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Therapeutic choices in the locomotor management of the child with cerebral palsy—more luck than judgement? Qualitative analysis of therapeutic motor interven- tion programmes for children with cerebral palsy: an update cheap generic escitalopram uk anxiety university california. Avellino Division of Pediatric Neurosurgery buy escitalopram mastercard anxiety psychiatrist, Children’s Hospital and Regional Medical Center generic 10mg escitalopram overnight delivery anxiety symptoms jitteriness, University of Washington School of Medicine, Seattle, Washington, U. INTRODUCTION Hydrocephalus is the abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles and subarachnoid spaces. It is often associated with dilatation of the ven- tricular system and increased intracranial pressure (ICP). The incidence of pediatric hydrocephalus as an isolated congenital disorder is approximately 1=1000 live births. Pediatric hydrocephalus is often associated with numerous other conditions, such as spina bifida, tumors, and infections. Hydrocephalus is almost always a result of an interruption of CSF flow and is rarely because of increased CSF production. CLINICAL PATHOLOGY—SITE OF OBSTRUCTION Historically, hydrocephalus has been classified as obstructive or nonobstructive,a somewhat misleading classification because all forms of hydrocephalus, except hydrocephalus ex vacuo (resulting from brain atrophy), involve some form of CSF obstruction. A more commonly used classification differentiates hydrocephalus between communicating or noncommunicating (Table 1). Traditionally, this classifica- tion was based on whether dye injected into the lateral ventricles could be detected in CSF extracted from a subsequent lumbar puncture. Currently, the term ‘‘noncom- municating hydrocephalus’’ refers to lesions that obstruct the ventricular system, either at the cerebral aqueduct of sylvius or basal foramina (i. The term ‘‘communicating hydrocephalus’’ refers to lesions that obstruct at the level of the subarachnoid space and arachnoid villi. Lateral Ventricle Choroid plexus tumors are rare in the pediatric population, with an incidence ran- ging from 1. Most choroid plexus tumors are choroid plexus papillomas, which usually present within the first 3 years of life. The CSF production rates three to four times the normal rate have been documented in children with choroid plexus papillomas. Removal of the papilloma resolves the 25 26 Avellino Table 1 Causes of Hydrocephalus Based on Site of Obstruction Lateral ventricle Choroid plexus tumor Intraventricular region glioma Foramen of Monro Congenital atresia Iatrogenic functional stenosis Stenotic gliosis secondary to intraventricular hemorrhage or ventriculitis Third ventricle Colloid cyst Ependymal cyst Arachnoid cyst Neoplasms such as craniopharngioma, chiasmal-hypothalamic astrocytoma, or glioma Cerebral aqueduct Congenital aqueduct malformation Arteriovenous malformation Congenital aqueduct stenosis Neoplasms such as pineal region germinoma or periaqueductal glioma Fourth ventricle Dandy–Walker cyst Neoplasms such as medulloblastoma, ependymoma, astrocytoma, or brainstem glioma Basal foramina occlusion secondary to subarachnoid hemorrhage or meningitis Chiari malformations hydrocephalus in approximately two-thirds of cases. The remaining third probably suffer from obstruction of the aqueduct and=or basal meninges and require a ventricular shunt presumably secondary to preoperative microhemorrhages or postoperative scarring of the arachnoid villae. Foramen of Monro Occlusion of one foramen of Monro can occur secondary to a congenital membrane, atresia, or gliosis after intraventricular hemorrhage (IVH) or ventriculitis. The result- ing unilateral ventriculomegaly is often occult until early childhood, and may enlarge the ipsilateral hemicalvarium. An iatrogenic functional stenosis of the foramen of Monro can develop in chil- dren with spina bifida whose hydrocephalus has been treated with a ventricular shunt. The contralateral nonshunted ventricle occasionally expands secondary to deformity of the foramen of Monro. If symptomatic, the patient can be treated with a shunt system having two ventricular catheters, each draining a separate lateral ven- tricle or an endoscopic fenestration of the septum pellucidum with one ventricular catheter draining both ventricles. Third Ventricle Cysts and neoplasms within the third ventricle commonly cause hydrocephalus. Col- loid cysts are uncommon neoplasms that present superiorly and anteriorly within the third ventricle, and usually obstruct both foramina of Monro. Considered to Hydrocephalus 27 be congenital lesions, they can become symptomatic at any age. However, they rarely present within the pediatric population, and are commonly symptomatic between the ages of 20 and 50 years. They can cause either intermittent, acute, life-threatening hydrocephalus or chronic hydrocephalus. They are customarily trea- ted with resection via craniotomy, endoscopic resection, or stereotactic aspiration of the cyst. Ependymal and arachnoid cysts within the third ventricle usually present with hydrocephalus in late childhood. Patients may present with bobble-head doll syndrome, a rhythmic head and trunk bobbing tremor at a frequency of two to three times per second.

SMITH-PETERSEN ment in the form of Vitallium mold arthroplasty purchase 20mg escitalopram amex anxiety symptoms losing weight, 1886–1953 with preliminary trials of several materials generic escitalopram 5mg on line anxiety young living oils, including glass (1923) escitalopram 5mg free shipping anxiety xanax and copd, viscoloid (1925), Pyrex Dr. Smith- virtue of his skill and thought, with reference to Petersen put into his work on arthroplasty of the hip joint surgery in particular, but throughout his hip provoked worldwide interest and progress, professional career his strong personality, mixed and it is to be noted that a long period of research with a great sense of humility and kindness, preceded his final operative technique. Not only was he the “surgical joint dates back to 1930-1931, when he intro- master,” but the friend and confidant of all who duced the use of the three-flanged nail for inter- had the privilege to come into contact with him. At that Although he was somewhat shy and sensitive as time, he wrote: “A great responsibility rests on the an individual, his powers of concentration and surgeon who introduces a new method of treat- real deep thinking made him a great leader and ment. The desire to have a new idea published is teacher in the art and science of orthopedic so great that the originator is often led astray, and surgery. His great aim, both in theory (Harvard) in 1914, and was awarded an Honorary and practice, was to be constructive, and thus we 310 Who’s Who in Orthopedics find him developing many procedures for the English-speaking orthopedic surgeons in London relief of pain and restoration of function in the and the provinces. Fortunately, he had a chance deformed joints of the unfortunate sufferers from of seeing most of his friends and was able to visit chronic arthritis. In 1946, he worked out on paper to the last detail, before was honored with the award of Commander of being put into effect most successfully and the Royal Norwegian Order of Saint Olaf, and dramatically. In honorary member of the Norwegian Surgical this respect he was much influenced by his early Association. Smith-Petersen undoubtedly was seen at his American Orthopedic Association, and held the best when dealing with patients, either on a ward office of president of the American Academy of round or in his office. During the Second vidual one, and with his quiet smile and sly wink World War, he was consultant in orthopedic he captivated both patients and pupils alike. He was also a man has ever portrayed the essential spirit of the member of the International Society of Orthope- doctor–patient relationship better. On social occa- dic Surgeons, and an associate member of the sions, he loved to be surrounded by the younger French Academy of Orthopedic Surgery. Smith-Petersen died on June 16, 1953 in a Scandinavian manner, and provoking both at the age of 67, after a short illness. After the Second World War, he visited Great Britain in 1947, 1948 and 1952. On the foremost occasion, he was made an Honorary Fellow of the British Orthopedic Association, and also deliv- ered the fourth Moynihan Lecture at the Univer- sity of Leeds. He also took charge of the orthopedic staff conference and operated before a distinguished audience at the London Hospital. At a reception following this occasion, the gift of his characteristic ties will long be remembered by the recipients. It was during this friendly and amusing ceremony that the household dog laid her favorite bone at Dr. Smith-Petersen’s feet, this bone was none other than half the pelvis including the hip joint! After the termination of this visit to England, a Jensen silver bowl was presented to him by the staff of the London Hospital at a simple and moving little ceremony, which brought tears to the eyes of this great and senti- mental man. Smith-Petersen, accompanied by his wife, visited London to be given the Honorary Fellowship of the Royal Society of Medicine, and to attend the meeting of 311 Who’s Who in Orthopedics control. In World War II, he served in the United States Army from 1942 to 1946, first with the Twenty- fifth Evacuation Hospital and then as chief con- sultant in orthopedic surgery to the South Pacific area, the Tenth Army at Okinawa, and the Pacific. He was awarded the Legion of Merit, a Bronze Star, and five battle stars, and achieved the rank of colonel. On returning to civilian life, he became chief surgeon at Shriners Hospital for Crippled Chil- dren in Chicago; he retained that post until 1965, after which he remained a consultant until his death. He succeeded Beveridge Moore, about whom he often spoke and whom he greatly admired. Sofield truly enjoyed caring for the children at Shriners and was well known for his Harold Augustus SOFIELD technique of multiple osteotomies and intramedullary fixation (the shish-kebab opera- 1900–1987 tion) for osteogenesis imperfecta. His attitude of Harold Augustus Sofield was born in Jersey City, open-mindedness, relaxation, good humor, and New Jersey, on March 27, 1900. His favorite salu- northern New Jersey, where he attended a two- tation to his young patients, “Hi there, Skeezix,” room elementary school that held eight grades. This was coordinated in New York City and then Northwestern Univer- with Shriners and with West Suburban Hospital sity Medical School in Chicago.

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He was able to perform animal research outside the university Gerhard Küntscher was born December 6 escitalopram 20mg with mastercard anxiety quizzes, 1900 only through considerable personal sacrifice purchase escitalopram 5mg overnight delivery anxiety symptoms keyed up. He passed the state examination in Jena in ative technique was standardized so that the same 1925 with the highest marks and was awarded the instruments and operative methods could be degree of doctor of medicine 10mg escitalopram anxiety krizz kaliko, summa cum laude, applied for all the long bones. He became qualified as a senior surgeon, medullary nail and improved the efficiency of and in 1942 he was elevated to the rank of the fixation. In 1946, he took The callus problem, the healing of fractures, charge of the surgical division of Kreis Hospital, pseudarthrosis, the infected fracture, the malu- Schleswig-Hesterberg. From 1957 until his statu- nited fracture—were all subjects with which he tory retirement in 1965, he was medical director intensely concerned himself. After establishing closed medullary nailing to the treatment of a center for nailing in Spain in 1966, he became pseudarthrosis signified another trail-blazing a visiting physician at St. Through a stab wound, widen- Flensburg, where he continued to work until his ing of the medullary canal and the introduction of death. He was the recipient of numerous intensifier fluoroscope with remote viewing on a awards, including the Danis prize of the Interna- television screen during the 1950s made closed tional Society of Surgeons, the gold medal of the nailing considerably easier. University of Santa Maria, Brazil, and the In his Hamburg period, Küntscher made two Paracelsus medal and honorary citizen of El Paso, more important contributions to bone surgery. He was also an honorary member of 12 developed the distractor, which made it possible German and foreign scientific societies and a cor- to do closed nailing of malaligned pseudarthroses responding member of numerous specialty groups and old fractures. After many years of Society in 1940, he attracted unusual attention effort, Küntscher could now do a closed osteot- with his report, “Medullary Nailing of Fractures,” omy with the medullary osteotome. This pioneer- which has been regarded as an important mile- ing achievement gave a new impetus to closed stone in the operative treatment of fractures. During the Hamburg period Küntscher that time, the name of Küntscher was associated produced an abundance of scientific papers, with a specific surgical technique. It disap- pointed him that his operative methods were regarded sceptically at first. Now he spoke at numerous conventions at home and abroad, drawing large audiences with his extemporaneous lectures, which were as entertaining as they were informative. The publication of a new book on fracture callus, The Callus Problem, drew favor- able attention. Despite all this work, he never omitted his daily plunge in the sea in all kinds of weather. Küntscher was a modest, kind, yet strong- willed man who lived a quiet, retiring life. He was an ingenious medical investigator, an exceptional surgeon, and an exemplary physician. To his juniors he was a generous Albin LAMBOTTE teacher and sympathetic chief, always available to his colleagues who sought his advice. It is a desk, as he worked on the completion of the man- record to place him in the front rank of orthope- uscript of the new edition of his book, Practice of dic surgeons of all time and also among the great Medullary Nailing. He was doctor, surgeon, pioneer in the surgical treatment of fractures and in osteosynthesis; inventor and designer of instruments and appli- ances, which are easily recognizable as the pat- terns for equipment that will be made ready for some distinguished surgeon today; master mechanic, who turned out in his own workshop the instruments he needed for his pioneer work in the operating room; musician and artist, who could relax by sketching or by playing Bach on one of the violins he had himself made; generous and beloved teacher; fighter, who persisted against long and strong professional opposition to win, finally, a host of world-spread honors and who died in comparative poverty at the age of 90 in Antwerp, on August 1, 1955. Albin Lambotte was graduated from the Uni- versity of Brussels in 1891 and went directly as an intern to the Stuyvenberg Hospital in Antwerp. His professional baptism came that same year when cholera ravaged the city. Volunteering, Lambotte performed enterostomies followed by intestinal washing. Léon On a long voyage to Buenos Aires, he became Desguin as chief surgeon of the Stuyvenberg interested in astronomy, and, once back in his Hospital and performed his first laminectomies workshop, made a telescope. He advocated, almost 100 erman, he designed and made his own feather- years ago, in carefully selected cases of cerebral weight reel and his own split bamboo rod. All of hemorrhage, prompt trephining and removal of these interests he offered to the men who studied the blood clot. Although his reputation as a general surgeon had already spread beyond the borders of Belgium, it was in a professional atmosphere of indifference and even hostility that, in 1902, he began his work on osteosynthesis of the femur. In the following years, his time was divided between operating room and his workshop, where he designed, forged, hammered and, on his lathe, turned his devices for fixation and the instruments for manipulating them.

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Computer-based methods The wide availability of computers and their everyday use in all areas of science and technology makes their integration into practical courses almost essential 20 mg escitalopram otc anxiety 7 year old boy. Early in the curriculum cheap 5mg escitalopram overnight delivery anxiety in children, there may be a need to have practical classes to teach students how to use computers 10mg escitalopram for sale anxiety symptoms zika. In the laboratory setting, computers may be interfaced with other equipment or used to enhance or even replace conventional practical work. Learning the skills of data analysis and interpretation is often linked to laboratory teaching. With the computer, it is possible to provide students with a wide range of data sets on which they can practice these skills at varying levels of complexity and sophistication. Simulations Simulations are playing an increasingly important role in practical teaching for many reasons. Some reflect a need to provide repetitive practice of basic and advanced skills which might not otherwise be readily available, be too complex (e. The types of simulations also vary widely, ranging from simple drill and practice (e. The computer is, of course, involved in many of the more complex simulations. The increasing sophistication of graphics and virtual reality will ensure a burgeoning industry in the instructional application of computer-based simulations. EVALUATING CLINICAL AND PRACTICAL TEACHING There are few well-developed procedures for evaluating your performance as a clinical teacher. The major reason for this is that much clinical teaching is done on a one-to- one basis or in very small groups over relatively short periods of time. This causes a problem in obtaining valid and reliable information about performance. However, this deficiency is a matter of concern and research is underway to develop more useful instruments. You can, of course, adapt the principles and procedures described in the chapter on small group teaching and integrate these with the checklist displayed at the very beginning of this chapter. You may have gained the impression that we favour the exclusive use of questionnaires in evaluation. Questionnaires are only one method which seek data from one source - typically your students. In all evaluation, including clinical and practical teaching, we would wish to encourage you to explore other methods and other sources of evaluative information which you will encounter throughout this book. GUIDED READING Although there are many good books written on how to perform a medical interview and a physical examination, there seems to be a dearth of recent books on clinical teaching. Whitman, Williams & Wilkins, Baltimore, 1987, is still a useful guide to the tasks faced by a medical teacher, including clinical teaching. A useful recent resource is a series of articles representing the output of the Ninth Cambridge Conference on Medical 87 Education which appear in Medical Education (2000), 34, No 10. For additional information on practical and laboratory teaching we recommend the following: A Handbook for Teaching and Learning in Universities and Colleges by R. Baillie, HERDSA Gold Guide No 4, 1998 available from HERDSA, PO Box 51, Jamieson, ACT, 2614, Australia. Unfortunately, there is no straightfor- ward formula to guide you in this activity. First, curriculum planning is a complex business involving more than purely educational con- siderations. For example, you will find that full account must be taken of the political and economic context in which you teach. Much curriculum development is a matter of revising and adapting existing courses or materials. And third, there are important differences between individuals – especially between individuals working in different disciplines – in the ways in which they view a variety of educational issues. You may, for instance, see your main function as transmitting appropriate knowledge, skills and attitudes. On the other hand you may perceive your role as being primarily concerned with the personal and social development of your students as well as with their intellectual development. In a book of this kind it is not possible to provide a discussion which can fully take into account these various orientations.

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The teacher can assist this process by providing a structure for material that is complex order escitalopram online now anxiety symptoms psychology. Diagrams and other schematic representations may be more valuable than simple prose escitalopram 20mg for sale anxiety symptoms ruining my life. This section will review their use in large group teaching for a variety of purposes including illustrating the structure buy escitalopram 10 mg with mastercard anxiety 6 months after quitting smoking, providing information and examples, stimulating interest and activity, and providing variety. The aids most likely to be used are handouts, the board, overhead transparencies, slides, videos and, increasingly, on-line Internet sessions. Handouts must serve a clear purpose and be used during the teaching session so that students are familiar with their content and simply do not file them away. Handouts may be valuable as a guide to the structure of your session and in this case may be very similar in content to the teaching plan. You may wish to use the handout to provide detailed information on an area not well covered in standard student texts or not covered in detail in your teaching. Handouts may also be used to guide further study and to provide references for additional reading. Whenever you distribute handouts, it is essential that you use them in some way with your students. Clear, legible and well-planned use of these basic aids is a delight to see and remain valuable allies in assisting you to communicate with your students. They are especially worthwhile for displaying an outline of your session or for recording feedback from students in response to questions you may have raised. The overhead projector is extensively used in teaching and is particularly useful for giving outlines and listing key points. A pen or pencil placed on the transparency itself should be used to direct the students’ attention to the appropriate point rather than using the pointer on the screen. Information may be added with a felt pen to the transparency as the teaching proceeds. We have found that the value of the overhead is seriously reduced 31 by four common practices. Secondly, the teacher works through the material too quickly or talks about something different while students are trying to read and take notes from the screen. Fourthly, and the most common abuse, is that material on transparencies is far too small to be read by students. The 35-mm projector is still widely used and some teachers build up an extensive collection of slides. However, many teachers are now incorporating their slides into Power- ® Point presentations. Those containing printed material should be kept simple and must be clearly visible at the back of the theatre with the lights on. Care must be taken when reproducing material from books and journals, which often contain far too much information. Coloured slides of relevant material are ideal for illustrating points and for adding variety and interest. When using slides, avoid turning off the lights for more than brief periods. The level of attention will rapidly fall, however interesting your slides happen to be. PowerPoint ) are rapidly taking over the function performed by both the overhead and slide projectors. If you teach in locations where you are confident of the technology then there are many advantages in using this aid including ease and flexibility of preparation and the capacity to generate student notes derived directly from your presentation. You can also incorporate video and sound in your presentation as required. In Chapter 9 we give you more information about preparing and using these systems. A computer presentation is governed by the same principles as those for slides and overheads – clear, legible text and pictures, and use in a room where sufficient lighting can be left on for student note-taking and activities. If you are not confident of the environment in which you are teaching and in case the technology fails, it is still wise to have overhead transparencies or slide backups.

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