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By X. Irmak. Butler University. 2018.

Participant observation can be carried out within any community cheap 20mg erectafil visa, culture or context which is different to the usual community and/or culture of the researcher buy 20mg erectafil mastercard. It may be carried out within a remote African tribe or in hospitals generic erectafil 20mg with mastercard, factories erectafil 20 mg visa, schools buy 20 mg erectafil with mastercard, prisons and so on, within your own country. The researcher immerses herself into the community – the action is deliberate and intended to add to knowledge. The researcher participates in the community while obser- ving others within that community, and as such she must 101 102 / PRACTICAL RESEARCH METHODS be a researcher 24 hours a day. In practice most research- ers find that they play more of a role as observer, than they do as a participant. GAINING ACCESS Participant observation, as a research method, cannot work unless you’re able to gain access to the community that you wish to study. Before you spend a lot of time plan- ning your project you need to find out whether you can ob- tain this access. The level of negotiation required will depend upon the community, culture or context. If it is a culture with which you already have a certain amount of familiarity, and vice versa, you should find it easier to gain access. However, if it is a secret or suspicious community, youmayfinditmuchhardertogainaccess. If you do expect to encounter difficulties, one way to over- come this problem is to befriend a member of that com- munity who could act as a gatekeeper and help you to get to know other people. Obviously, it is important to spend time building up the required level of trust before you can expect someone to introduce you into their community. If it is not possible to befriend a member of the community, you may have to approach the person or committee in charge, firstly by letter and then in person. First impressions are important and you need to make sure that you dress and act appropriately within the community. Some people will be suspicious of the motives of a researcher, especially if they’re not familiar with the research process. In the early stages it is better to answer any questions or suspicions directly and honestly rather HOW TO CARRY OUT PARTICIPANT OBSERVATION/ 103 than try to avoid them or shrug them off. ETHICS Because of the nature of participant observation, there tends to be more issues involving ethics and morals to consider. As you intend to become part of a specific group, will you be expected to undertake anything illegal? This could happen with research into drug use or crime syndicates where people may not trust you until you be- come one of them and join in their activities. Would you be prepared to do this and put up with any consequences which could arise as a result of your activities? If the group is suspicious, do you intend to be completely honest about who you are and what you’re doing? How would you deal with any problems which may arise as a conse- quence of your deception? What if your participation within a group causes pro- blems, anxiety or argument amongst other members? Would you be prepared to withdraw and ruin all your hard work for the sake of your informants? Also, there are many personal considerations and dilemmas which you need to think about before undertaking participant obser- vation, as illustrated below: 104 / PRACTICAL RESEARCH METHODS PERSONAL CONSIDERATIONS WHEN ENTERING THE FIELD Some people will not accept you. Are you prepared to spend many months studying others and not indulging in talk about yourself? Some researchers overcome this problem by making sure that they have someone outside the community who they can talk to if they need to. If you’re going to come across people with very different social and political beliefs, can you remain neutral and keep your opinions to yourself? Some researchers may try arguing their point in the hope that they will get more information and it will deepen their understand- ing. Are you prepared for the emergence of as yet uncon- scious emotional factors?

The Raman effect arises from the inelastic present in all spirochetes except 20 mg erectafil sale. That is cheap erectafil 20mg without prescription, the insect genes give new announced the determination of the sequence of the entire characteristics to the plant cheap erectafil 20 mg without prescription. In doing this buy erectafil 20 mg otc, the creation of trans- performed with firefly genes and tobacco plants buy cheap erectafil 20mg. Firefly genes genic humans could become more of a reality, which could were spliced into tobacco plants, which created new tobacco lead to serious ramifications. For a variety of genetic mixing, called recombinant , is the crux reasons, not all scientifically based, some people argue that of transgenics. The organisms that are created from mixing transgenic food is a consumer safety issue because not all of genes from different sources are transgenic. The glow-in-the- the effects of transgenic foods have been fully explored. Cell cycle (eukaryotic), genetic regulation of; Cell One of the major obstacles in the creation of transgenic cycle (prokaryotic), genetic regulation of; Chromosomes, organisms is the problem of physically transferring DNA from eukaryotic; Chromosomes, prokaryotic; DNA (Deoxyribo- one organism or cell into another. It was observed early on that nucleic acid); DNA hybridization; Molecular biology and bacteria resistant to transferred the resistance char- molecular genetics acteristic to other nearby bacterial cells that were not previ- ously resistant. It was eventually discovered that the resistant bacterial cells were actually exchanging plasmid DNA carry- ing resistance genes. In this way, susceptible bacterial cells Translation is the process in which genetic information, car- were transformed into resistant cells. Although there are some important differences characteristics to new cells when they reproduce because between translation in and translation in eukaryotic copies of the foreign transgenes are replicated during cell divi- cells the overall process is similar. Transformation can be either naturally occurring or the of translational control mechanisms that exist in eukaryotic result of transgenics. A molecule known as the ribosome is the site of the Certain chemicals make transgenic cells more willing to take-. The ribosome is protein bound to a second up genetically engineered plasmids. Several process where cells are induced by an electric current to take may attach to a single mRNA molecule, so that up pieces of foreign DNA. Transgenes are also introduced via many polypeptide chains are synthesized from the same engineered. The ribosome binds to a very specific region of the that infect bacterial cells are used to inject the foreign pieces mRNA called the promoter region. DNA can also be transferred using microinjection, of the sequence that will be translated into protein. A new technique to introduce transgenes into cells uses the amino acid sequence of a protein by adaptor molecules liposomes. Liposomes are microscopic spheres filled with composed of a third type of RNA known as transfer RNAs DNA that fuse to cells. There are many different species of tRNAs, with they deliver the transgenes to the new cell. In pro- composed of lipids very similar to the lipids that make up cell tein synthesis, the nucleotide sequence on the mRNA does not membranes, which gives them the ability to fuse with cells. Complementary tRNAs match up on the now use transgenics to accomplish the same results as selec- strand of mRNA every three bases and add an amino acid onto tive breeding. The three base sequence on the By recombining genes, bacteria that metabolize petro- mRNA are known as “codons,” while the complementary leum products are created to clean-up the environment, antibi- sequence on the tRNA are the “anti-codons. When the small subunit encounters the genic plants, food crops have enhanced productivity. There are Transgenic corn, wheat, and soy with herbicide resistance, for two sites in the large subunit, an “A” site, and a “P” site. The example, are able to grow in areas treated with herbicide that start signal for translation is the codon ATG that codes for kills weeds. A tRNA charged with methionine binds to the colorful tomatoes in greater abundance. After the first tRNA bearing the amino used to create immunizations and other vaccines. The Human Genome Project is a large sponding to the codon of the mRNA enters the “A” site.

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GUIDED READING The book we can still recommend for further reading is J cheap erectafil 20mg with mastercard. This pocket-sized do-it-yourself guide is not only valuable but also entertaining order erectafil 20mg online. It contains many useful illustrations and good advice about the preparation of visual aids buy erectafil 20 mg fast delivery. Race’s Conference Presentations and Workshops erectafil 20mg lowest price, University of Northumbria discount 20 mg erectafil fast delivery, 1986 (available through Amazon. Those interested in the organisation and evaluation of medical meetings are referred to a series entitled Improving Medical Meetings, written by D. Richmond and his colleagues, published in the British MedicalJournal (1983), 287, pp. For help with the design of charts and graphs check the references at the end of Chapter 9. This is a comprehensive reference work that has been written by a university lecturer. Later in the chapter we will address the issue of practical and laboratory based teaching. While it is increasingly likely that your institution will provide some form of ‘teach the teachers’ course it is relatively unlikely that it will specifically address clinical teaching. It is a fact that clinical teaching is the most neglected area of all teaching despite being the one where more deficiencies have been found than in any other. The conclusion of one extensive study was that ‘many (clinical) teaching sessions, particularly ward rounds, were hap- hazard, mediocre and lacking in intellectual excitement’. In one study of medical schools in North America, it was stated that there were few students who could report having been monitored in the interview and physical examination of more than one or two patients and that a surprising number had been awarded their degree without ever having been properly supervised in the complete data-collecting process of even one patient! It is our experience, with notable exceptions, that a similar situation can be found in many medical schools in other parts of the world. THE ATTRIBUTES OF AN EFFECTIVE CLINICAL TEACHER These have been identified on the basis of the opinions of experts, the perceptions of students and from the observations of actual clinical teaching. Considering the limited nature of the research there is a remarkable consistency in the results. It might be helpful to start by checking yourself against these attributes. Do you encourage active participation by the students and avoid having them stand around in an observa- tional capacity? Do you focus on the integration of clinical medicine with the basic and clinical sciences or do you spend 72 most of the time on didactic teaching of factual material? Do you closely supervise the students as they inter- view and examine patients at the bedside and provide effective feedback on their performance or do you rely on their verbal case presentations in the teaching room? Do you provide adequate opportunities for your students to practice their skills? Do you provide a good role model, particularly in the area of interpersonal relationships with your patients? Is your teaching generally patient-orientated or does it tend to be disease-orientated? Should your honest answer to some of these questions be ‘no’ then you are probably a typical clinical teacher as many studies have shown that all of these characteristics are rarely present. Just becoming aware of such attributes should encourage you to be more critical of your approach. The remainder of this chapter will deal more specifically with the planning and the techniques which can be introduced to enhance the effectiveness of your clinical teaching. IMPROVING CLINICAL TEACHING If you are a clinical teacher with no responsibilities for the planning of the curriculum, there may be few educational initiatives open to you other than to improve your hospital- based or community-based teaching. What you should aim to do is to try and acquire as many as possible of the attributes described in the previous section. There are no hard and fast rules as to how you can achieve this aim but the following points may be helpful. Plan the teaching: it is possible that you will have received highly specific instructions from the medical school particularly if you are teaching in a structured programme (see later). If not, it is worthwhile contacting the department head or the course co-ordinator to see if there are defined objectives for the part of the curriculum in which your teaching is placed. In doing so you must taken into account your time, the duration of the students’ attachment, the number of students and the seniority of the students. You must be realistic about what you can achieve and not attempt to cram too much into your sessions.

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He attributes great importance to the appreciate the greater safety of this procedure and imagination and its training by education; the pos- took a leading part in England in advocating session of this great faculty distinguishes man lithotrity in place of lithotomy discount erectafil 20mg with mastercard. All philosophies rest on at Betchworth purchase 20mg erectafil free shipping, Surrey buy discount erectafil 20mg on-line, which he purchased in certain assumptions and one such for Brodie was 1837 generic erectafil 20 mg line. Furthermore generic erectafil 20mg visa, he gave more attention to “the existence of one’s own mind is the only thing medical education and reform, both of which had of which one has any positive and actual knowl- always interested him. The object of this institution was “to unto himself, to find out his own deficiencies and insure the introduction into the profession of a endeavour to correct them, to doubt his own observations until they are carefully verified. By this though not perhaps handsome; his frame was instrument all power of election was vested in the slight and small but he had consuming energy. In Fellows; retention of office for life by examiners private life he was known for his playful humor and members of Council was abolished; the and fund of anecdote. As a lecturer “none who offices of president and vice-president were heard him can forget the graphic yet artless restricted to members of the Court of Examiners. A reg- leading surgeon in England, added to which he ister was to be established of persons holding a had more intimate contact with leaders of science diploma or license from a licensing body after and literature. Brodie was chosen to be the first a rare combination of surgeon, scientist and president of this Council. He had a Hunterian attitude towards 45 Who’s Who in Orthopedics surgery in that he regarded scientific research to be the handmaid of practice. He made a lasting contribution towards medical education whereby preliminary instruction in the arts and professional training were greatly improved. By his advocacy of reform of the Royal College of Surgeons, he helped to raise its status as a gov- erning body and enhanced the quality of those whom it approved to practice surgery. For the last few years of his life he suffered from double cataract, for the relief of which Sir William Bowman operated. In July 1862, he began to complain of pain in his right shoulder, caused by malignant disease; he died on October 21. Twenty-eight years before, he had fallen from a pony and dislocated this joint. British Journal of Surgery (1918) Sir Benjamin Gurdon Buck was a New Yorker, born on Fulton Collins Brodie. After graduating from the Nelson Classical Brodie’s Tumour, and Brodie’s Abscess. Brodie, Sir Benjamin Collins (1865) The Works of Europe where his marriage to Henrietta E. Wolff Sir Benjamin Collins Brodie arranged by Charles was celebrated in Geneva. London, Longman, York, he was appointed visiting surgeon to the Green, Longman, Roberts and Green New York Hospital. Holmes, Timothy (1898) Sir Benjamin Collins Eight years later, he described osteotomy in a Brodie. Fisher Unwin classic paper: “The knee-joint ankylosed at a right angle—restored nearly to a straight position after the excision of a wedge-shaped portion of bone, consisting of the patella, condyles, and articular surface of the tibia. Gurdon Buck, working at the New York Hos- pital, devised a simple traction system using either the elastic material or adhesive strips attached to a pulley apparatus. Because of its simple construction and easy application, the method won immediate worldwide acceptance. This was due in part to the fact that shortly after its presentation at the New York Academy of Medicine on March 20 and April 17, 1861 and its 46 Who’s Who in Orthopedics publication in the Academy’s Transactions, it was used extensively in the American Civil War. In military affairs, wars always are an invitation to observers from foreign services. The simplicity and effectiveness of Buck’s traction very quickly entered into European and subsequently world- wide use. Today, over 100 years after its presen- tation, Buck’s traction, whether attached to adhesive strips, moleskin, foam rubber strips or Steinmann nails, is still the most frequently employed apparatus to be found in civilian or armed service hospitals. Buck’s title refers to fractures of the femur because he used it first in such cases. It was shortly used in fractures of other long bones, especially tibia and humerus. It must be noted that the conception of pulley trac- tion was first presented by Guy de Chauliac of the University of Montpellier in the fourteenth century.

Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation Recently discount 20 mg erectafil free shipping, the excitatory amino acid neurotransmitters (ARREST) generic 20mg erectafil mastercard. The N-methyl- 80 17 Cardiac pacing and implantable cardioverter defibrillators Michael Colquhoun order 20mg erectafil with amex, A John Camm Cardiac pacing An artificial cardiac pacemaker is an electronic device that is designed to deliver a small electrical charge to the myocardium and thereby produce depolarisation and contraction of cardiac muscle buy 20mg erectafil overnight delivery. The charge is usually applied directly to the endocardium through transvenous electrodes; sometimes epicardial or oesophageal electrodes are used discount erectafil 20 mg on-line. They are all specialised invasive techniques and require considerable expertise and specialised equipment. Non-invasive external pacing utilises cutaneous electrodes attached to the skin surface and provides a quick method of achieving pacing in an emergency situation. It is relatively easy to perform and can, therefore, be instigated by a wide range of personnel and used in environments in which invasive methods cannot be employed. Increasingly, the defibrillators used in the ambulance service and the coronary care unit incorporate the facility to use this type of pacing. Pacemakers may be inserted as an interim measure to treat a temporary or self-limiting cardiac rhythm disturbance or implanted permanently when long-term treatment is required. A temporary pacing system is often inserted as a holding measure until definitive treatment is possible. Electrocardiogram appearances Dual chamber The discharge from the pulse generator is usually a square wave pacemaker in situ that rises almost instantaneously to a preset output voltage, decays over the course of about 0. The conventional electrocardiogram (ECG) monitor or recorder cannot follow these rapid fluctuations and when the pacing stimulus is recorded it is usually represented as a single spike on the display or printout; some digital monitors may fail to record the spike at all. Although this spike may lack detail, recognition of a stimulus artefact is usually adequate for analysis of the cardiac rhythm. With fixed rate, or asynchronous, pacing the generator produces stimuli at regular intervals, regardless of the underlying cardiac rhythm. Unfortunately, competition between paced beats and the Ventricular pacing spikes seen before the QRS complex intrinsic cardiac rhythm may lead to irregular palpitation, and stimulation during ventricular repolarisation can lead to serious ventricular arrhythmias, including ventricular fibrillation (VF). With demand, or synchronous, pacing the generator senses spontaneous QRS complexes that inhibit its output. If the intrinsic cardiac rate is higher than the selected pacing rate then the generator will be inhibited completely. If a spontaneous QRS complex is not followed by another within a predetermined escape interval an impulse is generated. This mode of pacing minimises competition between natural and paced beats and reduces the risk of inducing arrhythmias. Some pacemakers have an escape interval after a sensed event (the hysteresis interval) that is substantially longer than Atrial and ventricular pacing artefacts seen with dual chamber pacing 81 ABC of Resuscitation the automatic interval (the interval between two consecutive Principal indications for pacing stimuli during continuous pacing). This may permit more spontaneous cardiac activity before the pacemaker fires. Third-degree (complete) AV block: ● When pauses of three seconds or more or any escape rate temporary pacing systems a control on the pulse generator of more than 40 beats/min or symptoms due to the block allows selection of the pacing mode; with permanent systems occur the unit may be converted from demand to fixed rate mode by ● Arrhythmias or other medical conditions requiring drugs placing a magnet over the generator. Sinus node dysfunction with: arise because of failure of the sinoatrial node to generate an ● Symptomatic bradycardia or pauses that produce symptoms impulse or because failure of impulse conduction occurs in ● Chronotropic incompetence 3. Chronic bifascicular and trifascicular block associated with: the atrioventricular (AV) node or His–Purkinje system. Hypersensitive carotid sinus syndrome and neurally mediated Pacing is also used for tachycardia; a paced beat or sequence syncope of beats is used to interrupt the tachycardia and provides an 5. Atrial ● Symptomatic recurrent supraventricular tachycardia flutter and certain forms of junctional tachycardia may be reproducibly terminated by pacing, after drugs and catheter ablation fail to control the arrhythmia or produce terminated by atrial pacing. Ventricular burst pacing is intolerable side effects sometimes used to treat ventricular tachycardia (VT), but this ● Sustained pause-dependent VT when pacing has been requires an implanted defibrillator to be used as a backup. Pacing during resuscitation attempts In the context of resuscitation, pacing is most commonly used to treat bradycardia preceeding cardiac arrest or complications in the post-resuscitation period; complete (third-degree) AV block is the most important bradycardia in this situation. Pacing may also be used as a preventive strategy when the occurrence of serious bradycardia or asystole can be anticipated. This is considered further in the section on the Pacing may be used in the following management of bradycardia (Chapter 5).

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