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The current mode of document/data sharing involves all users within telehealth WAN (Wide Area Network) cluster to upload documents cheap prandin 1 mg, data and code to a central repository from where other users can extract materials of interest order prandin 1mg on-line. This mode of collaboration among users is not sufficient for many users to exchange complex ideas and viewpoints regarding various images and other documents in intricate detail cheap 2 mg prandin with amex. For example, medical researchers frequently need to locate and reference information that is not only physi- cally distributed across the sites of their collaborators, but also in an array of formats (images, reports generated based on experiments, or code execution). Often users collaborate by exchanging e-mail messages along with data/documents downloaded from a central Web server. Although this allows individuals to participate at their own pace, users invest much time typing descriptive text to discuss a particular topic, especially when expressing complex thoughts within context of a document or image. The problem becomes particularly acute when users are collaborating using document attachments. This mode leads to large documents being exchanged as attachments back and forth between users, with the potential for inconsistencies to arise between successive versions. Moreover, with clinicians collaborating across time zones on documents or images, a need has been observed for conveying complex information via rich multimedia. Presence-based communications enables the healthcare personnel to communicate in a very effective manner. By allowing users to collaborate in different modes within a browser-based environment on diverse medical data can facilitate a seamless collaboration workflow. These technologies can enhance typical telemedicine scenarios and also extend conventional doctor- patient interactions to include web-based interactions such as chronic care or follow-ups. This would not only allow researchers to collaborate based on their time and schedule, but also to search, retrieve and filter all comments and analysis made previously by collaborators on any multimedia document. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Multimedia Capture, Collaboration and Knowledge Management 143 The remaining sections describe ongoing efforts at Siemens Corporate Research to develop technological solutions driven by these anticipated future needs. Technological Building Blocks OpenScape (Siemens OpenScape) from Siemens Communications Networks (Siemens Information and Communications Networks) is a suite of communication applications designed to increase the productivity of information workers. It aims to control the panoply of communication applications and devices, on both fixed and wireless net- works, connected via local and wide area networks. OpenScape addresses the frag- mented nature of communication modalities and their separation and provides a unifying framework for integrating, managing and streamlining communication in the enterprise. It obviates redundant communication sessions, where a person calls multiple phone numbers and/or leaves duplicate voice, email, and instant messages in an effort to communicate urgent issues. Hence, it is possible to avoid: • Unnecessary cell phone intrusions into client meetings, work sessions or personal time; • Wasted time setting up conference calls, communicating call-in information, sending and synchronizing documents, and establishing separate sessions for voice, Web and video collaboration; and • The difficulty of mobilizing all key colleagues that may be equipped with different applications, or because setting up a collaborative session is too complex and time consuming. It provides healthcare personnel the experience of a single, synchronized set of commu- nication resources, sharing common controls and shared communication rules and intelligence. These capabilities can be accessed via a wide range of devices and interfaces to serve the constantly changing needs of mobile employees. OpenScape provides personal and workgroup communications portals for multiple healthcare domains. For example: • Off hook/on hook status of an IP desk phone or mobile phone • Instant Messaging (IM) application presence • Collaboration application presence indicating whether an individual has signed on to the application or not • On which terminal can the user be reached Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. A mobile phone or PDA, for instance will be able to negotiate with the remote communication party the type of information it can support, for instance video, audio, and so on. The IMS platform was standardized for new multimedia applications and services that could be rapidly deployed by mobile network operators, such as audio/ video conferencing, chat, and presence services over new mobile devices. Different from the legacy circuit-switched voice/data communication in regular phone calls, IMS is based on IP technology that can control real-time and non-real-time services on the same IP network. Together OpenScape, IMS and Soarian provide the core technological building blocks that enable the integration of the healthcare enterprise content repository with a Web- based infrastructure and presence and availability. Our research work is layered above these three pillars and the following sections illustrate the benefits of a converged communication healthcare enterprise. Copying or distributing in print or electronic forms without written permission of Idea Group Inc.

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This is in contrast to acute cholecystitis prandin 2mg for sale, where the rich collateral vascular supply from the liver bed ensures the rarity of gangrene of the gall-bladder even if the cystic artery becomes thrombosed prandin 2 mg with mastercard. The caecum is delivered into the wound and generic 1 mg prandin with mastercard, if the appendix is not immediately visible, it is located by tracing the taeniae coli along the caecum— they fuse at the base of the appendix. When the caecum is extraperitoneal it may be difficult to bring the appendix up into the incision; this is facilitated by first mobiliz- ing the caecum by incising the almost avascular peritoneum along its lateral and inferior borders. The appendix mesentery, containing the appendicular vessels, is firmly tied and divided, the appendix base tied, the appendix removed and its stump invaginated into the caecum. It commences anterior to the third segment of the sacrum and ends at the level of the apex of the prostate or at the lower quarter of the vagina, where it leads into the anal canal. The rectum is straight in lower mammals (hence its name) but is curved in man to fit into the sacral hollow. Moreover, it presents a series of three lateral inflexions, capped by the valves of Houston, projecting left, right and left from above downwards. They must be visualized in carrying out a rectal examination, they provide the key to the local spread of rectal growths and they are important in operative removal of the rectum. Posteriorly lie sacrum and coccyx and the middle sacral artery, which are separated from it by extraperitoneal connective tissue containing the rectal vessels and lymphatics. The lower sacral nerves, emerging from the anterior sacral foramina, may be involved by growth spreading posteriorly from the rectum, resulting in severe sciatic pain. Anteriorly, the upper two-thirds of the rectum are covered by peri- toneum and relate to coils of small intestine which lie in the cul-de-sac of the pouch of Douglas between the rectum and the bladder or the uterus. In front of the lower one-third lie the prostate, bladder base and seminal 82 The abdomen and pelvis Sacral promontory Symphysis Seminal vesicle pubis Rectum Fascia of Prostate Denonvilliers Anal sphincter Fig. A layer of fascia (Denonvil- liers) separates the rectum from the anterior structures and forms the plane of dissection which must be sought after in excision of the rectum. The mid-anal canal repre- sents the junction between endoderm of the hind-gut and ectoderm of the The gastrointestinal tract 83 Fig. Acarcinoma of the upper anal canal is thus an adenocarci- noma, whereas that arising from the lower part is a squamous tumour. The two venous systems communicate and therefore form one of the anastomoses between the portal and systemic circulations. Acarcinoma of the rectum which invades the lower anal canal may thus metastasize to the groin nodes. This comprises: •the internal anal sphincter, of involuntary muscle, which continues above with the circular muscle coat of the rectum; •the external anal sphincter, of voluntary muscle, which surrounds the internal sphincter and which extends further downwards and curves medi- ally to occupy a position below and slightly lateral to the lower rounded edge of the internal sphincter, close to the skin of the anal orifice. The lower- 84 The abdomen and pelvis most, or subcutaneous, portion of the external sphincter is traversed by a fan-shaped expansion of the longitudinal muscle fibres of the anal canal which continue above with the longitudinal muscle of the rectal wall. In carrying out a digital rectal examination, the ring of muscle on which the flexed finger rests just over an inch from the anal margin is the anorectal ring. This represents the deep part of the external sphincter where this blends with the internal sphincter and levator ani, and demarcates the junc- tion between anal canal and rectum. The anal canal is related posteriorly to the fibrous tissue between it and the coccyx (anococcygeal body), laterally to the ischiorectal fossae con- taining fat, and anteriorly to the perineal body separating it from the bulb of the urethra in the male or the lower vagina in the female. Note that the ischiorectal fossa is now often referred to, more accurately, as the ischio- anal fossa—it relates to the anal canal rather than the rectum. Rectal examination The following structures can be palpated by the finger passed per rectum in the normal patient: 1both sexes — the anorectal ring (see above), coccyx and sacrum, ischiorectal fossae, ischial spines; 2male—prostate, rarely the healthy seminal vesicles; 3female—perineal body, cervix, occasionally the ovaries. Abnormalities which can be detected include: 1within the lumen—faecal impaction, foreign bodies; 2in the wall—rectal growths, strictures, granulomata, etc. During parturition, dilatation of the cervical os can be assessed by rectal examination since it can be felt quite easily through the rectal wall. Clinical features Haemorrhoids Haemorrhoids (piles) are dilatations of the superior rectal veins. Initially contained within the anal canal (1st degree), they gradually enlarge until they prolapse on defaecation (2nd degree) and finally remain prolapsed through the anal orifice (3rd degree). Anatomically, each pile comprises: a venous plexus draining into one of the superior rectal veins; terminal branches of the corresponding superior rectal artery; and a covering of anal canal mucosa and submucosa. Occasionally, abscesses lie in the pelvirectal space above levator ani, alongside the rectum and deep to the pelvic peritoneum.

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