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By U. Marus. Allegheny College.

Bayes’ theorem is based on the concept that the value of the diagnostic tests depends not only on the characteristics of the test (sensitivity and specificity) discount female viagra 100 mg on-line pregnancy kidney pain, but also on the prevalence (pretest proba- bility) of the disease in the test population buy female viagra 100 mg amex women's health center queens ny. As the prevalence of a specific disease decreases, it becomes less likely that someone with a positive test will actually have the disease, and more likely that the positive test result is a false positive. The relationship between the sensitivity and specificity of the test and the prevalence (pretest probability), can be expressed through the use of Bayes’ theorem (see Appendix 2) (10,13) and the likeli- hood ratio. The positive likelihood ratio (PLR) estimates the likelihood that a positive test result will raise or lower the pretest probability, resulting in estimation of the posttest probability [where PLR = sensitivity/(1 - speci- 14 L. The negative likelihood ratio (NLR) estimates the likelihood that a negative test result will raise or lower the pretest probability, resulting in estimation of the posttest probability [where NLR = (1 - sensitivity)/speci- ficity] (40). The likelihood ratio (LR) is not a probability but a ratio of prob- abilities and as such is not intuitively interpretable. The positive predictive value (PPV) refers to the probability that a person with a positive test result actually has the disease. The negative predictive value (NPV) is the prob- ability that a person with a negative test result does not have the disease. Thus, the predictive values are affected by the prevalence of disease in the study population. A practical understanding of this concept is shown in examples 1 and 2 in Appendix 2. If the test information is kept constant (same sensitiv- ity and specificity), the pretest probability (prevalence) affects the posttest probability (predictive value) results. The concept of diagnostic performance discussed above can be summa- rized by incorporating the data from Appendix 2 into a nomogram for interpreting diagnostic test results (Fig. For example, two patients present to the emergency department complaining of left-sided weakness. The treating physician wants to determine if they have a stroke from carotid artery disease. Because of the patient’s young age and chronic history, he was determined clinically to be in a low-risk category for carotid artery disease–induced stroke and hence with a low pretest probability of 0. Conversely, the second patient is 65 years old and is complaining of acute onset of severe left-sided weakness. Because of the patients older age and acute history, he was determined clinically to be in a high-risk category for carotid artery disease–induced stroke and hence with a high pretest probability of 0. The available diagnostic imaging test was unenhanced head and neck CT followed by CT angiog- raphy. According to the radiologist’s available literature, the sensitivity and specificity of these tests for carotid artery disease and stroke were each 0. The positive likelihood ratio (sensitivity/1 - specificity) calculation derived by the radiologist was 0. The posttest probability for the 8-year-old patient is therefore 30% based on a pretest probability of 0. Conversely, the posttest probability for the 65-year-old patient is greater than 0. Clinicians and radiologists can use this scale to understand the probability of disease in different risk groups and for imaging studies with different diagnostic performance. For PLR, tests with values greater than 10 have a large difference between pretest and posttest probability with conclusive diag- nostic impact; values of 5 to 10 have a moderate difference in test proba- Chapter 1 Principles of Evidence-Based Imaging 15 Figure 1. Bayes’ theorem nomogram for determining posttest probability of disease using the pretest probability of disease and the likelihood ratio from the imaging test. Clinical and imaging guidelines are aimed at increasing the pretest probability and likelihood ratio, respectively. The role of the clinical guidelines is to increase the pretest probability by adequately distinguishing low-risk from high-risk groups. The role of imaging guidelines is to increase the likelihood ratio by recommending the diagnostic test with the highest sensitivity and specificity. Comprehensive use of clinical and imaging guidelines will improve the posttest probabil- ity, hence, increasing the diagnostic outcome (9).

A book cannot substitute for a doctor and it is not my intention to diagnose and xii Introduction treat through this book discount female viagra 50 mg without prescription 36 menstrual cycle. I consider it unethical and immoral to hold oneself out as a physician through a book or a videocassette discount female viagra 50mg with mastercard womens health 40. Pain syndromes must always be properly studied to rule out serious disorders such as cancer, tumors, bone disease and many other conditions. If one has persistent pain anywhere, it is imperative to see a doctor so that appropriate examinations and tests can be done. The primary purpose of this book is to raise consciousness both inside and outside the field of medicine, because these common pain syndromes represent a major public health problem that will not be solved until there is a change in the medical perception of their cause. Having stated the purpose of the book, I would be less than candid if I did not report that many readers of its predecessor, Mind Over Back Pain, reported amelioration or complete resolution of symptoms. This substantiates the idea that it is identification with and knowledge of the disorder which are the critical therapeutic factors. Before new concepts can be generally accepted they must be proven beyond all doubt. It is essential that the ideas advanced in this book be subjected to research study. In the tradition of scientific medicine I invite my colleagues to verify or correct my work. What they ought not do is ignore it, for the problem of back pain is too great and the need for a solution imperative. HEALING BACK PAIN 1 The Manifestations of TMS I have never seen a patient with pain in the neck, shoulders, back or buttocks who didn’t believe that the pain was due to an injury, a “hurt” brought on by some physical activity. Of course, if the pain starts while one is engaged in a physical activity it’s difficult not to attribute the pain to the activity. One often hears, “I’m afraid of hurting myself again so I’m going to be very careful of what I do. It has been assumed that 1 2 Healing Back Pain neck, shoulder, back and buttock pain is due to injury or disease of the spine and associated structures or incompetence of muscles and ligaments surrounding these structures—without scientific validation of these diagnostic concepts. On the other hand, I have had gratifying success in the treatment of these disorders for seventeen years based on a very different diagnosis. It has been my observation that the majority of these pain syndromes are the result of a condition in the muscles, nerves, tendons and ligaments brought on by tension. And the point has been proven by the very high rate of success achieved with a treatment program that is simple, rapid and thorough. Medicine’s preoccupation with the spine draws on fundamental medical philosophy and training. The body is viewed as an exceedingly complex machine and illness as a malfunction in the machine brought about by infection, trauma, inherited defects, degeneration and, of course, cancer. At the same time medical science has had a love affair with the laboratory, believing that nothing is valid unless it can be demonstrated in that arena. No one would dispute the essential role the laboratory has played in medical progress (witness penicillin and insulin for example). The emotions do not lend themselves to test tube experiments and measurement and so modern medical science has chosen to ignore them, buttressed by the conviction that emotions have little to do with health and illness anyway. Hence, the majority of practicing physicians do not consider that emotions play a significant role in causing physical disorders, though many would acknowledge that they might aggravate a “physically” caused illness. In general, physicians feel uncomfortable in dealing with a problem that is related to the emotions. They tend to make a sharp division between “the things of the mind” and “the things of the body,” and only feel comfortable with the latter. Although some physicians would dispute the idea, there is fairly wide acceptance among practicing doctors that ulcers are caused primarily by “tension. But failure to treat the primary cause of the disorder is poor medicine; it is symptomatic treatment, something we were warned about in medical school. But since most physicians see their role only as treating the body, the psychological part of the problem is neglected, even though it’s the basic cause. In fairness, some physicians make an attempt to say something about tension, but it’s often of a superficial nature like, “You ought to take it easy; you’re working too hard. In doing so, however, they are chiefly responsible for the pain epidemic that now exists in this country. If structural abnormalities don’t cause pain in the neck, shoulder, back and buttocks, what does?

For example buy female viagra 50 mg with amex menopause yahoo articles from yesterday, in Western culture Life Is A Journey from a source generic female viagra 100mg with visa women's health yearly check up, along a path to a goal. The tale of an illness is often structured as a journey as in the movie A Brief Vacation in which a life transformation is metaphorically structured as a journey in tandem with a literal journey for treatment in a tuberculosis sanatorium. Narratives of medical research are often structured cognitively like hunting trips or searches for buried treasure, to name a couple of the many types of journey which 32 CHAPTER 1 can act as source domains. The histories of medical institutions, organizations and professional specialties are commonly structured on the basis of our understanding of the growth of organisms. One effort to delineate some of many types of narrative structuring of illness is found in Arthur W. He shows that a narrative has historical particularity about it which does not apply to the more generic scenario. The experience of being a patient is generally disruptive, and integrating that experience into the life narrative can be an arduous task. Frank points out both that this task can be approached in a variety of ways and that sometimes illness simply cannot be made to fit in any meaningful story. Many experiences of suffering are belittled by attempts to accord them redeeming value. The life narrative of a person intersects at various points with a career narrative for the caregiver. Careers are often judged by standards which refuse to recognize the particularities of patients encountered. For example, pediatricians may be subjected to audits assessing how well their patients are immunized, how many blood pressures were taken, or whether a particular checkoff list of desiderata was performed at each well child visit. Rigid application of such criteria by any caregiver means that particular concerns are given less attention. People refusing to immunize their children, for instance, could be excluded from the practice. Important individual concerns could be silenced while the physician went on like a tape recorder addressing all the recommendations of the American Academy of Pediatrics. We will look in detail at external, rigid, standards versus mutable ones internal to particular situations and narratives in Chapters Four, Five and Six. The most usual scenario for a clinical encounter is that a patient suffering illness requests relief with the aid of a caregiver. The caregiver makes a diagnosis, prescribes or performs a treatment and if all goes well, the illness is cured and suffering is relieved. The history of symptoms, physical examination, laboratory and other findings result in a diagnosis on the basis of which a treatment course with the best chance of cure or palliation (given the resources available) is under- taken. Such a process is metaphorically understood in terms of a prototypical point to point journey. Whereas in reality there are many kinds of journeys, only one kind has been projected onto clinical problem solving in diagnosis and treatment in American medicine, and that journey has the features of a commute, an ambulance call or a trip across a desert to reach an oasis before the water runs out. This means that the journey projected onto care is only a nuisance, to be dispensed with as far as possible. Of course not all journeys are fire alarms, economy runs, or races wherein efficiency and routine modes of operation are paramount. Its logic can be compared to that of formal proof, in that the shortest compelling argument to a determinate conclusion is analogous to the shortest, fastest and cheapest route to a predetermined destination. But there are also Sunday drives, walks in the country, hunting and gathering outings and other exploratory adventures whose goals are not so well demarcated at the outset. On some journeys, such as quests, we expect the travelers and their values to be transformed, which will also change the idea of a desirable destination. It is possible to reconsider old ends and discover new ones just because the logic of ends and values, like the logic of causation, is embodied and imaginative. It is neither eternally ordered from a transcendent source nor purely capricious and arbitrary.