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This book also explores evaluating research and service and so comple- ments Scholarship Assessed which is noted below discount 10 mg sinequan with visa anxiety scale 0-5. On portfolios discount sinequan 10 mg anxiety and panic attacks, the most straightforward advice is contained in the original Canadian work on this subject by B. Another useful introduction to portfolios, which also considers their relationship to scholarship, is The Teaching Portfolio: Capturing the Scholarship of Teaching by R. If you are concerned to evaluate materials and educational technologies we suggest M. Tessmer, Planning and Conducting Formative Evaluations, Kogan Page, London, 1993. This is an interesting mixture of useful guidance on planning evaluations, evaluating materials, and the whole notion of formative evaluation. Hartley’s book is also helpful on evaluating materials; Designing Instructional Text, Kogan Page, London, 1994. Navigating student ratings of instruction, American Psychologist, November, 1198-1208. Scholarship Assessed, Evaluation of the Professoriate, Jossey-Bass, San Francisco, 1997. Student ratings, the validity of use, American Psychologist, November, 1218-1225. Rewarding good teaching: A matter of demonstrated proficiency or documented achievement? This section of the book will identify various resources which might be helpful. BOOKS AND JOURNALS We have already provided selected readings at the end of each chapter. There are some other texts which may be of more general interest and which cover a wider range than the selected readings. On the principles of good teaching in higher education we suggest Teaching for Quality Learning at University by J. Biggs, SRHE and Open University Press, Buckingham, 1999 and Learning to Teach in Higher Education by P. An excellent introduction to the important concept of life long learning which covers a wide range of related teaching issues is Lifelong Learning in Higher Education by C. For those wishing to delve more deeply into aspects of medical education research there is now a major text entitled An International Handbook for Research in Medical Education by J. Articles relating to medical education appear regularly in most of the major general medical journals. There are also several journals specifically concerned with publishing research and review articles in the field of medical education. Medical Education This is the official journal of the Association for the Study of Medical Education (ASME), which is the organisation catering for individuals interested in medical education in the United Kingdom. The Association also produces an excellent series of booklets dealing with various aspects of medical education and has a series on medical education research. As well as containing articles relating to teaching, this journal also deals with the broader issues of the organisation of medical education as it relates to the United States. It also publishes the Proceedings of the Annual Conference on Research in Medical Education which is the world’s premier medical education research meeting. Medical Teacher This journal is now published in collaboration with the Association for Medical Education in Europe. Rather, it has been a journal containing review articles and descriptions of educational activities by medical teachers from around the world. While this focus remains it is increasingly publishing quality research articles. Teaching and Learning in Medicine An American medical education journal gaining a reputation as a major international journal. Advances in Health Sciences Education A relatively new addition to the list of medical education journals. While published in Europe it has a prestigious international editorial board and is a source of high quality educational research and review articles. World Health Organisation The WHO has been very active for many years in the field of medical education.

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If auscultation shows that gas is entering one lung only sinequan 25mg lowest price anxiety 38 weeks pregnant, usually the right discount sinequan 10 mg overnight delivery anxiety symptoms of, withdraw the tube by 1cm while listening over the lungs. If this leads to improvement, the tip of the tracheal tube was lying in the main bronchus. If no improvement is seen then the possible causes include pneumothorax, diaphragmatic hernia, or pleural effusion. Severe bradycardia If the heart rate falls below 60 beats/min, chest compression must be started by pressing with the tips of two fingers over sternum at a point that is one finger’s breadth below an imaginary line joining the nipples. If there are two rescuers it is preferable for one to encircle the chest with the hands and compress the same point with the thumbs, while the other carries out ventilation. The chest should be compressed by about Bag mask for neonatal resuscitation one third of its diameter. Give one inflation for every three chest compressions at a rate of about 120 “events” per minute. If no improvement is seen within 10-15 seconds the umbilical vein should be catheterised with a 5 French gauge catheter. This is best achieved by transecting the cord 2-3cm away from the abdominal skin and inserting a catheter until blood flows freely up the catheter. The same dose of adrenaline (epinephrine) can then be given directly into the circulation. Although evidence shows that sodium bicarbonate can make intracellular acidosis worse, its use can often lead to improvement, and the current recommendation is that the baby should then be given 1-2mmol/kg of body weight over two to three minutes. Those who fail to respond, or who are in asystole, require further doses of adrenaline (epinephrine) (10-30mcg/kg). This can be given either intravenously or injected down the tracheal tube. It is reasonable to continue with alternate doses of adrenaline (epinephrine) and sodium bicarbonate for 20 minutes, even in those who are born in apparent asystole, Paediatric face masks. Resuscitation efforts should not be continued beyond 20 minutes unless the baby is making at least intermittent respiratory efforts. Pharyngeal suction Naloxone therapy ● Rarely necessary unless amniotic fluid Intravenous or intramuscular naloxone (100 mcg/kg) should stained with meconium or blood and the be given to all babies who become pink and have an obviously baby asphyxiated satisfactory circulation after positive pressure ventilation but fail ● Can delay onset of spontaneous respiration for a long time if suction is aggressive to start spontaneous respiratory efforts. Often the mothers have ● Not recommended by direct mouth suction a history of recent opiate sedation. Alternatively, naloxone can or oral mucus extractors because of be given down the tracheal tube. If naloxone is effective then congenital infection an additional 200 micrograms/kg may be given intramuscularly to prevent relapse. Naloxone must not be given to infants of mothers addicted to opiates because this will provoke severe withdrawal symptoms. Meconium aspiration A recent large, multicentre, randomised trial has shown that vigorous babies born through meconium should be treated conservatively. The advice for babies with central nervous system depression and thick meconium staining of the liquor remains—that direct laryngoscopy should be carried out immediately after birth. If this shows meconium in the pharynx and trachea, the baby should be intubated immediately and suction applied directly to the tracheal tube, which should then be withdrawn. Provided the baby’s heart rate remains above 60 beats/min this procedure can be repeated until meconium is no longer recovered. Hypovolaemia Acute blood loss from the baby during delivery may complicate resuscitation. It is not always clear that the baby has bled, so it is important to consider this possibility in any baby who remains pale with rapid small-volume pulses after adequate gas The goal of all deliveries—a healthy new born baby. Most babies respond well to a Steve Percival/Science Photo Library bolus (20-25ml/kg) of an isotonic saline solution. It is rarely necessary to provide the baby with blood in the labour suite. Pre-term babies Further reading Babies with a gestation of more than 32 weeks do not differ ● International guidelines 2000 for cardiopulmonary resuscitation from full-term babies in their requirement for resuscitation.

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Thus LeFanu explained the reversal of expert opinion on what constituted a healthy diet between the 1930s purchase sinequan 75 mg online anxiety symptoms dsm 5, when meat and dairy products were in favour buy 10 mg sinequan free shipping anxiety vs stress, and the 1980s, when these were displaced by fruit and fibre, by the swing from ‘“high church” virtues of sensuousness and elitism’ to ‘“low church” virtues of 88 THE POLITICS OF HEALTH PROMOTION asceticism and egalitarianism’ (LeFanu 1987:158). But this elegant theory only shifted the problem elsewhere: how do we explain the shift in popular perceptions of virtue and their consequences for health? The key defect of the right-wing critique of health promotion was its failure to grasp the dialectic between the state’s resort to health promotion to compensate for its problems of legitimacy and the popular insecurities that had been generated by the social and political trends of the past decade, which found particular expression around issues of health. This interaction, facilitated by compliant doctors and operating through the medium of health promotion, between a state seeking authority and individuals seeking reassurance, provided enormous scope for government intervention in personal life and guaranteed the popularity of such intervention, however inadequate its scientific justification. It is finally worth noting the fatalism of the right in what it regarded as a defensive, rearguard action against the advance of health promotion. As Kristol concluded gloomily, ‘the laws have been passed, the institutions set up, the rules made: and I think our experience of the past ten years under quite conservative admini- strations indicates the difficulty of rolling back the wave’ (Kristol 1994). When it came to policy alternatives to The Health of the Nation, the right-wing critics could only call for a return to old-style ‘health education’, with its explicit emphasis on individual responsibility (Anderson 1994). Not surprisingly, the right remained marginal and the health promotion wave kept on rolling. Health inequalities and social exclusion Tony Blair’s New Labour government signalled its commitment to the cause of health promotion by immediately appointing Tessa Jowell as Britain’s first minister of public health (though Yvette Cooper, who succeeded her in the October 1999 reshuffle, did not have a seat in the Cabinet). However, the subsequent policy documents revealed a high degree of continuity with The Health of the Nation policy (DoH December 1998, DoH July 1999). New Labour identified the same priority areas (though sexual health was hived off to a separate document), but cautiously reduced the number of targets to four—one in each area. In other respects the 1999 White Paper Saving Lives pushed forward along the same lines as the previous government (see Chapter One). To reflect the 89 THE POLITICS OF HEALTH PROMOTION commitment of all relevant government departments to ‘inter- sectoral collaboration’ in the cause of health, the White Paper was signed by nine other ministers. It pursued the strategy of institutional innovation through its emphasis on ‘health action zones’, ‘healthy living centres’ and ‘healthy citizens programmes’ as well as by its endorsement of NHS Direct. And to confirm that the old ‘victim- blaming’ spirit was still thriving, Saving Lives opened by reminding readers that ‘individuals too have a responsibility for their own health’. The most significant difference from the past was that New Labour’s health promotion initiative provoked virtually no opposition and very little criticism. The medical profession, which had been hostile to David Owen and ambivalent about Virginia Bottomley, greeted Tessa Jowell’s policy with approval, if not enthusiasm. The only significant problems encountered by the government in this area resulted from external factors—its retreat on tobacco sponsorship of motor racing and a legal challenge to its attempt to ban cigarette advertising. Saving Lives did focus on one subject that had been conspicuously avoided by the previous government—that of health inequalities. The White Paper emphasised that the government was ‘addressing inequality with a range of initiatives on education, welfare-to-work, housing, neighbourhoods, transport and environment, which will help health’ (DoH 1999:x) Critics pointed out that this wide range of government initiatives against inequality did not include the provision of higher levels of welfare benefits. The White Paper later asserted that ‘the strong association between low income and health is clear’ and immeditely added that ‘for many people the best route out of poverty is through employment’ (DoH 1999:45). For the many people for whom that route was not practicable, the White Paper offered no alternative. Given the continuing controversy around health inequalities, it is worth briefly tracing its evolution during the 1990s. The concerns of the 1980s that increasing differentials in income were resulting in a growing gap between the health of the rich and that of the poor, became an increasingly prominent focus of medical research and discussion in the 1990s. Encouraged by Donald Acheson, the Kings Fund sponsored a series of investigations and seminars which culminated in the publication of Tackling Inequalities in Health in 1995, subtitled ‘an agenda for action’ (Benzeval et al. The BMA produced a report in the same year recommending a wide range of economic and social policies in 90 THE POLITICS OF HEALTH PROMOTION response to this problem (BMA 1995). Both before and after its 1997 election victory, New Labour adopted the issue of health inequalities as one of its major themes, a preoccupation that is reflected in its public health policy documents. At first inspection, the extent of medical and political concern with health inequalities appears puzzling. Though, as we have seen, class differentials have persisted, in real terms the health of even the poorest sections of society is better than at any time in history: indeed the health of the poorest today is comparable with that of the richest only twenty years ago (see Chapter One). Furthermore, it appears that the preoccupation with social class in the sphere of health (as indicated by the scale of academic publications) has grown in inverse proportion to the salience of class in society in general. After the emergence of the modern working class following the industrial revolution in the mid-nineteenth century, the question of class and its potential for causing social conflict and, for some, social transformation, dominated political life. It appears that after this era finally came to an end with the collapse of the Eastern bloc and the Soviet Union in 1989–90, and the political and social institutions organised around class polarisation lost their purpose, the subject suddenly became of much greater medical and academic interest.

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A 1999 poll found that 57 percent of Americans believed that uninsured persons are “able to get the care they need from doctors and hospitals” (Institute of Medicine 2001b discount sinequan 25 mg with amex anxiety medications, 21) order sinequan 10mg mastercard anxiety klonopin. But this notion ignores the facts: among uninsured people, chronic dis- eases and disabling conditions are often neglected or poorly managed med- ically (22). Over the past twelve months, 10 percent of working-age people with major mobility problems did not get care they say they needed, and 28 percent say they delayed care because of cost concerns (Table 16). Working-Age People Who Did Not Get or Delayed Care in the Last Year Mobility Did Not Delayed Difficulty Get Care (%)a Care (%)b None 3 10 Minor 10 22 Moderate 13 28 Major 10 28 aAny time during the past 12 months, when a person “needed medical care or surgery, but did not get it. Almost 98 percent of elderly people have Medicare (Medicare Payment Advisory Commission 1999, 5). Voluntary employer-based private health insurance covers roughly two-thirds of the population, although it accounts for less than one-third of national health expenditures (Reinhardt 1999, 124). Medicare and Medicaid cover people who on av- erage have greater health-care needs than workers and their families. Nonetheless, working-age persons who do not qualify for Medicare or Medicaid are often out of luck, even if they are employed. Over half of uninsured people who have any disability work (Meyer and Zeller 1999, 11). Some employers avoid hiring disabled workers, fear- ing higher health insurance premiums (Batavia 2000). The ADA does not address employment-based health insurance explicitly, although it does prohibit employers from discriminating in “terms or conditions of em- ployment” against an employee. The ADA’s legislative history suggests that em- ployers and health insurers can continue offering health plans with restricted coverage “as long as exclusions or limitations in the plan are based on sound actuarial principles” (Feldblum 1991, 102). But only 76 percent of those with minor and moderate mobility problems have health insurance, while 83 percent of younger Who Will Pay? Health Insurance Coverage among Working-Age People Mobility Health Difficulty Insurance (%) Medicare Any Medicare Medicaid and Medicaid None 80 1 4 1 Minor 76 9 20 3 Moderate 77 16 27 5 Major 83 28 35 10 persons with major mobility difficulties are insured, primarily through Medicare and Medicaid (Table 17). More unemployed than employed working-age people with major mobility problems have insurance (86 versus 79 percent), because of these public programs. Even persons with health care insurance “are rarely covered for (and have access to) adequate pre- ventive care and long-term medical care, rehabilitation, and assistive tech- nologies. These factors demonstrably contribute to the incidence, preva- lence, and severity of primary and secondary disabling conditions and, tragically, avoidable disability” (Pope and Tarlov 1991, 280). Health insur- ers typically decide what to reimburse in two stages: organizationwide de- cisions about what services are “covered” by a particular plan; and case-by- case decisions about the “medical necessity” of covered services for individual persons (Singer and Bergthold 2001). A third-order decision, potentially critical for persons with mobility problems, is the setting of care: can patients receive services at home? For mobility-related services, two major concerns generally underlie coverage decisions for private and public health insurers: • How long will the person need the service? Neither issue is especially propitious for persons with progressive chronic conditions, who, by definition, generally need services long-term and are unlikely to improve. Private health insurance appeared about seventy years ago, partly to help acute- care hospitals make their increasingly costly services affordable to “the pa- tient of moderate means” (Law 1974, 6). To ensure their financial survival during the Great Depression, hospitals organized prepaid health insurance or Blue Cross plans, writing contracts with employers to insure their work- ers. Over ensuing decades, as new hospital-based technologies offered “medical miracles” to combat acute threats to life and limb, costly but time-limited hospital interventions became the cornerstone of most health insurance plans. Therefore, early and subsequent commercial plans primarily covered short-term, acute hospitalizations and physician services. Given today’s competitive pressures, private health insurers offer numerous plans to meet diverse demands. Private health plans typically cover acute medical and sur- gical hospitalizations and primary and specialty physician visits but differ widely in coverage for other services. Medicare and Medicaid, enacted in 1965, reflect decades of political ma- neuvering and compromises (Marmor 2000; Fox 1989, 1993).

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