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Disorders of the Vascular System Diseases affecting the vascular system typically present as an ischemic or hemorrhagic event erectile dysfunction caused by low testosterone discount super levitra 80 mg fast delivery, single or multiple erectile dysfunction pump covered by medicare 80mg super levitra for sale. The usual clue to erectile dysfunction vegan 80 mg super levitra amex a vasculopathy is multiple events involving different parts of the nervous system erectile dysfunction for young adults buy discount super levitra 80 mg online. Rare but important nonatherosclerotic conditions include vasculitis erectile dysfunction 23 purchase super levitra with mastercard, Moya-moya angiopathy, arterial trauma and dissections, fibromuscular dysplasia, migraine, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, amyloid angiopathy, and complications of radiation therapy. Cerebrovascular disease may complicate systemic conditions such as collagen vascular disease and hypertensive encephalopathy. Coagulopathies may cause bleeding, as from anticoagulant effects or disseminated intravascular coagulation. The most common condition causing hypercoagulability-related stroke is activated protein C resistance. Vasculitis may complicate infections such as meningitis, meningovascular syphilis or herpes zoster. Cerebral vasculitis may complicate systemic vasculitis, such as in systemic lupus, polyarteritis, Wegener’s granulomatosis, and Churg-Strauss syndrome. Other vasculitic disorders include Behcet’s disease, Susac’s syndrome, and Sneddon’s syndrome. Localization limits the etiologic differential diagnosis since certain disease processes typically involve or spare particular structures. Knowing the likely location of the pathology generally places thePthomegroup condition into a broad etiologic differential diagnostic category. Categories and etiologic classifications of neurologic disease are necessarily somewhat arbitrary, as is the category in which to place a given entity. For instance, subacute combined degeneration of the spinal cord could be seen as a metabolic disorder, a nutritional deficiency, or as a complication of a systemic illness, pernicious anemia. Porphyria is one example of many conditions that are both metabolic and genetic disorders. The etiologic classifications used here are neoplasm, vascular disease, infection, inflammatory and autoimmune disorders, trauma, pharmaceuticals and other chemical agents, substance-related disorders, toxins, metabolic disorders, demyelinating disease, congenital and developmental abnormalities, genetic disorders, degenerative conditions, disorders due to physical agents, environmental related conditions, mitochondropathies, channelopathies, paroxysmal disorders (seizures, headache and sleep), complications of systemic conditions, and nonorganic and psychiatric disease. Conditions such as epilepsy and migraine have important clinical manifestations far beyond the individual seizure or headache. The following paragraphs briefly summarize the features of some of these etiologic categories. Neoplasms Neoplasms may be divided into those that are intra-axial, arising within the brain or spinal cord substance, and those that are extra-axial, involving the meninges, cranial nerves, and other surrounding structures. Tumors are named according to their resemblance to cells that are found in the normal mature and developing nervous system. Examples of common intra-axial tumors include astrocytomas, oligodendrogliomas, ependymomas, medulloblastomas, and primary brain lymphoma. All are malignant because they invade the substance of the brain, but some more so than others. Common extra-axial tumors include pituitary adenoma, acoustic neuroma, and meningioma. Extra-axial tumors are more likely to be histologically benign and amenable to excision. They produce neurologic dysfunction primarily by exerting pressure rather than by invading. The symptoms and signs of intracranial tumors depend on their location, mass effect, pathologic characteristics, as well as their tendency to cause an increase in intracranial pressure. Focal manifestations of intracranial tumors include irritative phenomena such as seizures and symptoms of destruction such as progressively severe dysfunction of the structures involved. Of the primary intracranial neoplasms, approximately 50% belong to the glioma group. An acoustic neuroma (schwannoma, neurinoma, neurilemmoma) is a tumor that usually arises from the vestibular portion of the eighth cranial nerve; it is by far the most common tumor to involve cranial nerves. Pituitary adenomas are relatively common and may cause both endocrine disturbances as well as neurologic dysfunction because of mass effect. Craniopharyngiomas are tumors of congenital origin that arise from cell rests in the region of the pituitary. Malignancies can produce a host of nonmetastatic, paraneoplastic neurologic syndromes. The neurologic syndrome may precede the malignancy by months or years, occur simultaneously with presentation of the tumor, or develop in patients with known cancer. The paraneoplastic syndromesPthomegroup include but are not limited to progressive cerebellar ataxia, peripheral neuropathy, Lambert-Eaton syndrome, opsoclonus-myoclonus syndrome, “limbic encephalitis” (memory and emotional disturbances), and sensory ataxia due to dorsal root ganglion cell degeneration. Vascular Disease Stroke remains the third leading cause of death in the United States. Generally, cerebrovascular disease can be broadly divided into ischemic and hemorrhagic types (Table 53. It can be classified in a number of other clinically relevant ways: anterior circulation (carotid) versus posterior circulation (vertebrobasilar), large vessel (atherosclerotic) versus small vessel (hypertensive, diabetic, lacunar), and thrombotic versus embolic. Patients may present with many varieties of stroke related to these variables, as well as to the particular location of the event in the brain. The majority of initial ischemic strokes are atherothrombotic infarctions; cardiac embolism produces about 15% to 30% of cases, small vessel lacunar disease about 15% to 30%, and other types, such as vasculitis or arterial dissection, 3%. Ischemic disease tends to present with an acute focal deficit in an alert patient. Intracranial hemorrhage is more likely to have an apocalyptic onset with coma and a poor outcome. The onset of symptoms with all of these is usually abrupt, although the symptoms of thrombosis occasionally appear more gradually than those of either hemorrhage or embolism. It is important to identify precise time of onset, since this determines eligibility for treatment with tissue plasminogen activator, which must be given within 3 hours of symptom onset. Stenosis or occlusion of extracerebral and even extracranial arteries is responsible for a large proportion of cerebrovascular disease. Affected vessels may be in the neck or chest and include the common and internal carotids, the vertebrals, and the arch of the aorta. Small vessel disease involves deep, penetrating small arteries and arterioles and is frequently related to hypertension. Anterior circulation events typically produce hemispheric infarction causing hemiparesis and higher cortical function defects such as aphasia, whereas posterior circulation events cause brainstem or occipital lobe ischemia. Thrombotic events tend to have onset during sleep and cause less severe, more restricted deficits. Embolic events classically occur during activity, are more devastating, and are more likely to have associated cardiac disease. Anterior cerebral artery ischemia is characterized by disproportionate weakness and numbness of the contralateral leg. Patients with posterior cerebral artery strokes typically have homonymous hemianopia as the predominant clinical manifestation and may have no significant weakness or sensory loss. Of all fatal ischemic strokes, cerebral edema and increased intracranial pressure are the cause of death in about one-third. Brainstem strokes are characterized by “crossed” syndromes of cranial nerve dysfunction ipsilateral to the lesion and long motor or sensory tract dysfunction contralaterally. Many strokes are due to lacunar infarction related to fibrinoid necrosis, or lipohyalinosis, of small arterioles throughout the body. Lacunar infarcts primarily affect subcortical structures such as the basal ganglia, thalamus, internal capsule, subcortical white matter, cerebellum, and brainstem. Occlusion of these small endarteries produces infarction, and the small infarctions result in little cavities filled with fluid (Fr. It accounts for about 10% of patients with acute stroke, and 50% of patients with lacunar stroke. The lesion usually involves the posterior limb of the internal capsule, damaging the corticospinal tract fibers in isolation and causing a dense hemiparesis but no sensory loss, visual field deficit, speech disturbance, eye movement disorder, or other evidence of dysfunction of the cerebral cortex—a pure motor deficit. Pthomegroup In contrast to ischemic cerebrovascular disease, intracranial hemorrhage characteristically produces either severe headache or early impairment of consciousness, or both. Intracranial hemorrhage may occur into the parenchyma or into one of the spaces that surround the brain. Intraparenchymal bleeding may occur into the supratentorial compartment (intracerebral), the cerebellum, or the brainstem. Supratentorial hemorrhage is often further divided into basal ganglia (usually putaminal) hemorrhage, thalamic hemorrhage, and so-called lobar or subcortical hemorrhage, which involves the deep white matter in the corona radiata. Extraparenchymal hemorrhage may involve the subarachnoid, subdural, or epidural spaces. Spontaneous intracranial, extraparenchymal hemorrhage is usually into the subarachnoid space. Patients typically have apocalyptic events with dense deficits and rapid impairment of consciousness. The major etiologies of aneurysms are congenital, atherosclerotic, mycotic, and dissecting. Most saccular (berry) aneurysms occur at branching sites of the major arteries of the circle of Willis. About 80% of berry aneurysms involve the anterior circulation and about 20% are located in the vertebrobasilar system. Posterior communicating artery aneurysms frequently compress the oculomotor nerve. The patient develops a sudden, severe headache, often occipital or nuchal (thunderclap headache), often accompanied by convulsions, obtundation, or coma. Other causes of intracranial hemorrhage include amyloid angiopathy, vasculitis, and mycotic aneurysm. Most cerebrovascular disease is related to atherosclerosis and hypertension, but there are other important etiologies (see above). The clinical course may range from hyperacute (meningococcal meningitis), to chronic (tuberculous meningitis), to extremely chronic (prion infection). In acute bacterial meningitis, the patient typically appears acutely ill and toxic with fever, headache, altered sensorium, and stiff neck. Between 19 and 59 years, most cases are due to Streptococcus pneumoniae, and the next most common etiology is Neisseria meningitidis; over the age of 60, the most common organisms are S. Patients with viral aseptic meningitis present in much the same way as patients with bacterial meningitis, except they generally appear less sick. Other causes of an aseptic meningeal syndrome include neoplastic invasion of the meninges, reaction to certain medications, chemically induced meningeal inflammation, and infection by organisms difficult to culture. The term aseptic also applies toPthomegroup these forms of meningitis since routine bacteriologic cultures prove sterile, but aseptic is often used synonymously with viral meningitis. Major considerations include tuberculosis, cryptococcosis and other fungi, Lyme disease, and sarcoidosis. Brain abscesses can arise either because of direct spread from a contiguous infected source, such as a mastoid, or because of hematogenous spread. Patients typically present with varying combinations of headache, progressive neurologic deficits, seizures, and evidence of infection. However, fever and leukocytosis are absent in about half of the patients harboring a brain abscess.

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Therefore erectile dysfunction what is it purchase super levitra no prescription, screening and preventive interventions for parents as well as the child with diabetes are needed erectile dysfunction treatment dallas order super levitra overnight delivery. It is important to erectile dysfunction protocol reviews effective super levitra 80mg consider cultural variances in response to erectile dysfunction exam video order on line super levitra being diagnosed and living with a long term condition such as diabetes best erectile dysfunction pills for diabetes buy 80 mg super levitra. Following her study exploring physical and psychological wellbeing among adults with type 2 diabetes in New Zealand, with a particular aim to identify the experiences of Pacific peoples, Paddison (2010) concluded that adults with type 2 diabetes who are young, overweight, have concerns about prescribed medications, and those of Pacific ethnicity, were most likely to experience adverse health outcomes, including poor metabolic control and diabetes-related distress. She concluded that among Pacific peoples in particular, there is a need to address concerns about medication and emotional distress about diabetes, while maintaining a focus on improving metabolic control. For people with diabetes, it is important to make a distinction between depression and distress. According to Gonzalez et al (2011), a comprehensive approach ‘that distinguishes clinical depression from disease related distress and that offers support for the management of emotional distress as an integral part of providing support for the behavioural management of diabetes will have the greatest likelihood of clinical benefit for the vast majority of patients with diabetes’ (p 238). National Institute for Health and Care Excellence (2004) guideline type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults, provides a number of recommendations for screening and attending to psychological issues ( The American Diabetes Association’s Standards of Medical Care in Diabetes (2014) states: fi it is reasonable to include assessment of the patient’s psychological and social situation as an ongoing part of the medical management of diabetes fi psychosocial screening and follow-up may include, but are not limited to, attitudes about the illness, expectations for medical management and outcomes, affect/mood, general and diabetes-related quality of life, resources (financial, social, and emotional), and psychiatric history fi routinely screen for psychosocial problems, such as depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment. This gives examples of the information patients/carers/family/whanau may find helpful at the key stages of the patient journey. Health care professionals should: fi on those occasions where significant psychosocial problems are identified, explain the link between these and poorer diabetes control. They should advise patients where best to obtain further help, and facilitate this if appropriate fi be mindful of the burden caused by psychosocial problems (such as clinical and subclinical levels of depression) when setting goals and adjusting complex treatment regimens (typically adults and children will be less able to make substantial changes to their lives during difficult times). People with diabetes (or parents/guardians) should: fi try to speak to their general practitioner or diabetes team if they feel they (or their children) have significant psychosocial issues fi be mindful that many psychosocial problems make diabetes self-care more difficult and also that many difficulties can be successfully treated with the right help. These factors are significantly associated with poor diabetes self- management, a lower quality of life, and higher rates of diabetes complications. Holt et al (2012) undertook a systematic review to determine if there was evidence for a particular screening tool for depression in people with diabetes. They concluded that although a range of depression screening tools have been used in research, there remains few data on their reliability and validity. Further research is required in order to determine the suitability of screening tools for use in clinical practice and to address the increasing problem of co-morbid diabetes and 56 Quality Standards for Diabetes Care Toolkit depression. It is designed as a measure of depression and anxiety for hospital, out-patient, and community settings. Nineteen general practitioners in six clinics in New Zealand participated in the study which included 1025 consecutive patients receiving no psychotropic drugs. They concluded that adding a question inquiring if help is needed to the two screening questions for depression improves the specificity of a general practitioner diagnosis of depression ( Diabetes distress the Diabetes Distress 2 is another useful screening tool to rapidly assess diabetes distress in practice. Screening for depression in children and adolescents According to Hamrin et al (2010), screening for depression and gender-specific presentation is an important component of health assessment. If the clinician notes any symptoms of depression, parental concerns about their child’s mood, or a family history of mood disorders, or concerns about substance use, younger children should be screened and evaluated. A variety of screening tools exist to screen for depression, including written assessments to be completed by the parent or teen and interview style assessments to be administered by the practitioner. Initially developed by Goldenring and Cohen in 1988, further iterations have been made. This gives the interviewer a chance to establish trust and rapport with the teenager before asking the most difficult questions in the psychosocial interview (2. Bradford et al (2012) undertook a systematic review of psychosocial assessments for young people, in particular to examine the acceptability, disclosure and engagement, and predictive utility. They identified a number of potential tools; however, which tool is most appropriate for a clinician will depend on the domains they are most interested in, their preferred mode of delivery or available resources, available timeframe, and whether they work in a multidisciplinary environment. We tend to focus on specific goals which we decide on in collaboration with you and we also refer to other services if needed. We assist people diagnosed with a long-term health condition and their families/whanau cope with, and adjust to, their illness. We see people who live in the MidCentral region, who are dealing with or adjusting to a long term medical condition. There are a number of challenges you might face with a long-term health condition. For example you might feel distressed or overwhelmed, or you might be having some trouble adjusting to your condition. Psychological skills are important resources which will help you (and your family/whanau) to: fi manage stress associated with the condition fi deal with physical symptoms like pain, panic attacks and sleep problems fi manage fears, anxiety or depression fi improve relationship skills and build up support networks fi work with your health professionals fi make decisions and solve problems around living with the condition fi provide balance in dealing with health difficulties and getting on with everyday life. Quality Standards for Diabetes Care Toolkit 59 Assessment tools Structure Evidence of local arrangements to ensure that people with diabetes are assessed for psychological problems, which are then managed appropriately. Process (a) the proportion of people with diabetes assessed for psychological problems in the past 12 months. Numerator the number of people in the denominator receiving an assessment for psychological problems with at least a two item scale in the past 12 months Denominator the number of people with diabetes (b) the proportion of people with diabetes and psychological problems linked in to a local long term conditions programme. Numerator the number of people in the denominator who have been linked in to a long term condition programme Denominator the number of people with diabetes Structure Evidence of local arrangement s for screening people with mental health conditions for diabetes. Process the proportion of people with mental health conditions on an antipsychotic medication who have been screened for diabetes in the past 12 months. Numerator the number of people in the denominator who have been screened for diabetes in the past 12 months Denominator the number of people with mental health conditions on an antipsychotic medication Resources fi Depression. This website has been created to help people understand more about depression so they can find a way through it. Everyone’s experience of depression is different so take some time to explore the site and find what is going to work for you. The Ministry of Health has funded the Beating the Blues E-therapy tool for the assessment and treatment of mild to moderate depression for use in primary care nationwide. Beating the Blues is offered free of charge to general practices and some non-government organisations involved in primary care services. For assistance on how to register or for further information, please contact Andy Whittington of the E-Therapy Project Team: awhittington@medtechglobal. Effective communication is also empathetic communication: it involves listening to patients in a way that ensures that they feel understood. It focuses on non- medical issues which impact upon quality of life and diabetes self-management. The Notes are genuine, honest, and frank, and something any young person or those who care for someone with diabetes should understand. It is a tool to enable people with diabetes to make confident treatment choices with minimal anxiety. Six short questions invite people with diabetes to identify their level of agreement or disagreement with statements about different aspects of starting insulin. Based on the responses a personalised result will appear with a video providing facts to address and counter the concerns. Effect of the addition of a ‘help’ question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study. Psychosocial assessments for young people: A systematic review examining acceptability, disclosure and engagement, and predictive utility. Depression and diabetes: a large population-based study of sociodemographic, lifestyle, and clinical factors associated with depression in type 1 and type 2 diabetes. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Exploring physical and psychological wellbeing among adults with type 2 diabetes in New Zealand: Identifying a need to improve the experiences of Pacific peoples. Quality Standards for Diabetes Care Toolkit 63 Ross K, Malthus S, Berrett M, et al. Screening tools used for measuring depression among people with type 1 and type 2 diabetes: a systematic review. Psychological experience of parents of children with type 1 diabetes: a systematic mixed-studies review. Key practice points fi Medication decisions should be made jointly between health care professionals and the individual following discussion about the condition, goals and the role of medication. Read this standard in conjunction with the equity and diversity section in the Introduction to the Toolkit. What the quality statement means for each audience Service providers ensure that people with diabetes are able to agree with their health care professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with New Zealand guidelines. Also ensure that people with diabetes have access to appropriate blood glucose monitoring devices. Health care professionals ensure the person with diabetes understands and agrees with them to start, review and stop medication to lower blood glucose, blood pressure and blood lipids in accordance with New Zealand guidelines. Planners and funders ensure they commission services that enable the person with diabetes to agree with their health care professional to start, review and stop blood glucose, blood pressure and blood lipid lowering medications in accordance with New Zealand guidelines. Also ensure that services facilitate access for people with diabetes to appropriate blood glucose monitoring devices. People with diabetes agree with their health care professional to start, review and stop medications to lower blood glucose, blood pressure, and blood lipids and access appropriate blood glucose monitoring devices. There are two components to this Standard: fi medication management – this component describes agreement between patient and professional regarding the need for and adherence to medication for diabetes and related conditions fi blood glucose monitoring – this component covers blood glucose monitoring. These include: the acknowledgement and engagement of the patient as an active participant in treatment decision- making; individuals’ views on taking medication and the factors that influence adherence; and their satisfaction with their treatment – all of which may impact on medication use. Agreeing to start, review and stop medication is related to patient education (see Standard 1) in that people need to understand their condition/s, the way in which medication helps, and the importance of taking it appropriately and regularly. The Best Practice Advocacy Centre’s (2012a) article about people with type 2 and poor glycaemic control notes that an individual’s belief about the need for anti-diabetic medication can be influenced by factors such as fear, fatalism about the disease and family or whanau’s negative experiences with treatment. It continues to say that ‘a shared decision-making approach to management allows patients and health professionals to form an agreement on diabetes care that may also correct previous clinical assumptions, eg, concerning treatment adherence, health literacy or motivation. To do this well, primary care teams need to have a good understanding of the patient’s background, beliefs and priorities’ (p 41). A 2008 policy brief to the World Health Organization (Coulter et al) discusses the importance of patient involvement in treatment decision-making. They state in the summary: ‘One of the most common sources of patient dissatisfaction is not feeling properly informed about (and involved in) their treatment. Shared decision-making, where patients are involved as active partners with the clinician in treatment decisions, can be recommended as an effective way to tackle this problem. Clinicians and patients work together as active partners to clarify acceptable medical options and choose appropriate treatments. While not all patients want to play an active role in choosing a treatment – because of age-related and cultural differences – most want clinicians to inform them and take their preferences into account. Well-designed training courses can improve the communication skills of doctors, nurses and pharmacists. As patients become more involved, their knowledge improves, their anxiety lessens and they feel more satisfied. Patient coaching and question prompts help to empower patients to take a more active role in consultations. These prompts improve knowledge and recall and help patients feel more involved and in control of their care.

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Overt language policies erectile dysfunction diabetes uk order super levitra 80mg mastercard, which are explicit and formalized injections for erectile dysfunction treatment purchase super levitra with a mastercard, can also be contrasted with covert policies that are implicit impotence natural home remedies buy super levitra 80mg cheap, informal and unstated impotence nhs purchase super levitra overnight. Numerous theories in psycholinguistics and cognitive psychology attempt to erectile dysfunction treatment in pune purchase super levitra with american express account for the different processes involved in language production. Among the different stages involved are: Construction: the speaker or writer selects communicative goals, and creates propositions which express intended meanings. Transformation or articulation: meanings are encoded in linguistic form according to the grammar of the target language. Execution: the message is expressed in audible or visible form through speech or writing. An important issue in theories of language production is whether the pro- cesses involved are analogous to those involved in language comprehension (though in reverse order). This can be contrasted with language achievement, which describes language ability as a result of learning. In language teaching, decisions must be made as to whether a learner or group of learners requires a language for general purposes or for special purposes. Listening, speaking, reading, and writing are generally called the four language skills. Sometimes speaking and writing are called the active/ productive skills and reading and listening, the passive/receptive skills. Often the skills are divided into subskills, such as discriminating sounds in connected speech, or understanding relations within a sentence. Language socialization is thought to be a key to the acquisition of both linguistic and sociocultural knowledge. Thus acquisition of specific skills in a language is shaped by the culturally specific activities within which these skills are used. Such a survey may be carried out to determine, for example: a which languages are spoken in a particular region b for what purposes these languages are used c what proficiency people of different age-groups have in these languages. Positive transfer is transfer which makes learning easier, 322 language use and may occur when both the native language and the target language have the same form. For example, both French and English have the word table, which can have the same meaning in both languages. Negative transfer, also known as interference, is the use of a native-language pattern or rule which leads to an error or inappropriate form in the target language1. For example, a French learner of English may produce the incorrect sentence I am here since Monday instead of I have been here since Monday, because of the transfer of the French pattern Je suis ici depuis lundi (“I am here since Monday”). Although L1 to L2 transfer has been investigated most widely, it is also generally recognized that there can also be transfer from an L2 to one’s native language, as well as L2 to L3 transfer from one second or foreign language to another. This includes language planning by governments and government appointed agencies, but also includes such things as: language requirements for employment in a private company, company policy on style in business letters, trade-name spelling, publishers’ style sheets, and the treatment of language in dictionaries and usage guides (see usage2). For example, it has been suggested that: a if a language has dual number for referring to just two of something, it also has plural number (for referring to more than two). For example in a multilingual country such as Singapore with four official languages (English, Chinese, Malay and Tamil) a language use survey would seek to determine who uses which languages, for what purposes, and to what degree of proficiency. The term was used by the linguist Saussure to mean the system of a language, that is the arrangement of sounds and words which speakers of a language have a shared knowledge of or, as Saussure said, “agree to use”. Saussure called the actual use of language by people in speech or writing “parole”. Saussure’s distinction between “langue” and “parole” is similar to Chomsky’s distinction between competence and performance. But whereas for Saussure the repository of “langue” is the speech community, for Chomsky the repository of “competence” is the “ideal speaker/hearer”. So Saussure’s distinction is basically sociolinguistic (see sociolinguistics) whereas Chomsky’s is basically psycholinguistic (see psycholinguistics). For example, the vowel of feel glides to a noticeably more centralized position than the vowel of fee. It often includes an introduction to the topic of the text or task, and activities that activate background knowledge or pre-teach key words or other language that might be needed to complete the task. An adequate theory must explain how children are able to learn the grammar of their native language and must therefore provide for grammars of languages that are easily learnable. The psycholinguistic processing devices acquired at one stage are a necessary building block for the following stage. This implies a teachability hypothesis as well, since structures cannot be taught successfully if the learner has not learned to produce structures belonging to the previous stage. One proposal that has been advanced within generative grammar is the subset principle, which posits that language learners choose options that allow the smallest number of grammatical sentences. In general nativism, the same effect is achieved by the conservatism thesis, the idea that children make use of available concepts to formulate the most conser- vative hypothesis consistent with experience, and the trigger requirement, the principle that no change is made in the grammar without a triggering stimulus in the environment. This will be refiected in approaches to needs analysis, content selection, and choice of teaching materials and learning methods. Learners’ belief systems are relatively stable sets of ideas and attitudes about such things as how to learn language, effective teaching strategies, appropriate classroom behaviour, their own abilities, and their goals in language learning. Learner centredness may be refiected by: 1 recognizing learners’ prior knowledge 2 recognizing learners’ needs, goals and wishes 3 recognizing learners’ learning styles and learning preferences 4 recognizing learners’ views of teaching and of the nature of classroom tasks. In learner-centred approaches, course design and teaching often become negotiated processes, since needs, expectations, and student resources vary with each group. The materials normally: 1 have clearly specified goals 2 contain specific directions for their use 3 are graded according to difficulty level 4 contain means for self-checking. Learning contracts seek to develop independent learning, self-directed learning, and to encourage self-motivation and discipline. The following graph shows the development of negation in a 328 learning log Spanish-speaking learner of English. I don’t want) over time as found in taped samples taken over 20 different time periods. A learning or acquisition curve learning disability n a learning difficulty which affects a particular aspect of learning on the part of a learner whose other learning abilities are considered normal. For example, specific difficulties in learning to read (dyslexia) or to write (dysgraphia). Learning logs provide students with an opportunity to refiect on learning, and are usually shared with the teacher on a regular basis but not graded. In this way, the teacher may be able to find out how the student is progressing and the students gain additional opportunities to practise writing. In writing classes learning logs may be used as a prewriting activity (see composing processes) and also as a way of encouraging students to develop fiuency in writing through writing regularly on topics of their own choice. When learning logs are used as a way of establishing a dialogue between teacher and student (through comments, questions and reactions), they are sometimes referred to as dialogue journals or diaries. Learning outcomes help instructors and course designers to tell students what they are expected to do and what they can hope to gain from following a particular course or programme. Whenever a particular pathway through the network results in a successful outcome, the relevant connections are strengthened. When a particular pathway does not result in success, some network architectures implement a procedure called back propagation, which weakens connections. As these learning rules are applied repeatedly over a large number of training sessions, the system is increasingly fine-tuned and errors are reduced. In first language learning, the word “strategy” is sometimes used to refer to the ways that children process language, without implying either intentionality or awareness. For example, in trying to understand a sentence, a child may “use” the learning strategy that the first mentioned noun in a sentence refers to the person or thing performing an action. The child may then think that the sentence the boy was chased by the dog means the same thing as the boy chased the dog. In second language learning, a strategy is usually an intentional or potentially inten- tional behaviour carried out with the goal of learning. A number of broad categories of learning strategies have been identified, including cognitive strategies such as analyzing the target language, comparing what is newly encountered with what is already known in either the L1 or the L2, and organizing information; metacognitive strategies, which include being aware of one’s own learning, making an organized plan, and monitoring one’s progress; social strategies such as seeking out friends who are native speakers of the target language or working with peers in a classroom setting; and resource management strategies such as setting aside a regular time and place for language study. Learning strategies may be applied to simple tasks such as learning a list of new words, or more complex tasks involving language comprehension and production. Learners approach learning in different ways, and an activity that works with a learner whose learning style favours a visual mode of learning, may not be as successful with a learner who prefers auditory or kinesthetic modes of learning. Teachers are hence encouraged to try to recognize different learning styles among their learners. Several different learning styles are often referred to: 1 Analytic versus global refers to whether the learner focuses on the details or concentrates on the main idea or big picture. Study skills and learning strategies are examples of the domain of learning to learn. Left dislocation is a word order device which is often used to signal a new topic (topic2) or to give special emphasis. With right dislocation, a linguistic form appears to the right of its normal position. The left hemisphere has been shown to be especially important for language processing, and it is where both Broca’s area and Wernicke’s area are located. As a result, the less commonly-taught languages do not have nearly the same level of resources (textbooks, trained teachers, opportunities for secure employment, scholars who specialize in the language) as languages that have a long history of support by the educational establishment. Often, these levels are considered to form a scale or hierarchy from lower levels containing the smaller linguistic units to higher levels containing larger linguistic units. It is also sometimes said that the items on each level consist of items on the next lower level: clauses consist of phrases, phrases of words, words of morphemes, etc. It can occur in many different forms in actual spoken or written sentences, and is regarded as the same lexeme even when infiected (see infiection). For example, in English, all infiected forms such as give, gives, given, giving, gave would belong to the one lexeme give. Similarly, such expressions as bury the hatchet, hammer and tongs, give up, and white paper (in the sense of a government document) would each be considered a single lexeme. According to psycholinguistic models of speech production, vocabulary is stored in some form in the speaker’s lexicon and must be accessed in order to be used during the process of communication. The lexicon is seen as playing a much more central role in language organization, language learning, and language teaching than, for example, grammar, and occupies a more central role in syllabus design, course content, and teaching activities. For example, the hypothesis holds that language learners first acquire the English pro- gressive affix -ing in conjunction with specific verbs like play or read, which refer to actions that are inherently durative, rather than in connection with verbs like fall, which refers to an action that is inherently abrupt or non- durative (although it is possible to say I was falling, viewing the action as durative). Also according to this view, what appears to be the acquisition of tense in the early stages of language learning is more likely to refiect the encoding of aspect. Entries in a lexicon (see lexicon2) or dictionary usually show, among other information, the lexical category of a particular word. Many lexical corpora contain millions of words that can be analyzed by a computer. Lexical density is normally expressed as a percentage and is calculated by the formula: number of separate words Lexical density = fi 100 total number of words in the text For example, the lexical density of this definition is: 29 separate words fi 100 = 50. The information given in a lexical entry usually includes: a its pronunciation (see distinctive feature) b its meaning, which may be given in a formalized way. For example, kinship terms such as father, mother, brother, sister, uncle, aunt belong to a lexical field whose relevant features include generation, sex, membership of the father’s or mother’s side of the family, etc. The absence of a word in a particular place in a lexical field of a language is called a lexical gap.

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Such pharmacologic blockade can be distinguished by the failure to impotence quoad hoc meaning buy line super levitra respond to impotence caused by medication buy 80 mg super levitra amex full strength pilocarpine impotence urban dictionary super levitra 80 mg discount, which promptly constricts a large pupil of any other etiology impotence treatment drugs order line super levitra. Many older patients use pilocarpine eye drops to impotence young male purchase 80 mg super levitra visa manage chronic open angle glaucoma. Important neurologic conditions causing an abnormally small pupil include Horner’s syndrome and neurosyphilis. Horner (Swiss ophthalmologist), but the abnormality had beenPthomegroup described previously in animals by Claude Bernard (and others) and it is sometimes referred to as Bernard-Horner syndrome. Lack of sympathetic input to the accessory lid retractors results in ptosis and apparent enophthalmos. The lower lid is frequently elevated 1 to 2 mm because of loss of the action of the lower lid accessory retractor that holds the lid down (inverse ptosis). Since the fibers mediating facial sweating travel up the external carotid, lesions distal to the carotid bifurcation produce no facial anhidrosis except for perhaps a small area of medial forehead that is innervated by sympathetic fibers traveling with the internal carotid. Pupillary asymmetry greater in the dark than in the light generally means Horner’s syndrome. Recall that physiologic anisocoria produces about the same degree of pupillary asymmetry in the light and dark. In contrast, third nerve palsy and Adie pupil cause greater asymmetry in the light because of the involved pupil’s inability to constrict. Examining the eyes under light and dark conditions can help greatly in sorting out asymmetric pupils (Figures 14. Should the examiner err by having the patient fixate at near during testing, the pupillary constriction in the good eye may lessen the asymmetry and cause the abnormal pupil to be missed. The pupil in Horner’s syndrome not only dilates less fully, it dilates less rapidly. In the first few seconds after dimming the lights, the slowness of dilation of the affected pupil may cause the anisocoria to be even more pronounced (dilation lag). There is more anisocoria at 4 to 5 seconds after lights out than at 10 to 12 seconds. The causes of Horner’s syndrome are legion and include the following: brainstem lesions (especially of the lateral medulla), cluster headache, internal carotid artery thrombosis or dissection, cavernous sinus disease, apical lung tumors, neck trauma, and other conditions (Figure 14. The tiny and minimally reactive pupils seen commonly in pontine hemorrhage may represent acute, severe, bilateral oculosympathetic paresis. The rare condition of reverse Horner’s syndrome (Pourfour du Petit syndrome) is unilateral mydriasis, sometimes with facial flushing and hyperhidrosis, due to transient sympathetic overactivity in the early stages of a lesion involving the sympathetic pathways to one eye. Pharmacologic testing is occasionally done to help determine whether a miotic pupil is due to Horner’s syndrome. In about half the patients with Horner’s syndrome, the etiology is apparent from other signs and the history. In the other half, clinical localization is uncertain; pharmacologic testing may help determine the level of the lesion and guide further investigations. Interruption of the sympathetic pathways between the hypothalamus and the spinal cord. The third order neuron lies in the superior sympathetic ganglion; a lesion at or distal to here. With a third order Horner’s, the final neuron in the pathway dies and its peripheral processes atrophy and disappear. With first and second order Horner’s syndrome, the third order neuron is disconnected but intact, and its terminal connections sound and viable. Cocaine drops instilled into the eye can confirm the presence of Horner’s syndrome, but cannot localize the lesion; hydroxyamphetamine can distinguish a third order from other types of Horner’s syndrome. Cocaine blocks the reuptake of norepinephrine from the nerve terminals, increasing its effect. With Horner’s syndrome of any type, there is less norepinephrine being released, less accumulates at the pupillodilator, and cocaine will fail to dilate the affected pupil. Hydroxyamphetamine drops cause release of norepinephrine, but only from intact nerve endings. If the third order neuron is intact, as with first or second order Horner’s syndrome, the pupil will dilate in response to hydroxyamphetamine. In a third order Horner’s syndrome, there are no surviving nerve endings in the eye to release norepinephrine and the pupil will fail to dilate. Apraclonidine, a new selective fi agonist used to reduce intraocular pressure, may also be2 used to demonstrate denervation hypersensitivity, and is much more readily available than cocaine. Denervation hypersensitivity may occur as soon as 36 hours after development of the Horner’s syndrome. Other findings in Horner’s syndrome include loss of the ciliospinal reflex, ocular hypotonyPthomegroup, and increased amplitude of accommodation and vasodilation in the affected distribution. Congenital Horner’s syndrome may cause sympathetic heterochromia iridis and other trophic changes of the head and face. Argyll Robertson pupils are generally bilateral and asymmetric, but may be symmetric and rarely unilateral. Argyll Robertson pupils are the classic eye finding of neurosyphilis and when present they mandate appropriate serologic testing. Pupils with Abnormal Reactions Disruption of the afferent or efferent limbs of the pupillary reflex arcs, or disease of the brainstem pupil control centers, may alter pupil reactivity to light or near, as may local disease of the iris sphincter. Disease of the retina does not affect pupil reactivity unless there is involvement of the macula severe enough to cause near blindness. Cataracts and other diseases of the anterior segment do not impair light transmission enough to influence the pupil. Because of the extensive side-to-side crossing of pupillary control axons through the posterior commissure, light constricts not only the pupil stimulated (the direct response) but also its fellow (the consensual response). The eye with a severed optic nerve will show no direct response, but will have a normal consensual response to a light stimulus in the other eye, as well as constriction to attempted convergence (amaurotic pupil). The pupil frozen because of third nerve palsy will have no near response and no direct or consensual light response, but the other eye will exhibit an intact consensual response on stimulation of the abnormal side (Table 14. The pupillary reaction to light is normally equal to or greater than the reaction to near. Light near dissociation refers to a disparity between the light and near reactions. The most common form is a poor light response but good constriction with the near response; it is relatively common, and there are aPthomegroup number of causes. In the routine case, if the pupillary light reaction is normal, there is little to be gained by examining the near reaction. Disorders that affect the dorsal rostral brainstem may affect the light reaction but leave the near reaction intact. This anatomical arrangement likely explains many instances of the phenomenon of light near dissociation of the pupils. Pressure on the pupillary fibers in the region of the pretectum and posterior commissure. Afferent Pupillary Defect When testing the light reflex, the amplitude of the initial pupillary constriction and subsequent slight escape depend greatly on the specific circumstances of illumination. Therefore, the status of the light reflex must be judged by comparing the two eyes. The importance of the pupil light reflex as an indicator of optic nerve function has been recognized since antiquity; Hippocrates and Galen understood the basic concept. With mild to moderate optic nerve disease, it is difficult to detect any change in pupil reactivity to direct light stimulation. As provocatively pointed out by Landau, Marcus Gunn (in 1902) described pathologic pupillary escape, what he termed secondary dilatation under continued exposure (for 10 to 20 seconds), or the adapting pupillary response, due to optic nerve disease. In 1959, Levitan described looking for the Marcus Gunn pupillary sign by swinging a light back and forth between the two eyes (swinging flashlight test, alternating light test). He thought moving the light back and forth amplified the asymmetry of the pupillary escape. There seems to be general agreement that the swinging flashlight test is a very useful technique that can quickly and accurately compare the initial constriction and subsequent escape of the two pupils. It is a key clinical technique in the evaluation of suspected optic neuropathy, and it can often detect a side-to-side difference even when the lesion is mild and there is no detectable difference in the direct light reflex when testing each eye individually. In the first, the light is held about 1 in from the eye and just below the visual axis; the light is rapidly alternated, pausing for about one full second on each side. The examiner attends only to the stimulated eye, comparing the amplitude and velocity of the initial constriction in the two eyes. With stimulation of the good eye, both pupils constrict smartly due to the direct reflex in the stimulated eye and the consensual reflex in the opposite eye. After 3 to 5 seconds to allow the pupil to stabilize, the light is quickly swung to the bad eye. With an optic nerve lesion, the brain detects a relative diminution in light intensity and the pupil may dilate a bit in response. The pupil in the other eye dilates as well because the consensual reflex constricting the pupil in the good eye is less active than its direct reflex, but this is not observed. On moving the light back to the good eye, the more active direct response causes the pupil to constrict. On moving back to the bad eye, the pupil dilates because the direct light reflex is weaker than the consensual reflex that had been holding it down. As the light passes back and forth, the pupil of the good eye constricts to direct light stimulation and the pupil of the bad eye dilates to direct light stimulation. It may require several swings to find the optimum speed to bring out the dynamic anisocoria. Over severalPthomegroup cycles, it may be striking to see one pupil consistently dilate to the same light stimulus that causes the other to constrict. More formal grading may be done by placing neutral density filters over the good eye to create a conduction defect. The “reverse Marcus Gunn” is used to evaluate optic nerve function in an eye where pupillary function is impaired because of local disease, or the fundus obscured by cataract, by watching the reactions of the good eye on stimulating the bad eye. Unusual Disorders of the Pupil Some rare pupillary disorders include paradoxical pupils, springing pupil, tadpole pupil, oval pupils, and corectopia (Box 14. The phenomenon is seen in congenital retinal and optic nerve disorders; the mechanism is unknown. Springing pupil (benign, episodic pupillary dilation; mydriasis a bascule) is intermittent, sometimes alternating, dilation of one pupil lasting minutes toPthomegroup hours seen in young, healthy women, often followed by headache. Tadpole pupil is a benign condition in which a pupil intermittently and briefly becomes comma shaped because of spasm involving one sector of the pupillodilator; it may be a forme fruste of springing pupil. Periodic unilateral mydriasis has been reported in migraine and as an ictal phenomenon. Oval pupils usually portend major intracranial pathology and may be a transient phase in evolving injury to the third nerve nuclear complex. Corectopia iridis (ectopia pupillae, Wilson’s sign) is spontaneous, cyclic displacement of the pupil from the center of the iris; it is usually seen in severe midbrain disease.

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