Union College, Barbourville KY. F. Marcus, MD: "Buy Ramipril no RX - Best Ramipril no RX".
Writing the dissertation in an acceptable format will not only ensure its approval by examiners but will also help the young scientist in writing a good scientific paper order genuine ramipril online arteria innominada. Defnition Dissertation is a treatise or a written composition that deals with a subject formally and systematically discount 5 mg ramipril with amex hypertension kidney disease. Thesis is a proposition stated especially as a theme to be discussed or proved or maintained against attack or an essay based on research buy generic ramipril 5mg line fetal arrhythmia 32 weeks. Dissertation/Thesis are a proof that one cannot only do science, but also write science. I keep six honest serving men They taught me all I know Their names are what, why, when How, where and who. Thus while writing a dissertation the questions what, why, when, how, where and who should be answered. Dissertation/Thesis proposals are designed to: • Justify and plan (or contract for) a research project. Tips to Start Thesis/Dissertation Writing General Advice • Establish a writing schedule, preferably writing at the same time and place each day. Proposal-Specifc Advice • Understand that the proposal will be a negotiated document, so be prepared to draft, redraft, and resubmit it. Annexure Title The title should describe the content in the fewest possible words. The title needs to be accurate, specific, retrievable short yet sufficiently descriptive and as informative as possible. Do not produce long incomprehensible strings and adjectives as seen in this example: “Cytological changes in the conjunctiva in the patients with vitamin A deficiency with or without protein calorie malnutrition”. At the same time the title should not be made meaningless for the sake of brevity as seen in this example “Cell block study”. Thus it is worth analyzing the title and to make sure that it contains elements of the dissertation that it is intended to convey. For example: “Conjunctival Cytology in Xerophthalmia”, “Cell Block Study of Body Fluids”. Introduction The introduction should answer the question “why you want to do the study”? It should introduce the state of knowledge before the work was started, define the gaps in knowledge which the work will fill and state what works set out to do? A good introduction should: • Establish the general territory (real world or research) in which the research is placed. In other words, the introduction needs to provide sufficient background for readers to understand where from your study is coming. Aims and Objectives The objectives of the research project should summarize what is to be achieved by the study. Aim or the General Objective of a study states what is expected to be achieved by the study in general terms. It is possible (and advisable) to break down a general objective into smaller, logically connected parts. It is not necessary to review the entire story of the subject from Pythagoras to the present day but only relevant articles should be reviewed. We know a subject ourselves or we know where we can find the information about it”, said Dr Samuel Johnson. The literature review is a critical look at the existing research that is significant to the work that you are carrying out. Obviously, at this point you are not likely to have read everything related to your research questions, but you should still be able to identify the key texts with which 258 Research Methodology for Health Professionals you will be in conversation as you write your dissertation/thesis. Literature reviews often include both the theoretical approaches to your topic and research (empirical or analytical) on your topic. Writing the Literature Review Allows Understanding • How other researchers/scholars have written about the topic? The literature review has four major functions that you should keep in mind as you write: • It situates the current study within a wider disciplinary conversation. Effective Literature Reviews Should– • Take out the Introduction’s brief description of the background of your study. Tips on Drafting Your Literature Review • Categorize the literature into recognizable topic clusters and begin each with a sub-heading. Demonstrate the places where the literature is lacking, whether due to a methodology you think is incomplete or to assumptions you think are flawed. You should be tying the literature you review to specific facets of your problem, not to review for the sake of reviewing. As tempting as it might be to throw in everything you know, the literature review is not the place for such demonstration. Stick to those pieces of the literature directly relevant to your narrowed subject (question or statement of a problem). You should fight the temptation to strongly express your opinions about the previous literature. Your task is to justify your project given the known scholarship, so polemics, praise, and blame are unnecessary and possibly distracting. Key Points: After assessing the literature in your field, you should be able to answer the following questions: • Why should we study (further) this research topic/problem? Materials and Methods This section is essential and important to most good research proposals. This section includes a description of the general means through which the goals of the study will be achieved: Methods, materials, procedures, tasks, etc. An effective methodology section should: • Introduce the overall methodological approach for each problem or question. Are you going to take a special approach, such as action research, or use case studies? Your methods should have a clear connection with your research questions and/or hypotheses. In other words, make sure that your methods will actually answer your questions or stated objectives, i. One should also include inclusion, exclusion, eligibility and diagnostic criteria especially in medical and health research. Will you use specific theoretical perspectives to help you analyze a text or explain observed behaviors? For instance, if you propose to conduct interviews and use questionnaires, how do you intend to select the sample population? The description of the results of your work is the heart of your thesis/dissertation. In this section you might like to include illustrations, like photograph, sector graphs histograms, pie charts, tables and so on. Remember that illustrations should not be used as ornaments but should support the text and aid in clear description and concise explanations, use them to help convey the information accurately and succinctly. All photographs should have a figure number written in Arabic numerals a short caption or legend and in case of photomicrographs the stain used and magnification should be written, e. Punctuators particularly commas, full stops and quotation marks should be used carefully as wrong usage can alter the meaning totally for example– Go, slow work in progress.
Such applications in the setting of thrombolysis and in acute coronary syndromes have limited clinical utility because of the logistics of staffing and availability of radiopharmaceuticals purchase cheapest ramipril and ramipril blood pressure medication causes cough. Radionuclide-based assessment of ventricular function includes first-pass radionuclide angiocardiography and gated blood pool imaging purchase ramipril 2.5 mg heart attack kiss the way we were goodbye. First-pass radionuclide angiocardiography involves injection of a radionuclide and analysis as the agent passes through the central circulation cheap 10mg ramipril free shipping arteria volaris indicis radialis. Technetium 99m–labeled agents are typically administered in bolus form, and scintigraphic data are recorded for 15 to 30 seconds after injection. Multicrystal cameras oriented in a straight anterior projection are used for detection of count rates. For the in vivo method, the patient is administered intravenous stannous chloride. Then, a 2- to 3-mL sample of the patient’s blood is retrieved and bounded with technetium 99m pertechnetate. The stannous ions reduce the technetium, so they will not leak out of the tagged cells. The in vitro method binds the patient’s blood with the stannous ion and technetium prior to reinjection into the patient. Because multiple cardiac cycles are averaged to obtain the final images, this technique is not optimal for evaluating regional wall motion. The standard injection of 20 to 30 mCi of technetium 99m allows evaluation of perfusion and function in a single study. For example, if a region has a perceived fixed perfusion defect, yet wall motion is normal in the same region, artifact becomes a more likely consideration as the cause of the filling defect. However, wall motion abnormalities are typically not seen in ischemic segments after exercise nuclear testing because of the delay between peak stress and image acquisition. Comparison of this method with two-dimensional echocardiography in the evaluation of regional wall motion has shown good correlation between the two. Nuclear scintigraphy with 99m technetium pyrophosphate is used in the diagnosis of cardiac amyloidosis. Technetium pyrophosphate is a bone tracer that binds to the calcium in amyloid deposits, particularly in transthyretin amyloidosis; uptake is usually absent in light chain amyloid heart disease. Thus, this test is commonly used to diagnose transthyretin amyloidosis and differentiate it from light chain disease. Uptake is graded based upon visual assessment as well as comparing uptake in the heart versus the contralateral lung on planar images. Radiotracer analogues of sympathetic nervous system factors have been used to assess myocardial innervation and predict risk in certain conditions. The most striking finding was the greater than 99% negative predictive value; patients with normal uptake had very few cardiac events. Positron imaging agents can be divided into blood flow tracers and metabolic radiopharmaceuticals. A number of radiopharmaceuticals exist for the assessment of myocardial blood flow. Rubidium 82, the most readily used blood flow tracer, can be generated on-site without the use of a cyclotron. Much like thallium 201, rubidium 82 is a potassium analogue that is actively transported into myocytes through the Na–K pump. Because of a short half-life (76 seconds), rubidium 82–based imaging protocols can be used to assess myocardial blood flow rapidly (within 1 hour). Other perfusion agents include the cyclotron-produced nitrogen 13 ammonia (half-life 10 minutes) and oxygen 15 water (half-life 123 seconds). Image quality with oxygen 15 water is poor and requires extensive processing to subtract the blood pool, 13 thus is rarely used in current practice. Rb 82 and N-ammonia are the perfusion tracers that are used in clinical practice, with Rb 82 carrying the distinct advantage of requiring only a 13 generator instead of a cyclotron. The image quality of N-ammonia is excellent, although the impracticality of cyclotron production in most facilities is a limiting factor for this agent. There is diminished oxidation of long-chain fatty acids and increased use of glucose as a secondary fuel source during ischemia or hibernation. The release of this product of β-oxidation is reflective of long-chain fatty acid oxidation in myocardium. Measuring the production of [ C]carbon dioxide in this setting correlates with myocardial oxygen consumption. An attenuation scan is performed that allows the density of the surrounding thoracic structures to be subtracted to leave only cardiac count activity. After the attenuation scan, the positron-emitting radiopharmaceutical is injected, and images are obtained 2 to 5 minutes later. As mentioned earlier in the chapter, two photons are created by the annihilation of the emitted positron colliding with the nearest electron it meets in the tissue surrounding it. These two photons travel exactly 180° apart while the patient is lying in the circular scanner. The detector/analyzer merely has to “accept” the signal it receives only if a simultaneous signal strikes the detector directly across from it in the scanner. This dramatically improves the signal-to-noise ratio that can be achieved during imaging. As mentioned before, the ability to quantitate absolute blood flow regionally and globally may help improve the diagnosis of coronary ischemia in the setting of severe multivessel disease and balanced ischemia. The presence of a flow–metabolism mismatch, which indicates underperfusion in the presence of metabolically active myocytes, suggests hibernating myocardium. This utility of nuclear imaging has found increasing application in the selection of patients for revascularization who have ischemic cardiomyopathy and heart failure with low ejection fraction. Under fasting conditions, myocardial cells shift to utilizing predominantly fatty acids. Inflammatory cells in cardiac sarcoidosis utilize glucose because of high metabolic demands, even during fasting. Sarcoidosis nuclear protocols vary among institutions, but attempt to minimize physiologic glucose uptake in normal myocardial tissue. Patients are advised to prepare for the exam with a prolonged fast (12 to 18 hours) and high-protein, low-carbohydrate diet the day before the exam. Skiles, Gregory Bashian, and Santosh Oommen for their contributions to earlier editions of this chapter. Identification and differentiation of resting myocardial blood flow in man with positron emission tomography, 18F-labeled fluorodeoxyglucose and N-13 ammonia. Thallium-201 for myocardial imaging: relation of thallium-201 to regional myocardial perfusion. Technetium-99m hexakis 2-methoxyisobutyl isonitrile: human biodistribution, dosimetry, safety, and preliminary comparison to thallium-201 for myocardial perfusion imaging. Myocardial oxygen demand is determined by contractility (inotropy), heart rate (chronotropy), and wall stress (preload + afterload). Although a number of agents have been evaluated in combination with echocardiography, dobutamine is most widely used. Low-dose dobutamine has positive inotropic effects mediated through cardiac α - and β -receptors.
The discomfort is similar to that of angina pectoris cheap 5 mg ramipril blood pressure normal low pulse, but it is typically more severe order ramipril 10 mg young squage heart attack, of longer duration (usually >20 minutes) order ramipril 2.5mg with amex blood pressure chart urdu, and is not relieved with rest or nitroglycerin. The chest discomfort may radiate to the neck, jaw, back, shoulder, right arm, and epigastrium. Myocardial ischemic pain localized to the epigastrium is often misdiagnosed as indigestion. Symptoms may be atypical in the elderly, in women, and in patients with diabetes mellitus. If the pain is sudden, radiates to the back, and is described as tearing or knifelike, aortic dissection should be considered. Associated symptoms may include diaphoresis, dyspnea, fatigue, lightheadedness, palpitations, acute confusion, indigestion, nausea, or vomiting. The mechanical complications of papillary muscle rupture with acute mitral regurgitation and ventricular septal defect are often heralded by a new systolic murmur (see Chapter 3). Early diagnosis of these complications relies on well-documented examination findings at baseline and during the hospital course. The most common differential diagnostic considerations are discussed in the following text. Chest pain that is worse when the person is supine and improves when the person is sitting upright or slightly forward is typical of pericarditis. With myocarditis, a complete history may reveal a more insidious onset and an associated viral syndrome. In the absence of obstructive epicardial coronary artery disease, this clinical presentation may be explained by a stress-induced cardiomyopathy. Stress cardiomyopathy is also called apical ballooning syndrome as the regional wall motion abnormalities tend to preferentially affect the apex while sparing the basal and mid-ventricular segments, although many other variants have been described. The term “takotsubo” comes from the Japanese word for “octopus pot” as the apical ballooning as seen on imaging represents the shape of this octopus trap. Sharp, tearing chest pain that radiates through the chest to the back is typical of aortic dissection. Chest pain with new neurologic deficits or symptoms may also be a presenting sign of an aortic dissection with both coronary and carotid involvement. This type of chest pain pattern should be investigated thoroughly before administration of antithrombotic, antiplatelet, or fibrinolytic therapy. Gastroesophageal reflux disease, esophageal motility disorders, and esophageal hyperalgesia can cause chest pain, the character of which can mimic cardiac ischemic pain. These disorders can often coexist in patients with coronary disease, thereby complicating the diagnosis. Symptoms that may be suggestive but not diagnostic of chest pain of an esophageal origin include postprandial symptoms, relief with antacids, and a lack of radiation of the pain. Tenderness in the right upper quadrant, fever, and an elevated leukocyte count favor cholecystitis. Recently approved in the United States, the development of hs-cTn has increased our ability to detect myocardial injury early and accurately. By definition, hs-cTn must be able to detect concentrations below the 99th percentile above the assay’s lower limit of detection for more than 50% of healthy population and should have a coefficient of variance of <10% at the 99th percentile value. Hs-cTn assays are, however, best utilized to rapidly and reliably rule out myocardial ischemia, especially in patients presenting acutely with chest pain because of the test’s high negative predictive value. If the initial hs-cTn value is negative, a second value can be measured as early as 1 to 3 hours without compromising sensitivity or negative predictive value. Copyright © 2007 American College of Cardiology Foundation and the American Heart Association, Inc. Five simple baseline parameters have been reported to account for >90% of the prognostic information for 30-day mortality. These characteristics are given in descending order of importance: age, systolic blood pressure, Killip classification (Table 1. The strongest predictor of poor prognosis is advanced age (where age ≥75 years receives 3 points and age 65 to 74 years receives 2 points). Total point score of 3 yields ≥90% specificity and an 88% positive predictive value. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle branch block. Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. The dose should be four 81 mg chewable tablets (for more rapid absorption) or one 325 mg nonchewable tablet. If true aspirin allergy is present, clopidogrel monotherapy is the best alternative. Instead, arterial oxygen saturations should be checked in all patients and if <94%, oxygen therapy should be initiated. Supplemental oxygen should also be supplied to patients who are visibly cyanotic or are in respiratory distress. Administration through a face mask or endotracheal tube may be necessary for patients with severe pulmonary edema or cardiogenic shock. A 30% reduction in systolic blood pressure can be expected with appropriately aggressive dosing (10 to 20 µg/min with 5 to 10 µg/min increases every 5 to 10 minutes). Clopidogrel and prasugrel are thienopyridines that irreversibly inhibit the platelet adenosine diphosphate P2Y12 receptor, and ticagrelor is a reversible direct inhibitor of this same receptor. Pretreatment with prasugrel in these patients did not reduce major ischemic events within the first 30 days, but did increase the risk of bleeding. The recommended loading dose of prasugrel is 60 mg and ticagrelor is given as a 180 mg loading dose. This may be overcome by crushing these tablets prior to administration for more rapid absorption. In fibrinolysis patients, clopidogrel is the thienopyridine of choice, at a loading dose of 300 mg if the patient is ≤75 years and a loading dose of 75 mg if age >75 years. The duration of clopidogrel following fibrinolysis should be at least 14 days and ideally up to 12 months. The maintenance dose of clopidogrel and prasugrel is 75 mg daily and 10 mg daily, respectively. Prasugrel should, however, not be utilized in patients with a prior history of stroke or transient ischemic attack. Cangrelor is the only available intravenous P2Y12 inhibitor and binds reversibly to the receptor. The short plasma half-life of <5 minutes allows for near complete restoration of platelet function within 1 to 2 hours after stopping the infusion. This may be most effective in patients with extremely short door-to-balloon times because administration in this setting will ensure reliable platelet inhibition. Persistent ischemic symptoms after 12 hours may indicate a stuttering course of occlusion, spontaneous reperfusion, and reocclusion and may indicate potential continued benefit for early therapy. Although the current guidelines focus on door-to-balloon times, total ischemic time is the most important parameter.
Order ramipril 5mg mastercard. 7 Fruits That Cure High Blood Pressure.
