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Compared Slipped Capital Femoral Epiphysis Retrospective 71 60 Mild slip Moderate slip Severe slip 50 10 cases 5 cases 1 cases 40 37 54 29 78 30 48 20 37 59 10 19 10 7 1214 18 23 20 0 8 0 30 60 Posterior tilting angle(degree) Fig kamagra chewable 100 mg mastercard. Relation between head-shaft angle and posterior tilting angle with the mean statistical values purchase kamagra chewable 100 mg fast delivery, the height of the patients was −10 generic 100 mg kamagra chewable amex. Com- pared with the mean statistical values kamagra chewable 100mg, the weight of the patients was −10 cheap kamagra chewable 100mg on line. Endocrinological examination showed a low testosterone level in one patient. However, abnormalities could not be confirmed in any patient because they were in the growth stage. Surgery was performed in all patients; Southwick intertrochanteric osteotomy was performed in 5 patients and in situ pinning in 11. Contralateral preventive bone epiphyseal fixation was performed in all except 1 patient. The implant used for in situ pinning was the Knewles pin in 2 patients, Kirschner wire (k-wire) with thread in 3, and ACE(R) SCFE screw in 6. For contralateral preven- tive pinning, the Knewles pin was used in 2 patients, k-wire with thread in 3, ACE SCFE screw in 9, and Hannson pin in 1. For fixation after Southwick intertrochanteric osteotomy, the AO double angle plate (MIZUHO, Tokyo, Japan) was used. In all patients, epiphyseal fixation was added, and the implants used were the same materi- als as those used in preventive pinning. The flexion osteotomy angle was frequently 20°–30°, although it was 50° in 1 patient. Good reductions in both the posterior tilting angle and head–shaft angle were observed. Concerning surgical complications, methicillin-resistant Staphylococcus aureus infection associated with Southwick intertrochanteric osteotomy developed in one patient and k-wire breakage associated with in situ pinning in one. Leg length dis- crepancy after Southwick intertrochanteric osteotomy until the final observation was observed in three of five patients (0. Changes of head-shaft angle and pos- terior tilting angle after osteotomy 60 40 20 0 0 Head-shaft angle (degree) pre-operation post-operation limitation in flexion was observed in two, only that in internal rotation in two, and that in both flexion and internal rotation and both flexion and internal/external rota- tion in one each. Concerning sequelae, one patient showed narrowing of the joint space at the initial consultation, and although postoperative changes were negligible, the course has been observed. No avascular necrosis of the femoral head occurred, no pain of hip, and the patient has acquired a normal gait. Case Presentations Patient 1: 10-Year-Old Boy He noticed right hip joint pain in February 2002. On March 30 of the same year, he fell on the stairs, sustained injury, and was transported to a local hospital by ambu- lance. A diagnosis of femoral neck fracture was made by a surgeon at the first con- sultation, and he was referred to our hospital (Fig. A diagnosis of unstable slipped capital femoral epiphysis was made, and direct wire traction was performed for about 2 weeks from immediately after admission. Because the slipping angle as the posterior tilting angle was reduced from 59° to 17° by traction, in situ pinning was performed (Fig. Five years and 4 months after operation, he has no pain or limi- tation in the range of motion, showing a good course (Fig. Patient 2: 12-Year-Old Girl She noticed hip joint pain about 1 year earlier, visited a local hospital, but was told that there was no abnormality. After an athletic meeting, her hip joint pain increased, and she visited our hospital, was diagnosed as having slipped capital femoral epiphysis, and admitted (Fig. Even after direct traction, adequate reduction could not be achieved, and Southwick intertrochanteric osteotomy was performed. Three years and 8 months after operation, remodeling of the femoral head was good, but limitation in the range of motion in flexion (5°) remained (Fig. C Roentgenogram of the hip 44 months postoperation Slipped Capital Femoral Epiphysis Retrospective 75 Discussion In our patients, the correct initial diagnosis rate was only 31. The coefficient of the correlation between the duration until diagnosis and the slipping angle was 0. Some patients in this study required a considerably long time for diagnosis, increasing the slipping angle, and thus we confirmed the importance of early diagnosis.

Brainstem and cranial nerve dysfunction can produce apneic episodes and respiratory compromise generic 100 mg kamagra chewable with amex, the former occurring in association with agitation buy kamagra chewable 100mg with visa. Examination reveals nystagmus order kamagra chewable 100 mg on line, spasticity in the upper extremities cheap kamagra chewable 100mg without prescription, and fixed neck Table 2 Clinical Signs and Symptoms in Children with Chiari Malformations Chiari I Chiari II Infant Stridor Apnea-episodic Decreased gag reflex Aspiration Fixed neck extension (retrocollis) Weak cry Nystagmus Increased tone Upper extremity weakness Childhood Headache Headache Neck pain Neck pain Ataxia or balance problems Nystagmus Scoliosis Increased tone Upper extremity weakness Aspiration GE reflux Decreased cough reflux Adolescence Headache Neck pain Ataxia or balance problems Scoliosis Suspended sensory loss (due to syrinx) Hand or arm atrophy Chiari Malformations 45 extension or retrocollis kamagra chewable 100 mg low cost. These children often have other health problems and are failing to thrive, which can make evaluation difficult and the clinical picture confus- ing. Despite surgery in this patient group, many of these children continue with symptom progression and die due to progressive disease. It is essential to rule out hydrocephalus or shunt malfunction in a symptomatic infant as treatment of the hydrocephalus can reverse the clinical course. Although sequelae of cranial nerve dysfunction, such as aspiration or recurrent pneumonia, can be seen, motor symptoms become more common. These include an impact on motor development of the upper extremities and the appearance of spasticity. As the child gains language function, headache or neck pain become more common. The charac- ter of the headache is fairly consistent between Type I and II malformations and across ages. The pain can radiate to behind the eyes and is often described as a feeling of pressure. Exer- cise, straining, coughing, or any valsalva maneuver will bring on the pain, which tends to pass over a short period of time. Not uncommonly, parents note complaints of headache or pain during upper respiratory infection or asthma attacks. Since headaches in patients with Chiari malformations can occur in other locations on the head, one should not dismiss the diagnosis of this disorder just because the headache is atypical. In middle and late childhood, the clinical presentation is very similar to ado- lescence. These symptoms include sensory loss, hand and arm weakness, change in leg function, and extremity or torso pain that is often burning in character. The radiological evaluation should include at least the brain and cervical spine. Similarly, in a patient with scoliosis and a Chiari malformation, the entire spine should be imaged. The purpose of this extensive ima- ging evaluation is to evaluate for hydrocephalus, syrinx, tethered spinal cord, or other skull base anomalies associated with Chiari malformations. An additional helpful study is a cine-MRI that evaluates CSF flow across the foramen magnum. In patients with Chiari malformations, the reduced flow is found posterior to the cerebellum. The radiological evaluation is important because it helps guide the proposed treatment that may address associated findings rather than the Chiari malformation itself. TREATMENT The decision to treat, when to treat, and what to treat is very dependent on the sever- ity of the symptoms and the clinical presentation. For patients in whom pain or headache is the only symptom, medical management is the first line of therapy (see Chapter 20 on headaches). In patients who fail medical management or who have loss of neurologic function, surgical management is indicated. Accepted procedures range from a bony decom- pression only to a bony decompression with dural patch grafting, intradural dissec- tion, and tonsillar manipulation. In a 1998 survey of pediatric neurosurgeons, 81% of respondents favored observation with yearly neurological exams and MRI scans. In the survey, a third of respondents would place activ- ity restrictions, primarily avoidance of contact sports. If a follow-up MRI demon- strates progression of a syrinx, 61% of responding pediatric neurosurgeons would recommend surgical intervention. Chiari II Malformation and Myelomeningocele This group can be very challenging to manage due to the complexity of the myelo- meningocele patient.

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The other five blocks could then be used for each small group to work through some of the cases prepared earlier order 100 mg kamagra chewable fast delivery, followed by a debriefing session with the whole class (principles 5 and 6) cheap kamagra chewable 100mg on line. Case 3: General practice training Case 3 solution You are the trainer for a first year registrar in her You could first invite the registrar to observe you with patients kamagra chewable 100 mg line, first year of a general practice training and do a quick debrief at the end of the day (principles 2 generic kamagra chewable 100mg amex, 6 100mg kamagra chewable with visa, and programme. With help from you, she could then develop her own have very little time to spend with her. You learning goals, based on the certification requirements and wonder how you can contribute to providing a perceived areas of weakness (principles 1, 3, and 4). Finally, the registrar could begin to see patients alone and keep a journal (written or electronic) in which she records the results of “reflection on practice” (principle 6). She could also record in her journal the personal learning issues arising from her patients, could conduct self directed learning on these, and could document 3 ABC of Learning and Teaching in Medicine her findings in the journal (principles 1, 4, and 6). You could Teacher Learner Outcome provide feedback on the journal (principle 5). If practical, the cohort of registrars could communicate via the internet to Curriculum discuss their insights and experiences (principle 6). By using Clinical teaching and learning methods based on educational theories settings and derived principles, medical educators will become more effective teachers. This will enhance the development of From theory to practice knowledge, skills, and positive attitudes in their learners, and improve the next generation of teachers. Ultimately, this should result in better trained doctors who provide an even higher level of patient care and improved patient outcomes. Self-direction for lifelong learning:a comprehensive guide to theory and practice. Teaching and learning in medical education:how theory can inform practice. Educating the reflective practitioner:toward a new design for teaching and learning in the professions. The word curriculum has its roots in the Latin word for track or race course. From there it came to mean course of The planned curriculum study or syllabus. Today the definition is much wider and • What is intended by the designers includes all the planned learning experiences of a school or educational institution. Thecurriculummustbeinaformthatcanbe communicated to those associated with the learning institution, The delivered curriculum should be open to critique, and should be able to be readily • What is organised by the administrators transformed into practice. The curriculum exists at three levels: • What is taught by the teachers what is planned for the students, what is delivered to the students, and what the students experience. It is underpinned by a set of values and beliefs about what students The experienced curriculum should know and how they come to know it. The curriculum of • What is learned by the students any institution is often contested and problematic. Some people may support a set of underlying values that are no longer relevant. This is the so called sabretoothed curriculum, which is Three levels of a curriculum based on the fable of the cave dwellers who continued to teach about hunting the sabretoothed tiger long after it became extinct. In contemporary medical education it is argued that the curriculum should achieve a “symbiosis” with the health services and communities in which the students will serve. The values that underlie the curriculum should enhance health service provision. The curriculum must be responsive to changing values and expectations in education if it is to remain useful. Students Elements of a curriculum If curriculum is defined more broadly than syllabus or course of Education improves study then it needs to contain more than mere statements of clinical service content to be studied. A curriculum has at least four important Curriculum Health services communities elements: content; teaching and learning strategies; assessment Clinical service processes; and evaluation processes. Curriculum writers have tried to place some order or rationality on the “Symbiosis” necessary for a curriculum. From Bligh J et al (see “Further process of designing a curriculum by advocating models. A consideration of these models assists in Curriculum models understanding two additional key elements in curriculum Prescriptive models design: statements of intent and context. One of the more well known examples is the “objectives model,” which arose from the initial work of Ralph Tyler in 1949. According to this model, four important questions are used in curriculum design.

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She is also an Assistant Scientist at the Hospital for Special Surgery cheap kamagra chewable 100 mg with visa, New York purchase 100mg kamagra chewable visa. She received a FIRST Award from the National Institutes of Health in 1995 and a Faculty Early Career Development Award from the National Science Foundation in 1999 buy generic kamagra chewable 100mg line. Her scientific interests include skeletal mechanobiology and bone structural behavior buy kamagra chewable 100mg otc. Prendergast Born in Enniscorthy purchase kamagra chewable 100 mg fast delivery, Ireland, in 1966, Patrick Prendergast studied at Trinity College Dublin (TCD) where he graduated with a BAI in engineer- ing in 1987 and a PhD in 1991. He was a Council-of-Europe Scholar at the University of Bologna (Istituti Ortopedici Rizzoli) and a Marie Curie Fellow at the University of Nijmegen before being appointed a lecturer in TCD in 1995. He is on the editorial board of the Journal of Biomechanics and Clinical Biomechanics. He was President of the Section of Bioengineering of the Royal Academy of Medicine in Ireland from 1998 to 2000. Scientific inter- ests include computer simulation of tissue differentiation and bone remod- elling, and the design of medical devices. He studied medicine and biophysics at the Russian Medical University, Moscow, and obtained his PhD at the Berlin Charité. In 1992, Peter joined the Physiology Department at Oxford to continue his studies on the effects of mechanical stimulation on heart rate and rhythm. His work uses a variety of techniques, ranging from experiments on single cells and tissues to analytical models of cardiac mechano-electrical interactions. An unusual facet of his work is devoted to the investigation of the role of connective tissue in the regulation of electrophysiological behaviour of the heart. Peter likes to travel, preferably with his growing family, and enjoys water sports and landscape photogra- phy. His favourite – and by far most regular – recreational activity, though, is cooking. Contributor biographies 193 Denis Noble Denis Noble, 64, is the British Heart Foundation Burdon Sanderson Professor of Cardiovascular Physiology at the University of Oxford and a Fellow of Balliol College. In the early 1960s, he developed the first ‘ionic’ cell models of cardiac excitation and rhythm generation and has been at the forefront of computational biology ever since. As the Secretary-General of the International Union of Physiological Sciences, he has been pivotal to the initiation of a world-wide effort to describe human physiology by analytical models – the Physiome Project. In 1998 he was honoured by the Queen for his services to Science with a CBE. Denis Noble enjoys playing classical guitar, communicating with people all over the world in their mother-tongue, and converting the preparation of a meal into a gastro- nomic celebration. Winslow Raimond L Winslow, 45, is Associate Professor of Biomedical Engineering, with joint appointment in the Department of Computer Science, at the Johns Hopkins University School of Medicine and Whiting School of Engineering. He is co-Director of the Center for Computational Medicine and Biology, Associate Director of the Whitaker Biomedical Engineering Institute at Johns Hopkins University, and a member of the Institute for Molecular Cardiobiology. His work is aimed at understanding the origins of cardiac arrhythmias through the use of biophysically detailed computer models. These models span levels of analysis ranging from that of individ- ual ion channels, to cells, tissue, and whole heart. Contributor biographies 195 Peter Hunter Peter Hunter, 52, is a NZ Royal Society James Cook Fellow and Chair of the Physiome Commission of the International Union of Physiological Sciences. He founded the Biomedical Engineering Group at Auckland University which, in close collaboration with the Auckland Physiology Department, uses a combination of mathematical modelling techniques and experimental measurements to reveal the relationship between the electrical, mechanical and biochemical properties of cardiac muscle cells and the performance of the intact heart. A similar approach is also being used by the Auckland group to analyse gas transport, soft tissue mechan- ics and blood flow in the lungs with the aim of producing an anatomically detailed, biophysically based coupled heart–lung model for use in drug dis- covery and the clinical diagnosis and treatment of cardiopulmonary disease. Kolston Born in Wellington, New Zealand, Paul Kolston studied at Canterbury University (NZ) where he graduated in 1985 with first class honours in Electrical and Electronic Engineering. He obtained his PhD there in 1989, although he spent one year of his PhD studies at the Delft University of Technology, The Netherlands. After a one-year post-doctoral position at 196 CONTRIBUTOR BIOGRAPHIES the University Hospital Utrecht, The Netherlands, he moved to Bristol University (UK). In 1995 Paul was awarded a Royal Society University Research Fellowship, which he transferred to Keele University in 1999. Paul’s favourite scientific interest is computer modelling of biological systems; his favourite recrea- tional pursuit is body-surfing.

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