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But it is in precisely these circum stances that the qualitative researcher m ust ensure that (s)he has generic 60caps brafix fast delivery, at the outset, carefully delineated a particular focus of research and identified som e specific questions to try to answer (see Question 1 in section 11. The m ethods of qualitative research allow for and even encourage2 m odification of the research question in the light of findings generated along the way. Failure to recognise the legitim acy of this approach has, in the past, led critics to accuse qualitative researchers of continually m oving their own goalposts. W hilst these 169 H OW TO READ A PAPER criticism s are often m isguided, there is, as N icky Britten and colleagues have observed, a real danger "that the flexibility [of the iterative approach] will slide into sloppiness as the researcher ceases to be clear about what it is (s)he is investigating". It is debatable, therefore, whether an all-encom passing critical appraisal checklist along the lines of the "U sers’ guides to the m edical literature" (see references 8–32 in Chapter 3) could ever be developed. M y own view, and that of a num ber of individuals who have attem pted or are currently working on this very task,7, 12, 13, 14 is that such a checklist m ay not be as exhaustive or as universally applicable as the various guides for appraising quantitative research, but that it is certainly possible to set som e ground rules. The list which follows has been distilled from the published work cited earlier2, 7, 13 and also from discussions with D r Rod Taylor of Exeter U niversity, who has worked with the CASP Project on a m ore detailed and extensive critical appraisal guide for qualitative papers. Question 1 Did the paper describe an important clinical problem addressed via a clearly formulated question? Qualitative papers are no exception to this rule: there is absolutely no scientific value in interviewing or observing people just for the sake of it. Papers which cannot define their topic of research m ore closely than "W e decided to interview 20 patients with epilepsy" inspire little confidence that the researchers really knew what they were studying or why. You m ight be m ore inclined to read on if the paper stated in its 170 PAPERS TH AT G O BEYON D N U M BERS introduction som ething like, "Epilepsy is a com m on and potentially disabling condition, and up to 20% of patients do not rem ain fit free on m edication. Antiepileptic m edication is known to have unpleasant side effects, and several studies have shown that a high proportion of patients do not take their tablets regularly. W e therefore decided to explore patients’ beliefs about epilepsy and their perceived reasons for not taking their m edication". If the objective of the research was to explore, interpret or obtain a deeper understanding of a particular clinical issue, qualitative m ethods were alm ost certainly the m ost appropriate ones to use. If, however, the research aim ed to achieve som e other goal (such as determ ining the incidence of a disease or the frequency of an adverse drug reaction, testing a cause and effect hypothesis or showing that one drug has a better risk–benefit ratio than another), qualitative m ethods are clearly inappropriate! If you think a case- control, cohort study or random ised trial would have been better suited to the research question posed in the paper than the qualitative m ethods that were actually used, you m ight like to com pare that question with the exam ples in section 3.

Adaptability and Change Despite the permanence that institutions achieve in society generic brafix 60caps overnight delivery, they must also have the flexibility to adjust to changing conditions. As will be discussed later, no other institution has experienced such dramatic changes as health- care during the twentieth century. At the start of that century, healthcare was a rudimentary institution with limited visibility and little credibility in society. Hospitals were considered to be places where people went to die, and doctors were to be avoided at all costs. There was no agreement on the nature of health and illness, and scientists were only beginning to document the effectiveness of medical care. Healthcare was not even on the national radar screen for the first half of the twentieth century and accounted for a neg- ligible portion of the gross national product. Contrast that situation to the healthcare institution at the end of the twentieth century. Not only had the institution become well-established in the United States, but it had come to play a dominant role in U. The importance of the institution had become such that sociologists often referred to the medicalization of American society. In the latter half of the twentieth century the institution came to be accorded high prestige and exert a major influence over other insti- tutions. The healthcare institution today can claim 15 percent of the gross national product and 10 percent of the nation’s workforce. The significance placed on a particular institution varies from society to society. While all societies must address the same basic needs, the impor- tance accorded these needs and the significance of the associated institu- tion vary from system to system and from time period to time period. Economic success is a driving motivation for the behavior of Americans, who spend an inordinate amount of time earning money, spending money, and planning how to invest their money. Indeed, many of the activities in other institutions serve to support the goal of eco- nomic success.

Patient Controlled Analgesia (PCA) • Newer routes of administration such as buccal and PCA is a technique in which the patient self- intranasal may be useful generic 60 caps brafix mastercard. It has been shown to Local anaesthetics produce better analgesia and patient satisfaction with Local anaesthesia provides total pain relief for the no greater incidence of adverse effects. It is often used in the operating theatre equipment is expensive, staff need to be trained in the and may be continued for post-operative analgesia. For longer-lasting PATIENT WITH A PCA ROUTINE CARE Monitoring: On commencing infusion all observations are done 1/4 hourly for 1 hour, hourly for 4 hours, then 4 hourly if patient is stable. Paracetamol, NSAIDs) should be given regularly if prescribed) PROBLEMS Pain is not controlled Ensure maximum prescribed morphine is being used and maximum regular co-analgesia is given If this fails a re-loading dose should be given in increments intravenously by a doctor or the APS sister. Respiratory depression or over-sedation If: sedation score 2 ] Suspend opioids or: respiratory rate 10 ] Administer oxygen. Measure oxygen saturation or: syst BP 100 ] Measure RR at least every 30 min Opioids may be restarted, at a lower dose, once RR 10, syst BP 100 and sedation score 2. If: sedation score 3 ] Stop all opioids or: respiratory rate 8 ] Administer oxygen. Measure oxygen saturation or: syst BP 80 ] Call doctor Nausea and vomiting All patients on PCA should have an anti-emetic (e. If this is unsuccessful call the APS Itch May be treated with a very low dose Naloxone IV (20–50 g). IF IN ANY DOUBT, CALL APS: Bleep XXXX (in hours) and XXXX (out of hours) OXYGEN SCORE SEDATION SCORE PAIN SCORE NAUSEA/VOMITING SCORE 0 Oxygen saturation 92% on air 0 Alert/awake 0 No pain 0 No nausea/vomiting 1 Oxygen saturation 90% on oxygen 1 Dozing/drowsy 1 Mild pain 1 Nausea 2 Oxygen saturation 90% on oxygen 2 Asleep / rousable 2 Moderate pain 2 Vomiting 4 Asleep/unrousable 3 Severe pain 4 Unbearable pain DATE/TIME COMMENTS Figure 24. POST-OPERATIVE PAIN 169 analgesia repeated injections, or continuous infusion, Combinations of opioids and local anaesthetics act • is necessary. Wound infiltration • Mobilisation is improved, with patients able to Wound infiltration has been shown to be effective for cough and co-operate with physiotherapy. It is simple to perform, but likely to particularly useful for patients with respiratory wear off before the pain abates. Therefore, other anal- disease, or following upper abdominal and thoracic gesia must be instituted early.

Some cells that suppress reactions are called T suppres- sor cells; some cells that help reactions along are called T helper cells trusted brafix 60 caps. Cells in the immune system that target foreign bodies for destruction are called macrophages. Each of these cells has an important individual function; together they create the immune 9 PART I • The Disease and Its Management reaction. These reactions usually are beneficial and often life-sav- ing, but sometimes the system malfunctions and produces an autoimmune problem. This is what appears to happen in MS, which therefore often is referred to as an autoimmune disease. Other autoimmune diseases include systemic lupus erythematosus (SLE) and rheumatoid arthritis. All autoimmune disease involve the faulty regulation of the immune system, which appears to be overaggres- sive and may need to be suppressed. Many things influence the immune system, including exposure to foreign substances, stress, and life itself. Susceptibility to autoimmune diseases appears to be at least partly genetic, so that, although MS itself is not a hereditary disease, a hereditary factor may make an individual susceptible to its devel- opment. Approximately 10 to 20% of people with MS have MS in their extended families, a higher rate than would be expected by chance. Clearly, people do not inherit MS, but they may inherit the possibility of developing the disease. The likelihood of developing MS in the absence of its presence in close family mem- bers is 1:2000 (0. If a parent has MS, the probability that a daughter will develop the disease is 4:100 (4 percent), whereas a son’s chances are 2:100 (2 percent). Again, If MS was solely a hereditary disease, this figure would be 100%, but it does show that genetics plays some role in the development of the disease. Although these numbers are small, they are larger than would be expected if there were no genetic connection.