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1. Salinas RA, Alvarez G, Alvarez MI, Ferreira J. Corticosteroids for Bells palsy. The
Cochrane Database of Systematic Reviews, Cochrane Library number: CD001942. In:
The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently
2. Williamson IG, Whelan TR. The clinical problem of Bells palsy: is treatment with steroids
effective? Br J Gen Pract 1996;46:743-747
4. Sipe J, Dunn L. Acyclovir for Bells palsy (idiopathic facial paralysis). The Cochrane
Database of Systematic Reviews, Cochrane Library number: CD001869. In: The
Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently
5. Kati Juva and Sirpa Asko-Seljavaara, Article ID: ebm00785 (036.093) 2005 Duodecim
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1. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal
positional vertigo. The Cochrane Database of Systematic Reviews, Cochrane Library
number: CD003162. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
Updated frequently
2. van der Velde GM. Benign paroxysmal positional vertigo part II: a qualitative review
of non-pharmacological, conservative treatments and a case report presenting Epleys
canalith repositioning procedure, a non-invasive bedside manoeuvre for treating BPPV.
Journal of Canadian Chiropractic Association 1999;43:41-49
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1. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. The Cochrane
Database of Systematic Reviews, Cochrane Library number: CD000145. In: The Cochrane
Library, Issue 2, 2002. Oxford: Update Software. Updated frequently.
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2. Tramer MR, Moore RA, Reynolds DJ, McQuay HJ. A quantitative systematic review of
ondantseron in the treatment of postoperative nausea and vomiting. BMJ 1997;314:1088-1092
3. The Database of Abstracts of Reviews of Effectiveness (University of York), Database no.:
DARE-978098. In: The Cochrane Library, Issue 4, 1999. Oxford: Update Software
4. Figueredo ED, Canosa LG. Ondantseron in the prophylaxis of postoperative vomiting: a metaanalysis. J Clin Anesth 1998;10:211-221
6. Domino KB, Anderson EA, Polissar NL, Posner KL. Comparative efficacy and safety of
ondantseron, droperidol, and metoclopramide for preventing postoperative nausea and vomiting:
a meta-analysis. Anesthesia and Analgesia 1999;88:1370-1379
8. Lee A, Done ML. The use of nonpharmacologic techniques to prevent postoperative nausea and
vomiting: a meta-analysis. Anesthesia and Analgesia 1999;88:1362-1369
10.Editors Article ID: ebm00172 (008.002) 2005 Duodecim Medical Publications Ltd
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1. Robey RR. The efficacy of treatments for aphasic persons: a meta-analysis. Brain and
Language 1994;47:582-608
3. Robey RR. A meta-analysis of clinical outcomes in the treatment of aphasia. J Speech,
Language, and Hearing Research 1998;41:172-187
5. Greener J, Enderby P, Whurr R. Pharmacological treatment for aphasia following stroke.
The Cochrane Database of Systematic Reviews, Cochrane Library number: CD000424.
In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently
6. Anita Kiesilinen, ArticleID: ebm00770(036.040) 2005 Duodecim Medical Publications
Ltd
7. Robey RR. The efficacy of treatments for aphasic persons: a meta-analysis. Brain and
Language 1994;47:582-608
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1. Hermish H, Aizenberg D, Weizman A, Lapidot M, Mayor C, Munitz H. Risk for definite

neuroleptic malignant syndrome. Br J Psychiatry 1992;161:254-7
2. Keck PE, Pope HG, Cohen BM, McElroy SL, Nierenberg AA. Risk factors for neuroleptic
malignant syndrome. Arch Gen Psychiatry 1989;46:914-8

3. Sachdev P, Mason C, Hadzi-Pavlovic D. Case-control stydy of neuroleptic malignant
syndrome. Am J Psychiatry 1997;154:1156-8
4. Figa-Talamanca L, Gualandi C. Hyperthermic syndromes and impairment of dopaminergic
system: A case study. Ital J Neurol Sci 1989;10:49-59
5. ODwyer AM, Sheppard NP. The role of creatine kinase in the diagnosis of neuroleptic
malignant syndrome. Psychol Med 1993;23:323-6
6. Verhoeven WMA, Elderson A, Westenberg HGM. Neuroleptic malignant syndrome:
Successful treatment with bromocriptine. Biol Psychiatry 1985;20:680-4
7. Koponen H, Repo E, Lepola U. Long-term outcome after neuroleptic malignant syndrome.
Acta Psychiatr Scand 1991;84:550-1
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1. Heames RM, Sado D, Deadin CD. Do doctors position defibrillation paddles correctly?
Observational study. BMJ 2001; 322: 1393-4
2. Brimacombe J. The advantages of the LMA over the tracheal tube or facemask: a metaanalysis. Can J Anaesth 1995;42:1017-1023
4. Watts DD. Defibrillation by basic emergency medical technicians: effect on survival. Ann
Emerg Med 1995;635-639
6. Effect of out-of hospital defibrillation by basic life support providers on cardiac arrest
mortality: a meta-analysis. Ann Emerg Med 1995;25:642-648
8. Nichol G, Detsky AS, Stiell IG, ORourke K, Wells G, Laupacis A. Effectiveness of
emergency medical services for victims of out-of-hospital cardiac arrest: a meta-analysis.
Ann Emerg Med 1996;27:700-710
10.Nichol G, Stiell IG, Laupacis A, Pham B, De Maio VJ, Wells GA. A cumulative meta-analysis
of the effectiveness of defibrillator-capable emergency medical services for victims of outof-hospital cardiac arrest. Annals of Emergency Medicine 1999;34:517-525
11.The Database of Abstracts of Reviews of Effectiveness (University of York), Database
12.Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of
rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med
2000;343:1206-1209
13.Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression
for cardiopulmonary resuscitation. The Cochrane Database of Systematic Reviews,
Cochrane Library number: CD002751. In: The Cochrane Library, Issue 2, 2002. Oxford:
Update Software. Updated frequently
14.Kwan I, Bunn F, Roberts I, on behalf of the WHO Pre-Hospital Trauma Care Steering
Committee. Timing and volume of fluid administration for patients with bleeding following
trauma. The Cochrane Database of Systematic Reviews, Cochrane Library number:
CD002245. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated
frequently
15.The Albumin Reviewers (Alderson P, Bunn F, Lefebvre C, Li Wan Po A, Li L, Roberts
I, Schierhout G). Human albumin solution for resuscitation and volume expansion in
critically ill patients. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently.
16.Wade CE, Kramer GC, Grady JJ, Fabian TC, Younes RN. Efficacy of hypertonic 7.5%
saline and 6% dextran-70 in treating trauma: a meta-analysis of controlled clinical
studies. Surgery 1997;122:609-616
18.Jabbour M, Osmond MH, Klassen TP. Life support courses: are they effective? Ann
407
408
Emerg Med 1996;28:690-698

20.Sethi D, Kwan I, Kelly AM, Roberts I, Bunn F. Advanced trauma life support training for
ambulance crews. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently
21.McGee S, Abernethy WB, Simel DL. Is this patient hypovolemic? JAMA 1999;281:1022-1029
23.Kati Juva, Article ID: ebm00751 (036.005) 2005 Duodecim Medical Publications Ltd
24.Timo Jama, Article ID: ebm00341 (017.003) 2005 Duodecim Medical Publications Ltd
2. 3
3. 2007
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1. Kapoor WN. Diagnostic evaluation of syncope. Am J Med 1991;90:91-105

2. Calkins H et al. The value of the clinical history in the differentiation of syncope due to
ventricular tachycardia, atrioventricular block, and neurocardiogenic syncope. Am J Med
1995;98:365-73
4. Linzer M, Yang EH, Estes M, Wang P, Vorperian VR, Kapoor WN. Diagnosing syncope
part 1: value of history, physical examination, and electrocardiography. Ann Intern Med
1997;126:989-996
5. Martikainen K, Sepp K et al. Transient loss of consciousness as a reason for admission
to primary health care emergency room. Scand J Primary Health Care 2003; 21: 61-64
6. Zaidi A, Clough P, Cooper P ym. Misdiagnosis of epilepsy: many seizure-like attacks
have a cardiovascular cause. J Am Coll Cardiol 2000:36;181
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1. Hillbom M, Pieninkeroinen I, Leone M. Seizures in Alcohol-Dependent Patients.

Epidemiology, Pathophysiology and Management. CNS Drugs 2003;17:1013-1030.
2. Porter RJ et al. Alcohol and Seizures, Basic Mechanisms and Clinical Concepts. FA
Davis Company, Philadelphia. 1990:1-342.
3. Hauser WA et al. Alcohol, seizures and epilepsy. Epilepsia 1988; 29(Suppl. 2):S66S78.
4. Pieninkeroinen IP, Telakivi TM, Hillbom ME. Outcome in subjects with alcohol-provoked
seizures. Alcohol Clin Exp Res 1992;16:955-959
5. Earnest MP et al. Intracranial lesions shown by CT scans in 259 cases of first alcoholrelated seizures. Neurology 1988;38:1561-1565.
6. Shoenenberger RA, Heim SM. Indication for computed tomography of the brain in
patients with uncomplicated generalised seizures. Br J Med 1994;309:986-989
7. Hillbom M, Hjelm-Jger M. Should alcohol withdrawal seizures be treated with antiepileptic drugs. Acta Neurol Scand 1984;69:39-42
8. Brthen G, Brodtkorb E, Helde G. ym. The diversity of seizures related to alcohol use. A
study of consecutive patients. European Journal of Neurology 1999:6;697-703
9. Matti Hillbom, Article ID: ebm00769 (036.049) 2005 Duodecim Medical Publications
Ltd
2. 3
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- (-B).
1. Chadwick DW, Marson T, Kadir Z. Efficacy and tolerability of new antiepileptic drugs.
Epilepsia 1996;37(suppl 6):17-22
3. Berg AT, Shinnar S. Relapse following discontinuation of antiepileptic drugs: a metaanalysis. Neurology 1994;44:601-608
5. Vermeulen J, Aldenkamp AP. Cognitive side-effects of antiepileptic drugs. Epilepsy
Research 1995;22:65-95
7. Chilcott J, Howell S, Kemeny A, Rittey CD, Richards C. The effectiveness of surgery in
the management of epilepsy. Working Group on Acute Purchasing. Sheffield: University of
Sheffield, Trent Institute for Health Services Research. Guidance Notes for P. 1999. 1-54
9. Schierhout G, Roberts I. Anti-epileptic drugs for preventing seizures following acute
traumatic brain injury. The Cochrane Database of Systematic Reviews, Cochrane
Library number: CD000173. In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software. Updated frequently.
10.Marson AG, Williamson PR, Hutton JL, Clough HE, Chadwick DW; on behalf of the epilepsy
monotherapy trialists. Carbamazepine versus valproate monotherapy for epilepsy. The
11.Taylor S, Tudur Smith C, Williamson PR, Marson AG. Phenobarbitone versus phenytoin
monotherapy for partial onset seizures and generalized onset tonic-clonic seizures. The
12.Castillo S, Schmidt DB, White S. Oxcarbazepine add-on for drug-resistant partial epilepsy.

13.Ramaratnam S, Marson AG, Baker GA. Lamotrigine add-on for drug-resistant partial epilepsy.
The Cochrane Database of Systematic Reviews, Cochrane Library number: CD001909. In:
2. 3
3. 2007
10
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Thiopental38 5 mg/kg ,
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1. Reetta Klviinen; Article ID: ebm00766 (036.046); 2005 Duodecim Medical

Publications Ltd
2. 4
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1. Kati Juva, Article ID: ebm00783 (036.082) 2005 Duodecim Medical Publications Ltd
2. 4
3. 2008
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/ (-C).
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.
.
.
.
.
.
.
.
.
.
437
438

,
" (-C).
(-D).
1. Brooks BR. Clinical epidemiology of amyotrophic lateral sclerosis. Neuroepidemiology

1996;14(2):399-420
2. Chancellor AM, Warlow CP. Adult onset motor neuron disease: worldwide mortality,
incidence and distribution since 1950. J Neurol Neurosurg Psychiatry 1992;55:1106-15
3. Romn GC. Neuroepidemiology of amyotrophic lateral sclerosis: clues to aetiology and
pathogenesis. J Neurol Neurosurg Psychiatry 1996;61:131-7
4. Leigh PN, Ray-Chaudhuri K. Motor neuron disease. J Neurol Neurosurg Psychiatry
1994;57:886-96
5. Jackson CE, Bryan WW. Amyotrophic lateral sclerosis. Seminars in Neurology
1998;18(1):27-39
6. Louwerse ES, Wisser CE, Bossuyt PMM, Weverling GJ. Amyotrophic lateral sclerosis:
mortality risk during the course of the disease and prognostic factors. J Neurol Sci
1997;152(Suppl.1):S10-S17
7. Sufit R. Symptomatic treatment of ALS. Neurology 1997;48(Suppl. 4):S15-S22
8. Miller RG, Sufit R, Mitsumoto H, Gelinas DF, Brooks BR. ALS standard of care consensus.
Neurology 1997;48(Suppl. 4):S33-S37
9. OBrien T, Kelly M, Saunders C. Motor neurone disease: a hospice perspective. BMJ
1992;304:471-3
10.Miller RG, Rosenberg JA, Gelinas DF, Mitsumoto H, Newman D, Sufit R, Borasio GD,
Bradley WG, Bromberg MB, Brooks BR, Kasarskis EJ, Munsat TL, Oppenheimer EA.
Practice parameter: The care of the patient with amyotrophic lateral sclerosis (an
evidence-based review). Report of the Quality Standards Subcommittee of the American
Academy of Neurology
11.Lacomblez L, Bensimon G, Leigh PN, Guillet P, Powe L, Durrleman S, Delumeau JC,
Meininger V, ALS/Riluzole Study Group-II. A confirmatory dose-ranging study of riluzole
in ALS. Neurology 1996;47(Suppl. 4):S242-S250
12.Miller RG, Mitchell JD, Lyon M, Moore DH. Riluzole for amyotrophic lateral sclerosis
(ALS)/motor neuron disease (MND). The Cochrane Database of Systematic Reviews,
13.Wagner ML, Landis BE. Riluzole: a new agent for amyotrophic lateral sclerosis. Ann
Pharmacother 1997;31:738-744
15.Bensimon G, Lacomblez L, Meininger V, ALS/Riluzole Study Group. A controlled trial of
riluzole in amyotrophic lateral sclerosis. N Engl J Med 1994;330:585-91
16.Hannu Laaksovirta,Article ID:ebm00799 (036.084) 2005Duodecim Medical Publications
Ltd
17.Mitchell JD, Wokke JHJ, Borasio GD. Recombinant human insulin-like growth factor I
(rhIGF-I) for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database
Syst Rev. 2004;(2):CD002064.
18.Parton M, Mitsumoto H, Leigh PN. Amino acids for amyotrophic lateral sclerosis / motor
neuron disease (Cochrane Review). Cochrane Database Syst Rev 2003(4):CD003457
19.Ashworth NL, Satkunam LE, Deforge D. Treatment for spasticity in amyotrophic lateral
sclerosis/motor neuron disease. The Cochrane Database of Systematic Reviews,
Cochrane Library Number: CD004156. In: Cochrane Library, Issue 1, 2004. Chichester,
UK: John Wiley Sons, Ltd.
20.Orrell RW, Lane JM, Ross MA. Antioxidant treatment for amyotrophic lateral sclerosis
/ motor neuron disease. The Cochrane Database of Systematic Reviews, Cochrane
Library Number: CD002829. In: Cochrane Library, Issue 4, 2004. Chichester, UK: John
Wiley Sons, Ltd.
21.Editors, Article ID: evd01252 (036.084) 2004 Duodecim Medical Publications Ltd
22.Editors, Article ID: ime00711) 2004 Duodecim Medical Publications Ltd
23.Editors, Article ID: evd03516 2005 Duodecim Medical Publications Ltd
2. 4
3. 2007
1. Heimlich-
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;
: hemearginate57 3 mg/kg 4 (-C) (.. - 400g
).

57 .
;
- ;
() ;
.
1. Herrick AL, McColl KE, Moore MR, Cook A, Goldberg A. Controlled trial of haemarginate
in acute hepatic porphyria. Lancet 1989: 1295-7
2. Mustajoki P, Nordmann Y. Early administration of heme arginate for acute porphyric
attacks. Arch Intern Med 1993;153:20042008
3. Pertti Mustajoki, Article ID: ebm00221 (024.066) 2005 Duodecim Medical Publications Ltd
2. 4
3. 2008
441
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1. Principles of examination and treatment of stroke. Stroke unit, Neurology clinic, Helsinki
University Central Hospital
2. Stroke Unit Trialists Collaboration. Organised inpatient (stroke unit) care for stroke. The
The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently.
3. Koudstaal P. Anticoagulants for preventing stroke in patients with nonrheumatic atrial
fibillation and a history of stroke or transient ischemic attaks. The Cochrane Database of
Systematic Reviews, Cochrane Library number: CD000185. In: The Cochrane Library,
Issue 2, 2002. Oxford: Update Software. Updated frequently.
4. EAFT Study Group. Secondary prevention in nonrheumatic atrial fibrillation after transient
ischaemic attack or minor stroke. Lancet 1993;342:1255-1262
5. Koudstaal P. Anticoagulants versus antiplatelet therapy for preventing stroke in patients
with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attacks.
In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently.
6. Lyrer P, Engelter S. Antithrombotic drugs for carotid dissection. The Cochrane Database
of Systematic Reviews, Cochrane Library number: CD000255. In: The Cochrane Library,
Issue 2, 2002. Oxford: Update Software. Updated frequently
7. Gueyffier F, Boissel JP, Boutitie F, Pocock S, Coope J, Cutler J, Ekbom T, Fagard R,
Friedman L, Kerlikowske K, Perry M, Prineas R, Schron E. Effect of antihypertensive
treatment in patients having already suffered from stroke: gathering the evidence. Stroke
1997;28:2557-2562
62 .
449
450
9. Agency for Health Care Research and Quality (AHRQ). Diagnosis and treatment of
swallowing disorders (dysphagia) in acute-care stroke patients. Rockville, MD: Agency
for Health Care Research and Quality (AHQR). Agency for Health care Research and
Quality (AHQR). Evidence Report/tech. 1999.
10.The Health Technology Assessment Database, Database no.: HTA-998426. In: The
Cochrane Library, Issue 1, 2001. Oxford: Update Software
11.Counsell C, Sandercock P. Low-molecular weight heparins versus standard unfractionated
heparin for acute ischaemic stroke. The Cochrane Database of Systematic Reviews,
Update Software. Updated frequently.
12.Counsell C, Sandercock P. Antiplatelet therapy for acute ischaemic stroke. The
13.Wardlaw JM, Yamaguchi T, del Zoppo G. Thrombolysis for acute ischaemic stroke. The
14.Liu M, Councell C, Wardlaw J. Fibrinogen depleting agents for acute ischaemic stroke.
15.Horn J, Limburg M. Calcium antagonists for acute ischemic stroke. The Cochrane
16.He J, Whelton PK, Vu B, Klag MJ. Aspirin and risk of hemorrhagic stroke: a meta-analysis
of randomized controlled trials. JAMA 1998;280:1930-1935
18.Jorgensen HS, Nakayama H, Kammersgaard LP, Raaschou HO, Olsen TS. Predicted
impact of intravenous thrombolysis on prognosis of general population of stroke patients:
simulation model. BMJ 1999;319:288-289
19.Mazzone C, Chiodo Grandi F, Sandercock P, Miccio M, Salvi R. Physical methods for
preventing deep vein thrombosis in stroke. The Cochrane Database of Systematic
Reviews, Cochrane Library number: CD001922. In: The Cochrane Library, Issue 2,
2002. Oxford: Update Software. Updated frequently
20.Risto O. Roine, Article ID: ebm00759 (036.031) 2005 Duodecim Medical Publications
Ltd
2. 3
3. 2007

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1. Matchar DB, McCrory D, Barnett HJM et al. Medical treatment for stroke prevention. Ann
Intern Med 1994;121:41-53
3. Johnson ES, Lanes SF, Wentworth CE, Satterfield MH, Abede BL, Dicker LW. A
metaregression analysis of the dose-response effect of aspirin on stroke. Archives of
Internal Medicine 1999;159:1248-1253
5. Hankey GJ, Sudlow CLM, Dunbabin DW. Thienopyridine derivatives (ticlopidine,
clopidogrel) versus aspirin for preventing serious vascular events in high risk patients.
6. Algra A, Schryver ELLM, van Gijn J, Kappelle LJ, Koudstaal PJ. Oral anticoagulants
versus antiplatelet therapy for preventing further vascular events after transient
ischaemic attack or minor stroke of presumed arterial origin. The Cochrane Database of
7. Cina CS, Clase CM, Haynes RB. Carotid endarterectomy for symptomatic carotid
stenosis. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently.
8. Crouse JR, Byington RP, Hoen HM, Furberg CD. Reductase inhibitors and stroke
prevention. Archives of Internal Medicine 1997;157:1305-1310
10.Chambers BR, You RX, Donnan GA. Carotid endarterectomy for asymptomatic carotid
stenosis. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently
11.Hebert PR, Gaziano JM, Chan KS, Hennekens CH. Cholesterol lowering with statins
and risk of stroke. JAMA 1997;278:313-321
13.Bucher HC, Griffith LE, Guyatt GH. Effect of HMGcoA reductase inhibitors on stroke.
Ann Intern Med 1998;128:89-95
15.Frericks H, Kievit J, van Baalen JM, van Bockel JH. Carotid restenosis and risk of
ipsilateral stroke: a systematic review of the literature. Stroke 1998;29:244-250
1. EBM Guidelines 14.4.2004,www.ebm-guideines.com
2. 3
3. 2007
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1. Hankey GJ, Hon C. Surgery for primary intracerebral haemorrhage: is it safe and effective?
A systematic review of case series and randomized trials. Stroke 1997;28:2126-2132
no.: DARE-971406. In: The Cochrane Library, Issue 4, 1999. Oxford: Update Software.
3. Risto O.Roine, Article ID: ebm00761 (036.033) 2005 Duodecim Medical Publications Ltd
2. 3
3. 2007
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1. Schievink WI. Intracranial aneurysms. N Engl J Med 1997; 336: 28-40
461
462
2. Whitfield PC, Kirkpatrick PJ. Timing of surgery for aneurysmal subarachnoid haemorrhage.
3. Barker FG, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischaemic deficit
in subarachnoid haemorrhage: a meta-analysis. J Neurosurg 1996;84:405-414
5. Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for
unruptured intracranial aneurysms: a meta-analysis. Stroke 1998;29:1531-1538
7. Claiborne Johnson S, Colford JM, Gress DR. Oral contraceptives and the risk of
subarachnoid hemorrhage: a meta-analysis. Neurology 1998;51:411-418
9. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with with
subarachnoidal haemorrhage, cerebral aneurysm, and arteriovenous malformation: a
meta-analysis. Stroke 1999;30:317-320
11.Brilsra EH, Rinkel GJ, van der Graaf WJ, van Rooij WJ, Algra A. Treatment of intracranial
aneurysms by embolization with coils: a systematic review. Stroke 1999;30:470-476
2. 3
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1. Medication-induced headache: overview and systematic review of therapeutic

approaches. Annals of Pharmacotherapy 1999;33:61-72
3. Markus Frkkil Article ID: ebm00743 (036.065) 2005 Duodecim Medical Publications Ltd
2. 3
3. 2007
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1. Haddock CK, Rowan AB, Andrasik F, Wilson PG, Talcott GW, Stein RJ. Home-based
behavioural treatments for chronic benign headache: a meta-analysis of controlled trials.
Cephalalgia 1997;17:113-118
2. 4
3. 2008
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472

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, .
Lithium ( , ;
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1. Ekbom K, Monstad I, Prusinski A, Cole JA, Pilgrim AJ, Noronha D. Subcutaneous

sumatriptan in the acute treatment of cluster headache: a dose comparison study. The
Sumatriptan Cluster Headache Study Group. Acta Neurol Scand 1993;88:63-9
2. The Sumatriptan Cluster Headache Study Group (see comments). Treatment of acute
cluster headache with sumatriptan. N Eng J Med 1991;325:322-6
3. Markus Frkkil, Article ID: ebm00793 (036.068) 2005 Duodecim Medical Publications
Ltd
2. 4
3. 2008
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ergotamine/caffeine /metoclopramide
(-C).
1. Frishberg BM. The utility of neuroimaging in the evaluation of headache in patients with
normal neurological examination. Neurology 1994;44:1191-1197
3. Chabriat H, Danchot J, Hugues FC, Joire JE. Combined aspirin and metoclopramide
in the acute treatment of migraine attacks: a review. Headache Quarterly, Current
Treatment and Research 1997;8:118-121
5. Lipton RB, Stewart WF, Stone AM, Lainez JA, Sawyer JPC. Stratified care vs. step care
strategies for migraine: the disability in strategies of care (DISC) study: a randomised
trial. JAMA 2000;284:2599-2605
6. Harrison DL, Slack MK. Meta-analytic review of the effect of subcutaneous sumatriptan
in migraine headache. J Pharm Technol 1998;12:109-114
8. Theft-Hansen P. Efficacy and adverse events of subcutaneous, oral and intrnasal
sumatriptan used for migraine treatment: a systematic review based on number needed
80 .
477
478
to treat. Cephalalgia 1998;18:532-538

10.Oldman AED, Smith LA, McQuay JH, Moore RA. Rizatriptan for acute migraine. The
11.Smith LA, Oldman AD, McQuay HJ, Moore RA. Eletriptan for acute migraine. The
12.Ilerisch,L. An economic analysis of sumatriptan for acute migrainesummary. Ottawa:
Canadian Coodinating Office for Health Technology Assessmen/ Office Canadien de
Coordination de lEvaluation des Technologues de la sant,. Canadien Coordinating
Office for Health Technology Assessment (CCOHTA). 1997. 13.
13.The Health Technology Assessment Database, Database no.: HTA-978259. In: The
14.Markus Frkkil Article ID: ebm00792 (036.067) 2005 Duodecim Medical Publications Ltd

2. 3
3. 2007

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.
.
1. Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute

and chronic pain. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently
2. Lindstrm 1987, reported in brief
3. Zakrzewska JM, Patsalos PN. Oxcarbazepine: a new drug in the management of
intractable trigeminal neuralgia. Journal of Neurology, Neurosurgery Psychiatry
1989;52:472-6.
4. Farago F. Trigminal neuralgia: its treatment with two new carbamazepine analogues.
European Neurology 1987;26:73-83.
2. 3
3. 2007
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2. 3
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.
1. Rao J, Weinberger M, Oddone E, Allen N, Landman P, Feussner JR. The role of

antineutrophil cytoplasmic antibody (c-ANCA) testing in the diagnosis of Wegener
granulomatosis: a literature review and meta-analysis. Ann Intern Med 1995;123:925932
3. Tom Pettersson and Markku Ellonen, Article ID: ebm00449 (021.044) 2005 Duodecim
2. 3
3. 2007

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1. Mahoney FI, Barthel DW. Functional evaluation: The Barthel index. Maryland State Med
J 1965;14(2):61-5
2. 2.Katz S, Downs TD, Cash HR, Grotz RC. Progress in Development of the Index of ADL.
Gerontologist 1970;10:20-9
3. 3.Lawton MP, Brody EM. Assessment of older people: self-monitoring and instrumental
activities of daily living. Gerontologist 1969;9:179-86
4. 4.Yesavage JA, Brink TL, et al. Development and validation of a geriatric depression
screening scale : a preliminary report. J Psychiatr Res 1982-83;17:37-49
5. 5.Mulligan R, Mackinnon A, Jorm AF et al. A comparison of alternative methods of
screening for dementia in clinical setting. Arch Neurol 1996;53:532-6.
6. Kaisu Pitkl, Article ID: ebm00470 (022.021) 2005 Duodecim Medical Publications Ltd

2. 4
3. 2008
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1. McKeith I, Del Ser T, Spano P, Emre M, Wesnes K, Anand R, Cicin-Sain A, Ferrara

R. Efficacy of rivastigmine in dementia with Lewy bodies: a randomised, double-blind,
placebo-controlled international study. Lancet 2000;356:2031-36.
505
506
2. Kaufer DI. Pharmacologic treatment expectations in the management of dementia with

Lewy bodies. Dement Geriatr Cogn Disord. 2004;17 Suppl 1:32-9
3. Timo Erkinjuntti and Raimo Sulkava Article ID: ebm00757 (036.025)
2. 4
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85 .
507
508
1. Meyer JS, Rogers RL, McClintic K, Mortel KF, Lotfi J. Randomized clinical trial of daily
aspirin therapy in multi-infarct dementia. A pilot study. J Am Ger Soc 1989;37:549-555
2. Williams PS, Spector A, Orrell M, Rands G. Aspirin for vascular dementia. The Cochrane
Cochrane Library, Issue 2, 2002. Oxford: Update Software. Updated frequently.
3. Olin J, Schneider L, Novit A, Luczak S. Hydergine for dementia. The Cochrane Database
4. Lachner G, Engel RR. Differentiation of dementia and depression by memory tests: a
meta-analysis. J Nerv Ment Dis 1994;182:34-39
6. Meta-analysis of the Hachinski Ischaemic Score in pathologically verified dementias.
Neurology 1997;49:1096-1105
2. 4
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2 .
.
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.
(-B) (-C)
.

(-C).
1. Birks JS, Melzer D. Donepezil for mild and moderate Alzheimers disease. The Cochrane
2. Olin J, Schneider L. Galantamine for Alzheimers disease. The Cochrane Database of
3. Forbes DA. Strategies for managing behavioural symptomatology associated with
dementia of the Alzheimer type: a systematic overview. Canadian Journal of Nursing
Research 1998;30:67-86
5. Birks J, Flicker L. Selegiline for Alzheimers disease. The Cochrane Database of
6. Coelho Filho JR, Birks J. Physostigmine for Alzheimers disease. The Cochrane Database
7. Laake K, Oeksengaard AR.. The Cochrane Database of Systematic Reviews, Cochrane
Software.
8. Tabet N, Feldman H. Indomethacin for the treatment of Alzheimers disease patients.
In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
9. Katz IR, Jeste DV, Mintzer JE, Clyde C, Napolitano J, Brecher M. Comparison of
89 .
90 .
risperidone and placebo for psychosis and behavioral disturbances associated with
dementia: a randomized, double-blind trial. Risperidone Study Group. J Clin Psychiatry
1999;60(2):107-15
10.Doody RS. Current treatments for Alzheimers disease: cholinesterase inhibitors. J Clin
Psychiatry. 2003;64 Suppl 9:11-7
11.Tariot PN, Farlow MR, Grossberg GT, et al; Memantine Study Group. Memantine
treatment in patients with moderate to severe Alzheimer disease already receiving
donepezil: a randomized controlled trial. JAMA 2004 Jan 21;291(3):31724
12.Raimo Sulkava, Article ID: ebm00756 (036.024) 2005 Duodecim Medical Publications Ltd
13.Birks J, Grimley Evans J, Iakovidou V, Tsolaki M. Rivastigmine for Alzheimers disease.
The Cochrane Database of Systematic Reviews, Cochrane Library Number: CD001191.
14.Areosa Sastre A, Sherriff F. Memantine for dementia. Cochrane Database Syst Rev.
2004;(2):CD003154.
15.Hogervorst E, Yaffe K, Richards M, Huppert F. Hormone replacement therapy to maintain
cognitive function in women with dementia. The Cochrane Database of Systematic
2002. Oxford: Update Software.
2. 4
3. 2008
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-12, , ,
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513
514
1. Lanctot KL, Best TM, Mittman N, Liu BA, Oh PI, Einarson TE, Naranjo CA. Efficacy
and safety of neuroleptics in hehavioural disorders associated with dementia. J Clin
Psychiatr 1998;59:550-561
3. Lonergan E, Luxenberg J, Colford J. Haloperidol for agitation in dementia. The Cochrane
4. Olin J, Schneider L, Novit A, Luczak S. Hydergine for dementia. The Cochrane Database
5. Fioravanti M, Flicker L. Nicergoline for dementia and other age associated forms of
cognitive impairment. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently
6. Spector A, Orrell M, Davies S, Woods B. Reality orientation in dementia. The Cochrane
7. Opie J, Rosewarne R, OConnor DW. The efficacy of psychosocial approaches for
behavioural disorders in dementia: a systematic literature review. Australian and New
Zealand Journal of Psychiatry 1999;33:789-799
9. Fioravanti M, Yanagi M. Cytidinediphosphocholine (CDCIG) for cognitive and behavioural
disturbances associated with chronic cerebral disorders in the elderly. The Cochrane
10.Effects of memory training on the subjective memory functioning and mental health of
older adults: a meta-analysis. Psychology and Ageing 1997;12:150-161
2. 4
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1. Filippini G, Brusaferri F, Sibley WA, Citterio A, Ciucci G, Midgard R, Candelise L.

Corticosteroids or ACTH for acute exacerbations in multiple sclerosis. The Cochrane
2. Rice GPA, Incorvaia B, Munari L, Ebers G, Polman C, DAmico R, Filippini G. Interferon
in relapsing-remitting multiple sclerosis. The Cochrane Database of Systematic Reviews,
3. Parkin D, Miller P, McNamee P, Thomas S, Jacoby A, Bates D. A cost-utility analysis
of interferon beta for multiple sclerosis. Health Technology Assessment. The national
Coordinating centre for Health Technology Assessment (NCCHTA)13665278. Vol.2:
No.4.1998.pp58.
4. The Health Technology Assessment Database, Database no.: HTA-999898. In: The
5. Shakespeare DT, Young CA, Boggild M. Anti-spasticity agents for multiple sclerosis. The
6. Solari A, Uitdehaag B, Giuliani G, Pucci E, Taus C. Aminopyridines for symptomatic
treatment in multiple sclerosis. The Cochrane Database of Systematic Reviews,
7. Juhani Wikstrm Article ID: ebm00801 (036.075) 2005 Duodecim Medical Publications Ltd
2. 2
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1. Taricco M, Adone R, Pagliacci C, Telaro E. Pharmacological interventions for spasticity

following spinal cord injury. The Cochrane Database of Systematic Reviews, Cochrane
Software
2. Creedon SD, Dijkers MP, Hinderer SR. Intrathecal baclofen for severe spasticity: a metaanalysis. International Journal of Rehabilitation and Health 1997;3:171-185
2. 3
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1. Bakker JP, de Groot IJ, Beckerman H, de Jong BA, Lankhorst GJ. The effects of kneeankle-foot orthoses in the treatment of Duchenne muscular dystrophy: review of the
literature. Clinical Rehabilitation 2000;14: 343-359.
3. Hannu Somer Article ID: ebm00794 (036.085) 2005 Duodecim Medical Publications Ltd
2. 4
3. 2008
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-
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, (-C).
1. Mehndiratta MM, Hughes RAC. Corticosteroids for chronic inflammatory demyelinating

polyradiculoneuropathy. The Cochrane Database of Systematic Reviews, Cochrane
Software. Updated frequently
2. Umapathi T, Hughes RAC, Nobile-Orazio E, L,ger JM. Immunosuppressive treatment for
multifocal motor neuropathy. The Cochrane Database of Systematic Reviews, Cochrane
Software.
3. Van Schaik IN, Winer JB, de Haan R, Vermeulen M. Intravenous immunoglobulin for
chronic inflammatory demyelinating polyradiculoneuropathy. The Cochrane Database of
Issue 2, 2002. Oxford: Update Software.
4. Esa Mervaala and Juhani Partanen Article ID: ebm00781 (036.090) 2005 Duodecim
2. 4
3. 2008
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, QT- ), , ,
erytromicyn .
.
/ .
serotonin reuptake" (-C).
1. Kingery WS. A critical review of controlled clinical trials for peripheral neuropathic pain
and complex regional pain syndromes. Pain 1997;73:123-139
3. McQuay JH, Tramer M, Nye BA, Carroll D, Wiffen PJ, Moore RA. A systematic review of
antidepressants in neuropathic pain. Pain 1996;68:217-227
Updated frequently.
6. Zhang WY, Li Wan Po A. The effectiveness of topically applied capsaicin: a metaanalysis. Eur J Clin Pharmacol 1994;46:517-522
8. Jung AC, Staiger T, Sullivan M. The efficacy of selective serotonin reuptake inhibitors for
the management of chronic pain. J Gen Int Med 1997;12:384-389
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10.Esa Mervaala, Article ID: ebm00495 (023.042) 2005 Duodecim Medical Publications Ltd
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1. Bartels RH, Menovsky , Van Overbeeke JJ, Verhagen WI. Surgical management of
ulnar nerve comparession at the elbow. Journal of Neurosurgery 1998;89:722-727
3. Esa Mervaala Article ID: ebm00779 (036.088) 2005 Duodecim Medical Publications Ltd
2. 4
3. 2008
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, , .
1. Hughes RAC, van der Mech, FGA. Corticosteroid treatment for Guillain-Barr, syndrome.
2. Hughes RA, Raphael JC, Swan AV, van Doorn PA. Intravenous immunoglobulin for
Guillain-Barr, syndrome. The Cochrane Database of Systematic Reviews, Cochrane
3. Raphael JC, Chevret S, Hugjes RAC, Annane D. Plasma exchange for Guillain-Barr,
syndrome. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently
4. Markus Frkkil Article ID: 00796 (036.092) 2005 Duodecim Medical Publications Ltd
2. 3
3. 2007
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1. Trenkwalder C, Stiasny K, Pollmacher T, Wetter T, Schwarz, Kohnen R, Kazenwadel J,

Kruger HP, Ramm A, Kunzel M ym. L-dopa therapy of uremic and idiopathic restless legs
syndrome: a double-blind, crossover study. Sleep 1995;18:681-8.
2. von Scheele C. Levodopa in restless legs. Lancet 1986;2:426-7.
3. Wagner ML, Walters AS, Coleman RG, Hening WA, Grasing K, Chokroverty S.
Randomized, double-blind, placebo-controlled study of clonidine in restless legs
syndrome. Sleep 1996;19:52-8.
4. Ausserwinkler M, Schmid P. Erfolgreiche Behandlung des restless legs Syndroms bei
chronischer Niereninsuffizienz mit Clonidin. Schweiz Med Wochenschr 1989;119:184-6
2. 4
3. 2008
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1. Herxheimer A, Petrie KJ. Melatonin for preventing and treating jet lag. The Cochrane
2. 4
3. 2008

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.
1. McGrath JJ, Soares KVS. Neuroleptics reduction and/or cessation and neuroleptics
as specific treatments for tardive dyskinesia. The Cochrane Database of Systematic
2002. Oxford: Update Software. Updated frequently.
2. Soares KVS, McGrath JJ, Deeks JJ. Gamma-aminobutyric-acid agonist medication for
neuroleptic-induced tardive dyskinesia. The Cochrane Database of Systematic Reviews,
3. Hurtig HI, Stern MB. Movement Disorders. Neurologic Clinics 2001;19,(3):523-788.
4. Seppo Kaakkola Article ID: ebm00748 (036.006) 2005 Duodecim Medical Publications
Ltd
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1. Heikki Tervinen and Seppo Kaakkola; Article ID: ebm00744 (036.070); 2005
Duodecim Medical Publications Ltd.
2. 4
3. 2009
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1. Heikki Tervinen and Seppo Kaakkola, Article ID: ebm00797 (036.071) 2005
Duodecim Medical Publications Ltd
2. 4
3. 2009
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(-C).
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bromocriptine, (-B).
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levodopa (-C).
(-D).

(-C).

(-D).
, (-D).
-
. (-D).
1. Deane KHO, Jones D, Playford ED, Ben-Shlomo Y, Clarke CE. Physiotherapy for patients
with Parkinsons Disease. The Cochrane Database of Systematic Reviews, Cochrane
2. Ramaker C, van Hilten JJ. Bromocriptine versus levodopa in early Parkinsons disease.
575
576
3. Clarke CE, Speller JM. Pergolide versus bromocriptine for levodopa-induced motor
complications in Parkinsons disease. The Cochrane Database of Systematic Reviews,
4. Kottler A, Hayes S. Stereotactic pallidotomy for treatment of Parkinsons disease.
Technology Assessment Program 1998;8:1-17
6. Shepherd J, Clegg A. Entacapone as an adjunctive to levodopa in Parkinsons
disease. Southampton: Wessex Institute for Health Research and Development.
Development and Evaluation 1999;1-50
8. Clarke CE, Speller JM, Clarke JA. Pramipexole for levodopa-induced complications in
Parkinsons disease. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently
9. Clarke CE, Deane KHD. Ropinirole for levodopa-induced complications in Parkinsons
disease. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently
10.Clarke CE, Deane KH. Cabergoline for levodopa-induced complications in Parkinsons
disease. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently
11.Clarke CE, Deane KD. Cabergoline versus bromocriptine for levodopa-induced
complications in Parkinsons disease. The Cochrane Database of Systematic Reviews,
12.Ramaker C, Hilten JJ van. Bromocriptine/levodopa combined versus levodopa alone
early Parkinsons disease. The Cochrane Database of Systematic Reviews,
Update Software.
13.Klaassen T, Verhey FR, Sneijders GH, Rozendaal N, de Vet HC, van Praag HM. Treatment
of depression in Parkinsons disease: a meta-analysis. Journal of Neuropsychiatry and
Clinical Neurosciences 1995;7:281-286
15.Deane KHO, Whurr R, Playford ED, et al. Speech and language therapy for dysarthria in
Parkinsons disease. The Cochrane Database of Systematic Reviews, Cochrane Library
Updated frequently
16.Deane KHO, Ellis-Hill C, Playford ED, Ben-Shlomo Y, Clarke CE. Occupational therapy
for patients with Parkinsons disease. The Cochrane Database of Systematic Reviews,
17.Heikki Tervinen and Seppo Kaakkola Article ID: ebm00798 (036.072) 2005
Duodecim Medical Publications Ltd

2. 3
3. 2008
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, Failed Back Surgery Syndrome Complex

Regional Pain Syndrome Type I (-C).

; (-D).
1. Carroll D, Moore RA, McQuay HJ, Fairman F, Tramer M, Leijon G. Transcutaneous

electrical nerve stimulation (TENS) for chronic pain. The Cochrane Database of
2. Kingery WS. A critical review of controlled clinical trials for peripheral neuropathic pain
and complex regional pain syndromes. Pain 1997;73:123139
4. McQuay JH, Tramer M, Nye BA, Carroll D, Wiffen PJ, Moore RA. A systematic review of
antidepressants in neuropathic pain. Pain 1996;68:217227
Updated frequently.
7. Martina Bachmann, Article ID: ebm00931 (017.040) 2005 Duodecim Medical
Publications Ltd
2. 3
3. 2007
583
584
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1. Bednar MS. Ulnar tunnel syndrome. Hand clin 1996;12:(4)657-64.

2. 4
3. 2008
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588
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(-C).
1. Marshall S, Tardif G. Ashworth N. Local corticosteroid injection for carpal tunnel

syndrome. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently
2. Feuerstein M, Burrell LM, Miller VI, Lincoln A, Huang GD, Berger R. Clinical management
of carpal tunnel syndrome: a 12-year review of outcomes. Am J Indust Med 1999;35:232245
3. Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgical versus non-surgical treatment for
carpal tunnel syndrome. The Cochrane Database of Systematic Reviews, Cochrane
Software.
5. DArcy CA, McGee S,. Does this patient have carpal tunnel syndrome. JAMA
2000;283:3110-3117
2. 4
3. 2008
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1. Helakorpi S, Uutela A, Prttl R, Puska P. Suomalaisen aikuisvestn

terveyskyttytyminen, kevt 1996. Kansanterveyslaitoksen julkaisuja B 12, Helsinki
1996 (in Finnish) Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low back
pain evidence review. Royal College of General Practioners, London 1996
2. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us
about low back pain? JAMA 1992;268:760-765
3. Van den Hoogen HMM, Koes RW, van Eijk JTHM, Bouter LM. On the accuracy of history,
physical examination and erythrocyte sedimentation rate in diagnosing low-back pain in
general practice. A criteria-based review of the literature. Spine 1995;20:318-327
4. Kostuik JP, Harrington I, Alexander D ym. Cauda equina syndrome and lumbar disc
herniation. J Bone Joint Surg (Am) 1986;68:386-391
5. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery
1993;32:743-747
6. Andersson GBJ, Svensson HO, Oden A. The intensity of work recovery in low back pain.
Spine 1983;880-884
7. Nachemson A. Work for all. For those with low back pain as well. Clin Orthop 1983;179:7785
8. Nachemson A ( ed. ): Ont i ryggenorsaker, diagnostik och behandling. Statens beredning
fr utvrdering av medicinsk metodik (SBU), Norstedts Tryckeri AB, Stockholm 1991a
(in Swedish)
9. Bigos S, Bowyer O, Braen G, ym.: Acute low back problems in adults. Clinical practice
guideline No. 14. Agency for Health Care Policy and Research, Public Health Services,
U.S. Department of Health and Human Services. December 1994
10.Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal mainpulation for
low back pain. Ann Intern Med 1992;117:590-598
11.Deyo RA, Diehl AK: Psychosocial predictors of disability in patients with low back pain.
J Rheumatology 1988;15:1557-1564
12.Jones SL, Jones PK, Katz J. Compliance for low-back pain patients in the emergency
department: randomized trial. Spine 1988;13:553-556
13.Lindstrm I, hlund C, Eek C, Wallin L, Peterson L-E, Nachemson A. Mobility, strength,
and fitness after a graded activity program for patients with a subacute low back pain.
A randomized prospective clinical study with a behavioural therapy approach. Spine
1992;17:641-652
14.Ahlgren SA, Hansen T. The use lumbosacral corset prescibed for low-back-pain.
Prosthesis Orthoses Int 1978;2:101-104
15.Hurri H. The Swedish back school in chronic low-back pain. Part 1. Benefits. Scand J
Rehab Med 1989;21:33-40
16.Hurri H. The Swedish back school in chronic low-back pain. Part 2. Factors predicting
the outcome. Scand J Rehab Med 1989;21:414-444
17.Julkunen J, Hurri H, Kankainen J. Psychological factors in the treatment of chronic
low back pain: Follow-up study of a vack school intervention. Psychoter Psychosom
1988;50:173-181
18.Hrkp K, Mellin G, Jrvikoski A, Hurri H. A controlled study on the outcome of inpatient
and outpatient treatment of low-back pain. Part 3. Scand J Rehab Med 1990;22:181188
19.Mellin G, Hurri H, Hrkp K, Jrvikoski A. A controlled study on the outcome of inpatient
and outpatient treatment of low-back pain. Part 2. Scand J Rehab Med 1989;21:91-95
20.Mellin G, Hrkp K, Hurri H, Jrvikoski A. A controlled stud on the outome of inpatient

and outpatient treatment of low-back pain. Part 4. Scand J Rehab Med 1990;22:189194
21.Holstila A. Kuntoutumisen ennuste pitkaikaisissa tuki- ja liikuntaelinsairauksissa. KELA.
Sosiaali- ja terveysturvan julkaisuja 18, Turku 1997 (in Finnish)
22.Hrkp K, Jrvikoski A, Mellin G, Hurri H. A controlled study on the outcome of inpatient
and outpatient treatment of low-back pain. Part 1. Scand J Rehab Med 1989;21:81-89
23.Kansanelkelaitoksen tilastolliset vuosikirjat 1980-1995 (in Finnish)
24.Pope, MH, Frymoyer JW, Krag MH: Diagnosing instability. Clin Orthop 279: 6067,
1992
25.Romo M, Laasonen E, Alho A, ym.: Ty, selkvaivat ja rntgenlydkset. Suomen
Lkril 36: 417422, 1981 (in Finnish)
26.Seidenwurm D, Russell EJ, Hambly M: Diagnostic accuracy, patient outcome and
economic factors in lumbar radiculopathy. Radiology 190: 2130, 1994.
27.Thornbury JR, Fryback DG, Turski PA, ym.: Disc-caused nerve compression in patients
with acute low-back pain: Diagnosis with MR, CT myelography, and plain CT. Radiology
186: 731738, 1993
28.Albeck MJ, Hilden J, Kjaer L, ym: A controlled comparison of myelography, computed
tomography, and magnetic resonance imaging in clinically suspected lumbar disc
herniation. Spine 20: 443448, 1995
29.Amundsen T, Weber H, Lilles F, ym: Lumbar spinal stenosis. Clinical and radiologic
features. Spine 20: 1178-1186, 1995
30.Annertz M, Wingstrand H, Strmqvist B, ym. MR imaging as the primary modality for
neuroradiologic evaluation of the lumbar spine. Acta Radiol 37: 373380, 1996
31.Boden SD, Davis DO, Dina TS, ym.: Contrast-enhanced MR imaging performed after
successful lumbar disc surgery: prospective study. Radiology 182: 5964, 1992
32.Hession PR, Butt WP: Imaging of spondylolysis and spondylisthesis. Eur Radiol 6: 284
290, 1996
33.Jackson RP, Cain JE Jr, Jacobs RR, ym.: The neuroradiographic diagnosis of lumbar
herniated nucleus pulposus I: A comparison of computed tomography (CT), myelography,
CT-myelography, discography, and CT-discography. Spine 14: 13561361, 1989
34.Jackson RP, Cain JE Jr, Jacobs RR, ym.: The neuroradiographic diagnosis of lumbar
herniated nucleus pulposus II: A comparison of computed tomography (CT), myelography,
CT-myelography, and magnetic resonance imaging. Spine 14: 13621367, 1989
35.Jensen MC, Brant-Zawadski MN, Obuchowski N, ym.: Magnetic resonance imaging of
the lumbar spine in people without back pain. New Engl. J Med 331,2: 6973, 1994
36.Kent DL, Haynor DR, Larson EB, ym.: Diagnosis of lumbar spinal stenosis in adults: A
meta-analysis of the accuracy of CT, MR, and myelography. Amer J Roentgenol 158:
11351144, 1992
37.Kotilainen E, Alanen A, Erkintalo M, ym.: Magnetic resonance image changes and
clinical outcome after microdiscectomy or nucleotomy for ruptured disc. Surg Neurol 41:
432440, 1994
38.Tamreus S, Worhm A, Forshammar U. Vrmeackumulerande lndeuppstd minskar
sjukskrivningstiden vid akut lumgabo. Lkartidningen 1989;86:1983-4 (in Swedish)
39.Fries JF, Williams CA, Bloch DA ym. Non-steroidal anti-inflammatory drug-associated
gastropathy: incidence and risk factor models. Am J Med 1991;91:213-222
40.Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg 1966;78B:154-164
41.Virta L. Lumbar spondylolytic spondylolisthesis in adults. Thesis, Turun yliopisto, 1991
601
602
42.Leino P, Berg M-A, Puska P. Is back pain increasing? Results from national surveys in
Finland during 1978/9-1992. Scand J Rheumatol 1994;23:269-76
43.Wickstrm G. Effect of work on degenerative back disease. A review. Scand J Work
Environ Health 1978; Suppl 1: 1-12
44.Damkot DK, Pope MH, Lord J, Frymoyer JW. The relationship between work history,
work environment and low back pain in men. Spine 1984; 9: 395-9
45.Videman T, Nurminen T, Tola S, ym. Low-back pain in nurses and some loading factors
of work. Spine 1984; 9: 400-4
46.Walsh K, Varnes N, Osmond C, ym. Occupational causes of low-back pain. Scand J
Work Environ Health 1989; 15: 54-9
47.Kumar S. Cumulative load as a risk factor for back pain. Spine 1990; 15: 1311-6
48.Riihimki H. Back disorders in relation to heavy physical work. A comparative study of
concrete reinforcement workers and house painters. Helsinki 1990
49.Helivaara M, Mkel M, Knekt P, ym. Determinants of sciatica and low-back pain.
Spine 1991; 16: 608-14
50.Chaffin DB, Park KS. A longitudinal study of low-back pain associated with occupational
weight lifting factors. Am Ind Hyg J 1973; 34: 513-25
51.Gyntelberg F. One year incidence of low back pain among male residents of Copenhagen
aged 40-59. Dan Med Bull 1974; 21: 30-6
52.Helivaara M. Epidemiology of sciatica and herniated lumbar intwervertebral disc.
Helsinki: Kansanelkelaitoksen julkaisuja ML:76, 1988
53.Hrubec Z, Nashold BS. Epidemiology of lumbar disc lesions in the military in World War
II. Am J Epidemiol 1975; 102: 366-76
54.Troup JDG. Biomechanics of the vertebral column. Physiotherapy 1979; 65: 238-44
55.Leino P. Does leisure time physical activity prevent low back disorders? A prospective
study of metal industry employees. Spine 1993; 18: 863-871
56.Videman T, Sarna S, Batti, MC, ym. The long term effects of physical loading and
exercise lifestyles on back related symptoms, disability, and spinal pathology in men.
Spine 1995; 20: 699-709
57.Leino P. Physical loading and mental stress as determinants of musculoskeletal
disorders. Tampere: Acta Universitatis Tamperensis ser A vol 282, 1989
58.Mundt DJ, Kelsey JL, Golden AL, ym. An epidemiologic study of non-occupational lifting
as a risk factor for herniated lumbar intervertebral isc. Spine 1993; 18: 595-602
59.Kelsey JL. An epidemiological study of acute herniated lumbar intervertebral discs.
Rheumatol Rehabil 1975; 14: 144-59
60.Swrd L, Hellstrm M, Jacobsson B, ym. Disc degeneration and associated abnormalities
of the spine in elite gymnasts. A magnetic resonance imaging study. Spine 1991; 16:
437-43
61.Gundewall B, Liljeqvist M, Hansson T. Primary prevention of back symptoms and
absence from work. A prospective randomized study among hospital employees. Spine
1993; 18: 587-94
62.Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the
prevention of low back pain. JAMA 1994; 272: 1286-91
63.Frymoyer JW, Pope MH, Constanza MC, ym. Epidemiologic studies of low-back pain.
Spine 1980;5:419-23
64.Kelsey JL, Githens PB, O-Connor T, ym. Acute prolapsed lumbar intervertebral disc. An
epidemiologic study with special reference to driving automobiles and cigarette smoking.
Spine 1984; 9: 608-13
65.Kelsey JL, Hardy RJ. Driving of motor vehicles as a risk factor for acute herniated lumbar
intervertebral disc. Am J Epid 1975; 102: 63-73

66.Netterstrm B, Juel K. Low back trouble among urban bus drivers in Denmark. Scand J
Soc Med 1989; 17: 203-6
67.Pietri F, Leclerc A, Boitel L, ym. Low-back pain in commercial travelers. Scand J Work
Environ Health 1992; 18: 52-8
68.Riihimki H. Back and limb disorders. In: McDonald C, ed. Epidemiology of work related
diseases. Lontoo: BMJ Publishing Group, 1995
69.Troup JDG. Drivers back pain and its prevention. A review of the postural vibratory and
muscular factors, together with the problem of transmitted road-shock. Appl Ergonomics
1978; 9: 207-14
70.Rissanen A, Helivaara M, Knekt P, ym. Risk of disability and mortality due to overweight
in a Finnish population. BMJ 1990; 301: 835-7
71.Deyo RA, Bass JE. Lifestyle and low-back pain. The influence of smoking and obesity.
Spine 1989; 14: 501-6
72.Penttinen J. Back pain and sciatica in Finnish farmers. Helsinki: Kansanelkelaitoksen
julkaisuja ML:71,1987
73.Manninen P. Risk factors of musculoskeletal disorders and work disability among Finnish
farmers. Helsinki: Kansanelkelaitoksen julkaisuja ML, 1996
74.Helivaara M. Risk factors for low back pain and sciatica Ann Med 1989; 21: 257-64
75.Ernst E. Smoking, a cause of back trouble? Br J Rheumatol 1993; 32: 239-42
76.Wright D, Barrow S, Fisher D, ym. Influence of physical, psychological and behavioural
factors on consultations for back pain. Br J Rheumatol 1995; 34: 156-61
77.Batti, MC, Videman T, Gill K, ym. Smoking and lumbar intervertebral disc degeneration:
An MRI study of identical twins. Spine 1991; 16: 1015-21
78.Nachemson AL, Peterson LE. Effectiveness of treatment with brace in girls who have
adolescent idiopathic scoliosis. J Bone Joint Surg 1995;77-A:815-822
79.Ylikoski M, Peltonen J, Poussa M. Biological factors and predictability. Bracing in
adolescent idiopathic scoliosis. J Ped Orthop 1989;9:680-683
80.Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of
observation. Spine 1983;8:131-140
81.Wiesel SW, Tsourmas N, Feffer HL, ym.: A study of computer assisted tomography:
The incidence of positive CAT scans in an asymptomatic group of patients. Spine
1984;9:549-551
82.Boden SD, Davis DO, Dina TS, ym.: Abnormal magnetic-resonance scans of the lumbar
spine in asymptomatic subjects. J Bone J Surg 1990;72-A:403-408
83.Malmivaara A, Hakkinen U, Aro T, Heinrichs ML, Koskenniemi L, Kuosma E, Lappi S,
Paloheimo R, Servo C, Vaaranen V ym. The treatment of acute low back painbed rest,
exercises, or ordinary activity? N Engl J Med 1995;332:351-355
84.Gilbert JR, Taylor DW, Hildebrand A, Evans C. Clinical trial of common treatments for
low back pain in family practice. Br Med J 1985;291:791-794
85.Tulder MW van, Koes BW, Bouter LM. Conservative treatment of acute and chronic
nonspecific low back pain. A systematic review of randomized controlled trials of the
most common interventions. Spine 1997;22:2128-2156
86.Laporte JR, Carne X, Vidal X, Moreno V, Juan J. Upper gastrointestinal bleeding in
relation to previous use of analgesics and non-steroidal anti-inflammatory drugs. Catalan
countries study on upper gastrointestinal bleeding. Lancet 1991;337:85-9
87.Henry D, Linn LLY, Rodriguez LAG, Gutthann SP, Carson JL ym. Variability in risk of
gastrointestinal complications with individual non-steroidal anti-inflammatory drugs:
results of a collaborative meta-analysis. BMJ 1996;312:1563-1566
603
604
88.deCraen AJM, DiGiulio G, Lampe-Schoenmaechers AJEM, Kessels AGH, Kleijnen J.

Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol
alone: a systematic review. BMJ 1996;313:321-325
89.Turner JA. Educational and behavioral intervention for back pain in primary care. Spine
1996;21:2851-2857
90.Alaranta H, Rytkoski U, Rissanen A ym.: Progressive work hardening program for
patients with low-back pain: controlled clinical trial (AKSELI). Kansanelkelaitoksen
julkaisuja ML:103, 1991
91.Jrvikoski A, Mellin G, Estlander AM, Hrkp K, Vanharana H, Hupli M, Heinonen R.
Outcome of two multimodal back treatment programs with and without intensive psysical
training. Journal of Spine Disorders 1993;6:93-98
92.Caspar W, Campbell B, Barbier DD, ym.: The Caspar microsurgical discectomy and
comparison with a conventional standard lumbar disc procedure. Neurosurgery 28: 7887, 1991
93.Ebeling U, Reichenberg W, Reulen H-J: Results of microsurgical lumbar discectomy.
Review of 485 patients. Acta Neurochir (Wien) 81: 45-52, 1986
94.Kotilainen E, Valtonen S, Carlson C-: Microsurgical treatment of lumbar disc herniation:
Follow-up of 237 patients. Acta Neurochir (Wien) ;120:143-9, 1993
95.Nystrm B: Experience of microsurgical compared with conventional technique in lumbar
disc operations. Acta Neurol Scand 76: 129-141, 1987
96.Tullberg T, Isacson J, Weidenhielm L: Does microscopic removal of lumbar disc herniation
lead to better results than standard procedure? Results of a one-years randomized
study. Spine 18: 24-27, 1993
97.Kotilainen E, Alanen A, Parkkola R, ym.: Cross-sectional areas of lumbar muscles after
surgical treatment of lumbar disc herniation. A study with magnetic resonance imaging
after microdiscectomy or percutaneous nucleotomy. Acta Neurochir (Wien) 133:7-12,
1995
98.Revel M, Payan C, Vallee C, ym.: Automated lumbar discectomy versus chemonucleolysis
in the treatment of sciatica. A randomized multicenter trial. Spine 18: 1-7, 1993
99.Schnstrm N. The narrow lumbar spinal canal and the size of the cauda equina in man.
A clinical and experimental study. Thesis. University of Gothenburg. 1988
100. Eskola A, Alaranta H, Pohjolainen T ym. Calcitonin treatment in lumbar spinal stenosis.
Clinical observations. Calcif Tissue Int 1989;45:372-374
101. Herno A. Surgical results of lumbar spinal stenosis. Thesis. University of Kuopio,
1995
102. Johnsson KE. Lumbar spinal stenosis. A clinical, radiological an d neurophysiological
investigation. Thesis. University of Lund, 1987
103. Atlas SJ, Deyo RA, Keller RB ym. The Maine lumbar spine study. Part III. One-year
outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine
1996;21:1787-95
104. Poussa M, Schlenzka D, Seitsalo S, Ylikoski M, Hurri H, sterman K. Surgical treatment
of severe isthmic spondylolisthesis in adolescents. Reduction or fusion in situ. Spine
1993;18:894-901
105. Seitsalo S. Spondylolisthesis in children and adolescents. A long-term clinical and
radiological study. Thesis, Helsingin yliopisto, 1990
106. Indahl A, Velund L, Reiheraa S. Good prognosis for low back pain when left untampered.
A randomised clinical trial. Spine 1995;20:473-477
107. On the accuracy of history, physical examination, and erythrocyte sedimentation rate in
diagnosing low back pain in general practice. Spine 1995;20:318-327

no.: DARE-978022. In: The Cochrane Library, Issue 4, 1999. Oxford: Update
Software
109. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings
and nonspecific low back pain: a systematic review of observational studies. Spine
1997;22:427-434
Software
111. Kerry S, Hilton S, Patel S, Dundas D, Rink E, Lord J. Routine referral for radiography of
patients presenting with low back pain: is patients outcome influenced by GPs referral
for plain radiography? Health Technology Assessment. The national Coordinating
Centre for Health Technology Assessment (NCCAHTA). 136665278. Vol. 4: No. 20.
2000. 110.
112. The Health Technology Assessment Database, Database no.: HTA-20000883. In: The
113. Gibson JNA, Grant IC, Waddell G. Surgery for lumbar disc prolapse. The Cochrane
114. Hoffman RM, Wheeler KJ, Deyo RA. Surgery for herniated lumbar disc: a literature
synthesis. J Gen Intern Med 1993;8(120 suppl 1):487-496
Software
116. Stevens CD, Dubois RW, Larequi-Lauber T, Vader JP. Efficacy of lumbar discectomy
and percutaneous treatments for lumbar disc herniation. Sozial und Praventivmedizin
1997;42:367-379
Software
118. Hilde G, Hagen KB, Jamtvedt G, Winnem M. Advice to stay active as a single treatment
for low back pain and sciatica. The Cochrane Database of Systematic Reviews,
Cochrane Library number: CD003632. In: The Cochrane Library, Issue 2, 2002.
Oxford: Update Software.
119. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active
for acute low back pain. Br J Gen Pract 1997;47:647-652
Software
121. Van Tulder MW, Jellema P, van Poppel MNM, Nachemson AL, Bouter LM. Lumbar
supports for the treatment of low back pain. The Cochrane Database of Systematic
2002. Oxford: Update Software. Updated frequently
122. van Tulder MW, Scholten RJPM, Koes BW, Deyo RA. NSAIDs for low back pain. The
The Cochrane Library, Issue 2, 2002. Oxford: Update Software
123. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for
low back pain: an updated systematic review of randomised clinical trials. Spine
1996;21:2860-2871
605
606

Software
125. Andersson GBJ, Lucente T, Davisw AM, Kappler RE, Lipton JA, Leurgans S. A
comparison of osteopathic spinal manipulation with standard care for patients with low
back pain. N Engl J Med 1999;341:1426-1431
126. van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low back
pain. The Cochrane Database of Systematic Reviews, Cochrane Library number:
CD000335. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software
127. Hilde G, Bo K. Effect of exercise in the treatment of chronic low back pain: a systematic
review, emphasising type and dose of exercise. Physical Therapy Reviews 1998;3:107117
Software
129. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic
nonspecific low back pain: a systematic review of randomized controlled trials of the
most common interventions. Spine 1997;22:2128-2156
Software
131. Turner JA, Denny MC. Antidepressants for chronic back pain. J Fram Pract 1993;37:545553
Software
133. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections
for low back pain and sciatica: a systematic review of randomized clinical trials. Pain
1995;63:279-288
Software
135. Watts RW, Silagy CA. A meta-analysis on the efficacy of epidural corticosteroids in the
treatment of sciatica. Anaeshtesia and Intensive Care 1995;23:564-569
Software
137. Rozenberg S, Dubourg G, Khalifa P, Paolozzi L, Maheu E, Ravaud P. Efficacy of
epidural steroids in low back pain and sciatica: a critical appraisal by a French Task
Force on randomized trials. Revue Du Rheumatisme, English Edition 1999;66:79-85
Software
139. Tulder MW van, Esmail R, Bombardier C, Koes BW. Back schools for non-specific low
back pain. The Cochrane Database of Systematic Reviews, Cochrane Library number:
frequently.
140. Di Fabio RP. Efficacy of comprehensive rehabilitarion programs and back schools for
patients with low back pain: a meta-analysis. Phys Ther 1995;75:865-878

Software
142. Koes BW, van Tulder MW, Vanderwindt DAWM, Bouter LM. The efficacy of back
schools: a review of randomized clinical trials. J Clin Epidemiol 1994;47:851-862
Software
144. Cohen JE, Goel V, Frank JW, Bombardier C, Peloso P, Guillemin F. Group education
interventions for people with low back pain: an overview of the literature. Spine
1994;19:1214-1222
Software
146. Tulder MW van Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back
pain. The Cochrane Database of Systematic Reviews, Cochrane Library number:
CD001351. In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
Updated frequently.
147. Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the
prevention of low back pain. JAMA 1994;272:1286-1291
Software
149. Furlan AD, Brosseau L, Welch V, Wong J. Massage for low back pain. The Cochrane
150. Milne S, Welch V, Brosseau L, et al. Transcutaneous electrical nerve stimulation (TENS)
for chronic back pain. The Cochrane Database of Systematic Reviews, Cochrane
151. van Tulder MW, Osteolo RWJG, Vlaeyen JWS, Linton SJ, Morley SJ, Assendelft WJJ.
Bed rest for acute low back pain and sciatica. The Cochrane Database of Systematic
2002. Oxford: Update Software
152. Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C.
Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain. The
153. Gibson JNA, Waddell G, Grant IC. Surgery for degenerative lumbar spondylosis. The
154. Karas BE, Conrad KM. Back injury prevention interventions in the workplace: an
integrative review. AAOHN Journal 1996;44:189-196
Software
156. van Poppel MN, Koes BW, Smid T, Bouter LM. A systematic review of controlled clinical
trials on the prevention of back pain in industry. Occupational and Environmental
Medicine 1997;54:841-847
607
608

Software
158. van Dieen JH, Hoozemans MJ, Toussaint HM. Stoop or squat: a review of biomechanical
studies of lifting technique. Clinical Biomechanics 1999;14:685-696
Software
160. Ostelo RWJG, de Vet HCW, Waddell G, Kerckhoffs MR, Leffers P, van Tulder MW.
Rehabilitation after lumbar disc surgery. The Cochrane Database of Systematic
2002. Oxford: Update Software.
161. Brox JI, Hagen KB, Juel NG, Storheim K. (Is exercise therapy and manipulation
effective in low back pain?). Tidsskr Nor Laegeforen 1999;119(14):2042-50
162. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise Therapy for Low Back Pain. A
Systematic Review Within the Framework of the Cochrane Collaboration Back Review
Group. Spine 2000;25:2784-96
163. Burton AK, Waddell G, Burtt R, Blair S. Patient educational material in the management
of low back pain in primary care. Bull Hosp Jt Dis 1996;55(3):138-41
164. Fritzell P, Hgg O, Wessberg P, Nordwall A, and the Swedish Lumbar Spine Study
Group, 2001 Volvo Award Winner in Clinical Studies: Lumbar Fusion Versus Nonsurgical
Treatment for Chronic Low Back Pain. Spine 2001;26:2521-2532.
165. Karjalainen K, Malmivaara A, Pohjolainen T, Hurri H, Mutanen P, Rissanen P, Rissanen
P, Pahkajrvi H, Levon H, Karpoff H, Roine R. Mini-intervention for subacute low back
pain. A randomized controlled trial. Spine 2003;28(6):533-541.
2. 4
3. 2008
609
610
Algoritam 1.
Bolen so izgubena svest
Nepoznata anamneza
Poznata anamneza
-trauma
-epilepsija
- dijabetes
-intoksikacija
Nepoznata anamneza
Klini~ka egzaminacija
Bez nevrolo{ki znaci
Preku egzaminacija
Korisni laboratriski testovi

-krvna slika: anemija, infekcii
-glikemija:hipoglikemija,
dijabeti~na koma
-natrium, kalium
-CRP: infekcii
-etanol: alkoholna
intoksikacija
-amonium:hepati~na koma
-kreatinin, urea: uremija
-pulsna oksimetrija: hipooksija,
metabolna acidoza kaj metanol
intoksijacija
-EKG: aritmii
So nevrolo{ki znaci
Primarno intrakranijalna
pri~ina
nevroradiologija (KTM ili MR)
-mozo~en udar
-intrakranijalna hemoragija
-mozo~en tumor
Meningizmus :
(lumbalna punkcija)
1.SAH
2.meningitis
611
Algoritam 2. Sinkopa - po~etna evaluacija

Urgenten oddel, intra i vonhospitalni uslugi, op{t lekar
Po~etna evaluacija
Urgenten oddel, intra i vonhospitalni uslugi, op{t lekar
Sigurna dijagnoza
Sostojba
nalik na sinkopa
Suspektna ili
neobjasniva dijagnoza
Ispi{uvawe ili
tretman
Upatuvawe na
nevrologija/
psihijatrija, spored
indikacija
Ustanova za sinkopi
(Edinica za sinkopi)
Dostapnost na
kardiolo{ki i
avtonomni testovi i
specijalisti~ki
konsultacii
612
Algoritam 3. Tranzitoren gubitok na svest

Istorija, fizikalen pregled, krven
pritisok vo legnata i ispravena
polo`ba, standarden EKG
po~etna
evaluacija
Nesinkopalen
nastap
Sinkopa
Sigurna
dijagnoza
Suspektna
dijagnoza
Neobjasneta
sinkopa
Verojatno
kardiogena
Nevrogeno
êsti ili
predizvikana
intenzivni
ili verojatno
epizodi
ortostatska
Edine~ni/
retki epizodi
Kardijalni
testovi
Nevrolo{ki Nevrolo{ki
testovi
testovi
Nema
natamo{na
evaluacija
Povtorna
procenka
Tretman
Potvrduvawe
so specifi~ni
testovi ili
konsultacija
so specijalist
Tretman
Tretman
Povtorna
procenka
Tretman
Tretman
613
Algoritam 4. Tretman na sijalorea kaj amiotrofi~na lateralna skleroza (ALS)

(grià na pacient so ALS)
Klini~ka poplaka/zabale{ka:
sijalorea
Samo no}na sijalorea

(obi~no ne se tretira)
Evaluacija na teìnata na sijaloreata
Dnevna i no}na sijalorea
Glycopyrrolate
Benztropine
Transdermal hyoscine
Trihexyphenidyl hydrochloride
Atropine
Sledewe na
pacientot
Amitriptyline
(ako pacientot e vo depresija,
pseudobulbarni simptomi, naru{en
son)
DA
Klini~ki odgovor
NE
Nefarmakolo{ki pristap
3 meseci,
DA
614
Algoritam 5. Nutritivniot tretman na pacient so ALS

ALS PACIENT
Monitorirawe na telesnata teìna
Procena na disfagijata so skala
ili drug instrument(3)
Klini~ki kontroli na 3 meseci
Rano otkrivawe na disfagijata
Upatuvawe kaj nutricionist ili

Terapevt za govor
Nutritivna edukacija, vklu~uvaj}i

PEG(1)
Monitor na FVCili
VC*
Klini~ki kontroli sekoi 3 meseci
Progresija na simptomi (2)
FVC*>50%
Nizok rizik za PEG
Prifa}awe na PEG
Oralen vnes,
kolku se tolerira
FVC* 30-50%
Umeren rizik
Evaluacija za anestezija
Iskusen gastroenterolog
Enteralna nutricija
preku PEG, kolku e
potrebno
FVC*<30%
Visok rizik
PEG namaluvawe
Palijativna i.v.
Oralen vnes, kolku
hidracijaPalijati
se tolerira
vno NG hranewe
(1)
Isklu~eni kontraindikacii,
(2)
Prodolèno vreme za obrok, zavr{en obrok predvremeno zaradi tegobite, naglaseno gubewe na telesna
teìna zaradi namalen vnes na kalorii, zagriènost na familijata okolu problemite na hranewe
(*) Forsiran vitalen kapacitet (FVC) ili vitalen kapacitet (VC) moè da bide koristen. VC moè da bide
poto~en kaj bolnite so bulbarna disfunkcija.
(3) Na primer: Colorado Dysphagia Disability Inventory, Bulbar Questions in the ALS Functional Rating Scale i drugi skali/
instrumenti
PEG=perkutana endoskopska gastrostoma
615
Algoritam 6. Respiratorniot tretman na pacient so ALS

ALS PACIENT
Respiratorni simptomi ili FVC (1) < 50%
Neinvazivna ventilacija se prepora~uva
Neinvazivna ventilacija
namalena ili netolerabilna
Simptomatski tretman
Sovet za terminalnata faza
Upatuvawe vo bolnica
Neinvazivna ventilacija
vo soodvetna institucija
Namalena invazivna
ventilacija
Diskusija za opcii vo tretman

(ventilacija so traheostoma,itn)
i terminalna faza
Prifatena invazivna ventilacija

Palijativna grià
Diskusija vo uslovi na opovikuvawe(2)
Otstraneta invazivna ventilacija
Invazivna ventilacija vo institucija
(1)
FVC-forsiran vitalen kapacitet ili VC-vitalen kapacitet moè da se koristi.
VC moè da bide poto~en kaj bolen so bulbarna disfunkcija.
(2)
Soglasnost potrebna vo uslovi na opovikuvawe ili na vnes na konkurentska,
intituciska invazivna ventilacija (vo sostojbi kako {to e koma, locked in sindromot itn.)
616
Algoritam 7. Postapki pri suspekten mozo~en udar
Somnenie za mozo~en udar/TIA
Ne e mozo~en udar/TIA
Soodveten, specif. tretman
Osnovni investigacii:
KTM, kompletna krvna slika,
urea/elektroliti, glikemija,
lipidi, EKG, Rentgen-pulmo
TIA/ishemi~en insult
Specifi~ni investigacii,kako:
-karotidna sonografija
-cerebralna angiografija
-ehokardiografija
-koagulaciski skrining
Hemoragi~en insult
Specifi~ni investigacii,kako:
-cerebralna angiografija
Kardioembolizam
Simptomatska umerena(selektirani
pacienti) do te{ka karotidna stenoza
Aterotromboza
Drugi specif.
mehanizmi
Warfarin (INR*2,0-3,0)
Karotidna endarterektomija i
Antiagregaciski medikamenti
Antiagreganti
Specifi~na
terapija
-Rehabilitacija
-Namaluvawe na krvniot pritisok
-Kontrola na rizik faktorite
*INR=International Normalised Ratio
617
Algoritam 8. Ambulantski skrining

(dijagnoza i inicijalen tretman na ishemi~en insult)
Inicijalen kontakt so
pacient koj se àli na
na nevrolo{ki simptomi:
-lekar od op{ta praksa
-slu`ba za itna nega
-obra}awe po telefon
-vonmedicinska evaluacija
1. Inicijalen kontakt so
pacient koj se oplakuva na
nevrolo{ki simptomi (A)
2. Iten skrining za
ishemi~en insult (A)
3. Simptomi vo sklop na
nov ishemi~en insult, TIA
ili se u{te neodredeno
4. Upatuvawe vo oddel za itni slu~ai

ili vo lekarska soba koja e nameneta
za drugi kondicii
NE
DA
NE
10.Vozmo`na TIA, simptomite

nastanale pred 2 ~asa(A)
5. Sega{ni simptomi (A)
DA
DA
8. Da se aktivira 911
6. Vozmoèn cerebralen
cerebralen infarkt,
simptomite se pred 24~ (A)
DA
NE
NE
11 .Vozmo`na TIA, simptomite

nastanale >2 ~asa, vo poslednite
48 ~asa (A)
NE
9. Vidi go algoritamot za
Urgenten oddel
DA
NE
7. Vozmoèn cerebralen
infarkt, simptomite se blagi
i stabilni > 24~.
DA
12.Transport do UO so 911
slu`bata ili drugo (A)
DA
13. Vozmo`na TIA, ili

Simptomite nastanale
>48~, no vo poslednite
2 nedeli (A)
NE
16. Za simptomite nastanati

>2 nedeli, potrebno e
klini~ka kontrola po edna
nedela (A). A=komentar
DA
14. Drugi faktori koi se

predpostaven visok rizik
za itni, idni slu~ki (A)
NE
15. Treba da bide

klini~ki ispitan za
72 ~ (A)
618
Algoritam 9. Tretman vo urgenten oddel (UO)

(dijagnoza i inicijalen tretman na ishemi~en insult)
17. Vleguva vo UO preku:

-ispraten od lekarot vo primarna za{tita
-trijaà
-samostojno
18. Nevrolo{kiot deficit

e prisuten za vreme na
evaluacija?
19. UO evaluacija (osobeno

UO trijaà), von upatstvoto
NE
DA
20. Po~etokot na simptomite

dozvoluva evaluacija i tretman vo
prvite 180 min
(i.v.tromboliza)?(A)
DA
23. Vidi algoritam za ishemi~na {ifra(A)
NE
21. Kandidat za intraarteriska tromboliza?

(opcija od vrednost?)(A)
DA
24. Nadvor od upatstvoto
23. Celta na {ifrirawe na ishemi~en insult e brza evaluacija

i administrirwe na tPA kaj isleduvani kandidati. Od
po~etokot na simptomite do tretmanot treba da e vo ramkite na 180
minuti, no spored preporakite na National Institute of Health,
terapevtskiot prozorec e do 60 minuti
NE
22. Vidi za ish

emi~en insult
tretman vo UO
(netromboliti
~en kandidat)
algoritam 3
619
Algoritam 10.. [ifrirawe/prepoznavawe/odreduvawe na ishemi~en insult

(Dijagnoza i inicijalen tretman na ishemi~en insult)
25. [ifrirawe/prepoznavawe na ishemi~en

insult(A)
26. Evaluacija
(treba da e vo konkurencija so intervencijata)
-revidiraj ja anamnezata i indikaciite/
kontraindikaciite za tPA tretman;
-izvedi nevrolo{ka egzaminacija, (NIHSS) i na
vitalnite znaci na sekoi 15 min;
-registriraj ja procenetata teìna;
-analiza na krv;
-realiziraj EKG;
-realiziraj KTM bez kontrast;
-drugi kardiolo{ki testovi (telemetrija)(A)
DA
25.Bolnicite treba da se usmeruvaat kon

razvoj i implementirawe na soodvetni
upatstva, utvrdeni pravila na procesot
na prepoznavawe na ishemi~niot insult,
za dase izvede brza evaluacija i tretman
27. Intervencija
(treba da e konkurentna na evaluacijata)
-educiraj ja familijata na pacientot
-lekuvaj go krvniot pritisok, ako e povisok
od 185/110;
-odredi dve i.v. linii;
-vnesi i.v. rastvori;
-tretman na hipertermija;
-tretman na hipo i hiperglikemija;
-tretman na hipooksija;
-tretman na hipotenzija (A)
28. Pacientot se soo~uva so kriteriumi za tPA,

nema kontraindikacii i po~etokot na
simptomite e < 3 ~asa (A)
NE
30. Dokumentirana pri~ina
29. Iniciran tPA (A)
31. Indiciran e apirin ili

nekoj drug antitrombotik (A)
32. Post UO tretman

(post-tromboliza):
-priem vo oddel za intenzivna nega, ili oddel
so mo`nost za kardiolo{ki monitoring;
-kontrola na vitalnite znaci, nevrolo{ka
egzaminacija;
-lekuvaj go krvniot pritisok, ako e
povisok od 180/105;
-testovi na krvarewe;
-monitorirawe na CNS hemoragija;
-sprovedi anti-tromboti~na terapija 24 ~asa
po tPA (A)
33. Post UO tretman

(kandidat koj ne e za tromboliza):
-priem vo oddel za intenzivna nega, ili oddel
so mo`nost za kardiolo{ki monitoring;
-lekuvaj go krvniot pritisok ako e povisok od
220/120, ili ako sredniot arteriski pritisok e
povisok od 130;
-kontinuirana antitromboti~na terapija(A)
34. Drugi post UO tretman (prvite 24-48~):

-prodolì so tretmanot na hipertermija ili hiperglikemija;
-prodolì so i.v te~nosti, profilaksa na dlaboka venska tromboza
-ispitaj go goltaweto;
-rana fizikalna terapija
620
Algoritam 11. Tretman na ishemi~en insult vo urgenten oddel (pacient koj ne e za tromboliza)
(Dijagnoza i inicijalen tretman na ishemi~en insult)
35. Tretman na ishemi~en insult vo urgenten

oddel (UO)-pacient koj ne e za tromboliza
36. Evaluacija (treba da e konkurentna

na intervencijata):
-revidiraj ja anamnezata;
-izvedi nevrolo{ka egzaminacija;
-izvedi kardiolo{ki monitoring/oksimetrija
-izveduvaj nevrolo{ki probi na sekoi 15 min.
-vo tek na 1 ~;
-analiza na krv;
-realiziraj EKG;
-realiziraj KTM bez kontrast;
-drugi kardiolo{ki testovi/telemetrija(A)
DA
37. Intervencija (treba da e konkurentna na

evaluacijata):
-edukacija na pacientot/familijata;
-lekuvaj go krvniot pritisok koj e povisok od
220/120 ili sredniot povisok od 130 (kaj
ishemi~en insult ili konkurentno zaboluvawe
koe bara tretman-vidi zabele{ka 33)
-zapo~ni so i.v. vnes na rastvori;
-tretman na hipertermija;
-tretman na hipo/hiperglikemija;
-tretman na hipotenzija;
-vnes na 325 mg aspirin (ili drug
antitrombotik) so KTM kontroli za
otkrivawe na eventualna hemoragija (A)
38. Za pacientot odgovara hospitalizacija ? (A)
39. Vrati se vo 33, post UO medikamenten

tretman (pacient koj ne e za tromboliza)
NE
40. Inicirana e evaluacija i tretman kako vo

ambulantski uslovi, von upatstvoto
621
Algoritam 12. Skrining na procedurata na goltawe

Tretman na pacientot so mozo~en udar: identifikacija i tretman na disfagijata
Moè li pacientot da se smesti i

da ostane buden i svesen najmalku
15 minuti ?
Odrùvaj prazna usta, odrùvaj higiena.

Imaj vo predvid arteficielna nutritivna podr{ka.
Konsultiraj dietolog kako potrebno.
NE
DA
Dali ustata e ~ista?
NE
Zapo~ni so oralna higiena vedna{!
DA
Sedni go pacientot ispraveno i daj mu 3 mali
laìci voda. Postavi gi prstite na sredina,
nad i pod laringsot i po~uvstvuvaj go
goltaweto.
Opserviraj ja sekoja laìca!
Dali e pristuten nekoj od znacive?
-otsustvo na goltawe;
-ka{lawe;
-zakasneto ka{lawe;
-promena vo kvalitetot na glasot
(zamoli go bolniot da kaè Aah).
DA
Odrùvaj ja ustata prazna i upati

go bolniot na terapevt za govor.
DA
Odrùvaj ja ustata prazna i upati

go bolniot na terapevt za govor.
NE
Observiraj go kontinuiranoto
piewe na voda od ~a{a!
Dali e pristuten nekoj od znacive?

-otsustvo na goltawe;
-ka{lawe;
-zakasneto ka{lawe;
-promena vo kvalitetot na glasot;
(zamoli go bolniot da kaè Aah).
NE
Zapo~ni so hranewe (meka hrana) so vnimanie.

Prodolì da opservira{ dali ka{la ili
razviva belodrobna infekcija; kako neophodno
upati go bolniot na terapevt za govor
622
Algoritam 12 a. Skrining na procedurata na goltawe (prodolènie)

Tretman na pacientot so mozo~en udar: identifikacija i tetman na disfagijata
Pote{kotii vo goltaweto na
cvrsta hrana?
DA
Dali pri~inata e gastri~na ili
ezofagusna?
DA
Da se upati kaj medicinski tim
NE
Da se upati na stomatolog
DA
Dali bolniot ima adekvatno

zabalo/vilica ?
DA
Odrùvaj go bolniot na meka, prilagodena

dieta; kako neophodno da se upati na terapevt
za govor.
623
Algoritam 13. Vodewe grià/higiena na ustata

Dali pacientot e sposoben za samostojno odrùvawe na grià/higiena na usta?
DA
NE
Dali }e zapo~ne so gri`na na usta?
Koristej}i sretstvo za procena

(podolu), utvdi go nivoto za soodvetna
grià
NE
DA
Ohrabri go/pomogni mu 2 pati dnevno

Obezbedi mu: ~etka za zabi, pasta,krpa,voda,
plasti~na ~a{a, sad za zabaloto itn.
Celosna procena na statusot na ustata
Ako postojat nekoi abnormalnosti na ustata, na primer oboenost ili izgled na tkivata od ustata,lezii, krvarewe,
koli~estvo i konzistentnost na plunka, izgled na zabite/nepcata ili zabaloto.
DA
NE
Upati go na ponatamo{ni
Pomini na slednoto skalilo
egzaminacii
DA
Dali pacientot e intubiran?
êsto vr{i repozicija na sondata i

osiguri bezbednost, pred sproveduvaweto
na grià na ustata
NE
Pomini na slednoto skalilo
Dali pacientot gi poseduva svoite prirodni zabi?

NE
DA
Postavi go pacientot vo odredena
pozicija. Podgotvi materijal.
Profilaksa na koagulacija
Namasti gi usnite
Mekite tkiva se u{te baraat

higiena na ustata. Postavi go
bolniot vo soodvetna polo`ba.
Profilaksa na koagulacija.
Namasti gi usnite
Povle~i gi usnite/jazikot so gaza.êtkaj

gi zabite so fluoridna pasta/Clohexidine
Gel (zapomni: da ne se koristat pastata i
gelot zaedno) Ne`no ~etkaj gi nepcata.
Povle~i gi usnite/jazikot so gaza.

Ne`no ~etkaj gi nepcata.Ako ne e
vozmo`no, koristi gaza so
Chlohexidine Gel, zamotana okolu
prstite ili pak ispirawe na ustata
Ispiraj so voda({pric od 10ml)Aspiriraj koristej}i Yankauer.Na kajot, izmij go liceto, namasti gi usnite
DA
Dali pacientot poseduva ve{ta~ko zabalo
NE
îsti gi nad lavor so ladna voda, za da spre~i{ taloèwe,

êtkaj so neparfimiran doma{en sapun. Isplakni gi dobro
pred postavuvawe.îsti gi po sekoj obrok. Nepravilna i
mnogu ~esta upotreba na sretstvo za ~istewe zabalo }e gi
obeli/dekolorira zabite. Zabaloto treba da e markirano
so imeto na bolniot. ûvaj go zabaloto preku no} vo
markiran sad so ladna voda
Prodolì so griàta za ustata, kako {to e pogore napomenato, na sekoi ( ? ) ~asa. êstotata zavisi od
individualnata procena
624
Algoritam 14. Procena na sposobnosta na bolniot za postavuvawe na PEG (perkutana endoskopska

gastrostoma)
Nutritivniot skrining go odreduva kaj bolniot rizikot od malnutricija (koristi

lokalno sredstvo za nutritiven skrining ili konsultiraj se so dietolog)
DA
Dali gastroenteralniot trakt e vo funkcija?

Medicinski tim/op{t lekar
Isklu~i organski ili psihijatriski bolesti
Razmisli/proceni za ponatamo{ni investigacii
NE
Moè li pacientot da jade i pie? Pomo{ od

sestra (skrining na goltawe)
DA
NE
Proceni za parenteralen na~in
Dali bolniot ima disfagija? Procena za

terapija na govorot. Sledi go lokalniot
protokol (mo`na videofluoroskopija)
Dietetski sovet i monitorirawe gi sledat

lokalnite protokoli za upatuvawe
Modifikacija na dieta
Moè li na bolniot da mu se pruì soodvetna nutricija preku oralen vnes ?
Pomo{ od sestra ili negovatelka
DA
NE
Dali hraneweto so sonda e soodvetno? Proceni

kako tim-prognoza/kvalitet na ìvotot, utvrdi
gi sklonostite na bolniot (vnesi pi{ani
informacii i vklu~i semeen neguvatel)
DA
Dali na bolniot mu odgovara hranewe od min.
30 dena? Konsultiraj med. tim/op{t lekar
DA
Prodolì so
drugi na~ini na
nutricija
NE/NE ZNAE
Proceni za nazogastri~no hranewe i

utvrdi dali PEG e indicirana za podolg
period
NE
-Utvrdi gi rizicite i korista od gastrostomata,

dali korisnoto go nadvladuva te{koto?
-utvrdi ja celta na tretmanot;
-proceni ja anksioznosta;
(proceni/razmisli za psihi~kiot status);
-proceni gi doma{nite okolnosti:
1. Sposobnosta da uspee (nezavisen, bara malku
pomo{, bara celosna pomo{);
2. Razgovori so patrona`nite sestri i stru~en
tim;
3. Barawa za obuka;
4.Procena na rabotata na socijalniot rabotnik
Razgovori so timot
Prodolùva
625
Prodolènie
Kompletna onesposobenost
Medicinski tim
Kontraindikacii za perkutana
endoskopska gastrostoma (PEG)
-INR >1,5
-trombociti < 50x 10*/L
-intraabdominalen kancer ili
ascites;
-predhodna gastri~na hirur{ka
intervencija (isklu~ena
vagotomija piloroplastika);
-varicesi;
-aktivna peritonealna sepsa;
-opstruktiven oralen ili
esofagealen kancer (da se upati
na radiologija)
NE
Dali pacientot e vo sostojba da

donesuva odluki? Medicinski tim
DA
Razgovor so pacientot/neguvatelot
za potrebata za intervencija i
soodvetnata grià posle
postavuvaweto.
Da se sprovede pi{ana
dokumentacija, koja }e pomogne na
predhodno donesenata odluka
Tim
DA
Odluka da se postavi PEG
Dali mu preti rizik od gastri~na

ili pulmonarna aspiracija na
gastri~nata sodrìna?
Medicinski tim
Detektirani problemi za koi
treba da bide
konsultiran eden ili pove}e od
slednive:
-odgovoren konsultant;
-endoskopist;
-postar gastrointestinalen;
specijalist;
-anesteziolog
NE
Adekvaten endoskopski priod
(medicinski tim)
Kompletna soglasnost (li~no prevzemena)
Proceni za:
- respiratorna funkcija;
-signifikanten komorbiditet;
-stepen na zasegata svest: nerazbira komandi;
-konfuzen, agresiven;
-~ista usta;
-spazamot na muskulaturata na vilicata ja
spre~uva endoskopskata intubacija;
- trauma na abdomen;
-signifikantni rani;
-golemina/forma na teloto;
-fraktira na kranium;
-potpolna podvi`nost na vratot;
-potreba od infuzii
DA
Razmisli za
jejunostoma
Postavena PEG
Ako se vospostavi deka pacientot ne e vo sostojba za PEG , razmilsi/proceni za drugi formi na nutritivna
podr{ka ili palijativen tretman
^lenovi na timot od zaednicata/op{tinata:
-op{t lekar;
-patrona`na sestra
-dietolog;
-terpevt za govor
Tim:
-op{t lekar za konsultacija;
-sestrinska ekipa/patrona`na sestra;
-dietolog;
-terapevt za govor;
-pacient;
-neguvatel;
-tutor odgovoren za pravata na
blagosostojba na bolniot;
-psihijatar/psiholog,soc. rabotnik
626
Algoritam 15. Monitorirawe na pacientot so enteralna sonda, za hranewe vo doma{ni

uslovi, po ispisot od bolnica (za dietologot)
Ispi{an pacient
Doma{ni kontroli vo tek na 5 dena od ispisot
Po potreba telefonski kontakt
Kontroli vo tek na 4 nedeli

( doma{ni uslovi/ambulantski)
PROMENA-kompletna zamena
na dokumentacija i formulari
Kontrola po potreba
Minimum dva pati godi{no
Da se upati na koordinator
(dokumentacija/formulari)
Baza na podatoci
627
Algoritam 16. Dijagnoza na glavobolka

Dijagnoza i tretman na glavobolka
10
Pacientot se
oplakuva na
glavobolka
AD
11
Kriti~ni prvi ~ekori:
- Detalna istorija
- Fokusiran fizikalen
pregled
- Fokusiran nevrolo{ki
pregled
AD
12
Pri~ini za
zagriùvawe?
ne
14
Prisutni ???za
naru{uvawe so
primarna
glavobolka
AD
ne
16
Prodolùva
13
Razmisluvaj za
naru{uvawe so
sekundarna
glavobolka
A
da
15
Glavobolka
poinakva od
primarnata
Nadvor od
vodi~ot
da
21
24
Indikacija za da
Upatuvawe na
specijalisti~ki
specijalist za
konsultacii?
glavobolka
A
ne
ne
22
Pravewe
dijagnosti~ka
lista ako e
potrebno
AD
23
Naodi
konzistentni so
sekundarna
glavobolka
A
25
Potvrdena
dijagnoza na
primarna
glavobolka
da
da
26
16
628
Algoritam 16 a. (prodolènie)
14
25
25
ne
da
da
16
Evaluirawe na tipot na
primarna glavobolka
Otpo~nuvawe na
edukacija na pacientot i
sreduvawe na stilot na
ìvotot
AD
17
Migrena
(Vidi
algoritam za
migrena)
18
Tenziona
glavobolka
(vidi
algoritam)
26
Odreduvawe
na sekundarna
glavobolka
Nadvor od
vodi~ot
19
Cluster
(Vidi
algoritam)
20
Drugi nadvor
od vodi~ot
629
Algoritam 17. Dijagnoza i tretman na glavobolkata

(glaven algoritam)
1
Algoritam za dijagnoza
- Odreduvawe na tipot na glavobolkata
- Zemawe na detalna anamneza i odreduvawe na funkcionalnoto zasegawe
- Odreduvawe na pri~ini koi se zagriùva~ki
- Razmisluvawe za naru{uvawa so sekundarna glavobolka
- Upatuvawe na specijalist
2
Algoritam za tretman na
glavobolka
- Kategorizacija i odbirawe
na tretman vrz osnova na
teìnata i funkcionalnoto
zasegawe
- Razmisluvawe za specijalen
tretman (vklu~uvaj}i DHE)
za status glavobolka
- Edukacija na pacientot i
modifikacii na stilot na
ìveewe
3
Algoritam za tenziona
glavobolka
- Odreduvawe na
dijagnozata
- Akuten tretman
- Za{titen tretman
- Edukacija na pacientot
i modifikacija na
stilot na ìveewe
4
Algoritam za Cluster
glavobolka
- Odreduvawe na
dijagnozata
- Akuten tretman
- Preventiven tretman
- Edukacija na pacientot i
modifikacija na stilot na
ìveewe
5
Dali e pacientka?
da
6
Algoritam za
migrena
asocirana so
menstruacija
7
10
Algoritam za
migrena vo
perimenopauz
a/menopauza
9
Algoritam za
profilaksa
na migrena
8
Algoritam za migrena od upotreba na
kontraceptivi so estrogen
Razmisluvawe za kontraceptivi so
estrogeni
1
Migrenata e
naj~esto
sretnuvana
glavobolka vo
primarnata
zdravstvena
za{tita
A-zabeleùvawe
D-diskusija
630
Algoritam 18. Tenziska glavobolka

Dijagnoza i tretman na glavobolkata
Pacientot bi
se vodel po
ovoj algoritam
od pole 18 od
Algoritamot
za dijagnoza
58
Tenziska
glavobolka
59
Pacientot gi
ispolnuva
kriteriumite za
tenzionag
lavobolka?
AD
da
Dopolnitelna
terapija 62, 66
Terapija za
stres
Fizioterapija
61
Dali pacientot
ima aktuelna
glavobolka?
ne
62
Akuten tretman:
Acetaminophen
da
Aspirin
NSAID
Midrin
Dopolnitelna
terapija
AD
ne
64
Razmisluvawe za
procenka
Nadvor od
vodi~ot
ne
63
Dali
pacientot e
kandidat za
preventiven
tretman?
da
66
Preventiven tretman:
Amitriptyline
Drugi TCA
Venlafaxine XR
Tizanidine
Dopolnitelna
terapija
AD
67
Uspe{na
terapija?
da
69
Prodolùvawe
na terapijata
60
Vra}awe kon
Algoritamot
za dijagnoza
65
Uspe{na
terapija?
da
ne
68
Razmisluvaj za druga
akutna ili preventivna
terapija
Proveruvawe na
dijagnozata
Razmisluvawe za
predoziranost so lekovi
Razmisluvawe za
upatuvawe na
specijalist
ne
631
Algoritam 19. Migrena asocirana so menstrualen ciklus

Pacientot se vodi
spored ovoj
algoritam od pole
54 na Algoritamot
za tretman na
migrena
101
Migrena
asocirana so
menstrualen
ciklus
AD
Pacientot se
vodi spored
ovoj
algoritam od
pole 54 na
Algoritamot
za tretman na
migrena
ne
103
Vra}awe na
Algoritamot
za tretman na
migrena
da
104
Samo menstruacija:
- Glavobolki koi se
javuvaat isklu~ivo dva
dena pred/po po~etokot na
menstruacijata
107
Upatuva na
Algoritamot
za tretman na
migrena
108
Uspe{na
terapija?
106
Vra}awe kon Algoritamot za
za{titen tretman na migrena
da
ne
110
Cikli~na za{tita:
- NSAID
- Triptani
- Ergotamini
AD
111
Prodolùva
105
Asocirana so, no ne i
isklu~ivo so menstruacija:
- Pojavuvawe > 6-8 dena
mese~no ili
- Glavobolka > 3 dena mese~no
koga optimalno se tretira, no
se u{te e iscrpuva~ka
109
Prodolùvawe
na terapijata
632
Algoritam 19 a. (prodolùva) Migrena asocirana so menstrualen ciklus

110
111
Uspe{na
terapija?
da
112
Prodolùvawe
na terapijata
ne
113
Hormonalna za{tita:
- Nalepnici so estradiol
- Kontraceptivi so estrogeni
GnRH agonisti so add back
terapija
Upatuvawe kon Algoritamot za
migrena od kontraceptivi so
estrogeni
AD
114
Uspe{na
terapija ?
ne
116
Konsultacija
so specijalist
za glavobolka
da
115
Prodolùvawe
na terapijata
633
Algoritam 20. Migrena predizvikana od kontraceptivni preparati so estrogen

131
Primena na kontraceptivi so
estrogeni ili razmisluvawe
za kontaceptivi so estrogeni
i migrena
AD
132
Razmisluvawe za
neestrogena
kontracepcija ?
da
134
Progestin metodi:
- Kontraceptivi samo so
progestin
- Depo-Provera;
- Nehormonalni
kontraceptivni metodi;
- IUD; metoda na bariera
133
Razgleduvawe na rizik faktori
za udar:
- Rizik faktori za CAD
- Migrenozna aura
- Laboratoriski dokazi za
hiperkoagulabilnost
- Prethodna arteriska
tromboemboli~na bolest
- Pu{ewe
AD
ne
135
Rizi~na?
141
Prodolùvawe
na terapijata
ne
ne
140
Vlo{uvawe na
glavobolkite?
- Za~estenost
- Zasileni
- Razvoj na aura
136
Kontraceptivi so
malku estrogeni
D
da
ne
137
Vlo{uvawe na glavobolkite?
- Za~estenost
- Zasileni
- Razvoj na aura
138
da
139
Prodolùva
142
634
Algoritam 20 a. (prodolènie) Migrena predizvikana od kontraceptivi so estrogen

137
ne
138
Prodolùvawe
so za{titnata
terapija
140
da
139
- Razmisluvawe za oralno ili transdermalno davawe na
estrogen za vreme na placebo nedela
- Prekinuvawe so kontraceptivi so estrogeni
- Razmisluvawe za progestin metodi ili nehormonalni
kontraceptivni metodi
- Razgleduvawe na pri~ini za zagriènost
- Razmisluvawe za konsultacija so specijalist
D
da
142
- Razmisluvawe za prekin na progestin
- Revizija na pri~inite za zagriènost
- Razmisluvawe za konsultacija so specijalist
- Vra}awe na Algoritamot za za{titna terpija na
migrena
A-Zabele{ka
B-Diskusija
635
Algoritam 21. Tretman na migrena

Pacientot bi se vodel
spored ovoj algoritam
od pole 17 od
Algortamot za
dijagnoza
27
Pacientot gi ispolnuva
kriteriumite za migrena
A
28
Dali pacientot
ima tipi~na
glavobolka?
A
ne
29
Vra}awe na Algoritam
za dijagnoza
Nadvor od vodi~ot
da
30
Kategorizacija spored pikot na intenzitetot vrz
osnova na funkcionalnoto zasegawe, traeweto na
simptomite vo vremeto na pikot na vlo{uvaweto
A
31
Lesno
35
Sredno
38
Te{ko
43
Status (traewe >72 ~asa)
A
39
32
36
Intenziven
Lesen
Umeren
Chloropromazine
tretman:**
tretman:**
-Depacon
- APAP /ASA/
-DHE
-DHE
- Caffeine
-Ergotamine
-Ketarolac IM
- ASA
tartarate
-Magnesium
- Lidocaine
-Lidocaine
Sulfate IV
nazalen
nazalen
-5 HT agonisti
- Midrin
-Midrin
(triptani)
- NSAID
-NSAID
Vidi tretman
- 5 HT
-5 HT
pod 30
agonisti
agonisti
*dopolnitelna
(triptani)
(triptani)
terapija
Almotriptan
Vidi
D
Eletriptan
tretman pod
Frovatriptan
30
Naratriptan
*dopolnitel ne
Rizatriptan
ne na terapija
Sumatriptan
AD
Zolmitriptan
40
*dopolnitel
na terapija
37
AD
33
44
Dopolnitelna terapija
AD
45
Pacientot gi
ispolnuva
kriteriumite
za DHE?
A
46
Upatuvawe
kon DHE
Algoritam za
protokol
ne
47
Chlorpromazine
Valproate
sodium IV
Magnesium
sulfate IV
ili
prochlorperazine
AD
da
48
Uspe{no?
A
da
ne
41
Prodolùva
49
34
636
ne
33
Uspe{no?
AD
ne
37
Uspe{no?
A
ne
40
Uspe{no?
ne
ne
da
ne
41
Indicirana
specijalisti~ka
konsultacija?
50
da
Uspe{no?
ne
da
da
42
Konsultacija
so specijalist
za glavobolka
A
54
Upatuva na:
-algoritam
za migrena
asocirana so
ciklus
-algoritam za
migrena vo
perimenopauza ili vo
menopauza
-na
kontraceptivi so
estrogeni
(KSE) ili
razmisluvaj}i za KSE
i algoritam
za migrena
34
Sredena
glavobolka
da
ne
57
Upatuvawe na
Algoritamot za
profilakti~ki
tretman na
migrena
51
Dexamethasone
AD
ne
52
Uspe{no?
Dopolnitelna terapija 32, 36, 39, 44

Odmor vo tivka temna soba
I.v. rehidratacija
Antiemetici **
Hidroxyzine
Metoclopramide
Prochlorperazine
Promethazine
Caffeine
53
Dali e
migrena
povrzana so
hormoni?
55
Dali pacientot e
kandidat za
profilakti~en tretman?
49
Ketorolac ili
opijati
AD
ne
56
Prodolùvawe
na akutniot
tretman
A-zabeleùvawe
B-diskusija
637
Algoritam 22. Profilaksa na migrena

Diajgnoza i tretman na glavobolka
143
Pacientot gi
zadovoluva
kritertiumite
za migrena
Pacientot se vodi
po ovoj algoritam
od pole 57 od
Algoritamot za
migrena
144
Za{titen tetman
Odreduvawe na faktorite koi moè da bidat triger za migrena
Prva linija na tretman:
- Lekovi
Beta blokatori
Tricikli~ni antidepresivi
- Antiepilepti~ni lekovi
Valproat
Topiramat
Gabapentin
Verapamil
- Zasiluvawe na edukacijata i sreduvawe na stilot na ìveewe
- Razmisluvawe za druga terapija (biofidbek, relaksacija)
AD
145
Uspe{no?*
da
ne
146
Prodolùvawe na
tretmanot za 6-12 meseci,
potoa povtorna procenka
A
147
Obid so drug lek od
prvata linija ili drug
lek od istata klasa
A
148
Uspe{no?*
da
149
Prodolùvawe na
tretmanot za 6-12 meseci,
potoa povtorna procenka
ne
150
Obid so kombinacija
od betablokatori i
tricikli~ni
antidepresivi
A
151
Prodolùva
*145,148,151. Uspe{no?
Uspehot e odreden so:
- Glavobolkite se
namaluvaat za 50% ili
pove}e
- Prifatlivi nesakani
efekti
144.
Kriteriumi za pacientot za
primena na za{titna
terapija:
- 3 ili pove}e te{ki ataki
na migrena vo tek na mesec
koi ne reagiraat adekvatno
na terapijata
- Pomalku ~esti, no
prolongirani ataki koi go
vlo{uvaat kvlitetot na
ìvotot na pacientot
- Pacientot e
zainteresiran za za{titna
terapija
638
Algoritam 22 a. (prodolùva) Profilaksa na migrena

150
151
Uspe{no?*
da
ne
153
Treta linija na
za{titna terapija ili
konsultacija so
specijalist
A
152
Prodolùvawe na
tretmanot za 6-12
meseci, potoa povtorna
procenka
A-Zabeleùvawe
B-Diskusija

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-

2.2 - 4.2 mmol/l

150 - 450 mg/l

TPHA (treponemal haemagglutination assay)-

(m. levator palpebrae, m. tarsalis)

1. Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109:12021211

(nitrofurantoin, sulphasalazine, imidazoles)10, erythromycin,

Dexamethason: per os 3 x 0.53 mg.

1. EBM Guidelines, 14.7.2004, www.ebm-guidelines.com

1. Hermish H, Aizenberg D, Weizman A, Lapidot M, Mayor C, Munitz H. Risk for definite

malignant syndrome. Arch Gen Psychiatry 1989;46:914-8

Emerg Med 1996;28:690-698

1. Kapoor WN. Diagnostic evaluation of syncope. Am J Med 1991;90:91-105

grand mal" () 24,

1. Hillbom M, Pieninkeroinen I, Leone M. Seizures in Alcohol-Dependent Patients.

The Cochrane Database of Systematic Reviews, Cochrane Library number: CD002028.

1. 18 mg ( ), 25 mg/ml 150 mg/min.

1. Reetta Klviinen; Article ID: ebm00766 (036.046); 2005 Duodecim Medical

Quinine chloride45+ meprobamat46; quinine chloride + diasepam; phenytoin

Recombinant human insulin55, , Growth factor I56

1. Brooks BR. Clinical epidemiology of amyotrophic lateral sclerosis. Neuroepidemiology

1. EBM Guidelines, 8.6.2004, www.ebm-guidelines.com

1. Schievink WI. Intracranial aneurysms. N Engl J Med 1997; 336: 28-40

1. Medication-induced headache: overview and systematic review of therapeutic

Sumatriptan s.c.66 6 mg (-B).

1. Ekbom K, Monstad I, Prusinski A, Cole JA, Pilgrim AJ, Noronha D. Subcutaneous

Ergotamine tartrate78 12 mg per os ,

to treat. Cephalalgia 1998;18:532-538

1. Wiffen P, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute

Bovine spongiform encephalopathy () (

1. Rao J, Weinberger M, Oddone E, Allen N, Landman P, Feussner JR. The role of

MMSE- (Mini-Mental State

2. Katz- ADL Index-

3. IADL (instrumental activities of daily living) Lawton-Brody

1. EBM Guidelines, 5.4.2004, www.ebm-guidelines.com

1. McKeith I, Del Ser T, Spano P, Emre M, Wesnes K, Anand R, Cicin-Sain A, Ferrara

2. Kaufer DI. Pharmacologic treatment expectations in the management of dementia with

Codergocrine mesylate (hydergine)85 (-C).

1. Filippini G, Brusaferri F, Sibley WA, Citterio A, Ciucci G, Midgard R, Candelise L.

1. Taricco M, Adone R, Pagliacci C, Telaro E. Pharmacological interventions for spasticity

: anticholinesterase (Mestinon, Mytelase108, Ubretid109), ephedrine,

Wohlfart - Kugelberg - Welander-

125 - mononeuropathia multiplex

(amiodarone, propafenone), ethionamide142, glutethimide143,

156 Mononeuritis multiplex

1. Mehndiratta MM, Hughes RAC. Corticosteroids for chronic inflammatory demyelinating

Meralgia paresthetica-n. cutaneus femoris lateralis

serotonin reuptake" (-C).

N. cutaneus femoris lateralis

N. CUTANEUS FEMORIS LATERALIS

n.cutaneus femoralis lateralis, , 2 cm crista iliaca superior anterior.

1. Trenkwalder C, Stiasny K, Pollmacher T, Wetter T, Schwarz, Kohnen R, Kazenwadel J,

Melatonin179 0,5-5 mg (-A).

Entacapone cathecol-O-methyltransferase (COMT).

Entacapone on" (-C).

1. EBM Guidelines, 3.3.2005, www.ebm-guidelines.com

Venlafaxine mirtazapine204 amtriptylin, (-A).

Capsaicin208 (0,025% 0,075%) .

, Failed Back Surgery Syndrome Complex

1. Carroll D, Moore RA, McQuay HJ, Fairman F, Tramer M, Leijon G. Transcutaneous

1. Bednar MS. Ulnar tunnel syndrome. Hand clin 1996;12:(4)657-64.

1. Marshall S, Tardif G. Ashworth N. Local corticosteroid injection for carpal tunnel

1. Helakorpi S, Uutela A, Prttl R, Puska P. Suomalaisen aikuisvestn