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The normal Q–Q plot shows each data value plotted against the value that would be expected if the data came from a normal distribution discount voltaren arthritis medication that was recalled. The values in the plot are the quantiles of the variable distribution plotted against the quantiles that would be expected if the distribution was normal best voltaren 50mg arthritis pain chart. If the variable was normally distributed voltaren 50 mg otc arthritis in feet what to do, the points would fall directly on the straight line order voltaren once a day rheumatoid arthritis young. The detrended normal Q–Q plots show the deviations of the points from the straight line of the normal Q–Q plot. If the distribution is normal, the points will cluster ran- domly around the horizontal line at zero with an equal spread of points above and below the line. If the distribution is non-normal, the points will be in a pattern such as J or an inverted U distribution and the horizontal line may not be in the centre of the data. The box plot shows the median as the black horizontal line inside the box and the inter-quartile range as the length of the box. The inter-quartile range indicates the 25th to 75th percentiles, that is, the range in which the central 25–75% (50%) of the data points lie. If values are outside this range, they are plotted as outlying values (circles) or extreme values (asterisks). Extreme values that are more than three box lengths from the upper or lower edge of the box are shown as asterisks. Extreme and/or outlying values should be checked to see whether they are univariate outliers. If there are several extreme values at either end of the range of the data or the median is not in the centre of the box, the variable will not be normally distributed. If the median is closer to the bottom end of the box than to the top, the data are positively skewed. If the median is closer to the top end of the box, the data are negatively skewed. All of the plots should be inspected because each plot provides different 36 Chapter 2 information. These features indicate that the mean value will be an accurate estimate of the centre of the data and that the standard deviation will accurately describe the spread. The box plot for this variable appears to be symmetrical but has a few outlying values at the lower end of the data values. The box plot shows some outlying values and many extreme values at the upper end of the distribu- tion. Descriptive statistics 41 Detrended normal Q−Q plot of Length of stay 4 3 2 1 0 −1 0 50 100 150 200 250 Observed value 250 121 120 200 110 150 129 125 116 122 118 115 113 100 108 128 50 0 Length of stay Figure 2. The hypothesis of this test is that the distribution of the data is a particular distribution such as normal, uniform or exponential. To check for normality, a normal distribution is used for the Kolmogorov–Smirnov test. Decision The distribution of Birth weight is One-Sample Retain the 1 normal with mean 2,463. The distribution of Gestational age One-Sample Reject the 2 is normal with mean 36. The distribution of Length of stay is One-Sample Reject the 3 normal with mean 38. The P values for the test of normality in the One-Sample Kolmogorov–Smirnov Test table are different from Kolmogorov–Smirnov P values obtained in Analyze → Descrip- tive Statistics → Explore because the one-sample test shown here is without the Lilliefors correction. Without the correction applied this test, which is based on slightly different assumptions about the mean and the variance of the normal distribution being tested for fit, is extremely conservative. Once again, the P values suggest that birth weight is Descriptive statistics 43 Table 2. In this table, ‘Yes’ indicates that the check for normality provides evidence that the data follows an approximately normal distribution and ‘No’ indicates that the check for normality provides evidence that the data does not have a normal distribution. By considering all of the information together, a decision can be made about whether the distribution of each variable is approximately normal to justify using parametric tests or whether the deviation from normal is so marked that non-parametric or categorical tests need to be used. These decisions, which sometimes involve subjective judgements, should be based on all processes of checking for normality. The variable gestational age is approximately normally distributed with some indications of a small deviation. Parametric tests are robust to some deviations from normality if the sample size is large, say greater than 100 as is this sample. If the sample size had been small, say less than 30, then this variable would have to be perfectly normally distributed rather than approximately normally distributed before parametric tests could be used. Length of stay is clearly not normally distributed and therefore this variable needs to be either transformed to normality to use parametric tests, analysed using non-parametric tests or transformed to a categorical variable. There are a number of factors to consider in deciding whether a variable should be transformed. Parametric tests generally provide more statistical power than non-parametric tests. However, if a parametric test does not have a non-parametric equivalent then transformation is essential. However, difficulties arise sometimes in 44 Chapter 2 interpreting the results because few people think naturally in transformed units. For example, if length of stay is transformed by calculating its square root, the results of parametric tests will be presented in units of the square root of length of stay and will be more difficult to interpret and to compare with results from other studies. Various mathematical formulae can be used to transform a skewed distribution to normality. When a distribution has a marked tail to the right-hand side, a logarithmic transformation of scores is often effective. Either base e or base 10 logarithms can be used but base 10 logarithms are a little more intuitive in that 0 = 1(10 ), 1∘ = 10 (101), 2 = 100 (102), and so on and are therefore a little easier to interpret and communicate. Since logarithm functions are defined only for values greater than zero, any values that are zero in the data set will naturally be declared as invalid and registered as missing values in the transformed variable. In this data set, case 32 has a value of zero for length of stay and has been transformed to a system missing value for logarithmic length of stay. To ensure that all cases are included, for cases that have zero or negative values, a constant can be added to each value to ensure that the logarithmic transformation can be undertaken. This value can be subtracted again when the summary statistics are transformed back to original units. Descriptive statistics 45 Whenever a new variable is created, it should be labelled and its format adjusted. The log-transformed length of stay can be reassigned in Variable View by adding a label ‘Log length of stay’ to ensure that the output is self-documented. In addition, the number of decimal places can be adjusted to an appropriate number, in this case three and Measure can be changed to Scale.

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Direct microscopic examination of the respiratory samples (Gram stain purchase 50 mg voltaren visa mild degenerative arthritis in neck, potassium hydroxide buy discount voltaren 50mg on-line controlling arthritis with diet, or cotton blue preparations) were positive in 3/5 cases of aspergillosis and in 3/4 cases of nocardiosis (101) generic voltaren 100 mg amex arthritis medication with coumadin. The selection of the empirical therapy will be guided by the characteristics of the patient and the clinical situation order 50mg voltaren free shipping rheumatoid arthritis ocular manifestations. Postsurgical Infections Complications in the proximity of the surgical area must always be investigated. Surgical problems leading to devitalized tissue, anastomotic disruption, or fluid collections markedly predispose the patient to potentially lethal infection. Liver transplant recipients are at risk for portal vein thrombosis, hepatic vein occlusion, hepatic artery thrombosis, and biliary stricture formation and leaks. Heart transplant recipients are at risk for mediastinitis and infection at the aortic suture line, with resultant mycotic aneurysm, and lung transplantation recipients are at risk for disruption of the bronchial anastomosis. In intestinal transplant recipients, abdominal wall closure with mesh should be avoided because of the high rate of infectious complications (139). Occasionally, the complications will appear after the performance of some procedure such as a liver biopsy or a cholangiography. Most common microorganisms include Enterobacteriaceae bacilli, enterococci, anaerobes, and Candida. Biliary anastomosis leaks may result in peritonitis or perihepatic collections, cholangitis, or liver abscesses (144–146). Recent data suggest that duct-to-duct biliary anastomosis stented with a T tube tends to be associated with more postoperative complications (147). A percutaneous aspirate with culture of the fluid is required to confirm infection. In one series, median time from transplant to hepatic abscess was 386 days (range 25–4198). Clinical presentation of hepatic abscess was similar to that described in nonimmunosuppressed patients. Occasionally, the only manifestations are unexplained fever and relapsing subacute bacteremia. Prolonged antibiotic therapy, drainage, and even retransplantation may be required to improve the outcome in these patients. However, sterile fluid collections are exceedingly common after liver transplantation, so an aspirate is necessary to establish infection. Mediastinitis In heart and lung transplant recipients, the possibility of mediastinitis (2–9%) should be considered. Inflammatory signs in the sternal wound, sternal dehiscence, and purulent drainage may appear later. The most commonly involved microorganisms are staphylococci but gram-negative rods represent at least a third of our cases. Mycoplasma, mycobacteria, and other less common pathogens should be suspected in culture-negative wound infections (151,152). Risk factors are prolonged hospitalization before surgery, early chest reexploration, low output syndrome in adults and the immature state of immune response in infants. Therapy consists of surgical debridement and repair, and antimicrobial therapy given for three to six weeks. The incidence in patients not receiving prophylaxis has been reported to vary from 5% to 36% in recent series (157,158). The most common pathogens include Enterobacteriaceae, enterococci, staphylococci, and Pseudomonas (161). Other less frequent microorganisms like Salmonella, Candida,orCorynebacterium urealyticum pose specific manage- ment problems in this population (162). It is also important to remember the possibility of infection caused by unusual pathogens like Mycoplasma hominis, M. Tenderness, erythema, fluctuance, or increase in the allograft size may indicate the presence of a deep infection or rejection. Prolonged administration of broad-spectrum antimicrobial therapy has been classically recommended for the treatment of early infections, although no double-blind, comparative study is available (155). Gastrointestinal Infections Abdominal pain and/or diarrhea are detected in up to 20% of organ transplant recipients (135). Possible manifestations include gastrointestinal bleeding, diarrhea, abdominal pain, jaundice, nausea or vomiting, odynophagia, dysphagia, or just weight loss (166). Clostridium difficile should be suspected in patients who present with nosocomial or community-acquired diarrhea. It is more common in transplant population who frequently receive antimicrobial agents, and up to 20% to 25% of patients may experience a relapse (173–175). The most important factor in the pathogenesis of disease is exposure to antibiotics that disturb the homeostasis of the colonic flora. Most common clinical presentation is diarrhea, but clinical presentation may be unusually severe (176,177). Occasionally, patients present with an acute abdomen (179) or inflammatory pseudotumor (180). The reference method for diagnosis is the cell culture cytotoxin test that detects toxin B in a cellular culture of human fibroblasts (181). Culture in specific media is also recommended since it allows resistance study, molecular analysis of the strains, and the performance of a “second- look” cell culture assay that enhances the potential for diagnosis (182). Comparison of metronidazole’s activity with that of vancomycin in patients with moderately severe disease shows similar response rates. The former is preferred because of its reduced risk of vancomycin-resistance induction and lower cost. However, recent reports of severe clinical forms suggest that vancomycin may be preferable for these especially virulent strains. The administration of probiotics such as Saccharomyces boulardii or Lactobacillus spp. As mentioned, a substantial proportion of patients (10–25%) have a relapse usually 3–10 days after treatment has been discontinued, even with no further antibiotic therapy. The frequency of relapses does not seem to be affected by the antibiotic selected for treatment, the dose of these drugs, or the duration of treatment. Several measures have been suggested: gradual tapering of the dosage of vancomycin over one to two months, administration of “pulse-dose” vancomycin, use of anion-exchange resins to absorb C. Infectious enteritis is especially frequent in intestinal transplant recipients (39%). The bacterial infections tended to present earlier than the viral infections, and the most frequent presenting symptom was diarrhea (186). Immunosuppressive drugs such as mycophenolate mofetil, cyclosporine A, tacrolimus, and sirolimus are all known to be associated with diarrhea.

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It is used in this way: Most data produce only an approximately normal distribu- tion buy discount voltaren 50mg on-line arthritis finger joint, producing a roughly normal z-distribution 100 mg voltaren sale rheumatoid arthritis diet soda. However buy voltaren 50 mg overnight delivery running with arthritis in neck, to simplify things order voltaren visa multiple levels of arthritis in neck, we operate as if the z-distribution always fits one, perfect normal curve, which is the stan- dard normal curve. We use this curve to first determine the relative frequency of partic- ular z-scores. Then, as we did above, we work backwards to determine the relative frequency of the corresponding raw scores. This is the relative frequency we would expect, if our data formed a perfect normal distribution. Usually, this provides a reason- ably accurate description of our data, although how accurate we are depends on how closely the data conform to the true normal curve. Therefore, the standard normal curve is most accurate when (1) we have a large sample (or population) of (2) interval or ratio scores that (3) come close to forming a normal distribution. The first step is to find the relative frequency of the z-scores and for that we look at the area under the standard normal curve. Statisticians have already determined the pro- portion of the area under various parts of the normal curve, as shown in Figure 6. The numbers above the X axis indicate the proportion of the total area between the z-scores. The numbers below the X axis indicate the proportion of the total area between the mean and the z-score. The range is roughly between zs of ;3, a distance of six times the standard deviation. If the range is six times the standard deviation, then the stan- dard deviation is one-sixth of the range. Most often we begin with a particular raw score in mind and then compute its z-score (using our original z-score formula). We might first ask what proportion of scores are expected to fall between the mean and Cubby’s score. Then we would convert the above relative fre- quency to simple frequency by multiplying the N of the sample times the relative fre- quency. Recall that a percentile is the percent of all scores below—graphed to the left of—a score. After computing the z-score for a raw score, first see if it is above or below the mean. A positive z-score is above the mean, so Cubby’s z-score of 12 is above the 50th percentile. We usually round off percentile to a whole number, so Cubby’s raw score of 80 is at the 98th percentile. Conversely, anyone scoring above the raw score of 80 would be in about the top 2% of scores. On the other hand, say that Elvis obtained an attractiveness score of 40, producing a z-score of 22. We can also work in the opposite direction to find the raw score located at a particular percentile (or relative fre- quency). Say that we had started by asking what attractiveness score is at the 2nd per- centile (or we had asked below what raw score is. Then to find the raw score at this z, we use a formula for transforming a z-score into a raw score. Using the z-Table So far our examples have involved whole-number z-scores, although with real data a z-score may contain decimals. However, fractions of z-scores do not result in propor- tional divisions of the previous areas. Because this z is positive, we place this area between the mean and the z on the right-hand side of the distribution, as shown in Figure 6. Column C, labeled “Area Beyond z in the Tail,” contains the proportion of the area under the curve that is in the tail beyond the z-score. You must decide whether z is positive or negative, B B based on the problem you’re working. Sometimes, you will need a proportion that is not given in the table, or you’ll need the proportion corresponding to a three-decimal z-score. In such cases, round to the nearest value in the z-table or, to compute the precise value, perform “linear interpola- tion” (described in Appendix A. For example, say that we want to examine Bucky’s raw score, which transforms into the positive z-score of 11. If we seek the proportion of scores above his score, then from column C we expect that. If we seek the relative frequency of scores between his score and the mean, from column B we expect that. What is the relative frequency of scores ■ To find the raw score at a specified relative below 59? To find the score above the mean with 15% of the scores between it and the mean (or the score at the 65th percentile): From column B, the pro- portion closest to. Often, however, test results are also shared with people who do not understand z-scores; imagine someone learning that he or she has a negative personality score! To eliminate negative scores and decimals, sub-test scores are transformed so that the mean is about 500 and the standard deviation is about 100. When debating such issues as what a genius is or how to define “abnormal,” researchers often rely on relative standing. For example, the term “genius” might be defined as scoring above a z of 2 on an intel- ligence test. We’ve seen that only about 2% of any distribution is above this score, so we have defined genius as being in the top 2% on the intelligence test. Or, “abnormal” might be defined as having a z-score below 2 on a personality inventory. Such scores are statistically abnormal because they are very infrequent, extremely low scores. If the instructor defines A students as the top 2%, then students with z-scores greater than 2 receive As. If B students are the next 13%, then students having z-scores between 1 and 2 receive Bs, and so on. This procedure is very important because all inferential statistics involve computing something like a z-score for our sample data. We’ll elaborate on this procedure in later chapters but, for now, simply understand how to compute a z-score for a sample mean and then apply the standard normal curve model. The problem is the same as when we examined individ- ual raw scores: Without a frame of reference, we don’t know whether a particular sample mean is high, low, or in-between. Previously, a z-score compared a particular raw score to the other scores that occur in this situa- tion. Now we’ll compare our sample mean to the other sample means that occur in this situation.

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Differential diagnosis for the patient’s abdominal mass methods of the physical therapy for therapeutic enhancement purchase voltaren uk arthritis pain in feet relieve. It commonly occurs following trauma discount 50mg voltaren fast delivery arthritis problem means, burns order 50 mg voltaren with amex arthritis toe joint pain, neu- 1 rologic injuries order 50mg voltaren fast delivery arthritis in your neck and back, and major surgeries. Yoda 1Showa University School of Medicine, Department of Rehabilita- common in the second and third decade of life and in the arms and thighs in individuals with recent trauma. Physical therapy with as gait analysis employing a foot pressure measurement system. Conclusion: Rehabilitation gait was evaluated before and one month after the treatment by physicians should be aware of the possibility of nonhereditary my- means of gait analysis employing a foot pressure measurement sys- ositis ossifcans in patients with recent trauma/surgery. The measurements included gait speed and proportions of stance, swing, and double support in the gait cycle. Soon after fewer, vomiting and somnolence occurred and the patient was hospitalized. In his history, common cold symptoms 1Gaziantep University, Physical Medicine and Rehabilitation, Ga- were seen and 15 kg loss within 6 months was present. On physical ziantep, Turkey, 2Gülhane Military Medical Academy, Physical examination, deep tendon refexes were hyperactive in upper and Medicine and Rehabilitation, Ankara, Turkey lower limbs; pathologic refexes were present in addition to above- mentioned signs. The patient was hospitalized Lumbar puncture resulted with a positive culture for Cryptococcus for rehabilitation. Results: With help of these fndings the patient was were 2 in upper extremity, hand and lower extremity. He had spas- diagnosed as hemorrhagic stroke Related to Cryptococcal Menin- ticity in elbow fexor and forearm pronators. After medications and physical therapy, patient was during physical examination musculuskeletal sonography was per- signifcantly improved with independent ambulation and activities formed. He or his family did of stroke of unknown origin, particularly in young adults without not report any trauma to his left elbow before or after the stroke. Rehabilitation strategies should be a part of He also did not desribe pain in his elbow, but diffuse pain in left such patients’ management. Shoulder dislocation is commonly seen in stroke patients but radial head disloacation is very rare in stroke patients. In this patient etilogy was unclear whether it was occurred due to 407 a complication of stroke or trauma or congenital anomally. Multiple linear regression analysis was rapid recovery going from dense, faccid hemiplegia to near-nor- applied to evaluate the factors affecting the differencebetween the mal strength and minimal fne motor coordination impairments outcome measure scores on discharge and admission. In Apr 2015, there was a spike in New stroke and Bourges index), motricity index, Ashworth scale, New York City emergency room visits for patients with K2 complica- Functional Ambulation Categories, Mini Mental Status Examina- tions. It is either smoked or consumed in the daily activity domain was noted at 1st and 3rd months. The impaired postural control has the greatest marijuana but with K2 specifc urine tests. Postural control is the marijuana must be considered in the differential diagnosis of pa- best predictor of achieving independent living. A complete drug use history and K2 specifc urine test can help make the diagnosis. Give that Methods: Twenty-fve patients with stroke were randomly divided stroke is the main cause of adult disability, we want to understand into two groups: 12 in ankle stretching group (experimental group) if the same is true in Australia. Material and Methods: Our retro- and 13 in straight leg raising group (control group). We analyzed the patient data on the basis of age range (0–10, spasticity of the ankle joint were assessed by passively move the an- 11–20, etc. Results: Before training, there was no signifcant tal later than older ones, missing the chance for acute therapy and difference between two groups in all the measured parameters. Conclusion: As a 2 weeks training, the spasticity measured under different angular ve- word of caution, the results have yet to be adjusted for catchment locity showed a signifcant difference between the two groups except area changes, new stroke units opening, and changes in population 240°/s ; there was a signifcant difference between the two group on statistics. Nonetheless, our study suggests that stroke is becoming the muscle strength measured at the 60°/s, 120°/s, but not at 180°/s, more frequent in younger Australians. Do1 icine and Rehabilitation, Monastir, Tunisia 1Asan Medical Center, Rehabilitation Medicine, Seoul, Republic of Korea Introduction/Background: Postural problems are common follow- ing stroke and can resulting in a high incidence of falls particu- Introduction/Background: We studied the infuence of leukoaraio- larly in those patients with motor, sensory, cognitive and emotional sis on the functional outcome of subcortical stroke for the subacute impairments. Material and Methods: We retrospectively ana- and its impact on independence social participation and quality of lyzed 152 collected patients with acute subcortical infarct (corona life. Material and Methods: 31 right-handed patients (mean age radiate with or without basal ganglia infarct) at a single center from 61. Of these, the patients who previously had J Rehabil Med Suppl 55 Poster Abstracts 123 history of stoke or cognitive impairment had excluded and forty 415 one patients were enrolled. Cakci 1Dıskapı Yıldırım Beyazıt Education and Reserach Hospital, Physi- ity was graded as mild, moderate, or severe on the Fazekas scale. Rehabilitation Center, Department of Physical Therapy and Reha- Results: Severe leukoaraiosis was diagnosed in 2 patients (4. There to bilateral masseter muscles in early stroke patients with dyspha- were no signifcant difference in the baseline characteristics of the gia. Material and Methods: Ninety-eight patients with dysphagia study cohort by leukoaraiosis severity except for age and modifed within the frst month after ischemic stroke included in this study. Results: During inpatient rehabilitation, were administered at pretreatment, posttreatment, and 1-month he was consulted to psychiatry for suspected hallucinations and posttreatment. Recent studies has showed homocystein tendency of the Delta band power spectra in both brain hemispheres. Ahmad bilitation robot is a new physical therapy technology to provide 1Department of Rehabilitation Medicine, Penang General Hos- high-precision, high repeatability of training and visual, auditory pital, Penang, Malaysia, 2Rehabilitation Physician and Head of comprehensive feedback. Our study was designed to observe the Department, Department of Rehabilitation Medicine- Penang Gen- effect of upper limb rehabilitation robot for upper limb function in eral Hospital, Penang, Malaysia stroke patients. Material and Methods: One hundred patients with acute stroke were randomly divided into a control group (50 cases) Introduction/Background: Intensive rehabilitation medicine ser- and a therapy group (50 cases). All of the patients were treated vices, when offered as an organized and structured inpatient pro- with conventional medical treatment and rehabilitation training. Moreover, these scores continued to rise:12-week and daily sessions of therapy, with an average stay of 3. Conclusion: Robot- in chronic stroke patients and subsequently offers renewed hope based rehabilitation can be applied to patients with acute stroke in and potential for these patients who should no longer be side-lined a clinical setting and may be benefcial for improving the upper as “dead end cases”. The treatment group was treated with and lower limb function in post-stroke patients. Two cases of the observation group At the time of discharge, all of the evaluated items showed a statis- off, shedding 4. Three cases of the treatment group tically signifcant improvement relative to the scores at admission.