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Oxford: OUP order micardis 20mg without prescription, 2003: 479-494 Cross References Delirium; Dementia; Hallucination; Illusion; Intermetamorphosis; Misidentification syndromes; Reduplicative paramnesia] Dementia Dementia is a syndrome characterized by loss of intellectual (cognitive) functions sufficient to interfere with social and occupational functioning purchase 20 mg micardis. Cognition encompasses multiple functions including language micardis 20mg fast delivery, memory, perception, praxis, attentional mechanisms, and executive function (plan- ning, reasoning). These elements may be affected selectively or globally: older definitions of dementia requiring global cognitive decline have now been superseded. Amnesia may or may not, depending on the classifica- tion system used, be a sine qua non for the diagnosis of dementia. Attentional mechanisms are largely preserved, certainly in comparison with delirium, a condition which precludes meaningful neuro- psychological assessment because of profound attentional deficits. Although commoner in the elderly, dementia can also occur in the prese- nium and in children who may lose cognitive skills as a result of heredi- tary metabolic disorders. Multiple neuropsychological tests are available to test different areas of cognition. The heterogeneity of dementia is further exemplified by the fact that it may be acute or insidious in onset, and its course may be progressive, stable, or, in some instances, reversible (“dys- mentia”). A distinction is drawn by some authors between cortical and subcortical dementia: in the former the pathology is predominantly cor- tical and neuropsychological findings are characterized by amnesia, agnosia, apraxia, and aphasia (e. However, not all authors subscribe to this distinction, and con- siderable overlap may be observed clinically. Cognitive deficits also occur in affective disorders, such as depression, usually as a consequence of impaired attentional mechanisms. This syndrome is often labeled as - 91 - D Dementia “pseudodementia” since it is potentially reversible with treatment of the underlying affective disorder. It may be difficult to differentiate dementia originating from depressive or neurodegenerative disease, since depression may also be a feature of the latter. Impaired atten- tional mechanisms may account for the common complaint of not recalling conversations or instructions immediately after they happen (aprosexia). Behavioral abnormalities are common in dementias due to degenerative brain disease, and may require treatment in their own right. Recognized causes of a dementia syndrome include: ● Neurodegenerative diseases: Alzheimer’s disease, frontotemporal lobar degenerations (frontotemporal dementia, encompassing Pick’s disease; semantic dementia; primary progressive aphasia), dementia with Lewy bodies, Huntington’s disease, progressive supranu- clear palsy, corticobasal degeneration, prion disease, Down’s syndrome, dementia pugilistica. Cognitive dysfunction may be identified in many other neurological ill- nesses. Investigation of patients with dementia aims to identify its par- ticular cause. Because of the possibility of progression, reversible causes are regularly sought though very rare. Specific treatments for dementia are few: cholinesterase inhibitors have been licensed for the treatment of mild to moderate Alzheimer’s disease and may find a role in other conditions, such as dementia with Lewy bodies and vascular dementia, for behavioral as well as mnestic features. The decreasing prevalence of reversible dementia: an updated meta-analysis. British Journal of Hospital Medicine 1997; 58: 105-110 Growdon JH, Rossor MN (eds. New York: Wiley-Liss, 1998 Lezak MD, Howieson DB, Loring DW, Hannay HJ, Fischer JS. Philadelphia: Butterworth Heinemann, 2003 O’Brien J, Ames D, Burns A (eds. Philadelphia: Lippincott Williams & Wilkins, 2002: 19-26 Snowden JS, Neary D, Mann DMA. Fronto-temporal lobar degenera- tion: fronto-temporal dementia, progressive aphasia, semantic dementia. New York: Churchill Livingstone, 1996 Cross References Agnosia; Amnesia; Aphasia; Apraxia; Aprosexia; Attention; Delirium; Dysmentia; Pseudodementia; Psychomotor retardation De Musset’s Sign - see HEAD TREMOR Developmental Signs - see FRONTAL RELEASE SIGNS; PRIMITIVE REFLEXES Diagonistic Dyspraxia A dissociative phenomenon observed after callosotomy, probably identical to intermanual conflict. Studies on the corpus callosum, IV: Diagonistic dys- praxia in epileptics following partial and complete section of the corpus callosum. American Journal of Psychiatry 1944-1945; 101: 594-599 Cross References Alien hand, Alien limb; Intermanual conflict Diaphoresis Diaphoresis is sweating, either physiological as in sympathetic activation (e.

Furlong’s career was extraordinary in the true The medical world of the 1930s was very dif- sense of the word order 20 mg micardis, for nothing about him or what ferent from today discount 80mg micardis amex. To start with order micardis 20 mg free shipping, it was narily long hours but the pace of life was far less long, very long; indeed, it probably qualifies for frenetic. Will orthopedic in the surgeons’ room in classical Furlong style: surgery or, indeed, any branch of medicine, “The biggest inconvenience in the life of a Harley encounter again a doctor who spends 70 years in Street surgeon was that the dining room also acted active practice? As with most aspects of this as the patients’ waiting room so that lunch, by remarkable life, his medical career started with a necessity, had to finish by ten minutes to two. Born in 1909, he grew up in south those pre-antibiotic days, long-stay patients were London, being educated at Eltham College. At the lodged in a country hospital and there were age of 16 there was, it seems, a sharp disagree- several of these around London, for example ment between Furlong senior and the house Stanmore, Black Notley, Royal Sea Bathing master, who had taken exception to finding young at Margate and Lord Mayor Treloar’s at Alton. Furlong with his feet up on the mantelpiece while On Fridays, the “great man” from Harley some prospective parents were being shown Street/Teaching Hospital would come down in his round the school. Consequently, one week Rolls Royce, do his ward round, then operate on Furlong junior was a schoolboy and the next, Saturday morning. Sir Reginald Watson-Jones of 108 Who’s Who in Orthopedics the London Hospital went as far as Oswestry. Perkins hospital was the Church of England Home for thrust his hand into his mackintosh pocket, took Waifs and Strays at Pyrford, later renamed the out a large wad of pound notes, thrust them into Rowley Bristow Hospital. Furlong’s formative years were therefore spent He was, I understand, meant to come back as an between St. Thomas’ and Pyrford and periods out expert in spinal fusion and scoliosis, but spinal “on loan” to other friends. He was acclaimed for his surgeon to watch and much of the polish came via excellent monograph on hand injuries, published Sir Harold. Ronnie Furlong was to achieve inter- in the mid-1950s, but much of this was based on national acclaim in this field. He had a fine command of my registrar years was watching him do a of both written and spoken English, with an now unfashionable operation of fasciotomy for extraordinary ability to summarize complex con- Dupuytren’s contracture. As a registrar in the himself had a Dupuytren’s contracture in his left follow-up clinic, what more did you need to know little finger. Rowley Bristow had accounted for a about a patient than the simple statement “sciat- digital nerve and the situation had eventually been ica—all over the body! However, the Furlong diagnostic acumen was the tale of the Furlong thereafter had a touch of numbness on the butterfly, which was recounted to me by David ulnar side of his little finger, but it made no dif- Gruebel-Lee, chief assistant to Furlong and later ference to his technical excellence! He was The second phase of his career was wartime doing a clinic at the Queen Victoria Hospital, East experience. Thomas’, through the war, he never spoke about it and it the Rowley Bristow Hospital, Pyrford, and East was only when I read The Times obituary (August, Grinstead) when in came a lady in her thirties. He did not even know he had several well-known opinions in Harley Street, been appointed as a consultant at St. Thomas’ whose letters of explanation often ran to a page until some weeks after the appointments commit- or more. David Lee eventually came across the tee, for he was still too busily engaged in his Furlong contribution, which merely amounted to RAMC duties, including, of course, charging a single line: “Doesn’t want to be a butterfly in around Europe seeking Küntscher. Furlong stories finance for Fellowships was just as problematic were legion. Waiting at Waterloo to catch the boat holism; “My boy,”—all registrars were referred train to Southampton and thence America, he to as boys—“if a spouse specifically requests a observed a shadowy figure in a mackintosh single room for her/his husband/wife you can walking towards him. It is an With his turn of phrase and ready wit he was a extraordinary achievement for a surgeon to form brilliant teacher of undergraduates. Thomas’ career had lowing my first Furlong outpatient session as a been the period of enlightenment. Seminar sessions and problem case learn- had a great respect for Charnley, with whom he ing were not the order of the day but “theater” had served in the war, but he did not feel com- was. The outpatient teaching room in the old fortable with a 22mm femoral head. He tried the Victorian south wing was indeed like a theater McKee, but inserting the large socket seemed with banked rows of seats. Enter then this 32mm head of what was then called the broad, elegant, imposing man, an object flew Müller–Charnley seemed to him a practical solu- across the room toward the captain of rugby, tion.

He now adapted this critique to argue that ‘preventive health measures’ in relation to lifestyle could be an effective means of reducing health care costs (Owen 1976) cheap micardis 40mg on line. A key influence on Owen was the innovative policy document produced by Canadian health minister Marc Lalonde in 1974 buy micardis 80 mg low price, which recommended the pursuit of ‘healthy public policies’ by all government departments in support of the promotion of health (Lalonde 1974) discount micardis 80 mg online. While he recognised that ‘government interference in all these areas raises sensitive issues relating to individual freedom’—a concern conspicuously lacking in more recent health promotion policy—Owen attempted to shift some of the responsibility, and cost, of health from the state onto the individual (Owen 1976). In the inauspicious circumstances of the late 1970s, Owen’s preventive strategy made little impact. He was an unpopular minister in an unpopular government: the wave of trade union militancy provoked by its wage controls and cuts in public expenditure culminated in the notorious ‘winter of discontent’ in 1978–79, which led directly to the election of Margaret Thatcher’s first government in May 1979. As a result of a series of disputes over pay and private patients, the government had poor relations with the medical profession and, as an ambitious right-winger, Owen was regarded with particular suspicion by the unions (indeed he left Labour to set up the Social Democratic Party in 1981). Given the continuing strength of the collectivist traditions of the labour movement, the individualistic sentiments so bluntly expounded in Owen’s documents found little popular resonance. In the USA, where government concerns with escalating health care costs were even greater than in Britain and trade unionism much weaker, the doctrine of individual responsiblity for health won greater approval (US Department of Health, Education and Welfare 74 THE POLITICS OF HEALTH PROMOTION 1979, 1980). Federal health promotion connected with a growing interest in self-help and consumerism, and with the vogue for jogging, marathon running and other forms of physical fitness, which reached Britain a few years later. Government health promotion initiatives in the 1970s provoked a vigorous radical response, particularly in the USA. In a classic paper which anticipated subsequent trends with uncanny accuracy, the American sociologist Irving Zola commented that medicine was ‘becoming a major institution of social control’ (Zola 1972). He discerned a tendency towards the ‘medicalising’ of much of daily living which was proceeding in ‘an insidious and often undramatic’ way. Furthermore he noted that ‘the list of daily activities to which health can be related is ever growing and with the current operating perspective of medicine it seems infinitely expandable’. In the late 1970s, another American sociologist, Robert Crawford, characterised health promotion as ‘victim-blaming’, an ‘ideology which blames the individual for her or his illness and proposes that, instead of relying on costly and inefficient medical services, the individual should take more responsibility for her or his health. At- risk behaviour is seen as the problem and changing life-style, through education and/or economic sanctions, as the solution’ (Crawford 1977). On the one hand, they served to ‘reorder expectations and to justify the retrenchment from rights and entitlements for access to medical services’. On the other, they attempted ‘to divert attention from the social causation of disease in the commercial and industrial sectors’. The Health of the Nation It was not until after her third general election victory in 1987 that Margaret Thatcher seriously set about reforming the health service. The 1989 White Paper Working for Patients heralded the introduction of the internal market into the NHS, with hospital trusts and GP fundholding. Yet, by the time these measures became operational in 1991, Mrs Thatcher had been replaced by John Major, and it was under his leadership that the Health of the Nation policy was introduced, with a Green Paper in June 1991 and a White Paper in July 1992 (DoH 1991, DoH 1992). This comprehensive health promotion programme was ideally suited to Major’s attempt to 75 THE POLITICS OF HEALTH PROMOTION project a more conciliatory ‘one nation’ Toryism in contrast to his predecessor’s combative and divisive style. It also provided the perfect complement to the internal market reforms, appearing to soften their competitive edge while being quite consistent with their individualistic ethos. A cursory inspection of the Health of the Nation package reveals that many lessons had been learned from Owen’s ill-fated venture into health promotion in the 1970s. In his foreword to the Green Paper, health minister William Waldegrave indicated his concern to avoid criticism on the grounds of ‘victim-blaming’: ‘for too long… the health debate has been bedevilled by the two extreme claims of, on the one hand, “It’s all up to individuals”, and on the other, “It’s all up to Government”’ (DoH 1991:v). In what might be regarded as an early formulation of ‘the third way’, he insisted that ‘we need a proper balance between individual responsibility and Government action’. The subsequent White Paper, presented by Waldegrave’s successor Virginia Bottomley, continued this theme, emphasising that We must get the balance right between what the Government, and Government alone can do, what other organisations and agencies need to do and, finally, what individuals and families must contribute if the strategy is to succeed. The White Paper proposed a Cabinet-level coordinating committee and outlined specific roles for local authorities, the media, the Health Education Authority, and for employers and health professionals. It announced arrangements for providing funds for voluntary organisations, recognising that they could play a significant part through ‘self- help’, ‘bringing people together to share common problems’; through ‘direct service provision’, offering a ‘wide variety of services’; ‘community health’; ‘health education and promotion, education for health professionals, fund raising and support for research’ (DoH 1992:24–5).

Though this can be difficult to implement order 80mg micardis, we have found that attempting to do so is a powerful way of improving the validity of the assessment generic micardis 80mg. 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 micardis 40 mg cheap. 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. Several studies have shown significant differences between the marks allocated by difference examiners and even by the same examiner re-marking the same papers at a later date. In the extended response question the student’s factual knowledge and ability to provide and organise ideas, to substantiate them and to present them in coherent English are tested. The extended essay is useful for testing knowledge objectives at the higher levels such as analysis and evaluation.

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