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In addition 5gm bactroban with visa, some Canadian medical schools are beginning to integrate training in alternative and complementary therapies into their curriculum (Tataryn and Verhoef 2001) discount 5gm bactroban amex. For instance purchase 5 gm bactroban overnight delivery, 89 percent of the eight medical schools, and 90 percent of the twenty-eight nursing schools, Achilles et al. Further, some Canadian health care professionals “make referrals to complementary and alternative practitioners,” albeit almost always to chiropractors (Tataryn and Verhoef 2001:VII. Similarly, while the people who took part in this research were not referred per se, several of them did access alternative therapies through recommendations made by their physicians. Thus, it can be argued that the boundaries between allopathic and alternative approaches to health care are beginning to blur. For instance, Tataryn and Verhoef (2001:94–98) argue that both allopathic and alternative health care stress preventative and patient-centred care. They further assert that nursing and family medicine “share assumptions related to holistic care... For example, Crawford (1984) argues that there are two general lay concepts of health in contemporary culture: health as control and health as release. Health as control defines health as a status achieved by “self discipline, self denial, and will power;” and health as release, while seeming to reject the constraints of the control model, highlights “the psychological capacity for not worrying,” hinging on an individual’s self-control of stress (Crawford 1984:66,82). The alternative model of health’s insistence that individuals control their minds, lifestyles, and, in particular, stress, makes this model entirely consistent with a general cultural understanding of health. Hence, to the degree that allopathic and alternative paradigms can be harmonized, the integration of alternative therapies within Medicare will be facilitated. More precisely, to the extent that allopathy becomes more alternative and alternative becomes more allopathic, alternative health care could be said to be integrated into Canadian public health care provision. Furthermore, certain alternative or complementary therapies are already available under Medicare. For example, chiropractic and naturopathic treatment is provided under the public insurance programme in British Columbia; and Alberta, Saskatchewan, Manitoba, Ontario, and Quebec all allow some access to chiropractic under Medicare (Achilles et al. While very few alternative therapies are currently available under public Conclusion | 115 health insurance in Canada, the presence of chiropractic and naturopathy could represent the thin edge of the wedge where inclusion of other alternative healing modalities are concerned. Finally, there are a number of research initiatives focussing on alternative and complementary therapies that have been completed or are ongoing in Canada. Notably, Health Canada has funded and/or sponsored a number of these studies (Achilles et al. For instance, the Tzu Chi Institute has completed research on integrated health care and mapping of organizations that “deliver, educate, regulate, and support alternative and complementary” health care, among other projects and activities related to these approaches to health and healing (Achilles et al. The Calgary Research Centre for Alternative Medicine has completed case studies of alternative and complementary therapies, in addition to organizing several conferences on these forms of health care. They have also partnered with the federal government in the National Forum on Health and the Health Canada Expert Advisory Committee on Complementary Medicine (Achilles et al. While there is a certain amount of momentum towards integration of alternative and allopathic paradigms of health and healing, as well as the inclusion of alternative therapies within Medicare, there remain a number of significant barriers to overcome. To begin with, establishing the efficacy and safety of alternative and complementary forms of health care is argued to be crucial to the inclusion of these approaches within public health care provision (Achilles et al. However, a major constraint on inclusion is medical, scientific dominance over assessing the efficacy of alternative therapies. For example, many medical and health policy researchers argue that “only services for which there is convincing evidence of their benefits, preferably beyond the placebo effects and in referenced journals” should be provided by public health care (Crosby 1999; Ernst 1997; Ernst and Fugh-Berman 1999). Such assertions reveal a double standard inherent in 116 | Using Alternative Therapies: A Qualitative Analysis the current drive to evaluate the efficacy of alternative and complementary health care. Namely, while it is true that the efficacy of the majority of these therapies has not been formally established, neither has the effectiveness of upwards of 85 percent of medical interventions (Balon et al. This double standard works against the inclusion of alternative therapies within Medicare.

This means that the group does not exist as an entity at any one time or place generic 5gm bactroban overnight delivery, but that it is dispersed both in time (within limits) and place and that the group interacts ‘asynchronously’ at different times discount bactroban 5gm visa. Furthermore bactroban 5gm with amex, there are different rules of behaviour for electronic communication known colloquially as ‘neti- quette’ and which both you and your students should observe. To learn more about this topic you can search for it on the World Wide Web. EVALUATING SMALL GROUP TEACHING Evaluation implies collecting information about your teaching and then making judgements based on that information. Making judgements based on what one student says, or on rumour or intuition, is simply not good enough. You must collect information in a way that is likely to lead to valid conclusions. However, constant evaluation 50 of small group activities is not recommended as it may inhibit the development and working of the group. Informal evaluation: this can proceed from a careful reflection on what happened during your time with the group. You may do this by considering a number of criteria which you feel are important. For example, you may be interested in the distribution of discussion among group members, the quality of contribution, the amount of time you talked, whether the purpose of the session was achieved, what students have learned, and so on. Of course, your reflections will be biased and it is wise to seek confirmation by questioning students from time to time. However, the importance of informal evaluations lies in your commitment to turn these reflections into improve- ments. If you are concerned with your own performance, the assistance of a trusted and experienced colleague sitting in on the group, or even just a discussion of your own feelings about the group, may be very helpful. Formal evaluation: formal approaches to evaluation include the use of questionnaires or the analysis of video recordings of the group at work. Standard questionnaires are available which seek student responses to a set number of questions. Although such standard questionnaires can be useful you may find it more beneficial to design one that contributes more directly to answering questions which relate to your own course and concerns. As questionnaire design can be difficult, it is recommendedthat you seek the assistance of a teaching unit. The analysis of videos of your group at work is also a task which would require the expertise of someone from a teaching unit. WHEN THINGS GO WRONG You may encounter a variety of difficulties in your group sessions. For example, while you might decide to ignore a sleeping student or an amorous couple in a lecture class, providing it was not disruptive, it would be impossible to do so in a small group. An authoritarian approach would 51 almost certainly destroy any chance of establishing the co- operative climate we believe to be essential. It is generally more appropriate to raise the problem with the group and ask them for their help with a solution. One of your main roles as a group leader is to be sensitive to the group and the individuals within it. Research has identified a number of difficulties that students commonly experience. Understanding the conventions of group work and acceptable models of behaviour. They tend to be due to genuine confusion on the part of students combined with a fear of exposing their ignorance in front of the teacher and their peers. It is therefore essential for you to clarify the purpose of the group and the way in which students are to enter into the discussion.

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Complications In general purchase 5gm bactroban with amex, there should be no progressive neurological deterioration in HPE and in most cases some developmental milestones are attained generic bactroban 5 gm on line. Early medical issues relate to: (1) craniofacial aspects airway management due to cranofacial malfunctions effective bactroban 5gm, (2) issues of feeding and swallowing, (3) management of endocrine issues, (4) control of seizures, (5) maintenance of normal temperature, and (6) management of tone. If neurological and=or developmental regression occurs, one should search for struc- tural or metabolic abnormalities. Occasionally, hydrocephalus has developed even in the setting of severe microcephaly. Episodes of hypoglycemia can lead to seizures and=or alterations of baseline function. A gastrostomy tube is beneficial when poor oromotor function with or without gastroesophageal reflux is present. Abnormalities of sodium balance can present as a diabetes insipidus-like disorder, particularly during intercurrent ill- ness. Care must be utilized when treating with DDAVP to avoid over treatment with resultant hyponatremia and seizures. Disorders of temperature control are usually easily man- aged with environmental control and a warming blanket. Children with MIHF have greater cognitive and motor capabilities than those with ‘‘classical’’ HPE. Endocrine and autonomic dys- function is less common, but can be present. Proper diagnosis of HPE is essential for an etiological search, attempt at prog- nosis, and in the follow up for potential complications. The neurologist is in a unique position to assist both the patient, and family. It is this author’s opinion that complex condi- tions such as HPE are best managed in a longitudinal relationship in which educa- tion, support, and problem solving are essential components of the patient–physician relationship. Plawner LL, Delgado MR, Miller VS, Levey EB, Kinsman SL, Barkovich AJ, Simon EM, Clegg NJ, Sweet VT, Stashinko EE, Hahn JS. Neuroanatomy of holoprosencephaly as predictor of function: beyond the face predicting the brain. Endocrinopathies associated with midline cerebral and cranial malformations. INTRODUCTION Cerebral palsy describes a group of upper motor neuron syndromes secondary to a wide range of genetic and acquired disorders of early brain development. In addition to primary impairments in gross and fine motor function, there may be associated problems with cognition, seizures, vision, swallowing, speech, bowel=bladder, and orthopedic deformities. It is the most prevalent chronic childhood motor disability, affecting 2–3=1000 school aged children. Cerebral palsy is considered nonprogres- sive, but neurological findings may change or progress over time. Although compre- hensive longitudinal studies are limited, the majority of children with cerebral palsy develop into adulthood, actively participating in societal life. DIAGNOSIS=CLINICAL FEATURES Cerebral palsy is a clinical diagnosis, made on the basis of significant delay in gross and=or fine motor function, with abnormalities in tone, posture, and movement on neurological examination. While the neurological abnormalities in cerebral palsy include loss of selective motor control, agonist=antagonist muscle imbalance, impaired balance=coordination, and sensory deficits, diagnosis, classification, and treatment are often based on abnormalities in tone. Children may have relatively pure spastic, rigid, or dystonic hypertonicity or mixed degrees of these three types. Posi- tion, posture, movement, anxiety, or illness may influence the determination of tone. Spasticity, a velocity dependent increase in tonic stretch reflexes, is part of the upper motor neuron syndrome, including clonus, reflex overflow, hyperreflexia, posi- tive Babinski, loss of manual dexterity, and spastic weakness. Spastic hypertonicity is commonly seen in association with white matter injury (e.

Post-operative pain regimens for these patients included surgery per- 186 C safe 5gm bactroban. Intraoperative image at completion of surgery for which two-incision MIS approach technique shows an anterior Smith–Peterson incision for acetabular implantation and a sepa- rate posterior incision for femoral component implantation formed under regional anaesthesia purchase bactroban 5 gm with mastercard, a combination of non-narcotic analgesic medica- tions order 5 gm bactroban with mastercard, and the utilisation of portable local anaesthetic infusion pumps. Patients selected for this surgical approach all receive accelerated physical therapy with imme- diate weight-bearing and physiotherapy within the first 24h. Berger, one of the early enthusiastic proponents of the two-incision technique, reported on his, single-surgeon, results of the first 100 total hip arthroplasties performed using this approach. After the first 12 cases performed, he initiated an outpatient protocol in which 85% of patients were discharged home (not to other care facilities) on the day of surgery and the remaining 15% the day following surgery. One intraoperative proximal femoral fracture was reported for the first 100 cases. Radiographic analysis of component positioning for the first 30 cases showed 91% of femoral stems in neutral alignment (a range of neutral to 3° valgus). The average abduction angle for the ace- tabular component was 45° (range, 36°–54°). Berger concluded that the two-incision technique was safe and facilitated a rapid patient recovery. Mears’ results were similar in a highly selected patient population, with 90% of patients discharged home within 24h of surgery. Concerns regarding the two-incision technique are based on several factors. Furthermore, it has been claimed that this technique avoids muscle or tendon damage; however, a cadaveric study conducted and reported by Mardones et al. In addition, even those surgeons who Minimally Invasive Hip Replacement Surgery 187 advocate the benefits of this technique admit that there is a learning curve and that appropriate training is required. The early experi- ence of a group of 159 surgeons who had completed a designated training programme was followed. A learning curve over the first ten cases for the surgeons showed a sig- nificant decrease in mean operative and fluoroscopic screening time; however, key complications (fractures, dislocations, and nerve deficits) were not reduced over the first ten cases. Berger admits that the technique is technically challenging, and states that surgery via this approach should only be attempted after proper hands-on training, which should include cadaveric workshops as an essential component of that training process. The hope is that this training will lead to a decreased complication rate and assure success when the two-incision approach is performed on patients. The many surgeons who oppose the two-incision technique remain sceptical and claim that promotion of this form of minimally invasive hip arthroplasty is being commercially driven and has been marketed without appropriate evidence-based evaluation. Although there are reports from those who have developed the technique on the early clinical results, it will be several years before the mid- or long-term results are available on these patients [1,11]. In conclusion, two-incision minimally invasive total hip arthroplasty surgery is technically challenging and requires specialized training before use on patients. It is interesting to note that of those surgeons who train for the procedure, 90% gravitate to using another approach for total hip surgery. Anterolateral Approach Technique The anterolateral or direct lateral approach is well known to surgeons. A shorter skin incision is made and similar muscle dissection down to the joint is performed. They wanted to assess the accuracy and reproducibility of implantation, determine if obesity influenced the outcome and technique, and compare operative and post- operative outcomes. They found that the advantages of MIS were that the patients had a decreased transfusion requirement, had a better functional recovery, ambulated significantly earlier, required significantly less transfer assistance, and required sig- nificantly less skilled nursing care after discharge. There was no difference in the accuracy of implant positioning, and obesity did not adversely alter patients’ opera- tive approach or outcome. Posterior Approach Technique This “mini-incision” posterior approach is the most commonly used less-invasive surgical technique for total hip replacement. The less-invasive posterior approach involves a 10-cm oblique incision which, unlike the two-incision approach, is non- proprietary (Figs. Cemented or cementless prostheses can be implanted through this approach implant malpositioning hip. Acetabular socket retroversion (or varus posi- tioning of the femoral stem) are more common with this approach (Figs. Mean hospital stay was 3 days with 87% of patients discharged to their own home, the remaining 13% to a rehabili- tation facility.

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