By O. Steve. United States Coast Guard Academy.
It is fair to assume that if there are many cheap 50mg solian mastercard, many abnormalities on the initial scan generic 50mg solian overnight delivery, problems with func- tion will be forthcoming. Clearly 17 PART I • The Disease and Its Management the scan changes over time, sometimes actually improving. Some feel that routine checking of the MRI will give information about the future course of the disease, but that is not based on reality. Some feel that the brain of those with MS will shrink if treatment is not instituted immediately. Of course, all our brains shrink with age, but it is real- ly impossible to speculate at the front end of the diagnosis how much shrinkage will or will not occur. Thus, many unanswered questions remain that deserve an answer and undoubtedly will be answered in the next decade. In the meantime, there will be some disagreement as to when and which agent should be given and to whom. Clearly, this question must be answered by the physician who knows you and is monitoring your MS. High dose inter- feron (Betaseron®, Rebif®) appears to be stronger than low dose (Avonex®), which is a function of dose rather than the structure of the medication, because Avonex® and Rebif® are structurally identi- cal. Clearly, many people with MS can be successfully treated with a low dose, but many will need a higher dose with time. This is no dif- ferent from other diseases treated with multiple medications (high blood pressure, infections, etc). It appears that glatiramer acetate (Copaxone®) is as effective as the interferons and, in my opinion, falls between the high dose and low dose in terms of "potency. Just which treatment is given and when is a medical decision that should be made by your physician with input about to your lifestyle and desires. Numbness, tingling, dizziness, blurred vision, and pain do not seem to indicate a bad prognosis, while weakness, clumsiness, cognitive disturbance, lots of abnormality on initial MRI, and older onset (age 55 and up) may lead to a more difficult time quickly. These factors also must play a role in the choice of medica- tions, along with the fact that the interferons have more side-effects than glatiramer acetate and that depression can be made worse by 18 CHAPTER 2 • Managing the Disease Process interferon.
Despite not finding overall effects discount 50 mg solian free shipping, effects were observed from the encounter data that were specific to individual sites and consistent with their implementation strategies generic 50mg solian visa. The strongest of these were the Site A strategy to use back classes to reduce use of physical therapy, which was observed in the data as declines in physical therapy referrals; and the Site D strategy to establish the physical medicine clinic as gatekeeper and reduce inappropriate specialty referrals, which were observed in the data as 96 Evaluation of the Low Back Pain Practice Guideline Implementation shifts of referrals to the physical medicine clinic from other special- ties. The implications of these evaluation findings for ongoing implemen- tation of practice guidelines in AMEDD are considered in Chapter Seven. Chapter Seven LESSONS FROM THE LOW BACK PAIN DEMONSTRATION This first demonstration to field test methods for implementation of clinical practice guidelines yielded rich information and insights even as it struggled to achieve lasting new practices. Despite disap- pointing results in terms of the effects on treatment of acute low back pain, the demonstration contributed to improvements in methods for subsequent guideline demonstrations, and ultimately, for imple- mentation of the low back pain guideline in all Army health facilities as of the spring of 2000. In this chapter, we synthesize the factors influencing the successes and limitations of the low back pain guideline demonstration. We begin by examining how well the demonstration performed on the six critical success factors presented in the beginning of this report and reintroduced throughout, and we assess how this performance contributed to the demonstration results. Then we identify a number of issues for the MTFs that emerged from the demonstration that are likely to affect other MTF guideline implementation efforts. Finally, we discuss implications for MEDCOM with respect to approaches and methods as it moves forward with implementation of a number of DoD/VA practice guidelines in the Army health system. PERFORMANCE ON SIX CRITICAL SUCCESS FACTORS Research on practice guideline implementation has documented that a commitment to the implementation process, including use of multiple interventions, is required to achieve desired changes to 97 98 Evaluation of the Low Back Pain Practice Guideline Implementation clinical practices. Below are the six critical success factors that are es- sential for making lasting changes in the MTFs’ clinical and adminis- trative processes. We discuss here the extent to which this demon- stration realized these success factors, and we consider their effects on progress in implementing practice improvements. This demonstration provides a meaningful ex- ample of how leadership commitment can affect the ability to achieve practice improvements. The regional leadership endorsed the demonstration strongly, but local commanders exhibited mixed levels of commitment, and changes in command eroded this support yet further over time. Given that this was the first demonstration in a new MEDCOM initiative, it is understandable that it might be met with mixed reactions due to concerns regard- ing the initiative’s effects on MTF workloads and costs. Further, many providers, including physicians in leadership roles, have instinctive negative reactions to practice guidelines as "cookbook medicine," which indeed we heard in our evaluation. Unfortu- nately, passive or "wait and see" positions by command teams can become a self-fulfilling prophecy leading to failure because im- plementation teams are not given the motivation and support they need to change clinic procedures and mobilize providers and staff to accept the new practices.
In lesbian couples generic solian 100 mg with visa, there may be two persons socialized to seek and nurture relationships order solian 50mg online. If stereo- typically socialized, both could give too much to the detriment of self- development (Clunis & Green, 1988; Falco, 1991; Slater, 1995). A gay couple in which both men have been traditionally socialized may struggle with inti- macy and commitment (Harrison, 1995). Both types of couples would have the additional layers of cultural discrimination and homophobia complicat- ing their relational issues. Ethnic diversity would add further complexity (Greene, 2000; Lowe & Mascher, 2001). Worell and Remer (1992, 2003) have extrapolated from counseling and psychotherapy outcome studies in general to feminist therapy results by noting common successful characteristics. Process variables that have been found to be effective in ther- apy (Beutler et al. Other variables related to successful outcomes (Beutler, Crago, & Arizmendi, 1986; Beutler et al. Beutler and colleagues (2004) reviewed literature that suggested good outcomes were related to positive therapist behaviors (p. There also ap- pears to be a clinically weak but significant positive effect of therapist’s self-disclosure on therapy outcome. Feminist and Contextual Work 239 Specific research "into the process of marital therapy and its relationship to outcomes [was termed] still in its infancy" by Alexander, Holtzworth- Munroe, and Jameson in 1994 (p. Research in marital and couples therapy has grown significantly in recent years, and literature reviews in- cluding meta-analyses have demonstrated that couples therapy in general is an effective treatment. However, research comparing specific approaches and models has been sparse (Sexton et al. In addition, there are questions concerning the long-term effect of some couples therapies. One study (Johnson & Greenberg, 1988) reported more successful out- comes when partners became more affectionate with more softened feel- ings toward each other.
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