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By U. Benito. Loyola University, New Orleans. 2018.

The tasks of the group: clear definition of tasks is something that must be high on the agenda of the first meeting kamagra soft 100 mg line. The reason for the small group sessions and their purpose in the course must be explained generic kamagra soft 100 mg on-line. In addition, you should initiate a discussion about how you wish the group to operate, what degree of preparation you expect between group meetings, what role you intend to adopt, what roles you expect the students to assume and so on. Because such details may be quickly forgotten it is desirable to provide the students with a handout. Ideally it is one that is open, trustful and supportive rather than closed, suspicious, defensive and competitive. It is important to establish that the responsibility for group maintenance rests with the students as well as with the teacher. The firm but pleasant handling of the loquacious or dominating students early in the session or the encouragement of the quiet student are obvious examples of what can be achieved to produce the required environment for effective group discussion. The successfully managed group will meet the criteria shown in Figure 3. A structured approach to tasks and to the allocation of the time available is a useful tool for you to consider. An example of such a structured discussion session is illustrated in Figure 3. Note that the structure lays out what is to be discussed and how much time is budgeted. Such a scheme is not intended to encourageundue rigidity or inflexibility, but to clarify purposes and tasks. This may seem to be a trivial matter, but it is one which creates considerable uncertainty for students. You need to be alert to how time is being spent and whether time for one part of the plan can be transferred to an unexpected and important issue that arises during discussion. Another structure, not commonly used in medical educa- tion, is illustrated in Figure 3. From an individual task, the student progresses through a series of small groups of steadily increasing size. There are special advantages in using this structure which are worth noting: it does not depend on prior student preparation for its success; the initial individual work brings all students to approximately the same level before 45 discussion begins; and it ensures that everyone partici- pates, at least in the preliminary stages. INTRODUCING STIMULUS MATERIALS A very useful means of getting discussion going in groups is to use what is generally known as ‘stimulus material’. We have seen how this was done in the snowballing group structure described previously. It is limited only by your imagination and the objectives of your course. Here are a few examples: A short multiple-choice test (ambiguous items work well in small groups).

If a new alcohol is being oxidised order 100mg kamagra soft with mastercard, then the effect of the surroundings could be calculated buy cheap kamagra soft 100mg line, while the experimental protocol could be taken from the paper. The calculations would also guide the literature searching, because the calculation may suggest a side reaction which could be checked in the literature. Literature precedent may be a more reliable guide than calculation as to which of several possible reactions is likely to work best. It is only just becoming possible to use information technology to rou- tinely search the chemical literature and to do chemical calculations which are directly useful to synthetic chemists. Each of these fields is likely to develop in a powerful way in its own right over the next decades. GOODMAN However, it is the interaction between these field which gives the best chance of computers becoming the world’s best synthetic chemists. Chess is not solved, in the way the simple game noughts and crosses is solved, because the outcome of every game is not completely predict- able. In the same way, it may not be necessary for computers to analyse all possible routes to a molecule to be best at organic synthesis. This makes the problem much easier, if it is assumed that there are many good routes. The computer would begin by guessing a route, and if it did not work, partially retracing steps, and trying again, thus reusing the information which had already been gathered or calculated so far as possible. Thoroughly exploiting the information that was developed with each potential synthesis would be a crucial step. The time required for conformation searching is dramatically reduced, if similar molecules have already been investigated. For example, PM-toxin has a very compli- cated potential energy surface, which may be searched directly by tradi- tional methods, or which may be mutated from the conformation search of an alkane, which is easier as it is particularly susceptible to a genetic algorithm based approach. It depends how difficult syntheses are (and will provide a way of quantifying this). It may be that the best possible synthesis is not required, provided that a good route is available, as assessed by total cost (including waste disposal and safety pre- cautions), by time required, by certainty of success, by ease of using robots to follow the procedure, and so on. Brute force methods of calculating new synthetic routes will not be fea- sible for a very long time, and pure literature based methods will also be very time consuming, and will be restricted by the data available. An hybrid approach provides the best hope for designing a synthetic machine, and it is likely that such programs will become increasingly useful in the new millennium. Most of the elements of these programs are available now, but they are not sufficiently useful that they are an essential part of every chemist’s work. An exhaustive solution may not be possible, so it is World champion chemists 57 not certain that computers will beat people.

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The campaign implicitly accepted homosexuality (‘gay or straight’ generic 100mg kamagra soft overnight delivery, as the government’s propaganda put it discount kamagra soft 100 mg with mastercard, implying a moral equivalence that was anathema to the Christian right). It also accepted sex outside marriage, another unprecedented public gesture for a Conservative government. In the early stages of the Aids campaign, journalists were bemused to discover that cabinet ministers and senior civil servants were discussing the relative risks of vaginal and anal intercourse, the virtues of oral sex and the delights of condoms; within months these topics had moved to the mainstream media and before long were on the national curriculum. While radicals and gay activists applauded the government for its boldness in promoting open discussion about matters of sex and urged it to go further, they ignored the fact that the ‘safe sex’ code promoted by the Aids campaign simply replaced the traditional moral framework with a new one. It replaced the fear of eternal damnation, which no longer offered much of a deterrent to youthful sexual experimentation, with fear of a lethal disease, a much more potent force. The new moral code no longer exhorted people towards ‘goodness’, but replaced this with the ethic of ‘safety’, according to which all manner of sexual activity could be classified as ‘low’, ‘medium’ or ‘high risk’. Instruction in the new moral framework was provided by an army of Aids activists, employed at every level in health, education, local government as well as through television programmes, posters, leaflets, pamphlets and books. This should not be understood as a critical comment, but as a measure of Lawson’s approval. This article was prompted by the revelation that the government had grossly exaggerated the risk of the heterosexual spread of Aids as a way of discouraging young people from having sex. He accepted that the government’s campaign was based on an ‘untruth’, but argued that this was a ‘good lie’, because it had ‘spent a huge amount of money… encouraging reflection and discrimination in the area of sexual behaviour’. This liberal endorsement of the cynical manipulation of public fears of a terrifying, but mercifully rare disease, in the cause of promoting a new framework of sexual morality well sums up the cynical character of the Aids scare and the real moral corruption that it embodied—in medicine as well as in politics and journalism. It is unpardonable to try to alter the diet of an entire population without sufficient information. The discreet scepticism of these two eminent medical authorities regarding the central themes of government public health policy on both sides of the Atlantic indicates two things: that some medical experts question the scientific basis of this policy— and that this questioning has had done little to deter the rise of public health 35 THE REGULATION OF LIFESTYLE promotion to become a major influence in modern society and in the everyday lives of its citizens. The ‘big four’ injunctions of health promotion—to stop smoking cigarettes, to eat a healthy diet, to drink alcohol in moderation, and take regular exercise—have become firmly established in popular consciousness. People may not heed the advice coming at them from the government, the media, the medical profession, but nobody can now be unaware of the key components of what is officially regarded as a healthy life. The huddles of furtive smokers outside ordinary houses as well as public buildings symbolise the ascendancy of preoccupations about health over social behaviour. Over the past decade the reach of health promotion has widened and deepened. The evils of smoking have been compounded by the perils of passive smoking. Every schoolchild knows how to calculate the units of alcohol in different beverages and the approved limits for men and women.

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Fasciculations may be seen in: Motor neurone disease with lower motor neurone involvement (i buy kamagra soft 100mg overnight delivery. Fasciculations may need to be distinguish from myokymia or neuromyotonia buy cheap kamagra soft 100 mg online. Journal of the Neurological Sciences 1997; 152 (suppl1): S43-S48 Layzer RB. Muscle Nerve 1994; 17: 1243-1249 - 120 - Fatigue F Cross References Calf hypertrophy; Cramp; Fibrillation; Lower motor neurone (LMN) syndrome; Myokymia; Neuromyotonia Fast Micrographia In “fast” micrographia, written letters are microscopic from the outset, sometimes approximating to a straight line, though produced at nor- mal speed without fatigue. This pattern has been observed in progres- sive supranuclear palsy and with globus pallidus lesions, and contrasts with the “slow” micrographia, writing becoming progressively slower and smaller, seen in idiopathic Parkinson’s disease. Journal of Neurology, Neurosurgery and Psychiatry 2002; 72: 135 (abstract) Cross References Micrographia Fatigue The term fatigue may be used in different contexts to refer to both a sign and a symptom. The sign of fatigue, also known as peripheral fatigue, consists of a reduction in muscle strength with repeated muscular contraction. This most characteristically occurs in disorders of neuromuscular junction transmission (e. In myasthenia gravis, fatigue may be elicited in the extraocular muscles by prolonged upgaze caus- ing eyelid drooping; in bulbar muscles by prolonged counting or speech causing hypophonia; and in limb muscles by repeated contrac- tion, especially of proximal muscles (e. Fatigue in myasthenia gravis is understood as a decline in the amount of acetylcholine released from motor nerve terminals with successive neural impulses, along with a reduced number of functional acetylcholine receptors (AChR) at the motor end-plates, due to binding of AChR antibodies and/or comple- ment mediated destruction of the postsynaptic folds. This may occur in multiple sclerosis (MS), post-polio syndrome, post-stroke syndromes, and chronic fatigue syndrome (CFS). In MS and CFS, fatigue may be a prominent and disabling complaint even though neurological examination reveals little or no clinical deficit. This type of fatigue is ill-understood: in MS, frequency- - 121 - F Femoral Stretch Test dependent conduction block in demyelinated axons has been sug- gested, as has hypothalamic pathology. Current treatment is sympto- matic (amantadine, modafinil, 3,4-diaminopyridine) and rehabilitative (graded exercise). Fatigue may be evaluated with various instruments, such as the Krupp Fatigue Severity Score. Drugs 2004; 64: 1295-1304 Cross References Dystonia; Hypokinesia; Hypometria; Micrographia; Weakness Femoral Stretch Test The femoral stretch test, or reverse straight leg raising, consists of extension of the hip with the knee straight with the patient lying prone, a maneuver which puts traction on the femoral nerve or L3 root and may exacerbate pain in a femoral neuropathy or L3 radiculopathy, perhaps due to a retroperitoneal hemorrhage. Cross References Lasègue’s sign Fencer’s Posture, Fencing Posture Epileptic seizures arising in or involving the supplementary motor area may lead to adversial head and eye deviation, abduction and external rotation of the contralateral arm, flexion at the elbows, and posturing of the legs, with maintained consciousness, a phenomenon christened by Penfield the “fencing posture” because of its resemblance to the en garde position. To avoid falling and to maintain balance the patient must “chase”the cen- tre of gravity, leading to an increasing speed of gait and a tendency to fall forward when walking (propulsion). A similar phenomenon may be observed if the patient is pulled backward (retropulsion). Festination is common in idiopathic Parkinson’s disease; it is asso- ciated with longer duration of disease and higher Hoehn & Yahr stage. Festination may be related to the flexed posture and impaired postural reflexes commonly seen in these patients.

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Charcot joints were originally described in the context of tabes dorsalis (knees buy kamagra soft 100 mg lowest price, shoulders cheap kamagra soft 100 mg on-line, elbows, hips, ankles) but they may also be seen in: Syringomyelia (elbow) Hereditary sensory (and autonomic) neuropathies (HSAN, “con- genital insensitivity to pain”; ankles) Leprosy Diabetes mellitus References Pearce JMS. London: Imperial College Press, 2003: 563-565 Cross-References Analgesia; Main succulente Charles Bonnet Syndrome Described by the Swiss naturalist and philosopher Charles Bonnet in 1760, this syndrome consists of well-formed (complex), elaborate and often stereotyped visual hallucinations, of variable frequency and dura- tion, in a partially sighted (usually elderly) individual who has insight into their unreality. Predisposing visual disorders include cataract, macular degeneration, and glaucoma. There are no other features of psychosis or neurological disease, such as dementia. Reduced stimulation of the visual system leading to increased cortical hyperexcitability is one possible explanation (the deafferentation hypothesis), although the syndrome may occasionally occur in people with normal vision. Pharmacological treatment with atypical antipsychotics or anticonvulsants may be tried but there is no secure evidence base. Complex visual hallu- cinations in the visually impaired: the Charles Bonnet syndrome. Survey of Ophthalmology 2003; 48: 58-72 Cross References Hallucinations Chasm - see YAWNING - 71 - C Cheiro-Oral Syndrome Cheiro-Oral Syndrome - see PSEUDORADICULAR SYNDROME Cherry Red Spot at the Macula The appearance of a “cherry red spot at the macula,” caused by the contrast of a red macula against retinal pallor, occurs in a number of metabolic storage disorders, including: Sialidosis (type I = cherry red spot-myoclonus syndrome) Gangliosidoses (e. Annals of Neurology 1985; 17: 356-360 Cross References Maculopathy Cheyne-Stokes Breathing - see PERIODIC RESPIRATION “Chicken Wings” In facioscapulohumeral (FSH) muscular dystrophy, the bulk of the deltoid and forearm muscles is normally well preserved, while biceps and triceps are wasted (and may be weak), thus giving rise to an appearance of the upper limbs sometimes labeled as “chicken wings” or “Popeye arms. There may also be athetoid move- ments (slow, sinuous, writhing), jointly referred to as choreoathetosis. Severe proximal choreiform movements of large amplitude (“fling- ing”) are referred to as ballism or ballismus. When, as is often the case, such movements are confined to one side of the body they are referred to as hemichorea-hemiballismus. There may be concurrent abnormal muscle tone, either hypotonia or rigidity. Hyperpronation of the upper extremity may be seen when attempting to maintain an extended posture. The pathophysiology of chorea (as for ballismus) is unknown; movements may be associated with lesions of the contralateral sub- thalamic nucleus, caudate nucleus, putamen, and thalamus. One model - 72 - Chromesthesia C of basal ganglia function suggests that reduced basal ganglia output to the thalamus disinhibits thalamic relay nuclei leading to increased excitability in thalamocortical pathways which passes to descending motor pathways resulting in involuntary movements. Recognized causes of chorea and choreoathetosis are many, including: ● Hereditary: Huntington’s disease (HD) Dentatorubropallidoluysian atrophy (DRPLA) Neuroacanthocytosis Benign hereditary chorea Paroxysmal dyskinesias: paroxysmal kinesigenic choreoathetosis (PKC) and paroxysmal dystonic choreoathetosis (PDC) ● Sporadic: Drugs: levodopa therapy in later stages of idiopathic Parkinson’s disease Pregnancy: chorea gravidarum Hyperthyroidism Systemic lupus erythematosus (SLE) Sydenham’s chorea (post-infectious, rheumatic chorea, St. Vitus dance, PANDAS) Polycythemia rubra vera (hyperviscosity) AIDS Hyperosmolality (hyperglycemia, hypernatremia) CNS tumor Multiple sclerosis (rare) Variant Creutzfeldt-Jakob disease “Senile chorea” (diagnosis of exclusion, especially of HD) Where treatment is necessary, antidopaminergic agents, such as dopamine receptor antagonists (e.

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