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Public Interest Law Initiative

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By T. Roland. College of the Atlantic.

He has taught many aspects of PAIRS and has been active in developing and refining PAIRS programs discount 25mg sominex fast delivery fear of insomnia. He is currently the vice president of the PAIRS Foundation and serves on the executive board and steering committee of PAIRS buy discount sominex 25mg online sleep aid for diabetics. Adams co-authored a chapter on sensuality and sexuality in Building Intimate Relationships. Parsons) of func- tional family therapy (FFT), a nationally and internationally acclaimed and empirically demonstrated intervention model for juvenile delinquents, oppositional and conduct-disordered youth, and substance abusing youth. He is the 2001 recipient of the Distinguished Award for Lifetime Contributions to Family Therapy Research of the American Association for Marriage and Family Therapy. Alexander is the author of over 90 chapters and refer- eed journal articles, two books, and over 150 convention presentations and academic colloquia. He has also presented at over 300 national and interna- tional clinical training workshops. Alonzo, MA, is a member of the core faculty at Phillips Graduate In- stitute in Encino, California. He is a member of the Society for the Scientific ix x BOUT THE CONTRIBUTORS Study of Sexuality (SSSS) and has presented papers at the SSSS Western Regional Conferences and the Los Angeles SSSS Chapter. He is also a mem- ber of the American Association of Sex Educators, Counselors, and Thera- pists (AASECT), and he is an AASECT Certified Sex Therapist. In addition, he is an American Association for Marriage and Family Therapy Approved Supervisor and a California Association of Marriage and Family Therapy Certified Supervisor, providing supervision, training, workshops, and con- sultation with mental health agencies in the Los Angeles area. He has been a California Licensed Marriage and Family Therapist for more than 13 years, specializing in sexual minority mental health, couple therapy, and working with same-sex couples. Brent Bradley, PhD, is assistant professor of counseling and director of the marriage and family therapy track in the Graduate Counseling Department at Indiana Wesleyan University. He received his doctorate in Marriage and Family Therapy from Fuller Seminary School of Psychology in 2001. He is a clinical member of the American Association for Marriage and Family Therapy. Bradley has published original research in emotionally fo- cused couples therapy (EFT), and actively researches, writes, and presents the approach. Stephen Cheung, PsyD, is an interim core faculty of clinical psychology at Antioch University in Los Angeles. He is teaching Brief Therapy, Family Therapy, Group Therapy, and Psychological Testing. Cheung had been a program director and clinical psychologist at Asian Pacific Counseling and Treatment Centers (APCTC) in Los Angeles coordinating and supervising their children and adult programs for 12 years. For almost three decades, he has been providing short-term and longer-term psychotherapy to a wide variety of clients. He has specialized in: Eating, Substance-related, Personality, Mood, and Anxiety Disorders; grief therapy; and psychological testing. Since 1996, he has been teaching at Phillips Graduate Institute, California State University at Los Angeles, and Pepperdine University. He has also been presenting training in strategic and solution-focused brief therapy, an integrated treatment approach to eating disorders, and psychotheray with childhood abuse survivors in local, national, and international men- tal health conferences. Kahni Clements received her BA in psychology from the University of Cal- ifornia at Los Angeles. She is currently a graduate student in clinical psy- chology at Indiana University-Bloomington. Her research interests are relationship violence and couples communication interactions. Yolanda de Varela, PhD Candidate, is a clinical psychologist with a master’s degree in educational psychology and is completing her doctorate. She has About the Contributors xi been president of the Panamanian Psychological Association, a founding member of the International Institute of Object Relations Therapy, and direc- tor of the Panama Satellite Program of IIORT. She is author and co-author of many articles on object relations and on couples therapy.

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Regardless of whether a transpedic- ular or parapedicular route has been chosen buy 25 mg sominex amex sleep aid gabapentin, the tip of the needle should lie beyond the vertebral midpoint as viewed from the lateral projection buy 25mg sominex sleep aid vitamin. I usually try to obtain an even more anterior position by placing the needle tip at the junction of the anterior and middle thirds. This takes minimally longer than a single needle placement and affords a large margin of safety for being able to dependably com- plete a vertebral fill with a single mix of cement. There is no question that a single needle placement can give an adequate fill in a large num- ber of cases. However, the single-needle method fails to produce uni- form fills more often than the double-needle technique and may oblige the operator to accept a larger cement leak during filling (if the second needle is not in place as an alternate injection route). A B Venography Venography was never used much in Europe and was introduced in the United States in an attempt to discover potential leak sites prior to injecting cement. However, this technique worked poorly because the contrast material and the bone cement differ hugely in viscosity. I dis- continued using venography in 1996 and have found no disadvantage or added risk without its use. Cement with an appropri- ate opacification is prepared and injected using small syringes (typi- cally 1 mL) or devices made specifically for injection (Figure 14. The latter approach, which allows one to step back from the fluoroscopy beam during visualization, minimizes radiographic ex- posure to the operator. Any cement leak outside the vertebral body is an indication to stop the injection. If leakage is still seen, it is advisable to ter- minate the cement injection through this needle and move to the sec- ond needle. This will usually allow completion of the vertebral fill with- out further leakage, since the original leak now will be occluded by the initial cement, which will have hardened. This avoids contamination of both needles at once and preserves a route for subsequent injection if a leak is en- countered. Cement can still be introduced beyond the point at which the injection devices are able to deliver it. The trocar is useful to push additional thick cement from the cannula into the vertebra. The cannula can be removed safely without reintroduction of 264 Chapter 14 Percutaneous Vertebroplasty the trocar when the cement has hardened beyond the point at which it can be injected. Simply twisting the needle through several revolu- tions will break the cement at the tip of the cannula and will prevent leaving a trail of cement in the soft tissues. However, removing the cannula before the cement has hardened sufficiently can allow cement to track backward from the bone into the soft tissues and may create local pain. The amount of cement needed to produce pain relief has not been accurately documented in available clinical reports. We believe that pain relief is related to fracture stabilization, and thus the amount of cement needed to restore the initial vertebral body’s mechanical in- tegrity should also give an approximation of the quantity needed to relieve pain clinically. In an in vitro study, we showed that the initial prefracture strength and stiffness of a vertebra could be restored by in- jecting 2. The above described study suggests that relatively small amounts of cement are needed to restore initial biomechanical strength and that these amounts vary with the position in the spine, as well as individual vertebral body size and the degree of vertebral collapse. We have also demonstrated that significant strength restoration is provided to the vertebral body with a unipedicular injection, where ce- ment filling crosses the midline of the vertebral body. This fact notwithstanding, there is a higher likelihood of achieving more uni- form fills, with fewer leaks, when two needles are used rather than one (Figure 14. Postoperative Care After adequate vertebral filling has been achieved, the needle is re- moved. The patient is maintained recumbent for 1 to 2 hours after the procedure and monitored for changes in neurological function or for signs of any other clinical change or side effects. It is well known that 1 to 2% of patients will have a transient period of benign increase in local pain following PV. However, this is a diag- nosis of exclusion and should prompt extended monitoring (or hospi- talization if the pain is severe and requires aggressive therapy) and im- aging evaluation to exclude other causes for the pain (such as cement FIGURE 14.

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Separate communications departments may be established buy sominex 25 mg with amex insomnia icd 9, or this func- tion may overlap with the PR or community-outreach functions purchase sominex 25 mg insomnia oxycodone. Indeed, marketers have expended a great deal of effort in the examination of various models of communication (see Box 4. Community Outreach Community outreach is a form of marketing that seeks to present the pro- grams of the organization to the community and establish relationships with community organizations. Community outreach may involve episodic activities such as health fairs or educational programs for community residents. This function may also include ongoing initiatives involving out- reach workers who are visible within the community on a recurring basis. This aspect of marketing emphasizes the organization’s commitment to the community and its support of community organizations. While the benefits of community-outreach activities are not as easily measured as some more direct marketing activities, the organization often gains cus- tomers as a result of its health-screening activities, follow-up from educa- tional seminars, or outreach-worker referrals. One objective of community-outreach initiatives is to generate word- of-mouth communication concerning the organization or its services. Word- of-mouth communication occurs when people share information about products or promotions with friends. Efforts to generate positive word-of- mouth support are important, as word-of-mouth communication often tends to be negative. Theories in Communication refers to the transmission or exchange of information Marketing and implies the sharing of meaning among those who are communi- cating. Communication in marketing may be directed at (1) initiating actions; (2) making known needs and requirements; (3) exchanging information, ideas, attitudes, and beliefs; (4) establishing understanding; or (5) establishing and maintain- ing relations. Face-to-face commu- nication can involve formal meetings, interviews, and informal contact. Oral communi- cation can involve telephone contact, public-address systems, and video-conferencing systems. Written communication can include letters (external), memoranda (internal), e- mails, reports, forms, notice boards, journals, bulletins, newsletters, and organization manuals. Visual communication can include charts, films and slides, and video and video- conferencing. Electronic communication can include Internet chat, voicemail, and elec- tronic data interchange. A number of communication models have been developed for application to mar- keting. This marketing communica- tion model has the following eight components in healthcare. Also referred to as the communicator or the source, the sender is the "who" of the process and takes the form of a person, company, or spokesperson for someone else. Message refers to the combination of symbols and words the sender wishes to transmit to the receiver. This would be considered the "what" of the process and indicates the content the sender wants to convey. Encoding refers to the process of translating the meaning to be transmitted into symbolic form (e. Channel refers to the means used to deliver a marketing message from sender to receiver. This indicates the "how" of the process or what connects the sender to the receiver. The receiver is the party who receives the message, also known as the audience or the destination. Decoding refers to the process carried out by the receiver when he or she converts the symbols transmitted by the sender into a form that makes sense to him or her. This process assumes that the receiver is using the same basis for decoding that the sender used for encoding. This is the point at which the effect of the message and its meaning to the receiver are gauged, and it relates to the meaning the receiver attaches to it. Feedback refers to the aspect of the receiver’s response that the receiver communi- cates back to the sender. The type of feedback will depend on the channel, and the effectiveness of the effort is gauged in terms of the feedback.

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Initial evaluation emphasis is on documenting the extent to which effective action plans are devel- oped and the intended actions are actually implemented buy generic sominex 25 mg online sleep aid us. Process evaluation methods are used here order sominex 25mg with visa insomnia mayo clinic, 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. Although the sample sizes were too small to be used for any rigorous statistical analysis, the completed questionnaires offered useful in- sights that we considered in developing our findings. The survey re- spondents were those most actively involved with the guideline, which could bias the surveys to be more optimistic regarding imple- mentation progress. However, the broad distribution on survey re- sponses within the same site suggests no major bias is present. OUTCOME EVALUATION METHODS An interrupted time series control-group design was used to assess the effects of the low back pain guideline demonstration. Quarterly administrative data on service utilization and medication prescrip- tions were collected for low back pain patients served by the demon- stration and control sites. These data provided trend information both before and after introduction of the guideline in the Great Plains Region. The use of a control group allowed us to control for temporal trends that might be influencing observed effects. The six-month baseline period is October 1998 through March 1999, with the MTFs starting actions to implement the guideline in late March or early April 1999. Given that the kickoff conference was held 20 Evaluation of the Low Back Pain Practice Guideline Implementation Table 2.

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