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Sample size is usually not predetermined in such a case best erectile dysfunction pills uk order 20 mg adcirca mastercard, and the power of the samples used in qualitative studies reflects the robust richness of the textual data. Data collection usually continues until the researcher observes saturation or redundancy, or until nothing new is coming to light or being observed. Data analysis is conducted in a variety of ways, but usually produces findings that are richly descriptive in textual or thematic language. Choosing from among the many qualitative methods available requires that the researcher have an understanding of his or her disciplinary focus. Each area has its own complexity and methodology (a topic that goes beyond the scope of this chapter). For an easier understanding of some of the basic methods, the various qualitative research approaches have been organized here using general categories adapted from Polit and Beck (2012) to reflect the area of knowledge they explore. Understanding the Experiences and Processes of Health and Illness Many research questions in the healthcare realm address what it is like to go through a certain health event, for the purpose of helping us find ways to improve life for others who have similar experiences. These approaches focus on understanding the basic experiences and processes of how a person moves through the event. The methods used in such investigations come from the traditions of philosophy and sociology. The focus is on understanding what it is like for this person to be in this experience within the context of his or her life. These approaches range from understanding how people make sense of their social interactions (symbolic interaction) to discovering how social processes are structured and developed (grounded theory). Charon (1992) describes four central foci of symbolic interactionism: · the nature of the social interaction · Human action that both causes and results from social interaction · Present rather than past focus · Actions of the person who is unpredictable and active in his or her world Grounded theory was developed by Glaser and Strauss in the 1960s as a research method that addresses both the chief concern or problem for people and the basic processes available to address that concern (Glaser, 1978, 1992; Strauss & Corbin, 1998). The goal of this approach is to develop theory in a substantive area that is grounded directly in the data. Grounded theories "are likely to offer insight, enhance understanding, and provide a meaningful guide to action" (Strauss & Corbin, 1998, p. Understanding Human Behavior the tradition of psychology focuses specifically on how and why people act; its aim is to describe behavior. Studying human behavior can help us understand how behaviors are related to health and illness. Ethology examines the evolution of human behavior in its natural context (Polit & Beck, 2012); with this methodology, observations of human Using Evidence to Support Clinical Practice 49 behavior are used to expose structures essential to life. This observational approach can also be used from an environmental perspective, as in ecological psychology. Ecological models examine the relationship of environmental influences with specific human attributes (Humpel et al. Learning how people communicate is another approach to learning about human behavior. To explore the construction of meaning in the nuances of these processes, researchers use methods derived from both sociology and linguistics. Sociolinguistics is the examination of the forms and rules of conversation through discourse analysis (Polit & Beck, 2012). Mishler (1984) proposes that by examining the dialogue between clinicians and patients, we can encourage the development of noncoercive discourse and humane clinical practice. Understanding Cultural Traditions and Influences One of the oldest qualitative traditions comes from the field of anthropology, where scientists strive to understand cultural variations among the many peoples of the world. Although several approaches are used in this disciplinary area, ethnography is the most commonly employed. For example, Carney (2015) used ethnography to examine barriers that undocumented migrant Mexican and Central American women face in feeding their families and accessing formal health care, and their intersection with private food assistance programs. Synthesizing Qualitative Research Findings Meta-synthesis is another qualitative method. This research method analyzes, synthesizes, and interprets a specified body of research and holds the potential to provide valuable insight and knowledge about the distinctive aspects of a phenomenon (Kennedy, Rousseau, & Kane Low, 2003). It shares some commonalties with the type of meta-analysis conducted in quantitative research, but is distinguished by some important differences. Meta-synthesis provides an organized, yet interpretive approach to a specific group of qualitative studies (Korhonen et al. Sandelowski and her colleagues (1997) note that it is essential to systematically examine qualitative findings about a specific phenomenon to keep from repeating ourselves if we are to change practice and policy making. The meta-synthesis method involves identifying similar qualitative studies about a particular phenomenon, determining how they are related, and synthesizing their findings.

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C: the high-power view shows cytologic detail of the mantle lymphoma cells with a histiocyte nucleus (H) for size comparison impotence natural supplements order generic adcirca online. This peripheral blood smear shows medium to large atypical lymphoid cells with fine chromatin. The blastoid variant of mantle cell lymphoma is associated with a poor prognosis and p53 mutation. A: this lymph node is effaced by a nodular expansion of medium-sized lymphoid cells with a closed chromatin pattern and fairly regular nuclear contours. B: Low-power view of a reticulin-stained lymph node section highlights the nodular pattern of involvement. C: Admixed with the mantle lymphoma cells are occasional follicular dendritic cells, one delineated by an arrow showing classic "kissing" nuclei. Low- (A and C) and high- (B and D) power views of bone marrow biopsies from two cases of mantle cell lymphoma. The pattern of marrow involvement and the cytologic appearance of mantle cell lymphoma can be quite variable. Two different cases are demonstrated here, with one revealing a nodular pattern of infiltration (A and B) and the other displaying a diffuse pattern (C and D). Highpower views show small- to medium-sized (endothelial nuclei for comparison are delineated by arrows) lymphoma nuclei with condensed chromatin pattern and slightly irregular nuclear contours. The ideograms of chromosomes 11, 14, and the respective derivative chromosomes are illustrated on the left in color, and the corresponding G-banded chromosome pairs are on the right. This gross splenectomy specimen shows tiny macroscopically visible neoplastic nodules of follicular lymphoma diffusely involving the entire spleen. An enlarged submandibular lymph node shows numerous follicles of varying size that do not appear crowded. Focally (blue arrow), the lymphoid tissue extends outside the capsule into adjacent adipose tissue. This extracapsular tissue, however, contains reactive follicles similar to the follicles inside the capsule. The follicles contain prominent, well-defined germinal centers that have a reactive appearance, with frequent tingible body macrophages (black arrows) and mitotic lymphocytes (red arrow). Fibroadipose tissue is involved by crowded, diffusely distributed, uniformly sized aggregates composed almost exclusively of wellspaced centrocytes with cleaved nuclear contours. For comparison, the lower right corner of the bottom right smear shows benign centrocytes with regularly contoured nuclei and condensed chromatin (arrows). The lymph node architecture is completely effaced by uniform, crowded follicles, some of which merge into each other. Focal invasion into the capsule, without extension into perinodal tissue, is present. The neoplastic follicles consist of small cleaved (centrocytes) and large noncleaved (centroblasts; red arrows) cells. This lymph node shows numerous uniformly spaced and sized nodules composed almost exclusively of large nucleolated centroblasts. Squeezed between the malignant nodules of centroblasts are linear arrays of centrocytes. A retroperitoneal lymph node is replaced by numerous, back-to-back lymphoid follicles that often merge together. The follicles consist of monotonous, intermediate to large cells with irregular nuclei, vesicular chromatin, small distinct nucleoli, and scanty, basophilic cytoplasm. The proliferation extends through the lymph node capsule into surrounding adipose tissue (arrow). Medium-sized atypical lymphoid cells with cleaved nuclei are present in this aspirate from a marrow 553 replaced by follicular lymphoma. A and B: this bone marrow biopsy demonstrates extensive involvement by follicular lymphoma, with the multiple paratrabecular lymphoid aggregates closely hugging bony trabeculae. C: Closer inspection reveals that the lymphoid infiltrate consists primarily of small lymphocytes with coarse chromatin pattern and irregular nuclear contours. A: Medium-power view of biopsy from a case of follicular lymphoma show the characteristic paratrabecular aggregates. Nuclear morphology of chronic lymphocytic leukemia (A), follicular lymphoma (B), and large B-cell lymphoma (C) lymphocytes in biopsy.

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Because no well-defined immunophenotype exists in mixed phenotype acute leukemia cheap erectile dysfunction pills uk 20 mg adcirca purchase with amex, these cases must be evaluated on a case-by-case basis. Finally, both mixed phenotype acute leukemia and acute bilineal leukemia should be distinguished from undifferentiated acute leukemia. These neoplasms are defined by lymphoblast morphology and confirmed by immunophenotype. Whereas a population of some sIg+ and some sIg+ reactive B cells is called polytypic, a neoplastic population with only sIg+ or sIg+ is called "monotypic. For example, an sIgk+ lymphoma may exist in a specimen with a relatively large number of nonneoplastic B cells; because the background B cells have a normal:, the overall ratio may be skewed only slightly or not at all, depending on the size of the neoplastic population. In such cases, permeabilizing the cells and assessing cytoplasmic immunoglobulin light chain expression often shows clear monotypic expression. Whereas the process of B-cell ontogenic maturation is limited to peripheral lymphoid organs, T-cell populations are highly plastic at all sites. Also, temporary "abnormal" T-cell populations commonly arise during immune reactions and can be seen in numerous clinical scenarios in patients with different kinds of illnesses. Because any clinically relevant neoplasm is an abnormal growth, diagnosis of a neoplasm must be based upon demonstration of an expanded population. Although it involves skin and marrow, because it is typically leukemic, a blood sample usually is submitted for diagnosis. Because most patients are asymptomatic, a definitive diagnosis is not usually required. The diagnosis of lymphoma is typically easy to make on the basis of a large population of circulating and/or infiltrative, markedly atypical lymphoid cells. For these reasons, bone marrow core biopsy immunostaining is the best and most accurate technique for analysis of myeloma (see below). Because "junk" and dead cells typically fall on that line, in general, populations of cells in that location would be assumed to be "background," not representing true expression. An important concept that should be emphasized is that, consequent to the action of therapeutic drugs, often, the immunophenotype of the cancer cells changes after therapy. In others, there are subtle changes, like a decrease or increase in the level of expression of an antigen. In some cases, the changes are relatively dramatic, prompting reversion to genetic analysis, to prove the relationship to the prior cancer. The methods described are proprietary, requiring specific, nonstandard processing machinery, reagents, and cytometers; as such, the published methods for circulating tumor cell detection cannot be performed in a 90 standard laboratory. After the collection, the photographed events are visually examined by a technologist, who decides whether the "positive event" is actually a tumor cell. Moreover, its use seems to be waning and there are questions about the efficacy of the information. The advantages are cost savings due to the use of far less reagents and labor savings due to not having to maintain the flow cytometry apparatus. The downside is that, because the aliquots in the wells are so small, the number of cells analyzed is far less. Still, for most specimens, laser scanning cytometry works well for diagnostic purposes. The reasons for such limited use are not known, but may be due to resistance to change platforms and/or to a lack of effective marketing from laser scanning cytometry manufacturers. Although some practitioners are adept at analysis of maturation patterns for diagnostic purposes and have supported its use since the late 1990s, this technique has never found widespread acceptance for diagnostic purposes or been included in any well accepted scheme for diagnostic criteria. Unlike solid organs, in which most of the cells in a biopsy are tumor cells, in hematopoietic lesions, the cells of interest are admixed with large populations of background cells. For most purposes, a skilled practitioner can find a population of interest on one slide, then look at another slide and discern whether the second antigen is expressed by the population of interest, by inference from the spatial location in the tissue. In t(11;14), the Ig heavy chain gene regulatory elements on chromosome 14 cause massive overexpression of cyclin D1 by acting on the translocated gene.

Syndromes

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• Clubbing (thickening of the nail beds) on toes and fingers (late sign)
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Because of the Hyde Amendment erectile dysfunction and high blood pressure order adcirca american express, which prohibits the use of federal funds to pay for abortion services, in 33 states and the District of Columbia, women who are Medicaid recipients must also use alternative sources to pay when they have an abortion. Given that the average cost of a first-trimester abortion in the United States is approximately $500 (Jones & Jerman, 2014), this may represent a prohibitive expense for many women. In some cases, this cost has been linked to delays in obtaining services (Roberts et al. Nationally, a number of independent state and national funds have been established to assist women who are seeking but are unable to afford an abortion. For information on these funds, refer to the National Network of Abortion Funds (Box 17-3). In early abortions, evacuation of the uterus can be completed in a few minutes and through the use of suction alone. Some clinicians choose to curette the walls of the uterus after suctioning (a process referred to as dilation and curettage [D & C]) to ensure that the procedure is complete. However, because D & C has been associated with increased rates of complications and has no demonstrable benefits, the World Health Organization has recommended that this technique be replaced by suction alone for first-trimester abortions (Meckstroth & Paul, 2009). Research has shown D & E to be at least as safe and less physically and emotionally stressful for patients as labor induction (Hammond & Chasen, 2009; Henshaw, 2009). However, because second-trimester D & E requires more advanced training, the decision to employ labor induction instead of D & E may be based on clinician availability rather than patient preference or other medical considerations (Hammond & Chasen, 2009; Jerman & Jones, 2014). It may be accomplished either by inserting dilating rods of increasing diameter into the cervical os immediately prior to inserting the cannula or by placing osmotic dilators into the cervix several hours to a day before the procedure. In general, osmotic dilators are used in later abortions, although clinician Unintended Pregnancy 411 training and experience may guide this decision as well. Oral or vaginal pharmacologic agents, such as misoprostol, are also used in some settings to promote cervical softening and subsequent dilation (Meckstroth & Paul, 2009). In the United States, women are offered various options for pain relief during and following aspiration and D & E abortions. In most settings, a paracervical block is routinely administered prior to cervical dilation and is promoted as a standard of care (National Abortion Federation, 2015). In addition, many sites offer women options of intravenous or oral pain medications; in some facilities, general anesthesia is available. Studies suggest that the use of intravenous and general anesthesia increases patient satisfaction, contributes to faster recovery and improved physiologic benefits for patients, and may positively influence operative conditions for clinicians (Nichols, Halvorson-Boyd, Goldstein, Gevirtz, & Healow, 2009); however, these benefits must be weighed against the risks associated with the use of anesthesia. Nonpharmacologic approaches, including positive suggestion, relaxation, and guided imagery, have also been used successfully to decrease pain, including for women undergoing abortion (Nichols et al. There is a growing movement of "full-spectrum" and abortion-specific doula care providers in the United States. While no studies to date have been conducted that prove their presence reduces pain, intuitively such support would seem likely to help ameliorate the overall stressful experience that many women have when undergoing an abortion, possibly including with respect to pain. Table 17-5 provides more information on this option and ways to find a doula to support a woman who is having an abortion. Recovery after an abortion depends on the type of procedure and anesthesia used, the gestational age of the pregnancy, and whether the woman has any preexisting medical or psychosocial conditions or experienced any complications during the procedure. After an uncomplicated early abortion in which only local anesthesia was used, a woman may be able to leave the facility as soon as 20 minutes after the procedure. Greater levels of anesthesia generally require longer periods of stabilization and monitoring. Before discharge, women are instructed that they may resume regular activity as soon as they feel ready, although they are usually advised to not engage in sexual intercourse, rigorous exercise, or lifting heavy objects for a few days to a week after the procedure. Some abortion services providers advise women to return to the facility where the abortion was performed or to their primary care provider for a routine examination 2 to 3 weeks after the procedure to ensure a complete and uncomplicated recovery, assess emotional well-being, and initiate or follow up on any newly established contraceptive method. There is also little evidence to support this practice, which is costly for both women and the healthcare system. Alternative approaches for follow-up care have been suggested, including better patient education regarding self-monitoring for post-abortion complications and improved delivery of contraceptive services at the time of the abortion (Grossman, Ellertson, Grimes, & Walker, 2004; Kapp, Whyte, Tang, Jackson, & Brahmi, 2013). Currently, nearly one-fifth of all abortions performed in the United States are achieved through the administration of mifepristone in conjunction with misoprostol (Pazol et al.

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