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The greatly exaggerated perception (among doctors) of their loss of prestige reflects the underlying force driving this process forward: the crisis of confidence of the medical profession itself generic flagyl 500 mg fast delivery infection years after knee replacement. In invoking public demand for tighter regulation buy flagyl 500 mg on line antibiotics for acne doesn't work, the leaders of the medical profession have projected their own insecurities into society flagyl 200mg on-line antibiotic during pregnancy. To the extent that there is popular support for measures such as revalidation, it has largely been fostered by leading medical figures, such as GMC president Donald Irvine, in their responses to scandals such as Bristol and the Shipman case. The danger of the revalidation proposals is that they will exacerbate the medical profession’s loss of confidence rather than alleviating it. The problem is not merely that the drive towards revalidation will lead to the creation of scapegoats and a spate of early retirements, though it undoubtedly will. There is an even more serious danger that it will degrade the profession as a whole and do further damage to the relationship between doctor and patient. This statement followed a series of incidents in which environmental protestors had destroyed experimental GM projects and a media campaign for a ban on further developments. The BMA demanded that ‘the precautionary principle should be applied in developing modified crops or foodstuffs, as we cannot at present know whether there are any serious risks to the environment or to human health involved in producing GM crops or consuming GM food products’. The government, squeezed between a recognition of the substantial economic potential of GM products and mounting public anxieties, tried to hold the line. In May the government’s Chief Scientist (Robert May) and Chief Medical Officer (Liam Donaldson) issued a joint statement reassuring the public that there was ‘no current evidence to suggest that the process of genetic modification is inherently harmful’. In early 2000, however, the government crumbled and announced even tighter restrictions on the development of GM foodstuffs. In his classic text, The Mirage of Health, published forty years before the GM controversy, Rene Dubos noted the widespread conviction that maintaining the scientific status quo would safeguard humanity against new threats: ‘It is often suggested that a moratorium on science would give mankind the opportunity to search its soul and discover a solution to the problems that threaten its very survival’ (Dubos 1960:214). He commented that ‘this static formula of survival’ was ‘not new’: ‘indeed it has been used with much biological success by social insects’. Through a highly stratified and efficient mode of organisation, colonies of ants and termites had solved many of 155 CONCLUSION the problems which were the subject of endless discussions and conflicts in human societies. In a similar way, the ‘arrested societies’ of isolated aboriginal groups, which ‘resembled in some respects the societies of bees and ants’, confirmed the possibility of achieving a stable equilibrium with their environment—and ‘an acceptable degree of physical health and happiness’. However, though this stability may have allowed these societies to avoid the problems of adapting to change, it was also ‘incompatible with the growth of their civilisations, indeed, with the very growth of man’ (Dubos 1960:215). The approval of a moratorium on the development of GM food because of possible dangers to health, by prestigious bodies of the medical profession and the scientfic community as well as by the government, is a reflection of the fatalistic outlook of contemporary society. In the current climate, every scientific advance, from test-tube babies to key-hole surgery, provokes more anxiety at the possible adverse consequences than celebration of the potential benefits. Fears about the dangers of science are part of a wider pessimism about the prospects for the advance of humanity through active intervention in nature or in society (Gillott, Kumar 1995). Though the rising influence of environmentalism has not yet led to the promotion of insect colonies as a model for human society, the popular cult of the primitive (as reflected, for example, in the affinity of contemporary environmentalists for the tribal peoples of the rainforests) indicates the scale of disillusionment with achievements of civilisation (Bookchin 1995). Given the impracti-cability of a return to an idealised aboriginal state, this outlook is expressed in demands to call a halt to further attempts at human advance, whether through scientific or social initiatives. In a society of lowered horizons and diminished expectations, security and safety have become the highest values and the goal of preserving health has become the zenith of human aspirations. The idea that to safeguard health it is necessary to restrain, if not stop, scientific advance appears to be in stark contrast to the widely quoted utopian concept of health adopted by the World Health Organisation at its founding conference in 1946: ‘Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’ (MacKenzie 1946) Yet, as Dubos observed, dreams of an imaginary past and utopian visions of the future share a common theme: ‘different as they appear to be, both imply a static view of the world which is 156 CONCLUSION incompatible with reality, for the human condition has always been to move on’ (Dubos 1960:208). It is striking that, after its adoption in that brief period of hope for the future between the end of the Second World War in 1945 and the onset of the Cold War in 1947, the WHO’s definition of health disappeared from public view until it was rediscovered in the 1970s. If, as Dubos noted, myths of a golden age provide mankind with ‘solace in times of despair and with elan during the expansive periods of history’, then we can readily identify the heady days of post-war reconstruction with the latter, and the period of increasing gloom that began with the recession of the 1970s with the former. The defect of utopian visions and static formulas is that they are out of tune with that restless quest for change which distinguishes humanity from the rest of the natural world: Life is an adventure in a world where nothing is static; where unpredictable and ill-understood events constitute dangers that must be overcome, often blindly and at great cost; where man, like the sorcerer’s apprentice, has set in motion forces that are potentially dangerous and may some day escape his control. Far from being an end in itself, health was ‘the condition best suited to reach goals that each individual formulates for himself, in a process guided by social rather than biological urges (Dubos 1960:219). Writing in more optimistic times, he recognised that the pursuit of certain human ideals and goals may have unfavourable consequences for the human species, but accepted that this was a price that must be paid for progress. As he emphasised, ‘it is man’s dignity to value certain ideals above comfort, and even above life’. Indeed it is this human trait that makes medicine a philosophy that goes beyond the conception of man as a living machine to encompass ‘the collective aspirations of mankind’. From this perspective, a ‘perfect policy of public health’ is possible for a colony of insects or a herd of cows, but not for man: ‘human life implies adventure, and there is no adventure without struggles and dangers’. In the widely acclaimed formulation of one contemporary historian, the parallel triumphs of the West over the East, the free market over the planned economy, marked ‘the end of history’ (Fukuyama 1989).

In medicine we are often more concerned to establish that the students achieve some minimal standard of compe- tence order flagyl 400mg online antibiotic 1 hour prior to incision. In this case generic 400 mg flagyl visa antibiotics for acne bacteria, the criterion-referenced approach is 132 more appropriate buy flagyl 500mg online bacteria nintendo 64. Such an approach necessitates the determination of an absolute standard before administer- ing the assessment, rather than waiting to see the overall results before doing so. Though this can be difficult to implement, we have found that attempting to do so is a powerful way of improving the validity of the assessment. Everyone concerned is forced to consider each item in the assessment and ask themselves if it is relevant and set at the appropriate level of difficulty. Our own experiences with such an approach used to test clinical competence in the final year of the medical degree have been very revealing and rewarding. The issue of standard setting is one which is achieving growing attention as the focus of assessment moves from norm-referenced to criterion-referenced or competency based testing. Established procedures are available for setting absolute standards in objective-type tests but are less well developed for clinical examinations. This is too complex and too difficult an area to discuss in this book but reading the article by Norcini is strongly recommended if you have responsibility for a ‘high stakes’ examination. Positive impact on learning It is clear that how and what students learn is influenced more by our assessment practices than by any other factor in the curriculum. At a policy level, an over-emphasis on formal examinations and the implicit threat that this may carry will have a negative impact. At a methodological level, an emphasis on objective tests, such as true/false and multiple-choice, will almost certainly encourage and reward the use of surface learning strategies by students rather than approaches that demand higher-level intellectual processes such as reasoning and analysis. On the other hand, there are several assessment practices that can encourage and reward the kinds of learning that are more highly valued today. These approaches include direct assessments of performance, learning portfolios, research projects, self and peer assessment, and regular and constructive feedback on learning. In the criterion-referenced approach de- scribed above, the objectives are embedded in the assessment tasks, so if students focus on assessment, they will be learning what the objectives say they should be learning. This is a positive solution to the common problem of the negative impact of assessment. ASSESSMENT METHODS In planning your assessment, it is necessary to be aware of the variety of methods available to you. It is impossible to be comprehensive for reasons of space so we will restrict ourselves to some common methods. We will also include information about some innovative approaches developed recently, which may be of interest. We do this deliberately in an attempt to encourage you to become subversive! With your new-found knowledge of assessment you will soon be involved in situations where it is obvious that inappropriate methods are being used. The first two you may be able to influence by rational argument based on the type of information we provide in this book. TYPES OF ASSESSMENT 1 Essay Short-answer 2 Structured 3 Objective tests 4 Direct observation 5 Oral 6 Structured clinical/practical assessment 7 Self-assessment 8 Learning portfolio 9 1. ESSAY We suggest caution in the use of the essay, except in situations where its unique attributes are required. The essay is the only means we have to assess the students’ ability to compose an answer and present it in effective 134 prose. Of particular importance in higher education seems to be the assumption that the production of written language and the expression of thought are scholarly activities of considerable worth and that essays encourage students to develop more desirable study habits. Though they are relatively easy to set, essays are time- consuming to mark. The widespread use of multiple- choice tests and the advent of computer scoring has lifted the marking burden from many academics, few of whom would wish to take it up again. Excluding such selfish reasons, there are other grounds for being concerned about using essays.

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More recently best buy for flagyl xeroform antimicrobial, advances in computer tomography (CT) imaging and three-dimensional (3D) reconstruction have been adopted as standard diagnostic tools generic 200mg flagyl with amex virus your current security settings. Reconstruction provides detailed information about the cranial anatomy and sutures that are not possible with routine radiographs cheap 250mg flagyl with mastercard antibiotics for uti or bladder infection. Craniosynostosis 3 4 Carson Table 1 Clinical Differences Between (Common) Positional Plagiocephaly and (Rare) Lambdoidal Craniosynostosis Finding Positional plagiocephaly Lambdoidal craniosynostosis Occipital bone Flattening with little or Flattening with ridge along no ridging suture. Frequently there is an ipsilateral inferior bulge Ipsilateral ear position Displaced anteriorly Displaced posteriorly Forehead Ipsilateral bossing Little or no bossing, but if present, it is usually contralateral Head circumference Usually increased Normal or decreased Anterior subarachnoid Usually increased Normal spaces TREATMENT Indications for procedures need to be considered by the craniomaxillofacial team for each case based on clinical signs, syndromic and genetic information, radiographic indicators, and whether the child is stable or developing symptoms. Positional plagi- ocephaly can be corrected by changing the child’s position slightly during naps and sleeping. Frequently, neck exercises prescribed by an occupational therapist Figure 2 Illustrations of skull shapes and synostoses. Panel 2 (left to right): Typical elongated picture seen in sagittal synostosis. Panel 3: Anterior plagiocephaly characteristic of unilateral right coronal synostosis. Panel 4: Towering, bilateral widening, and forehead flattening with foreshortening characteristic of bilateral coronal synostosis. Panel 5: Keeled shape and bipar- ietal widening characteristically seen with metopic synostosis. Many therapists know how to carve a pillow out of foam rubber that redistributes the weight of the head and is comfortable for the child. Craniosynostosis is thought by some to be an aesthetic problem with infrequent consequences for brain function and devel- opment. Although clinical impressions have associated appearance with the adoles- cent’s ability to socialize, school performance, and adult behavioral problems, studies have suggested that abnormal skull shapes do not directly affect intelligence test scores. Mental development, measured by intelligence quotient tests, in infants with nonsyndromic, single-suture craniosynostosis appears to be normal in the absence of increased ICP and other pathologies. In this regard, it is of interest to note the anthropological studies of the many civilizations that practised cranial deforma- tion for cosmetic and political gains. Such practices imply that an abnormal skull shape does not interfere with normal intelligence, although one cannot conclude that the physiological results of congenital and cosmetic deformations are the same (4). Apparently well-tolerated craniosynostosis, however, can abruptly worsen either spontaneously or following head injury. Skull base deformities can worsen to the point of affecting vision, hearing, and breathing, and oral occlusion. Anoma- lies in skull morphology usually precede complications such as visual impairment and increased ICP. Multiple-suture synostoses and syndromic synostoses frequently associate with increased ICP, hydrocephalus, and progressive mental impairment. SURGICAL INTERVENTION The cranium, cranial base, and facial region must be evaluated as growing structures. The cranio- maxillofacial team also must evaluate midfacial growth in childhood and adoles- cence, as well as occlusion and mastication in the primary mixed and permanent dentition phase. A typical evaluation includes pediatric neurology, radiology, neuro- surgery, anesthesiology, ophthalmology, and orthodontics. Major issues to be con- sidered are: 1) frontal–orbital retrusion, usually manifest secondary to coronal synostosis affecting the frontal–orbital region; 2) posterior constraint occurring with growth anomalies in the parietal, occipital, and squamosal sutures; 3) posterior and anterior growth anomalies; and 4) midfacial anomalies. In addition, the evaluation frequently encounters Chiari malformations, hydrocephalus, hypertelorism, cleft palate, extraocular muscle movement, and ocular anomalies. Shunts further compli- cate reconstruction and increase opportunities for infection. Because abnormality at a single suture strongly influences the development of other areas in the craniofacial complex, there is a clinical impression that surgical correction during the neonatal period yields superior results, although in the absence of clinical or radiological signs of raised ICP, surgery may be delayed to 12–15 months (5). Numerous approaches have been described, and many are being refined with advances in adsorbable plating materials, hardware, and microsurgical technology.

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Scheuermann was the son of a practitioner from Hørsholm buy flagyl mastercard antibiotic cipro, near Copenhagen purchase 200mg flagyl safest antibiotic for sinus infection during pregnancy. From 1916 to 1919 order generic flagyl pills antimicrobial use density, he was assistant surgeon to the Society and Home for Crippled in Denmark. From 1935, he was chief radiologist to the municipal hospital, Sundby, Copenhagen. Robert SCHNEIDER Scheuermann described juvenile kyphosis in 1920–1921, when radiology was in its youth. His 1912–1990 concept of the pathology and disturbances in the ossification of the end plates of the vertebrae is Robert Schneider was born in Biel in 1912, not unanimously accepted, but his description of studied medicine in Bern and spent one semester the disease can be said to be classical and has not in Paris. In 1937, he began to specialize in general been improved upon by later authors. Apart from leanings, he took the post of surgeon-in-chief in his work on juvenile kyphosis, his studies from a community hospital in Grosshöchstetten, a rural 1932 on the normal and pathological sella turcica village near Bern. In 1937, he also met him and we developed a fraternal relation- described a radiographic technique for exposing ship, which lasted for 38 years. A year the doctorate degree of the University of Copen- later, we decided to found an “Association for the 298 Who’s Who in Orthopedics Operative Treatment of Fractures”—subse- quently AO. Documentation to include copies of all x-rays and slides, available to the group. Robert Schneider adhered to these principles throughout his professional career. In 1959, he became the first chairman of the AO—a post Sir Herbert SEDDON he held for 20 years. His critical self-evaluation, 1903–1977 his grasp of complex issues, his ability to unveil links between seemingly unrelated events, and his many discoveries, earned him great respect Sir Herbert Seddon was born in 1903 in Derby nationally and internationally. Bartholomew’s Hospital, A later book, 25 Years AO Switzerland, is a treas- graduating from the latter in 1928 with the ure house of AO information. In 1930, he went to Ann Arbor, the book sadly was never translated into English. There he Some 22 other publications were but a prelude to met a graduate of the university, Mary Lytle, and his major work, a 300-page treatise The Total Hip married her in Marquette, Michigan, in 1931. On Prosthesis, a Biomechanical Concept and Conse- his return to England, he was appointed resident quences. Robert Schneider received numerous surgeon at the then relatively new and small honors, but he remained, nonetheless, a modest, Stanmore branch of the Royal National Orthope- friendly man. In this period of his life, Seddon In many countries he was “the father of the developed his immense knowledge of spinal AO. These problems sudden death, just as he put in the last skin suture remained of interest to him throughout his life and after a hip arthroplasty. It was while at Stanmore that he made his initial contribution to the pathology of paraplegia in spinal tuberculosis. He clarified the patho- genesis of paraplegia and showed clearly that it was due to the intervertebral abscess bulging backwards against the cord, and that it was not the kyphosis that caused cord damage. He also distinguished between this early, acute paraplegia due to an abscess and late-onset paraplegia due to gliosis secondary to a long-standing kyphosis and ischemia. Seddon became highly expert in operat- chair of orthopedic surgery was funded by the ing on these cases and with Roaf and Lloyd National Fund for Research into Crippling Griffiths in 1956 published a monograph, Pott’s Diseases and he was appointed to this new Paraplegia. In 1940, he was appointed as the first Nuffield He was honored by a knighthood conferred in Professor of Orthopedic Surgery in Oxford Uni- 1964. His honorary degrees from Grenoble, Malta and early promise, evident at Stanmore, was amply Glasgow. Special units accurate observations, meticulous records and were created to concentrate on difficult orthope- scientific exactitude brought clarity to a surgical dic problems. Seddon’s work many contributions to orthopedic surgery during during this time undoubtedly contributed more to this epoch. He continued his interest He was a perfectionist and demanded similar until his death and was undoubtedly the foremost standards from those around him. His masterly book, Surgical worked with him, he became an admired senior Disorders of the Peripheral Nerves, first pub- and a warm friend. He showed them the potential lished in 1971, is the most important treatise on of scientific surgery and the role of the academic the subject. Surprisingly to some who did not know After the war, a most imaginative development him well, he had a marvelous, incisive wit, occurred in London.

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A diagnosis of CIDP is made primarily on the basis of nerve conduction studies (Table 4) generic 400 mg flagyl with visa prescribed antibiotics for sinus infection. Although decreased conduction velocities and prolonged distal motor latencies can be seen in both CIDP and hereditary demyelinating neuropathy purchase flagyl once a day virus transmission, CIDP is distinguished by the presence of 172 Sumner Table 4 Clinical and Electrophysiologic Criteria for Childhood CIDP Mandatory clinical criteria Progression of muscle weakness in proximal and distal muscles of upper and lower extremities over at least 4 weeks effective flagyl 250 mg antibiotic iv therapy, or rapid progression (GBS-like presentation) followed by a relapsing or protracted course (>1 year) Major laboratory features Electrophysiologic criteria Must demonstrate at least three of the following four major abnormalities in motor nerves (or two of the major plus two of the supportive criteria) A. Conduction block or abnormal temporal dispersion in one or more motor nerves at sites not prone to compression: a. Conduction block: at least 50% drop in negative peak area or peak-to-peak amplitude of proximal compound action potential (CMAP) if duration of negative peak of proximal CMAP is < 130% of distal CMAP duration. Temporal dispersion: abnormal if duration of negative peak of proximal CMAP is > 130% of distal CMAP duration. Reduction in conduction velocity (CV) in two or more nerves: <75% mean of mean CV value for age minus 2 standard deviations (SD). Prolonged distal latency (DL) in two or more nerves: >130% of mean DL value for age þ2SD. Absent F-waves or prolonged F-wave minimal latency (ML) in two or more nerves: >130% of mean F-wave ML for age þ 2SD. Supportive When conduction block is absent, the following abnormal electrophysiological parameters are indicative of nonuniform slowing and thus of acquired neuropathy: 1. Abnormal median sensory nerve action potential (SNAP) while sural nerve SNAP is normal. Abnormally low terminal latency index: distal conduction distance (mm)= (conduction velocity [m=sec]) Â distal motor latency [msec]). Side-to-side comparison of motor CVs showing a difference of >10 m=sec between nerves. Cerebrospinal fluid (CSF) criteria Protein > 45mg=dL Cell count <10 cells=mm3 Nerve biopsy features Predominant features of demyelination Exclusion criteria A. Clinical features of history of a hereditary neuropathy, other disease, or exposure to drugs or toxins known to cause peripheral neuropathy. Laboratory findings (including nerve biopsy or genetic testing) that show evidence of a cause other than CIDP. Electrodiagnostic features of abnormal neuromuscular transmission, myopathy, or anterior horn cell disease. Inflammatory Neuropathies: GBS and CIDP 173 Figure 1 Proposed treatment algorithm for childhood chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). A nerve biopsy is sometimes diagnos- tic, but not necessary and now not routinely done. An elevated CSF protein without pleocytosis is evident in at least 90% of children with CIDP. Magnetic resonance imaging can show gadolinium enhancement of nerve roots that favors a diagnosis of CIDP over CMT. Therapy The two most commonly used immunomodulatory therapies for children with CIDP are oral corticosteroids and IVIg. A detailed discussion needs to be undertaken with the patient and family to explain the rationale for treatment and the potential short- and long-term side effects. IVIg has been shown to be effective in clinical trials in adult patients. The reported experience in small case series of children also supports its use in this age group. Prednisone has been used for many years in childhood CIDP and reported to be effective in several case series. Unfortunately, there are many poten- tial side effects of prednisone including weight gain, hyperglycemia, neuropsychiatric disturbance, impaired wound healing, avascular hip necrosis, hyperlipproteinemia, accelerated atherosclerosis, osteoporosis, myopathy, peptic ulcer disease, and cataracts. In some cases intermittent high dose solumedrol infusions, weaning on interval rather than dose, may have enhanced efficacy without the same degree of Cushingoid side effects. There is little published experience with plasma exchange in the children with CIDP, likely due to the significant problems associated with maintaining vascular access. Other treatment options include azathioprine, metho- trexate, cyclosporine A, cyclophosphamide, and interferon beta. Because of the lim- ited experience and adverse effects of these drugs, IVIg and prednisone should be first line therapy. Prognosis The long-term prognosis for children treated for CIDP is favorable.

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