Rating questions: Example: On 0–10 scale levitra soft 20mg sale impotence pills, measure your satisfaction level by encircling the number (0 being extremely dissatisfied and 10 being extremely satisfied) buy levitra soft discount erectile dysfunction foods. It consists of several declarative statements/ items that express the view point on a topic. Topics/ Strongly Agree Not Disagree Strongly Questions agree decided Disagree 1 2 3 4 h. These are more sensitive for subjective experience than rating based categorical adjectives. It helps the investigator to efficiently quantify subtle gradations in the strength or intensity of an individual characteristics. Unbearable Advantages, Disadvantages and Measure to Improve Closed Ended Questions Advantages Disadvantages Measures to improve 1. Develop picture codes answer be exhaustive which can be used for illiterates as well as literates (e. First present the extremes analyze mutually exclusive and then the values in between so that the respondent is straight away aware of the range of answers. Ensure inclusion of follow ents, the interviewer may up questions to elaborate be tempted to read the list on reasons for choosing a of possible answers in the given rating. Comparing responses of different groups, or of the same group over time, becomes easier. Designing the Questionnaire/Interview Tool The questions should be clear, specific, simple (use simple and common words that convey the idea and avoid technical terms) and neutral (avoid jargons, loaded words and stereotypes that suggest that there is most desirable answer). Following steps may be adopted to design the questionnaire/ interview tool: • State objectives and variables of the research study. The questionnaire should be translated in order to standardize the way questions will be asked. After having it translated, it should be retranslated into the original language by a different person. One can then compare the two versions Designing Research Instruments, Interview Guides and Skills 199 for differences and make decisions concerning the final phrasing of difficult questions. Avoid Pitfalls • Double barreled questions: Each question should contain only one concept. It is important that the question matches the options provided for the answer, a task that seems simple but is often done incorrectly. When you Finalize the Questionnaire, be Sure that– A separate, introductory page is attached to each questionnaire, explaining the purpose of the study, requesting the informant’s consent to be interviewed and assuring confidentiality of the data obtained. Each questionnaire has a heading and space to insert the number, date and location of the interview, and, if required, the name of the informant. Sufficient space is provided for answers to openended questions, categories such as ‘other’ and for comments on pre-categorized questions. Self-administered (Written) Questionnaires All steps discussed above apply to written questionnaires as well as to guides/questionnaires used in interviews. For written questionnaires, however, clear guidelines will have to be added on how the answers to questions should be filled in. Self-administered questionnaires are most commonly used in large- scale surveys using predominantly pre-categorized answers among literate study populations. As a response rate of 50% or less to written questionnaires is not exceptional, these tools will rarely be used in smallscale studies. In exploratory studies which require intensive interaction with informants in 200 Research Methodology for Health Professionals order to gain better insight in an issue, selfadministered questionnaires would be inadequate tools. Steps • Meeting and informing the opinion leaders and key personnel the date and purpose of the study/ interview. Interviewer’s cloths should be culturally acceptable and as simple as possible (no fancy dresses, high heels or tight jeans in rural areas). When interviewer and informant are of opposite sex, more physical distance will usually be required than when they are of the same sex. This includes designing the forms for recording the measurements, choosing the software for data editing, dummy tabulations, etc. Data represent the information that will ultimately allow investigator to describe phenomena, predict events, identify and quantify differences between conditions, and establish the effectiveness of interventions, because of their critical nature. In addition to ensuring the confidentiality, the security of personal data is to be planned. The researcher should carefully plan how the data will be logged, entered, transformed and organized into a database that will facilitate accurate and efficient statistical analysis. Logging and Tracking Data Any study that involves data collection will require some procedure to log the information as it comes in and track it until it is ready to be analyzed. Without a well-established procedure, data can easily become disorganized, un-interpretable, and ultimately unusable. The recruitment log is a comprehensive record of all individuals approached about participation in a study. The log can also serve to record the dates and times that potential participants were approached, whether they met eligibility criteria, and whether they agreed and provided informed consent to participate in the study. Importantly, for ethical reasons, no identifying information should be recorded for individuals who do not consent to participate in the research study. The primary purpose of the recruitment log is to keep track of participant enrollment and to determine how representative the resulting cohort of study participants is of the population that the researcher is attempting to examine. Data Screening Immediately following data collection, but prior to data entry, the researcher should carefully screen all data for accuracy. The promptness of these procedures is very important because research staff may still be able to re- contact study participants to address any omissions, errors, or inaccuracies. In some cases, the research staff may inadvertently have failed to record certain information (e. In such instances, the research staff may be able to correct the data themselves if too much time has not elapsed. Because data collection and data entry are often done by different research staff, it may be more difficult and time consuming to make such clarifications once the information is passed onto data entry staff. One way to simplify the data screening process and make it more time efficient is to collect data using computerized assessment instruments. Computerized assessments can be programmed to accept only responses within certain ranges, to check for blank fields or skipped items, and even to conduct cross-checks between certain items to identify potential inconsistencies between responses. Another major benefit of these programs is that the entered data can usually be electronically transferred into a permanent database, thereby automating the data entry procedure. Although this type of computerization may, at first glance, appear to be an impossible budgetary expense, it might be more economical than it seems when one considers the savings in staff time spent on data screening and entry. Whether it is done manually or electronically, data screening is an essential process in ensuring that data are accurate and complete. Generally, the researcher should plan to screen the data to make certain that– Data Management, Processing and Analysis 203 1. Constructing a Database Once data are screened and all corrections made, the data should be entered into a well-structured database. When planning a study, the researcher should carefully consider the structure of the database and how it will be used.
Significantly symptomatic effective and preferred neurocardiogenic syncope associated with bradycardia documented spontaneously or at time of tilt table testing Class I: Conditions for which there is evidence and/or general agreement that pacing is beneficial cheap levitra soft 20mg free shipping erectile dysfunction in the young, useful order levitra soft 20mg with mastercard erectile dysfunction medications generic, and effective. This measurement may be corrected by subtracting the intrinsic sinus cycle length (in milliseconds) from the recovery time. The duration before the next spontaneous atrial impulse (A ) is2 3 measured and the baseline rate is subtracted. Treatment for symptomatic sinus node dysfunction may be pharmacologic, pacing, or a combination of both. Indications for pacing in sinus node dysfunction are largely determined by symptoms (e. Pacing may also be indicated when essential drug therapy that causes sinus node dysfunction cannot be stopped or changed. For patients with tachycardia–bradycardia syndrome, a pacemaker is often placed for management of the bradyarrhythmia, and antiarrhythmic or rate-controlling drugs are added for treatment of the tachycardia episodes. Acute treatment for patients with symptomatic sinus node dysfunction includes the following:. Isoproterenol (starting at 1 µg/min intravenously), which may be used as a bridge to pacemaker placement. These disturbances are classified as first-, second-, or third-degree block, depending on the severity of the conduction abnormality. In older individuals, it is most often caused by idiopathic degenerative disease of the conducting system. A total of 60% to 90% of cases of congenital complete heart block result from neonatal lupus. The amplitude of the arterial pulse and venous waveform varies, depending on the timing of atrial filling of the ventricles. Heart sounds are similarly affected by the change in filling duration of the ventricles. Using calipers, it is possible to march out the progression of the P-waves to determine the atrial rate. Targeted medical therapy ± temporary pacing is indicated for potential reversible causes prior to permanent pacemaker implantation. Junctional rhythm that is faster than the sinus rhythm is referred to as accelerated junctional rhythm. Patients usually do not develop symptoms that are directly attributable to accelerated junctional rhythm. Digitalis toxicity by itself does not seem to cause accelerated junctional rhythm, as evidenced in persons with normal hearts who take accidental overdoses of digoxin. Other causes of accelerated junctional rhythm are valve surgery, acute rheumatic fever, direct current cardioversion, cardiac catheterization, serious infection, chronic obstructive pulmonary disease, systemic amyloidosis, and uremia with hyperkalemia. Unless the junctional rhythm causes retrograde activation of the atria, the P-wave is normal in morphologic characteristics. Patients with accelerated junctional rhythm do not usually require therapy for the arrhythmia, although management of the underlying cause is indicated. Suppression of accelerated junctional rhythm may be achieved by increasing the atrial rate with drugs (e. Digoxin-induced accelerated junctional rhythm is an indication to stop digoxin, but it does not usually require administration of digoxin-specific Fab fragments. Bifascicular block is present when conduction disturbances affect two of the fascicles, most commonly the right bundle branch and the left anterior fascicle. Bradyarrhythmias following cardiac surgery and endovascular procedures are not uncommon. The risk following transcatheter aortic valve replacement appears to be much greater, ranging from 10% to 40% and highly manufacturer specific. Because postprocedural bradyarrhythmias are frequently temporary and resolve with time postprocedure, temporary pacing should be utilized initially, with the decision to proceed to permanent pacing made only after extended surveillance (institution and procedure-dependent, ranging from 5 to 14 days). Therapy Rapid management targeted at the suspected underlying cause is most likely to result in favorable outcome. Santosh Oommen, Christopher Cole, Gregory Bashian, and Oussama Wazni for their significant contributions to earlier editions of this chapter. The role of pacing for the management of neurally mediated syncope: carotid sinus syndrome and vasovagal syncope. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest. Mutations involving the desmosome result in fibrofatty infiltration of the right ventricle. The two variants of the syndrome include the more common autosomal dominant form (Romano–Ward syndrome) and the less common recessive form (Jervell and Lange-Nielsen syndrome), which is associated with congenital deafness. All patients are treated with β-blocker therapy; however, genotype-specific and individualized therapies are evolving. Laboratory data to rule out reversible causes, such as cardiac biomarkers, abnormal electrolytes, antiarrhythmic drug levels for toxicity, and urine screening for illicit drugs such as cocaine C. Echocardiography for the assessment of left ventricular function, valvular disease, cardiomyopathy, and hypertrophy. Nuclear or angiographic determinations of left ventricular function may be used but do not provide as much information as echocardiography. Testing in cases where a clear phenotype has not been established, or is not suggestive of a genetic disorder, is discouraged, because many variants are of uncertain significance. A positive genetic test is useful and facilitates family screening, but a negative test is not. There is an increasing effort to train police personnel, students, and the general public in resuscitation techniques, focusing on high-quality, uninterrupted chest compressions. Availability of these devices results in more rapid delivery of defibrillation and improved survival to hospital discharge in several large trials. Initial management is focused on establishing and maintaining hemodynamic stability and supportive care. Amiodarone or lidocaine (especially if ischemia is suspected as the trigger) is often used to prevent further ventricular tachyarrhythmias. Therapeutic hypothermia for patients who remain unconscious after resuscitation confers a modest improvement in neurologic outcome. Immediate coronary angiography, with revascularization if indicated, may improve survival in patients in whom an ischemic etiology is suspected. In general, the specificity and positive predictive value of these tests are poor, whereas the negative predictive value is much better (particularly for combinations of tests). Although a combination of different tests can improve sensitivity and specificity, the positive predictive value remains modest. Suppression of ventricular ectopy with antiarrhythmic drugs in such patients was, therefore, thought to be beneficial. Since its introduction by Mirowski in 1980, technical refinements have paralleled a series of clinical trials which extended indications to primary prevention in select populations. A wearable defibrillator is available for temporary use, while diagnostic testing is ongoing, or during periods of transient elevated risk. Syncope and advanced structural heart disease where thorough invasive and noninvasive investigat 4.
You should see slightly more on all incisors and canines (and most posterior teeth as well) purchase discount levitra soft line impotence libido. Maxillary central and lateral incisors cheap levitra soft 20mg with visa erectile dysfunction labs, incisal views, with type traits that distinguish maxillary central from lateral incisors, and traits that distinguish right and left sides. The mesiodistal measurement of the lateral incisor crown is also greater than the labiolingual The incisal outline of the maxillary central incisor measurement but less so than on the central incisor. The labial outline is broadly 54 Part 1 | Comparative Tooth Anatomy curved (on some teeth the middle third may be nearly it to the lingual (Appendix 2g). The incisal ridges on flat) forming the base of the triangle, and the other two lateral incisors are straighter mesiodistally than on the sides of the triangle converge toward the cingulum. The cingulum of the lateral incisor is nearly cen- these two traits are shown on page 2 of the Appendix, tered mesiodistally. Compare the triangular shape of showing two views of the same tooth, each having a the maxillary central incisor to the more round or slightly different alignment to accentuate the trait being slightly oval shape of the maxillary lateral incisor in discussed. These differences in outline shapes are evident when comparing the more triangular central incisors with the more oval or round lateral incisors in Figure 2-10. If you look at the facial surface of a curved from mesial to distal, the convexity being on the tooth with its root aligned correctly for the correct labial side. It terminates mesially and distally at the wid- arch and are able to identify the mesial or distal est portion of the crown (Appendix 1q). The position of surface, you can place the tooth in its correct the distoincisal angle is slightly more lingual than the quadrant (right or left) and assign its Universal position of the mesioincisal angle, which then gives the number. Evaluate the photographs of maxillary incisal edge its slight distolingual twist as though some- incisors in the figures in this chapter and, using one took the distal half of the incisal edge and twisted the chart in each figure, see how many “mesial versus distal” traits can be used to differentiate the mesial from the distal surfaces and therefore right from left incisors. If possible, repeat this on a model with • Describe the type traits that can be used to dis- one or more mandibular incisors missing. Then assign and the labial, lingual, and incisal surfaces for the a Universal number to it (which may not be pos- symmetrical mandibular central incisor (where the sible for the symmetrical mandibular central incisor mesial may be difficult to distinguish from the distal). Examine several extracted teeth and/or models as The crown of the mandibular lateral incisor resem- you read. Also, refer to page 2 of the Appendix and bles that of the mandibular central incisor, but it is Figure 2-13 while you study the labial surface of mandib- slightly wider and is not as bilaterally symmetrical. Hold mandibular teeth with the root down crown tilts distally on the root, giving the impression and crown up, the position of the teeth in the mouth. Look at the incisors Mamelons are usually present on newly emerged man- in Figure 2-13 and notice the lack of symmetry of the dibular incisors and reflect the formation of the facial surface by three labial lobes (Fig. Ordinarily, they are soon worn off by functional contacts against the maxillary incisors (attrition). All mandibular incisor crowns are quite narrow rela- tive to their crown length, but the mandibular central incisor crown is the narrowest crown in the mouth and is considerably narrower than the maxillary central incisor. Unlike maxillary incisor crowns in the sameJ mouth where the central is larger than the lateral, the mandibular lateral incisor crown is a little larger in all dimensions than the mandibular central incisor in the same mouth, as seen when comparing many central and lateral incisors in Figure 2-13. Further, the mandibular central incisor is so symmetrical that it is difficult to tell lefts from rights unless on full arch models or in the mouth. These mandibular incisors have remnants of is the greater mesial than distal curvature of the cervi- three mamelons that reflect the formation of the labial surface cal line (normally visible only on extracted teeth). This of incisors from three labial lobes (plus one lingual lobe forming trait would not be helpful in identifying one remaining the cingulum). These mamelons are partially worn away due to central incisor after an orthodontist has realigned the these teeth biting against maxillary incisors during function. Mandibular central and lateral incisors, labial views, with type traits that distinguish mandibular central from lateral incisors, and traits that distinguish right and left sides. Chapter 2 | Morphology of the Permanent Incisors 57 outline of most mandibular lateral incisors relative to distoincisal angles are very similar, forming nearly right the symmetry of the central incisors. The distoincisal angle may barely these teeth, be aware that the incisal edges may have be more rounded than the mesioincisal angle. This helps to distinguish rights developmental depressions in the incisal third if you from lefts prior to attrition (wear). Although both the tral incisor extends distal to its opposing mandibu- mesial and distal contacts are in the incisal third fairly lar central incisor because the maxillary central is close to the incisal edge, the distal contact is notice- wider by about 3. Also, notice that the maxil- ably cervical to the level of the mesial contact on lat- lary central incisors are wider and larger than the eral incisors. Refer to Table 2-3 for a summary of the maxillary lateral incisors and wider than both of the location of proximal contacts for all incisors. Therefore, the root-to- The crown of the mandibular central incisor is crown ratio is larger for both mandibular incisors com- nearly bilaterally symmetrical, so the mesioincisal and pared to maxillary central and lateral incisors. All contacts for both types of mandibular incisors are in the incisal third, as are the mesial contacts on maxillary incisors. Distal contacts of maxillary central incisors are near the incisal/middle junction, and the distal contacts on maxillary lateral incisors are most cervical: in the middle third. The apical end may curve slightly to the lies slightly distal to the axis line of the root (similar to distal (seen in some incisors in Fig. Mandibular central and lateral incisors, lingual views, with type traits that distinguish mandibular central from lateral incisors, and traits that distinguish right and left sides. Chapter 2 | Morphology of the Permanent Incisors 59 ridges, or pits), and shallow, just slightly concave in the The lingual outlines are “S” shaped, and the heights of middle and incisal thirds (Appendix 2m). The adjacent marginal ridges, if distinguishable, are scarcely discernible, unlike on maxillary incisors, where 4. The cervical portion mandibular incisors are mostly convex and slightly of the roots on mandibular incisors is considerably narrower on the lingual side than on the labial side. N You may see evidence of mesial and distal longitudinal There is usually a slight longitudinal depression on root depressions from these views. From the mesial side, the distolingual the lingual surface if the incisal ridge is just lingual to twist of the incisal ridge of the mandibular lateral inci- the root axis line. The crowns of both types of mandibular incisor are slightly wider labiolingually than mesiodistally. M The mandibular central incisor is practically bilaterally symmetrical with little to differentiate the mesial half 3. The mandibular lateral As on the labial outline of maxillary incisors, the labial incisor is not bilaterally symmetrical. If you align the heights of contour on both types of mandibular incisors incisal edge of the lateral incisor exactly horizontal, the are in the cervical third, just incisal to the cervical line. Mandibular central and lateral incisors, proximal views, with type traits that distinguish mandibular central from lateral incisors, and traits that distinguish right and left sides. It is nearly 2 mm thick and runs in a straight line mesiodistally toward both contact areas. The incisal ridge of both types of mandibular incisor is lingual to the mid-root axis. If you hold an extracted mandibular incisor with the root facing directly away from your sight line, slightly more of the labial than lingual surface is visible because of the lingually posi- tioned incisal ridge.
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Role of Oxidative Stress 5 and Infammation in Nutrition–Infection Interactions and the Potential Therapeutic Strategy Using Antioxidants and Modulating Infammation Elena Puertollano and Maria A. It recognizes and destroys foreign agents through two primary defense mechanisms: innate immunity and acquired immunity. On the other hand, the acquired immune system (specifc immune response) is acquired later in life (immunization or exposition to pathogens) and includes special cells called B lymphocytes and T lymphocytes that are capable of secreting a large variety of specialized chemicals (antibodies and cytokines) to regulate the immune response (Figure 5. The innate arm of immunity prevents the entry of foreign microorganisms into the body, playing a crucial role in the early control of infectious agents, as well as in the initiation and subsequent course of the acquired immunity. Therefore, innate response constitutes the frst line (early phase) of defense against pathogens. It is obvi- ous that innate immunity represents an important mechanism that rapidly destroys and eliminates microorganisms. In fact, innate immunity is the most effcient mech- anism to eliminate intracellular growth microorganisms. Innate resistance does not distinguish among microorganisms and does not change in intensity upon reexpo- sure. On the other hand, acquired immunity requires the identifcation of molecules from an invading agent.