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But in order to subserve motor learning cheap alfuzosin 10mg without a prescription prostate zones, M1 must maintain after readaptation a trace of the previous learning experience buy alfuzosin 10mg otc androgen hormone 2 ep1. And indeed, at the microscopic level of individual neurons M1 was very different in the Washout and in the Baseline, because for 40% of neurons the Washout PD was significantly different in the two conditions. Thus, M1 as a population may subserve both functions of motor performance and motor learning by letting individual neurons change their activity when monkeys learn a new dynamic (motor learning), while reorganizing itself at any time to meet behavioral needs (motor performance). More recent anatomical work, however, has found that direct projections to the spinal cord originate from a number of motor areas, including the dorsal premotor area (PMd), the ventral premotor area (PMv), the supplementary motor area (SMA), three or four cingulate motor areas, and M1. In a series of studies, we extended to SMA, PMd, and PMv the experiments first conducted on M1. In total, we recorded and analyzed the activity of 798 neurons from the 4 areas during a delay time (DT) window (500 msec before the cue) and during the movement-related time (MT) window (from 200 msec before the movement onset to the movement end). Likewise, evidence of neuronal plasticity associated with the learning of a new dynamic is found in all four areas. Numerous studies have found extensive cortical reorganization associated with perceptual and motor learning. For instance, in the visual domain, Sakai and Miyashita23 described neurons in the anterior tem- poral cortex that increased their activation in the delay following presentation of a (nonpreferred) visual stimulus arbitrarily associated with their preferred stimulus. Copyright © 2005 CRC Press LLC More recently Erickson and colleagues24 were able to induce similar response pref- erence in neurons of the perirhinal cortex after one day of exposure to complex visual stimuli, suggesting that clusters of neurons with similar stimulus preferences are shaped through experience. In the acoustic domain, the cortical representation of the frequency range that monkeys were trained to discriminate was found to be increased in the primary auditory cortex. Asaad and coworkers29 found that the latency of neuronal response (directional selectivity) of neurons progressively decreased over the course of learning. Several studies also found evidence of neuronal plasticity in various areas when monkeys learned a new conditional motor association. In the task of Wise and coworkers, a novel visual stimulus instructed one of four movements, arbitrarily selected, and the monkeys learned the correct association by trial and error. The authors found extensive learning-related plasticity in PMd30 and in the supplementary eye fields31 for conditional associations that instructed limb and eye movements, respectively. Hikosaka and coworkers recently obtained similar results in presupple- mentary motor area (preSMA). In a first set of experiments in both humans functional magnetic resonance imaging (fMRI) and monkeys (single-cell recordings and revers- ible lesions; reviewed in Reference 32), the authors contrasted the activity recorded during execution of new versus learned sequences of arm movements instructed by targets appearing on a computer screen. In particular, they found that neurons in preSMA were preferably activated during the execution of new sequences. Finally, plastic changes were also found in the motor cortex of rats learning new sensorimotor associations. In humans, it was found that the digit representation of the left hand in the M1 of string players was significantly enlarged. They found that the digit representation was enlarged following training in a small-object retrieval task, when the digits were actively used. Conversely, the wrist/forearm representation was enlarged following training in a key-turning task. Work by Donoghue and coworkers has found evidence of long- term potentiation (LTP) and strengthening of horizontal connection in the motor cortex of rats after learning a new motor skill. For instance, it was found that the training of one finger movements for 10 minutes changed the direction of movements evoked by focal TMS. In this task — sometimes referred to as acquisition of a new internal model for the kinematics45,46 — the experimenters manipulated the association between the visual stimulus and the instructed movement. Wise and colleagues found evidence of learning-related plastic changes in the activity of all three areas. An alternative scenario is that learning-related activity is embedded in the motor system, and that the same areas and the same neurons that process well-acquired movements also accommodate the new condi- tions when necessary. At least in part, the results of our studies seem more consistent with this second view, for two reasons. First, dynamics-related activity was present in multiple areas, and plastic changes associated with motor learning were similarly found in all of them.

The excitatory neuron classes in the periphery and SI cheap alfuzosin 10mg without prescription prostate cancer screening guidelines, trigem- inal neurons and RSUs generic alfuzosin 10mg fast delivery prostate ultrasound, showed significantly more precise tuning than the FSUs (Figures 2. The greater precision observed in the frequency tuning of RSU responses parallels the tuning precision observed for other features in SI, as RSUs also tend to have more precise spatial tuning and more precise direction-of- deflection representations. Complex Stimuli We also recorded the neural response in a subset of neurons evoked by natural and complex stimuli. As the speed of sandpaper motion was increased, the relative frequency of vibration of the vibrissa tip was correspondingly increased. Larger vibrissa oscillations were observed when the speed of the wheel combined with the prominent spatial frequencies of the sandpaper to drive the vibrissa at its resonance. In accordance, a greater mean firing rate was also observed in this recording when the vibrissa was driven at its resonance. These stimulus-generated velocities of vibrissa surface interaction are within the physiological range21,56 suggesting that increases in mean firing rate should be observed in the awake behaving animal as they explore textured surfaces. In further experiments in the periphery and SI, we created white noise stimuli that were the sum of all sinusoids from 0–600 Hz, where each sinusoid was calibrated to 80 µm amplitude and randomly phase shifted. These stimuli were then notch filtered by selectively removing frequencies that would have driven vibrissa resonance while compensating for the total power in the stimulus across frequencies. When complex stimuli were applied without notching, a robust vibrissa resonance was observed and correspondingly, a significant increase in the mean firing rate (Figure 2. When the majority of frequencies amplified by vibrissa resonance were removed, resonance was not observed and the mean firing rate was also significantly lower. These examples demonstrate that the neural correlates of vibrissa resonance are observed even when more natural and/or complex stimuli are presented to the vibrissa. SOMATOTOPIC FREQUENCY MAPPING AND ISOFREQUENCY COLUMNS A potentially important consequence of the discovery of vibrissa resonance was the simultaneous discovery of a novel frequency map laid across the somatotopic map of the face. Multi-unit activity was recorded in the trigeminal ganglion while a stimulus wheel covered in 80-grit sandpaper was rolled against the primary vibrissa (see Figure 2. As the wheel velocity increased, so did the vibrissa oscillation velocity (blue line). Vibrissa resonance amplification can be observed in the spike in vibrissa velocity (P(f)*f, top) at a wheel speed of 800 mm/s. Neural activity also showed a spike in mean firing rate at this velocity (green line). Neural activity also demonstrated a thresholded sensitivity to the increasing velocity of vibrissa oscillation at higher frequencies (≥ a wheel speed of 2000 mm/sec; see also Figure 2. Power spectra showing increased velocity of vibrissa motion or increased amplitude of neural activity (bottom) as a function of oscillation frequency and wheel speed. In the top panel, the peak in velocity signal at ~350 Hz (global increase in power) reflects the increased velocity of vibrissa motion generated when the wheel speed drove the pre- dominant spatial frequency present in the texture (shown in the diagonal bands) at the vibrissa resonance (blue box). The increased mean firing rate in the associated neural response is indicated by the vertical band of increased activity observed at a wheel speed of 800 mm/s in the bottom panel. Note also that a peak is present in MUA power spectrum at the vibrissa resonance (~350 Hz), indicating fine temporal fidelity of spiking activity in response to a complex stimulus presentation (see also Figures 2. White noise stimuli constructed as the sum of phase-shifted sinusoids from 0–600 Hz were presented through a piezoelectric stimulator to the vibrissa. A notched stimulus was also created in which the fundamental resonance and surrounding frequencies (400–500 Hz) were removed from the stimulus and the power adjusted across remaining frequencies. Vibrissa oscillations showed a resonance amplification at ~450 Hz when white noise stimuli were applied (green line) that is not present when notched stimuli were applied (blue line). These complex stimuli were presented while recording from a trigeminal ganglion single unit. As predicted by the differential increase in vibrissa motion, greater mean firing rate was evoked by the non-notched (green bar) than the notched stimulus (blue bar) (N = 37 trials, mean ± SE). As predicted by the consistent agreement between neural tuning and vibrissa tuning (Figure 2. Because vibrissae in the same arc possess similar lengths, they also possess similar resonance tuning, creating a band of vibrissae with similar frequency encoding properties and a systematic network of putative cortical isofrequency columns. Vibrissae along an arc may, in several perceptual contexts, encode substantially different kinds of inputs.

While they are constructivist in their perception of each phase process trusted alfuzosin 10 mg radiation oncology prostate cancer video, they are overall structurally positivist 10 mg alfuzosin sale androgen hormone replacement therapy. It is not uncommon to have this type of usually benign methodological schizophrenia, though it may well be more aesthetic not to. An alternative approach that is fundamentally critical (even though it entertains the notion of control) and that does not suffer from the above problem derives from viable systems theory. This does not see knowledge creation as a set of sequential steps, but rather as a set of phases that are constantly tested and examined through possibly complex feedback. Shifts from one phase to another may occur according to the control phenomena that drive particular perspectives. There are parallels between our proposed knowledge cycle (Figure 4) and that of Nonaka and Takeuchi (Figure 3). In the former knowledge can be created spontaneously within a migration process, and any socialization process that occurs is through communication that may be seen to act as a trigger for new knowledge. Unlike that of Nonaka and Takeuchi, our cycle is not required to be sequential continuous relative to a conditioning process. Rather, the process of continuity is transferred to the communication process, and knowledge creation is cybernetic, passing through feedback processes that can change the very nature of the patterns of meanings that were initiated through the semantic communications. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Telemedicine and its role in improving communication in healthcare, Logistics Information Management, 15(4), 309-319. Knowledge management, organizational learning and HR strategy: A model and case studies. Total quality management in the national health service: Final report of an evaluation. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The knowledge-creating company: How Japanese companies create the dynamics of innovation. The cult of information: A Neo-Ludite treatise on high-tech, artificial intelligence, and the true art of thinking. Do we practise what we preach: Are knowledge management systems in practice truly reflective of knowledge management systems in theory? Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Thus, it can be argued that issues such as Data Management, Data Modeling, and Knowledge Management have a long way to go before reaching the maturity level that other technologies have achieved in the medical sector. This chapter proposes to explore trends and best practices regarding knowledge management from the viewpoint of Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Key Performance Indicators and Information Flow 117 performance management, based upon the use of Key Performance Indicators in healthcare systems. By assessing both balanced scorecards and quality assurance techniques in healthcare, it is possible to foresee an electronic healthcare record centered approach which drives information flow at all levels of the day-to-day process of delivering effective and managed care, and which finally moves towards information assessment and knowledge discovery. Introduction The advantages of the introduction of Information and Communication Technologies (ICT) in the complex Healthcare sector have already been depicted and analyzed in the Healthcare Informatics bibliography (Eder, 2000; Englebardt & Nelson, 2002; Harmoni, 2002; Norris, Fuller, Goldberg, & Tarczy-Hornoch, 2002; Shortliffe, Perreault, Wiederhold, & Fagan, 2001; Stegwee & Spil, 2001). It is nevertheless paradoxical that, although several major technological discoveries such as Magnetic Resonance Imaging, Nuclear Medi- cine and Digital Radiology, which facilitate improvement in patient care, have been satisfactorily embraced by the medical community, this has not been the case with Healthcare Informatics. Thus, it can be argued that issues such as Data Management, Data Modeling, and Knowledge Management have a long way to go before reaching the maturity level that other technologies have achieved in the medical sector. A variety of reasons could be proposed for this issue, though with a short analysis it becomes rather clear that modern ICT present integration problems within the healthcare sector because of the way the latter is organized. Thus, if ICT intend to prove its advantages towards establishing an information society, or even more a knowledge society, it has to focus on providing service-oriented solutions. In other words, it has to focus on people and this has not been the case in most of the circumstances. It is common knowledge that in order to install any type of information system in healthcare, especially if it involves knowledge management, six main groups of issues have to be dealt with (Iakovidis, 1998, 2000): 1.

Term in- fants: Digitalization: 25–35 µg/kg PO or 20–30 µg/kg IV; give 1⁄2 the dose initially cheap alfuzosin 10 mg amex mens health questionnaire, then 1⁄4 of the dose at 8–12 h alfuzosin 10 mg mastercard prostate oncology specialists mark scholz. Toxicity symptoms: Nausea and vomiting, headache, fatigue, visual disturbances (yellow-green halos around lights), and cardiac arrhythmias; IM inj can be painful and has erratic absorption (See Drug Levels, Table 22–7, pages 631–634) Digoxin Immune Fab (Digibind) Used for emergency cardiac care (see Chapter 21) COMMON USES: Life-threatening digoxin intoxication ACTIONS: Antigen-binding fragments bind digoxin, rendering it inactive DOSAGE: Adults & Peds. See dosing charts provided with the drug SUPPLIED: Inj 38 mg/vial NOTES: Each vial binds ≅0. May begin cont inf of 5–15 mg/h SUPPLIED: Tabs 30, 60, 90, 120 mg; SR caps 60, 90, 120 mg; CD caps 120, 180, 240, 300, 360 mg, 420 mg; inj 5 mg/mL NOTES: Contra in sick sinus syndrome, AV block, and hypotension; Cardizem CD, Dilacor XR, and Tiazac not interchangeable Dimenhydrinate (Dramamine, other) COMMON USES: Prevention and Rx of nausea, vomiting, dizziness, or vertigo of motion sickness ACTIONS: Antiemetic DOSAGE: Adults. Hypersensitivity reactions possible, but only rarely with corticosteroid preparation. Cardiomyopathy rare but dose-related; limit of 550 mg/m2 cumulative dose (400 mg/m2 if prior his- tory of mediastinal irradiation) Doxycycline (Vibramycin) COMMON USES: Broad-spectrum antibiotic, including activity against Rickettsia spp. Test for MyG: 2 mg IV in 1 min; if tolerated, give 8 mg IV; a positive test is a brief increase in strength. If no reaction occurs, give the remainder of the dose in 1-mg increments to max of 10 mg SUPPLIED: Inj 10 mg/mL NOTES: Can cause severe cholinergic effects; keep atropine available Efavirenz (Sustiva) COMMON USES: HIV infections ACTIONS: Antiretroviral agent, nonnucleoside reverse transcriptase inhibitor DOSAGE: Adults. Refer to product information for dosing chart SUPPLIED: Caps 50, 100, 200 mg NOTES: Take hs, may cause somnolence, vivid dreams, dizziness; may cause rash Enalapril (Vasotec) COMMON USES: HTN, CHF, and asymptomatic LVD ACTIONS: ACE inhibitor DOSAGE: Adults. In acute cardiac settings, can be given via endotracheal tube if central line not available Epoetin Alfa [Erythropoietin] (Epogen, Procrit) COMMON USES: Anemia associated with CRF, zidovudine treatment in HIV-infected patients, and patients receiving cancer chemotherapy; reduction in transfusions associated with surgery ACTIONS: Erythropoietin supplementation DOSAGE: Adults & Peds. Surgery: 300 U/kg/d for 10 d prior to surgery SUPPLIED: Inj 2000, 3000, 4000, 10,000, 20,000 U/mL NOTES: May cause HTN, headache, tachycardia, nausea, and vomiting; store in refrigerator Epoprostenol (Flolan) COMMON USES: Pulmonary HTN ACTIONS: Dilates the pulmonary and systemic arterial vascular beds; inhibits platelet aggregation DOSAGE: 4 ng/kg/min IV cont inf; make dosage adjustments based on clinical status and package insert guidelines SUPPLIED: Inj 0. Initiate treatment with 500 µg/kg load over 1 min, then 50 µg/kg/min for 4 min; if inadequate response, repeat the loading dose and follow with maintenance infusion of 100 µg/kg/min for 4 min; continue the titration process by repeating the loading dose followed by in- cremental ↑ in the maintenance dose of 50 µg/kg/min for 4 min until the desired heart rate is reached or BP decreases ; average dose 100 µg/kg/min SUPPLIED: Inj 10, 250 mg/mL NOTES: Monitor closely for hypotension; ↓ or discontinuing infusion reverses hypotension in ≅30 min Estazolam (Prosom) [C] COMMON USES: Insomnia ACTIONS: Benzodiazepine DOSAGE: 1–2 mg PO hs PRN 22 SUPPLIED: Tabs 1, 2 mg 22 Commonly Used Medications 535 Esterified Estrogens (Estratab, Menest) COMMON USES: Vasomotor symptoms, atrophic vaginitis, or kraurosis vulvae associated with menopause; female hypogonadism ACTIONS: Estrogen supplementation DOSAGE: Menopause: 0. Repeated doses NOT recommended SUPPLIED: Tabs 25, 50 mg; powder for inj 50 mg NOTES: Contra in anuria; severe side effects reported Ethambutol (Myambutol) COMMON USES: Pulmonary TB and other mycobacterial infections ACTIONS: Inhibits cellular metabolism DOSAGE: Adults & Peds >12 y. Simplex: 125–250 mg PO bid SUPPLIED: Tabs 125, 250, 500 mg Famotidine (Pepcid) COMMON USES: Short-term Rx of active duodenal ulcer and benign gastric ulcer; maintenance therapy for duodenal ulcer, hypersecretory conditions, GERD, and heartburn ACTIONS: H2-antagonist; inhibits gastric acid secretion DOSAGE: Adults. Dose calculated from the narcotic requirements for the previous 24 h SUPPLIED: TD patches deliver 25, 50, 75, 100 µg/h NOTES: 0. Pain: 200 µg consumed over 15 min, titrate to appropriate effect SUPPLIED: Lozenges 100, 200, 300, 400 µg; lozenges on stick 200, 400, 600, 800, 1200, 1600 µg Ferric Gluconate Complex (Ferrlecit) COMMON USES: Iron deficiency in patients receiving supplemental erythropoietin therapy ACTIONS: Supplemental iron DOSAGE: Give test dose of 2 mL (25 mg Fe) infused over 1 h. Discontinue therapy when ANC >10,000 Finasteride (Proscar, Propecia) COMMON USES: BPH and androgenetic alopecia ACTIONS: Inhibits 5α reductase DOSAGE: BPH: 5 mg/d PO [Proscar]. Alopecia: 1 mg/d PO [Propecia] SUPPLIED: Tabs 1, 5 mg NOTES: Decreases PSA levels; may take 3–6 mo to see effect on urinary symptoms Flavoxate (Urispas) COMMON USES: Symptomatic relief of dysuria, urgency, nocturia, suprapubic pain, urinary fre- quency, and incontinence ACTIONS: Counteracts smooth muscle spasm of the urinary tract DOSAGE: 100–200 mg PO tid–qid SUPPLIED: Tabs 100 mg NOTES: May cause drowsiness, blurred vision, and dry mouth Flecainide (Tambocor) COMMON USES: Prevention of PAF/flutter and PSVT, Rx life-threatening ventricular arrhythmias ACTIONS: Class 1C antiarrhythmic DOSAGE: Adults. Myelosuppression (leukocytopenia, thrombocytopenia, and anemia); rash, dry skin, and photosensitivity frequent. Tingling in the hands and feet followed by pain (palmar-plantar 22 erythrodysesthesia); phlebitis and discoloration at inj sites 22 Commonly Used Medications 541 Fluorouracil, Topical [5-FU] (Efudex) COMMON USES: Basal cell carcinoma of the skin, actinic and solar keratosis ACTIONS: Inhibitor of thymidylate synthetase (interferes with DNA synthesis, S phase-specific) DOSAGE: Apply 5% cream bid for 4–6 wk SUPPLIED: Cream 1, 5%; soln 1, 2, 5% NOTES: Toxicity symptoms: Rash, dry skin, and photosensitivity Fluoxetine (Prozac, Sarafem) COMMON USES: Depression, OCD, bulimia, PMDD ACTIONS: SSRI DOSAGE: Initially, 20 mg/d PO; ↑to a max of 80 mg/24h; ÷ doses of >20 mg/d. PMDD: 20 mg/d SUPPLIED: Caps 10, 20 mg; tabs 10 mg; soln 20 mg/5 mL NOTES: May cause nausea, nervousness, and weight loss; hepatic failure dosage adjustment Fluoxymesterone (Halotestin) COMMON USES: Androgen-responsive metastatic breast cancer ACTIONS: Inhibition of secretion of LH and FSH by feedback inhibition DOSAGE: 10–40 mg/d SUPPLIED: Tabs 2, 5, 10 mg NOTES: Toxicity symptoms: Virilization, amenorrhea and menstrual irregularities, hirsutism, alope- cia and acne, nausea, and cholestasis. Hematologic toxicity symptoms: Suppression of clotting fac- tors II, V, VII, and X and polycythemia. Nasal: 1–2 sprays/nostril/d SUPPLIED: Nasal spray 50 µg/actuation Fluticasone Oral (Flovent, Flovent Rotadisk) COMMON USES: Chronic treatment of asthma ACTIONS: Topical steroid DOSAGE: Adults & adolescents. Maintenance: 90–120 mg/kg/d IV (Monday–Friday) SUPPLIED: Inj 24 mg/mL NOTES: Dosage must be adjusted for renal function; nephrotoxic; monitor ionized calcium closely (causes electrolyte abnormalities); administer through a central line Fosfomycin (Monurol) COMMON USES: Uncomplicated UTI 22 ACTIONS: Inhibits bacterial cell wall synthesis 22 Commonly Used Medications 543 DOSAGE: 3 g PO dissolved in 90–120 mL of water as single dose SUPPLIED: Granule packets 3 g NOTES: May take 2–3 d for symptoms to improve Fosinopril (Monopril) COMMON USES: HTN and heart failure ACTIONS: ACE inhibitor DOSAGE: Initially, 10 mg/d PO; may be ↑ to a max of 80 mg/d PO ÷ qd–bid SUPPLIED: Tabs 10, 20, 40 mg NOTES: ↓ Dose in elderly; may cause nonproductive cough and dizziness Fosphenytoin (Cerebyx) COMMON USES: Status epilepticus ACTION: Inhibits seizure spread in the motor cortex DOSAGE: Dosed as phenytoin equivalents (PE) Loading 15–20 mg PE/kg, maintenance 4–6 mg PE/kg/d SUPPLIED: Inj; 150 mg (= phenytoin 100 mg); 750 mg (= phenytoin 500 mg) NOTES: Requires 15 min to convert the prodrug fosphenytoin to phenytoin; administer at <150 mg PE/min to prevent hypotension; administer with BP monitoring; dosage adjustment/plasma moni- toring may be necessary in hepatic impairment Furosemide (Lasix) Used for emergency cardiac care (see Chapter 21) COMMON USES: Edema, HTN, and CHF ACTIONS: Loop diuretic; inhibits Na and Cl reabsorption in the ascending loop of Henle and the distal renal tubule DOSAGE: Adults. IV: 5 mg/kg IV q12h for 14–21 d, then maintenance of 5 mg/kg/d IV for 7 d/wk or 6 mg/kg/d IV for 5 d/wk. Prevention: 1000 mg PO tid SUPPLIED: Caps 250, 500 mg; inj 500 mg; ocular implant 4. Daily dosing becoming popular Gentamicin, Ophthalmic (Garamycin, Genoptic, Gentacidin, others) COMMON USES: Conjunctival infections ACTIONS: Bactericidal; inhibits protein synthesis DOSAGE: Oint apply bid or tid; soln: 1–2 gtt q2–4h, up to 2 gtt/h for severe infections 22 SUPPLIED: Soln and oint 0. Stimulates the release of insulin from the pancreas; increases insulin sensi- tivity at peripheral sites; reduces glucose output from the liver DOSAGE: 1–4 mg/d, up to max of 8 mg SUPPLIED: Tabs 1, 2, 4 mg Glipizide (Glucotrol) COMMON USES: Type 2 DM ACTION: Sulfonylurea.