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The main indications for plasma include bleeding in the setting of massive transfusion and for bleeding patients who are taking warfarin when other agents (such as prothrombin complex concentrates) are unavailable buy duetact 16mg without prescription definition insulin resistant diabetes. Other indications are bleeding in the setting of a factor defciency that does not have specifc factor concentrate available (e order duetact 16mg overnight delivery diabetes type 1 diagnosis in adults. There are several studies suggesting that prophylactic transfusion of plasma is not indicated discount duetact 16 mg visa diabetes type 2 in elderly. This leads to the circulation of only large von Willebrand multimers cheap 16 mg duetact free shipping diabetes type 2 quiz, with subsequent platelet activation and microthrombi formation. If line placement for plasma exchange is delayed, plasma (30 mL/kg for the frst 24 h followed by 15 mL/kg each day) may be given as bridging therapy before plasma exchange can be initiated. Diuretics may be considered if the patient cannot tolerate large volume of plasma infusion as bridging therapy. Patients with end stage liver disease typically have normal thrombin generation, and thus, a normal ability to form a clot. This is because both coagulation proteins and fbrinolytic proteins are decreased in liver disease. A “rebalancing” of these proteins occurs, such that thrombin generation is close to normal. In a nonbleeding patient with malnutrition, the physician should start with vitamin K administration (Answer C). This dose of plasma would be expected to increase coagulation factors by ∼10%–20% immediately after infusion. When one replaces coagulation factors using plasma administration to help manage bleeding, the target level of coagulation factor goal to establish adequate repletion is which of the following? There is a buffer zone (or reserve zone) for coagulation proteins, such that we only need approximately 40% total coagulation factors for hemostasis to occur. Note that many texts will cite a 30% level; however, these studies were for single coagulation factor defciencies, rather than the multiple factor depletion that arises with most forms of bleeding. The practical application of this is that our recommended plasma doses are smaller than would be needed if the goal were replacement to 100% levels. In fact, due to the dilutional effect of plasma transfusion, it is impossible (mathematically and practically) to achieve 100% coagulation factor postplasma transfusion. Other choices (Answers A, C, D, and E) represents the wrong target based on the above discussion. AdulT TrAnsfusion—PrinciPles And PrAcTice 183 Concept: There are several types of plasma products. Any of these products may be thawed, relabeled as thawed plasma, and stored under refrigerated conditions for up to 5 days. For thawed plasma, roughly 50% of the amount of coagulation factors remained after 5 days compared to the time of collection. Liquid plasma, the newest type of plasma available, is plasma that is never frozen following collection. It requires storage under refrigerated conditions and it expires 5 days after the expiration date of the whole blood, depending on the anticoagulant the whole blood is collected in. Anti-A and anti-B are very potent antibodies that, once bound to their respective antigen, activate complement. This is based on the fact that about 80% of patients (either type A or type o) will be compatible and group A individuals do not typically have high titer anti-B in circulation. It contains all of the same coagulation proteins as plasma, but in a higher concentration D. The cryo-depleted plasma (more commonly known as cryopoor plasma) is then removed, and both products may be refrozen. For transfusion in adults, 5–10 units are typically pooled together and transfused in order to achieve the desired increase in serum fbrinogen level. Preparation when transfusion is needed is then faster, with the thaw step being the only step needed prior to issue of the pool. Units pooled at the time of use expire in 4 h, whereas prepooled units expire in 6 h. Overall, the original unit of plasma will have a higher amount of fbrinogen (Answer A). This is very effective in raising the fbrinogen level, and thus, may be benefcial in bleeding control, while the clinical team decides what further measures they will take to stop the hemorrhage. Cryodepleted plasma is plasma without the cryoprecipitate, and therefore, much of the fbrinogen, removed (Answer E). This is also true for Rh compatibility and plasma that has been previously frozen. Apheresis-derived platelets have greater effcacy compared to whole blood-derived platelets 186 8. Platelets also provide phospholipid surface for coagulation factors during secondary hemostasis in order to generate a more stable fbrin clot. Secondary hemostasis is the end result of the coagulation cascade, where crosslinked fbrin seals down the platelet plug to form the more stable fbrin clot (Answer B). Apheresis-derived and whole blood-derived platelets (given in an equivalent dose) have the same effcacy (Answer E). One unit of apheresis-derived platelets is ordered for a 70-kg man with a platelet count of 10,000/µL due to chemotherapy for multiple myeloma. If the patient is not bleeding and is not refractory to platelet transfusion, what is the estimated/expected increment posttransfusion? This dose would be expected to raise the platelet count by 30,000–60,000/µL in an average size patient. If one were using whole blood-derived platelets, 6 units are typically considered to be an equivalent dose (to 1 unit apheresis-derived platelets). The disadvantages of using whole blood-derived platelets are multiple donor exposures and slightly higher risk of bacterial contamination without bacterial testing. Answer: C—One unit of apheresis-derived platelets would be expected to raise the platelet count by 30,000–60,000/µL in an average size patient. The other choices (Answers A, B, D, and E) are not correct based on the expected increment discussed above. How many unit(s) of apheresis platelets should be recommended to prevent spontaneous hemorrhage? Therefore, assuming that this patient is not bleeding and not refractory to platelet transfusion, 1 unit of apheresis platelet is enough to raise his platelet count to >10,000/µL. Based on the expected increment (see Question 23), other choices (Answers B, C, D, and E) are thus, wrong. Per the report of the oncology foor nurse, she has no fever and no signs of bleeding.

The investigator duetact 16mg on line managing diabetes zorgtraject, based on data collected proven duetact 16 mg diabetes mellitus on pregnancy, uses statistical tests to determine whether there is sufficient evidence to reject the null hypothesis in favor of alternative hypothesis that there is an association in the population order 17 mg duetact fast delivery diabetes type 2 eye problems. The standard for these tests is known as the Level of statistical significance (Table 4 buy duetact 16 mg lowest price blood sugar protein. If the P value is more than or equal to the cut-off point, the null hypothesis is accepted. It is the error of falsely stating that two drug effects are Formulation of Objectives, Research Questions and Hypotheses 35 significantly different when they are actually equivalent. It is the error of falsely stating that two drug effects are equivalent when they are actually different. Power (1-β): Probability that the test will correctly identify a significant difference/effect/association in the sample, should one exist in the population or correctly reject the null hypothesis. As per Kaplan (1964) and Pedhazur & Schmelkin (1991), measurement can be defined as a process through which researchers describe, explain, and predict the phenomena and constructs of our daily existence. For example, we measure that how long we have lived in years, our financial success in dollars, distance between two points in miles, etc. Important life decisions are based on performance on standardized tests that measure intelligence, aptitude, achievement, or individual adjustment. We predict that certain things will happen as we age, become more educated, or make other significant lifestyle changes. In short, measurement is as important in our daily existence as it is in the context of research design. First, measurement enables researcher to quantify abstract, constructs and variables. Research is usually conducted to explore the relationship between independent and dependent variables. Variables in a research study typically must be operationalized and quantified before they can be properly studied. Further the level of statistical sophistication used to analyze data derived from a study is directly dependent on the scale of measurement used to quantify the variables of interest (Anderson, 1991). An operational definition takes a variable from the theoretical or abstract to the concrete by defining the variable in the specific terms of the actual procedures used by the researcher to measure or manipulate the variable. For example, in a study of weight loss, a researcher might operationalize the variable “weight loss” as a decrease in weight below the individual’s starting weight on a particular date. The process of quantifying the variable would be relatively simple in this situation—for example, the amount of weight lost in kilograms or grams or pounds and ounces during the course of the research study. Without measurement, researchers would be able to do little and make unsystematic observations. Planning the Measurements 37 There are two basic categories of data: non-metric and metric. Non- metric data (also referred to as qualitative data) are typically attributes, characteristics, or categories that describe an individual and cannot be quantified. Metric data (also referred to as quantitative data) exist in differing amounts or degrees, and they reflect relative quantity or distance. Metric data allow researchers to examine amounts and magnitudes, while nonmetric data are used predominantly as a method of describing and categorizing. Nominal scales are the least sophisticated type of measurement and are used only to qualitatively classify or categorize. They have no absolute zero point and cannot be ordered in a quantitative sequence, and there is no equal unit of measurement between categories. In other words, the numbers assigned to the variables have no mathematical meaning beyond describing the characteristic or attribute under consideration— they do not imply amounts of an attribute or characteristic. This makes it impossible to conduct standard mathematical operations such as addition, subtraction, division, and multiplication. Common examples of nominal scale data include gender, blood type, religious and political affiliation, place of birth, city of residence, ethnicity, marital status, eye and hair color, and employment status. Notice that each of these variables is purely descriptive and cannot be manipulated mathematically. Ordinal scale measurement is characterized by the ability to measure a variable in terms of both identity and magnitude. This makes it a higher level of measurement than the nominal scale because the ordinal scale allows for the categorization of a variable and its relative magnitude in relation to other variables. In simpler terms, ordinal scales represent an ordering of variables, with some number representing more than another. Like nominal data, ordinal data are qualitative in nature and do not possess the mathematical properties necessary for sophisticated statistical analyses. The interval scale of measurement builds on ordinal measurement by providing information about both order and distance between values 38 Research Methodology for Health Professionals of variables. The numbers on an interval scale are scaled at equal distances, but there is no absolute zero point. Because of this, addition and subtraction are possible with this level of measurement, but the lack of an absolute zero point makes division and multiplication impossible. It is perhaps best to think of the interval scale as related to our traditional number system, but without a zero. In the Fahrenheit or Celsius scale, zero does not represent a complete absence of temperature, yet the quantitative or measurement difference between 10 and 20 degrees is the same as the difference between 40 and 50 degrees. There might be a qualitative difference between the two temperature ranges, but the quantitative difference is identical—10 units or degrees. Ratio scale of measurement has the properties identical to those of the interval scale, except that the ratio scale has an absolute zero point, which means that all mathematical operations are possible. It is possible to have no (or zero) money or a zero balance while checking account. Ten Euros/dollars is 10 times more than 1 Euros/ dollar, and 20 Euros/dollars is twice as much as 10 Euros/dollars. Ratio data is the highest level of measurement and allows for the use of sophisticated statistical techniques. Choosing a Measurement scale A good general rule is to prefer continuous variable, because the additional information improves the statistical efficiency. For example: Blood pressure in millimeters of mercury allows investigator to observe the magnitude of the change in every subject whereas measuring as hypertensive vs normotensive is unclear. Example: deter- mination of low birth weight babies, when there are options of designing the number of response categories in ordinal scale (taste of food – tasty, very tasty, fairly tasty, etc. Planning the Measurements 39 The reliability of a variable is the degree to which it is reproducible, with nearly the same value each time it is measured. In general, reliability refers to the consistency or dependability of a measure- ment technique. More specifically, reliability is concerned with the consistency or stability of the score obtained from a measure or assessment technique over time and across settings or conditions. If the measurement is reliable, then there is less chance that the obtained score is due to random factors and measurement error.

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Four sketches of teeth by first- quarter dental and dental hygiene students: although not perfectly drawn duetact 17mg free shipping diabetes mellitus type 2 behandling, each sketch is recog- nizable as the tooth being drawn buy duetact 17 mg with mastercard diabetes symptoms in 30 year old woman. It may be helpful to remember these basic guidelines Mandibular molars from the occlusal view are wider regarding pits and grooves buy duetact 16 mg lowest price blood sugar 300. Most premolars have a mesiodistally than buccolingually discount duetact 16 mg fast delivery diabetes medications supplement, whereas maxillary mesial and distal pit connected by a groove running molars are slightly wider buccolingually than mesiodis- mesiodistally between buccal and lingual cusps. The crests of curvature on molars and premolars molars (and three-cusped mandibular second premo- on the mesial and distal surfaces are located in the cen- lars) have three pits (mesial, central, and distal) that ter or slightly to the buccal of the buccolingual midline. Molars also have one located mesial to the middle, except on the buccal of the or two buccal grooves that separate the two or three mandibular first molar where it is close to the middle. On mandibular molars, the After the outline “box” is sketched and crests of curva- lingual groove comes off near the central pit, but on ture have been noted, sketch the crown outlines using maxillary molars, a lingual (distolingual) groove comes descriptions from the Appendix pages. An additional challenge on these views involves Developmental triangular or fossa grooves or supple- reproducing the location of the cusp tips, grooves, and mental grooves may angle off from the mesial and dis- pits (as must be accomplished by dental personnel tal pits of most posterior teeth, directed toward the every time a restoration is placed on an occlusal sur- “corners” of the tooth. See the student sketches of the face, finished and polished, or constructed or carved in occlusal views of two recognizable molars in Figure wax in the laboratory). While eventually you may be able to carve a tooth from a block of wax without preliminary measurement, the beginner can only do well by approaching the carving systematically in the same way you approached the drawings: first, by drawing a box on the wax block; second, by sketching an outline of the tooth in the box; and third, by carving around the sketch or out- line, one view or aspect at a time (sequence is shown in Fig. When approaching the task of carving a tooth, con- sider Michelangelo who conceived of his task of pro- ducing a marble statue by “liberating the figure from the marble that imprisons it. To minimize this, as you cut away wax, repeatedly examine your carving from all sides; turn it around and around and compare it with your speci- men from each view. Where too much wax has been removed, you have one of three choices: add molten wax to the deficient region, make the entire carving proportionally smaller, or start with a new block of wax. The sequential method described in this chapter for carving a tooth from a block of wax. Allowance is made for the greater length of some lingual cusps, which are longer than the measured buccal cusp. Figure 13-7 as you follow the following guidelines: Maxillary central incisor wax carvings by first-year dental hygiene students as seen from the mesial (M), Step 1: Shave the sides of the block flat and make all lingual (L), incisal (I), facial (F), and mesial-facial (M, F) aspects: The crown and half of the root were carved to specific angles right angles. These excellent carvings were each draw a line at this level, encircling the block (on all done in less than 3 hours as a required skill test. At this time, do not carve around here is to provide for the extra length of the lingual the outline of the tooth, but rather carve up to the cups on molars that are longer than the mesiobuccal straight vertical lines that form the box in which cusp that established crown length. Be Step 3: From the 2-mm line, measure the crown length sure they are perfectly flat and smooth. Step 12: Now carve away the shaded regions seen in Step 4: From this cervical line, measure one half of the Figure 13-7C around and down to the facial and lin- length of the root and draw a third line around the gual outlines of the tooth. Keep the carving surface smooth; Step 5: On the base of the block, carve, on appropriate if it becomes chopped up, it will be impossible to sides, F (facial), L (lingual), M (mesial), and D (dis- smooth it without losing both the shape and the size tal). F and L so that you will carve a right or a left tooth, Step 13: With a sharp pencil, very lightly draw center whichever you intend. Be sure they are exactly lengthwise on the block in the center of the mesial opposite. Using this the curved surface as wide as the greatest mesiodistal measurement, draw a line this distance on either crown measurement plus 0. These two outer lines length distance from the incisal edge on the facial should be parallel to the center line and extend and lingual sides (since the original line was carved from the top of the block to the base. Then draw the facial outline of the crown lines form a box whose dimension faciolingually and half of the root on the curved facial side of the is equal to the crown dimension plus 0. Step 16: On the lingual surface of the block, draw an Do not make trouble for yourself by allowing more outline the same shape as the one on the facial sur- than this extra 0. Be on the lingual surface too, so the crown will not be careful to place the incisal edge and the labial and too long. Your carving Step 17: Carve away all the wax outside the drawing will probably be no better than this drawing. Be sure that on both sides, the drawings roots may extend beyond the box lines, and these are oriented so that the facial surface of the tooth roots should be carved accordingly. Maxillary canine wax carvings viewed from the distal (D), lingual (L), incisal (I), and facial (F) aspects. First-year dental hygiene students carved these during a skill test (2 hours, 50 minutes time limit). Maxillary right canine carving done by senior made by dental hygiene students at The Ohio State dental student Keith Schmidt: observe the nearly perfect University, are shown in Figure 13-8. Five aspects contours from all aspects and that the root is not becoming of another very fine carving by a dental student are narrower as it joins the crown (a very common carving error in attempting to refine the cervical line). Outlines within which you may draw three views of a maxillary canine: the boxes are proportional to the natural tooth average measurements in Table 3-2. The widest portions of the crown (mesial and distal contacts) should touch the sides of the wider lower box. Only the widest part of the root should touch the sides of the narrower box above with the root apex touching the top of this box. On the incisal view, be sure to position the incisal ridge just labial to the faciolingual middle of this box. Drawing these three views will be helpful to you when you outline similar contours on a block of wax for carving a maxillary canine. Be an honest critic of your work, con- to sketch teeth into the blank boxes of Figure 13-12 is stantly looking for regions where the carving could shown in Figure 13-13. You do not discard your first ones, but keep them for future should have a tooth model or extracted tooth specimen comparisons. Proportionally outlined boxes for drawing the lower right first and second premolars and first molar in their usual relationship to one another: select three nice tooth specimens or tooth models and go to work. Outlined proportional boxes for drawing several views of the maxillary first and second premolars in their usual relationship to each other: Use Lingual the same guidelines given in the legend for Figure 13-10. A dental hygiene student’s drawing of these two teeth within the outlined boxes is seen in Figure 13-13. These drawings within the outlined boxes are examples to help you with your drawings in the blank boxes in Figure 13-12. For example, in the lingual view, the maxillary first premolar’s lingual cusp is too long. Berlin: Buch-und Zeitschriften-Verlag “Die Quintessenz,” Average measurements from 4572 extracted teeth are 1976. You may find the General References helpful in perfecting your carving techniques. Also, as you study this section, you should Foramen rotundum: a specific round foramen; recall relate the location of each bony structure on the skull the Capitol’s rotundum or dome is round when viewed to its location on your own head, that is, where it is from above located under the skin of the face or under the mucosa Meatus [me A tus]: a natural passage or opening in of the mouth. Many terms have similar defini- muscle is within the cheek; the buccal surface of a tions, so they are defined here in groups to facilitate tooth is the side toward the cheek learning. Since anatomy terms are often similar to com- Cervix: of the neck or neck-like; compare a cervical mon familiar words, the new terms are compared to vertebrae in the neck familiar words whenever possible. Planes of the Frontal plane head and directions used to iden- tify relative location of structures Inferior direction or surfaces of the head.