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Department of Education order raloxifene us women's health blood in the urine, primar- ily concerns information processing buy discount raloxifene 60mg online menstrual after miscarriage, language assessment generic raloxifene 60mg visa menopause insomnia treatment, and language intervention with school-age children with language impairments generic raloxifene 60 mg overnight delivery women's health center hudson ny. Gillam has been the associate editor of the American Journal of Speech-Language Pathology (1996–1999) and the Journal of Speech, Language, and Hearing Research (2001–2004; 2010–2013). Gillam has published three tests and two other books—Memory and Language Impairment in Children and Adults (Aspen, 1988) and Communication Sciences and Disorders: From Science to Clinical Practice (co-edited with Thomas Marquardt & Fredrick Martin; Singular, 2000; Jones & Bartlett, 2010, 2015). In addition to reviewing a model of intervention structure, we summarize trends in treatment development and implementation that serve as a backdrop for current and future actions by both researchers and clinicians. We also suggest ways that different audiences can take advantage of the book for their own purposes—placing great- est emphasis on how to use the intervention descriptions to inform decisions about whether and how to incorporate each intervention into plans for the management of language disorders in children. We introduce 14 evidence-based language interventions for children, and we provide specific infor- mation on how to conduct each treatment. Furthermore, we highlight claims of val- ue associated with each treatment approach and facilitate readers’ evaluations and comparisons of the interventions in terms of their clinical procedures and the extent of their research base. We want to help readers develop strategies for accessing and interpreting the complex web of information that constitutes evidence that does and does not support the value of an intervention. We consequently have planned the book’s organization carefully, recruited outstanding researchers as chapter authors, and diligently edited what they produced with the intent of giving readers the infor- mation they need regarding when a decision to use an intervention may be judged “evidence based” and how the intervention can be successfully implemented. Furthermore, families of affected children may find this a useful tool for investigating one or more interventions proposed for use with their child. To serve these broader purposes, we offer recommendations regarding how members of these differing audiences might select sections to read or ways to use and supplement the information they obtain. An entire section from the earlier edition that included nonlanguage interventions (e. This means that the book now contains just two sections, with one addressing language problems characteristic of infants, toddlers, and preschoolers and the other targeting problems found in school-age children. We have made significant changes in the interventions included in each section as well. Seven of the original chapters have been updated to reflect ongoing developments as the interventions have continued to be studied and implemented (Chapters 2, 3, 4, 5, 6, 8, and 10). Eight of the interventions from the first edition were not carried over to this edition, for reasons including insufficient fit with the new sectional organization, a lack of new research exploring their use, or their recent description in related volumes. Three of these new chap- ters expand the book’s attention to literacy and its precursors, including chapters on print referencing (Chapter 7), word decoding, reading comprehension (Chapter 11), and narration (Chapter 13). In addition, two of the new chapters target more complex language (Chapter 12) and social communication skills (Chapter 14) and two others address bilingualism (Chapter 9) and service delivery models (Chapter 15). As noted previously, we have included more interventions dealing with written language in this volume. In so doing, we have tried to maintain our focus on children who exhibit or have histories of spoken language disorders and the relationship be- tween these early problems and reading disabilities. Though we have intentionally paid greater attention to interventions targeting skills associated with early reading development, this is not designed to be a book on intervention for children with reading disabilities, per se. The template—a description of content areas and headings used to signal them— was devised to focus on theoretical and empirical information supporting an inter- vention’s use as well as practical and procedural information that can help clinicians determine the intervention’s feasibility for their setting and client population and, possibly, set the clinician on the path to learning and using it. Several relatively small adjustments to the earlier template version are noted in the description that follows. Following a very brief Abstract, a longer Introduction section provides more extensive, but still concise background information. The next section, Target Excerpted from Treatment of Language Disorders in Children, Second Edition by Rebecca J. Content specifications of the template followed within each chapter Section Content Abstract and Introduction Overview and broader introduction to the intervention and the chapter itself, including the specific individuals for whom the intervention is designed, the intervention’s basic focus, and its key methods Target Populations Description of populations for which empirical and/or theoretical sup- port is available with regard to variables such as age, diagnosis, and prerequisite skills Theoretical Basis Outline of the dominant rationale for the intervention, including as- sumptions about the deficit, compensatory strategy or strength that is targeted and the nature of the desired outcomes (e. Practical Requirements Time and personnel demands, including training for all intervention agents (e. Whereas in the earlier edition, discussion of assess- ments used to identify candidates for an intervention was included in this section, Excerpted from Treatment of Language Disorders in Children, Second Edition by Rebecca J. There are many terms that are used by the chapter authors to refer to children who experience significant difficulties learning and using language. The World Health Organization (2001) uses the word impairment to refer to any loss or abnormality of psychological, physiological, or anatomic structure or function. With respect to child language development, most authors have used the term language impair- ment to refer to describe children with significant delays in the development of language comprehension or use. However, most of the authors of the chapters in this volume have decided to refer to these groups separately because they are often treated that way by school assessment teams across the nation. Careful readers will note that the terms language impairment, specific lan- guage impairment, primary language impairment, language disorder, and language learning disability are used by the authors of the chapters of this book. Rather than restrict all the authors to the use of one term and, more importantly, to assign meanings to these terms that are not well recognized in the field, we have allowed authors to use terms of their own preference and to define the terms explic- itly when they have used them to refer to distinctive subgroups of children who have difficulties with language development. Although we risk adding to the terminology confusion, we believe that our use of multiple terms for developmental language difficulties is reflective of the current state of the literature in this area. Interventions often, if not always, are designed in light of more, or less, well-defined models or theories addressing the nature of problems underlying children’s delays or abnormalities in language acquisition and/or the mechanisms by which those prob- lems may be mitigated, resolved, or circumvented to improve a child’s language and communication function. In the Theoretical Basis section, authors are asked to ex- plicate these foundations for their intervention. This section can help a reader deter- mine whether an intervention seems of likely value on a rational basis in the absence of a long history of research or a history that fails to include research specific to the clinician’s caseload or context. The Empirical Basis section presents a summary of the current evidence sup- porting an intervention’s efficacy and effectiveness for specific populations. Thus, it is one of the most important sections for readers wanting to identify interventions with stronger rather than weaker research portfolios (a central tenet of evidence-based practice). When considered by itself, this section admittedly constitutes a narrative review written by committed developers or proponents of the intervention and, as such, is therefore necessarily subject to bias. However, the empirical summaries can orient readers to recent research on the intervention being addressed and provide preliminary accounts of the nature of existing support. In this edition, to bolster the transparency and accessibility of information about the quality of studies being cited, we have asked authors to tabulate levels of evidence for the studies they cite. It has even been argued that parallel evidence from related fields may sometimes prove valuable (e. Although it is always the case that generalizing from research on a group or even a well-described individual (e. Such decisions require greater scrutiny and usually warrant less influence on decision making. On the other hand, strong evidence is usually in short supply; clinicians who have strong evidence supporting use of an Excerpted from Treatment of Language Disorders in Children, Second Edition by Rebecca J. The section titled Overview of Assessment and Decision Making is intend- ed to allow authors to identify measures and methods for determining that a child is a likely candidate for the intervention and for examining how the child is responding to the intervention.

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In the Japanese case order 60mg raloxifene amex menstrual irregularities, the low numbers of trained doctors and high cost of treatment has severely constrained the growth of the medical tourism market (Hall purchase 60mg raloxifene with mastercard breast cancer jordans, 2009 buy discount raloxifene 60 mg on line women's health clinic birth control, Toyota cheapest generic raloxifene uk menstruation medicine, 2011, p. Indeed, as Connell highlights, Japan has until recently been primarily thought of as a source country rather than a destination country in terms of medical tourism, with large numbers of Japanese citizens travelling abroad for healthcare (Connell, 2006, p. The Japanese government has recently outlined plans to reverse the outbound medical tourism trend, rolling out a new organisation with the sole aim of increasing inbound medical tourism. The rationale being that Japan cannot compete with the lower costs offered in such markets and thus should concentrate on the types of procedure where access and quality are the primary motivations for medical tourism rather than simply the cost (Hall, 2009). In contrast to Japan, the Korean government have matched their commitment to the expansion of the inbound medical tourism market with investment in a market to directly compete with other Asian countries. The high quality and low cost of treatment is also being used as part of a targeted campaign to encourage Korean expatriates and members of Korean communities in countries such as the United States and New Zealand (Lee et al. As with Asian countries, State involvement varies from country to country with a mixture of private and public facilities catering for medical tourism. In Poland, a popular destination for dental tourists and cosmetic tourists, medical tourism is facilitated through private companies, many of the clinics used are state-owned, serving Polish citizens alongside medical tourism. This reflects the Polish government‘s desire to capture the potential of medical tourism and marked by the creation of the Polish Medical Tourism Chamber of Commerce (Reisman, 2010, p. While many of the clinics offering treatment to medical tourists are undoubtedly private, the role of the Hungarian government should not be overlooked. Beyond national strategies there a range of ways that national policy can directly foster the domestic medical tourism industry. There are a range of organisational dimensions related to the quality and safety of medical treatment abroad. Many of these are not necessarily unique to medical tourism in that health care is replete with information asymmetries and potential threats to the quality and safety of patient care pathways, but these are intensified given the dimensions of ―distance‖ including legal jurisdiction. Ideally, a common regulatory platform and reporting system would serve as the basis of an assessment of comparative quality of care using a range of performance indicators as facilitated by international accreditation and certification. Presently, there is a lack of comparative quality and safety data, and knowledge of infection rates for overseas institutions and reporting of adverse events is lacking. Importantly, bodies like the World Health Organisation have yet to publish any firm guidance on this and there does not appear to be any immediate intention to do so. For some, a lack of transparency on quality is an impediment to a fully developed market in medical tourism (Ehrbeck et al. Availability of evidence about the quality of a particular surgeon or clinical team, some suggest, would encourage more people to pursue medical tourism (Unti, 2009). As with all medical treatments, an element of risk exists to the patient‘s health, which is supposedly outweighed by the potential benefits resulting from the treatment. What can be gleaned from the literature concerning risk and safety-related incidents for medical tourism is limited. Medical tourism adds a new dynamic to this element of risk, due to the overseas travel involved. Travelling when unwell can lead to further health complications, including the possibility of deep vein thrombosis (Crooks et al. Despite medical tourism involving air travel, there is no published evidence on travel risk resulting from medical tourism, for example on thrombosis. Relatively little is known about the experience and satisfaction of medical tourists. Patient clinical outcomes and satisfaction do not necessarily go together and satisfaction is not always the primary indicator for some treatments such as dental work. Similarly, with regard to cosmetic surgery there is evidence that a small percentage of patients may suffer from psychological body-related issues that make such judgements problematic (Grossbart and Sarwer, 2003). Conversely, Hanna et al (2009) note that for a sample of outsourced patients (rather than medical tourists) whilst the majority of patients operated upon abroad obtained comparable functional results with those expected locally, they were often dissatisfied with the overall experience. There is a gap 24 in understanding of patient expectations and how these may be raised by individuals paying a market-price and taking responsibility for choosing a provider. Evidence of clinical outcomes for medical tourist treatments is limited and reports are difficult to obtain and verify. Little is known about the relative clinical effectiveness and outcomes for particular treatments, institutions, clinicians and organisations. There is scant evidence on long or short-term follow- up of patients returning to their home countries following treatments at the range of destinations. That a positive treatment outcome should result is important, not least because the patient‘s local health care provider takes on the responsibility and funding for post-operative care including treatment for complications and to remedy side-effects (Cheung and Wilson, 2007). In the event of an adverse outcome, it should be known whether, and to what extent, the patient has recourse for redress. Patient follow-up by providers is rare; a study of 20 patients presenting at a German university hospital after overseas refractive surgery concluded that there was insufficient management of complications and a lack of post-operative care (Terzi et al. For ‗transplant tourism‘, Canales‘ (2006) study of kidney patients transplanted abroad found that there was a high incidence of serious post- operative infections (6 serious infections for 4 patients), although graft survival and function were concluded to be good – see also Geddes‘ follow-up of kidney patients who had travelled from Scotland to Pakistan for treatment (Geddes et al. In an audit of the pan-Thames region, 35 out of 65 consultants replied to requests about cosmetic surgery impacts (Birch et al. Sixty per cent of those replying had seen complications and the majority of these cases (66%) were emergencies that required inpatient admission. Australian research on professionals raises a similar issue (MacReady, 2007) and there are detailed case studies of detrimental outcomes from surgery abroad incurring significant public costs to rectify poor outcomes (Cheung and Wilson, 2007). In terms of dental treatment abroad there are some reported cases of complications having to be dealt with by the home health system. Barrowman et al (2010) report cases histories of five Australian travellers requiring attention by oral and maxillofacial surgeons because of dental implants. In sum, relatively little is known about readmission, morbidity and mortality following self- funded medical treatment abroad (see also Balaban and Marano, 2010). The overseas and private nature of delivery explains why there is such a dearth of information relating to clinical outcomes, post-operative complications, lapses in safety and poor professional practice (cf Alleman et al. It is ethical to ensure that patients are as well cared for as possible and, to this end, patients should receive appropriate advice and input at all stages of the caring process. When medical treatment is sought abroad, the normal continuum of care may be interrupted. It is useful to consider the cycle of care through all its possible stages, pre- or post- the period of hospital care. Canales‘ (2006) study of kidney transplants, for example, concludes there was inadequate communication of information – immunosuppressive regimens and preoperative information. The medical traveller is usually in hospital for only a few days or even weeks, and then may go on the vacation portion of their trip or return home, when complications, side-effects and post-operative care then become the responsibility of the healthcare system in the patients‘ home country. It is not clear to what extent the European Health Card will foster improvements in this regard.

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Because suicidal ideation and suicide attempts are common discount 60 mg raloxifene overnight delivery menopause xerostomia, safety issues should be given priority generic raloxifene 60mg breast cancer oakleys, and a thorough safety evaluation should be done order generic raloxifene on line women's health fresh pond. This evaluation discount raloxifene 60mg on-line women's health center riverside hospital, as well as con- sideration of other clinical factors, will determine the necessary treatment setting (e. It is important at the outset of treatment to establish a clear and explicit treatment frame- work [I], which includes establishing agreement with the patient about the treatment goals. Psychiatric management Psychiatric management forms the foundation of treatment for all patients. The primary treat- ment for borderline personality disorder is psychotherapy, complemented by symptom-targeted pharmacotherapy [I]. In addition, psychiatric management consists of a broad array of ongoing activities and interventions that should be instituted by the psychiatrist for all patients with borderline personality disorder [I]. Regardless of the specific primary and adjunctive treatment modalities selected, it is important to continue providing psychiatric management throughout the course of treatment. The components of psychiatric management for patients with border- Treatment of Patients With Borderline Personality Disorder 9 Copyright 2010, American Psychiatric Association. Principles of treatment selection a) Type Certain types of psychotherapy (as well as other psychosocial modalities) and certain psycho- tropic medications are effective in the treatment of borderline personality disorder [I]. Pharmacotherapy often has an important ad- junctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behavior [I]. Flexibility is also needed to respond to the changing characteristics of patients over time. Treatment by multiple clinicians has potential advantages but may become frag- mented; good collaboration among treatment team members and clarity of roles are essential [I]. Specific treatment strategies a) Psychotherapy Two psychotherapeutic approaches have been shown in randomized controlled trials to have ef- ficacy: psychoanalytic/psychodynamic therapy and dialectical behavior therapy [I]. The treat- ment provided in these trials has three key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/super- vision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for borderline personality disorder has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psycho- therapeutic intervention has been provided; many patients require even longer treatment. Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used [I]. These features include build- ing a strong therapeutic alliance and monitoring self-destructive and suicidal behaviors. Other valuable interventions include validating the patient’s suffering and ex- perience as well as helping the patient take responsibility for his or her actions. Because patients with borderline personality disorder may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for pa- tients with borderline personality disorder include managing feelings (in both patient and ther- apist), promoting reflection rather than impulsive action, diminishing the patient’s tendency to engage in splitting, and setting limits on any self-destructive behaviors. Group approaches are usually used in combination with individual therapy and other types of treatment. The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment mo- dality. Symptoms exhibited by patients with borderline personality disorder often fall within three behavioral dimensions—affective dysregulation, impulsive-behavioral dys- control, and cognitive-perceptual difficulties—for which specific pharmacological treatment strategies can be used. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U. An algorithm depicting steps that can be taken in treating symptoms of affective dysregula- tion in patients with borderline personality disorder is shown in Appendix 1. As seen in Appendix 3, low-dose neuroleptics are the treatment of choice for these symptoms [I]. These medications may improve not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and counter- transference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behavior. The psychiatrist performs an initial assessment to determine the treatment setting, completes a comprehensive evaluation (including differential diagnosis), and works with the patient to mutually establish the treatment framework. The psy- chiatrist also attends to a number of principles of psychiatric management that form the foun- dation of care for patients with borderline personality disorder. Fi- nally, the psychiatrist selects specific treatment strategies for the clinical features of borderline personality disorder. Initial assessment and determination of the treatment setting The psychiatrist first performs an initial assessment of the patient and determines the treatment setting (e. A thorough safety evaluation should be done before a decision can be reached about whether outpatient, inpatient, or another level of care (e. Presented here are some of the more common indications for particular levels of care. Since indications for level of care are difficult to empirically investigate and studies are lacking, these recommendations are derived primarily from expert clinical opinion. Indications for partial hospitalization (or brief inpatient hospitalization if partial hospital- ization is not available) include the following: • Dangerous, impulsive behavior unable to be managed with outpatient treatment • Nonadherence with outpatient treatment and a deteriorating clinical picture • Complex comorbidity that requires more intensive clinical assessment of response to treatment • Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment Indications for brief inpatient hospitalization include the following: • Imminent danger to others • Loss of control of suicidal impulses or serious suicide attempt • Transient psychotic episodes associated with loss of impulse control or impaired judgment • Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment and partial hospitalization Indications for extended inpatient hospitalization include the following: • Persistent and severe suicidality, self-destructiveness, or nonadherence to outpatient treatment or partial hospitalization • Comorbid refractory axis I disorder (e. Comprehensive evaluation Once an initial assessment has been done and the treatment setting determined, a more com- prehensive evaluation should be completed as soon as clinically feasible. Such an evaluation in- cludes assessing the presence of comorbid disorders, degree and type of functional impairment, needs and goals, intrapsychic conflicts and defenses, developmental progress and arrests, adap- tive and maladaptive coping styles, psychosocial stressors, and strengths in the face of stressors (see Part B, Section V. The psychiatrist should attempt to understand the bi- ological, interpersonal, familial, social, and cultural factors that affect the patient (3). Special attention should be paid to the differential diagnosis of borderline personality dis- order versus axis I conditions (see Part B, Sections V. The prognosis for treatment of these axis I disorders is often poorer when borderline personality disorder is present. It is usually better to anticipate realistic problems than to encourage unrealistically high hopes. Establishing the treatment framework It is important at the outset of treatment to establish a clear and explicit treatment framework. The clinician and the patient can then refer to this agreement later in the treatment if the patient challenges it. Patients and clinicians should establish agreements about goals of treatment sessions (e. Patients, for example, are expected to report on such issues as conflicts, dysfunction, and impending life changes.

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