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One of the hardest parts in the early stages is to be able to define your project buy butenafine 15 mg lowest price fungus gnats potato slices, so much research fails because the researcher has been un- able to do this cheap butenafine 15 mg without prescription fungus gnats neem. If you are unable to do this generic 15mg butenafine antifungal kills hiv, the chances are your research topic is too broad, ill thought out or too obscure. Okay, you might have been told to do some research by your tutor or by your boss, but there should be another reason why you have chosen your particular subject. It might be solely to do with the fact that you are interested in the topic. This is a good start as you need to be inter- ested in your research if you are to keep up your enthu- siasm and remain motivated. Or you might have identified a gap in the research literature – this is good as it shows you have carried out careful background re- search. Or perhaps you want to try to obtain funding for a particular service or enterprise and you need to do some research first to find out if there is demand for what you are proposing. Whatever your reason, think very carefully about why you are doing the research as this will affect your topic, the way you conduct the research and the way in which you report the results. If you’re doing it for a university dis- sertation or project, does your proposed research provide the opportunity to reach the required intellectual stan- 6 / PRACTICAL RESEARCH METHODS dard? Will your research generate enough material to write a dissertation of the required length? Or will your research generate too much data that would be impossible to summarise into a report of the required length? If you’re conducting research for funding purposes, have you found out whether your proposed funding body re- quires the information to be presented in a specific for- mat? If so, you need to plan your research in a way which will meet that format. However, you should think about the type of people with whom you will need to get in touch with and whether it will be possible for you to contact them. If you have to conduct your research within a par- ticular time scale, there’s little point choosing a topic which would include people who are difficult or expensive to contact. Also, bear in mind that the Internet now pro- vides opportunities for contacting people cheaply, espe- cially if you’re a student with free internet access. Thinking about this question in geographical terms will help you to narrow down your research topic. Also, you need to think about the resources in terms of budget and time that are HOW TO DEFINE YOUR PROJECT / 7 available to you. If you’re a student who will not receive travel expenses or any other out of pocket expenses, choose a location close to home, college or university. If you’re a member of a community group on a limited bud- get, only work in areas within walking distance which will cut down on travel expenses. Also, you need to think about where you’ll be carrying out your research in terms of venue. If you’re going to con- duct interviews or focus groups, where will you hold them? Is there a room at your institution which would be free of charge, or are you going to conduct them in par- ticipants’ own homes? If you’ve answered ‘no’ to either of these last two questions, maybe you need to think again about your research topic. In 15 years I have encountered only one uncomfortable situation in a stranger’s home. Think very carefully about whether your chosen topic and method might have an influence on personal safety. Thinking about this question will help you to sort out whether the research project you have proposed is possible within your time scale. It will also help you to think more about your par- ticipants, when you need to contact them and whether they will be available at that time. For example, if you want to go into schools and observe classroom practice, you wouldn’t choose to do this research during the sum- mer holiday. It might sound obvious, but I have found 8 / PRACTICAL RESEARCH METHODS some students present a well-written research proposal which, in practical terms, will not work because the par- ticipants will be unavailable during the proposed data collection stage.

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Unfortunately safe 15 mg butenafine fungus hands, non-invasive pacing is not entirely reliable and is best considered to be a holding measure to allow time for the institution of temporary transvenous pacing discount butenafine online american express antifungal foot powder. External cardiac percussion is performed by administering firm blows at a rate of 100 per minute over the heart to the left of the lower sternum discount butenafine 15mg line fungus gnats cannabis hydroponics, although the exact spot in an individual patient usually has to be found by trial and error. The hand should fall a few inches only; the force used is less than a precordial thump and is usually tolerated by a conscious patient; it should be reduced to the minimum force required to produce a QRS complex. Non-invasive methods Fist or thump pacing When pacing is indicated but cannot be instituted without a delay, external cardiac percussion (known as fist or thump External cardiac pacemaker 82 Cardiac pacing and implantable cardioverter defibrillators pacing) may generate QRS complexes with an effective cardiac output, particularly when myocardial contractility is not critically compromised. Conventional cardiopulmonary resuscitation (CPR) should be substituted immediately if QRS complexes with a discernible output are not being achieved. Transcutaneous external pacing Many defibrillators incorporate external pacing units and use the same electrode pads for ECG monitoring and defibrillation. Alternatively, pacing may be the sole function of a dedicated external pacing unit. The pacing electrodes are attached to the patient’s chest wall after suitable preparation of the skin, if time allows. The cathode should be in a position corresponding to V3 of the ECG and the anode on the left posterior chest wall beneath the scapula at the same level as the anterior electrode. This configuration is also appropriate for defibrillation and will not interfere with the subsequent placement of defibrillator External pacemaker with electrodes electrodes in the conventional anterolateral position, should this be necessary. Both defibrillation and pacing may be performed with electrodes placed in an anterolateral position, but the electrode position should be changed if a high pacing threshold or loss of capture occurs. It is important to ensure that the correct Pacing procedure electrode polarity is employed, otherwise an unacceptably high ● Switch on unit pacing threshold may result. Modern units with integral cables ● Select pacing rate that connect the electrodes to the pulse generator ensure ● Choose demand mode if available the correct polarity, provided the electrodes are positioned ● Select fixed rate mode if significant correctly. If electrical ● Pacing artefact appears on ECG when interference is substantial (as may arise from motion artefact), capture occurs problems with sensing may occur and the unit may be ● Minimum current to achieve capture is the inappropriately inhibited; in this case it is better to select the pacing threshold fixed rate mode. The fixed rate mode may also be required if the patient has a failing permanent pacemaker because the temporary system may be inhibited by the output from the permanent generator. The pacing current is gradually increased from the minimum setting while carefully observing the patient and the ECG. A pacing artefact will be seen on the ECG monitor and, when capture occurs, it will be followed by a QRS complex, which is, in turn, followed by a T wave. Contraction of skeletal External pacing can be extremely uncomfortable for a conscious patient and muscle on the chest wall may also be seen. Once current that achieves electrical capture is known as the pacing successful pacing has been achieved, plans threshold, and a value above this is selected when the patient is for the insertion of a transvenous system paced. The presence of a palpable pulse confirms capture and should be made without delay because mechanical contraction. Failure to achieve an output despite external pacing is only a temporary measure good electrical capture on the ECG is analogous to electromechanical dissociation, and an urgent search for correctable causes should be made before concluding that the myocardium is not viable. When the external pacing unit is not part of a defibrillator, defibrillation may be performed in the conventional manner, but the defibrillator paddles should be placed as far as possible from the pacing electrodes to prevent electrical arcing. Invasive methods Temporary transvenous pacing A bipolar catheter that incorporates two pacing electrodes at Chest compression can be performed with the distal end is introduced into the venous circulation and transcutaneous pacing electrodes in place. Pacing is performed once a The person performing the compression is not at risk because the current energies are stable position with an acceptable threshold has been found, very small and the electrodes are well usually at a site near the right ventricular apex. It is usual practice, however, to turn is usually used to guide the placement of the pacing wire, but the unit off should CPR be required when this is not easily available flotation electrode systems, such 83 ABC of Resuscitation as the Swan-Ganz catheter, that feature an inflatable balloon near the tip offer an alternative method of entering the right ventricle. A central vein, either the subclavian or jugular, is cannulated to provide access to the venous circulation. Manipulation of the catheter is easier than when peripheral venous access is used, and the risks of subsequent displacement are less. Full aseptic precautions must be used because the pacemaker may be required for several days and infection of the system may be disastrous. Once a potentially suitable position has been found the pacing catheter/electrode is connected to a pulse generator and the pacing threshold (the minimum voltage that will capture the ventricle) is measured. This should be less than 1 volt, and the patient is paced at three times the threshold or 3 volts, whichever is the higher. If the threshold is high, the wire should be repositioned and the threshold measured again.

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This led to a very complex hypothesis concerning the unihemispheric nature of RS butenafine 15mg with visa fungus amongus incubus. They pro- posed that there was a focal disruption of the blood–brain barrier that permitted GluR3 antibodies to interact with the glutamate receptors generic 15mg butenafine with amex fungus control for lawns. Theorizing that if these antibodies could be eliminated 15mg butenafine with visa fungus mycelium, patients would improve, they treated a number of patients with plasmapheresis. The initial patient, and many others, responded initi- ally to this therapy with a decrease in seizures and improved function. However, over time repeated pheresis did not maintain this improvement and children deteriorated. This theory evokes an extensive lymphocytic infiltration by CD8 killer T cells. There is an extensive astroglial reaction, microglial activation, and cytolysis. CLINICAL ASPECTS Although RS is considered a disorder of childhood and one that affects only a single hemisphere, there have been reported instances of Rasmussen-like conditions that have begun in adulthood or that have involved both hemispheres. Classically, sei- zures begin in the early school years, with a range of onset from the second year of life to mid-teens. The initial seizure can be partial, generalized, or even an episode of status epilepticus. Seizures then typically evolve over time to produce a multifocal or unilateral condition of epilepsia partialis continua that is seen in slightly more than half of individuals with RS. The progression of a seizure is quite different from the well-understood Jacksonian march. Instead, one sees the clinical manifestations of separated areas of cortex firing independently. One can see the foot jerk, then the shoulder, then the thigh, then the hand, and then the face, with no contiguous march along the homunculus. It can almost be visualized as a popcorn effect: suddenly a seizure pops from one area, then another. This is also not like polymyoclonus, because the clonic activity can remain active in one area, but be rhythmically clonic at a different frequency in another area of the body. Another, somewhat less common presentation involves the basal ganglia and one can see expressions of dystonia and choreoathetosis in the setting of RS as well. Invariably, the process continues, resulting in hemiplegia or hemiparesis, homonymous hemianopia and functional deterioration. Neuroimaging has shown considerable utility because over time some degree of atrophy becomes appar- ent. Recent work has suggested that one can assess a hemispheric ratio from MRI studies to determine the degree and rate of atrophy of the hemisphere, with some evi- dence that most of the atrophy occurs in the first year of the disease. However, there is huge variability in RS and some individuals present with extensive atrophy at the time of their first seizure while others display a much slower course of progression. Other newer modalities may be useful, including magnetic resonance spectroscopy (MRS) in which N-acetyl-aspartic acid (NAA), a marker of neuronal death or injury, has been shown to be decreased beyond what would be expected based simply on atrophy. Other modalities such as diffusion-weighted imaging may also be helpful in the future. At best, it would show slowing over the affected hemisphere with multifocal spikes. At worst, because it can create doubt of the diagnosis, seemingly independent discharges can be seen bilaterally. With careful analysis, large asymmetries are usually apparent, and the spike from the truly abnormal hemisphere can often be seen to be leading the contralateral spike by milliseconds. We do not believe it is useful because we are aware of the pathology that can show normal tissue intimately adjacent to inflamed tissue. Even with use of MRI-guided biopsy we know that the biopsy can still be negative, sometimes interfering with the appropriate management of the condition. Rasmussen’s Syndrome 123 Unfortunately, this was never available on a standardized basis and the literature is clear that the test can be positive in some control individuals and negative in some with proved RS. At this time, the diagnosis remains clinical: unilateral progressive epilepsy in the setting of atrophying brain. Aggressive medical management with anticonvulsant medication is uniformly unsuccessful. Seizures can be contained to some degree, but they cannot be stopped; it is imperative that the physician pays careful attention to the amount of side effects produced by the medications, often for very little additional benefit.

NHS Training Manual All ambulance services in the United Kingdom now employ a system of prioritised despatch purchase butenafine with american express fungus back, either Advanced Medical Priority Despatch or Criteria Based Despatch 15mg butenafine with mastercard antifungal rinse, in which the call-taker follows a rigorously applied algorithm to ensure that the urgency of the problem is identified according to defined criteria and that the appropriate level of response is assigned generic butenafine 15mg with mastercard antifungal agents. Three categories of call are usually recognised: ● Category A—Life threatening (including cardiopulmonary arrest). The aim is to get to most of these calls within eight minutes ● Category B—Emergency but not immediately life threatening ● Category C—Non-urgent. An appropriate response is provided; in some cases the transfer of the call is transferred to other agencies, such as NHS Direct. L Having assigned a category to the call (often with the help of a computer algorithm), the call-taker will pass it to a dispatcher who, using appropriate technology such as automated vehicle location systems, will ask the nearest ambulance or most appropriate resource to respond. In the a case of cardiorespiratory arrest this may also include a a community first responder who can be rapidly mobilised with y an automated defibrillator. The ambulance control room staff will also provide Chain of survival emergency advice to the telephone caller, including instructions on how to perform cardiopulmonary resuscitation if appropriate. The speed of response is critical because survival after cardiorespiratory arrest falls exponentially with time. The Heartstart Scotland scheme has shown that those patients who develop ventricular fibrillation after the arrival of the ambulance crew have a greater than 50% chance of long-term survival. The ambulance controller should ensure that patients with suspected myocardial infarction are also attended promptly by their general practitioner. Such a “dual response” provides the patient with effective analgesia, electrocardiographic monitoring, defibrillation, and advanced life support as soon as possible. Early cardiopulmonary resuscitation The benefits of early cardiopulmonary resuscitation have been well established, with survival from all forms of cardiac arrest at least doubled when bystander cardiopulmonary resuscitation is undertaken. All emergency service staff should be trained in effective basic life support and their skills should be regularly refreshed and updated. In most parts of the United Kingdom ambulance staff also train the general public in emergency life support techniques. Ambulance dispatch desk 51 ABC of Resuscitation Early defibrillation Equipment for front-line ambulance Every front-line ambulance in the United Kingdom now carries ● Immediate response satchel—bag, valve, mask (adult and child), hand-held suction, airways, laryngoscopy roll, a defibrillator, most often an advisory or automated external endotracheal tubes, dressing pads, scissors defibrillator (AED) that can be used by all grades of ambulance ● Portable oxygen therapy set staff. In Scotland alone, where ● Sphygmomanometer and stethoscope currently over 35 000 resuscitation attempts are logged on the ● Entonox database, 16 500 patients have been defibrillated since 1988, ● Trolley cots, stretchers, poles, pillows, blankets ● Rigid collars with almost 1800 long-term survivors—that is, 150 survivors ● Vacuum splints per year—an overall one year survival rate from out-of-hospital ● Spine immobiliser, long spine board ventricular fibrillation of about 10%. The sensitivity and specificity of these ● Waste bins, sharps box defibrillators is comparable to manual defibrillators and the ● Maternity pack ● Infectious diseases pack time taken to defibrillate is less. AEDs have high-quality data ● Hand lamp recording, retrieval, and analysis systems and, most importantly, ● Rescue tools potential users become competent in their use after considerably less training. The development of AEDs has Drugs sanctioned for use by trained ambulance staff extended the availability of defibrillation to any first responder, not only ambulance staff (see Chapter 3). It is nevertheless ● Oxygen ● Nalbuphine ● Entonox ● Syntometrine important that such first responder schemes, which often ● Aspirin ● Sodium bicarbonate include the other emergency services or the first aid societies, ● Nitroglycerine ● Glucose infusion are integrated into a system with overall medical control usually ● Adrenaline (epinephrine) ● Saline infusion coordinated by the ambulance service. It emphasises the extended skills of venous cannulation, recording and interpreting electrocardiograms Outline syllabus for paramedic training (ECGs), intubation, infusion, defibrillation, and the use of selected drugs. In 1992 the Medicines Act was amended to Theoretical knowledge Basic anatomy and physiology permit ambulance paramedics to administer approved drugs ● Respiratory system (especially mouth and larynx) from a range of prescription only medicines. Four weeks of the course is ● Presentations of ischaemic heart disease ● Differential diagnosis of chest pain provided in hospital under the supervision of clinical tutors in ● Complications and management of acute myocardial cardiology, accident and emergency medicine, anaesthesia, and infarction intensive care. Training in emergency paediatrics and obstetric ● Acute abdominal emergencies care (including neonatal resuscitation) is also provided. All ● Open and closed injury of chest and abdomen grades of ambulance staff are subject to review and audit as ● Limb fractures part of the clinical governance arrangements operated by ● Head injury Ambulance Trusts. Paramedics must refresh their skills annually ● Fitting ● Burns and attend a residential intensive revision course at an ● Maxillofacial injuries approved centre every three years. Opportunities are also ● Obstetric care provided for further hospital placement if necessary. The precise role of ● Taking a brief medical history the ambulance service in delivering advanced life support ● Observing general appearance, pulse, blood pressure (with sphygmomanometer), level of consciousness (with Glasgow remains controversial, but the overwhelming impression is that scale) paramedics considerably enhance the professional image of the ● Undertaking systemic external examination for injury service and the quality of patient care provided. To allow interservice comparisons, most services audit their performance against outcome criteria, such as the return of spontaneous circulation and survival to leave hospital alive. Further reading The ambulance services now have their own professional ● National Health Service Training Directorate. Ambulance service association, the Ambulance Services Association, which sets and paramedic training manual.

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