Condet

Rui Fernandes, DMD, MD, FACS

• Assistant Professor, Chief, Section of Head and
• Neck Surgery
• Department of Surgery
• Divisions of Oral and Maxillofacial Surgery and
• Surgical Oncology
• Director of Microvascular Fellowship Program
• University of Florida College of Medicine
• Jacksonville, Florida

Given its current stage of development diagnostic assessment needs to be experimented systematically and empirically both in large and small scales through collaboration among different expert groups erectile dysfunction san francisco cheap 100 mg zenegra free shipping. Classroom-based diagnostic assessment A survey of various standardized classroom-based diagnostic assessments erectile dysfunction pills free trial purchase 100 mg zenegra amex, mostly in L1 reading erectile dysfunction doctors in queens ny cheap 100mg zenegra mastercard, suggests that despite their intended use for diagnostic purposes erectile dysfunction recreational drugs order 100mg zenegra amex, they appear to fall short. He needs to develop his vocabulary ability in order to comprehend text and relate it to his own experiences. He needs to develop skills related to comprehending implicit textual information, inferencing, and representing textual information in alternative modes using graphs and tables. A close review of a few K­12 diagnostic assessment tools helps us understand the status quo of contemporary diagnostic assessments available for classroom teachers. These are comprehensive, yet possess quite ambitious purposes, which I will revisit later in this section. During the individual conference, the teacher administers a running record (Clay, 2000) by introducing a text and recording the numbers of errors and self-corrections while the child is reading the text. It includes several subtests including reading interviews, a reading attitude survey, a reading interests inventory, a student self-assessment, and a reading comprehension test. The reading comprehension test includes 10 reading passages (five fiction and non-fiction each) per grade each of which includes eight multiple-choice questions. The results are reported in four levels of performance related to the tested elements. Though those assessments are widely used in classrooms for diagnostic and tracking purposes in Ontario, surprisingly there is no publicly available research evidence supporting their validity. However, 128 Diagnostic assessment in language classrooms research shows that teachers often do not design and implement such activities with diagnostic assessment in mind and spend a small amount of time assessing individual students (Edelenbos and Kubanek-German, 2004). Most teachers commence their careers with relatively less training in assessment issues than other subject-specific domains. Assessment topics in pre-service and in-service teacher training programmes are elective rather than core curriculum. For example, on the first day of my graduate-level assessment course, I heard a student (also a full-time secondary school teacher) saying: I did my pre-service teacher program at this institution, have taught students since then, and am head of the history department at my school. However, as I noted previously, they lack theoretical foundations precisely for the same reason. The following description illustrates how teachers can benefit from the use of proficiency descriptors in classrooms. Roussos is pleased that Sam, a Grade-6 new comer speaking Tagalog at home, demonstrated rapid growth in reading proficiency in the past year. He can now read and comprehend informational, graphic, and literary texts with visual support. He has developed comprehension strategies for connecting his prior learning to new textual information. His teacher notes that his oral and writing proficiency development is relatively slower than his reading given that Sam writes a limited range of familiar text forms using personally relevant vocabulary. Roussos plans to design some activities that will encourage Sam to focus on those aspects. Research shows that not all students use similar strategies in processing their language skills to solve tasks. If diagnostic assessment measures only known skills and strategies but fails to incorporate multiple pathways to completing given tasks, the resulting diagnostic outcomes may be of little use (Alderson, 2007). Students from different socio-linguistic and cultural backgrounds are more likely to approach tasks differently, which makes it difficult for assessors to anticipate all pathways. Students tend to react to diagnostic feedback by comparing it with their own self-assessment and decide whether or not to focus their learning on the areas of improvement (Jang, 2005, 2009). One implication is that a focus on marks and grades, on written work or in a regime of frequent testing, can do positive harm by developing obstacles to engagement, effects which can be as harmful to the high achievers as to the low. The view of students as change agents in diagnostic assessment should consider non-cognitive learner characteristics.

The posterior part becomes the external anal sphincter erectile dysfunction 24 zenegra 100mg lowest price, and the anterior part develops into the superficial transverse perineal erectile dysfunction after radiation treatment prostate cancer 100 mg zenegra with amex, bulbospongiosus erectile dysfunction 32 years old zenegra 100mg generic, and ischiocavernosus muscles erectile dysfunction protocol formula purchase zenegra 100mg on line. This developmental fact explains why one nerve, the pudendal nerve, supplies all these muscles. Mesenchymal proliferations produce elevations of the surface ectoderm around the anal membrane. As a result, this membrane is soon located at the bottom of an ectodermal depression-the proctodeum or anal pit (see. The anal membrane usually ruptures at the end of the eighth week, bringing the distal part of the digestive tract (anal canal) into communication with the amniotic cavity. The Anal Canal the superior two thirds (approximately 25 mm) of the adult anal canal are derived from the hindgut; the inferior one third (approximately 13 mm) develops from the proctodeum. The junction of the epithelium derived from the ectoderm of the proctodeum and the endoderm of the hindgut is roughly indicated by the irregular pectinate line, located at the inferior limit of the anal valves. This is approximately where the composition of the anal epithelium changes from columnar to stratified squamous cells. At the anus, the epithelium is keratinized and continuous with the skin around the anus. The other layers of the wall of the anal canal are derived from splanchnic mesenchyme. Similar to the pyloric sphincter and the ileocecal valve (sphincter), the formation of the anal sphincter appears to be under Hox D genetic control. B1, D1, and F1, Transverse sections of the cloaca at the levels shown in B, D, and F, respectively. Note that the postanal portion (shown in B) degenerates and disappears as the rectum forms from the dorsal part of the cloaca (shown in C and D). Note that the superior two thirds of the anal canal are derived from the hindgut, whereas the inferior one third of the canal is derived from the proctodeum. Because of their different embryologic origins, the superior and inferior parts of the anal canal are supplied by different arteries and nerves and have different venous and lymphatic drainages. Because of its hindgut origin, the superior two thirds of the anal canal are mainly supplied by the superior rectal artery, the continuation of the inferior mesenteric artery (hindgut artery). The venous drainage of this superior part is mainly via the superior rectal vein, a tributary of the inferior mesenteric vein. The lymphatic drainage of the superior part is eventually to the inferior mesenteric lymph nodes. Because of its origin from the proctodeum, the inferior one third of the anal canal is supplied mainly by the inferior rectal arteries, branches of the internal pudendal artery. The venous drainage is through the inferior rectal vein, a tributary of the internal pudendal vein that drains into the internal iliac vein. The lymphatic drainage of the inferior part of the anal canal is to the superficial inguinal lymph nodes. Its nerve supply is from the inferior rectal nerve; hence, it is sensitive to pain, temperature, touch, and pressure. The differences in blood supply, nerve supply, and venous and lymphatic drainage of the anal canal are important clinically. Tumors in the superior part are painless and arise from columnar epithelium, whereas those in the inferior part are painful and arise from stratified squamous epithelium. Anomalies of the Hindgut Most anomalies of the hindgut are located in the anorectal region and result from abnormal development of the urorectal septum. Clinically, they are divided into high and low anomalies depending on whether the rectum terminates superior or inferior to the puborectal sling formed by the puborectalis, a part of the levator ani muscle (see Moore and Dalley, 2006). The aganglionic distal segment (rectum and distal sigmoid colon) is narrow, with distended normal ganglionic bowel, full of fecal material, proximal to it. This disease affects one in 5000 newborns and is defined as an absence of ganglion cells (aganglionosis) in a variable length of distal bowel. The enlarged colon-megacolon (Greek, megas, big)-has the normal number of ganglion cells. The dilation results from failure of relaxation of the aganglionic segment, which prevents movement of the intestinal contents, resulting in dilation.

Exposure of the surgical site and globe protection is facilitated with the use of nonconducting retractors erectile dysfunction icd 9 code 2013 buy discount zenegra 100 mg on-line. The dissection is continued downward and forward until all the pseudoherniated fat is exposed sudden erectile dysfunction causes order zenegra 100mg on-line. Fat is removed to a depth 1 mm below the surface of the orbital rim with gentle pressure placed on the globe to assess for irregularity and asymmetry erectile dysfunction testosterone injections 100 mg zenegra otc. Skin may be resected as necessary using the "pinch" technique or may be combined with chemical peel or laser resurfacing to address superficial fine-line rhytides impotence from prostate surgery cheap 100 mg zenegra with mastercard. Transection of lower lid retractors may have the lower lid margin appear elevated for a few weeks. Advantages of the transconjunctival approach include avoidance of external scar, and potentially less risk of ectropion. Limitations include lack of addressing skin excess or hypertrophy of the orbicularis muscle. Lower eyelid blepharoplasty is associated with a higher rate of hematoma formation. It may occur up to a few days postoperatively and is treated with a lateral canthotomy and orbital decompression. Blindness Chronic G G G G G G G Ectropion Lagophthalmos Scleral show Ptosis Epiphora Inadequate excision of skin and fat Dry eyes Further Reading Bosniak S. The lateral skin is tightly adherent to the cartilage, whereas the medial or postauricular skin has loose connective tissue subcutaneously and thus can be easily separated and peeled from the underlying concha and scapha. The lobule has no cartilage and can have several anatomic configurations and positions. The abnormal development that results in deformities of the auricle usually originates from the second branchial arch. These abnormalities usually manifest themselves before the end of the first trimester of pregnancy; the frequency of variants is from 3 to 5% of the Western population. Also, aging makes the auricle appear larger, in part due to elongation of the lobule. N Evaluation of Aesthetic Deformities of the Auricle the helix, scapha/antihelix, posterior conchal wall, and conchal floor make up the four planes of the auricle. The angles between these planes and the auricle or scalp determine the degree of protrusion of the ear. The degree of protrusion or malformation is described as a variant from the normal concha­scapha angle. Normal ears have a concha­scapha angle of 75­105 degrees, with 90 degrees most common. An ear is classified as "protruding" when the concha­scapha angle 110 degrees, the angle of the ear to scalp 40 degrees, or the helical rim protrudes 3 cm. N Surgical Techniques Treatment of abnormally shaped ears commonly addresses two concerns: the lack of development of the antihelical fold and the deep concha cavum, respectively. The Mustarde-type approach utilizes permanent sutures to recreate the antihelical fold. The second approach utilizes scoring incisions, abrading, or filing the cartilage to alter its shape thus reestablishing a fold. A combination of the techniques may be utilized particularly if the scapha is resistant to reshaping via the suture placement. One is the Furnas-type approach of suturing posterior conchal cartilage to the mastoid periosteum. The other techniques involve excisions of conchal cartilage usually performed through the postauricular incision. The excisions can be elliptical or crescent-shaped with reapproximation of the cartilage or they can be disk shaped when combined with the conchal setback techniques. The goal is to reduce the height of the posterior conchal wall, thus reducing the prominence of the ear. Facial Plastic and Reconstructive Surgery 667 In the majority of patients, the permanent suture technique is utilized with or without scapha weakening. Deep conchal bowls are reduced by elliptical posterior cartilage excisions of 3 to 5 mm and usually followed by a conchal setback procedure. The procedure is done under general anesthesia in children and local anesthesia with sedation in adults. The incision is placed above the postauricular sulcus in an intermediate location between the mastoid and postauricular skin and the edge of the auricle.

Two plates or two lag screws are generally used in the symphyseal and parasymphyseal regions erectile dysfunction pills online generic zenegra 100 mg with mastercard, a single plate is commonly used along the mandibular body erectile dysfunction doctor austin discount zenegra 100mg with mastercard, and one or two plates (the choice is controversial) are used for angle fractures erectile dysfunction gene therapy treatment cheap 100mg zenegra amex. Compression plates can be used as well along the symphysis and body (not at the angle) erectile dysfunction solutions pump buy cheap zenegra 100 mg, but this requires bicortical screws placed along the inferior border, so tension band plates or arch bars must be applied to avoid distraction of the alveolar portion of the fracture. This requires the placement of longer, stronger reconstruction plates fixed with bicortical screws along the inferior border of the mandible. At least three and preferably four screws should be placed on either side of the fracture. Load-bearing reconstruction plate repairs are indicated to span areas of mandibular deficiency, such as defects, areas of comminution, atrophic mandibles (edentulous patients), and areas involved with infection (or previous nonunion). The reconstruction plate is also a fallback technique for any mandible fracture, particularly in the angle region after loss of an impacted third molar. Fractures of the condylar neck should be opened if there is significant foreshortening of the ramus of the mandible or persistent malocclusion. The endoscopic approach allows a mostly transoral repair of selected subcondylar fractures. Failure of fixation requires reoperation, and if infection has developed, a stronger, load-bearing repair will be necessary. Oral hygiene must be maintained, and antiseptic oral rinses are commonly used several times daily and after meals. A liquid diet is preferred initially, and this is advanced to a mechanical soft diet as tolerated. Facial Plastic and Reconstructive Surgery 619 satisfactory reduction of fractures. At this point, most fractures are stable enough to allow removal of the arch bars. Use of intraoperative computed tomography during repair of orbitozygomatic fractures. Etiology of the paralysis, oncologic status, type of injury, and location of injury all contribute to the selection of the most appropriate reanimation methods. Reanimation techniques are classified into four types: neural methods, musculofascial transpositions, facial plastic procedures, and prosthetics. For patients with facial nerve injuries, realistic expectations must be established at the initial encounter and candidly discussed between the physician and the patient and his or her family. First, no reanimation technique will restore the face exactly to its preparalyzed condition. The patient should understand that despite the most meticulous surgery some degree of synkinesis and residual weakness may persist. It is also important to stress that the results of these reanimation techniques may be augmented by physical therapy and rehabilitation. If added length is needed, careful rerouting of the tympanic and mastoid segments of the nerve may add enough length for an end-to-end anastomosis. Facial Plastic and Reconstructive Surgery 621 Intratemporal Intratemporal facial nerve injury is usually encountered in patients following external head trauma with skull base fractures, or iatrogenic injury during or following otologic surgery. Most temporal bone fractures result from motor vehicle accidents and violent encounters. In temporal bone trauma, facial nerve injury most often occurs in the perigeniculate and labyrinthine sections, with axonal degeneration extending a variable distance in both directions. Management of facial nerve injury following temporal bone trauma is controversial. Most patients who present with complete paralysis at the time of injury have a poorer prognosis than those with incomplete or delayed paralysis. Extratemporal Extratemporal injury to the facial nerve may occur during parotid surgery, temporomandibular joint procedures, or facelift procedures, or following traumatic lacerations of the face. The incidence of facial nerve paralysis after uncomplicated parotid procedures is reported at 20% for temporary palsy and 10% for permanent paresis of either the temporal or mandibular branches. Patients at higher risk for facial nerve injury during parotid surgery include children and those undergoing a total parotidectomy. Inadvertent transection of the nerve that is recognized during parotid surgery should be repaired as soon as possible.

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