By W. Umbrak. State University of New York College at Purchase.

In addition quality penegra 100mg prostate oncology questions, whilst the evidence that adm inistrative and financial strategies achieve changes in behaviour is strong quality 50mg penegra prostate cancer vs colon cancer, these changes m ay generate m uch resented "hassle" and are not always translated into desired patient outcom es. As Oxm an and colleagues concluded after reviewing 102 published studies on different ways to influence the behaviour of clinicians, "There are no ‘m agic bullets’ for im proving the quality of health care, but there is a wide range of interventions available that, if used appropriately, could lead to im portant im provem ents in professional practice and patient outcom es. These include: • G RiPP (G etting Research into Practice and Purchasing), led by the Anglia and Oxford Regional H ealth Authority46 • PACE (Prom oting Action on Clinical Effectiveness), led by the King’s Fund47 • PLIP (Purchaser Led Im plem entation Projects), led by the N orth Tham es Regional Office. G RiPP included the use of steroids in preterm delivery, the m anagem ent of services 188 IM PLEM EN TIN G EVID EN CE BASED FIN D IN G S for stroke patients, the use of dilatation and curettage (D & C) in wom en with heavy periods, and insertion of grom m ets into children with glue ear. The 12 PACE projects included initiatives to im prove hypertension m anagem ent by G Ps and leg ulcer care within an acute hospital. The PLIP projects were sim ilarly topic based initiatives, including prom oting secondary prevention of coronary heart disease in prim ary care and introduction of guidelines for the eradication of the ulcer causing bacterium H. Prerequisites for im plem enting changes in clinical practice are nationally available research evidence and clear, robust and local justification for change. There should be consultation and involvement of all interested parties, led by a respected product cham pion. Information about current practice and the effect of change needs to be available. Practitioners believe there is no need to change and/or that their practice is already evidence based. Stakeholders have other dem ands on their energies, such as reducing waiting lists or dealing with specific com plaints. H ealth outcom es are notoriously difficult to m easure, yet m any stakeholders m istakenly seek to m easure the success of the project in term s of bottom line health gains. U nfam iliar skills m ay be needed for effective clinical practice, such as those for searching and critical appraisal of research. M em bers of different disciplines m ay not be used to working together in a collaborative fashion. If the validity or relevance of the research literature itself is open to question, change will (perhaps rightly) be m ore difficult to achieve. Stakeholders m ay be pulled in a different direction from that required for clinical effectiveness, e. Changing practice requires a lot of enthusiasm , hard work, and long term vision on the part of the project leaders. Only health authorities and trusts, and the m anagers and clinicians who work within them , have the power (and the responsibility) to translate the evidence into real, m eaningful and lasting im provem ents in patient care. M uch effort will be wasted, and project workers will becom e dem oralised, if organisations are offered an idea whose tim e has not yet com e. The ideal topic for a change program m e is locally relevant, based on sound evidence, and able to dem onstrate tangible benefits in a short tim e. D rive, personality, m otivation, enthusiasm , and non-threatening style are necessary (but not sufficient) characteristics for success. An overworked project worker with conflicting dem ands on their tim e and a lim ited contract is likely to get distracted and start looking for another job. If the project is located, for exam ple, in prim ary care, the project worker needs to be based there. Being seen to be independent of statutory bodies and com m ercial com panies can add credibility and increase goodwill. If bodies (such as audit advisory groups or educational consortia) already exist and are arranging events, plug into these rather than setting up a separate program m e. G enuine com m itm ent from the "m overs and shakers", including funders, opinion leaders, and those in "political" positions, is crucial. Flexibility and responsiveness are particularly im portant when things seem to be going badly; for exam ple, when people say they have insufficient tim e or resources to deliver on a task. Think of ways of doing things differently, extend deadlines, com prom ise on the task, offer an extra pair of hands, and so on. If a project rests entirely on the enthusiasm of a key individual, it will alm ost certainly flounder when that individual m oves on.

Differentiation of the Various Types of Cerebral Ischemic Vascular Lesion 179 Tsementzis generic penegra 100mg prostate exam procedure, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved order penegra 50mg overnight delivery prostate zones diagram. New-onset headaches (simple or tal sinus from the hemi- severe headaches that can be posi- spheres and medial tionally aggravated) cerebral cortex! Increased intracranial pressure Extension of clot into the larger cere- bral veins (as is common in septic thrombosis and in a high percentage in the nonseptic type) may cause the following:! Pain, especially behind the ear from the posterior (coinciding with acute or chronic fossa otitis or mastoiditis)! Increased intracranial pressure confluence of Extension of infection into the veins sinuses (secondary draining the lateral surface of the to otitis media and hemisphere may cause the following: mastoiditis)! Orbital congestion with edema and ophthalmic artery chemosis of the conjunctivae and (originates in eyelids suppurative! Disks are swollen, with small hemor- rhages Differential diagnosis: a) orbital tumors in the region of the sphenoid; b) malig- nant exophthalmos; c) arteriovenous aneurysms CN: cranial nerve. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Spontaneous Intracerebral Hemorrhage 183 Spontaneous Intracerebral Hemorrhage Spontaneous intracerebral hemorrhage (ICH) accounts for approxi- mately 10% of cases of stroke. Arterial hypertension is by far the most common cause of ICH; other causes are the intracranial aneurysms, vascular malformation, bleeding diathesis, cerebral amyloidosis, brain tumors, vasculitis, or drug abuse. The clinical features of ICH depend on the location, size, direction of spread, and rate of development of the hematoma. The clinical presenta- tion of lobar hemorrhages is often misinterpreted as a thromboembolic cerebral infarction. Posterior fossa spontaneous hemorrhages occur in 10% of patients with spontaneous hemorrhage, and may affect either the cerebellum or the pons. Differentiation of cerebellar or pontine hemor- rhages often is not possible on clinical grounds, since they share the sud- den presenting symptoms and often signs. An accurate diagnosis is achieved quickly by computed tomography and magnetic resonance im- aging. Structure involved Clinical manifestations Lobar hemorrhage Frontal lobe – Abulia – Contralateral hemiparesis – Bifrontal headache (maximum ipsilateral) – Occasionally, mild gaze preference away from the hemiparesis Parietal lobe – Contralateral hemisensory loss – Neglect of the contralateral visual field – Headache (usually anterior temporal location) – Mild hemiparesis – Occasionally, hemianopia or anosognosia Temporal lobe – Wernicke’s aphasia (dominant temporal lobe) – Conduction or global aphasia (dominant temporal- parietal lobe) – Variable degrees of visual field deficit – Headache around or anterior to ipsilateral ear – Occasionally, agitated delirium Occipital lobe – Ipsilateral orbital pain – Contralateral homonymous hemianopia Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Spontaneous Intracerebral Hemorrhage 185 Structure involved Clinical manifestations Pontine hemorrhage Symptoms – Headache, vomiting, vertigo, dysarthria – Sudden loss of consciousness, often progressing into deep coma Findings – Sudden-onset coma – Quadriparesis, quadriplegia – Respiratory abnormalities – Hyperthermia – Pinpoint reactive pupils – Eyes fixed in a central position – Loss of brain stem reflexes, including the oculo- cephalic (doll’s head) and the ocuovestibular re- flexes – Ocular bobbing ICH: intracerebral hemorrhage. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Incorrect original diag- nosis Permanent nerve root Deafferentation pain, which is usually constant and injury from the original burning disk herniation Residual or recurrent disk Postoperative compli- cations – Immediate! Permanent injury to the nerve roots from surgery (deafferentation pain, which is usually constant and burning, and is responsible for 6–16% of persistent symptoms in postoperative patients)! Differential diagnosis includes: a) post- operative serous fluid collections, b) infected col- lections! Epidural fibrosis (scar or granulation tissue forma- tion, causing compression and mechanical distor- tion of the nerve root)! Once very common after contrast myelography, particularly with the combination of hemorrhage from myelography/surgery and re- tained contrast material. Differential diagnosis in- cludes: a) Intradural mass, b) CSF tumor spread, and c) spinal stenosis)! Differential di- agnosis includes: a) neoplasm, b) degenerative dis- ease, and c) osteomyelitis Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Diffuse Thickening of the Nerve Root 187 Insufficient root Stenosis of exit foramen, residual soft tissue such as a decompression by re- synovial cyst sidual soft tissue or bone Surgery at the wrong le- vel Disk herniation at anoth- er level Mechanical segmental instability Cauda equina tumor Lumbar spinal stenosis Recurrence at the level of the previous operation many years later, secondary stenosis after surgery at the adjacent level or at the level fused in the midline Causes of back pain un- Myofascial syndrome, paraspinal muscle spasm related to the original condition Psychological factors Secondary gains, drug addiction, poor motivation, psychological problems CSF: cerebrospinal fluid. Diffuse Thickening of the Nerve Root Carcinomatous meningitis Lymphoma Leukemia Arachnoiditis Neurofibroma Toxic neuropathy Sarcoidosis Histiocytosis Vascular anomalies (i. The addition Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Overall sagittal and axial T1-weighted pre–Gd-DTPA and post–Gd-DTPA MRI remains the single most effective method of evaluating the post- operative lumbar spine patient.

Analysis of Guideline Effects The purposes of the analysis of the effects of guideline implementa- tion were to • document the changes in clinical process and service activity in a program that is implementing a practice guideline • document changes in clinical practices that are attributable to the process changes that have occurred • develop metrics and measurement methods that can be adopted by the participating programs for routine monitoring of their continued progress on an ongoing basis 100 mg penegra free shipping prostate cancer psa levels. The first two purposes were the essence of the evaluation activities for the time period of the demonstration generic penegra 50 mg with visa man health 180. A viable monitoring pro- cess, including well-chosen, relevant measures, is essential for an MTF to be able to retain the gains it achieves by modifying practices as recommended by the guideline. This feedback loop continues to provide MTF staff with program quality information, and it main- tains the visibility of the measures being reported as priorities for quality performance. Chapter Two METHODS AND DATA The RAND evaluation for the low back pain guideline demonstration gathered information about both the processes of implementing the practice guideline at participating MTFs and the effects of these implementation activities on delivery of care for low back pain patients. In this chapter, we summarize the methods and data for these two evaluation components. Implementation of a clinical practice guideline is one type of quality improvement intervention. An evaluation of any quality improve- ment intervention should recognize the incremental nature of these processes, which require time to achieve lasting practice improve- ments. A comprehensive evaluation of guideline implementation, therefore, would encompass the following three phases of emphasis: 1. Initial evaluation emphasis is on documenting the extent to which effective action plans are devel- oped and the intended actions are actually implemented. Process evaluation methods are used here, and feedback to participants is provided early in the process and is designed to help them strengthen their interventions. Subsequent emphasis is on monitoring short-term effects of the quality improvement in- terventions on service delivery methods and activity, applying a combination of process and impact (outcome) evaluation methods. The impact evaluation works with quantifiable measures that are rel- evant to the desired changes in either clinical processes or proximal outcomes. Final emphasis takes a longer- term perspective, assessing the effects of program changes on client outcomes. Many of the measures developed to assess effects in the second and third evaluation phases can be used by the programs for ongoing monitoring. The RAND evaluation for the low back pain guideline demonstration encompasses the first two evaluation phases. Lessons were drawn from the implementation process itself to strengthen future guide- line implementation activities (introducing new practices), and data were analyzed to assess the early effects of the low back pain guide- line on health care processes (achieving intended changes in prac- tices). PROCESS EVALUATION METHODS In the process evaluation for the low back pain guideline demonstra- tion, we collected information from the participating MTFs through a series of site visits, monthly progress reports prepared by participat- ing MTFs, and questionnaires completed by individual participants. Three visits were conducted at each demonstration site: an introduc- tory visit before the kickoff conference, a post-implementation visit in June 1999 at three to four months after the MTFs began imple- menting the guideline, and another visit in February 2000 (at month nine or ten of implementation). All groups were candid in reporting progress and identifying issues and problems they encountered. At the conclusion of each evaluation visit, we briefed the MTF command group about what we had learned and issues identified. Summary reports of the results of the ______________ 1Following the kickoff conference in November 1998, there was a delay of approximately four months before the sites began implementation actions for the low back pain guideline. The delay was due to time conflicts during the holidays as well as delays in completion of the practice guideline, metrics, and toolkit items. Methods and Data 19 second round of site visits for the four participating MTFs are pre- sented in Appendix B. These reports document the status of the MTFs at essentially the end of their proactive implementation activi- ties. A second source of process evaluation information was monthly progress reports prepared by the participating MTFs and submitted to RAND. These reports provided valuable information on imple- mentation progress over time, and they also served as a stimulus for action by both the MTFs and MEDCOM as the MTFs identified issues requiring resolution. Finally, we developed brief questionnaires designed to assess the climate in the MTFs for guideline implementation, both at baseline and at the end of the demonstration, and to gather information from participants about their experiences in working with the guideline.

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