O. Zakosh. Western State University College of Law.

It is difficult to offer more precise advice about discovering the "spirit" or "identity" of an institution buy discount kamagra 100mg online erectile dysfunction cures over the counter. Of course some schools wear their hearts more on their sleeves than others or have a more easily identifiable image buy kamagra 100mg without prescription erectile dysfunction medication and heart disease, but often the traditional identities are past memories, especially in London, where medical schools’ identities have changed considerably in the past decade, particularly with recent amalgamations between medical schools and their mergers with larger multidisciplinary university colleges. In days gone by a choice had to be made between a hospital based medical school, such as several in London, or an initially firmly multifaculty university environment, with a much broader student community with greater diversity of personalities, outlooks, and opportunities. This distinction has largely now disappeared; soon only the course at St George’s in London will be hospital and medical school based throughout. Accommodation may play an important part in choice, as some colleges house all the medics in one hall of residence while others spread them out, so you may end up living on a corridor with a lawyer, a historian, a musician, a dentist, a physicist, and someone who seems to sleep all day and smoke funny smelling tobacco who is allegedly doing "Media Studies and Ancient Icelandic". Many find this kind of variety gives them exactly what they came to university for and would find spending all their work and play time with people on the same course socially stifling. While it is essentially a matter of personal preference, it is also worth noting that both have pros and cons—for example, when the workload is heavy it may be easier to knuckle down if everyone around you is doing likewise. Conversely when a bunch of medics get together they inevitably talk medicine, and, although recounting tales and anecdotes can amuse many a dinner party it may well breed narrow individuals with a social circle limited only to other medics. Choosing a campus site or a city site where you live side by side with the community your hospital serves may also have a different appeal. Increasing diversity is being introduced to the design of the curriculum and how it is delivered. The traditional method of spending two or three years studying the basic sciences in the isolation of the medical school and never seeing a patient until you embarked on the clinical part of the course has all but disappeared. The teaching of subjects is generally much more integrated both between the different departments and between clinical and preclinical aspects. Even so, some curriculums are predominantly "systems based" and others "clinical problem based". Much more emphasis is being placed in all courses on clinical relevance, self directed learning and problem solving rather than memorising facts given in didactic lectures. There is substantial variation in the extent to which these changes have evolved and in many respects there is greater choice between courses than ever before. Diversity of approach is a strength of the United Kingdom system: "You pay your money and take your choice". The courses at Oxford, Cambridge, and St Andrews remain more traditional in structure if not in subject matter and teaching methods. Cambridge and Oxford, however, have also introduced a four year course for graduate students, which combines the intellectual rigour of the traditional course with community-based clinical insights from the outset. At Oxford all the basic sciences required for the professional qualifications are covered in the intensive first five terms’ work and are then examined in the first BM. All students then take in their remaining four terms the honours school in physiology, a course much wider than its name suggests with options to choose from all the basic medical sciences, including pathology and psychology. All the essential components of the medical sciences course are covered in two years. The third year is spent studying in depth one of a number of subjects, the choice being determined partly by whether or not the student is going on to continue a conventional clinical course at another university, usually, but not exclusively, London or Oxford, or continue on to the shorter Cambridge clinical course. For students remaining in Cambridge for clinical studies, the third year choices are limited to subjects approved by the GMC as "a year of medical study"; apart from the normal basic sciences these include subjects such as anthropology, history of medicine, social and political sciences, and zoology. Those moving on to a conventional clinical course have the attractive opportunity to spend their third year reading for a part II in any subject—law, music, or whatever takes their fancy—provided they have a suitable educational background and their local education authority is sufficiently inspired to support them. At St Andrews the students spend three years studying for an ordinary degree or four years for an honours degree in medical sciences. Although strongly science based, clinical relevance is emphasised and some clinical insights are given, mainly in a community setting. Most St Andrews graduates go on to clinical studies at Manchester University, but a few go to other universities. With the recent expansion in medical school places, the government has approved four completely new undergraduate medical schools. The first two of these—Peninsula Medical School (Universities of Exeter and Plymouth) and the University of East Anglia—started their first students on a standard five year course in Autumn 2002. Two further schools, Hull–York Medical School and Brighton and Sussex Medical School, will have their first students in Autumn 2003. Unless you are an aficionado of architecture and simply could not concentrate unless in a neoclassical style lecture theatre or an art deco dissecting room, then what gives a place its unique character are the people who inhabit it; the biomedical science teachers, the hospital consultants who involve themselves in student life, the mad old dear who runs the canteen, the porter who knows everyone’s name and most people’s business, the all important dean and admissions tutor, and not least by any means the students themselves.

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This process is known as progressive overload kamagra 50 mg cheap erectile dysfunction treatment machine, and it should continue until the individual’s training goals are achieved generic 50 mg kamagra mastercard erectile dysfunction treatment options exercise. In order to achieve this overload, the exercise pre- scriber must consider the FITT (E) or FITT (A) principle. This principle describes the relationship between frequency, intensity, time and type of exer- cise, and it is an essential tool when prescribing effective exercise. Exercise prescription must be individualised to increase the likelihood of enjoyment (E) and/or adherence (A). FITT (E) and (A) stand for the following: F = FREQUENCY = number of days per week I = INTENSITY = exertion required T = TIME = minutes per day T = TYPE = specific activity (E) = ENJOYMENT (A) = ADHERENCE CARDIAC REHABILITATION PHASE III OVERLOAD Frequency Early studies into phase III cardiac rehabilitation (CR) programmes were based on exercise/education sessions that ran three days per week for eight weeks or longer (Jolliffe, et al. Various studies have been carried out to determine the optimum frequency for cardiac rehabilitation programmes. There is still on-going debate around this topic, but recent literature has shown that two–three times per week, for a minimum of eight weeks, is sufficient to achieve physiological and psychosocial adaptations (SIGN, 2002). It should be Exercise Prescription 105 emphasised that for patients to gain the optimum physiological and psy- chosocial benefits they will require prolonged exposure to exercise. Thus phase III should be considered as the minimum time for these changes to occur. The patients and significant others should be strongly encouraged to maintain exercise into phase IV. How and where phase III programmes are delivered will vary, but they are commonly held in a hospital or, more recently, in the community. The common goal is to encourage life-long adherence to improving and maintain- ing the individual’s exercise habits. By individualising exercise prescription and involving the patients in the exercise consultation process (see Chapter 8), they are more likely to enjoy (E) and adhere (A) on a long-term basis. Benefits to health and fitness can only be achieved if exercise levels are maintained. Intensity One of the aims of a cardiac rehabilitation programme is to improve cardio- vascular fitness and functional capacity. How hard an individual works to achieve this improvement will be dependent on the individual’s current exer- cise ability, motivation and choice of exercise. Current guidelines recommend that the benefits of a cardiac rehabilitation programme will be gained when exercise intensity is low-to-moderate and designed to suit a range of fitness levels (SIGN, 2002). Recommended intensity for cardiac patients is 60–75% HRmax or 40–60% HRRmax and 12–15 RPE. This will vary according to the risk stratification of the patient, determined during the individual’s initial assessment (as described in Chapter 2) and the agreed goals of the patient. Individuals with diminished functional capacity, or who have been identified as a higher risk, should start at a lower intensity (60% HRmax), and progress as able, whereas fitter or lower risk individuals can often work between 65 and 75% HRmax. Beta-blockers reduce the sub-maximal and maximal HR, so this will have to be taken into account when developing individualised training zones (see Chapter 3). Increasing intensity Depending on the patient, progression of intensity should be guided by the goals of the patient, vocational needs and their risk stratification. When work rate is chosen to increase intensity this can be indicated when there is a notice- able decrease in both HR (>5 beats·min-1) and RPE (≥1. In addition, observation by the exercise leader of the patient, the ease or difficulty of performing the class can add to the decision to increase intensity. The methods include the following: • maximal heart rate or peak heart rate; • Karvonen (Karvonen, et al. As described above, there is a variety of methods for determining the correct exercise intensity a participant should aim to achieve. However, it is essential that the exercise instructors do not neglect their skills of observation. Con- tinual assessment of quality of movement, excessive sweating or shortness of breath, skin colour and general fatigue are indicators for an individual to reduce intensity. Time The aerobic conditioning phase of a cardiac rehabilitation programme should last between 20 and 30 minutes (ACPICR, 1999; SIGN, 2002).

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In constant velocity running buy kamagra 50mg on-line neurogenic erectile dysfunction causes, the forward and backward impulses exerted by the ground must be equal in magnitude generic 50mg kamagra with mastercard erectile dysfunction pills that work. The risk of head injury from striking an automobile dash- board is often correlated with the maximum linear acceleration of the head during the collision. To better understand the mechanics of colli- sion, a team of researchers dropped rigid balls of different masses from a height of h onto an elastic surface with spring constant k. They found that the maximal displacement of the surface during the collision was given by the following relationship: D5(2m g h/k)0. Hint: Write down the equation of motion of the object in the vertical direction and substitute k D for the spring force. Your result should predict that the smaller the mass of the object, the greater the peak ac- celeration during impact. Based on this observation, some researchers argued that children may be at greater risks than adults when striking a padding surface. Assuming that the leg can be represented as a weightless uniform rod of length L with the lumped mass m of the body attached to it at the hip, determine the impulse exerted by the treadmill on the runner. About a quar- ter of the chemical energy used in muscle contractions goes into per- forming work against external forces. The primary method of assessing energy expenditure during an activity is through the evaluation of exchange of oxygen and carbon dioxide. The amount of oxygen and carbon dioxide exchanged in the lungs normally should equal to that used and released by the body tissues in converting food energy into heat and mechanical work. The carbon and oxygen contents of carbohydrates, fats, and proteins differ dramatically, and therefore the amount of oxygen used during metabolism depends on the type of food fuel being oxidized. This value reflects the minimum amount of energy required to carry out the body’s essential physiological functions. The basal metabolic rate is di- rectly related to the fat-free mass of the body because preserving fat re- quires almost no energy expenditure. The other factors that affect the basal metabolic rate are surface area of the body (the larger the surface area, the higher the rate of heat loss across the skin), age (metabolic rate de- creases with age), body temperature, stress, and various hormones. The body’s ability to gauge muscle needs for oxygen during exercise is not perfect. At the beginning of exercise, the oxygen transport system (res- piration and circulation) does not immediately supply the needed quan- tity of oxygen to the active muscles. The oxygen consumption requires several minutes to reach the required steady-state level while the body’s oxygen requirements increase markedly the moment exercise begins. As a result, after the completion of the exercise, even though muscles are no longer actively working, oxygen demand does not immediately decrease. The amount of energy expended for different activities varies with the intensity and the type of the exercise. Some activities such as bowling or archery require only slightly more energy than when at rest. At the other extreme, sprinting requires so much energy expenditure that it can be maintained for only a few seconds. The energy expenditure per minute during high-speed running and crawl swimming is probably the highest among athletic activities, followed in order by handball, basketball, weight lifting, cycling, and so on. The oxygen consumed during an athletic activity increases in propor- tion to the effort. For example, the oxygen uptake per minute is propor- tional to the speed of running. Eventually, as the speed of running fur- ther increases, the body reaches a limit for oxygen consumption. Even though the work intensity continues to increase, the oxygen consumption peaks and remains constant or drops. This parameter is re- garded as a measure of cardiorespiratory endurance and aerobic fitness. Part of the expenditure of energy during an athletic activity beyond that of the resting level results from the additional demands imposed on the heart and the rest of the circulatory system.

D id the com pany who funded the research provide new equipm ent which would not be available to the ordinary clinician? These factors would not purchase 50mg kamagra fast delivery impotence in the bible, of course generic kamagra 100 mg otc erectile dysfunction johannesburg, invalidate the study itself but they m ay cast doubt on the applicability of its findings to your own practice. Although the term inology of research trial design can be forbidding, m uch of what is grandly term ed "critical appraisal" is plain com m on sense. What specific intervention or other manoeuvre was being considered and what was it being compared with? It is tem pting to take published statem ents at face value but rem em ber that authors frequently m isrepresent (usually sub- consciously rather than deliberately) what they actually did and overestim ate its originality and potential im portance. If you had an incurable disease for which a pharm aceutical com pany claim ed to have produced a new wonder drug, you would m easure the efficacy of the drug in term s of whether it m ade you live longer (and, perhaps, whether life was worth living given your condition and any side effects of the m edication). You would not be too interested in the level of som e obscure enzym e in your blood which the m anufacturer assured you was a reliable indicator of your chances of survival. The m easurem ent of sym ptom atic (for exam ple, pain), functional (for exam ple, m obility), psychological (for exam ple, anxiety) or social (for exam ple, inconvenience) effects of an intervention is fraught with even m ore problem s. The m ethodology of developing, adm inistering and interpreting such "soft" outcom e m easures is beyond the scope of this book. Controls received neither" "W e m easured the use A system atic literature U noriginal study of vitam in C in the search would have found prevention of the num erous previous studies com m on cold" on this subject (see section 8. Rem em ber that what is im portant in the eyes of the doctor m ay not be valued so highly by the patient, and vice versa. System atic bias is defined by epidem iologists G eoffrey Rose and D avid Barker as anything which erroneously influences the conclusions about groups and distorts com parisons. They should, as far as possible, receive the sam e explanations, have the sam e contacts with health professionals, and be assessed the sam e num ber of tim es using the sam e outcom e m easures. Randomised controlled trials In a RCT, system atic bias is (in theory) avoided by selecting a sam ple of participants from a particular population and allocating them random ly to the different groups. Non-randomised controlled clinical trials I recently chaired a sem inar in which a m ultidisciplinary group of students from the m edical, nursing, pharm acy, and allied professions were presenting the results of several in-house research studies. All but one of the studies presented were of com parative but non-random ised design – that is, one group of patients (say, hospital outpatients with asthm a) had received one intervention (say, an educational leaflet), while another group (say, patients attending G P surgeries with asthm a) had received another 64 ASSESSIN G M ETH OD OLOG ICAL QU ALITY Target populations (baseline state) Allocation Selection bias (system atic Intervention group Control group differences in the com parison groups attributable to incom plete random isation) Performance bias (system atic Exposed to Not exposed to differences in the care intervention intervention provided apart from the intervention being evaluated) Exclusion bias (system atic Follow up Follow up differences in withdrawals from the trial) Detection bias (system atic Outcomes Outcomes differences in outcom e assessm ent) Figure 4. I was surprised how m any of the presenters believed that their study was, or was equivalent to, a random ised controlled trial. In other words, these com m endably enthusiastic and com m itted young researchers were blind to the m ost obvious bias of all: they were com paring two groups which had inherent, self selected differences even before the intervention was applied (as well as having all the additional potential sources of bias listed in Figure 4. As a general rule, if the paper you are looking at is a non- random ised controlled clinical trial, you m ust use your com m on sense to decide if the baseline differences between the intervention and control groups are likely to have been so great as to invalidate any differences ascribed to the effects of the intervention. Cohort studies The selection of a com parable control group is one of the m ost difficult decisions facing the authors of an observational (cohort or case-control) study. Few, if any, cohort studies, for exam ple, succeed in identifying two groups of subjects who are equal in age, gender m ix, socioeconom ic status, presence of co-existing illness, and so on, with the single difference being their exposure to the agent being studied. In practice, m uch of the "controlling" in cohort studies occurs at the analysis stage, where com plex statistical adjustm ent is m ade for baseline differences in key variables. U nless this is done adequately, statistical tests of probability and confidence intervals (see section 5. The best outcom e (in term s of prem ature death) lies with the cohort who are m oderate drinkers. But can we assum e that teetotallers are, on average, identical to m oderate drinkers except for the am ount they drink? As we all know, the teetotal population includes those who have been ordered to give up alcohol on health grounds ("sick quitters"), those who, for health or other reasons, have cut out a host of additional item s from their diet and lifestyle, those from certain religious or ethnic groups which would be underrepresented in the other cohorts (notably M uslim s and Seventh D ay Adventists), and those who drink like fish but choose to lie about it. The details of how these different features of "teetotalism " were controlled for by the epidem iologists are discussed elsewhere. Case-control studies In case-control studies (in which, as I explained in section 3. A good exam ple of this occurred a few years ago when a legal action was brought against the m anufacturers of the whooping cough (pertussis) vaccine, which was alleged to have caused neurological dam age in a num ber of infants. A control was an infant of the sam e age and sex taken from the sam e im m unisation register, who had received im m unisation and who m ay or m ay not have developed sym ptom s at som e stage. N ew onset of features of brain dam age in apparently norm al babies is extrem ely rare but it does happen and the link with recent im m unisation could conceivably be coincidental.

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