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The four-stage teaching approach This represents a staged approach to teaching a skill that is designed to apply the principles of adult learning to the classroom cheap 100 mg luvox with amex anxiety symptoms before sleep. The process is about knowledge and skill transference from an expert instructor to that of a novice (a candidate who aspires to be a member of the cardiac arrest team) buy luvox 50 mg on line anxiety after eating. In the staged approach the responsibility for performing the skill is gradually placed further away from the instructor and closer to the learner. The goal is a change in behaviour, with performance enhanced through regular practice. Group learning 92 Teaching resuscitation This approach places the emphasis on the candidate’s The four-stage teaching approach ability to frame learning around recognisable scenarios and removes the abstract thought necessary to acquire skills in Stage 1: silent demonstration of the skill In this first stage, the instructor demonstrates the skill as isolation. The procedure is performed at the normal speed to achieve realism and thereby help the student to absorb the instructor’s Training healthcare workers expertise. It allows the learner a unique “fly on the wall” insight into the performance of the skill. Through the instructor’s Resuscitation Council (UK) training courses demonstration the candidate has a benchmark of excellence, an Practical training is an essential component of all the ALS animated performance that will facilitate the acquirement of the skill, and help move him or her from novice to expert courses developed by the Resuscitation Council (UK). These Stage 2: repeat demonstration with dialogue informing learners of the cover the resuscitation of both adult (ALS) and paediatric rationale for actions subjects (PALS) and have become widely available during the This stage allows the transference of factual information from past 10 years. In order that the resuscitation courses whole performance of the skill, explain the basis for his actions, administered by the Resuscitation Council (UK) are based on and, where appropriate, indicate the evidence base for the skill. The opportunity to reinforce important principles helps to facilitate the integration focus is to develop the ability to teach the related core skills of of information and psychomotor skills. Importantly, the learner resuscitation within a universal approach to teaching. A study in 1981 found that in towards the learner, with emphasis on using cognitive a group of junior hospital doctors tested none were able to understanding to guide the psychomotor activity. By the talks the instructor through the skill in a staged and logical sequence based on recollection of the previously observed mid 1980s little had changed; although over half the junior practice. It is also the responsibility of the instructor to ensure doctors tested could attempt BLS, the standard to which it was that, in simulated practice, the skill is not seen in relative being performed was just as poor. Similar results were reported isolation but is placed within the proper context of a real among nursing staff. Time to reflect on the skill learnt and the College of Physicians recommended that all doctors, medical opportunity to ask questions all add to the importance of this students, nurses, dental practitioners, and paramedical staff stage, and positive reinforcement of good practice by the instructor helps to shape the future practice of the individual should undergo regular training in the management of learner cardiopulmonary arrest. Stage 4: repeat demonstration by the learner and practice of the skill by As a direct response, the first British course was held the same all learners year at St Bartholomew’s Hospital, London, using Resuscitation This stage completes the teaching and learning process, and Council (UK) guidelines. Over the following five years, ALS-type helps establish the ability of the student to perform a particular courses were set up in a variety of centres throughout the United skill. It is this stage that the skills are transferred from the Kingdom and by 1994 a standardised ALS course was established expert (instructor) to the novice (candidate), with the under the direction of the Resuscitation Council (UK). The aim candidate being an active investigator of the environment rather than a passive recipient of stimuli and rewards of the course was “to teach the theory and practical skills required to manage cardiopulmonary arrest in an adult from the time when arrest seems imminent, until either the successful resuscitation of the patient who enters the Intensive or Cardiac Care Unit, or the resuscitation attempt is abandoned and the patient declared dead. All participants, whatever their background or grade, are taught using standardised material and the latest European Resuscitation Council (ERC) guidelines and algorithms. For each course, the programme and participating instructors must be registered and approved by the Resuscitation Council (UK). Quality control is reinforced by evaluation forms completed by the candidates and by the use of regional representatives who are empowered to visit and inspect courses and provide independent feedback. The course is very intensive and lasts a minimum of two days, with a maximum candidate-to-faculty ratio of 3:1. The multidisciplinary faculty must be ALS instructors or instructor candidates (those who have completed the instructor course but have yet to complete two teaching assignments). All candidates receive the ALS course manual at least four weeks before attending the course, together with a multiple choice test for self-assessment, and are expected to be competent in BLS. During the course, a series of practical skill ALS manual 93 ABC of Resuscitation stations and workshops, supplemented by lectures, are used to By the end of 2001, over 65 000 healthcare professionals had teach airway management, defibrillation, arrhythmia successfully completed a Resuscitation Council (UK) ALS recognition, the use of drugs, and post-resuscitation care. The ALS course is now well established throughout the Causes and prevention of cardiac arrest, cardiac arrest in United Kingdom, with about 550 courses being run annually in special circumstances, ethical issues, and the management of over 200 centres. After the 1998 guidelines update, the course bereavement are also covered. The fourth edition of the ALS manual was published in 2000 and incorporated recommendations management of cardiac arrest.

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The X-ray findings show good joint congruency Imhaeuser’s Principle in Treatment for SFCE 55 Case with external rotation o o from 10 to 70 ( midpoint 40 ) Imhaeuser’s osteotomy 1 50mg luvox overnight delivery anxiety or heart attack. Scheme of Imhauser’s osteotomy [1 purchase luvox 50 mg with amex anxiety examples,2] shown by an example case with external mid- point of 40° (from 10° to 70° external rotation) Fig. She has two children, has no clinical complaints, and lives an active life as a housewife. Imhaeuser’s osteotomy [1,2] was performed on the left hip and a prophylactic pinning was done on the right hip (Fig. He works in a restau- rant as a cook and does not have any complaints about either leg. Right, prophylactic pinning; left, Imhaeuser’s osteotomy [1,2], 1 year postoperative 58 M. Pinning results Number of joints: 71 JOA hip score: 100 points for all joints Complications (AVN, chondrolysis, etc. In all cases the Japanese Orthopaedic Association (JOA) hip score was 100 points of a pos- sible 100 points. Complications such as avascular necrosis (AVN) of the femoral head or chondrolysis were not observed. Leg length was examined in 24 cases that were pinned on both hips; 20 cases had no discrepancy and 4 cases had some leg length discrepancy less than or equal to 1cm. Imhaeuser’s osteotomy results Number of cases (joints): 22 (23) JOA score: >90 points Complication (AVN, chondrolysis, etc. The postoperative JOA hip score was more than 90 points of a possible 100 points. Early complications, including femoral head necrosis or chondrolysis, were not observed. The preoperative tilt angle of epiphysis, on average 52°, was reduced to less than 30° with an average of 22° after surgery. As for leg length, 20 cases had a discrepancy of less than 1cm, whereas the remain- ing 2 cases had a discrepancy less than 3cm. Except for 1 hip with an advanced stage of osteoarthritic (OA) change, 15 hips developed normally. Although 7 hips showed coxa valga, there was good joint congruity and no findings of OA change. Conclusion Long-term follow-up of SFCE, treated in accordance with Imhaeuser’s principle, showed satisfying results. Imhaeuser G (1962) Ueber Dislokation der proximalen Femurepiphyse durch Schae- digung der Wachstumzone (Dislokation der Hueftkopfepiphyse nach vorn-unten). Sofue M, Endo N (1993) Slipping of the femoral capital epiphysis (in Japanese). In: Yamamuro T, Inoue S (eds) Comprehensive textbook of orthopaedic operations, vol 11. Sofue M, Endo N (1997) The results of epiphyseal slipping of femoral head treated with Imhaeuser’s method (in Japanese). Sofue M, Hatakeyama S, Endo N, et al (2005) Imhaeuser’s three dimensional osteot- omy for slipped femoral capital epiphysis (in Japanese). Eine klinische Untersuchungs- methode bei Epiphyseolysis capitis femoris. Zeichenbeschreibungen, aetiopathogene- tische Gedanken, klinische Erfahrungen. Z Orthop 117:333–344 In Situ Pinning for Slipped Capital Femoral Epiphysis Satoshi Iida and Yoshiyuki Shinada Summary. We reviewed retrospectively 28 hips of 25 patients (22 boys and 3 girls) after in situ pinning for slipped capital femoral epiphysis. Fourteen hips were mild slips (lateral head–shaft angle less than 30°), 10 hips were moderate (30°–59°), and 4 hips were severe (60° or greater). All patients had no hip pain at the latest follow-up; however, the range of internal rotation was mildly limited in 11 hips.

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We performed epiphysiodesis by a cancellous bone screw in this position cheap luvox 50mg anxiety symptoms valium treats. Neither defor- mity of the femoral head nor necrosis was found in the final follow-up period cheap luvox 100mg free shipping anxiety symptoms jumpy, and he had an excellent postoperative course (Fig. Posterior tilting angle (PTA) Type of slip Admission Postoperative Final follow-up Acute 54. Acute slipped capital femoral epiphysis (SCFE) in a 12-year-old boy with poste- rior tilting angle (PTA) of 65° on admission (a). We performed epiphysiodesis with cannulated screw fixation, PTA was 20° (b). At 6 months after epiphysiodesis, the cancellous bone screw was removed with excellent results (c) 12 M. We performed an anterior rotational osteotomy (ARO) of the femoral head using an F-system device. A limitation of internal rotation was seen 4 years postoperatively; however, X-rays and clinical examination findings were excellent during the course (Fig. After anterior rotational osteotomy (ARO) of the femoral head using an F-system device, PTA was 32° (b). Limitation of internal rotation was seen 4 years postoperatively (d) Treatment of Slipped Capital Femoral Epiphysis 13 c Fig. Continued Case 3 A 13-year-old boy suffered from acute SCFE with a PTA of 85°. We performed epi- physiodesis with cannulated screw fixation because the slip had been reduced by skeletal traction for 10 days. We feared the development of avascular necrosis of the femoral head; therefore, we applied a non-weight-bearing brace and observed the patient’s condition. However, we observed flattening of the lateral femoral head after 8 months. We removed the screws 2 years postoperatively and performed strut allograft bone grafting. Twenty years later, the patient was able to walk without pain but had developed a femoral head deformity (Fig. We performed epiphysio- desis with cannulated screw fixation, PTA was 18° (b). We removed the screws 2 years postoperatively and performed strut allograft bone grafting (d). At follow-up at 20 years, he could walk without pain but had developed a femoral head deformity (e) Treatment of Slipped Capital Femoral Epiphysis 15 Discussion For treatment, epiphysiodesis such as in situ pinning was performed for a slight slip of less than 30°. For a more than moderate slip, in situ pinning, rotational Sugioka osteotomy, three-dimensional Southwick osteotomy, Imhauser osteotomy, or a sub- capital osteotomy was performed [1–3]. The strategy of treatment for SCFE in our institution for acute or acute on chronic SCFE is to reduce the slip slowly by skeletal traction. After reduction and stabilization, we perform epiphysiodesis by pinning. We do not perform invasive manipulative reduction because that could lead to avascular necrosis of the femoral head. For chronic SCFE, we perform in situ pinning or an osteotomy, depending on the degree of slip. When the preoperative PTA is less than 30° in slip, we perform epiphysiodesis by in situ pinning. When the PTA is 30° to 50°, or moderate slip, we perform a valgus flexion osteotomy, and when the PTA is more than 50° in slip, we perform ARO (Fig. Regarding prophylactic fixation of the unaffected side, Hotokebuchi and Sugioka and Kato et al. We have always considered bilateral slip a high risk and have been concerned about the contralateral side of the slip. Therefore, we have performed prophylactic fixation of the unaffected side for all patients since 1985.

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Werecognize that the outcome in an icine that orthopedic surgery was ready to make individual case is not accurately predictable and that a substantial contribution to basic musculoskele- chance plays a role in determining the result cheap luvox 100mg fast delivery anxiety disorder 3000. buy 100 mg luvox anxiety symptoms perimenopause.. Barr was one of the founders and must use every means at our disposal to lessen the peril original members of the Orthopedic Research and of the surgical experiment. In this address he proposed a special committee The members of the many boards and commit- for the study of surgical materials. Barr served will long remem- organized and was chairman of a Joint Commit- ber the significant role that he played in their 23 Who’s Who in Orthopedics deliberations. He took an active part in the policy decisions and review of the services of the Shriners’ Hospital when he succeeded Dr. In 1955, he became a member of the Medical Advisory Board of the Alfred I. His counsel and advice had a great deal to do with the development of the institute’s present research and clinical programs. His long membership on the Board of The Journal of Bone and Joint Surgery was of tremendous assistance to the editor and associates. Following the war he was on the Orthopedic Committee of the National Research Council. While serving on this committee he was responsible for an excellent study of the treatment of carpal scaphoid fractures in the armed forces during the war. Barr became a founder member of the American Academy of Orthopedic Surgeons in 1794–1871 1934 and was its president in 1951–1952; he became a member of the American Orthopedic John Rhea Barton, the son of Judge William Association in 1937. His grandmother was the sister of the well- New England Surgical Societies, the American known astronomer David Rittenhouse; an uncle Academy of Arts and Sciences, the American was the early naturalist and antiquarian Benjamin Medical Association, the American College of Smith Barton. John Rhea Barton served his Surgeons, the American Board of Orthopedic apprenticeship in medicine in the Pennsylvania Surgery and the International Society of Ortho- Hospital, taking his medical degree in 1818. He was an worked under the celebrated Philadelphia physi- honorary member of The British Orthopaedic cians Philip Syng Physick (who treated bone Association. He was for many years the senior nonunions by the seton), Dorsey and Hewson. In operating, he was He was a careful, meticulous surgeon and an ambidextrous and rarely changed his position at excellent trainer and stimulator of the young the operating table. He unusual ability to analyze situations clearly and introduced bran dressings in the treatment of make wise decisions, for which ability he was compound fractures, which, as his biographer greatly admired by all who knew him. Kelly states, actually were an excellent breeding With the passing of Joseph Seaton Barr on place for myriads of bedbugs. His careful, precise December 6, 1964, at the age of 63, orthopedic observations led him to describe a rare type of surgery suffered a great loss. He will long be subluxation of the carpus that was associated with remembered by his host of friends, students, and a fracture of the articular rim of the radius, which associates; his many contributions to orthopedic to this day is known as a Barton’s fracture of the surgery can never be forgotten. In the absence of roentgenographic confir- mation, it is astonishing that he could separate this entity out of the large group of Colles fractures 24 Who’s Who in Orthopedics presenting themselves to him for treatment. His him in the forefront of that group of early three most noteworthy surgical contributions to American surgeons forming the vanguard of the the literature are the paper described above, his new American School of Surgery. As Oliver Longitudinal Section of the Lower Jaw for the Wendell Holmes said, “Genius comes in clusters, Removal of a Tumour, and his New Treatment for and shines rarely as a single star. He wired a fractured patella particularly as he made rounds in the hospital; he as early as 1854, and, although his patient died of spoke words of encouragement to each bed postoperative suppuration, Barton believed that inmate and left sympathy and comfort in his he had established a new principle in the treat- wake. Barton, then 32 years of age, was a young Although the Dictionary of American Biogra- attending surgeon on the staff of the Pennsylva- phy states that he retired from active practice in nia Hospital in Philadelphia. He had seen in the 1840, his obituary in the Lancaster Intelligencer hospital a sailor named John Coyle who had of 1871 states that in the steady pursuit of his pro- fallen from the ship’s hatchway into the hold a fession for 30 years he acquired an ample fortune, year previously and sustained some type of frac- which was increased largely by his marriage to ture of the hip. Due it is difficult to unearth further biographical mate- to the lack of roentgenograms in those days, rial of this distinguished man who, in the first 17 opinion varied as to the real nature of the primary years of his practice, was responsible for several injury sustained. There his practice was chiefly a consultative one; his was a history of prolonged inflammatory reaction advice was solicited by both physician and patient in the hip following the injury, so that the patient when difficult surgery was contemplated.

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