By W. Rufus. Green Mountain College.

Others may be obese or suffer penile retraction suhagra 100 mg visa impotence divorce, and condom sheath drainage may be impossible 100mg suhagra with amex erectile dysfunction oral treatment. The maintenance of continence is of vital importance to personal morale, and for the preservation of intact perineal and buttock skin. In female patients, DSD is very unusual, and severe incontinence rather than upper tract protection is the main indication for augmentation. After augmentation, inability to void is the rule rather than the exception, and the patient must demonstrate the willingness and ability to self-catheterise before surgery can be contemplated. Even after augmentation, anticholinergic therapy may be required to make the patient completely dry. Cystitis may be a recurrent problem after enterocystoplasty, and there remains a long-term theoretical risk of neoplastic transformation in the enteric patch, especially if this is colon. Nitrosamine production associated with UTI has been implicated in this process. For those who cannot access their own urethra (wheelchair- bound females being an especially important group), the simultaneous provision of a self-catheterising abdominal stoma Figure 7. Neuromodulation and sacral anterior root stimulation (SARS) In patients with complete suprasacral cord lesions, functional electrical stimulation of the anterior nerve roots of S2, S3 and S4 is very successful in completely emptying the paralysed bladder. Assisted defaecation, and in the male, implant-induced erections may be coincidental advantages of the implant. The device most commonly in use is the Finetech-Brindley stimulator; the anterior roots of S2, S3 and S4 are stimulated via a receiver block implanted under the skin, and a posterior rhizotomy is performed simultaneously. This cures reflex incontinence, improves bladder compliance and diminishes DSD, and thus ensures that neither the use of the implant nor overfilling of the bladder will trigger autonomic dysreflexia. No comparative or controlled prospective studies between augmentation cystoplasty and SARS are yet available, but despite its cost, the stimulator is amongst the first in a line of options designed to keep this group of patients catheter free. Stress incontinence Both male and female patients with conus and cauda equina lesions are vulnerable to sphincter weakness incontinence (SWI), as well as older women with pre-existing pelvic floor disorders, prolapse, etc. This often manifests itself later as the patient becomes more active during rehabilitation, urinary leakage occurring for example on transfer to and from the wheelchair. Colposuspension, pubo-urethral slings and, recently, tension free vaginal tapes are effective in treating SWI, though sometimes obstructive in patients with acontractile bladders attempting to void by straining or compression. In paraplegic females, urethral closure and SPC is a reliable method of Figure 7. Bladder neck injections with bulking agents have a less reliable record in this difficult group. Artificial urinary sphincters (AUS) have an excellent record of continence, but there is a higher attrition rate in paraplegics due to infection or cuff erosion, especially if ISC is undertaken regularly. Placement around the bulbar urethra should be avoided in patients confined to a wheelchair, and impotence frequently complicates cuff placement in the membranous position. For both male and female paraplegic patients the bladder neck is therefore the optimal site for AUS cuff placement. The acontractile bladder and assisted voiding Since the adoption and widespread use of intermittent Figure 7. Most patients with good hand function manage the technique, though paraplegic females have more difficulty accessing their urethra. This may be sufficient to cause them to abandon attempts in favour of long-term suprapubic catheterisation. Since Mitrofanoff first described his technique in children, the procedure has been adapted to other circumstances, including stomal intermittent self-catheterisation in the paraplegic wheelchair-bound female patient. Even in tetraplegic patients with limited hand function stomal ISC is sometimes feasible with careful siting of the channel. In those patients who have undergone a Mitrofanoff procedure, stomal ISC is usually regarded as preferable to urethral catheterisation, and females whose native urethra remains in situ and who have a stoma almost never catheterise their own urethra. Complications of the procedure are irritatingly frequent though rarely life-threatening. Minor “plastic” procedures for stomal stenosis are required in up to 30% of cases and complete channel revisions for leakage or failure are necessary in 15%. The procedure may be undertaken in conjunction with bladder augmentation and/or bladder neck closure for intractable incontinence. This may have colorectal dysfunction—use of the new antegrade and a devastating impact on rehabilitation, and the urologist should retrograde colonic wash-out methods. Malone 2000;38:255–61 described the effectiveness of the antegrade colonic • Galloway A.

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Example of a multiple order suhagra 100mg amex erectile dysfunction caused by radical prostatectomy, true or false question “Short answer” open ended questions Open ended questions are more flexible—in that they can test issues that require generic 100 mg suhagra overnight delivery impotence testicular cancer, for example, creativity, spontaneity—but they have lower reliability. Because answering open ended questions is much more time consuming than answering multiple choice questions, they are less suitable for broad sampling. They are Open ended questions are perhaps the also expensive to produce and to score. Their ended questions it is important to describe clearly how detailed format is commonly believed to be the answer should be—without giving away the answer. A good intrinsically superior to a multiple choice open ended question should include a detailed answer key for format. Short answer, open ended that this assumed superiority is limited questions are not suitable for assessing factual knowledge; use multiple choice questions instead. Short answer, open ended questions should be aimed at the aspects of competence that cannot be tested in any other way. Essays Essays are ideal for assessing how well students can summarise, hypothesise, find relations, and apply known procedures to new situations. They can also provide an insight into different aspects of writing ability and the ability to process information. Unfortunately, answering them is time consuming, so their reliability is limited. When constructing essay questions, it is essential to define the criteria on which the answers will be judged. A common pitfall is to “over-structure” these criteria in the pursuit of objectivity, and this often leads to trivialising the questions. Some structure and criteria are necessary, but too detailed a structure provides little gain in reliability and a considerable loss of validity. Essays involve high costs, so they should be used sparsely and only in cases where short answer, open ended questions or multiple choice questions are not appropriate. Key losing too much reliability feature questions seem to measure problem solving ability 30 Written assessment validly and have good reliability. In addition, most people Example of a key feature question involved consider them to be a suitable approach, which makes them more acceptable. Yesterday you made a house call on Mr However, the key feature approach is rather new and Downing. From your history taking and physical examination you therefore less well known than the other approaches. You gave an intramuscular injection of construction of the questions is time consuming; inexperienced 100 mg diclofenac, and you left him some diclofenac suppositories. Nevertheless, these questions are respond well to the diclofenac, but since 5 am he has also had a continuous pain in his right side and a fever (38. Students should understand that an option may be Example of an extended matching question correct for more than one vignette, and some options may not (a) Campylobacter jejuni, (b) Candida albicans, (c) Giardia lamblia, apply to any of the vignettes. The idea is to minimise the (d) Rotavirus, (e) Salmonella typhi, (f) Yersinia enterocolitica, recognition effect that occurs in standard multiple choice (g) Pseudomonas aeruginosa, (h) Escherichia coli, (i) Helicobacter pylori, (j) Clostridium perfringens, (k) Mycobacterium tuberculosis, (l) Shigella questions because of the many possible combinations between flexneri, (m) Vibrio cholerae, (n) Clostridium difficile, (o) Proteus mirabilis, vignettes and options. Also, by using cases instead of facts, the (p) Tropheryma whippelii items can be used to test application of knowledge or problem For each of the following cases, select (from the list above) the solving ability. They are easier to construct than key feature micro-organism most likely to be responsible: questions, as many cases can be derived from one set of options. On physical examination there is answers is easy and could be done with a computer. Abdominal radiography shows free air under the unknown, so teachers need training and practice before they diaphragm x A 45 year old woman is treated with antibiotics for recurring can write these questions. She develops a severe abdominal pain under-representation of certain themes simply because they do with haemorrhagic diarrhoea. Extended matching questions are best used pseudomembranous colitis is seen when large numbers of similar sorts of decisions (for example, relating to diagnosis or ordering of laboratory tests) need testing for different situations. Conclusion Choosing the best question type for a particular examination is Using only one type of question not simple. Extended-matching items: a practical alternative to free response questions. Further developments in assessing clinical competence;proceedings of the second Ottawa conference. Assessment of clinical competence: written and computer-based simulations.

For an introduction to practical strategies and theoretical issues in lifelong learning we recommend C purchase suhagra 100mg free shipping impotence tcm. Cropley order 100mg suhagra erectile dysfunction treatment germany, Lifelong Learning in Higher Education (2nd edition) Kogan Page, London, 2000, and P. O’Leary, Developing Lifelong Learning Through Undergraduate Education, Australian Govern- ment Publishing Service, Canberra, 1994. Both contain many exemplars of lifelong learning practices in higher education. Recent editions, from around 1997, of the journal Higher Education Research and Development have included several helpful papers about Asian students. A particularly relevant edition is Volume 16, Number 1, April 1997: ‘Common misconceptions about students from South-East Asia studying in Australia’ by D. A very useful book containing detailed advice on how to study is A Guide to Learning Independently by L. Relations between teachers’ approaches to teaching and students’ approaches to learning. The Adult Learner in Higher Education and the Workplace; The New Conversations about Learning. While the lecture is still a very common teaching method in most medical schools we want to encourage you to think more creatively about how you might best use your time when faced with a large group of students. There are good educational reasons for moving away from the traditional approach of ‘lecturing’ to groups of passive students to strategies which introduce more active learning. While the solution to this concern may, in part, involve replacing the notion of large group teaching with alternative approaches, such as small group teaching or distance learning, we recognize that other factors may preclude such options. Should this be the case we believe that you can employ a range of techniques in the large group situation which will engage your students enthu- siastically in active learning, provide them with immediate feedback and build a productive and scholarly relation- ship. Why do we want to support you in this move towards putting students at the centre of your thinking? Because the evidence continues to mount that, although the lecture is as effective as other methods to transmit information (but not more effective), it is not as effective as other methods to stimulate thinking, to inspire interest in a subject, to teach behavioural skills, or to change attitudes. These are among the objectives that many medical teachers aspire to when they lecture. On the other hand, if we seriously wish to foster lifelong learning skills and attitudes among our students, one of the worst things we can do is to encourage and reward the kinds of passivity that the lecture method commonly provides. This chapter seeks to provide you with practical sugges- tion on how you might approach the task if asked to give a ‘lecture’. THE CONTEXT OF LARGE GROUP TEACHING An important preliminary step in your preparation is to find out as much as you can about the context of your teaching in the overall teaching programme or course. Unfortunately this context is often ill defined and may be only a title in a long list of topics given out by the 16 department or school. This means enquiring about such things as: what students have been taught (and what they may know), what the purpose of your teaching session is to be, what resources, such as library materials, are available for students, what the assessment arrangements for the course or unit are, what methods have been used to teach students in the past. You may wish, after reading this chapter, to try out some new ideas with students. Students do appreciate good teaching but may resent the use of some techniques that seem irrelevant to their purposes, to the course aims, and to the way their learning is assessed. When introducing new learning and teaching techniques you must carefully explain the purpose of them to students. Be prepared for some resistance, especially from senior students if they do not appreciate the connection between the techniques and the assessment arrangements. The course co-ordinator, curriculum committee, head of department and other teachers in the course are all potential sources of advice and assistance to you. However, do not be surprised if you are told that you are the expert and that it is your responsibility to know what students should be taught! If this happens you should insist on some help to review what happened in the past. A declining proportion of university students enter directly from local secondary schools.

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Clinicians buy suhagra 100mg with mastercard erectile dysfunction pills australia, however buy 100mg suhagra with amex erectile dysfunction 32, must be aware of the possible toxic effects when the standard dose of 0. If the systolic blood pressure cannot maintain adequate perfusion pressure to produce an acceptable flow of urine after any hypovolaemia has been corrected, then inotropic medication with dopamine should be started. Cardiac arrest due to sudden hyperkalaemia after the use of Risk of hyperkalaemic cardiac arrest a depolarising agent such as suxamethonium for tracheal Beware—do not give suxamethonium from three days to nine months intubation is a risk in patients with spinal cord trauma between following spinal cord injury as grave risk of hyperkalaemic cardiac three days and nine months after injury. If muscle relaxation is arrest required for intubation during this period a non-depolarising muscle relaxant such as rocuronium is indicated to avoid the risk of hyperkalaemic cardiac arrest. Prophylaxis against thromboembolism Newly injured tetraplegic or paraplegic patients have a very high risk of developing thromboembolic complications. The incidence of pulmonary embolism reaches a maximum in the third week after injury and it is the commonest cause of death in patients who survive the period immediately after Box 4. The volume of urine in the bladder should never be allowed to exceed 500ml because overstretching the detrusor Beware of paralytic ileus: patients should receive intravenous fluids muscle can delay the return of bladder function. If the patient for at least the first 48 hours after injury is transferred to a spinal injuries unit within a few hours after injury it may be possible to defer catheterisation until then, but if the patient drank a large volume of fluid before injury this is unwise. In these circumstances, and in patients with multiple injuries, the safest course is to pass a small bore (12–14Ch) 10ml balloon silicone Foley catheter. The gastrointestinal tract The patient should receive intravenous fluids for at least the first 48 hours, as paralytic ileus usually accompanies a severe spinal injury. A nasogastric tube is passed and oral fluids are forbidden until normal bowel sounds return. If paralytic ileus becomes prolonged the abdominal distension splints the diaphragm and, particularly in tetraplegic patients, this may precipitate a respiratory crisis if not relieved by nasogastric aspiration. If a tetraplegic patient vomits, gastric contents are easily aspirated because the patient cannot cough effectively. Ileus may also be precipitated by an excessive lumbar lordosis if too bulky a lumbar pillow is used for thoracolumbar injuries. When perforation occurs it often presents a week after injury with referred pain to the shoulder, but during the stage of spinal shock guarding and rigidity will be absent and tachycardia may not develop. A supine decubitus abdominal film usually shows free gas in the peritoneal cavity. Use of steroids and antibiotics (b) An American study (NASCIS 2) suggested that a short course Figure 4. A later study (NASCIS 3) suggested that patients decubitus view showing massive collection of free gas under the anterior abdominal wall. Recently the use of or perforation steroids has been challenged, and their use has not been universally accepted. Policy concerning steroid treatment • Treat with proton pump inhibitor or H2-receptor antagonist should be agreed with the local spinal injuries unit. If treatment is When the patient is transferred from trolley to bed the whole started 3–8 hours after injury, the infusion is continued for of the back must be inspected for bruising, abrasions, or signs 47 hours. The patient should be turned every two 19 ABC of Spinal Cord Injury hours between supine and right and left lateral positions to prevent pressure sores, and the skin should be inspected at each turn. Manual turning can be achieved on a standard hospital bed, by lifting patients to one side (using the method described in chapter 8 on nursing) and then log rolling them into the lateral position. Alternatively, an electrically driven turning and tilting bed can be used. Another convenient solution is the Stryker frame, in which a patient is “sandwiched” between anterior and posterior sections, which can then be turned between the supine and prone positions by the inbuilt circular turning mechanism, but tetraplegic patients may not tolerate the prone position. Nursing care requires the use of pillows to separate the legs, maintain alignment of the spine, and prevent the formation of contractures. In injuries of the cervical spine a neck roll is used to maintain cervical lordosis. Care of the joints and limbs The joints must be passively moved through the full range each day to prevent stiffness and contractures in those joints which may later recover function and to prevent contractures Figure 4. In the lateral position, note the slight tilt on the opposing side to prevent the patient sliding keep the tetraplegic hand in the position of function are out of alignment.

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One clue has been the finding of a through the local population and often just as quickly ends generic 100 mg suhagra with mastercard impotence 23 year old. Subsequent per- protein has been suggested to function as a decoy for the son-to-person spread likely occurs by with the buy suhagra 100 mg erectile dysfunction in diabetes management, diverting the immune defenses from the infected blood or body tissues of an infected person in the actual site of viral infection. Another immunosuppressive home or hospital setting, or via contaminated needles. The mechanism may be the selective invasion and damage of the fact that infected people tend to be in more under-developed spleen and the lymph nodes, which are vital in the functioning regions, where even the health care facilities are not as likely of the immune system. The person-to-person passage is immediate; unlike all the more remarkable given the very small size of the viral the animal host, people do not harbor the virus for lengthy genome, or of genetic material. How the virus establishes an The possibility of air-borne transmission of the virus is infection and evades the host immune system with only the debatable. Ebola-Reston may well have been transmitted from capacity to code for less than twelve proteins is unknown. There was no halting the demand, however, and the Georg Speyer Haus ultimately manufactured and distributed 65,000 units of 606 to physi- cians all over the globe free of charge. Eventually, the large- scale production of 606, under the commercial name “Salvarsan,” was taken over by Höchst Chemical Works. The next four years, although largely triumphant, were also filled with reports of patients’ deaths and maiming at the hands of doctors who failed to administer Salvarsan properly. In 1913, in an address to the International Medical Congress in London, Ehrlich cited trypan red and Salvarsan as examples of the power of chemotherapy and described his vision of chemotherapy’s future. The City of Frankfurt hon- ored Ehrlich by renaming the street in front of the Georg Speyer Haus “Paul Ehrlichstrasse. In June 1914, Frankfurt city authorities took action against the newspaper and Ehrlich testified in court as an expert witness. Ehrlich’s name was finally cleared and the newspaper’s publisher sentenced to a year in jail, but the trial left Ehrlich deeply depressed. Ehrlich’s health failed to improve and the start of World War I had further discouraged him. Electron Homburg, Prussia (now Germany), on August 20, 1915, after microscopy can also be used to visualize proteins, virus parti- a second stroke. The could not detect an image smaller than the wavelength of light Institute for Experimental Therapy changed its name to the used. This was tremendously frustrating for physicists, who Paul Ehrlich Institute and began offering the biennial Paul were anxious to study the structure of matter on an atomic Ehrlich Prize in one of Ehrlich’s fields of research as a memo- level. Ruska, then a student at the History of immunology; History of microbiology; University of Berlin, wondered why a microscope couldn’t be History of public health; History of the development of antibi- designed that was similar in function to a normal microscope otics; Infection and resistance but used a beam of electrons instead of a beam of light. Such a microscope could resolve images thousands of times smaller than the wavelength of visible light. In a compound microscope, a series of lenses are used to focus, magnify, and refocus the image. In order for an Described by the Nobel Society as “one of the most important electron-based instrument to perform as a microscope, some inventions of the century,” the electron is a valu- device was required to focus the electron beam. The first working models that electrons could be manipulated within a magnetic field, were constructed by German engineers and Max and in the late 1920s, he designed a magnetic coil that acted Knoll in 1932, and since that time, the electron microscope has as an electron lens. With this breakthrough, Ruska and Knoll found numerous applications in chemistry, engineering, medi- constructed their first electron microscope. See also in situ mold chitin fungi See also Escherichia coli Growth of virus creates clearing in lawn of growing. This lasts from causes a slightly different form of illness in its human hosts. Here, the patient may exhibit Hantaan virus is carried by the striped field mouse, and exists no symptoms. The patient virus often causes a severe form of hemorrhagic fever with begins with a fever, muscle aches, backache, and abdominal renal syndrome (HFRS). Puumula virus is carried by bank voles, and exists in The cardiopulmonary stage. Puumula virus stage rapidly, sometimes within a day or two of initial symp- causes a milder form of HFRS, usually termed nephropathia toms; sometimes as long as 10 days later. Seoul virus causes a form of HFRS which is so rapid and so severe as to put the patient in respiratory fail- slightly milder than that caused by Hantaan virus, but results ure within only a few hours.

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