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The AMEDD central and regional leadership ex- pressed strong support for the demonstration cheap malegra fxt 140mg free shipping impotence with gabapentin, but initial verbal sup- port was not followed by actions to provide resources to support the work or require active monitoring and reporting of the sites’ perfor- mance in implementing new practices 140 mg malegra fxt free shipping erectile dysfunction treatment in kerala. Furthermore, the level of commitment by local MTF commanders varied, and changes in command further eroded support over time. This mixed response was understandable, given that this was the first demonstration in a new MEDCOM initiative and there were concerns regarding its ef- fects on MTF workloads and costs. Many providers, including physi- cians in leadership roles, have instinctive negative reactions to prac- tice guidelines as "cookbook medicine," which indeed we heard in our evaluation. Unfortunately, "wait and see" positions by command teams can become a self-fulfilling prophecy leading to failure of im- plementation efforts. We believe this lack of leadership commitment contributed to the limited results of the low back pain guideline demonstration. The demonstration did not perform well in the area of monitoring, in part because this was the first demon- stration and it was put into the field very quickly, even as the DoD/VA practice guideline was still being completed. The guideline expert panel did not select the key metrics for systemwide monitor- ing until well into the demonstration period. Further, MEDCOM did not have the resources to establish a monitoring system at the corpo- Summary xxiii rate level. Without structured guidance from the corporate level, the sites varied widely in their approach to monitoring, and most did not routinely measure their progress in introducing new practices or ef- fects on service delivery patterns. Not having such data is important because, in the absence of objective evidence, providers and clinic staff tend to believe that they are performing well and either do not have to make changes or that changes they made were successful. MEDCOM made a solid commitment to providing the MTFs with policy guid- ance and technical support to enhance their ability to implement best practices for low back pain treatment. Such support can also en- courage consistent practices across the Army facilities. The nature of this support evolved during the demonstration, ultimately including preparation of a toolkit of support materials, hands-on technical support through site visits, and coordination of information ex- change among the MTFs. MEDCOM staff limitations led to some de- lays in preparing the low back pain toolkit materials, especially at the start of the demonstration. We believe this committed support by MEDCOM has been a powerful foundation for the practice im- provements achieved in the guideline demonstrations, as MEDCOM learned from each field test and applied those lessons to subsequent demonstrations. From the start, MEDCOM identified Army-wide guideline champions who were re- spected leaders with a commitment to using the guideline to im- prove the quality of care. The participating MTFs also identified well- respected physicians to serve as guideline champions, and most of these physicians showed a commitment to leading the implementa- tion activities for their facilities. Some of the initial champions were replaced in the course of the demonstration because of rotations and deployments. This demonstration highlighted that it sometimes will be difficult to find a champion who both has enthusiasm for the guideline and is a respected opinion leader, and at times, facilities will have to make trade-offs between these factors. All of the MTF commanders designated champions to lead the implementation of the guideline, but few of the champions received tangible support for their activi- xxiv Evaluation of the Low Back Pain Practice Guideline Implementation ties (other than attendance at the kickoff conference). Most of them had to perform the implementation work in addition to their regular workload. In most of the MTFs, a facilitator designated by the MTF commander provided staff support to the champion, and for some facilitators, this role was an integral part of their regular job. The need to do "double duty" means that champions are able to make only a time-limited commitment to such an initiative, after which they either "burn out" or must turn their attention to other priorities. Thus it is important to integrate new practices into ongoing proce- dures as quickly and effectively as possible, within the available time of the champion. Staff turnover or shifts in policies at the command level can destabilize efforts to introduce and sustain new practices. Three of the participating MTFs made early progress in achieving practices consistent with the low back pain guideline. The fourth MTF viewed low back pain as a low prior- ity and planned few practice changes. Two of the active sites lost momentum over time, one because of heavy workload demands re- lated to deployments, and the other because of changing priorities associated with changes in command. These changes have a good chance of surviving because they addressed an issue that was important to providers and MTF leadership. We note, however, that even successful practice changes may be vulnerable to later policy shifts with subsequent changes in MTF leadership, which occur about every three years.

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Reconceptualizing multicul- tural counseling: Universal healing conditions in a culturally specific context discount malegra fxt 140 mg online online doctor erectile dysfunction. Lesbian generic 140mg malegra fxt erectile dysfunction kolkata, gay, and bisexual people of color: Understanding cultural complexity and managing multiple oppressions. Women and Mental Health: Annals of the New York Academic of Sciences, 789, 147–159. Reproducing gender in counseling and psychotherapy: Un- derstanding the problem and changing the practice. African-American women: Considering diverse identities and societal barriers in psychotherapy. Women and Mental Health: Annals of the New York Academy of Sciences, 789, 191–209. Cultural malpractice: The growing obsolescence of psychol- ogy with the changing U. An appraisal of the relationship between women and psy- chotherapy: 80 years after the case of Dora. Roles, identities, and sexual orientation: Homosexuality, het- erosexuality, and bisexuality. An investigation of the effect of male therapists’ views of women on the process and outcome of therapy with women. Gender differences in the diagnosis of mental disorders: Conclusions and controversies of the DSM-IV. Counseling with Native American Indians and Alaska Natives: Strategies for helping professionals. Psychologists’ attitudes and practices re- garding erotic and nonerotic physical contact with patients. Asian cultural values and the counseling process: Current knowledge and directions for future research. Sexist discrimination may ac- count for well-known gender differences in psychiatric symptoms. The role of sexual orientation in multicultural counseling: Integrating bodies of knowledge. Symposium presented at the annual conference of the American Association of Marriage and Family Therapy, San Francisco. Men’s and women’s gender role journeys: A metaphor for healing, transition, and transformation. Merger and fusion in lesbian relationships: A problem of diagnosing what’s wrong in terms of what’s right. Bridging sepa- rate gender worlds: Why men and women clash and how therapists can bring them to- gether. Therapist-patient sex as sex abuse: Six scientific, professional, and practical dilemmas in addressing victimization and rehabilitation. Sexual involvement with therapists: Patient assessment, subsequent therapy, forensics. The (mis)treatment of men: Effects of client gender role and life-style on diagnosis and attribution of pathology. Levels of evidence for the models of mechanisms of therapeutic change in family and couples therapy. Depression and schizophrenia in women: The intersection of gender, race/ethnicity, and class. SECTION III SPECIAL I SSUES FACED BY COUPLES CHAPTER 15 Managing Emotional Reactivity in Couples Facing Illness: Smoothing Out the Emotional Roller Coaster William H. I have to manage my pain AND my marriage" As psychotherapists, we can forget that our clients are biological crea- tures, that they have bodies as well as minds, and that body and mind are intimately connected. How our bodies function impacts not only our emo- tional lives but also the emotional lives of those with whom we are close. And, conversely, our emotional lives and the interpersonal contexts in which we live affect our physical and biological functioning. Since illness is considered to be the domain of medicine, therapists often are untrained and uninterested in dealing with these issues, despite their prevalence in the general population. Yet the emotional and relational dynamics that are of interest to therapists play a critical role in determining how in- dividuals and couples cope with illness, and the presence of illness in the family often has a profound impact on the individual and relational func- tioning.

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A guideline malegra fxt 140mg generic erectile dysfunction doctor kolkata, "Practice Management Guidelines for the Management of Mild Traumatic Brain Injury order malegra fxt 140mg free shipping erectile dysfunction and viagra use whats up with college-age males," developed by the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group (2001) (2), was based on level II evidence from several studies (three ret- rospective and one uncontrolled prospective). They reported that 3% to 17% of patients with mild injuries had significant CT findings, although they noted that there was no uniform agreement as to what constitutes a positive CT scan in different studies. They also reported that a patient with a normal head CT had a 0% to 3% probability of neurologic deterioration. Therefore, if a patient had a GCS of 15 and no neurologic/cognitive abnor- malities, it was recommended that the patient be discharged. One guideline for severe TBI, "Management and Prognosis of Severe Traumatic Brain Injury" (2000), was developed by the American Associa- tion of Neurological Surgeons (AANS), and approved by the American Society of Neuroradiology, the American Academy of Neurology, the American College of Surgeons, the American College of Emergency Physi- cians, the Society for Critical Care Medicine, and the American Academy of Physical Medicine and Rehabilitation (23,24). An extensive review of the CT literature supported the need for CT in the acute period. Computed tomography was reported to be abnormal in 90% of patients with severe head injury. Computed tomography is included as a necessary step in the algorithm of initial management. What Is the Sensitivity and Specificity of Imaging for Injury Requiring Immediate Treatment/Surgery? Summary of Evidence: Computed tomography is the mainstay of imaging in the acute period. The majority of evidence relates to the use of CT for detecting injuries that may require immediate treatment or surgery. Speed, availability, and lesser expense of CT studies remain important factors for using this modality in the acute setting. Sensitivity of detection also increases with repeat scans in the acute period (strong evidence). Supporting Evidence: The incidence of injury-related abnormalities on CT is related to the severity of injury. After minor head injury, the incidence is approximately 6% (25) and increases up to 15% in the elderly population (26); those with GCS 13 or 14 have higher frequency of abnormalities than those with GCS 15 (27). The incidence of CT abnormalities in moderate head injury (with GCS of 9 to 13) has been reported to be 61% (28). The sensitivity of CT for detecting abnormalities after severe TBI (GCS below 9) varies from 68% to 94%, while normal scans range from approximately 7% to 12% (29). Several studies have shown that the timing of CT studies also affects the sensitivity. Oertel and colleagues (30) (strong evidence) prospectively studied 142 patients with moderate or severe injury who had undergone more than one CT scan within the first 24 hours, and found that the initial CT scan did not detect the full extent of hemorrhagic injuries in almost 50% of patients, particularly if scanned within the first 2 hours. The likelihood of progressive hemorrhagic injury that potentially required sur- gical intervention was greatest for parenchymal hemorrhagic contusions (51%), followed by epidural hematoma (EDH) (22%), subarachnoid hem- orrhage (SAH) (17%), and subdural hemorrhage (SDH) (11%). Servadei and colleagues (31) (strong evidence) prospectively studied 897 patients with more than one CT scan, and found that 16% of patients with diffuse brain injury demonstrated significant evolution of injury. This was more frequent in those with midline shift, often evolving to mass lesions. Therefore, it is useful to perform repeat CT scans in the acute period, particularly after moderate and severe injury, although the timing has not been clearly determined. Summary of Evidence: The sensitivity and specificity of MRI for brain injury is generally superior to CT, although most studies have been retrospective and very few head-to-head comparisons have been performed in the recent decade. Computed tomography is clearly superior to MRI for the detec- tion of fractures, but MRI outperforms CT in detection of most other lesions (limited to moderate evidence), particularly diffuse axonal injury (DAI). Because different sequences vary in the ability to detect certain lesions, it is often difficult to compare results. Although MRI facilitates more detailed analysis of injuries, including metabolic and physiologic measures, further evidence-based research is needed. Supporting Evidence: Magnetic resonance imaging has higher sensitivity than CT, though most comparison studies were performed in the late 1980s and early 1990s (with older generation or lower field scanners). Orrison and colleagues (33) (moderate evidence) retrospectively studied 107 patients with MRI and CT within 48 hours and showed that MRI had an overall sensitivity of 97% compared to 63% for CT, even when a low-field MRI scanner was used, with better sensitivity for contusion, shearing injury, and subdural and epidural hematoma.

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