By I. Wilson. California University of Pennsylvania.
In m ost clinical problem s with individual patients purchase aurogra 100mg without a prescription, however 100mg aurogra, the "m anoeuvre" consists of a specific intervention initiated by a health professional trusted 100 mg aurogra. Thus buy cheap aurogra 100 mg line, in M rs Jones’ case, we m ight ask, "In a 68 year old white wom an with essential (i. N ote that in fram ing the specific question, we have already established that M rs Jones has never had a heart attack, stroke or early warning signs such as transient paralysis or loss of vision. If she had, her risk of subsequent stroke would be m uch higher and we would, rightly, load the risk–benefit equation to reflect this. In order to answer the question we have posed, we m ust determ ine not just the risk of stroke in untreated hypertension but also the likely reduction in that risk which we can expect with drug treatm ent. This is, in fact, a rephrasing of a m ore general question ("D o the benefits of treatm ent in this case outweigh the risks? Rem em ber that M rs Jones’ alternative to staying on this particular drug is not necessarily to take no drugs at all; there m ay 10 W H Y READ PAPERS AT ALL? N ot all of these approaches would help M rs Jones or be acceptable to her, but it would be quite appropriate to seek evidence as to whether they m ight help her. W e will probably find answers to som e of these questions in the m edical literature and Chapter 2 describes how to search for relevant papers once you have form ulated the problem. But before you start, give one last thought to your patient with high blood pressure. In order to determ ine her personal priorities (how does she value a 10% reduction in her risk of stroke in five years’ tim e com pared to the inability to go shopping unaccom panied today? In the early days of evidence based m edicine, there was considerable enthusiasm for using a decision tree approach to incorporate the patient’s perspective into an evidence based treatm ent choice. G o back to the fourth paragraph in this chapter, where exam ples of clinical questions are given. D ecide whether each of these is a properly focused question in term s of: • the patient or problem • the m anoeuvre (intervention, prognostic m arker, exposure) • the com parison m anoeuvre, if appropriate • the clinical outcom e. The m other believes that the steroids are stunting the child’s growth and wishes to change to hom eopathic treatm ent. W hat inform ation does the derm atologist need to decide (a) whether she is right about the topical steroids and (b) whether hom eopathic treatm ent will help this child? The GP decides that she m ight be having a m iscarriage and tells her she m ust go into hospital for a scan and, possibly, an operation to clear out the wom b. W hat inform ation do they both need in order to establish whether hospital adm ission is m edically necessary? Ignoring the social aspects of "well baby clinics", what inform ation would you need to decide whether the service is a good use of health resources? Effectiveness in health care: an initiative to evaluate and im prove m edical practice. Evidence based general practice: a retrospective study of interventions in one training practice. Evidence and expertise: the challenge of the outcom es m ovem ent to m edical professionalism. Practical issues of involving patients in decisions about health care technologies. You can apply all the rules for reading a paper correctly but if you’re reading the wrong paper you m ight as well be doing som ething else entirely. Every m onth, around 5000 m edical journals are published worldwide and the num ber of different journals which now exist solely to sum m arise the articles in the rem ainder probably exceeds 250. Only 10–15% of the m aterial which appears in print today will subsequently prove to be of lasting scientific value. A num ber of research studies have shown that m ost clinicians are unaware of the extent of the clinical literature and of how to go about accessing it. Browsing, in which we flick through books and journals looking for anything that m ight interest us. Reading for information, in which we approach the literature looking for answers to a specific question, usually related to a problem we have m et in real life. Reading for research, in which we seek to gain a com prehensive view of the existing state of knowledge, ignorance, and uncertainty in a defined area.
Addition- ally generic 100 mg aurogra free shipping, the husband had to exhibit no psychotic symptoms aurogra 100 mg free shipping, serious brain in- jury buy 100mg aurogra otc, psychopathic disturbance 100 mg aurogra overnight delivery, or substance abuse that was not being treated. Intake workers helped the wives construct individualized safety plans and provided them with information about community resources for battered women. O’Leary and colleagues (1999) conducted a study that included couples therapy as one treatment condition. To protect the safety of the wives, they included couples in the study only if they met the following criteria: the wife did not report sustaining injuries that required medical attention; the wife reported, during a private interview, feeling comfortable being assigned to conjoint treatment; the wife was not afraid of living with her husband; the husband did not meet criteria for alcohol dependence; and neither spouse reported psychotic symptoms nor met criteria for psycho- pathology severe enough to interfere with participation. Also, the man had to admit the perpetration of at least one act of physical aggression. Brannen and Rubin (1996) also included a conjoint therapy condition for husband violent couples. They did not exclude couples based on the severity of husband violence or alcohol abuse. A separate orientation was provided for the wives, in which wives were provided a 24-hour emergency phone number, and phone numbers for law enforcement officials and shelters. In addition, hus- bands and wives completed weekly reports concerning the use of psycholog- ical and physical abuse or threats. If any indication of a threatening situation existed, follow-up calls and additional help were provided for the wife. Based on clinical experience, others have suggested guidelines for deter- mining when conjoint therapy is inappropriate for violent couples (e. Most agree that conjoint treatment is only appropriate for low to moderate levels of ag- gression and only if the wife is not perceived to be in danger of imminent physical harm. Related to this, the wife must not fear the husband, must feel comfortable in therapy with him, and must not feel so intimidated by him that she can’t be honest in therapy. A conjoint format is inappropriate if one spouse Working with Couples Who Have Experienced Physical Aggression 295 does not acknowledge the existence or problematic nature of violence in the relationship or is not willing to take steps to reduce the violence. DATA REGARDING THE EFFICACY OF CONJOINT COUPLES TREATMENT It is standard to review the research data regarding treatment efficacy at the end of a chapter. However, given the strong political controversy concerning the question of whether conjoint treatment is ever appropriate for physically aggressive couples, we believe that a review of the research should be pre- sented before discussing possible conjoint interventions. Thus, we here re- view the only three published studies we know of that have examined the effectiveness of conjoint therapy with couples experiencing husband vio- lence. All three compared conjoint treatment with gender-specific treatment (GST—in which men are seen in a men’s treatment group and women are seen in a women’s support group). In the earliest study, Harris and colleagues (1988) recruited over 70 cou- ples who had experienced husband violence and were requesting therapy at a family service agency. Using random assignment, some couples were as- signed to a couples counseling program that explicitly addressed violence as the primary relationship problem. The other treatment condition involved a combination of gender-specific and couples groups (i. A large number of couples who began treatment did not complete it, particularly among the couples counseling condition (i. Nonetheless, the follow-up data indicated that the two treatment con- ditions were equally effective in reducing the husbands’ physical violence (based on wife report) and in improving the subjects’ sense of psychological well-being. Brannen and Rubin (1996) recruited a sample of couples who were re- ferred to batterer treatment by the court system and who indicated a desire to remain in their current relationship. The conjoint therapy was designed to address husband violence as a primary problem. In contrast to the study conducted by Harris and colleagues (1988), six of the seven batterers who dropped out of treatment were in the gender-specific intervention condition. Follow-up data, collected six months after the completion of treatment, showed no sig- nificant differences between the two groups in levels of recidivism; in both 301 basic goal of therapy—violence desistance—will remain the same for cou- ples of all ethnic backgrounds, as all individuals have the right to live in a violence-free relationship. To our knowledge no studies of physical aggression in same-sex relationships have included randomly selected, representative samples of gay or lesbian couples. Thus, although our understanding of this phenomenon is limited, research examining convenience samples suggests that rates of physical aggression are very similar to those in heterosexual re- lationships (Turell, 2000; Waldner-Haugrud & Gratch, 1997; West, 2002). For example, some same-sex couples have described one partners’ threats of outing the other partner as a means of psychological abuse or to prevent an abused partner from leaving the relationship (Freedner, Freed, Yang, & Austin, 2002).
The mean age of onset of polyps predates the mean age of onset of carcinoma by several years buy cheap aurogra 100 mg online, and cancer rarely develops in the absence of polyps (3) discount aurogra 100 mg overnight delivery. Patients with one or more large ade- nomatous polyps (≥1cm) are at increased risk of developing CRC (4 purchase aurogra 100mg online,5) generic aurogra 100 mg overnight delivery, most of which develop at the site of the polyp, if left in place (5). In addi- tion, patients with genetic predisposition to colonic polyp formation are at greatly increased risk of CRC (6). Finally, several studies have shown that polypectomy signiﬁcantly reduces the incidence of CRC (7–9). Importantly for imaging-based screening, the risk of a polyp harboring a carcinoma is related directly to the size of the lesion: in polyps less than 1cm in size, the risk is estimated to be <1%; in polyps measuring 1 to 2cm, the risk increases to 10%; and in polyps larger than 2cm, the risk is 25% or more (10). Initiation of CRC is thought to require only two mutations in the ade- nomatous polyposis coli (APC) gene (a tumor suppressor gene). The germline APC gene is mutated in familial adenomatous polyposis (FAP) coli (12). Progression from premalignant polyp to invasive carcinoma is the result of further mutations in other genes, including K-ras, DCC, and p53. Epidemiology Colorectal cancer remains the second most common cause of cancer-related death in the United States, with an estimated annual incidence of 150,000 (13). Mortality rates from CRC are equal in both sexes, with approximately 60,000 individuals in the U. The lifetime risk of developing CRC is approximately 6%, while the estimated lifetime risk of CRC-related death is approximately 2. The 5-year survival rate is 90% for early-stage CRC localized to the colon or rectum, 66% if there is regional spread, and 10% if there are distant metastases (13). Risk factors for CRC include FAP, hereditary nonpolyposis colorectal cancer (HNPCC), family history of CRC in a ﬁrst-degree relative before age 60, personal history of CRC, age, diet high in animal fat, chronic inﬂammatory bowel disease, obesity, physical inactivity, diabetes, smoking, and alcohol. Overall Cost to Society Treatment of colorectal carcinoma is estimated to cost between $5. All currently available screening strategies are estimated to cost less than $40,000 per year of life saved, comparable to other screening programs utilized in the U. Goals In general, screening for any disease can be justiﬁed in the following cir- cumstances: (a) the disease is prevalent and is associated with clinically signiﬁcant morbidity and mortality; (b) screening tests are available, Chapter 5 Imaging-Based Screening for Colorectal Cancer 81 acceptable, feasible, and sufﬁciently accurate for the detection of early disease; (c) earlier diagnosis and treatment is associated with improved prognosis; and (d) the sum of the beneﬁts associated with screening out- weighs the sum of the potential harms and costs. The goal of image-based screening is to detect premalignant adenomatous polyps in an average risk population, thereby enabling removal prior to the development of invasive CRC. There is growing consensus that the target lesion is the advanced adenoma, a polyp containing high-grade cellular dysplasia, the vast majority of which are >1cm in size (15). Methodology We reviewed listings and articles available by Medline (PubMed, National Library of Medicine, Bethesda, Maryland) related to colorectal cancer, colon cancer screening strategies, and cost-effectiveness of colon cancer screening. The search covered the period 1966 to January 2004, and employed search strategies including the terms colon cancer, colon cancer screening, barium enema, CT colonography, virtual colonoscopy, and colono- scopy. The authors performed preliminary evaluation of abstracts resulting from the on-line search and followed this with analysis of full articles; analysis was limited to articles and material relating to human subjects and published in English. Summary of Evidence: In a person with average risk for CRC, the most sig- niﬁcant risk factor for developing CRC is age. Average-risk individuals are those who are deemed not to have an increased or high risk for colorectal carcinoma. Individuals at increased or high risk are those who have a personal or family history of FAP syndrome, hereditary nonpolyposis colorectal cancer, adenomatous polyps, or colorectal cancer, or a personal history of inﬂammatory bowel disease, colonic polyps, or CRC. Methods to detect polyps and colon cancer include fecal occult blood testing (FOBT), ﬂexible sigmoidoscopy, and colonoscopy. Imaging-based screening methods are double-contrast barium enema (DCBE), and more recently computed tomographic colonography (CTC). Published randomized controlled trials (RCTs) and case-control studies have demonstrated that FOBT and sigmoidoscopy can reduce CRC incidence and mortality. To date, there are no RCTs evaluat- ing sigmoidoscopy, DCBE, or colonoscopy in average risk screening pop- ulations. Recent data suggest that CTC has performance characteristics equivalent to conventional colonoscopy for detection of polyps, when ade- quately trained radiologists employing state-of-the-art technique perform it. The American Cancer Society currently recommends that all adults aged 50 or older with average risk of CRC follow one of the following screen- ing schedules: FOBT every year; ﬂexible sigmoidoscopy every 5 years; annual FOBT and ﬂexible sigmoidoscopy every 5 years (preferred to either alone); DCBE every 5 years; colonoscopy every 10 years. In persons with increased risk of CRC, screening may be more frequent and start at an earlier age (see Special Case: Patients with Increased Risk of Colorectal Cancer, below).
They talked about a sense of well-being that they hadn’t experienced in a long time discount 100mg aurogra mastercard. But Richard Hazard also told us of the pain he endured during his recuperation from this very painful operation cheap 100 mg aurogra amex. It is believed that the results from implants that use fetal brain tissue are much better than those that use the patient’s own adre- nal gland buy discount aurogra 100mg. Although he had had Parkinson’s for twenty years aurogra 100 mg generic, he experienced real improvement in his mobility even a year after the implant. The results are considered to be the first well-documented and well-verified fetal implant results to be reported. The opera- tion was performed by the scientist Olle Lindvall and a group of other scientists in Sweden, where research with tissues of aborted fetuses is permitted. Before surgery, the man’s parkinsonian symp- toms were so severe that even with medication, he spent half of his time frozen in four or five "off " states per day. Within three months after surgery, with medication, he was experiencing only one or two brief "off " periods a day and mild symptoms. His medications and therapies 91 rigidity and bradykinesia were significantly reduced. Special brain tests called PET scans (positron emission tomography) showed that the fetal cells survived, grew, and pro- duced dopamine after they were implanted. Lindvall and the eighty to ninety cell researchers at Lund Uni- versity in Sweden have continued to make progress in the field. With the transplantation of fetal brain cells, some patients were able to stop taking medications such as levodopa altogether. Yet not all the patients experienced the same benefits, and some had negative side effects, such as dyskinesias. And, of course, the use of fetal brain cells remains controver- sial in many countries, leading scientists to look elsewhere. According to the BBC, Lindvall told a September 2003 con- ference of researchers in London that stem cells could be con- verted into new brain cells to slow physical deterioration. The hope, he said, was to chemically induce adult cells to change into the type needed for transplant—the dopamine- producing neurons. Bush agreed to allow federal funding for approximately sixty lines of already existing embryonic stem cells. Just months earlier, scientists at the National Institute of Neu- rological Disorders and Stroke, a part of the National Institutes of Health, had shown that they could use mouse embryo cells to reduce Parkinson’s symptoms in rats. Studies at the University of Minnesota Medical School also showed that adult human stem cells, taken from bone marrow, could be used to make every type of tissue found in the human body. In 1990, the provincial government of Nova Scotia, Canada, reversed its ban on fetal tissue transplants, thus permit- ting a team from Dalhousie University and Victoria General Hos- pital to prepare for the clinical trials of fetal tissue implants in 92 living well with parkinson’s four or five Parkinson’s patients. Action by the Nova Scotia divi- sion of the Parkinson Foundation of Canada, a telephone cam- paign by local chapters and members, and strong support from the media were largely responsible for the ban’s reversal. In 1996, Jim Finn of Rhode Island was one of the first dozen people to have fetal pig cells injected into his brain during a procedure at Lahey-Hitchcock Clinic in Burlington, Massachu- setts. While research on the use of animal tissue continues, the great- est hope may lie in using human sources, whether embryo or adult. While the federal government moves slowly along this line, private foundations press forward. Fox Foundation for Parkinson’s Research announced its bestowal of more than $4 million in grants on two scientific teams from Sweden and seven from the United States, to work specifically in the field of stem cell lines. The foundation followed up five months later with the MJFF Research Fellowship program, with plans to distribute more than $1 million in two fellowships. Currently, more than 50,000 Americans are diagnosed with Parkinson’s disease each year, contributing to a total of well over 1 million Parkinson’s patients across the country. By the fall of 2002, scientists were preparing to conduct trials for gene therapy, a project that would utilize a gene carried by a virus to help the brain make a chemical called GABA (gamma- aminobutyric acid) that helps to calm tremor. In the spring of 2001, the journal The Scientist reported that a DNA advisory committee at the National Institutes of Health had voted unanimously to recommend the protocol, which had proved successful in a study with rats. This advance not only was reported in the journal Science but was publicized widely through the print and broadcast media via the Associated Press.