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Words It is not uncommon for pain symptoms to be related used to describe location are often helpful generic finax 1 mg with visa treatment quotes. Superficial to a life event (either made worse by or start in rela- or deep pain may distinguish between somatic or vis- tion to it). Death, dis- type of clothes worn may provide a clue about allody- ease and divorce are commonly described. Tender- may look sad, or have difficulty concentrating and are ness is also a valuable symptom and may be associated difficult to communicate with. If the patient is accompanied, additional positive or negative factors may be revealed. If affective words are used, the interviewer may wish to explore the reasons behind the use of these words Where trauma is the initiating event a history of legal (e. Financial rewards may be The general health of the patient may reveal the cause maintaining pain – a history of disability payments, of the use of these words (e. Past pain history Behavioural assessment It is recognised that a previous history of pain may during history taking influence pain reports at a later date. Therefore, common problems should be specifically questioned The patient may be willing to describe their daily for. In women a menstrual and reproductive history function, or may find it quite difficult to develop this should be taken. If the patient is depressed and withdrawn very gical procedures should be documented, and for each little response to questioning may result. Remember, trauma question is to ask directly how the patient reached hos- includes sexual abuse of either sex at any age. If the history is copious and full of complaints, PAIN HISTORY 87 more specific questions are needed to reduce the time A good history should confirm any drug problem; for spent eliciting the basic information. Directed ques- example, multiple therapies for the same condition, tions can be made about: exercise, work, housework, allergies, abuse. It should also identify if drugs have driving, sitting, leisure, shopping, social functioning, been used in appropriate dosage and for a reasonable sexual function and sleep (e. A ranked order Previous pain therapies other (from easy to hard to achieve) may be a suitable target than medication for treatments. A review of previous pain therapies may reveal A baseline assessment of behaviour is useful and its patient preferences, beliefs, cognition and potential relation to factors, such as diurnal variation, response compliance. Activity can be quantified (unlike subjective assessments, such as • Physical therapies – for example, acupuncture, pain intensity) and may be recorded in a pain diary as braces, casts, trigger point injections, exercises, time ‘up’ and time ‘down’. Aggravating/relieving factors may indicate the types Situational therapies – for example, hypnosis, relax- • of behaviour that are avoided or sought. History elicited from a patient may usefully start a • Massage (physiotherapy, alternative practitioners). All questions should be directed at investigating the patient and occur with the patient’s permission: Medication What changes have you observed in the patient? A full medication history includes the following Do you think the pain has been getting worse? Keogh Overview Although there are many different types of emotion and mood, the greatest focus has been on those with a Our current understanding of pain is that it is not negative tone. Few investigations have examined positive just a sensory experience but also has a psychological emotions, such as joy and contentment. What we think, what we feel and how we have examined anxiety and depression, which is not behave can all influence the experience of pain. Indeed, surprising given that both can indicate serious mental such cognitive, emotional and behavioural processes illness. Depression is defined as a tendency towards are believed to moderate pain sensation by inhibiting experiencing negative thoughts and feelings about or facilitating noxious signals. It is associated with a lack of positive experiences can have little to do with nociception or affect (anhedonia), greater hopelessness and withdrawal. Clinically, there are therefore to: are a number of different types of anxiety, including generalised anxiety disorder, phobias (social events, • Provide readers with an overview of the contribu- spiders, etc. Role of psychology in the In terms of the effects that such negative emotions and experience of pain moods have on chronic pain patients, depression and anxiety predict a range of negative outcomes, including Emotions and moods greater pain, disability, health care utilisation and One of the main psychological responses to pain is an longer time to get back to work. When in pain, patients often report patients it has been shown that pre-operative anxiety feeling anxious, depressed, angry and/or frustrated.

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Although the 1950s is considered to mark the beginning of the "mar- keting era" in the United States cheap finax 1mg line medicine assistance programs, 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. The availability of consumer credit and a mind-set that emphasized "keep- The History of M arketing in Healthcare 5 ing up with the Joneses" generated a demand for a growing range of goods and services. America had given rise to the first generation of citizens with a consumer mentality. By the 1970s, there was a growing emphasis on self-actualization in American culture, often carried to the point of narcissism in the minds of many observers. Not only were individuals coming to be identified in terms of their material possessions, but the cultural environment encouraged peo- ple to "do their own thing. A growing consumer market with expand- ing needs, coupled with a proliferation of products, created a fertile field for the emergence of marketing. Underlying these developments was the growing emphasis being placed on change itself. Traditional societies (including the United States until World War II) emphasized stability; the status quo; and, as the name implies, tradition.

But when MR or CT is used early in the workup of LBP buy finax 1 mg visa medicine gabapentin, there is a very slight improvement in patient outcome. Supporting Evidence: While the majority of studies attempt to validate a modality by its diagnostic accuracy, possibly more important is whether the test actually alters patient outcomes. At 6 weeks and at 1 year, there was no difference between the groups in physical functioning, disability, pain, social functioning, general health, or need for further referrals. However, in the treatment arm at both 6 weeks and 1 year, there was a small improvement in self-reported overall mental health (Table 16. In a similar randomized controlled trial of 421 patients, Kendrick and colleagues (80) actually found a slight increase in pain dura- tion, and a decrease in overall functioning in the radiograph group at 3 months, though at 9 months there was no difference between the groups (strong evidence). However, while both groups improved from baseline, there was slightly more improvement in the early imaging arm at both 8 (p =. Our group also performed a randomized controlled trial assigning primary care patients with LBP to receive either lumbar spine radiographs or a rapid lumbar spine MR (83) (strong evidence). Vroomen and colleagues (84), however, did find in patients with leg pain, utilizing early MR helped predict the patient’s prognosis (strong evidence). Patient satisfaction and expectations must also be accounted for when developing an imaging strategy. Many patients with LBP believe imaging is important or necessary to their care (85–87). However, there are con- flicting results regarding improved satisfaction of care when imaging is actually performed. In their randomized trial using plain radiographs, Kendrick and colleagues (80) discovered that if participants had been given the choice, 80% would have elected to be imaged (strong evidence). They also found that while satisfaction was similar at 3 months in both the imaging and nonimaging groups (Table 16. In a comparable study, Kerry and colleagues (79) found no difference in early patient satisfaction (strong evidence). Finally, in our com- parison of rapid MR to radiographs, there was no difference in overall patient satisfaction between the two groups, but patients who received an MR were more reassured (83) (strong evidence). Patient outcome Imaging type Comparison Difference (95% CI, p) Plain radiographs Kerry et al. Prognostic value of MR for sciatic 2002 (84) Favorable prognosis, anular rupture p = 0. Patient satisfaction Difference (95% CI, Study Comparison p when provided) Kendrick Radiograph vs. What Is the Role of Vertebroplasty for Patients with Painful Osteoporotic Compression Fractures? Summary of Evidence: Percutaneous vertebroplasty, first described by Galibert et al. What is unknown is whether vertebroplasty increases the rate of adjacent vertebral fractures (89). Uncontrolled studies indicate that vertebroplasty is a promising therapy for patients with painful osteoporotic compression fractures, but confirmation by controlled trials is needed. Supporting Evidence: Osteoporotic vertebral compression fractures occur annually in about 700,000 Americans, including 25% of postmenopausal women (90,91) and often produces psychologically and physically devas- tating pain, as well as an increased risk of death. Although the pain of an acute fracture is usually relieved within several weeks by conservative treatment (bed rest, antiinflammatory and analgesic medications, calci- tonin, or external bracing), it occasionally requires narcotics, and even then may persist (92–94). Only case series and uncontrolled prospective studies have been published (95–107). As with most new technology assessments, initial reports have been positive and even enthusiastic. However, the lack of con- trolled data indicates the need for a prospective controlled trial to evalu- ate the efficacy of this procedure (insufficient evidence). Accuracy of imaging for lumbar spine conditions* Sensitivity Specificity Likelihood ratio + Likelihood ratio - X-ray Cancer 0. The likelihood ratio (LR) summarizes the sen- sitivity and specificity information in a single number, comparing the prob- ability of having a positive test result in patients with the disease with the probability of a positive test in patients without the disease, or LR+=(Prob- ability (+test|disease))/(Probability (+ test|no disease)).

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Finally discount 1 mg finax amex treatment goals for depression, Blaine learned of Merle Watson, a Parkinson’s patient who lives in a neighboring town. I called Merle’s wife, Barbara, and she gave me the addresses of 6 living well with parkinson’s the four national organizations concerned with Parkinson’s dis- ease. Their free materials, which I obtained in the mail, seemed to be the extent of the information available to patients in 1981. These depressing materials contained pictures of people with frozen facial expressions and thin, bent-over figures. Very little in the materials could give me much hope that I might live in reason- able comfort, as I later learned to live. However, I was now on sev- eral mailing lists, and soon newsletters began to appear. I had shared my "secret" of Parkinson’s disease with my students and colleagues, as well as with my family and friends, and they were all very helpful. Also, no matter how much they did, they could not take away the pain in my hips that made me limp, the all-over aching, and the extreme tiredness that kept me on the couch from the time I got home until bedtime. I learned the name of another neurolo- gist, and in February 1982, I visited my second specialist. He, too, was helpful and understanding, and I certainly could not find any fault with him. But what I was really looking for was a specialist who lived and breathed Parkinson’s disease. The ques- tion kept recurring in my mind: how much time do they really have to keep up with the latest findings on one disease—Parkinson’s? Blaine and I began thinking that we might start a Parkinson’s support group in our area. We needed to talk to others with Parkinson’s and felt that people in our area must have do not disturb! One person we talked to was Mary Dike of Gar- diner, Maine, whom we contacted after reading about her in a newspaper article. A home economics teacher a few years younger than I, Mary was about to leave teaching because of Parkinson’s disease. She told us about her doctor, Robert Feldman, a Parkin- son’s specialist at Boston Medical Center. We found him and his multidisciplinary team to be experts whose aim was to educate the patient about Parkinson’s disease and who knew how to treat the disease. Feldman, Blaine, and I talked together until we agreed on a course of treatment that was satisfactory to all of us. Thus, I have the security of knowing that if I have any imme- diate problems, my family doctor, close by, knows my status. I learned that I needed to take the responsibility of keep- ing myself as healthy as possible and to ask questions in the doc- tor’s office. I learned that doctors, too, are human: some find it difficult to say, "I don’t know," when they can’t diagnose an ill- ness. Parkinson’s is a progressive disease, but in most cases it progresses so slowly that it’s easy to ignore the first symptoms. They differ from person to person, but the ones I hear about most often are these: • Fatigue • Aches and pains that may be vague or may be severe enough to cause limping or all-over discomfort (they disappear when you rest for a while) • Slow movement: this makes you feel like you are in a slow- motion segment of a movie or are walking through water • Loss of the natural swing of your arms when you walk • Poor balance and falling (a feeling of awkwardness) • Tripping, caused by not lifting the feet sufficiently • Dragging a foot • Cramps or other weird sensations in the legs or the feet • Difficulty with handwriting: sometimes you feel that each letter must be drawn painstakingly. The writing may get smaller and smaller as you progress, and sometimes the lines of your writing slant downhill. If your suspicions are con- firmed, you can deal with your fears and find a Parkinson’s spe- cialist who will start you on a program of treatment. Go to the library, write to the national organizations concerned with Parkinson’s disease (see the names and addresses in the appendixes to this book), and join the nearest Parkinson’s support group. Enlist the support, the confidence, and the involvement of your spouse, close relatives, or close friends from the beginning. God give us grace to accept with serenity The things that cannot be changed, Courage to change the things That should be changed, And the wisdom to distinguish the one from the other.

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