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By H. Grompel. Maine Maritime Academy.

Copying or distributing in print or electronic forms without written permission of Idea Group Inc discount protonix 20 mg on-line. It has been argued that KM evolved from the applications of expert systems and artificial intelligence (Liebowitz & Beckman, 1998; Sieloff, 1999). Almost all of the definitions of KM state that it is a multi-disciplinary paradigm (Gupta, Iyer & Aronson, 2000) that has further accentuated the controversy regarding the origins of KM. One of the main factors behind widespread interest in KM is its role as a possible source of competitive advantage (Havens & Knapp, 1999; Nonaka, 1991). A number of leading management researchers have affirmed that the Hungarian chemist, economist and philosopher Michael Polanyi was among the earliest theorists who popularized the concept of characterizing knowl- edge as “tacit or explicit” which is now recognized as the accepted knowledge catego- rization approach (Gupta et al. The cornerstone of any KM project is to transform tacit knowledge to explicit knowledge so as to allow its effective dissemination (Gupta et al. Authors such as Blackler (1995) have reiterated that the concept of knowledge is complex and, in an organizational context, its relevance to organization theory has not yet been sufficiently understood and documented. This is one of the fundamental reasons why KM does not have a widely accepted framework that can enable healthcare institutions in creating KM systems and a culture conducive to KM practices. KM is underpinned by information technology paradigms such as Workflow, Intelligent Agents and Data Mining. According to Manchester (1999), a common point about software technologies such as (1) information retrieval, (2) document management and (3) workflow processing is that they blend well with the Internet and related technologies (i. As KM deals with the tacit and contextual aspects of information, it allows an organi- zation to know what is important for it in particular circumstances, in the process maximizing the value of that information and creating competitive advantages and wealth. Applicability of the KM Paradigm in Healthcare A KM solution would allow healthcare institutions to give clinical data context, so as to allow knowledge derivation for more effective clinical diagnoses. In the future, healthcare systems would see increased interest in knowledge recycling of the collaborative Copyright © 2005, Idea Group Inc.

Buckup effective 20 mg protonix, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. The affected arm is held in a middle position alongside the trunk with the elbow flexed 90°. The patient is asked to rotate his or her head toward the contralateral side (away from the side being examined). Assessment: Weakening or loss of the pulse in the radial artery, pain in the shoulder and arm, ischemic changes, and paresthesia are signs of a costoclavicular syndrome (compression of the subclavian artery be- tween the first rib and the clavicle) or of a scalene muscle syndrome (compression of the neurovascular bundle between the middle and anterior scalene muscles due to fibrosis or hypertrophy). Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Procedure: The patient is asked to supinate both arms and raise them to 90° while keeping his or her eyes closed. Procedure: The patient is supine and is asked to close his or her eyes and flex both hips and both knees. Assessment: The neurologic examination of the lower extremities in a patient capable of standing and walking begins with inspection of gait. With the Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Strength in the extensor digitorum and hallucis longus is tested by dorsiflexion of the toes (L5) against resistance, and strength in the triceps surae is tested by plantar flexion of the foot (S1) against resist- ance. It does so by highlighting those features of anatomy which are of clinical importance using a vertical blue bar, in radiology, pathology, medicine and midwifery as well as in surgery. It presents the facts which students might reasonably be expected to carry with them during their years on the wards, through their final examinations and into their postgraduate years; it is designed for the clini- cal student. Anatomy is a vast subject and, therefore, in order to achieve this goal, I have deliberately carried out a rigorous selection of material so as to cover only those of its thousands of facts which I consider form the necessary anatomical scaffolding for the clinician. Wherever possible practical appli- cations are indicated throughout the text— they cannot, within the limita- tions of a book of this size, be exhaustive, but I hope that they will act as signposts to the student and indicate how many clinical phenomena can be understood and remembered on simple anatomical grounds.

This age dependence of the rate of renal drug se- plicating observation is that a drug may primarily in- cretion may have important therapeutic implications hibit active reabsorption at one dose and active secre- and must be considered by the physician who prescribes tion at another discount protonix 20 mg otc, frequently lower, dose. The transport Prostaglandins Neostigmine mechanism is in the luminal portion of the membrane of the Salicylate Quinine proximal tubular cell. This is drugs pass through the hepatocyte membrane by diffu- offered as an explanation for the apparently paradoxi- sion. The subsequent passage of substances into the bile, cal effects of low and high doses of drugs on the total however, is much more selective. Compounds of group A are those whose concentration in bile and plasma are almost identical (bile–plasma ra- tio of 1). Extent of active tubular secretion of the com- However, biliary excretion plays a major role (5–95% of pound the administered dose) in drug removal for some an- 5. Possibly, extent of active tubular reabsorption ions, cations, and certain un-ionized molecules, such as cardiac glycosides. In addition, biliary elimination may Changes in any of these factors may result in clini- be important for the excretion of some heavy metals. In the final Cardiac glycosides, anions, and cations are trans- analysis, the amount of drug that finally appears in the ported from the liver into the bile by three distinct and urine will represent a balance of filtered, reabsorbed independent carrier-mediated active transport systems, (passively and actively), and secreted drug. For many the last two closely resembling those in the renal proxi- drugs, the duration and intensity of pharmacological ef- mal tubules that secrete anions and cations into tubular fect will be influenced by the status of renal function, urine. As is true for renal tubular secretion, protein- because of the major role played by the kidneys in drug bound drug is completely available for biliary active and metabolite elimination. Thus, the ability cleared by the kidney, and the potential for drug toxic- of certain compounds to be actively secreted into bile ity, especially if renal function is reduced.

As will be noted below under the discussion of prevention and treatment cheap protonix 20mg with mastercard, dietary and other prescriptions are to some extent based on dosha predominance and imbalance. A more comprehensive understanding of the effects of the doshas in the physiology requires an appreciation of sub-doshas of Vata, Pitta and Kapha. These are five named Ayurvedic medicine 179 subdivisions for each of the doshas, related to locations in the body where each dosha 37,38 exerts its influence. As will be discussed later, the first sub-dosha of Vata, prana vata, is responsible for the Vata influence on CNS function. PRAGYA APARADH AND THE BASIS OF ILLNESS The normal functioning of the physiology on the basis of balance of the doshas, the production of ojas, balanced dhatus and agnis and clear shrotas is, from a Vedic perspective, the normal state of the physiology. This is the state of human physiology that is able to reflect its infinite, unbounded source, the unified field underlying physiology, which we have previously identified as Consciousness. Less than perfect functioning of physiology is considered a result of less than perfect expression of Consciousness into matter or, more specifically, human anatomy and physiology. It is the intellect that loses sight of the unified field and identifies with the ever-changing relative values of physiology instead. These derangements involve the doshas, shrotas, agnis and dhatus, the lack of ojas—the finest product of Table 1 Characteristics of individuals in whom one of the doshas predominates Vata Pitta Kapha Light, thin build Moderate build Solid, heavier build Acts quickly Acts with medium speed Slow, methodical Averse to cold weather Averse to hot weather Averse to damp weather Irregular digestive power, Strong digestion, sharp appetite Slow digestion, mild irregular appetite Medium time to learn, medium appetite Quick to learn memory Slow to learn Quick to forget Tends to anger Slow to forget Tendency to worry Regular elimination Tranquil, steady Tendency to constipation Sometimes loose or frequent Regular elimination Vivacious, always moving stools Heavy, long sleep Stamina, Light, interrupted sleep, about 6h Sound sleep, medium length strength Tends to fatigue, less physical Enterprising, sharp Dark, full hair stamina Thin, fair hair Oily, smooth skin Curly hair more likely Reddish complexion, moles and Prominent joints, tendons and freckles veins Early graying or balding Dry skin Complementary therapies in neurology 180 Reproduced with permission from Elsevier from Sharma HM, Clark C. If pragya aparadh, the mistake of the intellect, allows the physiology to lose sight of the unified field at its basis, and thus entertain disease, then it is logical that a technique that allows for the direct experience of that unified field on the level of consciousness, the TM technique, should stand as the single most important therapeutic technique in Vedic medicine. Whether from an ayurvedic perspective an illness is due to weakened or excessive Vata, Pitta or Kapha, or a derangement of agni, dhatus or shrotas, experience of the unified field should enhance the re-establishment of homeostasis. The mechanism of the therapeutic effect of the TM technique is intriguing from a neurological perspective.

One general base for a BCI is that music or visual or motor imagery modifies neuronal activity and can result in measurable changes in firing patterns of cortical neurons and in the ongoing EEG and ECoG order 40 mg protonix free shipping. Aside from these, there are the important and established field of neurofeedback therapy and the upcoming field of multimedia and virtual reality applications. In this context, a BCI could be used for diverse tasks such as playing games or providing multidimensional feedback in virtual reality. Concerning the last point, BCI adds a new dimension in man–machine interaction and may be of great importance in multimedia applications. A BCI system is, in general, composed of the following components: signal acquisition, preprocessing, feature extraction, classification (detection), and appli- cation interface (Figure 14. The signal acquisition component is responsible for recording the electrophysiological signals providing the input to the BCI. Depending on the type of analyzed brain signals and the processing mode, sensory stimulation may be necessary. The classifier output is trans- formed into a device command, which, at the same time, provides feedback to the user. This can include artifact reduction methods and the application of advanced signal processing methods. After preprocessing, the signal is subjected to the feature extrac- tion algorithm. The goal of this component is to find a suitable representation (signal features) of the electrophysiological data that simplifies the subsequent classification or detection of brain patterns. That is, the signal features should encode the com- mands sent by the user, but should not contain noise and other patterns that can impede the classification process. A list (not exhaustive) of these methods includes amplitude measures, band power, Hjorth parameters, autoregressive models, and wavelets.