睿学教育Wisdome Education

Eric J. Topol, MD

• Professor of Genetics
• Department of Genetics
• Case Western Reserve University
• Cleveland, Ohio

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Recording clients’ decisions regarding consent to treatment It is essential that whenever possible diabetes mellitus que la causa discount 150 mg avapro, consent is obtained from the client before the start of treatment diabetes type 2 foot problems purchase avapro 150 mg online. Consent diabetes causes buy cheap avapro 300 mg, whether it is given verbally, in writ­ ing or by implication, must be recorded in the notes. Your records also need to show not only that the client consented but also that he or she was capable of making this decision. The client must have sufficient informa­ tion to consider the benefits and the risks of the proposed treatment in or­ der to make a decision (Rodgers 2000). It is the clinician’s responsibility to make sure that the client under­ stands: ° the nature of any procedures ° the likely positive and negative outcomes ° the risks. Part of this explanation might include the option to ‘do nothing’ and the associated benefits and/or risks. A record of the information given to the RECORD KEEPING 57 client is therefore an important part of the health record and might be­ come a vital factor if litigation arises. There are various ways of noting the decision to consent: ° A narrative account is written directly into the progress notes. Regardless of which method you choose you will need to be specific about the actions to which the client is consenting. This will also include a refer­ ence to the period of time to which the consent applies. Children and young people Consent for children under the age of 16 is most likely to be given by an adult with parental responsibility, although, in some cases, it may be the child who gives consent to treatment (see ‘Use and Protection of Informa­ tion’ in Chapter 3). The above advice on providing information applies equally to this client group. The clinician must ensure that sufficient infor­ mation is given to the adult or child giving consent to treatment. Refusal of treatment A refusal by the client of proposed treatment needs to be noted. This ap­ plies whether it is the whole or only parts of the treatment with which the client refuses to proceed. Record the reasons for refusal using the client’s words wherever possible, and detail your advice to the client on the possi­ ble risks or negative outcomes of his or her decision. This will provide evi­ dence to help protect the clinician against any future litigation for negligence. It will also provide useful information for other health profes­ sionals on the client’s attitudes, beliefs and wishes. It is important to check organisational and professional guidelines on procedures, which should include directions about record keeping. Difficulties in obtaining consent In some cases there may be difficulties or barriers to communicating the necessary information to clients. Examples might include clients with a different language from the clinician, clients with a communication dis­ ability following a stroke or clients with a hearing loss. It may be necessary to use interpreters or advocates to help communicate information effec­ tively about treatment options. Whatever method is used it is important that the way in which the client’s consent was obtained is clearly recorded. Clients who are not competent to consent In certain circumstances it may not be possible to obtain consent from the client prior to giving treatment, for example an unconscious client in acci­ dent and emergency. The reason for not obtaining consent must always be recorded, along with information about how a client was deemed to be in­ competent to give consent. This is particularly important in the case of cli­ ents with a mental health problem, and special forms are available for these situations (NHS Executive 1990). Writing your objectives Use the following guidelines to help you set clear, realistic and measurable goals for your client. Such choices of language are important when careplans are being set with the client. Use specific statements in your objectives that contain information about quantifiable behaviours to be observed in the client. Springhouse (1998) suggests that such statements will include the fol­ lowing three key components: ° an observable behaviour ° a measure of that behaviour ° the condition under which that behaviour will occur.

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A series of laboratory tests failed to identify any known pathogen diabetes symptoms young male discount avapro uk, including the one that caused bubonic plague in the Mid- dle Ages diabetic honey buy avapro canada. The Special Pathogens Branch of the CDC was notified diabetes type 2 cookbook order avapro 150 mg line, and the state health departments of all four states—as well as the University of New Mex- ico School of Medicine—became involved in trying to solve what rapidly became an outbreak of the mysterious disease. During the ensuing weeks, as additional cases were reported and many people died, physicians and other scientific experts worked intensively to narrow down a list of suspected causes. These included exposure to herbicides or the possibility of a new type of influenza virus. Finally, the virologists at the CDC linked this pul- monary syndrome with a previously unidentified type of hantavirus. Researchers examined lung tissue samples from people who had died years earlier from an unidentified lung disease with similar symptoms. They esti- mated the first known outbreak of this particular disease to be as early as 1959. Finally, someone had the bright idea of directly consulting with an out- side, nonmedical source—the Navajos themselves. Interestingly enough, while the nationally renowned medical experts did not recognize this virus, the Navajos at once identified the disease which, while unnamed, was doc- umented in their cultural records. Long ago, the Navajos had discovered a link between this virus and the animals involved in the dissemination of the hantavirus—mice. In fact, some of the Navajo elders had actually predicted the 1993 outbreak as well as earlier ones that took place in 1918 and 1933–34. The Navajo records reflected that each of these outbreaks had followed increases in rainfall, which subsequently resulted in larger piñon crops and accompanying increases in the numbers of mice feeding on them. The moral of the story is talk to everyone, scrutinize everything, and keep an open mind! As a mystery malady sufferer, you should seek as many alternative ideas from as many different sources as you have available. Medical problem solving, particularly as it relates to mystery mal- adies, cannot be limited to only the “recognized” experts. Give yourself per- mission to think creatively, look at everything, and consult everyone, including sources that are not necessarily medical in nature. We have been surprised by the consistency with which clinical solu- tions, especially in the case of mystery maladies, have come from places we least expected. If you keep an open mind, you make yourself available to help from all possible sources. And if you are open enough to allow your own creative thinking to emerge as you work through the Eight Steps for Self-Diagnosis, you are sure to help yourself. Becoming Your Own Medical Detective Diagnosing a mystery malady is much like solving a crime. The primary goal of any detective academy is to train officers to become capable and pro- ficient investigators. While the crimes themselves may vary from burglary to homicide, the basic investigative techniques used to solve the crimes remain constant. Similarly, the exact nature of your mystery malady (whether it is gastrointestinal, dermatological, or neurological) is irrelevant for the purposes of self-diagnosis; the medical investigative techniques pre- sented here will apply to all of them. Naturally, at different times during the investigation (whether it is criminal or medical), consultants with specific areas of expertise will be required, but the investigative method will not vary. Here’s what you generally need to know about basic criminal investi- gation: detectives, in responding to a crime scene, are trained to secure the entire immediate and surrounding area to preserve it. The investigative team then canvasses the scene, collecting and documenting the primary evidence of what’s present or absent at the time of their arrival. That evidence includes the location of all actual and potential witnesses, as well as any physical evidence. Refraining from judgment will be equally important for you, as we will discuss in the next chapter. The balance of the crime investigation is the following of every poten- tial lead and clue down to the last detail. This may include in-depth inter- views, research, fingerprints, photos, lineups, all-points bulletins, police sketches, subpoenas for more potential evidence, surveillance, computer crosschecks, and undercover work. It will also involve the processing and examination of all evidence by experts and crime labs with the latest crime scene investigative technology.

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Compared to twenty years ago diabetes symptoms 236 avapro 150 mg buy on line, today’s wheelchair market is vibrant with new ideas and diverse options for people who no longer walk blood sugar high in the morning generic 150 mg avapro otc, helping them to ride where and how they wish diabetes symptoms hyperglycemia buy avapro 300 mg free shipping. The old standard chrome model with leatherette sling back and sling seat remains ubiquitous in in- stitutions, to ferry patients around. Now comparatively inexpensive, these relatively heavy and uncomfortable wheelchairs are sometimes all people can afford, even for home and community use. But for people with money or generous insurance coverage, countless options exist, ranging from ul- tralightweight three-wheeled chairs for marathoners to plastic chairs with bulbous wheels for rolling along sandy beaches to all-terrain four-wheeled power wheelchairs for traversing rugged surfaces to technologically so- phisticated power wheelchairs controlled by pneumatic switches. The ma- jority of people have manual wheelchairs (90 percent), with 8 percent using power equipment and 10 percent scooters—about 8 percent have more than one type of chair. The list of selected resources at the back of the book offers suggestions for obtaining information about wheelchairs and other assistive technologies. Extensive additional information is available elsewhere (Scherer 2000; Currie, Hardwick, and Marburger 1998; Karp 1998, 1999) and through such sources as the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), magazines, the Internet, and advocacy groups. But in most instances health insurers ultimately determine which wheelchair people get (chapter 14). Independence and Safety The most basic decisions about which wheelchair to try revolve around in- dependence and safety. Sophisticated technologies now allow even persons with severe physical debilities to operate power wheelchairs and move in- dependently. If people choose independence, deciding between manual and power wheelchairs depends primarily on having the physical strength and stamina to self-propel a manual chair. Most manual wheelchairs have push handles, so that other people can help tired users. Addressing users, Karp suggests: “be hon- est with yourself about your strength and energy—you’ll need plenty of both to operate a manual chair” (1998, 49). Nevertheless, compared to power wheelchairs, major benefits of manual chairs include: • lighter weight • range not constrained by the charge capacity of a battery • lower purchase and maintenance price • more discreet appearance, less bulk, and little noise • easier to transport in cars, airplanes, trains, and buses • greater ability to surmount environmental barriers (persons who master the “wheelie” can “jump” a curb or step; some even use escalators) (1998, 49; 1999, 226–27) For people without adequate strength or endurance, “introducing pow- ered mobility equipment... Power wheelchairs offer the following advantages over manual chairs (Karp 1998, 50; Karp 1999, 227): 204 W heeled Mobility • conserves energy and minimizes exhaustion • reduces the likelihood of needing assistance when traveling long distances • climbs slopes that are not unduly steep • leaves one arm free to do other things, such as carry packages • offers technologies, such as powered tilt or reclining, which can lessen risk of pressure sores and improve comfort After the choice of manual or power wheelchairs, many decisions re- main, such as solid rubber versus pneumatic tires, fixed or swingaway footrests, seat depth and width, flat back versus lumbar back support, and type of cushions (e. Given this diversity and the complex technical decisions, the advice of knowledgeable professionals (e. With fewer moving parts, rigid-frame wheelchairs are very lightweight, strong, and energy-efficient. Streamlined and unobtrusive, they are the “de facto stan- dard for those who want to reduce the visual emphasis on their disability” (Karp 1999, 229). Rigid frames are extremely responsive—even minor movements of riders’ bodies can cause changes in direction. Athletes, espe- cially, find this sensitivity essential to their quick maneuverability, while others are unnerved by it. On uneven surfaces, rigid-frame wheelchairs give a bumpy ride, becoming dangerous when one or more wheels lift off the ground. Rigid-frame wheelchairs do not fold neatly for easy storage (although their wheels pop off) and are too bulky for some cars. The major success of E&J was designing a sturdy and reliable folding chair. Although flexible-frame chairs are heavier, they offer some advan- tages over rigid-frame models. They are safer on rough terrain, fold easily for storage, and fit into most cars. They routinely have push handles just in case the user cannot self-propel (many rigid-frame chairs do not). But their weight undeniably demands more energy to propel, and they appear more like the prototypical wheelchair. The choice of rigid- or flexible-frame wheelchairs involves more deci- sions: about wheel size; placement and angle (camber) of wheels; width of Wheeled Mobility / 205 hand rims for pushing wheels; and wheel locks or hand brakes. These deci- sions must consider not only the users’ physical attributes (e. The optimal design for a marathoner or rugby player differs significantly from that for a person who still walks but uses a wheelchair for traveling to and from work.

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In both systems the carbon dioxide is be portals for the entry of toxins quizlet diabetes medications purchase avapro cheap, undigested food diabetes diet news generic 150 mg avapro visa, bacteria diabetes insipidus definition generic avapro 300 mg otc, converted to chains that are comprised of sugars that have the and yeast. Both types of conversion take place in the presence and terium divides to yield two daughter cells that differ from one the absence of oxygen. The conversion of carbon dioxide to sugar is an When a bacterium divides, one cell is motile by virtue of energy-requiring process that generates oxygen as a by-prod- a single flagellum at one end. This daughter cell is cules is cycled further by microorganisms in a series of reac- called the stalk cell. The stalk is an outgrowth of the cell wall, tions that form the so-called tricarboxylic acid (or TCA) cycle. In anaerobic environments, microorganisms can cycle the car- The swarmer cell remains motile for 30 to 45 minutes. The cell bon compounds to yield energy in a process known as fer- swims around and settles onto a new surface where the food mentation. After settling, the flagellum is shed and the Carbon dioxide can be converted to another gas called bacterium differentiates into a stalk cell. This occurs in anaerobic environments, such cycle the stalk becomes longer and can grow to be several as deep compacted mud, and is accomplished by bacteria times as long as the body of the bacterium. The conversion, which The regulation of gene expression is different in the requires hydrogen, yields water and energy for the swarmer and stalk cells. To complete the recycling pattern another group occurs immediately in the stalk cell but for reasons yet to be of methane bacteria called methane-oxidizing bacteria or determined is repressed in the swarmer cell. However, when a methanotrophs (literally “methane eaters”) can convert swarmer cell differentiates into a stalk cell, replication of the methane to carbon dioxide. This conversion, which is an aer- genetic material immediately commences. Thus, the transition obic (oxygen-requiring) process, also yields water and energy. There they have access to the methane The genetics of the swarmer to stalk cell cycle are com- produced by the anaerobic methanogenic bacteria, but also plex, with at least 500 genes known to play a role in the struc- access to the oxygen needed for their conversion of the tural transition. Other microorganisms are able to participate in the Caulobacter crescentus can be grown in the laboratory cycling of carbon. For example the green and purple sulfur so that all the bacteria in the population undergoes division at bacteria are able to use the energy they gain from the degra- the same time. This type of growth is termed synchronous dation of a compound called hydrogen sulfide to degrade car- growth. Other bacteria such as Thiobacillus the various events in gene regulation necessary for growth and ferrooxidans uses the energy gained from the removal of an division. The anerobic degradation of carbon is done only by See also Bacterial appendages; Bacterial surface layers; Cell microorganisms. This degradation is a collaborative effort cycle (prokaryotic), genetic regulation of; Phenotypic variation involving numerous bacteria. Examples of the bacteria include Bacteroides succinogenes, Clostridium butyricum, and Syntrophomonas sp. This bacterial collaboration, which is CDC • see CENTERS FOR DISEASE CONTROL (CDC) termed interspecies hydrogen transfer, is responsible for the bulk of the carbon dioxide and methane that is released to the atmosphere. Cech has revolutionized the way in which scientists look at RNA and at proteins. Up to the time of Cech’s discoveries in 1981 and 1982, it had been thought that CAULOBACTER genetic coding, stored in the DNA of the nucleus, was Caulobacter imprinted or transcribed onto RNA molecules. These RNA Caulobacter crescentus is a Gram-negative rod-like bacterium molecules, it was believed, helped transfer the coding onto that inhabits fresh water. It is noteworthy principally because proteins produced in the ribosomes. Instead of dividing two was thus the information center of the cell, while protein mol- form two identical daughter cells as other bacteria do (a ecules in the form of enzymes were the workhorses, catalyz- process termed binary division), Caulobacter crescentus ing the thousands of vital chemical reactions that occur in the undergoes what is termed symmetric division. Conventional wisdom held that the two functions were 101 Cech, Thomas R. WORLD OF MICROBIOLOGY AND IMMUNOLOGY separate—that there was a delicate division of labor. Cech and others discovered that portions of seemingly noncoded DNA his colleagues at the University of Colorado established, how- were snipped out of the RNA and the chain was spliced back ever, that this picture of how RNA functions was incorrect; together where these intervening segments had been removed.

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Will your research generate enough material to write a dissertation of the required length? Or will your research generate too much data that would be impossible to summarise into a report of the required length? If you’re conducting research for funding purposes diabetic shoes discount 300 mg avapro otc, have you found out whether your proposed funding body re- quires the information to be presented in a specific for- mat? If so diabetes jewelry for women cheap avapro 150 mg buy online, you need to plan your research in a way which will meet that format diabetes type 1 books effective 150 mg avapro. However, you should think about the type of people with whom you will need to get in touch with and whether it will be possible for you to contact them. If you have to conduct your research within a par- ticular time scale, there’s little point choosing a topic which would include people who are difficult or expensive to contact. Also, bear in mind that the Internet now pro- vides opportunities for contacting people cheaply, espe- cially if you’re a student with free internet access. Thinking about this question in geographical terms will help you to narrow down your research topic. Also, you need to think about the resources in terms of budget and time that are HOW TO DEFINE YOUR PROJECT / 7 available to you. If you’re a student who will not receive travel expenses or any other out of pocket expenses, choose a location close to home, college or university. If you’re a member of a community group on a limited bud- get, only work in areas within walking distance which will cut down on travel expenses. Also, you need to think about where you’ll be carrying out your research in terms of venue. If you’re going to con- duct interviews or focus groups, where will you hold them? Is there a room at your institution which would be free of charge, or are you going to conduct them in par- ticipants’ own homes? If you’ve answered ‘no’ to either of these last two questions, maybe you need to think again about your research topic. In 15 years I have encountered only one uncomfortable situation in a stranger’s home. Think very carefully about whether your chosen topic and method might have an influence on personal safety. Thinking about this question will help you to sort out whether the research project you have proposed is possible within your time scale. It will also help you to think more about your par- ticipants, when you need to contact them and whether they will be available at that time. For example, if you want to go into schools and observe classroom practice, you wouldn’t choose to do this research during the sum- mer holiday. It might sound obvious, but I have found 8 / PRACTICAL RESEARCH METHODS some students present a well-written research proposal which, in practical terms, will not work because the par- ticipants will be unavailable during the proposed data collection stage. Once you have thought about these five ‘Ws’, try to sum up your proposed project in one sentence. When you have done this, take it to several people, including your boss and/or tutor, and ask them if it makes sense. If they don’t, ask them to explain their confusion, revise your statement and take it back to them. I can’t overemphasise the importance of this stage of the re- search process. If you get it right now, you will find that the rest of your work should flow smoothly. EXERCISE 1 Have a look at the three projects below and see if you can spot any potential problems. What questions would you ask to make the researchers focus in on their pro- posed project? Statement 1: This research aims to find out what people think about television. HOW TO DEFINE YOUR PROJECT / 9 Statement 2: My project is to do some research into Alz- heimer’s disease, to find out what people do when their relatives have it and what support they can get and how nurses deal with it. Statement 3: We want to find out how many of the local residents are interested in a play scheme for children dur- ing the summer holiday.

Syndromes

• General illness (from mild illnesses to serious conditions, such as operations, heart attacks, and pneumonia)
• Homemakers
• Blood tests to check thyroid level
• Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
• Keep a relatively constant temperature around the baby, protecting from heat loss
• Weakness
• Fatigue, exhaustion, and light-headedness

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Ohzono K diabetes test fasting blood sugar order avapro with a mastercard, Saito M blood sugar jumps 150 mg avapro order fast delivery, Sugano N diabetes type 2 criteria purchase 150 mg avapro visa, et al (1992) The fate of nontraumatic avascular necrosis of the femoral head. Sugano N, Atsumi T, Ohzono K, et al (2002) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. Gardeniers JWM (1993) The ARCO perspective for reaching one uniform staging system of osteonecrosis. In: Schoutens A, Arlet J, Gardeniers JWM, et al (eds) Bone circulation and vascularization in normal and pathological conditions. Jergesen HE, Kahn AS (1997) The natural history of untreated asymptomatic hips in patients who have non-traumatic osteonecrosis. Kopecky KK, Braunstein EM, Brandt KD, et al (1991) Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft patients. Nishii T, Sugano N, Ohzono K, et al (2002) Progression and cessation of collapse in osteonecrosis of the femoral head. Cheng EY, Thongtrangan I, Laorr A, et al (2003) Spontaneous resolution of osteone- crosis of the femoral head. Koo KH, Kim R, Ko GH, et al (1995) Preventing collapse in early osteonecrosis of the femoral head. Sakamoto M, Shimizu K, Iida S, et al (1997) Osteonecrosis of the femoral head: a pro- spective study with MRI. Mont MA, Carbone JJ, Fairbank AC (1996) Core decompression versus nonoperative management for osteonecrosis of the hip. Stulberg BN, Davis AW, Bauer TW, et al (1991) Osteonecrosis of the femoral head. Hernigou P, Poignard A, Nogier A, et al (2004) Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip. J Bone Joint Surg 86A:2589–2593 Large Osteonecrotic Femoral Head Lesions 113 22. Beltran J, Knight CT, Zuelzer WA, et al (1990) Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Holman AJ, Gardner GC, Richardson ML, et al (1995) Quantitative magnetic reso- nance imaging predicts clinical outcome of core decompression for osteonecrosis of the femoral head. Sugioka Y, Hotokebuchi T, Tsutsui H (1992) Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Sugioka Y, Katsuki I, Hotokebuchi T (1982) Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis. Koo KH, Song HR, Yang JW, et al (2001) Trochanteric rotational osteotomy for osteo- necrosis of the femoral head. Dean MT, Cabanela ME (1993) Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Rijnen WH, Gardeniers JW, Westrek BL, et al (2005) Sugioka’s osteotomy for femoral- head necrosis in young Caucasians. Phemister DB (1949) Treatment of the necrotic head of the femur in adults. Rosenwasser MP, Garino JP, Kiernan HA, et al (1994) Long term follow-up of thorough debridement and cancellous bone grafting of the femoral head for a vascular necrosis. Mont MA, Einhorn TA, Sponseller PD, et al (1998) The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. Buckley PD, Gearen PF, Petty RW (1991) Structural bone-grafting for early atraumatic avascular necrosis of the femoral head. Boettcher WG, Bonfiglio M, Smith K (1970) Non-traumatic necrosis of the femoral head. Bonfiglio M, Voke EM (1968) Aseptic necrosis of the femoral head and non-union of the femoral neck. Effect of treatment by drilling and bone-grafting (Phemister tech- nique). Smith KR, Bonfiglio M, Montgomery WJ (1980) Non-traumatic necrosis of the femoral head treated with tibial bone-grafting.

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The client’s experience of health care may be very different from the one in which you are working diabetes symptoms thirst generic 150 mg avapro amex. For example pre diabetes diet uk buy generic avapro online, a school for children with special needs may have a very different connotation for the client diabetes test fasting 300 mg avapro buy otc, or he or she may come from a health care system where the idea of a prescription is un­ known. Clients may hold a certain view about how a health professional should behave and the role of the client in getting better. For example, do they see the health professional as the person making all the decisions? Approaches to learning vary between cultures and this may influence how material is presented. For instance, drawings may be held in high regard in one culture whereas another may view their use in materials as childish and degrading. We can all quote examples we have seen or heard of comic errors in transla­ tion. However, such errors in translation of health material may be more serious in their effect. A back translation, although costly, is probably the best way of ensuring that details are correct and that there are no omissions in the material. Another less common problem is that some languages do not have a writ­ ten form. Sensory impairment Written material is a potential problem for clients with a visual impairment. Use large print and bright colours that contrast strongly with each other to help make text and visuals legible. Advice can be sought from the Royal National Institute for the Blind on how to prepare materials. Alternatives might be to have material translated into Braille or to use an audio record­ ing. However, the cost of these methods would have to be considered care­ fully in relation to the need. Evaluation It is crucial to incorporate a system of evaluation into your project. This will help improve the planning and execution of your present task as well as providing valuable insight for use in any future projects. The development stage A system for continuous review of the development process needs to be scheduled right at the start of your project. You will want to evaluate: (a) Timescales (b) Costs (c) Resources (d) Development team (e) Development process. INFORMATION LEAFLETS FOR CLIENTS 115 (b) Costs Developing written materials is a costly process. However, there are hidden costs that need to be accounted for when calculating the overall expense. For in­ stance, a one-hour planning meeting with four people is equivalent to four hours in terms of salaries. Continuous review of expenditure is needed if costs are not to esca­ late beyond your planned budget. Were all the resources that you required readily available, for example access to an evidence base via a library or a graphic artist for illustrations? The emphasis is on how you developed the materials and whether these procedures worked well. The validity of your written material Use the following checklist to help in evaluating the validity of your writ­ ten material: q Is it accurate? The effectiveness of your written material Evaluate the outcomes of your project. A first review might be best 12 months after the completion of your project. This is a fundamental question but not necessarily one that is easy to answer. There are a number of different methods you can use to help you evaluate the effectiveness of your written material. Try one or a combination of the following ways: ° User feedback from clients, clinicians and administrative staff.

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Before the advent of the CT scan blood sugar 97 avapro 150 mg buy on line, several studies attempted to investigate the prognosis of shunted vs blood glucose 240 order avapro 150 mg without a prescription. In 1963 diabetes mellitus ziele buy genuine avapro, Foltz and Shurtleff performed a 5-year study of 113 hydrocephalic children of whom 65 were shunted early, and 48 were not operated on. They found that shunted children had a significantly better survival and a higher percentage had an IQ of at least 75. In 1973, Young and colleagues performed an outcome analysis on a series of 147 shunted hydrocephalic children. They found a correlation between the width of the child’s cerebral mantle and IQ in that the IQ distribution approached a normal pattern when a cerebral mantle width of 2. Since the introduction of CT and MR imaging, there have been several studies investigating the outcomes of hydrocephalus secondary to specific etiologies. In 1985, Op Heij and colleagues followed children with congenital nonobstructive hydrocephalus and found that IQ was normal ( > 80) in 50% of cases and abnormal ( < 55) in 28%. There was no correlation with head circumference or degree of ventriculomegaly. They concluded that the degree of intellectual impairment had less to do with the severity of the hydrocephalus and more to do with the severity of underlying anomalies in the central nervous system and defects in the cytoarchitecture of the neocortex. Infants with PHH have a significantly higher mortality rate when compared with low-birth-weight infants without PHH. The correlation between severity of PHH and neurological disabilities is less clear. Historically, the mortality for infants with Dandy–Walker malformation approached 20–30%. However, in 1990, Bindal and colleagues demonstrated a mor- tality rate of 14% in their series. Lower IQ and neurological developmental delay are seen in children with Dandy–Walker malformations, but they are thought to be related to the associated anomalies in the central nervous system. Symptomatic ven- tricular shunt malfunction should be evaluated, recognized, and treated promptly to avoid undue morbidity. Ventricular shunt infection currently occurs in 1–15% of children who have shunts placed or revised, and the majority of infections 36 Avellino are detected within the first 1–6 months after a shunt procedure. The prognosis of pediatric hydrocephalus is dependent primarily on the underlying brain morphology. Morrison Department of Neurology, University of New Mexico, Albuquerque, New Mexico, U. INTRODUCTION Scoliosis is a lateral and rotational curvature of the thoracic and lumbar spine mea- suring greater than 10. The first, idiopathic scoliosis, accounts for 80% of cases with a predilection for adolescent females. The second category, neuromuscular scoliosis, describes an acquired deformity that results from neurologic impairment of either a peripheral or central nature. The third category involves those forms with congenital onset or that are attributable to other connec- tive tissue and musculoskeletal disorders. Children with severe neurological impair- ment are at high risk for the development of scoliosis, especially within certain diagnostic groups. For example, 90% of boys with Duchenne muscular dystrophy (DMD) will develop scoliosis. In cerebral palsy, the incidence is highest in those most severely affected, usually with quadraplegic, hemiplegic, and dystonic forms of CP. DIAGNOSIS AND EVALUATION The neurologist’s role in the evaluation of the child with scoliosis is to uncover dis- orders of the central or peripheral nervous system that might have additional impli- cations for prognosis or management. Most patients with scoliosis, however, have the idiopathic form of scoliosis or scoliosis due to obvious neurologic (Table 1) or musculoskeletal (Table 2) causes that do not require further diagnostic investigation. The most common problem, therefore, is to separate those with idiopathic scoliosis from those with scoliosis due to occult neurologic impairment. In most cases of idio- pathic scoliosis, curvature appears in preadolescence.

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But in evaluating walking difficulties diabetes problems generic avapro 150 mg on-line, some specialists inquire more about people’s daily lives and activities than do their primary care physicians diabetes diet in french 300 mg avapro purchase amex. Landau (a rheumatologist) is enhancing overall quality of life through un- 160 / Physicians Talking to Their Patients derstanding and improving function pre diabetes definition discount avapro 300 mg buy line. Some specialists thus know more about patients as people than might their primary care physicians. Physical Medicine and Rehabilitation Specialists The stated mission of physiatrists, physicians specializing in PM&R, is tailor-made for people with difficulty walking. Over 6,100 physiatrists practice throughout the United States, trained by eighty accredited PM&R residency programs. They assess functional needs and provide nonsurgical interventions, frequently working alongside physical and oc- cupational therapists (DeLisa, Currie, and Martin 1998). According to the American Academy of Physical Medicine and Rehabilitation (2000), whose motto is “physicians adding quality to life,” Physiatrists focus on restoring function. They care for patients with acute and chronic pain, and musculoskeletal problems like back and neck pain, tendinitis, pinched nerves and fibromyalgia. They also treat people who have experienced catastrophic events resulting in paraplegia, quadriplegia, or traumatic brain injury; and individuals who have had strokes, orthopedic injuries, or neurologic disorders such as multiple sclerosis, polio, or ALS. Melinda Whittier, a physiatrist in her early forties, put it succinctly: “Physiatrists look at the whole patient. The physiatrist could help clarify the diagnosis or recognize that something subtle is going on. Whittier recognizes that physiatry is often the last resort, after patients exhaust other specialists. You’re teaching individuals to improve their quality of life, their health status, within their environments. Another explana- tion is idiosyncratic: for historical reasons, physiatry has been slow to take root in Boston. The Graduate Medicine Education Na- tional Advisory Committee targeted PM&R as one of three medical spe- cialties facing personnel shortages (Pope and Tarlov 1991, 231). Established medicine came late to rehabilitation (Berkowitz and Fox 1989, 146). Treating wounded World War I soldiers gave orthopedics credibility and catalyzed initial medical rehabili- tation efforts—designing prosthetics and orthotics to improve mobility of injured veterans. Between world wars, improving function for polio sur- vivors gained attention, although the greatest advances involved non- physicians in Warm Springs, Georgia: Franklin Delano Roosevelt and the physical therapist Helena Mahoney. In the mid 1920s Roosevelt requested endorsement from the American Orthopedic Association (AOA), but the AOA refused to allow Roosevelt even to address their annual convention in Atlanta: “He was told he was a man without standing. Some disability rights ac- tivists argue that rehabilitation specialists further the medicalization of disability, exhorting people to “fit in or cope with ‘normal’ life and expec- tations so that they did not become a burden on the rest of society” (Barnes, Mercer, and Shakespeare 1999, 20). Leading PM&R specialists, however, assert their aims of assisting people to find and fulfill their own “desires and life plans. Patients, their families, and their rehabilitation teams work together to determine realistic goals.... Rehabilitation is a concept that should permeate the entire health-care system” (DeLisa, Cur- rie, and Martin 1998, 3). If patients can’t walk, the physiatrist’s job is to help find alternatives. If what’s causing [the mobility problem] is not easily reversible, then you’ve got to face up to the fact: “I’ve got an irreversible condition here, and I’ve got to compensate for it. So trouble with mobility is a very 162 / Physicians Talking to Their Patients complicated psychological and physical problem. Despite that, early on in my rehabilitation training, we often said that mobility prob- lems were the easiest things to rehabilitate. Fundamentally, the per- son still has their mind, they are a human being with their social re- lationships. It’s this nasty problem with physically moving their body from point A to point B.

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Journal of Neurology 1998; 245: 709-716 Cross References Athetosis; Ballism diabetes prevention herbs avapro 150 mg buy with visa, Ballismus; Dyskinesia; Hypotonia metabolic disease in children purchase avapro online, Hypotonus; Milkmaid’s grip; PseudoChoreoathetosis; Rigidity; Trombone tongue Chromesthesia - see SYNESTHESIA - 73 - C Chvostek’s Sign Chvostek’s Sign Chvostek’s sign is contraction of facial muscles provoked by lightly tap- ping over the facial nerve as it crosses the zygomatic arch diabetes type 2 uk statistics purchase avapro 150 mg with amex. Chvostek’s sign is observed in hypocalcemic states, such as hypoparathyroidism and the respiratory alkalosis associated with hyperventilation. There may be concurrent posturing of the hand, known as main d’accoucheur for its resemblance to the posture adopted for manual delivery of a baby. The pathophysiology of this mechanosensitivity of nerve fibers is uncertain, but is probably related to increased discharges in central pathways. Although hypocalcemia might be expected to impair neuromuscular junction transmission and excitation-contraction coupling (since Ca2+ ions are required for these processes) this does not in fact occur. Cross References Main d’accoucheur; Spasm Ciliospinal Response The ciliospinal response consists of rapid bilateral pupillary dilatation and palpebral elevation in response to a painful stimulus in the mantle area, for example pinching the skin of the neck. Neurology 1969; 19: 1145-1152 Cross References Pupillary reflexes Circumlocution Circumlocution refers to: ● A discourse that wanders from the point, only eventually to return to the original subject matter, as seen in fluent aphasias; ● A response to word-finding difficulties, as in early Alzheimer’s dis- ease or nonfluent aphasias: in response to familiar pictures, patients may comment that the name is on the tip-of-the-tongue but they cannot access it, and therefore give alternatives (e. Brain and Language 1996; 54: 196-215 Cross References Anomia; Aphasia; Dementia Clasp-Knife Phenomenon Clasp-knife phenomenon is the name sometimes applied to the sudden “give”encountered when passively moving a markedly spastic limb. Since the clasp-knife phenomenon is a feature of spasticity, the term “clasp- knife rigidity” is probably best eschewed to avoid possible confusion. Cross References Rigidity; Spasticity - 74 - Clonus C Claudication Claudication (literally limping, Latin claudicatio) refers to intermittent symptoms of pain secondary to ischemia. Claudication of the legs on walking is a symptom of peripheral vascular disease. Claudication of the jaw, tongue, and limbs (especially upper) may be a feature of giant cell arteritis. Neurology 1988; 38: 352-359 Claw Foot Claw foot, or pied en griffe, is an abnormal posture of the foot, occur- ring when weakness and atrophy of the intrinsic foot muscles allows the long flexors and extensors to act unopposed, producing shortening of the foot, heightening of the arch, flexion of the distal phalanges and dorsiflexion of the proximal phalanges (cf. This may occur in chronic neuropathies of early onset which involve motor fibers, such as hereditary motor and sensory neuropathies types I and II. Cross References Pes cavus Claw Hand Claw hand, or main en griffe, is an abnormal posture of the hand with hyperextension at the metacarpophalangeal joints (5th, 4th, and, to a lesser extent, 3rd finger) and flexion at the interphalangeal joints. This results from ulnar nerve lesions above the elbow, or injury to the lower part of the brachial plexus (Dejerine-Klumpke type), producing wast- ing and weakness of hypothenar muscles, interossei, and ulnar (medial) lumbricals, allowing the long finger extensors and flexors to act unopposed. Cross References Benediction hand; Camptodactyly Clonus Clonus is rhythmic, involuntary, and repetitive muscular contraction and relaxation. It may be induced by sudden passive stretching of a muscle or tendon, most usually the Achilles tendon (ankle clonus) or patella (patellar clonus). Ankle clonus is best elicited by holding the relaxed leg underneath the moderately flexed knee, then quickly dorsi- flexing the ankle and holding it dorsiflexed. A few beats of clonus is within normal limits but sustained clonus is pathological. Clonus reflects hyperactivity of muscle stretch reflexes and may result from self reexcitation. It is a feature of upper motor neurone dis- orders affecting the corticospinal (pyramidal) system. Patients with dis- ease of the corticospinal tracts may describe clonus as a rhythmic jerking of the foot, for example when using the foot pedals of a car. Clonus may also be observed as part of a generalized (primary or secondary) epilep- tic seizure, either in isolation (clonic seizure) or much more commonly following a tonic phase (tonic-clonic seizure). The clonic movements - 75 - C Closing-in Sign usually involve all four limbs and decrease in frequency and increase in amplitude over about 30-60 seconds as the attack progresses. Rather dif- ferent “clonic” movements may occur in nonepileptic seizures. A few clonic jerks may also be observed in syncopal attacks, leading the unini- tiated to diagnose “seizure” or “convulsion. It may be seen in patients with Alzheimer’s disease with deficits in visuospatial function.

Connor, 55 years: The British Heart Foundation has supported the concept of public access defibrillation After every 3 shocks If no circulation enthusiastically and provided many defibrillators for use by CPR 1 minute CPR 1 minute trained lay responders working in organised schemes under the supervision of the ambulance service. Rosenbaum’s son was eleven years old, he suddenly developed diarrhea, abdominal pain, bloating, gas, nausea, and vomiting. The wounds are cleansed for the next few days with 3% hydro- gen peroxide. McKhann attended the Yale Medical School, trained in pediatrics at Yale and Hopkins, received neurology training at Boston Children’s Hospital under the men- torship of Phillip Dodge, and spent several years studying cerebral metabolism at the NIH.

Treslott, 23 years: In grounded theory, methods such as focus groups and interviews tend to be the preferred data collection method, along with a com- prehensive literature review which takes place through- out the data collection process. At the end of the day, today’s junior doctors will be tomorrow’s consultants, and we need to see as many patients as pos- sible to gain the experience required to fulfil a consultant role. In the genetic change may be passed on to subsequent genera- another example, amonglycoside antibiotics can bind to a sub- tions of bacterial. The central concern of sexual health promotion is not to prevent disease but to preach a new form of sexual morality.

Umul, 32 years: Charles Heck that he should ladder; you may pass them again on the way leave an excellent orthopedic practice to become down. The diameter of the micelles depends on the exact nature of the sur- Chemistry on the inside 65 factant, but is typically of the order of 2–4nm. The SSA and workers’ compensation programs use different processes for evaluating dis- ability: the SSA’s “blue book,” Disability Evaluation Under Social Security (1998) for SSDI and SSI; and the American Medical Association’s Guides to the Evaluation of Permanent Impairment (1993; Cocchiarella and Andersson 2001), used for workers’ compensation disability determinations in most states. Bale Division of Neurology, Department of Pediatrics, The University of Utah School of Medicine, Salt Lake City, U.

Owen, 63 years: What a tragedy this My first contact with Reginald Watson-Jones, like would have been, especially in the year after the that of many other Liverpool undergraduates, was fall of France when we were “going it alone. These requirements meanwhile, after 19 years experience, are well accepted today and we use them before many others. Different types of virus can reduction in the number of chromosomes within sex cells is have different arrangements of the nucleic acid. The ability to generalise he found that there were many more from this type of sample is not the pupils in the arts than the sciences, goal, and, as with other sampling he could decide to choose a procedures, the researcher has to be disproportionate stratified sample aware of bias which could enter the and increase the sample size of the process.

Vibald, 41 years: Caribbean when they wash up onshore and become bleached When a chlorophyll molecule absorbs light energy, it by the sun. Nine of these 11 hips were steroid-induced osteonecrosis and the other 2 were alcohol- related osteonecrosis. Overcoming the natural Hiram Winnett ORR resistance to new techniques, he persisted in his attempts to teach other orthopedists its value as a 1877–1956 diagnostic tool as well as its potential for intra- articular surgery. With some disdain, the BMA noted ‘a demand which is scarcely rational for instant cures for the currently incurable diseases of mankind’ and dismissed the ‘ill-founded suspicion that nothing is being done to attack these problems’ (BMA 1986:4).

Pavel, 30 years: Intertrochanteric osteotomy was regarded as a safe and effective procedure. In their investigations of patients, Penfield and Rasmussen observed that stimulation of the brain regions responsible for seeing led patients to experience phosphenes which they described in terms such as ‘I saw just one star’ , ‘Silver things to the left of me’ or ‘red and blue wheels’. She decided to move to Philadelphia, where her mother’s sister lived, and begin a new life. In East London, we have been bombarded with methadone propaganda and invited to specially organised local seminars.

Bengerd, 29 years: The radiographic appearance, determined according to the staging system of the Japanese Investigation Committee, was stage 1 for 2 hips, stage 2 for 28, stage 3A for 15, stage 3B for 10, and stage 4 for 1 hip. Extension/flexion range of motion (ROM) should be at least 40° or more, prefera- bly 60° or more. Ventricular tachycardia characteristically has a broad width QRS complex, but some rare tachycardias arising below the 21 ABC of Resuscitation AV junction may have a complex width within the normal range. Primary Dystonia The major form of primary dystonia in children is childhood onset, generalized, idio- pathic torsion dystonia, formerly known as dystonia musculorum deformans.

Akascha, 59 years: This is because, if there is a complication, the nursing staff will need to inform you so you can attend to the patient. Thanks to his initiative, links were specialization evolved and, by 1962, he was able forged with Straumann, a metallurgical research to move to a modern hospital building with five institute, who helped to solve problems with the individual departments. Hazel, whom he met when both were ment with Gillette Children’s Hospital, which serving in the armed forces, was an enthusiastic continued throughout most of his professional partner in all his pursuits; their golden wedding career. Complications such as avascular necrosis (AVN) of the femoral head or chondrolysis were not observed.

Osko, 31 years: The formation of periodic minimal surfaces and other bicontinuous structures may be an inherent consequence, as seen in the prolamellar bodies of chloroplasts in plants. Hyperpronation - see CHOREA, CHOREOATHETOSIS; DECEREBRATE RIGIDITY Hyperreflexia Hyperreflexia is an exaggerated briskness of the tendon reflexes. He had a stock of useful home city of Basel, he built up his knowledge in aphorisms. It is useful to take a pen and notepad with you to the in- terview, even if you intend to use a recorder.

Masil, 57 years: He was, however, particularly free Kenneth Hampden PRIDIE from the shackles of tradition and was bold enough to cut a path of his own. In 1912, he was president of He returned to civilian practice in 1919 and the Hunterian Society and as orator took “The afterwards contributed a series of articles to the Surgery of Paralysis” as his subject. His first book in 1859 established his interest in the field, but his views were established in the more readable third edition of 1876. These sex cells are called two strands of DNA are intertwined while at the same time haploid cells (meaning half the number).

Deckard, 25 years: Try to remember that control over your condi- tion was only an illusion anyway, and the sooner you can accept this, the more peace of mind you will find. Qualifi- cation in medicine followed in 1905, and the higher degree in surgery (ChM) in 1907. Through a symbolic interactionist analysis of the experiences of the people who spoke with me, I have argued that objectivist definitions of alternative therapies are inherently problematic. However, the use of too low otics exert their effect by disrupting the manufacture of pepti- a concentration of an antibiotic or stopping antibiotic therapy doglycan, which is main stress-bearing network in the before the prescribed time period can leave surviving bacteria bacterial cell wall.

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