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Conﬁdence intervals provide information about the precision of an estimate (how wide are the conﬁdence intervals) buy extra super viagra 200 mg otc, the size of an estimate (magnitude of the conﬁdence intervals) buy extra super viagra 200 mg online, and the statistical signiﬁcance of an estimate (whether the intervals include the null) (5). If you assume that your sample was randomly selected from some pop- ulation (that follows a normal distribution), you can be 95% certain that the conﬁdence interval (CI) includes the population mean. More precisely, if you generate many 95% CIs from many data sets, you can expect that the CI will include the true population mean in 95% of the cases and not include the true mean value in the other 5% (4). Whereas the p value is often interpreted as being either statistically signiﬁcant or not, the CI, by providing a range of values, allows the reader to interpret the implications of the results at either end (6,7). In addition, while p values have no units, CIs are presented in the units of the variable of interest, which helps readers to interpret the results. The CIs shift the interpretation from a qualitative judgment about the role of chance to a quantitative estimation of the biologic measure of effect (4,6,7). As an example, two hypothetical transcranial circle of Willis vascular ultrasound studies in patients with sickle cell disease describe mean peak systolic velocities of 200cm/sec associated with 70% of vascular diameter stenosis and higher risk of stroke. However, the narrower conﬁdence intervals for the larger study reﬂect the greater precision, and indicate the value of the larger sample size. For a smaller sample: 50 95 CI 200 1 96( ) 50 95% CI 200 14 186 214 For a larger sample: 50 95 CI 200 1 96( ) 500 22 C. Type II Error The familiar p value does not provide information as to the probability of a type II or beta error. The size of the sample studied may be too small to detect an important difference even if such a difference does exist. The ability of a study to detect an important difference, if that difference does in fact exist in the underlying population, is called the power of a study. Power analysis can be performed in advance of a research investigation to avoid type II error. Power Analysis Power analysis plays an important role in determining what an adequate sample size is, so that meaningful results can be obtained (8). Power analy- sis is the probability of observing an effect in a sample of patients if the speciﬁed effect size, or greater, is found in the population (3). Mathemati- cally, power is deﬁned as 1 minus beta (1 -b), where b is the probability of having a type II error. The other type of error is type I or alpha (a), also known as false positives in a study population (7). By accomplishing this, false-negative and false-positive results are eliminated, respectively. In practice, however, powers near 100% are rarely achievable, so, at best, a study should reduce the false negatives b and false positives a to a minimum (3,9). Achieving an acceptable reduc- tion of false negatives and false positives requires a large subject sample size. Optimal power, a and b, settings are based on a balance between sci- entiﬁc rigorousness and the issues of feasibility and cost. Studies with more com- plete reporting and better study design will often report the power of the study, for example, by stating that the study has 90% power to detect a dif- ference in sensitivity of 10% between CT angiography and Doppler ultra- sound in carotid artery disease. The risk of an error from bias decreases as the rigorousness of the study design and analysis increases.
Finally cheap 200 mg extra super viagra mastercard, we m ight choose to study patients who gave birth in the setting of a large discount 200 mg extra super viagra with mastercard, m odern, "high- tech" m aternity unit as well as som e who did so in a sm all com m unity hospital. Of course, all these specifications will give us "biased" sam ples but that is exactly what we want. W atch out for qualitative research where the sam ple has been selected (or appears to have been selected) purely on the basis of convenience. In the above exam ple, taking the first dozen Punjabi patients to pass through the nearest labour ward would be the easiest way to notch up interviews, but the inform ation obtained m ay be considerably less helpful. Question 4 What was the researcher’s perspective and has this been taken into account? G iven that qualitative research is necessarily grounded in real life experience, a paper describing such research should not be "trashed" sim ply because the researchers have declared a particular cultural perspective or personal involvem ent with the subjects of the research. It is im portant to recognise that there is no way of abolishing, or fully controlling for, observer bias in qualitative research. If, for exam ple, the research concerns the experience of 172 PAPERS TH AT G O BEYON D N U M BERS asthm atic adults living in dam p and overcrowded housing and the perceived effect of these surroundings on their health, the data generated by techniques such as focus groups or sem istructured interviews are likely to be heavily influenced by what the interviewer believes about this subject and by whether he or she is em ployed by the hospital chest clinic, the social work departm ent of the local authority or an environm ental pressure group. But since it is inconceivable that the interviews could have been conducted by som eone with no views at all and no ideological or cultural perspective, the m ost that can be required of the researchers is that they describe in detail where they are com ing from so that the results can be interpreted accordingly. Question 5 What methods did the researcher use for collecting data and are these described in enough detail? I once spent two years doing highly quantitative, laboratory based experim ental research in which around 15 hours of every week were spent filling or em ptying test tubes. There was a standard way to fill the test tubes, a standard way to spin them in the centrifuge, and even a standard way to wash them up. W hen I finally published m y research, som e 900 hours of drudgery was sum m ed up in a single sentence: "Patients’ serum rhubarb levels were m easured according to the m ethod described by Bloggs and Bloggs [reference to Bloggs and Bloggs’ paper on how to m easure serum rhubarb]". I now spend quite a lot of m y tim e doing qualitative research and I can confirm that it’s infinitely m ore fun. I and m y research team spent an interesting few years devising a unique com bination of techniques to m easure the beliefs, hopes, fears, and attitudes of diabetic patients from a particular m inority ethnic group (British Sylhetis). W e had to develop, for exam ple, a valid way of sim ultaneously translating and transcribing interviews which were conducted in Sylheti, a com plex dialect of Bengali which has no written form. W e found that patients’ attitudes appear to be heavily influenced by the presence in the room of certain of their relatives, so we contrived to interview som e patients in both the presence and the absence of these key relatives. I could go on describing the m ethods we devised to address this particular research issue15 but I have probably m ade m y point: the m ethods section of a qualitative paper often cannot be written in 173 H OW TO READ A PAPER shorthand or dism issed by reference to som eone else’s research techniques. It m ay have to be lengthy and discursive since it is telling a unique story without which the results cannot be interpreted. As with the sam pling strategy, there are no hard and fast rules about exactly what details should be included in this section of the paper. You should sim ply ask "H ave I been given enough inform ation about the m ethods used? Question 6 What methods did the researcher use to analyse the data and what quality control measures were implemented? The data analysis section of a qualitative research paper is where sense can m ost readily be distinguished from nonsense. H aving am assed a thick pile of com pleted interview transcripts or field notes, the genuine qualitative researcher has hardly begun. It is sim ply not good enough to flick through the text looking for "interesting quotes" which support a particular theory. The researcher m ust find a systematic way of analysing his or her data and, in particular, m ust seek exam ples of cases which appear to contradict or challenge the theories derived from the m ajority.
These stories often focus on children’s fears in relationship to parents and siblings buy extra super viagra 200mg cheap. Thus fairy tales 200 mg extra super viagra sale, fables, and nature stories are customary by the time the child is in the sec- ond grade, just as from ages 18 months to 3 years old, when mental combi- nations are being formed and language develops, rhymed stories (Mother Goose and Dr. Unfortunately, many parents believe that the fairy tales of yesterday, particularly the Brothers Grimm, are too aggressive for young children. They look at the fairy tale with the eye of an adult and forget that as chil- dren the use of fantasy is a product of the ego structure of latency. They play with toys, and if these are not available a box becomes a fort while stuffed animals become noble steeds. If these are not available the power of the imagination places tea in empty cups and swords in bare hands. By age 9 the desire to break free of parental control pre- dominates, and thoughts of being a movie star or an accomplished athlete are prominent. And, alas, by the age of 12 fantasy is forsaken, symbols are lost, reality sets in, and adolescence begins (Sarnoff, 1974). With each of these developmental stages there are nursery rhymes, fairy tales, myth, leg- end, and literature, all with the power to express in masked forms the affect-laden memories of prelatency. It is because of this that fairy tales should not be afforded an explana- tion; the client understands the inner signiﬁcance without discussion. Just as a child walks into the world without the safety of his family—to school, to sleep-over parties, and the like—fairy tales not only depict that feeling of loneliness but teach autonomy and independence with which to over- come the odds and ﬁnd a path to riches and love. By the same token, the use of illustration becomes more a hindrance than an aid to the telling of the story. In the telling the imagination has already formed that image, and an artist’s depiction will only distract. If the parent, therapist, or counselor has an overwhelming need to discuss the story, then he or she should have the clients draw their own illustration. As anyone who has read these stories will attest, it becomes all too apparent when children have made a con- nection with the characters in the story, as they will demand to be told the story incessantly. It is at this point that the simplicity, directness, bravery, and value of the fairy tale have broken through. The ﬁgures and events have not only il- lustrated the inner conﬂicts but offered reassurance and hope for the future. When one is looking at the developmental needs of a child or develop- mentally delayed adult it is important to take into account what stage of growth the patient presently possesses. As stated earlier, reading a story be- yond or beneath the needs of an individual will fail miserably. Thus, the use of story, fable, and allegory must be tailored to meet changing needs and at- titudes. Nursery rhymes such as "Humpty Dumpty," "Hey Diddle, Diddle," or "Hickory, Dickory, Dock" are excellent for the child who is just begin- ning language development (Piaget’s sensorimotor and preconceptual stages) and will learn from and enjoy a symbolic and repetitious cycle. However, for the person who is learning to grapple with complex problems and is focused on the beginning stages of social participation (Piaget’s in- tuitive thought and early phase of concrete operations), nursery rhymes would seem infantile. Before I illustrate some of the better-known fairy tales it is important to 88 Adaptation and Integration outline the following concerns. The ﬁrst is that the tales that most touch a child’s, and adult’s, growing needs are those that have not been watered down. The tale must remain true to its source and related without the ben- eﬁt of condensing the story. An example would be Carlo Collodi’s story "The Adventures of Pinocchio," which was later to be made into the ani- mated ﬁlm and book by the name of Pinocchio.