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The tangential force F2 leads to shear stress and therefore is not con- sidered further order 100mg zoloft with mastercard anxiety techniques. The normal stress distribution from M buy cheap zoloft 25mg on-line anxiety 24 hour helpline, on the other hand generic zoloft 100 mg on line depression kidney disease, varies linearly as shown in Fig. To calculate the normal stress at a certain point in the cross section, one must add both contributions. In the ad- dition, tensile stress is considered positive, compressive stress negative. While she is climbing stairs, the high heel of a woman’s boot gets stuck in a small hole (a). The free-body diagram of the woman’s leg minus the lower part is illustrated in (b). The resultant stress distribution on the cross sec- tion BB9 is schematically shown in (c). Determine the axial stress versus axial strain curves of three specimens obtained from materials such as various fabrics, strings, springs, or leaves and branches. Quick-capture and digitize the data us- ing a computer and plot stress versus strain. If a specimen has a con- stant depth, like that of a fabric, one could use the parameter (force di- vided by the width of the specimen) as a substitute for stress. An elastic spring of stiffness k and force-free length Lo is at- tached to a plate at one end (Fig. The spring reaches steady-state length of L1 under the application of a large weight W1 at its free end. At that stage, the weight W1 is replaced with a smaller weight W while keeping the extended length of the spring constant. Show that the velocity v of the contracting spring is given by the following expression: v 5 [g/(k m)1/2] (m 2 m) sin ((k/m)1/2 t) 1 where m 5 W/g and m1 5 W1/g. To come up with a single velocity value for each differ- ent (m/m1) ratio, try two different definitions: (1) velocity v* is the max- imum velocity of mass m during the contraction of the spring, and (2) W1 L0 L1 L A W A A W W1 FIGURE P. Use the following parameter values in plotting v* as a func- tion of the relative load m/m1: m1 5 0. Compare your results with the force–velocity relationship of a con- tracting skeletal muscle fiber. Note that the contraction velocity V that was defined in the text is dimensionless. A 17-year-old girl with 5-cm tibial shortening underwent a single fracture limb lengthening (Fig. The limb-lengthening procedure on a patient whose left leg was 5 cm shorter than the right leg. F F 20o j j 20o d d1 W/6 W/6 x 1 W/2 W/2 d2 AA9 in the soft tissue when the lower leg is positioned horizontally im- mediately after the bones of the lower leg were cut into two? Determine the force FM produced by the principal abduc- tor muscle gluteus medius and the total hip joint force Fj during the standing position shown in Fig. The lever arm c of gluteus medius with respect to the center of rotation of the hip is equal to 7 cm. The femorotibial joint is not a simple hinge, but the bone force FR acts at a distance d 5 2. Compute the joint force FR and the tension T in the gluteus max- imus for an individual standing on one foot. A runner crushes down upon his or her heel with a briefly sustained but intense force that often reaches many times the body weight. Each heel strike sends shock waves through the body, causing ac- celerations as high as 15 g. Running is not the only mode of motion dur- ing which impulsive forces act on humans. Accidental falls are the lead- ing cause of death from injury among persons aged 65 years and older. Finally, it must be noted that car-crash injury is still the number one killer for adults under the age of 35 years. To that end, the mechanics of objects impacting on padded surfaces are of great interest in biomechanics. The risk of injury from striking an automobile dashboard is of obvious im- portance in everyday life. We illustrate how the impact forces affect the move- ment and motion of the human body. The analysis is based on the math- ematical relationship between impulse and momentum. If the force does not change direction during the time period Dt, the magnitude of the impulse is equal to the area under the iFi–time curve (Fig. The magnitude of the impulse z generated by F is equal to the area under the force–time curve. The linear momentum L of an object at time t was pre- viously defined as L 5 m vc (7. According to Newton’s second law, the equation of motion of the center of mass of an object is dL/dt 5SF where SF denotes the resulting force acting on the object. Integrating the equation of motion for the center of mass between time t 5 ti and t 5 tf, we obtain the following relationship: m vc 2 m vc 5Sz (7. The vec- torial sum of the impulse and the linear momentum before the impulse must be equal to the linear momentum after the impulse. According to this equation, the change in the linear mo- mentum of a body during the time interval Dt is equal to the impulse act- ing on the body during the same time interval (Fig. The linear mo- mentum of the body in the direction normal to the impulse remains unaffected. In some situations an external force acting on a body is large compared to other forces exerted on the body but the time interval during which the force acts is small. A force that becomes very large during a very small time interval is called an impulsive force. When an impulsive force acts on a body, there may be an appreciable alteration in velocity during the period of application of the force. If some of the external forces acting on the object during a time interval (tf 2 ti) are impulsive, we may neglect en- tirely the effect of all other external forces on the motion of the object in the same time interval. Although the velocities may be altered as a result of impulse, the change in the spatial position of an object is negligible. Determine the average impact force on a front-seat passenger who is (i) buckled and (ii) not buckled. Experments with dummies indi- cate that if a passenger were not to wear a seat belt, he or she would hit the windshield and that collision would take place in 1 ms. In this particular case, we assume the weight of the front-seat passenger to be 60 kg. Because the im- pulsive force from the collision is much greater than other forces acting on the front passenger (the weight of the passenger and the contact forces between the seat and the passenger), impulse z in both cases is equal to z 5 60 kg [0 2 (120 km/h)] e1 522000 kg?

Evaluation of the process of care in the VA Spirituality cooperative study of the outcomes of geriatric evaluation and management inpatient and outpatient care buy 100mg zoloft fast delivery mood disorder nos dsm criteria. What do we know about patient for whom spiritual activity (including formal religious targeting in geriatric evaluation and management (GEM) participation and private practices) is a critical compo- programs? Age buy generic zoloft 50 mg on-line depression symptoms long term, socioeconomic member if they are "providing care for anyone on a status cheap zoloft 100 mg fast delivery depression definition dictionary, and health. Racial inequalities in the use of • Ask about the intensity of care provision (primary procedures for patients with ischemic heart disease in versus secondary provider, daily basis or less often) Massachusetts. The twain meet: empirical explanations of sex differences on health and mortality. In: Binstock R, George cope) and feelings of helpless and hopelessness that L, eds. Impact of psycho- • Ask the patient if problem behavior exists in the logical factors on the pathogenesis of cardiovascular disease family, such as acts of violence or excessive force. Psychosocial Influences on Health in Later Life 63 ECG monitoring of men and women. Everson SA, Kaplan GA, Goldberg DE, Salonen R, patients about faith healing and prayer. Steinhauser K, Christakis N, Clipp E, McNeilly M, McIntyre tion: the mediating role of behavioral risk factors. New York: of different determinants of psychological distress in acute Springer; 2000. Geriatric Review of sympathoadrenal medullary activation in the initiation Syllabus: A Core Curriculum in Geriatric Medicine. Cytokines for psychologists: impli- child: a cause of psychological distress in the elderly? This page intentionally left blank 7 Principles of Pharmacology Jerry Avorn, Jerry H. Gurwitz, and Paula Rochon It is much easier to write upon a disease than upon a remedy. The latter will ever be subject to the whim, the inac- Another aspect of drug distribution that is likewise not curacies, and the blunder of mankind. In large populations, The proper use of medications represents one of the most clinically meaningful decreases in serum albumin have crucial ways in which the practice of geriatric medicine not been found, although there is a very modest re- differs from conventional medical care. Despite these observa- of the unique pharmacologic properties of drugs in this tions on serum proteins in healthy aging, it is crucial to population, as well as a grasp of the clinical, epidemiolo- consider that serum albumin levels may be markedly gic, sociocultural, economic, and regulatory aspects of decreased in older patients suffering from malnutrition medication use in aging. One of the more important risks of diminished binding Pharmacokinetics proteins is an iatrogenic one, resulting from misinter- pretation of serum drug levels. Many assays measure the Of the four traditional components of pharmacoki- total amount of drug that is present in serum, both netics—absorption, distribution, metabolism, and excre- protein-bound and unbound ("free"). The unbound tion—only the last three are meaningfully affected by concentration is more clinically relevant than the total age. In the absence of malabsorptive syndromes, tradi- concentration because only unbound drug is pharmaco- tional oral formulations of drugs are absorbed as well in logically active. Of course, the same concerns apply another deficiency in binding protein, any given serum in elderly patients as in those of any age concerning the drug level reflects a greater concentration of unbound possible adsorption of medications by antacids and the drug than the same level would signify in a patient with relation between the ingestion of meals and the taking normal protein-binding capacity. However, the well-reported changes in patient with a "normal" total serum drug concentration gastric motility and blood flow to the gut with aging do may actually have an unbound drug concentration that is not appear to alter meaningfully the efficiency with which unacceptably high. By contrast, the same patient with a medications move from the gastrointestinal tract into the slightly lower than normal total serum concentration may systemic circulation. For extensively protein-bound drugs whose potential age-related changes in their delivery rates. Simi- binding is reduced as a result of hypoproteinemia, clini- larly, data on the kinetics of transdermal, transbuccal, cians should expect both therapeutic and toxic events at and transbronchial drug administration in the elderly are lower total serum concentrations. Rochon which the interpretation of serum levels reflecting total ultrasound studies have found a progressive decrease in drug concentration (rather than the free drug concentra- liver mass after age 50. Regional blood flow to the liver tion) can be difficult in malnourished or chronically ill at age 65 is reduced by 40% to 45% relative to that in elderly patients. Such changes can is also important to recall that the therapeutic range rou- also result in reduced clearance rates for drugs exhibit- tinely reported on such assays may not be an accurate ing flow-dependent clearance characteristics ("first-pass guide to either efficacy or toxicity in the geriatric patient. Although mic differences (see following) or idiosyncratic aspects of many studies have reported reduced metabolic clearance specific patients. The volume of distribution is heavily influenced hepatic drug metabolism than the aging process itself. Therapeutic considerations therefore should be based Because the latter increases in the elderly at the expense on individual patient characteristics as well as expected of the former, lipid-soluble drugs (such as some benzo- physiologic changes due to aging. Women have a lower lean old age, amounting on average to a reduction in glomeru- body mass compared with men at all ages, and there lar filtration rate by nearly a third. Hepatic biotransformations of drugs wisdom and in nomograms used to calculate drug dosing are categorized into phase I (preparative) and phase II with age, these longitudinal studies make it clear that (synthetic) reactions. Phase I reactions include oxidations the effect of age on renal function (and therefore on the (hydroxylation, N-dealkylation, and sulfoxidation), re- excretion of many drugs) can be quite variable. Phase II reactions involve differences among patients often will be as important as conjugation of the drug molecule to glucuronides, sul- the changes attributed to the aging process itself. Although blood urea nitrogen (BUN) and serum cre- Earlier studies in animals had suggested that normal atinine levels may be useful (albeit crude) markers of aging is accompanied by reduced activity of liver micro- renal function, it must be remembered that each is sus- somal drug-metabolizing enzymes as well as diminished ceptible in its own way to perturbations that can occur microsomal enzyme induction, but data on hepatic drug with aging but have nothing to do with renal function metabolism in aging human subjects are much more itself. However, the origin of much of this ated with a reduction in the liver mass, as well as in urea is ingested protein, so that a malnourished older hepatic blood flow. These changes are likely responsible patient may not consume enough nitrogen to produce an for the reduction in hepatic metabolism of drugs, which appropriate rise in BUN, even in the face of renal impair- can be as great as 25% over the life span. Principles of Pharmacology 67 and if a patient has a markedly diminished muscle mass, ther magnified by its biotransformation into the active whether because of chronic illness or any other cause, he metabolite desalkylflurazepam, which also has benzo- or she may not produce enough creatinine to reflect a diazepine effects on the central nervous system. Thus, overreliance on "normal-appearing" BUN action of a drug is related to its half-life. Under this and creatinine in older patients can severely under- assumption, long elimination half-life implies a long dura- estimate the degree of renal impairment. Although this presumption is estimate renal function in older patients who are to sometimes incorrect,22 some epidemiologic data support receive potentially nephrotoxic drugs (e. It should be emphasized that these estimates are valid A common goal of long-term pharmacotherapy is to only in patients whose renal function is in steady state achieve and maintain a therapeutic steady-state serum and who are not taking medications that directly alter concentration. The steady-state drug concentration is renal function or affect creatinine excretion. This formula proportional to the medication dosing rate (dose/dosing has some utility in assessing renal function in healthy interval) and is inversely proportional to drug clearance. Although drug clearance is a biologi- cally determined characteristic of each patient over The elimination half-life of a medication (t1/2) is deter- which the prescriber has no control, dose and dosing mined by the volume of distribution (Vd) for that med- interval are variables that can be modified. To prevent the ication in a given individual, divided by its clearance (Cl) excessive accumulation of a drug when its clearance is in that subject (generally through metabolism in the liver reduced (as is often the case in an elderly patient), one and/or renal excretion); this can be expressed as follows: can reduce the dose, increase the interval between doses, or both, depending on the situation. If the volume of distribution is also increased (as with a lipophilic drug in an older Pharmacodynamic changes with aging (i. The study of this phenomenon is relationships are illustrated by the benzodiazepine hyp- complicated by the fact that the effect of many drugs is notic flurazepam.

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APPENDIX 1 217 Crossroads: Caring for Carers Dialability 10 Regent Place Oxford Centre for Enablement Rugby CV21 2PN Windmill Road Tel: 01788 573653 Headington OX3 7LD Fax: 01788 565498 Tel: 01865 763600 Wales: 02920 222282 Fax: 01865 764730 Website: www. Additional helplines: variety of leisure and recreation issues, holidays, sports and adult education. Also has Crossroads Scotland a showroom where equipment to aid people 24 George Square with disabilities can be viewed. Glasgow G2 1EG Tel: 0141 226 3793 Disabilities Trust Fax: 0141 221 7130 First Floor Website: www. Helpline: 0870 167 1677 Tel: 020 8940 4818 Disability Alliance Fax: 020 8940 7638 Universal House Website: www. Doncaster DN4 8QN Tel: 01302 310123 Disability Equipment Register Fax: 01302 310404 4 Chatterton Road Website: www. Tel: 020 7791 9800 Fax: 020 7791 9802 Disability Wales/Anabledd Cymru Provides free legal advice for people with Wernddu Court disabilities. Caerphilly Business Park Van Road Disability Now Mid Glamorgan CF83 3ED (campaigning newspaper) Helpline: 0800 731 6282 Editorial Department Tel: 0292 088 7325 6 Market Road Fax: 0292 088 8702 London N7 9PW Website: www. Neville House Neville Road Disability Rights Commission Bradford BD4 8TU FREEPOST Tel: 01274 370019 MID 02164 Fax: 01274 723861 Stratford upon Avon CV37 9BR Website: www. Special Ashley Avenue team of advisers can help with problems of Epsom KT18 5AD discrimination at work. Tel: 01372 737046 Fax: 01372 737040 Disability Sport England Minicom: 01372 737041 Solecast House Website: www. Provides opportunities for people of all ages with disabilities to take part in sport. APPENDIX 1 219 Disabled Drivers Association, National Disabled Motorists Federation Headquarters 145 Knoulberry Road Ashwelthorpe Blackfell Norwich NR16 1EX Washington NE37 1JN Tel: 0870 770 3333 Tel: 0191 416 3172 Fax: 01508 488173 Fax: 0191 416 3172 Website: www. Disabled Drivers Motor Club Cottingham Way Disablement Income Group Scotland Thrapston 5 Quayside Street Northants NN14 4PL Edinburgh EH6 6EJ Tel: 01832 734724 Tel: 0131 555 2811 Fax: 01832 733816 Fax: 0131 554 7076 Website: www. Disabled Living Centres Council DVLA (Drivers and Vehicles Licensing Redbank House Authority 4 St Chads Street Medical Branch Cheetham Longview Road Manchester M8 8QA Morriston Tel: 0161 834 1044 Swansea SA99 1TU Fax: 0161 839 0802 Helpline: 0870 600 0301 Textphone: 0161 839 0885 Tel: 0870 240 0009 Website: www. Offers lists of centres and the Government office offering advice to drivers different services they provide. Disabled Living Foundation Employment Opportunities for People 380–384 Harrow Road with Disabilities London W9 2HU 123 Minories Helpline: 0845 130 9177 London EC3N 1NT Tel: 020 7289 6111 Tel: 020 7481 2727 Fax: 020 7266 2922 Fax: 020 7481 9797 Textphone: (Minicom): 020 7432 8009 Website: www. FABB Scotland 5a Warriston Road FES Team Edinburgh EH3 5LQ Medical Physics Department Tel: 0131 558 9912 Salisbury District Hospital Headquarters in Scotland for network of local Salisbury SP2 8BJ groups who arrange integrated projects to Tel: 01722 336262 (ext. Foundation for Assistive Technology Family Fund Trust 12 City Forum PO Box 50 250 City Road York YO1 9ZX London EC1V 8AF Helpline: 0845 130 4542 Tel: 020 7253 3303 Tel: 01904 621115 Fax: 020 7253 5990 Fax: 01904 652625 Website: www. Researches into new driving lessons to families in the UK with equipment to aid people with disabilities. Foundations Bleaklow House Family Service Units Howard Town Mill 207 Old Marylebone Road Glossop SK13 8HT London NW1 5QP Tel: 01457 891909 Tel: 020 7402 5175 Fax: 01457 869361 Fax: 020 7724 1829 Website: www. These offer free families disadvantaged by poverty and at risk help to older or disabled home owners and of social exclusion. 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Disability Advisory Services Disabled Students Services Section National Childbirth Trust Walton Hall Alexandra House Milton Keynes MK7 6AA Oldham Terrace Tel: 01908 652255 London W3 6NH Fax: 01908 659956 Helpline: 08704 448708 Website: www. Breastfeeding Oxford Centre for Enablement counselling helpline available 8am–10pm. Also offers day respite care for people with other long term illnesses such as MS. Leaflets and many more overseas catering for a wide and directory of self-help groups available. Pensions Advisory Service (OPAS) 11 Belgrave Road Queen Elizabeth Foundation London SW1V 1RB for Disabled People Tel: 08456 012923 Leatherhead Court Fax: 020 7233 8016 Woodlands Road Website: www. Provides information, demonstrations, assessment and training on outdoor mobility PHAB for professionals and people with disabilities. 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Ankle-foot nursing home cheap zoloft 100 mg without prescription depression no friends, or the patient’s home 25 mg zoloft with amex depression cure, to provide rehabili- orthoses (AFO) are most commonly used in the elderly tation is complex cheap zoloft 50 mg with amex depression definition with reference. Two types are commonly the Post-Stroke Rehabilitation Guidelines28 has been employed: the double adjustable upright metal ankle- evaluated and revised slightly62 (Fig. Rehabilitation foot orthosis, used to stabilize a spastic ankle and provide "services" refer to a single discipline or type of therapy, some proprioceptive feedback to the knee; and the pos- whereas a rehabilitation "program" refers to multidisci- terior plastic AFO, which prevents footdrop but requires plinary, coordinated services. Seventy-eight percent to 85% of have good reliability for home and nursing facility place- patients are able to walk after 6 months. The patient’s deficits may go unde- tected until the patient’s ability to organize motor tasks in sequence is evaluated. For instance, spasticity sometimes Once the patient’s condition is reasonably stable, inten- can be controlled with the use of weighted utensils. Total stability is elusive in types of special utensils, such as rocker knives, plate the older person, and risks of an intervention must be guards, and reachers, enable persons with hemiplegia to weighed against risks of continued bed rest and decondi- function more independently. Early assessment for The next stage is mass flexor synergism; that is, the limb aphasia is critical to providing other team members will flex at multiple joints when movement is attempted. Once the Approximately 24% to 53% of stroke survivors are par- patient has an extensor synergy pattern, even with tially or totally dependent 6 months after their strokes. Poststroke depression is very progresses, selective flexion of individual joints usually common, affecting about 30% of survivors. It is especially follows, and finally selective extension with decreased likely with left hemisphere damage. Although the return of retards functional recovery and may be misinterpreted as motor function most affects ambulation (a value held "poor motivation. A l g o r i t h m f o r r e h a b i l i t a t i o n p l a c e m e n t d e c i s i o n s f o r s t r o k e p a t i e n t s. Psychotherapy and the may enhance the ability to participate in the rehabilita- judicious use of antidepressant medication are usually tion program. The choice of an antidepressant medication is the treatment program through training in caregiving usually made based on the side effect profile because all skills. A bedside graph to document progress made by the have more or less the same response rate. However, patient and a chart that specifies goals to be achieved can because most agents require at least 2 weeks to pro- also be helpful. This condition, thought to be caused by "disinhibition," responds to selective serotonin The chronic phase begins when the person who has suf- reuptake inhibitors. Raised toilet seats with arm frames, speech and language pathologist has been shown to be grab bars, and a bathtub bench with a handheld shower valuable,68 and early dietary consultation should occur on hose will often be required (Fig. Having access to one’s den- the need for ramps, the adequacy of lighting, and safety tures, eyeglasses, and clothing promotes self-esteem and features that may need modifications. Frank information should be pro- Weightbearing after surgery is often a source of con- vided regarding the fact that sexual activities following a fusion. The ideal surgical result would promote maximum stroke are quite safe, although new techniques are often independence and allow early ambulation to prevent needed. A orthopedists order weeks of nonweightbearing after the vocational rehabilitation counselor can assess and help placement of pins or nails, the most common type of with the return to employment if appropriate. It is very difficult for ments for transportation are particularly important, as older persons to bear weight with only touching their foot many geriatric patients stop driving after a stroke. There is no evidence that this practice The question of whether patients should receive is needed, and early weightbearing according to the further evaluations by rehabilitation therapists 1 to 2 patient’s tolerance of pain is recommended. In a randomized not appear that hip replacement facilitates better func- trial, physical therapy was offered to study patients with tional outcomes over other surgical approaches. The intervention group showed an improvement femoral head seen in subcapital fractures. This nondisplaced fractures are often treated with internal fix- benefit was lost, however, if patients stopped having ation, using nails or pins. In osteoporotic provided in a stroke clinic to 40 patients who were, on patients, subcapital fractures may be treated with average, 3 years poststroke. Significant Weightbearing to tolerance is allowed by the 2nd or 3rd improvements in balance and ADL performance were day. Three months following the intervention, the tion and internal fixation, often using a compression patients’ skills in balance and weight shifting, as well as screw. With this procedure, the patient usually can bear their ADL scores, were maintained. In the patient with a femoral neck fracture who has preexisting joint disease, a total hip prosthesis also may be indicated. Stabilization of Many patients with hip fractures can benefit from reha- life-threatening medical problems should occur before bilitation. If the patient is alert, preoperative payment in hospitals, more patients with hip fracture are evaluation by physical and occupational therapy and sent to nursing homes for longer periods of time. The patient can begin quadriceps contrac- been shown to be cost-effective,73,74 but inpatient reha- tions and, on the 1st postoperative day, can sit up and bilitation has not. Adduction, excessive flexion, and sions per week postoperatively are associated with better abduction at the hip should be avoided if the joint has health outcomes. The patient should support no independence in bathing and transfers, family involve- more than 20% to 25% of total body weight on a cane. Early discharge and home rehabilitation should be considered for those with (1) good health (the absence of significant medical prob- lems), (2) strong social supports (someone who can provide assistance), and (3) adequate performance of ambulation and activities of daily living within 2 weeks of surgery. The remainder may require more intensive therapy that can be effectively provided in a rehabilita- tion nursing facility. Lower Extremity Amputation Although most patients who experience a lower extrem- ity amputation (LEA) are between 51 and 69 years old, the age-related incidence of LEA in persons over age 80 has increased significantly. The older person’s care is more complex after amputation because of upper extremity weakness, underlying cardiovascular problems, skin that is prone to breakdown, and poor balance mechanisms. Older persons are more likely to have subsequent amputations on the contralateral side. The elbow is flexed 20° to 30° crucial role in managing these problems and in helping when holding the cane at the side. In frail older persons, the decision as to level of ampu- tation is often difficult. Stair training begins during the second week 90% success rate for healing a transtibial amputation. Patients need to practice advancing the walker attempts should be made to avoid serial amputations about 20 to 30 cm, then advancing the weak leg, and then (e. Some older persons may find it easier to transfemoral) because prolonged bed rest and its atten- advance the good leg first, but this practice increases dant complications are more likely. Crutches are very difficult for most There are three major types of lower extremity older persons to use.

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