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Recently purchase levitra plus 400 mg on-line, a third model for system development has been proposed that enables the clinician to request help from an outside source cheap levitra plus 400 mg on line. Using such a system, a clinician is still completely in-charge of making the request for information and the information can be automatically configured based on a sub-set of patient information (Cimino, 1996). The following diagram (Figure 1) is an attempt to illustrate both the key types of information or knowledge that investigators have focused on along with their mode of interaction [i. The boxes (yellow) represent the type of knowledge and the labels on the links (green) represent some of the key projects or concepts vendors have focused on this particular Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The aim of this figure is to highlight the myriad attempts that have been made to develop clinical knowledge management applications and to help everyone understand how different clinical knowledge resources and applications are both related in terms of what they are trying to accomplish and different in the resources they utilize. Although this diagram is fairly complex, it is only a small, imperfect and incomplete representation of the entire clinical decision support landscape. The first section focuses on “library-type” applications that enable a clinician to look up information in an electronic document. The second section describes a myriad of “real-time clinical decision support systems”. These systems generally deliver clinical guidance to clini- cians at the point of care within the CIS. The third section describes several “hybrid” systems, which combine aspects of knowledge-based clinical decision support systems with library-type information. Finally, section four looks at various attempts to bring clinical knowledge in the form of computable guidelines to the point of care. Library-Type Applications: Front-Ends to Applications That Directly Interact with Clinicians Bibliographic Databases (DBs) Biomedical bibliographic databases contain on the order of millions of records, each representing a unique scientific journal article that has been published. Each record typically contains the title of the article, the authors, their affiliation(s), and the abstract of the article. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. An Overview of Efforts to Bring Clinical Knowledge to the Point of Care 289 For the last 30 years, the National Library of Medicine has maintained the MedLine database, the most common bibliographic database used in clinical medicine. During that period, various attempts have been made to develop easy to use and reliable interfaces to this vast resource including Grateful Med (Cahan, 1989) and COACH (Kingsland, 1993). PubMed relies on a sophisticated free-text query processor to map freetext user queries to MeSH terms, when appropriate, and returns a highly relevant set of documents. For example, Ovid has developed an interesting MeSH mapper and query expander that has gathered outstanding reviews from highly trained librarians. Knowl- edge Finder has developed a fuzzy mapping algorithm that has also generated some good reviews. Unfortunately, none of these systems consistently enables clinicians to retrieve more than half of all the relevant articles on any particular topic (Hersh, 1998). In addition to these variations on a search interface, several projects have used automated differ- ential diagnosis generators, such as DxPlain, as an interface to the bibliographic DBs.

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After forelimb amputation levitra plus 400 mg on-line, stimulation of the deprived forelimb cortex moved the shoulder and stump of the missing limb (Figure 9 cheap levitra plus 400 mg with visa. In a second set of experiments with a chronically implanted stimulating elec- trode, changes in muscle targets did not appear immediately after the stimulated location was deprived by nerve section, but forelimb activity could be evoked from vibrissa cortex within hours of vibrissa nerve section. Because of the rapid change in the organization of M1, the reorgani- zation was attributed to a rapid strengthening of existing synaptic contacts, rather than the formation of new connections that would likely take longer to grow and become functional. One mechanism proposed for such reorganization was the long-term potenti- ation (LTP) of horizontal connections that are intrinsic to M1 and interconnect functionally distinct sectors of M1. A dorsolateral view of a brain of a rat (above) shows the location of M1 relative to primary somatosensory cortex (S1) primary visual cortex (Vis. In normal M1 (left), electrical stimulation of microelectrode site in caudomedial M1 produces hindlimb movements, and more rostrally, trunk movements. A large caudal region is devoted to forelimb movements, including a medial zone for shoulder movements. More rostrally, a large region relates to facial vibrissa movements, and a narrow zone is for eye movements and eye blinks. Reduced neural activity in M1 would result in activity dependent reductions in the expression of the inhibitory neural transmitter, GABA, and receptors for GABA. However, sectioning sensory neurons only, while leaving motor nerves intact, would also reduce the activity in M1, but peripheral sensory nerve section by itself does not appear to produce reorganization in M1 of rats. Reorganization of motor cortex (M1) in rats has also been studied after the descending corticospinal tract in the lower thoracic spinal cord was cut. In these experiments, there were no rapid reorganizations of the motor cortex, as microstimulation of the hindlimb cortex after two days of recovery continued to produce no motor responses. However, after 4 weeks of recovery, microstimulation of the hindlimb cortex produced whisker, forelimb, and trunk movements, demonstrating a functional reorganiza- tion of the motor cortex. Anterograde tracing of corticospinal axons from the reorganized hindlimb portion of M1 indicated that many of these axons had sprouted into the cervical spinal cord. Thus, much of this slowly emerging reor- ganization of the motor cortex could be attributed to the growth of new connections so that corticospinal axons reached new motor neuron pools. In related experiments, transected hindlimb corticospinal axons sprouted to contact propriospinal neurons that projected past the lesion to lumbar motor neurons for the hindlimb. Thus, neurons in the hindlimb motor cortex had indirect access to hindlimb muscles. The sprouting of cut corticospinal axons to form new connections likely contributed to the considerable behavioral recovery of hindlimb function in these rats. MOTOR SYSTEM PLASTICITY AFTER CORTICAL LESIONS IN RATS The plasticity of motor cortex in neonatal rats has also been investigated after partial lesion of M1 of one hemisphere.

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