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By N. Jesper. Nazarene Bible College. 2017.

These step changes include myocardial infarction discount 25mg cozaar otc, onset of angina cozaar 50 mg low cost, any emergency hospital admission for coronary heart disease, cardiac surgery or angioplasty and/or stent, and first diagnosis of heart failure (SIGN, 2002). Following an acute coronary event, phase I CR is important in assisting the patient’s pathway to recovery. The National Service Framework for CHD (DoH, 2000) states that the aim of this phase is to offer high-quality CR before discharge from hospital, and this should begin as soon as possible after someone is admitted with CHD. Phase I will be the patient’s first point of contact with the CR team, and this introduction to CR may favourably or adversely influence their perception of secondary prevention. At this stage, the patient may be anxious and depressed regarding the threat to their health (SIGN, 2002). An important aspect of phase I CR is to allay these fears and promote positive outcomes for both the patient and their significant others (Thompson, 1989). Content of Phase I Cardiac Rehabilitation The content of phase I CR has traditionally included assessment, education and exercise/mobilisation. There is an emphasis on reassurance and the posi- tive aspects of recovery post-ACS, revascularisation or other CHD-related admission, specific to each individual. Assessment involves identifying risk factors and risk stratification, with the educational aspect providing patients with appro- priate individual information regarding CHD, risk factors and lifestyle (BACR, 1995). Mobilisation may include graduated exercise, walking pro- grammes and stair practice. The current guidelines (BACR, 1995; DoH, 2000; SIGN, 2002) generally agree that the following are addressed: • risk stratification and lifestyle modification, as appropriate; • educational requirements; • psychological factors, including anxiety and depression; • needs of significant other(s); • social, vocational and cultural needs. Before discharge from hospital patients should be offered, as an integral part of acute care, the following: • assessment of physical, psychological and social needs for future CR; • negotiation of a written individual plan for meeting these needs; • prescription of effective medication, and education about its use, benefits and side effects; • involvement of relevant informal carer(s); • provision of information about cardiac support groups; • provision of locally relevant, written information about CR. The key elements of phase I include medical evaluation, reassurance, educa- tion regarding CHD, correction of cardiac misconceptions, risk factor assess- ment, mobilisation and discharge planning. In addition, the use of psychological measurement is recommended, using, for example, the hospital anxiety and depression scale (HADS) (Zigmond and Snaith, 1983).

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The process 210 THE ROLE OF EVIDENCE IN PAIN MANAGEMENT is laborious order 50mg cozaar visa, but the Cochrane Library has listed cit- Table 31 order 25 mg cozaar with visa. For topics that are of bias not mainstream the hand-searching process will still have to be done. Estimates of treatment Give a score of 1 point for each ‘yes’ and 0 points for efficacy from database data are therefore likely to be each ‘no’. Other influences, such as the medical Give 1 additional On question 1, the method of condition itself and other drugs, may confound the point if: randomisation was described issue. You then discover that 20 say that the inter- alternatively, or according vention is terrific, while 20 conclude that it should to date of birth, hospital never be used. Without a quality scale you the method of blinding was would vote for the intervention. The quality standards that you require cannot be absolute, because for some clinical questions A study may of course be both randomised and there may not be any RCTs. Setting RCTs as a min- double blind, and describe withdrawals and dropouts imum absolute standard would therefore be inappro- in copious detail (scoring well on this quality scale) priate for all the questions we might want to answer. Examples include: In the pain world however, there are two reasons for • The injection of morphine into the knee joint to setting this high standard and requiring trials to be reduce pain after arthroscopy. The first is that we do have, particularly was made after the operation without knowledge for drug interventions, quite a number of RCTs. The of whether the patients had enough pain for the second is that it is even more important to stress min- intervention to make a difference. If they had mild imum quality standards of randomisation and double pain it is possible that the success ascribed to the blinding when the outcome measures are subjective. The statistical significance leading to In this context, quality indicates the likelihood that this important conclusion came from a number of the study design reduced bias. Only by avoiding bias small trials with 30% mortality rates; the rates are so is it possible to estimate the effect of a given interven- high that one questions the validity of the trials. The simple scale as shown subsequent big RCT showed that the conclusion was in Table 31.