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By K. Cruz. Franciscan University of Steubenville. 2018.

The enzyme clots the plasma component of the tal biology by increasing scientists’ knowledge of gene struc- blood buy silvitra 120mg lowest price. This knowledge promised new ways to humans that produces coagulase is Staphylococcus aureus purchase 120mg silvitra free shipping. For example buy silvitra 120mg without prescription, the use of recombinant clotting of the plasma in the immediate vicinity of the bac- DNA methodology to overcome antibiotic resistance on the terium buy silvitra 120mg overnight delivery. The resulting increased effective diameter of the bac- part of bacteria anticipated the development of better vac- terium makes it difficult for the defense reactions of the host cines 120mg silvitra for sale. A new source for producing insulin and other life-sus- to deal with the infecting cell. In particular, the defensive taining drugs had the potential to be realized. And, by creating mechanism of phagocytosis, where the bacterium is engulfed new, nitrogen-fixing organisms, it was thought that food pro- by a host cell and then dissolved, is rendered ineffective. This duction could be increased, and the use of expensive, environ- enables the bacterium to persist in the presence of a host mentally harmful nitrogen fertilizers eliminated. Genetic immune response, which can lead to the establishment of n engineering also offered the promise of nonpolluting energy infection. Thus, coagulase can be described as a disease-caus- sources, such as hydrogen-producing algae. In the decades fol- ing (or virulence) factor of Staphylococcus aureus lowing the discovery of the means for propagating DNA, A test for the presence of active coagulase distin- many assumptions regarding the benefits of genetic engineer- guishes the aureus Staphylococcus from the non-aureus ing have proved to be viable, and the inventions and technol- Staphylococci. Staphylococcus aureus is one of the major ogy that were by-products of genetic engineering research causes of hospital-acquired infection. Antibiotic resistance became marketable commodities, propelling biotechnology of this strain is a major concern. This strain is also an important disease-causing Jersey, to Bernard and Ida Stolz Cohen. He received his under- organism in hospital settings and can establish infections on graduate education at Rutgers University, and his M. Then followed quickly and simply differentiate the two different types of medical positions at Mt. Sinai Hospital in New York City, Staphylococcus from each other enables the proper treatment University Hospital in Ann Arbor, Michigan, the National to be started before the infections become worse. Institute for Arthritis and Metabolic Diseases in Bethesda, In the test, the sample is added to rabbit plasma and held Maryland, and Duke University Hospital in Durham, North at 37° C or a specified period of time, usually bout 12 hours. Cohen completed postdoctoral research in 1967 at A positive test is the formation of a visible clump, which is the the Albert Einstein College of Medicine in the Bronx, New clotted plasma. This is because some strains that produce coagulase was appointed professor of medicine in 1975, professor of also produce an enzyme called fibrinolysin, which can dis- genetics in 1977, and became Kwoh-Ting Li professor of solve the clot. The formation of a At Stanford Cohen began the study of plasmids—bits clot by 12 hours and the subsequent disappearance of the clot of DNA that exist apart from the genetic information-carrying by 24 hours could produce a so-called false negative if the test chromosomes—to determine the structure and function of were only observed at the 24-hour time. But Cohen found that the independent See also Biochemical analysis techniques; Laboratory tech- plasmids had the ability to transfer DNA to a related-species niques in microbiology cell, though the phenomenon was not a commonplace occur- rence. In 1973 Cohen and his colleagues successfully achieved a DNA transfer between two different sources. They found that the DNA would repli- tally changed in 1973 when Stanley N. Next, the group tried this technique for transferring DNA, the molecular basis of hered- experiment with an unrelated bacteria, Staphylococcus. Not only was DNA propaga- too, showed that the original Staphylococcus plasmid genes tion made possible among different bacterial species, but would transfer their biological properties into the E. The second attempt at DNA replication between DNA or genetic engineering, introduced the world to the age unlike species was that of animal to bacteria. This experiment had great significance for DNA technology, attempting to ease concerns regarding DNA human application; bacteria containing human genetic infor- experimentation. The biological cloning DNA experiments resulted in an overly cautious approach methods used by Cohen and other scientists came to be pop- that slowed the progress of DNA research and reinforced the ularly known as genetic engineering. The cloning process public’s belief that real, not conjectural, hazards existed in consisted of four steps: separating and joining DNA mole- the field of biotechnology. In an article on this subject pub- cules acquired from unlike species; using a gene carrier that lished in 1977 for Science he pointed out that during the ini- could replicate itself, as well as the unlike DNA segment tial recombinant DNA experiments, billions of bacteria joined to it; introducing the combined DNA molecule into played host to DNA molecules from many sources; these another bacterial host; and selecting out the clone that carries DNA molecules were grown and propagated “without haz- the combined DNA. And the majority DNA research not only added to the store of scientific of these experiments were carried out prior to the strict knowledge about how genes function, but also had practical containment procedures specified in the current federal applications for medicine, agriculture, and industry. For instance, his work with bac- fact, insulin made from bacteria was just seven years from terial transposons, the “jumping genes” that carry antibiotic becoming a reality.

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Isolated dysfunction of these muscular groups allows diagnosis of a divisional palsy and sug- gests pathology at the superior orbital fissure or anterior cavernous sinus cheap silvitra 120mg otc. However generic silvitra 120 mg with mastercard, occasionally this division may occur more proxi- mally purchase silvitra 120 mg fast delivery, at the fascicular level (i 120mg silvitra mastercard. This may reflect the topographic arrangement of axons within the oculomotor nerve buy cheap silvitra 120 mg. Proximal superior division oculomotor nerve palsy from metastatic subarachnoid infiltration Journal of Neurology 2002; 249: 343-344 Cross References “False-localizing signs”; Oculomotor (iii) nerve palsy Dix-Hallpike Positioning Test - see HALLPIKE MANEUVER, HALLPIKE TEST Doll’s Eye Maneuver, Doll’s Head Maneuver This test of the vestibulo-ocular reflex (VOR) is demonstrated by rotating the patient’s head and looking for a conjugate eye movement in the opposite direction. Although this can be done in a conscious patient focusing on a visual target, smooth pursuit eye movements may compensate for head turning; hence the head impulse test (q. The maneuver is easier to do in the unconscious patient, when testing for the integrity of brainstem reflexes. While directly observing the eyes, “catch up” saccades may be seen in the absence of VOR. Measuring visual acuity (dynamic visual acuity, or illegible E test) two to three lines may be dropped on visual acuity with head movement compared to visual acuity with the head still if VOR is impaired. Cross References Bell’s phenomenon, Bell’s sign; Caloric testing; Coma; Head impulse Test; Oculocephalic response; Supranuclear gaze palsy; Vestibulo- ocular reflexes “Dorsal Guttering” Dorsal guttering refers to the marked prominence of the extensor tendons on the dorsal surface of the hand when intrinsic hand mus- cles (especially interossei) are wasted, as may occur in an ulnar nerve lesion, a lower brachial plexus lesion, or a T1 root lesion. Benign - 97 - D Double Elevator Palsy extramedullary tumors at the foramen magnum may also produce this picture (remote atrophy, a “false-localizing sign”). In many elderly people the extensor tendons are prominent in the absence of significant muscle wasting. Cross References Wasting “Double Elevator Palsy” This name has been given to monocular elevation paresis. It may occur in association with pretectal supranuclear lesions either contralateral or ipsilateral to the paretic eye interrupting efferents from the rostral interstitial nucleus of the medial longitudinal fasciculus to the superior rectus and inferior oblique subnuclei. Brain 1992; 115: 1901-1910 Cross References Bell’s phenomenon, Bell’s sign Downbeat Nystagmus - see NYSTAGMUS Dressing Apraxia - see APRAXIA Drooling - see SIALORRHEA Dropped Head Syndrome Dropped head syndrome (head droop or head drop) refers to forward flexion of the head on the neck, such that the chin falls on to the chest (cf. This syn- drome has a broad differential diagnosis, encompassing disorders which may cause axial truncal muscle weakness, especially of upper thoracic and paraspinous muscles. Of these, probably MND and myasthenia gravis are the most common causes. Treatment of the underlying condition may be possible, hence investigation is mandatory. References Katz JS, Wolfe GI, Burns DK, Bryan WW, Fleckenstein JL, Barohn RJ. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 218 (abstract 26) Rose MR, Levin KH, Griggs RC. The dropped head plus syndrome: quantitation of response to corticosteroids. Lancet 1998; 352: 758 Cross References Antecollis; Camptocormia; Myopathy Dynamic Aphasia Dynamic aphasia refers to an aphasia characterized by difficulty initi- ating speech output, ascribed to executive dysfunction. There is a reduction in spontaneous speech, but on formal testing no para- phasias, minimal anomia, preserved repetition and automatic speech. Dynamic aphasia may be conceptualized as a variant of transcortical motor aphasia, and may be seen with lesions of dorsolateral prefrontal cortex (“frontal aphasia”). Cambridge: MIT Press, 2003: 165-174 Esmonde T, Giles E, Xuereb J, Hodges J. Journal of Neurology, Neurosurgery and Psychiatry 1996; 60: 403-410 Robinson G, Blair J, Cipolotti L. Dynamic aphasia: an inability to select between competing verbal responses. Brain 1998; 121: 77-89 Cross References Echolalia; Transcortical aphasias - 99 - D Dysarthria Dysarthria Dysarthria is a motor speech disorder of neurological origin (cf. There are various syndromes of dysarthria, which have been clas- sified as follows: ● Flaccid or nasal dysarthria: hypernasal, breathy, whining output, as in bulbar palsy, myasthenia gravis. Philadelphia: Lippincott Williams & Wilkins, 2002: 236-243 Murdoch BE (ed. Cheltenham: Stanley Thornes, 1998 Cross References Anarthria; Aphasia; Asynergia; Broca’s aphasia; Bulbar palsy; Coprolalia; Dysphonia; Fatigue; Lower motor neurone (LMN) Syndrome; Parkinsonism; Pseudobulbar palsy; Scanning speech; Upper motor neurone (UMN) syndrome Dyscalculia - see ACALCULIA - 100 - Dysexecutive Syndrome D Dyschromatopsia - see ACHROMATOPSIA Dysdiadochokinesia Dysdiadochokinesia or adiadochokinesia is a difficulty in performing rapid alternating movements, for example pronation/supination of the arms, tapping alternately with the palm and dorsum of the hand, tap- ping the foot on the floor.

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The fact that some such cases have resulted in litigation has led to calls for doctors to make clear that smears may miss between 5 and 15 per cent of abnormalities and to ensure that patients are giving properly informed consent to this procedure (Anderson 1999; Nottingham 1999) generic silvitra 120 mg with visa. The low specificity of the smear test means that it yields a relatively high proportion of false positive results: that is buy cheap silvitra 120 mg line, it suggests that a woman has malignant or pre-malignant cells when more invasive procedures (involving the removal of a wider area of tissue in a ‘loop’ or ‘cone’ biopsy) confirm that this is not the case silvitra 120 mg otc. In day to day practice order 120 mg silvitra free shipping, this is by far the biggest problem arising from smear tests purchase 120mg silvitra with mastercard, causing enormous anxiety and distress, often continuing for weeks or months pending delays in further investigations. Bristol public health consultant Angela Raffle noted the tendency of staff, in response to publicity over missed cases, to over-diagnose minor abnormalities (Raffle et al. While patients suffered needless anxiety, staff lived in fear of failing to identify potentially malignant cases. As a result, ‘much of our effort in Bristol is devoted to limiting the harm done to healthy women and to protecting our staff from litigation as cases of serious disease continue to occur’. As Raffle recognised, many healthy women are left with worries about cancer and difficulties in obtaining life insurance. Those who receive treatment may experience considerable discomfort, bleeding and sexual 58 SCREENING problems—as well as long-term anxieties about fertility. Meanwhile women in that 10 to 15 per cent of the female population which has never had a smear, who are likely to be (like my two patients), older, poorer and from ethnic minorities, will ensure that the mortality figures remain fairly steady. Health promotion propaganda which characterises cervical cancer as a sexually transmitted disease (on the dubious grounds of an association with the wart virus) has undoubtedly deterred many women from having smear tests. The annual cost of the cervical cancer screening programme is £132 million (Quinn et al. This is about four times the cost of the breast screening programme—though the death rate from breast cancer is around ten times greater. Mammography Breast cancer is not only much more common than cancer of the cervix, but the number of cases has gradually increased over the past twenty years. After rising slowly through the 1970s and 1980s, the death rate declined in the 1990s. There are currently around 30,000 cases a year, accounting for one-third of cancer in women; breast cancer kills around 11,000 women every year, causing around one- fifth of female cancer deaths. In our surgery we see several new cases of breast cancer every year and one or two deaths. We see many more women who turn out not have breast cancer but are understandably terrified by the appearance of a lump or other breast symptoms. Trials of mammography—X-ray examination of the breast— for early detection of malignancy were carried out in the USA in the 1960s. Early results showed a resulting reduction in mortality among women over the age of fifty, but no benefit in younger women (Wells 1998). More extensive research in the 1970s confirmed the earlier results and mammography became established as a screening test for breast cancer. In Britain a national screening programme became operational in 1988; now women between the ages of 50 and 64 are invited for free mammography every three years. The combination of mammography with ultrasound and the microscopic study of cells extracted from a suspicious lump through ‘fine needle aspiration’ has greatly improved the diagnostic sensitivity of this process in the 1990s. In response, Professor Michael Baum, who had helped to set up the screening service, pointed out that though the mammography programme could not be expected to have an effect on mortality before 1997, the decline in the death rate began in 1985. Suggesting that a more likely explanation was the introduction of the drug Tamoxifen for the treatment of breast cancer, he argued that ‘to claim that any part of this 11 per cent fall is attributable to the screening programme is intellectually dishonest’ (Baum 1995). In protest, he resigned from the Department of Health’s breast cancer screening advisory group. Baum also pointed to the high level of false positive results generated by mammography, causing anxiety and leading to further investigations, either aspiration cytology or excision biopsy. He concluded that mammography was ‘not worth doing’ because it saved too few lives at too high a cost, while causing needless anxiety among thousands of healthy women by incorrectly suggesting that they have the disease (Rogers 1995). He suggested that the money spent on screening might be better spent on research and specialist treatment for women diagnosed with breast cancer. But breast cancer screening had acquired high political prestige; only three months earlier a parliamentary select committee had commended the mammography programme as a model of excellence in preventive health care and had called for it to be extended to cover women up to the age of 69. A study by a team from Denmark reviewed major trials of mammography in Sweden, Scotland, Canada and the USA, involving 500,000 women, and concluded that there was ‘no reliable evidence that screening decreases breast cancer mortality’ (Gotzsche, Olsen 2000). Prominent representatives of the government screening programme and the leading cancer charities immediately rejected this conclusion and asserted their conviction that mammography saved lives. Delyth Morgan, chief executive of Breakthrough Breast Cancer, insisted that ‘we must not be deterred from continuing our screening programmes until we have seen categorically that they are ineffective’ (Guardian, 7 January 2000). This ethical imperative to prove a negative stood in dramatic contrast to the one imposed twenty years earlier in what has become recognised as a classic paper (Cochrane, Holland 1971).

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Brown–Séquard syndrome Classically resulting from stab injuries but also common in Further reading lateral mass fractures of the vertebrae cheap silvitra 120 mg with mastercard, the signs of the Brown- Séquard syndrome are those of a hemisection of the spinal • Advanced trauma life support program for doctors order silvitra 120mg online, 6th edition buy 120mg silvitra mastercard. Power is reduced or absent but pain and temperature Chicago: American College of Surgeons buy silvitra 120 mg without a prescription, 1997 sensation are relatively normal on the side of the injury • Ko H-Y silvitra 120mg lowest price, Ditunno JF, Graziani V, Little JW. The pattern of because the spinothalamic tract crosses over to the opposite reflex recovery during spinal shock. The uninjured side therefore has good power 1999;37:402–9 but reduced or absent sensation to pin prick and temperature. A review of seven support surfaces with emphasis on their protection of the spinally injured. Conus medullaris syndrome J Accid Emerg Med 1996;13:34–7 • Maynard FM et al. International standards for neurological The effect of injury to the sacral cord (conus medullaris) and and functional classification of spinal cord injury. Most emergency departments rely on the use of mobile radiographic equipment for investigating seriously ill patients, but the quality of films obtained in this way is usually inferior. Once the patient’s condition is stable, radiographs can be taken in the radiology department. In the presence of neurological symptoms, a doctor should be in attendance to ensure that any spinal movement is minimised. Sandbags and collars are not always radiolucent, and clearer radiographs may be obtained if these are removed after preliminary films have been taken. Plain x ray pictures in the lateral and anteroposterior projections are fundamental in the diagnosis Figure 3. Spinal cord injury without radiological abnormality (SCIWORA) may occur due to central disc prolapse, ligamentous damage, or cervical spondylosis which narrows the spinal canal, makes it more rigid, and therefore renders the spinal cord more vulnerable to trauma (particularly in cervical hyperextension injuries). SCIWORA is also relatively common in injured children because greater mobility of the developing spine affords less protection to the spinal cord. Cervical injuries The first and most important spinal radiograph to be taken of a patient with a suspected cervical cord injury is the lateral view obtained with the x ray beam horizontal. This is much more likely than the anteroposterior view to show spinal damage and it can be taken in the emergency department without moving the supine patient. The lateral view should be repeated if the original radiograph does not show the whole of the cervical spine and the upper part of the first thoracic vertebra. Failure to insist on this often results in injuries of the lower cervical spine being missed. The lower cervical vertebrae are normally obscured by the shoulders unless these are depressed by traction on both arms. The traction must be stopped if it produces pain in the neck or exacerbates any neurological symptoms. If the lower cervical spine is still not seen, a supine “swimmer’s” view should be taken. With the near shoulder depressed and the arm next to the cassette abducted, abnormalities as far down as the first or second thoracic vertebra will usually be shown. This view is not easy to interpret, and does not produce clear bony detail (Figure 3. The interpretation of cervical spine radiographs may pose problems for the inexperienced. First, remember that the spine consists of bones (visible) and soft tissues (invisible) Figure 3. These are functionally arranged into three columns, anterior, middle, and posterior, which together support the stability of the spine (Figure 3. The bases of the spinous processes (ligamentum flavum)— spinolaminar line. The anterior arch of C1 lies in front of the odontoid process and is therefore anterior to the first line described (unless the odontoid is fractured and displaced posteriorly). Extended upwards, the spinolaminar line should cross the posterior Figure 3. A line drawn downwards from the dorsum sellae along the surface of the clivus across the anterior margin of the foramen magnum should bisect the tip of the odontoid process.

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This will help users in identifying the current epi­ sode and the most recent entry order silvitra 120mg otc. Arranging data into specific sections like assessments cheap silvitra 120mg online, treatment and so on may also help the reader to quickly locate the relevant information buy cheap silvitra 120 mg. Every clinician has a responsibility to check generic silvitra 120 mg without prescription, update and maintain the client records they are using discount silvitra 120 mg online. Identification details Each health record must contain the personal details that will enable the identification of the client to whom the information pertains. This will usually include the client’s: ° names (at least the first and the last name) ° title (Mr/Miss/Mrs/Dr) ° form of address preferred by the client (for example, first name or title with last name) ° address ° telephone number ° date of birth ° identification number (for example NHS number, social security number, number issued by health provider). Other relevant information would include: ° the name and address of the next of kin/carer/guardian ° preferred form of address for the next of kin/carer/guardian ° name and address of the client’s general practitioner ° details of other professionals in regular contact with the client. Referral stage One of the key pieces of information to note in the health record is the rea­ son why the client is being seen by your service. It is often the case that cli­ ents are referred by another health professional or an associated agency such as social services. In some cases there may be no referring agent, for instance clients who self-refer, or emergency admissions to accident and RECORD KEEPING 47 emergency. You will therefore need to record the circumstances or inci­ dent that has prompted the client’s attendance. Part of the record at this point in the process will include the client’s account of the reason for his or her contact with your service. In some cases it may be appropriate to also make a note about the attitude of the client or the family towards the referral. For example, parents may disagree that an appointment with the clinical psychologist is necessary, but still attend the appointment at the behest of the child’s school. A complete record at the referral stage in the care process will show: ° the name and position of the referrer ° the date of the referral ° the reason for the referral. Key documents to be kept on file: q referral letters/admission forms q reports accompanying referral. Initial assessment Assessment is a process that will involve gathering information through in­ terview, observation, clinical investigations and objective and behavioural tests. The type of information collected will relate to the theoretical ap­ proach of the record’s user (Pagano and Ragan 1992) – so the assessment process of a medic will differ from that of a nurse, and both will differ from that of a therapist. It is essential that, whenever possible, consent is obtained from the cli­ ent before assessment is initiated. This consent must be informed and the clinician has the responsibility to make sure that the client understands the nature of any assessment procedures, their purpose and any risks. Consent, whether it is given verbally, in writing or by implication, must be recorded in the notes. See the section in this chapter on ‘Writing a Careplan’ for a fuller discussion on recording consent and communicating risk. In general, the type of client data that is collected in assessment will in­ clude information about: ° physical signs, symptoms and behaviours that indicate the client’s current health status ° current health care (for example information on medication, other illnesses) 48 WRITING SKILLS IN PRACTICE ° psychological factors (for example mood and client’s response to the problem) ° psychosocial factors (for example culture, religion) ° predisposing factors to the problem ° cognitive skills (for example memory, language skills) ° environment (for example type of housing or support from family) ° lifestyle (for example habits, diet and exercise) ° daily living pattern (for example working, retired or looking after young children) ° self-care abilities ° risk factors (for example is the client prone to falls? In children you will also want to include information about developmental and behavioural patterns (Cohen 1983). Client data is used by the clinician: ° to identify the health problem, formulate a diagnosis and determine the likely prognosis ° to determine the need for further in-depth assessment or referral to other professionals ° to provide a baseline measure for evaluating progress ° to establish the need for intervention and prioritise individual clients within the general caseload ° to help plan intervention and set realistic outcomes ° to help plan for discharge. Taking a case history is an essential first step in collecting relevant client data. Information is usually provided directly by the client, but in some cir­ cumstances another may give it, such as a parent or friend. In the latter case, always record the name and relationship of the informant to the cli­ ent. RECORD KEEPING 49 Write a description of the problem using the client’s own words. Note the way in which it first became apparent to him or her and the develop­ ment of the problem. The onset and sequence of symptoms need to be dated as accurately as possible. Establish whether the problem has changed in character or severity, and note any circumstances that are associated with these changes – also, what does it mean for the client, impact on life­ style, degree of pain and so on. The information provided in the case history will be supported by your clinical observations, and by objective or behavioural tests that help to describe and quantify the presenting problem.

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