Here purchase lisinopril 17.5mg line blood pressure of 90/60, again cheap lisinopril 17.5mg free shipping young squage heart attack, the spatula cautery can be used to bluntly dissect the superior constrictor muscle off of the prevertebral fascia purchase lisinopril visa arrhythmia pvc. Inferiorly, the use of the robot gives the surgeon complete visualization of the tongue base, allowing a cuff of tongue base muscle to be included as the inferior margin of the resection (Fig. The styloglossus and sty- lopharyngeus muscles are encountered and care- fully dissected circumferentially and typically transected [9, 17]. Branches of the external carotid, including lingual artery, are encountered 5–8 mm deep to the styloglossus muscle and should be carefully avoided or ligated with surgi- cal clips. The glossopharyngeal nerve can also be iden- tifed at the junction of the posterior tonsillar pil- Fig. While distal branches and ter and instruments on each side oriented at 45° from the even the main trunk may require transection from center camera 7 Transoral Robotic Surgery for Tonsillar Cancer 55 Fig. Blood loss is incidence of bleeding following all transoral typically low for an oncologic resection, aver- robotic surgery has been reported as 9. Patients have short tonsil bed was found to be the second most com- hospital stays, ranging between 1 and 7 days, mon site of bleeding, following the base of tongue. Bleeding can be controlled Anywhere from 0% to 31% of patients require by a variety of methods including silver nitrate tracheotomy at some point during their treatment, cauterization, monopolar or bipolar cauterization, with patients with advanced-stage tumors requir- embolization, and transcervical arterial ligation. Additionally, if performed concur- radiation therapy may beneft from elective tra- rently with the primary tumor resection, the neck cheostomy at the time of surgery. Regional control was sality, lingual nerve numbness, postoperative achieved in 90% and distant control in 100%, trismus, dysgeusia, and cervicalgia. In a larger, If en bloc concurrent resection of primary and multi-institutional study of oncologic outcomes cervical lymph nodes is performed, as opposed to of 410 patients, 2-year locoregional control in staged neck dissection, the risk of creating a fs- tonsillar cancers was 97. The 2-year overall tula to the neck is closer to 30%, and some recon- survival was 95. If a small connection is created (<1 cm), primary closure, tissue sealant, and cervical drain may be suff- 7. If a larger defect is created, primary closure can be attempted, and local mus- Dysphagia is a frequently cited adverse effect of cle coverage using the digastric, mylohyoid, and/ treatment for tonsillar cancer. At 18 months after sur- dard monopolar and bipolar cautery tools, hemo- gery, nearly all patients continue to take an oral stasis clips, and the use of a capable bedside diet without the use of a feeding tube . Anderson Dysphagia Inventory) scores than Indeed, since 2009, evidence from the those patients treated with primary chemoradia- National Cancer Data Base shows that surgi- tion at 6 and 12 months after surgery. Although References there are reports of its use in more advanced tumors, one of the major benefts of utilizing 1. Primary surgery as robotic surgery is that it obviates the need for treatment for early squamous cell carcinoma of the tonsil. Kelly K, Johnson-Obaseki S, Lumingu J, Corsten invasive robotic surgery following chemoradiation M. Oncologic, functional and surgical outcomes of therapy due to the extent of recurrence . Robotic surgery for oro- lenging in minimally invasive robotic approaches pharyngeal cancer. Electrocoagulation in epitheliomas of the vessels are likely to be encountered in the oro- tonsils. Transoral laser microsurgery for squa- 7 Transoral Robotic Surgery for Tonsillar Cancer 59 mous cell carcinoma of the base of the tongue. Transoral robotic surgery robotic surgery for oropharyngeal squamous cell carci- alone for oropharyngeal cancer: an analysis of noma: a prospective study of feasibility and functional local control. Demonstration of transoral logic results of transoral robotic surgery for oropha- surgery in cadaveric specimens with the medrobotics ryngeal squamous cell carcinoma. Chemoradiation has resulted in equivalent Transoral approaches were technically challeng- oncologic control rates to those of open resection ing due to limitations in visualization and the techniques . With the success of chemoradia- acquisition of hemostasis, frequently resulting in tion techniques and the aforementioned chal- incomplete resections. Open approaches were lenges associated with older transoral and open looked upon unfavorably due to the relatively techniques, surgery was mostly relegated to high morbidity associated with lip split and man- application in salvage scenarios. In spite of its dibulotomy required for access, in addition to the increased utilization, chemoradiation has its need for tracheotomy and gastrostomy tubes. While these tri- and healthier patients than their historical coun- als were designed to demonstrate the effcacy of terparts whose tumors were due to tobacco and organ preservation therapy in the larynx, the alcohol exposure. After offce examination and maintaining excellent oncologic control and the acquisition of axial imaging techniques, improving long-term functional outcomes. Technological improvements, particularly adequate exposure can be obtained to perform a in the feld of transoral robotic surgery, have transoral resection. Following a staging exami- resulted in superior visualization due to innova- nation, the patient can be scheduled for resection tions in the optics of the endoscopes, tremor fl- of both the primary tumor and the draining tration, motion scaling, and increasingly agile regional lymphatics. When compared to beyond the scope of this chapter, surgeons have prior open techniques, transoral approaches offer the options of either staged or concurrent neck several benefts including decreased morbidity, dissection often combined with ligation of the decreased blood loss, shorter operative times, and external carotid arterial supply to the area of the decreased hospital stay . Consequently, there has been from the superior thyroid artery which often a trend in multiple centers nationally toward a supplies the vallecula. Oncologic contraindications include The new algorithm of applying surgery up front T4b disease, fxation to the retro- or parapharyn- in the treatment of tongue base cancers utilizes geal tissues, unresectable neck disease, and dis- neck dissection as well as transoral resection of tant metastatic disease. Patients with tongue base within the tongue base include the need to spare cancers are frst assessed with the in-offce the contralateral lingual vascular pedicle. In examination, including a fexible fberoptic order to preserve swallowing function, tumors examination and palpation of the tongue base that extend beyond 50 % of the tongue base are lesion to assess the extent of the tumor. Accurate considered poor surgical candidates due to the understanding of the extent of the tumor requires risk of future aspiration risks. If none of as it relates to the lingual pedicle as well as the these conditions exist, then the patient is consid- ability to assess the extent toward the midline of ered a candidate for resection. After adequate visualization is obtained, the endotracheal tube The patients should be intubated by an experi- is secured between the contralateral oral tongue enced anesthesiologist often with the use of a and the retromolar trigone with a silk suture that GlideScope or other fberoptic approaches as we keep long and attached to a clamp so it is not injury to the tongue base during intubation may forgotten about during extubation (Fig. A wire-reinforced endotracheal tube is required that should be secured contralaterally; our preference is to sew the tube to the contralateral melolabial crease to ensure it is not dislodged during the resection. Our preference is to give antibiotic prophylaxis with broad-spectrum anti- biotics that cover anaerobes within the upper aerodigestive tract. Our protocol includes the use of Unasyn in penicillin-tolerant patients and clindamycin in penicillin-allergic patients. A tongue stitch is applied anteriorly to retract the tongue anteriorly and aid in place- ment of the retractor. Adequate exposure includes visualiza- tion of an acceptable cuff of tongue base anteri- Fig. View from head of bed with intubated orly to ensure a clear margin as well the epiglottis patient in suspension with robotic arms in proper to aid in the medial and inferior incisions through orientation, demonstrating suture securing the vallecula. Our approach has always been have the tendency to carry their anterior cut too to perform a standard resection in the same manner superfcial and risk transecting the specimen in each time to make the resection easier to replicate the vallecula.
This capacity is related theoretically to the psychoanalytic construct of the “superego buy online lisinopril heart attack the alias club remix,” the mental agency concerned with self-approval and disapproval based on approximating one’s ego ideal purchase lisinopril paypal pulse pressure locations. Emotional interactions with caregivers influence the internalization of ideals purchase lisinopril 17.5mg on-line arteria gastroepiploica dextra, and consequently the development of moral competencies, ethical actions, and empathy. Schore (2003) posits that internal standards develop from early shame experiences: When a shame experience becomes humiliation because of a caregiver’s lack of attun- ement or inability to repair disruptions, secure attachment is compromised, along with the construction of flexible, integrated, and realistic internal standards. Neu- roscientific studies, including research on mirror neurons, support the importance of early relational experiences: The neural network underlying moral decisions appears to overlap with the network representing others’ intentions (i. Internal standards and ideals internalized early in life through interactions with caregivers are elaborated and refined in later interactions with peers and models (e. In rating this capacity, clinicians should consider the flexibility with which 114 I. High functioning requires that an individual’s moral reasoning be based not only on a set of cohesive core principles, but also on awareness of the impact of one’s decisions on others. The individual’s internal standards seem flexible and integrated with a realistic sense of the person’s capacities, values, ideals, and social contexts. Internal stan- dards support meaningful striving and feelings of authenticity and self-esteem. Feelings of guilt are balanced with a measure of self-compassion, and so are used as signals for reappraising one’s behavior. Internal standards and ideals are somewhat rigid and inflexible, or variable and inconsistent across contexts, driven more by the person’s needs, desires, and feel- ings than by a coherent set of moral guidelines. They are not fully integrated with a realistic sense of one’s capacities, values, and ideals or with social contexts. The individual’s self-esteem oscillates, and feelings of guilt are experienced more as paralyzing self-criticism than as signals for reappraising behavior. Internal standards and ideals seem either absent or rigid and inflexible, based on harsh, punitive expectations. The person lacks a realistic sense of his or her capaci- ties, values, and ideals, and is unintegrated with the social context and cultural milieu. The moral sense seems to have either an insignificant or a tyrannical role in organizing self-experience and in how the person interprets behavior of self and others. Feelings of guilt, if present at all, are not balanced with compassion and objective criticism; self and others are often viewed as “totally bad” or “totally good. Seven stories of moral dilemmas show conflicts among needs, wills, and desires of protagonists. Six motives are introduced for each decision; subjects assess the importance of each motive. Based on a semistructured interview and an extensive review of life records, items are scored on a 3-point scale (0 = not present, 1 = somewhat present, and 2 = definitely present). According to the four-factor model of psychopathy (Hare & Neumann, 2008), 18 of Profile of Mental Functioning—M Axis 115 the 20 items can be seen as representing four underlying constructs or first-order fac- tors: deceitful and manipulative (interpersonal factor); emotional detachment (affec- tive factor); reckless, impulsive, and irresponsible (lifestyle factor); and propensity to violate social norms (antisocial factor). The interpersonal and affective components, on the one hand, and the lifestyle and antisocial components, on the other, load on two second-level factors (Hare & Neumann, 2008). It has two 15-item subscales: The first measures the relevance ascribed to each foundation on a 7-point response scale (anchored by 1 = not at all relevant and 7 = extremely relevant); a sample item is “whether or not some people were treated differ- ently than others. It consists of two positively correlated scales: primary psychopathy (16 items), and secondary psychopathy (10 items). Agree- ment with each item is assessed via a Likert-type scale from 1 (strongly disagree) to 5 (strongly agree). Takes advantage of others; is out for number one; has minimal investment in moral values; 15. Tends to show reckless disregard for the rights, property, or safety of others; 39. Appears to gain pleasure or satisfaction by being sadistic or aggressive toward others (whether consciously or unconsciously); 57. Tends to be self-critical; sets unrealistically high standards for self and is intolerant of own human defects; 113. Appears to want to “punish” self; creates situations that lead to unhappiness, 116 I. Capacity for Meaning and Purpose The final capacity reflects the ability to construct a narrative that gives cohesion and meaning to personal choices. It includes a feeling of individuation, a concern for suc- ceeding generations, a capacity for psychological growth, and a spirituality (not nec- essarily traditional religiosity) that imbues one’s life with direction and purpose. It involves the ability to think beyond immediate concerns and grasp the broader impli- cations of one’s attitudes, beliefs, values, and behaviors. Individuals functioning at a high level of this capacity show a strong sense of direction and purpose; a coherent personal philosophy that guides decisions; com- fort with personal choices, including those that do not produce expected outcomes; acceptance of alternative viewpoints, even when these conflict with their own; a well- developed capacity for mentalization, reflected in sensitivity to others’ attitudes, val- ues, thoughts, and feelings; the ability to transcend immediate concerns and grasp “the big picture”; and a childlike curiosity, wonder, and freshness of perspective. Individuals at this level show a clear, unwavering sense of purpose and meaning, along with an intrinsic sense of agency and the ability to look outside the self and transcend immediate situational concerns. At this level, individuals show some sense of purpose and meaning, along with periods of uncertainty and doubt. The broader implica- tions of attitudes and beliefs are grasped, and alternative perspectives are accepted in certain conflict-free domains. Individuals at this level show lack of direction, aimlessness, and little or no sense of purpose. When asked, they are unable to articulate a cohesive personal philosophy or set of life goals. Whether or not they are aware of their lack of direction, they experience pervasive isolation, meaninglessness, alienation, and anomie. Grounded in Csikszentmihalyi’s (1990) nine-dimensional concept of flow, the scales measure challenges–skills balance, action–awareness merging, clear Profile of Mental Functioning—M Axis 117 goals, unambiguous feedback, concentration on task, sense of control, loss of self- consciousness, time transformation, and autotelic experience (sense of purpose and curiosity). Twelve subscale scores tap a range of traits, including inner-directedness, existentiality, spontaneity, self-acceptance, and capacity for intimacy. It enables clinicians to generate ratings of self-attributions and complexity of self-representation and to track changes in these areas over time (see Bers, Blatt, Sayward, & Johnston, 1993; Blatt, Auerbach, & Levy, 1997). It can also be used as a prompt for discussing the patient’s goals, aspirations, and feelings about past, present, and future events. Scores predict the individual’s behav- ior in several areas related to meaning and purpose, including empathy, forgiveness, self-direction (agency), warmth, and conscientiousness. Subscales relevant to meaning and purpose include self-acceptance, enlightened second nature, compassion, pure-hearted conscience, transpersonal identification, and spiritual acceptance. Summary of Basic Mental Functioning: M Axis To obtain a rating of a patient’s overall mental functioning, a clinician should add up the 5–1 point ratings assigned to each capacity (Table 2. This total permits provisionally assigning a patient to one of the categories outlined in Table 2. Schematically, healthy mental functioning corresponds to M01; neurotic to M02 and M03; borderline to M04, M05, and M06 (from high to low, from moderate impairments to significant defects); and psychotic to M07. Capacity for self-esteem regulation and quality of internal experience 5 4 3 2 1 7. Levels of Mental Functioning Level; range Heading Description Healthy M01; 54–60 Healthy/optimal mental Optimal or very good functioning in all or most mental capacities, with functioning modest, expectable variations in flexibility and adaptation across contexts. Neurotic M02; 47–53 Good/appropriate mental Appropriate level of mental functioning, with some specific areas of functioning with some difficulty (e.
However buy 17.5mg lisinopril overnight delivery heart attack zippy demi, there is a risk of bias lisinopril 17.5mg fast delivery heart attack jaw pain, as the sampling interval may coincide with a systematic variation in the sampling frame generic lisinopril 17.5 mg with mastercard heart attack low. For instance, if we want to select a random sample of days on which to count clinic attendance, systematic sampling with a sampling interval of 7 days would be inappropriate, as all study days would fall on the same day of the week (e. Stratifed Random Sampling The simple random sampling method described above has disadvantage that small groups in which the researcher is interested may hardly appear in the sample. If it is important that the sample includes representative study units of small groups with specific characteristics (for example, residents from urban and rural areas, or different religious or ethnic groups), then the Sampling Methods 133 sampling frame must be divided into groups, or strata, according to the characteristics. Random or systematic samples of a pre-determined size will then have to be obtained from each group (stratum). Stratified sampling is only possible if proportion of each group of the study population is known. Example: A survey is conducted on household water supply in a district comprising 20,000 households, of which 20% are urban and 80% rural. It is suspected that in urban areas the access to safe water sources is much more satisfactory. A decision is made to include 100 urban households (out of 4000, which means 1 in 40 households) and 200 rural households (out of 16000, which mean 1 in 80 households). As the sampling fraction for both strata is now known, the access to safe water for all the district households can be calculated after the study (by multiplying the findings for the urban households by 40 and those for the rural households by 80, and then calculating statistics for the total sample). Cluster (area) Random sampling It may be difficult or impossible to take a simple random sample of the units from the study population at random, because complete sampling frame does not exist. The selection of groups of study units (clusters) instead of the selection of study units (individuals) is called Cluster sampling. Using this list, a random sample of villages is chosen and all study units in the selected villages are interviewed. This is often the case in community-based studies, in which people are to be interviewed from different villages, and the villages have 134 Research Methodology for Health Professionals to be chosen from different areas. Example: In a study of utilization of pit latrines in a district, a total of 150 households are to be visited for interviews with family members as well as for observations on types and cleanliness of latrines. Since simply choosing house- holds in the centre of the village would produce a biased sample, the following sampling procedure is proposed: • Go to the centre of the village. If you reach the boundary of the village and you still do not have 10 households, return to the centre of the village, walk in the opposite direction and continue to select your sample in the same way until you have 10. Decide beforehand whom to interview (for example the head of the household, if present, or the oldest adult who lives there and who is available). The main advantages of cluster and multi-stage sampling are that: • A sampling frame of individual units is not required for the whole population. Only within the clusters that are finally selected is there a need to list and sample the individual units (if not using the bottle spinning method). However the disadvantage of Multi-stage sampling is: Compared to simple random sampling, there is a larger probability that the final sample will not be representative of the total study population. The likelihood of the sample not being representative depends mainly on the number of clusters that is selected in the first stage. The larger the number of clusters, the greater is the likelihood that the sample will be representative. Further, the sampling units at community level should be selected randomly (avoid convenience sampling! Sampling Methods 135 multi-phase sampling In this method, part of the information is collected from the whole sample and part from the sub sample. This may happen at the beginning of a study when researchers are merely orienting themselves, or, when there are many similar informants and the researchers do not have a preference for specific categories. When there seems no other choice (no one else available for an interview) researchers may also sample conveniently. Often different strategies are combined, depending on the topic under study, the type of information wanted and the resources of the investigator(s). Extreme case sampling: Selection of extreme cases, such as good or very poor compliers to treatment, is a powerful and rapid strategy to identify contributing factors to poor compliance. In the same way, selection of well-nourished children of the same age will help to identify contributing factors for malnutrition. Quota sampling: In quota sampling, we select people non- randomly according to some fixed quota. There are two types 136 Research Methodology for Health Professionals of quota sampling: Proportional and non-proportional. In proportional quota sampling we want to represent the major characteristics of the population by sampling a proportional amount of each. For instance, if we know the population has 40% women and 60% men, and we want a total sample size of 100, we will continue sampling until we get those percentages and then we will stop. In this method, we specify the minimum number of sampled units we want in each category. Instead, we simply want to have enough to assure that we will be able to talk about even small groups in the population. This method is the non-probabilistic analogue of stratified random sampling in that it is typically used to assure that smaller groups are adequately represented in the sample. In order to obtain insight in how stigma manifests itself in different cultures in males and females, in rural and urban areas, in well-to-do and poor patients, or in educated and illiterate ones, an investigator has to take care that all these groups are included in the sample. To assess whether social distance influences stigma, one could also interview blood relatives (parents or children), spouses, friends, near neighbors of patients and more distant community members. Homogeneous sampling: If someone likes to have specific information about one particular group only, such as, a group which, for unclear reasons, is more at risk than others: For example, in a country, death registers indicate that suicide among adolescents is on the increase at an alarming rate and within that group twice as many boys as girls commit suicide. Researchers may, therefore, want to concentrate on the boys to identify what factors may be contributing to these suicides, conducting in-depth interviews with parents, other close relatives, teachers and friends of a number of boys who committed suicide. Such descriptions are merely illustrative; they cannot be generalized for the whole group. Typical examples can either be selected with cooperation of key informants who know the study population well, or from a survey that helps to identify the normal distribution and the pattern of the characteristics we are interested in. Example: An investigator has developed a local weaning food that is considered to be affordable to all mothers. If they manage to produce and use it, this will indicate that it is affordable to the whole group. Snowball or chain sampling: This approach is particularly suitable for locating key informants or critical cases. We start with one or two information-rich key informants and ask them if they know persons who know a lot about the topic of interest. If a particular person is recommended by two or three different people one can be quite sure that he or she will be a valuable key informant. The same approach can be used if an in-depth interview leads to discoveries, which seem rewarding to follow-up by a number of interviews with an additional group of informants. The researcher then interviewed more adolescent boys and girls heading households, to see whether this gender difference in ability to cope was real, and how it could be explained. Patton labeled this kind of additional sampling during the study opportunistic sampling. It is exactly the opposite of the random sampling techniques discussed in the next section of 138 Research Methodology for Health Professionals this module, which are used in quantitative research to ensure representativeness of the sample for the total population.
By X. Kurt. Andrews University. 2019.