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Another study of endoscopic sinus surgery indicated that advanced staging of CT and a previous history of sinus surgery correlated with poor clinical outcome (60) discount clonidine 0.1 mg online. Does Sinus Computed Tomography Affect Treatment Decision Making in Chronic Sinusitis? Because sinus CT has uncertain diagnostic accuracy and poor correlation with patients’ clinical symptoms for chronic sinusitis cheap 0.1mg clonidine, some otolaryngologists advocate that a treatment decision should be based solely on clinical grounds (44 buy discount clonidine 0.1mg on line,46) purchase 0.1 mg clonidine with mastercard. Surgery is indicated when the maximum medical treatment fails to resolve the patient’s symptoms cheap clonidine 0.1mg otc. However, there is no consensus as to what repre- sents the maximum medical treatment. Moreover, the basis of treatment decisions, medical versus surgical, for patients with chronic sinusitis is not universally established. Whether or not a patient should be treated surgi- cally, despite normal sinus CT, remains controversial (62). It is an open question whether treatment decisions are purely based on physical exam- ination and clinical history alone, or if sinus CT alters the treatment deci- sions by ENT surgeons (limited evidence). We prospectively administered questionnaires to a surgeon specializing in endoscopic sinus surgery each time he saw a patient for suspected sinusitis (63). After obtaining a clinical history and physical examination, we first asked his treatment decision without a sinus CT, and then again after reviewing the sinus CT. The abstracted clinical information of 27 patients was presented to two other otolaryngologists, and the same ques- tionnaires were administered before and after reviewing the sinus CT. Sinus CT altered dichotomous treatment decisions (surgical versus non- surgical) by the surgeon in one third of patients (9/27) and there was a tendency to offer the surgical treatment after reviewing the sinus CT more than before. The agreement among surgeons with clinical history and physical examination alone was poor but was much improved after reviewing sinus CT. The results of this study indicate that sinus CT provides pivotal objective information that affects treatment decisions and improves the agreement of treatment plans among surgeons (limited evidence). Special Case: Cost-Effectiveness Analysis in Chronic Sinusitis There has been no CEA for chronic sinusitis from the U. Only one recent study from Taiwan assessed cost utility analysis of endoscopic sinus surgery. It measured the cumulative cost of treating chronic sinusi- tis with FESS based on severity of disease. The study revealed an average cost-utility ratio of $70,221 and a high cost-utility ratio of $103,872 (after conversion to U. The cost structure in their study showed that 66% of the total cost was the operation fee. Endoscopic sinus surgery is pri- marily performed on an outpatient basis in the U. Evidence is lacking in this field, and future research is needed (insufficient evidence). Health care costs for patients with chronic sinusitis were investigated in health maintenance organizations (HMOs) in the state of Washington. This study found that adult patients with chronic sinusitis have more nonurgent outpatient visits and fill more prescriptions than adult patients without a history of chronic sinusitis, not including endoscopic sinus surgery. The Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 229 Patients present with acute sinusitis symptoms Use clinical prediction rules or risk factors to differentiate bacterial and viral infection Suspect bacterial sinusitis Uncomplicate viral infection (high probability for ABS) (intermediate to low probability) ABX treatment Decongestant or anti-allergy Rx if h/o allergy Good clinical response Poor response Good clinical response Poor response No imaging study Screening sinus CT No imaging ABX depends on clinical exam Positive CT Negative CT Good clinical response Poor clinical response Change ABX Consider other diagnoses No imaging Screening sinus CT Positive CT Negative CT Change ABX Consider other diagnoses Figure 12. Decision tree for imaging evaluation and management of acute bacterial sinusitis (ABS). Take-Home Figures Decision trees for imaging evaluation and management of acute and chronic sinusitis are shown in Figures 12. Noncontrast screening sinus CT 5-mm-thick coronal images every 10mm 140KVP, 200MA Indications: sinusitis symptoms not responding to medical treatment Diagnosis of sinusitis is in doubt, rule out sinusitis Recent sinusitis, need to evaluate response to treatment 2. Patients with history of chronic sinusitis presented with sinusitis symptoms Treat with ABX and other medical management if applicable (i. If CT correlates w Search for underlying Controversial symptoms consider systemic disease surgery If refractory to the maximum medical Rx, a patient desires, consider surgery Figure 12. Indications: patients require imaging-guided monitoring for endoscopic sinus surgery for skull base lesions or complex sinus surgery Future Research • Randomized controlled trial of antibiotic for patients with mucosal thickening only on CT in order to determine if this group of patients benefits from antibiotic treatment for acute sinusitis. Summary Acute sinusitis • Despite inaccurate clinical diagnosis of acute or chronic sinusitis, the initial treatment decision is based on clinical diagnosis.

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Surely the public should be able to trust that such public bodies do not 1 Mehdi T buy 0.1 mg clonidine fast delivery, Wagner-Rizvi T buy discount clonidine 0.1mg online. Feeding fiasco—pushing commercial infant foods in favour commercial interests over public health generic 0.1mg clonidine free shipping. University of Cape Town said to industry representa- Penang:International Baby Food Action Network order clonidine 0.1 mg line,1998 0.1mg clonidine with amex. Violationsoftheinternationalcodeofmarketingofbreastmilk Research Organisation: "There is a hidden agenda in substitutes:prevalence in four countries. Getting research findings into practice Using research findings in clinical practice S E Straus, D L Sackett In clinical practice caring for patients generates many This is the fifth questions about diagnosis, prognosis, and treatment Summary points in a series of that challenge health professionals to keep up to date eight articles with the medical literature. A study of general analysing the Practising evidence based medicine allows practitioners in North America found that two gap between clinicians to keep up with the rapidly growing clinically important questions arose for every three research and body of medical literature patients seen. General Evidence based medicine improves clinicians’ physicians who want to keep up with relevant journals skills in asking answerable questions and finding NHS Research and face the task of examining 19 articles a day 365 days a the best evidence to answer these questions Development 2 Centre for Evidence year. Based Medicine, One approach to meeting these challenges and Evidence based medicine can provide a Nuffield framework for critically appraising evidence Department of avoiding clinical entropy is to learn how to practise evi- Clinical Medicine, dence based medicine. Evidence based medicine Oxford Radcliffe Practising evidence based medicine encourages Hospital NHS Trust, involves integrating clinical expertise with the best Oxford OX3 9DU clinicians to integrate valid and useful evidence available clinical evidence derived from systematic S E Straus, 3 with clinical expertise and each patient’s unique deputy director research. Individual clinical expertise is the profi- features, and enables clinicians to apply evidence D L Sackett, ciency and judgment that each clinician acquires to the treatment of patients director through clinical experience and practice. Best available Correspondence to: clinical evidence is clinically relevant research which Dr Straus may be from the basic sciences of medicine, but sharon. The box at the bottom of BMJ 1998;317:339–42 evidence based medicine is and how it can be practised the next page illustrates the five steps necessary to the by busy clinicians. Four components of the question must be specified: the patient or problem Clinical findings being addressed; the intervention being considered (a Which is the most accurate way of diagnosing ascites cause, prognostic factor, or treatment); another on physical examination: fluid wave or shifting intervention for comparison, when relevant; and the dullness? To illustrate how many questions may arise in the Differential diagnosis In a patient with cirrhosis and ascites which is most treatment of one patient consider a 65 year old man likely to cause gastrointestinal bleeding, variceal with a history of cirrhosis and ascites secondary to haemorrhage or peptic ulcer disease? On In a patient with suspected alcohol abuse is the use of examination he is disoriented and looks unwell but is the CAGE questionnaire specific for diagnosing afebrile. In addition to spider naevi and gynaeco- Does gastrointestinal bleeding increase the risk of mastia he has ascites. Dozens of questions may arise in treating this Treatment patient; some are summarised in the box opposite. The Does treatment with somatostatin decrease the risk of questions cover a wide spectrum: clinical findings, aeti- death in a patient with cirrhosis and variceal bleeding? This can be done by of ascites would I gain more from spending an hour in considering the question that would be most the library reading a textbook or spending 15 minutes important to the patient’s wellbeing and balancing it on the ward computer looking at the CD ROM against a number of factors including which question version of the same textbook? Most rigorous of these are the systematic reviews on the effects of Searching for the best evidence health care that have been generated by the Cochrane Collaboration, readily available as The Cochrane Library A focused question sharpens the search for the best on compact disc,7 and accompanied by abstracts for evidence. Strategies that increase the sensitivity and critically appraised overviews in the Database of specificity of searches have been developed and are Abstracts of Reviews of Effectiveness created by the NHS available both in paper4 and electronic forms (for 7 Centre for Reviews and Dissemination. A systematic example, at the site established by the NHS Research review from The Cochrane Library is exhaustive and and Development Centre for Evidence-Based Medi- therefore takes years to generate; reviews from the Database of Abstracts of Reviews of Effectiveness can be generated in months. Still faster is the appearance of clinical articles about diagnosis, prognosis, treatment, Steps necessary in practising evidence based quality of care, and economics that pass both specific medicine methodological standards (so that their results are • Convert the need for information into clinically likely to be valid) and clinical scrutiny for relevance and relevant, answerable questions that appear in evidence based journals such as the ACP • Find, in the most efficient way, the best evidence with Journal Club, Evidence-Based Medicine, and Evidence- which to answer these questions (whether this evidence comes from clinical examination, laboratory Based Cardiovascular Medicine. This selection process tests, published research, or other sources) reduces the amount of clinical literature by 98% to the • Critically appraise the evidence for its validity 2% that is most methodologically rigorous and useful to clinician. For example, the site established by the NHS Research and Develop- ment Centre for Evidence-Based Medicine (URL given above) permits browsers to apply the specificity of shifting dullness and the sensitivity of a history of ankle swelling to diagnose patients thought to have ascites; this information could be used to answer some of the questions posed in the diagnosis of the patient with cirrhosis. If the foregoing strategies for gaining rapid (clinicians who produce them become more effective access to evidence based medicine fail clinicians can in searching and critically appraising evidence) than to resort to the time honoured and increasingly user potential users (since the summaries undergo little friendly systems for accessing the current literature via peer review and may be useful mainly for their Medline and Embase, employing methodological qual- citations). Applying the evidence Critically appraising the evidence Applying the results of critical appraisals involves the Once clinicians find potentially useful evidence it has essential second element of evidence based medicine: to be critically appraised and its validity and usefulness integrating the evidence with clinical expertise and determined. Guidelines have been generated to help knowledge of the unique features of patients and their clinicians evaluate the validity of evidence about situations, rights, and expectations. Only after these diagnostic tests (was there an independent, blind com- things have been considered can we then decide parison with a gold standard of diagnosis? The whether endoscopic services are available for sclero- trend towards publishing more informative abstracts therapy or ligation of varices, and if somatostatin also makes it easier for clinicians to determine whether should be used in the interim if endoscopy is not read- research findings are applicable to their patients. Accordingly, the decision of whether to For the patient with cirrhosis and haematemesis, an treat the patient with somatostatin would have to grow assessment of the Cochrane review finds that it is valid, out of a therapeutic alliance with the patient who and the results showed that somatostatin did not have would have to be informed about the potential risks a statistically significant effect on survival.

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Before we review case illustrations 0.1 mg clonidine with visa, the directives for the modified HTP assessment are as follows: • Offer the client one sheet of 9" × 12" paper buy 0.1 mg clonidine amex. The psychosocial history reveals that the biological parents di- vorced when the children were toddlers generic 0.1mg clonidine otc. The mother quickly remarried purchase clonidine 0.1mg on line, and the children’s stepfather was physically abusive to the children as well 143 Reading Between the Lines 3 buy clonidine 0.1 mg low cost. At this point they were re- moved from their mother’s care and placed with the biological father. The house and tree are drawn in long strokes (apprehensive; requires support and reassurance), while the entire person (without face) is shaded and col- ored orange in an aggressive manner (concealment). Color usage is appro- priate; however, the roof of the home (orange) matches the color utilized for the person and points toward tensional intensity (anxiety). It has an inverted V roof, windows that are attached to the wall edge (need for support, fear of autonomy and independent action), and a door that floats above the baseline (interper- sonal inaccessibility). The chimney is detailed with cross-hatched brick (enriching detail devoid in other items) and a line of thick smoke em- anates from it (inner tension). The tree is to the viewer’s right and has two lines for the trunk and a looped crown (oppositional tendencies) in both brown and green. A person stands to the left of the home with outstretched arms (desire for affection), a circular face, dots for eyes, a nose, and a single line for the mouth. The head is connected directly to the squared trunk (body drives threaten to overwhelm). The figure has a rectangular body with reinforced shading of the body walls (need to contain and delineate ego boundaries); however, the figure has no hands or feet (inadequacy, helplessness, withdrawal). In addition to the HTP items, distant detailing appears in the upper left-hand corner in the form of an oversized sun with large rays (need for love and support; repre- sentative of parental love), and two blue clouds float over the home (gen- eralized anxiety). Her dependent reactions are in direct conflict with her need for industry and accomplishments. Moreover, the reinforcement found in the rendering of her person illustrates the struggles surrounding her sense of self. This, coupled with the thick smoke, exemplifies her overconcern with the emotional turbulence that is occurring within the home as well as the client’s own inner tension. This, however, is normal for this cli- ent’s age, when size and proportion are dependent upon emotional values rather than reality. The remainder of the drawing shows adequate line quality, strokes, shading, detailing, and use of color. There are ground lines added under both the tree and the house (provides stability and structure within the environment to reduce the stress when drawn by young chil- dren). The manner of scribbling or shading for the ground under the tree, however, bodes poorly for her ability to cope. The roof is patterned (normal use of detailing) as is the overly large chimney (exhibitionistic tendencies). A circular plume of smoke is seen escaping the home (emotional turbulence within the home). All windows are drawn high on the front of the house, and there is a tiny door (reluctant to permit access) that does not connect to the baseline (interpersonal inac- cessibility). Outside the home a purple-spiked ground line is drawn (pro- vides measure of security but also appears foreboding). An extremely tall tree (aggressive tendencies, need for dominance; feels constricted by and in the environment) is found just right of center and has a colored trunk with branches and foliage located on each branch. The person is placed on the right side with a cir- cular smiley face (typical for age group), thin neck, and long flowing red hair, wearing a brightly colored blue dress. She has well-detailed hands, considering the use of markers and difficulty associated with drawing fin- gers. Her one-dimensional legs appear slightly regressed (indicative of 6- year-old); however, the addition of high-heeled shoes shows her attention to detail and focus on shoes versus the legs. Just above the home is found a 146 Interpreting the Art sun (representative of parental love and support) wearing sunglasses with a "Charlie Brown" smile (normal for age group). When asked to tell what was going on in this picture she said the girl was her and that she lived in the house with her sister, Dad, and her Dad’s girlfriend. She titled the drawing using her own name (which has been changed): "Heather’s Creation. Since a medical etiology was ruled out for the somatic com- plaints, it would appear that she is experiencing a kinesthetic sensory system (Mills & Crowley, 1986) whereby anxiety is revealed through physical symptoms. The difference between her and her older sibling is that this child finds stability and structure within the environment, allowing her to move through the necessary stages of development.

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The low back pain champion also had responsibility to provide monthly reviews and reminders re- garding the low back pain guideline at TMC staff meetings buy clonidine 0.1mg fast delivery, although the new champion gave no indication that he had followed through on this function buy clonidine 0.1mg amex. For instance discount 0.1 mg clonidine, two PAs interviewed at a TMC said they were familiar with the guideline clonidine 0.1mg lowest price, but they were unaware that their practice of frequently prescribing muscle relaxants was not recom- mended by the guideline buy clonidine 0.1mg with amex. Most of the changes in administrative procedures in response to the low back pain guideline were made at the TMCs, reflecting Site B’s implementation strategy. Medics had been instructed to have patients fill out the form and to place it in the Reports from the Final Round of Site Visits 131 patient’s chart or have it available for the providers. Some providers resisted use of the form, calling it "paper pushing" and not useful. No compliance audit of the use of form 695-R was conducted, but PT staff estimated that the form was present in the chart for about 50 percent of the low back pain patients they saw. No procedural changes in support of the implementation of the low back pain guideline were made in either the family practice clinic or the internal medicine clinic. Neither clinic decided to use form 695-R in the processing of low back pain patients, and none of the individ- ual providers interviewed from these clinics used it either. Providers also did not use the standardized profile, even though the MTF staff had identified "a large variance in temporary profiles" as an issue (as documented in our three-month site visit report). At the time of our first site visit, the MTF had only one physical ther- apist, and hence, referrals to PT were discouraged. Most referrals were made to the two chiropractors participating in the Army chiro- practic demonstration. By the time of our last visit, four physical therapists had arrived at the MTF, and PT referrals were encouraged. Since the chiropractic demonstration ended, chiropractors have been integrated with PT. At the TMCs, the protocol was that patients with mechanical low back pain should be referred to PT be- fore they are sent to orthopedics. The orthopedics clinic at the MTF is the gatekeeper for MRI referrals and for care of chronic low back pain. This clinic either refers pa- tients out for surgery (the site does not have a neurosurgery capabil- ity) or writes a permanent profile that limits the functions an active duty person can perform. Representatives of the orthopedics clinic estimate they approve about 20 to 25 percent of requests for MRIs. They also report a high incidence of inappropriate referrals, which were contributing to a two-week backlog for the clinic. As of the final site visit, Site B had not changed its coding of visits to use only 724. Patient education for low back pain is conducted individually at the discretion of providers and medics at each clinic. In general, providers use the MEDCOM patient education brochure, and medics give a copy of the brochure to patients during the visit screening. The brochure is also available in the waiting room for pa- tients to take with them. One TMC designated a medic to conduct patient education, and he sees about 25 to 30 percent of the cases. However, MTF and TMC providers do not refer active duty patients to the wellness center because the center is seen as serving primarily family mem- bers. Metrics and Monitoring Site B has monitored two metrics: • number of visits for low back pain per type of patients, using ADS • number and disposition of MEBs. MEDCOM documentation No specific comments by primary care providers; ortho- form 695-R pedists liked it. General comments that the form was good to collect data and saves the provider time. Sugges- tion to add a diagram in the patient portion of the form to show location of the pain. Key elements cards Providers said pocket card was nice for PAs to have as a reminder. Reports from the Final Round of Site Visits 133 About 54 percent of outpatient visits for low back pain were for active duty personnel. Between calendar years 1998 and 1999, the number of low back pain visits increased 40 percent for active duty personnel and 27 percent for non–active duty individuals.

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