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Uncertainty about any of the specific steps of a new procedure dis- courages providers and clinic staff from adopting it and thus be- comes a barrier to implementing new practices discount 10mg prinivil blood pressure kits walmart. In some cases generic 10mg prinivil with amex heart attack remix dj samuel, such as regulations regarding placement of a documentation form in a medical chart, MEDCOM has the responsibility to revise procedures to support use of new practices. In other cases, such as specifying clearly which staff are responsible for completing the encounter documentation form, the responsibility belongs to the MTFs. Integrating New Practices Perhaps the most important lesson from the low back pain demon- stration was the importance—and difficulty—of successfully inte- grating new practices into the way MTFs routinely "do business" for patient care. A practice guideline can be said to be implemented only when such lasting changes in practices are made. Few of the MTFs participating in the demonstration were able to maintain the new practices they introduced at the start of the implementation period. A variety of reasons for this inability to "institutionalize" the new practices can be identified, depending on the site and practice in- volved, including limited leadership support, inadequate buy-in from providers or clinic staff, lack of clarity of roles and responsibili- ties, and absence of monitoring and feedback on progress. As guide- lines are introduced across the AMEDD system, ongoing monitoring and technical support from MEDCOM will be needed to help ensure the retention of desired new practices for treatment of patients served by the Army MTFs. Chapter Six EFFECTS OF GUIDELINE IMPLEMENTATION In this chapter, we examine the extent to which introduction of the low back pain guideline at the four demonstration MTFs changed clinical practices in those facilities. Using information from the pro- cess evaluation and the analysis of encounter data, we (1) assessed how well providers at the demonstration sites appeared to under- stand and accept the guideline, (2) summarized reports from the sites regarding estimates from their analyses of the effects of their implementation activities on clinical practices, and (3) analyzed trends of service utilization for the six identified indicators of low back pain care, comparing the demonstration sites with control sites that had not used the guideline. We synthesize the results of these three analyses to identify areas where demonstration site practices appeared to change and where the perceptions of the sites differed from results of the independent data analysis. PROVIDER KNOWLEDGE AND ACCEPTANCE OF THE GUIDELINE Provider Knowledge and Views of the Low Back Pain Guideline Primary care providers participating in the RAND site visits generally acknowledged the guideline was a potentially useful resource, but many of them viewed it without much enthusiasm. Acceptance var- ied widely across demonstration sites and among primary care providers within each site. Nurse practitioners and PAs had more fa- vorable views of the guideline than physicians because it offered 71 72 Evaluation of the Low Back Pain Practice Guideline Implementation them potential for greater autonomy and technical support as they treated low back pain patients, reducing their need to turn frequently to providers for guidance. For example, we heard statements that the guideline • "stimulates an emphasis on prevention and patient self-man- agement" • "provides specific guidance for when to refer a patient for more definitive diagnostic procedures" • "helps reduce referrals to physical therapy and specialists" • "should increase the quality, continuity, and consistency of care" • "will have no impact on care. In excess of 90 percent of providers agreed "slightly" to "strongly" with the state- ments that clinical practice guidelines help deliver better care, re- duce variations in clinical practice, and are a good way to summarize and reenforce scientific evidence on diagnosis and management of specific conditions. At the same time, a significant minority (from 20 to 35 percent) thought that clinical practice guidelines oversim- plify diagnostic and treatment decisions in medicine, limit a physi- cian’s freedom to take action, and reduce provider efficiency. When asked about the low back pain guideline, none of the providers agreed with the statements that the low back pain guideline "has re- duced my flexibility to treat low back pain patients" or "has in- creased the time I spend with low back pain patients. Effects of Guideline Implementation 73 By the end of the demonstration, many providers were knowledge- able about the conservative treatment recommended by the guide- line for acute low back pain patients, but a sizable minority still had not gained that knowledge. For instance, 25 percent of the providers responding to our survey did not know or remember that the guide- line prescribes no more than 48 hours of bed rest, and one in three providers did not know the guideline does not recommend the use of muscle relaxants for management of pain. At one site, 60 percent of the providers surveyed did not know these guideline provisions. Effects of the Guideline on Providers’ Behavior A majority of the providers participating in our focus groups reported the guideline had improved the way they deliver care for low back pain patients. Of those responding to our survey, 60 percent agreed with the statement that "the guideline had helped me to provide better care for my low back pain patients" and with the statement that "the guideline has reduced variations in the way I treat low back pain patients. Providers also generally agreed that the guideline had not "increased the time I spent with low back pain patients. These trainees stay on post for only a short period of time, and when a trainee has a health problem, the MTF is under heavy pressure to return her or him to duty as rapidly as pos- sible to minimize interruption of training. Providers reported that the key question they ask themselves for one of these patients is, "If I let this individual return to basic training while the back pain is still present, will the training harm her or him? To examine this question, we asked the implementation team and providers in our 74 Evaluation of the Low Back Pain Practice Guideline Implementation focus group which practice changes they think occurred and any evi- dence they had that documented such changes. We also obtained reports from some sites with data they had developed on trends of low back pain encounters. Primary Care Services Three of the demonstration sites analyzed data on frequency of en- counters and length of treatment, the results of which suggested there was general adherence with conservative treatment of low back pain patients, as recommended by the guideline. One site reported that 47 percent of patients had only one encounter for low back pain. Another reported that two-thirds of its low back pain patients had no more than two encounters and another 20 percent of its patients had three encounters.

When the cluster of cognitive models for "mother" acts as a source domain for understanding target domains metaphorically order 10mg prinivil mastercard blood pressure medication vitamins, the structure of this cluster suggests the meaningful metaphorical extensions cheap prinivil 2.5 mg with amex heart attack feat sen city. Like "mother," "game" and "business," "disease" is a cluster of related cognitive models at least close to those I have suggested below. The second part of the chapter details why the "disease" category must be understood as a radial category, extended by many devices from central prototypical members. If anything is close to foundational in this semantic structure, I will contend that it is "symptoms. These include "crime," "weakness," "old age," "lack of fertility," "suffering," "eccentricity" and probably others. Similarly, health is near to "normalcy," "youth," "strength," "fecundity," "wealth," and "happiness. It should be pointed out that these concepts have both to do with what disease is thought to be in itself and with how we imaginatively structure our responses to it. They also figure in both popular and professional characterizations of disease, but to a different degree. For instance, (4) Disease Is Disorder is probably more important for professional conceptualization and discourse than for that of the general public, whereas (7) Disease Is Being Under Attack is prominent in the thinking of patients and the public as well as traditional allopathic practitioners, with the classic response being to drive off, poison or cut out the metaphorical "enemy. That is because the most vivid and literal examples of mechanical breakdown, imbalance, disinte- gration, and disorder are not diseases, and the way the terms are used to describe disease borrows from these more literal domains. For example, our understanding of mechanical breakdown starts with broken tools and machines, of imbalance with tripping and falling, of disintegration with objects breaking up or falling apart, and of disorder with domestic messes or social chaos. In the case of (6) Loss Of A Vital Fluid, bleeding is the literal and central example but is a symptom, and not a disease. Based on the logic of this symptomatic event, health and disease seen as fullness and deficiency of a vital fluid are cognitively mapped out. And finally, our knowledge of attacks is one more metaphorical source domain for the understanding of disease. There is a related reverse metaphor which sees War As Disease but it is not well elaborated or important in our understanding of war so far. The model Disease Is The Abnormal is a special case, not truly metaphorical but probably related to the common association of anomalies with symptoms. The health models are not as well developed as those for disease and are often understood mainly as contraries of the disease depictions, secondarily generated from them. Like "peace," health is often seen as the absence of something negative rather than a positive presence with its own integrity and content. Unfortunately, this view means that the nourishment of health as well as peace are typically neglected since, unlike the disruptions of disease and war it is easy to think of health and peace as "uncaused. These descriptions are preliminary, not definitive, and are subject to alteration upon more reflection and empirical study. But it does matter that concepts of health and disease are plural and often metaphorical, and that can be established. The conceptual structures matter because qualitative symptoms cannot be quantified into units of suffering with the help of a single standard of disease. They matter because the relevance and seriousness of any definable condition is peculiar to each particular case, and no comprehensive formula for health applies in full to any unique situation. They matter because the logic used to decide what is desirable and what is not cannot itself be mechanized when imaginative and conflicting models are so pervasive in conceptualizing health and disease. Disease Is Mechanical Breakdown In this model the body is a large machine made up of the organs which are smaller machines. The mind is also a machine, more or less tightly tethered to the body at the locus of the brain, one of the constitutive machines. One difficulty with this model when it is looked at closely, is that of specifying what all the organs should be doing when they are working well or optimally. There is a dispute between those who believe that an objective concept of proper working can be developed, usually on the basis of evolutionary fitness or some other measure of adaptation, and those who believe that the definition of proper function is a value judgment.

In general 10mg prinivil for sale blood pressure xls, the number of elderly zoster patients 45 time of rash healing by a mean of 1 to 2 days generic 2.5 mg prinivil overnight delivery blood pressure medication side effects. Specific data on pain duration in elderly zoster patients is limited by the lack of population-based studies of this phenomenon. Nonetheless, data from patient groups and The principal goal of the treatment of herpes zoster in recent clinical trials provide some useful information. Anti- p p 72 Elder Mistreatment Terry Fulmer and Maria Hernandez Elder mistreatment (EM) is a complex syndrome includ- assess in older adults who are likely to have other ing such actions as abuse, neglect, exploitation, and aban- geriatric syndromes, which may mask or mimic mistreat- donment of an older person. Over the past two decades, mandatory state re- overlooked by clinicians who are not careful to elicit a porting laws and a heightened sensitivity to the problem detailed history and physical to determine the nature of have helped clinicians define and channel cases of common signs and symptoms, which can be ascribed to mistreatment. In every setting (hospitals, Within the broad category of elder mistreatment, four nursing homes, clinics), there is an opportunity to screen, patterns are generally discussed in the literature,2 includ- diagnose, and treat cases of elder mistreatment. In this ing physical abuse, psychologic abuse, financial abuse, and chapter, the authors present an overview of the problem, neglect. Conceptual definitions appear to be consistent provide specific screening approaches for different but the operational definitions categorize abuse in dif- patterns of mistreatment, and discuss intervention pro- ferent ways. The mistreatment literature is quite compartmen- Elder mistreatment is a form of family violence that talized. Literature searches on the topic of domestic takes place in the homes and lives of people every day. The goals of Healthy People 2010, the different terms and, therefore, do not overlap across age national health promotion and disease prevention initia- groups. Discussion of child abuse and elder abuse take tive, is to increase the quality and years of healthy life and place in specialty journals with little synthesis across the eliminate health disparities. Some domestic violence is addressed within the sections per- investigators have begun by looking at widely held beliefs taining to age groups (e. There is no overall estimate of prevalence for the belief that individuals who are abused as children are domestic violence across the lifespan, but instead esti- more likely to abuse their own children was examined. Family violence encompasses much of what can go In 10 studies, the relative risk (RR) of maltreatment in wrong among and between individuals in a family or children was significantly increased (RR 4. Physical abuse, financial exploita- whereas in 3 others the relative risk was less than 2 and tion, neglect, and abandonment of older adults take place not significant. It is a part of the constel- dence that a relationship exists between child abuse and lation of domestic violence that can affect individuals at abusing one’s own child. Lifespan studies will help place any point in the lifespan, and it is particularly difficult to knowledge of elder mistreatment in a context and frame- 1057 Intervention and case management: part 2. Summary igure Treatment of Frailty Organizational Approaches Effective for Frail Older Adults Principles of High-Quality Care for Frail Older Adults This page intentionally blank able Agitation Psychotic Symptoms: Delusions, Hallucinations, Paranoia, Suspicions 74. A naturalistic the treatment of mild-moderate Alzheimer’s disease: an study of trazodone in the treatment of behavioral compli- audit of the assessment and treatment of patients in routine cations of dementia. Interim results from an resperidone and placebo for psychosis and behavioral dis- international clinical trial with rivastigmine evaluating a turbances associated with dementia: a randomized, double- 2-week titration rate in mild to severe Alzheimer’s disease blind trial. Efficacy and safety ment of psychotic and behavioral symptoms in patients with of rivastigmine in patients with Alzheimer’s disease: inter- Alzheimer’s disease in nursing care facilities: a double- national randomized controlled trial. Quetiapine, choline receptors as a treatment strategy for Alzheimer’s a novel antipsychotic: experience in elderly patients with disease. Treatment of behavioral symptomatology of therapeutic strategy for Alzheimer’s disease. A controlled of selegiline, alpha-tocopherol, or both as treatment for clinical trial of sertraline in the treatment of depression in Alzheimer’s disease. III and V in the neocortex, although their density varies considerably among cortical regions, primary sensory and motor regions having many fewer NFT than association areas. In addition, considerable differences in laminar NFT distribution exist among neocortical regions. With a few exceptions, SP show a generally comparable distri- bution among neocortical areas. Feedfor- ward connections originate mostly from neurons located in the superficial layers of the cortex and terminate in the F 75. Regional and laminar NFT formation and neu- deep portion of layer III and in layer IV of the target ronal loss in normal aging and AD. The flameshaped structures cortical region, feedback projection neurons are located represent a semiquantitative assessment of NFT densities.