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Depolarisation of a critical mass His first success came in 1947 when VF developed in a 14 year of myocardium is necessary and this depends on the old boy whose chest was being closed after surgery for funnel transmyocardial current flow (measured in Amperes) rather chest generic doxepin 25mg online. Kouwenhoven was also instrumental in the development of the external defibrillator discount doxepin 25 mg visa, which was first successfully than the energy of the delivered shock (measured in Joules) buy cheap doxepin 25 mg online. This technique is most likely to be by Pantridge in 1967 successful if applied very soon after onset of the arrythmia doxepin 10mg otc, so a thump should be considered in cases of witnessed order doxepin 25 mg without prescription, particularly monitored, cardiac arrest. A continuous electrocardiogram recording showing the successful treatment of VF by a countershock (delivered at the arrow) 6 Ventricular fibrillation Factors influencing defibrillation Determinants of current flow Transmyocardial current flow ● Energy of delivered shock ● Transthoracic impedence A shock that is too low in energy may result in a current flow ● Electrode position that is inadequate to achieve successful defibrillation. Higher ● Shock waveform energy shocks may result in greater current flow but carry the ● Body size risk of causing damage if the current is too high. The optimal ● Electrode size shock energy is one that will achieve defibrillation successfully while causing minimal electrical injury to the myocardium. Achieving an appropriate current flow will reduce the number of shocks required and may limit further myocardial damage. The magnitude of the current passing through the heart will depend on the voltage delivered by the defibrillator and the transthoracic impedance—that is, the resistance to current flow through the chest wall, lungs, and myocardium. The Determinants of current flow E relationship between these factors can be expressed by a simple I TT1 mathematical equation. I peak discharge current E energy selected Transthoracic impedence TTI transthoracic impedance In adults transthoracic impedence averages about 60Ohms, with 95% of the population lying in the range of 30-90Ohms. Current flow will be highest when transthoracic impedence is at its lowest. To achieve this the operator should press firmly when using handheld electrode paddles. A conductive electrode gel or defibrillator pads should be used to reduce the impedance at the electrode and skin interface. Self-adhesive monitor or defibrillator electrodes do not require additional pressure. In patients with considerable chest hair, poor Determinants of transthoracic electrode contact and air trapping will increase the impedance. Transthoracic impedance is ● Electrode size about 9% lower when the lungs are empty, so defibrillation is ● Electrical contact ● Number of and time since previous shocks best carried out during the expiratory phase of ventilation. It is ● Phase of ventilation also important to avoid positioning the electrodes over the ● Distance between electrodes breast tissue of female patients because this causes high ● Paddle or electrode pressure impedance to current flow. Defibrillator shock waveform The effectiveness of a shock in terminating VF depends on the type of shock waveform discharged by the defibrillator. Traditionally, defibrillators delivered a monophasic sinusoidal or damped sinusoidal waveform. Recently it has been shown that biphasic waveforms (in which the polarity of the shock changes) are more effective than monophasic shocks of equivalent energy. Defibrillators that deliver biphasic shocks are now in clinical use, and considerable savings in size and weight 50 Edmark result from the reduced energy levels needed. Biphasic shocks 2000 40 have been widely employed in implantable cardioverter Gurvich defibrillators (ICDs) because their increased effectiveness 30 allows more shocks to be given for any particular battery size. Defibrillators that use biphasic waveforms offer the 1000 20 potential of both greater efficiency and less myocardial damage 10 than conventional monophasic defibrillators. Much of this evidence has been gained from studies conducted during the 0 0 implantation of cardioverter defibrillators but some evidence shows that the increased efficiency of biphasic waveforms leads –10 to higher survival rates during resuscitation attempts. For example, a success rate of 70% means Edmark monophasic and Gurvich biphasic defibrillator waveforms failure in 30 out of 100 patients. If a further shock, with the same 70% chance of success, is given to those 30 patients an additional 21 successes will be achieved (70% of 30). When using a defibrillator with a monomorphic waveform it is recommended that the first shock should be at an energy 7 ABC of Resuscitation level of 200 J. Should this be unsuccessful, a second shock at the same energy level may prove effective because the Electrode position transthoracic impedance is reduced by repeated shocks. If two ● The ideal electrode position allows maximum current to flow shocks at 200 J are unsuccessful, the energy setting should be through the myocardium. This will occur when the heart lies in the direct path of the current increased to 360 J for the third and subsequent attempts. Although this equivalence is not left intercostal space clearly defined, and may vary between different types of ● An alternative is to place one electrode to the left of the biphasic waveform, a biphasic shock of 150 J is commonly lower sternal border and the other on the posterior chest wall below the angle of the left scapula considered to be at least as effective as a 200 J monophasic ● Avoid placing electrodes directly over breast tissue in women shock. Many automated biphasic defibrillators do not employ escalating shock energies and have produced similar clinical outcomes to the use of conventional monophasic defibrillators Electrode size or surface area in which the third and subsequent shocks are delivered at 360 J. Another technique to increase efficiency is the use of sequentially overlapping shocks that produce a shifting electrical vector during a multiple pulse Body size shock.

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Original statement 2: My project is to do some research into Alzheimer’s disease discount doxepin 25 mg on line, to find out what people do when their relatives have it and what support they can get and how nurses deal with it order 75 mg doxepin with mastercard. Also doxepin 75mg discount, he found out some more information about whether his research needed to go to a Research Ethics Committee by checking out the website www generic doxepin 25 mg visa. This site gives details about the committees generic 10mg doxepin with amex, a list of meeting dates, guidance notes and application forms for those researchers interested in putting forward a proposal. Revised statement 2: The aim of this research is to find out how many relatives of Alzheimer’s patients use the Maple Day Centre, and to ascertain whether the ser- vice is meeting their needs. The research population is limited to relatives of Alzhei- mer’s patients who use the Maple Day Centre. One clue 22 / PRACTICAL RESEARCH METHODS to the methodology is in the words ‘how many’ which suggests a quantitative study. However, he is also inter- ested in finding out whether the service meets their needs, which requires some more in-depth inquiry. Original Statement 3: We want to find out how many of the local residents are interested in a play scheme for chil- dren during the summer holiday. The tenants’ association thought carefully about the is- sues in which they were interested, eventually coming up with the following revised statement: Revised Statement 3: This research aims to find out how many people from our estate are interested in, and would use, a children’s play scheme in the school summer holiday. The tenants’ association wanted to obtain funding for their play scheme and felt that it was important to gather sta- tistics which they could take to possible funding organi- sations. SUMMARY X The research methodology is the philosophy or general principle which guides the research. HOW TO DECIDE UPON A METHODOLOGY / 23 X Examples of qualitative methodologies include action research, ethnography, feminist research and grounded theory. X Quantitative research generates statistics through the use of large-scale survey research. X Neither qualitative nor quantitative research is better – they are just different. X Your own intuition and the words you use will give pointers to whether qualitative or quantitative research is more appropriate for your chosen project. X The term ‘triangulation’ is used when a combination of qualitative and quantitative forms of inquiry are used. FURTHER READING The theoretical and philosophical issues raised in this chapter are detailed and complex and cannot be discussed in depth in this book. However, if you wish to pursue any of these topics, some of the useful publications are listed below under the relevant topics. Qualitative research Over recent years there has been a great deal of innova- tion in the use of qualitative methodologies. Listed below are some of the more traditional texts and a selection of the newer, innovative texts. Before you de- cide which would be the most appropriate methods for your research, you need to find out a little more about these tools. This chapter gives a description of the meth- ods of interviewing, focus groups, questionnaires and par- ticipant observation. Chapters 7–10 will go on to describe in detail how to use each of these methods. The most common of these are unstructured, semi-structured and structured interviews. If you want to find out about other types of interview, relevant references are given at the end of this chapter. Unstructured interviews Unstructured or in-depth interviews are sometimes called life history interviews. This is because they are the fa- voured approach for life history research. In this type of interview, the researcher attempts to achieve a holistic un- derstanding of the interviewees’ point of view or situation. For example, if you want to find out about a Polish man’s experiences of a concentration camp during the war, 27 28 / PRACTICAL RESEARCH METHODS you’re delving into his life history. Because you are unsure of what has happened in his life, you want to enable him to talk freely and ask as few questions as possible. It is for this reason that this type of interview is called unstruc- tured – the participant is free to talk about what he or she deems important, with little directional influence from the researcher.

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This A form of the metal platinum called cisplatin stops can- structure is very similar to that of cellulose cheap 10mg doxepin amex. Newer groups of chitin is known as acetamide cheap 25mg doxepin free shipping, whereas cellulose has treatments that are biological or based on proteins or genetic material and can target specific cells are also being developed 10 mg doxepin. Monoclonal antibodies are genetically engineered copies of Chitin is a noteworthy biological feature because it is proteins used by the immune system to fight disease purchase 10 mg doxepin mastercard. Rituximab was the first moncoclonal antibody approved for In contrast generic doxepin 25mg with visa, most polymers are man-made and are comprised use in cancer, and more are under development. The purpose of chitin is to provide support for the Interferons serve to alert the body’s immune system of an organism. The degree of support depends on the amount and impending attack, thus causing the production of other pro- the thickness of chitin that is present. Interferons are being studied for rooms, chitin confers stability and rigidity, yet allows some treating a number of cancers, including a form of skin cancer flexibility. This allows the mushrooms to stand and still be called multiple myeloma. A third group of drugs are called flexible enough to sway without snapping. Although many new- the peptidoglycan supportive layer that is a feature of Gram- borns develop only mild pneumonia, because the lungs of a positive and Gram-negative bacteria. The think peptidoglycan newborn are fragile, especially in pre-term babies, any infec- layer in Gram-positive bacteria provides a rigid and robust sup- tion of lung tissue is serious and can be life-threatening. The peptidoglycan layer in Gram-negative bacteria that is Specific antibiotics are used to fight chlamydial pneu- only one molecule thick does not provide the same degree of monias. Other mechanical elements of the Gram- to combat Chlamydia pneumoniae and Chlamydia trachoma- negative cell wall are necessary to shore up the structure. Tetracycline is usually effective against Chlamydia In the ocean, where many creatures contain chitin, sea- psittaci. The bacteria are able to See also Bacteria and bacterial infection; Transmission of break down the polymer and use the sugar molecules as meta- pathogens bolic fuel. See also Fungi CHLORAMPHENICOL • see ANTIBIOTICS Chlamydial pneumoniaCHLAMYDIAL PNEUMONIA CChlorinationHLORINATION Chlamydial pneumonia is a pneumonia cause by one of sev- Chlorination refers to a chemical process that is used primarily eral forms of Chlamydial bacteria. The three major forms of to disinfect drinking water and spills of microorganisms. The Chlamydia responsible for pneumonia are Chlamydia pneu- active agent in chlorination is the element chlorine, or a deriv- moniae, Chlamydia psittaci, and Chlamydia trachomatis. Chlorination is a In reaction to infection, infected lung tissue may swift and economical means of destroying many, but not all, become obstructed with secretions. As part of a generalized microorganisms that are a health-threat in fluid such as drink- swelling or inflammation of the lungs, the fluid or pus secre- ing water. Blockage of the alveoli results in a of its ability to kill bacteria and other disease-causing organ- decreased oxygenation of the blood and deprivation of oxygen isms at relatively low concentrations and with little risk to to tissues. Much of the Chlamydia pneumoniae (in older literature known as killing effect in bacteria is due to the binding of chlorine to “Taiwan acute respiratory agent”) usually produces a condi- tion known as “walking pneumonia,” a milder form of pneu- reactive groups within the membrane(s) of the bacteria. As well, chlorine inhibits various bio- tating and dangerous to at risk groups that include the elderly, chemical reactions in the bacterium. In contrast to the rapid young children, or to individuals already weakened by another action of chlorine, other water disinfection methods, such as illness. Chlamydia pneumoniae spreads easily and the high the use of ozone or ultraviolet light, require minutes of expo- transmission rate means that many individuals within a popu- sure to a microorganism to kill the organism. In many water treatment facilities, chlorine gas is Species of chlamydiae can be directly detected follow- pumped directly into water until it reaches a concentration that ing cultivation in embryonated egg cultures and immunofluo- is determined to kill microorganisms, while at the same time rescence staining or via polymerase chain reaction (PCR). The exact con- Chlamydiae can also be detected via specific serologic tests. Chlamydia psittaci is an avian bacteria that is transmit- For example, surface waters contain more organic material that ted by human contact with infected birds, feathers from acts to absorb the added chlorine. Thus, more chlorine needs to infected birds, or droppings from infected birds.

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While some Medicaid programs closely follow Medicare’s definition of medical necessity cheap doxepin 75mg on-line, others set their own standards buy doxepin 10 mg otc. For Medicaid managed-care contracts with health plans doxepin 25 mg on-line, most states have put together definitions of medical ne- cessity buy discount doxepin 25mg on line, if not details of decision criteria (Rosenbaum et al buy generic doxepin 10mg on line. Medical necessity definitions from three states underscore the diversity of lan- guage. Their language about medical necessity is often vague or open to interpre- tation. The standards of medical necessity vary widely, and private plans’ decisions on medical necessity ultimately come from physicians, typically the insurers’ medical directors (Singer and Bergthold 2001). In making de- cisions, medical directors depend to varying degrees on contractual lan- guage, expert opinions, scientific evidence, professional experiences, local practices, and the enrollee’s characteristics and preferences. For mobility-related services, questions about scientific evidence show- ing the effectiveness of interventions loom large. Although the activities of physical and occupational therapists make theoretical, clinical, and practi- cal sense, few clinical trials or large observational studies have analyzed the outcomes and effectiveness of these services. Research on OT outcomes is especially rare, particularly for home-based services. PT has a larger evi- dence base, focused primarily on inpatient rehabilitation or short-term outcomes. Mobility aids attract little research; studies generally involve small numbers of nondisabled volunteers in laboratory settings. The scarcity of research evidence about the effectiveness and clinical outcomes of therapy and assistive technology compromises efforts to make objective medical necessity decisions about the merit of mobility-related items and services. Medical necessity decisions frequently appear idiosyncratic and subjec- tive. As one disability rights activist said, “Health plans are pretty much free to manipulate the definition of medical necessity. Conflicting motivations heighten concerns: The need to control costs and generate profits also brings into ques- tion the reliability and soundness of decision making by insurers. The sine qua non of scientific research is the production of objective results, and objectivity is ensured through a process of open and vig- orous debate among persons who have no financial stake in the out- come. Yet much of the decision making about insurance coverage is based on unpublished, proprietary, and unreviewed data. Further- more, methods are undisclosed and unexamined unless litigation en- sues. Growing numbers of lawsuits are questioning health plans’ medical neces- sity decisions. Thus, decisions about medical necessity often encounter that uncom- fortable nexus, balancing personal needs against plan costs. On the one hand, persons may have such severe mobility limitations that traveling to an office or clinic for physical or occupational therapy would be a hardship. Receiving care at home maximizes convenience and perhaps the benefit of therapy, by eliminating travel fatigue and thus en- hancing the ability to exercise. OT in homes is essential for therapists to identify safety hazards and help modify people’s daily routines. On the other hand, an explicit purpose of therapy and of mobility aids is to allow people to leave their homes comfortably and safely. But this goal directly conflicts with policies such as Medicare’s coverage rules for power wheel- chairs (described in chapter 14). In addition, Medicare and most private in- surers view such equipment as grab bars and shower seats as “convenience items,” and therefore not covered benefits. Since the 1970s, Medicare regulations have stipulated that to qualify for home-based services, people must be “homebound,” having “a condition that results in a normal inability to leave home except with considerable and taxing effort, and absences from home are infrequent or of relatively short duration or are attributable to receiving medical treatment” (U. A law enacted 21 December 2000 loos- ened this requirement somewhat: attending religious services was deemed Who Will Pay? Persons must require skilled care, under a physician’s explicit treatment plan.

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