By G. Daro. Hofstra University. 2018.
Interrater agreement on the diagnosis of dementia and AD with the DSM-IIIR and NINCDS-ADRDA criteria has been good [k=0 discount cialis super active 20mg on-line impotence of organic origin icd 9. Does Neuroimaging Increase the Diagnostic Accuracy of Alzheimer Disease in the Clinical Setting? Structural Neuroimaging Summary of Evidence: The traditional use of structural neuroimaging to differentiate potentially reversible or modiﬁable causes of dementia such as brain tumors buy discount cialis super active 20mg on line erectile dysfunction doctors in ny, subdural hematoma, normal pressure hydrocephalus, and vascular dementia from AD is widely accepted (28). There is strong evi- dence that structural imaging inﬂuences patient management during the initial evaluation of dementia. There is moderate evidence that the diag- nostic precision of structural neuroimaging is higher with volume mea- surements than visual evaluation, especially in mildly demented cases, but the ﬁgures are still comparable to clinical evaluation. Supporting Evidence: Besides the potential causes of dementia mentioned above, structural neuroimaging can also identify anatomic changes that occur due to the pathologic involvement in AD (29). Neuroﬁbrillary pathology, which correlates with neuron loss and cognitive decline in patients with AD, follows a hierarchical topologic progression course in the brain (10,30–32). The macroscopic result of this pathologic involvement is atrophy, which is related to the decrease in neuron density (33). For this reason, the search for anatomic imaging markers of AD has targeted the anteromedial temporal lobe, particularly the hippocampus and entorhinal cortex, which are involved earliest and most severely with the neuroﬁbril- lary pathology and atrophy in AD. Visual evaluation or measurements of the anteromedial temporal lobe width with computed tomography (CT) detected 80% to 95% of the patho- logically conﬁrmed AD cases (23,35). However, the accuracy declined to 57% when only mild AD cases with low pretest probability were quota studied, and the clinical diagnosis with the NINCDS-ADRDA criteria was more accurate than CT measurements for identifying AD patients at patho- logically early stages of the disease (strong evidence) (35). One study with a pathologically conﬁrmed cohort (34) revealed that structural neuroimaging can help to identify vascular dementia or vascu- lar component of AD (mixed dementia) by increasing the sensitivity of the clinical evaluation from 6% to 59%, and management of the vascular com- ponent may in turn slow down cognitive decline (strong evidence). Special Case: Volumetric Measurements A reliable and reproducible method for quantifying medial temporal lobe atrophy is magnetic resonance imaging (MRI)-based volume measure- ments of the hippocampus and the entorhinal cortex (29,36). Antemortem hippocampal atrophy was not found to be speciﬁc for AD in a pathologi- cally conﬁrmed cohort; however, hippocampal volumes on MRI correlated well with the pathologic stage of the disease (r =-0. Structural neuroimaging changed the clinical diagnosis in 19% to 28% of the cases, and changed patient management in 15% (38) (strong evidence). Visual evaluation of the anteromedial temporal lobe for atrophy on MRI to differentiate patients with AD from normal subjects had a sensitivity of 83% to 85% and a speciﬁcity of 96% to 98% in clinically conﬁrmed cohorts (38,39). Although visual evaluation of the temporal lobe accurately distin- guishes AD patients in experienced hands, evidence is lacking on the pre- cision of visual evaluation at different clinical settings. Diagnostic accuracy of this technique for distinguishing AD patients from normal has been 79% to 94% in clinically conﬁrmed cohorts (40,41), being comparable in mildly and moderately demented cases (42). Routine use of volumetry techniques for the diagnosis of AD may be time-consuming and cumbersome in a clin- ical setting. However, the intimate correlation between pathologic involve- ment and hippocampal volumes is encouraging for the use of hippocampal volumetry as an imaging marker for disease progression (moderate evidence). By differentiating potentially treatable causes, structural imaging with either CT or MRI inﬂuences patient management during the initial evalu- ation of dementia (strong evidence). Computed tomography may be appropriate when a brain tumor or subdural hematoma is suspected, and MRI may be the modality of choice for vascular dementia because of its superior sensitiv- ity to vascular changes. The decision should be based on clinical impres- sion at this time (insufﬁcient evidence). Functional Neuroimaging Summary of Evidence: Single photon emission computed tomography (SPECT) and positron emission tomography (PET) are the two widely investigated functional neuroimaging techniques in AD. Measurements of regional glucose metabolism with PET, and regional perfusion measure- ments with SPECT indicate a metabolic decline and a decrease in blood ﬂow in the temporal and parietal lobes of patients with AD relative to normal elderly. There is moderate evidence that the diagnostic accuracy of either SPECT or PET is not higher than the clinical criteria in AD. Nonethe- less, both functional imaging techniques appear promising for differenti- ating other dementia syndromes (frontotemporal dementia and dementia with Lewy bodies) from AD due to differences in regional functional involvement. Supporting Evidence: With visual evaluation of SPECT images for tem- poroparietal hypoperfusion, the sensitivity for distinguishing AD patients from normal differed from 42% to 79% at a speciﬁcity of 86% to 90%, being lower in patients with mild AD than in patients with severe AD in both clinically and pathologically conﬁrmed cases (43–45), and not superior to the clinical diagnosis based on NINCDS-ADRDA criteria (46) (strong evi- dence). The regional decrease in cerebral perfusion with SPECT correlated with the neuroﬁbrillary pathology staging of AD (47) (strong evidence); SPECT increased the accuracy of clinical evaluation for identifying AD pathology, but cases with other types of dementia were not included (48) (moderate evidence). The sensitivity and speciﬁcity of the temporoparietal metabolic decline on PET for differentiating patients with pathologically conﬁrmed AD from normal subjects was 63% and 82%, respectively, similar to the sensitivity (63%) but lower than the speciﬁcity (100%) of clinical diagnosis in the same cohort (49) (strong evidence). On the other hand, occipital hypometabo- lism on PET distinguished pathologically conﬁrmed patients with demen- tia with Lewy bodies from AD patients with a comparable speciﬁcity (80%) and higher sensitivity (90%) than clinical evaluation (strong evidence) (50,51). Visual evaluation of SPECT images for temporoparietal hypoperfusion distinguished clinically conﬁrmed AD patients from those with fronto- temporal dementia by correctly classifying 74% of AD patients with decreased blood ﬂow in the parietal lobes and 81% of frontotemporal dementia patients with decreased blood ﬂow in the frontal lobes (52) (moderate evidence).
The evaluation of the maximal values of shear and normal stress is important in the consideration of failure of a material buy generic cialis super active 20 mg line erectile dysfunction medications list. Some materials fail easily under tension (compression) and others fail readily under shear stress buy cialis super active 20mg lowest price erectile dysfunction treatment bangkok. Concrete is not resilient to tension whereas steel can withstand both tension and compression. If the circular cylinder under consideration had low resistance to shear but high resistance to tension, it would fail in the form of a tear that occurs at 45° relative to the axis of the cylinder. As illustrated by the previous examples, in many cases Newton’s sec- ond law allows us to compute contact forces and the resultant internal forces at a cross section. Once we know the resultant force carried by a structural member, we can compute the average stress by dividing the value of the force with the cross-sectional area of the planar cross section. The question that comes to mind is how close is the average stress to the actual stress. The large body of literature in solid mechanics allow us to provide some insights. First, in the presence of cracks or holes, the aver- age stress is not an accurate indicator of the actual stress. Also, if the cross section cuts across a number of different materials with different stiffness, stress in the material with higher stiffness may be greater than the one with lower stiffness. We can illustrate this by considering a cylindrical speci- men consisting of two materials under the action of a tensile force (Fig. Imagine this to represent a long limb of the human body, a long bone surrounded by soft tissue. The total force acting on the cross sec- tion must be equal to F, and this leads to the following equation: F 5 s p r 2 1 s p (r 2 2 r 2) (6. We assume that planar cross sections that are normal to the axis of the specimen remain plane and normal to the axis. Thus, every line element parallel to the axis of the specimen un- dergoes the same extension D. A circular cylindrical r specimen made of two different ma- 1 r terials is under tensile force (a). The mate- r r rial occupying the core of the cylin- 2 1 der is stiffer than that of the outer L σ shell. If the cross-sectional areas of the two ma- terials are comparable and if E1 is much greater than E2, then material 1 carries much of the force applied on the specimen. This would be the case of a relaxed limb that is under tension; bone would carry much of the ap- plied load. Approximately 30% of the cross-sectional area is bone and the rest is composed of muscle and fat tissue. Because the fat tissue is much more compliant than muscle, it would carry practically no force. The cross-sectional area that effectively carries the traction force must be that of the cross-sectional area of the muscle and the bone. In the fol- lowing, we briefly review the physical properties of a muscle fiber, mea- sured in vitro, and then move on to the properties of whole muscles. The fiber will elongate rapidly in response to the applied load and then will appear to reach a steady-state configu- ration. The experi- ment is continued in this fashion with the addition of extra load and al- (a) A (b) σ contracting muscle L resting muscle ε B W 1. The isometric stress–strain re- lation of the fiber during passive relaxed state and fully contracted isometric state is shown in (b). The fiber stress versus sarcomere length in the midregion of the fiber is illustrated in (c). The force–velocity relation of the muscle fiber during iso- tonic contraction is represented in (d).
Patients at high risk and those undergoing high intensity training should only exercise at venues with full resuscitation facilities and staff trained in advanced life support buy cialis super active 20 mg mastercard erectile dysfunction thyroid. Phase III can also be structured to be sited in the hospital for the ﬁrst half order cialis super active 20 mg on line erectile dysfunction doctor manila, and in the community for the second half of phase III CR (Armstrong, et al. This design helps to introduce patients early to a community setting, where phase IV will be based, thus exposing them to a less medical environment and using community facilities. In addition, these may be run as outreach programmes by hospital- based CR professionals, to improve access to services for patients and to overcome space and equipment limitations in hospital sites, or they may be staffed by community health professionals. Recommendations from a British Heart Foundation survey of all CR programmes in England and Wales (Fearnside, et al. SUMMARY The leadership characteristics and roles of the exercise leader and assistants have been described for the ﬁrst time focusing on a UK context. Safety in the delivery of the exercise session and in the use of different equipment is the responsibility of the exercise leader. Protocols for care and use of equipment are also required to be developed by the CR team. Should any medical inci- dent occur, this chapter provides a template for actions to be taken. REFERENCES American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (2004) Guidelines for Cardiac Rehabilitation and Secondary Prevention Programmes, 4th edn, Human Kinetics, Champaign, IL. American College of Sports Medicine (ACSM) (2000) ACSM’s Guidelines for Exercise Testing and Prescription, 6th edn, Williams and Wilkins, Baltimore, MD. American College of Sports Medicine (ACSM) (2001) ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 4th edn, Williams and Wilkins, Baltimore, MD. American Heart Association (AMA) (1998) Operation Heartbeat Implementation Guide, American Heart Association, Dallas, TX. American Physical Therapy Association (2003) Minimum eligibility criteria for cardiovascular and pulmonary physical therapy. Association of the Chartered Physiotherapists Interested in Cardiac Rehabilitation (ACPICR) (2003) Standards for the Exercise Component of the Phase III Cardiac Rehabilitation, The Chartered Society of Physiotherapy, London. Association of the Chartered Physiotherapists Interested in Cardiac Rehabilitation (ACPICR) (2005) Competencies for the Exercise Component of Phase III Cardiac Rehabilitation,CSP, London. British Association for Cardiac Rehabilitation (BACR) (1995) Guidelines for Cardiac Rehabilitation, Blackwell Science, Oxford. British Association for Cardiac Rehabilitation (BACR) (2002) BACR Exercise Instruc- tor Training Module,3rd edn, Human Kinetics, Leeds. Chartered Society of Physiotherapy (CSP) (2002) Physiotherapy Care and Service Standards, CSP, London. Joint Commission on Accreditation of Healthcare Organisations (2002b) Ambulatory care. Cochrane Database for 180 Exercise Leadership in Cardiac Rehabilitation Systematic Reviews. In ACSM’s Resource Manual for Guidelines for Graded Exercise Testing and Exercise Prescription (eds S. Resuscitation Council UK (2000) CPR Guidance for Clinical Practice Training in Hospitals, Resuscitation Council, London. Skills for Health (2004) Coronary heart disease national workforce competence guide: Version 2. Exercise and physical activity in prevention and treatment of atherosclerotic cardiovascular disease. United States Department of Health and Human Services (1996) Physical Activity and Health: A report of the Surgeon General. US Department of Health and Human Services, Centres for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Atlanta, GA. US Department of Health and Human Services, Agency for Health Care Policy and Research and National Heart, Lung and Blood Institute. Thow Chapter outline The previous chapters give the exercise leader both information and practical suggestions on risk assessment, exercise prescription, content and construction for a safe, effective and interesting CR exercise class. There is little literature or guidance on the best practice and skills required not only to lead but also to teach cardiovascular group CR exercise classes. This chapter focuses on the skills required for the exercise leader to teach a CR group class.
Quantitative studies of human move- ment bring to light the healthcare-related issues facing classical mechan- x Preface ics in the twenty-first century quality cialis super active 20 mg erectile dysfunction symptoms age. There are already a number of outstand- ing statics and dynamics books written for engineering students purchase 20 mg cialis super active with amex erectile dysfunction diagnosis. In re- cent years, with each revision, these books have incorporated more ex- amples, more problems, and more colored photographs and figures, a few of which touch on the mechanics of human movement. Nevertheless, the focus of these books remains almost exclusively on the mechanics of man- made structures. It is my hope that Human Body Dynamics exposes the reader not only to the principles of classical mechanics but also to the fas- cinating interplay between mechanics and human body structure. Vector alge- bra and vector differentiation are introduced in the text and are used to describe the motion of objects. Advanced topics such as three-dimensional motion mechanics are treated in some depth. Whenever possible, the analysis is presented graphically using schematic diagrams and software- created sequences of human movement in an athletic event or a dance performance. I have spent long days in the library reading scientific journals on biomechanics, sports biomechanics, orthopaedics, and physical therapy so that I could conceive realistic examples for this book. The references included provide a list of sources that I used in the preparation of the text. The book contains mechanical analysis of dancing steps in classical ballet, jumping, running, kicking, throwing, weight lifting, pole vaulting, and three-dimensional diving. Also included are examples on crash me- chanics, orthopaedic techniques, limb-lengthening, and overuse injuries associated with running. Although the emphasis is on rigid body mechanics and human motion, the book delves into other fundamental topics of mechanics such as de- formability, internal stresses, and constitutive equations. If Human Body Dynamics is used as a textbook for a graduate-level course, I would rec- ommend that student projects on sports biomechanics and orthopaedic engineering become an integral part of the course. The references cited at the end of the text provide a useful guide to the wealth of information on the biomechanics of movement. Human Body Dynamics should be of great interest to orthopaedic sur- geons, physical therapists, and professionals and graduate students in sports medicine, movement science, and athletics. They will find in this book concise definitions of terms such as linear momentum and angular ve- locity and their use in the study of human movement. My colleagues and students at The Catholic University of America helped me refine my teaching skills in biomechanics. Professor Van Mow provided me with generous resources during my sabbatical at Columbia University where I prepared most of the text. Bülent Atabek of The Catholic University of Amer- ica for his careful reading of the manuscript. Professor Atabek corrected Preface xi countless equations and figures and provided valuable input to the con- tents of the manuscript. DiMaggio of Columbia University, also spent considerable time reviewing the manuscript. Rukmini Rao Mirotznik enriched the text with her beautiful sketches and sublime figures. Chernow and her associates contributed to the book with careful editing and out- standing production. The abbreviations kg, m, N, and s stand, respectively, for kilogram, meter, Newton, and second. For simplicity, we omit the superscript when the reference frame is one that is fixed on Earth. Frequently, we omit this superscript when the text clearly indicates which point or body is being referred to. The biggest part of the human body is the trunk; comprising on the average 43% of total body weight. The thighs, lower legs, and feet constitute the remaining 37% of the total body weight. The frame of the human body is a tree of bones that are linked together by ligaments in joints called articulations.
It is important to make a distinction between a coping mechanism and a defense mechanism cialis super active 20mg discount erectile dysfunction causes natural cures. In the examples provided generic cialis super active 20mg amex erectile dysfunction statistics cdc, the individuals employed a rigid, unconscious style of thinking to protect themselves from anxiety, 43 Defense Mechanisms and the Norms of Behavior whereas a coping mechanism implies a desire to meet the troubles and con- tend with them on a conscious or, at worst, a preconscious level. A mal- adaptive defense mechanism is never utilized deliberately or consciously, while a coping mechanism can be called upon to master the problem rather than masking it. We are now ready to examine adaptive adjustment through a discussion of how behavior develops in typical and predictable sequences and how these stages apply both to art therapy and to defense mechanisms. For example, Wilhelm Reich (1949) found a relationship be- tween character and defense formation, while Meissner, Mack, and Sem- rad (1975) have grouped select defenses according to developmental phases. Malerstein and Ahern (1982) in their discussion of character structure had this to say about defense mechanisms: The psyche of a person is not a disjunctive aggregate, but, over the years, has developed into an organized, integrated, abiding system of approaches.... These mechanisms will have certain coherence with each other as well as with the other functions of a person’s psyche. Thus, the whole of the individual must be taken into ac- count, and this includes their nonverbal communication. To this end, art therapy allows the nonverbal expression of unconscious defense mecha- nisms. However, if we now employ the use of developmental theory and couple this with the ensuing defense mechanism, we can arrive at a very accurate clinical picture and create a treatment plan that will beneﬁt the whole person as he or she approaches the world. As stated in the example, the client’s verbalizations, though 45 Defense Mechanisms and the Norms of Behavior abundant, were merely rationalizations about her sexual abuse. She parented her mother and sister to make up for the guilt she felt over having taken away the husband and father. All the difﬁculties that this client exhibited were dealt with outside of herself. Thus, when the stress, humiliation, and shame mounted, she would act out (ultimately on the two people she was parenting—her sister and mother), purge herself of her shame through aggression, and then become the symbol of perfection. She formed a pestle and mortar (penis and va- gina), exploding crowns on the trees, a bodiless person, and on and on. In this client’s case her inductive reasoning surrounded the belief that if bad things happen it is because you are bad. Overall, shame and humilia- tion are prominent as the child begins to struggle with complex problems. Thus, ﬁxated as she was at the intuitive stage of development, rationaliz- ing was her main verbal defense, which made traditional therapy ineffec- tive. Yet with art therapy the thoughts and feelings she had hidden from consciousness were allowed symbolic expression, and the defense mecha- nisms of conversion and reaction formation were then articulated. In the end it is the typical and predictable sequences of behavior that I utilize to guide my use of the art, choice of media, and the ensuing direc- tives. For without a cornerstone to guide us we would be hard pressed to in- terpret the artwork in any manner other than a haphazard one. The art of art therapy is less about how pleasingly the drawing is ren- dered and more about the elements that are either drawn or disregarded. It has been suggested in psychological as well as art literature that individuals project their personality into their drawings. Lowenfeld and Brittain (1982) state, "The child draws only what is actively in his mind. Therefore the drawing gives us an excellent record of the things that are of importance to the child during the drawing process. In the same manner any person, regardless of age, whether versed or not in the art of drawing, utilizes an unconscious process that allows for more freedom than verbalization affords. Other drawings that this client pro- duced showed he was capable of drawing people, places, and environments. Unfortunately, as he emotionally decompensated, his drawings increas- ingly worsened until they took on an infantile quality (which is often char- acteristic of coartated schizophrenics). This is an important distinction to make, as interpre- tation revolves around not only the completed art project but also the cli- ent’s verbal statement regarding the rendering. As Lowenfeld and Brittain (1982) aptly state, To examine the picture without understanding what the child’s intention was, to make assumptions about personality from one example of artwork, or to assess competence in art on the basis of what is included or omitted from the product, does both the product and the child an injustice.
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