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Outcome of patients referred to the M. D. Anderson Cancer Center between 1985 and 2003 was reviewed, of 1448 patients referred 11% of whom were 70 years of age, the median age at diagnosis of CLL in the USA ; , 321 went on to receive immediate treatment i.e. 1127 were elected for a `watch-and-wait' strategy ; . Survival in patients who did not receive immediate treatment appears to be better than in those treated immediately, but both groups have a poor 18-year survival rate Figure 6 ; . Stratification of patients in the watch-and-wait group according to the prognostic groupings Table 5 ; revealed that patients with a prognostic score 9 were likely to have a median survival of about 8 years. Thus, perhaps this simple stratification strategy will be able to identify patients who should be considered for treatment. Interestingly, many patients in the low-scoring group who survived for 15 years did not fulfill the NCI guidelines for treatment throughout this period, so again, a method to accurately predict outcome in patients with a low tumor burden could dramatically change the clinical management of these patients. Dr Hallek assessed whether there is justification for revising specific recommendations in the NCI 1996 guidelines. Areas for consideration for revision, proposed by Dr Hallek, included the contribution of immunophenotype and molecular biology cytogenetics, and eligiblity criteria for clinical trials. He noted that, given the rapid progress in the field, several parameters in the guidelines may need to be addressed to allow comparison between future clinical trials.
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Page 8 Access to Medications in Medicare Part D the prior authorization is needed. Plan B again only shows that prior authorization is needed without indicating which drugs may overlap with Part B coverage. Neither formulary even mentions dual eligible individuals or Medicaid. These are often the persons with the least resources to research complexities of the program. There are no guidelines or instructions to help dual eligibles understand how the formulary limitations apply to them. Even though the statute restricts the Part D plans to using only two formulary tiers for dual eligibles, this is not mentioned anywhere in either formulary. Of course, there is also no mention of long-term care or special provisions e.g. lack of cost sharing for dual eligibles ; that apply to them. Dual eligibles will thus be totally dependent on outside parties with extensive knowledge of Part D to help them understand these formularies. Some plans have separate formularies for dual eligibles on individuals receiving the low-income subsidy from Part D, but these are not easily available. Overview Some physicians hope to minimize the administrative burden from Medicare Part D by just giving up and using whichever drugs the plans want them to use. The analysis of the formularies provided below shows how that strategy will not work. ALL of the statin medications, including generic lovastatin, have quantity limit requirements in both of the formularies reviewed. It may not be possible for a physician to put a patient on a statin and keep them on it without getting permission from the Part D plan. All of the newer hypnotic agents are restricted. Ambien and Sonata have quantity limits with both plans. Lunesta has quantity limits with Plan A and is non-formulary with Plan B. Ambien Pak, though, is available from Plan B with no restrictions. All proton pump inhibitors are restricted. Plan A has quantity limits on all of them. Plan B only has omeprazole, Nexium, and Preavcid on the formulary. The rest are non-formulary. All those covered have prior authorization and quantity limit requirements. All angiotensin II receptor antagonists e.g. Cozaar, Diovan ; , used for hypertension, have quantity limits on both formularies. With the Plan B formulary, many angiotensin converting enzyme ACE ; inhibitors are excluded from their formulary, and all remaining ACE inhibitors, including generics e.g. Capoten, Vasotec ; , have quantity limits as well. These ACE inhibitors are routinely used in individuals with diabetes or heart failure. This exclusion will be especially burdensome for physicians of beneficiaries who sign up for this plan.
Change in sleep patterns insomnia or hypersomnia ; Fatigue or loss of energy nearly every day Psychomotor agitation or retardation nearly every day Significant weight loss when not dieting ; or weight gain or a decrease or increase in appetite nearly every day Diminished ability to think or concentrate or indecisiveness nearly every day Workup rules out a medical illness e.g., Parkinson's disease ; that could be causing the depression The symptoms are not better accounted for by schizoaffective disorder, schizophrenia, or delusional disorder The patient has never had a hypomanic, manic, or mixed episode No evidence that the patient has recently used a drug e.g., interferon ; that can cause depression and psilocybin.
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