Vice Chair, University of Illinois College of Medicine
Finally erectile dysfunction natural remedies diabetes cost of kamagra oral jelly, we offer our thanks to our RAND colleagues Paul Shekelle and Marge Pearson for their thoughtful review of an earlier draft of this final report erectile dysfunction for young adults buy generic kamagra oral jelly 100 mg on line. Any errors of fact or interpretation are erectile dysfunction commercial bob buy 100mg kamagra oral jelly otc, of course, the responsibility of the authors and not of any of those who pro- vided feedback on our efforts. ACRONYMS AND ABBREVIATIONS ACH Army community hospital ADS Ambulatory Data System AMC Army medical center AMEDD Army Medical Department CBC complete blood count CEIS Corporate Executive Information System CHCS the MTFs’ clinical information system CHES Center for Health Education and Studies CHPPM Center for Health Promotion and Preventive Medicine CIW Clinical Integrated Workplace CME continuing medical education CTMC Consolidated Troop Medical Clinic DoD Department of Defense ER emergency room ESR erythrocyte sedimentation rate FY fiscal year KMN Knowledge Management Network MEB Medical Evaluation Board xxxi xxxii Evaluation of the Low Back Pain Practice Guideline Implementation MEDCOM United States Army Medical Command MEPRS Medical Expense and Performance Report System for Fixed Military Medical and Dental Treatment Facilities MTF military/medical treatment facility NSAID nonsteroidal anti-inflammatory drug PA physician assistant PASBA Patient Administration Systems and Biostatistical Activity PEC PharmacoEconomic Center PT physical therapy QI quality improvement QM quality management SADR Standard Ambulatory Data Record SIDPERS Standard Installation/Division Personnel System TMC troop medical clinic UM utilization management USPD Uniformed Services Prescription Database VA Veterans Affairs, Department of Chapter One INTRODUCTION The Army Medical Department (AMEDD) is committed to establish- ing a structure and process to support its military/medical treatment facilities (MTFs) in implementing evidence-based practice guidelines to achieve best practices that reduce variation and enhance quality of medical care. AMEDD contracted with the RAND Corporation to work as a partner in the development and testing of guideline im- plementation methods for ultimate application in an Army-wide guideline program. Taking the approach of testing new methods on a small scale, the AMEDD/RAND project fielded three sequential demonstrations over a two-year period, in each of which participating MTFs implemented a different clinical practice guideline. All of the demonstrations worked with practice guidelines that were established collaboratively by the Departments of Veterans Affairs (VA) and Defense (DoD). In the first demonstration, four MTFs in the Great Plains Region im- plemented the practice guideline for low back pain. The asthma guideline was implemented by four MTFs in the Southeast Region, and the diabetes guideline was implemented by two MTFs in the Western Region. RAND performed evaluations for each demonstration that included a process evaluation and an analysis of effects on service delivery. Specific components of this work included the following: • Process evaluation documented the implementation activities of participating MTFs, described their successes in changing clini- cal practices, identified successes and challenges reported by the 1 2 Evaluation of the Low Back Pain Practice Guideline Implementation sites, and obtained their feedback regarding U. This report presents the results from our evaluation of the imple- mentation of the low back pain guideline in the Great Plains Region demonstration. These findings build on and extend the results of our process evaluation of the first three months of activity for the low back pain demonstration. Chapter Three reports the benchmarking of baseline performance of the nine MTFs in the study on each of the six measures (see Table 3. Results of the pro- cess evaluation are reported in Chapters Four and Five, and results of the evaluation of guideline effects are presented in Chapter Six. Fi- nally, in Chapter Seven we synthesize the results of the full evalua- tion and identify lessons learned, issues to be addressed, and impli- cations for systemwide guideline implementation strategies. Introduction 3 THE DoD/VA GUIDELINE ADAPTATION PROCESS DoD and the VA initiated a collaborative project in early 1998 to es- tablish a single standard of care in the military and VA health sys- tems. This project is led by a working group consisting of two repre- sentatives from each of the three military services and the VA. The goals of this project are (1) adaptation of existing clinical practice guidelines for selected conditions, (2) selection of two to four indica- tors for each guideline to benchmark and monitor implementation progress, and (3) integration of DoD/VA prevention, pharmaceutical, and clinical informatics efforts. The DoD/VA working group designated an expert panel for each practice guideline, consisting of representatives from the three mili- tary services and the VA, with a mix of clinical backgrounds relevant to the health condition of interest. The expert panel reviewed exist- ing national guidelines for that condition, examined and updated the scientific evidence supporting the guidelines, and established an adaptation of one or more of the guidelines for use in the military and veteran health systems. Each panel was also asked to develop recommendations to the DoD/VA guideline working group for the metrics to be used by the military services and the VA to monitor progress in guideline implementation. With this approach to guideline development, DoD and the VA have made a commitment to use of evidence-based practices in their health care facilities. Each practice guideline is a statement of best practices for the management and treatment of the health condition it addresses.
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Fighting against medical charlatanism means, above all, explain- ing and explaining again, spelling things out, making it clear to the pa- 134 Cancer, AIDS and Eternal Youth tients that such techniques may or may not produce the advertised ef- fects, that a technique may succeed in laboratory testing but still may not necessarily work for the patient, and that such and such biochemi- cal effect, even if it is experienced as advertised, is not necessarily the sign of a physiological healing action. In the case of the Solomidès synthetic physiatrons, the officials should have taken the time to explain that they were prohibited not only because the components were toxic, but also because of the ab- sence of any real clinical trials that might have proven both the effec- tiveness of the treatment and its long-term harmlessness for the pa- tient. Indeed, some experiments have been conducted in an effort to prove the effectiveness of the Solomidès products, but they are uncon- vincing, for two reasons: - they were carried out in vitro on isolated cells, which is abso- lutely not proof that the product works in the context of a human organism; - the tests that were conducted on individual patients were car- 2 ried out on too small a sample to be persuasive. The patamedicine lobby includes spin-masters highly accom- plished in the art of publishing and distributing "white papers" in- tended to reveal a plot on the part of the great pharmaceutical compa- nies, the medical Mafia and the Government to prohibit a certain tech- nique that is supposed to be THE definitive solution to medical prob- lems. The authorities who are responsible for maintaining public health must stop leaving themselves exposed to this criticism from the followers of patamedicine and should publish in their turn articles and papers exposing these endless hoaxes. In this period that is so critical for the future of the health care system, when the chaotic proliferation 135 Healing or Stealing? Given the debate over how the role of the State and the insurance companies in the health care system, given our growing anguish as we recognize the limits of medicine, the patient may be tempted to take refuge in illusory paradises maintained by the special interest groups promoting fake natural health remedies. And when medical decisions are delegated to bean- counters and government bureaucrats, it certainly does not help get the ship back on course. The Beljanski Scandal The revelation that French President François Mitterrand had cancer touched off a debate that actually had its roots some fifteen years earlier. The president was supposedly one of the recipients of a miracle drug produced by Mirkos Beljanski. At the end of the 1980’s, the holding company Abraxas, gave Pro- fessor Jean Cahn a product to test, to verify whether it was effective 3 against the AIDS virus. Andrieu, Director of the Tumor Immunology Laboratory at the Laennec Hospital in Paris, and by Dr. Chantal Damais, Research Direc- tor at INSERM, the tests showed "remarkable" results, and according to the experimenters the product, in vitro, inhibited the release of Inter- leukin 6 by white blood cells from seropositive patients. In spite of these promising results, Beljanski never got clearance from the French equivalent of the FDA to bring his products to market. On the con- trary, Beljanski refused any study that might have been able to assess 136 Cancer, AIDS and Eternal Youth fairly the viability of his products. After Monod, Lwoff and Jacob won the Nobel Prize in medicine in 1965, Beljanski was upset with his former colleagues and left the Pasteur Institute. He then took a job as research director in the Pharmacy School of Châtenay-Malabry. And at that time he devoted his applied research to cancer, in particular, and then to AIDS. In 1983, Beljanski made waves by marketing a product that claimed to restore the percentage of white blood cells in a patient’s blood. This product was presented by the patamedical press as a won- der drug for desperate cases, such that of young Valerie, an eleven year old, who was cured of medullary aplasia after treatment with BRL (Beljanski Remote Leucocyte). Fifteen years later, BRL has not, to our knowledge, had any major medical repercussions — which is astonish- 4 ing, for a drug of such a great importance. After retiring in 1988, Beljanski holed up in a garage that he bap- tized with the pompous title of the Center for Biological Research (CERBIOL).
Following this declaration statistics of erectile dysfunction in us order kamagra oral jelly 100 mg with visa, homeopathy would make great strides erectile dysfunction treatment online order 100 mg kamagra oral jelly overnight delivery, marching forward in time with the lyric fantasies of the Reich erectile dysfunction treatment jaipur generic kamagra oral jelly 100mg on line. At the same time, tests were ordered, which were carried out under the direction of Dr. Fritz Donner, a renowned homeopath, and under the supervision of a pharmacologist and an internist. However, the results were not published; on the contrary, they were completely hidden from the entire international medical commu- nity, for many long years. A translation of the report written by Donner in 1966 finally appeared in a French journal in 1969 (the report was never published by the German press). Moreover, the book by Henri 14 Broch, who reported these facts, quotes two letters from F. Unseld, President of the Central German Associa- tion of Homeopathic Doctors, and the other to H. These long and closely argued letters show, among other things, that: 38 And Then Came Hahnemann x the results were all negative; x Dr. Donner was pressured to cover up these results; 15 x certain pathogeneses are purely products of the imagination; x one can expect to find approximately 1000 symptoms if one gives 30 testers, for one month, only. Donner adds: The real situation of homeopathy cannot be communicated to the homeopaths and cannot be published in homeopathic newspapers. In the best homeopathic tradition, everyone can utter the greatest nonsense in the world and it will be printed; on the other hand, a paper on the solid bases of an important drug against diphtheria will never be published, and any researcher working on its sources will be threatened with immediate dismissal! Fritz Donner, a homeopath whose critical mind deserves recogni- tion, gave an assessment of this verification of homeopathic methods that requires no further comment: "Complete Failure". And yet, he con- fesses honestly: "I avoided to the maximum extent mentioning in my report anything that would have proven fatal to homeopathy. If all testing procedures suggested are refused by the homeopaths, this refusal is the proof that the treatments are indeed not effective and that the producing laboratories are privately convinced, as are their zealous practitioners, that it would be dangerous to submit to a really inde- pendent series of tests. Oscillococcinum, the Miracle Drug Personalized treatment is the decisive argument advanced by all homeopaths who deny the value of double blind testing, homeopathy against placebo; they say that this type of test cannot apply to homeo- pathic treatment because it is adapted to the individual patient, and is not based on pathology alone but also on the "temperament" and the "biotype" of the patient. However, these same homeopaths, convinced as they are of the need to tailor the treatment to the individual, are strangely quiet when it comes to discussing the value of homeopathic treatments that are broadly prescribed, such as Arnica, for various and sundry afflictions, and especially Oscillococcinum, the miracle anti-influenza drug that en- joys constant publicity in all the media as soon as the weather turns nippy and people start to come down with colds and flus of all kinds. Oscillococcinum is one of the ten top-selling drugs in France and it is prescribed for both the flu and the cold, abandoning all the principles of individualized treatment. Oscillococcinum, so felicitously named, seems to be a weakened form of some unspecified bacillus of the "coccus" family — pneumococcus, en- terococcus, streptococcus and so on. Our oscillococcus is the homeopathic dilution of an extract of duck liver and heart. It should be noted that this "original" product takes advantage of a special ruling in the public health code. It is the only product to have officially bene- fited from a specific measure — allowing it to be manufactured accord- 17 ing to the Korsakovian principle of dilution, which was prohibited in France until 1992. In 1919, during a worldwide flu epidemic, a French doctor named Joseph Roy observed an "oscillating" variation in his patients’ conditions and an "oscillating" amount of a certain microbe, which he decided to call the oscillococcus. He went 40 And Then Came Hahnemann on to observe the same thing in a certain number of viral diseases — herpes, chicken pox, shingles — and for good measure, he also detected it in the blood of cancer patients. Fortified by these observations, he decided to test a vaccinotherapy, based on an extract of oscillococcinum, on cancer patients. The results were not entirely encouraging; the pa- tients, after suffering a brief aggravation of their condition, died. Roy went looking for it among various types of animals and ended up discovering it in the liver of the Long Island duckling.
Physicians and other health professionals are increasingly recognizing the need that couples and families have for assistance in dealing with the psychosocial impact of illness erectile dysfunction jacksonville purchase 100mg kamagra oral jelly, from infertility and epilepsy to cancer and heart disease erectile dysfunction blood flow purchase 100mg kamagra oral jelly with amex. It behooves us in the mental health professions to equip our- selves to deal with these needs erectile dysfunction caused by statins purchase 100mg kamagra oral jelly overnight delivery. This chapter discusses how illness affects couples, reviews the basics of medical family therapy, and presents a tech- nique for addressing emotional roadblocks in the marital or couple relation- ship that can emerge as couples deal with the particular challenges that illness presents. A REVIEW OF THE LITERATURE ON PSYCHOTHERAPY WITH COUPLES FACING ILLNESS A significant body of research examines the impact of couple relationships on health, and the impact that chronic illness or disability has on the couple (Campbell, 2003; Kiecolt-Glaser & Newton, 2001; Osterman et al. Very few studies, however, focus on couple inter- ventions that might inform psychotherapeutic treatment. We review two cases here and then turn to the clinical literature on couple interventions with medically ill patients that provides guidance for therapists working with this population. Early research focused on couple interventions to improve disease man- agement, medical compliance, quality of life, and mortality for patients with chronic illness. In another controlled study (Taylor, Bandura, Ewart, Miller, & De- Busk, 1985), wives of heart attack patients were asked either to observe their spouse take a treadmill stress test or to take the test with their spouse, three weeks after the heart attack. Wives who walked the treadmill and directly experienced what their husbands were capable of were significantly more confident and less anxious about their husbands’ health and capability than the wives who only observed the test. They were also less overprotective of their husbands, which may relate to the finding that their husbands showed improved cardiac functioning at 11 and 26 weeks after the heart attack. Managing Emotional Reactivity in Couples Facing Illness 255 Although there is a significant body of clinical literature that addresses psychotherapy with families facing illness (see McDaniel, Hepworth, & Doherty, 1992), literature that focuses on helping couples in particular is still relatively scarce—usually found either in textbooks on couples therapy with illness treated as a special issue (e. A wide variety of specific approaches have been offered on the subject of couples and illness, including behavioral (Schmaling & Sher, 2000), existen- tial (Lantz, 1996), and interpersonal (Lyons, Sullivan, Ritvo, & Coyne, 1995). Many of these approaches delineate key issues that couples must con- front when illness strikes and offer strategies, drawn from their particular theoretical framework, to help couples negotiate these issues. Rolland (1994) addresses the impact of illness on intimacy in the couple relationship, focusing in particular on the need for the therapist to assist the couple in addressing the relationship imbalances (skews) that can emerge as a result of illness in one member. Differences in ability that de- rive from the health status of each member of the couple can translate into differences in power and control between them, leading to tension, re- sentment, guilt, distance, and discouragement. Rolland recommends that the couple redefine the illness as "our" problem, rather than "your" or "my" problem, and work as partners to manage the challenges they both face as a result of the illness. Rolland also suggests that therapists as- sist the couple to resist the tendency of illness to dominate the family identity by drawing a boundary around the illness. This can be done by, for example, establishing protected time in which illness talk is off limits as well as by maintaining their pre-illness family and social routines as much as possible. Kowal, Johnson, & Lee (2003) have applied the tenets of Emotionally Focused Therapy (EFT) to working with couples and illness; EFT is an in- tegration of experiential and systemic approaches to therapy that under- stands couple conflict as relating to behaviors and emotions that express underlying attachment needs. They argue that since attachment style has been shown to be related to the onset and exacerbation of chronic illness as well as to a variety of health-related behaviors, then addressing attach- ment needs and the emotions they generate by use of EFT is a promising avenue for assisting couples dealing with chronic illness. They go on to note that "the goals of EFT in working with chronic illness in couples are to normalize and validate each partner’s experience, to help partners process their emotional experiences, to externalize negative interaction 256 SPECIAL ISSUES FACED BY COUPLES cycles, and to help partners seek safety, security, and comfort from each other (i. COUPLES AND ILLNESS—STATEMENT OF THE PROBLEM Factors that influence how illness affects a couple include the nature and severity of the illness; individual variables such as age, gender, ethnicity, general coping style, and previous experience with illness; and relation- ship variables such as degree of conflict, stability, and trust, communica- tion and problem-solving styles, and relationship satisfaction. Issues facing couples dealing with illness include loss—of ability, of a sense of normalcy, of expectations for the future, and possibly loss of life; identity changes precipitated by the presence of the illness; relationship imbalances deriv- ing from the loss of function in the ill spouse; the need to communicate about difficult subjects; establishing the meaning of the illness; the legacy of transgenerational family experiences with illness, vulnerability, and loss; gender issues; caregiver burden and burnout; and the ill spouse’s feel- ings of guilt and uselessness. Literature about helping couples deal with the impact of illness gener- ally addresses the emotional and pragmatic impact of illness on the couple relationship, including loss of function and identity, reassignment of roles, learning to communicate about difficult issues, and so on. What has re- ceived less attention is how to understand and address complicated emo- tional reactions to illness—reactions that seem to go beyond what would be expected, even given the extremely difficult nature of the challenges that illness can present. For some couples, illness presents an opportunity to put things in per- spective, resulting in increased intimacy and relationship satisfaction in the face of challenge.
If she had losartan causes erectile dysfunction 100 mg kamagra oral jelly with mastercard, her risk of subsequent stroke would be m uch higher and we would erectile dysfunction ginkgo biloba effective 100 mg kamagra oral jelly, rightly impotence groups discount kamagra oral jelly online, 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.
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