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Using a herbal medicine textbook [13 ] we identied those remedies most likely to be used for cognitive symptoms of dementia memory loss and decreased concentration ; and related psychiatric symptoms depression, anxiety and insomnia ; . The ve herbal therapies we identied were St. John's wort, ginkgo biloba, kava, valerian, and ginseng. To identify relevant articles we conducted MEDLINE searches limited to English-language articles published between 1980 and 2000. We searched under the term `drug interactions' combined with each of the herbal therapies. All references of MEDLINE articles were checked and potentially relevant articles were obtained and assessed for possible inclusion. Other sources used were a textbook on herbal medicine [13 , 14], handbooks [15], guidelines [16] and the internet. Chinese herbs were not included. The review focuses on clinical reports although animal studies, pharmacologic studies, and clinical trials are cited where relevant. Accurate documentation can be crucial in avoiding liability if you're named in a lawsuit. A medical record should be a detailed account of a patient's health status, including the treatment you've provided and the patient's response. Changes in medical condition and information that you've shared with other healthcare providers should also be recorded. In addition, you need to chart a patient's refusal of treatment or noncompliance with ordered treatment, any patient teaching that you've done and any telephone instruction you've provided.
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REFERENCES Jasinski, D.R.; Pevnick, J.S. & Griffith, J.D. 1978. Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. Arch Gen Psychiatry 35 4 ; : 501-16. Mendelson, J.; Jones, R.T.; Fernandez, I.; Welm, S.; Melby, A.K. & Baggott, M.J. 1996. Buprenorphine and naloxone interactions in opiate-dependent volunteers. Clin Pharmacol Ther 60 1 ; : 105-14. FOOTNOTES 1. Narcotic is a legal term, and can refer to heroin and other opiates, cocaine and sometimes even marijuana. 2. Formerly Reckitt and Colman Pharmaceuticals 3. Drug Enforcement Administration, Proposed Rules, Federal Register vol. 67, no 55, March 21, 2002, pp 13114-6. 4. Ibid pp 13114-5.

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None of the circulating metabolites are presently used as markers for disease activity or prognosis in daily practice. But the research in connective tissue metabolites gives us information of importance for our understanding of the inflammatory processes in the various joint compartments 27-28 ; . If we can identify patients with subclinical or preclinical RA the next question would be if we should treat them with DMARDs. A recent Dutch study focused on this issue 29 ; . 110 unclassified arthritis patients with 2 to 3 swollen joints were treated with MTX or placebo. They were followed every third month. MTX or placebo was increased if inflammation persisted. From month 12 to 18 the patient still blinded was tapered off treatment. If patients during the study fulfilled ACR criteria for RA they were changed to open treatment with MTX. There was a decrease or delay in development of RA in anti-CCP positive patients on MTX, whereas MTX had no preventive effect in the anti-CCP negative patients. MTX reduced or delayed the radiological progression in anti-CCP positive patients, but had no preventive effect in the anti-CCP negative patients. The study group concluded that there was a window of opportunity in anti-CCP positive patients to delay fulfillment of criteria for RA by initiation of MTX treatment in preclinical RA. Let us now focus on established RA. What should our treatment goal be? Should we go for a certain degree of disease suppression as with the ACR 20% or 50% response criteria, or should we go for a certain level or disease activity as with the Disease Activity Score DAS score ; . Scores or criteria to describe disease activity or the effect of a given treatment have primarily been developed for research purposes. They are often rather complicated to use, and the need of clinical and serological parameters and mathematical calculations has limited their use. The perfect score has not been developed yet, but the DAS score has been used extensively in prospective studies. The score is calculated based on information about number of swollen and tender joints, an acute phase reactant and a visual analog scale indication of the patient global health. The score is determined by a calculator. A low DAS score indicates low disease activity whereas high levels are seen in patients with severe disease activity 30 ; . The Scottish TICORA study used a DAS score to regulate aggressive non-biological DMARD treatment in RA with up to 5 years of disease duration 31 ; . The treatment was regulated every third. Individual "personal best" peak flow measurements can be used to determine asthma action or treatment zones. Green: 80-100% of "personal best" peak flow. Continue current asthma plan. Yellow: 50-80% of "personal best" peak flow. Caution. Use quick relief medication as needed to improve peak flow or relieve symptoms. Monitor peak flow after treatments. Red: Less than 50% of "personal best" peak flow. Danger. Use quick relief medication and seek immediate medical attention.

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