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Randomly assigned buy 5mg kemadrin with amex treatment interstitial cystitis, receiving intended treatment buy kemadrin 5mg without a prescription treatment 4 anti-aging, completing the study protocol, and analysed for the primary outcome. Describe protocol deviations from study as planned, together with reasons Recruitment Dates defining the periods of recruitment and followup Baseline data Baseline demographic and clinical characteristics of each group. Numbers analysed Number of participants (denominator) in each group included in each analysis and whether the analysis was by ‘intention-to-treat’. A summary of results for each group and the estimated effect size and its precision (e. Statistics in Clinical Practice, 2nd edi- factors in randomized controlled trials and the association tion. European Medicines Agency (EMEA) Deriving dichotomous outcome measures from continuous (http:\www. The simple principle of randomisation is that each patient has the same probability of receiving any of Finding and using the best available evidence should the interventions being compared. There are several interlinked strands: Randomisation also helps to ensure that other factors, • Finding the evidence. Inadequate randomisation, • Making the evidence (doing trials or systematic or inadequate concealment of randomisation, lead to reviews (SRs)). This is elegantly demonstrated in an SR of transcuta- neous electrical nerve stimulation (TENS) in post- SRs and large randomised trials constitute the most operative pain. Seventeen reports on 786 patients reliable sources of evidence we can muster (Table were randomised studies in acute post-operative pain. Put simply, they are the best chance we have to Of these, 15 demonstrated no benefit of TENS over determine what is true. The randomised controlled trial (RCT) is the most To produce valid reviews of evidence a systematic reliable way to estimate the effect of an intervention. In practice, evidence, May 2001) constrained by time and cost, reviewers have to com- Level Therapy/prevention, aetiology/harm promise hoping that what they have found is a repre- sentative sample of the unknown total population of 1a SR (with homogeneity) of RCTs trials. The more comprehensive the searching, the 1b Individual RCT (with narrow confidence interval) more trials will be found and any conclusions will 1c All or none* then be stronger. This failure may be because trials are still 3a SR (with homogeneity) of case–control studies ongoing, or completed but unpublished (publication 3b Individual case–control study 4 Case-series (and poor quality cohort and bias) or because although published the search did case–control studies) not find them. Trying to identify unpublished trials 5 Expert opinion without explicit critical by asking researchers has a very low yield and is not appraisal, or based on physiology, bench cheap. Registers of ongoing and completed trials are research or ‘first principles’ another way to find unpublished data, but such regis- ters are rare. The process 210 THE ROLE OF EVIDENCE IN PAIN MANAGEMENT is laborious, but the Cochrane Library has listed cit- Table 31. For topics that are of bias not mainstream the hand-searching process will still have to be done. Estimates of treatment Give a score of 1 point for each ‘yes’ and 0 points for efficacy from database data are therefore likely to be each ‘no’. Other influences, such as the medical Give 1 additional On question 1, the method of condition itself and other drugs, may confound the point if: randomisation was described issue. You then discover that 20 say that the inter- alternatively, or according vention is terrific, while 20 conclude that it should to date of birth, hospital never be used. Without a quality scale you the method of blinding was would vote for the intervention. The quality standards that you require cannot be absolute, because for some clinical questions A study may of course be both randomised and there may not be any RCTs. Setting RCTs as a min- double blind, and describe withdrawals and dropouts imum absolute standard would therefore be inappro- in copious detail (scoring well on this quality scale) priate for all the questions we might want to answer. Examples include: In the pain world however, there are two reasons for • The injection of morphine into the knee joint to setting this high standard and requiring trials to be reduce pain after arthroscopy. The first is that we do have, particularly was made after the operation without knowledge for drug interventions, quite a number of RCTs. The of whether the patients had enough pain for the second is that it is even more important to stress min- intervention to make a difference. If they had mild imum quality standards of randomisation and double pain it is possible that the success ascribed to the blinding when the outcome measures are subjective. The statistical significance leading to In this context, quality indicates the likelihood that this important conclusion came from a number of the study design reduced bias. Only by avoiding bias small trials with 30% mortality rates; the rates are so is it possible to estimate the effect of a given interven- high that one questions the validity of the trials.

In Europe cardiovascular disease accounts for around 40% of all deaths under the age of 75 years purchase kemadrin 5mg on line treatment wpw. One third of patients with coronary artery disease die before they reach hospital (Evans generic 5mg kemadrin mastercard medications online, 1998; Resuscitation Council UK, 2000). In most of these deaths the presenting rhythm is ventric- ular fibrillation (VF) or pulseless ventricular tachycardia, both potentially reversible by defibrillation. In the USA there are 450000 unexpected cardiac arrests each year, 25% of which occur in public places (Caffrey, et al. The ‘Chain of Survival’ is a well-documented model for effective car- diopulmonary resuscitation for the past decade (Cummins, et al. It sets out four components required to achieve survival following cardiac arrest: early access to help, early basic life support (BLS), early defibrillation and early advanced life support. Given that rapid defibrillation is considered the only treatment for VF, all health care professionals, especially those working in the CR setting, should be trained in the use of automated defibrillators (AED). This is now particu- larly pertinent to the increasing numbers of programmes held in a community setting, where a 999 ambulance would be the first emergency responder. There have also been developments in public access to defibrillation equipment, largely based on a recent study conducted in Chicago airports (Caffrey, et al. With ambulance response times of 8 to 15 minutes, they identified average percentage of survival without an AED present of only 5 to 10%. However, with an AED available, and administered within five minutes, long- term survival increased to 67%. With each minute of delay before attempted defibrillation, the chance of a successful outcome reduces by 7–10% (American Heart Association, 1998; Evans, 1998). Emergency plan Care of A Patient Following Collapse All staff are trained in basic life support procedures, with at least one member of staff able to use an AED. When there is a situation in a class and a patient collapses, there should be an agreed and established emergency protocol with designated responsibili- ties. The following is an example of a plan of action at a phase III exercise class: Leadership, Exercise Class Management and Safety 173 •A local plan of action should be established and adopted as the emer- gency protocol, where specific responsibilities to manage the emergency incident are assigned: Role A lead nurse responsible for immediate care of patient, delega- tion of activities to other staff and responsibility for using AED; Role B staff member deemed competent in airways management, responsible for maintaining patient’s airway in event of a cardiac arrest and assisting lead nurse in BLS procedures; Role C staff member responsible for emergency call and care of other group members. Emergency plan of action Once a patient has collapsed, the following steps should be taken: • assessment by the lead nurse, and BLS commenced as appropriate (Role A); • emergency help called, AED provided; assistance from other staff (Role B); • other patients reassured, removed from area and appropriate cool-down and monitoring undertaken by other team member (Role C); • resuscitation procedures continued until arrival of medical/emergency services; • clinical details of patient and incident given to medical services by lead nurse; • care of patient’s partner, if present; or contact partner to inform about the incident; • continued management and reassurance of group before discharge home. Management of medical problems Care of A Patient with Chest Pain In the event of a patient experiencing chest pain, the immediate aims are to stop the patient exercising, assess and manage the patient’s symptoms and obtain medical help if necessary. The nurse should: • seat the patient, away from the main exercising group, in a half-sitting position, with head/shoulders and legs supported (if preferred); • reassure the patient and assess the nature, scale and duration of symptoms; • if there is no relief of symptoms within two to three minutes of resting, the patient should be encouraged to administer, or be given, as appro- priate, a glyceryl trinitrate (GTN) spray up to three times, at five-minute intervals, following the locally agreed chest pain management protocol. The nurse should monitor heart rate, check blood pressure and undertake a 12-lead ECG, if equipment is available; • if the angina persists after 15 minutes, either an ambulance should be called, if the class is held in a community setting, or hospital medical help should be summoned immediately in order to assess, treat and admit the patient, as appropriate. The patient should be reassured and monitored closely until emergency medical help arrives, with staff ready to follow protocols for cardiac arrest, should the patient deteriorate. The patient’s relatives should be advised of the incident and informed of hospital transfer or admission; • if the angina symptoms resolve completely with the use of GTN spray within 15 minutes, and in the absence of any other symptoms and with satisfactory heart rate and blood pressure measurement, the nurse may decide that the patient is fit to return to the exercise group. Before resum- ing the conditioning component of the exercise session an appropriate warm-up must be undertaken, with close monitoring of the patient to ensure there is no recurrence of angina. The heart rate and workload at which exercise-related ischaemia occurred should be documented, and future exercise prescription adjusted by the exercise leader accordingly. Care of a Patient with Diabetes Given that exercise has an insulin-like effect, exercise-induced hypoglycaemia is the most common problem for exercising diabetics who take exogenous insulin or, to a lesser degree, oral hypoglycaemic agents. Hypoglycaemia can occur either during exercise or up to four to six hours after exercise. Guide- lines from The Health Professional’s Guide to Diabetes and Exercise (Berger, 1995; Gordon, 1995) cited in ACSM (2000) and AACVPR (2004) advised that: •adiabetic patient’s blood glucose level must be under control before beginning an exercise programme; • patients should not exercise if blood glucose levels are >300mg/dL; Leadership, Exercise Class Management and Safety 175 • an insulin-dependent patient should have a carbohydrate snack of 20–30g before exercise if blood glucose is <100mg/dL; • blood glucose should be measured before, during and after exercise; • adjustments in carbohydrate dose and /or insulin may be necessary before or after exercise. It is most important that patients and staff are knowledgeable about the signs and symptoms of a hypoglycaemic attack. Prompt action in response to signs of weakness, faintness, sweating, pallor, confusion or belligerence can avoid a loss of consciousness. In the event of a hypoglycaemic episode where the patient is still conscious: • immediately remove the patient from the exercise environment and sit him/her down; • administer a glucose drink or supplement to rapidly raise blood sugar level; • if there is a good response, give more food and drink and allow the patient to rest until he/she feels fully recovered; • encourage close monitoring of blood sugar level throughout the rest of that day; • discuss the hypoglycaemic episode with a doctor and adjustment to exer- cise prescription and/or insulin and carbohydrate dosage, as required. If the patient loses consciousness: • summon emergency medical help immediately; • maintain airway and resuscitation if necessary; • monitor the patient in the recovery position until medical help arrives. The exercise leader may wish to have stock items, such as stopwatch, whistle, exercise instruction and demonstration cards, music (or voice microphone, as appro- priate) and heart rate monitors for assessing exercise heart rate.

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The associated histologic changes include thin- position poorly purchase 5 mg kemadrin amex medicine urinary tract infection, so an efficient examination is important order 5 mg kemadrin visa symptoms ketosis. Gynecologic Urologic The cervix undergoes significant change and change in Health maintenance: most recent Urethral syndrome/irritative position with aging. The cervical os becomes stenotic and PAP smear symptoms decreases in caliber, often to be virtually unidentifiable in Mammogram Dysuria the elderly woman. The cervix itself may become com- Thyroid-stimulating hormone Frequency pletely flush with the vaginal wall, which has important (TSH) Urgency Hematuria considerations for potential diagnostic capability for Menopausal status Nocturia endometrial assessment. The ability to identify or dilate Age at menopause the cervix for endometrial assessment in the office may Natural or surgical Urinary incontinence Hormone replacement Duration, worsening be limited. The cervix also loses sympathetic and Ever or current (regimen) Stress related parasympathetic innervation, but this has little clinical Most recent bleeding Urge related significance. In terms of position, the cervix regresses to Amount of urine lost (spurt, Estrogen deprivation symptoms the top of the vagina. With the decrease in uterine size large amount, variable) Hot flushes and volume, the cervix may actually appear elongated Fluid intake and pattern Night sweats/sleep disturbance Caffeine and alcohol when compared with the size of the uterus. Vaginal dryness/dyspareunia Both the myometrium and the endometrium undergo Vaginal discharge Voiding dysfunction Difficulty initiating stream atrophy with aging. The postmenopausal uterus dimin- Prolapse symptoms Weak stream ishes in size and weight, with associated decrease in Protrusion Prolonged voiding 4 Pelvic pressure capacity of nuclear binding of estrogen. Feeling of being unemptied Bladder dysfunction: Postvoid dribbling Urinary incontinence Difficulty voiding Bowel dysfunction The size of the ovary has been noted to decrease begin- Digital manipulation 5 Stool incontinence/soiling ning at age 35, with a marked decrease after age 45. Constipation Histologically, the atrophic ovary has lost primordial Rectovaginal Examination Examining the Combative Patient Ovaries and Adnexa Postmenopausal Bleeding References Conclusion 758 C. Changes in symptom score should be interpreted on the basis of expected intraindividual variation. Data from untreated men with symptomatic BPH who had AUA scores repeated 30 days apart sug- gest that changes greater than 4. This point should be kept in mind when interpreting treatment studies in which smaller AUA or IPSS changes reach statistical significance because of study size. Any magnitude of change can be due to factors independent of BPH or its progression (see Table 51. The effect of LUTS on quality of life is central, because for the majority of men the need for treatment depends F 51. Bother may reflect interfer- sia (BPH),bladder outlet obstruction (BOO),and lower urinary ence with daily activities, work, sleep, or sexual function; 40 worry or embarrassment; or physical discomfort. Older men are bothered significantly more by nocturia, frequency, and urgency, independent of overall LUTS severity and the 45 presence of BOO. LUTS are the usual motivation for men to seek evalua- The initial step in evaluation always should be a full tion, especially when symptoms bother, worry, or embar- investigation of potential factors other than benign rass them. LUTS are quantified using indices such as prostate disease that can cause these symptoms. Indeed, the American Urological Association (AUA) symptom the evaluation of older men with LUTS closely parallels score41 (Table 51. Because LUTS are not specific details of such an evaluation, see Chapter 63 on Urinary for prostate disease, these indices should never be used Incontinence; the additional points specific to benign for screening or diagnosis of BPH-related LUTS but only prostate disease are emphasized here. The American Urological Association Symptom Index (score range, 0–35 points) Less than Less than About More than Not at one time half the half the half the Almost all in five time time time always 1. Over the past month or so, how often have you had a sensation of 0 1 2 3 4 5 not emptying your bladder completely after you finished urinating? Over the past month or so, how often have your had to urinate 0 1 2 3 4 5 again less than 2 hours after you finished urinating? Over the past month or so, how often have you found you stopped 0 1 2 3 4 5 and started again several times when you urinated? Over the past month or so, how often have you found it difficult to 0 1 2 3 4 5 postpone urination? Over the past month or so, how often have you had a weak urinary 0 1 2 3 4 5 stream?

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Never have more than three words per bullet point and try to include lots of pictures buy kemadrin 5 mg fast delivery medications used to treat migraines. If you discover they haven’t understood buy kemadrin 5 mg on line treatment pancreatitis, let alone bought, the message then at least you have one last chance to get things right. A great presentation can be lost if the presenter is not interacting with the audience, while a poor presentation can become a great one with an engaged audience. Actors are often taught that to really interact with an audience they need to demonstrate a level of emotion and animation. To help analyse this emotional element, a ladder of seven emotional presentation styles was developed by a French actor in the 1960s: Level one: Total exhaustion. This style puts your audience at their ease and allows you to appear confident and unthreatening. This alludes to the neutral figures in black outfits who walk briskly onto the stage, move a piece of furniture then walk off again. This is the state in which most people present and not surprisingly they do not succeed in connecting with their audience. Typically the presenter speaks in a monotone with an unemotional voice with few movements of any kind. The presenter feels as if he or she is in command of the room, looking at each member of the audience as he/she makes a point and only moving eye contact once the point has been made. Always try to be in either the Californian or the director mode – years of practice has shown that these styles work. And don’t forget to be positive and interested, ensuring that there is plenty of inflection in your voice. When you get to your key messages, try pausing to heighten the level of interest; emphasise them and, if necessary, repeat them to ensure you get the point across. This may sound fundamental, but it is amazing how dislocated many of us become when we are having to present. In summary, then, successfully selling messages in a presentation involves the development of a very few simple messages; understanding the audience’s needs; selling benefits, not features, and ensuring (through practice) the correct projection of emotion and interest. Summary • Be clear about what your messages are and try to keep them simple • Only have two or three key messages in your presentation • Ensure that the audience understands the benefits of the messages • Maintain the right projection of emotion and interest Further reading Fisher R, Ury W, Patton B. Century Business Books, 1990 57 HOW TO PRESENT AT MEETINGS 8 How to deal with questions SIR ALEXANDER MACARA "We are in danger to be called to question" Acts of the Apostles, xix, 40 It is to be hoped that readers will find that questions provide opportunities rather than dangers. Like ancient Gaul, this chapter falls into three parts: how to answer questions after giving a presentation at a meeting; how to handle interviews from the "media"; and how to cope with a "brains trust" or panel discussion. Questions following a presentation The story is told of an eminent physicist who had reluctantly accepted an invitation to address a predictably tiresome meeting. On arrival, his disinclination to speak overcame any sense of obligation, and he decided to rest in his car whilst sending the student, armed with his PowerPoint presentation, to give the lecture. The eager acolyte coped competently with the presentation itself and with agreeably animated discussion until he was fazed by a particularly difficult challenge. Obviously, one should try to avoid accepting unwelcome invitations and, if one has to delegate the invitation to a colleague, albeit armed with your prepared script, bear in mind that he might have problems dealing with questions. Moreover, care must be taken not to underestimate the intelligence or knowledge of the 58 HOW TO DEAL WITH QUESTIONS audience; invariably someone will know more about some aspects of the subject than the speaker. You can choose what to say or not to say in the presentation, but you can only speculate about questions, and "being called in question" clearly presents more dangers than the presentation itself. Invited to address French professors of social medicine in the elegant Chateau de Longchamps in Paris about a European Association to which I wanted to recruit them, I was unexpectedly bidden to speak in French. The chairman came to the rescue: "They all speak English, mon ami, so it is only fair now to switch to your language. For example, if addressing "clinical advances in late onset diabetes", one should review the epidemiology, the history of the diagnosis, treatment and management of the disease, together with its effect on the person as a whole, its relationship to other conditions, and its social, occupational, and economic implications. Turning up in a dinner jacket and finding everyone else in casual smart attire, the late Sir John Brotherston – then CMO Scotland – explained, "I have just come from the office".

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