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Greatest Benefit (greatest + benefit)
Selected AbstractsDrug prevention programmes for young people: where have we been and where should we be going?ADDICTION, Issue 10 2010Richard Midford ABSTRACT Aim Substance use by young people has long been a concern of western society, but opinion is mixed as to which prevention approach offers the greatest benefit, and whether indeed there is any benefit at all. This paper reviews the nature of prevention programmes, the research evidence that underpins these programmes and the prevention objectives against which effectiveness is measured. The aim of this is to create better understanding of the elements that maximize programme effectiveness, what can be achieved by prevention programmes and how programmes can be improved. Findings There is a range of prevention approaches for which there is evidence of effectiveness. Some are classroom-based; some focus upon parenting; some have substantial whole-of-school and community elements; and some target risk and protective factors in early childhood. All, however, are based substantially on the social influence model. In an attempt to improve practice lists of effective programmes have been developed, but there are concerns about the science behind selection. On balance, there is consistent evidence that social influence prevention programmes do have a small, positive effect on drug use, but this then raises the question as to whether harm, rather than use, would be the more worthwhile target for prevention. Prevention that seeks to reduce harm has been demonstrably effective, but has found little support in some jurisdictions. Conclusion Research has created a progressively better understanding of how to optimize programme effectiveness and what can be achieved realistically by even the most effective programmes. However, further research is required to identify which, if any, particular approach offers greater promise. The effectiveness of harm reduction should be compared with more traditional abstinence and the additional effects of whole of school, parent and community elements need to be measured more accurately. Contemporary social influence prevention programmes are flawed, but the approach is still the best way of influencing drug use behaviour in young people as a whole. Evidence-based refinement is the best option for greater benefit. [source] Lenalidomide in combination with dexamethasone at first relapse in comparison with its use as later salvage therapy in relapsed or refractory multiple myelomaEUROPEAN JOURNAL OF HAEMATOLOGY, Issue 6 2009Edward A. Stadtmauer Abstract This subset analysis of data from two phase III studies in patients with relapsed or refractory multiple myeloma (MM) evaluated the benefit of initiating lenalidomide plus dexamethasone at first relapse. Multivariate analysis showed that fewer prior therapies, along with ,2 -microglobulin (,2.5 mg/L), predicted a better time to progression (TTP; study end-point) with lenalidomide plus dexamethasone treatment. Patients with one prior therapy showed a significant improvement in benefit after first relapse compared with those who received two or more therapies. Patients with one prior therapy had significantly prolonged median TTP (17.1 vs. 10.6 months; P = 0.026) and progression-free survival (14.1 vs. 9.5 months, P = 0.047) compared with patients treated in later lines. Overall response rates were higher (66.9% vs. 56.8%, P = 0.06), and the complete response plus very good partial response rate was significantly higher in first relapse (39.8% vs. 27.7%, P = 0.025). Importantly, overall survival was significantly prolonged for patients treated with lenalidomide plus dexamethasone with one prior therapy, compared with patients treated later in salvage (median of 42.0 vs. 35.8 months, P = 0.041), with no differences in toxicity, dose reductions, or discontinuations despite longer treatment. Therefore, lenalidomide plus dexamethasone is both effective and tolerable for second-line MM therapy and the data suggest that the greatest benefit occurs with earlier use. [source] Comparative performances of staging systems for early hepatocellular carcinomaHPB, Issue 5 2009Hari Nathan Abstract Background:, Several staging systems for patients with hepatocellular carcinoma (HCC) have been proposed, but studies of their prognostic accuracy have yielded conflicting conclusions. Stratifying patients with early HCC is of particular interest because these patients may derive the greatest benefit from intervention, yet no studies have evaluated the comparative performances of staging systems in patients with early HCC. Methods:, A retrospective cohort study was performed using data on 379 patients who underwent liver resection or liver transplantation for HCC at six major hepatobiliary centres in the USA and Europe. The staging systems evaluated were: the Okuda staging system, the International Hepato-Pancreato-Biliary Association (IHPBA) staging system, the Cancer of the Liver Italian Programme (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, the Japanese Integrated Staging (JIS) score and the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) staging system, 6th edition. A recently proposed early HCC prognostic score was also evaluated. The discriminative abilities of the staging systems were evaluated using Cox proportional hazards models and the bootstrap-corrected concordance index (c). Results:, Overall survival of the cohort was 74% at 3 years and 52% at 5 years, with a median survival of 62 months. Most systems demonstrated poor discriminatory ability (P > 0.05 on Cox proportional hazards analysis, c, 0.5). However, the AJCC/UICC system clearly stratified patients (P < 0.001, c= 0.59), albeit only into two groups. The early HCC prognostic score also clearly stratified patients (P < 0.001, c= 0.60) and identified three distinct prognostic groups. Discussion:, The early HCC prognostic score is superior to the AJCC/UICC staging system (6th edition) for predicting the survival of patients with early HCC after liver resection or liver transplantation. Other major HCC staging systems perform poorly in patients with early HCC. [source] Maintenance of healthy skin: cleansing, moisturization, and ultraviolet protectionJOURNAL OF COSMETIC DERMATOLOGY, Issue 2007J Frank Nash PhD Summary Background, The human skin is exposed to an extraordinary hostile environment over the course of a lifetime. Whereas there are multiple product types that consumers may select to help preserve and protect the skin, at a minimum cleansing, moisturization, and protection against solar ultraviolet radiation are elements of any strategy designed for skin health. To achieve the greatest benefit from these treatment modalities, products must be carefully formulated, chosen, and used, since poorly designed or misused products may exacerbate symptoms associated with unhealthy skin. Aims, The objective of this review is to present the principle elements of cleansing, moisturization, and sun protection modalities that are, in some measure, responsible for maintaining healthy skin. Conclusion, Healthy skin is a universal desire of humans. The regular and proper use of cleansing, moisturization, and solar protection regimens plays a key role in maintaining skin health. These are lifetime practices wherein product technologies evolve even as the essential function remains. [source] Strategies for Implementing School-Located Influenza Vaccination of Children: A Systematic Literature ReviewJOURNAL OF SCHOOL HEALTH, Issue 4 2010John Cawley PhD BACKGROUND: The Advisory Committee on Immunization Practices (ACIP) recommends influenza vaccinations for all children 6 months to 18 years of age, which includes school-aged children. Influenza immunization programs may benefit schools by reducing absenteeism. METHODS: A systematic literature review of PubMed, PsychLit, and Dissertation Abstracts available as of January 7, 2008, was conducted for school-located vaccinations, using search words "School Health Services" and "Immunization Programs"; limited to "Child" (6-12 years) and "Adolescent" (13-18 years) for PubMed and "mass or universal" and (immuniz* or immunis* or vaccin*) and (school or Child or Adolescen*) for PsychLit and Dissertation Abstracts. Fifty-nine studies met the criteria for review. RESULTS: Strategies such as incentives, education, the design of the consent form, and follow-up can increase parental consent and number of returned forms. Minimizing out-of-pocket cost, offering both the intramuscular (shot) and intranasal (nasal spray) vaccination, and using reminders can increase vaccination coverage among those whose parents consented. Finally, organization, communication, and planning can minimize the logistical challenges. CONCLUSIONS: Schools-based vaccination programs are a promising option for achieving the expanded ACIP recommendation; school-located vaccination programs are feasible and effective. Adhering to lessons from the peer-reviewed scientific literature may help public health officials and schools implement the expanded recommendation to provide the greatest benefit for the lowest cost. Given the potential benefits of the expanded recommendation, both directly to the vaccinated children and indirectly to the community, prospective, well-controlled trials to establish the cost-effectiveness of specific vaccination strategies should be high priorities for future research. [source] Omalizumab therapy: patients who achieve greatest benefit for their asthma experience greatest benefit for rhinitisALLERGY, Issue 1 2009M. Humbert Background:, Asthma and rhinitis are considered components of a single IgE-mediated inflammatory disorder. However, despite being shown to often co-exist, they are typically treated as independent conditions. Omalizumab, an anti-IgE antibody, has proven effective in the treatment of both asthma and rhinitis. Aims:, To examine whether a response to omalizumab in terms of asthma control predicts a higher likelihood of rhinitis response in patients with concomitant allergic asthma and rhinitis. Methods:, This post hoc analysis was conducted on efficacy results from the SOLAR trial in which patients with moderate-to-severe asthma and rhinitis were randomized to receive omalizumab or placebo for 28 weeks. Patients were classified as asthma responders based on the physician's overall assessment (complete control or marked improvement in a five-level evaluation). Rhinitis responders were identified using the Rhinitis Quality of Life Questionnaire (RQLQ) questionnaire (, 1.0 point improvement in overall score). Results:, Data were available for 207 omalizumab-treated patients and 192 placebo patients. According to the physicians overall assessment, 123 (59.4%) of omalizumab-treated patients were asthma responders, with the likelihood of a rhinitis response significantly (P < 0.001) greater in these patients than in the placebo group. The odds ratio for rhinitis response in omalizumab-treated asthma responders vs nonresponders was 3.56 (95% CI: 1.94,6.54). Conclusions:, A response in terms of asthma following omalizumab therapy is associated with a significantly increased probability of improvement in rhinitis. [source] Recommendations for the use of icodextrin in peritoneal dialysis patientsNEPHROLOGY, Issue 1 2003Review Article SUMMARY: Icodextrin is a starch-derived, high molecular weight glucose polymer, which has been shown to promote sustained ultrafiltration equivalent to that achieved with hypertonic (3.86%/4.25%) glucose exchanges during prolonged intraperitoneal dwells (up to 16 h). Patients with impaired ultrafiltration, particularly in the settings of acute peritonitis, high transporter status and diabetes mellitus, appear to derive the greatest benefit from icodextrin with respect to augmentation of dialytic fluid removal, amelioration of symptomatic fluid retention and possible prolongation of technique survival. Glycaemic control is also improved by substituting icodextrin for hypertonic glucose exchanges in diabetic patients. Preliminary in vitro and ex vivo studies suggest that icodextrin demonstrates greater peritoneal membrane biocompatibility than glucose-based dialysates, but these findings need to be confirmed by long-term clinical studies. This paper reviews the available clinical evidence pertaining to the safety and efficacy of icodextrin and makes recommendations for its use in peritonal dialysis. [source] The Glass Half Empty or Half Full,How Effective Are Long-Term Intrathecal Opioids in Post-herpetic Neuralgia?NEUROMODULATION, Issue 3 2009A Case Series, Review of the Literature ABSTRACT Objectives.,Post-herpetic neuralgia (PHN) is a painful complication of herpes zoster infection and a common cause of chronic severe pain in elderly and/or debilitated patients. Although a wide range of treatments have been tried, a substantial number of patients continue to experience pain which remains refractory to all therapies. Increasingly, studies have demonstrated that oral opioids can have a beneficial effect on neuropathic pain. However, to date, few studies have examined the potential benefit(s) of chronic intrathecal opioids in the treatment of PHN. Methods.,Long-term outcome results of four PHN patients who had a successful intrathecal opioid trial and underwent implantation of an intrathecal opioid pump were examined. Data were analyzed using univariate analysis of variance. Results.,Duration of continuous intrathecal opioid therapy ranged from five to 50 months and mean pain reduction was 41% (range 27,50%) as measured by a verbal pain score (0,100), with the greatest benefit noticed earlier in therapy. Mean 24-hour intrathecal morphine dose was 2.29 mg (range 0.78,3.94 mg). Intrathecal therapy was discontinued in two patients because of opioid side-effects, depression, and loss of efficacy. Revision surgery was required in two cases. Patients most commonly reported improvement in the deep component of their pain, next allodynia, and less so superficial lancinating pain. Conclusions.,In conclusion, while a complex therapy, long-term use of intrathecal opioids is well tolerated, doses are titratable, administration is safe, and may help relieve severe short- and long-term neuropathic pain in selected PHN patients. Whether the addition of newer investigational intrathecal agents could improve these results is yet to be determined. [source] Use and adherence to beta-blockers for secondary prevention of myocardial infarction: who is not getting the treatment?,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 11 2004Li Wei Abstract Purpose To characterise those who receive beta-blocker therapy after MI and to estimate the effect of adherence to beta-blocker use on subsequent mortality and recurrent MI. Methods A community-based observational cohort study was done using a record linkage database. Patients were those discharged from hospitals after their first MI between January 1994 and December 1995 and who also survived for at least 1 year. The outcome was all cause mortality and recurrent MI. Results were adjusted for age, sex, social deprivation, airways disease, peripheral vascular disease (PVD), diabetes mellitus, cardiovascular drug use, steroid use and hospitalisation for cardiovascular disease using a logistic regression model and a Cox regression model. Results A total of 865 patients were included in this study. 386 (44.6%) were on beta-blocker treatment during the year after MI. Beta-blocker use was lower amongst high-risk patients (older patients, patients with obstructive airway disease, PVD and those with a previous hospitalisation for heart failure). Mortality was lower in patients treated with beta-blockers compared with those untreated. Good adherence (,80%) was associated with a lower adjusted relative risk of mortality compared with unexposed patients (0.49, 95%CI 0.30,0.80, p,<,0.01). Within the high-risk subgroup of patients, the adjusted relative risk of mortality with good adherence was 0.40 (0.17,0.93, p,=,0.03). Conclusions Beta-blocker use was lower in older patients, patients with airways disease, PVD and heart failure, but these patients appeared to have the greatest benefit from beta-blockers. Good adherence to beta-blocker treatment after MI was associated with a lower risk of mortality. Copyright © 2004 John Wiley & Sons, Ltd. [source] An evidence-based review of yoga as a complementary intervention for patients with cancerPSYCHO-ONCOLOGY, Issue 5 2009Kelly B. Smith Abstract Objective: To conduct an evidence-based review of yoga as an intervention for patients with cancer. Specifically, this paper reviewed the impact of yoga on psychological adjustment among cancer patients. Methods: A systematic literature search was conducted between May 2007 and April 2008. Data from each identified study were extracted by two independent raters; studies were included if they assessed psychological functioning and focused on yoga as a main intervention. Using a quality rating scale (range,=,9,45), the raters assessed the methodological quality of the studies, and CONSORT guidelines were used to assess randomized controlled trials (RCTs). Effect sizes were calculated when possible. In addition, each study was narratively reviewed with attention to outcome variables, the type of yoga intervention employed, and methodological strengths and limitations. Results: Ten studies were included, including six RCTs. Across studies, the majority of participants were women, and breast cancer was the most common diagnosis. Methodological quality ranged greatly across studies (range,=,15.5,42), with the average rating (M,=,33.55) indicating adequate quality. Studies also varied in terms of cancer populations and yoga interventions sampled. Conclusions: This study provided a systematic evaluation of the yoga and cancer literature. Although some positive results were noted, variability across studies and methodological drawbacks limit the extent to which yoga can be deemed effective for managing cancer-related symptoms. However, further research in this area is certainly warranted. Future research should examine what components of yoga are most beneficial, and what types of patients receive the greatest benefit from yoga interventions. Copyright © 2008 John Wiley & Sons, Ltd. [source] Changes in skin colour and cortisol response of Australian snapper Pagrus auratus (Bloch & Schneider, 1801) to different background coloursAQUACULTURE RESEARCH, Issue 5 2009Ben J Doolan Abstract A two-factor experiment was carried out to investigate the change in skin colour and plasma cortisol response of cultured Australian snapper Pagrus auratus to a change in background colour. Snapper (mean weight=437 g) were held in black or white tanks and fed diets containing 39 mg unesterified astaxanthin kg,1 for 49 days before being transferred from white tanks to black cages (WB) or black tanks to white cages (BW). Skin colour values [L* (lightness), a* (redness) and b* (yellowness)] of all snapper were measured at stocking (t=0 days) and from cages of fish randomly assigned to each sampling time at 0.25, 0.5, 1, 2, 3, 5 and 7 days. Plasma cortisol was measured in anaesthetized snapper following colour measurements at 0, 1 and 7 days. Fish from additional black-to-black (BB) and white-to-white (WW) control treatments were also sampled for colour and cortisol at those times. Rapid changes occurred in skin lightness (L* values) after altering background colour with maximum change in L* values for BW and WB treatments occurring within 1 day. Skin redness (a*) of BW snapper continued to steadily decrease over the 7 days (a*=7.93 × e,0.051 × time). Plasma cortisol concentrations were highest at stocking when fish were held at greater densities and were not affected by cage colour. The results of this study suggest that transferring dark coloured snapper to white cages for 1 day is sufficient to affect the greatest benefit in terms of producing light coloured fish while minimizing the reduction in favourable red skin colouration. [source] Determining the Optimal Dose of Intravenous Fat Emulsion for the Treatment of Severe Verapamil Toxicity in a Rodent ModelACADEMIC EMERGENCY MEDICINE, Issue 12 2008Eric Perez MD Abstract Objectives:, Recent animal studies have shown that intravenous fat emulsion (IFE) increases survival and hemodynamics in severe verapamil toxicity. However, the optimal dose of IFE is unknown. The primary objective was to determine the optimal dose of IFE based on survival in severe verapamil toxicity. Secondary objectives were to determine the effects on hemodynamic and metabolic parameters. The hypothesis was that there is a dose-dependent effect of IFE on survival until a maximum dose is reached. Methods:, This was a controlled dose-escalation study. Thirty male rats were anesthetized, ventilated, and instrumented to record mean arterial pressure (MAP) and heart rate (HR). Verapamil toxicity was achieved by a constant infusion of 15 mg/kg/hr. After 5 minutes, a bolus of 20% IFE was given. Animals were divided into six groups based on differing doses of IFE. Arterial base excess (ABE) was measured every 30 minutes. Data were analyzed with analysis of variance. Results:, The mean survival time for each dose of IFE was 0 mL/kg = 34 minutes, 6.2 mL/kg = 58 minutes, 12.4 mL/kg = 63 minutes, 18.6 mL/kg = 143.8 minutes, 24.8 mL/kg = 125.6 minutes, and 37.6 mL/kg = 130 minutes. Post hoc testing determined that the 18.6 mL/kg dose resulted in the greatest survival when compared to other doses. It increased survival 107.2 minutes (p = 0.004), 91.2 minutes (p = 0.001), and 80.8 minutes (p = 0.023) when compared to the lower doses of 0, 6.2, and 12.4 mL/kg, respectively. There was no added benefit to survival for doses greater than 18.6 mL/kg. The secondary outcomes of HR, MAP, and ABE showed the most benefit with 24.8 mL/kg of IFE at both 30 and 60 minutes. Conclusions:, The greatest benefit to survival occurs with 18.6 mL/kg IFE, while the greatest benefit to HR, MAP, and BE occurs at 24.8 mL/kg IFE. The optimal dose for the treatment of severe verapamil toxicity in this murine model was 18.6 mL/kg. [source] Intensified Process for the Purification of an Enzyme from Inclusion Bodies Using Integrated Expanded Bed Adsorption and RefoldingBIOTECHNOLOGY PROGRESS, Issue 4 2006Matthew H. Hutchinson This work describes the integration of expanded bed adsorption (EBA) and adsorptive protein refolding operations in an intensified process used to recover purified and biologically active proteins from inclusion bodies expressed in E. coli. ,5 -3-Ketosteroid isomerase with a C-terminal hexahistidine tag was expressed as inclusion bodies in the cytoplasm of E. coli. Chemical extraction was used to disrupt the host cells and simultaneously solubilize the inclusion bodies, after which EBA utilizing immobilized metal affinity interactions was used to purify the polyhistidine-tagged protein. Adsorptive refolding was then initiated in the column by changing the denaturant concentration in the feed stream from 8 to 0 M urea. Three strategies were tested for performing the refolding step in the EBA column: (i) the denaturant was removed using a step change in feed-buffer composition, (ii) the denaturant was gradually removed using a gradient change in feed-buffer composition, and (iii) the liquid flow direction through the column was reversed and adsorptive refolding performed in the packed bed. Buoyancy-induced mixing disrupted the operation of the expanded bed when adsorptive refolding was performed using either a step change or a rapid gradient change in feed-buffer composition. A shallow gradient reduction in denaturant concentration of the feed stream over 30 min maintained the stability of the expanded bed during adsorptive refolding. In a separate experiment, buoyancy-induced mixing was completely avoided by performing refolding in a settled bed, which achieved comparable yields to refolding in an expanded bed but required a slightly more complex process. A total of 10% of the available KSI,(His6) was recovered as biologically active and purified protein using the described purification and refolding process, and the yield was further increased to 19% by performing a second iteration of the on-column refolding operation. This process should be applicable for other polyhistidine tagged proteins and is likely to have the greatest benefit for proteins that tend to aggregate when refolded by dilution. [source] Knowledge Translation in International Emergency Medical CareACADEMIC EMERGENCY MEDICINE, Issue 11 2007L. Kristian Arnold MD More than 90% of the world population receives emergency medical care from different types of practitioners with little or no specific training in the field and with variable guidance and oversight. Emergency medical care is being recognized by actively practicing physicians around the world as an increasingly important domain in the overall health services package for a community. The know-do gap is well recognized as a major impediment to high-quality health care in much of the world. Knowledge translation principles for application in this highly varied young domain will require investigation of numerous aspects of the knowledge synthesis, exchange, and application domains in order to bring the greatest benefit of both explicit and tacit knowledge to increasing numbers of the world's population. This article reviews some of the issues particular to knowledge development and transfer in the international domain. The authors present a set of research proposals developed from a several-month online discussion among practitioners and teachers of emergency medical care in 16 countries from around the globe and from all economic strata, aimed at improving the flow of knowledge from developers and repositories of knowledge to the front lines of clinical care. [source] Application of activity-based costing (ABC) for a Peruvian NGO healthcare providerINTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT, Issue 1 2001Dr. Hugh Waters Abstract This article describes the application of activity-based costing (ABC) to calculate the unit costs of the services for a health care provider in Peru. While traditional costing allocates overhead and indirect costs in proportion to production volume or to direct costs, ABC assigns costs through activities within an organization. ABC uses personnel interviews to determine principal activities and the distribution of individual's time among these activities. Indirect costs are linked to services through time allocation and other tracing methods, and the result is a more accurate estimate of unit costs. The study concludes that applying ABC in a developing country setting is feasible, yielding results that are directly applicable to pricing and management. ABC determines costs for individual clinics, departments and services according to the activities that originate these costs, showing where an organization spends its money. With this information, it is possible to identify services that are generating extra revenue and those operating at a loss, and to calculate cross subsidies across services. ABC also highlights areas in the health care process where efficiency improvements are possible. Conclusions about the ultimate impact of the methodology are not drawn here, since the study was not repeated and changes in utilization patterns and the addition of new clinics affected applicability of the results. A potential constraint to implementing ABC is the availability and organization of cost information. Applying ABC efficiently requires information to be readily available, by cost category and department, since the greatest benefits of ABC come from frequent, systematic application of the methodology in order to monitor efficiency and provide feedback for management. The article concludes with a discussion of the potential applications of ABC in the health sector in developing countries. Copyright © 2001 John Wiley & Sons, Ltd. [source] Real-life impact of early interferon, therapy in relapsing multiple sclerosis,ANNALS OF NEUROLOGY, Issue 4 2009M. Trojano MD Objective Recent findings support greater efficacy of early vs. delayed interferon beta (IFN,) treatment in patients with a first clinical event suggestive of multiple sclerosis (MS). We aimed to evaluate the effectiveness of early IFN, treatment in definite relapsing-remitting MS (RRMS) and to assess the optimal time to initiate IFN, treatment with regard to the greatest benefits on disability progression. Methods A cohort of 2,570 IFN,-treated RRMS patients was prospectively followed for up to 7 years in 15 Italian MS Centers. A Cox proportional hazards regression model adjusted for propensity score (PS) quintiles was used to assess differences between groups of patients with early vs. delayed IFN, treatment on risk of reaching a 1-point progression in the Expanded Disability Status Scale (EDSS) score, and the EDSS 4.0 and 6.0 milestones. A set of PS-adjusted Cox hazards regression models were calculated according to different times of treatment initiation (within 1 year up to within 5 years from disease onset). A sensitivity analysis was performed to assess the robustness of findings. Results The lowest hazard ratios (HRs) for the three PS quintiles,adjusted models were obtained by a cutoff of treatment initiation within 1 year from disease onset. Early treatment significantly reduced the risk of reaching a 1-point progression in EDSS score (HR = 0.63; 95% CI = 0.48,0.85; p < 0.002), and the EDSS 4.0 milestone (HR = 0.56; 95% CI = 0.36,0.90; p = 0.015). Sensitivity analysis showed the bound of significance for unmeasured confounders. Interpretation Greater benefits on disability progression may be obtained by an early IFN, treatment in RRMS. Ann Neurol 2009;66:513,520 [source] | ||||||||||