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By J. Aidan. Huntingdon College.

Primary growth deficiency is due to an intrinsic defect in the skeletal system discount cialis extra dosage 50mg with amex, such as bone dysplasia order cialis extra dosage 50mg otc, resulting from either a genetic defect or prenatal damage and leading to shortening of the diaphysis without significant delay of epiphyseal matura- tion discount 60mg cialis extra dosage visa. Hence buy generic cialis extra dosage 100 mg online, in this form of growth disorder cialis extra dosage 50 mg on line, the potential normal bone growth (and therefore, body growth) is impaired, while skeletal age is not delayed or is delayed much less than is height. Secondarygrowthdeficiencyisrelatedtofactors,generallyoutsidethe skeletal system, that impair epiphyseal or osseous maturation. These fac- tors may be nutritional, metabolic, or unknown, as in the syndrome of idio- pathic (constitutional) growth delay. In this form of growth retardation, skeletal age and height may be delayed to nearly the same degree, but, with treatment, the potential exists for reaching normal adult height. The distinction between these categories may be difficult in some in- stances in which skeletal age is delayed to a lesser degree than height. In general, however, differentiation between primary and secondary catego- ries of growth failure can be determined from clinical findings and skeletal age. Final Height Predictions The adult height of a child who grows up under favorable environmental circumstances is, to a large extent, dependent on heredity. The final height of the child may, therefore, be postulated from parental heights. Indeed, various methods of final height predictions, which take into account paren- tal height, have been described. A child’s adult height can also be pre- dicted from his or her heights at earlier ages, with correlations on the order of 0. However, children differ greatly in rate of development; some attain maturity at a relatively early age, while others have a slow tempo and finish Conventional Techniques for Skeletal Determinations 5 growing relatively late. Hence, knowledge of the degree of development in- creases the accuracy of final height predictions. The only practical guide to acquire this knowledge is by assessment of skeletal maturity, usually esti- mated from a hand and wrist radiograph. Tables for prediction of ultimate height based on the individual’s height, skeletal age, sex, age, and growth rate have been published. Using skeletal ageforpredictionofultimateheight,itisalsopossibletomakearoughcal- culation as follows: measure the individual’s height, plot it on a standard growth curve, and extrapolate the value horizontally to the age on the chart that is equal to the bone age. If the point of extrapolation falls between the 5th and 95th centiles, then a guarded prediction of normal adult stature can be given. The closer the extrapolated value is to the 50th centile, the more accurate it is likely to be. Other bone age and height prediction methods commonly in use are those of Bayley-Pinneau, Roche et al and Tanner-Whitehouse [7–9]. All of these methods use radiographs of the hand and wrist to assess skeletal ma- turity and were based on population data from normal children followed to adult height. Overall, these methods have 95% confidence intervals of 7 to 9 cm when used to predict the final height of individuals. It is necessary to realize,however,thatestimationsoffinalheightaremostaccurateinchil- dren who are healthy, and, in the sick, these predictions are less reliable. Tanner et al: Predicted Final Height = Height Coefficient × Present Height (cm) + Age Coefficient × Chronological Age (years) + Bone Age Coefficient × Bone Age (years) + Constant In girls, these investigators incorporated knowledge of whether or not menarche had occurred, which improved their predictions. The tables for the coefficients for prediction of adult height are on pages 93 and 94. Conventional Techniques for Skeletal Determinations In the evaluation of physical development in children, variations in matu- ration rate are poorly described by chronological age. Thus, for many de- cades, scientists have sought better techniques to assess the degree of devel- opment from birth to full maturity. Measures of height, weight, and body mass, although closely related to biological maturation, are not sufficiently accurate due to the wide variations in body size. Similarly, the large varia- 6 Bone Development tions in dental development have prevented the use of dental age as an over- all measure of maturation, and other clinically established techniques are of limited value. As examples, the age at menarche, although an important bi- ological indicator, relates to only half the population, and determinations of sexual development using the Tanner classification, while an extremely useful clinical tool, is subjective and restricted to the adolescent period. Unfortunately, most available maturational "age" scales have specific uses and tempos that do not necessarily coincide. Skeletal age, or bone age, the most common measure for biological matu- ration of the growing human, derives from the examination of successive stages of skeletal development, as viewed in hand-wrist radiographs. This technique, used by pediatricians, orthopedic surgeons, physical anthropol- ogists and all those interested in the study of human growth, is currently the only available indicator of development that spans the entire growth pe- riod, from birth to maturity.

In the U K N ational H ealth Service cheap cialis extra dosage 200mg with visa, all doctors cialis extra dosage 50 mg visa, nurses purchase 100 mg cialis extra dosage fast delivery, pharm acists generic cialis extra dosage 60mg overnight delivery, and other health professionals now have a contractual duty to provide clinical care based on best available research evidence buy cialis extra dosage 60 mg on-line. W hilst the m edicolegal im plications of "official"guidelines have rarely been tested in the U K,12 U S courts have ruled that guideline developers can be held liable for faulty guidelines and that doctors cannot pass off their liability for poor clinical perform ance by claim ing that adherence to guidelines corrupted their judgem ent. An early system atic review of random ised trials and "other robust designs" by G rim shaw and Russell13 dem onstrated that, in the research setting (in which participants were probably highly selected and evaluation was an explicit part of guideline introduction), all but four of 59 published studies dem onstrated im provem ents – i. G rim shaw subsequently set up a special subgroup of the Cochrane Collaboration (see section 2. You can find details of the Effective Practice and Organisation of Care (EPOC) G roup on the Cochrane website. Both G rim shaw and Russell13 and others15, 16 found wide variation in the size of the im provem ents in perform ance achieved by clinical guidelines. The form er authors concluded that the probability of a guideline being effective depended on three factors which are sum m arised in Table 9. G rim shaw’s conclusions were initially m isinterpreted by som e people as im plying that there was no place for nationally developed guidelines since only locally developed ones had any im pact. In fact, whilst local adoption and ownership is undoubtedly crucial to the success of a guideline program m e, local team s would be foolish not to draw on the range of expensively produced resources of evidence based national and international recom m endations. For a m ore detailed discussion on the barriers to im plem enting guidelines, see Grim shaw and Russell’s com prehensive discussion of the subject,19 the review on developing17 and using20 guidelines from the BMJ’s 1999 series on guidelines, and original research by other writers. In preparing the list which follows, I have drawn on a num ber of previously published checklists and discussion docum ents. I will resist labouring the point, but a drug com pany that m akes 144 PAPERS TH AT TELL YOU W H AT TO D O horm one replacem ent therapy or a research professor whose life’s work has been spent perfecting this treatm ent m ight be tem pted to recom m end it for wider indications than the average clinician. Question 2 Are the guidelines concerned with an appropriate topic, and do they state clearly the goal of ideal treatment in terms of health and/or cost outcome? Key questions in relation to choice of topic, reproduced from an article in the BMJ,26 are given in Box 9. A guideline which says "do this" without telling the practitioner why such an action is desirable is bad psychology as well as slack science. The intended outcom e if the guideline is followed m ight be better patient survival, lower com plication rates, increased patient satisfaction or savings in direct or indirect costs (see section 10. Question 3 Was the guideline development panel headed by a leading expert in the field and was a specialist in the methods of secondary research (e. If a set of guidelines has been prepared entirely by a panel of internal "experts", you should, paradoxically, look at them particularly critically since researchers have been shown to be less objective in appraising evidence in their own field of expertise than in som eone else’s. Question 4 Have all the relevant data been scrutinised and do the guidelines’ conclusions appear to be in keeping with the data? On the m ost basic level, was the literature analysed at all or are these guidelines sim ply a statem ent of the preferred practice of a selected panel of experts (i. If the literature was looked at, was a system atic search done and if so, did it follow the m ethodology described in section 8. W ere all papers unearthed by the search included or was an explicit scoring system used to reject those of poor m ethodological quality and give those of high quality the extra weight they deserved? Of course, up to date system atic reviews should ideally be the raw m aterial for guideline developm ent. G iven that in m any clinical areas, the opinion of experts is still the best "evidence" around, guideline developers should adopt rigorous m ethods to ensure that it isn’t just the voice of the expert who talks for longest in the m eetings that drives the recom m endations. Paul Shekelle from the RAN D Corporation in the U SA has undertaken som e exciting research into m ethods for im proving the rigour of consensus recom m endations so as to ensure, for exam ple, that an appropriate m ix of experts is chosen, everyone reads the available research evidence, everyone gets an equal vote, all points of contention (raised anonym ously) are fully discussed, and the resulting recom m endations indicate the extent of agreem ent and dissent between the panel. It would be foolish to m ake dogm atic statem ents about ideal practice without reference to what actually goes on in the real world. There are m any instances where som e practitioners are 146 PAPERS TH AT TELL YOU W H AT TO D O m arching to an altogether different tune from the rest of us (see section 1. Another thorny issue which guidelines should tackle head on is where essential com prom ises should be m ade if financial constraints preclude "ideal" practice. If the ideal, for exam ple, is to offer all patients with significant coronary artery disease a bypass operation (at the tim e of writing it isn’t, but never m ind), and the health service can only afford to fund 20% of such procedures, who should be pushed to the front of the queue? In other words, can you trust them , and if a different guideline developm ent panel addressed the sam e question, would they com e up with the sam e guidelines? The academ ic validity of guidelines depends on whether they are supported by high quality research studies and how strong the evidence from those studies is.

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If the ball points to it discount cialis extra dosage 100 mg visa, it’s supposed to lead them to knowledge cialis extra dosage 60 mg overnight delivery, and it will take them to the person who can seek knowledge buy 40 mg cialis extra dosage visa. Randy: The story begins with a monster that comes from beneath buy generic cialis extra dosage 200 mg line, and he was condemned by a higher power when he was little generic 40mg cialis extra dosage fast delivery. What the higher power did was put a rope around him saying that the only way he can remove the rope, which took away his happiness, was to find the guidance he needed to succeed. He was clever and smart and waited until someone came along to show him the guidance. When he arrived he first tried to trick them [Bob and John], but they were wise to his ways. Then he tried to force them, but they were wise to his ways and they hid on Paradise Island and were protected by Ug and Thug who hid them. Terrell’s time was almost up and he would have to go back beneath the sea and he started begging them to take off the rope. He climbed the rope and was told that he needed to apologize for what he did and not to do it again. Then he got the rope off of him and he too became very wise in the ways of others and started helping them. Randy: When he found the guidance he needed, he thought it in his head 238 Individual Therapy: Three Cases Revealed and the rope lost what it was supposed to do, you know, take away his happiness, and it fell off. Randy: Yes, when he first came he was trying to trick them and they thought he was a sly monster. Randy: Instead of trying to abuse people and getting what you want, try to ask them. In the sequel Randy now begins to identify with a "monster" who through no fault of his own was condemned at a young age. If we interpret this story from a developmental point of view, Randy has taken us from the stage of infantile hopes (waiting for another to meet needs) to that of ado- lescence, with its models of leadership. As we walk through the story we see Randy’s infantile hopes of care and nurturance only assuaged when Terrell the monster "went to seek the truth. This regres- sion gives way to humility as he speaks to the wise counsel about his anxiety- laden fears. Terrell is then seen climbing the rope (industry) and in receiv- ing guidance is able to help others through care and trustworthiness. With this interpretation the following story was told: Therapist: Once upon a time there was a man named Ug who lived on Paradise Island who had a misunderstanding with Thug a long time ago, but they resolved their differences and they are now friends. They find out that there are problems on a neighboring island, and soon Terrell shows up at Par- adise Island, and he is vexed with all types of problems. Terrell came to Paradise Island to bully and trick Ug and Thug, but the power of friendship was too strong for anyone to harm them and they saw through his anger. So Ug and Thug sent Terrell to the Island of Guidance to get help, and they built a bridge that provided shelter and light for his trip. But once he arrived he noticed the caring and gentle expressions of the 239 The Practice of Art Therapy wise men and he spoke with them. Once there, the blue ball revealed his inner secrets and showed him a true reflection of himself. In the process the rope around him uncoiled [note that at this point Randy began to uncoil the rope]. Therapist: The moral is that no one is a misfit who is willing to look at the truth. In this retelling, the story combines the misfit theme with a thrust toward cooperation, but it also presents Ug and Thug as competent guides who take care of not only one another but others in pain. Compared to Randy’s, this story offers a healthier adaptation, as it involves action by all the characters, protagonists and antagonists. Once Terrell (the lost youth condemned) found the strength to seek help and support, he was offered a true reflection of himself: He was not a monster. This metaphorical gesture is signif- icant because Randy takes action against his past rather than passively re- living the experiences. Prior to working evocatively, Randy had spent much of his time attempting to change the environment; his punitive retaliations caused further rejection and intensi- fied his internalized sense of himself as a "monster. With every story and subsequent retelling, Randy al- lowed himself to identify with the characters he had created as well as in- ternalizing their awareness, insight, problem solving, and affiliation. Through the method of the mutual storytelling technique, he shared his suffering and opened the door for corrective healing of his experiences.

But of honour buy cheap cialis extra dosage 40mg, wisdom discount cialis extra dosage 50mg, and pleasure discount cialis extra dosage 40 mg on line, just in respect of their goodness trusted cialis extra dosage 50 mg, the accounts are distinct and diverse proven cialis extra dosage 200mg. CHAPTER 6 FULL SPECTRUM MEANS AND ENDS REASONING " something unpredictable, spontaneous, unformulable and ineffable is found in any terminal object. Standardization, formulas, generalizations, principles, universals, have their place, but the place is that of being instrumental to better approximation of what is unique and unrepeatable. The second part of the chapter will offer suggestions for bettering our individual and institutional capacity for deliberation and judgment. The glory of the medical art is the creative ways it negotiates the interface of fact and value, weaving the two together. INFORMAL JUDGMENT AND THE ART OF MEDICINE Behind the closed door of every examination room there is a surprise. Whether the patient is familiar and has a routine problem named on the chart, or is a stranger with a mysterious complaint, no true physician can open that door without some thrill of anticipation. Is it an adolescent with a sore throat whose arms, when the pulse is taken, reveal neat parallel scratches of self-mutilation? Is it a newborn whose father says, "Remember, you treated me for meningitis when I was at college in 1976? On another occasion, seemingly idle talk during the freezing of a wart leads to the discovery of an unsuspected pregnancy. Perhaps the workup for a patient’s numbness in the feet reveals not a neurological disease, but a short in her electric blanket. There are times to keep the eye fixed on one, but it is well to remember that others are circulating. Recognizing that there are instances when speed is of the essence, assumptions must be made rapidly, constellations of signs and symptoms recognized hurriedly and acted upon; still, such instances should be few. The pursuit of a preordained end along the shortest, cheapest path between beginning and end 153 154 CHAPTER 6 points which are presumed to be known and unalterable is rarely all that can or should be going on. I have argued that informal means/ends reasoning, exemplified in but certainly not exclusive to medical care, applies to situations and in contexts which are inhospitable to formulaic treatment. The prevalence and variety of such situations is larger than has been appreciated. Unexpected contingencies frequently intrude even upon encounters which initially look routine. The full spectrum consideration of means and ends makes use of all our abilities: perception, knowledge, emotion and reason. To get any endeavor off the ground, there must be many unconscious or unexamined assumptions already in place. Means and ends deliberation this time necessarily involves a limited number of matters. How stringently limited such matters are depends on the clarity of the problem, the level of urgency when it becomes clear, the degree of typicality, the detail and seriousness of agreed commit- ments, and whether the endeavor to be undertaken is immediate and specific or long range and comprehensive. While formulaic protocols and decision trees have "decision nodes," these are only metaphoric forks in the shortest roads to fixed ends. At such nodes, alternatives are excluded in a compulsory fashion depending on particular prescribed inputs. We have seen detailed reasons in the previous chapters why informal means/ends reasoning is different. Adapting to fluid contexts, it takes account of the non- classical internal structure of categories as well as their vague, shifting and overlapping boundaries. It selects metaphors for causation judged appropriate to the circumstances, rather than using only the billiard-ball model. It considers what level of causation to address, recognizing that proximate causation at the level of middle sized objects is only one among many types predisposing to an event. Such reasoning can conceptualize the pursuit of ends in terms of progeneration, nurtu- rance, adventure, exploration, acquisition and so forth; not merely as a journey with only cost and length needing to be minimized. Compared to formal procedures moving from concrete "facts" to fully known goals, informal reasoning looks differently at ends. Then intermediate motivators ("ends-in-view") can be sought, and roundabout approaches taken, to valued but not yet sufficiently desired long-term ends. Means, despised in theory, turn out in practice to have their own great satisfac- tions. Value of whatever kind is often recognized by informal means/ends reasoning FULL SPECTRUM MEANS AND ENDS REASONING 155 to be spread out over endeavor, not simply concentrated at its terminus. Furthermore, specific values attain their significance not by themselves, but in relation to one another.

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