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While formulaic protocols and decision trees have "decision nodes trusted 125mg sinemet symptoms 4 days after conception," these are only metaphoric forks in the shortest roads to fixed ends order sinemet 110 mg free shipping medicine 657. At such nodes, alternatives are excluded in a compulsory fashion depending on particular prescribed inputs. We have seen detailed reasons in the previous chapters why informal means/ends reasoning is different. Adapting to fluid contexts, it takes account of the non- classical internal structure of categories as well as their vague, shifting and overlapping boundaries. It selects metaphors for causation judged appropriate to the circumstances, rather than using only the billiard-ball model. It considers what level of causation to address, recognizing that proximate causation at the level of middle sized objects is only one among many types predisposing to an event. Such reasoning can conceptualize the pursuit of ends in terms of progeneration, nurtu- rance, adventure, exploration, acquisition and so forth; not merely as a journey with only cost and length needing to be minimized. Compared to formal procedures moving from concrete "facts" to fully known goals, informal reasoning looks differently at ends. Then intermediate motivators ("ends-in-view") can be sought, and roundabout approaches taken, to valued but not yet sufficiently desired long-term ends. Means, despised in theory, turn out in practice to have their own great satisfac- tions. Value of whatever kind is often recognized by informal means/ends reasoning FULL SPECTRUM MEANS AND ENDS REASONING 155 to be spread out over endeavor, not simply concentrated at its terminus. Furthermore, specific values attain their significance not by themselves, but in relation to one another. Informal reason considers the effects of harmony and disharmony on the mutual enhancement of particular ends. Instead of the "decision nodes" in algorithms, informal reasoning centers on what I will call "foci for judgment. They are locations of meaning in a metaphorical "cognitive space," not points in physical space or time. Inputs to and outputs from such foci of deliberation potentially come from and go out to all of experience; past, present and future. At these foci, interacting facts and values are brought to bear on problems of action, always with one eye open for novel possibilities. Many matters for judgment have emerged in the previous chapters, and I will not try to review all of them here. There could be no exhaustive list, considering all the surprises that experience has yet to reveal. But, to recapitulate and offer illustrations, I offer some of the important foci of judgment here. Judgments About the Setting In the example of medicine, clinical judgment takes account of and depends on the setting. When the setting is accustomed and stable, few decisions related to it are needed. It makes an obvious difference whether care is occurring on the street, in a clinic or in the hospital. It makes an obvious difference whether one is working in a tent near battle lines, an impoverished clinic in Afghanistan, a rural area or an inner city, a helicopter or the intensive care unit of a university hospital. The availability of resources including information, specialty care, medication, equipment and transport has to be taken into account in deciding what to do. Disasters call for triage, shortages for substitutions, threats for security measures, epidemics for higher indices of suspicion. Regarding diagnosis, the Bayesian concept of "prior probability" is all about assessing the setting. For example, in a college health setting working with generally healthy young adults, very few laboratory tests are likely to turn up positive diagnostic results. The sensible practitioner learns in this setting to be very conser- vative about conducting "fishing expeditions" for pathology. But in an emergency department used by many old and/or very ill people, the yield of positive and significant results on extensive testing is generally much higher. In this setting, it is proper to conduct much more aggressive diagnostic testing lest something important be missed. A sense of what is likely to be found, or researched data on "prior probability" if available, affects the chance that specific investigations will make a difference.

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DICOM also provides a means by which users of imaging equipment may assess whether two devices claiming conformance will be able to exchange meaningful information buy sinemet 300 mg line medications pancreatitis. The future ad- ditions to DICOM include support for creation of ®les on removable media (such as optical disks or high-capacity magnetic tape) purchase sinemet 125 mg without a prescription medications and mothers milk 2016, new data structures for x-ray angiography, and extended hard copy print management. The derived medical data will be the subsequent diagnosis and in various formats, including text. The reconstructed medical data will consist of, for example, computer-generated models. The raw medical data will be stored in DICOM picture archiving and communication system (PACS) and multimedia databases in multimedia RIS and hospital information system (HIS) databases. The unique property of the WWW is that it provides a uniform meta-operating system, allowing computer platforms of various top- ologies to communicate. With the introduction of Java and Java script, it is now possible to run the same application programs (applets) on di¨erent com- puting platforms without any porting problems (Fig. Based on this meth- odology, the accessibility of patient information is reduced to the notion of navigating or sur®ng the Web. There are currently a number of software pro- viders o¨ering WWW DICOM interfaces for archiving stores. One system, implemented at the University of Joensuu within the framework of EUROMED project (58). To use the WWW DICOM system, the user ®rst runs a WWW browser (Mosaic, Netscape,orLynx) and speci®es a URL on one of DICOM PACS Unix workstations. The query form contains a number of ®elds, such as patient name and medical record number. The user may specify any or all ®elds and can use wildcards in ®elds such as the name ®eld. The HTML form submits the query to a common gateway interface (CGI) program, which executes on the DICOM PACS server. It then communicates with the archive via DICOM to determine patients who match the search criteria. The user may then choose a patient, which in turn causes the studies for the patient to be displayed. Finally, the user may select a study that causes those images to be retrieved from the archive and be displayed via the Web browser. The result of this system is an easy-to-use interface that is accessible for any Web-supported computing platform to a DICOM PACS with the option to query and move images from the PACS. Alternative public DICOM implementations can be found at the Pennsyn- valnia State University, the University of Oldenburg, and the Mallinckrodt Institute of Radiology (the premier of publicly available DICOM implementa- tions). There are also a number of hospitals currently using WWW browsers to access a DICOM PACS system. One such implementation is at the Medical Imaging Unit Center of Medical Informatics, Geneva University Hospital, where the conventional PACS environment was replaced by a prototype of the WWW browser that directly triggers a speci®c program for displaying medical images from a conventional Netscape or Mosaic browser. A specially designed interface written in HTML can be used from any conventional WWW browser or any platform. Accessing a DICOM PACS through a Web interface is one aspect of a newly emerging telemedical information society. There are, however, many other as- pects that need to be considered, for example, locating the text data and visu- alization data. The development of a global telemedical information society should not be allowed to develop in an ad hoc manner. It is the objective of EUROMED (34±36, 50, 59) to standardize the foundational elements of such a society. It is only when all the steps and, therefore building blocks, are put together that a telemedical infor- mation society becomes a realistic possibility. It is, therefore, possible to conceive that everybody will have access to a computer, especially in a working envi- ronment. And everybody will have a unique identiifcation number or URL 70 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY Figure 3. Thus, it is not unrealistic to assume that all medical practitioners will have access to a computer.

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SI’s hamstrings may be trying to control or decelerate the forward jerky motion at the hip (flexion) and knee (extension) cheap 125mg sinemet visa treatment vs cure. The primary role of the hamstrings in normal gait is to stabilise the hip and knee at heel strike purchase sinemet 110mg medications before surgery. Though SI’s adductor longus seems a little dys- phasic (its highest activity level is during late stance, rather than at toe-off), it is the 69 DYNAMICS OF HUMAN GAIT Cerebral palsy adult male 80 60 EMG Right Erector 40 Spinae ( V) 20 0 80 60 EMG Right Gluteus Maximus ( V) 40 Figure 5. Although you have to be careful when comparing activity levels from two muscles in the same person, it is noteworthy that the EMG for a normal man’s tibialis anterior reaches almost 400 µV just after heel strike. In contrast, SI’s tibialis anterior is active throughout most of the gait cycle, but its activity level is amately the CLINICAL GAIT ANALYSIS — A CASE STUDY 70 Cerebral palsy adult male 120 EMG Right Gluteus 80 Medius ( V) 40 0 120 EMG Right 80 Hamstrings ( V) 40 0 60 EMG Right Rectus 40 Femoris ( V) 20 Figure 5. Pre-operatively, the neurophysiologist described this muscle as having “scarce, denervated-type muscle potentials. This point was highlighted with regard to the movement chain described in chapter 1 (cf. Longus ( V) 20 0 400 300 EMG Right Tibialis 200 Anterior ( V) 100 0 200 EMG Right Triceps 150 100 Surae ( V) 50 0 0 20 40 60 80 100 b % Gait Cycle Perhaps the most interesting feature of Figure 5. Although lacking this pushoff function, which is characteristic of normal gait, SI’s triceps surae are active before and after heel strike. Nevertheless, you can recognise SI’s gait without seeing him because you can hear the characteristic slapping sound of his feet. This is almost certainly a result of the weakness in the tibialis anterior and its inability to control the plantar flexion that occurs just after heel strike CLINICAL GAIT ANALYSIS — A CASE STUDY 72 Kinetic Comparisons Figure 5. Perhaps the only real clue that these force patterns are the result of some underlying pathology are the exaggerated dips in the curves during midstance. However, as indicated by Vaughan, du Toit, and Roffey (1987b), this pattern could also be produced by a normal person walking at a fast pace. Cerebral palsy adult male 800 Force Plate 1 FZ (N) 400 0 800 Force Plate 2 FZ (N) 400 Figure 5. Normal adult male 600 400 Force Plate 1 200 FZ (N) 0 -200 600 400 Force Plate 2 200 FZ (N) 0 -200 0. In chapter 1 we stated that gait analysts should try to work as far up the movement chain as possible. We also stressed that the key to understanding a person’s gait is to integrate the actions at different levels: muscular, joint, and kinematic. Notice that the plantar flexion and dorsiflexion angles are very similar; the only difference (and this is slight) is that SI o strikes the ground with his foot in about 10 of plantar flexion, hence the slapping action described earlier. The moments at the ankle joint are remarkably similar, with Cerebral palsy adult male 100 75 EMG Right Triceps 50 Surae ( V) 25 0 90 Joint Dynamics Right 60 Ankle Moment (N. EMG Right Triceps 150 100 Surae ( V) 50 0 90 Joint Dynamics Right 60 Ankle Moment (N. What may at first seem puzzling is this: The plantar flexor moment for SI is at its maximum at the same time that the plantar flexor muscle group, the triceps surae, is almost quiescent. Because of SI’s lurching style of gait, he is able to “throw” his body forward, thus ensuring that the ground reaction force passes in front of his ankle joint. To overcome this action, a plantar flexor moment is generated about the ankle joint. Despite the weakness in the triceps surae, the effect of the arthrodesis is to prevent collapse of the subtalar joint, thus assisting with the produc- tion of a plantar flexor moment. However, on closer examination you will see that in midstance (just before left heel strike), the knee goes into recurvatum (about 10 of extension), the knee momento changes from extension to flexion, and the rectus femoris, a knee extensor, shows its maximum activity. It appears that the knee is compensating in some way for the deficiencies that SI experiences more distally around his ankle joint. With the knee snapping back into hyperextension, the rectus femoris is actively assisting this move- ment, thus endangering the posterior capsule of the knee. When the knee moment is in flexion, the ground reaction force is acting in an anterior direction. This force is trying to push the knee into further hyperextension, and to overcome this tendency, a net flexor moment must be exerted across the joint.

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This means using your muscles for practical discount sinemet 125mg with amex treatment myasthenia gravis, enjoyable activities and planning the use of time accordingly purchase 110mg sinemet overnight delivery medications containing sulfa. For example, difficult activities should be done before those that are easier to perform. The appropriate use 44 CHAPTER 5 • Weakness of assistive devices also may be extremely helpful in increasing overall efficiency. Strength also may be increased with the use of an aero- bic exercise machine such as an exercycle or a rowing machine. However, the principle of not becoming fatigued and exercising those muscles that can be strengthened to compensate for the weaker muscles must be applied. This symptom of MS often is associated with difficulty in bal- ance and coordination. There are many different kinds of tremors; some have wide oscillations (a gross tremor), while others are barely perceptible (a fine tremor); some occur at rest, others occur only with purposeful movement; some are fast, others are slow; some involve the limbs, while others affect the head, trunk, or speech; some are disabling, but others are merely a nuisance; and some are treatable, while some are not. As with all symptoms, proper diagnosis is essential before correct management decisions can be made. BALANCE Balance is necessary to perform coordinated movements, whether one is standing, sitting, or lying down. The cerebellum is the main center for bal- ance, but the eyes, ears, and nerves to the arms and legs also con- tribute to balance. An impairment in any of these areas may cause balance to worsen, and it may help to compensate for others that are 46 CHAPTER 6 • Tremor and Balance The Management of Tremor •Exercises for balance and coordination – patterning –vestibular stimulation – Swiss ball – computerized balance stimulation •Medications • Mechanical approaches –immobilization –weighting –stabilization with braces not working properly. For example, a person with a balance problem caused by poor sensation in the feet may use her eyes to see the ground and avoid falling; obviously, this is a problem in the dark. No medication is available to improve balance, so it is neces- sary to rely on exercises. Although there are no specific exercises for tremor, there are exercises for balance and coordination. Patterning refers to a technique that is used by physical and occu- pational therapists to trace and repeat basic movement patterns. It is based on the theory that certain muscles may be trained to move in a coordinated fashion by repeatedly using the nervous circuit that is involved in a movement. These normal movements are guided and assisted by the therapist until they become automatic. Minor resistance is then added and removed while the patient repeats the pattern independently. The muscles gradually appear to develop increased endurance for these learned movements and manage to retain control when the patterns are applied to func- tional tasks. Vestibular stimulation refers to increasing the amount of stimu- lation received by the balance centers in the brain stem, thus allow- ing the brain to function more normally. The techniques used chal- lenge your sense of balance by rocking, swinging, or spinning, using 47 PART II • Managing MS Symptoms such activities as sitting on a beach ball or swinging in a hammock. This large ball may become part of a balance program designed to stimulate many different balance centers within the body. If a person is able to stand, computerized balance stimulation with a machine dubbed a "balance master" may be helpful. The person stands on a platform that is in contact with a video screen via a computer. Movements of the feet influence the screen much like a video game, and this may be used to teach the person how to achieve better control of balance. The most common tremor seen in MS, and the most difficult to treat, occurs as a result of demyelination in the cerebellum. This area of the brain is responsible for balance and has connections throughout the brain stem (the back of the brain) and the spinal cord. Demyelination in this area often results in a gross tremor that is relatively slow and occurs during purposeful movements of the arm or leg. The reason for this is not known, but exacerba- tion by stress is true of most of the neurologic symptoms of MS. Therefore, one mode of managing the problem is treatment with drugs that have a calming or sedative effect. For example, Hydroxyzine (Atarax®, Vistaril®) is an antihistamine whose effect is to settle a minor tremor that has been magnified by stress.

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