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Single-neuron modeling order genuine super p-force oral jelly online, emphasizing the use of Our focus is on how various parts of the cortical and computational models as links between the prop- sub-cortical motor system contribute to the control erties of neurons at several levels of detail buy super p-force oral jelly 160mg on-line. Top- and learning of movements 160mg super p-force oral jelly mastercard, and how motor disor- ics include thermodynamics of ion fow in aque- ders arise from damage to these neural structures purchase super p-force oral jelly 160 mg line. Recommended: Matlab of liquids and polymers, theory of chemical reac- tions in complex environments, stochastic models, This course focuses on principles and applications dynamics of membrane and channels, theory of in cell engineering. Class lectures include an over- biological motors, computer simulation of liquids view of molecular biology fundamentals, experi- and proteins. Lectures will cover the effects The course discusses the principles of biosensing of physical (e. Furthermore, topics in metabolic measurements of biological phenomena, and clini- engineering, enzyme evolution, polymeric biomate- cal applications. The course is This course focuses on the application of engi- designed for students who wish to pursue research neering fundamentals to designing biological tis- in magnetic resonance. Clinical and regulatory perspectives will be steady-state imaging and contrast mechanisms, discussed. Examples State-of-the-art methods in dynamic vision, with will be drawn from studies in cardiology, brain func- an emphasis on segmentation, reconstruction, tion, and the oculomotor system. This course introduces the probabilistic foundations Recommended prerequisites: 580. Advanced Topics in Machine Learning: Mod- “Computational Models of the Cardiac Myocyte” will eling and Segmentation of Multivariate Mixed present a comprehensive review of all aspects of Data. The the foundations of computational methods for the course will be presented in an innovative way. Stu- statistical and dynamical modeling of multivariate dents will be expected to review web-based course data. Weekly three- use methods from algebraic geometry, probability hour lab session will be used to interact with the theory and dynamical systems theory to build mod- instructors, and to implement and study computa- els of data. We will apply these tools to equilibrium and non-equilibrium statistical mechan- model data from computer vision, biomedical imag- ics and apply them to topics in modern molecular ing, neuroscience, and computational biology. Kinetic theory, master A weekly seminar course that covers recent equations, and Fokker-Planck equations are dis- research papers in the feld of sensorimotor neuro- cussed in the context of ion channels and molecular science. Topics will include probabil- nologies to probe from neurons and brain, and ity theory, score matrices, hidden Markov models, development and application of neural stimulators, maximum likelihood, expectation maximization and prosthesis, and deep brain stimulations and robot- dynamic programming algorithms. During the second semester, the students will then engage in a short project of clinical (or sci- This course will explore the recent advances in entifc) signifcance to increase awareness of the lit- Systems Biology analysis of intracellular process- erature, work with the faculty members and their lab es. Ph D students only studies of metabolic, genetic, signal transduction, and cell cycle regulation networks will be studied in Pattern Theory: From Representation to Infer- detail. Students will take course begins with the study of Markov processes part in reading the literature, learning about the on directed acyclic graphs, including Markov chains state-of-the-art through journal papers and patents, and branching processes, and on random felds and discussing, critiquing, and improving on these on regular lattices. Finally, they will be implementing a selected course examines Gaussian random felds, second idea into an advanced group project. Introduction to non-invasive techniques as applied to an early diagnosis of disease, altered gene Prerequisite: 520. Includes magnetic interested in learning basic biomedical instrumen- resonance imaging, radionuclide imaging, and opti- tation design concepts and translating these into cal imaging techniques. Covered will be: principles advanced projects based on their research on cur- of specifc targeting and non-specifc uptake of rent state-of-the-art. At the ing using reporter genes, theranostics (combined end of the course, students would get an excellent therapeutics and diagnostics), imaging cancer, awareness of biological or clinical measurement imaging of neurodegenerative disease, and imag- techniques, design of sensors and electronics (or ing of cardiovascular disease. The emphasis of the electro-mechanical/chemical, microprocessor sys- overall course is to learn how molecular/cellular tem and their use). They will systematically learn imaging will change the way future diagnostic radi- to design instrumentation with a focus on the use ology and drug development will be practiced. Fur- neering on a tutorial basis by prior arrangement ther, they will be “challenged” to come up with with a member of the faculty. The student will participate in “Journal Professor of Biological Chemistry, Professor of Club,” in which important papers in the front-line Biophysics and Biophysical Chemistry biomedical literature will be discussed. Enrollment of non-medical students requires Professor of Radiology, Professor of Biophysics approval from the course director. At least one upper-level course in Bio- Professor of Biophysics and Biophysical chemistry or Cell Biology is strongly recommended. Dynamics of gene regulation and cell division using single-molecule fuorescence microscopy 100. See Biological Chemistry Prerequisites: Calculus, elementary physics, and for course description. One hour per week to macromolecular structure, with emphasis on the throughout the academic year. Lectures will offer an introduction to the mathemati- cal aspects of computer representation and manip- The structure and properties of biological macro- ulation of macromolecules followed by discussions molecules will be presented. Experimental and of important topics in the computational chemistry computational methods used to study macromo- of macromolecules including: forces and potential lecular structure including X-ray crystallography, felds, molecular mechanics, Monte Carlo methods magnetic resonance, spectroscopy, microscopy, and others. A laboratory course can be taken simul- and mass spectrometry will also be covered. M/W/F, 9-10:30 The laboratory course will familiarize students with The physical and chemical principles underlying practical aspects of molecular modeling. Elementary concepts of of proteins, docking of drugs in proteins, and other statistical thermodynamics will be introduced as a applications will be introduced. A lecture course way of correlating macroscopic and microscopic can be taken simultaneously (100. The course will follow the text by author will cover the basic theory underlying x-ray crys- Barnard Rupp and will require written homework. Classes will combine lectures with The thousands of structures in the Protein Data real-time demonstrations. The course provides a comprehensive, Associate Professor of Anesthesiology and fully integrated coverage of the molecular basis of Critical Care Medicine, Associate Professor of cellular metabolism and function. The course will Biomedical Engineering, Associate Professor of emphasize small group learning and problem solv- Cell Biology, Associate Professor of Pediatrics ing. Enrollment of non-medical Associate Professor of Medicine, Assistant students requires approval from the course director. At least one upper-level Assistant Professor of Cell Biology, Assistant course in Biochemistry or Cell Biology is strongly Professor of Oncology recommended. Elective courses must be Professor of Pharmacology and Molecular approved by preceptor; any member of the Sciences department may act as preceptor. Individual immunological synapse; mechanisms of T cell supervision of reading and laboratory work is avail- activation and induction of tolerance. Fellowships covering normal mechanical basis for cytokinesis and cellular living costs and tuition are available. Transcriptional regulation and neoplasia of cell Prerequisites: Cell Structure and Dynamics or per- metabolism. What are the limits of optical reso- in polarized epithelia; Wilson and Menkes lution and how does it mesh with digital imaging? Time on micro- eton in disease, and chemical approaches to the scopes available for demonstrations by Microscope cytoskeleton. This short lecture course will ers the molecular and cellular basis of embryonic cover fundamental principles of genetics, focus- development in multiple organisms. Arrangements have to be made between the interested student and the fac- aspects of the skin and at clinical cutaneous ulty member who will be mentoring him/her. The disease during each of the medical school main objective of this elective is active participation years. The emphasis of the department is in a small clinical research project, or clinical and upon the pathophysiology of cutaneous reac- scholarly work with faculty member with a certain tion patterns, a correlation of skin lesions specialty focus. The faculty mentor will provide the (gross Pathology) with microscopic changes, specifc schedule. Students are encouraged to the recognition and treatment of diseases participate in all didactic activities including Grand that primarily affect the skin and the identif- Rounds and faculty lectures during the time spent cation of skin changes that refect diseases in in the department.

Bicarbonate administration There is no place for administration of bicarbonate to counteract acidosis or to improve cardiac function in patients with a pH over 7 order super p-force oral jelly mastercard. Possible benefit maybe seen if the pH is lower cheap super p-force oral jelly uk, however cheap 160 mg super p-force oral jelly with mastercard, there is no consensus on this generic super p-force oral jelly 160mg. Intermittent boluses are preferred to continuous infusions, and daily interruption of sedation enables early weaning. Activated protein C Human recombinant activated protein C has been shown in a large multicentre trial to improve survival in patients with severe sepsis and a high risk of death. Severe sepsis & septic shock 76 Handbook of Critical Care Medicine Bleeding is the most important side effect. Correction of haemoglobin and blood product administration Blood transfusion is not recommended unless the haemoglobin drops to 7g/dL. A haemoglobin of over 10g/dL is required only in patients with ischaemic heart disease. Platelet transfusion is 3 required only if the platelet count drops below 5000/mm in the absence of 3 bleeding, and below 30000/mm with active bleeding. Stress ulcer prophylaxis Stress ulcer prophylaxis should generally be given; proton pump inhibitors are more effective than H2 receptor blockers. The above therapies are based on clinical evidence, and contribute to better outcome. Recommendations are based on the Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock 2008. Consideration for limitation of support In spite of the best of care, severe sepsis and septic shock has a high mortality. The patient becomes progressively worse, and generally resistant hypotension develops as a terminal event. Severe sepsis & septic shock 77 Handbook of Critical Care Medicine It is important to discuss severity of illness and possible adverse outcome with the patient’s family, and make sure that expectations are realistic. If recovery seems unlikely, decisions of limitation or withdrawal of support should be considered. Since severe sepsis can suddenly affect previously well patients, this is all the more difficult. Severe sepsis & septic shock 78 Handbook of Critical Care Medicine Evaluating respiratory disease & airway management This section discusses the structure of the respiratory system and how to evaluate respiratory disease, and also deals with how to manage the airway. The respiratory system is divided into two parts – the upper and lower respiratory tract. The respiratory centres are stimulated by hypoxia, hypercapnoea, acidosis, and through various receptors within the lungs. The history, examination and investigations help to identify the abnormality in the respiratory system, diagnose its cause, and fine tune management appropriate to the patient. History Ask for a history of previous lung disease: x Asthma: duration, severity, compliance with medications, severity of exacerbations, previous intubation. Calculate the number of pack years (1 pack or 20 cigarettes for 1 year = one pack year). Has the patient Evaluating respiratory disease 79 Handbook of Critical Care Medicine stopped smoking now? Endocrine diseases: Cushing’s disease results in impaired immunity and increased risk of lung infections. Drug induced lung diseases: x Beta blockers: obstructive airways disease x Methotrexate, amiodarone: lung fibrosis x Corticosteroids and other immunosuppressive agents: increased risk of lung infections Cardiac diseases: valvular and congenital heart disease resulting in cor- pulmonale Previous lung surgery: patients maybe left with reduced lung reserve. Family history: Cystic fibrosis, alpha-1 antitrypsin deficiency, Kartegener’s syndrome, primary pulmonary hypertension Evaluating respiratory disease 80 Handbook of Critical Care Medicine Symptoms and signs Cough: the commonest respiratory symptom. Dry cough is seen in lung fibrosis, certain types of bronchiectasis, and pleurisy. Productive cough with purulent sputum is seen in bacterial infections of the lung. Cough can also be present in upper respiratory infections, such as laryngitis, pharyngitis, tonsillitis, sinusitis with post nasal drip. Sputum: most bacterial infections of the lung cause sputum production, which can be very variable depending on the type and severity of infection. The sputum is characteristically yellow in pyogenic infection, and is due to the presence of neutrophils. Yellow sputum is also seen in asthma due to large numbers of eosinophils in the sputum. The sputum in pneumonia is characteristically ‘rusty’, due to the presence of red blood cells. In lung abscess, the sputum is purulent and offensive, and halitosis is often present. In the past, amoebic liver abscesses were known to rupture into the lung, producing the characteristic ‘anchovy sauce’ sputum. Haemoptysis is always a serious symptom, and may be due to a sinister cause such as pulmonary tuberculosis, bronchial carcinoma, bronchiectasis, or pulmonary infarction. Dyspnoea is an important symptom of respiratory disease; it can be caused by anything that stimulates or increases the work of breathing – hypoxia, hypercapnoea, acidosis, consolidation, pneumothorax, pleural effusion, heart failure etc. Inflammatory conditions of the lung may involve the pleura and cause pleuritic chest pain, which characteristically worsens on breathing in and out. Cyanosis: this is the presence of more than 5g/dL of deoxygenated haemoglobin in the blood. Central cyanosis can be caused by any lung Evaluating respiratory disease 81 Handbook of Critical Care Medicine condition which causes severe hypoxia, or by cardiac right to left shunts. Peripheral cyanosis is caused by conditions which slow the peripheral circulation resulting in increased extraction of oxygen from haemoglobin – vasoconstriction, low cardiac output states. Clubbing: clubbing is seen in squamous cell bronchial carcinoma, suppurative lung disease (bronchiectasis, lung abscess, empyema), fibrosing alveolitis, and congenital or acquired cyanotic heart diseases (where a right- to-left shunt is present). Examination of the chest: The standard examination of the chest will reveal conditions such as pleural effusions, pneumothorax, localised consolidation, basal fibrosis, bronchiectasis etc. Investigations Chest radiograph An essential investigation in diagnosing respiratory disease. Because of this, it is prudent to be careful when interpreting subtle and minor radiological appearances which could be artefactual. It is mandatory that the person who did the procedure checks the chest radiograph. Always look carefully at the margins of the lung fields for air in the pleural space. PaO2 The partial pressure of oxygen determines the degree of oxygen saturation of haemoglobin (SaO ). The arterial oxygen content is dependent on the2 oxygen saturation and the haemoglobin. Thus the arterial oxygen content is determined by the following formula: Arterial O content = (SaO x Hb x 1. A small2 2 fall in PaO will not drop the SaO much, and hence, will not affect arterial2 2 oxygen content. Oxygen delivery to the tissues is dependent on the arterial oxygen content and the cardiac output. If the blood pressure is low, even though the arterial oxygen content is adequate, tissue oxygen delivery will be low. If oxygen utilisation in the tissues exceeds oxygen delivery, the cells revert to anaerobic metabolism, leading to lactic acidosis. The pulse oxymeter measures phasic changes in the intensity of transmitted light – hence, it works only with pulsating arteries, thus eliminating possible errors created by light reflection from other tissues. Pulse oxymetry can be affected by low perfusion states, skin pigmentation, nail polish, and its accuracy is poor when the saturation drops below 83%. Much information can be2 determined by analysis of the capnograph curve, which is beyond the scope of this book. Ultrasound scanning of the chest This is used mainly for chest tube placement, and to look at pleural pathologies. It is sometimes useful to identify tumours or masses within a collection of fluid in the chest. Ventilation-perfusion scans Used primarily to diagnose or exclude pulmonary embolism.

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If we take seriously the feminist challenge to modern bioethics when we deal with patients from diVerent cultural backgrounds generic super p-force oral jelly 160mg, we can Wnd a proper Multicultural issues in maternal–fetal medicine 59 way to promote the health and well-being of women and children without ignoring diVerence buy super p-force oral jelly 160mg overnight delivery, social ties and local cultures generic super p-force oral jelly 160 mg mastercard. In order to promote health as well as justice purchase discount super p-force oral jelly online, we need to take into account the local context and the particular physical, social and cultural circumstances of the particular patient. This means that the delivery of health services to individuals has to start by focusing on their characteristi- cs and powers of their communities, instead of promoting standardized benchmarks. Sensitivity to diVerences between individuals and social collectives, and a focus on the positive features of particular cultural systems, help us to turn communities into progressive rather than regressive forces in the improve- ment of maternal and fetal health. Strong communal and family values, diVerent cultural beliefs and social practices should not be condemned, rather they should be objectively considered as an integral part of develop- ment. No culture is inherently unreasonably resistant to development and change towards better living conditions as long as enough sensitivity and respect is shown towards its particular, local characteristics. To summarize, this chapter aims to show that it is not impossible to Wnd a shared set of values that can be universally promoted in diVerent types of cultures, without requiring cultural assimilation. While individuals may disregard their communities, there is no logically valid or morally legitimate reason why they should not work for the good of these communities – as long as we treat the individual members as equally valuable. A recent breakthrough in research has shown that mother-to-child transmission (vertical transmission) can be reduced with the use of anti-viral drugs (Connor et al. This exceedingly bleak outlook is relieved in part by the discovery that the following measures can reduce vertical transmission: ∑ Avoidance of breast-feeding decreases transmission after birth by about 14 per cent (Dunn et al. In fact, provided that the resources are available, vertical transmission rates can now be reduced to less than two per cent (Tudor-Williams and Lyall, 1999). Neverthe- less, pregnant women in these countries can at least be conWdent that their oVspring can escape infection, and, that if they accept treatment, they themselves may beneWt from earlier diagnosis (de Cock and Johnson, 1998). Studies in the early 1990s in Kenya and other African countries have shown that the epidemic has had little impact on attitudes and subsequent child- bearing (Ryder et al. In addition, some countries, such as Uganda and Senegal, have managed to reduce transmission by vigorous public health education programmes (Anonymous, 2000b). Pregnant women are considered an ‘epi- demiological useful’ group because they represent a stable sub-group of the heterosexually active population at ‘normal risk’. I shall now consider the potential implications of a positive result, the nature of the relationship between the health professional and the pregnant woman, and the process of consent, as these are all relevant to a discussion about the ethics of anonymized and named testing. The implications of a positive result A pregnant woman is likely to experience considerable distress on discovery of her positive status (Manuel, 1999), particularly as she may feel more vulnerable and dependent on others, and she has the added responsibility of motherhood ahead of her. Once born, however, the interests of the child are paramount, and parental views may be overridden if they are seen to conXict with the child’s welfare. Babies can still gain protection from infection if given antiviral treatment within 48 hours of birth, even if the mother has refused to take medication or have a Caesarean section (Wade et al. It is beyond the scope of this discussion to consider the poignant dilemma for parents of whether or not to disclose to their child his or her incurable infection and uncertain life expectancy, or to explore the burden of imposing life-long unpleasant treatment on a child, and of protect- ing him or her from stigma. It is evident from the case above, however, that women may Wnd that breast-feeding causes disapprobation, and may even result in their infants being considered ‘at risk’. Abstention from breast-feeding creates particular diYculties in countries and cultures where breast-feeding is the norm, and bottle-feeding stigmatizes a woman (Graham and Newell, 1999). The relationship between the health professional and the patient As I have discussed elsewhere (de Zulueta, 2000a), the relationship between a health professional and a patient can be characterized as a Wduciary one. The health professional is therefore entrusted to put the patient’s interests Wrst, and to hold certain things (such as conWdential information) ‘in trust’. As Brazier succinctly expresses this: ‘It is trite to describe the health profes- sional’s relationship with his or her patient as a relationship of trust, yet the description encapsulates the very heart of the relationship’ (Brazier and Lobjoit, 1999: p. The health professional has a duty to promote the well-being of both the mother and the unborn child, but should only provide care that the mother agrees to. Failure to seek the patient’s consent is not only a moral failure, but, in English law, also leaves the doctor liable to the tort or crime of battery or to the tort of negligence. The information required is such that the patient understands in broad terms the nature and purpose of the procedure, and the principal risks, beneWts and alternatives (Chatterton v Gerson, 1981). Consent is a process, not an event, and involves a continuing dialogue between the health care professional and the patient, such that there is genuine shared decision-making. I submit that in the case of anonymized testing, and in the case of ‘routine’ voluntary named testing, consent is often vitiated by a lack of understanding and information, and sometimes by coercion. This may be justiWed in countries where the resources are not available to oVer counselling or treatment, and where the data may be used to galvanize the developed world into providing aid. These Wgures, it is argued, can then be used to provide the justiWcation for allocating more resources to the treatment and prevention of the disease, particularly in areas of high prevalence. But I would counter-argue that it is unprofessional and unethical to encourage individuals to relinquish beneWts that may aVect third parties (human fetuses), even if these are not ‘legal persons’. Finally, it could be argued that if an informed mother agrees to anony- mized testing, she does not intend to deprive the fetus of beneWt, as she does not know if she harbours the virus. This argument is also used to justify the health professional’s behaviour – no harm is intended, and there is no responsibility to act upon the result since it is unobtainable. A woman attending an antenatal clinic carries the reasonable expecta- tion that all tests and procedures are done either directly to beneWt her or her unborn child (de Zulueta, 2000a). The case for abuse of trust is even stronger than with anonymized testing of pregnant women, as the mothers are even more likely to assume that all tests are for the baby’s beneWt. Since the baby relies entirely on others to protect his interests, it is arguably even more unethical to use the baby ‘merely as a means, rather than as an end in himself’, to paraphrase Kant. In order to make an informed choice, the woman needs to understand the nature of the test itself, as well as the advantages and disadvantages of not receiving the result should it be positive. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines. Women at high risk in ‘low-prevalence areas’ may well miss out; this resource allocation dilemma is one well known to all screening programmes, and diYcult to resolve. This merits further discussion, but suYce to say that if resources are available, there is a strong argument for recommending a universal policy for all pregnant women (Hudson et al. The American Medical Association recently voted in favour of mandatory testing of pregnant women, although mandatory testing is a legal requirement in only a few states such as Texas and New York (Phillips et al. The reasons for this include the following: ∑ ‘high status coercion’ by professionals (see below); ∑ imposed targets, placing health professionals under duress to maximize uptake; ∑ multiple tests, creating confusion; ∑ lack of time and resources to allow a discussion suYciently detailed for women to understand the nature and purpose of the test. A health professional occupies a position of authority, and if he or she recommends a test, many women would feel that it is not within their rights to refuse. The strongest factor inXuencing uptake, excluding the direct oVer of a test, has generally been the individual midwife interviewing the woman (Jones et al. These Wndings reinforce the hypothesis that consent is driven by the health professional’s agenda, and that routine testing may not always be fully voluntary. Women most at risk (aside from intravenous drug users) are from high-prevalence areas, particularly from sub-Saharan Africa, and their Wrst language is not English or any other Western language. Schott and Henley (1996) quote studies that show that women who speak little or no English are given fewer choices and less information, and that health professionals tend to be paternalistic and insensitive towards them, concluding that: ‘They cannot give genuinely informed consent’ (Schott and Henley, 1996: p. The individual is seen as an integral part of the family or community and a woman has to consult her spouse, or other members of the family, and even elders, before consenting to medical or surgical procedures (Schott and Henley, 1996; NuYeld Council on Bioethics, 1999; de Zulueta, 2001). There are no clear guidelines for how long pre-test discussion should take, but it seems unlikely that all the issues referred to can be discussed in such a short time span. They point out the conXicts for the health professionals in providing an ‘ideal’ pre-test counselling practice with ‘the time and cost constraints of busy practices and managed care plans’. Some tests, for example, for Down’s syndrome, are done with the implicit understanding that if they prove positive, the mother is expected to have an abortion.

Prolonged occlusion can result in both proximal and distal reactive vasospasm discount super p-force oral jelly 160 mg, further aggravating the insult to the intestines super p-force oral jelly 160mg free shipping. Mesenteric venous thrombosis occurs dur- ing the classic hypercoagulable states as well as during malignancy super p-force oral jelly 160 mg on line, abdominal trauma super p-force oral jelly 160mg without a prescription, and estrogen therapy. Additionally, regional vasospasm can result from use of vasoactive medications, such as digoxin, diuretics, cocaine, or vasopressin. Clinical Presentation and Diagnosis • The historical factors may be nonspecific, but the diagnosis should be pursued in any person >50 yr old with sudden onset of acute abdominal pain and with an associated low flow, atherosclerotic, or hypercoaguable disease state. Abdominal 5 distention and rectal bleeding may be the only initial complaint in up to 25% of the cases. The only initial abnormality on physical exam may be the presence of fecal occult blood, occurring in over half of the cases. Additionally, metabolic acidosis with a base deficit, an elevated amylase, and evidence of hemoconcentration are sensitive (present in more than half the cases) but nonspecific findings. They may show pneumatosis intestinalis, portal vein gas, or thumb printing in late disease. Angiography is contraindicated in shock states or with patients on vasopressor therapy because they confound the diagnosis of nonocclusive mesenteric ischemia. Common initial misdiagnoses include con- stipation, gastroenteritis, ileus, and small bowel obstruction. Younger pa- tients with collagen vascular disease are also at risk of aortic dissection. This dilatation is a mechanism of the artery to compensate for a proximal stenosis. Clinical Presentation • Classical presentation of pulsatile mass in the patient with abdominal pain and pulse deficits is not always present. Patients presenting with an abdominal aneurysm with abdominal pain are ruptured until proven otherwise and surgical consult is mandatory. Rupture unstable: surgical repair The differentiation between a stable and unstable rupture is trivial as the process is dynamic. The perioperative mortality is over 25% secondary acute myocardial infarction in emergent surgery compared to fewer than 5% for elective. Therefore it is preferred, but not always possible, to prime the patient for the operating room. Bowel Obstruction Risk Factors/Etiology • Small bowel obstruction is typically caused by postoperative adhesions, hernias, or tumors. It is likely due to a hereditary hypofixation of the cecum to the posterior abdominal wall. Clinical Presentation and Diagnoses • Acute onset of severe intermittent abdominal pain followed by nausea and vomiting is the common clinical manifestation. Obstipation may be absent early on or in a partial obstruction, and its absence does not exclude the diagnosis. A supine abdominal film along with either a lateral decubitus or upright abdominal films are minimally needed for diagnosis. An upright chest film may be added to search for free air under the dia- phragm indicating a perforated viscous. The small bowel is differentiated from the large bowel by the presence of “valvulae conniventes” which are numerous, narrowly spaced and cross the entire lu- men. A “string of pearls” sign is highly suggestive of small bowel obstruction and is described as a line of air pockets in a fluid filled small bowel. Air fluid levels in a stepladder pattern are also suggestive of a small bowel obstruction. If not, sigmoid volvulus can be diagnosed by the classic “birds beak” sign on barium enema. Distended large bowel in the left lower quadrant with absence of right-sided gas may indicate a cecal volvulus. The intermittent nature of the pain is suggestive of bowel obstruction but is also present in mesenteric ischemia. Treatment • Early nasogastric decompression, aggressive fluid resuscitation, broad spectrum anti- biotics including coverage of Gram negatives and anaerobes, and early surgical consul- tation are the mainstays of treatment of small and large bowel obstructions. Up to 75% of partial small bowel obstructions and up to one-third of complete small bowel obstructions will resolve with decompression and fluid resuscitation alone. Strangu- lated obstructions indicated by fever, tachycardia, and/or localized tenderness are op- erative cases. Uncomplicated obstructions are usually initially treated conservatively, with surgery reserved for treatment failures. Disposition • These patients are all admitted to the hospital, almost always under the care of a surgeon. The highest incidence occurs in 10-30 yr olds, with atypical presentations more common in the very young or very old and women of child-bearing age. Clinical Presentation and Diagnoses • The classic description is of periumbilical, epigastric, or diffuse dull pain migrating over several hours to McBurney’s point in the right lower quadrant, with the pain changing in character from dull to sharp as the overlying peritoneum becomes in- flamed. Peritoneal signs, including involuntary guarding, rigidity and diffuse percus- sion tenderness may indicate perforation. Less specific and less frequently associated symptoms include fever, chills, diarrhea, dysuria and frequency, and constipation. A pelvic appendix may irritate the bladder, result- ing in suprapubic pain or dysuria, while a retroileal appendix may irritate the ureter, causing testicular pain. More than two-thirds of appendices lie within 5 cm of McBurney’s point, with more inferior and medial. Perforation is the most common malpractice claim for ab- dominal emergencies and the fifth most expensive claim overall in emergency medicine. Abdominal plain films have little or no utility and should not be routinely ordered, as even the finding of an appendicolith are neither sensitive nor specific for appendicitis. Ultrasound has reported sensitivity up to 93% and specific- ity up to 95% and is the preferred test in children and pregnant women. Other diagnoses to consider include testicular torsion, ruptured ectopic pregnancy, peptic ulcer disease, billiary tract disease, diverticulitis, abscesses, renal colic, pyelonephritis, bowel obstruction, and abdominal aortic aneurysm. Colonic Diverticulitis Risk Factors/Etiology • 96% of patients are older than 40 yr of age. Microperforations in the colon then occur producing a pericolic abscess or even peritonitis. Clinical Presentation and Diagnoses • Persistent abdominal pain, initially vague and diffuse, later localizing to the left lower quadrant is the most common presentation of sigmoid diverticulitis. Dysuria and frequency are also common due to irritation of the nearby bladder and ureter. The rectal exam may reveal local tenderness and will often be fecal occult blood positive. Iron deficiency anemia is un- common and should prompt a look for other causes, such as carcinoma. An upright chest X-ray may also be obtained to look for free air under the diaphragm, signaling a perforated viscus. Other diagnoses high in the differential include colon carcinoma with localized perforation, ischemic colitis, ulcerative colitis, and bacterial colitis. Colovesicular fistulas present with pneumaturia, fecaluria, dysuria, frequency, or incontinence. Acute Pancreatitis Risk Factors/Etiology • The underlying etiology of pancreatitis is most commonly due to gallstones or alco- holism. Clinical Presentation and Diagnoses • The typical presentation of pancreatitis is epigastric pain radiating to the back. Amylase is both of salivary and pancreatic origin, but most labs do not differentiate between the two. Caution should be used with administration of insulin as there is exaggerated response with pancreatitis and profound hypoglycemia may result. Cimetidine, glucagon and atropine fail to show any benefit in alleviating symptoms or complications.

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The health professional is therefore entrusted to put the patient’s interests Wrst buy super p-force oral jelly 160mg without a prescription, and to hold certain things (such as conWdential information) ‘in trust’ cheap 160 mg super p-force oral jelly fast delivery. As Brazier succinctly expresses this: ‘It is trite to describe the health profes- sional’s relationship with his or her patient as a relationship of trust purchase super p-force oral jelly 160mg with amex, yet the description encapsulates the very heart of the relationship’ (Brazier and Lobjoit purchase generic super p-force oral jelly online, 1999: p. The health professional has a duty to promote the well-being of both the mother and the unborn child, but should only provide care that the mother agrees to. Failure to seek the patient’s consent is not only a moral failure, but, in English law, also leaves the doctor liable to the tort or crime of battery or to the tort of negligence. The information required is such that the patient understands in broad terms the nature and purpose of the procedure, and the principal risks, beneWts and alternatives (Chatterton v Gerson, 1981). Consent is a process, not an event, and involves a continuing dialogue between the health care professional and the patient, such that there is genuine shared decision-making. I submit that in the case of anonymized testing, and in the case of ‘routine’ voluntary named testing, consent is often vitiated by a lack of understanding and information, and sometimes by coercion. This may be justiWed in countries where the resources are not available to oVer counselling or treatment, and where the data may be used to galvanize the developed world into providing aid. These Wgures, it is argued, can then be used to provide the justiWcation for allocating more resources to the treatment and prevention of the disease, particularly in areas of high prevalence. But I would counter-argue that it is unprofessional and unethical to encourage individuals to relinquish beneWts that may aVect third parties (human fetuses), even if these are not ‘legal persons’. Finally, it could be argued that if an informed mother agrees to anony- mized testing, she does not intend to deprive the fetus of beneWt, as she does not know if she harbours the virus. This argument is also used to justify the health professional’s behaviour – no harm is intended, and there is no responsibility to act upon the result since it is unobtainable. A woman attending an antenatal clinic carries the reasonable expecta- tion that all tests and procedures are done either directly to beneWt her or her unborn child (de Zulueta, 2000a). The case for abuse of trust is even stronger than with anonymized testing of pregnant women, as the mothers are even more likely to assume that all tests are for the baby’s beneWt. Since the baby relies entirely on others to protect his interests, it is arguably even more unethical to use the baby ‘merely as a means, rather than as an end in himself’, to paraphrase Kant. In order to make an informed choice, the woman needs to understand the nature of the test itself, as well as the advantages and disadvantages of not receiving the result should it be positive. They cite a case when a doctor was found in breach of duty for failing to inform a woman of the potential consequences of not agreeing to a cervical smear. In addition, the leaXet issued by the Department of Health, in circulation after 1994, does not refer to treatments available for reducing vertical transmission. In any case, the notion of passive consent, that is to say that consent is implied unless there is a verbal refusal, is ethically unsound and ‘a concept quite alien in English law’ (Brazier and Lobjoit, 1999: p. In clinics that pro- vide universal testing (see later), the women should have received the relevant information from a pre-test discussion with the midwife, and the 70 P. In one study only Wve per cent fully understood the nature of the testing, and a signiWcant proportion believed that they would be informed should the result be positive (Chrystie et al. The principle of autonomy is frequently infringed by the process of anonymized testing, and, as Brazier says, ‘Consent truly is a myth’ (Brazier and Lobjoit, 1999: p. The ethics of named testing The Department of Health’s Unlinked Anonymous Surveys Steering Group in 1989 rejected mass voluntary testing as an alternative to anonymized testing. As argued above, the beneWts of named testing, and the arguments in favour of truth-telling are further strengthened, particularly as third parties are placed at risk by non-disclosure. The majority of industrialized countries adopted a universal testing policy (whereby all women were oVered the test), and developed their own guide- lines. Women at high risk in ‘low-prevalence areas’ may well miss out; this resource allocation dilemma is one well known to all screening programmes, and diYcult to resolve. This merits further discussion, but suYce to say that if resources are available, there is a strong argument for recommending a universal policy for all pregnant women (Hudson et al. The American Medical Association recently voted in favour of mandatory testing of pregnant women, although mandatory testing is a legal requirement in only a few states such as Texas and New York (Phillips et al. The reasons for this include the following: ∑ ‘high status coercion’ by professionals (see below); ∑ imposed targets, placing health professionals under duress to maximize uptake; ∑ multiple tests, creating confusion; ∑ lack of time and resources to allow a discussion suYciently detailed for women to understand the nature and purpose of the test. A health professional occupies a position of authority, and if he or she recommends a test, many women would feel that it is not within their rights to refuse. The strongest factor inXuencing uptake, excluding the direct oVer of a test, has generally been the individual midwife interviewing the woman (Jones et al. These Wndings reinforce the hypothesis that consent is driven by the health professional’s agenda, and that routine testing may not always be fully voluntary. Women most at risk (aside from intravenous drug users) are from high-prevalence areas, particularly from sub-Saharan Africa, and their Wrst language is not English or any other Western language. Schott and Henley (1996) quote studies that show that women who speak little or no English are given fewer choices and less information, and that health professionals tend to be paternalistic and insensitive towards them, concluding that: ‘They cannot give genuinely informed consent’ (Schott and Henley, 1996: p. The individual is seen as an integral part of the family or community and a woman has to consult her spouse, or other members of the family, and even elders, before consenting to medical or surgical procedures (Schott and Henley, 1996; NuYeld Council on Bioethics, 1999; de Zulueta, 2001). There are no clear guidelines for how long pre-test discussion should take, but it seems unlikely that all the issues referred to can be discussed in such a short time span. They point out the conXicts for the health professionals in providing an ‘ideal’ pre-test counselling practice with ‘the time and cost constraints of busy practices and managed care plans’. Some tests, for example, for Down’s syndrome, are done with the implicit understanding that if they prove positive, the mother is expected to have an abortion. The empirical studies highlight the diYculty for the health professionals in delivering a culturally sensitive policy, whilst not depriving an at-risk group of advice which may be of particular value and relevance. Some would question how much the individual’s right to make a choice should be respected if this autonomy jeopardizes the future of the next generation. It can be argued that the women are hiding their heads in the sand, for sooner or later the disease will manifest itself, and they will have lost opportunities for themselves and their oVspring. For a trial to be ethical the researchers must be in a position of equipoise: they do not know which therapy will be the most eVective (Freed- man, 1987). The patient must not only understand the process of randomization, but also the risks and beneWts of treatment and non-treatment, and the treatments currently available. Lurie and Wolf also argue that the trials contravene existing guide- lines – in particular, the Declaration of Helsinki (World Medical Association, 1996) and the international ethical guidelines for biomedical research involv- ing human subjects of the Council for International Organizations of Medi- cal Sciences (1993). They also question the scientiWc rationale for placebo controls, and suggest equivalency trials, using the best known regimen compared against another: ‘We believe that such equivalency studies of alternative antiretroviral regimens will provide even more useful results than placebo-controlled trials, without the deaths of hundreds of newborns that are inevitable if placebo groups are used’ (Lurie and Wolf, 1997: p. Marcia Angell (1997) takes an even more critical stance, comparing some of the placebo-controlled trials to the infamous Tuskegee syphilis experiment (Anonymous, 1992). She maintains, as do Lurie and Wolf, that researchers have an obligation to provide the controls with the best current treatment, rather than the best locally available one. To do otherwise, she argues, is to adopt a double standard in research, or an ethical relativism that ‘could result in widespread exploita- tion of vulnerable third world populations for research programmes that could not be carried out in the sponsoring countries’ (Angell, 1997: p. Even informed consent is insuYcient protection, she argues, ‘because of the asymmetry of knowledge and authority between researchers and their subjects’ (Angell, 1997: p. The NuYeld Council on Bioethics, in their discussion paper, proposed an interpretation of principle 11–3 of the Helsinki Declaration (World Medical Association, 1996) such that ‘the best proven diagnostic and therapeutic method’ is interpreted as meaning ‘the best locally available diagnostic and therapeutic method’ (NuYeld Council on Bioethics, 1999: p. This sits uncomfortably with Article One of the Declaration, which deWnes the researcher’s duty ‘to remain the protector of the life and health of that person on whom biomedical research is being carried out’. In conclusion, research into the prevention of vertical transmission has engendered a public and acrimonious debate and a schism in the medical profession. Perhaps we are witnessing the clash between an ethic of science Wrmly rooted in the mechanistic-reductionist or modernist paradigm, and an ethic based on a more humanistic, postmodern worldview. It can provide us with useful evidence for the beneWt of interventions, but, in order to achieve this, it eschews individual concerns, needs and relationships. The postmodern ethic, on the other hand, allows for the individual voice to be heard and tolerates uncertainty (Bauman, 1993; Hodgkin, 1996; Laugharne, 1999). One response to the criticisms – a revision of the research guidelines – may lead to a dangerous shift in the ethical require- ments for research, such that research subjects from poor countries could be more readily exploited. Furthermore, the justiWcations do not satisfactorily address the importance of trust, intrinsic to the relationship between the health professional and the woman seeking antenatal care. Amended by the 29th World Medical Assembly, Tokyo, Japan, October 1975; 35th World Medical Assembly, Venice, Italy, October 1983; 41st World Medical Assembly, Hong Kong, September 1989 and the 48th World Medical Assembly, Somerset West, Republic of South Africa, October 1996. It is already possible to test embryos for several conditions at the pre-implanta- tion stage (through pre-embryo biopsy) and to test fetuses for even more conditions during the course of their gestation (through amniocentesis, chorionic villus sampling and umbilical cord blood sampling) (Robertson, 1994: pp.

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When the patient makes a respiratory effort discount 160mg super p-force oral jelly, a negative pressure is applied to the inspiratory valve buy super p-force oral jelly now. When this negative pressure exceeds a certain value (usually around negative 2mmHg) buy discount super p-force oral jelly on-line, inspiration is ‘triggered’ - the valve opens and inspiration begins purchase generic super p-force oral jelly pills. When the inspiratory flow falls below a certain value, the inspiratory valve closes, and expiration begins. Ventilation 109 Handbook of Critical Care Medicine Assist control ventilation In this mode, a tidal volume and respiratory rate are set on the machine. Every inspiratory effort triggers the machine to deliver a full breath of the set tidal volume. If the patient’s own respiratory rate is less than the set respiratory rate, the ventilator will ensure that the required breaths are given. Let us take an example where the set rate is 14 breaths per minute, and the tidal volume is 500ml. Each time the patient attempts to take a breath, the ventilator will deliver a tidal volume of 500ml. The disadvantage is that if the patient’s respiratory rate is high, the minute ventilation can be significantly high, resulting in respiratory alkalosis. However the additional breaths will not have the same tidal volume as the set tidal volume, and will be spontaneous breaths. The tidal volume of these breaths will depend on the respiratory effort, and the amount of pressure support applied. Ventilation 110 Handbook of Critical Care Medicine For example, if the patient has a spontaneous rate of 20, and the set rate is 14 with tidal volume of 500ml, the patient will receive 14 breaths with a tidal volume of 500mL. The remaining 6 breaths will have a tidal volume depending on the patient’s respiratory effort, airway resistance, and the pressure support. The higher the pressure support, the larger the tidal volume of these breaths (because in effect these breaths are similar to pressure control ventilation). If respiratory alkalosis develops, the respiratory drive will fall, and the patient will breathe less frequently. Because there is a mandatory set rate, the required minimum minute ventilation is ensured. Spontaneous ventilation with pressure support In this form of ventilation, there is no set rate or tidal volume. The inspired tidal volume depends on the respiratory effort, airway resistance, and the pressure support. Usually however, the machine has a minimum limit, and if the patient does not breathe adequately the alarm will sound, and the machine will take over and ventilate the patient. This mode is an effective weaning mode – if the pressure support is sufficiently low, and the patient’s respiratory parameters and blood gases are adequate, he is probably ready for extubation. A pressure support of approximately 8mmHg is just sufficient to take away the dead space effect of the endotracheal tube. Choice of ventilator modes and settings These depend on the requirements of the patient. Neuromuscular blockade is usually required, although if the patient has little spontaneous respiration this could be done without. How to determine the initial settings in a patient who has just been ventilated The usual set rate will be between 10 and 14 breaths per minute. The tidal volume is usually between 6 and 12 ml/kg body weight, preferably closer to 6ml/kg. Start with a high FiO2, and then reduce it to maintain a pulse oxygen saturation of over 95%. The ratio between the inspiratory time and expiratory time must also be set; this is known as the I:E ratio and is generally between 1:2 and 1:1. Note that these values are just rough guides, and will depend on the individual patient, and underlying condition. This can be done by the following Ventilation 112 Handbook of Critical Care Medicine o Suctioning out bronchial secretions which are blocking the airways and causing collapse of distal alveoli. Increasing the minute ventilation is not a useful manoeuvre to improve oxygenation. This can be done by reducing the set rate or reducing the tidal volume and the pressure support. Biphasic ventilation Biphasic ventilation is another mode of ventilation where the machine controls only pressure, which moves up and down within a lower and upper baseline. If the patient is breathing spontaneously, the spontaneous breaths are freely superimposed on the moving pressure baseline. De-escalation of ventilation, and weaning the patient off the ventilator De-escalation or reduction of ventilator support should be commenced as soon as the patient’s respiratory parameters show signs of improvement. However, in patients with severe lung disease, de-escalation should be performed very slowly and carefully. If the patient tolerates a level of reduced support, further de-escalation should be attempted. Weaning can be considered if several basic criteria are satisfied, namely: x Improvement in the patient’s primary lung disease or underlying condition. Weaning is considered if the patient is on the lowest possible ventilator support. Consider the following when attempting to wean: x The patient is breathing spontaneously and comfortably with adequate spontaneous tidal volumes and respiratory rate. Usually, this is best done in the mornings, when the full complement of staff is around. Ventilation 114 Handbook of Critical Care Medicine Some people prefer a trial of T-Piece prior to extubation. This is not essential however, if the patient is on spontaneous mode with minimal pressure support, there is no evidence that a T-Piece trial gives better weaning results. What is a T-Piece trial and what does a T-Piece do A T-Piece is a tube shaped like a T. An oxygen supply is connected to one end of the T, and this drives the expired air out. The need for this oxygen flow is to ensure that expired air is expelled, or else the dead space would be too large. After extubation Generally, a repeat arterial blood gas is done about 30 minutes after extubation. Sometimes however, the patient may be unable to breathe on his own and may require reintubation. Tracheostomy is advantageous in that it makes suctioning easier, reduces the risk of nosocomial infection, and avoids the possibility of tracheal stenosis and tracheomalacia due to prolonged intubation. Less severe and recurrent embolism can result in episodic breathlessness and cough with desaturation. A fourth heart sound and loud P2 may be present, and evidence of right heart failure may manifest. Pulmonary embolism 116 Handbook of Critical Care Medicine Diagnosis Since the signs and symptoms are non-specific, a high index of suspicion must be maintained until the condition is excluded. Pulmonary embolism 117 Handbook of Critical Care Medicine Treatment Resuscitate the patient first. A fluid challenge should be given carefully, as volume overload may result in right heart failure. Investigations for a thrombotic tendency cannot be correctly interpreted soon after a thrombotic event, and should be delayed. Patients at high risk should be given prophylactic anticoagulation, usually subcutaneous low molecular weight heparin. Pulmonary embolism 118 Handbook of Critical Care Medicine Hypertensive problems in critical care Severe hypertension can develop in people with chronic hypertension. Severe hypertension can result in life threatening complications, and early and careful therapy is important. Acute elevation in blood pressure may be the primary presenting feature in a critically ill patient, or may complicate patients with other critical illness.

Although it may be enough to set that person on Movement (or the ability to move) is the first defin- the right track to ‘finding more food’ purchase super p-force oral jelly 160 mg line, it will likely ing component of a living organism order super p-force oral jelly 160mg online. Hence even the only provide a short-term remedy to their predica- most primitive of organisms were able to move; they ment as their behavior has not been modified – it has had some level of motility discount super p-force oral jelly amex. Teaching someone to fish is an act of empowerment purchase 160mg super p-force oral jelly fast delivery, and pro- vides a life-long tool for survival within their Dimensional mastery environment. It is a commonly stated that, as a loose To provide a natural insight into rehabilitation and rule, ontogeny recapitulates (or recaptures/mimics) re-education movement approaches, it is important to phylogeny (Heglund & Schepens 2003). At the cellular level, radial contraction is multipla- nar and therefore direction non-specific. This might be termed as movement in the ‘primal dimension’ – Phylogeny: dimensional mastery the first space manipulation – literally manipulating the space which the organism occupies, most likely to Primal dimension create pressure differentials encouraging diffusion into, or out of, the cell: a kind of primitive ingestion/ Cellular life – radial/multiplanar/ excretion system. In more complex organisms, radial direction non-specific contraction is organized about skeletal structures, The most primal phylontogenetic dimension is that of fascial sleeves, non-compressible visceral compart- radial contraction – a contraction and expansion of the ments and around complex pressure mechanisms outer borders of the organism without any necessary associated with air, fluids and diaphragms. This was first the domain of the group of more complex organisms, to which we single-celled organism. And didn’t cells simply get larger rather than join together for nigh-on the next 3 billion years single-celled organ- to form multicellular organisms? If we take the tract and produce the first form of space manipulation example of oxygen, a hypothetical cell of – a radial contraction. When such contraction is 10 mm diameter would require an increase of released we have a radial relaxation or relative atmospheric oxygen pressure to 25 times its expansion. This may be paralleled in the radial contraction – which was the primal form of macroscopic world with the herding instinct, space manipulation, and is seen as the primary form with what drives tribal/family associations (1st of locomotion in many of the most ancient species left chakra principles) in Ayurveda, or the on the planet (bacteria, comb jellies, jelly fish and sea grounding or Earth element principles in anemones) – is ontogenetically the first form of move- traditional Chinese medical philosophy. This kind of contractile such systems, these are foundational principles mastery is essential in the most fundamental of sur- of health – to belong. Right it seems, have an extraordinary drive to from as early as 5 months in utero, the human fetus assemble (Bryson 2003). Of This view, which touches on matters of spirituality, course, the first thing that the baby does when it’s may be viewed as naturopathic inasmuch as it implies Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 319 that ‘God’ is in everyone and in everything – omni- Respiratory scient, omnipresent and omnipotent. Note: Not neces- diaphragm sarily omnipotent in the ‘all powerful’ way that many classic scriptures might be interpreted, but in the way that every atom in existence has potential. In this line of thinking, which has scientific foundation in quantum physics (McTaggart 2003), we all can be viewed as ‘God’ at the subatomic level – with extraor- Transversus dinary potency, in the same way that we are all a part Pelvic (Bisected on left) of Mother Nature, no greater or lesser than the next diaphragm cluster of atoms alongside us – and with lots of poten- tial! Interestingly, breath work is most commonly uti- Posterior view lized in disciplines with a spiritual leaning, such as Figure 9. Hartley (1995), primal dimensional mastery (or ‘the Reproduced with permission from Hodges (1999) cellular respiration pattern’) is linked in to the mindset of ‘being’. Movement in the primal dimension therefore is first When breathing is calm and relaxed, the parasympa- about incorporation of nutriment from outside of the thetic nervous system is stimulated, sending organism – truly a primary requirement for life. Diaphragmatic excur- From the early 1990s the manual therapy literature sion – a product of relaxed breathing – massages the has thoroughly explored the concept of core stability, digestive organs, stimulating further peristalsis. Although opment of humans, each person must reflect his or her still considered by some to be controversial (Siff 2003), phylogenetic development by first learning to maneu- the concept of core stability, motor control, and ver within the limited space in the womb. This will specifically the role of the transversus abdominis in initially involve swallowing – which is almost cer- maintaining optimal spinal function are now well tainly related to the primitive method of ingestion established in the scientific literature. Collectively, these active lum- Since respiration is arguably more critical for sur- bopelvic support tissues are known as the inner unit vival in the moment than swallowing (Chek 1994), (Lee 2004). This ontogenetic sequence follows any joint complex – not just the spinal joints – as typi- the phylogenetic pattern, the first form of respiration cally the deeper the muscle the higher the preponder- in species being photosynthesis in water, then later ance of slow twitch muscle fibers (Williams 1995) and being associated with various gill apparatus in sea- the smaller the lever arm. Hence, deep inner unit life, and it was only at the stage when the organism muscles are more suited for postural use. This is 2002, Caine 2004, Chaitow 2004, Gilbert 1998) and achieved in part by the fact that low threshold motor 320 Naturopathic Physical Medicine neurons predominate in the nerve supply to these Hence we can see that nutrition and/or respiration muscles (Kuno 1984). A low threshold to stimulus was probably the primitive drive to develop the ability means only a small neural drive is required to activate to move in the earliest plant species. In contrast, outer unit muscles have a is important to first understand how it was built. The characteristic leverage that is better suited to mobilize study of body plans or ‘bauplans’ allows us to see the joint(s) over which they act – commonly using which body architectures were successful and there- the deeper inner unit muscles in a way similar to fore preserved through the evolutionary process. Of these 37, only four are The relevance of this to the phylontogenetic discus- prevalent (Erwin et al 1997). These four will be dis- sion is that, just as our phylogenetic relations are cussed below to demonstrate how natural selection reflected in the various layering and overlayering of may have prioritized certain features and have driven the brain, so our biomechanical architecture reflects our biomechanical design. These basic animal body this process with deeper structures being of older plans are half a billion years old. The commonality of phylogenetic origin – particularly at the spine (Kent anatomic features in these body plans cannot be & Carr 2001). This anatomic progression is similarly ascribed to chance alone, and, moreover, those fea- echoed physiologically in the motor control literature tures are components of a deeply integrated shared (Haynes 2003, Richardson et al 1999). Sponges are widely acknowledged, through mor- Multicellular life – radial/multiplanar/ phological and molecular evidence, to be the most direction non-specific primitive of animal phyla and have been traced as far back as the Neoproterozoic (570 mya). Plant life It was at this stage of evolution that multicelled As described above, clustered cells, such as algae, organisms started to develop cells with specialized emerged around 1 billion years ago, though they did functions (Erwin et al 1997), rather than simply repro- not proliferate until around 565 million years ago, in ducing piece-meal. Three fun- one of the simplest cells in the plant kingdom and damental embryological categories exist, as outlined contain within their cell walls an architectural arrange- in Table 9. The cytoskeleton is a Sponges were the first animals to exhibit specializa- set of small filaments that is found in the cytoplasm tion of cells, though at this stage they were still only of eukaryotic cells (cells containing a nucleus). Although some authorities purpose of the cytoskeleton is to maintain the cell’s suggest that sponges do not have motility, they have structural integrity. The cytoskeleton acts as both a high cellular motility (primal dimension movement) skeleton and a muscle. There are three filaments that (Lorenz et al 1996), their larvae are motile and they make up the cytoskeleton: actin filaments, microtu- commonly have flagella to draw in nutrients from the bules and intermediate filaments. The sliding, phagocytose foodstuffs (Leys & Eerkes-Medrano assembly, and disassembly of actin and microtubules 2006), such as bacteria, demonstrates that radial con- cause cell movement. The microtubules and the actin traction is still a key movement pattern in sponges. The transpor- As cellular differentiation became better defined, so tation method of endocytosis (drawing nutrition into the first of the major body plans arose, the diploblastic the cell from the outside) requires the cytoskeleton. The diploblastic body plan uti- The cytoskeleton helps the cell acquire particles. In modern times: A the diploblastic body plan is found in anemones and jellyfish; B the triploblastic acelomate body plan is found in flatworms; C the triploblastic, with hemocele plan is found in roundworms; and D the triploblastic with celom basic architecture is found in fish, amphibians, lizards and mammals all the way through to man 322 Naturopathic Physical Medicine anemones and jelly fish – each of which exhibits this ‘The importance of movement approaches to naturo- same radial contraction pattern as their primal dimen- pathic patients’ above). The majority of body plans from the late Neopro- Such organisms often float on the currents and the terozoic are represented by the sponges or the comb direction of their efforts may be governed more sig- jellies, jelly fish and sea anemones (Erwin et al 1997). Their movements may be is widely described as the ‘Cambrian explosion’, due seen as ‘preconscious’ or autonomic – reflecting their to the proliferation of multicellular organisms, brought close association with respiration and digestion. By the has relevance with regard to the ontogenetic develop- close of the Cambrian, some 490 mya, all body plans ment of movement. They are exposed to the natural were established – and even migration from sea-based rhythms and cycles of life and literally have to go with living to life on land brought with it only minor the flow. How this pertains to human development How this pertains to human development and movement rehabilitation and movement rehabilitation Activation of the deep intrinsic muscles of the spine Our phylogenetically oldest muscles are ontogeneti- and the peripheral joints should be effortless and cally the first we learn to use, both in utero and in occur without the need for thought. This learning reason that ‘feeling’ commands, instead of ‘doing’ occurs early in life before volitional motor control and commands (Lee 2003), should be utilized when cause/effect learning have developed (see Table 9. Such segmentation allows for muscles and the only ones to retain their primitive sequential radial contraction and is the basis for the two metamerism. They extend between two successive largest animal groups on Earth, the vertebrates and the transverse processes, neural spines, neural arches insects (Drews 1995). In humans, the only examples would Kent & Carr (2001) state that the immediately evident be rectus capitis posterior minor, obliquus capitis feature of axial muscles in fish and tetrapods is their superior, obliquus capitis inferior, interspinales, metamerism. This primitive arrangement, in combination intertransversarii anteriores/posteriores/laterales/ with a metameric vertebral column, allows fish and mediales, rotatores, and possibly levatores costarum. Note: The Disappearance of epaxial myosepta (literally meaning intercostals would not be categorized – even though segmented back muscles) in amniotes gave rise to long, they are depicted as segmentally attached between strap-like or pennate bundles disposed of dorsally to the ribs, which are a component of axial anatomy. This is transverse processes (erector spinae), leaving only a because the intercostals, the scalenes and the entire vestige of metamerism in the deepest bundles. Such abdominal wall are formed from one embryonic sheet bundles in modern-day humans would include the and the ribs literally grow around from the spine and intertransversarii, the interspinales and the rotatores through this muscle sheet to artificially divide it. Hypaxial myomeres (abdominal muscle segments) were gradually replaced by strata of broad muscular Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 323 Flatworms – radial/direction specific and into the outside world. In the same way trate sequential contraction and, as such, required that cell size in Earth’s environment is limited due to greater computational power through an organized atmospheric oxygen pressure and the ability to oxy- and complex nervous system.