Describe and evaluate two treatments of unipolar depression Essay Example for Free

Describe and evaluate two treatments of unipolar depression Essay Describe and evaluate two treatments for unipolar depression (25 marks). It has been believed that psychological disorders, like physical illnesses, have organic causes. Therefore, mental disorders are treated just like physical ones. Earlier treatments have included things like trepanning which was carried out in the stone again. Nowadays we have much safer and effective treatments such as therapies and drug treatment. Low levels of both noradrenaline (nora) and serotonin (sero) have been found as being important in unipolar depression (UD) and so it seems logical to treat depression with drugs which increase the availability of these neurotransmitters. Tricyclic, a type of anti-depressant, appears to work by blocking the reuptake of nora and sero. They block the transport route that would normally allow these neurotransmitters to be taken back into the pre-synaptic neurones. This means that nora and sero remain in the synapse longer which leads to an increase in the synaptic activity in the neurones. This helps the transmission of impulses to neurones which use up nora and sero. Another type of drug treatment is the use of selective serotonin reuptake inhibitors (SSRIs). SSRIs work in a similar way to tricyclics but affect only the levels of serotonin in the synapses. In order to make efficient use of the body’s resources there is a system whereby serotonin isn’t wasted in the synapse but ‘taken back’ by the pre-synaptic neuron. If this mechanism is impaired by using inhibitor drugs then the sero which isn’t received by the post-synaptic neuron remains in the synapse. This extends the duration of the message being transmitted and/or increases the message intensity. Both SSRIs and tricyclics reduce the symptoms of depression and improves mood. However, these drug treatments don’t always work. The success rate for them is around 60% but it varies from person to person, as do the side effects. There is, however, many different types of drug and each may have a  different success rate. It must be remembered that the ‘success’ of drug treatments for one person may be seen as something completely different to another. Kirsch et al collected data for the licensing of four new-generation anti-depressants. These were all SSRIs. A meta-analysis was carried out comparing the improvements seen in patients taking SSRIs with the improvements in control patients who had received placebos. They found that there was ‘no difference at moderate levels of initial depression’ between the improvements of those receiving SSRIs and those receiving placebos. This shows that the placebo appeared to benefit moderately depressed individuals. This could be due to the sufferers being presented with hope of reducing their symptoms. This contrasts with the results found of severely depressed groups who experienced lessened symptoms, which discredits the placebo effect. It could be argued that the drug itself may have a ‘placebo effect’ where a person feels that they are getting better because they are taking a pill, no matter what the pill is. It could be that the person is helping themselves and the drug is simply supplying the idea that they’re getting better when it does nothing to them. Geller et al found that double blind studies showed anti-depressants to be more effective than placebos for children and adolescents. This could be because there are differences in development between children’s and adult’s brains concerning their neurochemistry. Therefore, children and teenagers may not need to use chemistry altering drugs and could just take a placebo instead as they seen to work better than anti-depressants. Furthermore, Ferguson et al found that those treated with SSRIs were twice more likely to attempted suicide than those treated with a placebo. However, a later review found that a higher risk of suicide was amongst adolescents and decreased amongst adults. This supports Geller’s theory that SSRIs are more effective on adults than adolescents, reinforcing Geller’s view. Drugs have been found to be appropriate and effective at preventing relapse and giving the sufferer a good quality of life meaning they can integrate  back into society and return to everyday tasks. Alternatively, research such as Kirsch, Geller and Ferguson is based on correlational studies. This makes it difficult to say whether UD is caused by low levels of neurotransmitters or if it’s visa-versa. Cognitive behavioural therapy (CBT) is a therapy which treats depression by combining both cognitive and behavioural techniques. The aim of this is to help people who have mental disorders to cope better with their lives and coincidentally feel better. Ellis suggests that depression is due to irrational beliefs but is also maintained by reinforcement. Rational Emotive Behavioural therapy (REBT) aims to replace self-defeating beliefs with adaptive beliefs and uses the ABC model. An example of this is a student getting a good grade for their essay. This is the ‘activating’ of an event. How the person interprets an event or situation is where the ‘belief system’ comes in. The emotional response is then observed which is the ‘consequence’ of the action is. The aim of REBT is to develop a ‘D’ aspect adding a ‘dispute system’ to replace B, adding an adaptive belief, so the person realises they do not have to be perfect. The therapist will ‘test’ patient’s beliefs with actions which challenge their faulty thinking. Often they can be blunt with clients and not show sympathy in order to avoid reinforcing the problem. Cognitive therapy (CT) by Beck involves the use of ‘thought catching’ and ‘behavioural activation’. Thought catching involves the observation of client’s thinking and see how their thoughts influence their feelings. This brings around the realisation that even though their thoughts can seem factual, they are often not. Behavioural activation is where the client is encourage to find activities they might enjoy and put themselves in a position where they may have to deal with ‘cognitive obstacles’ so they can see that they are getting better whilst being active. Butler et al looked at a meta-analyse of the effectiveness of CBT in the treatment of a variety of conditions and found it was ‘somewhat superior to anti-depressants in the treatment of adult depression’. This shows that CBT  is highly effective for treating UD as supporting evidence was found across an entire range of data, making the results more reliable due to the large amount of information covered. However, Holmes reported that in ‘the single largest study’ of treatments for depression, CBT appeared to be less effective than other psychotherapies and drug treatments. It was also pointed out that evidence for the effectiveness of CBT comes from studies of patients who have depression but no other symptoms. This suggests that CBT may be less effective for people who have multiple diagnoses or are considered to have comorbidity. It may be that CBT’s nature is to only focus on one mental illness due to how quick it is compared to other treatments for mental health disorders and therefore isn’t able to relieve all. In conclusion, the diathesis-stress model would suggest that someone is born with a predisposition for UD but something from their environment must trigger it in order for them to suffer from it. Therefore it makes sense that a physiological treatment such as drug therapy should be used alongside a psychological therapy such as REBT in order to ensure that the treatment does in fact work as Holmes’, Geller’s and Ferguson’s research has shown it may not.

The Impact Of Advertising On Consumer Price Sensitivity Marketing Essay

The Impact Of Advertising On Consumer Price Sensitivity Marketing Essay Selling things are the focus of any business and to sell a product marketing is a key factor and main step to make people buy the product. In addition, the foremost thing under marketing is advertising, which is the only way with which you can change the perspective of the product in peoples mind. It is actually a form of communication intended to persuade and audience (viewers, listeners or readers) to purchase the product. The intention of actually enlightening on advertising is to know whether advertising has any impact on consumer price sensitivity or not. It does affect the consumer and their buying behavior but to what extent what are the variables and how this is effecting consumers sensitivity toward purchasing a certain product is been elaborated below. H0: Advertising Have an Impact on Willingness to Pay by a Consumer It is relevant to my article because of using demand curve to gather the impacts of advertising on consumer price sensitivity. In this paper The Impact of Advertising on Consumer Price Sensitivity in Experienced Goods Markets written by Tullen Erdem, Michael Keane, Baohong Son (2007), four categories of consumer goods are considered to examine how TV advertising and other marketing activities affect the demand curve facing a brand. Advertising affects consumer demand in many different ways. The authors observed in this article, that advertising is a reason to fall consumers price sensitivity for a particular brand. To understand how advertising effects price sensitivity one needs to estimate how it shifts the shape of the demand curve, which means estimating a demand system for all brands. Estimation of demand among four products, resulting one had a different response in WTP and that is because of focusing on one distinctive feature of the product. The effects of advertising on the shape of the demand curve depend on vertically or horizontally differentiated (attributes) of the product. Advertising stresses on vertical (claims marginal consumers) and horizontal characteristics (a brand perceived as having an advantage) will increase WTP most for those infra-marginal consumers. A supermarket scanner data used on four product categories to examine how advertising use experience, price, promotional activity in the determination of demand. Advertising affect the price elasticity of demand in two different ways: Firstly, advertising affect the limits of the demand functions of individual consumers more or less price sensitive, secondly advertising may affect the number of the set of consumers. The toothpaste and toothbrush panels cover 157 weeks including households in Chicago and Atlanta while ketchup and detergent panels cover 130 weeks included households in Sioux Falls, South Dakota and Springfield. Weekly advertising intensity measures gross saving points for each brand in the market and 60% of households linked to TV ads for last 51 weeks restricted only who bought 3 times over the period. The toothpaste panel contains 345 households who made 2880 purchases, toothbrush panel contains 167 households who made 621 purchases; detergent panels contains 581 households who made 3419 purchase and ketchup panel contains 135 households who made 1045 purchases. Advertising provides more soft information in the ketchup category (differentiated horizontally e.g. thickness in Heinz) and more hard information (vertically differentiated like quality, such as cavity fighting power in toothpaste, removal of plaque in toothbrush and cleansing power in detergent) and is obvious that nat ure of ad varies according to product. Advertising is more likely to increase price sensitivity and lead to more pro- competitive effects when the hard information is in advertising (e.g. relative quality information) rather than soft (e.g. image oriented). All products observed by different brands of same category by market share, mean price, ad frequency, display frequency, feature frequency and mean coupon availability. The statistics are in this way that there are three kinds of variables, like percentage of purchases (covers brand loyalty), ad viewing habits, and willingness to pay with reference to prices that offered. For all 18 brands, advertising reduces price sensitive but increases the prices. Advertising is not profitable because it lowers the elasticity of demand, but lifts the level of demand. The more the noisy signs of product attributes in advertisements have lower variance alternative and have greater WTP while non-risky consumers have higher variance even for the same features. This relates to the view that non-price advertising affect differently due to consumers diverse tastes. Advertising raises the level of demand by increasing the equilibrium price elasticity and decreasing the equilibrium price. Price advertising and non-price advertising affects the demand curves by costs of gaining information related to price, types of consumers and consumers tastes that visits the stores. People who are less sensitive to price are uncertain about attributes. Price advertising affects stores demand curves differently if consumers have different costs of acquiring price information, and differe nt types of consumers visit each store. It means that advertising is complimentary to consumption and is consistent with models where advertising increases WTP for a brand by producing artificial differentiation and conveying information about brand attributes Variables: Brand choice, Information and market power, Quality of the brand, Existence of the brand, Heterogeneity of consumers tastes, Attributes of the brand, Awareness of substitutes, Ad design, Brand differentiation, Barriers to entry and Experience. H0: consumer price sensitivity moderated by brand credibility This article How Advertising Influences Brand Credibility and Consumer Price Sensitivity written by Tulin Erdem, Joffre Swait, Jordan Louviere (2001), connects with my topic in this way that it explains the implication brand credibility of an advertised brand on consumer price sensitivity. Every brand has different affects on consumers on various stages on their decision of choices of a brand. It passes through different utility functions. The paper enlightens the fact, brand effects with information economics depth to analyze whether consumer price sensitivity, consumer valuation of a products overall attractiveness or utility, has an impact by brand credibility, after making a choice of a brand by advertising. The impact of brand credibility on consumer price sensitivity across class that absorbs different levels of consumer ambiguity, four different types of products utility analyzed which are Frozen concentrated juice (Dole, Minute Maid, Sunkist, Tropicana and Welshs); Jeans (Cal vin Klein, Gap, Lee, Levis, Wranglers); Shampoos (Clairol, Herbal Essence, Pantene Pro- V, Pert Plus, Salon Selective) and Personal computers (Apple, Compaq, Dell, Gateway, IBM) Two types of data relevant the hypothesis; firstly, confirmatory factor analysis (CFA) to obtain brand credibility of the most advertised brands at individual level in each of the four categories; and secondly, by price manipulations of the same brand to know the credibility. Subjects rated all five brands individually to estimate the credibility by them and completed a simple pricing choice experiment involving 17 choice sets in each of two product categories in addition to this, there was a distracter task that includes questions regarding their personal values to minimize the chances of linking two tasks. These four products chosen subjects could relate to them. They asked to assess how confident they would feel measuring new products in 21 different product categories before trial, after one trial and after a year of use (using 7- point agree/disagree scales) These results suggested that, as a group, the subjects viewed frozen juice concentrate more as a search good, jeans and shampoo as more short- to medium-term experience goods, and a PC as a longer-term experience good. Subjects in the pre-test (n = 31), main and supplementary (n = 170) surveys were undergraduate students at two major North American universities. Final sample sizes for the main survey were, respectively, 221, 232, 217 and 198 for juice, jeans, shampoo and PCs. The main survey took approximately 35-40 minutes to complete. Brand credibility decreases price sensitivity but the intensity of the consumers choices differs with products. The emphasis is on the product category factors that could affect the impact of brand credibility on price sensitivity. Consumer characteristics also might determine the level of impact of brand credibility and price sensitivity. Observed results suggest that the interaction between brand price and credibility is heterogeneous, which suggests that it is likely to be associated with consumer specific characteristics and the level of advertisement occur in certain period. These types differ in consumer uncertainty about product attributes plus in specific features in categories that affect sensitivity to uncertainty. It argues on the impact of price on consumption of a credible brand when there is asymmetric information through advertising. Economic framework suggests that brand credibility moderates price sensitivity under uncertainty. In high latent risk and high involvement categories, in which consumer purchase decisions may be quite complicated, the predicted effect was bigger. Price effects strongly recommend that credibility offer number of consumer benefits, which decreases price sensitivity. Variables: Brand credibility (trustworthiness, expertise, usage), Brand choice, Product category, Product attributes, Brand name and Consumer benefits. H0: online medium effects consumer price sensitivity more than offline medium To see the impact of online advertisement on advertising price sensitivity is the reason behind choosing this article. According to article The online medium and consumer price sensitivity written by Venkatesh Shankar, Arvind Rangaswamy, Michael Pusater (1999), paper explains a logical framework regarding the assumption that internet increases price sensitivity and intensify price competition and factors characterizing the online medium, consumers and intermediaries to explain the main reasonable effects of the online medium in price sensitivity. The articles inspect two main aspects of price sensitivity, the intensity of customer attaches to price relative to other attributes (Price importance and price search). About 1/4th of revenues in online shopping industry come from travel services, data set 1comprises of both medium but specified only to Marriott international and a same with data set 2 for making different hotel reservation but for any hotel chose by the respondent with same questionnaires. They asked questions regarding most recent online reservation and most recent offline reservations. Investigation in data set 1extends from the brand level to the product category level and overcomes problems due to self- selection bias in data set 1, to reduce impartiality, the differences in the frequency of shopping between the samples accounted for analysis. For data set 1 primary data collected for the customers of Marriott international and comparing the attitudes and behavior demographically to the population that differ in the medium usage, examine the online medium moderation on price sensitivity and lastly stresses the effects of website factors on price sensitivity. For offline medium consumers questionnaires mailed to customers through Marriott international customers data while for online customers, the survey posted on Marriotts website with a new tag. Only 214 form online and 306 from offline usable recipients (15%) enabled to respond. Data set 2 had to go through a test provided by hospitality sales and marketing association international and customers chose on the basis of using both online and offline medium, Receiving 144 responses from a sample of 2000 customers randomly selected from the list, who chose hotel both online and offline (a response rate of 7.2%) Talking about online medium factors interactivity and perceived depth of the message helps dampen price importance but at the same time ease of price search increases price importance, content and information interactivity does not give any significant result. Using an intermediary and product/price bundling increases price comparison and price importance. Brand loyalty and time value reduces online price search. Looking at offline medium, the perceived range of option does not diminish price importance or price search; but price search reduce because of product/price bundling by an intermediary. Price comparisons using intermediaries has a much stronger impact on price search offline than online. For both sets, the result is consistent as the online and offline models are similar. Online medium effects price importance more because Highlights the range of product options and price bundling by an intermediary to diminish the price importance then it put emphasis on brand loyalty which decreases price search and the effect of price comparison by an intermediary and lastly it is easier to search for price information which reduces the search cost and time as well. Price/product bundling proves to be a strategic advantage for the firms, more online than offline. The price comparison using intermediaries will be more beneficial if online intermediaries are used and provide proper service/ good description with prices and get it linked to the other sites as well. Variables: Price search, Price importance, Price information, Non-pricing advertising, Web-site design, Targeting distribution, Brand loyalty, value of time, frequency of shopping, Alliance strategies, Online attributes price importance influence by medium- product category, demographics. H0: Advertising Effects Evaluates In Three-Dimensional Space of Product (Experience, Affect, Cognition) This paper named How Advertising Works written Demetrios Vakratsas, Tim Ambler (1999) by related to my topic in this way that it talks about the impacts of advertising on consumers which helps observe what features of ads influences consumer behavior or changing their buying behavior. The authors gather the information about how advertising affects the consumer. Advertising effects classified into intermediate effects, for example, on consumer beliefs and attitudes, and behavioral effects, which relate to purchasing behavior, for example, on brand choice. The authors propose that advertising effects studied in a space, with affect, cognition, and experience as the three dimensions. The EAC Space adjusted according to the context: product category, competitive environment, other marketing mix components, stage of the product life cycle, and target audience. The article has reviewed former research of intermediate and behavioral effects of advertising using models from market response. Advertising can be estimate in a three-dimensional space using the dimensions of experience, affect, and cognition (the EAC Space). The coordinates of the three dimensions can verify the importance of a specific advertising promotion. The article have classified and reconsider preceding research of intermediate and behavioral effects of advertising using a arrangement of models preliminary from market response and ending with integrative and nonhierarchical models. The principal overview concerned the persuasive hierarchy (CA) category of models of advertising effects. Although such models dynamically engaged for 100 years but still flawed on two bases: the concept of hierarchy on which its origin cannot empirically sustained, and have eliminated experience effects. The article suggest that behavioral (brand choice, market share) and cognitive and affective (beliefs, attitudes, awareness) directed industry to analyze the edge of context, intermediate effects, and long- and short-term behavior. In this attempt, determination of affective reactions from cognitive partiality evaluated and this is especially important for low-involvement products for which habit and affect are much more important than cognition. On the contrary, it is safe to say that effects of advertising can calculated by (EAC) space of any product but the dimensions can vary from product to product and hence the importance of dimensions as well. Variables: Consumers beliefs, Consumers attitudes, Purchasing behavior, Brand choice, Ads goal diversity, Product category, Competition, Stage of product cycle, Target market, Market share and Awareness H0: Price Advertising Positioning Tactics Increases Brand Equity, Price Importance and Consumer Price Sensitivity H1: Non-Price Advertising Positioning Tactics Decreases Brand Equity, Price Importance and Consumer Price Sensitivity The article The impact of advertising positioning strategies on consumer price sensitivity written by Ajay Kalra and Ronald C. Goodstein (1998) examines the relationship of brands positioning strategies through advertising with consumer price sensitivity. The authors examine the link between advertising and price effects and that this bond depends on the definite advertising positioning strategies. The advertising has different objective, depending on the competitive perspective of the brand and others positioned to narrow the supposed difference between brands. The authors recognize that price- oriented advertising raises sensitivity while non-price oriented advertising decreases sensitivity. Non-price advertising examines two tactics that fail to increase brand price equity: value-oriented positioning, attribute (meaningless) differentiation, while comparative tactics increase price importance and sensitivity at the category level. In addition, findings bring about that advertising effectiveness measured at both the brand and category levels. The hypothesis tested in two experiments transversely different product categories, entailing that advertising effectiveness must extend other than brand rate related to attitude. Testing of how non-price advertising positioning strategies affect brand equity, price importance, and category price sensitivity. Opposing to the accepted vision, numerous types of non-price positioning tactics can diminish equity and increase price sensitivity. Ninety graduate students at a major west coast university volunteered to contribute in experiment carry out in one of four experimental surroundings and as an incentive for $100 lottery given. They asked to analyze a rough advertisement for a new product and under high-involvement, circumstances and advertising positioning varied without the alteration in the brand attribute information in the advertising copy. The experiment designed within one factor and four level of advertisement positioning. An advertisement can have particularly dissimilar effects at each level like at comparative level will be beneficial for minor brands but not for premium brands, because it will increase price sensitivity for whole product category. The results also suggest that brand equity and advertising effects must assess in terms of both attitudes and behavioral manifestation. Pricing effects happen because of advertising, when attitudes extracted from the analysis. Nevertheless, the case is different in low involvement where meaningless attribute positioning and celebrity endorsements could significantly affect brand equity and category price sensitivity. Emotional appeals and fear appeals as attitudinal effects also influence advertisements in a cognitive manner. On this note, the conclusion made that non-price advertising positioning strategies affect brand equity, price importance, and price sensitivity and promotional price advertising increases price sensitivity, whereas non-price advertising decreases price sensitivity. Several types of non-price positioning tactics can decrease equity and increase price sensitivity and brand equity measures extend beyond attitudes and include the ability to demand a premium price. Variables: Advertising- positioning strategies, Brand equity, Celebrity endorses positioning, Meaningless attribute differentiation, unique features positioning, Brand comparison and Value positioning H0: Price Sensitivity is Measureable The paper Price Sensitivity Measurement written by Robert C. Lewis and Stowe Shoemaker (1997) elaborates on the measurement of price sensitivity through hospitality industry, to see the determinants of price sensitivity are the reason of choosing this article. Instead of using price methods on trial basis and error to determine the right price for products or services, a hotel or restaurant operator can use a relatively simple survey tool to measure customers price sensitivity. The prices for services faces at least three complicating factors: Customers often have inaccurate or limited reference prices (i.e. right prices) for services, they use price as a key signal for quality and monetary price is the only cost for service customers. Reference prices have complicated the different needs of customers in two ways: The interpretation of price (value based) on the buyers view and the relationship between price and value. A price sensitivity measurement determines how consumers percepti ons of the value affected by the interaction of price and quantity. A study conducted in which consumers asked to state the highest and lowest prices to which they purchase selected inexpensive items, showed that price act as a quality indication but not an absolute barrier to purchase. Actually, the price sensitivity measurement examines price perceptions by determining levels of customers resistance as they relate to perceived quality and the market range of acceptable prices for a specific product or services. Authors examined the application of the price sensitivity measurement model (PSM) to the association meeting market. The five components of our hypothesis are as follows: firstly, a point at which hotel room rates considered cheap or expensive; the price considered too cheap and quality questioned; no matter what the quality and price is, it is too expensive and purchase is beyond consideration and lastly a way to measure the above points. In addition, these are the questions to analyze the value of a product or service. The last two questions are actually to measure the optimal price point. Room rates are a definite factor in the meeting planners purchase decision. The hypothetical situation considered was to plan an annual convention for organization to hold in Des Monte with expected attendance of 300- 500 attendance, which will last four days, and hosted in first class hotel. Rooms single occupied and participants will stay at the same hotel and the chosen (four) hotels without a ny prior experience. Final decision based on four questions and the design made with two objectives in mind: to minimize the intervening variables that might enter into the situation, thereby affecting their respondents and expect respondents to projects their associations needs and into the situation. Survey to send to a random sample of 443 association-meeting planners and received 115 usable responses (constituting 33% response rate). The study has indicated the existence of a range of acceptable prices for meeting planners. it can be helpful in determining to compare the perception of specific brands, the competition and variables within a product line. The result showed that the price sensitivity measurement technique could most likely apply to the hotel industry though there is no basis for interpreting the results. It could give the indifferent point, an indifference percentage, and an optimum pricing point, a stress level and a range of acceptable prices on lodging industry benchmarks with which to compare those values. In addition, the conclusion made that some meeting planners have in mind threshold prices outside of which price will inhibit their decisions to purchase. The degree to which they are price sensitive (respondents) is difficult to determine. Variables: Quality, Product features, and consumers perception of value H0: An increase in non-price advertising leads to lower price sensitivity among consumers H1: The use of price advertising leads to lower prices H2: An increase in price advertising leads to higher price sensitivity among consumers The paper Empirical Generalizations about the Impact of Advertising on Price Sensitivity and Pricewritten by Anil Kaul and Dick R. Wittink (1995), is linked to my topic in this way that this paper have made generalization statements which works as a medium for measuring the impact of advertising on consumer price sensitivity. The term empirical generalizations suggest the same results comes out in different circumstances and are gathered on outcomes from varied marketing strategies and the result will help estimating the price insensitivities and making a strategic decision about market segmentation, price-marketing activities and competitive market strategies. Two types of advertising are Non-price advertising (national advertising) gives the information about the brand positioning and its intentions to communicate about the characteristics (unique) of the brand and Price advertising (local characteristics) gives the information related to price and availability of the brand. A chan ge in price sensitivity is measured either by Researchers employing experiments (interaction between advertising and price) or by econometric researchers (use price elasticity). It generates a set of three empirical generalizations after studying the previous marketing methods: The approach is to analyze the characteristics and results of previous studies providing explanations on the relevance of these generalizations means the relationship between advertising and price sensitivity observed by an overview of 18 studies. The observations made from a large set of products e.g., new products, mature products, consumer (non-durables) and durables, services with identification the type of product, the number of brands, the type of advertising, the measure of advertising and price sensitivity, and the type of interaction (result). Three implications considered to assess the link between advertising and price sensitivity: Firstly, the difference between price sensitivity of current consumers from additional consumers attracted by increased advertising. Secondly, the measurement of price sensitivity whether aggregate (price elasticity) or disaggregate (brand choice to price) data. Third consideration is about target market. If market were highly price-sensitive, t hen the ceiling effect would be a partial effect of price advertising on sensitivity but if it is of price-insensitive, non-price advertising will slightly influence the price receptiveness. The results specify that in nine studies price sensitivity increases with higher advertising, in seven studies it decreases with higher advertising, and in two cases both effects are attained. Considering only those cases where at least three studies have provided the same result. Focus is on the area of price advertising as moderators such as market share, similarity of brands characteristics or benefits, product life cycle, and the number of competitors, in affecting this relationship and is large enough to alter the brand choice. Moreover, creates variation on price sensitivity due to increase advertising from 20% to 180%. Considering this fact that product-related and other factors that affect the amount of change in price sensitivity in such situations, the conclusion is that non-price advertising reduces the price sensitivity( accepts H0 ) and falsifies H1 and H2. Variables: Brand positioning, Product information, Product differentiation, Brand loyalty, Brand choice, Product market level, Type of product (new products, mature products, consumer nondurables and durables, services), Advertising content, Market share, Similarity of brands characteristics or benefits, Product life cycle and Number of competitors. H0: Advertising Builds Market Power Similar to above article this article Price Sensitivity and Television Exposures written by Vinay Kanetkar, Charles B. Weinberg, Doyle L. Weiss (1992) elaborates the contradictory findings with regard to increases in brand advertising activities lead to increase /decrease in price sensitivity. Mentioning the lack of data to measure the revelation of ones households to advertisements and to restrain competitive activities has been a major limitation to date. This paper finds in high-level of publicity of the product, house- holds brands choice and price sensitivity can decrease for two frequently purchased products though it says that increased advertising linked with increase households brand choice and price sensitivity as well. For a number of decades researchers have been attempting to understand the impact of marketing mix variables (price and advertising) on sales (or market share) of purchased goods. However, the interaction of price and advertising has not completely measured. Set of models designed to examine the effects of advertisings on price sensitivity. Dry dog food accounts for about 60% of total consumer expenditures and eighteen of the 39 brands have large differences in advertising intensity with only one brand had a market share greater than 10%, there were 186 unique brand available to consumers. Because of so many brand choices, minor brands combined into aggregate brand categories. In addition, brand-sizes ignored for three reasons. First, television advertising focuses on brand benefits and does not deal with package size. Second, the package size decision is likely, not a purchase-to-purchase decision. Finally, for the sample households, more than 70% of the dog food purchases were for a package size of five pounds. To reduce the number of alternatives to a manageable size, brands grouped into aggregate categories according to the size of their market share of 5% and brands advertised and not advertised, so the number of alternative comes down to 11. All brands attributes compared to each other as alternative of others. A similar procedure applied to the aluminum foil data. The aluminum foil market (in the test city) was aggregated to consist of three brands or choice alternatives, one major brand, private brands, and generic brands. Only the major brand advertised on television and the results were similar of that dog food. The results are steady with the point of view that increased advertising is associated with increased brand choice and price sensitivity. In light of the effect of advertising on sales, several points noted. Firstly, the purchases vary in buying behavior of households and reflect only short run effects for advertising and the other mix variables. Price sensitivity effects are generally short-lived. In addition, results show that the indirect effects of advertising have an important effect on price sensitivity; usually that the immediate impact of advertising is still low as compared to that of other variables. In turn, the hypothesis is constant with the confirmation that the information conveyed to consumers may not be underpinned the distinct traits and attributes of a brand. Rather, advertising may be increasing consumers brand awareness, strengthen resemblance with other brands, and increasing price competition at the retail level. The interpretation of this means that good advertising that builds market power is difficult to develop and maintain. Variables: Brand choice, Market share, preferred brands, Direct competition, Awareness among consumers, Search costs, Brand equity, Display activities, and Brand loyalty. H0: Advertising diminishes the effect of Consumer Price Sensitivity The article The Effects of Advertising on Co

Treating Long Head of Biceps (LHB) Pathology

Treating Long Head of Biceps (LHB) Pathology Abstract Background Clinical examination of the shoulder joint has gained attention in recent years as clinicians aim to practice with an evidence-based and accurate clinical examination of the biceps tendon. There is an increased desire for proper diagnosis while simultaneously minimizing costly imaging procedures and unnecessary procedures. Thus, the purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing and subsequently treating long head of biceps (LHB) pathology. Methods A literature review of level one and two diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of Pubmed, Medline, Ovid and Cochrane Review databases. Tests were combined in series and parallel to determine final sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pre-test probability. The gold-standard for diagnosis in all studies included was arthroscopy or arthrotomy. Results Seven studies regarding LHB clinical diagnostic testing met inclusion criteria. The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test; adding a third test decreases accuracy. Conclusion Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting. Level of Evidence: II Systematic Review and Meta-Analysis Key Words: biceps tendon; long head; physical examination; pathology; diagnosis; shoulder examination Introduction The physical examination is a requisite and inexpensive component to medical diagnosis. The shoulder examination, in particular, encompasses a myriad of special provocative maneuvers, displaying a wide range of sensitivities and specificities pertaining to diagnostic accuracy. Accurate understanding from the correct sequence of maneuvers or tests increases diagnostic yield. In the modern era, clinical diagnosis heavily relies on imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), arthrography, and arthroscopy to diagnose shoulder pathology21,33. Current gold standard diagnostic testing options have limitations. MRI has poor statistical characteristics for diagnostic accuracy as it very reader and technician dependent, adds both direct and indirect costs, and may be less accurate than the physical exam37. Diagnostic arthroscopy is successful in diagnosing intra-articular pathology, but is limited in visualization for extra-articular pathology, is costly, and increases patient risk37. Increased use of diagnostic imaging contributes to rising health care costs14,30,32,38. According to the Centers for Medicare and Medicaid Services (CMS), diagnostic imaging costs are significant, accounting for up to 40% of overall healthcare expenditure increases over the past 10 years25. Advanced imaging techniques res ult in not only higher direct costs, but may increase indirect costs and jeopardize outcomes36,39. As the healthcare landscape transitions to cost minimization and value-based healthcare delivery, the development of an efficient, cost-effective, shoulder examination is desired. Shoulder examinations have poor sensitivity and/or specificity that makes diagnosing certain pathologies difficult4,28,30,33. Thus, evaluating the long head of the biceps brachii tendon (LHB) pathology with high-yield examination maneuvers can aid physicians through increasing the accuracy of shoulder diagnoses and aid in surgical decision making. Previously published studies focused on the following questions: whether physical examination special tests correlate with surgical findings; whether imaging correlates with surgical findings; and whether physical exam tests are accurate enough to diagnose pathology effectively5,9,10,26,28,29,33. Currently, there is a need to develop new algorithms to provide shoulder practitioners with a practical but comprehensive evidence-based approach to diagnose LHB pathology during an office visit and to further reduce the need for diagnostic imaging20,22,34. The purpose of this study was to perform a systematic review and a secondary sensitivity analysis based on pre-formed likelihood scenarios based on the history of present illness (HPI) past medical history (PMH), and epidemiology to provide clinicians a practical, evidence-based clinical (P.E.C) physical examination algorithm to accurately diagnose patients with LHB pathology. Specific objectives were to: compile the peak performing physical exam tests extracted from level I and II studies within the English literature; synthesizing the most accurate test combination; develop a clinical algorithm to provide quantify LHB diagnostic accuracy; and create a diagnostic accuracy reference guide. Materials and Methods A systematic literature review with the terms proximal, biceps, clinical and examination in the Medline database through the Pubmed, Medline, Ovid and Cochrane Review databases was completed in May 2015. The searches included the use of Boolean operators such as AND and OR. The databases were scrutinized independently by three authors. Inclusion criteria included studies that were focused on physical examination tests and compared to the diagnostic gold standard from Level I and II studies published in scientific journals. Exclusion criteria were: non-English, non-full text, level III of evidence or lower, related to superior labrum anterior to posterior (SLAP) lesions, investigated rheumatoid arthritis patients, or did not compare tests to a validated gold standard. The validated gold standard utilized for all studies and systematic reviews included were diagnostic arthroscopy or arthrotomy to confirm anatomical findings. Relevant studies were independently assessed, and conflicting studies were included only if there were consensus amongst the authors. References of included studies were additionally evaluated to identify additional articles for inclusion. Applicable data was extracted by reverse calculation where the information desired was not directly stated. Using PRISMA guidelines for systematic reviews (Fig. 1), our original search retrieved 2,086 studies from Pubmed, Medline, Ovid and Cochrane Review databases. Twenty-eight additional records were included through a review of references from each article included in the systematic review. After duplicates were removed, the initial search yielded 2,112 studies. Subsequently, 1,689 studies were removed for irrelevant titles or abstracts, and an additional 362 were excluded because they were not in English. Lastly, the remaining 63 articles were assessed for eligibility; 14 were excluded for non-full text, 22 were excluded for not being level I or II study, and 18 were excluded for non-relevant data. The data extracted was summarized and analyzed according to the statistical methods described by Eusebi et al. focusing on test specificity, sensitivity, positive predictive value and negative predictive value12. Next, clinical tests were combined to assess improved diagnostic accuracy. The clinical tests were applied both in parallel and in series. The first approach in parallel analysis, consists of two special tests performed in theory at approximately the same time. The parallel analysis can interpret the findings in an and or or technique. When a parallel analysis is performed in an or technique, the overall sensitivity of the two tests is greater than the sensitivity of either special test alone. This parallel analysis allows for two opportunities to observe the potential pathology. If both tests are negative then it is considered a negative finding in the algorithm and rule out the pathology, but if just one of the two special tests is positive then it is not considered a negative result in parallel analysis. The second approach in series analysis, consists of two special tests performed; however, the overall negative or positive finding depends on the outcomes of both special tests. By utilizing two special tests in an and technique in series, the specificity for both tests is higher than for either test alone. If both special tests are positive, then it is considered a positive result. If either special test is negative, then the in series analysis cannot be considered a positive result. In order to calculate the post-test diagnostic probability of LHB diagnosis, we performed calculations for each test with four pre-test probability options. Pre-test probability is defined as the probability of a patient having the target disorder before a diagnostic test result is known. Therefore, pre-test probability is based on patient history, subjective complaints, epidemiologic probability and the medical opinion of the provider ordering the test. The ordinal scale created has four different probabilities: very unlikely 0.2 (20%); unlikely 0.4 (40%); likely 0.6 (60%); and very likely 0.8 (80%). The physical exam test combination with the optimal test performance was identified (named the PEC exam). A decision tree analysis was developed to determine the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A table was created as a simple reference guide to use in the clinical setting. Results The initial electronic database search retrieved 2,112 unique articles, with 28 obtained from a manual search of reference lists. Of these, 2051 studies were found unrelated to the topic of interest based titles and abstract review, resulting in 63 full-text articles evaluated according to selection criteria. Fifty-four articles were excluded for the following: full-text unavailable (N=14), not a Level I/II study (N=22), and irrelevant data after full-text review (N=18). Seven relevant (N = 7) articles were identified through the systematic review and scrutinized (Supplementary Table S1). From the reviewed articles, special tests and modalities evaluated included Speeds, Yergasons, bicipital groove tenderness, uppercut, bear hug, belly press, OBriens, and anesthetic injection. Statistical characteristics for each test are documented in (Supplementary Table S2). The bear hug and uppercut special tests demonstrated the highest sensitivity for the physical examination special maneuvers (79%, 73% respectively), whereas the belly press and Yergasons tests demonstrated the lower spectrum of sensitivity (31%, 41% respectively). The belly press and OBriens special tests demonstrated the highest special test specificities (85%, 84% respectively), whereas the bear hug and bicipital groove tenderness tests showed the lowest specificities (60%, 72% respectively). Diagnostic ultrasound, used as a reference and also included to study as a potential application for in-office point of service testing, demonstrated the highest sensitivity and specificity of all statistical characteris tics revealed through the review (Sensitivity 88%, Specificity 98%). In series and in parallel assessments determined two physical exam tests improved test performance over any single test. Performing more than two physical examination tests decreased diagnostic accuracy. The uppercut test combined with the tenderness to palpation of the LHB test provided the highest physical examination accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3%. We characterize this as the PEC exam. Additional combinations, including diagnostic ultrasound, are reported in (Supplementary Table S3). The uppercut test and diagnostic ultrasound in parallel revealed the highest sensitivity (97%). Each of the Speeds, Yergasons and upper cut tests paired with diagnostic ultrasound all achieved the highest specificity (100%). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability (Fig. 2). A quick reference guide is provided to use in the clinical setting (Fig. 3). Discussion LHB pathology is an increasingly recognized generator of shoulder pain and functional impairment in symptomatic patients. Physicians are faced with diagnostic challenges due to non-specific clinical presentations and lack of direction based on physical exam findings. As such, the purpose of this study was to perform a decision-tree analysis to create a clinical algorithm to diagnose biceps pathology with increased accuracy compared to previously reported diagnostic examinations 8,11,15-17,19,22,24. This was achieved by conducting a systematic literature review including only level I and II studies. Special test sensitivities and specificities were combined in series and parallel. Analysis showed that the uppercut test combined with tenderness to palpation of the LHB within the bicipital groove provided the highest accuracy physical exam tests for diagnosing pathology at the proximal biceps. Application of this PEC exam, coupled with pre-test probability assignments can now provide cl inicians diagnostic confidence in the office. In equivocal cases, point of care ultrasound examination can further improve diagnostic accuracy2,31. Applying the PEC algorithm provides a simple, efficient and reproducible physical examination protocol for shoulder clinicians yielding an accurate diagnosis in the clinic. Now, with the calculated accuracy reference guide available, a clinician may rely on the office-based diagnosis with improved certainty and may consider forgoing advanced imaging, thereby avoiding additional cost, treatment delays and possible patient risk. In order to cover an array of clinical scenarios, we used a pretest probability range of 20-80% at 20% increments according to the likelihood of pathology. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. If the pre-test probability was above 90% or below 10%, we then assume there is no need to perform additional testing with acceptance of a 10% error rate. Combination of physical examination techniques demonstrated that the uppercut test combined with tenderness to palpation of the LHB provided the highest accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3% (Supplementary Table S3). The values of the test used in series and in parallel were definitive and overpowered the value of the pre-test probability assessment in many clinical scenarios. This adds credibility to a reproducible, simplified two-step P.E.C. examination without the need for additional maneuvers to be performed. Furthermore, we feel that the application of the PEC test is generalizable to non-shoulder specialists, facilitating both increased utilization and diagnostic accuracy of LHB disease. Many studies have explored the accuracy of physical examination and special test maneuvers in diagnosing LHB pathology with limited conclusions regarding its efficiency18,22,23,37. However, our study is unique in that it additionally produces a diagnostic tool, both enabling accurate point of care diagnosis of LHB injury and minimizing the need for advanced imaging. The value of the P.E.C. examination corroborates with current clinical recommendations. In 2009, Churgay et al. stated that bicipital groove point tenderness is the most common isolated finding during physical examination of patients with biceps tendinitis, and that ultrasonography is the best modality for evaluating isolated biceps tendinopathy extra-articularly3,6. With regards to diagnostic accuracy and fluidity of exam, our study revealed that the best maneuver combination for diagnosing biceps pathology are the uppercut test and tenderness to palpation. Incidentally, our study has also concluded that use of ultrasound after equivocal physical examination findings improves the sensitivity and specificity of all evaluated test combinations. Unlike past studies, we incorporated a diagnostic algorithm to aid efficient shoulder examination and to increase physician confidence in biceps tendon diagnosis. In addition to enhancing diagnostic accuracy, development of a value-based clinical decision pathway may play a small, but essential role in the improvement of the current state of the healthcare system. High-yield, algorithm-derived examination like our proposed sequence further alleviate the number of follow-up visits needed until diagnosis, which often delay expedient care delivery35,39. Moreover, simplified diagnostic algorithms may also result in cost reduction and decreased iatrogenic injury associated with unnecessary advanced imaging studies. A shoulder examination that provides accurate diagnosis provides multiple advantages that benefits both physicians and the healthcare system with the ultimate goal of improving patient outcomes. However, it is important to note that clinical decisions should be tailored to patient clinical presentation, and that MRI may be a more appropriate diagnostic modality for surgical candidates or patients with inconclusive preliminary workup. These findings provide evidence towards the current trend in orthopedic surgery education as more national conferences and residency programs are increasing musculoskeletal ultrasound (US) courses incorporated into their curriculums. Accordingly, the American Medical Association for Sports Medicine has endorsed increased integration of sports US into sports medicine fellowship curriculums13. Studies have proposed that proficient level diagnostic skills may be quickly obtained by the inexperienced orthopedist with an established examination protocol1. Murphy et al. conducted a study investigating diagnostic improvement in four orthopedic surgeons who attended a formal training course to identify and size tears on the rotator cuff through US. In the later training period, results showed positive predictive value improving by 16%27. An additional study by Roy and colleagues also demonstrated improved diagnostic accuracy of US irrespective of whether a trained radiologist, sonographer or orthopedic surgeon operated the device32. US requires further studies to evaluate its cost effectiveness compared to advanced imaging techniques like MRI or arthroscopy, but an algorithm(Fig. 3) may provide a simple evidence-based decision analysis for physicians to rely on when considering LHB as the major source of pain. This study, however, also has its limitations. Foremost, a majority of the studies included in our data collection did not solely focus on LHB pathology. True positives may have included superior labrum, anterior to posterior (SLAP) lesions within the diagnosis of biceps pathology. Studies may have also incorporated biceps pathology into other diagnostic categories (e.g. impingement). Therefore, it was difficult to find studies which solely focused on diagnostic accuracy of LHB pathology. Additionally, only level I or II studies were considered for diagnosis, which routinely compare diagnostic testing algorithm (DTA) to the gold standard of diagnosis. Unfortunately, there is no clearly defined arthroscopic findings for diagnosis of LHB pathology. To aid in any study misinterpretations due to inaccurate language translations, only articles originally written in English were evaluated, and only published articles were included. This may have introduced both publication and/or selection bias. A method to eliminate some of these potential biases would be to perform a truly systematic review and meta-analysis combining results from multiple studies; however, even this can be hindered by bias with the lack of currently published methods for meta-analyses evaluating diagnostic testing. Another future direction for this study may be to further evaluate the accuracy of new special tests described to evaluate long head of the biceps pathology, specifically the uppercut test. Currently the uppercut test has only been described and analyzed in a single level I or II study that we utilized for our algorithm24. Further validation testing for this specific test may be warranted. Conclusion Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting. References 1. Amoo-Achampong K, Nwachukwu BU, McCormick F. An orthopedists guide to shoulder ultrasound: a systematic review of examination protocols. Phys Sportsmed. 2016 Aug 22;1-10. doi: 10.1080/00913847.2016.1222224 2. Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR. Shoulder impingement syndrome: relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil. 2006 Jan 1;85(1):53-60. doi:10.1097/01.phm.0000297449.72296.3d 3. Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg. 2006 Jan-Feb;15(1):7-11. doi:10.1016/j.jse.2005.04.008 4. Arrigoni P, Ragone V, DAmbrosi RI, Denard P,Randelli F, Banfi G, et al. Improving the accuracy of the preoperative diagnosis of long head of the biceps pathology: the biceps resisted flexion test. Joints. 2014 Jul 8;2(2):54-8. doi:10.11138/jts/2014.2.2.054 5. Bennett WF. Specificity of the Speeds test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy. 1998 Nov-Dec;14(8):789-96. No doi 6. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009 Sep 1;80(5):470-6. 7. Chu K. An introduction to sensitivity, specificity, predictive values and likelihood ratios. Emergency Medicine Australasia. 1999 Sep 8;11(3):175-81. doi:10.1046/j.1442-2026.1999.00041.x 8. Chen HS, Lin SH, Hsu YH, Chen SC, Kang JH. A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound Med Biol. 2011 Sep 30;37(9):1392-8. doi:10.1016/j.ultrasmedbio.2011.05.842 9. Cohen SB, Valko C, Zoga A, Dodson CC, Ciccotti MG. Posteromedial elbow impingement: magnetic resonance imaging findings in overhead throwing athletes and results of arthroscopic treatment. Arthroscopy. 2011 Oct 31;27(10):1364-70. doi:10.1016/j.arthro.2011.06.012 10. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166. doi:10.3310/hta7290 11. Dubrow SA, Streit JJ, Shishani Y, Robbin MR, Gobezie R. Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI. Open Access J Sports Med. 2014 Apr 28;5:81-7. doi:10.2147/OAJSM.S58225 12. Eusebi P. Diagnostic accuracy measures. Cerebrovasc Dis. 2013 Oct 16;36(4):267-72. doi:10.1159/000353863 13. Finnoff JT, Berkoff D, Brennan F, DiFiori J, Hall MM, Harmon K, et al.. American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Br J Sports Med. 2015 Feb;49(3):145-50. doi:10.1136/bjsports-2014-094220 14. Freeman R, Khanna S, Ricketts D. Inappropriate requests for magnetic resonance scans of the shoulder. Int Orthop. 2013 Nov;37(11):2181-4. doi:10.1007/s00264-013-1968-4 15. Gazzillo GP, Finnoff JT, Hall MM, Sayeed YA, Smith J. Accuracy of palpating the long head of the biceps tendon: an ultrasonographic study. PM R. 2011 Nov;3(11):1035-40. doi:10.1016/j.pmrj.2011.02.022 16. Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. Physical examination for partial tears of the biceps tendon. Am J Sports Med. 2007 Aug;35(8):1334-40. doi:10.1177/0363546507300058 17. Gilmer BB, DeMers AM, Guerrero D, Reid JB, Lubowitz JH, Guttmann D. Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy. 2015 Jan;31(1):29-34. doi:10.1016/j.arthro.2014.07.025 18. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD007427. doi: 10.1002/14651858.CD007427.pub2 19. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011 Oct;20(7):1069-73. doi:10.1016/j.jse.2011.04.004 20. Hegedus EJ. Physical Examination of the Shoulder and Elbow with a Focus on Orthopedic Special Tests. In: Park JY, editor. Sports Injuries to the Shoulder and Elbow. Heidelberg: Springer. 2015. p. 35-44. (ISBN No. 978-3-642-41794-8. doi:10.1007/978-3-642-41795-5 21. Hegedus EJ, Cook C, Lewis J, Wright A, Park JY. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Phys Ther Sport. 2015 May;16(2):87-92. doi:10.1016/j.ptsp.2017.08.001 22. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al.. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78. doi:10.1136/bjsports-2012-091066 23. Jordan RW, Saithna A. Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid. Knee Surg Sports Traumatol Arthrosc. 2015 Nov 26 [Epub ahead of print]. doi:10.1007/s00167-015-3862-7 24. Kibler BW, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009 Sep;37(9):1840-7. doi:10.1177/0363546509332505 25. Health Care Spending and the Medicare Program. Medicare Payment Advisory Commission. Washington DC: 2011. p.1-207. 26. Momenzadeh OR, Gerami MH, Sefidbakht S, Dehghani S. Assessment of correlation between MRI and arthroscopic pathologic findings in the shoulder joint. Arch Bone Jt Surg. 2015 Oct;3(4):286-90. 27. Murphy RJ, Daines MT, Carr AJ, Rees JL. An independent learning method for orthopaedic surgeons performing shoulder ultrasound to identify full-thickness tears of the rotator cuff. J Bone Joint Surg Am. 2013 Feb 6;95(3):266-72. doi:10.2106/JBJS.K.00706 28. Naredo E, Aguado P, De Miguel E, Uson J, Mayordomo L, Gijon-Banos J, et al. Painful shoulder: comparison of physical examination and ultrasonographic findings. Ann Rheum Dis. 2002 Feb;61(2):132-6. doi:10.1136/ard.61.2.132 29. ÃÆ'-stà ¶r AJ, Richards CA, Tytherleigh-Strong G, Bearcroft PW, Prevost AT, Speed CA, et al. Validation of clinical examination versus magnetic resonance imaging and arthroscopy for the detection of rotator cuff lesions. Clin Rheumatol. 2013 Sep;32(9):1283-91. doi:10.1007/s10067-013-2260-0 30. Razmjou H, Fournier-Gosselin S, Christakis M, Pennings A, ElMaraghy A, Holtby R. Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy. J Shoulder Elbow Surg. 2016 Jan;25(1):38-44. doi:10.1016/j.jse.2015.06.020 31. Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg. 1998 May-Jun;7(3):264-71. doi:10.1016/S1058-2746(98)90055-6 32. Roy JS, Braà «n C, Leblond J, Desmeules F, Dionne CE, MacDermid JC, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. Br J Sports Med. 2015 Oct;49(20):1316-28. doi:10.1136/bjsports-2014-094148 33. Sandrey MA. Special physical examination tests for superior labrum anterior-posterior shoulder tears: an examination of clinical usefulness. J Athl Train. 2013 Nov-Dec;48(6):856-8. doi:10.4085/1062-6050-48.3.14 34. Sciascia AD, Spigelman T, Kibler WB, Uhl TL. Frequency of use of clinical shoulder examination tests by experienced shoulder surgeons. J Athl Train. 2012 Jul-Aug;47(4):457-66. doi:10.4085/1062-6050-47.4.09 35. Seagger R, Bunker T, Hamer P. Surgeon-operated ultrasonography in a one-stop shoulder clinic. Ann R Coll Surg Engl. 2011 Oct;93(7):528-31. doi:10.1308/147870811X13137608454939 36. 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Am J Sports Med. 2012 May;40(5):1144-7. doi:10.1177/0363546512436944 Figure and Table Legends Figure 1: PRISMA Systemic Review Flow Diagram: This figure displays the process and rationale behind why studies were omitted from the systemic review. Figure 2: (A) Diagnostic Combination to Rule in Pathology: These findings demonstrate that the combination of tests that best help rule out pathology are the TTP + Uppercut test when performed in series. If both tests are negative in a scenario with a low pre-test probability (i.e. prevalence), then there is a very small chance of pathology being present. TTP = Tenderness to palpation (of the long head of the biceps within the bicipital groove); Diamond = TTP + Uppercut in series, square = TTP + Speeds in Series, triangle = TTP + Yergasons in Series (B) Diagnostic Combination to Rule Out Pathology: These findings demonstrate that the combination of TTP + upper

Immigration Policy :: essays research papers

American Immigration Policy Immigration has held a major role in shaping our country. Immigrants have provided many things such as customs, manufacturing, inventions, and entertainment. Many people today don't realize how greatly we have been affected by immigration. A survey was given to ten people. The survey contained a list of people who were all immigrants. When asked how many actually were, only one person got the question right. Old Immigration occurred between 1840-1890. Immigrants during this time period came from countries such as Ireland, Germany, and Scandinavian countries (Norway, Denmark, Sweden, and Finland). Next came the period of New Immigration. These newcomers came from Italy, Russia, Poland, Lithuania, Greece, Austria, etc., most of whom were peasants who couldn't speak English. The people who migrated during the period of Old Immigration disliked these aliens because it meant lower wages for themselves and the new immigrants had greater advantages including poor and political machines. These people also were not willing to adapt to American ways of life, created their own little towns that resemble their homeland. They were treated as outcasts. New Immigration ended with World War I when the immigrant boats were being sunk. Immigration is still continuing today. Current Immigration includes people from Latin America, the Philippines, and Asia. Laws regarding immigration are constantly changing to fit the needs of society. In 1854, the Know-Nothing Party declared the need for strict limits on Immigration. Members of this party felt it was necessary that immigrants must be residents of the United States for 21 years before being granted citizenship. The campaign ended in 1860 during the time of the Civil War due to the demand of immigrants needed to enlist in the Union Army. Ten years later, the Naturalization Act is passed. This states that only "white persons and persons of African descent, " are able to become citizens. This excludes all Asians. This trend continues for several decades. In 1921, Congress decides to pass immigration restrictions, first establishing a quota of 350,000 immigrants. The quota is increased as times change. In 1995, it was passed that the total number of legal immigrants allowed to enter the United States be limited to 650, 000 a year. Immigrants were given visas, which allowed them to come to this country. Visas were distributed for family and employment-based immigrants, and persons from "adversely affected" countries. Strict regulations have also been made due to the large amount of people entering the country illegally. The nation is on the right track.

A Midsummer Nights Dream by William Shakespeare :: A Midsummer Nights Dream, William Shakespeare

William Shakespeare's A Midsummer Night's Dream is very unique because there is a play within a play. Shakespeare uses the interesting qualities of the characters to narrate the play. The characters can be divided into four groups: The Athenian Court (The Duke, Hippolyta, Egeus, and Philostrate); the young lovers (Hermia, Lysander, Helena, and Demetrius); the fairy kingdom (Oberon, Titania, Puck, and the lesser fairies); and the workmen (Bottom, Quince, Flute, Snout, Starveling, and Snug). The Athenian court is the obvious upper class division of scoiety in Athens. Theseus is head of the Athenian state and his role is to maintain justice. Hippolyta is Theseus's new bride and shows sympathy to the young lovers. Both Theseus and Hippolyta are classified as legendary characters and collectively show their maturity and commitment to marriage. Egeus is a stubborn father whose character loses worth toward the end of the plot, while Philostrate's part is short and undeveloped. Despite being a group, the young lovers are more interesting than the Athenian court. 2 The male young lovers are somewhat similar in qualities. They are young and fall in and out of love quickly. For example Demetrius and Lysander both reject a girl they once loved; they fight over a one girl and then over the other. On the other hand, Hermia and Helena are not as similar because Hermia is short and Helena is tall. These characters are more interesting than the Athenian court because they provide the theme of commitment and being unfaithful. The young lovers are touched by magic by the fairy kingdom members. A member of the fairy kingdom, Oberon is resentful and generous at that the same time. Case in point, Oberon is resentful toward Titania refuses to hand over her boy, and generous in his attempt to make things go well for the the young lovers. Titania is a strong individual and stands up for herself against Oberon. But Titania too also is generous showing love for Bottom. Lastly, Puck is as servant for Oberon and does exactly what he says. Unfortunately he does not do everything correctly. For instance, Oberon requests that Puck use magic on Demetrius to return Helena's love, however he employs the magic upon Lysander instead. Puck means well but isn't necessarily given the respect due to him.

Economic growth and economic development Essay

Like the infrastructure development, improvement of legal mechanism Can now be regarded as the most important precondition for sustainable Growth, a stronger economy, and pro-people system of governance, Writes M S Siddiqui Economic development generally refers to sustained and concerted actions, taken by the policy-makers and communities, which promote the standard of living and economic health of a specific area. Economic development can also refer to as being quantitative and qualitative changes in the economy. Such actions might involve multiple areas including development of human capital, critical infrastructure, regional competitiveness, environmental sustainability, social inclusion, health, safety, literacy, and other initiatives. Economic development differs from economic growth. Whereas economic development is a policy intervention endeavour with aims of economic and social well-being of the people, economic growth is a phenomenon of market productivity and rise in GDP (gross domestic product). According to Amartya Sen, â€Å"economic growth is one aspect of the process of economic development.† Despite the good performance of Bangladesh in terms of many growth indices, it has been lagging behind in building a necessary infrastructure for achieving goals for the country to be treated as a middle-income one. Economic governance embraces all macroeconomic, microeconomic and fiscal policies, public economic agencies, regulatory bodies, company laws and legal institutions connected with economic matters. Good governance means an efficient, open, accountable and audited public service, which has the bureaucratic competence to help design and implement appropriate public policies and, at the same time, an independent judicial system to uphold the law. Good governance is a system of governance that is able to unambiguously identify the basic values of society, where values are economic, political and socio-cultural issues including human rights, and pursue these values through an accountable and honest administration. It is obvious that good governance is a must for the development and growth of a nation. Good governance generally implies a number of institutions, which regulate the behaviour of public bodies, stimulate citizens’ participation in government and control public-private relations. Governance is government plus the private and third (not for profit) sectors. In the 1992 report titled â€Å"Governance and Development†, the World Bank gave its definition of good governance. Good governance is defined as â€Å"the manner in which power is exercised in the management of a country’s economic and social resources for development†. In an October 1995 policy paper called â€Å"Governance: Sound Development Management†, the ADB outlined its policy on this topic. Further, in a separate opinion issued by the ADB General Council, it was explained that governance has at least two dimensions: (a) political (e.g., democracy, human rights); and (b) economic (e.g., efficient management of public resources). The United Nations Development Programme’s (UNDP) definition of good governance is spelled out in a 1997 UNDP policy document titled â€Å"Governance for Sustainable Human Development†. The document states that governance can be seen as the exercise of economic, political and administrative authority to manage a country’s affairs at all levels. The key elements of good governance as defined by UNDP are listed below: Participation: Participation by both men and women is a key cornerstone of good governance. All men and women should have a voice in decision making either directly or through legitimate intermediate institutions that represent their interests. Rule of law: Legal frameworks should be fair and enforced impartially, particularly the laws on human rights. Transparency: Transparency is built on the free flow of information. Processes, institutions and information are directly accessible to those concerned through it, and enough information is provided to understand and monitor them. Responsiveness: Good governance requires that institutions and processes try to serve all stakeholders within a reasonable timeframe. Consensus orientation: There are several actors and as many viewpoints in a given society. Good governance requires mediation of different interests in society to reach a broad consensus on what is in the best interest of the whole community and how this can be achieved. Equity: All men and women have opportunities to improve or maintain their well-being. Effectiveness and efficiency: Good governance means that processes and institutions produce results that meet the needs of society, while making the best use of resources at their disposal. Strategic vision: Leaders and the public have a broad and long-term perspective on good governance and human development, along with a sense of what is needed for such development. There is also an understanding of the historical, cultural and social complexities, in which that perspective is grounded. The rule of law as gauged by the responses to ‘efficient functioning of judiciary’ indicates that most low and middle-income countries rate it as a much higher obstacle than their high-income counterparts. The aggregate average of street crime, organised crime, and corruption are all higher in these countries than in the developed world. There are many problems that come up as barriers to good governance. To ensure sound local development, action should be taken to work towards achieving good governance. The legal policy regime of a country provides base to the potential Foreign Direct Investment (FDI). Unequivocal, neutral legal framework and better protection of property rights can lead to higher FDI. The legal and regulatory environment does matter for financial development. Countries with legal and regulatory systems that give a high priority to creditors receive the full value of their claims on cooperation, have better- functioning financial intermediaries than countries where the legal system provides much weaker support to creditors. Bangladesh is the seventh largest country in the world in terms of its population and now it is treated as ‘N-11’ after the BRICS countries. However, without progress in legal arenas, such as making suitable laws and their appropriate execution, speedy resolution of all corporate and financial disputes, and quick and transparent transfer of properties, some vital sectors of Bangladeshi economy may suffer irreparable loses. Like the infrastructural development, improvement of legal mechanism can now be regarded as the most important precondition for sustainable growth, a stronger economy, and pro-people system of governance. The writer is pursuing PhD at the Open University, Malaysia. shah@banglachemical.com

Scarlet Letter Notes Ch. 8-10

Scarlet Letter Notes American Lit. ACC Per. 1 9/17/11 Chapters 8-10 Plot- (Chapter 8) Hester and Pearl meet Governor and guests. Governor and Wilson call Pearl a child of Satan or sin? Governor wants to remove Pearl from Hester’s care Hester says she can teach Pearl from her mistakes. Wilson questions Pearl regarding Christian faith. Pearl tries to escape through the window and refuses to answer his questions even though she probably would of gotten them right. Pearl announces she was not made but plucked from the rose bush. Wilson states Pearl should not be with HesterHester argues her case but the governor and Wilson don’t listen to her so she goes to Dimmesdale for help. Dimmesdale comes to her aid and argues her case. Succeeds and Minister and Governor rests the case. Pearl shows a sign of love towards Dimmesdale and he kisses her on her brow in return. Chillingworth tries to get the men to look for the father. Men refuse his plan. Governor’s sister invites H ester to witch’s ceremony. Hester refuses (CHAPTER9) Describes Chillingworth. He left behind his entire identity after he found out that his wife committed adultery.He severed all ties with his past life and created a new identity as the town physician. The people like him because of his vast knowledge of herbs and medicine that he learned from being with native Americans for a long time. Treats Reverend Dimmesdale. People start to wonder if Dimmesdale wants to die or something else after he refuses treatment but later on accepts. Chillingworth scrutinizes Dimmesdale’s actions and finds something suspicious in them. The two men reside in the same house so that Chillingworth can take care of him. Dimmesdale has no interest in marrying any of the townswomen.They have live in two completely different kinds of rooms (holy vs. scientific) People start to wonder about the physician and the more they look at him his face becomes more evil and sooty. They began the theory that the physician was sent by the devil and is fighting a war with Dimmesdale making him sick. (CHAPTER10) CHillingworth wants to find out more about Dimmesdale’s background and his story. The men are talking about burying sin and a heart of sin They hear pearl and Hester outside in the graveyard. Pearl runs away telling her mom that the devil has gotten the minister and she dosent want him to get them too.The two men talk and when the minister falls asleep, Chillingworth opens his shirt and finds something on him and rejoices. Setting- Governor Billingham’s Estate- grand estate filled with pictures of the Governor’s ancestors and decorated with medieval things (ex. The armor) Old English castle like. Chillingworth and Dimmesdale’s house- in between the church and the graveyard. Characters- Governor Billingham- old, elderly man who governs the town. Likes Old English things ( his house) John Wilson- strict pastor Hester Prynne- committed adultery and had a b aby, Pearl.Pearl- child of Hester and is accused of being a witch or child of Satan Dimmesdale- town’s reverend, health declining due to pastoral duties Chillingworth- friends with Dimmesdale, been in town for two to three years, physician Conflict- Hester Prynne v. Society- the people want to take away Pearl to educate her in a Christian manner but Hester states that Pearl is better of with her because she can learn from Hester’s mistake. Dimmesdale saves her by arguing her cause. Dimmesdale v Himself: He is described as more ill than before. He keeps his hand to his heart and â€Å"his large dark eyes had a world of pain in heir troubled and melancholy depth† (101). Religion v. Science- There had been many arguments between science and the divine nature. Chillingworth is science driven while Dimmesdale is devoted to God and his religion. This can become a greater conflict later on in the book. Chillingworth v. Dimmesdale- chillingworth is trying to find out th e mystery behind the reverend. Townspeople v. Chillingworth- at first welcome him but then grow weary when his facial features turn evil and deceiving. Symbolism- Pearl- she is a physical representation of the scarlet letter, a constant reminder of Hester’s sin.Saved Hester from becoming a witch after she was granted guardianship of Pearl forever. â€Å"Heavenly Father†- represents the God as the father of everyone and also my theory about Dimmesdale being the father since he is holy and a reverend. The House- it is pretty but it resides on and in between the graveyard and the church kind of like Dimmesdale himself. He is a reverend yet he looks physically dead because of his illness and heartache. Chillingworth- the Devil, from what Hester called him when they talked and what the people and the narrator describe as his changing features (demon-like)