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By X. Esiel. Lipscomb University.

A random phenom- mental finding inconsistent with a theory suggests enon is one where the outcome cannot be predicted that a theory should be revised or rejected discount aldactone 100 mg line. Experimental outcomes contradicting the an identical effect in the same patient under identi- theoretical predictions would lead to a reassess- cal conditions on separate occasions cheap aldactone 25mg without prescription. That In other words aldactone 25mg cheap, a scientific theory is always tenta- is, one can assign numerical values describing the tive and entirely dependent on experimental likelihood, or probability, of the possible outcomes. Similarly, an True state Decision isolated successful drug treatment outcome does Accept hypothesis Reject hypothesis not prove that the drug is efficacious. This substitution raises a host of conceptual then the smaller the probability that the observed issues beyond the scope of this discussion, except to difference is random, the higher the probability say that this approach has its opponents and is not that rejecting the hypothesis of no efficacy is cor- accepted by all statisticians. Let us illustrate the statistical method with an The key difference between the statistical example: method and the scientific method is that statistic- A pharmaceutical company has developed an ally, no matter how unlikely a result may be, it is antihypertensive drug that is theorized to lower not impossible. Thus, the simple experiment described Seemingly, therefore, whether a drug is efficacious above cannot be used to disprove the hypothesis or not is a dichotomy. Since blood pressure is naturally variable, drug in lowering diastolic blood pressure, then how do we know whether the difference in blood lack of efficacy corresponds to E ˆ 0. Positive effi- pressure before and after treatment is due to the cacy corresponds to E > 0, which contains a con- drug or to the natural randomness of blood pres- tinuum of possibilities depending on the strength of sure? Thus, the hypothesis of no efficacy is variability of diastolic blood pressure; and (b) de- very specific in terms of the size of the effect and termine whether the change in blood pressure is is called a simple hypothesis, while a hypothesis likely to result from natural variability. In drug testing, is measured in all subjects before treatment and the statistical experiment is designed to reject the at some time point when the drug effect should null hypothesisÐthe hypothesis that there is no be measurable if the drug is efficacious. Because rejection of due to the drug and to measure their magnitude, the null hypothesis enables one to make the scien- and to determine adverse effects related to the tific claim that the study was performed to prove, drug. When the result of a test is declared significant, giving a particular drug at a particular dose) causes the only error that could occur is type I error. The probability of a type I error is sufficient, since both A and B could be caused by called the significance level of the test and is de- an effect C. The alternative to the null tion can be established by conducting an experi- hypothesis, on the other hand, is typically a com- ment both when effect A is absent and when effect posite hypothesis. In our example, the power of In studying drug effects in humans, the con- the test at E ˆ 10 is the probability that the statis- trolled clinical trial is the preferred method to es- tical test would be significant if the effect of the drug tablish causality. In this way, any differences in clinical out- pressure by an average of about 10 mmHg, the come should be due only to the investigational drug statistician would want a to be small, say 0:05, (controlled clinical trials will be discussed in greater and 1 À b to be large, say! Causality, in the Example strict sense discussed in the previous section, can no longer be established when outcome of an experi- Suppose 10 hypertensive subjects are treated with a ment is subject to variability. The third row gives the Another issue is that when the measurement of change (D) in diastolic pressure (row 1 minus row efficacy is variable, it is impossible to determine 2). Instead, we calcu- measure the blood pressure of an individual repeat- late the mean of the squares of the deviations about edly before and just after administering an antihy- the mean as a measure of variability. The variance is an average of measurements will be dispersed around different non-negative numbers and it is, therefore, always central values, the post-treatment lower than the a non-negative number. It does, though, give factor equal to the square root of the number of us an idea of the magnitude of the response to measurements used to calculatep the mean. This is because our conclusion izing the trial is the study protocol, the document that the drug is effective was based on the mean of defining the subjects eligible for inclusion in the 10 measurements rather than on a single measure- study, the study procedures and schedules. However, the method has the advantage a variety of characteristics that could influence that it guarantees a maximum balance in the their response to treatment. The method of allocat- ing subjects to treatment must make sure that the resulting treatment groups are balanced with re- Bias and Blinding spect to such factors. Statisticians routinely use data balance by using a systematic, non-random alloca- obtained from a sample to estimate a parameter of tion scheme that will force the balance. Thus, using different and Any non-random method inevitably involves a de- independent samples would result in different cision by the individual making the allocation. Furthermore, tends to overestimate the quantity of interest, and there might be some other variables which affect when it is negative, it tends to underestimate it. For the ognized as such at the time the study is planned, or purpose of our discussion, we will sometimes use are impossible to balance for logistical reasons. We would refer to bias as the effect of any ically protect the investigator against such prob- factor, or combination of factors, resulting in infer- lems. The from subjects being selected to the different treat- requirement that each letter appears in the block ment groups in a way that creates an imbalance in as frequently as any of the other two letters implies one or more prognostic variables. The number of the investigator or other people who can influence such random blocks generated must be such that the enrollment of subjects into the trial, or a faulty the number of letters in the resulting string equals treatment allocation method. Subjects are then assigned sequentially to away from the enrolling investigator and place it in the treatment group corresponding to the next un- the hands of chance. Also, there are many parison of two oral drugs, one of which is a tablet other ways that are not affected by randomization and the other a capsule, each subject receive a in which the investigator can influence the trial tablet and a capsule, one of which contains the outcome. Often the mere expectation that the that would reveal the identity of the treatment, drug will have a therapeutic effect produces the either to the investigator or to the subject, or effect. Once bias is introduced, it is very difficult ments are masked from both the investigator and and sometimes impossible to adjust for it at the the subject, the trial is called double-blind. A trial designed to compare A graduate student in public health is conduct- the effectiveness of two surgical procedures is an ing a research project on the health-related habits example for a trial that cannot be blinded. It is also wise to identify calculated the mean of the combined group, we important prognostic variables and design the trial ignored the fact that the group consisted of two so as to stratify according to them. If one measures the effect example, if one wants to stratify by sex and race, of treatment by calculating the overall mean effect when sex has two categories (male and female) and in the population, although this mean represents an race four (White, Black, Hispanic and other), the estimate of the treatment effect in this population, number of strata is eight. Adding another variable it might be associated with a large measurement with three categories, such as disease severity (mild, error which could make it difficult to distinguish moderate, severe), will bring the number of strata the signal from the background noise. If one can data centers performing the randomization would identify a priori certain subgroups, or strata, in the have to manage 24 randomization tables for each study population that are more homogeneous with investigator, one for each stratum, which is utterly respect to the efficacy variable of interest in the impractical. For a study of moderate size of 100± trial, then by estimating the effect within each of 500 subjects, a large number of strata may mean these strata, and combining these estimates, one that some strata may contain very small number of may increase substantially the power of the analy- subjects, which complicates the statistical analysis sis because the noise masking the effect of interest is and its interpretation.

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This seminar-style course is intended for students How do metaphors in science aldactone 100 mg cheap, technology discount 100 mg aldactone free shipping, and in the basic sciences and in the history of science medicine originate and how do they infuence and medicine buy 25mg aldactone with visa. The course explores such exam- twentieth-century physiology, immunology, genet- ples as William Harvey’s analogy between the heart ics, and neuroscience using both original research and a pump, Charles Darwin’s concepts of the papers and historians’ accounts. Themes under struggle for existence and natural selection, military discussion will include theory and experiment, metaphors in the history of public health, the use of styles of research, ethics of experimental work and metaphors of production in medicine, and the com- scientifc publishing, and the impact of social inter- parison of the brain to a computer. This course will examine the impact of colonial and For doctoral candidates and other advanced stu- post-colonial development on patterns of sickness, dents engaged in original research under faculty health, and health care in Africa. What were the range of responses from will explore the various economic and political inter- religious to therapeutic to disease in China? What ests, as well as the cultural assumptions, that have are Chinese acupuncture, moxibustion, and herbal shaped the development of ideas and practices medicine? Who practiced medicine in China; what associated with international health in “developing” did they practice; and how do we know what we countries. Third, their attention is direct- Professor of International Health ed to the patient as a problem, and they are R. They record their refections and structured cine will be assigned to a preceptor who will patient exercises in an online Learning Portfolio. It is particularly small group discussions and further instruction in clinical skills with their college faculty. To ft the interests They are assessed by their preceptors and with and ability of the student, considerable fex- structured observation of clinical skills in the Simu- ibility in the choice of elective program will be lation Center, as well as for their written work and a possible. After completing the An interdepartmental course in the clinical tech- four week course, students will be able to describe niques of patient evaluation. Students working in the factors that render microorganisms virulent and small groups with an instructor from the clinical correlate these factors with disease processes. A differential diagnosis is of infectious diseases and understand how indi- formed. Whereas the major instruction is from Inter- vidual variability impacts manifestations observed nal Medicine, also included is instruction given by on a population level. Students spend This course is a prerequisite for all clinical clerk- 1-2 afternoons per week, usually working in groups ships and ordinarily will be taken between the third of 5 with their college advisor, to learn and gain and fourth quarters of the second year. Its purpose confdence with best practices in doctor-patient is to prepare new clerks for the daily activities of communication, how to obtain, organize, and com- patient care. Through a combination of lectures, municate to colleagues a patient’s medical history, laboratory exercises and small group discussions, and how to perform a multi-system physical exami- students will learn practical aspects of relating to nation. Students will be prepared for participation patients and their families; to provide care accord- in the Longitudinal Clerkship beginning in January ing to diagnostic probabilities and relative priorities; of Year 1. Resources to assist students in learn- to recognize and manage common acute problems; ing include volunteer outpatients, standardized and to order, perform and interpret the results of patients, trained physical exam teaching associ- basic laboratory tests. Medicine—Second, Third and Fourth The small group format provides students with Years multiple opportunities to learn and practice these This required clinical course is repeated each quar- important skills in a safe environment, enriched by detailed feedback, and supplemental practice ses- ter of the academic year and in the summer. Prerequisite for admission is satisfactory comple- The goal of the Longitudinal Clerkship is to inte- tion of the frst two years of the curriculum at Johns grate the learning of basic science and clinical sci- Hopkins School of Medicine. Available four quarters weeks on the medical service of The Johns Hop- and summer (except July). On most of medical decision making and treatment with the these services students work under the supervision assistance of the housestaff team. Students partici- and tutelage of interns, residents, and the admitting pate in teaching attending rounds, house staff work physician. On the hospitalist service, students work rounds, and both student and housestaff focused directly with the attending hospitalist physicians. Medical students These courses generally involve clinical work in a may join the team, take night call with house staff, medical subspecialty. The student participates in obtain histories and perform physical examinations, all clinical activities of the division, including con- gather and integrate laboratory data and pertinent sultations and outpatient clinics; there is a varying information from literature, participate in decision amount of initial evaluation and follow-up of inpa- making, write admission and progress notes, etc. Students are encouraged to follow a few patients The Medicine Core Clerkship is often a prerequisite. Advanced Clinical Clerkships tion on daily morning rounds which are conducted from 8:30-10:30 a. The nursing staff will provide These courses involve direct management of inpa- instruction in critical care skills such as endotrache- tients to a degree expected of interns (hence the al suctioning, management of multiple intravenous common appellation “subinternship’’). Lecture Courses, Tutorials, and Seminars catheters, proper administration of medications These courses have widely varying prerequisites such as antibiotics and pressors, etc. Individual Preceptorship (such as a lumbar puncture) performed with, and Each division has faculty and specialized clinical under the direction of, the house offcers. Available September through June; 3 in clinics and on the wards under the guidance of students. Opportunities exist for clinical inves- tigations of various types, including the study of Prerequisite: Medicine Core Clerkship. There are also opportunities in resident and an attending physician on one of the most divisions for laboratory investigation. The responsibilities are similar of ing on the background and interests of the student, those of an intern on the service, but with fewer he or she may participate in a current investigation patients and with even more direct resident super- or undertake independent investigation using the vision. The student will admit patients in rotation, laboratory and clinical facilities of the department. The student func- tory research in some of the divisions, the student tions as part of a ward team which takes long call may fnd it advantageous to become identifed with every fourth day and short call in-between. Typi- one of these research programs early in his or her cally, the subintern admits one to two patients on medical school career. Advanced Clinical Clerkship in Medi- imaging of coronary atherosclerosis; subclinical cine.

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Gonzalez-Suarez1 treated with low frequency electric stimulation and assisted bal- 1University of Santo Tomas Hospital generic aldactone 25 mg, Physical Medicine and Reha- loon dilatation for 3 weeks buy aldactone 100mg overnight delivery. All of them were assessed by vide- bilitation discount 100 mg aldactone otc, Manila, Philippines ofuoroscopic swallowing study and conscious of diffculty swal- lowing pre and post treatment. Results: Pharyngeal delay time Introduction/Background: In the literature, there is no clear con- and cricopharyngeal opening of both groups were improved after sensus regarding terminology and etiology for pain in the anterior treatment (p<0. However, based on the invalid swallowing as well as the aspiration rate were decreased present literature, it may not be possible to decide what is the most (p<0. Among them there was a sig- We have selected the case of an athlete who underwent a new tech- nifcant decrease (p<0. Conclusion: of the patient and physicians (orthopedic surgeon, anesthesiolo- Balloon dilatation combined with low frequency electric stimu- gist, and sonologist) present during the procedure was conducted lation therapy will have synergistic effect and they can improve to validate and supplement the information obtained from the chart patients’ swallowing function after radiation induced cranial review. Pain scores were graded retrospectively by recall of pre- nerve damage, thus improve the survival quality of patients. Results: This study assisted balloon dilatation without anesthesia had better effect described an ultrasound-guided, percutaneous technique that uti- than that of surface anesthesia. Stewart2 Mackay Memorial Hospital, Physical Medicine and Rehabilita- 1The Hong Kong Polytechnic University, Rehabilitation Sciences, tion, Taipei, Taiwan Kowloon, Hong Kong- China, 2Hong Kong Rugby Football Union, Introduction/Background: Sport for people with disabilities is an Hong Kong Rugby Football Union, Hong Kong, Hong Kong- China important measure for both rehabilitation and participation. However, their sport in- Introduction/Background: Rugby is a demanding game with many juries and musculoskeletal injuries are not understood. Material physical collisions and tackles potentially leading to musculoskel- and Methods: We set up a special clinic for disabled sports athletes etal injuries. Because of the nature of the sports, rugby not only in a tertiary hospital in Taipei Taiwan. This clinic was run on one requires a range of individual skills but also well-developed ftness. This clinic is organ- The role of physical ftness in the risk of rugby-related injury is ized by a rehabilitation specialist with international classifcation not well known. The purpose of this prospective cohort study was experience, one resident, one nurse, and equipped with radiogra- to determine the infuence of physical ftness as risk factors for in- phy, musculoskeletal ultrasonography and other imaging modali- juries, taking exposure time into account. Results: Thirteen national and international level Rugby players from 3 Hong Kong universities (n=84; 75M:9F; athletes were evaluated. Players were asked to complete a questionnaire relating to letes, 3 specialize in para-badminton, 1 in wheelchair dance, 1 in demographic characteristics, playing experience and history of pre- archery and 1 in athletics. The players then underwent pre-season assessment spinal cord lesion, 1 with lower limb trauma and 1 with achondro- of physical ftness including power, strength, speed, agility, endur- plasia. Most patients reported more than 2 active musculoskeletal ance, stability and fexibility. Noteworthy was that many of them reported multiple during the season were reported online. At the end of the season, in- experiences of offce visits in clinics and treatment failures. Shoul- dependent variables were selected and analysed using Cox propor- der pain and elbow pain were top two complaints. Results: complaints were hand numbness, hip pain, upper back pain and low The injury incidence was 47. A majority of injuries (70%) occurred in the frst visiting the sport clinic for disabled athletes will help further im- 35 hours of exposure. The aim of this trail is sys- history and female players are at a greater risk for rugby-related tematically evaluate the protective effects of Baduanjin exercise injuries in university players. The transition from off-season train- on ischemic stroke risk in the community elder population with ing to increase in training volume may need careful consideration high risk factors. Acknowledgments: The authors thank the Hong participants were randomly allocated into the Baduanjin exercise Kong Rugby Football Union and players from the 3 university and control group (usual physical activity group) in a 1:1 ratio. Participants in the Baduanjin group accepted a 12-week Badu- anjin exercise training with a frequency of 5 days per week and 60 minutes one day, while those in the control group maintained 807 their original physical activity. It affects the sport clusion: Regular Baduanjin exercise may be beneft to improv- performance, absence from training sesions or games and reduce ing cerebral hemodynamic parameters, blood pressure, sleep and quality of life. Risk factor of sport injury of lower extremity can mood in community elder adults with risk factors of ischemic be classifed as intrinsic risk, exposure to extrinsic risk and inciting stroke. Acknowledgements: This study is supported lete, exposure to extrinsic risk factors make the susceptible athlete by the Program for Fujian Provincial Health and Family Planning and inciting event factors will trigger injured athlete. At very early phase, the identifcation of intrinsic risk factors is very important. Type of sport were classifed from most high contact/impact to less high contact/impact. Landing task 2 2 2 2 was correlated positively to non weight bearing quadriceps angle Ogurkowski , I. Introduction/Background: Raising a child with a disability re- duces fulfllment parents, which contributes to a reduction in the quality of life of caregivers. Results: The studies that women Rehabilitation Medicine, Fuzhou, China, 2Fujian University of are weaker than men emotionally. The results showed that among Traditional Chinese Medicine, Department of Physical Education, the families surveyed more frequent in girls with disabilities. Frequently deterioration in the relationship between parents dete- 811 riorating since the emergence of a disabled child. Community-based programs can be an appropri- ate approach to address developmental needs of youth refugees. Participants engaged in ten one-hour group training, incorporating Bandura’s Self-Effcacy theory and the logic model rology- Department of Education and Research, Taipei, Taiwan, 2 process. The Program included fve modules: attitude, responsibil- National Taipei University of Nursing and Health, Department of 3 ity, communication, problem solving and college or job prepara- Health Care Management, Taipei, Taiwan, National Yang-Ming tions.

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Patches and gums probably deliver nicotine too slowly buy 100 mg aldactone with mastercard, often to a sub-optimal level cheap aldactone 100mg online, and nicotine sprays are often unpleasant generic aldactone 25mg overnight delivery. Nicotine delivery systems are often used not for smoking cessation but to ward of withdrawal symptoms during periods of enforced abstinence, such as air travel. Jain (2003) describes it as 2490 being no better than sham (not penetrating the skin) acupuncture. According to Coleman,(2004b) intensive behavioural support from a trained counsellor is the most effective non-drug intervention, whilst a combination of such counselling and drug treatment is best of all. Twenty percent of those given nicotine replacement therapy with a specialist counsellor’s support will remain non-smokers for one year. The actions of nicotine replacement cannot be explained on the basis of a placebo effect; the effect is dose-related, e. There is some evidence that it might be useful in helping people quit smoking if combined with nicotine patches. An abridged version of the motivational approach to interviewing recommended by the Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives (2000) is shown in the box. Youngsters may see no urgency in quitting and services may be viewed as being more geared for their elders; also, cannabis smoking using tobacco as a vehicle is a major obstacle to successful intervention. Prognosis: Two-thirds of smokers express a desire to stop and one-third try to quit the habit each year, only 2% succeeding. At least 80% have returned to smoking within 12 months (Jarvis [2004] puts the number of quits sustained to 12 months at < 3%). About half of all regular smokers die prematurely; stopping to smoke in middle age avoids the bulk of the risk. A Cochrane review found that nicotine substitution treatment increased abstinence up to twofold, but, even with psychotherapy and behavioural therapy, abstinence rates remain very low at 5- 15%. Brief interventions in cardiac inpatients have been shown to help motivated lightly-dependent smokers. It is considered a ‘white collar’ form of tobacco because it does not induce spitting. Children should be the prime targets for campaigners; older people respond less to health publicity. Counselling of mothers may reduce passive smoking by children in the home; however, reductions in passive smoking in England since the 1980s is attributable to less smoking parents and not to parents who 2494 still smoke not smoking near their children. Advertising , which has its political protectors, should be banned, as it tends to target women and young people, emphasising the ‘stylishness’ of smoking. Counter-advertising should be financially supported and tobacco company sponsorship of sports should be made illegal. Involving teenagers in an anti-tobacco company poster campaign may be effective in reducing the number of youngsters who smoke. England has been much slower than Ireland in this regard, and one Bill suggested that formula one racing should be exempt for four years! The Irish Public Health (Tobacco) Amendment Act 2004 is monitored by an Office of Tobacco Control. Health Boards may take proceedings against persons breaching the provisions of the Act. As of July 1, 2009, anyone who sells tobacco must be registered with the Office of Tobacco Control. There is evidence that legislation for smoke-free workplaces does protect non- smoking bar workers. In February 2006, the British Parliament voted for a total ban on smoking in public places. Many authorities have banned smoking in the workplace, public areas, prisons, and restaurants, except in designated areas. In July 2008, the German Constitutional Court upheld the case of small bars that held that because large bars had enough room to divide off areas for smokers the smaller establishments did not have this option, so throwing the German ban into disarray. Smoke-free workplaces protect against passive smoking and encourage smokers to quit or reduce consumption. Stubbs ea (2004) found that smokers and nurses in an English psychiatric hospital were more permissive toward smoking on wards than were non-smokers and psychiatrists. A short- 756 Requirements of a national tobacco control policy are shown in the box. Components of a national tobacco control policy2497 Increase price of and taxes on tobacco at rate above inflation Ban all advertising and sponsorship by tobacco industry Restrict smoking to designated areas (public places and work sites) Reduce passive tobacco exposure, including in utero Target people at-risk for starting to smoke “Proof of age” cards required when purchasing tobacco; retailers to be banned from selling tobacco (or worse, e. However, despite calls for weaker cigarettes, smokers may compensate for low nicotine yield by puffing more often and deeper, and by smoking more cigarettes. From January 2001 all cigarette packets in Canada carried health warnings that occupy 50% of the front of the pack, although attempts to ban sponsorship of public events by tobacco companies was watered down by the Quebec Court of Appeal in 2005. Changing to cigarettes with a lower tar yield may not reduce the chances of myocardial infarction if one continues to smoke. Young Irish children could until recently readily buy cigarettes from retail outlets and retailers are obliged to ensure that prospective customers are at least 18 years of age. Iran and Uruguay have total bans on smoking in public places, Syria following them in 2009. Some American insurance firms owned by tobacco companies have charged smokers almost double for term life insurance! Tobacco companies pressurised companies producing nicotine replacement products to tone down anti-smoking messages. Tobacco dependence is a chronic disorder requiring repeated attempts aimed at eventual abstinence. Practical counselling and social support are important ingredients in management, as are sustained-release bupropion hydrochloride (e. The present author agrees with Howell (2002) that smoking cessation products should be free to all who wish to stop smoking, not just to those who qualify for medical cards.

Aldactone
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