Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use. in Software

Integrating qrcode in Software Copyright 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.

Perseus is another circumpolar constellation with an elongated, rather complicated shape (Fig. 2-6). A mythological hero, Perseus holds the decapitated head of Medusa, a mythological female monster with hair made of snakes and a countenance so ugly that anyone who looked on it was turned into stone. Perseus is low in the northwestern sky in springtime, half above and half below the northern horizon in the summer, high in the northeastern sky in the fall, and nearly overhead in the winter.
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Perhaps you still wonder, What s all this fuss about root multiplicity If an equation has one real root, isn t that all there is to be said about it The answer is, Not exactly. Let s look at three equations that have identical solution sets. The first-degree equation 2x 3 = 0 has one real solution, x = 3/2. The fourth-degree equation (2x 3)4 = 0 has a single real root, x = 3/2. But there s something about the fourth-degree equation that makes it conceptually different than the first-degree equation. We can rewrite the fourth-degree equation as (2x 3)(2x 3)(2x 3)(2x 3) = 0
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these latter cases the illness thereafter becomes relapsing or it simply worsens slowly and progressively. An antecedent infection is identi ed far less regularly in patients with CIDP than in those with GBS and is probably not a necessary component of the disease. Furthermore, CIDP may be distinct immunologically from GBS, insofar as certain HLA antigens occur with greater frequency in patients with CIDP than they do in the normal population, whereas there are no clear HLA propensities in patients with GBS. Finally, in contrast to acute GBS, many cases of CIDP respond favorably to the administration of prednisone. An ambiguity is introduced here because, as mentioned earlier, Hughes has described a group of patients with polyneuritis in whom weakness progressed steadily for 4 to 12 weeks and who responded to corticosteroids, thus again blurring the distinction between GBS and CIDP. The chronic symmetric sensorimotor loss coupled with EMG ndings of demyelination largely de ne the illness. The typical EMG ndings are of multifocal conduction block as described in Chap. 45, prolonged distal latencies (distal block), nerve conduction slowing to less than 80 percent of normal in several nerves, loss of late responses, and dispersion of the compound muscle action potentials, further re ecting demyelination in motor nerves. One or several of these changes have been present in more than three quarters of our patients (Gorson, Ropper, et al). In the early stages of the disease demyelinative features must be carefully sought by testing multiple nerves at several sites along this course. After several months there is often some degree of axonal change (30 percent of our series), but the fundamental process continues to be one of multiple foci of demyelination. Most dependable is the absence of denervation changes early on despite weakness and reduced amplitude of the motor action potential, indicative of a demyelinating block to conduction at a proximal site. Several large series of CIDP cases are available for review. Dyck and colleagues (1975) studied 53 patients in whom the neuropathy progressed for more than 6 months. The clinical course was monophasic and slowly progressive in about one-third, stepwise and progressive in another third, and relapsing in the remaining third. The periods of worsening or improvement were measured in weeks or months. Infections and inoculations in the 3 months preceding the onset of CIDP were no more frequent than in the population at large. Weakness of the limbs, particularly of the proximal leg muscles, or numbness, paresthesias, and dysesthesias of the hands and feet were the initial symptoms. In 45 of the 53 patients, the signs were those of a mixed sensorimotor polyneuropathy with weakness of the shoulder, upper arm, and thigh muscles, in addition to motor and sensory loss in the distal parts of the limbs. In 5 patients the neuropathy was purely motor, and in 3, purely sensory. Cranial nerve abnormalities were distinctly unusual. Enlarged, rm nerves were found in 6 patients. Not emphasized in their series is the common occurrence of a cerebellar-like tremor in cases of long-standing. In the series reported by McCombe et al comprising 92 patients, two major subgroups were recognized relapsing (corresponding to the relapsing and stepwise progressive cases of Dyck et al) and nonrelapsing ones. In our own series of more than 100 patients, we have been impressed with several additional unusual patterns of clinical presentation. In 10 percent, numbness and weakness of the hands preceded involvement of the feet, which is unusual in other polyneuropathies. A sensory ataxic form, a purely motor form, and mononeuropathies superimposed on a mild generalized polyneuropathy each accounted for approximately 5 percent of the cases. As mentioned earlier, a small pro-
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Parameter Display Width in Pixels (WIDTH); Height in Pixels (HEIGHT); Visibility (VISIBILITY); With Tray (WITH_TRAY) Internal Display Button Width (BUTTON_WIDTH) Default value: 0 List of Buttons (BUTTON_LIST)
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The details of the legend are very clear and consistent across the report. The color choices are good, clear, and accurate. As you can see, the final results of WAD reports are not only about the data but also about the presentation. Many projects encounter issues and setbacks due to the customer being uncomfortable with the finished look of the report or being confused by the approach to the display. A dashboard may not be well received due to issues with coloring or the look and feel. Therefore, this is a good example of a finished product. Finally, the additional tabbed page can be used for detailed reports or other activities such as alerts or documentation. Tabbed pages make the display much more user friendly and more manageable to read. There is a tremendous amount of information concerning the formatting and functionality of creating dashboards or any reports required for management. We will discuss this information in 6. Another very good example of a finished WAD report is shown in the following illustration. In this case, the customer is looking for a more consistent and static reporting view of the data. As you can see, there are no additional options for drilldown on the screen other than buttons at the top that will execute changes to the current graphic. This is also a very good option since most of the time business users both casual and executive want to be able to just click a button rather than doing the analysis process of right-clicking and
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What happens when we plug the solution for x 2 into the second original equation in the above system (instead of the first one, which we already did) and solve for y
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ever, exceptions. Inability to produce vertical saccades and, later, paralysis of upward and downward gaze and eventually of lateral gaze with retention of re ex eye movements establish the diagnosis in most cases. Strict adherence to the diagnostic criteria for Parkinson disease also permits its differentiation from corticostriatospinal, striatonigral, and corticobasal ganglionic degeneration as well as Machado-Joseph disease all of which are discussed in other parts of this chapter. The rapid onset of parkinsonism should suggest exposure to neuroleptic medications or a variant of Creutzfeldt-Jakob disease. Paucity of movement, unchanging attitudes and postural sets, and a slightly stiff and unbalanced gait may be observed in patients with an anergic or hypokinetic ( retarded ) type of depression. Since as many as 25 to 30 percent of parkinsonian patients are depressed, the separation of these two conditions is at times dif cult. The authors have seen patients who were called parkinsonian by competent neurologists but whose movements became normal when antidepressant medication or electroconvulsive therapy was given. Several such patients have nonetheless insisted that levodopa helps them in some nondescript way. The rapid onset of the Parkinson syndrome, especially in conjunction with other medical diseases, should always raise the suspicion of drug effects; phenothiazines, haloperidol, and the neuroleptics pimozide and metoclopramide, used at times as antiemetics, all cause a slight masking of the face, stiffness of the trunk and limbs, lack of arm swing, ne tremor of the hands, and mumbling speech. They may also evoke an inner restlessness, a muscular impatience, an inability to sit still, and a compulsion to move about much like that which occurs at times in the parkinsonian patient (akathisia; page 97). Spasms of the neck, face, and jaw muscles (open mouth, protruded tongue, retrocollis or torticollis, grimacing) may also be provoked by such drugs. Even the newer antipsychotic medications, favored speci cally because of a putative lack of extrapyramidal effects, may be at fault. A mild, localized rigidity of an arm due to local tetanus was studied by R. D. Adams in a patient who had been referred as a case of acute parkinsonism. All in all, if one adheres to the strict de nition of Parkinson disease bradykinesia, resting tremor, postural changes and instability, cogwheel rigidity, and response to L-dopa errors in diagnosis are few. Yet in a series of 100 cases, studied clinically and pathologically by Hughes and associates, the diagnosis was inaccurate in 25 percent. The reasons are that about this number of Parkinson patients fail to display the characteristic tremor and about 10 percent are said to not respond to L-dopa. These authors noted that early dementia and autonomic disorder and the presence of ataxia and corticospinal signs were reliable guides to an alternate diagnosis. Pathology and Pathogenesis The most constant and pertinent nding in both idiopathic and postencephalitic Parkinson disease is a loss of pigmented cells in the substantia nigra and other pigmented nuclei (locus ceruleus, dorsal motor nucleus of the vagus). The substantia nigra is visibly pale to the naked eye; microscopically, the pigmented nuclei show a marked depletion of cells and replacement gliosis, and some of the remaining cells have reduced quantities of melanin, ndings that enable one to state with con dence that the patient must have suffered from Parkinson disease. Also, many of the remaining cells of the pigmented nuclei contain eosinophilic cytoplasmic inclusions, surrounded by a faint halo, called Lewy bodies (Fig. 39-5). These are seen in practically all
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is to the zero addedto the end of the mantissa not significantbut is merely appended fill the empty spacecreatedby the shift. Even more dramaticresultswould be obtainedwhen the numbers very closeas in are 0.1642 x 103 -0.7641 x 103 0.0001x lOj which would be convertedto 0. 1000 x 100: 0. 1000.Thus, for this case,threenonsignificant zerosare appended. The subtractingof two nearly equal numbersis called ts handlemathematics leadto the classicexampleof how the mannerin which computers can numericalproblems.Other calculations that can causeproblemsinclude: Lorge Computotions. Certainmethodsrequireextremelylargenumbersof arithmetic In are manipulations arrive at their final results. addition,thesecomputations often interto That is, the later calculations dependent the resultsof earlierones.Condependent. are on sequently, eventhoughan individualroundofferrorcould be small,the cumulative effect A overthe course a largecomputation be significant. very simplecaseinvolvessumof can ming a roundbase- number l0 thatis not roundin base-2. Suppose thefollowingM-file that is constructed: function
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Period Nov., Dec., Jan. June, July, Aug. Dec., Jan., Feb. Oct., Nov., Dec. Average 3 months
Figure 14-10
2. Erase the triangles. 3. Save your work and close the drawing.
Observing the Invisible
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done her share of volunteer work, but now she wanted to become a caring nurse. Aware that in some areas there was no need for additional nurses, she knew she would need to do some research before relocating. When she vacationed in Florida, she visited a number of hospitals, nursing homes, and life-care establishments and decided that she could find employment once she obtained the necessary training. A year later, she had her LPN certificate and fulfilled her goal. Similarly, Roderick Hector, a high school coach, realized that with the school budget crunch in California, it would be only a matter of time before he lost his job. Like Hilda, he wanted to work with people in a health setting and decided to become a physical therapist, another occupation that called for only a year in graduate school since he already had a bachelor s degree. Hilda and Roderick are examples of how those approaching midlife can switch occupations and pursue a far more satisfying career with proper preparation!
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