in 1977 [49], about 140 miles per year for the plague in Europe in 1347–1350 [166], and worldwide in one year for influenza in the 20th century [176]. Epidemiology mod- els with spatial structures have been used to describe spatial heterogeneity [12, 96, 110] and the spatial spread of infectious diseases [38, 54, 59, 90, 166, 193]. Diffusion epidemiology mod- els are formulated from nonspatial models by adding diffusion terms corresponding to the random movements each day of susceptibles and infectives. Dispersal-kernel models are formulated by using integral equations with kernels describing daily con- tacts of infectives with their neighbors. For both types of spatial epidemiology models in infinite domains, one often determines the thresholds (sometimes in terms of R0) above which a traveling wave exists, finds the minimum speed of propagation and the asymptotic speed of propagation (which is usually shown to be equal to the minimum speed), and determines the stability of the traveling wave to perturbations [161, 172].

This means that For example buy discount secnidazole 500mg on line, high doses of vitamins order 500mg secnidazole, even vitamin C order secnidazole 500mg line, may they have proper training in their field. If you want to confirm the answer, ask Do you know of studies that prove it helps? Other Questions To Ask Yourself Do you see other patients with my type of cancer? Just remember, if it sounds too good to be true, it How current is the information? Health Information on the Internet: Questions and However, some may be unreliable or misleading. A number of books Does the book offer different points of view, or does have been written it seem to hold one opinion? If you want to look for articles you can trust, ask your If you go to the librarian to help you look for medical journals, books, library, ask the staff and other research that has been done by experts. Or if Articles in popular magazines are usually not written by you live near a college experts. Rather, the authors speak with experts, gather or university, there information, and then write the article. Local bookstores may The authors may not have expert knowledge in this area; also have people on staff who can help you. When you read these articles, you can use the same Questions to ask: process that the magazine writer uses: Is the author an expert on this subject? Thechnologies for data capture and manage- shown in parentheses below and Annex A) clustered un- ment and development of high quality databases will der fve challenges. Translational research infrastruc- the beneft of patients, citizens and society as a whole (see tures and data harmonisation of structured, semi-struc- the paragraph Looking Forward below). This starts with the integration of all ‘omics’ data to Innovation’ approach (27). A Europe-wide process to evaluate and validate biomarkers, together with longitudinal and Challenge 5 – Shaping Sustainable in-depth studies to further characterise diseases and their Healthcare progression would support on-going eforts towards this integration and re-classifcation (18,19). Patients and the citizen will play an increasingly important role in adopting and controlling the use of data from electronic health records and in developing Challenge 4 – Bringing Innovation prospective surveillance and monitoring systems for per- to the Market sonal health data (30,32). Alto- funding agencies, public health agencies, policy makers, gether 27 organisations from 14 countries across Europe industry, regulatory authorities, health insurers and, cruci- and beyond have contributed directly to this document, ally, the citizen. Specifying the chal- of molecularly defned tumour subgroups to specifc inhi- lenges and obstacles that will be faced by researchers, bitors. In comparison to chemotherapy a substantially im- industry, policy makers and healthcare providers will faci- proved outcome is described in an increasing number of litate the development of strategies and the identifcation cancer entities with this approach. An additional beneft is that an difer widely, depending on factors such as scientifc evi- innovation-driven healthcare system is one of the biggest dence, the particular professional context, personal experi- driving forces not only for a competitive healthcare indus- ence or values, and difering applied quality standards. In addition, key Europe- nal high-level stakeholders participants were introduced an organisations and institutions have published reports, to the topic and made familiar with the results of the ana- guidelines and roadmaps. From this analysis an inventory of the sessions were presented and discussed with the of recommendations was prepared and grouped into key entire audience to ensure that cross-sectoral issues were areas. These stakeholders were invited to the PerMed work- shops and/or participated in semi-structured interviews. Interviews were conducted either fa- PerMed webpage) ce-to-face or over the phone. In total 35 experts from the following four areas were interviewed: (1) basic research Dialogue platform exclusively for funding organisa- and new technologies, (2) translational research, (3) regu- tions – ‘Round Table PerMed’: As part of the dialogue lation and reimbursement, and (4) healthcare systems in platform the PerMed ‘Round Table PerMed’ was set up. All fnal interview summaries were approved by Round Table is a forum for ministries and funding organi- the respective experts. Key issues include: the establishment of a strong ‘Personalised Medicine refers to a medical model culture of collaboration between all relevant research using characterisation of individuals’ phenotypes and areas in a true public–private partnership, the adaptation genotypes (e. On the other hand, diseases that display rather dife- using omics and related technologies (e. These developments are occur- wider populations and individuals, it will become possible ring alongside a growing involvement of patient and ci- to better predict the best course of treatment or preventi- tizen interests, the increased role of patient advocacy and on for each citizen, thereby introducing a radically diferent support groups, the ubiquitous availability of information approach to healthcare on a broad scale. The approach has through the internet and the consequent rise in health li- the potential to ofer medium- and long-term gains – to teracy of patients and citizens. These trends are likely to patients and to society – and should signifcantly outweigh change the way that healthcare clients and providers in- the required initial investment. This can being defned as the entire range of research along the only be achieved when standard protocols with regard to healthcare value chain. This includes not only basic and diagnostic tests and treatment are used in treatment cent- translational research, but also research relating to regu- res; these centres can then serve as partners jointly execu- latory aspects, new fexible health technology assessment ting a particular trial. Furthermore, there are manifold interrelations between the fve challenges; these have not been indicated in order to keep the clearness of the fgure. This is not meant to imply that the particular recommendation may not be equal- Recommendations on biomedical, health-related ly relevant to other challenge areas. All recommendations ces research have been colour-coded according to the activities re- ferred to, which are grouped into three broad areas. In these cases, the recommendation has 11 4) Challenges for the further implementation of Personalised Medicine Challenge 1 – Developing Aware- tive Pathways to Patients) represents a frst and welcome ness and Empowerment step in this direction. Instead of lenges in the areas of patient information, data protection merely treating a disease, a shift to a more holistic appro- and data ownership. In order to do this, it will be patients feel more ‘left alone’, becoming responsible them- fundamental to establish shared practices and a com- selves for managing complex treatment regimens, which munication network. Furthermore, a move towards more preventive approaches to healthcare Empowerment – Providers in the health sector, citizens, is expected and needed. Networks of stake- challenges, and are capable and willing to support its im- holders, researchers, clinicians and patients/citizens who plementation. In addition, the stu- dy of genomics can provide information about an individu- 1. Provide further evidence for the beneft deli- al’s reaction to a particular pharmaceutical product. Once clinical and personal utility cons of this option will support decision-makers in this as well as economic sustainability are proven in a precisely sensitive feld. These developments should be supported defned indication, a strategy for the communication and in the light of a holistic approach carefully avoiding the dissemination of the possibilities, challenges and potenti- risk that the citizen might only be seen as a ‘sum of data’. One example could be feasibility studies on health data cooperatives with an assessment of ethical, legal and soci- 2. Develop and promote models for individual al implications comparing diferent European healthcare responsibility, ownership and sharing of per- system settings. An appropriate data ownership framework for ment pathways and track the safety and efec- patients will therefore be needed, especially given that tiveness of these interventions. For this reason, issues relating interfaces is needed to enable the use of smartphones, to data ownership, storage, handling, editing, sharing, tablets, other mobile services, ‘smart home’ and tele-he- controlling and access regulations have to be addressed. The implementation of this recommen- ethical basis for integrating data generated about and by dation 2 and 3 will strengthen the fnality for the patients’ users into health information collected by medical profes- beneft.

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A more responsive approach to chronic disease would recognize that chronic disease: Is ongoing order secnidazole 500 mg online, and therefore warrants pro-active purchase 500 mg secnidazole visa, planned cheap secnidazole 500mg fast delivery, integrated care within a system that clients can easily navigate Involves clients living indefinitely with the disease and its symptoms, requiring them to be active partners in managing their condition, rather than passive recipients of care Requires multi-faceted care which calls for clinicians and non-clinicians from multiple disciplines to work closely together, to meet the wide range of needs of the chronically ill Can be prevented and therefore warrants health promotion and disease prevention strategies targeted to the whole population, especially those at high risk for chronic disease. Internationally and within Canada there is growing interest in redesigning health care organizations and practice to improve the quality of care and to close the gap in care between what is known to improve outcomes, and what is practiced. This will require health care organizations to re-think current approaches to chronic disease management while exploring ways to build health promotion and disease prevention into health care practice and the lives of their clients. It supports health care system changes from one that is designed for episodic, acute illness to one that will support the prevention and management of chronic disease. In practice, jurisdictions have found that simply adding new elements such as self-management programs or client registries to a system solely focused on episodic, acute care does not change delivery of care substantially or improve health outcomes. Changing delivery of care to improve outcomes requires fundamental system changes in the design of practice and provision of self-management supports. The Framework is a ‘roadmap’ to a chronic care delivery system that provides effective care and better health outcomes. The Framework can be applied to both specific and generic chronic disease practice, and to different types of health care organizations. The Framework’s roadmap for effective chronic disease management addresses the distinct needs of clients with chronic conditions as it aims to provide multi- faceted, planned, pro-active seamless care in which the clients are full participants in managing their care and are supported to do this at all points by the system. Ontarians with chronic conditions will experience a change both in their care and their disease management. They will become equal partners in their own health and full collaborators in managing their conditions, and they will be supported in this. Their care will be organized and delivered to give the expert care they need when and where they need it, without their having to struggle through the system on their own, bounced from provider to provider. Their care will be planned and based on the best evidence, and both providers and clients will be supported in following through with the plan. Effective chronic disease management includes the implementation of prevention measures to halt the disease’s progress and to prevent complications and co-morbidities. Prevention in the Charter includes interventions both to reduce the risk of disease among chronically ill individuals and individuals at high risk of developing disease, as well as broad initiatives to improve health 9 within the population as a whole and prevent new cases of chronic disease from occurring. The Charter identifies five action areas in which to do this: Development of personal skills necessary to staying healthy Re-orientation of health services to greater health promotion and disease prevention Building public policies that promote health and prevent disease Creating environments supportive to health Strengthening community action. Actions in these areas not only address the risk factors for an Determinants of health: individuals’ health, but also • Income and social status address the full range of factors • Education and literacy that determine the populations’ • Social support networks health. The determinants of • Employment/working conditions health range from individual • Social environments genetic make-up to socio- • Physical environments economic factors such as • Personal health practices and coping skills income and education. Community agencies deliver much of the promotion/prevention in Ontario, especially promotion/prevention directed at populations of individuals. The Framework makes community providers important partners, linking them with health care providers – through systematic referrals, collaborations to reach underserved populations – for example, to exploit fully the capacity and resources of both sectors to deliver quality care, support client self-management, and prevent chronic disease. The Framework also promotes broader community strategies – led by individuals, families, advocates, and/or agencies – to improve health and reduce the incidence of disease among Ontarians through activities that address the determinants of health. These outcomes will result from both increased prevention/promotion in clinical practice and in the community, as well as improved delivery of chronic disease care. The improved delivery of care will not only ensure quality care in the appropriate setting by the appropriate provider at the right time, but will also increase efficiency in the system. Evidence also indicates that the Framework’s approach will save health care system resources by reducing hospitalizations and use of emergency departments, reducing duplication of services, and helping Ontarians to stay healthy. As indicated earlier, major chronic diseases and injuries account for 33% of 3٫ 4 direct health care costs and 55% of direct and indirect health costs in Ontario. A high proportion of these costs are consumed by the relatively small proportion of individuals with multiple serious chronic conditions. Studies in British Columbia found that in that province, individuals with very high co-morbidity used seven times the inpatient hospital days, four times the physician visits, five times the home care (nursing, rehab), and two and a half times the home support 25٫ 26 services as the population average. Between 1995 and 2002 the number of acute operating beds decreased from 52,000 to 19,000 and the average daily in-patient population dropped about 60%. In Canada, specific asthma programs featuring treatment, education, assessment and follow-up have been shown to save $501-597 per person 28 enrolled. A recent Alberta study of heart failure care after hospitalization 11 reduced hospital use by an average of 3. The remainder of this section of the paper will be devoted to describing the main elements of Ontario’s Chronic Disease Prevention and Management Framework. Health Care Organizations The health care system is the main provider of health care to chronically ill Ontarians, and a provider of chronic disease prevention. Their role is to champion the Health Care Organizations changes required to shift from reactive episodic acute care to proactive • Strong leadership chronic disease prevention and • Aligned resources and incentives management. Leadership, resources, • Commitment to quality improvement • Accountability for outcomes incentives, and quality improvement across the health care system and within individual organizations, are pre-requisite to successful implementation of the Framework’s practice and system changes. Strong Leadership Strong organizational leadership that visibly supports chronic disease prevention and management is central to success. Committed leaders have a clear understanding of what’s involved, and ‘walk the talk’ through ongoing organizational quality improvement to identify innovative and effective delivery strategies, based on best evidence. They also work to mobilize all partners and stakeholders within the health care sector and community to build an environment and service system that result in optimal care and reduced incidence of chronic disease. Leadership across the health care system must assign human and financial resources to Framework practices and redesign. In most jurisdictions, current incentives and performance measures continue to reinforce acute, episodic care in medical practice. Individual clinicians’ and organizations’ productivity, for example, is still largely measured by numbers of visits and technical procedures completed. Clinicians do not often get paid for conducting assessments of clients’ risk for disease, general health status or ability to care for themselves. Current reimbursement structures discourage proactive outreach planned care and alternative visit structures such as telephone or email interactions with clients. The Framework emphasizes clinical chronic disease prevention and management for the whole population. One way to do this is to offer population-based funding incentives – for example, reward organizations or sectors if cholesterol rates fall in the local population, or if smoking rates drop. Commitment to Quality Improvement Best practices in implementing Framework elements continue to evolve. Organizations need to foster a culture of quality improvement to identify innovative and effective delivery strategies, based on new best evidence, that are most effective in preventing and managing chronic disease. Initiatives could include continuous learning forums and systematic use of quality improvement tools. Quality improvement from the top levels to the front lines needs to be promoted and be a part of job descriptions and performance appraisals. Accountability for Outcomes Strong leadership, within the health care system as well as within health care organizations engages partners in defining common goals, setting a collective vision, determining performance measures, and evaluating and reporting on that performance. The result – shared commitment and defined accountability, with greater likelihood of improvements in health care and health system outcomes. Building Framework practice and system changes into performance measures is a proven, effective strategy to ensure organizations implement best practice approaches to chronic disease prevention and management.

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Cognitive Impairment Several participants highlighted the cognitive effects of Parkinson’s disease on their day to day activities secnidazole 500mg without a prescription. For some participants cheap 500 mg secnidazole otc, cognitive impairment was manifested as being unable to remember words cheap secnidazole 500mg on-line, particular periods of time and people. Participants shared specific instances: • “If you asked me, I wouldn’t [be able to] tell you what I had for breakfast. A wide range of sleep disturbances were reported, including difficulties falling asleep and staying asleep. Participants also mentioned that sleep disturbances sometimes lead to fatigue symptoms which may persist into the next day. One woman stated, “Using the restroom is difficult…because my stomach muscles are often too cramped. Some participants expressed the need for constant monitoring of their diet due to constipation. One participant shared, “I have to really watch meat…it will take me several days to digest and cause constipation. One participant commented that her anxiety occurred whenever she needed to “complete a particular task. Overall impact of Parkinson’s disease on daily life Throughout the meeting, participants described the physical and social impact that living with Parkinson’s disease has had on their lives. Many also highlighted the emotional burden of living with Parkinson’s disease, sharing that their condition felt “frustrating” and “incredibly scary. Several participants highlighted the effect of this reliance upon how they care for and are perceived by their family. One participant noted that family members sometimes become frustrated with his lack of ability to complete a task. He shared his family’s sentiments: “Better not give him that assignment if you want it done before the end of the day. The following examples illustrate the experiences shared in the discussion of this impact: o “I’m supposed to be the caregiver of my children…they’re only teenagers, and they’re beginning to help. Participants shared that their symptoms, particularly motor symptoms, impaired balance, and cognitive impairment, had significant impacts on their ability to perform at their job. One participant shared an experience of quitting a position due to impaired balance, stating, “the responsibility [of the position]…it was just haunting me and causing me to fall down. Many participants commented that the lack of energy, anxiety, and motor symptoms led to social isolation. One participant shared that she had increased anxiety when making social plans, saying, “, I often cancel at the last minute because I get so anxious going out. Some participants shared instances of being characterized as lazy or “looking a little slow. Topic 2: Patient Perspectives on Treatments for Parkinson’s disease The second discussion topic focused on patients’ experiences with therapies used to address their Parkinson’s disease symptoms. Five panelists, including four men and one woman, provided comments to start the dialogue. Two men discussed the hardships of pursuing treatment due to lack of timely diagnosis, one man shared detailed experiences with deep-brain stimulation, another man stressed the importance of seeking healthcare professionals which specialize in Parkinson’s disease management and one woman highlighted the importance of emerging research in stem cells and regenerative medicine. Panelists shared their experiences with complex regimens which included a variety of prescription treatments, alternative therapies, and lifestyle changes. In the large-group facilitated discussion that followed, experiences voiced by participants reflected those shared by panelists. Participants identified the importance of a personalized treatment regimen incorporating experiences of supplement and vitamin use, prescription drugs and lifestyle modifications in efforts to manage symptoms. Participants described in detail the benefits and downsides of their current treatment regimens. Participants also shared their considerations for what an ideal treatment for Parkinson’s disease would be. Prescriptions and over-the-counter drugs According to a polling question (Appendix 3, Q7), the majority of in-person and web participants reported experiences taking carbidopa-levodopa formulations, dopamine agonists, and other drug therapies. Prescription drug therapies were described as having widely varying degrees of effectiveness, 9 and many participants noted limited or decreased benefit over time because of Parkinson’s disease progression and harmful side effects. Many participants expressed specific improvements in managing tremor, balance, gait, and overall mobility with carbidopa-levodopa. Some participants described carbidopa-levodopa as a “miracle drug” which showed significant improvement in their condition. One participant shared that taking Sinemet with amantadine greatly improved his dyskinesia. Several participants commented that they had to increase the formulation strength or dosing frequency of Sinemet as their symptoms worsened. One woman shared that the dosage of her original regimen of carbidopa-levodopa nearly doubled over the course of five years. Several participants commented that despite the benefits of carbidopa-levodopa, they experienced significant down-sides. Most participants identified developing severe dyskinesia, which “became more of a problem than the actual symptom [the medication] was treating. Meeting participants acknowledged familiarity with the Duopa formulation; however, there were no comments provided on experiences using it. One caregiver shared that the lack of experience with new formulations may be due to, “debating the pros and cons of each medication and the hesitation to change something that seems to be working. One participant stated, “ropinirole has been very helpful for restless leg syndrome at bedtime. Some participants discontinued Mirapex due to “sleep attacks,” which were described as moments when “[your] conscious mind is switched off and [you] sort of go blind. Another participant said that she experienced orthostatic hypotension whenever she missed a Mirapex dose. Participants also described experiences of impulsive behavior and feet swelling as reason for reducing Mirapex use. Another participant shared an experience of using apomorphine to control unexpected symptoms in the work place. Additional treatments Participants also briefly mentioned the use of additional therapies to address their Parkinson’s disease symptoms. One participant shared that following deep brain stimulation surgery he was “disease-free from a motor standpoint. One participant shared his experience of using an assistive device to address the “head-drop” he has experienced with Parkinson’s disease. He shared that “without this [device] my chin would be on my chest” and also noted additional discomfort with use of the device. Non-drug therapies Nearly all meeting participants commented on the importance of a holistic approach to managing their Parkinson’s disease symptoms.

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