Midamor

By T. Raid. Wofford College. 2018.

Tips on using pattern notes effectively Use the whole of the page for your diagram midamor 45mg low price. Use colour or different styles of lettering to differentiate between main topics and subtopics midamor 45mg otc. NOTE-TAKING 161 Note-taking in different contexts Lectures You will be more able to cope with new information if you have done some preparation before your lecture 45 mg midamor amex. Make sure you know how and where the lecture fits into your course outline discount midamor 45 mg mastercard, and complete any recommended pre­ paratory reading. This includes making time to reread notes from any pre­ vious lectures or related clinical experience. This is more likely to help you focus your attention by making you an ac­ tive participant rather than a passive recipient of information. Alternatively you can try some lateral thinking during the class by writing the questions you think the lecturer is trying to answer in his or her talk. As stated above it is not a good idea to try to write down everything that you hear or copy every diagram and drawing. It is very unlikely that you will be able to keep up with the pace of the lecturer, and it is difficult to listen at the same time as you are writing. You must therefore make deci­ sions about which pieces of information to note. Burnett (1979) reminds us that it is the ‘point’, not just the words, that needs to be recorded. What point or message do you think the lecturer is attempt­ ing to communicate? The lecturer will often help you by giving verbal and non-verbal cues about the importance of an item and how topics link together. Listen out for prompt phrases that signal a main point, for example, ‘this is the key concept’ or ‘there are three principles’. Other phrases, like ‘in contrast’ or ‘simi­ larly’, tell you about the connection between ideas. Non-verbal cues will also give you information; for example, speakers often pause before an im­ portant point. Make a conscious selection from the explanations, examples and refer­ ences used to support the lecturer’s main arguments. Thinking of your own examples is one way to help make sense of the information. Set aside 20 minutes to review your notes as soon as possible after the end of the lecture. This task is often more usefully done in conjunction with another student or in a study group. Check you have all the main points and look out for any informa­ tion you have omitted or were unclear about. Try to fill in the gaps or iden­ 162 WRITING SKILLS IN PRACTICE tify where you can follow up information. This may be in a tutorial or a reading session, or you may need to go back to the lecturer. Written material Before making any notes think carefully about your purpose in reading the material. This will help you in only not­ ing the details relevant for your task, rather than spending time in writing a précis of the whole article or chapter. This includes dates, names, references to further reading, quotes and defini­ tions. However, in written material it may be quicker to photocopy reference lists and de­ tailed illustrations.

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Representation of the pore structure of HZSM5 discount 45 mg midamor with visa, one of the most important zeolites industrially midamor 45 mg without prescription. The vertical cylinders represent one pore network buy 45 mg midamor, and the other cylinders an interconnecting network purchase midamor 45 mg on line. The narrow pores, and their almost complete uniformity, means that only some molecules can enter. Others are excluded, and cannot react at the active sites, which are found within the structure. Thus, the reactivity of a molecule is determined by its shape and size, rather than by its electronic properties. Such a situation is almost unique, with the only exception being enzymes, where molecules must fit into the enzyme active site in order to react. This leaves a highly regular structure which has holes where the template molecules used to be. It is in these pores and cages, also of very regular size and shape, that the catalytically active groups can be found (Figures 4. As we will see, it is this exceptional degree of regularity which is the key to the success of these materials. Zeolites based on silicon and aluminium are acidic catalysts and are extremely thermally stable. This makes them ideal for use in the petro- chemical industry, where some of the largest scale and most high energy transformations are carried out. Larger molecules can enter this structure, which is more open, and slightly less regular than HZSM5 (Figure 4. Nevertheless, there are still many important molecules which cannot enter the pores of this zeolite, one of the most accessible of the class. Since the catalytic groups of the zeolite are found within the structure, the molecules must be able to diffuse into the structure before they can react. The size of the pores and channels of the zeolites are designed to be very close to the dimensions of the molecules to be reacted. This means that small changes in size and shape can dramatically alter the ability of the molecule to reach the active site. Under ‘normal’ chemical conditions, molecules react according to their electronic properties – i. Harsh conditions usually allow many different reactions to take place, and are thus to be avoided if, as is almost always the case, a selective reaction is required. However, in the case of zeolites, the only molecules which can react are those which can fit into the pore structure and get to the active site. Similarly, the only products which can be formed are those which are of the right shape and size to escape from the catalytic sites, migrate through the pores, and out of the catalyst. This phenomenon is known as shape selectivity, although size selectivity might be a more accurate description. Chemistry on the inside 63 H H H H para 10000 H H H H H H H H H H H H H meta 1 H H H H H H H H ortho 1 H H H H H Isomer relative diffusion rate Figure 4. The shaded areas are the pore walls, the unshaded parts the vertical pore system from Figure 4. As can be seen, the rate of diffusion varies enormously with only very small changes in molecular size and shape. This allows the zeolite to discriminate almost completely between the three molecules shown, a situation which is unprecedented in traditional, homogeneous chemistry. An example of this is the commercial process for preparing para-xylene, the precursor to terephthalic acid, which is polymerised to give poly(ethy- lene terephthalate) (PET). In this case, the mixture of xylenes obtained from crude oil is reacted in a zeolite (known as HZSM5). The relative rates of dif- fusion in and out of the pores are sufficiently different (by a factor of about ten thousand) to allow the extremely efficient and selective conversion of all the isomers to the desired para isomer, which is the narrowest and can thus move through the structure most rapidly (Figure 4. This type of selectivity is extremely valuable, as it gives chemists the opportunity to direct reactions in different ways to those available using con- ventional, electronically controlled, systems. MACQUARRIE have searched for many years for materials with the same degree of unifor- mity displayed by the zeolites, but with larger pores. This would allow the concept of shape selectivity to be extended to larger molecules such as phar- maceutical intermediates, and other highly functional compounds.

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The most important factors predisposing to spinal deformity are the nature of the original bony or ligamentous injury purchase midamor 45mg with mastercard, age at injury and the level and completeness of the cord lesion generic midamor 45 mg online. The growing child is most at risk of developing a major spinal deformity buy generic midamor 45 mg on line, usually a scoliosis midamor 45 mg sale. The higher the neurological level and the more complete the lesion, the greater the tendency to spinal deformity. Inadequate early treatment of the bony injury or inappropriate surgical exploration by laminectomy without stabilisation and fusion may also lead to late deformity. Inadequate postural management, particularly in seating, with muscle imbalance, may lead to an excessive lumbar lordosis with an anterior pelvic tilt. Conversely a severe lumbar kyphosis with the patient sitting on the sacrum is often associated with the Figure 13. In adults with thoracolumbar injury bracing is often advisable even if internal fixation has been performed. High thoracic spinal deformity severe enough to require surgical correction requires careful preoperative assessment, respiratory complications being a particular hazard of the operation. After injury to the spinal cord, bones in the paralysed limbs become osteoporotic, and pathological fractures may occur with minimal or even no obvious trauma. A common injury is a supracondylar fracture of the femur caused by the patient falling out of the wheelchair on to his or her knees. Violent spasticity of the hip flexors, particularly if the leg rotates, can fracture the femoral shaft. If a circular cast is used it should be split, allowing the skin to be inspected daily for signs of pressure. Insufficient padding or failure to split a cast on a paralysed limb carries a high risk of producing pressure sores and painless ischaemia secondary to swelling. Immobilisation should not be prolonged as it is important to avoid joint stiffness, which might limit the patient’s independence. It is particularly important to maintain the range of hip and knee movements, so that the patient’s posture in the wheelchair is unaffected. Fortunately, fracture healing is usually satisfactory and callus formation good. There may, however, be an exacerbation of spasticity in the injured limb, which can complicate management of the fracture. Post-traumatic syringomyelia, an ascending myelopathy due to secondary cavitation in the spinal cord, is seen in at least 4% of patients. Symptoms may appear as early as two months after injury or in rare instances be delayed for over 30 years, the average latent period having previously been reported as eight to nine years. The commonest presenting symptom is pain in the arm, usually unilateral, described as a dull ache but occasionally as burning or stabbing. The syrinx also often extends below the level of the spinal cord lesion, and in these instances bladder and bowel function can be further affected. The earliest sign is usually a dissociated sensory loss, with impaired or absent pain and temperature sensation (spinothalamic loss) and preservation of light touch and joint position sense (posterior column sparing). Some patients also have sensory loss over the face due to an extension of the cavitation into the upper cervical cord, which affects the spinal tract of the trigeminal nerve and, in rare instances, the brain stem. When present, motor loss is of a lower motor neurone type and is usually unilateral. Though there may be remissions, the condition may progress, perhaps even to the extent of converting low paraplegia into tetraplegia. Though essentially clinical, the diagnosis is confirmed by magnetic resonance imaging (MRI) or in rare instances myelography with computed tomography (CT). Surgical treatment includes decompression or drainage of the syringomyelic cavity. Pain is usually relieved, but relief of sensory symptoms and motor loss is less predictable. Pain Pain relief in the acute stage of spinal cord injury has been discussed in chapters 1 and 4.

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Mayo Clinic Proceedings 1998; 73: 67-71 Cross References Babinski’s sign (2); Bell’s palsy; Dyskinesia; “False-localizng signs” Hemiinattention - see NEGLECT Hemimicropsia - see MICROPSIA Hemineglect - see NEGLECT Hemiparesis Hemiparesis is a weakness affecting one side of the body cheap 45mg midamor mastercard, less severe than a hemiplegia generic midamor 45 mg online. Characteristically this affects the extensor mus- cles of the upper limb more than flexors buy 45mg midamor visa, and the flexors of the leg more than extensors (“pyramidal” distribution of weakness) purchase midamor 45 mg online, pro- ducing the classic hemiparetic/hemiplegic posture with flexed arm and extended leg, the latter permitting standing and a circumduct- ing gait. Hemiparesis results from damage (most usually vascular) to the corticospinal pathways anywhere from motor cortex to the cervical spine. Accompanying signs may give clues as to localization, the main possibilities being hemisphere, brainstem, or cervical cord. Hemisphere lesions may also cause hemisensory impairment, hemi- - 150 - Hemiplegia Cruciata H anopia, aphasia, agnosia or apraxia; headache, and incomplete unilat- eral ptosis, may sometimes feature. Spatial neglect, with or without anosognosia, may also occur, particularly with right-sided lesions pro- ducing a left hemiparesis. Pure motor hemiparesis may be seen with lesions of the internal capsule, corona radiata, and basal pons (lacu- nar/small deep infarct), in which case the face and arm are affected more than the leg; such facio-brachial predominance may also be seen with cortico-subcortical lesions laterally placed on the contralateral hemisphere. Crural predominance suggests a contralateral paracentral cortical lesion or one of the lacunar syndromes. Brainstem lesions may produce diplopia, ophthalmoplegia, nys- tagmus, ataxia, and crossed facial sensory loss or weakness in addition to hemiparesis (“alternating hemiplegia”). Hemiparesis is most usually a consequence of a vascular event (cerebral infarction). Tumor may cause a progressive hemiparesis (although meningiomas may produce transient “stroke-like” events). Transient hemiparesis may be observed as an ictal phenomenon (Todd’s paresis), or in familial hemiplegic migraine which is associated with mutations in a voltage-gated Ca2+ ion channel gene. Cross References Agnosia; Anosognosia; Aphasia; Apraxia; Babinski’s sign (1); “False- localizing signs”; Hemianopia; Hemiplegia; Neglect; Ptosis; Upper motor neurone (UMN) syndrome; Weakness Hemiparkinsonism Hemiparkinsonism describes the finding of parkinsonian signs restricted to one side of the body, most usually akinesia, in which case the term hemiakinesia may be used. Idiopathic Parkinson’s disease may present with exclusively or predominantly unilateral features (indeed, lack of asymmetry at onset may argue against this diagnosis) but persistent hemiparkinsonism, particularly if unresponsive to ade- quate doses of levodopa, should alert the clinician to other possible diagnoses, including corticobasal degeneration or structural lesions. Cross References Hemiakinesia; Parkinsonism Hemiplegia Hemiplegia is a complete weakness affecting one side of the body, i. Cross References Hemiparesis; Weakness Hemiplegia Cruciata Cervicomedullary junction lesions where the pyramidal tract decus- sates may result in paresis of the contralateral upper extremity and - 151 - H Hennebert’s Sign ipsilateral lower extremity. There may be concurrent facial sensory loss with onion skin pattern, respiratory insufficiency, bladder dysfunction and cranial nerve palsies. Hennebert’s Sign Hennebert’s sign is the induction of vertigo and nystagmus by pressure changes in the external auditory canal, such as when using pneumatic otoscopy or simply with tragal pressure. These findings are highly sug- gestive of the presence of a bony labyrinthine fistula. Cross References Nystagmus; Vertigo Hertwig-Magendie Sign - see SKEW DEVIATION Heterochromia Iridis Different color of the irides may be seen in congenital Horner’s syn- drome, and in Waardenburg syndrome of nerve deafness, white fore- lock, abnormal skin pigmentation, and synophrys. Cross References Horner’s syndrome Heterophoria Heterophoria is a generic term for a latent tendency to imbalance of the ocular axes (latent strabismus; cf. This may be clini- cally demonstrated using the cover-uncover test: if there is movement of the covered eye as it is uncovered and takes up fixation, this reflects a phoria. Phorias may be in the horizontal (esophoria, exophoria) or vertical plane (hyperphoria, hypophoria). London: BMJ Publishing, 1997: 253-282 Cross References Cover tests; Esophoria; Exophoria; Heterotropia; Hyperphoria; Hypophoria Heterotropia Heterotropia is a generic term for manifest deviation of the eyes (man- ifest strabismus; cf. This may be obvious; an amblyopic eye, with poor visual acuity and fixation, may become deviated. Sometimes it may be more subtle, coming to attention only with the patient’s complaint of diplopia. Using the alternate cover (cross cover) test, in which binocular fix- ation is not permitted, an imbalance in the visual axes may be demon- strated, but this will not distinguish between heterotropia and heterophoria. To make this distinction the cover test is required: if the uncovered eye moves to adopt fixation then heterotropia is confirmed. London: BMJ Publishing, 1997: 253-282 Cross References Amblyopia; Cover tests; Esotropia; Exotropia; Heterophoria; Hypertropia; Hypotropia Hiccups A hiccup (hiccough) is a brief burst of inspiratory activity involving the diaphragm and the inspiratory intercostal muscles with reciprocal inhibition of expiratory intercostal muscles. The sound (“hic”) and discomfort result from glottic closure immediately after the onset of diaphragmatic contraction, i. Hiccups may be characterized as a physiological form of myoclonus (or singultus).

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