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And do you suppose heart surgeons reconnect vagal branches during transplant operations? Its name reflects both its wide distribution and the type of sensation it conveys (Latin: vagus – vague buy metformin 500 mg cheap diabetes mellitus blood sugar levels, indefinite buy metformin 500 mg amex diabetes symptoms negative test, wandering). In and below foramen are two sensory ganglia: jugular and nodose, containing cell bodies of sensory fibres. Auricular branch passes through canal in temporal bone and conveys sensory fibres from external acoustic meatus and tympanic membrane. The vagus nerve (X) 87 Nucleus of solitary tract From skin of EAM and tympanic membrane Sensory from pharynx and upper larynx Nucleus ambiguus (branchiomotor) Motor to pharynx Dorsal motor nucleus (parasympathetic) Sensory and branchiomotor fibres in recurrent laryngeal nerves X continuing to thorax Subclavian artery (right side), and abdomen ligamentum arteriosum (left side) Fig. Gives pharyngeal branches, and superior laryngeal nerve which has internal (sensory above vocal cords) and external (cricothyroid) branches. Both ascend between trachea and oesophagus to laryngeal muscles (not cricothyroid) and sensation of larynx below vocal cords, trachea, oesophagus. Enters abdomen through oesophageal hiatus in diaphragm as anterior and posterior trunks and 88 Glossopharyngeal, vagus and accessory nerves contributes fibres to abdominal viscera and to coeliac, superior mesenteric and myenteric plexuses. Branches pass in lesser omen- tum alongside lesser curvature of stomach to innervate pyloric antrum (nerves of Latarjet), and to give hepatic branches. Structures derived from these include the pharyngeal and laryngeal cartilages and muscles. The sixth arch artery on the left gives rise to the ductus arteriosus (ligamentum after birth) around which the left sixth arch nerve, the recurrent laryngeal, is caught when the artery descends. The sixth arch artery on the right degen- erates, so the right recurrent laryngeal nerve is related to the most caudal persisting branchial arch artery, the fourth, which becomes the right subclavian. The motor function of the vagus in the neck is branchiomotor (special visceral motor): motor function in the thorax and abdomen is parasympathetic (general visceral motor). Dorsal motor nucleus of vagus (DMNX) in medulla gives pregan- glionic axons to innervate heart and thoracoabdominal viscera (foregut and midgut). Cell bodies of postganglionic neurons are generally in wall of destination organ, for example cardiac, myen- teric plexuses. The vagus nerve (X) 89 Somatic sensory fibres: to sensory nuclei of the trigeminal nerve From posterior wall of external auditory meatus and posterior por- tion of external surface of tympanic membrane, fibres pass in auricular branch of X to main trunk in jugular foramen. Taste fibres from epiglottic area, visceral sensory fibres from hypopharynx, larynx, oesophagus, trachea, thoracoabdominal vis- cera and aortic baro- and chemo-receptors. This develops from heart tubes formed by angiogenetic cells initially found in the wall of the yolk sac, from which the gut tube develops. Perhaps we have been too eager to over-analyze the vagus into parasympathetic, branchiomotor, and so on. Perhaps the "big picture" is that the vagus is the yolk sac nerve; the nerve of sustenance. Laryngeal speech indicates that the vagus is intact at least to the level of the upper thorax. The mediastinal course of the left recurrent laryngeal nerve means that left mediastinal tumours may present as voice changes. The superior laryngeal artery is related to the external laryngeal nerve near the origin of the artery, and the recurrent laryngeal nerve is related to the inferior thyroid artery close to the gland. Damage to the recurrent laryngeal nerves at this point nearly always affects fibres innervating the vocal cord abductors before those affecting adductors. This is serious, since if abduction is lost, the cords will be adducted and breathing will be difficult. Oddly enough, when clinicians refer to the eleventh cranial nerve, or acces- sory nerve, they almost always mean spinal accessory, which is not really a cranial nerve at all! Cranial accessory This arises from a caudal extension of the nucleus ambiguus by rootlets below and in series with those of IX and X. It joins the vagus, from which it is functionally indistinguishable (its name: accessory vagus). Some people hold that the muscles of the larynx and pharynx are innervated by the cranial accessory, leaving the vagus ‘proper’ with parasympathetic fibres only, but this is not certain. Clinically, such distinctions are unnecessary in any case, since when something goes wrong, it tends to affect a large area of the brain stem such that X and XI are likely to be affected along with other nerves. This is motor to the muscles bounding the posterior triangle of the neck: sternocleidomastoid and trapezius.

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Because human beings are born in a physiologically immature state and remain helpless for a very long time afterward effective 500mg metformin metabolic disease list, humans are dependent for their survival on the efforts of others buy 500 mg metformin visa blood sugar quit smoking. Until a human being becomes capable of economic independence, togetherness needs remain paramount. This im- balance in favor of togetherness needs leads most individuals to spend the rest of their lives struggling to increase their ability to define a self in re- sponse to the individuality life force. For this reason, much of Bowen ther- apy focuses on increasing the power of the individuality life force in the process of self-definition. However, the goal of this emphasis on individual- ity is to achieve a more equal balance between the two life forces, not to em- phasize the individuality life force at the expense of the togetherness force. One side of the scale repre- sents individuality needs, the other togetherness needs. Until adolescence or early adulthood, the scale is severely weighted toward the togetherness force. Each of us is strongly influenced by what our family and friends think are the appropriate ways to organize our lives, regardless of our personal preferences. An individual could spend the rest of her life trying to develop an authentic self that was not unduly influenced by the desires of her family, and never quite achieve an equal balance between the two sides of the scale. Bowen Family Systems Theory as Feminist Therapy 105 Without a solid grounding in the theoretical relations between the togeth- erness and individuality life forces, a reader could interpret this emphasis on individuality as an emphasis on autonomy and separation. Differentiation of self reflects the ability to define authentic life goals without needing the ap- proval of one’s family, while at the same time remaining in active emotional contact with them. The goal for both men and women would be to define a self that expresses our need for individuality, while at the same time, ac- knowledging our continuing need for togetherness. Thus, the critique that Bowen theory idealizes emotional separateness and masculine gender role values is not accurate. Bowen’s origi- nal theory, in its acceptance of our culture’s binary definition of gender, failed to acknowledge the ways in which this binary system automatically encouraged men and women to give up self. Bowen theory does not acknowledge that husbands and wives have differing amounts of power and therefore differ in their flexibility, both to initiate change and to resist the system’s pressure not to change. It is these two aspects of Bowen theory—its failure to address both the ways in which gender roles encourage women and men to give up self and the inequalities between men and women within patriarchal culture—that limit its sensi- tivity to feminist goals. Traditional gender roles can be seen as examples of cultural prescriptions that are transmitted unconsciously through the multigenerational transmis- sion process. The traditional feminine gender role prescribes that women be- come facilitating environments for others, rather than defining and pursuing personal goals that are not related to family roles. A woman can now have per- sonal goals, primarily work-related goals, but if she is a wife and mother, she still must remain a facilitating environment for her husband and children. Masculine gender role prescriptions socialize men to focus on achieve- ment in the world of paid employment and to deny their need for intimacy and closeness. The more modern masculine role prescribes that men must be nurturing fathers, even while they remain the primary providers for their families. However, this continuing focus on economic provision keeps men away from their families and makes intimate relationships with their children exceedingly difficult. It is especially interesting that Bowen did not understand the function of gender roles in family systems, because he was extremely clear about the 106 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES function of sibling positions. Bowen integrated Walter Toman’s (1961) re- search on sibling position into family systems theory. Toman suggested that certain fixed personality characteristics were determined by an indi- vidual’s place in the sibling configuration of their family. For example, Toman found that oldest children tend to be overly responsible, naturally accepting responsibility for what needs to be done. A youngest child, in contrast, tends to assume that others will get things done and that he will be taken care of. The concept of functioning sibling position predicted that people from different classes, races, and cultures would have certain personality char- acteristics in common if they shared the same sibling position within their families of origin. Family systems theory assumes that as long as one indi- vidual performs certain functions, other individuals will not perform those functions.

In no other industry do parties who are not the end user exert such an influence on the process (see Box 2 discount 500 mg metformin with amex diabetes urination. Referral relationships as used here include any Importance of mechanism for the steering of consumers by a third party into the dis- Referral tribution channels of a healthcare organization or any use of an inter- Relationships mediary to promote goods and services to healthcare consumers cheap metformin 500 mg on-line diabete type 3. The importance of such relationships in healthcare is reflected by the fact that the end users of health services frequently do not make the consumption decision themselves. The purchase decision may be made by a physician, health plan, or some other party. This means that the marketer is more likely to target physicians, provider networks, health plans, and other gatekeepers that may influence the referral process rather than the end user. A wide range of consumer health products are marketed like any other retail product, and over-the- counter pharmaceuticals are marketed in the same manner as other goods. With the advent of Internet-purchase options, an increasing range of health-related products are offered directly to consumers. Elective procedures are often promoted directly to prospective patients, with the organizations offering them using standard promotional techniques to attract customers. Nevertheless, the bulk of health services utilization is a function of referral rela- tionships and intermediaries. The most entrenched example of this is the requirement of a physician referral for hospital admission. Patients cannot present themselves directly to a hospital for purposes of admission; they must have an admitting physician. Even emer- gency cases require that a physician take responsibility for admitting the patient before he or she will be accepted into the hospital. If a physician does not have admitting priv- ileges at a particular hospital, he or she cannot admit a patient there or treat patients hos- pitalized by other physicians. Other institutions, such as nursing homes and hospices, may depend on referrals from physicians as well. Physicians themselves often depend on referrals from other physicians and, in some cases, health or social service agencies for customers. Medical and surgical spe- The Challenge of Healthcare M arketing 29 Healthcare Products The goods and services that constitute healthcare products are also some- what unique to healthcare. Indeed, even the most common of consumer-oriented healthcare products—pharmaceuticals—must be prescribed by a middleman before they can be acquired and consumed. Instead, they rely on referrals from other physicians who are usually generalists. With most contemporary health insurance arrangements, a referral from a primary care physician to a specialist may be required before the insurer will cover the treatment episode. Depending on their specialty, physi- cians may also depend on referrals from nonphysician providers. Providers such as psy- chologists, optometrists, and chiropractors may make referrals to psychiatrists, ophthalmologists, and neurosurgeons, respectively, if the treatment requirements exceed their capabilities. Mental health centers and social service agencies may be major sources of patients for some specialists, as these agencies represent the front line of contact with many potential patients. Prescription drugs are becoming an increasingly important aspect of patient care, and this area also involves indirect access to the end user. Except in the case of over-the-counter drugs, pharmaceutical companies cannot deal directly with patients. The patient must have a prescription written by a physician to obtain the drug from a pharmacist, and numerous safeguards prevent unauthorized access to prescription drugs. The pharmaceutical company relies on the physician to recommend its brand of drug, and, understandably, the main thrust of pharmaceutical marketing is toward physicians. A final example of the referral process involves the steering of patients on the part of health insurance plans. Whether a plan is offered by a traditional indemnity insurer, health maintenance organization, preferred provider organization, or employer with a self-insured plan, there will virtually always be restrictions placed on providers that can be used.

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The morbidity associated with this procedure is primarily related to the time required (several hours) and complications associated with extensive arterial catheterization and repeated ¯uoroscopy proven metformin 500 mg diabetes definition english. There is signi®cant promise for de- creasing the time for and improving the accuracy of the localization of sensing electrodes by automated analysis of real-time intracatheter or transesophageal ultrasound images buy 500mg metformin free shipping managing type 1 diabetes in pregnancy. Any methodology that can signi®cantly reduce procedure time will reduce associated morbidity; and the improved accuracy of the map- ping should lead to more precise ablation and an improved rate of success. My group is developing a system wherein a static surface model of the target heart chamber is continuously updated from the real-time image stream. A gated 2-D image from an intracatheter, transesophageal, or even hand-held transducer is ®rst spatially registered into its proper position relative to the heart model. The approximate location of the sectional image may be found by spatially tracking the transducer or by assuming it moved very little from its last calculated position. More accurate positional information may be derived by surface-matching contours derived from the image to the 3-D surface of the chamber (36). As patient-speci®c data are accumulated, the static model is locally deformed to better match the real-time data stream while retaining the global shape features that de®ne the chamber. Once an individual image has been localized relative to the cardiac anatomy, any electrodes in the image may be easily referenced to the correct position on the chamber model, and data from that electrode can be accumulated into the electrophysiologic mapping. To minimize the need to move sensing electrodes from place to place in the chamber, Mayo cardiologists have developed ``basket electrodes,' or multi-electrode packages that deploy up to 64 bipolar electrodes on ®ve to eight ¯exible splines that expand to place the electrodes in contact with the chamber wall when released from their sheathing catheter (37). The unique geometry of these baskets make the approximate positions of the elec- trodes easy to identify in registered 2-D images that capture simple landmarks from the basket. Cardiac electrophysiology displayed on left ventricle viewed from (A) outside and (B) inside the left ventricle. Most of the techniques are used for the management of pain and include deep nerve regional anesthesiology procedures. The process of resident training involves a detailed study of the anatomy associated with the nerve plexus to be anesthesitzed, including cadavaric studies and practice needle insertions in cadavers. Because images in anatomy books are 2-D, only when the resident examines a cadaver do the 3-D anatomic relationships become clear. In addi- tion, practice needle insertions are costly because of the use of cadavers and limited by the lack of physiology. To address these issues, my group has been developing an anesthesiology training system in our laboratory in close coop- eration with anesthesiology clinicians (38). A variety of anatomic structures were identi®ed and segmented from CT and cryosection datasets. The segmented structures were subsequently tiled to create models used as the basis of the training system. Because the system was designed with the patient in mind, it is not limited to using the Visible Human Anatomy. Patient scan datasets may be used to provide patient-speci®c anatomy for the simulation, giving the system a large library of patients, perhaps with di¨erent or interest- ing anatomy useful for training purposes. This capability also has the added bene®t of allowing clinicians to plan, rehearse, and practice procedures on dif- ®cult or unique anatomy before operating on the patient. At the least complex, the anatomy relevant to anesthesiologic procedures may be studied from a schematic standpoint, i. These views are quite ¯exible and can be con®gured to include a variety of anatomical structures; each structure can be presented in any color, with various shading options and with di¨erent degrees of transparency. Virtual patient for anesthesiology simulator with needle in position for celiac block. Simulation of a realistic procedure is provided through an immersive environ- ment created through the use of a head-tracking system, HMD, needle tracking system, and haptic feedback. The resident enters an immersive environment that provides sensory input for the visual and tactile systems. As the resident moves around the virtual operating theater, the head-tracking system relays viewing parameters to the graphics computer, which generates the new viewing position to the HMD. For more than a decade, these capabilities have provided scientists, physicians, and surgeons with power- ful and ¯exible computational support for basic biologic studies and for medical diagnosis and treatment.

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This opened the door for market research and the emergence of profes- sional marketers to exploit consumer desires metformin 500mg discount diabetes mellitus type 2 hormones. These new market-driven firms adopted an outside-in way of thinking that considers service delivery from the point of view of the customer discount metformin 500 mg free shipping diabetes symptoms feet and ankles. 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. Pharmaceutical companies, consumer-product vendors, and health plans The History of M arketing in Healthcare 7 have a long history of marketing activities; indeed, some of these organi- zations devote an inordinate proportion of their budgets to marketing. These types of organizations are addressed throughout this book, although the emphasis is on marketing on the part of healthcare providers. While marketing was noticeably absent from the functions of most healthcare providers until the 1980s, precursors to marketing had long been established. Every hospital and many other healthcare organizations had well-established public relations (PR) functions. PR involved dissem- inating information concerning the organization and announcing new developments (e. They disseminated press releases, responded to requests for information, and served as the interface with the press should some negative event occur. Large provider organizations also typically had communication func- tions, although they were often carried out under the auspices of the PR department. Communications staff would develop materials for dissemi- nation to the public and the employees of the organization. Internal (and, later, patient-oriented) newsletters and patient-education materials were frequently developed by communications staff. Some of the larger organizations (and certainly the major retail firms and professional associations) established government-relations offices. These staff members were responsible for tracking regulatory and legisla- tive activities that might affect the organization. They served as the inter- face with government officials and provided lobbying efforts as appropriate. The government-relations office frequently became involved in certificate- of-need activities. This function has historically been critical for many health- care organizations because of the constant pressure on not-for-profit healthcare organizations to justify their tax-exempt status. In addition to these formal precursors of marketing, healthcare organ- izations of all types were involved in informal marketing activities to a cer- tain extent. This occurred when hospitals sponsored health education seminars, held an open house for a new facility, or supported a community event. Hospitals marketed by making their facilities available to the com- munity for public meetings and by otherwise attempting to be good cor- porate citizens. Physicians marketed themselves through networking with their colleagues at the country club or medical-society–sponsored events. They sent letters of appreciation to referring physicians and provided serv- ices to high school athletic teams. Ultimately, low-budget PR departments were transformed into mul- timillion-dollar marketing programs.

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