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Intramuscular use of fosphenytoin: whose disadvantages include a tendency to accumulate an overview discount 20 mg escitalopram free shipping anxiety symptoms feeling cold. Practitioners of evidence based care Not all clinicians need to appraise evidence from scratch but all need some skills igh quality health care implies practice that is and values discount 5mg escitalopram fast delivery anxiety 18 weeks pregnant. H tively appealing way to achieve such evidence After a decade of unsystematic observation of an based practice is to train clinicians who can independ- internal medicine residency programme committed to ently find, appraise, and apply the best evidence (whom systematic training of evidence based practitioners,1 we we call evidence based practitioners). Indeed, we have concluded—consistent with predictions2—that not ourselves have advocated this approach. Firstly, attempts to the original literature that bears on a clinical dilemma change doctors’ practice will sometimes be directed to they face. Thus,two reasons exist why training evidence ends other than evidence based care, such as based practitioners will not, alone, achieve evidence increasing specific drug use or reducing healthcare based practice. Clinicians with advanced skills in interpreting the ested in gaining a high level of sophistication in using medical literature will be able to determine the extent the original literature, and, secondly, those who do will to which these attempts are consistent with the best often be short of time in applying these skills. Secondly, they will be able to use the original In our residency programme we have observed that literature when preappraised synopses and evidence even trainees who are less interested in evidence based based recommendations are unavailable. At the same methods develop a respect for, and ability to track down time,educators,managers,and policymakers should be and use, secondary sources of preappraised evidence aware that the widespread availability of comprehen- (evidence based resources) that provide immediately sive preappraised evidence based summaries and the applicable conclusions. Having mastered this restricted implementation of strategies known to change set of skills, these trainees (whom we call evidence users) clinicians’ behaviour will both be necessary to ensure can become highly competent, up to date practitioners high levels of evidence based health care. Time limitations dictate that evidence based practitioners also rely heavily Gordon H Guyatt on conclusions from preappraised resources. Such Maureen O Meade resources, which apply a methodological filter to Roman Z Jaeschke original investigations and therefore ensure a minimal Deborah J Cook standard of validity, include the Cochrane Library, ACP R Brian Haynes clinical epidemiologists Journal Club, Evidence-based Medicine, and Best Evidence Department of Clinical Epidemiology and Biostatistics,McMaster and an increasing number of computer decision University,Hamilton,Ontario,Canada L8N 3Z5 (guyatt@fhs. Thus, producing more comprehensive and more easily accessible preappraised resources is a We thank the following for their input: Eric Bass, Pat second strategy for ensuring evidence based care. Brill-Edwards, Antonio Dans, Paul Glasziou, Lee Green, Anne The availability of evidence based resources and rec- Holbrook, Hui Lee, Tom Newman, Andrew Oxman, and Jack ommendations will still be insufficient to produce Sinclair consistent evidence based care. Habit, local practice pat- terns, and product marketing may often be stronger determinants of practice. Generalpractitioners’perceptionsof conversations with an expert, computerised alerts and the route to evidence based medicine: a questionnaire survey. No magic bullents: a strategies include restricted drug formularies, financial systematic review of 102 trials of interventions to improve professional incentives, and institutional guidelines. Achieving health gain through clinical these strategies, which do not demand even a rudimen- guidelines II: Ensuring guidelines change medical practice. Quality in tary ability to use the original medical literature and Health Care 1994;3:45-52. Effects of computer-based clinical decision support systems on physician behaviour and patient third strategy for achieving evidence based care. System s for em ergency care Integrating the components is the challenge he British government’s announcement of the macies, and community mental health teams, for first 36 new NHS "walk in centres" is the latest example, were either negligible or non-existent. T in a series of important changes in the The recent development of triage and advice provision of immediate access services over the past 20 telephone services, such as NHS Direct,3 has further years. Those who accept your their name to prestigious non-governmental organisa- [industries’] support are often perceived to be less tions, United Nations agencies, and doctors; affect the likely to give you a bad scientific press. They may come direction and outcome of research; create dependency; up with the results that cause you problems, but they create public confusion about the real causes of will put them in a context in a way that leaves you hap- poverty. My own observation and com- and improve products, and of necessity they must ment is that this hidden effect is powerful, more power- employ scientists. But such involvement inevitably cre- ful certainly than we care to state loudly, from the point ates a conflict of interest, and this is why corporations of view of honour either in science or in industry. It go to such lengths to ensure that their scientists sit on takes a lot to bite the hand that feeds you. If sustainable solutions are to be found, food standards for the world), the new Food Standards surely it is imperative that adequate public funds are set Agency, or the European Scientific Committee for aside for this purpose—instead of money that has Food. Some of these committees have already had an already been allocated by industry for an entirely important influence on food laws and the public and different purpose, namely marketing. Surely the public should be able to trust that such public bodies do not 1 Mehdi T, Wagner-Rizvi T. Feeding fiasco—pushing commercial infant foods in favour commercial interests over public health. University of Cape Town said to industry representa- Penang:International Baby Food Action Network,1998.

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A cheap 5mg escitalopram with mastercard anxiety 8 year old boy, B: Axial supine and prone CTC images (viewed on lung settings) reveal a polypoid lesion (arrow) in the region of the splenic flexure escitalopram 10mg free shipping anxiety symptoms long term. C, D: Three-dimensional (3D) reconstruction of region in A and B support the presence of a polypoid mass in the splenic flexure. A: Axial supine CTC image (viewed on lung settings) reveals a polypoid mass in the ascending colon. B, C: Three-dimensional (3D) reconstruction of the region renders an endolumial view of the lesion (B). Digitally subtracted 3D image of the ascending colon provides a lesion projection similar to double con- trast barium enema (DCBE) (C). Axial supine (A) and prone (B) CTC images (viewed on lung settings) reveals a polypoid mass in the sigmoid colon. C: Three-dimensional (3D) endoluminal reconstruction supports the findings on axial imaging. D: Colonoscopy performed on the same day as the CTC in a trial protocol was negative. Suggested Imaging Protocol for Asymptomatic Screening Patients The following protocol pertains to a General Electric 16-slice CT scanner: • Indication: structural evaluation of the colon in patients without colon symptoms or completion CTC if the patient presented to colonoscopy for asymptomatic screening, and no polyps, strictures, or masses found • Bowel preparation: standard catharsis and air insufflation (patient or technician controlled) • Collimation 2. Citarda F, Tomaselli G, Capocaccia R, Barcherini S, Crespi M, Italian Multi- centre Study Group. Special case: can imaging be used to differentiate posttreatment necrosis from residual tumor? Special case: neuroimaging modality in patients with suspected brain metastatic disease D. What is the role of proton magnetic resonance spectroscopy (MRS) in the diagnosis and follow-up of brain neoplasms? What is the cost-effectiveness of imaging in patients with suspected primary brain neoplasms or brain metastatic disease? Key Points Brain imaging is necessary for optimal localization, characterization, and management of brain cancer prior to surgery in patients with sus- pected or confirmed brain tumors (strong evidence). Due to its superior soft tissue contrast, multiplanar capability, and biosafety, magnetic resonance imaging (MRI) with and without gadolinium-based intravenous contrast material is the preferred method for brain cancer imaging when compared to computed tomography (moderate evidence). No adequate data exist on the role of imaging in monitoring brain cancer response to therapy and differentiating between tumor recur- rence and therapy related changes (insufficient evidence). No adequate data exist on the role of nonanatomic, physiology-based imaging, such as proton magnetic resonance spectroscopy (MRS), per- fusion and diffusion MRI, and nuclear medicine imaging [single photon emission computed tomography (SPECT) and positron emis- sion tomography (PET)] in monitoring treatment response or in pre- 102 Chapter 6 Imaging of Brain Cancer 103 dicting prognosis and outcome in patients with brain cancer (insuffi- cient evidence). Human studies conducted on the use of MRS for brain tumors demon- strate that this noninvasive method is technically feasible, and suggest potential benefits for some of the proposed indications. However, there is a paucity of high-quality direct evidence demonstrating the impact on diagnostic thinking and therapeutic decision making. Definition and Pathophysiology The term brain cancer, which is more commonly referred to as brain tumor, is used here to describe all primary and secondary neoplasms of the brain and its covering, including the leptomeninges, dura, skull, and scalp. Brain cancer comprises a variety of central nervous system tumors with a wide range of histopathology, molecular/genetic profile, clinical spectrum, treat- ment possibilities, and patient prognosis and outcome. The pathophysiol- ogy of brain cancer is complex and dependent on various factors, such as histology, molecular and chromosomal aberration, tumor-related protein expression, primary versus secondary origin, and host factors (1–4). First, the brain is covered by a tough, fibrous tissue, the dura matter, and a bony skull that protects the inner contents. This rigid covering allows very little, if any, increase in volume of the inner content, and therefore brain tumor cells adapt to grow in a more infiltra- tive rather than expansive pattern. Second, the brain capillaries have a unique barrier known as the blood—brain barrier (BBB), which limits the entrance of systemic circulation into the central nervous system. Cancer cells can hide behind the protective barrier of the BBB, migrate with minimal disruption to the structural and physiologic milieu of the brain, and escape imaging detection since an intravenous contrast agent becomes visible when there is BBB disruption, allowing the agent to leak into the interstitial space (5–9). Epidemiology Primary malignant or benign brain cancers were estimated to be newly diagnosed in about 35,519 Americans in 2001 [Central Brain Tumor Registry of the United States (10). Nearly 13,000 people die from these cancers each year in the United States (CBTRUS, 2000). Almost one in every 1300 children will develop some form of primary brain cancer before age 20 years (11).

Attachment injuries in couple re- lationships: A new perspective on impasses in couple therapy safe escitalopram 10 mg anxiety jar. The development and implementation of an affect regulation and attachment intervention for incarcerated adolescents and their parents escitalopram 20 mg sale anxiety symptoms one side. Towards a developmental family therapy: The clinical utility of research on adolescence. The feminist/emotionally focused therapy prac- tice model: An integrated approach for couple therapy. CHAPTER 12 Strategic and Solution-Focused Couples Therapy Stephen Cheung OUPLES THERAPY IS very complex. Couples therapy must be sensitive to and simultaneously address a myriad of variables, such as the Cfirst person’s unique life challenges, personal developmental stage, and interpersonal style vis-à-vis those of the second person; the couple’s collective challenges; the couple’s progress in their developmental life cycle; the interaction between the couple; and the interaction between the first person and/or the second person with another outside the couple re- lationship. These variables all impact the couples and the way they per- ceive their problems and their resources to solve their problems (Berg & de Shazer, 1993; Berg & Miller, 1992; Carter & McGoldrick, 1999; Haley, 1973, 1987, 1990, 1996; Madanes, 1981, 1990, 1991; O’Hanlon & Weiner- Davis, 1989). From the inception of psychotherapy until recently, many therapists had a one-size-fits-all mentality toward couples therapy and individual therapy in general. In other words, therapists tended to believe that one kind of therapy would be suitable for all couples and that one type of therapy would adequately address all problems between these couples. However, in the twenty-first century, therapists, informed by modern and postmodern schools of therapy, are more humble and realis- tic, and have rejected the one-size-fits-all approach. Instead, they realize their own limitations and those of their favorite therapy approaches (Cheung, 2001; Corey, 2004; Ivey, D’Andrea, Ivey, & Simek-Morgan, 2002; Prochaska & Norcross, 2003). They further respect the phenomenal world of the individual and trust his or her ability to solve problems. In 194 Strategic and Solution-Focused Couples Therapy 195 this zeitgeist, this chapter presents strategic and solution-focused couples therapy (SSCT) and discusses how SSCT can be beneficially applied to couples. SSCT selectively integrates principles from two therapy ap- proaches: namely, strategic couples therapy (SCT) and solution-focused therapy (SFT). A brief review of the existing theoretical and clinical literature on SCT is first described. Next comes a brief review of the existing theoretical and clinical literature on SFT. The methodology of SSCT that selectively inte- grates principles of SCT and techniques of SFT is then presented. After that, the methodology of SSCT is applied to a specific case to illustrate how it is utilized to address problems presenting in a couple. Last, the chapter explores how cultural and ethnic sensitivity in the application of SSCT can lead to beneficial results. REVIEW OF THEORETICAL AND CLINICAL LITERATURE SCT is based on Milton Erickson’s Strategic Therapy. Underlying Assumptions and Key Concepts Haley and Madanes concur with Erickson’s emphasis on tolerance of the idiosyncrasies of the indi- vidual. They also agree that it is the therapist’s responsibility to initiate what happens during therapy and to design a particular approach for solving each of the client’s problems (Haley, 1973, 1987, 1990, 1996; Madanes, 1981, 1991). Being highly practical, they deem it appropriate for the thera- pist to borrow any useful technique from other therapy models to address the presenting problem. They moreover espouse the epistemology of structuralism and a systemic perspective. The epistemology of structural- ism attempts to identify the objective truth of universals and structures and principles underlying and governing human behavior; it holds that symptoms result from some underlying psychic or structural problem, such as an enmeshed family boundary, incongruous family hierarchies, or psychotic family games (Haley, 1987, 1990; Madanes, 1981, 1990; Minuchin, 1974; Minuchin & Fishman, 1981; Selvini-Palazzoli, 1986; Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978). A systemic perspec- tive assumes recursiveness or circular causality that views people and events in the context of mutual interaction and mutual influence. Instead of examining individuals and events in isolation, a systemic perspective examines the relationships between individuals and events, how each in- teracts with and influences the other. In other words, according to the systemic perspective, meaning is derived from the relationship between individuals and events, where each defines the other. There must be great tolerance of all the different ways cou- ples find to live together or apart. A more sensible focus would seem to be on the particular problem a couple is having within their type of marriage.

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