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For example purchase propranolol with a visa heart attack high come over to the darkside feat jimi bench, in mar- ket research this could be a discussion centred on new packaging for a breakfast cereal buy 80 mg propranolol amex blood pressure chart based on age, or in social research this could be to discuss adults’ experiences of school proven propranolol 40 mg blood pressure juicing. She makes sure that no one person dominates the discussion whilst trying to ensure that each of the participants makes a contribution 80 mg propranolol sale blood pressure instruments. THE FOCUS GROUP METHOD: ADVANTAGES AND DISADVANTAGES ADVANTAGES DISADVANTAGES Can receive a wide range of Some people may be responses during one meeting. Helps people to remember issues Other people may contaminate they might otherwise have an individual’s views. Helps participants to overcome Some researchers may find it inhibitions, especially if they difficult or intimidating to know other people in the group. The group effect is a useful Venues and equipment can be resource in data analysis. Participant interaction is useful Difficult to extract individual to analyse. QUESTIONNAIRES There are three basic types of questionnaire – closed- ended, open-ended or a combination of both. Closed-ended questionnaires Closed-ended questionnaires are probably the type with which you are most familiar. Most people have experience of lengthy consumer surveys which ask about your shop- ping habits and promise entry into a prize draw. This type of questionnaire is used to generate statistics in quantita- tive research. As these questionnaires follow a set format, and as most can be scanned straight into a computer for ease of analysis, greater numbers can be produced. Open-ended questionnaires Open-ended questionnaires are used in qualitative re- search, although some researchers will quantify the an- swers during the analysis stage. The questionnaire does not contain boxes to tick, but instead leaves a blank sec- tion for the respondent to write in an answer. Whereas closed-ended questionnaires might be used to find out how many people use a service, open-ended question- naires might be used to find out what people think about a service. As there are no standard answers to these ques- tions, data analysis is more complex. Also, as it is opi- nions which are sought rather than numbers, fewer questionnaires need to be distributed. Combination of both Many researchers tend to use a combination of both open and closed questions. That way, it is possible to find out how many people use a service and what they think about that service on the same form. Many questionnaires begin with a series of closed questions, with boxes to tick or scales to rank, and then finish with a section of open- questions for more detailed response. This suggests that soon there might be a new category of ques- tionnaire – the interactive questionnaire, which allows re- spondents to work with the researcher in both the development and completion of the questionnaire. PARTICIPANT OBSERVATION There are two main ways in which researchers observe – direct observation and participant observation. Direct ob- servation tends to be used in areas such as health and psy- chology. It involves the observation of a ‘subject’ in a certain situation and often uses technology such as video cameras or one-way mirrors. For example, the interaction of mother, father and child in a specially prepared play room may be watched by psychologists through a one- way mirror in an attempt to understand more about fa- mily relationships. In participant observation, however, the researcher becomes much more involved in the lives of the people being observed. Participant observation can be viewed as both a method and a methodology (see Chapter 10).

Some newborns may not need treatment with anticonvulsant medication purchase propranolol 80 mg visa heart attack at 25, for instance generic 40mg propranolol mastercard prehypertension 126, those with seizures due to reversible and appropriately treated metabolic derange- ments purchase genuine propranolol line arteria pharyngea ascendens, or those with rare order propranolol 40mg otc heart attack 02 50 heart attack enrique iglesias s and love, short-lived events. However, in considering a decision not to treat, it is important to recognize that a significant proportion of newborns with electroclinical seizures have additional clinically silent electrographic seizures. Table 2 Initial Management of Acute Metabolic Disorders Hypoglycemia 10–15% dextrose, 2–3 mL=kg IV Hypocalcemia 5% calcium gluconate, 2 mL=kg IV Hypomagnesemia 2–3% magnesium sulfate, 2 mg=kg IV 64 Bergin This is particularly likely in premature infants and those with severe encephalopathy. Prolonged EEG monitoring is helpful in identifying the presence of unsuspected elec- trographic seizures. The importance of these subclinical events in the genesis of sei- zure-related neuronal injury is unknown at present. In the setting of severe neonatal encephalopathy, these events may be prolonged and refractory to treatment, and efforts to eliminate them may be limited by systemic vulnerability to the circulatory effects of anticonvulsant medications. A number of factors alter the pharmacokinetics of the anticonvulsant drugs in neonates. Physiological immaturity delays drug elimination, and asphyxial injury to the liver and kidney may further delay metabolism. Maturation of the various path- ways involved in drug metabolism occurs at variable rates over the first weeks of life, and recovery from perinatal injury improves hepatic and renal function. Overall, there is a dramatic increase in the ability to eliminate the commonly used anticonvul- sant drugs, so that changes in dosing are required to maintain therapeutic drug levels over the first weeks of life. When anticonvulsant treatment is indicated, phenobarbital is the drug most commonly used as first-line therapy. Other first-line options include benzodiazepines (diazepam, lorazepam), and phenytoin or, if available, its prodrug fosphenytoin. There have been few studies comparing the efficacy of these drugs in the treatment of neonatal seizures. Typical initial doses of the first-line drugs are provided in Table 3, and additional discussion of the individual drugs is given below. Phenobarbital: Phenobarbital affects GABAA receptors to enhance GABA- related inhibition. It may also inhibit excitatory amino acid transmission and block voltage-activated calcium currents. Phenobarbital is subject to protein binding, and it is the unbound (free), unionized fraction that is active. Alterations in acid–base balance in the newborn may impact efficacy of the drug for this reason. Its half-life is long, from 100 to 300 hr, or longer in prema- ture infants, but declines to 100 hr or less over the first weeks of life. An initial intra- venous (IV) loading dose of 20 mg=kg may be followed by increments of 5–10 g=kg IV to a total of 40 g=kg, with higher doses associated with improved efficacy. Careful monitoring of cardiac and respiratory function may be required in vulnerable infants. Table 3 Anticonvulsant Drug Doses for Initial Management of Neonatal Seizures Drug Initial dose Maintenance Phenobarbital 20 mg=kg IV. Consider further Check drug levels—may not need 5–10 mg=kg increments to a further doses for many days.

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From my experience of working at several different hospitals these matters are dealt with very differently from place to place discount 40mg propranolol overnight delivery blood pressure vs pulse pressure. Some hospitals are very keen on re-educating staff and improving policy buy 80mg propranolol otc arteriosclerosis,but sadly some other trusts adopt a‘sweep it under the carpet’approach buy generic propranolol 40 mg line blood pressure lisinopril. This dangerous and downright negligent attitude usually spreads from the head of department and senior nursing staff down propranolol 80mg sale heart attack at 30. Fortunately, in a department like that you will always find someone else, either medical or nursing, who is of the same mindset as you and they can be a valuable ally. Locum Posts Medical temping is commonplace in fields other than doctoring. In fact, it is difficult to find a single occupational therapist, physiotherapist or nurse who does not work as a locum or bank staff member (a locum within a single National Health Service trust only) at some point in their career. Locum doctors (also known as Larry, as in Larry the locum) are becoming more common. With the government and public demanding more doctors and the European Work Time Directive decreasing the amount of hours training staff can work, the chasm of vacant doctor posts has to be filled with trust grade and locum doctors. Locums have always had a bad reputation and are often seen as ‘less capable’ or ‘less intelligent’. Thankfully this somewhat unfair ethos is decreasing as more train- ing doctors do the occasional locum job on the side to supplement their income. With the changes in pay banding of most posts down to band 2B we are all losing our income. When saving for a deposit on a property or a holiday, locum work can work well in your favour. Getting on in Your Senior House Officer Post 83 Obtaining locums within your own hospital is extremely easy to organise and financially easier than looking outside your trust. The easiest way to do this is to give your details to the secretary organising locum work for your department or, alterna- tively, for locums in other specialities, visit the medical staffing department and give your details to the ‘recruitment manager’ organising locum work. If you are already on the payroll then your fee will simply be added to your monthly salary and tax deducted accordingly. This process is known as‘internal locuming’ and is much pre- ferred by the trust, as you will know the hospital and how it runs. Working as a locum in a trust in which you are not employed is known as ‘exter- nal locuming’. This is not difficult to arrange,but it can be more difficult to do the job as you may not know the hospital and its staff. Finding jobs is best done through a locum agency of which there are many. If you ask ten of your colleagues they will give you ten different recommendations! The agency will, of course, take their finders fee out of your pay, so you will find that you get paid less as an external locum. However, it is strongly advisable to book study leave at least six weeks in advance or longer if it is for an examination. It is common for senior house officers (SHOs) to book study leave up to three months in advance for examinations and the week before examin- ations to study in order to ensure they get the dates they wish.

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And then I can lift it and get onto the second step purchase generic propranolol canada arteria braquial, and then I would release the door buy generic propranolol from india arrhythmia medscape. cheap 80mg propranolol with mastercard heart attack the song. buy propranolol no prescription arterial nicking.. Every morning, they drop the newspaper right outside the door, beyond the step. But instead of going down the step, I use my grab- ber to pick it up so I don’t have to go up and down the step. Esther’s “grabber” is a rodlike device with pinchers to reach inconveniently placed items. Many people resist changing their houses or decor, living with incon- veniences—and safety risks (chapter 10). One woman with severe back pain has “three stairs to get into my house, but that’s all right. Tina DiNatale installed a grab bar At Home—with Family and Friends / 89 in her bathroom but told the workman,“ ‘I don’t want anything to look too handicapped. A few wealthy people built new houses or performed substantial renovations. But for renters, finding exist- ing and accessible housing with reasonable rents is hard. Lonnie Carter, the disability activist, worried, “Landlords want to rent their apartments at market value. It’s bad news about acces- sible housing—its getting cut for minorities, for whoever you are. But mice was all on the table, the stove, all over the furni- ture they crawled. Then I live in the basement floor, which was like a handicap unit, and it was easy for me. After they start to broke into my house, I got this house where I’m right now. I get very scare sometime because I slip coming out of the bathroom, nothing to hold onto, and I hit my head. Joe Warren, a wheelchair user, had been in his mid twenties when he moved into a public apartment complex constructed specifically for the “elderly and handicapped. The older people that didn’t have anything to do saw me come in with friends and just made up stories. A half-dozen interviewees temporarily or permanently moved their bed- rooms from an upper floor to the ground level. Two put in lifts along stair- cases, although one didn’t use his because he was “insecure getting on and off. Tina DiNatale replaced her wall-to-wall 90 / At Home—with Family and Friends carpets with highly polished hardwood floors, which she viewed as both el- egant and functional, but they proved too slippery. According to a 1990 nationwide survey, the most common home adap- tation is installing grab bars or special railings, followed by ramps, making extrawide doors, and raised toilet seats (LaPlante, Hendershot, and Moss 1992, 3). Some men start using a urinal at night rather than getting to the bathroom. Some use “life- line” services that summon emergency assistance if they press the button on a pendant worn around the neck. Tom Norton replaced a pic- turesque but irregular flagstone walkway with smooth pavement. Interviewees who still walk frequently rearrange household items for “furniture surfing”—placing objects strategically to grab for balance. This tactic won’t work unless furnishings are tall enough to be within easy reach. Many people, especially those with arthritis, avoid low furniture al- together.