U. Reto. Mansfield University.
G eneral practitioners’ perceptions of the route to evidence based m edicine: a questionnaire study buy 200 mg avana with mastercard. Cross sectional survey of cervical cancer screening in wom en with learning disability discount avana 50 mg mastercard. Severity of osteopenia in estrogen- deficient wom en with anorexia nervosa and hypothalam ic am enorrhea order avana 200mg otc. Com pleteness of reporting of trials published in languages other than English: im plications for conduct and reporting of system atic reviews avana 50 mg low cost. The Cochrane Collaboration: preparing, m aintaining, and dissem inating system atic reviews of the effects of health care. In 1979, the editor of the British Medical Journal, D r Stephen Lock, wrote "Few things are m ore dispiriting to a m edical editor than having to reject a paper based on a good idea but with irrem ediable flaws in the m ethods used". M ost papers appearing in m edical journals these days are presented m ore or less in standard IM RAD form at: Introduction (why the authors decided to do this particular piece of research), M ethods (how they did it and how they chose to analyse their results), Results (what they found), and D iscussion (what they think the results mean). If you are deciding whether a paper is worth reading, you should do so on the design of the m ethods section and not on the interest value of the hypothesis, the nature or potential im pact of the results or the speculation in the discussion. Conversely, bad science is bad science regardless of whether the study addressed an im portant clinical issue, whether the results are "statistically significant" (see section 5. Strictly speaking, if you are going to trash a paper, you should do so before you even look at the results. W hen I teach critical appraisal, there is usually som eone in the group who finds it profoundly discourteous to criticise research projects into which dedicated scientists have put the best years of their lives. On a m ore pragm atic note, there m ay be good practical reasons why the authors of the study have "cut corners" and they know as well as you do that their work would have been m ore scientifically valid if they hadn’t. M ost good scientific journals send papers out to a referee for com m ents on their scientific validity, originality, and im portance before deciding whether to print them. This process is known as 40 G ETTIN G YOU R BEARIN G S peer review and m uch has been written about it. I recently corresponded with an author whose paper I had refereed (anonym ously, though I subsequently declared m yself) and recom m ended that it should not be published. On reading m y report, he wrote to the editor and adm itted he agreed with m y opinion. H e described five years of painstaking and unpaid research done m ostly in his spare tim e and the gradual realisation that he had been testing an im portant hypothesis with the wrong m ethod. H e inform ed the editor that he was "withdrawing the paper with a wry sm ile and a heavy heart" and pointed out several further weaknesses of his study which I and the other referee had m issed. H e bears us no grudge and, like Kipling’s hero, has now stooped to start anew with worn-out tools. The assessm ent of m ethodological quality (critical appraisal) has been covered in detail in m any textbooks on evidence based m edicine,3–7 and in Sackett and colleagues’ "U sers’ guides to the m edical literature" in the JAMA. Appendix 1 lists som e sim pler checklists which I have derived from the users’ guides and the other sources cited at the end of this chapter, together with som e ideas of m y own. If you are an experienced journal reader, these checklists will be largely self explanatory. If, however, you still have difficulty getting started when looking at a m edical paper, try asking the prelim inary questions in the next section. The introductory sentence of a research paper should state, in a nutshell, what the background to the research is. For exam ple, "G rom m et insertion is a com m on procedure in children and it has been suggested that not all operations are clinically necessary". This statem ent should be followed by a brief review of the published literature, for exam ple, "G upta and Brown’s prospective 41 H OW TO READ A PAPER survey of grom m et insertions dem onstrated that. It is irritatingly com m on for authors to forget to place their research in context, since the background to the problem is usually clear as daylight to them by the tim e they reach the writing up stage. U nless it has already been covered in the introduction, the m ethods section of the paper should state clearly the hypothesis which the authors have decided to test, such as "This study aim ed to determ ine whether day case hernia surgery was safer and m ore acceptable to patients than the standard inpatient procedure". Again, this im portant step m ay be om itted or, m ore com m only, buried som ewhere m id-paragraph. If the hypothesis is presented in the negative (which it usually is), such as "The addition of m etform in to m axim al dose sulphonylurea therapy will not im prove the control of type 2 diabetes", it is known as a null hypothesis. The authors of a study rarely actually believe their null hypothesis when they em bark on their research.
The middle cerebral artery gives branches to the upper ﬁbres of optic radiations and inconsistently to the occipital poles effective avana 50mg. Regarding the development and anatomy of the ear: (a) After birth the inner ear continues to grow and attains adult proportions by 2 years of age safe avana 100 mg. Regarding the middle ear and mastoid: (a) The middle ear is housed in the petrous bone with the tympanic membrane laterally and inner ear medially order avana 100mg online. Regarding the middle ear: (a) The ossicular chain of malleus buy 100 mg avana mastercard, incus and stapes connect the tympanic membrane with the round window. The inner ear develops with the formation of the optic capsule at about the third week of gestation. Therefore, congenital anomalies of the external ear and middle ear are commonly associated and those of the inner ear are usually isolated. The mesotympanum and hypotympanum are the middle and inferior divisions which are formed by lines drawn along the superior and inferior margins of external auditory meatus. The round window, which is covered by membrane, is below and behind the promontory. Regarding the inner ear: (a) The membranous labyrinth surrounds the bony labyrinth of the inner ear. Regarding the internal auditory meatus: (a) The anterior wall of the internal auditory canal is shorter than the posterior. The saccule and utricle situated anteriorly and posteriorly within the vestibule cannot be resolved separately by MRI. In the majority of cases studied with axial high resolution T2-weighted MRI the facial nerve can be seen separately anterior to the vestibulocochlear nerve. The cochlear branch of the vestibulocochlear nerve occupies the antero-inferior quadrant. The superior and inferior vestibular branches of the vestibulocochlear nerve are found in the posterior quadrant. Regarding the facial (seventh) nerve: (a) The intermediate nerve of the facial nerve is the large motor root. Regarding the cerebellopontine angle cistern: (a) The ﬂocculus of the cerebellum forms the anterior boundary. Therefore, this part of the facial nerve is vulnerable to inﬂammatory disease of the middle ear. Coronal CT through the cochlea shows the facial canal twice to produce ‘snake’s eyes’ appearance of the facial nerve above the cochlea. This nerve transmits taste ﬁbres from the anterior two-thirds of the tongue to the lingual nerve and the motor ﬁbres to the submandibular and sublingual gland. Regarding surface anatomy: (a) The nasion overlies the suture between the frontal and ethmoid bones. Regarding the anatomy of the head and neck: (a) The parotid duct can be rolled across the anterior border of the masseter muscle just below the zygomatic bone, with teeth clenched. Concerning vertebral levels: (a) Atlas and dens of axis lie in the horizontal plane of the open mouth in an AP projection. The coronoid process can be identiﬁed by placing a ﬁnger in the angle between the zygomatic arch and the masseter muscle. Also, the vertebral artery usually passes into the foramen transversarium of the cervical vertebra. Regarding the head and neck: (a) The tongue receives innervation from nerves of the ﬁrst, second, third and fourth pharyngeal arches. Regarding the head and neck: (a) The pterygomaxillary ﬁssure opens into the infratemporal fossa through the pterygopalatine fossa. Regarding the mandible and the temporomandibular joint: (a) Each half of the body of the mandible is ﬁxed anteriorly in the midline at the mental symphysis. Therefore, on axial images the lateral and medial pterygoid appear to be at the same level. In the nose: (a) The hiatus semilunaris is situated beneath the ethmoid bulla in the middle meatus.
In the first of several integrative approaches to working with couples generic 100 mg avana free shipping, Bradley and Johnson (Chapter 11) present emotionally-focused therapy discount avana 200mg without a prescription, an inte- gration of collaborative client-centered order 100 mg avana with visa, gestalt buy avana 200 mg with visa, systems approaches, con- structivist thinking, and understandings derived from attachment theory and the empirical literature. Cheung (Chapter 12) proposes the integration of strategic family therapy and solution-focused approaches to working with couples. In Chapter 13, Pitta describes integrative healing couples therapy that uses psychodynamic, behavioral, communication, and sys- temic theories in understanding the couple’s functioning. Concluding this part, Nutt (Chapter 14) describes feminist and contextual approaches to working with couples. Section III approaches couples’ interventions from the perspective of common presentations in therapy. Thus, Watson and McDaniel (Chapter 15) describe the work with couples who are confronting medical concerns. The interface of the biological and the emotional provide the framework for their work in medical settings. In Chapter 16, Harway and Faulk consider how a history of sexual abuse in one member of the couple may affect the overall couple’s functioning and may lead to difficult therapeutic concerns. Holtzworth-Munroe, Clements, and Farris (Chapter 17) discuss the implica- tions of intervening with these types of couples. Stanton (Chapter 18) reviews key elements of couples therapy for the treatment of addictive be- haviors. Infidelity is said to affect a large number of couples and presents particular challenges. In Chapter 19, Lusterman explores issues related to working with couples who have been touched by infidelity and proposes an effective model for intervention. Psychotherapists are often uncomfortable with exploring spiritual issues in therapy. Yet, spiritual and religious differ- ences, like other forms of cultural difference, contribute to some couples’ dissatisfaction with their relationship. Serlin (Chapter 20) considers how to interweave spiritual concerns in the course of psychotherapy. While couples comprised of two same-sex partners share many of the same issues as het- erosexual partners, Alonzo (Chapter 21) describes some unique issues for gay or lesbian couples. Kaslow (Chapter 22) examines the impact of socio- economic factors on couples’ functioning and describes some approaches to working with money issues in therapy. Not all couples presenting for psychotherapy are there to improve the couple’s bond. Some couples initiate therapy to provide a smoother transi- tion to divorce, while other couples initiate therapy in the hopes of sav- ing their relationship but ultimately decide instead to focus on marital 4 S ETTING THE STAGE FOR WORKING WITH COUPLES dissolution. Finally, while many of the chapters interweave empirical information with clinical information, in Chapter 24, we consider what the research has to tell us about the nature of couples functioning and the effectiveness of our interventions. Stabb reviews both the literature on well-functioning and dysfunctional couples and research that elucidates what is useful in couples therapy interventions. Chapter 25 summarizes the multiplicity of threads that have been developed in the many outstanding contributions to this volume. Nonetheless, since couples and families provide the major building blocks of our society, the work that we do in shoring up the foundations has impact beyond those we touch di- rectly. As we know from systems theories, the concentric circles of involve- ment of the individuals who comprise our families and couples, within the larger context of our communities and cultures, makes our impact ricochet from its point of impact to the entire pond. As such, couples therapists have the possibility of being change agents at a much wider scale than they may have believed. Number, timing and duration of mar- riages and divorces: 1996 (Current population reports). SECTION I LIFE CYCLE STAGES CHAPTER 2 Premarital Counseling from the PAIRS Perspective Lori H. Adams HE PREMARITAL COUPLE treads a challenging path between falling in love and solidifying a commitment. Premarital couples seek profes- Tsional help to prevent or to understand and resolve relationship diffi- culties that may have arisen even before marriage.
EXERCISE HISTORY During a holistic assessment of individuals about to embark on CR generic 100 mg avana, exercise history can be an important aspect cheap avana 100mg on line. It gives the exercise professional a point of reference for the patient’s life experience of exercise order avana 200 mg without a prescription. The information gained from this subjective discussion can highlight possible barriers to suc- cessfully completing a CR purchase avana 200mg mastercard, such as having been sedentary and having no exer- cise history (ACSM, 2001) or having negative memories of physical education at school. This can create a lack of self-efﬁcacy, a known predictor of poor car- diovascular outcomes. At the other end of the scale, those with a history of competitive sports may highlight a tendency to fail to comply with a given exercise prescription, which itself is recognised as a risk factor for exercise-induced event and therefore a direct link to the risk stratiﬁcation process. The discussion between CR exercise leader and participant may also high- light cardiac misconceptions, such as a fear of physical exertion, which are gen- erally accepted as related to poorer outcomes and reduced self-efﬁcacy and programme compliance (Maeland and Havik, 1988; SIGN, 2002). The exercise leader can further discuss these misconceptions and attempt to correct them. PHYSICAL ACTIVITY LEVELS Cardiac rehabilitation exercise professionals are unlikely to argue with the importance of assessing and documenting baseline physical activity levels or changes in physical activity levels over time. However, despite 40 years of using questionnaires to measure physical activity there are still questions over the best method to achieve it (Shephard, 2003). There are practical uses of gathering these data: • as an auditable outcome of physical activity behaviour at key time points, e. Although many programmes collect a measure of physical activity, there is often wide varia- tion in the tools used, making comparisons between programmes extremely difﬁcult. Def- initions of physical activity, such as those adopted by Health Education Board for Scotland (HEBS) (2001) relate to either moderate or vigorous activity and do not take into account mild activity, such as bowling, slow walking, dancing or golﬁng, the activities often reported by the CR patient population. A ques- tionnaire being piloted by the British Heart Foundation (BHF), as part of their proposed minimum data set for CR, aims to address this problem (Lewin, et al. STAGE OF CHANGE Assessing a patient’s readiness to change in relation to exercise behaviour should always be a component of the exercise professional’s assessment. An evaluation of a CR programme which forms part of the Scottish Executive Demonstration Project, Have a Heart Paisley (HHP, 2004), reported that individuals assessed to be pre- contemplative and contemplators at baseline were less likely to attend. Using the stage of change model during assessment can alert the clinician to those individuals least likely to take up or complete CR, enabling them to target resources to those most ready to change. It is also important to ensure that mechanisms are in place for pre-contemplative patients to be referred for other components of rehabilitation, such as smoking cessation, diet and nutri- tion, psychology and relaxation, and to access exercise services at a later date, should they reach a different stage of physical activity (see Chapter 8 for more on stages of change). RISK STRATIFICATION FOLLOWING PHASE III The ultimate aim of CR is the long-term adoption of healthy behaviours by the patient in an attempt to decrease the risk of further events or mortality and to maintain the beneﬁts gained during the rehabilitation programme (SIGN, 2002). The exercise professional must remember that risk stratiﬁcation is not a static entity. Continuous reassessment and monitoring by the profes- sional and development of self-monitoring skills by the patient are required throughout the course of rehabilitation. Risk Stratiﬁcation and Health Screening for Exercise 39 Post-rehabilitation risk stratiﬁcation should be formally undertaken to: • ascertain whether the patient is suitable either for discharge to inde- pendent exercise or for referral to structured supervised exercise; • recommend a speciﬁc level of supervision, dovetailing with the exercise leader’s training and competencies. As with Phase III cardiac rehabilitation patients, patients moving to phase IV should not be excluded from continuing exercise as far as possible, with deci- sions based on health screening, risk stratiﬁcation and also patient preference. However, as long-term community-based phase IV exercise opportunities are a relatively new development in CR there does not appear to be an exten- sive body of evidence for risk stratiﬁcation speciﬁcally for post-phase III reha- bilitation assessment. It is likely that local programmes have tended to set their own criteria for discharge or referral to phase IV, based on their local patient population, on the availability and type of phase IV opportunities and on the level of qualiﬁcation of instructors. The same principles of risk stratiﬁcation apply as outlined in this chapter; each patient must be considered individually. The ACSM (2001) and the BACR (2002) have published guidelines for independent exercising and refer- ral to phase IV, which is shown in Table 2. Guidelines for referral to phase IV Independent exercise with • Functional capacity ≥8 METs minimal or no supervision • Cardiac symptoms stable or absent (ACSM, 2001) • Appropriate BP response to exercise and recovery • Appropriate ECG response to exercise (i. It may be more practical to screen patients prior to discharge using a set of exclusion criteria such as the following, which are currently prac- ticed in the author’s programmes. Phase IV exercise leaders The BACR (2002) has also, in recent years, established an accredited qualiﬁ- cation for community instructors providing exercise to cardiac rehabilitation phase III graduates.