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Final emphasis takes a longer- term perspective proven prednisolone 20 mg allergy forecast victoria tx, assessing the effects of program changes on client outcomes buy prednisolone 10mg with amex allergy medicine ok while breastfeeding. Many of the measures developed to assess effects in the second and third evaluation phases can be used by the programs for ongoing monitoring. The RAND evaluation for the low back pain guideline demonstration encompasses the first two evaluation phases. Lessons were drawn from the implementation process itself to strengthen future guide- line implementation activities (introducing new practices), and data were analyzed to assess the early effects of the low back pain guide- line on health care processes (achieving intended changes in prac- tices). PROCESS EVALUATION METHODS In the process evaluation for the low back pain guideline demonstra- tion, we collected information from the participating MTFs through a series of site visits, monthly progress reports prepared by participat- ing MTFs, and questionnaires completed by individual participants. Three visits were conducted at each demonstration site: an introduc- tory visit before the kickoff conference, a post-implementation visit in June 1999 at three to four months after the MTFs began imple- menting the guideline, and another visit in February 2000 (at month nine or ten of implementation). All groups were candid in reporting progress and identifying issues and problems they encountered. At the conclusion of each evaluation visit, we briefed the MTF command group about what we had learned and issues identified. Summary reports of the results of the ______________ 1Following the kickoff conference in November 1998, there was a delay of approximately four months before the sites began implementation actions for the low back pain guideline. The delay was due to time conflicts during the holidays as well as delays in completion of the practice guideline, metrics, and toolkit items. Methods and Data 19 second round of site visits for the four participating MTFs are pre- sented in Appendix B. These reports document the status of the MTFs at essentially the end of their proactive implementation activi- ties. A second source of process evaluation information was monthly progress reports prepared by the participating MTFs and submitted to RAND. These reports provided valuable information on imple- mentation progress over time, and they also served as a stimulus for action by both the MTFs and MEDCOM as the MTFs identified issues requiring resolution. Finally, we developed brief questionnaires designed to assess the climate in the MTFs for guideline implementation, both at baseline and at the end of the demonstration, and to gather information from participants about their experiences in working with the guideline. Although the sample sizes were too small to be used for any rigorous statistical analysis, the completed questionnaires offered useful in- sights that we considered in developing our findings. The survey re- spondents were those most actively involved with the guideline, which could bias the surveys to be more optimistic regarding imple- mentation progress. However, the broad distribution on survey re- sponses within the same site suggests no major bias is present. OUTCOME EVALUATION METHODS An interrupted time series control-group design was used to assess the effects of the low back pain guideline demonstration. Quarterly administrative data on service utilization and medication prescrip- tions were collected for low back pain patients served by the demon- stration and control sites. These data provided trend information both before and after introduction of the guideline in the Great Plains Region. The use of a control group allowed us to control for temporal trends that might be influencing observed effects. The six-month baseline period is October 1998 through March 1999, with the MTFs starting actions to implement the guideline in late March or early April 1999. Given that the kickoff conference was held 20 Evaluation of the Low Back Pain Practice Guideline Implementation Table 2. This delay was due to several factors: the holiday sea- son, delay by DoD and the VA in completing the practice guideline it- self, and the time it took MEDCOM to provide the participating MTFs with the implementation tools and other support materials that had been identified at the conference. We designed the analysis of guide- line effects to reflect the realities of this field experience. Choice of Demonstration and Control Groups The demonstration sites for this evaluation were the four low back pain guideline demonstration sites in the Great Plains Region. Two sets of MTFs were selected to serve as control sites: • MTFs in the Great Plains Region that were introduced to the low back pain guideline but received no additional external assis- tance to facilitate implementation. Differences in performance between these MTFs and the demonstration MTFs yielded esti- mates of the extent to which the intensive implementation sup- port activities provided during the demonstration contributed to implementation progress. The peer groupings developed by the Army Patient Administration Systems and Biostatistical Activity (PASBA) were used to identify control MTFs that were similar to the demonstration MTFs in terms Methods and Data 21 of size and service mix. In addition, the control sites outside the Great Plains Region were chosen to match sites included in the FMAS low back pain study performed for the National Quality Management Program, with the goal of facilitating combined analysis of the RAND data and FMAS chart abstraction data.

Good visual aids always enhance a presentation and their skillful use should be learnt at an early stage in a medical career cheap 10mg prednisolone otc dog allergy grass treatment. The basic aids are: • board and coloured pens • flipchart • overhead projector and acetate sheets • video • slides order prednisolone 10 mg with mastercard gluten allergy symptoms joint pain. The most commonly used visual aid is the slide, either prepared before the talk or projected from a PC. Board and coloured pens The forerunner of this technique was the blackboard and coloured chalks. Unless you really wanted to be an artist or graphic designer and have the necessary talent, do not bother to consider this as a possible medium. I have seen brilliant displays with coloured pens by anatomists as they have slowly and patiently explained the development of an organ but this is a dying art and 26 VISUAL AIDS far beyond mere mortals. Flipcharts These are best kept for those in medical management who wish to scribble two or three words on a large piece of paper before hurriedly covering it lest their illogical thinking is obvious to the audience. However, if you belong to the "I love clinical governance" minority sect you may find a flipchart helpful in confusing the audience. Overhead projector The acetate sheets needed for this visual aid must be prepared just as rigorously as slides (see below). With the introduction of PowerPoint the overhead projector has become less popular but it is still useful for a brief, 5–10 minute, presentation. Videos Videos are occasionally valuable in demonstrating a new practical technique. It is essential to obtain expert help, often from the university or medical school audio-visual department, to ensure that the video is of high quality. Do not assume that, because you can film the family barbecue on a damp Sunday in Sidcup, you are a budding Scorcese. Slides The guidelines for the preparation of slides have been well known for many years and yet basic mistakes continue to be made. If you are a novice, seek help and advice from senior colleagues who are recognised for their presentational skills. In many medical schools the audio-visual department is very willing to give practical advice and even show examples of how not to do it. Remember that visual aids are used to add to the content of the talk and should not 27 HOW TO PRESENT AT MEETINGS distract with garish colours, silly logos, and sound effects suitable for children’s television. The ready availability of computer software packages such as PowerPoint (Microsoft) means that it is easy to prepare clear slides. However, it is also possible to make a visual mess with this programme (see Chapter 5). Guidelines for slide preparation can be considered under the following headings: • general format • text • figures • tables. A problem with using programmes, such as PowerPoint, is that it is easy to present too many slides, so that the impression left with the audience may be literally that of a "moving picture show" as slides flash by. The absolute maximum number of slides is one for each minute of the talk and a more sensible rate of projection is six slides per ten minutes of talk. Avoid logos: most of the audience are not interested in where you work and know that they are attending the Third International Congress on Equine Euthanasia. Avoid frilly edges to the slide: the audience will think that you are a dress designer or worse; and avoid moving images, unless you want to ensure that the slide is not read. It is traditional to use a light colour on a dark background, such as yellow or white on a blue background and many different shades of these colours are available. The original technique was to use black lettering on white (a positive slide) and this is useful in situations in which the light in the lecture room can only be partially dimmed. Never use dark colours on a dark background – red on a dark blue background is a favourite combination and it is hopeless. Remember that the road signs in the UK are yellow on a dark green background or black on a white background because these combinations have been found to be the easiest to read. If you are unsure about the colours to use, let the Department of Transport be your guide. Standard slides are mounted in 50·8 mm (2 in) square mounts, but produce rectangular images. Most slides are shown with the long axis horizontally and the short axis vertically (approximate proportions of 3:2). If you use slides with a vertical layout then you run the risk of losing the top or bottom of the slide as some lecture theatres cannot deal with this orientation.

Once the cause and patho- with some aspect of personhood prednisolone 10mg with amex milk allergy symptoms 1 year old, but when it destroys or physiology are known buy prednisolone 10 mg amex allergy testing via blood, intervention ideally includes is perceived to destroy the integrity of the person, as just therapy to relieve the symptoms as well as to treat under- define. The goals of care may involve weighing the benefits Identification of suffering requires a high index of sus- and risks of treatments aimed at relief of suffering versus picion in the presence of serious disease and distressing those aimed at prolongation of life. Ask directly,"Are either cause (or are perceived to cause) a higher risk of you suffering? Intervening analgesics given at doses sufficient to relieve pain to to try to relieve distress or suffering can only be accom- simultaneously lead to respiratory depression. For most patients, physical pain is only one of Nebulized morphine or hydromorphone: several sources of distress. Physical aspects of pain cannot be effectively Plus or minus treated in isolation from the emotional and spiritual com- Albuterol 0. The various components of suffering Dexamethasone 16 mg initial, then must be addressed simultaneously. Many sources of dis- 8 mg bid ¥ 2 days, then 4 mg bid ¥ 2 days, then 2 mg bid tress and suffering are not visible and frequently are not Prednisone pulse spontaneously reported by patients. Formal and regular 40 mg po bid ¥ 5–7 days assessment is therefore critical to identification and Oxygen appropriate treatment of diverse symptoms. Physical and psychologic symptoms have been assessed most frequently using simple, validated measures, often in the form of symptom checklists. The Edmonton signs of respiratory function,9 and its management can Symptom Assessment Scale (ESAS) evaluates eight symptoms on visual analogue scales and has been exten- be challenging. It is important to diagnose and treat the sively used in palliative care research. Symptom Assessment Scale (MSAS) is a validated When therapy specific to the underlying cause is unavail- patient-rated measure that provides multidimensional able or ineffective, several techniques may alleviate information about a diverse group of common breathlessness. Simple techniques include pursed-lip 8 breathing and diaphragmatic breathing, leaning forward symptoms. It characterizes 32 physical and psych- ologic symptoms in terms of intensity, frequency, with arms on a table, cool air ventilation (fan or open 8 window), and nasal oxygen. Other frequently used symptom assessment instruments may be found on the numerous studies to be highly effective in the ameliora- tion of dyspnea. In addition, suffering caused ing cause, steroids and oxygen therapy may be of benefit. Cough is a normal but complex physiologic mechanism that protects the airways and lungs by removing mucus and foreign matter from the larynx, trachea, and bronchi. Management of cough should be determined by the type Dyspnea and the cause of the cough, as well as the patient’s general 9 Dyspnea is a subjective sensation of shortness of breath condition and likely diagnosis. When possible, the aim that is described in 70% of cancer patients during the last should be to reverse or ameliorate the cause, combined 6 weeks of life and in 50% to 70% of patients dying of with appropriate symptomatic measures. It is a common symptom associated with factors should be defined, and simple measures such as pneumonia, congestive heart failure exacerbations, and a change in posture can be very helpful. Breathlessness chronic obstructive pulmonary disease—all illnesses can trigger cough and vice versa. Nevertheless, dyspnea may be also precipitate vomiting, exhaustion, chest or abdominal a subjective symptom that may not match any objective pain, rib fracture, syncope, and insomnia. Sources of Suffering in the Elderly 313 Cough suppressants are usually used to manage dry Two organ systems are particularly important in cough. The most effective antitussive agents are the nausea and vomiting: the central nervous system and the opioids. Methadone can be the vestibular apparatus, and the cortex are all involved particularly effective at night, but due to its prolonged in the physiology of nausea. Other useful center from one or more of these areas is mediated measures include decongestants, antihistamines, and through the neurotransmitters serotonin, dopamine, corticosteroids. Serotonin seems to be important in the gastric lining and central nervous system, whereas acetylcholine and histamine are im- Gastrointestinal Symptoms portant in the vestibular apparatus. Cortical responses are mediated via neurotransmitters as well as through Nausea and Vomiting learned responses (e. Dopamine-mediated nausea is probably the easy to achieve with the appropriate use of medications. Etiology Pathophysiology Therapy Metastases Cerebral Increased intracranial pressure Steroids, mannitol Direct chemoreceptor trigger zone Antidopamine, antihistamine Liver Toxin buildup Antidopamine, antihistamine Meningeal irritation Increased intracranial pressure Steroids Movement Vestibular stimulation Antiacetylcholine Mentation (e. Constipation Oral medications: Constipation can be defined as the passage of small hard Dexamethasone 2–8 mg q 6–12 h 17 feces infrequently and with difficulty.