By R. Fraser. Southern Connecticut State University.
Choice is reasonable when it induces us to act reasonably; that is with regard to the claims of each of the competing habits and impulses generic mentax 15mg on line. CHAPTER 4 JOHN DEWEY’S VIEW OF SITUATIONS cheap mentax 15mg without a prescription, PROBLEMS, MEANS AND ENDS The general purpose of reflectively based action for Dewey is to transform an "unsatisfactory situation" into a "satisfactory" one. Medical encounters, both narrowly circumscribed brief ones and broad continued ones, exemplify Deweyan "situations. While acknowledging that even after a close look there are residual ambiguities in Dewey’s theory of means and ends, the theory illuminates much of what is actually at stake in offering medical care, and what constraints exist on our responses to health problems in the real world. For we never experience nor form judgments about objects and events in isolation, but only in connection with a contextual whole. The "situation" for Dewey encompasses the relation of an individual (not neces- sarily a person) to its surroundings. On many occasions (as Dewey indicates when discussing the quality which is shared by everyone at a ball game when the umpire yells, "You’re out! There would be no point in talking if we could not use the conventional commonality of words to enhance mutual participation in and evaluation of situations that underlie joint endeavor. An experience is always what it is because of a transaction taking place between an individual and what, at the time, constitutes his environment. It should be noted that such an environment is not solely "given" and "out there" apart from the individual, but is in several key ways dependent on the individual. The capacities of the individual to be affected already equip and limit any possible environment. The physical disposition of a person, including positioning and focus of attention, screens potential environmental inputs. And finally, there are all the unintentional marks and intentional artifacts of individuals which shape their surroundings. An illness exemplifies a situation marked by alteration in the relationship of an individual and her or his environment. Prototypically this comes from an environ- mental insult on the individual, as we have seen, but sometimes it arises primarily from what seems to be an internal source. TERTIARY QUALITIES Dewey gives several examples of "tertiary qualities" which define, delimit, charac- terize and "pervade" the various types of situations into which organisms and their environments can come.
At the same time mentax 15 mg fast delivery, patients we interviewed expressed the views that providers are mistrustful about the reality of patients’ pain and the 134 Evaluation of the Low Back Pain Practice Guideline Implementation patients’ wish for more empathy cheap mentax 15mg fast delivery. In addition, orthopedics clinic providers estimated that 20–30 percent of low back pain patients do not get the correct treatment. As stated by a site participant, they are "given a dose of Motrin and told to go away. Thus, while no effects of the guideline on practices might have been achieved at this MTF, there is some qualitative evi- dence that such changes may be needed. Conclusions Site B limited its strategy for implementing the low back pain guide- line to care for active duty personnel, and therefore, it limited inter- ventions to its TMCs. Even on this limited scale, however, implemen- tation of the guideline was approached with little support from the leadership and little guidance from the champion or the members of the implementation team. It has been particularly difficult to gauge the extent to which the guideline has actually been used. The MTF staff participating in the site visit consistently stated that they believe they were already practicing consistent with the guideline, and they were focused more on reporting the other priorities that compete with their ability to work on strengthening practices for low back pain patients. In the face of these statements, however, orthopedics providers report a continuing high incidence of inappropriate refer- rals for MRIs or for chronic care. Also, the MTF has not examined al- ternatives to strengthen the way it practices patient education: one- on-one at the discretion of providers and medics. While a majority of providers in the family and internal medicine clinics reportedly have been introduced to the low back pain guide- line, implementation has been left to the discretion of each provider within these clinics. Providers in these clinics tend to believe even more strongly than TMC providers that their practices already are consistent with the guideline. In the words of one of the MTF providers, they "recognize that the MTF is a long way from implementing the guideline. Given the contrasting reports we heard re- garding the appropriateness of and variations in practices for low back pain care, it will be important to track trends in key measures to assess the status of practice quantitatively. A change in MTF command as well as in staff leading the implementation team may have contributed to shift emphasis away from implementation of the low back pain guideline to other priori- ties. One issue that has hampered implementation has been the continuing inability to gain support of the nursing and ancillary staff to use the documentation form 695-R when they process low back pain patients for provider visits.
Despite the aforementioned nonspeciﬁc clinical presentation of subjects with brain cancer purchase mentax 15 mg with amex, Table 6 discount mentax 15 mg line. Clinical symptoms suggestive of a brain cancer Nonmigraine, nonchronic headache of moderate to severe degree (see Chapter 10) Partial complex seizure (see Chapter 11) Focal neurologic deﬁcit Speech disturbance Cognitive or personality change Visual disturbance Altered consciousness Sensory abnormalities Gait problem or ataxia Nausea and vomiting without other gastrointestinal illness Papilledema Cranial nerve palsy Chapter 6 Imaging of Brain Cancer 107 cancer. A relatively acute onset of any one of these symptoms that pro- gresses over time should strongly warrant brain imaging. Supporting Evidence: It remains difﬁcult, however, to narrow down the criteria for the "suspected" clinical symptomatology of brain cancer. In a retrospective study of 653 patients with supratentorial brain cancer, Salcman (22) found that the most common clinical features of brain cancer were headache (70%), seizure (54%), cognitive or personality change (52%), focal weakness (43%), nausea or vomiting (31%), speech disturbances (27%), alteration of consciousness (25%), sensory abnormalities (14%), and visual disturbances (8%) (moderate evidence). They found that the most frequent clinical features were headache (55%), cog- nitive or personality changes (50%), ataxia (40%), focal weakness (36%), nausea or vomiting (36%), papilledema (27%), cranial nerve palsy (25%), seizure (24%), visual disturbance (20%), speech disturbance (20%), sensory abnormalities (18%), and positive Babinski sign (17%). No combination of these factors has been shown to reliably differentiate brain cancer from other benign causes. Applicability to Children Brain cancers in childhood differ signiﬁcantly from adult lesions in their sites of origin, histological features, clinical presentations, and likelihood to disseminate throughout the nervous system early in the course of disease. Whereas the great majority of adult tumors arise in the cerebral cortex, about half of childhood brain cancers originate infratentorially—in the cerebellum, brainstem, or fourth ventri- cular region. Brain metastasis from systemic cancer is rare in children, whereas it is common in adults owing to the preponderance of systemic cancer (lung and breast being the two most common). Metastatic cancers in childhood mainly represent leptomeningeal dissemination from a primary brain lesion (25) such as medulloblastoma, pineoblastoma, or ger- minoma—hence the importance of imaging the entire neuroaxis in these patients (i. The incidence of primary brain cancer in children is most common from birth to age 4 years; the vast majority of histologic types are medulloblastomas and juvenile pilocytic astrocytomas (JPAs). Headache, posterior fossa symptoms (such as nausea and vomit- ing), ataxia, and cranial nerve symptoms predominate in children due to the fact that about half of pediatric brain cancer occurs infratentorially (12,25,26). Nonmigraine, nonchronic headache in a child should raise a high suspicion for an intracranial mass lesion, especially if there are any additional posterior fossa symptoms, and imaging should be conducted without delay (see Chapter 10). Summary of Evidence: The sensitivity and speciﬁcity of MRI is higher than that of CT for brain neoplasms (moderate evidence). Therefore, in high- risk subjects suspected of having brain cancer, MRI with and without gadolinium-based contrast agent is the imaging modality of choice to further characterize the lesion. There is no strong evidence to suggest that the addition of other diag- nostic tests, such as MRS, perfusion MR, PET, or SPECT, improves either the cost-effectiveness or the outcome in the high-risk group at initial presentation.