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By: Brent Fulton PhD, MBA

• Associate Adjunct Professor, Health Economics and Policy

https://publichealth.berkeley.edu/people/brent-fulton/

Validity: reflects the accuracy with which a test measures what it is purported to measure 909 treatment 300 mg retrovir with amex. It is a qualitative factor that evaluates the authenticity of an assessment and its fitness for purpose symptoms 8 days after conception purchase 300mg retrovir. Educational impact: assessment is an important driver of learning; appropriate assessment tools encourage learners to acquire the desired knowledge, skills and attitudes. Cost-effectiveness: reflects the practical aspects of assessment and helps determine the choice of assessment tool. Acceptability: successful assessment formats must be acceptable to the teaching faculty and the learners. Blueprinting: ensures the assessment tool samples content across the full range of learning objectives for the curriculum. Assessment 67 Standard setting Numerous methods to determine pass-marks for different assessment formats are available. Norm-referencing: in norm-referenced assessments the pass mark is determined by examiners using comparison within the cohort of examinees and thus the pass-mark varies at each sitting. A percentage of candidates will pass the assessment on each occasion (Fixed Percentage Method). Norm-referencing does not take account of the content of the assessment or the competence of the candidates. Criterion-referencing: in criterion-referenced assessments the pass-mark is set in advance by a team of experienced examiners using their judgement about the degree of difficulty of the assessment and the minimum score expected of a candidate who just reaches the acceptable standard. A number of criterionreferenced standard setting methods are described including the Angoff and Ebel procedures. Good practice for summative assessments in medical education demands that a minimum competence (safety) level should be set ­ the assessment should identify the Pass/Fail border and all candidates who reach the required standard should pass the examination. Assessments should thus be criterion-referenced by experienced examiners who recognise the standard required of the candidates at whatever level of undergraduate or postgraduate experience. In addition, the examiner awards the candidate a global score, based on an overall judgement of performance. These methods have gained credibility as they allow experienced clinicians to make judgements about professional competence and they are currently the gold-standard methods for assessments of clinical competence. Assessments in medical education fall into three main categories ­ those that measure knowledge, competence and performance. Checks sensation starting distally with joint position sense, then light touch, pin prick 11. Checks for walking in lower limb examination and prontor drift in upper limb examination 12. Examines patient in a professional manner (gentle, watches for pain, maintains dignity and privacy) 14. Closure (thanks patient, leaves patient comfortable) Examiner to ask: "Please summarise your key findings" 15. Candidate presents summary in a fluent, logical manner "What do you think is the most likely diagnosis? Good news Bad news Neither Management Please mark one of the circles for each component of the exercise on a scale of 1 (extremely poor) to 9 (extremely good). A score of 1­3 is considered unsatisfactory, 4­6 satisfactory and 7­9 is considered above that expected, for a trainee at the same stage of training and level of experience. Please note that your scoring should reflect the performance of the SpR against that which you would reasonably expect at their stage of training and level of experience. You must justify each score of 1­3 with at least one explanation/example in the comments box, failure to do so will invalidate the assessment. Organisation/Efficiency Not observed or applicable 2 3 4 5 6 7 8 9 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 7. Reproduced by kind permission of the Joint Royal Colleges of Physicians Training Board. Please use this space to record areas of strength or any suggestions for development. They are more difficult to design and implement and few are in widespread use; these include the multi-rater (or 360-degree) assessment, observed consultations and patient reports on practice. Does it include practical, communication and clinicalskills stationsor justoneof these? Can you examine each of the major systems accurately and efficiently within the allotted time?

Syndromes

• Shower the night before or the morning of your surgery.
• You have numbness, tingling, or weakness in the wrist, hand, or fingers with pain.
• Folate-deficiency anemia
• Return of the disease
• Infection (a slight risk any time the skin is broken)
• Jumpiness or shakiness
• Dissecting aortic aneurysm

Facial Nerve Schwannomas Facial nerve schwannomas most commonly occur at the geniculate ganglion medication 3 checks cheap retrovir 100 mg free shipping, but can involve any portion of the facial nerve symptoms quitting smoking discount 300 mg retrovir. These include paragangliomas (glomus jugulare neoplasms), hemangiomas, and aneurysms. These lesions occur because of errors in embryogenesis that allow vestigial structures to remain and grow during adult life. The presenting symptoms are very similar to , if not indistinguishable from, those of vestibular schwannoma, and only imaging allows their differentiation. The treatment is surgical, but total removal is more difficult than in vestibular schwannoma and is not always necessary. Paragangliomas (Glomus Jugulare Neoplasms) Glomus jugulare tumors arise from paraganglionic tissues (chief cells) and have intracranial extension in 15% of cases. These neoplasms are slow growing and present initially with pulsatile tinnitus and conductive hearing loss. Further growth at the jugular foramen causes lower cranial nerve neuropathies, and then intracranial extension into the posterior fossa may lead to sensorineural hearing loss and dizziness. Paragangliomas cause irregular expansion of the jugular foramen, whereas lower cranial nerve schwannomas cause smooth enlargement of the jugular foramen. Extension to the carotid artery or intracranial extension requires an infratemporal fossa approach. This epithelial lining originates from a duplication of the arachnoid membrane and has secretory capabilities. The treatment involves diuretics, shunting procedures, and marsupialization of the cyst into the subarachnoid space. Hemangiomas Hemangiomas of the temporal bone often involve the geniculate ganglion and the internal auditory meatus. The hemangiomas involving the geniculate ganglion cause progressive facial paresis. The facial paresis occurs sooner with hemangiomas than with facial nerve schwannomas. The small size of the soft tissue mass, irregular bony erosion, and presence of calcium in the tumor are all suggestive of a geniculate ganglion hemangioma versus a facial nerve schwannoma. They are due to congenital malformations that lead to proliferation of adipocytes in subarachnoid cisterns or ventricles. Therefore, the surgical treatment of these lesions, if they become symptomatic, is conservative debulking. Cerebellopontine angle arachnoid cysts in adult patients: what is the appropriate management? The treatment involves surgical removal when there is significant facial nerve dysfunction. Because hearing is often intact, the middle fossa approach provides good surgical exposure and allows for hearing preservation. The chance of an intact facial nerve after removal of a hemangioma is higher than with a facial nerve schwannoma. Short-term tumor control and acute toxicity after stereotactic radiosurgery for glomus jugulare tumors. Cholesterol Granulomas the petrous apex of the temporal bone lies anterior and medial to the inner ear and posterior and lateral to the clivus and contains pneumatized air cells in one third of temporal bones. The obstruction of these air cells leads to inflammation and hemorrhage into the air cells. The phagocytosis of red cells leads to deposition of cholesterol crystals and a foreign body reaction in the petrous apex. When symptomatic, the treatment is surgical drainage rather than complete excision. Imaging characteristics suggestive of an extra-axial neoplasm include bony changes, widening of the subarachnoid cistern, displacement of brain and blood vessels away from the skull or dura, and sharp definition of the tumor margin.

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Intradural penetration of jugular foramen tumors will be discussed with transjugular craniotomy treatment uterine fibroids purchase retrovir 300 mg fast delivery. Ear canal closure is carried out with a meticulous three-layer technique to withstand cerebrospinal fluid pressure medicine naproxen cheap retrovir 300mg mastercard, if necessary. In one commonly used system of nomenclature, the various depths of infratemporal fossa dissection are referred to as approaches A, B, and C (Figures 66­12 and 66­13). The opening is created by removing the calvaria immediately behind the sigmoid and below the transverse sinus. Some of the complex issues in this involved subject are considered, in greater depth, in the chapter that discusses vestibular schwannomas (see Chapter 56, Vestibular Disorders). Neurophysiologic monitoring of the lower cranial nerves in jugular foramen surgery. Overview of posterior fossa approaches to the cerebellopontine angle: retrosigmoidal, retrolabyrinthine, translabyrinthine, and transcochlear. The translabyrinthine approach is primarily used for vestibular schwannomas, although it has some role in posterior fossa meningioma surgery as well. The primary advantage of the middle fossa approach is its superior ability to preserve hearing. The primary disadvantage is the inconvenient location of the facial nerve on the superior surface of the tumor that must be manipulated to a greater degree and thus has a higher rate of temporary postoperative dysfunction. Quality of life after unilateral acoustic neuroma surgery via middle cranial fossa approach. Suboccipital retrosigmoid approach for removal of vestibular schwannomas: facial nerve function and hearing preservation. When properly performed, it provides excellent exposure of the lateral aspect of the pons and upper medulla. Retrosigmoidal approach to a small vestibular schwannoma that extends only partly down the internal auditory canal. Note that the inner ear overlies the lateral one third of the internal auditory canal. Note that the craniotomy extends from the posterior edge of the external auditory canal to a distance behind the sigmoid sinus, which is posteriorly displaced. Note the deviation and splaying of the facial nerve on the anterior surface of the tumor. In the past, these tumors were commonly approached with a multistage procedure in which the skull base and neck component were removed separately from the intracranial portion. This procedure involves the creation of a posterior fossa craniotomy through resection of the sigmoid sinus and jugular bulb, both of which have usually been occluded by tumor growth (Figures 66­21 and 66­22). This maneuver provides direct visualization of the intracranial aspect of the jugular foramen, including the lower nerve roots emanating from the lateral aspect of the medulla. Some tumors, especially meningiomas, but occasionally lower cranial nerve schwannomas as well, are largely intracranial with little or no foraminal involvement. It is possible, from this perspective, to drill open the introitus of the intracranial aspect of the jugular foramen from above. Surgical resection of jugulare foramen tumors by juxtacondylar approach without facial nerve transposition. Transcochlear Approach In the past, lesions situated anterior to the brainstem were considered to be unresectable. Typical tumors of the region include clival meningiomas and chordomas that had broken through the posterior surface of the clivus to become intradural. Radical petrosectomy, also known as the transcochlear approach, is one method used to expose this inaccessible region (Figure 66­23). This procedure entails complete rerouting of the facial nerve, which results in a complete paralysis that recovers only partially and with synkinesis; sacrifice of the entire inner ear; closure of the external auditory meatus and eustachian tube; and skeletonization of the intrapetrous carotid artery. After removal of the apical petrous bone, petroclival junction, and even the lateral aspect of the clivus, an excellent view of the ventral surface of the pons and upper medulla is obtained with minimal brain retraction. Transjugular craniotomy is conducted through resection of the sigmoidjugular system (usually occluded preoperatively by tumor growth). This affords an excellent view of the intracranial aspect of the jugular foramen nerves as well as the lateral aspect of the pons and upper medulla. Note that although the facial nerve is rerouted in this illustration, this is not necessary in most cases.

Diseases

• Attenuated FAP
• Kartagener syndrome
• Achondrogenesis type 1B
• Follicular atrophoderma-basal cell carcinoma
• Hennekam Beemer syndrome
• Lipid storage myopathy
• Acrocephaly
• Retinohepatoendocrinologic syndrome
• Tuberculosis, pulmonary

References:

• https://ecfsapi.fcc.gov/file/1060927842647/irradiated.pdf
• https://www.foodchemicalscodex.org/sites/fcconline/files/usp_pdf/EN/fcc/index_fcc10_s2.pdf
• https://elephantconservation.org/iefImages/2015/06/CompleteHusbandryGuide1stEdition.pdf