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E½cient shape-based algorithms for modeling patient speci®c anatomy from 3D medical images: applications in virtual endoscopy and surgery buy cheap extra super viagra 200mg on line erectile dysfunction and alcohol. Patient speci®c anatomic models: geometric surface generation from 3-dimensional medical images using a speci®ed polygonal budget. Robust 3-D reconstruction and analysis of microstructures from serial histologic sections, with emphasis on microvessels in prostate cancer. Three-dimensional reconstruction of aqueous channels in human trabecular meshwork using light microscopy and con- focal microscopy. Light, electron, and confocal micro- scopic study of the mouse superior mesenteric ganglion. The use of three-dimensional CT scanning in planning head and neck reconstruction. Paper presented at the Plastic Surgical Forum of the annual meeting of the American Society of Plastic and Reconstructive Surgeons. Three-dimensional imaging in craniofacial surgery: a review of the role of mirror image production. Resection of a large temporooccipital parenchymal arteriovenous ®stula by using deep hypothermic circulatory bypass. Paper presented at Applications of Computer Vision in Medical Images Processing, Stanford University, 1994. Perspective volume rendering of CT and MR images: applications for endoscopic imaging. Virtual endoscopy: evaluation using the visible human datasets and comparison with real endoscopy in patients. A new approach to 3-D registration of multi-modality medical images by surface matching. Intracardiac ultrasound guidance of multi- polar atrial and ventricular mapping basket applications. ISBNs: 0-471-38863-7 (Paper); 0-471-21669-0 (Electronic) CHAPTER 2 VEs in edicine; edicine in VEs ADRIE C. That theory was a point of departure for the work by Wheatstone in 1833, to create a breakthrough with his stereoscope. An inge- nious system of mirrors presented depth cues to a subject who looked at two perspective drawings. Yet an- other breakthrough in the long history of VE technology was the demonstra- tion of the experience theater called Sensorama by the American Morton Heilig 33 34 VES IN MEDICINE; MEDICINE IN VES (mid-1950s). Heilig, a photographer and designer of cameras and projectors in Hollywood, devised a machine to stimulate all human senses. The subject in Sensorama experienced the crowd in a street from a motorbike, which could be altered into a helicopter or luxurious car in a split second. VE techniques were developed worldwide by, among others, Ivan Sutherland and David Evans in the 1960s. Revolutionary developments in computer graphics display hardware and software revolutionized airline safety in the form of real-time interactive ¯ight simulators. The real hype started in 1989, when Jaron Lanier, who is often called the step-father of VEs, generated business from VE technology. He succeeded at that time in developing and selling sensor technology to interface the subject with the computer in such a way that a nearly natural communication with the system was possible. The historical experience with interactive ¯ight simulators and their revolutionary e¨ect on airline safety is used today as an argument to proceed with developing simulators for medical training and certi®cation. His e¨ort led Charles Dotter to start experi- menting with threading radio-opaque catheters through blood vessels under ¯uoroscopic-image guidance in the 1960s. Those experiments were a trigger point for the avalance of minimally invasive imaging procedures emerging today in clinical practice. Dotter was the ®rst to interact and intervene with a patient in an indirect way: He looked at shadow images in stead of the patient. This chapter advocates the use of VE technologies in the ®eld of medicine to render medical services in a virtual world: to bring medical care to the patient and to improve care by dedicated training and skills building. Therefore, I start with highlighting the technologies involved with VE and how these technologies create bene®ts for the medical community. The second part of the chapter illustrates that the combined e¨orts of the medical and computer societies have already created real products.

The broad doubly incontinent buy extra super viagra 200 mg otc impotence vs impotence, confused, aphasic, and requiring total categories commonly used to define ethnic minorities— nursing care. African-Americans, American and Alaskan Natives, Her prefracture problem list of (1) degenerative Asian-Americans, and Hispanics—do not capture the osteoarthritis of the knee causing slow gait, (2) atrophic wide array of cultural differences that can affect defini- vaginitis causing urinary urgency, (3) osteoporosis, (4) tion of illness and selection of treatment. It is important cataracts, (5) periodontal disease, (6) type II diabetes to view elders with multicultural sensitivity and to under- mellitus, and (6) coronary insufficiency had never been stand that there may be great heterogeneity within cul- assembled or considered by her physician, who thought tural or ethnic groups. Another unique Her gait had not been evaluated, either for primary challenge is presented by the care of persons who have treatment of the underlying arthritis nor for support with come to the United States in late life, often to join sons a walking aid. Her cataracts had not been considered, nor and daughters who previously emigrated. Late detection of treat- able problems whose neglect and interaction have led to Multiple Pathology functional decline is common in older patients and can Multiple pathology, or concurrence of diseases, is com- be one of the few discouraging features of geriatric care. An early Scottish study of Preventive dental and medical care could have avoided community-dwelling persons over age 65 reported 3. Multiple pathology poses multiple risks to older A second risk is that unidentified multiple pathologies patients and their physicians. The more frail and delicately compensated 82-year-old man with coronary heart disease and im- the patient, the more quickly unattended disease pro- paired systolic function presents to an urgi-center for duces major functional losses; these can be permanent in shortness of breath; treatment is begun with furose- spite of subsequent detection and treatment. Diabetes mellitus (type II, dwelling widow who walks slowly and limps because of diet-controlled), prostatism, and early Parkinsonian left knee pain, who chews incompletely because of gum gait are not considered. Dehydration is precipitated by pain, who sees poorly, and who has urinary urgency and furosemide and exacerbated by poor oral intake result- "a touch of diabetes. The intense diuresis also results in urinary reten- her way to the bathroom to urinate, she is incontinent of tion with overflow incontinence. Now confused, drib- slips, falls backward onto her right greater trochanter, and bling urine, and unsteady, he falls, hits his head on the sustains a hip fracture. The clinical evaluation identifies hyperosmolar dehydration resulting outcome is dismal; no longer able to walk, confused, and from out-of-control diabetes and right intertrochanteric afflicted with three pressure sores and a urethral catheter, hip fracture. Bacteremia is discovered; it and fever are he requires permanent nursing home residence. Treatment is initiated his (1) poorly fitting dentures, (2) diabetes, (3) prostatism, for all these conditions and, on the 5th day, the hip frac- and (4) gait difficulty has transformed a well-intentioned ture is successfully repaired with a compression screw. Perturbation of homeostasis by disease, trauma, or drug toxicity will be manifest in the Functional loss is a final common pathway for most clin- most vulnerable organ, or weakest link, resulting from ical problems in older persons, especially in persons over 30 interactions of biologic aging and chronic disease. Additionally, it may be the only sign or symptom locus of deficit, which reliably identifies the root of of important underlying disease when more specific and pathology in younger patients (immobility originates in typical symptoms of a particular disease are absent. Func- musculoskeletal or neurologic disorders, confusion arises tional impairment means decreased ability to meet one’s from brain disease, incontinence stems from urinary tract own needs and is easily measured by assessing activities problems, and undernutrition is gastrointestinal), is a less of daily living (ADL) and instrumental activities of daily reliable guide in older patients. In addition, objective assessments of nerable systems are likely to decompensate from sys- cognition and behavior and of social, economic, and temic impact of disease anywhere in the body. The lesson emotional state are required to document health-related 31–35 for physicians and for older persons and their families is function of older persons (see Chapter 17). A sys- 36 that functional loss, especially if abrupt, is a reliable sign tematic literature review identified risk factors highly of disease; rapid and comprehensive evaluation is the correlate with functional decline, including cognitive only appropriate clinical response. Blunting or older), impaired functioning and cognition predict 6 absence of typical or classic symptoms and signs is institutionalization. In a study of Presentation of illness in older persons less often is a 55 elderly patients presenting to the emergency room single, specific symptom or sign, which in younger with suspected hypovolemia, seven signs correlated best patients, announces the organ with pathology. Older with dehydration: confusion; extremity weakness; non- persons often present with nonspecific problems that 29,37 fluent speech; dry mucous membranes; dry tongue; are in fact functional deficits. None of these find- drinking, or the new onset of falls, confusion, lethargy, 39 ings is particularly helpful when present in isolation. Likewise, among patients 70 years syndromes; they devastate independence without pro- and older, hyperthyroidism infrequently presented with ducing obvious or typical indications of disease. Geriatric tremor, hyperactive reflexes, increased sweating, heat syndromes may be defined as a set of lost specific func- intolerance, nervousness, polydipsia, and increased tional capacities potentially caused by a multiplicity of appetite.

A sys- 36 that functional loss purchase 200mg extra super viagra erectile dysfunction johnson city tn, especially if abrupt, is a reliable sign tematic literature review identified risk factors highly of disease; rapid and comprehensive evaluation is the correlate with functional decline, including cognitive only appropriate clinical response. Blunting or older), impaired functioning and cognition predict 6 absence of typical or classic symptoms and signs is institutionalization. In a study of Presentation of illness in older persons less often is a 55 elderly patients presenting to the emergency room single, specific symptom or sign, which in younger with suspected hypovolemia, seven signs correlated best patients, announces the organ with pathology. Older with dehydration: confusion; extremity weakness; non- persons often present with nonspecific problems that 29,37 fluent speech; dry mucous membranes; dry tongue; are in fact functional deficits. None of these find- drinking, or the new onset of falls, confusion, lethargy, 39 ings is particularly helpful when present in isolation. Likewise, among patients 70 years syndromes; they devastate independence without pro- and older, hyperthyroidism infrequently presented with ducing obvious or typical indications of disease. Geriatric tremor, hyperactive reflexes, increased sweating, heat syndromes may be defined as a set of lost specific func- intolerance, nervousness, polydipsia, and increased tional capacities potentially caused by a multiplicity of appetite. For example, roid patients than in younger patients were anorexia dizziness among community-dwelling elderly people was and atrial fibrillation. Only three signs occurred in more shown to be associated with seven characteristics: anx- than half the older patients: tachycardia, fatigue, and iety; depressive symptoms; impaired hearing; use of weight loss. Goiter, seen in 94% of younger patients, pre- five or more medications; postural hypotension; impaired 44 38 sented in only 50% of the older subjects. Comprehen- attention to the muted picture of lobar pneumococcal sive evaluation is usually required to identify and treat pneumonia: "Pneumonia in the aged may be latent and underlying causes. Although in many instances a geriatric set in without a chill; the cough and expectoration are syndrome has several contributing causes, remedying slight, the physical signs ill-defined and changeable, and even one or a few may result in major functional the constitutional symptoms out of all proportion to the improvement. Clinical Approach to the Older Patient 153 Evaluating the Patient patient is dressed appropriately to the outside tempera- ture. Accordingly, examining rooms should be kept be- Much of what has been written on evaluation of the older tween 70°F and 80°F. Brighter lighting is required for patient is simply attention to the details of careful clini- adequate perception of the physician’s facial expression cal assessment. Contemporary emphasis on efficiency and gestures by the older patient, whose lenses admit less and effectiveness of clinical care requires thoughtfulness than half the light they did in youth, due to cross-linking about any extension of the already lengthy evaluation of lens proteins. Brief screening questions background noise more distracting and interferes with rather than elaborate instruments are appropriate for the patient’s hearing. Even in a quiet setting, the high- first encounters52; more detailed assessment should be tone loss of presbycusis makes consonants most difficult 35 to discriminate; speaking in a lower-than-usual pitch will reserved for patients with demonstrated deficits. Even at its most parsimonious, the initial evaluation of older help the patient hear, and facing the patient directly will patients with multiple disorders and treatments will gen- improve communication by allowing lip reading. The erally be prolonged, as compared with time needed for patient’s eyeglasses, dentures (to enhance the patient’s younger persons. Dividing the new patient assessment speech), and hearing aid (with a functional battery) into two sessions can spare both patient and physician an should always be brought to and used at the physician exhausting and inefficient 2-h encounter. Chairs with a higher-than-standard seat or a personnel can collect much information by questionnaire mechanical lift to assist in arising are useful for frail older before the visit, from previous records, and from patient persons with quadriceps weakness, and a broad-based and family before the physician’s contact. It is essential step stool with handrail can make mounting and dis- that good care, fully informed by current geriatrics mounting the examining table safe. Drapes for the knowledge, be delivered within a reasonable time alloca- patient should not exceed ankle length so as not to be a tion consistent with contemporary patterns of primary risk for tripping and falling. One hour for a new visit and 30 min for a follow-up are an absolute maximum in most environments. The Acute Hospital or Nursing Home Completing a home visit may also provide valuable The patient room is commonly the site of evaluation for insight into a patient’s environment and daily functional the nursing home resident or hospitalized older adult. How mobility may affect function in a particular Little is different in evaluating older persons in the hos- environment, real insight into nutrition, medication use pital; the patient is usually confined to bed, so that safety and compliance, and social interactions and support can and comfort are dictated by the hospital amenities. In one well- other considerations relevant in the ambulatory setting designed trial, in-home comprehensive geriatric assess- apply.

WHEN GAMES ARE POOR MODELS Whenever internal values are maximized generic extra super viagra 200mg otc erectile dysfunction doctor in philadelphia, external concerns tend to get short shrift, which has been pointed out by many authors in many contexts. What has not been brought out so distinctly, however, is the absolute dependency of games on their external support, and the vulnerability of such games to failure and abandonment in the wider context when externalities are ignored. The big money, petulant behavior and lack of respect for academic values which has been increasingly manifested in college sports risks undermining university-wide support for the emphasis on winning itself. High-debt strategies for maximizing the return on equity leave companies with no reserves for coping with downturns. Layoffs and plant closings in rapid response to drops in demand, when widespread, accentuate drops in demand and sharpen recessions. Over aggressive sales policies, poor quality control, careless environmental protection, cuts in research and development and discon- tinuation of low-profit product lines result in adverse publicity, lawsuits, high insurance costs, fines, antitrust actions and consumer dissatisfaction. In the medical arena, specifically, "charging all that the market will bear" on the part of drug companies, insurance and health organization executives and certain physicians degrades the standing of the entire health system and risks a response that may throw out the good with the bad. Species most perfectly and efficiently (and therefore narrowly) adapted to their environments go extinct more easily with environ- mental fluctuation and permanent change. Extreme preventive regimens and onerous treatments may make life not worth living. Thus, the long term survival and flourishing of activities promoting specific values depends upon reasonable integration with and respect for other values. As was indicated earlier with respect to economic, aesthetic and moral values; when one leg of this tripod gets too long it will tip over. If games are poor stand-ins for most endeavors, "utility" is even less representative of various satisfactions. Bentham’s original identification of utility with pleasures and pains at least had the merit of excluding something, since not all behaviors were interpreted as somehow maximizing pleasure and minimizing pain. It was assumed that we know what pleasures and pains are without taking a poll based on imputations from observed behavior. But establishing any connotation for pleasure and pain necessitates the inconvenience of arguing for it. Arguments for a hedonistic utility must show that intuitions about pleasure and pain are widely shared, and also that they are "justified" in the sense that indulgence of them is not self-defeating. The pleasure-principle itself does not sufficiently adjudicate between immediate and long-term pleasures, for example, or between the pleasures of a despot and those of his slaves. Considerations of justice and fairness keep creeping back in, with all their attending controversy. Enormously complex decision rules for honoring whose pleasure, when and where can become even more formidable than the hedonistic calculus itself. And then, as many authors have pointed out, qualitatively disparate pleasures and pains truly do not fit any mold or measure. As if these difficulties were not enough, the hedonistic theory does not know what to make of shortcuts like direct electrical and chemical stimulation of the brain to produce pleasure. Why undergo any kind of prolonged endeavor or delay of grati- fication if the most intense ecstasies can be produced instantly? Eventual suffering weighs only quantitatively against drug derived or electrostimulated instant gratifi- cation for this theory; and according to many eyewitness reports, these experiences can be so intense that merely quantitative arguments against them, based on adverse consequences, are not compelling. Difficulties with quantifying pleasure as well as the seeming crassness of hedonism invite the consideration of alternate concepts. The most prominent of these, called "decision utility" by Daniel Kahneman,38 infers utility from preference. The idea is that strengths of preference might be easier to measure than strengths of pleasure or pain, so that a study of preferences could be the key to determining the utility of their objects. But subjective expected utility, outside of games, requires that preferences as indicated by people’s decisions stand in a one-to-one relationship to the utility of the ends preferred. Multiple problems with this notion have become apparent, as already discussed in connection with the basic axioms and enumerated below: 1. These judgments are subject to continuing modification because perspectives and context alter, contrasts enhance or dim, and remembrance is not reduplication. Try to remember the quality of one piece of music, for example, when another one is playing. Therefore, as noted previously, attempts to identify ends on the basis of behaviors can overestimate the extent to which those behaviors are goal-directed as opposed to merely expressive or random.

Defining Risk of Occult Spinal Dysraphism Summary of Evidence: The prevalence of OSD ranges from as low as 0 order extra super viagra 200 mg without prescription erectile dysfunction treatment testosterone replacement. Supporting Evidence: Children in the low-risk group included those with simple skin dimples as the sole manifestation, or newborns of diabetic mothers. Intergluteal dimples over the sacrococcygeal area rarely extend into the spinal canal (40,41,43). Caudal regression syndrome has been reported in children born to diabetic mothers (42). The prevalence (pretest probability) of a dysraphic lesion among low-risk patients has been esti- mated at 0. Children in the intermediate-risk group included those with complex skin stigmata (hairy patch, hemangiomas, lipomas, and well-defined dorsal Table 18. Risk groups for occult spinal dysraphism Variable Baseline value Reference Low-risk group Offspring of diabetic mothers 0. Chapter 18 Imaging of Spine Disorders in Children 341 dermal sinus tracks), or low and intermediate anorectal malformations. The prevalence (pretest probability) of a dysraphic lesion among intermediate- risk patients has been estimated at 27% to 36% (Table 18. Children in the high-risk group included those with high anorectal malformations, cloacal malformation, and cloacal exstrophy. The preva- lence (pretest probability) of a dysraphic lesion among high-risk patients has been estimated at 44% to 100% (Table 18. What Is the Natural History and Role of Surgical Intervention in Occult Spinal Dysraphism? Summary of Evidence: Early detection and prompt neurosurgical correction of occult spinal dysraphism may prevent upper urinary tract deterioration, infection of dorsal dermal sinuses, or permanent neurologic damage (44–48) (moderate and limited evidence). Several studies have demon- strated that motor function, urologic symptoms, and urodynamic patterns may be improved, stabilized, or prevented by early surgical intervention in patients with occult spinal dysraphism (49,50) (moderate and limited evidence). The surgical outcome may be better if intervention occurs before the age of 3 years (49–51) (moderate and limited evidence). Spinal neu- roimaging, therefore, has the important role of determining the presence or absence of an occult spinal dysraphic lesion so that appropriate surgi- cal treatment can be instituted in a timely manner. At our institution, occult dysraphic lesions diagnosed in the newborn period are usually operated at age 2 to 3 months. Therefore, if ultrasound is indicated, it is performed in the early newborn and infancy period to avoid a limited sonographic window from posterior element mineralization (52,53). Supporting Evidence: In the newborn period most children with OSD are neurologically asymptomatic (29). Symptoms from occult spinal dys- raphism are often not apparent until the child becomes older and is ambu- lating (29) (moderate evidence). The most common clinical presentations for occult dysraphic patients later in life include delay in walking, delay in development of sphincter control, asymmetry of the legs or abnormali- ties of the feet (i. Several studies have demonstrated improvement of the multiple symp- toms associated with occult dysraphism if surgical intervention is per- formed (49–51) (moderate and limited evidence). However, there are differences in outcome depending on the timing of surgery (51). Using surgical outcome data from the study by Satar and colleagues (51), in the children diagnosed and surgically treated before the age of 3 years, 60% became asymptomatic, 30% were unchanged, and 10% worsened. Con- versely, the same study data for the children diagnosed and surgically treated after age 3 years demonstrated that 27% became asymptomatic, 27% improved, 27% were unchanged, and 19% worsened (51). Dysraphic patients with a central nervous system communicating dorsal dermal sinus (i. Meningitis in the patient with a communicating dorsal dermal sinus may be caused by aggressive 342 L. Meningitis mortality rate in patients with communicating dorsal dermal sinus ranges between 1% and 12% (58–62) (limited evidence). Severely symptomatic patients with dysraphism are at high risk of upper urinary tract deterioration (30,63). In this population up to 15% may have upper urinary tract deterioration (30,63) and of those with progressive renal damage, 7.

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