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By X. Asam. Robert Morris College, Illinois. 2018.

X The purpose of the research will provide an indicator to the most appropriate methods purchase voveran 50mg fast delivery muscle relaxant adverse effects. X You should think about your personality safe 50 mg voveran spasms going to sleep, strengths and weakness, likes and dislikes when choosing re- search methods. This will help you to become more familiar with your topic and intro- duce you to any other research which will be of benefit to you when you begin your own project. PRIMARY RESEARCH AND SECONDARY RESEARCH There are two types of background research – primary re- search and secondary research (see Table 2). Primary re- search involves the study of a subject through firsthand observation and investigation. This is what you will be doing with your main project, but you may also need to conduct primary research for your background work, especially if you’re unable to find any previously pub- lished material about your topic. Primary research may come from your own observations or experience, or from the information you gather personally from other people, as the following example illustrates. I had noticed how some children didn’t fit the classic description of a truant and I wanted to find out more as I thought it might help me to deal with some of the problems children were experiencing. So I guess you’d say my own experience provided me with some initial data. Then I decided to go and have a dis- cussion with some of my colleagues and see if they’d noticed anything like me. It was really useful to do this because they helped me to think about other things I hadn’t even thought of. One of them told me about a new report which had just come out and it was useful formetogoandhavealookatitasitraisedsome of the issues I was already thinking about. Actually this made me change the focus of my work a little because I soon found out that there had been a lot of work on one area of what I was doing, but not so much on another area. It was really useful to have done this before I rushed into my research as I think I might have wasted quite a bit of time. In the above example, Jenny mentions a recently pub- lished report which she has read. This is secondary re- search and it involves the collection of information from studies that other researchers have made of a subject. The two easiest and most accessible places to find this informa- tion are libraries and the internet. However, you must re- 42 / PRACTICAL RESEARCH METHODS member that anybody can publish information over the internet and you should be aware that some of this infor- mation can be misleading or incorrect. Of course this is the case for any published information and as you develop your research skills so you should also develop your criti- cal thinking and reasoning skills. What motives did the publishers have for making sure their information had reached the public domain? Using web sites By developing these skills early in your work, you will start to think about your own research and any personal bias in your methods and reporting which may be present. The web sites of many universities now carry information about how to use the web carefully and sensibly for your research and it is worth accessing these before you begin your background work. When you’re surfing the net, there are some extra precau- tions you can take to check the reliability and quality of the information you have found: X Try to use websites run by organisations you know and trust. X Check the About Us section on the web page for more information about the creator and organisation. X Use another source, if possible, to check any informa- tion of which you are unsure. For example, if you’re interested in medical information you can check the HOW TO CONDUCT BACKGROUND RESEARCH / 43 credentials of UK doctors by phoning the General Medical Council. X You should check the national source of the data as in- formation may differ between countries. X For some topics specific websites have been set up that contain details of questionable products, services and theories. Interlibrary loans If you are a student your institutional library will prob- ably offer an interlibrary loan service which means that you can access books from other university libraries if they are not available in your library. This is a useful service if, when referencing, you find that a small amount of infor- mation is missing (see Example 5 below). EXAMPLE 5: GILLIAN Nobody told me the importance of keeping careful re- cords of my background research.

Then the whole lot is brought Surviving the Pre-registration House Officer Post 15 back to the ward order voveran 50mg with amex muscle relaxant and tylenol 3. Medical ward rounds are notori- ously slow and TTA sheets can usually be written on the round while the SHO writes in the patient notes purchase voveran 50mg online xanax muscle relaxer. Surgical rounds are a little too short and sweet and TTA sheets are therefore normally written afterwards (note that the rounds are so short you will need to write in the notes after the round). As a house officer you will often have three to five TTA sheets to write per day. It is sensible to prioritise these as there will always be late or unexpected patient discharges and their TTA sheets should be done first. Note Keeping This is one of the arms of clinical governance and it has received a lot of attention over the last few years. Medico-legally, each piece of paper or document regarding a patient must have the following information on it: patient surname, forename and hospital number. With each entry it is important to have the following clearly written in the notes: date, time, surname of the staff member seeing the patient, position and bleep number. Each individual should be responsi- ble for his or her own actions and by identifying yourself you are taking that responsibility. The nurses may query any instructions or plans that you write in the notes and they may wish to discuss them with you. Finally and by no means least, if you perform a practical procedure, for example a catheterisation, chest drain insertion, etc. This is because, if there is a complication, the nursing staff will need to inform you so you can attend to the patient. This is also for your own education so you can see if you have made an error and therefore learn from your mistakes. Medical Notes and Medical Records More often than not your consultants and seniors will recount tales of old about long searches for radiographs and patient notes for ward rounds and meetings. Hundred of hours a month are wasted searching for patient notes and their radiographs in preparation for ward rounds and elective patient admissions. Thankfully, with the advent of twenty-first-century information technology into the health service some of us are now ‘privileged’ to work in hospitals with digital radiology. By 2010 the Electronic Patient Record should be in place making paper notes a thing of the past. Unfortunately, until such times arrive it will still be the task of the PRHO to locate files and films for the consultant or SpR. The medical records department is a large vault of a department that is usually located in the bowels of the hospital, the basement being the commonest site. All patient notes should be stored in the medical records department unless someone in the hospital is using them. Each consultant or office, department and cleric in the hospital has their own code and when notes are taken from the medical records department it should be recorded on the medical records department computer system, providing they have been booked or ‘tracked’ to the person who has borrowed them. For example, if a patient attends the chest clinic the notes will be booked out to the clinic under the name of the consultant they are seeing. When the patient has been seen and the clinic letter typed, the notes should then be returned to the medical records department. When you are asked to get a set of case notes the first thing to do is to ask your con- sultant’s secretary to check where the notes are on the computer system (usually called the Patient Administration System or PAS). If the notes are in the medical records department then the task is easy: go and collect them,but remember to book them out to your consultant. If they are not in the medical records department then see if they have been booked out, when they were and to whom. Get the telephone extension of the person who has booked them out and ask them if they have them, etc. When notes are not where they should be problems occur and usually it is not possible to find them.

Persons with mobility difficulties have 50mg voveran visa spasms mouth, on average trusted 50 mg voveran muscle relaxant natural, less education than people without impairments, so their job opportunities are more limited from the outset (Table 9). About 70 percent of working-age people report- ing major mobility difficulties cannot work because of their health condi- tions, compared to only 3 percent among those without mobility prob- lems. Over 26 percent of all adults reporting major and moderate mobility difficulties have incomes below the poverty level, compared to 21 percent with minor mobility problems and only 9 percent without impairments. Walter Masterson modified his job to match his diminishing physical abilities. These changes carried costs: I’ve really not done any company traveling in a year and a half, and that’s beginning to restrict my effectiveness in strategic plan- ning.... Those aren’t the words being used, but that, in effect, is what is about to occur. Attending physicians would say I was doing really well and that I would find a great job. Then I became friendly with another doctor who has muscular dystrophy, and he said, ‘What you’re doing is wrong. He wanted me to use some mobility device, like a scooter, before I was ready to do it. At one interview, “I had to ask the person’s assistance in getting up from the chair. Education and Employment Among Working-Age People Education (%) Employment (%) Employed/ Unemployed Mobility High School Beyond Attending Because Difficulty or Less College School of Health None 14 10 82 3 Minor 27 5 55 32 Moderate 34 3 40 56 Major 31 4 29 70 have a lot of people applying, and we just can’t take someone like you. Farr now has a job but has made compromises—not taking the more prestigious but rigorous tenure-track academic position with its employ- ment assurance, instead working under contract, year-to-year. Many interviewees no longer work because of mobility problems, sometimes compounded by their underlying medical conditions. Stella Richards, an accountant formerly anticipating a generous governmental pension, was matter-of-fact about her losses. I kept asking him to give me some- thing for the pain because I couldn’t even lie down to take X rays. I told him I had to work Monday, and he said, “I’ll give you some- thing for the pain, but I’m afraid you won’t be able to go to work for at least two or three weeks. I lay in the fetal position in my bed, except for my hospital appointments, until the operation.... It never entered my mind that anything like this would ever happen to me. When I re- tired, I planned to be traveling, not walking around here on a walker. Some interviewees have private, 110 / Outside Home—at Work and in Communities table 10. Annual Income Below Poverty Income $50,000 Level (%) or More (%) Mobility Age 18–64 Age 18–64 Difficulty years Age 65+ years Age 65+ None 9 6 34 14 Minor 23 10 16 9 Moderate 29 13 13 8 Major 29 15 14 7 long-term disability pensions or insurance, purchased individually or through their employers. Other unemployed working-age people receive incomes through the federal “safety-net”—Social Security. Society helps disabled people because they find them- selves in bad circumstances through no fault of their own. People who are unemployed because of disability have a higher moral claim because (it is assumed) they really wish to work. Title II authorizes payment of SSDI benefits to persons who have worked and contributed to the Social Security trust fund through taxes on their earnings. Workers injured on the job who receive cash through state- run, employer-financed workers’ compensation programs generally have Outside Home—at Work and in Communities / 111 their Social Security benefits reduced by the workers’ compensation amount. People who have received SSDI cash benefits for two years be- come eligible for Medicare (in 2001, the two-year wait was waived for peo- ple with ALS). Title XVI provides SSI payments to disabled persons, in- cluding children, who have passed a means test documenting limited income and resources. Some states add dollars to federal SSI payments, and persons receiving SSI get Medicaid coverage.

Patients may have increased sitting or standing height purchase voveran 50 mg otc muscle relaxant natural remedies, and improved self- esteem due to diminished deformity purchase voveran 50mg without prescription muscle relaxant alcohol addiction. Potential risks include anesthetic complications, bleeding, postoperative pain, pulmonary complications, infection, and even death. Because children in wheelchairs may have an increased sitting height, transportation needs may be altered by the procedure. Changes in body mechanics can impair the independent ability to perform many simple tasks such as arising from the floor, or important self-care activities such as feeding and personal hygiene. If a neuromuscular diagnosis is suspected, it may be an opportune time to obtain a muscle biopsy. Preoperative consultation with a pediatric anesthesiologist is required for many muscle disorders, such as central core myopathy, where there is enhanced risk for malignant hyperthermia. Operative Approaches The choice of posterior fixation only, or posterior and anterior fixation combined, is a complex matter that includes assessment of the severity of curvature, number of segments over which the angulation occurs, level of skeletal maturity, and the degree of planned correction. Addition of an anterior approach with discectomy and bone Scoliosis 41 grafts between vertebral bodies increases the potential correction, and removal of the growth plate can alter later growth as necessary. Anterior spinal fusion is, however, associated with greatly increased operative morbidity. Sometimes the surgery can be done in two stages to minimize complications associated with a long procedure with large fluid shifts. In some cases of a short segment severe curvature, anterior access can be accomplished with an endoscopic approach using minimally invasive instru- ments. An anterior approach to shorten the vertebral column by removal of the discs and portions of one or more vertebral bodies may be necessary in cases where sig- nificant lordosis is to be corrected. Without this intervention, there is a risk that excessive traction on the posterior elements can lead to ischemic changes in the spinal cord. In the earliest version of posterior spinal fusion, a ‘‘Harrington rod’’ was placed and secured at both ends; this procedure has been replaced by a variety of segmental procedures where wires or hooks are affixed to posterior elements of the spine at multiple locations. The advantage is substantial; with modern techniques the patients can be mobilized much sooner and usually do not require postoperative external fixation to achieve a good fusion. In many centers, continuous intraoperative monitoring of the posterior col- umns with somatosensory evoked potentials, or the corticospinal tract with cortical evoked motor potentials, provides the surgeon with an ongoing assessment of spinal cord function. A 50-year natural history study of untreated idiopathic scoliosis by Weinstein et al. With more severe curves, however, and in patients with other neurologic impairments, the consequences of unrepaired scoliosis can be more significant, and include con- finement to bed with persistent pain and potential for visceral complications. When- ever possible, careful positioning in wheelchairs equipped with three-point lateral trunk supports, molded backs, special seats and seat covers to minimize pressure points, and tilt-in-space options to relieve pressure are all of value. SUMMARY Idiopathic scoliosis can usually be successfully treated with bracing or surgical meth- ods. Children with congenital or neuromuscular scoliosis are more challenging to treat because of associated medical, orthopedic, and neurological disorders. Sur- geons and families may opt for conservative management with bracing, but ulti- mately surgical arthrodesis with instrumentation is often necessary. The ideal outcome requires both careful patient selection and preoperative evaluation. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. INTRODUCTION Chiari malformations are hindbrain herniation syndromes that occur in children and adults. This classifi- cation scheme does not imply a spectrum of increasing severity of the anatomical abnormality or the clinical significance (i. Anatomically, Chiari I and II differ in the degree of herniation of the posterior fossa contents through the foramen magnum. In Chiari I, only the cerebellar tonsils are descended or herniated through the foramen magnum. The extent of tonsillar hernitaion can vary from a few millimeters to greater than a centimeter. The radio- graphic diagnosis uses tonsillar ectopia of greater than 3–5 mm below the foramen magnum as a diagnostic criterion. Recently, Milhorat has focused on the importance of a decrease in the CSF spaces surrounding the cerebellum and brainstem at the foramen magnum, suggesting that tonsillar descent of less than 3 mm may be clinically relevant in some patients.

It is ironic that young women are often advised to examine their breasts every month—an arbitrarily selected frequency that happens to coincide with the menstrual cycle — though the large majority of women with breast cancer are post- menopausal order voveran 50 mg muscle relaxant antagonist. Similarly 50mg voveran with visa muscle relaxant options, young men now turn up at the surgery after reading about prostate cancer in their men’s magazines and request screening for a condition that only rarely appears before retirement age. The parallel between screening tests for cervical and prostatic cancer is symbolic. Just as the smear test exposes women not merely to the medical gaze but to vaginal penetration, so the palpation of the 63 SCREENING prostate involves digital penetration of the male rectum. The slippery finger may be less impressive than the metal speculum, but it is no less significant as an instrument of symbolic domination. Rejecting the evidence of the ineffectiveness of mammography, Delyth Morgan of Breakthrough Breast Cancer insisted that ‘what we should be debating is how best to screen women’ (Guardian, 7 January 2000). This response provides striking confirmation of the observation made fifteen years earlier in another critique of screening: ‘In “keeping the faith”, screening advocates may find themselves forced to accept or reject evidence not so much on the basis of its scientific merit as on the extent to which it supports or rejects the stand that screening is good’ (Sackett, Holland 1975). The danger of this approach is not only that it leads to the continuation of costly and ineffective programmes. It also means that the harms of screening are passed over in silence: to mention them could discourage people from taking up the offer of testing. Indeed this was the first concern of the cancer charities in response to reports of the Danish study of mammography quoted above; public reassurances about the quality of the national cervical screening programme accompany every exposure of poor standards. Yet the harms resulting from screening are substantial: for every woman who benefits, tens of thousands undergo testing and hundreds receive unnecessary treatment. In presenting screening as an unequivocal benefit to women, doctors become advocates of state policy rather than of their patients’ interests. State intervention in personal life In the screening programme the author was assigned an ‘adviser’ who would ‘help her with her health’ on an ongoing basis and monitor her progress towards ‘better health’. The extensive questionnaire Taking the first step to better health’ included the tendentious and extraordinarily patronising statement that the screening ‘has been devised to help you change the way you look after your health. The author took umbrage at (a) the assump-tion that she was not healthy already, and (b) the assumption she didn’t know how to look after herself… 64 SCREENING The questionnaire also included a ‘Women’s section’ of questions from the banal to the intrusively, impertinently and offensively intimate to ‘help her with her health’. The author objected and was told that she was unusual in questioning the questions (most women, apparently don’t because they trust doctors and have been brainwashed into believing that they need this nonsense). Over the past twenty years there has been, in the name of health promotion, a dramatic increase in state intervention in the personal life of the individual—ironically in a period when the state has been inclined to withdraw from economic and social commitments. The immediate consequence has been a stricter regulation of individual behaviour, though because this has been justified in the cause of improving the health of both the individual and the nation, it has not generally been experienced as coercive. The changed relationship between the state and the individual that is reflected in the greatly enhanced role of health has also changed the role of the medical profession and has given rise to a range of new institutions and professionals working in the sphere of health promotion. The origins of each of the lifestyle interventions we have examined lie within the world of medicine and its attempts to tackle the ‘modern epidemics’ of heart disease and cancer. However, as is clear from our brief survey of the development of these interventions, at a certain point each was taken up by the state and transformed into a major national initiative. In the case of smoking, this occurred with the shift of focus to passive smoking in the late 1980s; in relation to CHD, government promotion of ‘healthy eating’ began earlier but also became a major campaign in the late 1980s and in the Health of the Nation initiatives of the early 1990s; both the cervical and breast screening programmes were nationalised in 1987–88. The state’s assumption of a leading role in health promotion inevitably changed the character of these initiatives. Once they had acquired a wider political and ideological role, their contribution to health became of secondary importance. At a time when politicians were preoccupied with the declining prestige of government, projecting an image of concern with health helped to shore up public 65 SCREENING approval. Successive governments recognised the potential of health as a means of establishing points of contact between the state and an increasingly atomised society, a trend which reached its apotheosis in NHS Direct, the 24-hour telephone advice line set up in 1999, claimed by Tony Blair as one of the greatest achievements of his first 1,000 days in office. Employers too recognised the potential of health promotion in managing relations with workers. In a perceptive study, Margaret May and Edward Brunsdon noted the shift in the 1980s away from traditional ‘occupational health’ concerns towards ‘new “wellness” interventions’, including medical ‘check-ups’, ‘health risk appraisal’, screening tests and preventive lifestyle advice (May, Brunsdon 1994). They characterised this as ‘a new form of employee control’, far beyond the familiar organisation of work, as the jurisdiction of the employers extended into workers’ private lives. They commented on the convergence of management theory and government health policy around the themes of personal responsibility.