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By U. Arokkh. Hannibal-LaGrange College.

For ease of administration I will outline the components necessary for introduction of the technique discount 60 mg raloxifene fast delivery. First I must state that prior to any art as- sessment I perform a verbal interview (which includes a mental status exam) discount raloxifene 60mg visa. This procedure affords an opportunity to bond and often offers in- formation that will later clarify issues that arise during the art production. Some clinicians prefer to offer the client a single pencil with eraser; I, on the other hand, prefer to offer a pack of fine-line markers or colored pen- cils. I have found that giving the client a range of colors with which to work yields another layer of personality dynamics, diagnostic indicators, and in- formation that is missing from an achromatic drawing. In addition, the cli- ent is unable to erase with a fine-line marker, and the client’s reaction to this limitation offers information on frustration tolerance and problem solving. Secondary to the markers, I offer each client the same type of 9" × 12" drawing paper (80-pound weight). This paper allows the client to work with a large drawing surface and is a weight that works well with markers, pen, pencil, and watercolors. The room should have ample space for the examinee to rest comfortably while drawing. With these considerations in place we are ready to introduce the projective test to the client. Give the client this directive: "Using as many or as few colors as you like, draw the best person you can. It is best to counter these state- ments with gentle prompting, such as "this is not a test of your artistic tal- ent. Once the figure is complete, have the client give it a name and write it on the paper. This helps to identify the sex, as sometimes clients will draw a figure in a manner that is at best asexual. Once you have deciphered the gender, provide the client with another sheet of paper and ask the exami- nee to "draw a male/female/boy/girl," whichever represents the opposite sex to the first figure. After the client has completed this drawing, ask him or her to give this drawing a name and write it on the paper. I then place 117 Reading Between the Lines both drawings side by side and request that the client "tell me something about these two. If he or she is having a difficult time, I ask the client to "choose one that you want to talk about first. As for the first concern, the client will draw as you request, sometimes only with the aid of positive reinforcement, but they will draw regardless of age or gen- der. Most clients’ objections arise from the thought of having to draw and their lack of ability rather than an outright rejection of the task. If you are comfortable with the request and sensitive yet firm in response to your cli- ent’s protestations, you will end up with an art production. With regard to note taking, this is a matter of comfort and personal pref- erence. Depending upon your training, you may have been instructed to take copious notes, use recall after the session, or use some combination of notes and recall. Throughout the years I have developed an ability to write in a shorthand that allows me to combine the two. However, when the cli- ent is relating the story of the figures I prefer to take notes verbatim. It is important not only to have this as a record for later use but also to use the statements, as noted earlier, when seeking a symbolic abundance of ideas. Often the words of an examinee can convey a metaphor that becomes im- portant when looking at the assessment as a whole. Before we review case illustrations, the directives for the DAP art as- sessment are as follows: • Direct the client: "Using as many or as few colors as you like, draw the best person you can. However, the client’s personal informa- tion has been replaced to retain confidentality.

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Interventions can include individual patient care or population health activities (for example purchase 60mg raloxifene, screening for diseases such as cervical or prostate cancer) generic 60mg raloxifene mastercard. Example 1 A 28-year-old male presents with recurrent furunculosis for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. To convert this to an answerable question, use the P I C O method as follows : P Population/patientPopulation/patient = patients with recurrent furunculosis II Intervention/indicatorIntervention/indicator = prophylactic antibiotics CC Comparator/control = no treatment O Outcome = reduction in recurrence rate of furunculosis Question: ‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate? Other interventions you know about are nicotine replacement therapy and antidepressants. Develop a clinical research question using P I C O: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 27 Example 3 At a routine immunisation visit, Lisa, the mother of a -month-old, tells you that her baby suffered a nasty local reaction after her previous immunisation. Recently, a colleague told you that needle length can affect local reactions to immunisation in young children but can’t remember the precise details. Develop a clinical research question using P I C O to help you find the information you need: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 28 Example 4 In browsing one of the medical weeklies, you come across mention of imiquimod cream for treatment of basal cell carcinomas (BCC). Te idea of a cream for BCCs is surprising, so you wonder about the effectiveness and particularly the long-term cure rate of imiquimod cream. Develop a clinical research question using P I C O to help answer your query: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 29 Aetiology and risk factors Questions of aetiology and risk factors are about what causes a disease or health condition. Tey are the reverse of intervention questions because they deal with the harmful outcomes of an activity or exposure. Such questions commonly arise in relation to public health issues, such as whether eating certain foods increases the risk of heart disease, or being exposed to an environmental chemical increases the risk of cancer, and so on. Example 1 George has come in to your surgery to discuss the possibility of getting a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life. P Population/patientPopulation/patient = adult males II Intervention/indicatorIntervention/indicator = vasectomy CC Comparator/control = no vasectomy O Outcome = testicular cancer Question: ‘In men, does having a vasectomy (compared to not having one) increase the risk of getting testicular cancer in the future? She has been reading about the potential benefits and harms of giving newborn babies vitamin K injections. She is alarmed by reports that vitamin K injections in newborn babies may cause childhood leukaemia. Develop a clinical research question using P I C O to help answer Susan’s question: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 31 Frequency or rate Questions of frequency (prevalence) are about how many people in the population have a disease or health problem, such as what is the frequency of hearing problems in infants or the prevalence of Alzheimer’s disease in the over 70s. If the question also includes a time period, such as for cases of influenza in winter versus summer, it becomes a question of rate (incidence). P Population/patientPopulation/patient = infants II Intervention/indicatorIntervention/indicator = premature CC Comparator/control = full-term O Outcome = sensorial deafness Question: ‘In infants born prematurely, compared to those born at full term, what will the prevalence of sensorial deafness be? She has never had such pain before and is convinced that it must be caused by something really serious. You take a history and examine her but find no indicators of a more serious condition. You reassure her that the majority of acute low back pain is not serious but she is still not convinced. Develop a clinical research question using P I C O to help reassure Mrs Smith: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 33 Diagnosis Diagnosis questions are concerned with how accurate a diagnostic test is in various patient groups and in comparison to other available tests. She had her first baby when she was 33 and had amniocentesis to find out if the baby had Down syndrome. Te test was negative but it was not a good experience as she did not get the result until she was 18 weeks pregnant. She is now 35, one month pregnant and asks if she can have a test that would give her an earlier result. Te local hospital offers serum biochemistry plus nuchal translucency ultrasound screening as a first trimester test for Down syndrome. You wonder if this combination of tests is as reliable as conventional amniocentesis.

The choice of which assessment instrument to use is Another element to consider is the contrast between based on a careful consideration of its relative strengths measures of capacity and those of performance generic raloxifene 60 mg on-line. For instance 60 mg raloxifene with visa, comprehensive but lengthy interview-based Capacity refers to what patients report they are able to questionnaires may be appropriate for research settings do. As the task or skill at issue is not actually performed but not in clinical practice. Patients are usually unwilling in an observed setting, the rating process can be com- to submit to prolonged interviews, and practitioners are pleted quickly. The chief disadvantage of capacity assess- fulfill all these requirements, these principles should be ment is the reliance on patients’ subjective estimates considered when deciding whether it is worth assessing a of their abilities. Because some patients function substantially below their capacity, this approach may underestimate their functional ability. Dimensions of Geriatric Assessment Performance-based measures are direct observations of particular actions. Advantages include an increase in Cognitive Function objectivity as patients’ biases and those of their proxies are minimized. Disadvantages include the need to train Assessment of the cognition of elderly patients generally the observer and the costs for specialized equipment to focuses on detection of dementia and delirium. Although create the task being observed: an audiometer to create these two conditions can be distinguished by time course, a tone, stairs to climb, etc. In fact, the presence of dementia is a risk factor for Patient factors may also affect the performance of the the development of delirium in elderly hospitalized instrument in clinical settings; these include educational patients. Finally, each test has a limited range in which it is sen- The prevalence of dementia, an acquired, progressive sitive, commonly referred to as ceiling and floor effects. Therefore, the yield of screening for cognitive impair- ment because virtually everyone scores at the top. Because the initial Conversely, a floor effect is when everyone scores at the phases of impairment can be quite subtle, it can be dif- bottom of the scales. For example, in a population of ficult for a clinician to make the incidental discovery healthy community-dwelling older persons, the ceiling of cognitive impairment. Structured examination tech- effect would apply if one measured basic activities of niques may be helpful in detecting early dementia. Such daily living (BADL, discussed below); almost all the detection has become increasingly important because a patients are able to complete all the relevant tasks. Sim- number of pharmacologic and behavioral interventions ilarly, in a nursing home population, almost all patients have been shown to slow the progression of symptoms will be dependent in all items of the instrumental activi- and delay nursing home placement for patients with ties of daily living scale (IADL; discussed below); thus, moderate Alzheimer’s disease. Practitioners must be aware of the range of bers and caregivers to plan for the future. It principles of screening derive from preventive services is easy to apply and interpret. Screening has been defined as using "a test or be given by office staff after minimal training. It requires that the least five requirements for screening: (1) a screening test patient answer many of the same orientation questions as must have acceptable sensitivity and specificity; (2) the the MMSE but also asks for the name of the current and test must detect a condition in a presymptomatic stage; past president, the patient’s mother’s maiden name, and (3) there must be a proven treatment for this condition; his or her birthday, address, and phone number. As the (4) there must be additional benefit derived from receiv- questionnaire is shorter, it takes less time to administer. Reuben Other useful and rapidly administered tests are the attention, such as digit span or stating the months of the Clock Drawing task and the Time and Change test. Both year backward, may also help detect delirium at an early are performance-based tests. Because of the temporal variability that is the hall- tive function and visuospatial skills by having the patient mark of delirium, a patient may seem entirely lucid at the draw a clock face and place the hands at 10 min after 11 time of evaluation. There are standardized scoring methods17 for the out reports from collateral informants, family or nurses. It is associated with sig- shown to be accurate in both inpatient and outpatient nificant morbidity and mortality. A score under 15 is considered abnormal,22 concise approach, a single question screen,"Do you often although there are concerns about its sensitivity even at feel sad or depressed? In one trial, 17% of demented patients affirmatively, it should be followed by the 30-question demonstrated a perfect score. The single question may be as accurate to any lists of relevant words before the test begins and in identifying depression as the long version of the GDS,37 are expected to create their list de novo. This test exam- although this technique identifies too many false posi- ines a number of cognitive domains including language, tives to be useful as a screening instrument.

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First generic 60mg raloxifene otc, the left arm must rotate in the same direction as the right leg and vice versa to cancel the contributions of arm and leg swing to the moment of momentum of the human body generic raloxifene 60 mg with amex. Second, because the lower limbs are longer and heavier than the upper limbs, the arms must rotate faster to cancel out the twisting effect of the legs. As the arms and the legs have the same period of swing, the way to achieve zero moment of momentum from swing is to increase the amplitude of swing of the arms while also increasing their rate of rotation. Linear momentum of a system of particles is defined as the sum of the products of the mass of each particle with its velocity: L 5S(mi vi) in which mi is the mass of particle i and vi is its velocity. Writing Newton’s second and third law for each particle in a system of particles and sum- ming over all particles in the system, one can show that dL/dt 5SFi where SFi denotes the sum of all external forces acting on the system of particles. Gravitational force and the forces that arise as the result of contact of particles in the system with the particles outside the system are external forces. Newton’s third law re- quires that forces that act between particles in the system under study do not contribute to the change of linear momentum. The center of mass of a system of particles is defined by the relation: (Smi) rc 5S(mi ri) in which rc denotes the position of center of mass with respect to a Carte- sian reference frame and ri is the position vector of particle i. The center of mass is not necessarily occupied by any particle in the system of par- ticles. Using this definition in the equation for the conservation of linear momentum, one obtains an equation governing the position of the cen- ter of mass as a function of time: SFi 5 (Smi) ac in which ac is the acceleration of the center of mass. The term moment of momentum about a point fixed on earth is defined by the following equation: Ho 5Sri/o 3 mivi in which ri/o denotes the position vector from the stationary point O to the particle i. The conservation of moment of momentum dictates that dHo/dt 5Sri/o 3 Fi Again, in this equation, Fi represents the external force i acting on the ith particle of the system. Conservation of moment of momentum about the center of mass is governed by an equation of the same form: dHc/dt 5Sri/c 3 Fi where Hc 5Sri/c 3 mivi and ri/c is the position vector from the center of mass to the particle i. During a triple axel, a figure skater covers a horizontal dis- tance of 3 m and reaches a maximum height of 0. In speed skating, the skater pushes off against the ice as the skate is gliding forward (Fig. The direction of push-off is per- pendicular to the gliding direction of the skate. This action results in a sinusoidal trajectory of the center of mass of the skater when skating along the straightaways. A sideways push off the right leg causes a left- ward movement of the center of mass and vice versa. During the side- ways push-off of the right leg of a 70-kg skater, projection of the push- off force onto the horizontal plane was measured to be 3600 N. The velocity of the center of mass before the pushoff was in the direction of gliding and the speed was equal to 15 m/s. Determine the speed of the center of mass immedi- ately after the completion of the push-off. The curved line in (b) that is identified with symbol C represents the path of the center of mass of the skater whereas the straight line along the e1 axis represents the path of the skate A. Note that e1 and e2 make a right-handed co- ordinate system in the horizontal plane. Using a palms-down grip and hands close together, an ath- lete holds a barbell at the thighs at 0. Then he pulls the barbell up to his chin with an acceleration of 6 m/s2 upward (Fig. Let u and f be the angles the forearm and the upper arm make with the horizontal axis e1, as shown in Fig. Using the fact that the horizontal distance between the man’s two hands (D) does not change during the chin-ups, develop an equation that relates u to f. Let u and f be the angles the forearm and the upper arm make with the horizontal axis e1. Assuming also that d2f/dt2 5 2 rad/s2 at t 5 0, determine the force (F) exerted by the hold- ing bar on the fists of the man at the initiation of motion.

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Several studies have shown that the timing of CT studies also affects the sensitivity generic 60mg raloxifene amex. Oertel and colleagues (30) (strong evidence) prospectively studied 142 patients with moderate or severe injury who had undergone more than one CT scan within the first 24 hours discount 60mg raloxifene otc, and found that the initial CT scan did not detect the full extent of hemorrhagic injuries in almost 50% of patients, particularly if scanned within the first 2 hours. The likelihood of progressive hemorrhagic injury that potentially required sur- gical intervention was greatest for parenchymal hemorrhagic contusions (51%), followed by epidural hematoma (EDH) (22%), subarachnoid hem- orrhage (SAH) (17%), and subdural hemorrhage (SDH) (11%). Servadei and colleagues (31) (strong evidence) prospectively studied 897 patients with more than one CT scan, and found that 16% of patients with diffuse brain injury demonstrated significant evolution of injury. This was more frequent in those with midline shift, often evolving to mass lesions. Therefore, it is useful to perform repeat CT scans in the acute period, particularly after moderate and severe injury, although the timing has not been clearly determined. Summary of Evidence: The sensitivity and specificity of MRI for brain injury is generally superior to CT, although most studies have been retrospective and very few head-to-head comparisons have been performed in the recent decade. Computed tomography is clearly superior to MRI for the detec- tion of fractures, but MRI outperforms CT in detection of most other lesions (limited to moderate evidence), particularly diffuse axonal injury (DAI). Because different sequences vary in the ability to detect certain lesions, it is often difficult to compare results. Although MRI facilitates more detailed analysis of injuries, including metabolic and physiologic measures, further evidence-based research is needed. Supporting Evidence: Magnetic resonance imaging has higher sensitivity than CT, though most comparison studies were performed in the late 1980s and early 1990s (with older generation or lower field scanners). Orrison and colleagues (33) (moderate evidence) retrospectively studied 107 patients with MRI and CT within 48 hours and showed that MRI had an overall sensitivity of 97% compared to 63% for CT, even when a low-field MRI scanner was used, with better sensitivity for contusion, shearing injury, and subdural and epidural hematoma. Ogawa and colleagues (34) (moderate evidence) detected more lesions with conventional MRI than with CT, with the exception of subdural and subarachnoid hemorrhages, in a prospective study of 155 patients, although they were studied at vari- able time points. Other studies (moderate evidence), showed better detec- tion of nonhemorrhagic contusions and shearing injuries (35) and of brainstem lesions (36). Some lesions, such as DAI, are clearly better detected with MRI, and have been reported in up to 30% of patients with mild head injury with normal CT (37) (limited evidence). Gradient echo (GRE) sequences are best for detecting hemorrhagic DAI, although the proportion of hem- orrhagic versus nonhemorrhagic DAI is not truly known. An early report (limited evidence) suggested that fewer than 20% of DAI lesions were visibly hemorrhagic (38), but this is likely to be erroneously low, due to poor sensitivity of the imaging methods available at that time. We have recently studied a new susceptibility-weighted imaging (SWI) sequence (at 1. Scheid and colleagues (moderate evidence) (40) prospectively studied 66 patients using high-field (3. The fluid- attenuated inversion recovery (FLAIR) sequence is useful for detecting SAH, SDH, contusions, nonhemorrhagic DAI, and perisulcal lesions, but there are few studies comparing the sensitivity of FLAIR to other sequences. One study (limited to moderate evidence) found that FLAIR sequences were significantly more sensitive than spin echo (SE) sequences (p <. Diffusion weighted imaging (DWI) has also recently been shown to improve the detection of nonhemorrhagic shearing lesions, although there are only a few small studies describing sensitivity. A small study (insuf- ficient evidence) of patients scanned within 48 hours found that DWI identified an additional 16% of shearing lesions that were not seen on conventional MRI. Another descriptive study (limited evidence) characterized several different types and patterns of DWI lesions, although there was no comparison with other MRI sequences or analysis of diffu- sion changes over time (43). A recent study (limited evidence) found a strong correlation between apparent diffusion coefficient (ADC) his- tograms and GCS score (44). A few small studies (insufficient or limited evidence) have shown decreased anisotropy in brain parenchyma of TBI patients (45–47). Chapter 13 Neuroimaging for Traumatic Brain Injury 241 Although CT and MRI are often limited to observing structural abnor- malities associated with TBI, magnetic resonance spectroscopy (MRS) can detect subtle cellular abnormalities that may more accurately estimate the extent of brain injury, particularly DAI. However, the sensitivity and speci- ficity of MRS are not easily addressed, as only a small number of studies have been published. Several small studies have been performed using single voxel spectroscopy (SVS), although measured at variable time points. These have reported (insufficient evidence) decreased N-acetylas- partate (NAA) in the frontoparietal white matter (WM) (48,49), gray matter (GM) (50), or normal-appearing brain (51).

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