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By R. Surus. Eastern Mennonite University.

University of Cape Town said to industry representa- Penang:International Baby Food Action Network generic 10 mg haldol with visa medications zoloft,1998 buy cheap haldol 1.5mg online 911 treatment. Violationsoftheinternationalcodeofmarketingofbreastmilk Research Organisation: "There is a hidden agenda in substitutes:prevalence in four countries. Getting research findings into practice Using research findings in clinical practice S E Straus, D L Sackett In clinical practice caring for patients generates many This is the fifth questions about diagnosis, prognosis, and treatment Summary points in a series of that challenge health professionals to keep up to date eight articles with the medical literature. A study of general analysing the Practising evidence based medicine allows practitioners in North America found that two gap between clinicians to keep up with the rapidly growing clinically important questions arose for every three research and body of medical literature patients seen. General Evidence based medicine improves clinicians’ physicians who want to keep up with relevant journals skills in asking answerable questions and finding NHS Research and face the task of examining 19 articles a day 365 days a the best evidence to answer these questions Development 2 Centre for Evidence year. Based Medicine, One approach to meeting these challenges and Evidence based medicine can provide a Nuffield framework for critically appraising evidence Department of avoiding clinical entropy is to learn how to practise evi- Clinical Medicine, dence based medicine. Evidence based medicine Oxford Radcliffe Practising evidence based medicine encourages Hospital NHS Trust, involves integrating clinical expertise with the best Oxford OX3 9DU clinicians to integrate valid and useful evidence available clinical evidence derived from systematic S E Straus, 3 with clinical expertise and each patient’s unique deputy director research. Individual clinical expertise is the profi- features, and enables clinicians to apply evidence D L Sackett, ciency and judgment that each clinician acquires to the treatment of patients director through clinical experience and practice. Best available Correspondence to: clinical evidence is clinically relevant research which Dr Straus may be from the basic sciences of medicine, but sharon. The box at the bottom of BMJ 1998;317:339–42 evidence based medicine is and how it can be practised the next page illustrates the five steps necessary to the by busy clinicians. Four components of the question must be specified: the patient or problem Clinical findings being addressed; the intervention being considered (a Which is the most accurate way of diagnosing ascites cause, prognostic factor, or treatment); another on physical examination: fluid wave or shifting intervention for comparison, when relevant; and the dullness? To illustrate how many questions may arise in the Differential diagnosis In a patient with cirrhosis and ascites which is most treatment of one patient consider a 65 year old man likely to cause gastrointestinal bleeding, variceal with a history of cirrhosis and ascites secondary to haemorrhage or peptic ulcer disease? On In a patient with suspected alcohol abuse is the use of examination he is disoriented and looks unwell but is the CAGE questionnaire specific for diagnosing afebrile. In addition to spider naevi and gynaeco- Does gastrointestinal bleeding increase the risk of mastia he has ascites. Dozens of questions may arise in treating this Treatment patient; some are summarised in the box opposite. The Does treatment with somatostatin decrease the risk of questions cover a wide spectrum: clinical findings, aeti- death in a patient with cirrhosis and variceal bleeding? This can be done by of ascites would I gain more from spending an hour in considering the question that would be most the library reading a textbook or spending 15 minutes important to the patient’s wellbeing and balancing it on the ward computer looking at the CD ROM against a number of factors including which question version of the same textbook? Most rigorous of these are the systematic reviews on the effects of Searching for the best evidence health care that have been generated by the Cochrane Collaboration, readily available as The Cochrane Library A focused question sharpens the search for the best on compact disc,7 and accompanied by abstracts for evidence. Strategies that increase the sensitivity and critically appraised overviews in the Database of specificity of searches have been developed and are Abstracts of Reviews of Effectiveness created by the NHS available both in paper4 and electronic forms (for 7 Centre for Reviews and Dissemination. A systematic example, at the site established by the NHS Research review from The Cochrane Library is exhaustive and and Development Centre for Evidence-Based Medi- therefore takes years to generate; reviews from the Database of Abstracts of Reviews of Effectiveness can be generated in months. Still faster is the appearance of clinical articles about diagnosis, prognosis, treatment, Steps necessary in practising evidence based quality of care, and economics that pass both specific medicine methodological standards (so that their results are • Convert the need for information into clinically likely to be valid) and clinical scrutiny for relevance and relevant, answerable questions that appear in evidence based journals such as the ACP • Find, in the most efficient way, the best evidence with Journal Club, Evidence-Based Medicine, and Evidence- which to answer these questions (whether this evidence comes from clinical examination, laboratory Based Cardiovascular Medicine. This selection process tests, published research, or other sources) reduces the amount of clinical literature by 98% to the • Critically appraise the evidence for its validity 2% that is most methodologically rigorous and useful to clinician. For example, the site established by the NHS Research and Develop- ment Centre for Evidence-Based Medicine (URL given above) permits browsers to apply the specificity of shifting dullness and the sensitivity of a history of ankle swelling to diagnose patients thought to have ascites; this information could be used to answer some of the questions posed in the diagnosis of the patient with cirrhosis. If the foregoing strategies for gaining rapid (clinicians who produce them become more effective access to evidence based medicine fail clinicians can in searching and critically appraising evidence) than to resort to the time honoured and increasingly user potential users (since the summaries undergo little friendly systems for accessing the current literature via peer review and may be useful mainly for their Medline and Embase, employing methodological qual- citations). Applying the evidence Critically appraising the evidence Applying the results of critical appraisals involves the Once clinicians find potentially useful evidence it has essential second element of evidence based medicine: to be critically appraised and its validity and usefulness integrating the evidence with clinical expertise and determined. Guidelines have been generated to help knowledge of the unique features of patients and their clinicians evaluate the validity of evidence about situations, rights, and expectations. Only after these diagnostic tests (was there an independent, blind com- things have been considered can we then decide parison with a gold standard of diagnosis? The whether endoscopic services are available for sclero- trend towards publishing more informative abstracts therapy or ligation of varices, and if somatostatin also makes it easier for clinicians to determine whether should be used in the interim if endoscopy is not read- research findings are applicable to their patients. Accordingly, the decision of whether to For the patient with cirrhosis and haematemesis, an treat the patient with somatostatin would have to grow assessment of the Cochrane review finds that it is valid, out of a therapeutic alliance with the patient who and the results showed that somatostatin did not have would have to be informed about the potential risks a statistically significant effect on survival. After finding an article and determining if its To complete the cycle of practising evidence based results are valid and useful, it is often helpful to file a medicine clinicians should evaluate their own per- summary so that it can be referred to again or passed formance. One way to do this is to prepare a each stage by asking whether their questions were one page summary that includes information on the answerable, by asking if good evidence was found patient, the evidence, and the clinical bottom line quickly, by asking if evidence was effectively appraised, organised as a critically appraised topic (CAT).

Bone Scanning and Single Photon Emission Computed Tomography In two studies generic 5mg haldol fast delivery medications you can take while nursing, bone scan sensitivity ranged from 25% to 85% buy 10mg haldol free shipping medicine omeprazole 20mg, with the higher sensitivity achieved by using SPECT (73,74) (both studies moderate evidence). These studies suffered from a lack of high-quality reference standards and independent interpretations. What Is the Role of Imaging in Patients with Back Pain Suspected of Having Spinal Stenosis? On MR, the radiologists’ general impression, rather than a mil- limeter measurement, is valid. Plain Radiographs No studies provided good estimates of radiographic accuracy in detecting central stenosis. Since radiographs can only estimate bony canal compro- mise, the sensitivity for central stenosis is undoubtedly poorer than that of CT or MR, which depict soft tissue structures. Methodologic quality was variable but generally poor, making pooling of the data impractical. Central stenosis is also common in asymptomatic persons, with a prevalence of 4% to 28% (limited evidence) (76), and thus the specificity of CT for central stenosis, as it is for disk herniations, is likely less than the reported estimates. Of note, two recent studies suggest that the readers’ general impres- sion of central stenosis is valid. In a retrospective study comparing elec- tromyogram (EMG) findings to radiologists’ MR interpretations, Haig Chapter 16 Imaging of Adults with Low Back Pain in the Primary Care Setting 311 et al. Two neurosurgeons, two orthopedic spine surgeons, and three radiologists reviewed MRs from patients with a clinical and radiologic diagnosis of lumbar spinal stenosis. In concordance with Haig’s work, they found that the readers’ subjective evaluation of stenosis significantly correlated with the calculated cross-sectional area (p <. Bone Scanning and Single Photon Emission Computed Tomography Bone scanning has no role in central stenosis imaging. Summary of Evidence: The majority of patients with LBP think imaging is an important part of their care. However, in patients who are imaged, results of satisfaction with care are conflicting and overall not significantly higher than in those who were not imaged. Additionally, when plain radi- ographs are obtained, outcome is not significantly altered (and in some cases, is worse). But when MR or CT is used early in the workup of LBP, there is a very slight improvement in patient outcome. Supporting Evidence: While the majority of studies attempt to validate a modality by its diagnostic accuracy, possibly more important is whether the test actually alters patient outcomes. At 6 weeks and at 1 year, there was no difference between the groups in physical functioning, disability, pain, social functioning, general health, or need for further referrals. However, in the treatment arm at both 6 weeks and 1 year, there was a small improvement in self-reported overall mental health (Table 16. In a similar randomized controlled trial of 421 patients, Kendrick and colleagues (80) actually found a slight increase in pain dura- tion, and a decrease in overall functioning in the radiograph group at 3 months, though at 9 months there was no difference between the groups (strong evidence). However, while both groups improved from baseline, there was slightly more improvement in the early imaging arm at both 8 (p =. Our group also performed a randomized controlled trial assigning primary care patients with LBP to receive either lumbar spine radiographs or a rapid lumbar spine MR (83) (strong evidence). Vroomen and colleagues (84), however, did find in patients with leg pain, utilizing early MR helped predict the patient’s prognosis (strong evidence). Patient satisfaction and expectations must also be accounted for when developing an imaging strategy. Many patients with LBP believe imaging is important or necessary to their care (85–87). However, there are con- flicting results regarding improved satisfaction of care when imaging is actually performed. In their randomized trial using plain radiographs, Kendrick and colleagues (80) discovered that if participants had been given the choice, 80% would have elected to be imaged (strong evidence).

However order haldol 5 mg line symptoms constipation, because of the complexity that is often involved in using CBCT techniques appropriately haldol 10 mg on-line treatment chronic bronchitis, clinicians are advised to be skilled in applying them. Continuing education, reading, and supervision can assist in devel- oping competence for ethical, effective practice. Therapists need to be open to using a systematic approach in order for CBCT to be successful. A large number of therapists from all disciplines identify themselves as cognitive behavioral. Training programs and continuing education are increasingly emphasizing CBCT methods. It is clear that CBCT is highly adaptable to short-term and managed-care models as well, and extensive, ongoing CBCT research will 136 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES continue to demonstrate its applicability to clients, insurers, and clinicians. Psychotherapy integration is also a growing trend, and the natural appeal of blending theories and techniques will undoubtedly persist and increas- ingly be validated by research. It is hoped that these trends will be accom- panied by recognition by all in the psychotherapy field of the need for a complete understanding and thorough training in the foundations of cogni- tivism, behaviorism, and other relevant integrative approaches. Short-term behavior interventions with delinquent families: Impact on family process and recidivism. A comparison of behavioral contracting and problem solv- ing/communications training in behavioral marital therapy. The role of cogni- tions in marital relationships: Definitional, methodological, and conceptual is- sues. The usefulness of cognitive restructuring as an adjunct to behavioral marital therapy. Supplementing behavioral mari- tal therapy with cognitive restructuring and emotional expressiveness train- ing: An outcome investigation. Assessing the effects of behavioral mar- ital therapy: Assumptions and measurement strategies. Theoretical foundations and clinical applications of the premack principle: Review and critique. Cognitive and behavioral interventions: A com- parative evaluation with clinically distressed couples. Behavioral couple therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. The effects of communication skills training and contracting on marital relations. A marital/family discord model of depres- sion: Implications of therapeutic intervention. Effectiveness of behavioral marital ther- apy: Empirical status of behavioral techniques in preventing and alleviating marital distress. Effects of behavioral marital therapy on couples’ communication and problem-solving skills. A comparison of the gen- eralization of behavioral marital therapy and enhanced behavioral marital therapy. A component analysis of behavioral marital therapy: The relative effectiveness of behavior exchange and communication/problem solv- ing training. Clinical significance of improvement re- sulting from two behavioral marital therapy components. Variability in outcome and clinical significance of behavioral marital therapy: A reanalysis of outcome data. Component analysis of behavioral marital therapy: 2-year follow-up and prediction of re- lapse. Differential effects of experiential and problem-solving interventions in resolving marital conflict. The generalisation of cognitive behavioural marital therapy in behavioural, cognitive and physiological domains.