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Professional thinking purchase renagel 400mg mastercard, behaviour trusted renagel 400 mg, and attitudes are “modelled” by teachers cheap renagel 800mg with visa. It is the only setting in which the skills of history taking, physical examination, clinical Clinical teaching in general practice reasoning, decision making, empathy, and professionalism can be taught and learnt as an integrated whole. Despite these potential strengths, clinical teaching has been much criticised for its variability, lack of intellectual challenge, and haphazard nature. In other words, clinical teaching is an educationally sound approach, all too frequently undermined by problems of Common problems with clinical teaching implementation. Far from compromising spontaneity, planning provides structure and context for both teacher and students, as well as a framework for reflection and evaluation. Preparation is recognised by students as evidence of a good clinical teacher. How doctors teach Almost all doctors are involved in clinical teaching at some point in their careers, and most undertake the job Questions to ask yourself when planning a clinical teaching session conscientiously and enthusiastically. However, few receive any formal training in teaching skills, and in the past there has been an assumption that if a person simply knows a lot about their subject, they will be able to teach it. In reality, of course, although subject expertise is important, it 25 ABC of Learning and Teaching in Medicine is not sufficient. Effective clinical teachers use several distinct, if overlapping, forms of knowledge. Knowledge about Learning learning and How students learn context teaching Understanding the learning process will help clinical teachers to be more effective. Several theories are relevant (see first Knowledge Case about based Knowledge article in the series, 25 January). All start with the premise that about the the "teaching learning is an active process (and, by inference, that the learners scripts" subject teacher’s role is to act as facilitator). Cognitive theories argue that learning involves processing information through interplay between existing knowledge and new knowledge. An important Knowledge about influencing factor is what the learner knows already. The quality the patient of the resulting new knowledge depends not only on “activating” this prior knowledge but also on the degree of elaboration that takes place. The more elaborate the resulting knowledge, the more easily it will be retrieved, particularly when Various domains of knowledge contribute to the idiosyncratic teaching strategies (“teaching scripts”) that tutors use in clinical settings learning takes place in the context in which the knowledge will be used. How to use cognitive learning theory in clinical teaching Experiential learning Help students to identify what they already know Experiential learning theory holds that learning is often most x “Activate” prior knowledge through brainstorming and briefing effective when based on experience. Several models have been Help students elaborate their knowledge described, the common feature being a cyclical process linking x Provide a bridge between existing and new information—for concrete experience with abstract conceptualisation through example, use of clinical examples, comparisons, analogies x Debrief the students afterwards reflection and planning. Reflection is standing back and x Promote discussion and reflection thinking about experience (What did it mean? How does it x Provide relevant but variable contexts for the learning relate to previous experience? Planning involves anticipating the application of new theories and skills (What will I do next time? The experiential learning cycle, which can be entered at any stage, provides a useful framework for planning teaching sessions. Example of clinical teaching session based on experiential learning cycle Setting—Six third year medical students doing introductory clinical skills course based in general practice Topic—History taking and physical examination of patients with musculoskeletal problems (with specific focus on rheumatoid arthritis); three patients with good stories and signs recruited from Experience Reflection the community The session Planning—Brainstorm for relevant symptoms and signs: this activates prior knowledge and orientates and provides framework and structure for the task Experience—Students interview patients in pairs and do focused physical examination under supervision: this provides opportunities to implement and practise skills Planning Theory Reflection—Case presentations and discussion: feedback and discussion provides opportunities for elaboration of knowledge Theory—Didactic input from teacher (basic clinical information about rheumatoid arthritis): this links practice with theory Planning— “What have I learned? Two important areas of communication for effective teaching are questioning and “clarifying” (or “probing”) questions. Both are underpinned by attentive Closed questions invoke relatively low order thinking, often listening (including sensitivity to learners’ verbal and simple recall. It is important to allow learners to at all (for example, because the learner is worried about being articulate areas in which they are having difficulties or wrong), and the teacher may end up answering their own which they wish to know more about question.

Metals act like glue to hold various wall retained on the surface of the filter it contacts generic renagel 800 mg otc. Filtration is indirectly metallic species include calcium and magnesium renagel 800mg discount. Out-com- bactericidal since the bacteria that are retained on the filter peting these species by supplying large concentrations of will order renagel 400 mg visa, for a time, be alive. However, because they are also another metal, the influence of the normal metallic species can removed from their source of nutrients, the bacteria will even- be assessed. The energy membrane, where the underlying attachment to the rigid pep- of the radiation severs the strands of deoxyribonucleic acid in tidoglycan layer is disrupted. With only The use of specific antibodies to determine the molecu- one exception, the damage is so severe that repair is impossi- lar arrangement of ultrastructural constituent targets greatly ble. The exception is the radiation resistant bacterial genus enhances the effectiveness of agents to be used in drug therapy. This genus has the ability to piece together the fragments of DNA in their original order and enzy- See also Atomic force microscope; Bacterial appendages; matic stitch the pieces into a functional whole. Bacterial surface layers; Caulobacter; Electron microscope, Exposure to chemicals can be bacteriocidal. For exam- transmission and scanning; Electron microscopic examination ple, the gas ethylene oxide can sterilize objects. Solutions con- of microorganisms; Sheathed bacteria taining alcohol can also kill bacteria by dissolving the membrane(s) that surround the contents of the cell. Laboratory benches are routinely “swabbed” with an ethanol solution to BACTERIOCHLOROPHYLL • see PHOTOSYNTHESIS kill bacteria that might be adhering to the bench top. Care must be taken to ensure that the alcohol is left in contact with the bacteria for a suitable time (e. Otherwise, bac- BBacteriocidal, bacteriostaticACTERIOCIDAL, BACTERIOSTATIC teria might survive and can even develop resistance to the bac- tericidal agent. Other chemical means of achieving bacterial Bacteriocidal is a term that refers to the treatment of a bac- death involve the alteration of the pH, salt or sugar concentra- terium such that the organism is killed. Penicillin A bacteriocidal treatment is always lethal and is also referred and its derivatives are bactericidal because they act on the pep- 54 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Bacteriophage and bacteriophage typing tidoglycan layer of Gram-positive and Gram-negative bacte- rial cell, and the host cell commences to transcribe and trans- ria. By preventing the assembly of the peptidoglycan, peni- late the viral genes. One of the first genes that it translates cillin antibiotics destroy the ability of the peptidoglycan to encodes an enzyme that chops up the E. At the end of the lytic because they prevent the manufacture of DNA or protein. The resistance by clinically important bacteria is a major problem destroyed or lysed cell releases up to 200 phage particles ready in hospitals. On the other hand, the lysogenic cycle Bacteriostatic agents prevent the growth of bacteria. Instead, the phage DNA is Refrigeration can be bacteriostatic for those bacteria that can- incorporated into the host cell’s chromosome where it is then not reproduce at such low temperatures. Every time the host cell divides, it repli- riostatic state is advantageous as it allows for the long-term cates the prophage DNA along with its own. Ultra-low temperature freezing and two daughter cells each contain a copy of the prophage, and lyophilization (the controlled removal of water from a sample) the virus has reproduced without harming the host cell. Another bacteriocidal tech- certain conditions, however, the prophage can give rise to nique is the storage of bacteria in a solution that lacks nutri- active phages that bring about the lytic cycle. Various buffers In 1915, the English bacteriologist Frederick Twort kept at refrigeration temperatures can keep bacteria alive for (1877–1950) first discovered bacteriophages. Twort iso- infectants; Laboratory techniques in microbiology lated the substance that was killing the bacteria and hypothe- sized that the agent was a virus. The significance of this discovery was not INFECTION appreciated, however, until about thirty years later when sci- entists conducted further bacteriophage research.

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The more centrally situated cervical tracts supplying the arms suffer the brunt of the injury so that classically there is a flaccid (lower motor neurone) weakness of the arms and relatively strong but spastic Brown–Séquard syndrome (upper motor neurone) leg function discount renagel 800mg with visa. Sacral sensation and bladder and bowel function are often partially spared buy renagel 400 mg mastercard. Posterior cord syndrome This syndrome is most commonly seen in hyperextension Cauda equina syndrome injuries with fractures of the posterior elements of the Injury to the lumbosacral nerve roots (as at C cheap 800mg renagel with amex, Figure 2. There is contusion of the posterior columns so the results in areflexia of the bladder, bowel, and lower limbs. Brown–Séquard syndrome Classically resulting from stab injuries but also common in Further reading lateral mass fractures of the vertebrae, the signs of the Brown- Séquard syndrome are those of a hemisection of the spinal • Advanced trauma life support program for doctors, 6th edition. Power is reduced or absent but pain and temperature Chicago: American College of Surgeons, 1997 sensation are relatively normal on the side of the injury • Ko H-Y, Ditunno JF, Graziani V, Little JW. The pattern of because the spinothalamic tract crosses over to the opposite reflex recovery during spinal shock. The uninjured side therefore has good power 1999;37:402–9 but reduced or absent sensation to pin prick and temperature. A review of seven support surfaces with emphasis on their protection of the spinally injured. Conus medullaris syndrome J Accid Emerg Med 1996;13:34–7 • Maynard FM et al. International standards for neurological The effect of injury to the sacral cord (conus medullaris) and and functional classification of spinal cord injury. Most emergency departments rely on the use of mobile radiographic equipment for investigating seriously ill patients, but the quality of films obtained in this way is usually inferior. Once the patient’s condition is stable, radiographs can be taken in the radiology department. In the presence of neurological symptoms, a doctor should be in attendance to ensure that any spinal movement is minimised. Sandbags and collars are not always radiolucent, and clearer radiographs may be obtained if these are removed after preliminary films have been taken. Plain x ray pictures in the lateral and anteroposterior projections are fundamental in the diagnosis Figure 3. Spinal cord injury without radiological abnormality (SCIWORA) may occur due to central disc prolapse, ligamentous damage, or cervical spondylosis which narrows the spinal canal, makes it more rigid, and therefore renders the spinal cord more vulnerable to trauma (particularly in cervical hyperextension injuries). SCIWORA is also relatively common in injured children because greater mobility of the developing spine affords less protection to the spinal cord. Cervical injuries The first and most important spinal radiograph to be taken of a patient with a suspected cervical cord injury is the lateral view obtained with the x ray beam horizontal. This is much more likely than the anteroposterior view to show spinal damage and it can be taken in the emergency department without moving the supine patient. The lateral view should be repeated if the original radiograph does not show the whole of the cervical spine and the upper part of the first thoracic vertebra. Failure to insist on this often results in injuries of the lower cervical spine being missed. The lower cervical vertebrae are normally obscured by the shoulders unless these are depressed by traction on both arms. The traction must be stopped if it produces pain in the neck or exacerbates any neurological symptoms. If the lower cervical spine is still not seen, a supine “swimmer’s” view should be taken.

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Woman’s Hospital in New York City instituted Upon his return to Boston buy renagel 400mg without prescription, Codman resolved to almost in toto the End Result System; other New abstain from any new projects and determined to York hospitals accepted certain features of it 800 mg renagel fast delivery. This fundamental piece Hospital honored him with the appointment of of work gave him much personal satisfaction but Consulting Surgeon order renagel 800 mg overnight delivery. He used this study to these acknowledgments was the acceptance of the demonstrate again the value of the End Result cartoon by the Boston Medical Library; it was System in hospital organization. He became an mounted on cloth and arranged like a folding authority on the subject of bone tumors and mag- map. As the years went by, more and more nanimously offered his services as consultant free hospitals adopted some features at least of the to his colleagues. It was a great comfort to who had acquired sufficient knowledge of the Codman that the members of the Society of varieties and the behavior of bone tumors to 71 Who’s Who in Orthopedics warrant their making a diagnosis and recom- trend toward specialization had started before mending treatment with reasonable certainty. Codman’s time, no one can deny that “special Many limbs were sacrificed needlessly; on the assignments” in hospitals gave it impetus. At this time the four eminent the American College of Surgeons to standardize authorities were Bloodgood, Coley, Ewing and hospitals in the United States. These men supported Codman in his ambition in life was the establishment of the End study. By his attitude and his particular knowl- Result System in every hospital, and he employed edge of the subject, he decried surgeons who every means at his command to this end. His assumed the responsibility of treatment without knowledge of the shoulder joint was molded consulting those more versed in the subject of toward this end. Also, he brought these facts employees and insurance directors he stressed vigorously before trustees of hospitals in order continually the need of early diagnosis of rupture to emphasize the point that surgeons were not of the supraspinatus tendon. He pointed out that appointed to hospital positions because of their failure to diagnose resulted in marked disability knowledge. Offense neglected cases of this lesion might cost more was taken, particularly by the most successful than the gross income of the average doctor in a surgeons of the day who, as Codman stated, lifetime. In this way he hoped to acquaint all those “spent their lives in the practice of the art of med- involved in medical care with the merits of the icine rather than in that of the science, and, being End Result System and to interest them in financially successful, are able to influence the installing it in their particular fields of endeavor. It is a sad com- results; (and) comparison of achievements would mentary that so few physicians know of his life be, to them, as odious as a comparison of and achievements. Many of his ideas have already been From this brief sketch of Codman’s life, one is accepted; many others will yet be. This was the uphill battle that he was fighting when he said, true of him until his death in Boston on Novem- “Honors, except those I have thrust on myself, are ber 23, 1940. Now let us mention some of his conspicuously absent on my chart, but I am able ideas and the effect that they have had on medi- to enjoy the hypothesis that I may receive some cine. Much that he attempted was not achieved in from a more receptive generation. His contributions in the field of x-rays, gastrointestinal diseases, the shoulder and bone tumors have stood the test of time and attest to his powers of clinical observa- tions. His End Result Idea has taken root in many disciplines and provides the means for accurate evaluation of methods and practice in medicine and surgery. The bulk of the medical literature in all specialties is based on this system of evaluation. It is a method that will gain in depth and breadth, and never will be abandoned by the medical profession. By establishing the policy of “special assign- ments” to young men in the profession, much good has been achieved.

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In that situation order 800 mg renagel otc, it is important to set realistic treatment endpoints generic renagel 400 mg on-line. Quality of Life Issues It is easy to lose sight of quality of life issues in our focus on the medical aspects of myoclonus (Table 4) buy 400mg renagel free shipping. However, patients and their families carry a burden of living with a chronic disease, whether or not it is progressive, often without prospects for significant improvement. Severe myoclonus may rob adolescents of the necessary ‘‘breaking away’’ from parents, which leads to maladaptive behaviors and habitual family conflicts. Isolation, inactivity, and a decline in physical strength result in marginalization and reduced quality of life. Perhaps confidence is the most essential element to reinforce because it carries over so prominently into activities of daily liv- ing. When we cannot cure myoclonus, we must at least improve the way individuals with myoclonus feel about themselves. With gene therapy on the forefront, we must keep them in the best possible mental and physical shape. On the one end of the spectrum, benign neonatal sleep myoclonus usually resolves during infancy. While essential myoclonus does not resolve, it typically does not increase much over time, in contrast to PME, which by definition, worsens stea- dily. Even with PME, the prognosis varies considerably, ranging from lethality within 7–10 years in Lafora disease to a reasonably normal lifespan in EPM1. The myoclonus of biotin deficiency remits so long as the patient remains on biotin replacement therapy. In opsoclonus–myoclonus syndrome, myoclonus may remit, reappear during relapses, or progress depending on inflammatory activity of the 158 Pranzatelli Table 4 Improving Quality of Life in Patients with Severe Myoclonus Goal Means Continue education Tutors Counter depression Pharmacologic and nonpharmacologic Decrease strife Counsellor=psychiatrist, individual, and family Encourage independent living Assisted living; visiting health aide Establish medical contingencies for travel Take emergency drugs on vacations Increase safety in wheelchair Wheelchair seat belt Improve quality of sleep Sleep study; treat depression Maintain strength Physical therapy; regular exercise program Prevent obesity Diet and exercise; offset drugs that cause hyperphagia Maintain peer contact School, church, community Make home more accessible Wheelchair ramps, move downstairs, make bathrooms handicap accessible Prevent loneliness Companion dog Prevent pulmonary infections Immunize Reduce myoclonus when Re-arrange dosing schedule patient most needs to Reduce stress Modify school schedule Set practical goals Educational and vocational counseling immune system, which involves both T-cells and B-cells. All of these different pat- terns emphasize the need to press for an etiologic diagnosis even in the most complex presentations of myoclonus and tailor the therapy to the etiology. SUMMARY The approach to a patient with myoclonus should focus on identifying the underly- ing etiology in the hope that the disorder can be reversed. The context in which myo- clonus occurs is the single most useful clinical clue to etiology, often narrowing the scope of otherwise extensive diagnostic investigations. Neurophysiologic tests are the cornerstone of myoclonic classification and may indicate productive avenues of ther- apy. Restoring activities of everyday living should be a fundamental therapeutic goal. Responses to an agent are sometimes dramatic, but more often the improvements are incremental. In patients with substantial myoclonus, the combination of pharmacologic and nonpharmacologic measures can be effective. Therapeutic failure should prompt re-evaluation of the diagnosis and treatment plan and a search for exacerbating factors. In the end, sensitivity to quality of life issues can be the most important contribution a clinician can make. Shibasaki H, Ikeda A, Nagamino T, et al: Cortical reflex negative myoclonus. Cohn Johns Hopkins Hospital, Children’s Center, McKusick-Nathans Institute of Genetic Medicine, Baltimore, Maryland, U. A number of clinically distinct disorders of muscle manifest abnormalities in other organs, most often the brain. The most common of these, Duchenne muscular dystrophy, is discussed in a separate chapter. The disorders that predominantly affect muscle, but manifest with distinctive abnormalities of brain as well, likely do so because of widespread gene expression and other commonalities of brain and muscle.

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