By O. Quadir. Georgia Southwestern State University.

Modern cars have powerful headlights which provide a clear view of the road ahead even without overhead lighting buy 20mg cialis sublingual with mastercard. There is also evidence to suggest that when drivers move from an area with lighting to an area without they are more likely to have an accident than those drivers who have driven exclusively on roads without lighting cheap 20mg cialis sublingual with amex. D Research suggests that older drivers find driving without lighting more difficult discount cialis sublingual 20mg otc. There is evidence that there are fewer daytime accidents on those motorways without E lighting purchase 20 mg cialis sublingual visa. The grey squirrel cheap 20mg cialis sublingual with visa, a small, tree-dwelling rodent introduced to Britain over a century ago, is breeding so rapidly that the native red squirrel is disappearing. Encouraging the consumption of the grey species as food may help protect the red one, in her view. However, we can challenge this, as it is all just a cheap publicity stunt to increase business in the restaurant. Which one of the following is the best statement of the flaw in the above argument? D It assumes the disappearance of the red squirrel justifies eating the grey squirrel. They need a stable environment and clean water, uncontaminated by perfume or lotions. There should be a complete ban on this type of pedicure, or else there will soon be no garra rufa. Which one of the following is the best statement of the flaw in the above argument? Badgers are animals believed to be responsible for the spread of bovine tuberculosis which results in large numbers of cows having to be destroyed every year. Animal rights supporters have criticised the proposal, but it is clear that the lives of more cattle can be saved by destroying a smaller number of badgers. Which one of the following is the best statement of the flaw in the above argument? It assumes that the arguments from the animal rights supporters are about the number of A deaths. It assumes that the animal rights supporters believe that badgers have a greater right to B life than cows. It assumes that the animal rights supporters believe that animals that are living freely C have a greater right to life than those that are being bred on farms. However, some observers report that the real number of accidents may be much higher than is shown in the official records as many accidents are not reported by drivers. They also say that during the time when accident figures have decreased, the number of people going to hospitals because of road accidents has stayed constant. Positive views about continually improving road safety may not be supported by what A actually happens. B Government programmes have been unsuccessful in reducing the number of accidents. Hospital admissions are a good way of measuring changes in the number of accidents C on our roads. Biology 41 The following organelles are involved in processing amino acids into glycoprotein: 1. A ii and v B ii and iv C i and iii D iii and v E i and iv 46 Which one of the following molecules will contain the greatest number of different elements? Which one of the following pairs of elements is most likely to form a covalent bond? A first = slightly exothermic; second = very endothermic B first = slightly exothermic; second = very exothermic C first = slightly endothermic; second = very exothermic D first = slightly endothermic; second = very endothermic E first = very exothermic; second = very exothermic 64 In the following reactions, which substances are acting as oxidising agents? A 3 only B 1 only C 2 only D 2 and 3 only E none 66 What is the total number of electrons in the ions of sodium chloride? Amines Amides Row 1 Ethanoic acid reacts does not react Row 2 Nitrous acid reacts reacts Row 3 Sulphuric acid does not react hydrolyses A Rows 1 and 2 B None of the rows C Rows 1 and 3 D Rows 2 and 3 E All of the rows 68 Consider the following reactions. Physics and Mathematics 70 In a group of students, exactly 2 are male and exactly 1 study mathematics. The probability that a 5 3 male student chosen at random from the group studies mathematics is p. The transformation R is a rotation about the origin and maps A to B, B to C, C to D, etc. A R R S R S R B R S R S C S R D R S R R E S R R S R S 72 The line L has equation y = 2x - 1.

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Alternans Pulsus alternans describes a pulse with alternating strong and weak beats cialis sublingual 20 mg visa. Bisferiens This is the waveform that reults from mixed aortic stenosis and regurgitation purchase cialis sublingual 20mg fast delivery. The percussive wave P T (P) is due to ventricular systole buy cialis sublingual 20 mg otc, the tidal wave (T) is due to vascular recoil causing a palpable double pulse i cialis sublingual 20mg fast delivery. Paradoxus This is an accentuation of the normal situation with an excessive and palpable fall of the pulse Inspiration pressure during inspiration order cialis sublingual 20mg mastercard. Once the atrium is filled with blood it contracts to give the ‘a’ wave a The ‘a’ wave is lost in atrial fibrillation. The ‘a’ wave is increased in pulmonary stenosis, pulmonary hypertension and tricuspid stenosis (as a consequence of right atrial or right ventricular hypertrophy). The atrium relaxes to give the ‘x’ descent; however, the start of a ventricular contraction causes ballooning of the tricuspid valve as c it closes, resulting in the ‘c’ wave. The further ‘x’ descent is due to descent of the closed valve towards the cardiac apex. This may occur in right-sided heart Timing to systole or diastole is achieved by palpation failure, congestive cardiac failure and pulmonary em- of the carotid pulse whilst auscultating. Murmurs are further described according to their Precordial heaves, thrills and pulsation relationship to the cardiac cycle. Thisoccursinmitralregurgitation, ventricular hypertrophy when the impulse is at the tricuspid regurgitation and with a ventricular septal same time as the apex beat and carotid pulsation. It is heard r A thrill is a palpable murmur and is due to turbulent with aortic stenosis, pulmonary stenosis and with an blood flow. For example, a diastolic thrill at r A late systolic murmur is heard in mitral valve pro- the apex is suggestive of severe mitral stenosis (aortic lapse. This is most tercostal space) and the relationship to the chest (mid- helpful when the flow of blood is considered according clavicular line, anterior axillary line, etc). The normal to the lesion, for example aortic stenosis radiates to the position is the fourth or fifth intercostal space in the neck, mitral regurgitation radiates to the axilla. Investigations and procedures Heart murmurs Coronary angioplasty Heart murmurs are the result of turbulent blood flow. Coronary angioplasty is a technique used to dilate stenosed coronary arteries in patients with ischaemic heart disease. These slowly disease or triple vessel disease to be treated by bypass release a drug (e. In addition, patients with concomitant condi- Coronary artery bypass surgery tions precluding bypass surgery, e. It has Early angiography and angioplasty is now being in- also been shown to improve outcome in patients with creasingly used immediately following a myocardial triple vessel disease or left main stem coronary artery infarction, in order to reduce the risk of further infarc- disease. A small whilst maintaining an adequate circulation to the rest balloon is passed up the aorta via peripheral arterial ac- of the body cardiopulmonary bypass is most commonly cess under radiographic guidance. A cannula is placed in the right atrium in order fected coronary artery, the balloon is inflated to dilate to divert blood away from the heart. The blood is then the stenosis, compressing the atheromatous plaque and oxygenated by one of two methods: stretching the layers of the vessel wall to the sides. A stent r Bubble oxygenators work by bubbling 95% oxygen is often used to reduce recurrence. If the myocardium is to be opened, cross-clamping the Complications aorta gives a bloodless field; the heart is protected from The main immediate complication of balloon angio- ischaemia by cooling to between 20 and 30˚C. Systemic plasty is intimal/medial dissection leading to abrupt ves- cooling also lowers metabolic requirements of other or- sel occlusion. Beatingheartbypassgraftingisnow has been largely resolved with the routine implantation possible using a mechanical device to stabilise the target of a stent. There is a risk of complications, including surface area of the heart, but access to the posterior sur- emergency coronary artery bypass surgery, myocardial face of the heart can be difficult. More commonly, local The internal mammary artery is the graft of choice haematoma at the site of arterial puncture may occur. The coronary arteries are opened distal to the obstruction and the grafts are placed. If the saphenous Prognosis vein is used, its proximal end is sewn to the ascend- Depending on the anatomy of the lesion, significant ing aorta.

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Reduce mosquito breeding habitat: Reduce the number of isolated cialis sublingual 20 mg cheap, stagnant trusted cialis sublingual 20mg, shallow (5-7 cm deep) areas buy cialis sublingual 20mg. Construct a vegetation buffer between the adjacent land and the wetland to filter nutrients and sediments buy cialis sublingual 20mg with amex. Install fences to keep livestock from entering the wetland to reduce nutrient-loading and sedimentation problems cheap cialis sublingual 20mg with amex. In ornamental/managed ponds: Add a waterfall, or install an aerating pump, to keep water moving and reduce mosquito larvae. Keep the surface of the water clear of free-floating vegetation and debris during times of peak mosquito activity. Chemical control It may be necessary to use alternative mosquito control measures if the above are not possible or ineffective. The environmental impact of vector control measures should be evaluated and appropriate approvals should be granted before undertaken. This method is deemed least damaging to non-target wildlife and should be used before adulticides. During periods of flooding, the number and extent of breeding sites is usually too high for larvicidal measures to be feasible. Open marsh water management Control mosquitoes by introducing their natural predators to areas of tidal marsh using a system of pools connected by radial ditches. Fish feed on mosquitoes during high tide, then retreat to sumps or reservoirs at low tide. Environmental management – adapting behaviour of people and animals People: Wear light coloured clothing which covers arms and legs. Use impregnated mosquito netting when sleeping outdoors or in an open unscreened structure. Avoid physical exertion, and use colognes and perfumes sparingly as these may attract mosquitoes. Note that some repellents cause harm to wildlife species, particularly amphibians. Use screened housing with measures to eliminate mosquitoes from inside structures. Alter flow rate and water levels to disturb snail habitats and their food sources: Include ‘v’ shaped banks in irrigation channels. Remove vegetation/silt in channels to avoid a drop in velocity which may lead to further vegetation growth and good habitat for snails. Note that personnel involved in the manual removal of vegetation are increasing their exposure to snails. Flow rate should only be addressed with knowledge of the ecology of the snail in question e. Borrow-pits, small pools and ponds serving no special purpose (for humans, wildlife or livestock) may be drained to eliminate breeding sites. Expose snail habitat: Remove littoral vegetation from the sides of canals feeding irrigation projects to expose snail habitat. Thought should be given to downstream conditions and the potential for the liberated snails to recolonise new habitat. Where possible dry out littoral zones to strand snail populations, however take into account the specific ecology and the resilience of the target species. Chemical control Use of molluscicides may cause environmental damage and should be avoided. Applications are usually restricted to places frequently used by people for swimming, bathing etc. Environmental management – adapting behaviour of people and animals People: Where possible, avoid new human settlements near infested wetlands. It is safest to consider all freshwater bodies in endemic areas as potential transmission sites if sites otherwise not identified. For agricultural workers at constant risk of infection, periodic examination and treatment may be the most feasible approach to disease control. A clean water supply and improved sanitation (including on board boats) must be provided to stop human excrement entering wetlands.

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The authors should also contact the authors of all the studies found and ask them about other researchers working in the area who may have unpublished studies available generic cialis sublingual 20 mg overnight delivery. Also cialis sublingual 20mg mastercard, the National Library of Medicine and the National Institutes of Health in the United States have an online repository of clinical tri- als called www purchase cialis sublingual 20 mg otc. Were explicit methods used to determine which articles to include in the review and were the selection and assessment of the methodologic quality of the primary studies reproducible and free from bias? Objective selection of articles for the meta-analysis should be clearly laid out and include inclusion and exclusion criteria discount cialis sublingual 20mg mastercard. This includes a clearly defined research and abstraction method and a scoring system for assessing the quality of the included studies buy cialis sublingual 20mg online. The publication status may sug- gest stronger studies in that those that were never published or only published in abstract form may be significantly deficient in methodological areas. A well-designed obser- vational study with appropriate safeguards to prevent or minimize bias and con- founding, will also give very strong results. The methods of meta-analysis include ranking or grading the quality of the evidence. The study sites and patient populations of the individual studies may limit generalizability of the meta-analysis. We will discuss issues of how to judge homogeneity and combine heterogeneous studies. Independent review of the methods section looks at inclusion and exclusion criteria, coding, and replication issues. There must be accurate and objective abstraction of the data, ideally done by blinded abstracters. Two abstracters should gather the data independently and the author should check for inter- rater agreement. The methods and results sections should be disguised to pre- vent reviewers from discovering the source of the research. Once this has been established, a single coder can code all the remaining study results. Were the differences in individual study results adequately explained and were the results of the primary studies combined appropriately? Testing for heterogeneity of the stud- ies is done to determine if the studies are qualitatively similar enough to com- bine. The tests for heterogeneity include the Mantel–Haentszel chi-squared test, the Breslow–Day test, and the Q statistic by the DerSimonian and Laird method. However, the absence of statistical significance does not mean homogeneity and may only be present due to low power of the statistical test for heterogeneity. The presence of heterogeneity among the studies analyzed will result in erro- neous interpretation of the statistical results. If the studies are very heteroge- neous, one strategy for analyzing them is to remove the study with most extreme or outlier results and recalculate the statistic. If the statistic is no longer statisti- cally significant, it can be assumed that the outlier study was responsible for all or most of the heterogeneity. That study should then be examined more closely to determine what about the study design might have caused the observed extreme result. This could be due to differences in the population studied or systematic bias in the conduct of the study. Analysis and aggregation of the data can be done in several ways, but should consider sample sizes and magnitude of effects. A simple vote count in which the number of studies with positive results is directly compared with the number of studies with negative results is not an acceptable method since neither effect Meta-analysis and systematic reviews 371 size nor sample size are considered. Pooled analysis or lumped data add numer- ators and denominators of each study together to produce a new result. This is better than a vote count, but still not acceptable since that process ignores the confidence intervals for each study and allows errors to multiply in the process of adding the results. Simple combination of P values is not acceptable because this does not consider the direction of the effect or magnitude of the effect size.

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