By H. Yussuf. Santa Clara University.

He became most impassioned in discussing today’s low standards on television discount ginette-35 2 mg amex, which, in his view, should be family-friendly. Goodall repeatedly mentioned his age (he is about fifteen years older than his wife) and his fears of burdening her. He frequently searches the Internet, looking for advances in treating MS. At the follow-up focus group, about eighteen months after our initial interview, his walking had worsened slightly. Esther Halpern Mid seventies; white; married to Harry, with one grown daughter; completed college; retired flute teacher; middle income; spinal stenosis (back problem); uses a four-wheeled rolling walker. Harris is a black woman in her late forties with arthritis of her knees and hands and severe back pain. When we met at my office, she wore a plush pur- ple pants suit, and her face was carefully made up, her hair arrayed in dozens of braids lengthened by hair extenders. She wasn’t antagonistic—just emphatic and sure of the realities of her experiences. Harris had earned her high-school equivalency diploma and had worked in a department store stockroom. But she left the job because of painful arthritis in her hands and is now unemployed and low income, receiving Med- icaid. She lives in a first-floor apartment in a crowded working-class town near Boston. Harris works hard as a divorced single mother raising children: she had seven children living with her, two of them her biological children, and her older children come round to help care for the younger ones. Harris con- siders all these children as her own, treating this responsibility as central to her life.

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There are few data available on the use of intrathecal baclofen in primary dystonia and the use of this therapy in primary dystonia is controversial order 2mg ginette-35 with mastercard. Several other medications may be effective in a minority of children with primary dystonia. Botulinum toxin injections are highly effective in focal and segmental dystonias due to the limited number of muscles involved. It plays a smaller role in treatment of generalized dystonia because of the large number of involved muscles. However, it can be quite helpful in reducing symptoms when isolated problematic muscle groups are targeted. Nonpharmacologic Treatment Promising neurosurgical treatments of dystonia include thalamotomy, pallidotomy, and deep brain stimulation (DBS) of the globus pallidus pars interna. Thalamotomy was the most frequently performed ablative procedure in the past. However, when performed bilaterally, there is a high incidence of dysarthria and dysphagia. More recently, pallidotomy has been pre- ferred to thalamotomy because of the lower morbidity. Direct comparison has not been performed, but data suggest that pallidotomy is more effective than thalomot- omy in DYT-1 dystonia. Most recently, pallidal DBS has been used to treat DYT1 dystonia with promising early results. The effects of DBS are similar to those of pallidotomy, but DBS is programmable and does not involve a destructive lesion. Physical and occupation therapy can be helpful in maximizing the function of individuals with primary generalized dystonia. Secondary Dystonia Some secondary dystonias may also respond to levodopa and therefore, a trial of levodopa is recommended for any child in whom dystonia is a prominent component Dystonia 143 of their neurologic syndrome. For example, if the cause is a medication or other toxin, the best course is to eliminate that agent.

Erythrocytes are…’ Using examples Use examples as part of your explanations to illustrate or help to clarify a point purchase ginette-35 2mg visa. Students need to avoid the standard textbook ones, as tutors will be only too familiar with these. Use case studies or examples from clinical practice as these are particularly effective. The wording must be ex­ act and a reference provided to indicate the source. Use quotes: ° to corroborate (for example statistical evidence) ° to give authority ° to illustrate ° to help explain ° to add new information ° to provide interest ° to make use of a unique expression. Paraphrasing This is where an original text is rephrased by the writer in his or her own words. Paraphrasing is a common way of referring to material from other WRITING AS AN AID TO LEARNING 137 sources. However, in order to fully understand the original, the writer must be effective in interpreting the material. Remember you still need to acknowledge your source by providing a reference. Writing a summary Written summaries are a brief and concise review of the main points ex­ tracted from a longer composition. The conclusion at the end of a piece of writing often contains a summary. They are also used within the main body of the text before a topic shift. These periodic reviews of the content help consolidate the reader’s understanding and add emphasis to the writer’s message.

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The Nobel laureate Peter Medawar dismissed problems arising from the apparently ‘oceanic volume of scientific knowledge’ as ‘essentially technological problems buy cheap ginette-35 2mg on-line, for which adequate technological solutions are rapidly being found’ (Medawar 1986:70). As Flexner wrote, ‘the teacher cannot provide the student with bits of information likely to be useful, nor can study be prolonged to include everything’ (Flexner 1925:13). The increase in the scale of medical knowledge over the past century makes no qualitative difference to this judgement. The key issue was not facts, but ‘habituation to method’; the role of the teacher was to select knowledge to exemplify scientific procedure. He insisted that ‘the facts in question cannot be passively learned and mechanically applied’ (Flexner 1925:13). The object of medical education was ‘primarily the effort to train students in the intellectual technique of inductive science’ This required ‘an extraordinarily active and oft-repeated mental process, involving observation, sorting out, combining, inferring, trying’. The real problem of medical teaching over the years has not been a surfeit of facts but a deficit of training in the intellectual technique of inductive science. Unfortunately, the promoters of the new curriculum have responded to popular criticisms of ‘overload’ by replacing inductive science with a vulgar empiricism. Medical 149 THE CRISIS OF MODERN MEDICINE science is disparaged as ‘knowledge’ and reduced to easily assimilated fragments of a ‘core’ curriculum, according to the criteria of relevance and enjoyability. The main concern of medical schools has shifted towards the inculcation of what are considered to be the correct attitudes. The Oxford physician David Weatherall is one of the few leading medical figures to have pointed—in a strikingly tentative way—to the dangers of this approach: While the motives behind these changes are admirable, it is essential that, while trying to improve the social, pastoral and communication skills of our future doctors, we do not dilute their scientific education. Indeed such teaching has extended rapidly into the post-graduate domain and into the ‘continuing medical education’ of practising doctors. Inadequacies in communication skills are one of the most frequently cited problems of ‘poorly performing doctors’ and the provision of appropriate tuition in this area is one of the functions of the ‘assessment and support centres’ proposed by the government. To anybody who has encountered a doctor who was rude or patronising or who spoke in incomprehensible medical jargon (and anecdotal evidence suggests that these are all familiar experiences) it would seem a good idea that medical students should be taught how to communicate with their future patients. In one widely used set of guidelines on communication, there is a striking combination of the most elementary ‘basic steps’ and suggestions about profoundly difficult matters such as ‘responding to patient feelings’ (Buckman 1994).

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The answer was right there ginette-35 2mg lowest price, and my spirits began to buoy as I came to under- stand that if I were to have any hope of “flying,” I had to release anything that was weighing me down. Sure, the pain was taking a toll, but it was really all those negative thoughts and attitudes that were my shackles. Recognizing Self-Destructive Attitudes and What to Do About Them The following common attitudes or responses to mystery maladies have the potential for being self-destructive and drowning us in pessimism. If you can learn to recognize and deal with these and other self-destructive atti- tudes before they get the upper hand, serious psychological distress can be avoided and progress toward your diagnostic solution can continue. Self-Medicating to the Point of Addiction Some of us self-medicate to the extent that we use drugs for more than our physical pain. Admittedly, it takes a great deal of honesty to face either possibility. If you are taking pain medication for more than just physical relief or your intake of pain medication keeps escalating, be willing to explore the possibility that you are using it to dull more than your physical pain or that you may be hooked. Seek an opinion from those around you about this issue and then get help. Rosenbaum had to admit to himself that he had begun using his pain medication to numb his feelings of rage and shame. It was easier for him to make progress in coping with his mystery malady once he did. After all, most mystery malady patients have been told this more than once in the process of trying to find a diagnosis and cure. Unless you are suffer- ing from somatization disorder (described in Chapter 12), this thought is dangerous for a whole host of reasons. Believing our problem is psychological, we may ask for or be placed on antidepressants and antianxiety drugs when they are not necessarily what we need. In A Dose of Sanity: Mind, Medicine, and Misdiagnosis (John Wiley & Sons, 1996), psychiatrist Sydney Walker writes that one of the reasons patients with mysterious diseases like lupus don’t always get diagnosed early on is because they often develop psychiatric problems before their physical symptoms appear.

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