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By C. Chenor. McMurry University.

The social structure of a society order amoxil 250mg amex treatment for feline uti, along with its cul- tural values purchase amoxil 500 mg mastercard antibiotic resistant uti, establishes the parameters for the healthcare system. In this sense the form and function of the healthcare system reflect the form and function of the society in which it resides. Ultimately, the development of marketing in healthcare (or any industry) reflects the characteristics of both that industry and the society in which it exists. Each of the parts is interconnected either directly or indirectly; thus, all are interdependent with the others. These parts working in concert create a dynamic, self-sus- 51 52 arketing Health Services taining system that maintains a state of equilibrium. The various parts per- form their respective functions, and each component must work in syn- chronization with the others if the system is to function efficiently and, indeed, survive as a system. These major components can be thought of as institutions; rather than being tangible objects, they constitute patterns of behavior directed toward the accomplishment of certain societal goals. Every society must perform the functions of reproducing new soci- ety members; socializing the new members; distributing resources; main- taining internal order; providing for defense; dealing with the supernatural; and, importantly, providing for the health and well-being of its population. Some form of family evolves to manage reproduction; some form of edu- cational system deals with socialization; some form of economic system deals with the allocation of resources; and so forth. A healthcare or social service system of some type evolves to ensure the health and welfare of the population. These social institutions are gradually established through the repeated behavior of individuals attempting to address personal needs within the context of the societal framework. Some institutions, like healthcare, are dependent on a certain level of knowledge, and even technology, to be able to fully develop. The factors that influence the form a particular institution takes include the society’s cultural history, environment, relationships with other societies, and demographic characteristics. Numerous forms can be taken by the family, political institution, and economic institution, with the particular form being uniquely tailored to the situation of that society. Like other institutions, healthcare establishes rules that guide the behavior of individuals within the institutional context. For example, guide- lines are put forth for living a long, healthy life; if citizens do not follow these rules, they risk sickness and death. Thus, all individuals are required to obtain certain childhood immunizations, addicts are forced to enter rehabilitation, and patients with contagious dis- eases are isolated from the rest of the population. On another level, rules state that patients must have insurance before being treated by certain healthcare providers, receive annual checkups to maintain their low insurance premiums, and pay higher prices for insur- ance if they are involved in risky activities. While no systematic plan for encouraging or discouraging the behaviors that support the healthcare sys- tem exists, various parties, appearing to act in their own self-interest, work toward the goals of the healthcare institution through the promulgation of such rules. Adaptability and Change Despite the permanence that institutions achieve in society, they must also have the flexibility to adjust to changing conditions. As will be discussed later, no other institution has experienced such dramatic changes as health- care during the twentieth century. At the start of that century, healthcare was a rudimentary institution with limited visibility and little credibility in society. Hospitals were considered to be places where people went to die, and doctors were to be avoided at all costs. There was no agreement on the nature of health and illness, and scientists were only beginning to document the effectiveness of medical care. Healthcare was not even on the national radar screen for the first half of the twentieth century and accounted for a neg- ligible portion of the gross national product. Contrast that situation to the healthcare institution at the end of the twentieth century. Not only had the institution become well-established in the United States, but it had come to play a dominant role in U. The importance of the institution had become such that sociologists often referred to the medicalization of American society. In the latter half of the twentieth century the institution came to be accorded high prestige and exert a major influence over other insti- tutions.

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In contrast to individual growth activities order 500mg amoxil with visa antibiotics for acne problems, such as individual counseling or therapy safe 250 mg amoxil antibiotic augmentin, PAIRS highlights the importance of the couple as a crucible from which healing, personal growth, and the development of higher capacities can emerge. Thus, sustained intimacy and pleasure are assured and the re- lationship becomes a lasting source of authentic love, mutual respect, and trust between two growing and evolving partners. They acquire mentors, role models, support figures, and (for the younger premarital cou- ples) new surrogate mothers and fathers to support them and reparent them toward successful marriage. Couples considering a second marriage find opportunities to explore what went wrong for each earlier and take re- sponsibility for their part so that the old maladaptive patterns do not reemerge in their new relationship. Many divorced individuals who take PAIRS as singles have vowed never to reenter another relationship until they understand what happened and acquire the skills to assure a different outcome the next time around. PAIRS training provides the strongest op- portunity for the newly committing couple to acquire the skills, concepts, understandings, self-knowledge, and strategies for building deep intimacy and assuring a lasting, healthy marriage. PREVENTIVE MAINTENANCE PROGRAMS At the close of the semester program, participants often wish to continue their group learning and practice in a preventive maintenance format. Requests from class groups often include a desire for periodic weekend workshops, usually once or twice a year. Repeating the Bonding Weekend Workshop is most often requested because it helps to maintain access to the core emotional openness needed for bonding and intimacy. A PAIRS Three-Year Preventive Maintenance Program is under develop- ment for graduates to sustain their strong foundation for loving, healthy marriage and family relationships. This program provides opportunities for those who have had PAIRS experiences (including premarital assess- ment and OFFICE PAIRS) to refresh and practice a wide range of skills, such as the Fair Fight for Change with Peer Coaches, PARTS Parties, Dia- logue Guides, Daily Temperature Readings, and Genograms. Options in this program include continuing monthly three-hour classes, periodic six- month one-session check-ups, and twice-yearly day-long seminars. Based on years of experience conducting PAIRS programs, relationships clearly benefit from a psychoeducational program in knowledge and skills in building and sus- taining intimacy in relationships and this benefit can be sustained with regular preventive support. SUMMARY PAIRS premarital counseling and training offers premarital couples rich resources that will enhance not only their intimate relationship but also en- rich and emotionally deepen their personal and family lives. Research doc- uments that the PAIRS experience results in achieving far higher levels of self-worth, emotional literacy, emotional maturity, and relationship satis- faction. Love and community are well documented to be potent healing powers that create longer, healthier, more joyful lives (Ornish, 1990). This chapter presented premarital assessment, counseling, training sequences, and preventive support from the PAIRS perspective, as applications of a powerful technology for healing, building, strengthening, and sustaining healthy marital and family relationships. The PAIRS technology is available to train counselors and through them their clients in how to build lasting, satisfying, healthy, successful relation- ships. With successful lifelong marriages, there will be healthier children and reduced suffering in successive generations. It is the profound hope of the PAIRS network of leaders and trained professionals that PAIRS, as an educational and counseling resource, will become an essential part of the training for all those who provide therapy, counsel, assist, and train cou- ples, particularly premarital couples. This knowledge base needs to be cul- turally incorporated as a universally expected foundation for every new couple considering a permanent commitment to building a lasting, stable marriage and healthy family life together. Premarital Counseling from the PAIRS Perspective 23 APPENDIX: RESOURCES USED TO DEVELOP PAIRS Adams, T. A time for caring: How to enrich your life through an in- terest and pleasure of others. Satisfaction, couple type, divorce potential, attachment patterns, and romantic and sexual satisfaction of married couples who participated in marriage en- richment program. Building intimate relationships: Bridging treatment, education and enrichment through the pairs program. The use of bonding and emotional expressiveness in the PAIRS training: A psychoeducational approach for couples. A longitudinal evaluation of the effectiveness of the PAIRS psychoeducational program for couples. Not just friends: protect your relationship from infidelity and heal the trauma of betrayal. The dance of intimacy: A woman’s guide to courageous acts of change in key relationship. Mind as healer, mind as slayer: A holistic approach to preventing stress disorders. Pamper your partner: An illustrated guide to soothing and relaxing your mate with the sensual healing arts. Marriage contracts and couples therapy: Hidden forces in intimate re- lationships.

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This technique has failed to improve consistently the accuracy of staging purchase amoxil 250 mg line antibiotics long term, but it is claimed to show enhanced delineation of the prostate capsule (114 purchase 250mg amoxil free shipping antibiotics for mrsa,115), a weak correlation between tumor permeability and MR stage (116), and accuracies of 84% to 97% in detecting specific features of extracapsular extension (117). A novel use of an MR contrast agent was reported for investigating nodes (30); administration of nanoparticles permitted identi- fication of nonenlarged nodes (118) with focal regions of tumor and per- mitted 100% sensitivity in identifying patients with nodal metastases. Investigators have also presented data regarding the ability of MRI find- ings to predict posttherapy PSA failures (106,109,111,119,120) and positive margins in surgical specimens (121). MRI in combination with other data permitted improvements of these prediction rates, but, as in evaluations of its ability to predict exact stage, did not achieve accuracies of 100%. Given the inability of MRI to achieve very high degrees of accuracy among all patients undergoing initial evaluation for prostate cancer, attempts have been made to find some groups in which MRI might be particularly useful. One of these investigations found that if MRI were limited to a subgroup of those with a Gleason score of 5 to 7 and a PSA higher than 10 to 20ng/mL, increased accuracy for both extracapsular extension and seminal vesicle invasion could be achieved (107). Another study investi- gated only the ability of MRI to detect enlarged nodes, and suggested that the examination could be withheld from patients with a serum PSA of less than 20ng/mL (122). In summary, MRI probably permits better local staging than older tech- niques in certain subgroups of patients but with considerably less than 100% accuracy; the inability to detect microscopic invasion remains an important limitation, as does the inability to detect disease in nonenlarged lymph nodes with standard techniques. These facts have led to only cau- Chapter 7 Imaging in the Evaluation of Patients with Prostate Cancer 129 tious and scattered acceptance of the technique. Currently, it is probably wise to restrict its use to a subgroup of patients—those whose physical examination, PSA, Gleason score, results of standard workup for metasta- tic disease, and personal preferences leave them on the cusp of choosing surgery or local radiotherapy. When interpreting examinations in these patients, it should be remembered that diagnosis or exclusion of micro- scopic invasion cannot be performed with accuracy, but that visualization of gross tumor extension beyond the capsule or into the seminal vesicle is a relatively specific sign of invasive disease. Magnetic Resonance Spectroscopic Imaging In addition to high spatial resolution imaging by proton MRI, technology for spatially resolved spectroscopy of the prostate has been under devel- opment for some years. Proton spectroscopic data can be acquired from a three-dimensional array of voxels. These voxels are about two orders of magnitude larger than the voxels used for proton imaging, but can be superimposed on proton MRI maps to permit reasonably accurate spatial identification of the intraprostatic region supplying specific spectra. Spectral analysis relies on the fact that normal prostate tissue and the tissue of benign prostatic hypertrophy secrete relatively large amounts of citrate; prostate adenocarcinoma elaborates much less citrate, but produces a relatively elevated amount of choline; the ratios between the spectral peaks for these molecules are used to distinguish voxels containing neo- plasm from those that do not (123,124). Currently, the potential uses for magnetic resonance spectroscopic imaging (MRSI) of the prostate might be original diagnosis, biopsy guid- ance, local staging, and evaluation of recurrent following local therapy. With regard to diagnosis, several studies have shown that MRSI analy- sis of small groups of patients containing those without tumor and those with tumor can identify and localize tumors with reasonable, if less than perfect, sensitivity and specificity (125–128). But no sufficiently large or sufficiently well-controlled investigation has addressed whether MRSI is effective in screening for disease in a large sample reflecting either the pop- ulation at large or those at increased risk because of an elevated PSA. And given that many prostate tumors are considerably smaller than the MRSI voxels, it is unlikely that sensitivity can ever be very high until consider- able improvements in spatial resolution can be made. Series have been published to investigate whether patients whose prostate biopsies have been negative, even though their elevated PSA levels suggest tumor, might be aided by using MRSI to guide further attempts at biopsy. The data show that biopsies using information from MRI and MRSI converts some of these patients from being false negative (for the original biopsy) to true positive for the MR-guided biopsies, but there are few data to show that adding MRSI information to the MRI infor- mation is of significant benefit in guiding these biopsies (129). Further- more, the studies lack controls to investigate the possibility that the subsequent biopsies might have retrieved tumor tissue even without MR guidance. For patients who have had hormonal therapy (130) or who have had intraprostatic hemorrhage from a recent biopsy, localization of tumor by MRI can be difficult; MRSI may permit tumor identification in these cir- 130 J. Newhouse cumstances (131), however, so if MRI-guided biopsy ever becomes wide- spread, MRSI may be of benefit. There are also series that investigate whether MRSI might improve the accuracy of MRI for prostate staging (130,132). In one, the addition of MRSI data to MRI data enabled inexperienced readers to become as accurate as experienced readers were with MRI alone, but, for experienced readers, MRSI data did not improve accuracy. However, MRSI may help in assess- ing overall tumor volume, which is also a factor in staging. But whether this information actually changes treatment decisions for the better has yet to be investigated. The feasibility of using MRSI to localize prostate cancer in aiding place- ment of radioactive seeds for brachytherapy and adjusting local doses for external beam therapy has been established (133,134). But whether this capacity actually improves outcomes, either in terms of disease control or complication reduction, is not yet known.

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