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X. Khabir. University of the District of Columbia.

Though such a programme is far from perfect buy generic malegra fxt 140 mg, it was introduced within a traditional curriculum and with the minimum of resources malegra fxt 140 mg free shipping. The main change was a reallocation of staff time away from didactic activities and into more direct observation of student performance generic 140 mg malegra fxt mastercard. A perusal of the medical educational literature will provide you with other examples of structured clinical teaching cheap 140 mg malegra fxt otc. Increasingly you will find descriptions of the use of clinical skills laboratories where medical schools have set up fully staffed and equipped areas devoted to putting groups of students through an intensive training in clinical skills, often using a wide range of simulations. You will also find many examples of training students in interpersonal and communication skills using simulated patients. All have the same general approach: to undertake the training of various clinical skills in a structured and supervised way to ensure that all students achieve a basic level of competence. TECHNIQUES FOR TEACHING PARTICULAR PRACTICAL AND CLINICAL SKILLS Many practical and clinical skills can be taught as separate elements. Because there is a wide range of these elements, and as clinical teaching is generally opportunistic, many medical schools have established programmes to teach basic skills in a piecemeal fashion. This is normally done early in the students’ career, often just prior to their first clinical attachments. This section will introduce you to a variety of ways of teaching basic skills some of which may not be of immediate relevance but some of which ought to be in operation in your medical school because of their proven efficacy. Video recording: any department which has the respon- sibility for teaching aspects of history taking or inter- personal skills should have access to video recording equipment, preferably of the portable kind that can be set up in ward side rooms, outpatients and other teaching situations. You should become familiar with the technical operation of the equipment. The simplest is to record examples of interviewing techniques (good and bad) for demonstration purposes. You may also wish to have an example of a basic general history so the novice student can get an idea of the questions that are routinely asked. Some medical schools have recorded segments of interviews with patients which show various emotional reactions (e. The most powerful way of using the video is to record the student’s interview with a patient remembering that informed consent is essential. This may be initially stressful but both student and patient usually forget they are being recorded after a few minutes. The student, or a small group of students, meet later with the teacher to review the tape. Firstly, the situation must be a supportive one to allow frank and open discussion. Secondly, the teacher must have a clear idea of what the students should be learning. Such things as non-verbal cues, aspects of doctor-patient relationships, avoidance of jargon, adequacy of questions, direction of the enquiry, directive versus non-directive questioning, hypothesis generation and many other issues can be 81 identified and discussed, both with the interviewing student and with the student’s peers. There are clearly several advantages of this approach over direct observation: the teacher is not committed to be present at the actual interview; the teaching can be scheduled at a convenient time; a recorded interview can be interrupted as often as necessary; and most importantly the students can review their own performance. The latter by itself often produces a striking impact and a rapid improvement in competence. Simulation: the use of simulated (or standardised) patients is another well-proven and powerful method for teaching interview skills. However, if does require some expertise to train the simulated patients and if you wish to pursue this technique we strongly recommend that you read the book by Barrows. The simulated patient offers certain distinct advantages over the real patient particularly for the novice student. The analogy has been drawn with the value of flight deck simulators in pilot training. The advantages include: the ability to schedule interviews at a convenient time and place; all students can be faced with the same situation; the interview can be interrupted and any problems discussed freely in front of the ‘patient’; there is no risk of offending or harming the patient (often a concern of new students); the student can take as much time as necessary; the same ‘patient’ can be re-interviewed at a later date; and the simulator can be trained to provide direct feedback, particularly in the area of doctor-patient relationships. Simulations can also be developed for situations that are usually impossible for students to experience with real patients. With all these advantages it is surprising how long it has taken for this technique to become widely used.

There is an increased risk of oligohydrosis and heat stroke in patients taking topiramate order 140 mg malegra fxt amex. Zonisamide may be a suitable alternative to topiramate in those using oral contra- ceptive medications as topiramate can interfere with the efficacy of estrogen contain- ing contraceptive medications 140mg malegra fxt with mastercard. ALTERNATIVES Other agents effective in migraine prophylaxis include calcium channel blockers generic 140mg malegra fxt otc, selective serotonin reuptake inhibitors order 140mg malegra fxt mastercard, gabapentin, zonisamide, and tizanidine. Botulinum toxin injections to the frontal and posterior neck muscles have been well studied in adult migraine, and have an extremely low risk of adverse effects. Never- theless, it remains a relatively unappealing option for both pediatric patients and families. Feverfew is a popular herbal remedy for fever and inflammation and more recently for headache prevention. There are little data on its use in pediatric patients and its safety profile is not well established. The dose for young patients (up to 6 years) is 100 mg daily, 6–8 years 200 mg daily, 8–13 years 300 mg, and 13 years and up 400 mg. It tends to have a strong odor and taste and produces bright yellow urine. Magnesium at doses of 200–400 mg daily usually produces no side effects. Stress reduction techniques such as biofeedback yoga, counseling for stress management techniques, and exercise are complimentary to pharmacologic therapy. LONG-TERM CONTROL Although prophylactic medication is often necessary to break the cycle of chronic headache, optimal management of most chronic headache syndromes will rely on identification and avoidance of trigger factors. Once headaches are well controlled on preventative medication, the dose should be slowly tapered off. Often headaches remain under reasonable control, especially if patients begin to adopt lifestyle changes to avoid headache triggers. A comprehensive treatment plan including realistic patient expectations, patient education, and judi- cious use of abortive and preventative medications is necessary for successful long-term control of migraines. The efficacy of divalproex sodium in the prophylactic treatment of children with migraine. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. INTRODUCTION While migraine is a well-recognized phenomenon in adults, it is often overlooked or minimized in children and adolescents. Headache is quite a common complaint in chil- dren, and migraine often has its onset in the first two decades of life. Recognition and appropriate treatment can have a significant impact on the quality of life for young sufferers as well as their caregivers, and may ultimately impact the course of the illness. The criteria in children less than 15 years requires headaches of 1–48 hr in duration instead of the 4–72 hr in individuals greater than 15 years of age. The remainder of the criteria is similar to the adult diagnostic criteria including: at least five attacks with photo- phobia and phonophobia, nausea or vomiting; and two symptoms out of unilateral pain, throbbing or pulsatile pain, moderate or severe pain intensity, or exacerbation by routine activity. The treatment of migraine in children and adolescents follows the same general principle as for adults, including lifestyle modification, trigger avoidance, nonphar- macologic treatments, acute treatment, rescue treatment and, where appropriate, preventive treatment. It is very important to establish the diagnosis of migraine and convey this clearly to the patient and parents. Many parents are concerned that there is an underlying organic cause for their child’s headache, and unless these fears are dispelled, treatment plans are often unsuccessful. Patients and parents are much more likely to accept a treatment plan if they believe the diagnosis. Therefore, it is important to spend time with the patient and the parents explaining the diagnosis and the disorder. This needs to be done at a level that the child and parents can understand. Reading materials, booklets, brochures, diaries, and videos can help teach the patient and their families about what to expect from their disorder, how to recognize an attack and management goals.

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Paper Use good quality A4 paper that has been designed for your particular type of printer order malegra fxt 140mg with visa. Page layout Allow plenty of space when you set up your margins and line spacing generic malegra fxt 140mg mastercard. The copy-editor or designer may need to use these for marking corrections or giving instructions to the typesetters proven 140mg malegra fxt. Line spacing Lines may be single spaced malegra fxt 140 mg without prescription, one and a half spaced or double spaced. This will also apply to any text in tables, the index and captions for illustrations. Margins Check your publisher’s house style rules on the required width for mar­ gins. For instance, some like to have the first line of a para­ graph indented by several spaces. Never justify text so that spacing between words is altered to produce lines of equal length. Font The design of lettering will affect the readability of a manuscript. Fancy scrolls may look attractive, but make text very difficult to read. You can see the effects of different fonts in the example below: font font font font font font Choose a font with simple lettering of medium density. Remember to check that your printer is able to produce the font you are using on your computer screen. A font that appears on the screen and the printer is known as a TrueType font. Choose a font size that makes the text easy to read without being overlarge. Compare the word ‘font’ when produced in various sizes: Font (8) font (10) font (12) font (14) Font size 12 is easily read. Style Various characteristics can be applied to lettering like italic or bold. Avoid overusing these style formats, as this can make the text confusing to read. Use any special effects judiciously and be consistent in applying them, for instance using a particular style to indicate all the main headings. Always PRESENTING YOUR WORK 261 check your publisher’s house style rules, which may give specific instruc­ tions on adding style to text. Some stipulate that certain characteristics are omitted, for example using bold. It is not your job to arrange and design the manuscript as if it were the final printed version. Your role is to prepare and present your work in a form that the editor can deal with quickly and efficiently. Spelling Computers help us by providing tools that check spelling and grammar in a document. For example, a computer will not correct mistakes such as ‘The children took their dog fore a walk’ or ‘The children took there dog for a walk’. Make sure you have manually checked the spelling and grammar of your final draft. This is especially im­ portant if somebody else has typed or word-processed your manuscript. There are certain spelling conventions to which you will need to ad­ here. Always check your publisher’s house style rules on the following: ° Variant spellings.

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Knee injury patterns among men and women in collegiate basketball and soccer buy malegra fxt 140 mg line. Flipped patellar tendon autograft anterior cruciate ligament reconstruction buy malegra fxt 140mg line. Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate liga- ment reconstruction: study of results effective 140 mg malegra fxt, morbidity malegra fxt 140 mg without prescription, and complications. Long-term follow-up of 53 cases of chronic lesion of the anterior cruciate ligament treated with an artificial Dacron Stryker ligament. A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction. The use of hamstring tendons for ante- rior cruciate ligament reconstruction. The natural history of conservatively treated partial anterior cruciate ligament tears. Quadrupled semitendinosus anterior cruciate ligament reconstruction: 5-year results in patients without meniscus loss. In: Knee Ligaments: Structure, Function, Injury, and Repair, Akeson WHA, Daniel DM, and O’Connor JJ (eds. Patellar tendon or Leeds-Keio graft in the surgical treatment of anterior cruciate ligament ruptures. A method to help reduce the risk of serious knee sprains incurred in alpine skiing. The natural history and diagnosis of anterior cruciate lig- ament insufficiency. Semitendinosus tendon anterior cruciate ligament reconstruction with LAD augmentation. Follow-up study of Gore-Tex artificial ligament– special emphasis on tunnel osteolysis. An alternative cruciate reconstruction graft: The central quadriceps tendon. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. Hamstring tendon grafts for recon- struction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. The effect of neuromuscular training on the incidence of knee injuries in female athletes. Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. Biologic incorporation of allograft anterior cruciate ligament replacements. Five- to ten-year follow-up evalu- ation after reconstruction of the anterior cruciate ligament. The association of the menstrual cycle with the laxity of the anterior cruciate ligament in adolescent female athletes. Evaluation of hamstring strength following use of semitendinosus and gracilis tendons to reconstruct the anterior cruciate ligament. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction, patellar tendon vs semi- tendinosus and gracilus tendons. Long-term results of anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons with Kennedy ligament augmentation device compared with patellar tendon auto- grafts. Allograft reconstruction of the anterior and posterior cruciate ligaments: report of ten-year experience and results. High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees. Bone-patellar ligament-bone and fascia lata allografts for reconstruction of the anterior cruciate ligament. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and recon- struction. Part I: the long-term functional disability in athletically active individuals.

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