By S. Ugo. University of the South. 2018.

Mild slip was observed in 10 patients discount 100 mg pristiq with mastercard, moderate slip in 5 generic pristiq 50 mg without a prescription, and severe slip in 1 order 50mg pristiq mastercard. Surgery was performed in all patients; Southwick intertrochanteric osteotomy was performed in 5 patients and in situ pinning in 11 buy pristiq 100 mg cheap. Concerning surgical complications pristiq 100mg with mastercard, methicillin-resistant Staphy- lococcus aureus infection developed in 1 patient and k-wire breakage in 1. Limitation of motion remained in 6 hips, but no hip pain, and normal gait was attained. Slipped capital femoral epiphysis, Retrospective evaluation, Osteotomy, In situ pinning, Early diagnosis Introduction The report in 2004 by the Multicenter Study Committee of the Japanese Pediatric Orthopaedic Association showed a definite increase in patients with slipped capital femoral epiphysis during the previous 25-year period in Japan. However, physi- cians other than pediatric surgeons are infrequently aware of slipped capital femoral epiphysis and do not include this entity in diseases for differential diagnosis; there- fore, its diagnosis rate is low. In addition, there are no treatment methods with established evidence at present. We encountered 16 patients with slipped capital 1Department of Orthopedic Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0944, Japan 2Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan 69 70 M. Subjects and Methods The subjects were 16 patients (12 boys and 4 girls) encountered during the previous 16-year period. The evaluation items were chief complaint, mechanism of injury, initial diagnosis, disease type, radio- graphic findings such as the slipping angle, physique and endocrinological abnor- malities, treatment methods, and complications. For radiographic evaluation, the head–shaft angle on frontal images and the pos- terior tilting angle in the frog-leg position were measured, and the right–left differ- ence was regarded as the slipping angle. The severity of the disease was evaluated mainly based on the posterior tilting angle. Results The chief complaint was hip joint pain in 11 patients, pain from the hip joint to the knee in 3, pain from the hip joint to the thigh in 1, femoral pain in 1, and lower limb pain in 1. The mechanism of injury was sports in 8 patients, falling during running in 1, falling on the stairs in 1, long-distance walking in 1, and unknown in 3: most patients had relatively mild injuries. The mean interval between the onset of symp- toms to the initial visit to the hospital was 69 days and that from the initial visit to diagnosis was 30 days. The duration until diagnosis was relatively short in patients with acute slip but considerably longer in some patients with chronic or acute on chronic slip. The coefficient of the correlation between the onset of symptoms and diagnosis was 0. The initial treatment was performed by an orthopedic surgeon in 11 patients, a surgeon in 3, a pediatrician in 2, and a bonesetter in 1. The initial diagnosis was slipped capital femoral epiphysis in 5 patients, absence of abnormalities in 3, Perthes disease in 2, unknown in 2, and growing pain, transient synovitis of the hip, and femoral neck fracture in 1 each. At the time of the visit to our hospital, a correct diagnosis was soon made in all patients. The disease type was acute slip in 2 patients, chronic slip in 8, and acute on chronic slip in 6. Mild slip (between 0° and 30°) was observed in 10 patients, moderate slip (between 30° and 60°) in 5, and severe slip (>60°) in 1 (Fig. The mean interval between the onset of symptoms and the initial visit to the hos- pital was 69 days and that from the first visit to diagnosis was 30 days. The physique (height, weight) of the patients was compared with its distribution according to age reported by the School Health Statistic Survey in 2005. 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. Relation between head-shaft angle and posterior tilting angle with the mean statistical values, the height of the patients was −10. Com- pared with the mean statistical values, the weight of the patients was −10. 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.

As early as 1907 it had Merseyside because this was so much cheaper become obvious that extensive accommodation than bringing an assistant from Baschurch cheap pristiq 100mg on line. Even and excellent facilities in the central hospital the perambulator wheels were of significance generic 50mg pristiq fast delivery. Many families only one shilling; the ticket for a handcart was had spent their lives in the wilds of Blaenau much more expensive; and it needed only the Ffestiniog pristiq 50mg with amex, or some remote hamlet buy pristiq 100mg with mastercard, with a geo- good-humored domination of Miss Hunt to per- graphical horizon limited to a 20-miles radius buy pristiq 100 mg without prescription. Doctor Urwick was admitted to hospital, could the week-by-week of Shrewsbury accepted the responsibilities of supervision of after-treatment be continued over medical superintendent. More and more beds many months and years when every hospital visit became available and the facilities were steadily called for one day’s travel in each direction? After the 1914–1918 war, a hutted was not enough for the patient to go to the hos- army hospital was taken over. And so still remain and the private wing, known face- a system of after-care clinics was established—a tiously as Harley Street, consists still of the horse- plan that may now appear obvious but which at boxes, which were unwanted after the first war. The first after-care center Girdlestone, Naughton Dunn, McCrae Aitken, was established in Shrewsbury, and as the influ- and many other distinguished contemporary sur- ence of the hospital widened, so were its outposts geons, made it certain that the Baschurch Conva- created. Today, in an area that includes many lescent Home should serve the county and counties, and covers hundreds of miles of rural become the Shropshire Orthopedic Hospital, and and sometimes densely populated country, there in due course should serve the whole country and are 36 after-care centers visited daily or weekly become the Robert Jones and Agnes Hunt Ortho- by orthopedic nurses, physiotherapists, and social pedic Hospital. Gradually, the hospital was rebuilt service workers, and at less frequent intervals by in accordance with Agnes Hunt’s ideals. Every clinic is served by a County the man who was “found” by Sister Hunt, was Voluntary Orthopedic Association. Hundreds inspired by her, and for so many years had served of women, previously untrained as nurses but faithfully as secretary–superintendent. Under his quickly acquiring sufficient knowledge to recog- direction new open-air wards were built; the nize early cases, using their influence to ensure gardens, lawns, and trees, which were imagined that such cases were brought within the ambit of by Miss Hunt, became a reality; and the labora- the center and thus applying themselves to the tory facilities, x-ray equipment, and operating important tasks of preventive treatment, learning 150 Who’s Who in Orthopedics to carry out the instructions of orthopedic nurses within a year, Mr. Rhaiadr Jones and his wife and orthopedic surgeons, giving encouragement were appointed manager and matron, and thereby and moral support to cripples and their parents the Cripples’ Training School gained the services during long months and years of treatment, have of a first-class financier and a devoted woman, devoted their lives and given whole-time service, who have applied themselves to this task. They college was established for the training of crip- were inspired by Agnes Hunt because she worked pled children, of whom no less than 90% have with them; she herself attended the clinics and made their own livings. Let us hope and believe that this Twenty years later, the Disabled Persons’ spirit of devotion, which has been maintained for Employment Act was passed by the government a full generation, will not be dispelled, or even of this country, and the Disabled Persons’ dimmed, by the reforms of hasty planning. Of the one million It was in 1927 that Sister Hunt succumbed to disabled who are now registered in Great Britain, the stimulation of Robert Jones and agreed that a high proportion have been trained to take their the problem was not yet solved. It was not enough place in the open labor market and have proved to search out cripples and arrange hospital and themselves to be no less efficient than their able- after-care treatment. Those few whose disabilities be taught not only the joys of normal recreation were so grave that they could not have been but also the responsibilities of normal work. A expected to compete in the open market have retraining scheme was necessary. She wrote: “I been engaged in the sheltered factories of the collected four boys, already training in the boot Disabled Persons’ Corporation, the trade name of and blacksmith’s shops, and two girls from which is “Remploy. Loyes’ College for informed them that they were ‘The Shropshire Training and Rehabilitation of the Disabled, Orthopedic Training School for Cripples. As this was more than Crafts’ School, Chailey; the Lord Roberts’ I could tell them the meeting adjourned. Institute for the Deaf; and the Duchess of Port- “Before you could say ‘knife’we had one hundred land’s Training College for the Disabled, Not- and fifty names on the waiting list: and not even tingham. Where were they to be realize, when they were appointed solemnly as a housed and fed? How would the hospital forerunners of a great reform in resettlement of committee take this new venture? With Miss Sankey, who is well remembered Cross in 1918, and was created a Dame of the as a superb after-care superintendent, Miss Hunt British Empire in 1926—the highest honor that moved into the Derwen, which was to become the can be awarded to any woman in this country— Cripples’ Training College. There was an early was responsible for important advances in pre- stage when, after being granted £50 by the com- ventive treatment, the creation of an orthopedic mittee, “we also annexed some unconsidered hospital, the organization of an after-care system, trifles from the hospital. Shortly before she died, she asked and wrote: “Ten shillings for leather and two days herself to name the essential qualities of a nurse of man’s time at three pounds ten shillings a week and replied: “Common sense, gentleness, kindli- plus 5 per cent profit equals—?

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The other is to assess their abilities for the purposes of decision making or grading (summative assessment) discount pristiq 50 mg overnight delivery. Formative assessment is a crucial part of the educational process buy cheap pristiq 100 mg on line, especially where complex intellectual and practical skills are to be mastered generic pristiq 100 mg on line. Such assessment is notoriously deficient in medical schools buy 100 mg pristiq mastercard, particularly in regard to clinical teaching (see Chapter 5) pristiq 50mg without a prescription. As no formal examination is required at the completion of the course, the major emphasis of the assessment activities is formative. However, assessment activities of a summative type are conducted during the final two weeks of the programme when aspects of the students’ performance are observed by preceptors and by other staff members. You will note that the assessment of knowledge is left largely to the students themselves. In other circumstances we might have used a written test to assess this component of the course. SEQUENCING AND ORGANISING THE COURSE It is unlikely that the way in which you have set out your objectives, teaching and assessment on the planning chart will be the best chronological or practical way to present the course to students. There are likely to be circumstances in your own context that influence you to sequence a course in a particular way, such as semesters or teaching terms. However, there are also a number of educational grounds upon which to base the sequencing. These include: Proceeding from what students know to what they do not know; Proceeding from concrete experiences to abstract reasoning; The logical or historical development of a subject; Prioritising important themes or concepts; Starting from unusual, novel or complex situations and working backwards towards understanding (e. As our understanding of how different factors can influence learning advances, you should give consideration to the ways in which you can facilitate deep-learning approaches by your students through the way in which you organise 104 105 and manage the course and the kinds of intellectual and assessment demands you place on them. We suggest that you review the relevant sections in Chapter 1 to guide you in this matter. Finally, you will need to consider the broad organising principles behind your course. Will you, for example, offer it in a traditional way with a set timetable of carefully sequenced learning activities culminating in an end-of- year examination? Or will you design your course more flexibly around a completely different approach such as problem-based learning? OTHER COURSE DESIGN CONSIDERATIONS Many of the important educational considerations in designing a course have been addressed, but there are other matters that must be dealt with before a course can be mounted. These are only briefly described because the way in which they are handled depends very much on the administrative arrangements of the particular situation in which you teach. Having said that, we are not suggesting in any way that your educational plans must be subservient to administrative considerations. Clearly, in the best of all possible worlds, the administrative considerations would be entirely subservient to the educational plans but the reality is that there will be a series of trade-offs, with educational considerations hopefully paramount. In planning your new course, you will need to take the following into account. Administrative responsibilities: it will be necessary for one person to assume the responsibility of course co- ordination. This job will require the scheduling of teachers, students, teaching activities, assessment time and re- sources. Allocation of time: many courses are over ambitious and require far more time (often on the part of the students) for their completion than is reasonable. In allocating time, you will need to consider the total time available and its breakdown, and how time is to be spent in the course. It is often desirable to use blocks of time to deal with a particular topic, rather than ‘spinning it out’ over a term, semester or year. It is important that all competing claims are settled early so that orderly teaching can take place. Technical and administrative support: whether you teach a course alone, or as one of a team, you will find a need for support of some kind or other. It may be as simple as the services of someone to prepare course notes and examination papers, or as complex as requiring, at different times, the assistance of technicians and laboratory staff. EVALUATING THE COURSE Many teachers may find a discussion of course evaluation in a chapter on planning rather odd, perhaps believing that this activity is something that takes place after a course has been completed. It is our contention that in teaching you should continually evaluate what you are doing and how the course design and plans are working out in practice. In this way, modification and adjustments can be made in a systematic and informed manner.

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He attended to waste any time when travelling between the McGill University and the McGill Medical many hospitals order pristiq 100mg fast delivery, he used to read journals or correct School cheap pristiq 50 mg without prescription, graduating in 1926 discount pristiq 100 mg line. Bosworth’s hobbies the University of Iowa where he was a student of included boating order 100 mg pristiq overnight delivery, flying buy 50mg pristiq fast delivery, and photography. His Arthur Steindler, and where he received a Masters skill with his Leica cameras was such that he did Degree in orthopedics. His orthopedic career was his own photography for all of his publications. He was a member of the faculty of the of the Year, 1954 University of British Columbia. Boucher was —Internship—Los Angeles County Hospital, a member and past president of the Canadian 1932 Orthopedic Association, the International Society —Surgical residency—Kern County Hospital, of Orthopedic Surgery and Traumatology, and the Bakersfield, California, 1932–1934; surgical American Academy of Orthopedic Surgeons. He coached Canadian football for —Orthopedic residency—Campbell Clinic, several years and wrote several books for the use Memphis, Tennessee, 1934–1936 of trainers and coaches. He was an avid hunter —Orthopedic practice—White Memorial Hospi- who enjoyed training his own hunting dogs. Farm work and car- Section, National Institutes of Health, pentry added much to the strength, endurance, 1957–1961; Orthopedic Research and Educa- and manual dexterity that were later to enhance tion Foundation, Trustee, 1964, President, his surgical skills. After attending Emmanual 1966; Campbell Foundation, President, Missionary College in Berrien Springs, Michigan, 1970–1974 he entered the College of Medical Evangelists, —Military—orthopedic consultant to the army in now Loma Linda University. Japan and Korea, 1951 A brief outline of his activities reflects his —Extraordinary honor—the National Order of diverse interests and the high esteem of his the Southern Cross, Brazil, 1953 peers: 33 Who’s Who in Orthopedics Dr. Boyd had the main ingredients that are nec- total hip replacements, and the electrical stimula- essary to be a good physician and surgeon: intel- tion of bone for nonunion. He contributed more ligence, integrity, compassion, humility, and than 60 articles to the literature and participated dedication, sprinkled with a dash of humor. He in the six editions of Campbell’s Operative also possessed the quality of greatness: the ability Orthopedics. His interest in research continued to evaluate a problem logically, to separate the throughout his retirement. He had the with his thoughtfulness and genuine interest in pleasure of knowing intimately all of the presi- people, endeared him to his patients as well as his dents of the Academy up to the time of his death. All who knew him could appreciate During his tenure as secretary of the Academy the high quality of this man, especially the young, (from 1947 to 1952), there was no full-time exec- for he could always find the time to be with them utive director; he always believed that one of his and to let them know that he appreciated their major contributions to the Academy was his part efforts. Charles Heck that he should ladder; you may pass them again on the way leave an excellent orthopedic practice to become down. His vast knowl- Photography was one of his few hobbies, and edge of medicine and his ability to evaluate many have enjoyed his travelogue sound-slide people objectively, as well as his willingness to programs. The first was a result of his camera listen and provide service and his extraordinary hunt of wild game in Africa. Background music judgment were such that he developed a large was provided by his close friend, Hugh Smith. Many patients This was the stimulus for the educational sound- from Central and South America sought his slide program of the Academy. He truly enjoyed the practice of medicine, Traveling was his true avocation. He and his and no problem was too small to attract his wife, Jean, meticulously planned the trips, read interest. He was truly a usually knew more of the history of an area than surgeon’s surgeon. He always could find time to allowed him to apply his great knowledge of visit some medical institution or friend, and often anatomy and vast surgical experience, so that he did some lecturing on these trips. He enjoyed official orthopedic ambassador to Central and teaching while he was operating or assisting a South America, as well as to Europe and the Far young surgeon, and emphasized atraumatic tech- East. He was a master in manipulation of frac- subsequently led to the first group of orthopedic tures of the proximal end of the femur and surgeons sponsored by the American Orthopedic especially in supracondylar fractures of the Association visiting the orthopedic centers of that humerus in children. Boyd always was interested in research and poorly, he informed them that their English was very cognizant of the need for both laboratory and much better than his Japanese, Portuguese, or clinical investigation. Boyd enjoyed teaching—whether from the bone grafting for nonunion, femoral neck and podium, in the operating or dressing room, or trochanteric fractures, and dislocations of the even over a meal—and for these sessions many shoulder. His original contributions were in the medical students, residents, and practicing physi- areas of dual-onlay bone grafts for nonunions, an cians are most indebted to him.

With the human genome deciphered and significant medical advances hovering nearby buy 50 mg pristiq mastercard, funding health care into the future is a pressing concern pristiq 50mg low price. Important causes of mobility problems order 100mg pristiq overnight delivery, such as diabetes generic 50 mg pristiq overnight delivery, Parkinson’s dis- ease order pristiq 50 mg overnight delivery, and ALS, may succumb to genetic insights. Major progressive chronic causes of mobility difficulties—degenerative arthritis, back problems, heart and lung disease, stroke—might escape gene-derived “silver bullets. Nevertheless, even without fundamental cures, treatments will im- prove, including targeted pain medications, longer-lasting artificial hips and knees, and new approaches to restoring cartilage eroded from joints. Fund- ing the fruits of medical discoveries, even if expensive, will likely prove politically popular. Such new treatments epitomize the physician-hospital- science enterprise long accepted as meriting reimbursement. But will func- tion-related therapies, assistive technologies, home modifications, and related services remain on that reimbursement boundary line? This chapter describes basic policy issues raised in decisions to fund function-related items and services, while chapter 14 looks at how these policies specifically affect provision of physical and occupational therapy, mobility aids, and home modifications. For both chapters, I draw heavily on Medicare policies, publicly available in statute and regulation. I also touch on policies of state Medicaid and private insurers, which vary widely. A 1999 poll found that 57 percent of Americans believed that uninsured persons are “able to get the care they need from doctors and hospitals” (Institute of Medicine 2001b, 21). But this notion ignores the facts: among uninsured people, chronic dis- eases and disabling conditions are often neglected or poorly managed med- ically (22). Over the past twelve months, 10 percent of working-age people with major mobility problems did not get care they say they needed, and 28 percent say they delayed care because of cost concerns (Table 16). Working-Age People Who Did Not Get or Delayed Care in the Last Year Mobility Did Not Delayed Difficulty Get Care (%)a Care (%)b None 3 10 Minor 10 22 Moderate 13 28 Major 10 28 aAny time during the past 12 months, when a person “needed medical care or surgery, but did not get it. Almost 98 percent of elderly people have Medicare (Medicare Payment Advisory Commission 1999, 5). Voluntary employer-based private health insurance covers roughly two-thirds of the population, although it accounts for less than one-third of national health expenditures (Reinhardt 1999, 124). Medicare and Medicaid cover people who on av- erage have greater health-care needs than workers and their families. Nonetheless, working-age persons who do not qualify for Medicare or Medicaid are often out of luck, even if they are employed. Over half of uninsured people who have any disability work (Meyer and Zeller 1999, 11). Some employers avoid hiring disabled workers, fear- ing higher health insurance premiums (Batavia 2000). The ADA does not address employment-based health insurance explicitly, although it does prohibit employers from discriminating in “terms or conditions of em- ployment” against an employee. The ADA’s legislative history suggests that em- ployers and health insurers can continue offering health plans with restricted coverage “as long as exclusions or limitations in the plan are based on sound actuarial principles” (Feldblum 1991, 102). But only 76 percent of those with minor and moderate mobility problems have health insurance, while 83 percent of younger Who Will Pay? Health Insurance Coverage among Working-Age People Mobility Health Difficulty Insurance (%) Medicare Any Medicare Medicaid and Medicaid None 80 1 4 1 Minor 76 9 20 3 Moderate 77 16 27 5 Major 83 28 35 10 persons with major mobility difficulties are insured, primarily through Medicare and Medicaid (Table 17). More unemployed than employed working-age people with major mobility problems have insurance (86 versus 79 percent), because of these public programs. Even persons with health care insurance “are rarely covered for (and have access to) adequate pre- ventive care and long-term medical care, rehabilitation, and assistive tech- nologies. These factors demonstrably contribute to the incidence, preva- lence, and severity of primary and secondary disabling conditions and, tragically, avoidable disability” (Pope and Tarlov 1991, 280). Health insur- ers typically decide what to reimburse in two stages: organizationwide de- cisions about what services are “covered” by a particular plan; and case-by- case decisions about the “medical necessity” of covered services for individual persons (Singer and Bergthold 2001). A third-order decision, potentially critical for persons with mobility problems, is the setting of care: can patients receive services at home? For mobility-related services, two major concerns generally underlie coverage decisions for private and public health insurers: • How long will the person need the service?

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