By Y. Asaru. Fontbonne University. 2018.

Comprehensive Functional Assessment for geriatric assessment: a meta-analysis of controlled trials order vantin 200 mg amex antibiotic 83 3147. Alcoholism medical history taking as part of a population based survey screening questionnaires: are they valid in elderly in subjects aged 85 and over quality vantin 200mg virus yole. Smoking effects of the presence of a third person on the physician- cessation and decreased risk of stroke in women. A short native medicine use in the United States, 1990: results of physical performance battery assessing lower extremity a follow-up national survey. Population- in the aged: the index of ADL, a standardized measure based study of social and productive activities as pre- of biological and psychosocial function. Why do physicians fail to recognize and treat ambulatory elderly: clinical confirmation of a screening malnutrition in older persons? Patterns of ortho- level and physical disability as predictors of mortality in static blood pressure change and their clinical correlates older persons. The management of chronic pain in alcoholism screening questionnaires in elderly veterans. Screening College of Rheumatology 1990 criteria for the classifica- for drinking disorders in the elderly using the CAGE ques- tion of giant cell arteritis. Oral assessment of the dentu- of basic functional mobility for frail elderly persons. Breast cancer in aging parison of neurologic changes in "successfully aging" women. Neurologic signs in of ambulatory electrocardiographic findings in apparently Alzheimer’s disease. Prevalence of between primitive refelxes, extra-pyramidal signs, reflec- arrhythmias detected by 24-hour ambulatory electrocar- tive apraxia and severity of cognitive impairment in diography and value of antiarrhythmic therapy in elderly dementia of the Alzheimer’s type. Bloom The term disease management has evolved within the past The proliferation of managed care has given great decade to become defined as a systematic, population- impetus to the establishment of disease management pro- based approach to identify persons with a given disease grams with considerable help from pharmaceutical com- or persons at risk for that disease, followed by implemen- panies. A push by insurers and employers to measure tation of therapeutic or preventive interventions, finally clinical and other outcomes has also contributed to its followed by measurement of clinical and other (e. Indeed, some would argue that such programs 1,2 lization of services, costs) outcomes. Chronic disease are simply marketing and packaging devices, yet there is management places an emphasis upon coordination a small but growing literature indicating significant value and comprehensiveness of care along the continuum of for properly designed and implemented programs. The pre- quality, better coordinated, and appropriately utilized valence of congestive heart failure, hypertension, dia- care, coupled with control of costs, are its major goals. These aspects include attention to syndromes, question, including approaches to prevention, diagnosis, not just diseases; the frequent presence of accompany- treatment, and palliation; information systems for clinical ing comorbidities; cognitive impairment as a frequent and administrative data that allow for continuing analysis complicating factor; the high prevalence of functional of practice patterns and outcomes; and a philosophy and dependencies; the involvement of family caregivers; and active program for continuous quality improvement. Additionally, careful include the following5: attention to the transition between these settings (e. Interventions can range from very "low- • Promote correct diagnosis and treatment planning tech" patient-focused steps (e. Steps for developing an evidence-based disease management with attention to dietary interactions with management program. The major goals of the programs were to improve literature Cirtically appraise and synthesize the evidence patient adherence with therapeutic recommendations, Evaluate the benefits, harms, and costs increase patients’ understanding of their disease, allow Develop evidence-based practice guidelines, clinical pathways, and for and provide easy access for communication during algorithms careful follow-up surveillance, decrease unplanned hos- Create a system for process and outcome measurement and reporting pital readmission, improve functional status, and reduce Implement the evidence-based guidelines, pathways, and algorithms Complete the quality improvement cycle overall medical costs. Most studies were at least 3 months in duration, with 6- to 18-month follow-up periods. Other programs targeting older patients with chronic non- led multidisciplinary team including a geriatric cardio- valvular atrial fibrillation have utilized expert nurses as logist, dieticians, social workers, and home health teachers and managers to assist physicians by helping professionals. The control group received usual care and educate patients about the condition, its potential com- follow-up. Positive outcomes included improved quality plications, and the rationale and method of medication of life measures, a 56% reduction in hospital admission Figure 15. Chronic Disease Management 165 rate, and a savings of $1,058 per patient in health care years) demonstrated that home visits by occupational costs. Another study with 97 individuals whose interven- therapists making environmental modifications could tion was a single home visit by a nurse and a pharmacist prevent falls among those at risk of falling by both home 1 week after hospital discharge for acute heart failure environmental modifications and subsequent behavioral resulted in a significant reduction in unplanned hospital changes in those at risk.

Ligaments like ten- dons carry tension and again like tendons can store elastic energy purchase vantin 200mg visa bacteria causing diseases. They will stretch small amounts under the application of tensile force generic 100 mg vantin mastercard antibiotics before root canal, and un- der normal circumstances, they return to their resting length upon the lifting of load. Long bones are irreg- ular hollow cylinders filled with a loose cellular tissue (the marrow) con- taining blood and other matter. The compact bone is a composite of or- ganic and inorganic material, the organic phase being nearly all collagen. The inorganic phase consists of water and a mineral salt called hydrox- yapatitie. Electron microscopy has shown that the hydroxyapatite is in the form of very fine needles only 15 nm wide and up to 10 times as long. The bone matrix in which they are embedded lowers the stiffness and protects the needles from breaking. The average value of Young’s modulus (stiffness coefficient) is 20,000 N/mm2, about one-tenth of that for steel. If the bones taken from a ca- daver are dried and then tested, they fail at a tensile stress of about 100 6. A man whose humerus had fractured ear- lier believed that he was now healed but that he had a stiff elbow. His friend placed one hand on the forearm just below the elbow and the other just above the wrist and pushed in opposite directions with a force of 15 N. Apparently, he had pushed too strongly; the humerus failed at its weakest point, the original fracture site, shown as BB9 in the figure. Determine the maximum tensile stress that occurred at the fracture site during bending. Assume that the normal stress varied linearly along the cross section of the humerus. Fracturing of the humerus bone of a person with stiff elbow, re- sulting from incorrect manipulation at the forearm (a). Internal Forces and the Human Body Solution: The free-body diagrams of the arm is shown in Fig. Because the el- bow was stiff, it did not bend during the manipulation of the forearm. According to the free-body diagram, the magnitude of the net mo- ment acting on a cross section of the humerus is given as follows: M 5 15 N? We had seen earlier (in Chapter 5) that bending moment caused axial stress in a cantilever beam. If the humerus could be considered as a linearly elastic solid, the stress distri- bution would be linear (Fig. This maximum stress (so) is re- lated to the moment M acting on the cross section by the formula: so 5 M (h/2)/Jx (6. The cross section of the humerus occupied by compact bone could be represented as an annulus with outer radius equal to 3. Under these con- x ditions the maximum normal stress so corresponding to the cross- sectional moment of 2. Alterations in the distribution of stress in a bone could yield in significant growth or re- modeling. In the low-gravity situation of space flight, the compressive stresses acting on the bones are much less than that on earth, and bones 6. On the other hand, on earth, the bones of the leg, which carry the weight of the body, thicken with age. Orthopaedic surgeons have begun exploiting the relationship between bone stress and bone growth to correct skeletal abnormalities. In the 1940s, in an isolated hospital in Siberia, Professor Gavriil Ilizarov came up with an ingenious method to treat limb length inequality, congenital limb de- ficiency, and other types of bone or joint deformities. Limb correction (lengthening) is reshaping of a limb involving little invasive treatment. Ilizarov in an article entitled "Clinical Application of the Tension-Stress Effect for Limb Lengthening" that appeared in 1990 in Clinical Orthopaedics and Related Research. Briefly, an external fixator (much like a bone scaffold) is applied on the affected bone (Fig.

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Further attention to prevention is even more important after the wound has healed because the area remains vulnerable to re-injury purchase vantin 100mg fast delivery antimicrobial laundry soap. If careful attention is paid to the preventive measures described here purchase vantin 200mg online antibiotic resistance related to natural selection, the chances of a pressure sore forming will be minimized. Bladder symptoms usually can be controlled with medication or other approaches that minimize any changes in daily activities and life-style. THE URINARY SYSTEM AND ITS CONTROL The following figure shows the urinary system, whose main func- tion is to collect and eliminate bodily wastes in the form of urine. The urinary system includes • the kidneys, which filter the blood to remove waste prod- ucts and produce urine at a rate of approximately one ounce (30 cc) per hour • the bladder, a muscular sac that stretches to store the urine until it is emptied by urination, a process referred to as voiding • the urethra, a hollow tube through which urine passes from the body when voiding occurs • the urethral sphincter, a valvelike muscle that opens and closes to control whether urine remains in the bladder or is voided 64 CHAPTER 10 • Bladder Symptoms Kidney Ureter The urinary system. Bladder Urethral sphincter Urethra When 6 to 8 ounces (180 to 240 cc) of urine is present in the bladder, it becomes sufficiently stretched to stimulate nerve end- ings located in its wall. These nerves send a signal of fullness to an area in the spinal cord that may be thought of as a "voiding reflex center" (Figure A). This center in turn sends the signal on to the brain, and you become aware of the need to urinate. The brain then signals the spinal center, which sends two signals, one to the blad- der telling it to contract and a second to the urethral sphincter mus- cle telling it to relax. This combination of a contracted bladder and a relaxed sphincter permits urine to flow from the bladder. BLADDER PROBLEMS ASSOCIATED WITH MULTIPLE SCLEROSIS The elimination of urine by conscious choice is dependent on the integrity of the spinal cord pathways that connect the brain and the 65 PART II • Managing MS Symptoms voiding reflex center. The downward command by the brain to "empty" causes relaxation and opening of the sphincter, whereas the command to wait signals the sphincter to remain closed. The pathways between the reflex center and the brain may be damaged or interrupted in MS, producing a variety of problems and/or symp- toms. For example, if the connections between the reflex center and the brain are severely damaged, the reflex center may assume direct control of voiding and automatically stimulate the bladder to empty whenever it fills. The most common bladder problems associated with MS are increased frequency of urination, urgency, dribbling, hesitancy, and incontinence. Frequency involves an increase in the number of times urina- tion occurs within the day. In some people, voiding may occur as often as every 15 to 20 minutes, usually in small amounts each time. The frequency of urination depends on the rate at which urine is formed and the ability of the bladder to store it. Urgency is the feeling of having to empty the bladder immedi- ately, combined with an inability to "hold" urine once the urge to void is felt. In some cases, a person may only be aware of this problem when damp undergarments are noted. Hesitancy involves difficulty in beginning to urinate after the urge to void is felt. This symptom may be associated with urgency, so that one is unable to urinate while the urge to do so remains. It may result either from not being able to reach the toilet in time or from being unaware of the need to empty the bladder because of block- age of the pathways between the voiding reflex center and the brain. Despite the ability of the bladder to stretch as it fills, it can hold only a certain amount of urine and empties spontaneously after this limit is reached. Because the pathways to the brain are blocked, bladder emptying no longer is under voluntary control. Voiding then becomes a reflex activity, with messages to "empty" coming only from the spinal center. A small spastic bladder may produce symp- toms of increased frequency, urgency, dribbling, and/or incontinence. Types of Bladder Dysfunction Problem Symptoms Treatment Small, spastic Increased Oxybutynin (Ditropan®, bladder frequency, urgency, Ditropan XL®) (failure to dribbling, and/or Hyoscyamine store) incontinence (Levsinex®, Levbid®) Tolterodine tartrate (Detrol®) Flavoxate HCl (Urispas®) Imipramine (Tofranil®) Antihistamines Flaccid (big) Frequency, urgency, Credé technique bladder dribbling, hesitancy, Intermittent (failure to incontinence self-catheterization empty) Dyssynergic EITHER Alpha blockers bladder (a) urgency followed (conflicting) by hesitation in beginning to void; OR (b) dribbling or incontinence 67 PART II • Managing MS Symptoms Brain At the appropriate And on time, the brain to the 3 4 sends release brain. Spinal Cord Message is sent From here, the bladder muscles are to the VRC in 2 5 instructed to A, contract the bladder the spinal cord.

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It will be the 94 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY role of European Commission±funded programs (e cheap vantin 200 mg amex antibiotics for dogs ear infection uk. The society must be promoted through various marketing channels so that medical vendors take an integral part in the development of the society purchase vantin 100 mg otc antibiotics for acne for 6 months. Does the general practitioner really want to look like the one potrayed in Figure 3. By varying initiatives the implications on the health-care community should be presented so the results can be disseminated to the end users. One example for promoting the update of Web-based technology within the medical discipline is the on-line magazine Virtual Medical Worlds (http://www. All aspects relating to the update of a telemedical information society are being addressed by the e-zine (Fig. The next step is the visualization and manipulation of these data, as shown in Figure 3. At each virtual medical world, the practitioner has the possibility to initiate a service, which may be local or remote. For example, it may be to initiate a publicly available Web plug-in such as a Cooltalk session. A service may also be used to construct 3-D models from 2-D slices, manipulate the generated 3-D models, and create a 4-D model (78). Another service may take these 3-D or 4-D VRML reconstructed models and use a VR interface to perform, for example, a virtual colonoscopy (39). The advantages of the services approach is analogous to that of Web-based plug-ins; they are used when and where required and where they are supported. It is envisaged that a hospital information system of the future will consist of a local application server and access to remote services (Fig. The services could also be advanced visualization services, such as using VR techniques to provide a true 3-D model (79). For example, to sustain the illusion of reality, a surgical planning interface needs to generate smoothly animated images (80). To do this, the system must be able to sustain a display update rate of at least 30 frames per second. Research has shown that delays above 300 ms can cause the user to overcompensate for system delay, and delays above 300 ms can cause user discomfort, including motion sickness (7, 81, 82). Owing to the currently available computer hard- ware, these requirements limit the complexity of the generated images and/or of the immersive simulation of real-world tasks. Work done by Arthur and Booth (83) and by Sollenburger and Milgram (84) shows that error rates for such tasks as tracing, movement, and localization improve when users are given a head-coupled stereo display over a noncoupled (static) display, with head coupling being the dominate factor (83). The use of bio- medical data as the basis for models within a virtual environment poses some unique problems. Although currently available rendering algorithms can gen- erate photorealistic images from rather dense volumetric data (78, 85, 86), ray tracing algorithms cannot sustain the visual updated rate required for real-time display. In addition, most surface-display algorithms generate images from polygon representations of the surface(s), using extremely high numbers of polygons. To be successful, a medical VR system requires a means of trans- forming volumetric image data into reasonable geometric (polygonal) models. This requires the ability to accurately segment the desired object from the scan data, detect its surface, and generate the best possible polygonal representation of the surface from a ®xed polygonal ``budget' (de®ned as the constraint on the number of polygons for e¨ective display rates). Currently available hardware is able to render and manipulate in real time approximately 20,000 complex polygons (including shading, texture mapping, and anti-aliasing). Current poly- gonization algorithmsÐsuch as marching cubes (87, 88), spiderweb (84), and the wrapper (89)Ðproduce high-resolution surfaces with polygonal counts ranging from 40,000 to several million polygons. The VR system must also be able to simulate some, if not all, of the physical properties of the objects being modeled to generate an illusion of reality (6, 90). At a minimum, the biomedical model should properly deform when exposed to external forces and give the appearance of weight. Ideally, for surgery, a VR system would react properly to directed manipulations, i. The resources must also be homogeneous and transparent to the user, who will be able to request the gen- eration of a reconstructed model. The computation of the reconstructed model may be executed on a number of computing platforms.

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