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Although early experiences of proton therapy in the management of pituitary adenomas date back to the 1950s gastritis diet ëó÷øèå order metoclopramide 10mg, the resources of proton therapy facilities have been relatively scarce because of the complexity and capital cost of these centers gastritis weed best 10 mg metoclopramide. In the last decade gastritis diet suggestions purchase metoclopramide 10 mg, the compelling clinical benefits of proton therapy and the technological advancements of commercial proton therapy units have resulted in a significant rise in proton centers across the United States and the world gastritis diet îäíîêëàñíèêè metoclopramide 10mg. The radiation source is radioactive isotope cobalt-60, which is housed within the machine. Patients are held in place by a metal head frame, and the machinery has the capacity of aiming multiple beams of radiation of defined width at the desired intracranial target. Treatments are typically limited to one visit because the head frame is attached to the scalp with pins that are minimally invasive. Linear accelerator the linear accelerator is the most common form of therapeutic delivery of radiation today. The radiation beam is shaped and attenuated to the desired specification and then directed to the clinical target. These machines have varying degrees of sophistication to ensure accurate set-up and radiation delivery. A few treatment principles have been seen consistently across multiple institutional series. Another consistent observation is that smaller tumors are associated with both higher response to radiation and lower risk of new hypopituitarism, supporting the role for debulking surgery when possible (5, 6, 8 Â11). Nonfunctioning pituitary adenoma Radiation therapy in the management of nonfunctioning adenomas is given adjuvant to subtotal resection or as primary therapy in the setting of surgical inaccessibility, medical inoperability, or by patient choice. From surgical-alone series, the rate of tumor progression or recurrence is approximately 50% for subtotally resected tumors and as high as 10 Â 25% for gross totally resected adenomas at 10 yr (12Â17). Not all series suggest an elevated risk of recurrence of gross totally resected tumors. One prognostic indicator of recurrence may be tumor involvement of the cavernous sinus, which has been associated with tumor progression (12, 16, 18). Partial shrinkage and less commonly complete resolution may occur in approximately two thirds of cases (9, 20) but is secondary in intent. Choice of radiation therapy is dependent upon safety of delivering single fraction radiosurgery. Histological and molecular analyses of tumors such as tumor proliferative index may lead to the ability to predict those tumors most likely to recur and may be useful to guide the choice of adjuvant radiation therapy in the future (30, 31). For fractionated radiation, 45Â 60 Gy is commonly used, with the optimal dose range being 45Â50. Fractionated radiation therapy experiences from multiple series report remission rates of 0 Â 84%, but with a tighter range of 50 Â 80% likely to be more representative of response with modern therapy. It is unclear whether many patients may have been counted multiple times because several studies are from the same institution and may represent updates of prior studies, but the reported rate of response would still be expected to be a good estimate. Remission increases to 65Â 87% at 15 yr, demonstrating that response after radiation may require several years to evolve (Table 3). Again, local tumor control rates are excellent at 95Â100% in most series (Table 3). Prolactinoma Medical therapy is the standard first-line treatment for prolactinomas that are indicated for treatment. Dopamine agonists provide normalization of prolactin levels in 90% of microadenomas and slightly less for macroadenomas (51). Radiation therapy for prolactin-secreting pituitary adenomas First author, year (Ref. Complete normalization with radiation alone occurs in approximately 25Â50% of patients. With the addition of medical therapy, normalization approaches 80 Â 100% of patients over a median time to response between 1 and 10 yr, with higher doses seeming to achieve a faster response (27, 54, 56). Treatment approaches are generally extrapolated from management of other secretory adenomas. This may be the only option if a tumor target is less than 5 mm removed from the chiasm and larger than 3 cm in diameter. Final evaluation and confirmation should be made by a radiation oncologist because the actual determinant is the dose that is delivered to the normal tissues. The reason for the secondary or tertiary use of radiation therapy is largely due to the potential adverse effects of radiation, most of which are not reversible. Because hypopituitarism is a late effect of irradiation that evolves over years from treatment, accurate assessment of its incidence requires many years of follow-up, whereas most published reports average less than 10 yr of follow-up data.
This coed squad of talented kids gastritis all fruit diet buy 10 mg metoclopramide, ages 7-12 gastritis caused by diet order 10 mg metoclopramide, debuted in 2006-07 and was an immediate hit gastritis for dogs cheap 10mg metoclopramide. The group of all-star kids from all over Houston perform hip-hop and novelty dance routines at weekend and special games throughout the year eosinophilic gastritis symptoms proven 10mg metoclopramide. Their energetic performances include tumbling, stunting and break dancing which always bring the crowd to its feet. The Little Dippers love to participate in the Rockets game experience and also perform at community events. Rockets Space City Seniors the Space City Seniors are another great performance group for the Rockets. Consisting of several "young at heart" retirees, these seniors wow Toyota Center crowds on a regular basis with their current and old-school hip hop moves. Sonic Boom Drumline the Sonic Boom Drumline is the newest and loudest Entertainment Group of the Houston Rockets. The Sonic Boom Drumline can be heard performing within the arena during pregame, halftime & postgame, and their on-court performances are loud and entertaining. Anti-Gravity the Rockets Dunk Team, Anti-Gravity, was introduced to Rockets entertainment in 2010. This powerful and explosive group of trampoline dunkers consists of gymnasts and performers who perform during quarter breaks at selective home games. They bring the energy and never cease to amaze the fans of Toyota Center with their one-of-a-kind acrobatic dunks. The Clutch City Foundation serves as the umbrella organization for all Rockets community initiatives. Through the foundation, Rockets players, coaches and staff participate in a myriad of programs for those who are in need; especially children. Since its inception, the Clutch Foundation has raised over $15 million for those in need here in Houston and throughout the world. Rockets Give Back Program Houston Rockets and Toyota Center employees take part in the Rockets Give Back Program by volunteering with our community partners. Last season, over 1,200 volunteer hours were spent serving homeless families, assisting in food pantries, delivering meals to children, providing gifts for children during the holidays, playing basketball and video games with youth Â just to name a few projects. Hoops for Troops Each season, Rockets players, legends and members of the military host a joint community service project that benefits a local non-profit. A Season of Giving During the holiday season, Rockets players, coaches and staff host a series of events for members of the community who are less fortunate. Each year, hundreds of children and their families are the recipients of private parties, gifts and surprise visits by players. Heroes Program Presented by Bowen, Miclette & Britt and Burns & McDonnell During the season, the Rockets recognize men and women who commit their lives to serving others. The Heroes Program honors members of the armed forces, police and fire departments, and people from all walks of life who contribute to make Houston a world-class city. Honorees and their guests are hosted in the Heroes Suite during the game and are recognized on-court for their contributions. In Arena 50/50 Raffle the Rockets are excited to host the 50/50 Raffle for the second consecutive year. Implemented at every home game during the regular season, as well as playoffs, last year the 50-50 raffle raised $628,000. Again this season, one lucky fan will win 50% of net proceeds raised each night, with the other 50% going to the Clutch City Foundation. First Shot Prior to every home game, a featured celebrity or local personality is given the opportunity to shoot one free throw, with a made attempt earning $5,000 for the Clutch City Foundation. Patriot Day of Service Each year on Patriots Day, the Rockets host a companywide service initiative to mark the heroic sacrifices made by first responders on September 11. Rockets players, executive team, and more than 100 staff honor members of the Houston Police Department and Houston Fire Departments by personally visiting each location. As a show of gratitude and appreciation, the group delivers tickets and t-shirts to each of the police and fire stations. From camps, to clinics, to leagues, hundreds of children each year enroll in Rockets year-round grassroots basketball programs.
These apparent incongruities arise because strategy formulation is not undertaken by rational decision-makers gastritis diet äîì trusted metoclopramide 10mg, but by managers who socially construct reality helping to create their managerial vision gastritis workup 10mg metoclopramide. Furthermore diet gastritis erosif quality 10 mg metoclopramide, complex relationships between the internal configuration of organisational strategies and structures have been considered in terms of how these meet variable external influences gastritis diet äîì2 quality 10mg metoclopramide. Throughout, the prescriptive and conceptual nature of much of the work in this field was highlighted as detrimental to the theoretical robustness of the models and their utility in practice. Equally, the under-specification of national institutional factors in combination with strategic issues was evident. However, these issues tend to be considered in relative isolation from each other. However, the two approaches should not be seen as being in opposition to each other; they are appropriate, in effect, for answering different parts of the same basic question as to how firms with employees in more than one country coordinate their human resource management systems. One weakness of the models available is that national contextual factors, while acknowledged, are not fully explained. One useful starting point here is the,Ð”Ñ‚four influences,Ð”Ñ„ model elaborated by Edwards and Ferner (2000). It should be noted, however, that the twin policies of,Ð”Ñ‚lifetime,Ð”Ñ„ employment and seniority-based pay and promotion, seen as cornerstones of the domestic Japanese system, have not been transferred to foreign environments. Second, economic dominance has been illustrated recently in widespread attempts at the diffusion of,Ð”Ñ‚Japanese,Ð”Ñ„ forms of work organisation in the 1980s and 1990s. Whatever the source of,Ð”Ñ‚dominance,Ð”Ñ„ is, the management methods of that country may become seen as a cross-national,Ð”Ñ‚best way,Ð”Ñ„. In the 1980s and 1990s, the widespread debate on,Ð”Ñ‚global Japanisation,Ð”Ñ„ (Oliver and Wilkinson, 1992) arose not merely because of investment by Japanese firms in the West, but mostly because of the attempts made by Western firms to copy such enterprises. The demands for integration and the mechanisms adopted have been addressed at length above. Integration applies not only when there is substantial intra-corporate trade, but also where customers themselves are large multinationals which desire commonality of service provision worldwide, as discussed in Prahalad and Doz,Ð”Ñ„s I,Ð”Ð¼R grid. Corporations also display a tendency to attempt integration in order to mitigate the inevitable problems of controlling subsidiary behaviour. This may be achieved through attempts to impose uniformity of vision around a,Ð”Ñ‚corporate culture,Ð”Ñ„, as well as through formal rules and/or financial controls. Carrying out production or service provision abroad will involve employing workers and managers from the host country. On the other, the firm will have to obey the legal and collective employment regulations of the home country, with inevitable effects on the conduct of employment relations and human resource management. Meanwhile, it is important to recognise that host country regulations and historically embedded features of business systems can provide,Ð”Ñ‚foreign,Ð”Ñ„ firms with resources, as well as the more widely recognised constraints. However, it provides an attempt to bring together work from two divergent fields of study, namely institutional and strategic. It is clear that national business systems, and elements within them, do not exist independently of global economic dynamics; they must react to global pressures within the international economic system. Does this mean that countries facing similar pressures are likely to react in similar ways, however? Evidence from recent history would tend to show that significant global pressures and structural crises during the past century,Ð”Ð¼ such as the Second World War, the collapse of fixed exchange rates and the postwar economic order centred around the dollar, the oil and commodities crises of the 1970s and 1980s, the Kuwait crisis, and the emergence of new economic powers such as Japan and the East Asian,Ð”Ñ‚tiger,Ð”Ñ„ economies,Ð”Ð¼ were managed in nationally specific ways. The comparative approach to the analysis of business systems and associated institutional characteristics such as the management of human resources examines how global pressures for and processes of economic and political change are filtered, mediated and structured in nationally specific ways. It is frequently argued that economic,Ð”Ñ‚globalisation,Ð”Ñ„, however defined, is a major contributory factor to the pressures being faced in recent years by the more densely institutionalised business and employment systems. The argument is that the recent increase in global forms of competition is likely to lead to ,Ð”Ñ‚convergence,Ð”Ñ„ in human resource practices across the world, such that employment policy and practice throughout the (developed? To this will be added policies, such as employee involvement, and company-specific training programmes, believed, from the experience of competition with Japan, to boost productivity and performance. We have seen, for example, that there is evidence of performance-related elements in pay packages becoming a more prominent feature in the German and Japanese systems than previously. However, there remain several grounds on which assumptions of convergence can be challenged.
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Of course gastritis cronica cheap 10 mg metoclopramide, this is a challenge in itself because in what circumstances do you apply one criterion and not the other? A woman applies for a job as an adviser selling financial products in a company that is dominated by men gastritis fish oil safe metoclopramide 10 mg. Scenario 1: she has the same qualifications and experience as male applicants gastritis ginger generic 10mg metoclopramide, but the all-male selection panel might reject her because they consider that she would not gastritis symptoms at night best 10 mg metoclopramide,Ð”Ñ‚fit in,Ð”Ñ„ with the competitive, aggressive culture of the organisation. Sameness Guiding principle: Equal treatment Difference Collectivist strand Guiding principle: Special treatment according to social group membership Individualist strand Guiding principle: Special treatment according to individual needs Scenario 2: she has the same qualifications as male applicants but has taken a career break for childcare purposes. The selection panel reject her because compared with men of the same age she has less work experience. In the first scenario the panel are rejecting her by using the criterion of difference (recognising gender); in the second by using the criterion of sameness (ignoring gender). But if the panel were to reverse their logic of difference and sameness, it might lead them to different conclusions. In the first scenario, if the panel ignored gender, they would arrive at the conclusion that she was appointable. In the second scenario, if they recognised that, because of her gender, she has had extra domestic commitments so cannot be compared with men of the same age, then again they might conclude she is appointable. This illustrates that managers have a key role in dealing with disadvantage because they determine the criteria and define the circumstances in which sameness and difference are either recognised or ignored. Institutional discrimination One of the key issues that managers must face is whether their organisation operates in ways that are fundamentally discriminatory. This is sometimes referred to as institutional racism, institutional sexism, institutional homophobia and so on. The term means that rather than discrimination being seen simply as the actions of individuals, it is deeprooted in the processes and culture of the organisation. Examples of processes that are sometimes described as evidence of institutional discrimination are:,ÑƒÐ¸,ÑƒÐ¸,ÑƒÐ¸,ÑƒÐ¸,ÑƒÐ¸,ÑƒÐ¸ word-of-mouth methods for recruitment; dress codes that prevent people practising their religious beliefs; promotions based on informal recommendations, rather than open competition; informal assessments rather than formal appraisals; assumptions about training capabilities; assumptions about language difficulties and attitudes. Institutional discrimination 249 Often these types of processes are not recognised as being discriminatory and have been in operation for many years. It is only when a company is faced with a legal challenge that such practices are seen to be having a discriminatory impact. Managers should regularly scrutinise organisational procedures, and the use of data collected through equal opportunity monitoring can be particularly effective in highlighting areas where the processes might be disadvantaging particular groups. Most of its employees are sewing machine operators (all women) who assemble the garments. It has a stable core workforce, but there is fluctuation in demand for its products, so extra employees are brought in when the order books are full and,Ð”Ñ‚let go,Ð”Ñ„ at slack periods. When managers need to recruit extra employees, or when they need to replace someone, they rely on word-of-mouth methods. When likely candidates are identified their names are given to the factory manager. If he approves them he asks the supervisor to check if the candidate has the required sewing skills. Just as pernicious are workplace cultures that have the effect of excluding people from particular social groups by making them feel unwelcome or uncomfortable. This is a key issue for managers because organisations might have cultures that are long established and deeply embedded. An interesting review of the way organisational cultures can marginalise social groups is provided by Kirton and Greene (2000: 76,Ð”Ð¼93). Most notable among their conclusions are the following points: Organisational cultures are infused with gendered meanings, which are often unarticulated and thus rendered invisible. The gendered hierarchy is an example, as are various unwritten codes, rules, customs and habits which guide gendered behaviour and underpin expectations of organisational members. Even when institutional discrimination has been identified, there is no incentive to make changes because those people in positions of influence have benefited (and continue to benefit) from the system.
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