Similarly impotence depression cheap super p-force oral jelly 160 mg amex, a clear description of the potential sources of bias within the synthesis process itself helps establish credibility with the reader buy generic erectile dysfunction drugs buy super p-force oral jelly 160 mg on line. Decisions about the strength of evidence are explicit although the criteria used are often debated erectile dysfunction treatment nhs order super p-force oral jelly 160 mg amex. Such a discussion would provide information on both the robustness and generalisability of the synthesis erectile dysfunction latest medicine order super p-force oral jelly 160mg with visa. Checking the synthesis with It is possible to consult with the authors of included primary authors of primary studies studies in order to test the validity of the interpretations developed during the synthesis and the extent to which they are supported by the primary data food erectile dysfunction causes super p-force oral jelly 160 mg with amex. The requirements for a careful and thoughtful approach erectile dysfunction doctors san antonio buy genuine super p-force oral jelly on-line, the need to assess the robustness of syntheses erectile dysfunction exercise buy generic super p-force oral jelly 160 mg on line, and to reect critically on the synthesis process erectile dysfunction treatment in vijayawada order super p-force oral jelly uk, apply equally but are not repeated here. This section aims to outline the rationale for quantitative synthesis of comparative studies and to focus on describing commonly used methods of combining study results and exploring heterogeneity. A more detailed overview of quantitative synthesis for systematic review is given in the Cochrane Handbook. However, as synthesis depends partly on what results are actually reported, some planned analyses may not be possible, and others may have to be adapted or developed. Any departures from the analyses planned in the protocol should be clearly justied and reported. Decisions about what studies should and should not be combined are inevitably subjective and require careful discussion and judgement. As far as possible a priori consideration at the time of writing the protocol is desirable. Reserving meta analyses for only those studies that evaluate exactly the same interventions in near identical participant populations would be severely limiting and seldom achievable in practice. For example, whilst it may not be sensible to average the results of studies using different classes of experimental drugs or comparators, it may be reasonable to combine results of studies that use analogues or drugs with similar mechanisms of action. Likewise, it will often be reasonable to combine results of studies that have used similar but not identical comparators. Where there are substantial differences between studies addressing a broadly similar question, although combining their results to give an estimate of an average effect may be meaningless, a test of whether an overall effect is present might be informative. It can be useful to calculate summary statistics for each individual study to show the variability in results across studies. It may also be helpful to use meta-analysis methods to quantify this heterogeneity, even when combined estimates of effect are not produced. Reasons for meta-analysis Combining the results of individual studies in a meta-analysis increases power and precision in estimating intervention effects. Large numbers of events are required to detect modest effects, which are easily obscured by the play 54 Core principles and methods for conducting a systematic review of health interventions of chance, and studies are often too small to do so reliably. Thus, in any group of small trials addressing similar questions, although a few may have demonstrated statistically signicant results by chance alone, most are likely to be inconclusive. However, combining the results of studies in a meta-analysis provides increased numbers of participants, reduces random error, narrows condence intervals, and provides a greater chance of detecting a real effect as statistically signicant. Meta-analysis also allows observation and statistical exploration of the pattern of results across studies and quantication and exploration of any differences. Combining comparative study results in a meta-analysis Most meta-analyses take a two-step approach in that they rst analyse the outcome of interest and calculate summary statistics for each individual study. In the second stage, these individual study statistics are combined to give an overall summary estimate. This is usually calculated as a weighted average of the individual study estimates. The greater the weight awarded to a study, the more it inuences the overall estimate. Studies are usually, at least in part, weighted in inverse proportion to their variance (or standard error squared), a method which essentially gives more weight to larger studies and less weight to smaller studies. It is also possible to weight studies according to other factors such as trial quality, but such methods are very seldom implemented and not recommended. Fixed-effect models weight the contribution of each study proportional to the amount of information observed in the study. This considers only variability in results within studies and no allowance is made for variation between studies. Random-effects models allow for between-study variability in results by weighting studies using a combination of their own variance and the between-study variance. Where there is little between-study variability, the within-study variance will dominate and the random-effects weighting will tend towards that of the xed-effect weighting. If there is substantial between-study variability, this dominates the weighting factor and within-study variability contributes little to the analysis. In this way, all trials will tend towards contributing equally towards the overall estimate and it can be argued that small studies will unduly inuence the estimate. Those in favour of random-effects argue that it formally allows for between-study variability and that the xed-effect approach unrealistically assumes a single effect across trials and gives over-precise estimates. In practice, with well-dened questions, the results of both approaches are often very similar and it is common to run both to test robustness of the choice of statistical model. Generic inverse variance method of combining study results the generic inverse variance method is a widely used and easy to implement method of combining study results that underlies many of the approaches that are described later. It is very exible and can be used to combine any type of effect measure provided that an effect estimate and its standard error is available from each study. Effect estimates may include adjusted estimates, estimates corrected for clustering and repeat measurements, or other summaries derived from more complex statistical methods. Although, in everyday use, the terms risk and odds are often used to mean the same thing, in the context of statistical evaluation they have quite specic meanings. Risk describes the probability with which a health outcome will occur and is often expressed as a decimal number between 0. Odds describe the ratio of the probability that an event will happen to the probability that it 57 Systematic Reviews will not happen and can take any value between zero and innity. Odds ratios can be combined using the generic inverse variance method applied to the log odds ratio and its standard error as described above. The Mantel-Haenszel method for combining risk ratios or odds ratios, which uses a different weighting scheme, is more robust when data are sparse, but assumes a xed effect model. Combining studies using the Peto method is straightforward, and it may be particularly useful for meta-analysis of dichotomous data when event rates are very low, and where other methods fail. The approach is commonly used to combine data from cancer trials which generally conform to these expectations. Correction for zero cells is not necessary (see below) and the method appears to perform better than alternative approaches when events are very rare. However, the Peto method does give biased answers in some circumstances, 58 Core principles and methods for conducting a systematic review of health interventions especially when treatment effects are very large, or where there is a lack of balance in treatment allocation within the individual studies. Although both risk ratios and odds ratios are perfectly valid ways of describing a treatment effect, it is important to note that they are not the same measure, cannot be used interchangeably and should not be confused. When events are relatively rare, say less than 10%,141 differences between the two will be small, but where the event rate is high, differences will be large. For treatments that increase the chance of events, the odds ratio will be larger than the risk ratio and for interventions that reduce the chance of events, the odds ratio will be smaller than the risk ratio. Thus if an odds ratio is misinterpreted as a risk ratio it will lead to an overestimation of the effect of intervention. Unfortunately, this error in interpretation is quite common in published reports of individual studies and systematic reviews. Although some statisticians prefer odds ratios owing to their mathematical properties (they do not have inherent range limitations associated with high baseline rates and naturally arise as the antilog of coefcients in mathematical modelling, making them more suitable for statistical manipulation), they have been criticised for not being well understood by clinicians and patients. Neither the risk ratio nor the odds ratio can be calculated for a trial if there are no events in the control group (as calculation would involve division by zero), and so in this situation it is customary to add 0. These situations are likely to occur when the event of interest is rare, and in such situations the choice of effect measure requires careful thought. A simulation study has shown that when events are rare, most meta-analysis methods give biased estimates of effect,144 and that the Peto odds ratio (which does not require a 0. Continuous outcomes Continuous outcomes are those that take any value in a specied range and can theoretically be measured to many decimal places of accuracy, for example, blood pressure or weight. Many other quantitative outcomes are typically treated as continuous data in meta-analysis, including measurement scales. Where studies assess the same outcome but measure it using different scales (for example, different quality of life scales), the individual study results must be standardised before they can be combined. The third differs from the other two by standardizing by the control group standard deviation rather than an average standard deviation across both groups. The standardised mean difference assumes that differences in the standard deviation between studies reect differences in the measurement scale and not differences between the study populations. The summary intervention effect can be difcult to interpret as it is presented in abstract units of standard deviation rather than any particular scale. Time-to-event outcomes Time-to-event analysis takes account not only of whether an event happens but when it happens. This is especially important in chronic diseases where even although we may not be able to ultimately stop an event from happening, slowing its occurrence can be benecial. For example, in cancer studies in adult patients we rarely anticipate cure, but hope that we can signicantly prolong survival. Each study participant has data capturing the event status and the time of that status. An individual may be recorded with a particular elapsed time-to-event, or they may be recorded as not having experienced the event by a particular elapsed time or period of follow-up. When the event has not (yet) been observed, the individual is described as censored, and their event-free time contributes information to the analysis up until the point of censoring. Meta-analyses that collect individual participant data are able to carry out such analysis for each included study and then pool these using a variant of the Peto method described above. Meta-analyses of aggregate data often treat time-to-event data as dichotomous and carry out analyses using the numbers of individuals who did or did not experience an event by a particular point in time. However, using such dichotomous measures in a meta-analysis of time-to-event outcomes is discarding information and can pose additional problems. If the total number of events reported for each study is used to calculate an odds ratio or risk ratio, this can involve combining studies reported at different stages of maturity, with variable follow-up, resulting in an estimate that is both unreliable and difcult to interpret. Although this makes estimates comparable, interpretation can still be difcult, particularly if individual studies contribute data at different time points. In this case it is unclear whether any observed difference in effect between time points is attributable to the timing or to the analyses being based on different sets of contributing studies. Furthermore, bias could arise if the time points are subjectively chosen by the researcher or selectively reported by the study author at times of maximal or minimal difference between intervention groups. These are sometimes analysed as continuous data, with each category being assigned a numerical value (for example, 0 for none, 1 for mild, 2 for moderate and 3 for severe). This is usual when there are many categories, as is the case for many psychometric scales such as the Hamilton depression scale or the Mini-Mental State Examination for measuring cognition. Methods are available for analysing ordinal data directly, but these typically require expert input. Counts and rates When outcomes can be experienced repeatedly they are usually expressed as event counts, for example, the number of asthma attacks. When these represent common events, they are often treated and analysed as continuous data (for example, number of days in hospital) and where they represent uncommon events they are often dichotomised (for example, whether or not each individual had at least one stroke). Although these can be combined as rate ratios using the generic inverse variance method, this is not always appropriate as it assumes a constant risk over time and over individuals, and is not often done in practice. It is important not to treat rate data as dichotomous data because more than one event may have arisen from the same individual. Presentation of quantitative results Results should be expressed in formats that are easily understood, and in both relative and absolute terms. It also gives a good visual summary of the review ndings, allowing researchers and readers to get a sense of the data. Forest plots provide a simple representation of the precision of individual and overall results and of the variation between-study results. Forest plots can be used to illustrate results for dichotomous, continuous and time-to-event outcomes. The condence interval expresses the uncertainty around the point estimate, describing a range of values within which it is reasonably certain that the true effect lies; wider condence intervals reect greater uncertainty. Although intervals can be reported for any level of condence, in most systematic reviews of health interventions, the 95% condence interval is used. Thus, on the forest plot, studies with wide horizontal lines represent studies with more uncertain results. Different sized boxes may be plotted for each of the individual studies, the area of the box representing the weight that the study takes in the analysis providing a visual representation of the relative contribution that each study makes to the overall effect. The plot shows a vertical line of equivalence indicating the value where there is no difference between groups. For odds ratios, risk ratios or hazard ratios this line will be drawn at an odds ratio/risk ratio/hazard ratio value of 1. Studies reach conventional levels of statistical signicance where their condence intervals do not cross the vertical line. Summary (meta-analytic) results are usually presented as diamonds whose extremities show the condence interval for the summary estimate. A summary estimate reaches conventional levels of statistical signicance if these extremities do not cross the line of no effect. If individual studies are too dissimilar to calculate an overall summary estimate of effect, a forest plot that omits the summary value and diamond can be produced. Odds ratios, risk ratios and hazard ratios can be plotted on a log-scale to introduce symmetry to the plot. The plot should also incorporate the extracted numerical data for the groups for each study. These relative effects do not provide information on what this comparison means in absolute terms. Although there may be a large relative effect of an intervention, if the absolute risk is small, it may not be clinically signicant because the change in absolute terms is minimal (a big percentage of a small amount may still be a small amount). There may be situations where the former is judged to be clinically signicant whilst the latter is not. Meta-analysis should use ratio measures; for example, dichotomous data should be combined as risk ratios or odds ratios and pooling risk differences should be avoided. However, when reporting results it is generally useful to convert relative effects to absolute effects. Absolute change is usually expressed as an absolute risk reduction which can be calculated from the underlying risk of experiencing an event if no intervention were given and the observed relative effect as shown in Box 1. Even if there is no evidence that the relative effects of an intervention vary across different types of individual (see Subgroup analyses and Meta-regression below), if the underlying risks for different categories of individual differ, then the effect of intervention in absolute terms will be different. It is therefore important when reporting results to consider how the absolute effect of an intervention varies for different types of individual and a table expressing results in this way, as shown in Table 1. The underlying risk for different types of individual can be estimated from the studies included in the meta-analysis, or generally accepted standard estimates can be used. The lower the number needed to treat, the fewer the patients that need to be treated to prevent one event, and the greater the efcacy of the treatment. Sensitivity analyses Sensitivity analyses explore the robustness of the main meta-analysis results by repeating the analyses having made some changes to the data or methods. For example, analyses might be carried out on all eligible trials and a sensitivity analysis restricted to only those that used a placebo in the control group. If results differ substantially, the nal results will require careful interpretation. However care must be taken in attributing reasons for differences, especially when a single or small numbers of trials are included/excluded in the sensitivity analysis, as a study may differ in additional ways to the issue being explored in the sensitivity analysis. Some sensitivity analyses should be proposed in the protocol, but as many issues suitable for exploration in sensitivity analyses only come to light whilst the review is being done, and in response to decisions made or difculties encountered, these may have to change and/ or be supplemented. Exploring heterogeneity There will inevitably be variation in the observed estimates of effect from the studies included in a meta-analysis. Some of this variation arises by chance alone, reecting the fact that no study is so large that random error can be removed entirely. Statistical heterogeneity refers to variation other than that which arises by chance. Exploring statistical heterogeneity in a meta-analysis aims to tease out the factors contributing to differences, such that sources of heterogeneity can be accounted for and taken into consideration when interpreting results and drawing conclusions. There is inevitably a degree of clinical diversity between the studies included in a review,160 for example because of differing patient characteristics and differences in interventions. If these factors inuence the estimated intervention effect then there will be some statistical heterogeneity between studies. Methodological differences that inuence the observed intervention effect will also lead to statistical heterogeneity. For example, combining results from blinded and unblinded studies may lead to statistical heterogeneity, indicating that they might best be analysed separately rather than in combination. Although it manifests itself in the same way, heterogeneity arising from clinical differences is likely to be because of differences in the true intervention effect, whereas heterogeneity arising from differences in methodology is more likely to be because of bias.
As Beidler and Tong (1991) point out erectile dysfunction urethral medication buy cheap super p-force oral jelly 160mg line, although sexual harassment and intimidation are always wrong erectile dysfunction 43 years old 160 mg super p-force oral jelly with visa, any romantic rela tionship between a student and an instructor may be suspect causes of erectile dysfunction in 20s buy 160mg super p-force oral jelly with amex, even when it is consensual and there is no overt exploitation erectile dysfunction diabetes permanent buy generic super p-force oral jelly 160 mg line. In fact erectile dysfunction medication uk discount super p-force oral jelly express, several colleges and universities across the country have undertaken reviews of this issue and have proposed or approved policies that ban consensual sexual liaisons between teachers and students as unprofessional erectile dysfunction foods super p-force oral jelly 160 mg lowest price. En thusiastic behavior on your part might be misperceived by some students as sexual harassment erectile dysfunction causes tiredness super p-force oral jelly 160mg overnight delivery. For example erectile dysfunction medication free samples cheap super p-force oral jelly online, suggesting that a student take an indepen dent study under your direaion could be misread as an expression of personal rather than professional interest. Minimize the chances for misin terpretation by, for example, leaving your office door open during student conferences, meeting with students outside of class and during office hours in small groups rather than one-to-one, and avoiding physical contact with students. Treat students of both sexes evenhandedly so that all have the opportunity for informal contact with you. Do not, however, feel so con strained and anxious about sexual harassment that you sacrifice the basic tenets of good teaching. Shrug ging off the behavior or remaining silent may be misconstrued as tacit approval. Instead respond, "It is inappropriate for me to discuss these personal issues with you. If the student persists, keep a record of the incident, including the date, time, place, people involved, and what was said and done. Manhattan: Center for Faculty Evaluation and Development, Kansas State University, 1980. How College Affects Students: Findings and Insights From Twenty Years of Research. As in any team-teaching effort, the success of the course depends on the quality of team communication in both the planning and the conduct of the course. Meet with them regularly, listen carefully to what they have to say about the course and student problems, and give them responsibilities commensurate with their experience. What is to be covered in sections: review lecture, present new material, go over homework, discuss the readings, answer student questions Review topics presented in pre vious classes and topics to be introduced in the coming ones, and discuss teaching strategies. See "Watching Yourself on Videotape" for suggestions on how to conduct observations. Writing Letters of Recommendation the Last Days of Class 47 the end of the term is hectic for everyone: faculty are rushing to make sure they get through the last topics in the course; students begin thinking about finals and are less receptive to new information (Goldsmid and Wilson, 1980). In addition to finishing the syllabus, there are three other tasks you may want to undertake during the last days of class: (1) hold a review session before the final exam, (2) give your students a sense of closure, and (3) ad minister an end-of-course student rating form. For information on designing and administering student rating forms, see "Student Rating Forms. Such a session can also offer students the opportunity to practice skills needed on the exam, to verify what is expected of them on the final, or to gauge the knowledge and skills they have acquired over the term. Though empirical evidence is sketchy, faculty who offer review sessions believe that students who attend them tend to do better on the final ("Exam Review Sessions," 1988). Most students appreciate having time to acknowledge the end of the term, either informally or by completing an end-of-course questionnaire. A handout, distributed with the syllabus or near the end of the term, will help students understand your expectations for the review session. Sahadeo and Davis (1988) recommend holding your review sessions in the evening one or two days before the final exam. They report that students perform better on the final if the review is held after classes end, when students have had a chance to study and are ready to review. If you hold the review during the last class session or two, students may put off studying until they have been told what the test will cover. Scheduling a review outside of regular class hours, however, makes it hard for some students to attend because of work obliga tions, family commitments, or other conflicts. Put nervous stu dents at ease by reassuring them that they can succeed on the final. Give students a handout listing the time and place of the exam, what to bring, assignments due prior to the exam, the specific readings or topics the exam will cover, and the number and format of questions. You can give students thirty to sixty minutes to work on typical or previous exam problems or questions and then discuss the answers as a group or in subgroups. A professor of psychology reports success in structuring his review sessions like "Jeopardy. The instructor gener ates "answers" of increasing difficulty within each category. During the review session, he serves as the emcee and student teams amass points by answering correctly. Ask students to identify the most important topics, themes, or points from the course. Focus your overview/review on the connections among the topics covered in the course. For example, you might list the major topics in the sequence in which you taught them (or have the students generate such a list). Then briefly discuss the important concepts within each major topic and show how they relate to each other. The challenge of preparing this kind of review is to distill the essence of the course into one relatively short presentation. You can structure the entire session as an open question-and-answer period: Students can ask specific questions, describe the types of problems they would like to solve, or name the topics they want to review. If their questions take only fifteen or twenty minutes, you can end the review at that point or move on to another activity that helps them establish priorities or a focus for their studying. For example, discuss the value of studying in groups, give students strategies for pacing themselves, and alert them to common pitfalls (for example, read the instructions carefully; remember to leave time to reread your essays). Sometime during the last week of class, ask your students to write down what they regret not having said during the course. If your class is small enough, devote some time to discussing such issues as, What would have made the material easier to learn San Diego: the Teach ing Assistant Development Program, University of California, n. Now such forms have become commonplace because it makes sense to survey students to find out what they think about their experiences in the class over the term and also because a substantial body of research has concluded that administering questionnaires to students is both valid and reliable. Students of highly rated teachers achieve higher final exam scores, can better apply course material, and are more inclined to pursue the subject subsequently. No consistent relationships have been found between student ratings and such variables as the amount of homework assigned or grading standards. If you are free to design and administer your own questionnaire, the suggestions below (adapted from Davis, 1988) will help you make the most of student rating forms. If you use the standard campus questionnaire, these suggestions can improve the way you administer the forms and interpret the results. Davis (1988) presents sample student rating forms and items that can be used in end-of-course questionnaires, grouped by such categories as accessibility, organization and preparation, and interaction. Theall and Franklin (1990) offer cautions in developing your own questionnaire: it is a time-consuming process to produce a valid and reliable form. For example: "instructor defines new or unfamiliar terms," "repeats difficult concepts," "provides frequent examples. For example, current students can judge how well prepared instructors are, how effectively they make use of class time, how well they explain things and with what level of enthusiasm, and how responsive they are to difficulties the students may be having in the course. Students can also comment on whether the instructor promotes original thinking and critical evaluation of ideas. In contrast, current students are not qualified to judge whether instructors are up-to-date in their field or to rate how adequately a course prepares them for advanced course work in the field. For example, "The instructor routinely summa rizes major points" is unambiguous, while "The instructor is well prepared and gives fair exams" confounds two different issues. Use either a 5-point or 7-point scale, with 1 representing "not at all descriptive" and 5 (or 7) "very descrip tive. Include at least one quantitative measure on the overall effectiveness of the instructor. For example: Considering both the limitations and possibilities of the subject matter and course, how would you rate the overall effectiveness of this instructor Moderately Extremely effective effective effective 12 3 4 5 6 7 Include at least one open-ended item that asks about the overall effec tiveness of the instructor. Student characteristics have relatively little influence on ratings of overall effective ness (Cashin, 1990a). You might want to know, however, whether students are taking the course as an elective or to fulfill a requirement. Since students may fill out evaluation forms for all their instructors, questionnaires should be brief. Administering the Questionnaire Announce in advance the date on which rating forms will be handed out. Schedule the time sometime during the last two weeks of the term; allow ten to fifteen minutes for this activity. Do not distribute forms at the final exam, when students are preoccupied with other matters. It is helpful to stress to students that their ratings and comments are important and will be used by both you and your department. Here are some sample instructions that can be placed on the rating forms and read aloud: 400 Student Rating Forms We hope you will take the time to answer each question carefully. The information you provide will be part of our ongoing efforts to improve the curriculum and the teaching in this department. In addition, your comments will be summarized and used in faculty promotions and reviews [if this is true on your campus]. To main tain confidentiality, these forms will be collected by someone other than the instructor and will not be available to the instructor until after the course grades have been submitted. Research shows that requiring students to sign the forms inflates the ratings (Cashin, 1990b). Designate a student from the class (or a department staff member) to supervise questionnaire administration. You may hand out the forms (always bring several more than the official number of students enrolled), but you should not be present while students complete the questionnaires, and you should not collect the forms. Ask the designated collector to place the forms in a large manilla envelope, noting on the outside your name, the course number, the total number of students present, the total number of forms collected, and the date. Do not look at the forms until after you have submitted final grades for the course. Some campuses provide the faculty with summaries of their rating forms, including computer printouts that show trends and com parative data. If your campus does not provide such a service, you will want to analyze and summarize the data yourself. Summarizing Responses Look at the number of students who completed forms and the total class enrollment. Ideally, you would like a response rate (number of com pleted forms divided by number of enrolled students) of 80 percent or higher. When less than two-thirds of the enrolled students in classes of one hundred or fewer students or less than one-half of the enrolled students in classes of more than a hundred students have submitted forms, the data should be interpreted cautiously if the questionnaires are being used for personnel decisions, such as merit, tenure, or promotion. Aggregating data for several different courses may obscure differences in teaching effectiveness for various kinds of instruction and may raise questions of proper weighting of the responses in each course. Aggregating data for several offerings of the same course may obscure long-term trends toward increased or decreased student satisfaction. Student questionnaires from independent reading courses or seminars with very small enrollments may be accumulated over several terms and summa rized when their numbers are sufficiently large. The summary should reflect the entire range of comments as well as their preponderance. In deciding what to ignore and what to consider, take into account your goals for the course, your values and emphases, and your teaching style (Lunde, 1988). Also re member that it is human nature to focus on that piercing negative comment to the exclusion of the positive remarks from most of the class. Interpreting Responses For quantifiable questions, determine the percentage of omitted re sponses. Items 402 Student Rating Forms with low response rates should be interpreted cautiously. Average ratings can be interpreted on an absolute scale and in relation to the ratings of other similar courses and instructors. For example, a mean rating of 4 on a 7-point scale for overall course evaluation may be labeled "moderately effective. There is some debate within the field on whether such comparisons are meaningful (Theall and Franklin, 1990), even among courses similar in level (lower division, upper division, gradu ate), size, format (lecture, laboratory, and so on), and student demograph ics. Cashin (1992) argues for using comparative data, pointing out that because students tend to rate most items high, a score of 3. In using student ratings to improve your teaching, try to incorporate some comparative information to better understand your own strengths, weaknesses, and accomplishments (Kulik, 1991). Perhaps the best comparative information, as Kulik suggests, comes from noticing changes in the ratings of a course you have taught several times. For example, the average of all ratings for your course may be 5 on a 7-point scale. But notice whether all students rated the course as 4,5, or 6 or whether some 2 and 3 ratings were balanced out by some 7s. One way to analyze student ratings is to calculate the averages for individual questions and note your highest and lowest rated items. See whether your strengths and weaknesses cluster in patterns on any of the following topics: organization and clarity, enthusiasm and stimulation of student interest, teacher-student rapport, teaching and communication skills, course work load and difficulty, fairness of exams and grading, classroom climate. In looking at your highest and lowest rated items, try to identify specific behaviors of yours that might have caused students to give you those ratings. If you do this exercise with a colleague who has administered the same form to his or her students, you can exchange examples of behaviors that lead to high ratings. Then determine whether the complaint is justified (in this case by looking at the syllabus and handouts). If the worry is legitimate, identify specific steps you can take to address the weakness. Keep in mind that students give few detailed suggestions on how to improve a course; they are better at spotting problems (Braskamp, Brandenburg, and Ory, 1984). If you have the time or can prevail upon an experienced teaching consultant, you could analyze open-ended comments using a grid technique, a method for determining whether students who rate a course highly are saying the same things as those who rate the course lower (Lewis, 1991). Small classes, electives, and courses in the humanities tend to receive more favor able ratings. For each characteristic the differences are minimal, but together they may be meaningful (Sorcinelli, 1986). It may also be helpful, in inter preting the results, to take into account whether this course is your favorite, one you frequently teach, or a course that you are teaching at the request of the department chair. Others find it helpful to review the ratings with a knowledgeable colleague or teaching consultant, available on some campuses. Consultants can help you interpret the results and explore strategies for improvement. Many faculty members in these departments or on these campuses believe that because faculty mem bers work harder at their teaching when they know the results are on view to their peers and to students, teaching is of higher quality when the rating forms are publicly available. Manhattan: Center for Faculty Evaluation and Devel opment in Higher Education, Kansas State University, 1990b. Ann Arbor: Center for Research on Learning and Teaching, University of Michigan, 1991. If you do not know a student well or have a lukewarm opinion of his or her work, explain to the student that you will be unable to write a persuasive letter of recommendation and ask the student to turn to another instructor. If you agree to write the letter, here are some suggestions for producing the most effective recommendation. General Strategies Let students know the general tone of what you are likely to write. Especially if your letter will include reservations, let the student know in private what you plan to say so he or she can decide whether to use you as a reference. Use anecdotes and specific examples to give substance and shape to your appraisal. To avoid any possibility of complaints about libel or discrimina tion, some observers suggest faculty preface negative remarks with such phrases as "to the best of my knowledge. Under the Family Educational Rights and Privacy Act of 1974, a student has the right to see a copy of your recommendation unless he or she signs a waiver. If you want your letter to remain confidential, ask the student to sign the waiver. If a third party requests a letter because you have been listed as a reference, check with the student to see if this is true. Of course, courteous students let you know in advance that they are listing you as a reference. Some graduate schools or fellowship programs request letters of recommendation on a special form. Make sure you have all the information you need, including where to send the letter and the deadline.
Boosting innovation and cooperation in European cancer control: key findings from the European partnership for action against cancer erectile dysfunction treatment with exercise buy 160mg super p-force oral jelly visa. Lessons learnt from a population-based pilot programme for colorectal cancer screening in Catalonia (Spain) impotence nitric oxide best purchase super p-force oral jelly. Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom erectile dysfunction medscape buy super p-force oral jelly 160 mg line. Revisiting Wilson and Jungner in the genomic age: a review of screening criteria over the past 40 years depression and erectile dysfunction causes 160 mg super p-force oral jelly fast delivery. Anttila A erectile dysfunction treatment pills buy super p-force oral jelly canada, Arbyn A erectile dysfunction natural remedies at walmart safe 160mg super p-force oral jelly, De Vuyst H causes juvenile erectile dysfunction buy super p-force oral jelly 160mg overnight delivery, Dillner J 60784 impotence of organic origin purchase 160mg super p-force oral jelly amex, Dillner L, Franceschi S, Patnick J, Ronco G, Segnan N, Suonio E, Tornberg S & von Karsa L(eds. Vicus D, Sutradhar R, Lub Y, Elit L, Kupets R, Paszat L, on behalf of the Investigators of the Ontario Cancer Screening Research Network. Cervical screening and cervical cancer death among older women: a population-based, case control study. Lonnberg S, Sekerija M, Malila N, Sarkeala T, Leja M, Majek O, Zappa M, Heijnsdijk E, Heinavaara S, de Koning H, Anttila A. Cancer screening: Policy recommendations on governance, organisation and evaluation of cancer screening. Burden of breast, cervical and colorectal cancer in the European Union 53 54 Figure 1. Screen positive patient is informed through the treating physician to have further investigation; In Czech Republic the invitations are sent only to the women upto 70 years of age; In Italy the target age is 45-74 years only in Piemonte and Emilia Romagna. In other regions the target-age is 50 69 years; In Lithuania the invitation is sent through primary health care. Only in select municipalities the invitation include a fixed appointment date; The Cancer Screening and Registry Act came into force in Germany in 2013. The Federal Joint Committee is responsible for the further regulation and implementation of the Cancer Screening and Registry Act. The Act regulates data linkage between organised screening programmes and cancer registries (epidemiological/clinical). Screen positive patient is informed through the treating physician to have colonoscopy; The population based programme in the Czech Republic started in 2014. The invitations are sent only to the individuals up to 70 years of age; In Estonia the population based pilot programme started in 2016 among a 60 years old age cohort, with an intended target group of 60-69 years old; In Germany, screening activities started in 1974, and a population-based programme is planned to start in 2016. It created the legal framework to turn the current opportunistic screening programmes for cervical and colorectal cancer into organised, population based screening programmes. The Act regulates data linkage between organised screening programmes and cancer registries (epidemiological/clinical); In Hungary, women who have already been screened opportunistically are not invited; Ireland is planning to extend the target age to 55-74 years; In Italy, screening started in 1982 in Florence, and between 2000 and 2004 in other regions; In Lithuania, the population based programme started in 2009 in two districts, and became nationwide in 2014. It may or not be by letter; In Luxembourg a population based programme is planned to start in 2016; In Sweden, only Stockholm Gotland region has introduced screening; Year of programme initiation: England 2006, Northern Ireland 2010, Scotland 2007, Wales 2008. The Act regulates data linkage between organised screening programmes and cancer registries (epidemiological/clinical); In Ireland, linkage between screening data and cancer registry and the first performance reports are in preparation as the program was launched few years back. Tests in parentheses currently used less Excluded: 50-69-year-old women in regions and/or age ranges not targeted by planned or existing programmes due to lack of nationwide policy and/or due Countries or regions with narrow age-range: Estonia 50-64, Hungary 45-64 Regional programmes: see continued table below. Women age 40-44 or 75+ years may contact Cyprus: programme implemented in areas effectively controled by the Republic of Cyprus. Cervical cancer screening programmes in European Union Member States 2016 30-59-year-old women in estimated national target populations Population estimates by screening test, programme type and country implementation status Population-based Non-population No programme or Total Screening programmes based programmes excluded population test women women excluded women member women status status (x1,000) (x1,000) due to (x1,000) states (x1,000) Austria Cytology Nationwide 1,859 1 1,859 Belgium Cytology Regional, rollout ongoing 1,313 Regional 985 1 2,298 Bulgaria No progr 1,490 1 1,490 Croatia Cytology Nationwide, rollout ongoing 882 1 882 Cyprus No progr 195 1 195 Czech Republic Cytology Nationwide, rollout ongoing 2,225 1 2,225 Denmark Cytology Nationwide, rollout complete 1,105 1 1,105 Estonia Cytology Nationwide, rollout complete 271 1 271 Finland Cytology Nationwide, rollout complete 1,042 1 1,042 France Cytology Regional, rollout ongoing 1,788 Regional 11,279 1 13,067 Germany Cytology Nationwide, planning 16,974 Nationwide 16,974 1 16,974 Greece Cytology Nationwide 2,348 1 2,348 Hungary Cytology Nationwide, rollout ongoing 2,091 1 2,091 Ireland Cytology Nationwide, rollout ongoing 986 1 986 Italy Cytology Nationwide, rollout ongoing 13,187 1 13,187 Latvia Cytology Nationwide, rollout complete 423 1 423 Lithuania Cytology Nationwide, rollout ongoing 612 1 612 Luxembourg Cytology Nationwide 125 1 125 Malta Cytology Nationwide, piloting 18 Age 67 1 85 Netherlands Cytology Nationwide, rollout complete 3,425 1 3,425 Poland Cytology Nationwide, rollout complete 8,330 1 8,330 Portugal Cytology Regional, rollout ongoing 1,616 Regional 676 1 2,293 Romania Cytology Nationwide, rollout ongoing 4,166 1 4,166 Slovak Republic Cytology Nationwide, planning 1,197 1 1,197 Slovenia Cytology Nationwide, rollout complete 440 1 440 Spain Cytology Nationwide 10,491 1 10,491 Sweden Cytology Nationwide, rollout complete 1,842 1 1,842 United Kingdom Cytology Nationwide, rollout complete 13,078 1 13,078 Total 77,012 27,086 2,428 28 106,527 Abbreviations: No progr No programme Unless otherwise indicated in footnotes: estimates of age-eligible population are based on Eurostat projections for 2016. Ireland Cytology rollout complete 377 1 13,078 Scotland Cytology rollout complete 1,118 Wales Cytology rollout complete 595 Abbreviations: No progr No programme Unless otherwise indicated in footnotes: estimates of age-eligible population are based on Eurostat projections for 2016. Breast cancer screening programmes in the European Union: performance indicators 95 96 97 Table 4. Austria, Czech Republic and Lithuania did not issue or could not document personal invitations at the time of the index year. Cervical cancer screening programmes in the European Union: performance indicators 129 130 Figure 4. For example: A) Women 25-64 years screened every 3 years: denominator is female Pop25-64 3 B) Women 25-49 years screened every 3 years and 50-64 screened every 5 years: denominator is Pop25-49 3 + Pop50-64 5 30-59 years All ages Women invited Notes N D % N D % Belgium 257,259 760,521 33. For example: A) Women 25-64 years screened every 3 years: denominator is female Pop25-64 3 B) Women 25-49 years screened every 3 years and 50-64 screened every 5 years: denominator = Pop25-493 + Pop50-645 30-59 years All ages Notes N D % N D % Belgium 29,752 760,521 3. Women invited during the index year and screened during the subsequent year (within April 30 as general rule, within June 30 in Sweden and Denmark) included. For example: A) Women 25-64 years screened every 3 years: denominator is female Pop25-64 3 B) Women 25-49 years screened every 3 years and 50-64 screened every 5 years: denominator = Pop25-493 + Pop50-645 30-59 years All ages Notes N D % N D % Belgium Flemish region 182,685 436,976 41. Colorectal cancer screening programmes in the European Union: performance indicators 145 146 147 Table 4. Annual populations are estimated by dividing the national or regional population in the respective age range by the screening interval in years. For countries not providing data as well as for those in the planning phase a 2-year interval is assumed in the default age range. Coverage by invitation is calculated only for countries or regions with population-based programmes providing data on the number of persons invited in the respective index year. Coverage by examination is calculated only for countries or regions with population-based or non-population based programmes providing data on the number of persons screened in the respective index year. Nationwide coverage in programme-specific age ranges is calculated only for countries with programme policy (age range and interval) adopted in all regions. Country subtotals are included for countries with regional programmes or multiple screening tests; the subtotals are adjusted to avoid double counting due to possible multiple testing. Coverage is calculated by dividing the annual number of persons invited, or screened, by the annual population in the respective programme-specific age range. Programme-specific age ranges: the screening age ranges set by the programme policies in respective countries or regions. Annual populations are estimated by multiplying the national or regional population by the proportion of the population to which the programme was rolled out in the index year. For the countries and regions shown, the screening programme type in the index year is the same as in Table 3. The actual figures for invitation coverage over the target populations of population based programmes is 62. The actual figures for invitation coverage over the target populations of population based programmes is 26. List of figures Burden of breast, cervical and colorectal cancer in the European Union Figure 1. Snapshot of the web based data collection platform Status of implementation and programme organization Figure 3. List of tables Burden of breast, cervical and colorectal cancer in the European Union Table 1. Status of data collection from the different countries for the second report Table 2. Index years of reporting of the performance of breast, cervical and colorectal cancer screening Status of implementation and programme organization Table 3. Breast cancer screening programmes in European Union member states 2016: estimated number of 50-69-year-old women in national target populations Table 3. Cervical cancer screening programmes in European Union member states 2016: estimated number of 30-59-year-old women in national target populations Table 3. Colorectal cancer screening programmes in European Union member states 2016: estimated number of 50-74-year-old women and men in national target populations 209 Breast cancer screening programmes in the European Union: performance indicators Table 4. Having regard to the proposal from the Commission, Having regard to the opinion of the European Parliament, (6) Important factors which have to be assessed before a population-wide implementation is decided upon include, inter alia, the frequency and interval of the appli Whereas: cation of the screening test as well as other national or regional epidemiological specificities. The main indi fight against the major health scourges, by promoting cator for the effectiveness of screening is a decrease in research into their causes, their transmission and their disease-specific mortality. As in the case of cervical prevention, as well as health information and education. In addition mated number of 1 580 096 new cancer cases, to its beneficial effect on the disease-specific mortality, excluding non-melanoma skin cancer, occurred in the screening can also have negative side effects for the European Union in 1998. Healthcare providers should be cancers, 13 % breast cancers, 14 % colorectal cancers aware of all the potential benefits and risks of screening and 9 % prostate cancers. Cervical and breast cancer for a given cancer site before embarking on new popula constituted 3 % and 29 %, respectively, of new cancers tion-based cancer screening programmes. Prostate cancer constituted 17 % of new for the informed public of today, these benefits and risks cancers in men. These two documents form, (10) Ethical, legal, social, medical, organisational and together with the current best practice in each of the economic aspects have to be considered before decisions cancer screening fields, the basis for the present recom can be made on the implementation of cancer screening mendations. The application of recommended screening meth odologies should therefore be accompanied by simulta neous assessments of the quality, applicability and cost (20) Specific performance indicators have been established effectiveness of new methods if available epidemiological for cancer screening tests. Monitoring (a) regularly monitor the process and outcome of organised screening and report these results quickly to the public 1. Implementation of cancer screening programmes and the personnel providing the screening; (a) offer evidence-based cancer screening through a (b) adhere to the standards defined by the European systematic population-based approach with quality Network of Cancer Registries in establishing and main assurance at all appropriate levels. The tests which taining the screening databases in full accordance with should be considered in this context are listed in the Annex; relevant legislation on personal data protection; (b) implement screening programmes in accordance with (c) monitor the screening programmes at adequate inter European guidelines on best practice where they exist vals. Training (c) ensure that the people participating in a screening programme are fully informed about the benefits and adequately train personnel at all levels to ensure that they risks; are able to deliver high quality screening. Compliance following evidence-based guidelines of those with a positive screening test are provided for; (a) seek a high level of compliance, based on fully informed consent, when organised screening is offered; (e) make available human and financial resources in order to assure appropriate organisation and quality control; (b) take action to ensure equal access to screening taking due account of the possible need to target particular (f) assess and take decisions on the implementation of a socioeconomic groups. Introduction of novel screening tests taking into account and pilot projects; international research results (g) set up a systematic call/recall system and quality assur (a) implement new cancer screening tests in routine health ance at all appropriate levels, together with an effective care only after they have been evaluated in randomised and appropriate diagnostic and treatment and after-care controlled trials; service following evidence-based guidelines; (b) run trials, in addition to those on screening-specific (h) ensure that due regard is paid to data protection legisla parameters and mortality, on subsequent treatment tion, particularly as it applies to personal health data, procedures, clinical outcome, side effects, morbidity and prior to implementing cancer screening programmes. Registration and management of screening data methods by pooling of trial results from representative settings; (a) make available centralised data systems needed to run organised screening programmes; (d) consider the introduction into routine healthcare of potentially promising new screening tests, which are currently being evaluated in randomised controlled (b) ensure by appropriate means that all persons targeted trials, once the evidence is conclusive and other relevant by the screening programme are invited, by means of a aspects, such as cost-effectiveness in the different health call/recall system, to take part in the programme; care systems, have been taken into account; (c) collect, manage and evaluate data on all screening tests, (e) consider the introduction into routine healthcare of assessment and final diagnoses; potentially promising new modifications of established screening tests, once the effectiveness of the modifica (d) collect, manage and evaluate the data in full accordance tion has been successfully evaluated, possibly using with relevant legislation on personal data protection. To encourage cooperation between Member States in report to the Commission on the implementation of this research and exchange of best practices as regards cancer Recommendation within three years of its adoption and screening with a view to developing and evaluating new subsequently at the request of the Commission with a view screening methods or improving existing ones. To report on the implementation of cancer screening programmes, on the basis of the information provided by Done at Brussels, 2 December 2003. Member States, not later than the end of the fourth year after the date of adoption of this Recommendation, to For the Council consider the extent to which the proposed measures are working effectively, and to consider the need for further the President action. The requested aggregate data is broken down by the variables:: Country (or Region) Index year Age group stratification In addition, data in all tables should be stratified per Age group. Please check the availability of your data and follow the corresponding instructions (according to these three scenarios): 1) If data can be stratified by age groups, please fill in the first 8 rows. Index year: Please fill in all tables using the data from the calendar year 2013. If data from that year are not yet available, use the most recent available year and indicate the year in Table 1. Screening interval Target population in years ages A B Total number of age-eligible women obtained from official statistics A Target population (irrespective of the screening interval). Screening interval in Interval (in years) between routine screens decided upon in each B years screening programme dependent on screening policy. Please indicate the number of women C st st invited in index year invited from January 1 to December 31 of the index year. Do not include invitations to intermediate mammograms (short terms recalls) in this column. It is also Individuals screened of D acceptable, assuming steady state, to estimate this number using the invited in index year number of attenders in the index year regardless of their invitation date. Do not include tests referring to intermediate mammograms (short terms recalls) in this column. Individuals screened in E Do not include tests referring to intermediate mammograms (short terms index year recalls) in this column. The numbers collected in the three subtables should refer to strictly distinct sets of women. Further assessment may have taken place on the same day as the screening examination or on recall. It may include breast clinical examination, additional imaging and invasive investigations (cytology, core biopsy). Consider for example in a country where: Individuals screened in F 20 regions provide relevant information for calculating index year compliance 15 of these regions have data on recall In this case: the no. Women who have been recommended further assessment (it is a subset G Positive of F). Women who have not been recommended further assessment (it is a H Negative subset of F). Women who actually underwent further imaging and/or invasive further Further assessment J assessment, irrespective of whether further assessment was complete or performed not. In the programmes or areas where data is available on treatment referral, Further assessment these are the women who actually underwent imaging and/or invasive M performed further assessment, irrespective of whether further assessment was complete or not. Women referred to open surgical biopsy or surgical intervention or neo Treatment/Surgery N adjuvant therapy as a result of assessment, including also those with referral or inoperable ca cancers that are not fit for surgery or other treatment (it is a subset of M). This includes all other possible known results of assessment (it is a subset of M). Please include also "Short Term recall", being a mammogram performed out of sequence with the screening interval (say O Negative at 6 or 12 months for programmes with two-years screening interval), as a result of the screening test (not recommended by the European Guidelines) or as a result of further assessment. Control sums If the database for Table 5 is smaller than for Tables, 2, 3 or 4, eg because data is not available from all regions covered by Table 4, the difference should be reflected in the middle column of the control sums table. This column refers to the denominator of the "Detection Rate" indicator, so if the numerator (number of cases detected) has not been provided by P Individuals screened all areas, then report the number of women screened in the areas where data on detection are available. This column refers to the denominator of the "Positive Predictive Value" indicator, so if the numerator (number of cases detected) has not been Further assessment Q provided by all areas, then report the number of women who actually performed underwent further assessment in the areas where data on detection are available. Invasive breast Women with invasive breast cancers detected (including microinvasive T cancers detected cancers or cancers for which is unknown if they are invasive or in situ). Women with lesions detected with other histology (for example non U Other histology epithelial cancers). Control sums If the database for Table 6 is smaller than Tables 2-5 (individuals screened) eg because respective data is not available from all regions covered by Table 6, the difference should be reflected in the middle columns of the control sums tables. If available, please also send flowcharts for management of a positive primary test. The requested aggregate data is broken down by the variables: Country (or Region) Index year Age group stratification In addition, data in all tables should be stratified per Age group. Up to 19 10000 20-24 10000 25-29 10000 30-34 10000 35-39 10000 40-44 10000 45-49 10000 50-54 10000 55-59 10000 60-64 10000 65-69 10000 70-74 10000 75-79 10000 Unknown [Automatic sum Total of above figures] 2) If data cannot be stratified by age groups, put the total amount irrespective of age in the last row. Up to 19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 Unknown 130000 [Automatic sum Total of above figures] 266 3) In a mixed situation, with data from some areas which can be stratified and other data that cannot be stratified, please fill separately the first rows for the formers and the last row for the latter. Note that in Table 2 of each Excel file some data will be required up to June of the following year. Target population age group(s) A Total number of age-eligible women obtained from official statistics A Target population (irrespective of the screening interval). The requested aggregate data is broken down by the variables: Country (or Region) Index year Screening Protocol Protocol stratification Stand-alone cytology: All women are tested just for cytology. Age group stratification In addition, data in all tables should be stratified per Age groups. Please check the availability of your data and follow the corresponding instructions (according to these three scenarios): 1) If data can be stratified by age groups, please fill in the applicable cells first 13 rows. Up to 19 9000 20-24 9000 25-29 9000 30-34 9000 35-39 9000 40-44 9000 45-49 9000 50-54 9000 55-59 9000 60-64 9000 65-69 9000 70-74 9000 75-79 9000 Unknown 13000 N. Index year: Please fill in all tables using the data from women invited or screened (whichever applies) in the most recent calendar year (2013 at latest) for which complete data are available (see here below) and indicate the year in Table 1. Note that Tables 2 5 of each Excel file ask, among other things, for data on triage testing (which include test repetitions) and on all colposcopies and histologies derived from the considered screening episode. You should include data on triage testing, colposcopies and histologies performed up to June, 30 of the subsequent year. You should include data on triage testing, colposcopies and histologies performed up to June, 30, 2014. See instructions in tables 3-5 to determine which women should be included in each column Screening interval: (years) Time interval between routine screens; the interval is set by the policy of each screening programme. Cohorts identified by column D (if filled) or column C (if D is not filled) will be followed up in subsequent Tables.
For this reason erectile dysfunction middle age order 160mg super p-force oral jelly amex, it appears reasonable that the same follow-up recommendations for non-serrated adenomas should apply after the removal of serrated adenomas (for details see section 6 erectile dysfunction what is it generic super p-force oral jelly 160 mg line. An incomplete endoscopic removal of adenomas is generally associated with an increased risk of interval cancer ([627]) erectile dysfunction treatment youtube cheap 160mg super p-force oral jelly with amex. The goal is therefore to achieve a complete removal which is pathologically confirmed erectile dysfunction joliet discount super p-force oral jelly 160mg line. Consequently erectile dysfunction symptoms purchase super p-force oral jelly 160 mg, it also appears useful to perform a control examination of the removal site after the removal of adenomas >5 mm for which a complete removal cannot be confirmed histologically erectile dysfunction icd 0 buy super p-force oral jelly without prescription. Even if no comparative data are available erectile dysfunction mayo clinic order super p-force oral jelly with paypal, it is recommended that the control should be carried out after around 6 months erectile dysfunction gluten purchase 160 mg super p-force oral jelly with visa, analogous to the removal using the piecemeal technique. For smaller adenomas, the assessment of the completeness of the removal by forceps can be difficult to impossible for the pathologist. For this reason, the endoscopic assessment of the completeness of the removal is decisive in these cases, and a repeated examination of the removal site is superfluous. After removal of flat or sessile adenomas in piecemeal technique, the recurrence rate is significantly increased, especially with larger adenomas (9-28%) [612-616]. The use of argon plasma coagulation to remove remaining tissue to ensure a complete removal can be helpful [613, 616]. Evidence-based Recommendation 2008 Grade of Secondary chemoprevention following polypectomy should not be performed Recommendation outside of studies. B Level of Evidence Sources: [80-82, 629-631] 1b Strong consensus Background Even though a limited preventive effect has been demonstrated for low-dose aspirin in several prospectively randomised studies with high levels of evidence (1b) [629, 630], an intake of aspirin to lower the risk of adenoma recurrences cannot be recommended owing to the limited effect (reduction of the adenoma recurrence rate by max. The reduction of the adenoma recurrence rate of 12% with calcium appears to be too low to recommend the longer-term administration for this indication [631]. Introduction In the following the general principles of diagnosis and therapy will be shown in a summary fashion for both entities, as long as they apply to both colon and rectal cancer. The therapy of colorectal cancers should always be planned on the basis of a histopathological examination. A colorectal cancer is defined by atypical epithelial formations infiltrating the submucosa (pT1 or more). Not included are the so-called mucosal cancer or intraepithelial cancer (pTis) that have no metastatic potential and can be treated by local excision alone. Definition of Colon and Rectal Cancer the border between the colon and rectum has been defined differently. The intra operative assessment using the end of the taeniae or the peritoneal fold is different for each individual and depends upon age, sex, and other factors. The pre-operative determination of the distal tumor margin with a flexible endoscope is unreliable. According to the international documentation system [636, 637] rectal cancer have aboral borders of 16cm or less from the anocutaneous line as measured by rigid rectoscopy. This is based on the significantly higher local recurrence rate of tumors with less than 12cm distance from the anocutanoeus line [641]. Members of the conference should include the following experts: a gastroenterologist, a hematologist/oncologist, a visceral surgeon, a radiotherapist, a radiologist, and a pathologist. To evaluate the primary or secondary resectability of liver metastases, an experienced liver surgeon should be consulted. If one is not available on site, an external second opinion by an expert should be sought. In certain cases, a presentation at the tumor conference is necessary before therapy has been initiated. For example, for patients with rectal cancer it must be decided upon whether a neoadjuvant therapy should be performed. A study showed that the presentation at a tumor conference and the interdisciplinary determination of a therapy concept significantly reduced the rate of involved circumferential resection margins in the surgical specimen [642]. If distant metastases are present, it must be determined whether a purely palliative concept should be followed or whether the patient can be cured by primary or secondary resection of metastases (especially liver metastases). Also patients with distant metastases or local recurrences during the disease course should be presented first to the conference to decide on further concepts. Patients with a planned local ablative procedure should also be presented to discuss alternative treatment options. For colon cancer without distant metastases, an oncologic resection of the cancer is usually done as primary treatment. In a British study this procedure led to a higher rate of adjuvant chemotherapy and a significant increase in patient survival [644]. Also patients with distant metastases who have begun primary chemotherapy should be presented again to a tumor conference (with consultation of an experienced liver or lung surgeon) during the course of therapy. Before therapy of a patient with a colorectal cancer, a colonoscopy with a biopsy has to be performed. Since these can be missed during intra-operative evaluation, a colonoscopy of the entire colon should be performed [645-647]. If for technical reasons a complete colonoscopy is not possible, an alternative radiological procedure should be used (see Chapter 6. Evidence-based Recommendation 2008 Grade of If the colonoscopy is incomplete for other reasons. B Level of Evidence 410] 4 Strong consensus Background In this case a virtual colonography is a promising alternative [410]. If a complete colonoscopy is not possible due to a stenotic process, a colonoscopy should be done 3 to 6 months after resection. A pre-operative colon contrast enema is of little value and in the case of stenoses has the danger of causing an ileus. Consensus Background the goal of pretherapeutic imaging is to clarify whether distant metastases are present. At the time of initial diagnosis of colon cancer, 25% of patients have distant metastases: in 13% limited to one organ (M1a), in 12% more than one organ or in the peritoneum are involved (M1b). Liver metastases are found in 19%, lung metastases in 3%, and peritoneal metastases in 9%. Other distant metastases located in non-regional lymph nodes (2%), the skin (2%), the ovaries (1%), the bones (<1%), or other locations (2%) are rare. The incidence of distant metastases for rectal cancer at first diagnosis is 18%: in 12% limited to one organ (M1a), in 6% more than one organ or in the peritoneum are involved (M1b). Other distant metastases are in the peritoneum 3 %, in non-regional lymph nodes 2 %. Distant metastases in skin, bone, brain, ovaries, or other locations are found in less than 1% of patients [Data from the Clinical Cancer Registry of the Surgical University Clinic Erlangen Nurnberg]. A primary abdominal ultrasound should be used to evaluate the presence of liver metastases (sensitivity 63-86%, specificity 98%) [648-650]. This is necessary to evaluate the resectability of liver metastases (see Chapter 7. However, it requires adequate quality standards (technical equipment and experience of the examiner) [649, 650, 652]. Consensus Background Neoadjuvant therapy for colon cancer without extensive distant metastases is currently only considered in exceptional cases. However to optimize the therapy algorithm for patients, the use of corresponding pre-operative imaging procedures is increasingly being discussed. The validity of pre-operative abdominal ultrasound examinations is insufficient in this respect. However, the detection of local lymph node metastases is much less sensitive (70%) with the same specificity (78%) [655]. The Grade of Recommendation was developed under additional inclusion of the clinical evaluation of the procedure. The consensus recommendation here is especially supported by the full published study by Ruers [672] which has, however, methodological weaknesses. It should also be critically noted that the endpoint "change in patient management" in contrast to "reduction of futile operations" was not considered patient relevant. Underestimated results were observed in 52% in the chemotherapy group and only 34% in the group without chemotherapy. Another prospective trial [675] and a retrospective study [676] reached similar results. Strong consensus Background Rigid rectoscopy allows an exact determination of the distance of the distal tumor margin from the dentate line and is of major importance for determining further therapy. If a T1-cancer Recommendatio n is suspected, an endoscopie ultrasound should be performed. Evidence-based Statement 2013 Level of the accuracy of all imaging procedures for the evaluation of the lymph node status is Evidence very questionable. Strong consensus Background In rectal cancer local staging is essential for further therapy planning. While local removal is sufficient for low-risk T1-carcinomas, for high-risk T1 and T2-cancers a resection according to oncologic criteria is necessary. In Germany, neoadjuvant therapy is recommended if tumor infiltration in the mesorectum (T3) has been identified. If neighboring organs have been infiltrated (T4), neoadjuvant radiochemotherapy is recommended. For T3-cancers there are data which indicate that the extent of the mesorectual infiltration especially the distance from the mesorectal fascia are of important prognostic relevance [684]. A number of studies on the value of different methods for local staging of rectal cancer had to be excluded in the literature search, because study collectives also included patients who had had radio-or radiochemotherapy. The accuracy of individual diagnostic methods depends on the technical characteristics of the equipment. An endosonography is often technically not possible if high-grade stenoses are present or the tumors are localized in the proximal rectum. Its high sensitivity and specificity was confirmed in a more recent meta-analysis [687]. However, they are more costly, are considered unpleasant by patients, and are established at very few sites. For T4-cancers the meta-analysis showed no significant differences between the procedures. When evaluating lymph nodes the sensitivity (55-73%) and specificity (74-78%) of all methods are currently insufficient [686, 687]. The reasons include, on the one hand, reactive lymph node enlargement and, on the other hand, lymph nodes 5mm and smaller that may contain metastases. Therefore, the indication for neoadjuvant therapy should be made very carefully if it is solely based on suspected lymph nodes seen in pretherapeutic imaging. Furthermore, it must be considered that the accuracy of the individual methods depends greatly on the local expertise. Excluding short term radiation, neoadjuvant therapy impairs the accuracy of individual diagnostic procedures (see evidence report). If the infiltration of the vagina, uterus, or adnexa is suspected, a gynecologic exam should be done. In contrast to the previous guideline, a urine sediment is no longer recommended for rectum or sigma cancers, because the test is too unspecific. If the pre-operative diagnostics are sufficient, the diagnostic benefit of intra-operative ultrasound to look for further metastases does not justify its effort. Consensus Background Due, nowadays, to the quality of magnetic resonance imaging and computer tomography, during a laparotomy usually only subserosal liver metastases (< 2mm) are additionally detected by intra-operative inspection and palpation. However, the sensitivity and the positive predictive value of the intra-operative ultrasound examination with contrast medium is very high (in a single series with 24 patients at 100 % each) [695]. Intra-Operative Pathological Examination In general, rapid sections should be used only if this has direct consequences. With local surgical excision (full wall excision), the important question is whether a cancer proven by previous biopsy was excised with tumor-free margins. However, this cannot be adequately determined intra-operatively using rapid sections. In the case of a deep-seated rectal cancer, rapid section examination of the aboral resection margin can help to decide whether total rectal extirpation should be performed. With segmental resections of large colon polyps, especially of villous histology, in which pre-operative evaluation failed to confirm an invasive neoplasm, an assessment of malignancy using rapid section is frequently not possible due to technical reasons (examination of multiple tissue blocks! Therefore in these cases, the use of standard oncological resection is recommended. In case of adherence of a tumor to neighboring organs it is not possible to determine macroscopically whether an infiltration of the neighboring organs or only a peritumorous inflammatory reaction is present. In such cases, biopsies with rapid sections should be strictly avoided, because of possible local tumor cell dissemination, which can be associated with reduced survival [696]. This is the reason for the en-bloc resection in all cases of tumor adherence to neighboring organs or other structures (see section 7. Consensus Background In case of unclear liver lesions (see below) with therapeutic consequences, a histologic work up preferably with a needle biopsy passing through the healthy liver parenchyma should be performed. This is done to avoid more extensive dissection that would result in increased morbidity rates in patients with histologically negative sentinel lymph nodes. In addition, it was questioned whether ultra-staging (immunohistochemical preparation) of the sentinel lymph node would change the tumor stage with the corresponding need for adjuvant therapy [697, 698]. Extent of Lymph Node Dissection: If there is lymphogenic metastazation of the colon cancer, it occurs according to a regular metastazation pattern. At first, it metastasizes longitudinally to both sides of the tumor into the paracolic lymph nodes, then to the intermediary lymph nodes along the radial arteries to the central lymph nodes at the origin of the supplying arteries. The paracolic metastazation never exceeds a distances of more than 10 cm [699-701]. The extent of the colon resection is defined by the transsection of the central arteries. Cancer lymph node metastases at the terminal ileum on the right side, however, seldom occur and if so, only in very advanced cancer [702]. Therefore, a resection of the terminal ileum of maximally 10 cm is sufficient for right hemicolectomies. Resection of cancers of the Coecum and the Ascending Colon Cancers in this area metastasize centrally via the ileocolic artery and the right colic artery. However, a real colic artery originating from the superior mesenteric artery is present in less than 15 % of all cases [705]. Accordingly if the vessel ist not present, branches leading to the right from the origin of the middle colic artery are centrally ligated. Parts of the major omentum only have to be resected if there is direct tumor contact. Resection of cancers of the Right Colonic Flexure and Proximal Transverse Colon For the extended hemicolectomy, the ileocolic artery, the right colic artery (if present), and the middle colic artery are centrally ligated. Accordingly, the distal resection margin is in the area of the left transverse colon. In this tumor localization a lymphogenic metastazation also takes place via the major omentum in the direction of the gastric antrum and on to the pancreatic head [700]. Thus, aside from skeletonizing the greater gastric curvature and resecting the gastroepiploica-dextra-arcade and, thus, parts of the right-sided omentum, the lymph nodes cranial of the pancreatic head should also be dissected. Resection of cancers of the Middle Transverse Colon these tumors metastasize via the middle colic artery centrally toward the superior mesenteric artery, and via the left colic artery toward the inferior mesenteric artery. If metastazation towards the greater gastric curvature via the major omentum has occurred, a omentum resection corresponding to the tumor site as well as skeletonizing of the greater gastric curvature with removal of these lymph nodes must also be performed. The arcade principle must be observed for the omentum resection (inclusion of the omentum artery within an arcade of 10 cm to both sides of the cancer). Resection of cancers of the Distal Transverse Colon and Left Colonic Flexure Here the tumor metastasizes to the right via the middle colic artery and to the left via the left colic artery. Thus, the middle colic artery is centrally ligated and the left colic artery is cut descending from the inferior mesenteric artery. An advantage of the greater radicality of removing the inferior mesenteric artery has not been confirmed. Due to metastazation via the major omentum towards the greater gastric curvature, the left sided parts of the omentum with dissection of the arcade at the greater gastric curvature must also be removed. If the tumor is advanced in this region, the lymph nodes at the left pancreas lower margin may also be affected. Resection of cancers of the Colon Descendens In this case a left hemicolectomy with central ligature of the inferior mesenteric artery is necessary. The distal resection margin lies in the upper third of the rectum, the proximal one in the left flexure region. Accordingly, it may be necessary to resect possible adherent parts of the omentum. The proximal transsection of the bowel is performed in the descending colon with central ligation of the inferior mesenteric artery. For the distal bowel dissection the guidelines for rectal cancers in the upper third of the rectum also apply.
Indeed erectile dysfunction 5gs purchase super p-force oral jelly 160 mg online, all of these types of outcomes can contribute erectile dysfunction doctor philippines purchase 160 mg super p-force oral jelly visa, causally erectile dysfunction otc purchase genuine super p-force oral jelly, to distress and to disorders of mood erectile dysfunction 22 super p-force oral jelly 160mg with amex. The disorders of mood related to increased irritability erectile dysfunction drugs viagra order super p-force oral jelly 160mg amex, intolerance impotence essential oils discount super p-force oral jelly 160 mg with amex, reduced patience and mood reactivity may be related to the neurobiological impact of the injury and/or a reaction to challenges of managing stimulation early on following the injury erectile dysfunction high cholesterol super p-force oral jelly 160mg low price. At the psychological level they may experience acute stress due to their experience of trauma or injury erectile dysfunction doctor boston buy super p-force oral jelly 160 mg on line, as well as in response to the consequences to their functional abilities resulting from the injury. Their injury status may disrupt their occupational status, leisure activities and interpersonal interactions. Delays can, and often do, contribute to worse outcomes, and so it is important that primary care providers intervene as soon as possible. Screening for mental health symptoms and determining their etiology as well as prescribing treatment is crucial to facilitating a positive recovery. Intervening at the level of improving sleep, managing pain and correcting metabolic imbalances may result in improving reports of low affect. Some medications can also contribute to worsening of balance impairment, or dizziness, and other symptoms. In general, psychotropic medications should be used with caution, and non-medication options selected as much as possible. Assessment Acute concussive symptoms can include irritability, anxiety, emotional lability, depressed mood and apathy. Pre-existing diffculties such as substance use disorders and poor psychosocial adjustment also place patients at risk for a protracted recovery or a recovery that is much longer than expected. If a mental health condition exists appropriate care should be provided or appropriate referrals made. Mental Health Disorders Management Treatment is indicated when symptom levels cause distress and negatively impact interactions, function and quality of life or clearlyareimpedingrecovery. Education about regular light exercise should be provided, as well as other important lifestyle information including balanced meals, keeping a routine, seeking social support, etc. Given the evidence, psychotherapy should be recommended for patients with persistent mood and anxiety issues following concussion. Mental Health Disorders Pharmacological interventions Medication may be required for those with moderate to severe, persistent depressive or anxiety symptoms. Strategies related to discontinuation of pharmacoptherapy should be based on guidelines appropriate to the diagnosed mental health condition. Other antidepressants may also be considered as described in the accompanying text. Use caution when initiating pharmacologic interventions to minimize potential adverse effects on arousal, cognition, motivation and motor coordination. Follow-up should occur at regular intervals: initially more frequently while increasing medication to monitor tolerability and effcacy. Psychiatric disorders following traumatic brain injury: their nature and frequency. Functional limitations and depression after traumatic brain injury: examination of the temporal relationship. Currently, it remains unclear whether persistent cognitive symptoms result from the pathophysiological effects of the injury and/or are infuenced by other factors that can impact cognitive functioning such as pain, cognitive fatigue, medications, sleep disturbance, vestibular disturbance, visual changes, pre-morbid personality factors, cognitive reserve, psychological factors and emotional disturbance. A patient with a frst-time concussion should be advised through early education, support and/ 9. Cognitive Diffculties There is good evidence that early education intervention is associated with a signifcant reduction in the persistence and misattribution of symptoms. The individual exhibits persisting cognitive impairments on formal evaluation, and/or A b. If persisting cognitive defcits are identifed by neuropsychologists or other healthcare professionals, implement temporary work or school accommodations or modifcations and 9. Treatment of persistent post-concussion syndrome due to mild traumatic brain injury: current status and future directions. Cognitive function and other risk factors for mild traumatic brain injury in young men: nationwide cohort study. Perfusion computed tomography in the acute phase of mild head injury: regional dysfunction and prognostic value. Cognitive Improvement after Mild Traumatic Brain Injury Measured with Functional Neuroimaging during the Acute Period. The Association between Pain-Related Variables, Emotional Factors, and Attentional Functioning following Mild Traumatic Brain Injury. Cognition and return to work after mild/moderate traumatic brain injury: A systematic review. These attacks typically last less than 30 seconds but can be quite disabling and can occur multiple times per day. Patients with dizziness frequently experience concurrent psychological disorders such as anxiety. When assessment suggests vestibular dysfunction, vestibular interventions can be considered. While historically, medications have been used to suppress vestibular symptoms, including nausea, current evidence does not support this approach. Others A should be referred to an otolarynthologist or a healthcare professional certifed in vestibular therapy. A When the patient identifes a problem with hearing the following steps should be followed: 1. Rehabilitative interventions include vision therapy, reading spectacles, prism spectacles and/or tinted spectacles. Clinical characteristics and treatment of benign paroxysmal positional vertigo after traumatic brain injury. Effects of specifc rehabilitation for dizziness among patients in primary health care. Occurrence of ocular disease in traumatic brain injury in a selected sample: a retrospective analysis. A systematic review of fatigue in patients with traumatic brain injury: the course, predictors and consequences. Unique contribution of fatigue to disability in community-dwelling adults with traumatic brain injury. Measuring the functional impact of fatigue: initial validation of the fatigue impact scale. Fatigue after traumatic brain injury: Association with neuroendocrine, sleep, depression and other factors. Methylphenidate reduces mental fatigue and improves processing speed in persons suffered a traumatic brain injury. Long-term treatment with methylphenidate for fatigue after traumatic brain injury. Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial. Complementary and alternative interventions for fatigue management after traumatic brain injury: a systematic review. While a short period of physical and cognitive rest may be benefcial, particularly to limit symptom aggravation, evidence suggests prolonged rest and/or avoidance of activities may worsen outcomes. Evidence indicates complete bed rest in excess of 3 days should be avoided2,5 and gradual resumption of pre-injury activities should begin as soon as tolerated. When advising patients on return-to-activity, it is important to consider both physical and cognitive activities because both have the potential to exacerbate symptoms10,11 Cognitive load refers to mental activities requiring attention, concentration and problem solving. Activity resumption recommendations should seek to achieve maximal participation in pre-injury activities while minimizing symptom exacerbations. Patients should be advised that subsymptom threshold levels of activity are recommended. Identify limitations (functional capacity: physical, cognitive, emotional) Professional 3. Tolerance refers to the ability of a patient/worker to tolerate symptoms and is not a medically-answerable question. It is important to note that the existence of symptoms at baseline is not, in and of itself, a basis for no return to work. Workers with symptoms that are present but do not change with an increase in the work activity can begin to transition back to work. Therefore, reasonable advice is to encourage the worker to engage in activities (physical, cognitive, emotional/ behavioral) as much as possible and, in response to symptom exacerbations, the worker should temporarily reduce the physical and cognitive demands and resume graduated return to work at a slower pace. Not only does the nature of program requirements differ at the post-secondary level, but so does the nature of the accommodations and concessions that can be provided, which limit the applicability of the aforementioned guidelines. Regular communication between the student, the primary care provider and teachers/administrators regarding progress, challenges and changes in symptoms. In addition, the student should be offered psychoeducation and modifed at-home study tasks as tolerated. After 2 weeks post-injury: the student should start attending school (non-physical activities) very gradually as tolerated and with accommodations, even if the student is still experiencing symptoms. A systematic review of psychological treatments for mild traumatic brain injury: an update on the evidence. Association of returning to work with better health in working-aged adults: a systematic review. Relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status following mild traumatic brain injury: a follow-up study. Function after motor vehicle accidents: a prospective study of mild head injury and posttraumatic stress. A model to guide the rehabilitation of high-functioning employees after mild brain injury. School and the concussed youth: recommendations for concussion education and management. Is the individual experiencing persistent symptoms or is unable to successfully re A more in-depth assessment of symptoms and sume pre-injury work duties For a narrative description and guideline recommendations related to this algorithm, please refer to Section 12. Throughout student assessment: Symptoms of anxiety and/or depression should During the frst 72 hours, is the student be monitored in students with persistent symp symptomatic Gradually resume academic activities under After 72 hours, is the student symptomatic Communicate to student services/special needs department that the student is still symptomatic and will require support for re-integration. Start attending school (non-physical activities) very gradually and with accommodations. Is re-integration ineffective (symptoms Continue attending academic activities very No plateau or worsen) at 4 weeks post-injury Steps 2 through 9 were revisited and improved to enhance development and effcient use of the guidelines for healthcare professionals. In regard to healthcare professions, a wide range of disciplines including emergency medicine, family medicine, sports medicine, neurology, physical medicine and rehabilitation, radiology, psychiatry, psychology, physical therapy, chiropractor and occupational therapy were represented. Lastly, in regard to geographic location, the members forming the expert consensus group were recruited from Ontario, across Canada and the United States. The following key words were used in combination for all searches: brain injuries, head injuries, traumatic brain injury, concussion, guidelines, practice guidelines, and best practice. This search was repeated again in May 2017 to ensure to capture any guidelines released within that year. All search terms were also truncated to ensure that every alteration of that search word was captured. However, the reference lists of narrative review papers were examined to ensure all relevant literature was included. Resource Evaluation: While completing the literature search the project team fagged any tools, tables, resources algorithms or fgures that could be used in the guideline. A manual search was then completed to look for updates of existing clinical tools. Key determinants in the use of a resource were accessibility of the tool and ease of use. Reviewers are also asked to provide an overall quality assessment of the guideline taking into account the criteria considered in the assessment process, as well as whether he/she would recommend use of the guideline. Scores from these rating scales were provided with the respective article summary to all experts before, during and after the consensus conference in the Excel sheets. The checklist contains 27 items which are added to provide a total score out of 32. Reporting (criteria 1-9): assesses whether the information provided in the paper is suffcient to allow a reader to make an unbiased assessment of the fndings of the study. External validity (criteria 11-13): assesses the extent to which the fndings from the study can be generalized to the population from which the study subjects were derived. Levels of Evidence A At least one randomized controlled trial, meta-analysis, or systematic review. Sex and Gender Considerations An increasing amount of research and clinical discussion is occurring that addresses the infuence of sex and gender on concussion symptom presentation, recovery trajectory, risk profle and coping differences. There is body of literature that addresses the epidemiology, clinical manifestations, injury characteristics and outcomes. It appears as if females have a higher risk of persistent post-concussion symptoms (Table 1). The current gap in the evidence is in the need for sex-specifc assessment (although female sex is a risk-factor) and approaches to treatment. Each group worked on updating their assigned recommendations prior to sending out to the entire expert group. The experts collaboratively discussed what edits were to be made to each of the recommendations based on feedback from the votes. The Project Team took notes on this discussion and afterwards began drafting the updated recommendation. Resource voting A signifcant component of the guideline are the resources that accompany the guideline recommendations. Working Group members were sent a list of the current resources, along with any updated versions and possible new resources that could be added to the guideline. These contained information on reliability/validity, method of administration, ease of use, whether it is proprietary or not, time to administer, etc. If a recommendation met at least one of the following criteria, it was retained: 1) based on level A evidence; 2) received either a minimum of 75% endorsement by the Expert Consensus Group; or 3) represented an important care issue. Experts were also asked to prioritize the top 20 most important recommendations for implementation. Specifcally, experts were allowed to provide four priority votes for each of the fve ranking categories (5-high to 1-highest) for a total of 20 prioritization votes. This can help the treating healthcare professional with evaluation and implementation of the guideline recommendations, since it can guide where and how efforts should be made to change practice, especially early on. After review 91 recommendations remained comprising of 4 novel recommendations, 87 unique recommendations. Algorithms, patient handouts and reference guides were reported as the most frequently used tools; however it was important that tools and resources were created to be more printer friendly. More specifc information regarding pharmacological treatment was noted as an important aspect to include in the updated guideline. Ongoing Update and Review Further feedback from frontline clinicians and their patients during the implementation phase, as well as fndings from an ongoing literature review, will inform the update of these recommendations scheduled for 2021.
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