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When you Finalize the Questionnaire buy nemasole 100 mg with amex, be Sure that– A separate buy nemasole 100mg free shipping, introductory page is attached to each questionnaire order nemasole 100 mg on-line, 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. In many cases, it may be helpful to think backward and to begin by anticipating how the data will be analyzed. This will help the researcher to figure out exactly which variables need to be entered, how they should be ordered, and how they should be formatted. Moreover, the statistical analysis may also dictate what type of program you choose for your database. For example, certain advanced statistical analysis may require the use of specific statistical programs. While designing the general structure of the database, the researcher must carefully consider all the variables that will need to be entered. Forgetting to enter one or more variables, although not as problematic as failing to collect certain data elements, will add substantial effort and expense because the researcher must then go back to the hard data to find the missing data elements. The Data Codebook In addition to developing a well-structured database, researchers should take the time to develop a data codebook. A data codebook is a written or computerized list that provides a clear and comprehensive description of the variables that will be included in the database. Moreover, it serves as a permanent database guide, so that the researcher, when attempting to reanalyze certain data, will not be stuck trying to remember what certain variable names mean or what data were used for a certain analysis. Ultimately, the lack of a well-defined data codebook may render a database un-interpretable and useless.
In patients2 with pulmonary disease nemasole 100 mg for sale, direct measurements of percent saturation of arterial oxygen (SaO ) correlate reasonably well with SpO (±2%–3%) provided SpO2 2 2 remains >85% (3 cheap 100 mg nemasole free shipping,10) buy generic nemasole 100 mg on line. An absolute decrease in SpO ≥5% during exercise is2 considered an abnormal response suggestive of exercise-induced hypoxemia, and follow-up testing with arterial blood gases may be indicated (3,10). An SpO2 ≤80% with signs or symptoms of hypoxemia is an indication to stop a test (3). The measurement of SpO with pulse oximetry through a fingertip probe can be2 affected by low perfusion or low pulse wave, dyshemoglobinemias (i. Failure to continue a test until the patient attains maximal exertion or a clinical limitation will result in an underestimation of the patient’s peak exercise capacity. However, exercise cessation can cause an excessive drop in venous return resulting in profound hypotension during recovery and ischemia secondary to decreased perfusion pressure into the myocardium. Therefore, continuation of low-intensity active recovery during the postexercise period is often practiced in order to support venous return and hemodynamic stability. Each laboratory should develop standardized procedures for the postexercise recovery period (active vs. Safety Although untoward events do occur, clinical exercise testing is generally safe when performed by appropriately trained clinicians. The classic data of Rochmis and Blackburn (56) reported a rate of serious complications (morbidity or mortality) of 34 events per 10,000 tests. Excluding studies of patients tested with a history of life-threatening ventricular arrhythmias, among 17 studies, serious complications during clinical exercise tests ranged from 0 to 35 events per 10,000 tests, with rates typically higher among patients known to have higher mortality rates, such as patients with heart failure (46). However, prior studies might overestimate the risk of today’s patients given advances in medicine, such as the implantable cardioverter defibrillator (46). However, for most test indications, patients are encouraged to continue to take their medications on the day of testing (21). All estimates have large interindividual variability with standard deviations of 10 beats or more (11). An abnormal chronotropic response provides prognostic information that is independent of myocardial perfusion. The combination of a myocardial perfusion abnormality and an abnormal chronotropic response suggests a worse prognosis than either abnormality alone (29). On average, this response is greater among men; increases with age; and is attenuated in patients on vasodilators, calcium channel blockers, angiotensin-converting enzyme inhibitors, and α- and β-adrenergic blockers. There is a linear relationship between myocardial oxygen uptake and both coronary blood flow and exercise intensity (17). Rate-pressure product is a repeatable estimate of the ischemic threshold and more reliable than external workload (17). The normal range for peak rate- −1 pressure product is 25,000–40,000 mm Hg · beats · min (17). Rate-pressure product at peak exercise and at the ischemic threshold (when applicable) should be reported. However, this response has a low positive predictive value; it is often categorized as equivocal. In general, dysrhythmias that increase in frequency or complexity with progressive exercise intensity and are associated with ischemia or with hemodynamic instability are more likely to cause a poor outcome than isolated dysrhythmias (17). Although ventricular ectopy is more common with some pathologies, such as cardiomyopathy, in general, frequent and complex ventricular ectopy during exercise and especially in recovery are associated with increased risk for cardiac arrest (17). There are several relative termination criteria related to atrial and ventricular dysrhythmias and blocks that should be considered based on the presence of signs or symptoms of myocardial ischemia or inadequate perfusion (17) (see Box 5. Compared to angina or leg fatigue, an exercise test that is limited by dyspnea has been associated with a worse prognosis (17). Exercise Capacity Evaluating exercise capacity is an important aspect of exercise testing. A high exercise capacity is indicative of a high peak and therefore suggests the absence of serious limitations of left ventricular function. Within the past two decades, several studies have been published demonstrating the importance of exercise capacity relative to the prognosis of patients with heart failure or cardiovascular disease (3,8,10,37). Either absolute or age- and gender- normalized exercise capacity is highly related to survival (8,37). A significant issue relative to exercise capacity is the imprecision of estimating exercise capacity from exercise time or peak workload (8). Estimating exercise capacity on a treadmill is confounded when patients use the handrail for support which will result in an overestimation of their exercise capacity (34). Although equations exist to predict exercise capacity from an exercise test using handrail support, the standard error of the estimate remains large (34). Safety of treadmill walking is always an important consideration, and allowing a patient to use the handrail should be determined on a case-by-case basis. Reference tables are also available to provide a percentile ranking for an individual’s measured exercise capacity by gender and age categories (see Table 4. The vast majority of these references are based on apparently healthy individuals. In order to provide a comparative reference specific to patients with established heart disease, Ades et al. Cardiopulmonary Exercise Testing A major advantage of measuring gas exchange during exercise is a more accurate measurement of exercise capacity. However, the determination of what constitutes “maximal” effort, although important for interpreting test results, can be difficult. This criterion has fallen out of favor because a plateau is not consistently observed during maximal exercise testing with a continuous protocol (51). There is no consensus on the number of criteria that should be met in order to call a test maximal (38). In addition, interindividual and interprotocol variability may limit the validity of these criteria (38). In the absence of data supporting that an individual reached their physiologic maximum, data at peak exercise are commonly described as “peak” (e.
It is absolutely imperative to do a funduscopic examination to look for papilledema and hypertensive retinopathy generic nemasole 100mg overnight delivery. If pressure on the jugular veins relieves the headache generic 100mg nemasole visa, the patient may have a postspinal tap headache nemasole 100mg for sale. Marked tenderness of the superficial temporal artery on one side should suggest temporal arteritis. If a pseudoephedrine spray (Neo-Synephrine) relieves the headache, the patient may have allergic or vasomotor rhinitis. Finally, sumatriptan relieves both migraine and cluster headaches and is therefore useful in the diagnosis. If the physician sees the patient when the headaches are not occurring, a nitroglycerin tablet under the tongue assists in the diagnosis. Histamine sulfate subcutaneously may precipitate a headache in both patients with migraine and in those with cluster headaches. An injection of lidocaine 1% into the occipital nerve roots may relieve tension headaches. Note that many patients with so-called tension headache actually have common migraine. Hip Pain When examining a patient with a history of trauma, the physician will undoubtedly obtain an x-ray of the hips before proceeding with an extensive clinical examination. If there is no evidence of fracture, he or she may proceed with an examination of the range of motion (extension and flexion, internal and external rotation) and palpation for point tenderness. Greater trochanter bursitis is a common cause of hip pain and is easily diagnosed by palpation over the greater trochanter bursa and subsequent relief of the pain by injecting the bursa with 1% to 2% lidocaine. Range of motion is restricted, and Patrick test (pain on external rotation of the hip) is positive in both osteoarthritis (and other forms of arthritis) and greater trochanter bursitis. It is wise to do a femoral stretch test and straight leg raising test to be sure one is not missing a herniated lumbar disc in these patients. Test for loose collateral ligaments by fully extending the joint at the knee and attempting to move the tibia, medially and laterally. Flex the knee on the thigh and with the foot rotated first internally and then externally slowly extend the knee. If a “pop” or locking of the joint is heard, the test is positive for a torn meniscus, and a referral to an orthopedic surgeon is necessary. Finally, use the drawer test to check for anterior or posterior cruciate ligament tears or rupture. With the foot dangling over the examination table, attempt to pull the tibia forward and backward on the femur. Examine the knee for fluid by pressing the patella distally and feeling for ballottement (the patella bobs up and down on pressure). It is worthwhile to inject them with 1% to 2% lidocaine to see if significant relief of knee pain is achieved. Leg, Foot, and Toe Pain No doubt the reader does not need instruction in performing inspection and palpation of the lower extremities for cellulitis, hematoma, or other mass lesions. The author also does not think it is necessary to discuss the examination of the bones and joints for inflammation or fracture dislocations. However, the physician should not forget to perform a test for Homan sign to rule out thrombophlebitis and palpate for diminished pulses, not just the dorsalis pedis and tibial pulses, but also the popliteal and femoral pulses. Also, listen for bruits over the femoral arteries to detect significant occlusion of the femoral arteries or terminal aorta (Leriche syndrome). Often, this is the only way to detect unilateral swelling (in thrombophlebitis) or atrophy (in a herniated lumbar disc syndrome). A clinician should keep a tape measure on his or her person or in his or her bag at all times. One should perform a straight leg raising test to rule out radiculopathy 44 and external rotation of the hip joint (Patrick test) to rule out hip pathology. Finally, a good sensory examination does not just help diagnose radiculopathy or polyneuropathy but also rules out tarsal tunnel syndrome or Morton neuroma. Low Back Pain In cases of both acute and chronic low back pain, the physician’s main consideration is to rule out a herniated disc once he or she has ruled out a fracture with plain films. Perform a straight leg raising test, look for Lasègue sign (flexing the leg at both the hip and the knee and gradually straightening the leg), and check for a reduced ankle jerk (on the side of the pain) in L4–L5 and L5–S1 disc herniations. Also check for loss of pain and touch in the big toe (in L4–L5 disc herniations) and the lateral surface of the foot and little toe (in L5–S1 disc herniations). A foot drop or weakness of dorsiflexion of the big toe is a sign of L5 radiculopathy (or an L4–L5 disc herniation). In cases of chronic low back pain, measure the circumference of the calves and thighs because there is usually wasting on the side of the lesion. A clinician will miss a disc herniation at L3–L4 or L2–L3 if he or she stops the examination at this point. With the patient stretched out in the prone position, raise the lower leg and flex it onto the thigh. At 100 degrees or less, the patient resists further movement if an L3–L4 herniation is present. No back examination is complete without examining for sacrospinalis (paraspinous) muscle spasm. With the patient standing in the “at ease” position (relaxed with feet 12 inches apart), one should palpate the paraspinous muscles and compare one side with the other. When one is more tense than the other, a lumbosacral sprain or disc herniation is likely, although many other pathologic conditions of the lumbosacral spine may also be the cause. The physician should not forget to check for tenderness of the sacrosciatic notches. A rectal examination is important to check for sphincter tone and control, which may be lost in a cauda equina syndrome. As mentioned on page 291, many cases of low back pain are due to a short leg syndrome, so measure the leg length.