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Today’s well-informed consumers are aware of the level of medical errors characterizing hospital care and the amount of system-induced mor- bidity associated with healthcare settings cheap provigil 200mg amex. Even if individuals remain stoic with regard to their own care 100 mg provigil, they are likely to exhibit an emotional dimension when the care concerns a parent, child, or some other loved one. Whether this emotionally charged and personal aspect of the health- care episode prevents the affected individual from seeking care, colors the choice of provider or therapy, or leads to additional symptoms, the choices made by the patient or other decision makers are likely to be affected. The fact that many consumers cannot bring themselves to even say the word "cancer" supports this view; emotions like fear, pride, and vanity often come into play. Given the pervasiveness of marketing in the United States, how can we explain the relative lack of marketing within an industry that accounts for 15 percent of the gross national product? A number of reasons can be cited to explain this situation, and most reflect characteristics noted in the earlier discussion of health industry attributes. The following fac- tors can be seen as barriers to the incorporation of marketing within the healthcare arena. No (Real or Perceived) Need Until the 1980s most healthcare organizations felt they had no competi- tors. There were plenty of patients, and revenues were essentially guaran- teed by third-party payers. Competition had been minimized through gentlemen’s agreements among various healthcare providers. If providers did not overtly collude to carve up the patient market, they respected infor- mal boundaries set to reduce competition. They maintained monopolies or oligopolies in their market areas and evinced a product orientation. These factors contributed to the perception (and, in many cases, the reality) that marketing was an unnecessary activity for healthcare organi- zations. From the perspective of mainstream providers, physicians referred their patients to the hospital and insurance plans steered their enrollees to the facility. This mind-set perpetuated the impression that marketing was 36 arketing Health Services not needed and overlooked the important marketing tasks of physician- relationship development and health plan contract negotiation. No Knowledge of Marketing Few healthcare administrators in the past were schooled in the business aspects of healthcare, and fewer still had training or experience in market- ing. Many senior healthcare administrators had not received formal train- ing in their field, and those trained prior to the 1980s were not likely to have received much exposure to healthcare marketing. The almost total absence of marketing within healthcare provided no exposure for health- care executives, and the fact that their fellow administrators were similarly unenlightened with regard to marketing further underscored the lack of knowledge about marketing on the part of health professionals. Even if a healthcare administrator had some interest in marketing, until recently few sources of information related to the topic existed.

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The resulting sensitivity and negative predictive value were 96% and 94% purchase 200mg provigil with visa, respectively (22) 100 mg provigil overnight delivery. A guideline, "Practice Management Guidelines for the Management of Mild Traumatic Brain Injury," developed by the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group (2001) (2), was based on level II evidence from several studies (three ret- rospective and one uncontrolled prospective). They reported that 3% to 17% of patients with mild injuries had significant CT findings, although they noted that there was no uniform agreement as to what constitutes a positive CT scan in different studies. They also reported that a patient with a normal head CT had a 0% to 3% probability of neurologic deterioration. Therefore, if a patient had a GCS of 15 and no neurologic/cognitive abnor- malities, it was recommended that the patient be discharged. One guideline for severe TBI, "Management and Prognosis of Severe Traumatic Brain Injury" (2000), was developed by the American Associa- tion of Neurological Surgeons (AANS), and approved by the American Society of Neuroradiology, the American Academy of Neurology, the American College of Surgeons, the American College of Emergency Physi- cians, the Society for Critical Care Medicine, and the American Academy of Physical Medicine and Rehabilitation (23,24). An extensive review of the CT literature supported the need for CT in the acute period. Computed tomography was reported to be abnormal in 90% of patients with severe head injury. Computed tomography is included as a necessary step in the algorithm of initial management. What Is the Sensitivity and Specificity of Imaging for Injury Requiring Immediate Treatment/Surgery? Summary of Evidence: Computed tomography is the mainstay of imaging in the acute period. The majority of evidence relates to the use of CT for detecting injuries that may require immediate treatment or surgery. Speed, availability, and lesser expense of CT studies remain important factors for using this modality in the acute setting. Sensitivity of detection also increases with repeat scans in the acute period (strong evidence). Supporting Evidence: The incidence of injury-related abnormalities on CT is related to the severity of injury. After minor head injury, the incidence is approximately 6% (25) and increases up to 15% in the elderly population (26); those with GCS 13 or 14 have higher frequency of abnormalities than those with GCS 15 (27). The incidence of CT abnormalities in moderate head injury (with GCS of 9 to 13) has been reported to be 61% (28). The sensitivity of CT for detecting abnormalities after severe TBI (GCS below 9) varies from 68% to 94%, while normal scans range from approximately 7% to 12% (29). Several studies have shown that the timing of CT studies also affects the sensitivity. Oertel and colleagues (30) (strong evidence) prospectively studied 142 patients with moderate or severe injury who had undergone more than one CT scan within the first 24 hours, and found that the initial CT scan did not detect the full extent of hemorrhagic injuries in almost 50% of patients, particularly if scanned within the first 2 hours. The likelihood of progressive hemorrhagic injury that potentially required sur- gical intervention was greatest for parenchymal hemorrhagic contusions (51%), followed by epidural hematoma (EDH) (22%), subarachnoid hem- orrhage (SAH) (17%), and subdural hemorrhage (SDH) (11%).

Guyatt G cheap provigil 100 mg free shipping, Rennie D cheap provigil 100mg visa, Evidence-Based Medicine Working Komen Breast Cancer Foundation; August 2001. How to Read a Paper: The Basics of How to use an article about disease probability for differ- Evidence-Based Medicine, 2nd ed. Evidence-Based Medicine: How to Practice and to finding and using the best evidence in caring for patients. Are there general Nomenclature principles that may usefully apply generally to senes- cence, or is senescence simply a collection of degenera- Aging: showing the effects of time; a process of change, usually tive entropic processes that have in common only that gradual and spontaneous they occur over time? Both views are supportable; Senescence: the loss of the power of cell division and growth indeed, the latter is perhaps the more common view (and function with time, leading to death) (The New Shorter among gerontologists and is the most supportable by evo- Oxford Dictionary) 1 Gerontologists consider the term aging insufficiently lutionary theory. However, gerontology, like geriatrics, has evolved precise because any process that occurs over time, for into a discipline in part because senescence entails example, rusting or development, may be reasonably several general characteristics and because impairments referred to as aging. Furthermore, although there are associated with senescence are largely predictable within reasons to imagine that "aging" is a continuum beginning a species. For example, mortality (and other senescent with development, these two terms are usually used to changes) conform (within limits) to a precise mathemat- refer to distinct processes. Specifically, development (as in ical description, the Gompertz curve, whose parameters an embryo) refers to a generative process over time nec- 2 essary for (and primarily evident at the beginning of) life, are characteristic of each species. Similarly, dietary restriction dramatically reduces many age-related whereas senescence refers to a degenerative process ulti- impairments and increases maximum life span across a mately incompatible with (and primarily evident at the wide range of phyla. Whether development and aging form, in any These general characteristics and the specificity of informative way, a mechanistic continuum is a hypothe- senescence require explanation, and seeking these ex- sis that is far from proven. Furthermore, base searches have been greatly complicated by the recent studies have suggested that senescence may entail assignment of the term aging to the process of develop- simpler and more orderly molecular processes than ment, without a concomitant general use of the term previously assumed. Thus, for example, the some of these age-related impairments as any other wisdom (or, at any rate, experience that ought to lead to disease. This integration of geriatrics into the tradi- that occur during aging are usefully considered a mani- tional medical model is an outcome of recent progress in festation of senescence. Mobbs Theories of Aging convincingly by evolutionary biologists, that senescence did not evolve because it bestowed advantage on the species, but rather senescence is essentially an evolu- Is Senescence an Entropic Process? An Evolutionary Theories of Aging essential feature of life is the low level of internal entropy that characterizes biologic entities compared to the envi- The fact that each species is characterized by a charac- ronment. Organisms maintain that low entropy state by teristic maximum life span whose value is essentially conversion of external energy (with the result of a net independent of environment indicates that, among increase in entropy, of course, when the organism and its species, senescence is determined genetically. Mechanical constraint on maximum life span and rate of senescence objects such as automobiles or test tubes are also in a has given rise to much speculation concerning the evolu- state of low entropy, but without the capacity to reduce tion of senescence. Early speculation around the turn of internal entropy by converting external energy.

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