By B. Kerth. Grand Valley State University. 2018.
Department of managed care cheap medrol 16 mg line gouty arthritis in dogs, such global changes are equally difﬁcult to Health and Human Services; 1987:6(13) buy 4 mg medrol with mastercard arthritis pain medication rx. A ran- ing that a chronic disease self-management program can domized trial of comprehensive geriatric assessment in improve health status while reducing hospitalization: a the care of hospitalized patients. Silverman M, Musa D, Martin DC, Rave JR,Adams J, Ricci ability and managing chronic illness in frail older adults: a EM. Evaluation of outpatient geriatric assessment: a randomized trial of a community-based partnership with randomized multi-site trial. A Controlled Chronic care clinics: a randomized controlled trial of a new trial of inpatient and outpatient generic evaluation and model of primary care for frail older adults. The effectiveness and efﬁciency of outpatient group outpatient visits for chronically ill older HMO geriatric evaluation and management. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, continued geriatric outpatient management on health Kowal J. Physician imple- process of care in hospitalized older patients: a randomized mentation of and patient adherence to recommendations controlled trial of acute care for the elders (ACE) in a com- from comprehensive geriatric assessment. Outpatient geriatric evaluation and care to prevent cognitive and functional decline in hospi- management: results of a randomized trial. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, patients with congestive heart failure. A randomized clinical trial of outpatient comprehen- of impact of model of integrated care and case management sive geriatric assessment coupled with a intervention to for older people living in the community. Keeler EB, Robalino DA, Frank JC, Hirsch SH, Maly RC, home care services on hospital use. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 203 33. In: Grosel C, Hamilton M, controlled trial of nurse case management of frail older Koyano J, Eastwood S, eds. Albert A variety of cognitive disorders occur with increasing is much that a geriatrician can do to identify the presence frequency as people age; these include progressive de- of cognitive dysfunction and see that it is properly menting disorders, acute confusional states, and cognitive assessed. Epidemi- ologic studies indicate that approximately 15% of the population over 65 years of age suffers from some form 1 Interview with Patient of dementia. However, the probability of having a dementing disorder increases dramatically with age. Data There are two sources of information concerning the concerning the prevalence of dementia in a community- cognitive status of patients: (1) patients themselves and dwelling population indicate that between the ages of 65 (2) patients’ families. Unless a family member has and 74 years the prevalence of dementia ranges from 2% approached the physician with concerns about the to 3%; this increases to 22% to 23% among those persons patient’s cognitive function, it is not likely a family 75 to 84 years and to 47% to 48% among those persons 2 member will be routinely involved in a geriatric assess- aged 85 years and older. Therefore, the physician is initially limited to to the incidence and prevalence of acute confusion in information that is obtainable from the patient. Several studies have information can be most easily gathered in two ways: (1) reported that 25% to 35% of hospitalized geriatric from an interview of the patient in the course of con- patients on a general medical service who are cognitively ducting a medical evaluation and (2) from brief mental intact at admission develop acute confusion. There are few systematic studies of the preva- lence of cognitive disorders secondary to psychiatric Medical Examination syndromes, but numerous clinical reports state that their prevalence is greater among elderly patients than young In the course of a routine medical examination, there is patients. Because the bidity and mortality, and although only some of them can most common causes of cognitive decline in elderly be completely reversed with treatment, appropriate man- patients produce a memory disorder (speciﬁcally a dif- agement can substantially improve the quality of life and ﬁculty with learning and retaining new information), reduce the development of secondary conditions. Thus, it greatest emphasis should be placed on ascertaining infor- is in the best interests of the patient if one can become mation about the memory function of the patient. This increasingly attuned to the possible presence of cognitive may be accomplished by a discussion of current events. For focuses on the role of neuropsychologic testing in the one patient; it may be politics, for another, sports, and assessment of cognitive dysfunction in elderly patients, for another, the stage of the planting season. If there is a particularly as it applies to the geriatrician, because there particularly dramatic event in the news that most people 205 206 M. There- plane crash), this may be useful for persons of diverse fore, it is ideal if this can be supplemented by a brief test backgrounds.
Chapter 5 examines the current status of marketing in healthcare buy medrol 4 mg visa bee venom arthritis pain relief, identifying the types of organizations that are most actively involved in promotional activities medrol 16 mg with mastercard arthritis pain relief medication. The regard with which marketing is held in health- care today is noted, and current trends in the application of marketing tech- niques in healthcare are reviewed. CHAPTER 1 THE HISTORY OF MARKETING IN HEALTHCARE espite its short history, healthcare marketing has experienced many twists and turns. Since the notion of marketing was introduced to D healthcare providers during the 1970s, the field has gone through var- ious periods of growth, decline, retrenchment, and renewed growth. It is a uniquely American concept, and the English word "marketing" has been adopted by other languages that lack a word for this concept. Although the 1950s is considered to mark the beginning of the "mar- keting era" in the United States, the establishment of the marketing func- tion within the U. This production orientation assumed that the producer knew a priori what the consumer needed. Products were produced to the specification of the manufacturer, and then customers were sought. A "here is our product, take it or leave it" approach charac- terized most industries during this period. The mind-set was that a good product would sell itself; thus, there would be no need for marketing even if the field had existed. In the days before the standardization of production, there was enough variation among products offered by dif- ferent producers that the differences generally spoke for themselves (with- out benefit of marketing). Furthermore, until the prosperity of the 1950s, the concept of consumer was poorly developed. The existence of a weak consumer segment lacking consumer credit and an acquisitive mind-set was not conducive to the development of the marketing enterprise. Stage One: Product Differentiation and the Consumer Mentality The postwar period witnessed the emergence of a wide variety of new prod- ucts, particularly in the consumer-goods industries. Newly empowered con- sumers demanded a growing array of goods and services, even if existing goods and services had adequately served previous generations. This development contributed to the emergence of marketing for at least two reasons. First, consumers had to be introduced to and educated about these new goods and services. Second, new market entrants introduced a level of competition unknown in the prewar period. This meant that mecha- nisms had to be developed to both make the public aware of a new prod- uct and to distinguish that product from those of competitors’ in the eyes of potential customers. Consumers had to be made aware of purchase opportunities and then convinced to buy a certain brand. The standardization of existing products that occurred during this period further contributed to the need to convince newly empowered consumers to purchase a particular good or service. These developments resulted in a shift away from a seller’s market to a buyer’s market. Once the consumer market began to be tapped, it was realized that the demand for many types of goods was highly elastic. The prewar mentality had emphasized the meeting of consumer needs and assumed that a finite amount of goods and services could be purchased by a population. With the increase in discretionary income and the introduc- tion of consumer credit after World War II, consumers began to satisfy wants. Fledgling marketers found out that they could not only influence consumers’ decision-making processes but could even create demand for certain goods and services. The postwar period was marked by a growing empha- sis on consumption and acquisition. The frugality of the Depression era gave way to a degree of materialism that was shocking to older generations.
M ost papers appearing in m edical journals these days are presented m ore or less in standard IM RAD form at: Introduction (why the authors decided to do this particular piece of research) trusted 16 mg medrol arthritis pain relief balm kingston chemicals, M ethods (how they did it and how they chose to analyse their results) purchase medrol 4mg line arthritis medication weight gain, Results (what they found), and D iscussion (what they think the results mean). If you are deciding whether a paper is worth reading, you should do so on the design of the m ethods section and not on the interest value of the hypothesis, the nature or potential im pact of the results or the speculation in the discussion. Conversely, bad science is bad science regardless of whether the study addressed an im portant clinical issue, whether the results are "statistically significant" (see section 5. Strictly speaking, if you are going to trash a paper, you should do so before you even look at the results. W hen I teach critical appraisal, there is usually som eone in the group who finds it profoundly discourteous to criticise research projects into which dedicated scientists have put the best years of their lives. On a m ore pragm atic note, there m ay be good practical reasons why the authors of the study have "cut corners" and they know as well as you do that their work would have been m ore scientifically valid if they hadn’t. M ost good scientific journals send papers out to a referee for com m ents on their scientific validity, originality, and im portance before deciding whether to print them. This process is known as 40 G ETTIN G YOU R BEARIN G S peer review and m uch has been written about it. I recently corresponded with an author whose paper I had refereed (anonym ously, though I subsequently declared m yself) and recom m ended that it should not be published. On reading m y report, he wrote to the editor and adm itted he agreed with m y opinion. H e described five years of painstaking and unpaid research done m ostly in his spare tim e and the gradual realisation that he had been testing an im portant hypothesis with the wrong m ethod. H e inform ed the editor that he was "withdrawing the paper with a wry sm ile and a heavy heart" and pointed out several further weaknesses of his study which I and the other referee had m issed. H e bears us no grudge and, like Kipling’s hero, has now stooped to start anew with worn-out tools. The assessm ent of m ethodological quality (critical appraisal) has been covered in detail in m any textbooks on evidence based m edicine,3–7 and in Sackett and colleagues’ "U sers’ guides to the m edical literature" in the JAMA. Appendix 1 lists som e sim pler checklists which I have derived from the users’ guides and the other sources cited at the end of this chapter, together with som e ideas of m y own. If you are an experienced journal reader, these checklists will be largely self explanatory. If, however, you still have difficulty getting started when looking at a m edical paper, try asking the prelim inary questions in the next section. The introductory sentence of a research paper should state, in a nutshell, what the background to the research is. For exam ple, "G rom m et insertion is a com m on procedure in children and it has been suggested that not all operations are clinically necessary". This statem ent should be followed by a brief review of the published literature, for exam ple, "G upta and Brown’s prospective 41 H OW TO READ A PAPER survey of grom m et insertions dem onstrated that. It is irritatingly com m on for authors to forget to place their research in context, since the background to the problem is usually clear as daylight to them by the tim e they reach the writing up stage. U nless it has already been covered in the introduction, the m ethods section of the paper should state clearly the hypothesis which the authors have decided to test, such as "This study aim ed to determ ine whether day case hernia surgery was safer and m ore acceptable to patients than the standard inpatient procedure". Again, this im portant step m ay be om itted or, m ore com m only, buried som ewhere m id-paragraph. If the hypothesis is presented in the negative (which it usually is), such as "The addition of m etform in to m axim al dose sulphonylurea therapy will not im prove the control of type 2 diabetes", it is known as a null hypothesis. The authors of a study rarely actually believe their null hypothesis when they em bark on their research. Being hum an, they have usually set out to dem onstrate a difference between the two arm s of their study. But the way scientists do this is to say "Let’s assume there’s no difference; now let’s try to disprove that theory". If you adhere to the teachings of Karl Popper, this hypotheticodeductive approach (setting up falsifiable hypotheses which you then proceed to test) is the very essence of the scientific m ethod. Rem em ber, however, that not all research studies (even good ones) are set up to test a single definitive hypothesis. Qualitative research studies, which are as valid and as necessary as the m ore conventional quantitative studies, aim to look at particular issues in a broad, open-ended way in order to generate (or m odify) hypotheses and prioritise areas to investigate.
This application is cur- rently running on a SGI Onyx2 In®nite Reality machine (Fig cheap medrol 4 mg with visa arthritis in dogs and walking. In this application the spaceball is used to walk (navigate inside or outside of the colon) and the HMD is used for viewing the colon cheap 16mg medrol free shipping arthritis care medication. The 3-D model of the colon is currently in an Inventor ®le format and has been reconstructed from CT images of the Visible Human Male Dataset. The reconstruction was made with the Analyze software package developed at the Mayo Biomedical Imaging Resource Laboratory (24, 92). Currently, the application supports the following modes and features: 110 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY Mode 1. Free ¯ythrough using the input devices that give the user the ability to examine the inner and the outer surface of the colonic wall. This is helpful when the user detects a tumor on the inner surface and wants to see if the tumor extends to the other surface. The mode gives the impression of relating to the user and keeps him or her inside the colon. It is helpful for quick examination of the colon and does not warn the user when he or she is stuck on the colonic wall. The three features allow the viewing position to be reset to an initial position and increase and decrease the scale. Much less patient discomfort results because there is no need to reposition the patient. The radiation dose used in virtual endoscopy is one half of one quarter of the average exposure in barium enema and an unlimited number of viewing angles can be exploited. There is also no need for sedation, and the patient can resume normal activities immediately after the CT scanning procedure. In addition, by adopting a virtual medical worlds interface, the pragmatics of de®ning and creating virtual envi- ronments are abstracted from the practitioner. A practitioner then has a choice, depending on the availability of supportive hardware, on how to visu- alize patient data. This chapter was not concentrated with the speci®cs of vir- tual reality techniques and did not provide detailed explanations of its use. It outlined a possible framework for how these advanced imaging techniques could be integrated into a general telemedical information society. Presently, the cost of VR hardware and software has restricted its usage to only a few medical institutions. However, it is envisaged that as these costs are reduced, the technology will become more widespread. Surgery planning programs such as VRASP are already available to allow a surgeon to practice an operation on a virtual model of the patient and then use this virtual operation to assist during the real operation. It seems quite REFERENCES 111 possible that this approach could be taken even further so that a surgeon could be in one location and either a robot or another, less specialized, surgeon could perform the operation at another location (112±118). This approach could be used in specialized cases, natural disasters, isolated regions, and even military situations. It is also possible that VR techniques could be used for telepresence to create a virtual practitioner to guide a less quali®ed practitionerÐa VR form of teleconferencing. However, with the introduction of any new technology the factors of its safe and healthy use need to be considered along with its ethics (119). Clearly, there are many diverse potential uses of VR techniques; and even through VR is in its development stages, it is providing another tool to aid practitioners not only in training but also in diagnosis and treatment planning (120, 121). It is my opinion that only if such techniques can be truly integrated into a uniform frameworkÐincluding telecommunications, computing, and data managementÐwith all other forms of medical imaging techniques and developing technologies (e. Applied virtual reality for simula- tion of endoscopic retrograde cholangio-pancreatoraphy (ERCP). Virtual endoscopy of the head and neck: diagnosis using three-dimensional visualisation and virtual representation. Towards performing ultrasound-guided needle biopsies from within a head-mounted display. The dimensionally integrated dental patient record: digital dentistry virtual reality in orthodontics. Paper presented at the 12th International Symposium on the Creation of Electronic Health Record System and Global Conference on Patient Cards.
Muscle fatigue during prolonged low-to-moderate intensity exercise is linked to reductions in carbohydrate reserves (Newsolme purchase 4mg medrol visa arthritis shoulder pain, et al cheap medrol 4mg with amex osteoporosis arthritis in feet. It can therefore be seen why both the effect of reduced fatty acid metabolism and non-cardioselective beta-blockade may cause an increased local/peripheral perception of effort. Furthermore, during prolonged (>60 minutes) and/or higher intensity (>65%VO2 max) exercise there will be an increased susceptibility to an earlier onset of muscle fatigue due to increased reliance on limited carbohydrate substrates. Duration of exercise has been regarded as a modulator of RPE whether under beta-blockade or not, from the effects of reductions in carbohydrate energy substrates, increased body temperature and the psychological concept of duration-fatigue (Potteiger and Weber, 1994; Kang, et al. SUMMARY OF KEY POINTS FOR THE EFFECTIVE USE OF RPE The following points include the key instruction statements recommended by Maresh and Noble (1984). Before using the scale see if they can grasp the concept of sensing the exercise responses (breath- ing, muscle movement/strain, joint movement/speed). Anchor the perceptual range, which includes relating to the fact that no exertion at all is sitting still, and maximal exertion is a theoretical concept of pushing the body to its absolute physical limits. Patients should then be exposed to differing levels of exercise intensity (as in an incremental test or during an exercise session) so as to understand what the various levels on the scale feel like. Just giving them one or two points on the scale to aim for will probably result in a great deal of variability. Use the above points to explain the nature of the scale and explain that the patient should consider both the verbal descriptor and the numerical value. They should ﬁrst concentrate on the sensations arising from the activity, look at the scale to see which verbal descriptor relates to the effort they are experiencing and then link it to the numerical value. Make sure the patient is not just concentrating on singular sensations, known as differentiated ratings (see Figure 3. Differentiated ratings can be used during muscular strength activity or where exercise is limited more by breathlessness or leg pain, and not cardiac limitations, as in the case pulmonary or peripheral vascular disease, respectively. There are three important cases where the patient may give an incorrect rating: a. When the patient already has a preconceived idea about what exertion level is elicited by a speciﬁc activity (Borg, 1998). He/she is not aware that what is required is to rate the amount of effort at this very moment, not what they think a typical level of exertion is for that activity. Similar to heart rate, RPEs should be taken while the patient is actually engaged in the movements, not after they have ﬁnished or in the break between stations. Simply pleasing the exercise practitioner by stating what should be the appropriate level is a regular observation in the author’s experience. In the early stages of rehabilitation, the patient’s exercise inten- sity should be set by HR or workrate (e. Once it has been established that the patient’s rating concurs with the target heart rate or MET level reliably, moving them on to production mode can be considered. It is known that endurance athletes in a race situation work very hard mentally to concentrate (cognitively associate) on their sen- sations in order to regulate their pace effectively (Morgan, 2000). ESTIMATED METABOLIC EQUIVALENTS The metabolic equivalent (MET) is widely used in cardiovascular population exercise guidelines as a means of quantifying the energy demands of physical activity. It relates the rate of the body’s oxygen uptake (VO2) for a given activ- ity as a multiple of an individual’s resting VO2. It is important to recog- nise that these values are estimates, which means that each individual patient could be working above or below this estimate. The variability of the estimate depends on the simplicity or complexity of the movements. For example, the variability of pedalling an exercise cycle ergometer will likely be less than that of stepping or walking. The motor skill involved in cycle ergometry is ﬁxed by the motion of the pedal crank and mainly involves the legs. Stepping and walking require the individual to balance and use arm and trunk motions, which can vary much more than cycling. In cardiac rehabilitation, the MET values from the patients’ exercise ECG stress test are typically reported. These data provide the exercise leader with information of both intensity and functional capacity. It should be noted, if the ETT is carried out using a motorised treadmill, how much the MET value can be altered by the patient holding on to the handrail.