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A premium was placed on the old ways of doing things buy cheap forzest 20 mg line, and impending change engendered skepticism buy forzest 20mg low cost, if not outright resistance. Clearly, previous generations were oriented to the present (or even the past) in terms of their cultural moorings. The prospect of change had always threatened deep-seated convictions that had survived for generations. By the 1970s, not only had change become accepted as inevitable as society underwent major transformations, but change began to take on a pos- itive connotation. Individuals began switching jobs, residences, and even spouses at a rate that shocked their forefathers. It became a maxim that the American dream involved the advancement of each generation over the previous one. Stage Two: The Emerging Role of the Sales Representative The second stage of marketing evolution focused on sales. Under these conditions, sales representatives took orders from what was essentially a captive audience. However, as competition increased in most industries following World War II, these regional monopolies disintegrated, especially with the increased mobility available to sales forces. However, sales representatives eventually served as a bridge between the production economy and the service econ- omy as they developed and maintained relationships. Sales representatives 6 arketing Health Services progressed from their roles as "order takers" to become "consultants" to their clients. This created a conduit for information to flow from customers back to producers, thereby facilitating the emergence of a market orienta- tion for U. Stage Three: A Customer-Driven Approach The third stage in the evolution of the field actually focused on marketing per se. By the end of the twentieth century, the industrial economy had given way to a service economy and the remaining production industries became increasingly standardized. This shift from a product orientation to a service orientation represented a sea change vis-à-vis marketing. For the first time, progressive managers in a wide range of industries sought to determine what consumers wanted and then strove to fulfill those needs. This opened the door for market research and the emergence of profes- sional marketers to exploit consumer desires. These new market-driven firms adopted an outside-in way of thinking that considers service delivery from the point of view of the customer. The emergence of a service economy had important implications for both marketing and healthcare. Services are distinguished from products because they are generally produced as they are consumed and cannot be stored or taken away. For example, an x-ray machine is a product that is used to provide a service (medical diagnostics); the service is provided as the patient "consumes" it (by being subjected to the procedure). Unlike a tangible prod- uct, the standard of service may differ each time it is produced (e. The marketing of services is different from the marketing of prod- ucts; this creates a challenge for marketers in any field. The development of capabilities for marketing services occurred slowly as the United States became a service-oriented economy. There are considerable differences between marketing goods and marketing services, and a new mind-set and new promotional approaches had to be developed. This does not mean that certain healthcare organizations in the retail and supplier sectors had not been involved in marketing activities.
In temporal lobe epilepsy the diagnostic sensitivity for ictal or postictal SPECT is 90% and the speci- ﬁcity of 73% generic 20mg forzest otc. In extratemporal lobe epilepsy ictal SPECT sensitivity decreases to 81% and speciﬁcity increases to 93% when using EEG criteria as the standard of reference best 20 mg forzest. Interictal SPECT sensitivity and speciﬁcity were found to be signiﬁcantly lower, at 66% and 68%, respectively, for temporal lobe, and at 60% and 93%, respectively, for extratemporal regions when compared to EEG. The pooled data were gathered from 624 interictal, 101 postictal, and 136 ictal cases. The results from this study showed that the sensitivity of technetium-99m labeled hexamethyl-propylene amine oxime (HMPAO) SPECT in localizing a temporal lobe epileptic focus increases from 44% in interictal studies to 75% in postictal studies and reaches 97% in ictal studies. In 119 patients with known unilateral temporal lobe epilepsy, correct localization by ictal SPECT was demonstrated in 97% of cases. In extratemporal epilepsy, the yield of ictal SPECT studies was 92% and that of postictal SPECT studies was 46%. In 58% of the studies the sub- traction images "contributed additional information" but were confusing in 9%. In a level III study (limited evidence) of 312 patients pooled by Spencer (38), PET was compared to EEG for localization. A total of 205 patients had reduced temporal lobe metabolism of which 98% were concordant with EEG ﬁndings. Thirty-two patients had hypometabolism in an extratempo- ral location, which was concordant with EEG in 56% of cases. The abnor- malities in 75 patients were not localized by PET, 36 of whom had temporal lobe EEG abnormalities. The diagnostic sensitivity for ﬂuorodeoxyglucose (FDG)-PET was 84% (speciﬁcity of 86%) for temporal, and 33% (speciﬁcity of 95%) for extratemporal epilepsy, respectively. A level III study (limited evidence) of single-voxel proton MR spec- troscopy (MRS) was performed to lateralize seizures; MRS was compared with MRI and PET in a case series of 33 HS patients (48). The sensitivity of MRS and PET in lesion lat- eralization was 85% for both, using MRI as the reference standard. Functional MRI is a new technique based on the ability to detect small amounts of paramagnetic susceptibility produced by blood-oxygen level changes linked to brain cortical activity. Although fMRI is still under inves- tigation and is without Food and Drug Administration (FDA) approval, it has shown promise as an examination that might replace the more inva- sive and expensive Wada intracarotid amobarbital exam in the lateraliza- tion and location of language in patients who are candidates for epilepsy surgery. One level III case-series paper (limited evidence) (49) describes procedures and results of language dominance lateralization in 100 patients with partial epilepsy performing a covert word generation task. The reference standard was a bilateral Wada intracarotid amobarbital test (IAT) performed in all cases. Divergent results between the tasks included two cases in which the IAT showed absence of lateralization. One case showed Chapter 11 Neuroimaging of Seizures 209 bilateral fMRI activation and lateralized IAT. The Miami Children’s Hospital Group, in a prospective study (moder- ate evidence), enrolled prospectively 60 subjects to determine the role of fMRI in the diagnostic evaluation and surgical treatment of patients with seizure disorders. The authors concluded that fMRI inﬂuences the seizure team’s diagnostic and therapeutic decision making (51). A recent study compared the costs of fMRI and IAT (Wada test) in the workup of language lateralization in patients who where candidates for epilepsy surgery (52). Altman Future Research • To deﬁne better the different seizure risk groups so neuroimaging can be tailored appropriately. Commission on Classiﬁcation and Terminology of the International League Against Epilepsy.
Conventional arthrography is falling out of favor but it still remains useful for identifying capsulitis (by showing increase of resistance on Table 15 generic 20mg forzest with mastercard. Some of the common radiologic investigations available for shoulder problems Examination Radiation Cost Plain radiograph AP/axial Plain radiographs under ﬂuoroscopy ++ ++ Ultrasound Arthrography under ﬂuoroscopy +++ ++ CT +++ ++ CT arthrography +++ +++ MRI - +++ MRI indirect arthrography - ++++ MRI direct arthrography - ++++ Chapter 15 Imaging for Knee and Shoulder Problems 287 Table 15 buy forzest 20 mg cheap. Diagnostic accuracy of ultrasound, MRI, and MRA for rotator cuff (RC) tears Pooled Pooled Pooled positive Pooled negative Modality Lesion sensitivity* speciﬁcity* likelihood ratio likelihood ratio Ultrasound Full-thickness 87 (84–89)† 96 (49–97)† 13. It also provides unequivocal proof of a full-thickness RC tear (by showing direct extension of contrast medium into the subacromial space). Ultrasound is a relatively inexpensive but highly operator dependent investigation that can potentially yield exquisite views of the distal rotator cuff. These studies were highly heterogeneous, both in the quality of the research design adopted and in their ﬁndings. The overall trends from these studies indicate that ultrasound has high speciﬁcity for all RC tears, but sensitivity was lower for both full- and particularly partial-thickness tears (Table 15. Therefore, in secondary care settings, a patient with pos- itive ultrasound ﬁndings is very likely to truly have a RC tear and could be considered a potential surgical candidate. However, ultrasound has several potential diagnostic pitfalls (81) and, unlike MRI, cannot provide an entire anatomical overview of the shoulder. Magnetic resonance imaging can show most of the relevant anatomical features and can identify a large proportion of RC tears (Fig. Indeed an MR roadmap of anatomical features is often required before a surgeon will contemplate surgery; the anatomy of the acromioclavicular joint is well demonstrated and most surgeons now require information about this area before performing decompression (e. The pooled results of 20 diagnostic accuracy studies indicate that MRI is not substantially more accurate than ultra- sound in detecting RC tears (Table 15. In fact, a review of 14 studies focusing on partial-thickness tears indicated that the sensitivity of MRI is only 44%, lower than that of ultrasound (18). Few of these studies used fat- suppressed MRI techniques, which might have increased the diagnostic accuracy for partial-thickness tears. On this fat-suppressed T2- weighted MRI, the high signal intensity defect in the distal supraspinatus tendon provides convincing evidence of a full-thickness rotator cuff tear (arrows). The surgeon can readily assess the degree of retraction, which is essential information before considering repair. Although ultrasound could give some of this informa- tion, the full relationship of the damaged frayed tendon with the subacromial region is well demonstrated here. The majority of ﬁve studies that conducted head-to-head compar- isons of MRI and ultrasound against a common reference standard have concluded that MRI has equal or better accuracy than ultrasonography (82–86). However, taken in aggregate, data from these studies suggest that both the sensitivity and speciﬁcity of ultrasound and MRI are similar (18). It is important that imaging ﬁndings are closely correlated with the patient’s symptoms when selecting management strategies; asymptomatic full-thickness RC tears may be present in one quarter of adults aged 60 or over (87). The anatomy of this structure, along with the anterior extent of the anterior joint capsule, is crucial for the surgeon considering strength procedures for anterior instability. Estimates of the sensitivity of MRI without intra-articular contrast range from 55% to 90% (88–92). It has been claimed that MR arthrography (MRA) procedures (indirect or direct) can help clarify the detection of partial RC tears and labral tears (93–97).
Patients also rate the degree to tify responses to pain induced via the application of which pain interferes in multiple aspects of life purchase 20 mg forzest fast delivery. This tool has been ing (QST) refers to the evaluation of somato-sensory widely used with cancer patients generic 20mg forzest with visa. It provides infor- responses to controlled and quantiﬁable physical mation not only about pain severity, but also pain- stimuli, administered under standardized conditions. QST can be used to address a variety of questions These scales have the disadvantage of requiring more relevant to pain: time for administration and scoring compared to sin- • To examine individual difference variables (e. Faint Slightly unpleasant To provide diagnostic information among patients • Moderate Slightly annoying with chronic pain and related sensory dysfunction, Barely strong Unpleasant including mechanistically based identiﬁcation of Intense Annoying Weak Slightly distressing patient subgroups. For Very mild Distressing example, patients match an experimentally Extremely intense Very annoying induced pain stimulus to their clinical pain. More Very weak Slightly intolerable sophisticated approaches, such as triangulation, Slightly intense Very distressing may also help. Triangulation refers to a psy- Very intense Intolerable chophysical procedure in which patients rate both Mild Very intolerable their clinical pain and an experimental pain stimu- lus using the same measurement scale, following which they are asked to match their clinical pain to Table 10. By triangulating their responses it is possible to Pain ratings (0–10) Interference of pain in activities (0–10) determine whether patients are using the pain scales consistently. Current pain General activity • As a valuable outcome measure for documenting Worst pain (last 24h) Mood patients’ responses to treatment. Investigators are Least pain (last 24h) Walking ability increasingly using QST in clinical outcome studies. Average pain (last 24h) Normal work Relations with other people Multiple sensory stimuli have been used for QST. Sleep They differ along important dimensions including tem- Enjoyment of life poral and spatial qualities, anatomical site stimulated, 74 PAIN ASSESSMENT speciﬁcity of afferent ﬁbres stimulated and whether the then a clinically relevant stimulation method that can evoked pain mimics clinical pain (Table 10. However, stimulation method(s) should mimics those pain qualities would be preferred be chosen based on the scientiﬁc or clinical purpose (e. For example, if an ations, using multiple stimulation methods that differ investigator wishes to examine alterations in pain along important dimensions will be most informative. A common measure used in QST 100 is the pain threshold, deﬁned as the minimum amount 80 of stimulation required to produce a pain. Another measure is pain tolerance, which refers to the maxi- 60 Clinical pain rating (55) mum amount of stimulation an individual is willing to experience. These measures have the advantages of 40 being intuitively appealing and quantitative. However, 20 Actual pain Predicted pain they are also one dimensional and likely represent match (49. The self-report methods described Temperature (ºC) above can also be used to assess perceptual responses to supra-threshold painful stimuli. Behavioural and physi- is predicted that the patient will match his/her clinical pain ological measures can also be obtained. The actual temperature (49°C) to which the patient matched his/her clinical pain is quite close to the predicted temperature, suggesting that this Behavioural measures patient used the VAS scale consistently to rate both clinical and thermal pain. Triangulation provides a measure of clini- Research in non-human animals has long relied on cal pain anchored to an experimental pain stimulus as well behavioural responses to noxious stimuli as indices as an index of how consistently the patient is rating pain of nociceptive processing. PAIN MEASUREMENT IN HUMANS 75 Technically, self-reports of pain, such as those reliably elicit changes in measures including blood described above, can be construed as verbal pain pressure, heart rate, electro-dermal responses and behaviours; however, pain behaviour typically refers pupil dilatation. Other emotional and physical and quantifying overt pain behaviours exhibited by stressors are able to evoke similar patterns of auto- patients with clinical pain have been described and nomic activation. Commonly observed pain behaviours can be accompanied by increased responses on some include guarding (e.