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By C. Gorok. Castleton State College. 2018.

W hen I finally published m y research doxycycline 100 mg cheap, som e 900 hours of drudgery was sum m ed up in a single sentence: "Patients’ serum rhubarb levels were m easured according to the m ethod described by Bloggs and Bloggs [reference to Bloggs and Bloggs’ paper on how to m easure serum rhubarb]" doxycycline 200 mg cheap. I now spend quite a lot of m y tim e doing qualitative research and I can confirm that it’s infinitely m ore fun. I and m y research team spent an interesting few years devising a unique com bination of techniques to m easure the beliefs, hopes, fears, and attitudes of diabetic patients from a particular m inority ethnic group (British Sylhetis). W e had to develop, for exam ple, a valid way of sim ultaneously translating and transcribing interviews which were conducted in Sylheti, a com plex dialect of Bengali which has no written form. W e found that patients’ attitudes appear to be heavily influenced by the presence in the room of certain of their relatives, so we contrived to interview som e patients in both the presence and the absence of these key relatives. I could go on describing the m ethods we devised to address this particular research issue15 but I have probably m ade m y point: the m ethods section of a qualitative paper often cannot be written in 173 H OW TO READ A PAPER shorthand or dism issed by reference to som eone else’s research techniques. It m ay have to be lengthy and discursive since it is telling a unique story without which the results cannot be interpreted. As with the sam pling strategy, there are no hard and fast rules about exactly what details should be included in this section of the paper. You should sim ply ask "H ave I been given enough inform ation about the m ethods used? Question 6 What methods did the researcher use to analyse the data and what quality control measures were implemented? The data analysis section of a qualitative research paper is where sense can m ost readily be distinguished from nonsense. H aving am assed a thick pile of com pleted interview transcripts or field notes, the genuine qualitative researcher has hardly begun. It is sim ply not good enough to flick through the text looking for "interesting quotes" which support a particular theory. The researcher m ust find a systematic way of analysing his or her data and, in particular, m ust seek exam ples of cases which appear to contradict or challenge the theories derived from the m ajority. One way of doing this is via content analysis: drawing up a list of coded categories and "cutting and pasting" each segm ent of transcribed data into one of these categories. This can be done either m anually or, if large am ounts of data are to be analysed, via a tailorm ade com puter database. The statem ents m ade by all the subjects on a particular topic can then be com pared with one another and m ore sophisticated com parisons can be m ade, such as "D id people who m ade statem ent A also tend to m ake statem ent B? A good qualitative research paper m ay show evidence of "quality control"; that is, the data (or at least a sam ple of them ) will have been analysed by m ore than one researcher to confirm that they are both assigning the sam e m eaning to them. In analysing m y own research into health beliefs in diabetic patients, three of us looked in turn at a typed interview transcript and assigned codings to particular statem ents. W e then com pared our decisions and argued (som etim es heatedly) about our disagreem ents. Our analysis revealed differences in the interpretation of certain statem ents which we were unable to fully resolve; in other words, our inability to "wrap up" all aspects of the interpretation was itself an im portant 174 PAPERS TH AT G O BEYON D N U M BERS item of data. W hat is not legitim ate is to assum e that there is a single "right" way to interpret the data. H aving said that, there are som e researchers who feel strongly that only the person m ost im m ersed in the fieldwork has genuine insight into the m eaning of the data; in other words, interpretation should not be "triangulated" by all and sundry sim ply to give a show of im proving validity. W e obviously cannot assess the credibility of qualitative results via the precision and accuracy of m easuring devices, nor their significance via confidence intervals and num bers needed to treat. It takes little m ore than plain com m on sense to determ ine whether the results are sensible and believable and whether they m atter in practice. One im portant aspect of the results section to check is whether the authors cite actual data. Claim s such as "G eneral practitioners did not usually recognise the value of audit" would be infinitely m ore credible if one or two verbatim quotes from the interviewees were reproduced to illustrate them. The results should be independently and objectively verifiable – after all, a subject either m ade a particular statem ent or (s)he did not – and all quotes and exam ples should be indexed so that they can be traced back to an identifiable subject and setting.

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When blood transfusion is urgent doxycycline 200mg low cost, it should be given together with measures to ensure restoration of the blood volume discount 200 mg doxycycline overnight delivery. The goal in treating anemia is to increase or completely restore the circulating red cells to normal levels. The appropriate strategies for increasing the red cell mass should be specifically directed by the urgency of the need for treatment and the underlying cause of the anemia. This strategy represents the ideal for management of Some remediable causes of anemia and their key labora- anemia. A diagnostic process clearly identifies a defi- tory findings and treatment, are displayed in Table 55. Etiology Laboratory results Treatment and other interventions/studies Iron deficiency Microcytic RBC Identify source of iron loss and correct. Reduced Tf saturation Reticulocytes not increased Anemia of chronic disease Normo- or microcytic RBC Identify underlying inflammatory disease. Reduced Tf saturation Reticulocytes not increased B12, folate-deficient anemia Macrocytic RBC Evaluate diet for sources of B12, folic acid. Reduced B12 or folic acid Megaloblastic changes on bone marrow exam Reticulocytes not increased Protein-calorie-deficient anemia Normocytic RBC Restoration of protein-calorie nutrition restores the hematocrit to Reduced lymphocyte count normal. Left-sided heart failure present- lence, and relationship to lifestyle and health status. The effect of irritant purgatives on the myenteric Development Conference on gallstones and laparoscopic plexus in man and mouse. The natural history of silent ethylene glycol electrolyte lavage solution) as a treatment gallstones: the innocent gallstone is not a myth. Treatment Prophylactic cholecystectomy or expectant management of constipation with high bran bread in long term care of for silent gallstones: a decision analysis to assess survival. Diverticular disease in papillotomy compared with conservative treatment for the elderly. Constipation,irri- Philadelphia: table bowel syndrome, and diverticulosis in older people. Con- and Crohn’s disease of the colon: a comparison of the clin- stipation in long stay elderly patients; its treatment and ical course. The use of a 2- large reservoir of oxygen or oxygen-producing device week course of antibiotics in patients with severe chronic that cannot easily be moved, including compressed gas bronchitis and bronchiectasis can break the cycle and cylinders (H or K size), liquid oxygen reservoirs, and provide relief. Portable oxygen equipment can be with such exacerbations are , moved or transported by the patient. Ambulatory oxygen physician must be aware of local sensitivity and resistance can be carried by most adults on their person during patterns. Trimethoprim-sulfamethoxazole, amoxicillin- activities of daily living; these are small liquid oxygen clavulanate, and third-generation cephalosporins or canisters or lightweight high-pressure cylinders, with a macrolides may provide broad coverage and can be regulator. The liquid oxygen reservoir for home use with very effective in treatment of exacerbations. Cost issues an ambulatory liquid system offers an ideal arrangement are, of course, also a consideration in the choice of for the ambulatory patient requiring continuous oxygen antibiotic therapy. The reservoir prevent exacerbations in patients with COPD is of un- will provide a 1-month supply of oxygen and serves as a proven value, although some interesting new immuno- source to refill the portable ambulatory system, which stimulating vaccines may prove helpful in reducing such weighs 5 to 7lb and provides about 4h of oxygen. A supply relieves breathlessness, all of which can improve mo- of smaller cylinders is necessary for out-of-home use. Those patients who are stable on a wheelchair but are cumbersome and are a potential optimal bronchodilator treatment with an arterial oxygen cause of falls. Careful evaluation of the patient and level of less than 55mmHg (or 55–59mmHg with con- knowledge of the patient’s activity level and concerns comitant polycythemia, pulmonary hypertension, or right about oxygen therapy will help determine the appropri- heart failure) are appropriate for treatment and eligi- ate system. Patients As with most older patients (Chapter 21), the peri- started on oxygen therapy often incorrectly assume that operative period becomes a time of great hazard for this represents the end of a useful and independent exis- patients with COPD. They need to be clearly counseled about benefits complications increases with age, particularly if these of oxygen supplementation and told that therapy will patients undergo thoracic or upper abdominal proce- most likely improve overall status and the quality as well dures. Stationary systems refer to any Specific risk factors for an adverse outcome include a PaCO2 level greater than 45mmHg, poor nutritional status with recent weight loss, current cigarette smoking, T 57. Careful preoperative evaluation with pulmonary function and arterial blood gas mea- PaO2 55mmHg (on room air) surements is crucial, and judicious use of analgesics post- Oxygen saturation 88% (on room air) P 0 59mm with at least one of these four findings: operatively to avoid respiratory depression, delirium, and a 2 Secondary polycythemia (hematocrit 55%) oversedation are important strategies. Recent studies do Clinical cor pulmonale indicate that elderly postoperative patients in the ICU Established right ventricular hypertrophy who need intubation and mechanical ventilation (MV) Pulmonary hypertension under any circumstances do as well as younger patients Optimal medical management established in terms of outcome, although if they have been nutri- P O , partial pressure of arterial oxygen.

Central Nerve Blocks To determine whether a sensory nerve root is generating pain purchase doxycycline 100mg mastercard, we block central nerves by injecting local anesthetic under fluoroscopic guidance 46 Chapter 3 Patient Evaluation and Criteria for Procedure Selection into the epidural space or onto selected dorsal roots generic doxycycline 200 mg with amex. The use of a con- trast medium helps ensure proper needle placement and spread of the local anesthetic. If the block results in pain relief, we presume that the pain generator is distal to the anesthetized site. If the block results in numbness but no pain relief, we presume the pain generator is proxi- mal or collateral to the anesthetized site. Differential epidural blocks can reveal whether pain is arising from the somatic nerves, the sympathetic nervous system, or the central ner- vous system. If the placebo relief is long lasting, it is possible that the pain is centrally main- tained or psychogenic. If the placebo provides no pain relief, we ad- minister three injections of successively higher concentrations of local anesthetic. If the lowest concentration of anesthetic provides pain relief, we consider the pain to be sympathetically maintained. If the next level of anesthetic provides relief, we presume that the pain is somatosensory. If the pain persists, we inject the highest concentration, which usually causes a temporary loss of motor function. If this fails to provide relief, we presume the pain is centrally maintained or psychogenic. Psychological Evaluation Pain is, by definition, a sensory and emotional experience of actual or perceived tissue damage. The challenge for the pain practitioner is to differentiate between the component that is biologi- cally driven and the component that is magnified by emotions. This evaluation is an important part of a medical approach to their pain and is essential before they receive interventional therapies. Medical Therapies 47 Patients with major depressed mood, anxiety, or other negative af- fective states report more pain with noxious stimuli than do controls with positive affective states. We believe that emotionally depressed patients can be appropriate candidates for interventional therapies; it is simply necessary to be especially careful when offering them thera- pies that carry significant risks. While it may be obvious that patients with severe pain caused by a peripheral pain generator will also ex- perience depression or anxiety, it is less obvious that the same nega- tive affective states actually increase the experience of pain itself. De- pressed affective states can also maintain pain and cause it to take on a life of its own by dramatically amplifying what would otherwise be a relatively minor pain generator. Frequently, a physician can determine the severity of emotional dys- function during an initial encounter. If the patient reports anhedonia, depressed or increased appetite, a history of major depression, or dif- ficulty sleeping, a physician should be alert to the possibility that de- pressed mood is an exacerbating component of the pain. When a ma- jor depression is suspected, it should be treated prior to initiating interventional techniques, directly or by referral to a competent physi- cian who can help with this aspect of pain. Pain Management To reiterate: in order to determine the most appropriate therapeutic strategy, it is vital to begin by making an accurate and comprehensive pain diagnosis. The treatment of neuropathic pain might be very dif- ferent from that of nociceptive pain. Likewise, the treatment of myo- fascial pain is very different from that of discogenic pain, and so forth. Frequently, the tools just discussed are sufficient to establish the diag- nosis, the severity of symptoms, and the prognosis of the patient with pain. Once the diagnosis has been established, it is important to de- sign the most appropriate strategy. This involves choosing the best strategy for the patient and selecting the appropriate patient for a given procedure. In other words, certain conditions may call for certain ther- apies, but for a specific patient suffering from one such condition, the usual therapies may be inappropriate. In addition, some therapies may fail in some patients and succeed in others with the same condition. It is, thus, important that the physician involved in interventional pain medicine be familiar with the full spectrum of diagnostic and ther- apeutic care and with ways to determine appropriate patient selection for any given procedure. They should be considered as tools in a toolbox, however, not as a list of medica- tions that must be tried prior to initiating interventional therapies. When applied to peripheral pain fibers, prostaglandins (PGE2 in particular) amplify the experience of pain.

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How doxycycline 100mg, I wondered buy 100mg doxycycline fast delivery, will I ever know what to do and be able to treat people as well as they did, and, more worrying, how will I be able to stay awake that long? GR 79 LEARNING MEDICINE One of the most valuable experiences towards the end of training, which most schools encourage, is a period of several weeks shadowing a junior doctor. This usually occurs in medicine, surgery, or obstetrics and may take place in a general hospital away from the medical school. This allows only one or two students to be placed in each location, maximising their exposure to patients and teaching, and giving the opportunity for close supervision as clinical skills such as bladder catheterisation or intravenous cannulation are practised. By the time I had wearily put on my shoes and rushed to her cubicle, she had already begun to push. Jane, the midwife, decided that there was not time for me to put on a gown, so I just put on the gloves. The mother to be began to scream as the contractions became stronger and with each push the baby descended further. I placed my left hand on the head as the crown appeared to stop it rushing out too quickly, while supporting the mother with my right. Any remaining signs of tiredness had now completely disappeared in all the excitement. First the baby’s head appeared, and I pulled it down gently to release the anterior shoulder. The family wouldn’t let me go until they had taken a photograph of me holding him in my arms. By the time I had helped the midwife clear the mess and made sure all was well, it was way past 5 am. FI The clinical subjects The major subjects to be learnt are general medicine and general surgery, and these are often studied in several blocks throughout the later years. Increasingly, the emphasis is on core clinical skills rather than an encyclopaedic knowledge of different disciplines. The boundaries between "subjects" are blurred and they are learned in a more integrated way and examined in integrated clinical exams. If they are not integrated, and as medicine and surgery become ever more specialised, the best general experience is often achieved by rotating through several firms covering a range of subjects as well as being around when the firm is "on take" (the team responsible for general admissions on that day). An eight week medical attachment may involve a fortnight each of chest medicine, infectious diseases, endocrinology, and cardiology. A similar rotation in 80 MEDICAL SCHOOL: THE LATER YEARS surgery could include gastrointestinal surgery, vascular surgery, urology, and orthopaedics. Generally, students are split into small groups and allocated to a particular firm in the relevant specialty. The firm is the working unit of hospital medicine and usually comprises a consultant or professor, one or two specialist registrars (who qualified several years before and are in training for that specialty), a senior house officer (who is usually a couple of years out of medical school and may be wanting to follow that specialty or may be in training for general practice or may just be drifting waiting for inspiration), and a house officer (who is newly qualified and will try and whisper the answers to the boss’s questions to you, which is generally why you will get them wrong). The patients in hospital (inpatients) under the care of that team also provide the teaching subjects for the students and are shared out between the students, who are expected to talk to their patients and examine them before being taught on ward rounds or teaching sessions by the senior members of the team. In the past much of this teaching was in the form of humiliation; ritualistic grillings of students in front of patient and colleagues alike, in the style of Richard Gordon’s character Sir Lancelot Spratt and his blustering, "You boy! While the occasional medical dinosaur can still be found eating a brace of medical students for lunch, it is no longer acceptable today and is much less likely to occur. The student who has taken the effort to prepare for such teaching can gain enormous benefit from seeing a condition he or she has previously only read about being illustrated in flesh and blood, making far easier the committing to memory of facts and figures as they suddenly take on real meaning and significance. The use of community-based services as resources for learning is growing in all schools, some at a faster rate than others. For example, Bristol now has a series of clinical academies across the West Country in Bath, Swindon, and Taunton for instance, where students spend several months at a time 81 LEARNING MEDICINE on attachment to various teaching firms. As more care passes from hospital to community, such as in mental illness or child health, and as hospital stays tend to be much shorter, such as after having a baby or having day surgery, students are having to go to where the patients are. General practitioners are playing an increasing part in undergraduate teaching of clinical skills, such as examination of body systems, in addition to their traditional role of teaching consultation skills and health promotion. Insight can also be gained into a broader spectrum of disease and social problems than is apparent in hospitals, learning to deal appropriately with minor everyday illnesses or major personal upheavals that affect people’s lives.

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