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By Y. Cronos. New Brunswick Theological Seminary. 2018.

Effective clinical teachers use several distinct purchase extra super viagra 200 mg zantac causes erectile dysfunction, if overlapping discount extra super viagra 200 mg overnight delivery impotence yohimbe, 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. The purpose of clarifying and probing questions is x Restrict use of closed questions to establishing facts or baseline knowledge (What? There are close analogies between teacher-student and doctor-patient x Check understanding before you start, as you proceed, and at the end—non-verbal cues may tell you all you need to know about communication, and the principles for giving clear explanations someone’s grasp of the topic apply. Many studies have shown that a disproportionate amount of time in teaching sessions may be Patient Teach general spent on regurgitation of facts, with relatively little on checking, encounter principles probing, and developing understanding. Models for using time (history, ("When that more effectively and efficiently and integrating teaching into examination, etc) happens, do this... One such, the “one-minute preceptor,” comprises a series of steps, each of which involves an easily performed task, which when combined form an integrated teaching strategy. Get a commitment Help learner ("What do you identify and think is give guidance Teaching on the wards going on? None the less, with preparation and of Y was a forethought, learning opportunities can be maximised with possibility, minimal disruption to staff, patients, and their relatives. Probe for in a situation underlying like this, Z is Approaches include teaching on ward rounds (either reasoning more likely, dedicated teaching rounds or during “business” rounds); ("What led because... Teaching in the clinic Although teaching during consultations is organisationally Teaching during consultations has been much criticised appealing and minimally disruptive, it is limited in what it can for not actively involving learners achieve if students remain passive observers. With relatively little impact on the running of a clinic, students can participate more actively. For example, they can be 27 ABC of Learning and Teaching in Medicine asked to make specific observations, write down thoughts about differential diagnosis or further tests, or note any questions—for Patient "Sitting in" as observer discussion between patients. His or her findings can be checked with the patient, and Teacher discussion and feedback can take place during or after the Student encounter.

He was it seems never to have occurred to him to seek no narrow-minded specialist buy extra super viagra 200 mg free shipping erectile dysfunction treated by, and it was fitting his own advancement; his thoughts were for that the first and moving tribute paid to his the benefit of his patients and of any organiza- memory came from his friend and colleague buy discount extra super viagra 200mg on-line biking causes erectile dysfunction, tion with which he was connected. It life was distinguished by simplicity and content- was the breadth of his interests that made Ellis ment. Few orthopedic sur- dren and there was a quiet elegance about their geons nowadays can claim to have a proper charming house in a pleasant backwater of knowledge of every aspect of their work, but Ellis Paddington. It was furnished with perfect taste; could and this invested his opinions with unusual there were even tapestries that Ellis himself value. He was very well read and by means of had worked in his odd moments of leisure. The other appointments, as at Lord Mayor Treloar’s garden was his particular delight and he would Hospital, Alton, and at the Heatherwood Hospi- invite the visitor to inspect his 15 varieties of lily, tal, Ascot, he accumulated a vast and varied expe- though his descriptions of their characteristics rience. His versatility was reflected in the papers were always punctuated by powerful impreca- he wrote; they were not numerous, just over 20, tions against his only enemies—the stray cats of but each dealt with some important aspect of a Paddington. This Three of his activities as a surgeon are partic- all-round competence in orthopedics was ularly noteworthy. Burns, 95 Who’s Who in Orthopedics his closest friend since they were undergraduates together, wrote Recent Advances in Orthopedic Surgery, an exceptionally valuable book that should have gone into further editions; it revealed the breadth of the authors’ interests. During the war, Ellis was posted to the emergency hospital at Park Prewett in Hampshire, where he worked with unremitting devotion. In 1945, he and Innes published a short but significant paper on “Battle Casualties Treated by Penicillin,” based on a study of no less than 15,000 cases. A quotation from this paper reveals his sanity at a time when there was much uncritical enthusiasm: “Penicillin has made no difference to the paramount impor- tance of early and adequate surgery; it has, in addition, produced new difficulties in that the effect of penicillin on contaminated wounds obscures the extent of the infection of the tissues, and makes it difficult to judge how radical surgery R. Elmslie spent the whole of his professional immense value in the elucidation of injuries of life as student and surgeon at St. Bartholomew’s the rotator cuff, and his published papers give Hospital and at the Royal National Orthopedic some indication of what might have been Hospital, except during World War I, when he was expected from him, had he lived longer. Ellis had just seen the last patient at strator of pathology and his knowledge of this his fracture clinic at St. As an orthopedic surgeon, Elmslie was one of the greatest of his day, next only to Robert Jones and perhaps Tubby. His ability to think clearly, his wisdom, imperturbability and admirable judg- ment were his powerful assets. Indeed the writer has never worked with anyone whose judgment always proved so sound; it seemed that he was incapable of being wrong. He was a competent and neat operator who devized several first-class procedures. His only expressed vanity was to pride himself on sewing skin in, as he put it, “the manner of those who know best how to sew— women. He was in great demand for committee work in his own hospital, government departments, the Royal College of Surgeons (on the council of which he served from 1933 until his death), the British Orthopedic Association, the British Medical Association, the Chartered Society of Physiother- 96 Who’s Who in Orthopedics apy, and the Central Council for the Care of Crip- second year of residency at the Pennsylvania ples. His clear and logical exposition before the Crippled Children’s Hospital in Elizabethtown, Select Committee of the House of Lords is said he decided that working with crippled children to have carried the greatest weight in deciding the was to be his specialty. As a man, Elmslie lacked the warmth Washington, DC area and began his practice, of Robert Jones, whose friend and admirer he which was to continue until his retirement in always was. He started as assistant to another physician, reserve did not prevent him inspiring the greatest but he was impatient to do more work with crip- enthusiasm and devotion in his pupils, which pled children and saw a glaring need for such they still retain. The area had no facilities that special- ized in orthopedic deformities, which were far more common in the past than they are today. Poliomyelitis was a major problem, and club foot, dislocated hips, osteomyelitis, and curvature of the spine also contributed to the need for recon- structive surgeons and long-term hospital care. Engh opened his own practice in 1938, in his home in Alexandria, Virginia, but he had a desire to own a clinic or hospital. He bought land in Arlington and established offices, which he called the Anderson Clinic.

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In future cheap 200 mg extra super viagra overnight delivery erectile dysfunction pump.com, suc- cessful products will increasingly be tuned to flow with the stream of human physiological function order 200 mg extra super viagra fast delivery erectile dysfunction drugs uk, even to mimic it in fine detail. Modelling and computation are set to make major contributions, since: • devices become sufficiently ‘intelligent’, with their on-board comput- ing power, to use analytical descriptions of (patho-)physiological organ function; 148 P. Future medical training, diagnosis and – even surgical – treatment will increasingly be performed remotely. Thus, the combination of sophisti- cated sensory devices with advanced micro-manipulation equipment will, together with 3D ‘interactive feedback’ models, provide new tools and approaches for the medical profession. Analytical bio-modelling is also set to make major practical contribu- tions and to transform the way society handles health-related matters. The ‘added benefit’ of in silico technologies for health care includes the following: • New, interactive in silico teaching and educational tools will be avail- able for doctors and the greater public. This will help to improve pro- fessional skills and general health awareness. Future health-related implications of an individual’s behavioural patterns or of various treat- ment strategies can be assessed and compared on the basis of long-term case predictions. The latter will be based on improved access to expert information, statistics, case reports, etc. Medium-term deci- sions will benefit from the early recognition of epidemiological pat- terns, etc. Long-term policies can be based on detailed investigations into the cost-benefit-relation of restorative versus preventative strate- gies which, undoubtedly, will consolidate the case of preventative med- icine. The making of the virtual heart 149 • In silico models will aid both the standardisation and individualisation of medical care. Standardisation of diagnoses, drug and device descrip- tions, procedures, etc. On the other hand, advanced models will allow development of patient-specific procedures for diagnosis and treat- ment. This will move the focus from the treatment of diseases to the curing of patients. Kolston MacKay Institute of Communication and Neuroscience, University of Keele, Sta≈ordshire ST55BG, UK 9. Even when you are sitting still in a quiet room your blood is being pumped to every tissue, your kidneys are filtering body fluids, your immune system is guarding against infection and your senses are continuously monitoring all kinds of information from their surroundings. Scientists are very good at studying single molecules and single cells but the challenge of understand- ing molecular and cellular processes in entire organs or body systems is a daunting one. Their behaviour is controlled by basic laws of physics that can be described by mathematical equations. By solving these equations on com- puters, scientists are able to investigate the operation of complete organs with a flexibility and level of detail that is impossible experimentally. This article shows how computers have already illuminated the work- ings of a variety of biological systems, with a particular emphasis on the operation of the ear. Soon it will be possible to represent in a computer model every single cell contained within a whole organ. These models will lead to a profoundly deeper understanding of how biological organs work, whilst reducing dramatically the need for animal experimentation. Longer term, computer modelling will provide a valuable tool in the design of new, simpler cellular structures that would mimic the known operation of a bio- logical organ to either replace their defective counterparts or to perform 151 152 P. KOLSTON entirely new tasks with efficiencies that are impossible using current tech- nologies. Given the impressive specifications of such organs, these new devices – manufactured in carbon or silicon – could have numerous research, clinical and industrial applications. Cars must both protect the occupants from physical intrusions into the passenger compartment, and minimise the deceleration forces that act upon them. The first of these requirements could be achieved easily by making the car body rigid. Unfortunately, the deceleration forces would then be intolerably large, so instead the design aim is to make those parts of the vehicle that are outside the passenger compartment absorb as much of the impact energy as possible, by making them deform in the pre- defined time-dependent manner that minimizes peak deceleration levels. In the past when car crashworthiness was designed entirely experi- mentally, full-sized prototypes were subjected to the crash scenarios required by the relevant authorities. If the performance was unacceptable, the shape deformations of the components making up the prototype were examined. A new prototype was engineered empirically to overcome the identified weaknesses before being built and then destroyed in a subse- quent test.

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Surgical Indications 41 Do I Need the Surgery If I Am Not Involved in Pivoting Sports? Some- times the giving way sensation may be the result of a torn meniscus that may be repaired with a minor operation order extra super viagra 200 mg free shipping erectile dysfunction red pill. An older generic extra super viagra 200 mg amex erectile dysfunction nclex questions, recreational athlete may function fine with activity modification and the use of a brace. Every surgical procedure has a risk benefit, and ACL reconstruction is no exception. If the patient can modify activities to avoid pivotal motions, the knee may function well without surgery. The patient pursuing this approach will probably suffer giving way episodes, accompanied by pain and swelling. In the long term, this will cause wearing of the inside of the knee (osteoarthritis). The patient who wants to carry on with vigorous pivoting sports should have an opera- tion to reconstruct the knee. It does not matter whether the ligament is partially or completely torn. If the knee is lax, as can be measured by clinical examination or with the KT-1000 arthrometer, the ACL is not functioning to protect the knee against pivotal motions. The MRI can determine if the ligament is com- pletely torn, but cannot differentiate the degree of laxity. After the initial injury, there is a 50% chance of damage to the menis- cus. In the chronic situation, the incidence of meniscal tear is 75%, and the torn portion of the meniscus usually has to be removed. In the long term, the removal of all, or part of the meniscus, is associ- ated with an increased incidence of osteoarthritis. What Is the Average Time Needed Before the Patient Can Return to Sports After the Surgery? The answer is four to six months, but sometimes, it may take as long as one year to fully return to a pivotal sport. Treatment Options for ACL Injuries How Long Will the Patient Be Out of Work? If the work involves physical activity, it will take three to four months or until your legs are strong enough. Physical therapy is necessary for approximately one to six weeks postoperatively. The therapy goal is to reduce the pain and swelling, regain range of motion, and increase the strength of the muscles. Therapy may have to be modified based on the individual’s progress through the weeks of rehabilitation. The outcome of the ACL reconstruction depends not so much on the type of graft, but on the technique of placing the graft in the correct position, the fixation of the graft, and the postoperative rehabilitation. Because of the minimum harvest site morbidity, the most common graft used in our sports clinic is the hamstring graft. The patellar tendon graft is used for the athlete who wants to return to sports quickly, for example, at three months. The earlier return to activities is based on the faster healing of the bone-to- bone healing of the patellar tendon graft when compared to the tendon- to-bone healing with the hamstring graft. In a recent metaanalysis of the literature com- paring the hamstring and patellar tendon grafts, no significant difference in outcome was found. However, the patellar tendon grafts were a little more stable, and the patient was able to return to the same level of sports 18% more often than those who received the hamstring graft. Synthetic materials are not routinely used to substitute for the ACL because of the higher incidence of failure.