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The only way to truly discern if something is going to work reliably from patient to patient, and to rule out the effect of something else, is to systematically test it with a group of patients, as is done in research. This program is supported by education grants from Boehringer Ingelheim Pharmaceuticals, Inc. It is supported by charitable contributions from the Bristol-Myers Squibb/Sanof Pharmaceuticals Partnership, Pfzer Inc, Genentech, Inc. Of the 795,000 Americans who have a stroke each year, 5 to 14 percent will have a second stroke within one year. Percentage of Reoccurrence After First Stroke Within 30-Days 3% to 10% Within 1-Year 15% to 14% Within 5-Years 25% to 40% Your Lifestyle Choices Everyone has some stroke risk. By making simple lifestyle changes, you may be able to reduce the risk of a frst or recurrent stroke. Monitor Your Blood Pressure High blood pressure is one of the most important and easily controlled stroke risk factors. The frst number, the systolic blood pressure, is a measurement of the force your blood exerts on blood vessel walls as your heart pumps. The second, diastolic blood pressure, is the measurement of the force your blood exerts on blood vessel walls when your heart is at rest between beats. If yours falls in this range, you are more likely to progress to high blood pressure. If you are at risk for high blood pressure, ask your doctor how to manage it more aggressively. Adults should do some form of moderate physical activity for at least 30 minutes fve or more days per week, according to the Centers for Disease Control and Prevention. Many drugs can help treat high blood pressure, and most dont produce side effects. You and your doctor may have to try several different drugs before you fnd one that works for you. Once you fnd a drug that works, take it as directed and exactly as prescribed, even when you feel fne. In addition to those that treat high blood pressure, drugs are also available to control high cholesterol and treat heart disease. It is important that people prescribed an anticoagulant are regularly monitored by a healthcare provider. High Cholesterol High levels of cholesterol may also increase stroke risk by not letting blood move freely through the arteries. Several drugs, including a class of drugs called statins, may help lower cholesterol levels. Unless cholesterol levels are already low, taking a statin is generally benefcial. Blood Clotting There are two classes of drugs that can help prevent clotting: anticoagulants and antiplatelets. During surgery, blockages and build-up in the arteries are removed to restore the free fow of blood. By understanding the basis for these decisions, youll be better able to follow the suggestions and make informed choices that will help reduce your risk of stroke. If you experience any of these symptoms, for even the briefest amount of time or notice them in someone else, seek medical attention immediately. In addition to lifestyle changes such as diet and exercise, your doctor may recommend drugs to treat high blood pressure, high cholesterol or heart disease. There are many medicines that help prevent blood clots from forming, reducing the risk of a full blown stroke. Eat Foods with Adequate Starch and Fiber Complex carbohydrates are better than simple carbohydrates, such as sugars, because they contain essential nutrients and fber. These foods include beans, peas, nuts, fruits, vegetables, whole grain breads and cereals. If sucrose, glucose, maltose, dextrose, lactose, fructose or syrups are listed frst among the ingredients, then there is a large amount of sugar in that product. Avoid Excess Fat the intake of fat, particularly saturated animal fat, trans fat and cholesterol, is a contributing factor in developing atherosclerosis, which is associated with stroke and heart disease. Avoid Excess Sodium Excess salt in your diet increases the risk of high blood pressure, which is a major factor in heart disease and stroke. Di-sodium phosphate, monosodium glutamate, sodium nitrate, and any other sodium compound in the list of ingredients indicates a high sodium content. Heavy drinking may lead to serious physical and mental deterioration and may increase risk of stroke. Maintain Ideal Weight Being overweight increases the risk of a number of diseases including hypertension, coronary atherosclerosis and diabetes. To lose weight you must decrease calories without sacrifcing essential nutrients, and start or maintain an exercise program. Most places offer apple slices, baby carrots, broccoli forets, celery sticks, mixed vegetables, salad greens and spinach. As a result, about 40 percent of stroke survivors have serious falls within a year of their strokes. Movement the most common physical effect of stroke is muscle weakness and having less control of an affected arm or leg. Survivors often work with therapists to restore strength and control through exercise programs. Paralysis and Spasticity Paralysis is the inability of muscle or group of muscles to move on their own. This damage can cause an arm or leg to become paralyzed and/or to develop spasticity. It can be found throughout the body but may be most common in the arms, fngers or legs. Depending on where it occurs, it can result in an arm being pressed against the chest, a stiff knee or a pointed foot that interferes with walking. Therapy can include range-of-motion exercises, gentle stretching, and splinting or casting. Exercise Walking, bending and stretching are forms of exercise that can help strengthen your body and keep it fexible. Mild exercise, which should be undertaken every day, can take the form of a short walk or a simple activity like sweeping the foor. Stretching exercises, such as extending the arms or bending the torso, should be done regularly. Swimming is another benefcial exercise if the pool is accessible and a helper is available. Use an exercise program that is written down, with illustrations and guidelines for a helper if necessary. The frst is for the person whose physical abilities have been mildly affected by the stroke. If you are not sure which one is appropriate, consult the profle that precedes each program. However, for many stroke survivors, it is advisable for someone to stand nearby while an exercise session is in progress. For instance, some stroke survivors are not aware that their balance is unsteady, nor can they tell left from right. Others may have lost the ability to read the exercise instructions, or may need assistance to remember a full sequence of movements. The exercise session should be scheduled for a time of day when you feel alert and well. Because the effects of stroke vary, it is impossible to devise a single exercise program suitable for everyone. You should consult an occupational therapist and/or physical therapist, who can help in selecting the specifc exercises that will beneft you, and who will provide instruction for both you and your caregiver. Resources For referral to an occupational or physical therapist, consult your doctor or contact a home health agency, a family service agency, or the physical therapy department of your community hospital. You may also try contacting the American Occupational Therapy Association at (301) 652-2682 or the American Physical Therapy Association at (800) 999-2782 for a referral in your area. As with any exercise program, consult with your doctor and/or therapist before beginning this program. If any exercises are too diffcult and cause pain or increased stiffness in your limbs, do not do them. You may also have some obvious stiffness or muscle spasms, particularly with fatigue or stress. For managing longer distances or uneven terrain, you may require some minimal assistance from another person, a more supportive walking aid or a wheelchair. Abnormalities may be present when you walk, but may be corrected by exercise and by ftting shoes with lifts or wedges. A prescription for these shoe modifcations can be obtained from a doctor following evaluation by a physical therapist. You can usually use the stairs with or without handrails, with a helper close by or with very minimal assistance. Sturdy, well-constructed shoes with non-skid soles, such as athletic shoes, are recommended at all times. Reddened areas and pressure marks should be reported to a doctor or physical therapist. Also, the word foor has been used to simplify the instructions; the exercises can be performed on the foor, on a frm mattress, or on any appropriate supportive surface. Keep your elbow straight, lift your affected arm to shoulder level with your hand pointing to the ceiling. Hold for three to fve seconds, and then relax, allowing your shoulder blade to return to the foor. Exercise 2 To strengthen the shoulder muscles as well as those which straighten the elbow a. Lying on your back, grasp one end of an elasticized band* in each hand with enough tension to provide light resistance to the exercise, but without causing undue strain. To start, place both hands alongside the unaffected hip, keeping your elbows as straight as possible. Move your affected arm upward in a diagonal direction, reaching out to the side, above your head, keeping your elbow straight**. They are available in varying strengths (color coded) to provide progressive resistance. To increase resistance as strength improves, the next density of Theraband can be purchased, or two or more bands of the original density can be used at once. Similar elastic bands or cords are also available at many sporting goods stores where exercise equipment is sold. If you cannot grip with your hand, a loop can be tied at the end to slip your hand partially through the loop, leaving the thumb out to catch the loop during upward movement. Lie on your back with your arms resting at your sides and a rolled towel under the affected elbow. Slowly bring the heel of your affected leg along the foor, returning to the starting position. Lie on your unaffected side with the bottom knee bent for stability and your affected arm placed in front for support. Starting with your affected leg straight, bend your affected knee, bringing the heel toward your buttocks, then return to the straightened position. Concentrate on bending and straightening your knee while keeping your hip straight.

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Also medications diabetes effective 100 mcg combivent, when asked symptoms 0f parkinsons disease best purchase for combivent, Eden says her physical therapist medicine cabinet home depot order combivent uk, MacKenzie medications that cause tinnitus combivent 100mcg with visa, is her best friend medications band purchase combivent without a prescription. Eden needs to be on her feet and bearing weight to eventually hold up an adult body medications may be administered in which of the following ways buy combivent with visa, says Hoelscher. The best way to combat your feelings of helplessness and confusion is to arm yourself with information on what a spinal cord injury is, and what it means in terms of short term planning and long-range goals. This section of the book helps those who are beginning to locate spinal cord injury information for a loved one or friend who has been recently injured. The Infor mation Specialists at the Paralysis Resource Center specialize in answering questions about new injuries. You dont have to go this alone: Join the online Paralysis Community to connect with and gain support from others whose circumstances are similar to yours. Since each injury is different as to its level and severity, the information is provided in general terms. Acute Management the first few hours are critical after a spinal cord injury, as life-saving interven tions and efforts to limit the severity of the injury take precedence. Ideally, a spinally injured person should be transported to a Level I trauma center for multidisciplinary expertise. If cervical spine injury is suspected, the head and Paralysis Resource Guide 174 3 neck are immediately stabilized. Cooling has been tested in clinical trials and appears promising, but protocols for temperature, duration, etc. Once a person reaches the acute hospital, several basic life-support pro cedures may occur. Tracheostomy or endotracheal intubation is often done even before location of injury is established. Early surgery (within hours of injury) to decompress or align the spinal canal is often done. Evidence from animal studies supports this as a means to improve neurologic recovery but the timing of this intervention is subject to debate; some surgeons wait several days to allow swelling to subside before decompressing the cord. Spinal cord injuries commonly lead to paralysis; they involve damage to the nerves within the bony protection of the spinal canal. The most common cause of spinal cord dysfunction is trauma (including motor vehicle accidents, falls, shallow diving, acts of violence, and sports injuries). Damage can also occur from various diseases acquired at birth or later in life, from tumors, electric shock, and loss of oxygen related to surgical or underwater mishaps. For cervical fractures, the spine is often stabilized by a bone fusion, using grafts from the fibula (calf bone), tibia (shin bone) or iliac crest (hip). To stabilize spinal bones, a spinal fusion might be done, using metal plates, screws, wires and/or rods and sometimes small pieces of bone from other areas of the body. A spinal cord injured patient will typically encounter several external devices, including braces, traction pulleys, skull tongs, turning frames, molded plastic jackets, collars and corsets. Bracing devices are often used early on; they allow vertebral bones to heal but allow patients to be up and around, protecting them from the effects of bed rest. Classifying the Injury: Once physicians determine the level and extent of the injury, the patient will also undergo a thorough neurological examination. This looks for signs of sensation, muscle tone and reflexes of all limbs and the trunk. These folks are most likely to be ventilator dependent and typically need 24-hour attendant care with total assistance with bowel and bladder management, bed mobility, transfers, eating, dressing, grooming, bathing and transportation. They can power an electric wheelchair and can be independent communicators with the right equipment; they need to be able to explain everything an assistant needs to know about their care. May be able to breathe without a ventilator, otherwise, similar profle as the C1-3 group: total assistance needed for all tasks except power wheelchair use. These people can eat independently if meals are set up for them but still need some assistance for grooming, bed transfers and dressing. Some people with a C5 injury can drive a vehicle with the right specialized equipment and training. No wrist fexion or hand movement but can push a manual chair and do weight shifts. Personal care needed but on a limited basis; getting up in the morning, grooming, going to bed. Level C7/8: Paralysis of trunk and legs but with greater arm and hand dexterity, including elbow, wrist and thumb extension. Some compromised vital capacity but independent for almost all functional self-care activities. Level T10-L1: Paralysis of legs but good trunk stability; intact respiratory system. Level L2-S5: Partial paralysis of legs, hips, knees, ankles and feet, good trunk support. Get a copy of Expected Outcomes, What You Should Know, (choose the one for your level of injury). An incomplete injury means that the ability of the spinal cord to convey messages to or from the brain is not completely lost. A complete injury is indicated by a total lack of sensory and motor function below the level of injury. But the absence of motor and sensory function below the injury site does not necessarily mean that there are no remaining intact axons or nerves crossing the injury site; just that they do not function appropriately following the injury. It is essential to optimal recovery to initiate rehab interventions immediately after injury to prevent secondary complications, including throm boembolism, skin breakdown, and respiratory issues. This is also the key time to discuss assistive devices and information services, insurance issues, internet resources, etc. Depending on other medical issues related to the injury, most people leave the acute hospital within days and enter into rehabilitation. See Early Acute Management in Adults with Spinal Cord Injury, a guide from the Consortium for Spinal Cord Medicine. This publication, along with nine additional Clinical Practice Guidelines, can be downloaded at no cost; go to Most people have no experience with rehab or the effects of paralysis, so assessing the quality of a rehab program can be stressful and complex. Hospitals that accept federal money must provide a certain amount of free or reduced-fee care. To start the process, meet with a caseworker at the hospital to gather relevant paperwork and begin applying for Medicare/Medicaid and Social Security. Not everyone will qualify for Medicaid, a state-administered program established to provide healthcare to low-income individuals and families. Applications and rules vary from state to state, so contact your local Medicaid ofce directly or work with the hospital caseworker. Contact relevant beneft ofces to set up any appointments or interviews needed to expedite the process; confrm the documentation needed. Be sure to keep accurate and thorough records of everyone you are in contact with. If you are doubtful of your eligibility, it is best to apply and have a caseworker or lawyer review your application. Caseworkers or social workers are sometimes assigned by your hospital (though you may have to ask for one). Patients usually pay no costs for covered medical expenses, although a small co-payment may be required. Medical bills are paid from trust funds into which those people covered have paid. It mainly serves people 65 and over, whatever their income, and serves younger disabled people after they have received disability benefts from Social Security for 24 months. Children may also be eligible for some disability benefts from Supplemental Security Income. Medical rehab is increasingly specialized; the more patients a facility regularly treats with needs similar to yours, the higher the expertise of the staff. High-quality programs are often located in facilities devoted exclusively to providing rehabilitation services or in hospitals with designated units. Generally speaking, a facility with accred ited expertise is preferable to a general rehabilitation program. For those with a spinal cord or brain injury, there are groups of specialized hospitals called Model Systems Centers. These are well-established facilities that have qualified for special federal grants to demonstrate and share medical expertise (see pages 11 and 50). Rehab teams should include doctors and nurses, social workers, occupational and physical therapists, recreational therapists, rehabilitation nurses, rehabilitation psychologists, speech pathologists, vocational counselors, nutritionists, respiratory experts, sexuality counselors, rehab engineering experts, case managers, etc. If you still need assistance, there are some non-proft organizations that provide grants for individuals. Please call the Reeve Foundation at 1-800-539-7309 for more information on organizations that provide grants to individuals as well as those that provide wheelchairs and other equipment. An organization called HelpHopeLive assists individuals with raising funds from their communities and social networks for uninsured expenses related to catastrophic injury. Donors receive tax deductions and recipients protect their ability to receive income-dependent benefts. Peer support is often the most reliable and encouraging source of information as people make their way in the new world of rehab and recovery. You might also ask these types of questions: What have been the results for people like me who have used your services The ultimate measure of good rehab is the breadth and quality of the professional staff on hand. Physiatrists treat a wide range of problems from sore shoulders to acute and chronic pain and musculoskeletal disorders. Physiatrists coordinate the long-term rehabilitation process for people with paralysis, including those with spinal cord injuries, cancer, stroke or other neurological disorders, brain injuries, amputations and multiple sclerosis. A physiatrist must complete four years of graduate medical education and four years of postdoctoral residency training. Residency includes one year spent developing fundamental clinical skills and three years of training in the full scope of the specialty. They have special training in rehabilitation and understand the full range of medical complications related to bladder and bowel, nutrition, pain, skin integrity and more, including vocational, educa tional, environmental and spiritual needs. Rehab nurses provide comfort, therapy and education and promote wellness and independence. The goal of rehabilitation nursing is to assist individuals with disabilities and chronic illness in the restoration and maintenance of optimal health. They recommend and train people in the use of adaptive equipment to replace lost function. The occupational therapist guides family members and caregivers in safe and effective methods of home care; they will also facilitate contact with the community outside of the hospital. When pain is an issue, physical therapy is often the first line of defense; thera pists use a variety of methods including electrical stimulation and exercise to improve muscle tone and reduce contractures, spasticity and pain. One very good way to stay connected with family, friends and colleagues before, during and after hospitalization and rehabilitation is by way of a private, personalized website such as Caring Bridge, Lotsa Helping Hands or CarePages. These free websites allow you to post entries on the condition and care of your loved one in the care of a hospital or rehabilitation center. You can also receive messages of encouragement to help sustain you during this difcult transition in your life. It has been well established that exercise, fitness and relaxation reduce stress and contribute to improved cardiovascular and respiratory function, and increased strength, endurance and coordination. Skin sores and urinary tract infections, for example, are significantly reduced in wheelchair athletes, as compared to non-athletes. Active involvement in recreation leads to improved life satisfaction, better social relationships and lower levels of depression. Then they work with various government agencies to obtain equipment, training and placement. Vocational therapists also educate disabled individuals about their rights and protections under the Americans with Disabilities Act, which requires employers to make reasonable accommo dations for disabled employees. Vocational therapists may mediate between employers and employees to negotiate reasonable accommodations. Sometimes, changing body position and posture while eating can bring about improvement. Speech-language pathologists help people with paralysis develop strategies for language disabilities, including the use of symbol boards or sign language. They also share their knowledge of computer technology and other types of equipment to enhance communication. Neurologist A neurologist is a doctor who specializes in the diagnosis and treatment of disorders of the nervous system (brain, spinal cord, nerves and muscles). Rehabilitation Psychologist A rehab psychologist helps people deal with life-changing injury or disease, offering tools to cope with the effects of disability. Therapy might be offered individually or in a group to speed the adjustment to changes in physical, cognitive and emotional functioning. The psychology team also offers marital and family therapy and sexual or family planning counseling. A case manager may arrange for purchases of special equipment and/or home modifications.

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After training treatment wax order 100 mcg combivent fast delivery, the probabilities of the sequences represented at each level are conditioned by feedback from above medications 247 order 100mcg combivent with visa. For example symptoms 9 days after embryo transfer purchase 100mcg combivent mastercard, if a movie is presented in which a small corner is moving from left to right in the pixel patch marked A medications with sulfur generic combivent 100mcg amex, and if such a small corner moved in this way frequently during training treatment xanthoma effective 100mcg combivent, then node a in level 1 would predict that it will continue its motion medications errors combivent 100mcg on line. As we proceed up the hierarchy of levels, each node receives inputs, albeit indirectly, from larger and larger segments of the image. Finally, the node at the top (level 3 in the diagram) represents a probability distribution over the categories of images that the network has seen. When the network is operating in recognition mode (after training), the top node identi es the most probable category of the image on the retina. The network was able to learn to recognize a variety of simple images used by George in his dissertation work. George is continuing his work at Numenta, a company founded by Hawkins for the purpose of developing these kinds of networks. Although the models described so far have been developed for perception tasks, they could, with some elaboration, serve as foundations for general architectural schemes for intelligent agents. Of course, if these models are at all relevant to how the neocortex might work (as their proponents claim they are), then they would need to be able to do more of what the neocortex does, including planning and executing actions. As Thomas Dean, who has built probabilistic models of the neocortex, points out, The availability of cortex-scale models will facilitate not only our understanding of the brain but enable researchers to combine lessons learned from biology with state-of-the-art machine-learning techniques to design hybrid systems that combine the best of biological and traditional computing approaches. In fact, Russell Kirsch is quoted in an interview as saying by 1957 I was intrigued by what the linguists were able to do with grammar on computers. So I asked what seemed to me to be sort of an obvious question: Could you do the same thing with pictures When nished, the Kirsches showed their generated image to the artist himself, who agreed it looked strikingly similar to something he would be likely to paint. In fact, the computer simulation was almost identical to one that Diebenkorn had already painted. He and colleagues have developed stochastic grammars of images, which can be used to decompose images into their component parts. Work on computer vision has made amazing progress in the past several years and is an important part of many applications, including53 detecting events (such as tra c violations), medical imaging, tracking objects (such as faces, pedestrians, and vehicles), visual prostheses, nding objects in photographs, inventory control in warehouses, robot vehicle navigation and mapping, character and handwriting recognition, danger warning systems, process control, circuit board inspection, grading fruits and vegetables, topographic mapping, forest surveys, recognizing and identifying faces in a crowd, Internet image search, image compression, and agricultural crop 555 Copyright c 2010 Nils J. Readers who would like to learn more will nd a wealth of material in textbooks, in computer vision publications, and on the Internet. Researchers have come up with several ways to integrate component technologies in what they call architectures. Kaplan and Joan Bresnan, Lexical-Functional Grammar: A Formal System for Grammatical Representation, in Joan Bresnan (ed. Sag, Head-Driven Phrase Structure Grammar, Chicago: University of Chicago Press, 1994. Jay Earley, An E cient Context-Free Parsing Algorithm, Communications of the Association for Computing Machinery, Vol. Younger, Recognition and Parsing of Context-Free Languages in Time n3, Information and Control, Vol. Marcus, Beatrice Santorini, and Mary Ann Marcinkiewicz, Building a Large Annotated Corpus of English: the Penn Treebank, Computational Linguistics, Vol. The grammar is an adaptation of one from Chapter 11 of the Manning and Sch utze book with accompanying slides available online at nlp. Derek Hoiem, Alexei Efros, and Martial Hebert, Recovering Surface Layout from an Image, International Journal of Computer Vision, Vol. Also see a homepage for the algorithm, with pointers to examples and papers, at homepages. Dickmanns, Dynamic Vision for Perception and Control of Motion, Berlin: Springer-Verlag, 2007. Fukushima, Neocognitron: A Self-organizing Neural Network Model for a Mechanism of Pattern Recognition Una ected by Shift in Position, Biological Cybernetics, Vol. Tai Sing Lee and David Mumford, Hierarchical Inference in the Visual Cortex, Journal of the Optical Society of America A, Vol. Hinton, Simon Osindero, and Yee-Whye Teh, A Fast Learning Algorithm for Deep Belief Nets, Neural Computation, Vol. Dileep George, How the Brain Might Work: A Hierarchical and Temporal Model for Learning and Recognition, Ph. Dean, formerly a computer science professor at Brown University, now is a scientist at Google. Russell Kirsch and Joan Kirsch, The Structure of Paintings: Formal Grammar and Design, Environment and Planning B: Planning and Design, Vol. Azriel Rosenfeld, Isotonic Grammars, Parallel Grammars, and Picture Grammars, in Bernard Meltzer and Donald Michie (eds. Song-Chun Zhu and David Mumford, A Stochastic Grammar of Images, Foundations and Trends in Computer Graphics and Vision, Vol. David Lowe, a professor in the Computer Science Department of the University of British Columbia, maintains a Web site of companies selling computer vision products. The traditional framework that controls the running of most programs involves having a main program that runs through its instructions step by step, retrieving from and storing data in memory, executing various operations on such data, and taking other allowed actions. Some of the instructions in the main program might be to call a subprogram, handing control over to it. After a subprogram nishes doing what it has been called to do, overall control returns to the program that called it, which might then call another subprogram, and so on until control nally returns to the main program. Eventually, the main program can nally quit running, having accomplished all that it was supposed to do, or it can continue running (in principle, forever) because, like a program that makes airline reservations on demand for all who use it, its work is never done. Computer operating systems, for example, depend on interrupts to be responsive to user inputs and to other things going on with the computer hardware. So-called garbage collection routines scanned computer memory from time to time to nd list structures that would not ever be used again. The memory used to store these structures could then be reclaimed to be used to store new list structures. In contrast with the von Neumann idea of executing instructions one after another in sequence, one can conceive of an architecture in which many instructions are executed simultaneously. One can accomplish such parallelism, either by actually having several hardware processors to which programs are farmed out for execution or by the simulation of parallel operation on the simpler von Neumann architecture in which the programs are actually being executed in sequence but the programmers, for all they know, think of them as running simultaneously. For example, in the nonsymbolic world of neural networks, one could imagine groups of neural elements operating simultaneously, even though simulations of these networks have to consider each neural element in turn sequentially. Simulation of parallelism can also be accomplished by a time-sharing system, in which the user (or several di erent users) can imagine that their programs are all running simultaneously. They exploit both actual parallel hardware (as in so-called multicore systems) and time-sharing, so that users can run their e-mail programs, for example, simultaneously (for all they know) with their spreadsheet programs. In this chapter, Im going to describe some of the ways researchers have organized their programs to achieve intelligent behavior. Some of them were inspired mainly by engineering and computational considerations and some by cognitive science in its attempt to model psychological data. Parallel operation is assumed in many of these architectures, even though it is often of the simulated variety. Three-layered architectures, such as the one used by Shakey, were (and still are) used in several other robot systems. As Erann Gat, a researcher who has used these architectures at the Jet Propulsion Laboratory, points out in his survey paper,1 the three-layer architecture arises from the empirical observation that e ective algorithms for controlling mobile robots tend to fall into three distinct categories: 1) reactive control algorithms which map sensors directly onto actuators with little or no internal state, 2) algorithms for governing routine sequences of activity which rely extensively on internal state but perform no search, and 3) time-consuming (relative to the rate of change of the environment) search-based algorithms such as planners. Originally called subsumption architectures, these were later called behavior-based because they were composed of speci cally programmed robot behaviors. The di erent behaviors, for example wander, avoid obstacles, and explore, are arranged in levels, each responsive to its own set of environmental stimuli and each able to control the robot depending on the sensed situation. This close coupling and interaction with what is going on in the environment causes what some have called emergent behavior. It clusters these elements into computational nodes that have responsibility for speci c subsystems, and arranges these nodes in hierarchical layers such that each layer has characteristic functionality and timing. This process of creating higher and higher level abstractions proceeds in stair-step fashion up the Perception and Model Towers. In the Action Tower, the lowest level action routines are simple re exes, evoked by predicates in the Model Tower corresponding to the primitive predicates. More complex actions are evoked by more abstract predicates appropriate for those actions. High-level actions call other actions until the process bottoms out at the primitive actions that actually a ect the environment. The actions in the Action Tower were all to be programmed using my teleo-reactive language (see p. The perceived e ects of these actions, in turn, change the values of predicates in the Model Tower, evoking, perhaps, di erent actions. The only implementation of this architecture that I know of was to control a block-stacking simulated robot. As I quoted Russell and Norvig earlier, Blackboard systems are the foundation of modern user interface architectures. The result of all of this is a very dynamic process in which the data on the Blackboard are constantly evolving, eventually producing desired information, such as the prediction of a gene location, recognition of a sentence, or interpretation of ocean sonar signals. Shakey, for example, had beliefs (its world model), at any time it was given a desire (its goal), and its executive system sometimes was in the process of executing a plan (its intention) to achieve that goal. Some beliefs are installed initially by the designer and some are obtained by the agent through its perceptual apparatus and by its inference mechanisms. Ingrand, Decision-Making in an Embedded Reasoning System, Proceedings of the Eleventh International Joint Conference on Arti cial Intelligence, pp. There have been several proposals for systems capable of what is called meta-level reasoning, that is, reasoning about how to reason. Meta-level reasoning systems have also been proposed by Pat Hayes,19 Michael Genesereth,20 and Stuart Russell and Eric Wefald. Such a society would be composed of a large number of simple agents, none of which was powerful or complete enough to be an intelligent entity itself, but a mind would presumably emerge from their joint behaviors and interactions. In a similar vein, William Kornfeld and Carl Hewitt suggested that an intelligent system ought to be organized in a manner similar to a scienti c community, exploiting individual and parallel research, publication, and criticism. Many of these agents will collaborate or compete in the performance of their tasks. These interactions use restricted versions of natural language or some other kind of user interface apparatus. Indeed, the world is full of computers communicating with other computers over networks using specially designed protocols. Moreover, they must be able to interpret communications from other agents along with interpreting other perceptual data. To do so they must take into account the expected actions, knowledge, and goals of other agents. They provide optional facilities for knowledge representation (world knowledge, models of other agents, their goals and plans, their roles and capabilities, etc. An interesting application for multiagent systems research involves cooperative (and competitive) robots. She has, in addition to her work on research on intelligent robots that Cooperate, Observe, Reason, Act, and Learn,32 been active in the RoboCup matches of soccer-playing robots. Typically in these matches each robot has its own sensing and processing capabilities. Each needs to take into account the actions of other players and what they might do. When the environment includes other agents with whom an agent must cooperate or compete, it is important for that agent to have models of those other agents as part of its environmental model. These models should include information about what other agents believe and how those beliefs might be modi ed. To deal with matters like these, researchers began to consider problems such as how an agent A should represent for itself that agent B knows some fact P and under what circumstances agent A should tell some fact, P, to agent B. One major di culty was how to distinguish between A knowing that B knows (P Q) and A knowing either that B knows P or that B knows Q. They are usually called speech acts even when communication is by means other than speech. Many of these types had been classi ed earlier by John Searle following the work of John L. Once communication between agents is regarded in terms of actions, one can think about generating plans using these actions. Conditions and e ects were stated in terms of logical expressions occurring in (or derivable from) the knowledge bases of the sender and receiver.

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Supine Hypotension Syndrome: o If mother has hypotension before delivery symptoms 7 days after implantation buy generic combivent, place patient in left lateral recumbent position or manually displace gravid uterus to the left is supine position necessary o Knee-chest position may create safety issues during rapid ambulance transport 2 medicine 2015 cheap combivent line. If possible medicine ketoconazole cream discount combivent on line, transport between deliveries if mother is expecting twins Notes/Educational Pearls 1 treatment regimen discount combivent american express. Provide adequate treatment for eclampsia-related seizures Patient Presentation Inclusion Criteria 1 treatment wrist tendonitis cheap combivent 100 mcg free shipping. Female patient medicine 2015 lyrics buy cheap combivent 100mcg, more than 20-weeks gestation, presenting with hypertension and evidence of end organ dysfunction, including renal insufficiency, liver involvement, neurological, or hematological involvement 2. Eclampsia/pre-eclampsia associated with abruptio placenta and fetal loss Exclusion Criteria Chronic hypertension without end organ dysfunction. Symptoms suggestive of end organ involvement such as headache, confusion, visual disturbances, seizure, epigastric pain, right upper quadrant pain, nausea, and vomiting c. May repeat every 10 min X 2 for persistent severe hypertension with preeclampsia symptoms ii. May repeat 10mg after 20 min for persistent severe hypertension with preeclampsia symptoms ii. Benzodiazepine, per Seizure guideline, for active seizure not responding to magnesium Caution: respiratory depression 3. Patients in second or third trimester of pregnancy should be transported on left side or with uterus manually displaced to left if hypotensive Patient Safety Considerations 1. Delivery of the placenta is the only definitive management for pre-eclampsia and eclampsia 2. Early treatment of severe pre-eclampsia with magnesium and anti-hypertensive significantly reduces the rate of eclampsia use of magnesium encouraged if signs of severe pre eclampsia present to prevent seizure Pertinent Assessment Findings 1. Vital signs assessment with repeat blood pressure monitoring before and after treatment 2. American College of Obstetricians and Gynecologists Committee on Obstetric Practice Magnesium sulfate use in obstetrics. American College of Obstetrics and Gynecologists Task Force on Hypertension in Pregnancy. Report of the American College of Obstetricians and Gynecologists task force on hypertension in pregnancy. Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Early standardized treatment of critical blood pressure elevations is associated with reduction in eclampsia and severe 158 maternal morbidity. Revision Date September 8, 2017 159 Obstetrical and Gynecological Conditions Aliases None noted Patient Care Goals 1. Recognize serious conditions associated with hemorrhage during pregnancy even when hemorrhage or pregnancy is not apparent. Provide adequate resuscitation for hypovolemia Patient Presentation Inclusion Criteria 1. Maternal age at pregnancy may range from 10 to 60 years of age Exclusion Criteria 1. Abruptio placenta: Occurs in third trimester of pregnancy; placenta prematurely separates from the uterus causing intrauterine bleeding a. Intermittent pelvic pain (uterine contractions) with vaginal bleeding Patient Management Assessment 1. Disposition transport to closest appropriate receiving facility Patient Safety Considerations 1. Patients in third trimester of pregnancy should be transported on left side or with uterus manually displaced to left if hypotensive 2. Do not place hand/fingers into vagina of bleeding patient except in cases of prolapsed cord or breech birth that is not progressing Notes/Educational Pearls Key Considerations Syncope can be a presenting symptom of hemorrhage from ectopic pregnancy or causes of vaginal bleeding. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice (3rd edition). Revision Date September 8, 2017 162 Respiratory Airway Management (Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline Model Process) Aliases Asthma, upper airway obstruction, respiratory distress, respiratory failure, hypoxemia, hypoxia, hypoventilation, foreign body aspiration, croup, stridor, tracheitis, epiglottitis Patient Care Goals 1. Provide necessary interventions quickly and safely to patients with the need for respiratory support 4. Identify a potentially difficulty airway in a timely fashion Patient Presentation Inclusion Criteria 1. Children and adults with signs of severe respiratory distress/respiratory failure 2. Patients in whom oxygenation and ventilation is adequate with supplemental oxygen alone, via simple nasal cannula or face mask Patient Management Assessment 1. Signs of a difficult airway (short jaw or limited jaw thrust, small thyromental space, upper airway obstruction, large tongue, obesity, large tonsils, large neck, craniofacial abnormalities, excessive facial hair) Treatment and Interventions 1. Maintain airway and administer oxygen as appropriate with a target of achieving 94 98% saturation b. This is especially important in children since endotracheal intubation is an infrequently performed skill in this age group and has not been shown to improve outcomes 4. Other indications may include potential airway obstructions, severe burns, multiple traumatic injuries, altered mental status or loss of normal protective airway reflexes c. Monitor clinical signs, pulse oximetry, cardiac rhythm, blood pressure, and capnography for the intubated patient d. Video laryngoscopy may enhance intubation success rates, and should be used when available. Consider using a bougie, especially when video laryngoscopy is unavailable and glottic opening is difficult to visualize with direct laryngoscope 5. Continuously monitor placement with waveform capnography during treatment and transport c. Continuously secure tube manually until tube secured with tape, twill, or commercial device i. Note measurement of tube at incisors or gum line and monitor frequently for tube movement/displacement ii. Cervical collar and/or cervical immobilization device may help reduce neck movement and risk of tube displacement d. Ventilate with minimal volume to see chest rise, approximately 6 7 mL/kg ideal body weight 2. Gastric decompression may improve oxygenation and ventilation, so it should be considered when there is obvious gastric distention 7. When patients cannot be oxygenated/ventilated effectively by previously mentioned interventions, the provider should consider cricothryoidotomy if the risk of death for not escalating airway management seems to outweigh the risk of a procedural complication 8. Transport to the closest appropriate hospital for airway stabilization when respiratory failure cannot be successfully managed in the prehospital setting Patient Safety Considerations 1. When compared to the management of adults with cardiac arrest, paramedics are less likely to attempt endotracheal intubation in children with cardiac arrest. This is an important adjunct in the monitoring of patients with respiratory distress, respiratory failure, and those treated with positive pressure ventilation. Contraindications to these non-invasive ventilator techniques include intolerance of the device, severely impaired consciousness, increased secretions inhibiting a proper seal, or recent gastrointestinal and/or airway surgery 4. Appropriately-sized masks should completely cover the nose and mouth and maintain an effective seal around the cheeks and chin b. Ventilation should be delivered with only sufficient volume to achieve chest rise c. When advanced airway is in place, ideally ventilations should be on upstroke between two chest compressions ii. In adults who are not in cardiac arrest, ventilate at rate of 12 breaths per minute iii. In children, ventilating breaths should be delivered over one second, with a two second pause between breaths (20 breaths/minute) in children 5. In addition to preoxygenation, apneic oxygenation (high-flow oxygen by nasal cannula) may prolong the period before hypoxia during an intubation attempt d. Positive pressure ventilation after intubation can decrease preload and subsequently lead to hypotension consider providing vasopressor support for hypotension. Appropriate attention should be paid to adequate preoxygenation to avoid peri intubation hypoxia and subsequent cardiac arrest f. Prompt suctioning of soiled airways before intubation attempt may improve first pass success g. Less optimal methods of confirmation include bilateral chest rise, bilateral breath sounds, and maintenance of adequate oxygenation. Visualization with video laryngoscopy, when available, may assist in confirming placement when unclear due to capnography failure or conflicting information. This is especially true for children since pediatric intubation is an infrequently utilized skill for many prehospital providers. Video laryngoscopy may be helpful, if available, to assist with endotracheal intubation 6. Verification of endotracheal tube placement by prehospital providers: is a portable fiberoptic bronchoscope of value Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers. The efficacy of pediatric advanced life support training in emergency medical service providers. First responder performance in pediatric trauma: a comparison with an adult cohort. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. Prehospital oral endotracheal intubation by rural basic emergency medical technicians. Prehospital emergency endotracheal intubation using the Bonfils intubation fiberscope. Effect of emergency medical technician-placed Combitubes on outcomes after out-of-hospital cardiopulmonary arrest. Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation. Assessment of the speed and ease of insertion of three supraglottic airway devices by paramedics: a manikin study. Randomized trial of endotracheal tube versus laryngeal mask airway in simulated prehospital pediatric arrest. The impact of prehospital continuous positive airway pressure on the rate of intubation and mortality from acute out-of-hospital respiratory emergencies. Prehospital endotracheal intubation for severe head injury in children: a reappraisal. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. Pediatric major resuscitation-respiratory compromise as a criterion for mandatory surgeon presence. Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana. Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol. Populations at risk for intubation nonattempt and failure in the prehospital setting. Effect of out-of hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Feasibility of laryngeal mask airway use by prehospital personnel in simulated pediatric respiratory arrest. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Prehospital and emergency department verification of endotracheal tube position using a portable, non-directable, fiberoptic bronchoscope. Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. A comparison of GlideScope videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children. The assessment of four different methods to verify tracheal tube placement in the critical care setting. A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement. The effect of a rapid sequence induction protocol on intubation success rate in an air medical program. Intubation success rates improve for an air medical program after implementing the use of neuromuscular blocking agents. Paramedic King Laryngeal Tube airway insertion versus endotracheal intubation in simulated pediatric respiratory arrest. Verification of endotracheal tube placement following intubation, Prehosp Emerg Car. A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department. Comparison of a conventional tracheal airway with the Combitube in an urban emergency medical services system run by physicians. Can an airway assessment score predict difficulty at intubation in the emergency department Apneic oxygenation may not prevent severe hypoxemia during rapid sequence intubation: a retrospective helicopter emergency medical service study. Before and after establishment of a rapid sequence intubation protocol for air medical use.

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