By G. Nerusul. Allen College.
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Book with organization as author and an editor(s) American Association of Neuroscience Nursing. Book published with equal text in two languages Chemically-defined flavouring substances = Substances aromatisantes chimiquement definies. La lengua cientifica griega: origenes, desarrollo e influencia en las lenguas modernas europeas. Evolucionismo y cultura: darwinismo en Europa e Iberoamerica [Evolution and culture: Darwinism in Europe and Latin America]. Studies of fall risk and bone morphology in older women with low bone mass [dissertation]. Dance/movement therapy with frail older adults: a controlled experiment to demonstrate effect on mood, social interaction, and physical functioning 140 Citing Medicine of nursing home residents and adult day health clients [microfiche]. Boston: Hebrew Rehabilitation Center for Aged, Research and Training Institute; 1996. Manuale di psichiatria: per studenti, medici, assistenti sociali, operatori psichiatrici. Self-image pattern and treatment outcome in severely disturbed psychiatric patients.
In the first approach order cytotec 200mcg visa, the quest for political consensus raises the issue of the danger of emptying morality of its content and also depriving it of rigorous moral analysis 200 mcg cytotec with amex. This political move transforms morality into a set of procedures designed to provide a justification for what is socially suitable The Hippocratic Oath and Contem porary Medicine 121 and acceptable for the sake of a particular social order. More importantly, if we accept the second approach, it implies that one s understanding of medicine and certain ethical issues related to it are understood only within particular communities independently of what the practice of medicine requires for professionals. It does not follow, however, that that particular individual can justify the killing based on his personal convictions while acting as a profes- sional in a clinical setting. As a doctor this individual is obliged to act according to some particular professional standards. Of course, one might answer that a professional association may impose on a minority of physicians the professional obligations to practice what would be considered as morally wrong action (i. It is important to distinguish between refraining from partaking in unethical actions (which has no consequences for one s moral integrity) and imposing on others, through specific actions, one s moral views (i. In the latter case, moral wrong is acted upon the patient and the family (by imposition) while in the second case one is free to refrain from participating in a specific action, thus leaving the decision to others and creating a moral space in which one can act as a professional and as a moral agent. Furthermore, even if a professional association would impose particular obligations contrary to one s convictions, there is always the possibility to resign or simply not be a member of the association. But what is im portant to keep in m ind for the sake of this article is that m edicine is practiced by a variety of people of different socio-cultural backgrounds who are required to respect fundamental professional principles and a set of moral norms regulating their practice. Undoubtedly, our social context reveals various communities with different competing and sometimes incompatible moral understandings. Nevertheless, despite the differences, it does not fol- low that some overlap between communities and moral traditions cannot occur. W ildes argues, health care is a collaborative enterprise that does not limit moral problems to particular communities (W ildes, 2000, p. Moral discourse in bioethics and medicine (moral philosophy of med- icine), from a collaborative perspective, can take the form of what he calls acquaintanceship. In this type of moral relationship people do not necessarily share moral views but rank values (i. The result is that a moral discourse can be established between acquaintances through a web of partial understandings of moral issues, in spite of moral disagreements. He shows by indirection how accounts of medical professionalism are strongly structured by particular social perspectives framed within particular cultures. Here one might recall his recasting of the Greek and Hippocratic sense of dik (jus- tice) in service of his particular views regarding health care reform. His study also shows by indirection the power and allure of the Hippocratic tra- dition, which entrances people with a purported moral tradition over time, without substantiating that such a tradition exists. Indeed, it is interesting that Miles does not successfully show how the ethical principles in the Oath (and here again one must note that the Oath s sense of ethical principles is surely not ours) and the symbolic force of the Oath can direct the contem- porary project of reclaiming a sense of medical professionalism. W hat he does show is that there is m uch re-im aging of w hat the Hippocratic O ath, tradition, and ethos should mean, not what they actually meant. These brief reflections on the Oath and Stephen Miles study of that Oath disclose major challenges in recapturing a coherent sense of medical professional identity and medical professionalism. It would be well to recall that the Oath is in fact puzzling because of the numerous levels of concerns it compasses beyond the ethical. It directs itself to religious concerns, to an esoteric sense of esprit-de-corps, and to special obligations binding students to teachers (and by extension medical professionals to each other). Medical professionalism may be grounded in much more than the supposed universal moral commitments that most contemporary scholars attempt to read back into the Oath. It indeed compasses moral claims that could be understood in universal terms, but it is inevitably a particularistic document that aims at creating a particular sense of identity for the Hippo- cratic practitioners. One must take much more seriously the complexity of the Oath and the complexity of medical professionalism. All of this substantiates the crucial need to take the philosophy of med- icine seriously. Such a philosophy of medicine should turn to developing a medical-moral philosophy that can place or locate bioethics. An effort to revisit the philosophy of medicine seems necessary in the light to the cur- rent condition of bioethical reflection (e. First, contemporary medicine must think through what is involved in professional commitments, what is The Hippocratic Oath and Contem porary Medicine 123 necessary for professional identity, and what internal values should be nur- tured by the profession. Second this assessment may draw strength from a critical appreciation of the extent to which, if any, contemporary medical professionalism is rooted in a Hippocratic tradition and morality. Third, the political, economic, and social aspects associated with medicine should be considered in terms of a philosophically enriched understanding of the final analysis of bioethical issues. The major attributes of Hippocratic m orality can be summarized as follows: the first characteris- tic is that Hippocratic medicine is individualistic, that is, the physician acts always in the best interest of the patient, which implies the moral obligation of beneficent and consequently nonm aleficent. The aim of any medical procedure is the good of the patient independently of other factors, such as the ability to pay or the background of the patient (i. Other characteristics include confidentiality (willing- ness to restrain from divulging information); prohibition to practice euthanasia and abortion; refraining from sexual relationships with patients.
In the limiting situation every newborn infant has passive immunity buy cytotec 200mcg, so that m0 1 and s0 0 200 mcg cytotec with amex. Note that the formula for is for an endemic steady state for a virulent disease, so it does not imply that R0/( + d + q) > 1 is the threshold condition for existence of a positive endemic steady state age distribution; compare with [12, p. Thus for a very virulent disease, adding a passively immune class to a model increases the average age of attack by the mean period of passive immunity. Solving for R0 in terms of the average period p of passive immunity and the average lifetime L =1/d, we obtain [q +1/(A p)](1 + pq) (5. In epidemiological terminology, g is the product of the fraction vaccinated and the vaccine ecacy. This vaccination at age Av causes a jump discontinuity in the sus- ceptible age distribution given by s(Av +0)=(1 g)s(Av 0), where s(Av 0) is the limit from the left and s(Av + 0) is the limit from the right. The details are omitted, but sub- stituting the steady state solutions i(a) on these intervals into the expression for yields R0(d + q) (1 s0) (+d+q)Av (+d+q)Av (5. Recall that a population has herd immunity if a large enough fraction is immune, so that the disease would not spread if an outside infective were introduced into the population. To determine this threshold we consider the situation when the disease is at a very low level with nearly zero, so that almost no one is infected. Thus the initial passively immune fraction m0 is very small and the initial susceptible fraction s0 is nearly 1. If the successfully vaccinated fraction g at age A is large 0 v enough so that (d+q)Av (5. A similar criterion for herd immunity with vaccination at two ages in a constant population is given in . Intuitively, there are so many immunes that the average infective cannot replace itself with at least one new infective during the infectious period and, consequently, the disease dies out. If the inequality above is not satised and there are some infecteds initially, then we expect the susceptible fraction to approach the stable age distribution given by the jump solution with a positive, constant that satises (5. The negative signs in the expression for A make it seem as if A is a decreasing function of the successfully vaccinated fraction g, but this is not true since the force of infection is a decreasing function of g. For the demo- graphic model in which everyone survives until age L and then dies, d(a) is zero until age L and innite after age L, so that D(a) is zero until age L and is innite after age L. Expressions similar to those in this section can be found for a nonconstant population with = q/(1 eqL), but they are not presented here. Typically the lifetime L is larger than the average age of attack A 1/, and both are much larger than the average latent period 1/ and the average infectious period 1/. Hence many of the formulas for 0 0 Type I mortality in the Anderson and May book [12, Ch. In sections 7 and 8 we estimate the basic reproduction number in models with age groups for measles in Niger and pertussis in the United States. The boundary values at age 0 are all zero except for the births given by S(0,t)= 0 f(a)U(a, t)da. The population is partitioned into n age groups as in the demographic model in section 4. Because the numbers are all growing exponentially by eqt, the fractions of the population in the epidemiologic classes are of more interest than the numbers in these epidemiologic classes. Here we follow the same procedure used in the continuous model to nd an expression for the basic re- production number R0. Substituting s successively, we nd that s = C /[ ] 1 1 1 i1 i i1 i 1 for i 2, where Ci1 stands for ci1 c1c1P1. When the expressions for ei and ii1 are substituted into the expression for i in (6. Now the expressions for i and = kb can be substituted into this j=1 j j i i i last summation to obtain n j bj bj1 b1 (6. Here the feasible region is the subset of the nonnegative orthant in the 4n-dimensional space with the class fractions in the ith group summing to Pi. Using s P, n n n j1 j1 j j1 j1 n1 1 i i we obtain V (R 1) b i 0ifR 1. The set where V = 0 is the boundary of 0 j j 0 the feasible region with ij = 0 for every j, but dij/dt = jej on this boundary, so that ij moves o this boundary unless ej = 0. Thus the disease-free equilibrium is the only positively invariant subset of the set with V = 0, so that all paths in the feasible region approach the disease-free equilib- rium by the Liapunov Lasalle theorem [92, p. Thus if R0 1, then the disease- free equilibrium is asymptotically stable in the feasible region. If R0 > 1, then we have V> 0 for points suciently close to the disease-free equilibrium with s close to P and i i ij > 0 for some j, so that the disease-free equilibrium is unstable. A deterministic compartmental mathemati- cal model has been developed for the study of the eects of heterogeneous mixing and vaccination distribution on disease transmission in Africa . This study focuses on vaccination against measles in the city of Naimey, Niger, in sub-Saharan Africa. The rapidly growing population consists of a majority group with low transmission rates and a minority group of seasonal urban migrants with higher transmission rates. De- mographic and measles epidemiological parameters are estimated from data on Niger.
These lesions are characteristically associated with lower motor neurone signs at the level of transection and upper motor neurone signs below the level buy cytotec 200 mcg amex. There are also ipsilateral upper motor neurone signs below the level of the lesion and lower motor neurone signs at the level of the lesion buy cytotec 200 mcg otc. Common causes are st- will cause weakness and wasting of the small muscles rokes(vascularocclusionorhaemorrhage)andtumours. Ask the patient to say r Decreased power in the distribution of the affected British Constitution or West Register Street. Usually due to a cervical spinal cord lesion, occasionally bilateral cerebral lesions. Hemiplegia Weakness of one half of the body (sometimes including the face) caused be a contralateral cerebral hemisphere lesion, a brainstem lesion or ipsilateral spinal cord lesion (unusual). Paraplegia Affecting both lower limbs, and usually caused by a thoracic or lumbar spinal cord lesion e. Bilateral hemisphere (anterior cerebral artery) lesions can cause this but are rare. Monoplegia Contralateral hemisphere lesion in the motor cortex causing weakness of one limb, usually the arm. Test the abil- r Bradykinesia (slowness in movements) is noticeable ity of the patient to sit on the edge of the bed with their when doing alternate hand tapping movements, or arms crossed. Micro- r Gait:Wide-basedgait,withatendencytodrifttowards graphia (small, spidery handwriting). Even a mild cerebellar problem makes tiation of movement is impaired (hesitancy) with the this very difcult. A festinating gait is Causes include the following: r when the patient looks as though they are shufing in Multiple sclerosis r order to keep up with their centre of gravity, and then Trauma r has difculty in stopping and turning round. The three groups of tremor are distinguished by obser- r Metabolic: Alcohol (acute, reversible or chronic de- vation (see Table 7. If unilateral, the leg is swung out to the side to move it forwards (circumduction). If bilateral, the Extrapyramidal signs (Parkinsonism) pelvis has to alternately tilt and the gait often becomes r Appearance: Expressionless face. Thepatientcanstandontip-toe,butoften Resting tremor which is slow and classically pill- not on their heels. Even if mildly affected the patient is unable to strating whether seizure activity is suppressed by walk heel-toe in a straight line. In or encephalitis, as well as occurring in focal status Parkinson s disease, this pattern tends to be asym- epilepticus. They are useful in the di- agnosis of muscle disease, diseases of the neuromuscular Electroencephalography junction, peripheral neuropathies and anterior horn cell disease. It is obtained by placing electrodes on the scalp, using a jelly to reduce electrical Electromyography resistance. A recording of at least half an hour is usually Aneedleelectrodeisplacedintomusclesandinsertional, needed, to maximise the chances of picking up tran- resting and voluntary electrical activity is studied, using sient abnormalities. Its main use is for the classication of epilepsy, but is r Peripheral neuropathies and anterior horn cell disease it may also be useful in the diagnosis of other brain dis- lead to a reduced number of motor units, which re orders such as encephalitis. Surface electrodes or occasionally needles are used both r Suspected spinal cord compression. The knees are drawn up as far as possible and uation of brachial and lumbosacral plexus and nerve the neck exed, to open up the spinous processes of the roots. The lumbar puncture needle is inserted in the midline Lumbar puncture with its stylet in place aiming slightly towards the um- bilicus. If the needle encounters rm resistance, it Indications should be withdrawn and another approach tried. When any of the following are suspected: Sometimes the patient will feel a pain radiating into r Infection (meningitis, encephalitis, fungal infections the leg or back this is due to the needle touching a or neurosyphilis). A simultaneous blood diagnosis of idiopathic (benign) intracranial hyperten- sample for glucose should be sent. Thereisadiffer- in the case of sick patients, is relatively unaccessible ence in healthy tissue and infarcted, infected or oedema- although some units have facilities for ventilation in the tous tissue. Cerebrovascular disease Faster scans are now possible particularly helpful for patients unwilling or unable to lie at for long, although in some cases general anaesthetic may be necessary for Stroke unco-operative patients. Magnetic resonance imaging uses the magnetic proper- ties of protons to generate images of tissues. It has the advantage of not exposing the patient to ion- Incidence ising radiation (particularly important in young infants, Third commonest cause of death in Western World (1 2 childrenandpregnantmothers). Geography Posterior circulation (the vertebral, basilar arteries and Black community, Japanese more common. They are predisposed to by hypertension and diabetes, are often asymptomatic but may cause focal neurologi- Pathophysiology cal defects such as weakness of a single limb, or limited Haemorrhagic strokes are discussed elsewhere. The nal picture may affected, and whether there is temporary or permanent include dementia and a shufing gait which resembles ischaemia and hence infarction. In clinical situations a full neurological examination Clinical features should be performed and a careful cardiovascular ex- Anterior circulation (carotid territory) strokes are the amination in order to reveal any source of embolus or most common, in particular those involving a branch of other predisposing disease.
Suppression of artefacts is carried out using lters in the frequency domain buy 100mcg cytotec visa, but also wavelet transformation is applied 100mcg cytotec with visa, since it allows for best possible frequency separation simultaneously with good temporal resolution. Detection of data intervals of 7 diagnostic relevance is realized by rst extracting characteristic features using mathematical methods followed by a mathematical classication (nearest neigh- bor, Bayes-maximum-likelihood, neural networks etc. Once these rules will have been found, the detection of any deviation is an indication to an early stage of a disease. For example, most often stable trajectories can be found in the state space of the heart, but sometimes they pass through bifurcations into chaos (like brillation ). But the computer with its implemented algorithms can already today give valuable advice to the physician and this trend will continue and gain relevance. In the second stage, values of diagnostic importance are determined quantitatively. Often the decision to choose one or another line of 8 therapy depends on whether a specic value is above or below a given thresh- old. Using mathematical methods these values can be found as accurately as possible even in disturbed and noisy data. Finally, mathematical methods can be employed to optimize therapy by trying out various variants and evaluate the outcome using objective and traceable criteria. In future, it will be decisive for manufacturers of medical devices to integrate the huge amount of patient data into a comprehensive view in an intelligent way and to support the medical doctor in his/her diagnosis and therapy decision. Only companies that can oer these options will play a major role in the future world market. Mathematical methods will play a major role in integrating all these data into a comprehensive picture about the state of the patient. Some of these functional data can be gained from medical imaging devices: metabolism, e. The objective is to integrate all these data into a complete patient model so that nally important functional characteristics can be determined. Mathematical models of heart and circulation have many interesting applications in cardiology and heart surgery. Using uid dynamical models of vessels one can better understand the etiology of stenoses (plaque in a blood vessel), optimize stents to open stenoses and to treat aneurysms. Using circulation models it will be possible to evaluate new drugs to treat hypertension (high blood pressure), control extracorporal circulation during heart surgery. For the purpose of further explaining these options, one of them is highlighted in the following. Using an image guided catheter the tissue is heated locally above 42 C so that the proteins are coagulated in an area near to the tip of the catheter. Electrophysiological computer models of the heart start with the various ion channels in the membrane of cardiac cells. The dynamics of ion channels can be described by sti ordinary dierential equations. Single cells lead to a nonlinear system of about 20 coupled dierential equations. The spatial coupling of the cells is modelled by partial dierential equations, e. As eventually electric potentials in the body are to be determined, basically the equations of electromagnetic eld theory have to be applied. Elec- trophysiological processes in the human body are comparably slow, which is why only the Poisson equation of electrostatic problems - an elliptic partial dieren- tial equation - has to be solved. Numerical simulation of these equations requires the discretization of space and time. In biomedical engineering, an explicit Euler discretization is preferred up to now, , whereas the mathematical community applies sti integrators as a standard (see  and references therein). In case of uniform discretization a problem with some million degrees of freedom has to be solved, preferably in the clock pulse of a second. For this application, new parameters have to be assigned to the atrial tissue that are able to describe the pathological case. In this case, the computer model switches into a chaotic state so that patterns of depolarization can be observed in the model which amazingly well resemble the patterns ob- served in real patients that actually suer from atrial brillation. What would be the best choice of ablation points and lines in the atrium so that brillation is terminated reliably using as little scar as possible and, in addition, protecting the patient from aring up of the disease? Computer models can indeed answer this question by testing dierent strategies in the virtual atrium. With a reset the virtual atrium can be switched back to the original situation and a new test can be started.
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