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If we let f 5 p/6 and (df/dt) 5 0 at t 5 0 we obtain f 5 (p/6) cos [(3g/2L)1/2 t] for t $ 0 (4 discount 160mg malegra dxt plus visa. For a simple pendulum composed of a slender rod of length L and a bob of mass m buy 160mg malegra dxt plus, the period of oscillation is equal to 2p(L/g)1/2 order malegra dxt plus 160mg free shipping. Therefore purchase 160mg malegra dxt plus fast delivery, the rod with uniform mass distribution rotates around point O much like a classical pendulum with effective length equal to 2L/3 160mg malegra dxt plus visa. Thus, in using the lumped-mass approach, we would have achieved an exact solution if we had placed the lumped mass at a distance 2L/3 from the fixed point O. Next, let us turn our attention to the forces exerted by the hinge on the rod at point O. These forces are the gravitational force 2mg e2 acting at the center of the rod and the force (F1 e1 1 F2 e2 ) exerted by the pin at point O. According to the equation of motion of the center of mass, the net resultant force acting on an object must be equal to the mass of the object times the acceleration of the center of mass. The position, ve- locity, and acceleration of the center of mass are given by the following expressions: r 5 (L/2) [sin f e1 2 cos f e2] (4. Note that when the pendulum is at rest in the vertical position we have F1 5 0 and F2 52mg. However, because the distance be- tween any two points in a rigid body remains constant, this integral can be reduced to a simple algebraic form. The point C is the center of mass, and P and Q are two arbitrary points of the rigid body B undergoing pla- nar motion parallel to the (e1, e2) plane (Fig. General e2 j (a) F plane motion of a rigid object B parallel to the (e , B 1 P e2) plane (a). Also, because the motion occurs parallel to the (e ,e ) 1 2 plane, the angle u remains constant; therefore, du/dt 5 0. Note that in a plane parallel to the (e1, e2) plane, angle f can be any angle, taken counterclockwise from a line element 90 4. This is true because all such angles differ from each other by a constant and there- fore have the same time derivative. If (df/dt) , 0, then the object B rotates clockwise and it is said to have a negative angular velocity. Note also that angular velocity may vary with time but does not vary from point to point in a rigid body. Thus, knowing the velocity of a single point in a rigid body and its angular velocity, we can determine the velocity of any other point in the rigid body. In this example we seek to understand the contributions of segmental rotations of body parts to the vertical ve- locity of the body’s mass center during vertical jumping. The dimensions of the athlete are given as follows: Lf (length of the foot) 5 27 cm, Ll (length from ankle to knee) 5 48 cm, Lt (length from knee to hip) 5 50 cm, and Lc (length from hip to center of mass) 5 28 cm. Angles between body segments and the horizontal in the fixed refer- ence frame E are indicated by ff, fl, ft, and fc. As usual, the segment orientation angle is positive when taken counterclockwise from horizon- tal. The counter movement begins at t 5 0 when the body segments make the following angles with the horizontal: ff 5 0, fl 5 66°, ft 5243°, and fc 5 23°. Thus, at this instant, the feet are flat on the ground, the knee bent, and the upper body bent forward. Employing the inverse dynam- ics approach and using a videocamera and a computer, these body seg- ment angles were measured as a function of time for t. The rate of rotation R φ Q of a rigid body in planar motion E φ is equal to the time rate of P change of angle f. The angle f need not be uniquely defined O e because the rate of rotation is 1 the time derivative of angle f. The figure shows two angles whose time derivatives give the same value for the angular ve- e3 locity. The symbols F, A, K, H, and C denote the tip of the foot, ankle, knee, hip, and the center of mass of the athlete, respectively. Bodies in Planar Motion ing upright position, the jumper is not in that configuration at time t 5 0. The center of mass of the jumper has already moved downward to- ward the ground at t 5 0 so that this instant does not correspond to the beginning of the preparatory phase of jumping. Solution: Our aim is to compute the velocity of the center of mass of the athlete.

Spinal cord infarction often occurs in boundary zones or "watersheds buy malegra dxt plus 160 mg without prescription," especially at the T1–T4 segments and the L1 segment Caused by: – Aortic dissection – Atherosclerosis of the aorta and its branches – After surgery of the abdominal aorta – Syphilitic arteritis – After fracture dislocation of the spine Tsementzis buy generic malegra dxt plus 160mg on line, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved purchase malegra dxt plus 160 mg on line. Infarction in syndrome this area of supply is uncommon Neurological manifesta- – Loss of proprioception and vibration sense below tions the level of lesion – Loss of segmental reflexes Cauda Equina Mass Lesions Compression of the lumbar and sacral roots below the L3 vertebral level causes the cauda equina syndrome cheap malegra dxt plus 160 mg with visa. Characteristics of the cauda equina syndrome – Early bilateral and asymmetrical radicular pain in the distribution of the lum- bosacral roots buy malegra dxt plus 160 mg line, increased by the Valsalva maneuver – Absence of the Achilles reflexes (S1–2 roots); the patellar reflexes (L2–4 roots) have a variable response – Flaccid, hypotonic, areflexic paralysis affecting the gluteal muscles, posterior thigh muscles, and the anterolateral muscles of the leg and foot (true pe- ripheral-type paraplegia) – Late asymmetrical sensory loss in the saddle region, involving the anal, per- ineal, and genital regions and extending to the dorsal aspect of the thigh, the anterolateral area of the leg, and the outer aspect of the foot – Late sphincter dysfunction; autonomous neurogenic bladder, constipation, impaired erection and ejaculation Central disk hernia- A small central disk herniation can produce tension tion and deform the richly innervated posterior longitudi- nal ligament, with its pain fibers, causing marked low back pain. A larger central disk herniation results in neurological compression of the cauda equina Tumors of the cauda equina Ependymoma Smooth or nodular rings of ependymal cells, surround- ing and incorporating the nerves of the cauda equina Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Sensory dissociation ent) presents early (absent) presents relatively late Motor findings! The neurologic examination: incorporating the fundamentals of neuroanatomy and neurophysiology, 4th ed. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Funicular; burning in type and distribution; an type, poorly localized early and important symp- tom Sensory changes! Dissociation of sensa- and temperature; ipsi- tion; spotty changes lateral loss of propriocep- tion (Brown–Sequard type) Changes in pain and! Less marked than at temperature sensations of lesion; sensory level level in the saddle area may be located below site! Can be marked and involvement widespread, with atrophy and fascicu- lations Upper motor neuron! The neurologic examination: incorporating the fundamentals of neuroanatomy and neurophysiology, 4th ed. Cervical Spondylotic Myelopathy In its complete form, this condition is characterized by neck pain and brachialgia, with radicular motor sensory reflex signs in the upper ex- tremities, in association with myelopathy. Similar clinical findings can be produced by other causes of spinal cord compression, such as those listed below. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. There is often a history of prior malignancy, and the radiological studies show findings of neoplasia Metastatic neoplasms – Lung 53% in men, 12% in women – Breast 59% in women – Lymphoma 20% in men, 9% in women – Prostate 8% in men – Kidney 12% in men, 6% in women – Miscellaneous Primary spinal tumors – Multiple myeloma 10–15% of cases – Osteogenic sarcoma – Chordoma – Chondrosarcoma – Benign tumors and! Fibrous dysplasia – Lipoma Intradural and extra- medullary tumors Meningioma 25% Nerve sheath tumors 29% Vascular malformations and tumors Epidermoid and der- 1–2% moid cysts and tera- tomas Lipoma 0. The most common among tumors arising within the spinal cord per se Metastases Chronic progressive radiation myelopathy Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The CSF and spinal imaging studies are not revealing in amyotrophic lateral sclerosis Subacute combined In contrast to spondylosis, signs of peripheral neu- degeneration due to vi- ropathy are often present, and the loss of position tamin B12 deficiency sense in the lower extremities is more marked in this type of combined disease. Laboratory findings of vi- tamin B12 deficiency are usually diagnostic CSF: cerebrospinal fluid. Spinal Hematoma Patients have local and/or radicular pain, neurological symptoms and signs of spinal cord or cauda equina dysfunction, and rapidly developing paraparesis or tetraparesis. Herniated disk Neoplasm – Extradural – Intradural and extramedullary – Intramedullary Abscess Sequelae of trauma Intramedullary diseases – Acute and subacute transverse myelitis – Demyelinating disease Spinal cord infarction Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Spinal Cord Compression 215 Spinal Cord Compression Nonneoplastic causes Spondylosis Intervertebral disk herniation Spinal stenosis and neuro- genic claudication Paget’s disease (osteitis deformans) Osteoporosis Syringomyelia Arachnoid cysts Pyogenic infections Other infectious and inflammatory diseases – Tuberculosis – Fungal infections – Parasitic disease – Sarcoidosis – Rheumatoid arthritis – Ankylosing spondylitis Spinal hemorrhage Intramedullary, subarachnoid, subdural, and epidural Neoplastic causes Epidural tumors – Metastatic! Benign tumors Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Neurofibromas – Vascular malformations and tumors – Epidural and dermoid cysts and teratomas – Lipoma Intramedullary tumors – Ependymoma – Astrocytoma – Intramedullary metastases Leptomeningeal metastases Noncompressive myelo- pathies simulating spinal cord compression Transverse and ascending myelitis – Postinfectious and postvaccination myelitis – Multiple sclerosis – Devic’s disease (optic neuromyelitis) – Acute necrotizing myelitis Viral myelitis – Acute anterior polio- myelitis – Postpoliomyelitis syndrome – Herpes zoster – AIDS-related myelopathies Spirochetal disease of the spinal cord – Syphilis – Lyme disease (Borrelia burgdorferi) Toxic and deficiency myelo- pathies – Myelopathy after aorto- graphy – Myelopathy due to in- Penicillin, methylene blue, spinal anesthetics, trathecal agents intrathecal chemotherapy with methotrexate, cytosine, arabinoside, and thiotepa Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Epidural Spinal Cord Compression 217 – Spinal arachnoiditis – Radiation myelopathy – Electrical injuries Metabolic and nutrition- al myelopathy – Subacute combined Multiple nutritional deficiencies degeneration of the cord – Nutritional myelopathy Nicotinic acid and several other vitamin deficien- cies, as well as caloric malnutrition – Myelopathy associat- ed with liver disease Spinal cord infarction – Arterial infarction – Venous infarction Autoimmune diseases – Sjögren’s syndrome – Systemic lupus ery- thematosus Paraneoplastic myelo- pathy Neuronal degeneration – Spinocerebellar ataxia (Friedreich’s ataxia) – Hereditary motor neuron disease – Charcot–Marie–Tooth disease – Werdnig–Hoffmann disease AIDS: acquired immune deficiency syndrome. Epidural Spinal Cord Compression Magnetic resonance imaging (MRI) and myelography may identify most spinal epidural illnesses causing myelopathy from spinal cord compres- sion, such as intramedullary tumors, leptomeningeal metastases, radia- tion myelopathy, arteriovenous malformations, and epidural lipomato- sis. Some epidural diseases, however, can be confused both clinically and radiologically with epidural spinal cord compression from systemic tumor, e. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved.

A piece of intestine is used to divert the urine to a bag on the body like a colostomy cheap malegra dxt plus 160mg online. This pro- cedure is reserved for extreme situations buy discount malegra dxt plus 160mg, but it does permit infec- tion to be controlled more easily best 160 mg malegra dxt plus. INCONTINENCE PADS The number of incontinence devices and pads multiplied during the last decade buy 160 mg malegra dxt plus fast delivery. The key is to prevent skin irritation malegra dxt plus 160mg without prescription, to have no specif- ic offensive odor, and to be comfortable. It is beyond the scope of this chapter to discuss this topic in detail, but improvements are occurring constantly and must be assessed accordingly. These difficulties may be effectively managed with medica- tions and other treatments. THE GASTROINTESTINAL TRACT AND ITS CONTROL The gastrointestinal (GI) tract is a hollow, muscular tube that extends from the mouth to the anus and is responsible for the digestion and absorption of food followed by elimination of the waste products of the digestion process. The stomach primarily acts as a storage chamber and is the first site of major digestive processes. It slowly passes food to the small intestine, which in turn sends it to the large intestine by a propul- sive movement. The large intestine is approximately five feet long and is divid- ed into four sections: the ascending, transverse, descending, and sigmoid colon. In the sigmoid colon, stool is concentrated into a solid mass by the absorption of much of the fluid that is present in other areas of the tract. The reflex process that leads to a bowel movement (defecation) occurs when stool moves from the sigmoid colon into the rectum, the last four to six inches of the tract. In a manner similar to what happens when the bladder initiates urination, filling of the rectum with stool causes nerve endings in the rectal wall to transmit a message of fullness to an area of the spinal cord that is involved in bowel function. As stool leaves the rec- tum, it passes through the anal canal, which contains the internal and external sphincter muscles. The sphincters, ring-shaped muscles that control the opening and closing of the passageway from the rec- tum, normally are contracted to prevent leakage. The internal sphincter is under the control of the spinal cord; its relaxation is what is termed an involuntary reflex because it is not under con- scious control, and its relaxation depends only on stretching of the rectal wall by stool. In contrast, the external sphincter is under the joint control of the spinal cord and the brain, so that a bowel move- ment may be consciously delayed by constricting the anus if the time is not appropriate for a bowel movement. The most common bowel problems associated with MS are constipation, diarrhea, and incontinence. CONSTIPATION Constipation is defined as the infrequent or difficult elimination of stool. It is by far the most common bowel problem associated with MS and may result from one or several problems that are direct or indirect consequences of the disease. A slower than normal passage of stool through the bowel results in more water being removed from it than is normal, which results in hard, constipating stool. If fluid intake is insufficient to allow the body to 80 CHAPTER 11 • Bowel Symptoms meet its basic needs, more water will be absorbed as the stool passes through the colon, which also produces hard, compacted stool that is difficult to pass. Some of the medications taken for other problems such as blad- der frequency or depression also may slow the bowel. THE DEVELOPMENT OF GOOD BOWEL HABITS Dietary Management Good eating habits are important to achieving good bowel control. It is important to have a routine and to eat balanced meals at regular times and in a relaxed atmosphere. The intake of adequate amounts of liquid (8 to 12 cups daily) and the addition of fiber to the diet gen- erally alleviates constipation. Dietary fiber is that portion of plant materials that is resistant to digestion; its addition to the diet aids in the formation of softer stool and decreases the amount of time required for stool to pass through the intestinal tract. A high-fiber diet includes raw fruits and vegetables, nuts and seeds, and whole grain breads and cereals such as cornmeal, cracked and whole wheat, barley, graham, wild and brown rice, and bran (one of the most concentrated sources of dietary fiber). To increase the amount of fiber in your diet, your daily intake should include: • One serving of fruit (with the skin left on) or vegetable, served cooked, raw, or dried; • One half to one serving of whole wheat or rye bread, or fruit juice; and • One serving of bran (one tablespoon), bran cereal, shredded wheat, nuts or seeds; raw bran may be eaten plain; mixed 81 PART II • Managing MS Symptoms Bowel Management • Eat a high-fiber diet of balanced meals • Drink 8 to 12 cups of fluid daily • Establish a bowel program •Medications with cereal, applesauce, soups, yogurt, or casseroles; or added to flour in cooking or baking. Incorporating bran and other high-fiber foods into the diet too quickly may produce gas, distention, and occasionally diarrhea.

Malegra DXT Plus
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