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Type of meeting This should be obvious from the invitation order sumycin 500 mg line antibiotics c diff, but it isn’t always so purchase sumycin 250mg on line antibiotics for acne treatment reviews. If the latter, ask for a copy of the programme so that you know who the other speakers are in your session. As the subjects are likely to be similar in your session, it is never a bad idea to contact the other speakers to find out what they are going to cover. If it is a research meeting of a society, you are not usually invited, but rather told by someone that you are speaking. Subject If you are speaking at a symposium there is little leeway with regard to the subject, but if it is a guest lecture, then you can negotiate with the organiser. Establish whether they want a review of the topic, or some of your original research around which you can build up a story, or whether they just want a discussion on future developments. Very often they will leave the entire content to you and, on occasion, allow you to choose whatever subject you like. Under these circumstances you have no excuse whatsoever to deliver a poor lecture. Timing Again this should be obvious, but check, and also see if there will be time for questions. It is never acceptable to talk over your allotted time, but no one will ever complain if you finish a little early. Abstract Establish at this stage whether an abstract is required for the meeting and if so what is the deadline. As abstracts are often 10 PREPARATION OF THE TALK required several months in advance for major meetings, this usually precedes the start of preparation of your lecture and merely indicates that they are of little value. However, if you know an abstract is required, it should be delivered by the deadline (and might even persuade you to start on your talk much earlier); not to do so is unprofessional. Audience Basic to the preparation of any lecture is a knowledge of who the audience are likely to be. This gives you some idea of what "level" to pitch the lecture; on the vast majority of occasions of course, these are your peers and therefore there will be no problem. The great mistake is to misjudge your audience, which is not a fault confined to prime ministers. You will leave a very bad impression if you "talk down" to an audience, or on the other hand, "talk over their heads". This is one of the most difficult aspects of lecturing and applies especially if there are lay people present. How to judge this will only come with experience, but a basic rule is not to try to impress the audience but rather to interest them. If you can do this, then they will be impressed, especially if you have been dealing with a difficult and complex topic. It is also nice to know whether any eminent members of the profession and your specialty are going to be present, that is any "heavies". You should certainly not be put off by this, but in fact should feel proud that they have come to your talk. Contrary to popular belief, they are not there to shoot you down at the end of your talk; they have all been through what you have and the majority are extremely helpful and complimentary. If they think that you might have gone off the track somewhere, they will tell you politely and usually after question time to save embarrassing you. However, as you will certainly have prepared your talk properly, such a situation will not arise. You will do exactly the same amount of preparation and rehearsal for an audience of 10 or 1000. Title The only thing that an individual sees about a forthcoming lecture is the title, so some thought should be given to making it attractive. A teaching lecture requires a short, didactic title, while 11 HOW TO PRESENT AT MEETINGS an eponymous lecture usually has an obscure title which attracts people out of curiosity if nothing else. The philosophy of Richard Asher, one of the greatest medical writers, with regard to titles of papers applies just as well to a lecture.

The trainee then competes for a surgical specialist registrar post purchase sumycin 250 mg amex antibiotic wiki, which provides training in both general surgery and a subspecialty purchase sumycin 250mg line virus structure, except for those who concentrate entirely on becoming ear, nose, and throat (ENT) or eye (ophthalmic) surgeons. Towards the end of this period of surgical specialist training there is a further examination, the FRCS, which is an examination run by the four surgical colleges of Great Britain and Ireland. The examination particularly tests clinical skills and, together with the necessary years of experience, qualifies the trainee for the CCST. Public health medicine Public health is the medical specialty which is concerned with the improvement of the health of populations—by health promotion and disease prevention and by commissioning high quality, cost effective health care from providers of health care, mainly hospitals and general practitioners. Public health doctors work closely with doctors in many specialties and with other health professionals, with managers, and with governmental and voluntary organisations. If all members of society are to achieve a better and more equitable health status and health experience, collective action is essential. It is worth remembering that public health doctors have had every bit as great, if not greater, impact on improving health than physicians and surgeons. A tablet to William Henry Duncan, Medical Officer of Health of Liverpool, who died in 1863, records that "... Epidemiology, the discipline concerned with describing and explaining the 128 CAREER OPPORTUNITIES occurrence of disease in populations (originally epidemics of infectious disease) and of the outcome of measures to improve health and prevent disease, is the science fundamental to public health medicine and indeed to a substantial proportion of modern medical research. Public health doctors also require a range of other skills, most crucially those associated with management, interpersonal, and political skills in representing the need for more resources for health care and for better use of them. Public health physicians work in a number of settings within the NHS, the university, central government, and national agencies, such as the Health Education Authority and the Communicable Diseases Surveillance Centre (which is part of the Public Health Laboratory Service (PHLS)). Two years of general professional and early specialist training culminate in part I of the examination for membership of the Faculty of Public Health Medicine (MFPHM of the Royal College of Physicians of London), which covers epidemiology, statistics, social and behavioural sciences, the principles of prevention of disease and promotion of health, assessment of health needs and audit of services provided, environmental health, and the management and organisation of health services. During three years of higher specialist training, the trainee in public health medicine writes a report on practical projects as part of the requirement for part II of the MFPHM examination. Community health Doctors working in community health are clinical specialists providing a wide range of services, including child health; family planning; mental and physical handicap; genetic counselling; occupational, environmental, and port health; and community services for the elderly. A relevant clinical specialist training or general practitioner vocational training is the usual qualification for this work, but there are, as yet, no formal relevant community higher specialist training programmes or qualifications. Most of the doctors are in the grades of clinical medical officer (CMO) and senior clinical medical officer (SCMO). A small but increasing number of consultant posts have been established in these community specialties and training programmes for such posts are being developed. Other specialties Clinical academic medicine A degree of creative tension often exists between the NHS consultants and clinical academic (university) staff, well expressed by the Royal Commission on Medical Education in 1968: There are still full-time academic teachers who see the part-timer as a prosperous busy practitioner who owes his success to clinical acumen rather than painstaking investigation, whose teaching is based on personal dogma 129 LEARNING MEDICINE rather than scientific fact and whose interests require the whims of private patients to take priority over the needs of his students. There are still part-time teachers who see the full-timer as a desiccated preacher more interested in the advancement of medicine than in the welfare of his patients and unable to offer his students any guidance to the realities of life outside the ivory tower. There is a smattering of truth in each perspective to the extent that the clinical academic physician or surgeon was described by Dean Holly Smith as "an uneasy hybrid who constantly feels attenuated at both ends". An academic career in university posts is possible in practically all hospital specialties, general practice, and public health, though the number of posts is small. Clinical senior lecturers, readers, and professors all normally have NHS consultant responsibilities, but they generally have less clinical service work and relatively more time than NHS consultants for teaching and research. Basic medical sciences It is widely but not universally believed that medical students benefit from being taught anatomy, physiology, biochemistry, and pharmacology by medical graduates because they best understand the clinical context of these sciences and their relevance to clinical medicine. Few medical graduates, however, now work in these university departments, not least because salaries are lower than those of clinical academics and of other doctors working in the NHS. Full time research A small number of full time research posts are available to medical graduates, mainly in institutions of the Medical Research Council or in the pharmaceutical industry. Occupational medicine Doctors have long been involved in the understanding and preventing of health risks in the workplace but only recently has occupational medicine developed as a clinical specialty rather than as a branch of public health. The specialty is concerned with identifying and investigating the medical problems associated with different working environments and with advising both management and employees on the prevention of occupational medical hazards. The examination for membership of the Faculty of Occupational Medicine (MFOM) of the Royal College of Physicians of London is taken after four years of training and experience in occupational medicine; a formal higher specialist training programme leads up to it.

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Despite the absence of an overall guideline effect on specialty refer- rals buy sumycin 500 mg free shipping measuring antibiotic resistance (kirby-bauer), the trend in specialty mix at one demonstration site purchase sumycin 250mg without prescription infection prevention society, Site D, rep- resented successful implementation of a key element of its action plan. The site shifted low back pain referrals away from other spe- cialties and toward physical medicine and rehabilitation, which took on the gatekeeper role for low back pain care (see Figure 6. Prescription of Muscle Relaxants The low back pain guideline specifically states that the scientific evi- dence shows that muscle relaxants do not help ease the back pain, and therefore they should not be prescribed for patients. Given that muscle relaxants were prescribed for almost one-half of the acute low back pain patients at the demonstration and control sites before the demonstration, as shown in Chapter Three, we hypothesized 88 Evaluation of the Low Back Pain Practice Guideline Implementation RANDMR1758-6. How- ever, we found no change in the prescribing of muscle relaxants during the demonstration. A total of 15,570 patients were prescribed muscle relaxants, and there were no observable trends in prescrip- tion rates over time for either demonstration or control sites or for any individual demonstration site (Table 6. Statistical tests (see Appendix C) confirmed that trends for the demonstration and control sites were not significantly different. The absence of declines in use of muscle relaxants indicates that the demonstration sites did not address this provision of the guideline at all. Given that an average of 33 percent of acute low back pain patients at the demonstration sites had been prescribed narcotics during the baseline period (see Chapter Three), we hypothesized there would be a decline in the percentage of pa- tients prescribed narcotics during the conservative treatment period. A total of 10,113 low back pain patients were prescribed narcotics, representing almost one-third of the patients. We found modest rates of reductions in narcotic prescription rates during the demonstration period for both the demonstration and control sites. This result indicates that providers’ prescribing pat- terns were changing in the desired direction, as recommended by the guideline, but introduction of the guideline at the demonstration MTFs did not affect the trends at those sites (Table 6. Statistical tests (see Appendix C) confirmed that trends for the Effects of Guideline Implementation 91 Table 6. Of the four demonstration sites, Site C had the lowest narcotics pre- scription rates, and Site D had the largest reduction in narcotics pre- scriptions during the demonstration period (Figure 6. With this information available to the sites, we hypothesized that use of high-cost NSAIDs at the demonstration sites would decline during the demonstration period. However, the percentages of high- cost NSAIDs increased substantially at one demonstration site (Site D) and moderately at one control site (Site C1) during the demon- stration period (Table 6. Also of note, the percent- age of high-cost NSAIDs prescribed at one of the demonstration sites (Site C) steadily decreased in the period following introduction of the guideline, although this probably was coincidental because the site had not defined actions on this issue in its implementation action plan. We examined trends in use of high-cost NSAIDs for all the demonstration and control sites as well as for the two groups after removing episodes of care for patients at the two MTFs with increas- ing use of the high-cost NSAIDs (Figure 6. No significant change in the rate of prescription of high-cost NSAIDs is observed for the demonstration or control sites during the demonstration period, and statistical tests confirmed that trends for the demonstration and control sites were not significantly different (see Appendix C). For example, providers re- ported they increased physical therapy referrals, while some sites reported declines in referrals, and we found trends of declining refer- ral rates in the encounter data. Others reported rates of follow-up visits that were consistent with those estimated from the encounter data. For pain medications, providers correctly reported no change in use of muscle relaxants, but their perceptions of use of NSAIDs and narcotics were not confirmed by the pharmacy data. Most sites in this demonstration generated fairly limited objective data on their utilization trends, which precluded greater compar- isons between such local data and the centralized encounter data (SADR, Standard Inpatient Data Record, and pharmacy data from the PharmacoEconomic Center). The local data were limited in part because low back pain metrics were not established until later in the demonstration. Other factors also contributed to limited monitoring by the sites, including competing demands for the implementation team members’ time, mixed reactions by providers and clinic staff to using the guideline, and lack of mandates from MTF commands. Effects of the demonstration on care for low back pain patients were limited during the first year the sites worked with the practice guide- line, and effects that were found were for patterns of service delivery rather than for prescribing of pain medications. The only overall ef- fect for the demonstration was a decline in physical therapy referrals during the demonstration period. The decline in numbers of follow- up primary care visits in the last quarter of the demonstration may be an early sign of a trend, but additional data for later months would be needed to verify such a trend was real.

Definition and Pathophysiology The consensus now holds that in the vast majority of sporadic cases discount sumycin 250mg visa antibiotic resistance project, col- orectal cancer (CRC) arises within a precursor lesion purchase sumycin 250mg on-line antibiotics chicken, the adenomatous polyp (1,2). The mean age of onset of polyps predates the mean age of onset of carcinoma by several years, and cancer rarely develops in the absence of polyps (3). Patients with one or more large ade- nomatous polyps (≥1cm) are at increased risk of developing CRC (4,5), most of which develop at the site of the polyp, if left in place (5). In addi- tion, patients with genetic predisposition to colonic polyp formation are at greatly increased risk of CRC (6). Finally, several studies have shown that polypectomy significantly reduces the incidence of CRC (7–9). Importantly for imaging-based screening, the risk of a polyp harboring a carcinoma is related directly to the size of the lesion: in polyps less than 1cm in size, the risk is estimated to be <1%; in polyps measuring 1 to 2cm, the risk increases to 10%; and in polyps larger than 2cm, the risk is 25% or more (10). Initiation of CRC is thought to require only two mutations in the ade- nomatous polyposis coli (APC) gene (a tumor suppressor gene). The germline APC gene is mutated in familial adenomatous polyposis (FAP) coli (12). Progression from premalignant polyp to invasive carcinoma is the result of further mutations in other genes, including K-ras, DCC, and p53. Epidemiology Colorectal cancer remains the second most common cause of cancer-related death in the United States, with an estimated annual incidence of 150,000 (13). Mortality rates from CRC are equal in both sexes, with approximately 60,000 individuals in the U. The lifetime risk of developing CRC is approximately 6%, while the estimated lifetime risk of CRC-related death is approximately 2. The 5-year survival rate is 90% for early-stage CRC localized to the colon or rectum, 66% if there is regional spread, and 10% if there are distant metastases (13). Risk factors for CRC include FAP, hereditary nonpolyposis colorectal cancer (HNPCC), family history of CRC in a first-degree relative before age 60, personal history of CRC, age, diet high in animal fat, chronic inflammatory bowel disease, obesity, physical inactivity, diabetes, smoking, and alcohol. Overall Cost to Society Treatment of colorectal carcinoma is estimated to cost between $5. All currently available screening strategies are estimated to cost less than $40,000 per year of life saved, comparable to other screening programs utilized in the U. Goals In general, screening for any disease can be justified in the following cir- cumstances: (a) the disease is prevalent and is associated with clinically significant morbidity and mortality; (b) screening tests are available, Chapter 5 Imaging-Based Screening for Colorectal Cancer 81 acceptable, feasible, and sufficiently accurate for the detection of early disease; (c) earlier diagnosis and treatment is associated with improved prognosis; and (d) the sum of the benefits associated with screening out- weighs the sum of the potential harms and costs. The goal of image-based screening is to detect premalignant adenomatous polyps in an average risk population, thereby enabling removal prior to the development of invasive CRC. There is growing consensus that the target lesion is the advanced adenoma, a polyp containing high-grade cellular dysplasia, the vast majority of which are >1cm in size (15). Methodology We reviewed listings and articles available by Medline (PubMed, National Library of Medicine, Bethesda, Maryland) related to colorectal cancer, colon cancer screening strategies, and cost-effectiveness of colon cancer screening. The search covered the period 1966 to January 2004, and employed search strategies including the terms colon cancer, colon cancer screening, barium enema, CT colonography, virtual colonoscopy, and colono- scopy. The authors performed preliminary evaluation of abstracts resulting from the on-line search and followed this with analysis of full articles; analysis was limited to articles and material relating to human subjects and published in English. Summary of Evidence: In a person with average risk for CRC, the most sig- nificant risk factor for developing CRC is age. Average-risk individuals are those who are deemed not to have an increased or high risk for colorectal carcinoma. Individuals at increased or high risk are those who have a personal or family history of FAP syndrome, hereditary nonpolyposis colorectal cancer, adenomatous polyps, or colorectal cancer, or a personal history of inflammatory bowel disease, colonic polyps, or CRC. Methods to detect polyps and colon cancer include fecal occult blood testing (FOBT), flexible sigmoidoscopy, and colonoscopy. Imaging-based screening methods are double-contrast barium enema (DCBE), and more recently computed tomographic colonography (CTC). Published randomized controlled trials (RCTs) and case-control studies have demonstrated that FOBT and sigmoidoscopy can reduce CRC incidence and mortality.

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