By C. Chenor. Westmont College. 2018.

On the other hand order zofran 4 mg on line symptoms juvenile diabetes, you do know who the editor will be – and by carefully studying the journal (see evidence-based writing) order 4mg zofran visa medications kidney damage, you will have a good idea of what he or she likes. Try to distinguish between reviewers who throw in additional facts and tamper with the style on the one hand, and those who give useful macro-editing feedback on the other. If you feel that the final decision rests on a mistake made by the reviewers, consider appealing (see dealing with rejection). Many writers spend hours complaining about the injustices of the system when they could be learning how to play the game. Editors and their staff may go to enormous lengths to ensure that they treat their contributors fairly. But, as long as journals are run as a business and there are more papers than space available, then the final choice will be made on commercial grounds. You should certainly take advantage of 93 THE A–Z OF MEDICAL WRITING such an offer. Flawed and misleading it may be, but it does mean that you get experienced people commenting on what you have written – and all for free. As long as you realize that these comments are almost, by definition, coming from a biased source, they can be extremely useful. In other kinds of publishing you will get nothing like this level of feedback (see journal booklist). This is scientific fraud, and there is no excuse for it under any circumstances. Citing the good things others have said, however, is part of writing, and there should be no problem as long as you acknowledge clearly what you have done and have sought and received the appropriate permission (see copyright). Plain English movement This is the idea that everyone, especially those who draw up our laws and run our bureaucracies, should write in a way that everyone can understand. Groups have risen up in most of the English-speaking world to push for such reforms. In England the Plain English Campaign is one of them; for a fee it will put your text into plain English and award a crystal mark. Since most of us can communicate simply when we want to, it is not a matter of skill, but of culture and attitude. Political correctness All around us are examples of how language is being deliberately changed to meet political agendas. But, irrespective of whether we think some of the changes go too far, there is a valid reason for consciously trying to change the words we use. Language has a profound effect on how we view the world, and if we want social changes, then we must change the language being used. For writers the implications are clear: using inappropriate words may cause people to reject your arguments and (worse still) stop reading what you have written. But suppress any anxieties you might have about this during the actual writing stage. The time to take care of them is during the rewriting phase (see micro-editing). If you are working in a particularly sensitive field, ask someone who knows about the political nuances to go through what you have written – and advise if you have inadvertently given offence. Writers should give offence from time to time, but it should always be premeditated, not accidental. Political writing This is the ability to take a simple statement and make it so hard to understand that the reader becomes confused. Add some peripheral uninteresting information and avoid using one word when several will start to confuse things beautifully. Some bureaucrats have raised it to an art form, but it is not effective writing as discussed generally in this book. Politics of writing When we write we literally put our thoughts in black and white, thus making us an excellent target for anyone who wants to criticize. Not surprisingly, writing often becomes a battleground, where those who have power give a hard time to those who might wish to wrest power from them in the future.

Discuss the role of financial compensation strategies as part of the process to reduce variation in medical practice discount zofran 8mg line medicine 1900. How effective are these financial incentives 8 mg zofran amex medicine escitalopram, especially in terms of timing or use with other strategies? Identify different ways to distinguish between random and assigna- ble variation. In many cases, improvements in healthcare quality are small incre- mental, or evolutionary, changes and not necessarily break- through, or revolutionary, changes. Discuss the value of multiple small variations to effect long-term, sustained improvement. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. A Study in Hospital Efficiency as Demonstrated by the Case Report of the First Five Years of a Private Hospital. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. V ariation in Medical Practice and Implications for Quality 59 Dartmouth Atlas of Health Care. Striving for Quality in Health Care: An Inquiry into Practice and Policy. This page intentionally left blank CHAPTER 4 QUALITY IMPROVEMENT SYSTEMS, THEORIES, AND TOOLS Mike Stoecklein This chapter describes some of the tools and methods that can be used to improve the quality of healthcare. Included are a number of different tool- kits and approaches to quality improvement. Although they may have dif- ferent names and categories, you will recognize core commonalities in methods across these approaches. The contributions of some of the primary quality improvement thought leaders are summarized. In 1924, Shewhart explained how a control chart can differentiate random variation (common cause) from assignable (special) causes. Prior to this, workers reacted to each new data point in an effort to improve the future output. Shewhart felt that his most important contribution was not the control chart, but rather his work on operational definitions, ensuring that people used common operations to define what they measured (Kilian 1988). Edwards Deming Deming combined what he learned from Shewhart and others and, over the course of several decades, developed a theory of improvement. In the 1970s, Deming provided his 14 Points for Western Management in response requests from U. Deming was one of several statisticians and advisors who provided guid- ance at the request of Japanese industry leaders in the 1950s. Create constancy of purpose for continual improvement of products and service to society. Eliminate the need for mass inspection as a way of life to achieve quality. Improve constantly and forever every process for planning, produc- tion, and service. Institute modern methods of training on the job for all, including management. Adopt and institute leadership aimed at helping people to do a bet- ter job. Encourage effective two-way communication and other means to drive out fear throughout the organization. Eliminate the use of slogans, posters, and exhortations for the work- force that do not provide methods. Eliminate work standards that prescribe quotas for the workforce and numerical goals for people in management. Remove the barriers that rob hourly workers, and people in manage- ment, of their right to pride of workmanship. Institute a vigorous program of education and encourage self- improvement for everyone. Over time, Deming spoke less about the 14 points and more about their source—a system of profound knowledge.

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Depresses contractility of the heart and vascu- given to maintain anesthesia buy 4 mg zofran mastercard medicine 44175. Bradycardia is common; ventricular dysrhythmias are uncom- mon unless ventilation is inadequate purchase 8mg zofran fast delivery medicine venlafaxine. Sensitizes heart to catecholamines; increases risk of cardiac dysrhythmias 5. Depresses respiration and may produce hypox- emia and respiratory acidosis (hypercarbia) 6. May cause malignant hyperthermia Isoflurane (Forane) Similar to halothane but less likely to cause cardio- Used for induction and maintenance of general vascular depression and ventricular dysrhythmias. Nitrous oxide Nonexplosive gas; good analgesic, weak anesthetic; Used in balanced anesthesia with IV barbiturates, one of oldest and safest anesthetics; causes no neuromuscular blocking agents, opioid anal- appreciable damage to vital organs unless hy- gesics, and more potent inhalation anesthetics. Note: Nitrous oxide is an gesia in dentistry, obstetrics, and brief surgical incomplete anesthetic; that is, by itself, it cannot procedures. Sevoflurane (Ultane) Similar to isoflurane Used for induction and maintenance of general anesthesia General Intravenous Anesthetics Alfentanil (Alfenta) Opioid analgesic–anesthetic related to fentanyl and May be used as a primary anesthetic or an analgesic sufentanil. It produces sedative and used together for neuroleptanalgesia and com- antiemetic effects. Fentanyl citrate (Sublimaze) is bined with nitrous oxide for neuroleptanesthesia. Innovar is a fixed-dose combination of the riety of diagnostic tests or minor surgical proce- two drugs. Additional doses of fentanyl are often dures can be done, such as bronchoscopy and needed because its analgesic effect lasts approxi- burn dressings. Consciousness returns rapidly, but recently issued a warning about serious cardiac respiratory depression may last 3–4 hours into dysrhythmias, including torsades de pointes, as- the postoperative recovery period. Ketamine (Ketalar) Rapid-acting nonbarbiturate anesthetic; produces Used most often for brief surgical, diagnostic, or marked analgesia, sedation, immobility, amnesia, therapeutic procedures. It also may be used to in- and a lack of awareness of surroundings (called duce anesthesia. If used for major surgery, it dissociative anesthesia); may be given IV or IM; must be supplemented by other general anesthet- awakening may require several hours; during re- ics. It is generally contraindicated in clients with covery, unpleasant psychic symptoms may occur, increased intracranial pressure, severe coronary including dreams and hallucinations; vomiting, artery disease, hypertension, or psychiatric dis- hypersalivation, and transient skin rashes also orders. Methohexital sodium (Brevital) An ultrashort-acting barbiturate similar to thiopental See thiopental, below. May cause hypotension, nance of general anesthesia or sedation in inten- apnea, and other signs of CNS depression. Remifentanil (Ultiva) An opioid analgesic–anesthetic with a rapid onset Used for induction and maintenance of general and short duration of action anesthesia Sufentanil (Sufenta) A synthetic opioid analgesic-anesthetic related to May be used as a primary anesthetic or an anal- fentanyl. Compared with fentanyl, it is more po- gesic adjunct in balanced anesthesia tent and faster acting and may allow a more rapid recovery. Thiopental sodium Ultrashort-acting barbiturate, used almost exclu- Thiopental is commonly used. A single dose produces (Pentothal) sively in general anesthesia; excellent hypnotic unconsciousness in less than 30 seconds and but does not produce significant analgesia or lasts 20–30 minutes. Usually given to induce anes- muscle relaxation; given IV by intermittent injec- thesia. For major surgery, it is usually supplemented by inhalation anesthetics and muscle relaxants. Se- other disorders are also involved, the risks of anesthesia and vere anxiety, for example, may be a contraindication to re- surgery are greatly increased. Because of the risks, general gional anesthesia, and the client may require larger doses of anesthetics and neuromuscular blocking agents should be preanesthetic sedative-type medication. General Anesthesia General anesthesia can be used for almost any surgical, diag- Regional and Local Anesthesia nostic, or therapeutic procedure. If a medical disorder of a vital organ system (cardiovascular, respiratory, renal) is present, it Regional or local anesthesia is usually safer than general should be corrected before anesthesia, when possible.

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Con- tinuing education is provided through numerous symposia offered by the colleges and professional organizations devoted to Oriental medicine purchase 8 mg zofran fast delivery medicine side effects. Often buy 4mg zofran with mastercard symptoms anemia, these meet- ings focus on the treatment of specific diseases or training in the use of a special- ized acupuncture technique or valuable herb formula. Chinese herbs are provided in the United States as food supplements, not as drugs. Thus, they are not strictly regulated by the FDA except for monitoring the cleanliness of manufacturing facilities (for those materials made in the U. Random testing of crude herb materials and herb prod- ucts made in the United States indicate that they are free of harmful bacteria and chemical contaminants. Imported products must be used with some caution, as some of them are problematic, yet get past the investigators. There are a few patent remedies that are labeled with only herb ingredients, but also contain several West- ern drugs. Some patents from China contain only Western drugs (and say so on the box, in Chinese), but purchasers may be unaware of this because they are told only that this is an effective remedy that came from China. Thus, imported Chinese herb products should be taken solely on the basis of a prescription from a trained health professional. Negative interactions with Western drugs have not been noted for any of the common herb materials when used in the normal dosage range. A few people ex- perience allergic reaction to individual herbs, a problem that often cannot be pre- dicted in advance because these are idiosyncratic responses. A more common reaction is a gastrointestinal response, which might include constipation or diar- rhea, nausea or bloating. Such reactions may occur if the individual has poor diges- tive functions, or if the herbal formula is not quite right for the needs of the individual. In a few cases, use of Chinese herb formulas may cause dizziness, headache, agitation, sleepiness, hunger, decreased appetite, sensation of heat or cold, or other sensory reactions. If such responses persist after about three days of using the herbs, it may be necessary to change formulas. Most American practitioners find themselves too busy (because of the small number of practitioners in this country) to prepare detailed reports of their suc- cessful cases; thus, it is necessary to rely primarily on the large-scale clinical trials conducted in China to learn about the success rates. Such clinical reports, pub- lished in the Chinese language, are abstracted and published in English by the Chinese University of Hong Kong. Massage Chinese massage, or Tui Na as it is called, is a healing modality older than even acupuncture and herbs. It all began when prehistoric man discovered an ache on his body, began to (instinctively) rub it, and found that it felt better as a result. This ancient Chinese bodywork is now gaining rapid acceptance in the Western world. Tui Na (pronounced twee-nah) massage is a complete healing system, like acu- puncture and Chinese herbal medicine. It is probably the oldest system of body- work still practiced, yet its popularity continues to grow. Massage as a part of Chinese medical treatment goes back about 4,000 years. Written massage textbooks began to appear as early as the 4th century B. Massage appears to have developed along- side both therapeutic exercise (Qigong) and acupuncture, as it depends on the same understanding of the meridians and the flow of Qi in the human body. The type of massage known as Qi healing, or curing with external Qi (Medical Qigong Therapy), was developed by Master teachers of Qigong. Benefits Chinese massage is not intended to be an experience of pampering or relax- ation. It is a form of deep tissue therapy that conveys the following benefits: Speeding the healing of injuries and clearing bruises. Some forms of Chinese massage do not require extensive training and can be used at home—two more benefits. Chinese massage therapists use a range of techniques to accomplish this: They press, knuckle-roll, squeeze, knead, dig, drag, pluck, tweak, hammer, push, stretch, vibrate, knock, and even tread on the body with their feet.

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