DOCSLIB.ORG

Practitioner's Guide to the Dizzy Patient

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Practitioner's Guide to the Dizzy Patient PRACTITIONER’S GUIDE TO THE DIZZY PATIENT Alan L. Desmond, AuD Wake Forest Baptist Health Otolaryngology ABOUT THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT The information in this guide has been reviewed for accuracy by specialists in Audiology, Otolaryngology, Neurology, Physical Therapy and Emergency Medicine ABOUT THE AUTHOR Alan L. Desmond, AuD, is the director of the Balance Disorders Program at Wake Forest Baptist Medical Center and a faculty member of Wake Forest School of Medicine. He is the author of Vestibular Function: Evaluation and Treatment (Thieme, 2004), and Vestibular Function: Clinical and Practice Management (Thieme, 2011). He is a co-author of Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. He serves as a representative of the American Academy of Audiology at the American Medical Association and received the Academy Presidents Award in 2015 for contributions to the profession. He also serves on several advisory boards and has presented numerous articles and lectures related to vestibular disorders. HOW TO MAKE AN APPOINTMENT WITH THE WAKE FOREST BAPTIST HEALTH BALANCE DISORDERS TEAM Physician referrals can be made through the STAR line at 336-713-STAR (7827). PRACTITIONER’S GUIDE TO THE DIZZY PATIENT TABLE OF CONTENTS How to Use the Practitioner’s Guide to the Dizzy Patient . 2 Typical Complaints of Various Vestibular and non-Vestibular Disorders . 3 Structure and Function of the Vestibular System . 4 Categorizing the Dizzy Patient . 5 Timing and Triggers of Common Disorders . 6 Initial Examination Checklist for Acute Vertigo: Peripheral versus Central . 7 Diagnosing Acute Vertigo . 8 Fall Risk Questionnaire . 10 Physician’s Guide to Fall Risk Questionnaire . 11 Detailed Dizziness History Questionnaire . 12 Short Form Dizziness Questionnaire . 14 Vestibular Function Tests . 16 MOTT (Most of the Time) List . 17 Common Vestibular and Non-Vestibular Disorders PRACTITIONER PATIENT REVIEWS EDUCATION Benign Paroxysmal Positional Vertigo (BPPV) . 18 . 19 Acute Vestibular Syndrome: Vestibular Neuritis / Labyrinthitis . 20 . 21 Ménière’s Disease . 22 Vestibular Migraine . 24 . 25 Superior Canal Dehiscence Syndrome . 26 . 27 Anxiety/Hyperventilation . 28 . 29 Orthostatic Hypotension . 30 . 31 Multifactorial Dysequilibrium . 32 . 33 Central Dizziness . 34 . 35 Canalith Repositioning . 36 . 37 Vestibular and Balance Exercises . 38 . 39 Blood Pressure Log . 40 THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT | 1 HOW TO USE THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT This guide is intended to be used as quick access to information when seeing a patient complaining of dizziness . There are many different sensations, with many different causes, that a patient may describe as “feeling dizzy .” The most common causes of dizziness are covered in this guide, but there are many causes of dizziness that are not covered here . The goal of this guide is to increase efficiency and accuracy, while minimizing time spent gathering pertinent case history information and disseminating patient educational information . This guide begins with the typical complaints of various disorders causing dizziness, imbalance, and/or vertigo on a short, easy access list . This list is also displayed on the inside back cover of this guide . This can be kept by the practitioner’s side during the case history interview . As the patient relays their symptoms, the practitioner can flip to the appropriate page to assist in gathering additional relevant information . For each disorder there is a Practitioner Review page and a Patient Education page . The information on the Practitioner Review page lists typical complaints associated with each disorder .* Since many patients do not provide a clear description of their symptoms, there are defining questions to extract more detailed information . Medical history questions may provide a connection between the patient’s current complaints and a previously diagnosed medical condition . A short diagnosis/definition of the disorder is listed on each practitioner review page, followed by some management options. The Patient Education page is designed as a patient handout . These are brief, informative, and written in non-medical terminology . There are several options included that may be used as intake forms . One option is to copy the inside back cover and have the patient circle the block that best describes their symptoms . There is a two-page traditional dizziness history questionnaire, and an eight-question short form questionnaire with an interpretation guide . The short form questionnaire also appears in the accompanying Balance Disorders Program brochure . There is a fall risk questionnaire with an interpretation guide to help explore the multiple factors that can lead to increased fall risk . These should be given to the patient to fill out prior to their appointment . * A patient education page for Ménière’s disease is not included, due to the detailed and controversial nature of this condition . A specific patient education handout is recommended in the text of the practitioner review . 2 | THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT TYPICAL COMPLAINTS OF VARIOUS VESTIBULAR AND NON-VESTIBULAR DISORDERS Benign Paroxysmal Positional Vertigo (BPPV) Superior Canal Dehiscence PAGES 26–27 PAGES 18–19 “ I get dizzy around loud noise or when I blow my “I woke up and the bed was spinning .” nose .” “ I bent over (rolled over, turned quickly, laid down, “My voice sounds like I am in a barrel .” sat up from bed, etc .) and everything started “ I hear my pulse or chewing louder than I should .” spinning around .” “ Every time I tried to get up I fell back on to the Anxiety/Hyperventilation PAGES 28–29 bed .” “ I felt like my heart was pounding out of my chest .” Vestibular Neuritis/Labyrinthitis PAGES 20–21 “I felt like I was dying .” “ I had constant spinning and nausea for about three days .” “I couldn’t breathe .” “ After the worst of it (vertigo and nausea) I was okay if I didn’t move . If I moved I was off balance Orthostatic Hypotension PAGES 30–31 and would get nauseous if I moved too much .” “I get dizzy and off balance when I stand up .” Ménière’s Disease PAGES 22–23 “ I get up and start to walk and feel like I am going to fall over .” “ I have had several episodes of severe vertigo with nausea, lasting for hours at a time .” “When I get up quickly, I feel like I could faint .” “I feel so much pressure in my head (ear) .” Multifactorial Dysequilibrium PAGES 32–33 “My ear was roaring .” “I have had several falls .” “ After an episode, I need to sleep for several “ I feel very unsteady when I am in a crowd or hours .” unfamiliar setting .” Vestibular Migraine PAGES 24–25 “ I want to hold on to someone/something when I walk .” “ I have episodes of spinning and nausea that come on without warning, but had no ear symptoms .” Central Dizziness PAGES 34–35 “ I felt a sudden wave come over me, like the floor “I stagger when I walk .” shifted .” “If I lose my balance, I just go over .” “ I can’t stand any type of motion . It never “I have this constant feeling in my head .” bothered me when I was a kid .” THE PRACTITIONER’S GUIDE TO THE DIZZY PATIENT | 3 STRUCTURE AND FUNCTION OF THE VESTIBULAR SYSTEM: A BRIEF OVERVIEW The primary role of the balance system is saccule registers primarily vertical movements to allow us to interact and maintain contact such as the sensation experienced when moving with our surroundings in a safe and efficient in an elevator . The utricle senses horizontal manner . As we move through our environment, movements such as moving forward in a car . information is gathered through our visual, The vestibular-ocular reflex (VOR) can be defined somatosensory and vestibular senses and sent as reflexive eye movement in response to head to our brainstem for integration, then finally on movement . The role of the VOR is to allow stable to our cortex for perception and processing . Our gaze or clear, focused vision while the head is visual and somatosensory reference information moving . It performs this function by causing eye is constantly changing as we move, but our movements that are equal to and opposite of vestibular reference — gravity — is unchanging . head movement — in effect, visually canceling As long as the information coming in from these out head movement . A simple demonstration of sources is predictable and non-conflicting, our the VOR can be done while reading this page . equilibrium is stable and we move about freely Simply hold this page 18 inches (or so) in front of with little thought regarding balance . When you, and move your head back and forth at the a sensory conflict occurs, the brainstem must maximum speed that still allows for clarity and efficiently and quickly (reflexively) adjust the level easy reading . Then, with your head stationary, of priority given to the conflicting information, move the page back and forth in front of you at or a sensation of imbalance may occur . Since the the speed nearly equal to the speed at which you known constant in the mix is gravity, the brainstem moved your head . A noticeable degradation in tends to rely more on vestibular information for visual acuity occurs . It is impossible to voluntarily maintenance of balance . When the vestibular move the eyes at speeds that are needed system is compromised, the patient may become to maintain visual acuity during typical head more dependent of visual and tactile feedback for movements . The latency of the response for the maintenance of balance and orientation . VOR is five times faster than the fastest voluntary The peripheral vestibular apparatus (labyrinth) eye movement, and ten times faster than the consists of matched pairs of sensors that are typical eye movement . stimulated by any type of head movement, The VOR is compromised with damage to one with specific sensors responsible for specific or both peripheral vestibular apparatus .
Load more

Recommended publications
  • Differentiating Between Anxiety, Syncope & Anaphylaxis
    Differentiating between anxiety, syncope & anaphylaxis Dr. Réka Gustafson Medical Health Officer Vancouver Coastal Health Introduction Anaphylaxis is a rare but much feared side-effect of vaccination. Most vaccine providers will never see a case of true anaphylaxis due to vaccination, but need to be prepared to diagnose and respond to this medical emergency. Since anaphylaxis is so rare, most of us rely on guidelines to assist us in assessment and response. Due to the highly variable presentation, and absence of clinical trials, guidelines are by necessity often vague and very conservative. Guidelines are no substitute for good clinical judgment. Anaphylaxis Guidelines • “Anaphylaxis is a potentially life-threatening IgE mediated allergic reaction” – How many people die or have died from anaphylaxis after immunization? Can we predict who is likely to die from anaphylaxis? • “Anaphylaxis is one of the rarer events reported in the post-marketing surveillance” – How rare? Will I or my colleagues ever see a case? • “Changes develop over several minutes” – What is “several”? 1, 2, 10, 20 minutes? • “Even when there are mild symptoms initially, there is a potential for progression to a severe and even irreversible outcome” – Do I park my clinical judgment at the door? What do I look for in my clinical assessment? • “Fatalities during anaphylaxis usually result from delayed administration of epinephrine and from severe cardiac and respiratory complications. “ – What is delayed? How much time do I have? What is anaphylaxis? •an acute, potentially
    [Show full text]
  • Essays in Economics of Education
    Essays in Economics of Education A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY Claudia Bueno Rocha Vidigal IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Paul Glewwe, Adviser February 2019 © Claudia Bueno Rocha Vidigal 2019 ACKNOWLEDGEMENTS I would like to express my deepest gratitude to my advisor, professor Paul Glewwe, for his continuous support, guidance and encouragement. I had the great fortune to have worked with him and I am deeply indebted to his patient advice over the years. I am also grateful to my committee members, professors Deborah Levison, Joe Ritter, and Marc Bellemare, for their thoughtful comments and suggestions on my dissertation. I am also thankful for having had the opportunity to meet amazing colleagues and professors in my doctoral program. This long process would not have been possible without their support and friendship. I am profoundly grateful to my family, especially my parents, who have been a great source of support throughout my academic journey. Lastly, but most importantly, my husband and classmate, Vinicius Vidigal, deserves heartfelt thanks for his love, encouragement, and support. i DEDICATION To my mother, Katia Lucila Bueno, and my grandmother, Maria Angela Sotovia Bueno, whose love, encouragement and support made all this possible. ii ABSTRACT This dissertation consists of three essays in the economics of education. It investigates the effects of educational programs in primary and secondary schools in Brazil, as well as the effects of racial and low-income quotas in Brazilian universities. The first essay analyzes the impact of Brazil’s Multifunctional Resources Classroom Inclusion Program on the academic outcomes of disabled and non-disabled students in primary and secondary schools.
    [Show full text]
  • Fullness, and Tinni- Tus
    Neurology® Clinical Practice The evaluation of a patient with dizziness Kevin A. Kerber, MD Robert W. Baloh, MD Summary Dizziness is the quintessential symptom presenta- tion in all of clinical medicine. It can stem from a disturbance in nearly any system of the body. Pa- tient descriptions of the symptom are often vague and inconsistent, so careful probing is essential. The physical examination is performed by observ- ing the patient at rest and following simple move- ments or bedside tests. In general, no special tools are required. The causes of dizziness range from benign to life-threatening disorders, and features that distinguish among these may be subtle. When diagnostic testing is considered, parsimony should be the rule. Identifying common peripheral vestibu- lar disorders is a priority. Picking this “low hanging fruit” can be the key component to excluding more serious central causes of dizziness. eurologists play an important role in the evaluation and management of pa- tients with dizziness. The possibility of a serious neurologic disorder is un- Nnerving to front-line physicians who have ranked decision support for identifying central causes of vertigo as a top priority.1 Although dangerous cen- tral disorders do not commonly present as isolated dizziness, stroke and other neurologic disorders can occur in this manner. The history and physical examination are the critical elements in determining the management of these patients. In this article, we review the approach to the evaluation and management of patients with dizziness. History The first step in assessing a patient presenting with dizziness is to define the symptom (table 1).
    [Show full text]
  • Balance and Aging by Charlotte Shupert, Phd, with Contributions by Fay Horak, Phd, PT Oregon Health & Science University, Portland, Oregon
    TH 5018 NE 15 AVE · PORTLAND, OR 97211 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · VESTIBULAR.ORG Balance and Aging By Charlotte Shupert, PhD, with contributions by Fay Horak, PhD, PT Oregon Health & Science University, Portland, Oregon One of the leading health concerns for in the feet and legs; and degeneration of people over the age of 60 is falling, which the vestibular system. is often related to balance problems. The percent of people falling increases from Balance is also dependent on muscle 40% to 65% to 82% with each decade strength, joint mobility, and healthy feet. after age 65 years. A sedentary lifestyle, painful arthritis or diseases of bones and muscles can The consequences of falls can be compromise strength, mobility, and the disastrous; between 12% and 67% of base of foot support. elderly adults who fracture a hip die Balance control also depends on healthy within one year. Even if a bone is not brain function across many brain areas. fractured during a fall, falls cause pain The brain needs to process and interpret and injury while reducing future mobility sensory information, select appropriate and quality of life. As a result, major balance strategies, and adapt and learn scientific efforts are devoted to deter- new strategies with practice. As we age, mining the causes of falling in older adults brain processing can slow down, which in an attempt to reduce this significant results in slower balance responses. health hazard. People with cognitive problems also have balance problems, showing the Causes of imbalance in older people importance of higher level brain Balance in walking and standing is processing in balance control.
    [Show full text]
  • Vertebral Artery Dissection Presenting As Transient Global Amnesia: a Case Report and Review of Literature
    Dementia and Neurocognitive Disorders 2014; 13: 46-49 CASE REPORT http://dx.doi.org/10.12779/dnd.2014.13.2.46 Vertebral Artery Dissection Presenting as Transient Global Amnesia: A Case Report and Review of Literature , Yeonsil Moon*, Seol-Heui Han* † Vertebral artery dissection is one of the most common causes of stroke in young adults. The course of the vertebral artery dissection is usually benign, and pure transient amnesia as an initial symptom has Department of Neurology*, Konkuk University Medical Center, Seoul; Center for Geriatric been rarely reported. We describe a patient with vertebral artery dissection who presented with acute Neuroscience Research, Institute of transient amnesia, and review the medical literatures about the pathophysiological mechanism of tran- Biomedical Science†, Konkuk University, sient global amenesia (TGA). This case could be a one of evidence which supports the cerebrovascular Seoul, Korea mechanism of TGA. Received: May 19, 2014 Revision received: June 26, 2014 Accepted: June 26, 2014 Address for correspondence Seol-Heui Han, M.D. Department of Neurology, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea Tel: +82-2-2030-7561 Fax: +82-2-2030-7469 E-mail: [email protected] Key Words: Transient global amnesia, Vertebral artery dissection, Cerebrovascular Vertebral artery dissection is one of the most common longed cognitive decline and review the medical literatures causes of stroke in young adults [1]. The course of the verte- about the pathophysiological mechanism of transient global bral artery dissection is usually benign, but seldom reaches to amenesia (TGA). severe complication, such as brainstem infarction, subarach- noid hemorrhage (SAH) or death [2].
    [Show full text]
  • Second Edition
    COVID-19 Evidence Update COVID-19 Update from SAHMRI, Health Translation SA and the Commission on Excellence and Innovation in Health Updated 4 May 2020 – 2nd Edition “What is the prevalence, positive predictive value, negative predictive value, sensitivity and specificity of anosmia in the diagnosis of COVID-19?” Executive Summary There is widespread reporting of a potential link between anosmia (loss of smell) and ageusia (loss of taste) and SARS-COV-2 infection, as an early sign and with sudden onset predominantly without nasal obstruction. There are calls for anosmia and ageusia to be recognised as symptoms for COVID-19. Since the 1st edition of this briefing (25 March 2020), there has been a significant expansion of literature on this topic, including 3 systematic reviews. Predictive value: The reported prevalence of anosmia/hyposmia and ageusia/hypogeusia in SARS-COV-2 positive patients are in the order of 36-68% and 33-71% respectively. There are reports of anosmia as the first symptom in some patients. Estimates from one study for hyposmia and hypogeusia: • Positive likelihood ratios: 4.5 and 5.8 • Sensitivity: 46% and 62% • Specificity: 90% and 89% The US Centres for Disease Control and Prevention (CDC) has added new loss or taste or smell to its list of recognised symptoms for SARS-COV-2 infection. To date, the World Health Organization has not. Conclusion: There is sufficient evidence to warrant adding loss of taste and smell to the list of symptoms for COVID-19 and promoting this information to the public. Context • Early detection of COVID-19 is key to the ongoing management of the pandemic.
    [Show full text]
  • COVID-19 Vaccines: Update on Allergic Reactions, Contraindications, and Precautions
    Centers for Disease Control and Prevention Center for Preparedness and Response COVID-19 Vaccines: Update on Allergic Reactions, Contraindications, and Precautions Clinician Outreach and Communication Activity (COCA) Webinar Wednesday, December 30, 2020 Continuing Education Continuing education will not be offered for this COCA Call. To Ask a Question ▪ All participants joining us today are in listen-only mode. ▪ Using the Webinar System – Click the “Q&A” button. – Type your question in the “Q&A” box. – Submit your question. ▪ The video recording of this COCA Call will be posted at https://emergency.cdc.gov/coca/calls/2020/callinfo_123020.asp and available to view on-demand a few hours after the call ends. ▪ If you are a patient, please refer your questions to your healthcare provider. ▪ For media questions, please contact CDC Media Relations at 404-639-3286, or send an email to [email protected]. Centers for Disease Control and Prevention Center for Preparedness and Response Today’s First Presenter Tom Shimabukuro, MD, MPH, MBA CAPT, U.S. Public Health Service Vaccine Safety Team Lead COVID-19 Response Centers for Disease Control and Prevention Centers for Disease Control and Prevention Center for Preparedness and Response Today’s Second Presenter Sarah Mbaeyi, MD, MPH CDR, U.S. Public Health Service Clinical Guidelines Team COVID-19 Response Centers for Disease Control and Prevention National Center for Immunization & Respiratory Diseases Anaphylaxis following mRNA COVID-19 vaccination Tom Shimabukuro, MD, MPH, MBA CDC COVID-19 Vaccine
    [Show full text]
  • Dizziness Related to Anxiety and Stress
    Dizziness Related to Anxiety and Stress Author: Laura O. Morris, PT, NCS Fact Sheet Why does anxiety and stress cause me to be dizzy? Dizziness is a common symptom of anxiety stress and, and If one is experiencing anxiety, dizziness can result. On the other hand, dizziness can be anxiety producing. The vestibular system is responsible for sensing body position and movement in our surroundings. The vestibular system is made up of an inner ear on each side, specific areas of the brain, and the nerves that connect them. This system is responsible for the sense of dizziness when things go wrong. Scientists believe that the areas in the brain responsible for dizziness interact with the areas responsible for anxiety, and cause both symptoms. Produced by The dizziness that accompanies anxiety is often described as a sense of lightheadedness or wooziness. There may be a feeling of motion or spinning inside rather than in the environment. Sometimes there is a sense of swaying even though you are standing still. Environments like grocery stores, crowded malls or wide-open spaces may cause a sense of imbalance and disequilibrium. These symptoms are caused by legitimate physiologic changes within the brain. A Special Interest Group of If there is an abnormality in the vestibular system, the symptom of dizziness can be the result. If one already has a tendency toward anxiety, dizziness from the vestibular system and anxiety can interact, making symptoms worse. Often the anxiety and the dizziness must be treated together in order for improvement to be made. How does physical therapy help? Contact us: ANPT Scientists are starting to better understand how dizziness and 5841 Cedar Lake Rd S.
    [Show full text]
  • Signs and Symptoms
    Signs and Symptoms Some abnormal heart rhythms can happen without the person knowing it, while some may cause a feeling of the heart “racing,” lightheadedness, or dizziness. At some point in life, many adults Rapid Heartbeat – Tachycardia have had short-lived heart rhythm When the heart beats too quickly changes that are not serious. (usually above 100 beats per minute), the lower chambers, or Certain heart rhythms, especially ventricles, do not have enough time those that last long enough to af - to fill with blood, so they cannot ef - fect the heart’s function, can be fectively pump blood to the rest of serious or even deadly. the body. When this happens, some Palpitation or Skipped Beat people have symptoms such as: Although it may seem as if the Skipping a beat Slow Heartbeat – Bradycardia heart missed a beat, it has really had an early heartbeat — an extra If the heartbeat is too slow (usually Beating out of rhythm below 60 beats per minute), not beat that happens before the heart Palpitations has a chance to fill with blood. enough blood carrying oxygen Fast or racing heartbeat Therefore the squeeze is empty flows through the body. The symptoms of a slow heartbeat are: and results in a pause. Shortness of breath Fatigue (feeling tired) Fluttering Chest pain A fluttering sensation (like butter - Dizziness Dizziness flies in the chest) is usually due to Lightheadedness extra or “skipped beats” that occur Lightheadedness Fainting or near fainting one right after the other, or may be Fainting or near fainting caused by other kinds of abnormal heart rhythms.
    [Show full text]
  • Grammar for Academic Writing
    GRAMMAR FOR ACADEMIC WRITING Tony Lynch and Kenneth Anderson (revised & updated by Anthony Elloway) © 2013 English Language Teaching Centre University of Edinburgh GRAMMAR FOR ACADEMIC WRITING Contents Unit 1 PACKAGING INFORMATION 1 Punctuation 1 Grammatical construction of the sentence 2 Types of clause 3 Grammar: rules and resources 4 Ways of packaging information in sentences 5 Linking markers 6 Relative clauses 8 Paragraphing 9 Extended Writing Task (Task 1.13 or 1.14) 11 Study Notes on Unit 12 Unit 2 INFORMATION SEQUENCE: Describing 16 Ordering the information 16 Describing a system 20 Describing procedures 21 A general procedure 22 Describing causal relationships 22 Extended Writing Task (Task 2.7 or 2.8 or 2.9 or 2.11) 24 Study Notes on Unit 25 Unit 3 INDIRECTNESS: Making requests 27 Written requests 28 Would 30 The language of requests 33 Expressing a problem 34 Extended Writing Task (Task 3.11 or 3.12) 35 Study Notes on Unit 36 Unit 4 THE FUTURE: Predicting and proposing 40 Verb forms 40 Will and Going to in speech and writing 43 Verbs of intention 44 Non-verb forms 45 Extended Writing Task (Task 4.10 or 4.11) 46 Study Notes on Unit 47 ii GRAMMAR FOR ACADEMIC WRITING Unit 5 THE PAST: Reporting 49 Past versus Present 50 Past versus Present Perfect 51 Past versus Past Perfect 54 Reported speech 56 Extended Writing Task (Task 5.11 or 5.12) 59 Study Notes on Unit 60 Unit 6 BEING CONCISE: Using nouns and adverbs 64 Packaging ideas: clauses and noun phrases 65 Compressing noun phrases 68 ‘Summarising’ nouns 71 Extended Writing Task (Task 6.13) 73 Study Notes on Unit 74 Unit 7 SPECULATING: Conditionals and modals 77 Drawing conclusions 77 Modal verbs 78 Would 79 Alternative conditionals 80 Speculating about the past 81 Would have 83 Making recommendations 84 Extended Writing Task (Task 7.13) 86 Study Notes on Unit 87 iii GRAMMAR FOR ACADEMIC WRITING Introduction Grammar for Academic Writing provides a selective overview of the key areas of English grammar that you need to master, in order to express yourself correctly and appropriately in academic writing.
    [Show full text]
  • Performance of Students Admitted Through Affirmative Action in Brazil.Latin American Research Review
    Valente, R R and Berry, B J L. Performance of Students Admitted through Affirmative Action in Brazil.Latin American Research Review. 2017; 52(1), pp. 18-34. DOI: https://doi.org/10.25222/larr.50 SOCIOLOGY Performance of Students Admitted through Affirmative Action in Brazil Rubia R. Valente and Brian J. L. Berry University of Texas at Dallas, US Corresponding author: Rubia R. Valente ([email protected]) Following the implementation of the Lei das Cotas (Affirmative Action Law) in Brazil, there has been debate as to whether students who were admitted through affirmative action perform at the same level as students admitted through traditional methods. This article examines the results of the Exame Nacional de Desempenho dos Estudantes (ENADE) from 2009 to 2012 to determine whether there is a relationship between students’ performance at the university level and the manner of their admittance. We find that students admitted to public universities under affirmative action perform at similar levels to students who were not, whereas quota students in private universities perform slightly better than students admitted through traditional methods. Com a implementação das Lei das Cotas no Brasil, tem se debatido se estudantes admitidos através de ação afirmativa demonstram o mesmo nível acadêmico dos estudantes admitidos através de métodos tradicionais. Este artigo analisa os resultados do Exame Nacional de Desempenho dos Estudantes (ENADE) durante o período de 2009 á 2012 para determinar se existe uma relação entre o desempenho dos alunos no âmbito universitário e as modalidades da sua admissão. Nossa análise revela que os estudantes que foram admitidos em universidades públicas através de ações afirmativas têm o mesmo desempenho acadêmico de estudantes que não se beneficiam de ações afirmativas, enquanto alunos cotistas em universidades privadas têm um desempenho ligeiramente melhor do que alunos admitidos através de métodos tradicionais.
    [Show full text]
  • All the World's a Song: Shakespeare Series Assembly on Jazz
    teacher resource guide assembly series all the world’s a song: shakespeare on jazz An interview with Daniel Kelly about the performance Award-winning composer and pianist Daniel Kelly takes Daniel Kelly, composer and pianist Frederick Johnson, vocalist Sarah Elizabeth Charles, vocalist Shakespeare’s words and moves them into jazz renditions in Award-winning composer and pianist Daniel Kelly’s music has Frederick Johnson has spent the past 35 years presenting Sarah Elizabeth Charles is a rising New York City vocalist/ this amazing performance of jazz vocalists Frederick Johnson been declared “powerfully moving” by Time Out New York. He international concerts seminars on the power of creative composer. She has worked and studied with artists such as and Sarah Elizabeth Charles. Such Shakespearean standards has performed with GRAMMY®-winning jazz legends Michael expression as a tool for personal well-being and healing. An George Cables, Geri Allen, Nicholas Payton, Sheila Jordan, as the “Double, double toil and trouble” verses from Macbeth Brecker and Joe Lovano, hip-hop star Lauryn Hill, modern accomplished vocalist and percussionist, he is recognized Jimmy Owens and Carmen Lundy. Sarah has performed at The (Act 4, Scene 1) and the beautiful poetry “I Do Wander classical giants Bang on a Can All-Stars, and many others. internationally as one of the world’s greatest vocal jazz White House, Carnegie Hall’s Weill Recital Hall, Gillette Stadium Everywhere” from A Midsummer Night’s Dream (Act 2, Scene 1) Kelly toured Southeast Asia and India as a part of the Kennedy improvisers and one of the world’s most passionate and as a National Anthem singer for the New England Patriots, are given new life by being put to jazz.
    [Show full text]