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This may occur when the bullet strikes the body at a surface directly adjacent to underlying bone purchase speman 60pills otc mens health quiz questions. This is an example with bullet fragmentation purchase 60pills speman with visa prostate cancer 6 stage, partial exit zebeta 5 mg cheap, and underlying keyhole deformity of the skull. The direction of fre is from the decedent’s front to back, as indicated by the arrow. Part of this bullet entered the cranium and a portion of the bullet exited the body. Such injuries Note the perforation on the right side has a more uniform often occur in regions of the body where skin folded on oval shape with a more symmetric margin of abrasion. Note the irregular where the bullet passed very close to the undersurface of nature of the torn skin and irregular abrasions at the exit the skin, causing stretching and darker drying of the skin reentry site. Both nail guns used were similar to the one depicted above, which used gunpowder-loaded cartridges. Both entrance wounds consisted of circular perforations with symmetric margins of abrasion indistinguishable from typical entrance gunshot wounds. Note the orange plastic ejected into the entrance perforation of the temporal skull, which is used in some nail guns to hold and steady the nail prior to discharge. The individual was wearing a medallion on a string, which was struck by the bullet as it exited the body, producing an imprint on the skin surface. The chest surface was most likely pressing against another object when the bullet exited. The photograph illustrating the medallion actually demonstrates it facing the wrong way. Among other points arguing this to be an exit wound was the sternum fracture with bone splinters pointing in an outward anterior direction. Autopsy examination revealed a perforating wound to the aorta where the bullet ricocheted off vertebrae back into the aortic lumen and then embolized to the left femoral artery. One of the bullets entered the lung parenchyma and embolized to the heart where it got wedged in papillary mus- cles of the left ventricle. He developed a bronchopneumonia and his lung wound reopened causing hemorrhage and death. The gunshot wounds to the fetus were atypical due to the intermediate tar- gets including the mother, uteroplacental unit, and amniotic fuid. Note the irregular nature of the entrance gunshot wound just beneath the eye and the elongated abrasion extending across the cheek to the decedent’s ear, corresponding to the eyeglass frame. Another case where a glass fragmentation caused other adjacent orbital lacerations. Note the irregu- lar nature of this entrance gunshot wound through one of the plaques. The skin had small radiating lacerations and decreased abrasion similar to what is sometimes seen with gunshot wounds through thick skin found on the palms of the hands or soles of the feet.

When H0 : b1 ¼ 0 Is Rejected Now let us consider the situations in a population that may lead to rejection of the null hypothesis that b1 ¼ 0 cheap speman 60 pills free shipping prostate oncology 21st. Assuming that we do not commit a type I error order speman overnight prostate 1 vogel, rejection of the null hypothesis that b1 ¼ 0may be attributed to one of the following conditions in the population: (1) the relationship is linear and of sufficient strength to justify the use of sample regression equations to predict and estimate Y for given values of X; and (2) there is a good fit of the data to a linear model discount colospa 135 mg mastercard, but some curvilinear model might provide an even better fit. Thus, we see that before using a sample regression equation to predict and estimate, it is desirable to test H0 : b1 ¼ 0. We may do this either by using analysis of variance and the F statistic or by using the t statistic. Before we do this, however, let us see how we may investigate the strength of the relationship between X and Y. The Coefficient of Determination One way to evaluate the strength of the regression equation is to compare the scatter of the points about the regression line with the scatter about y, the mean of the sample values of Y. We would not wish, however, to decide on this basis alone that the equation is a useful one. The situation may not be always this clear-cut, so that an objective measure of some sort would be much more desirable. The Total Deviation Before defining the coefficient of determination, let us justify its use by examining the logic behind its computation. We begin by considering the point corresponding to any observed value, yi, and by measuring its vertical distance from the y line. The Explained Deviation If we measure the vertical distance from the regression line to the y line, we obtain ^yi À y , which is called the explained deviation, since it shows by how much the total deviation is reduced when the regression line is fitted to the points. Unexplained Deviation Finally, we measure the vertical distance of the observed point from the regression line to obtain yi À ^yi , which is called the unexplained deviation, since it represents the portion of the total deviation not “explained” or accounted for by the introduction of the regression line. The difference between the observed value of Yand the predicted value of Y, yi À ^yi ,isalsoreferredtoasaresidual. The set of residuals can be used to test the underlying linearity and equal-variances assumptions of the regression model described in Section 9. It is seen, then, that the total deviation for a particular yi is equal to the sum of the explained and unexplained deviations. If we measure these deviations for each value of yi and ^yi, square each deviation, and add up the squared deviations, we have X X X 2 2 2 ð yi À y ¼ ^yi À y þ yi À ^yi (9. The reader will recognize this term as the numerator of the familiar formula for the sample variance. Explained Sum of Squares The explained sum of squares measures the amount of the total variability in the observed values of Y that is accounted for by the linear relationship between the observed values of X and Y. It would be of interest, then, to determine the magnitude of this proportion by computing the ratio of the explained sum of squares to the total sum of squares. This is exactly what is done in evaluating a regression equation based on sample data, and the 2 result is called the sample coefficient of determination, r.

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The variable marital status purchase discount speman line prostate weight, for example buy 60 pills speman with amex androgen hormone imbalance in women, is a qualitative variable whose categories are “single 17.5mg lisinopril sale,” “married,” “widowed,” and “divorced. In certain situations an investigator may suspect that including one or more variables such as these in the regression equation would contribute significantly to the reduction of the error sum of squares and thereby provide more precise estimates of the parameters of interest. Suppose, for example, that we are studying the relationship between the dependent variable systolic blood pressure and the independent variables weight and age. We might also want to include the qualitative variable sex as one of the independent variables. Or suppose we wish to gain insight into the nature of the relationship between lung capacity and other relevant variables. Candidates for inclusion in the model might consist of such quantitative variables as height, weight, and age, as well as qualitative variables such as sex, area of residence (urban, suburban, rural), and smoking status (current smoker, ex-smoker, never smoked). Dummy Variables In order to incorporate a qualitative independent variable in the multiple regression model, it must be quantified in some manner. The term “dummy” is used to indicate the fact that the numerical values (such as 0 and 1) assumed by the variable have no quantitative meaning but are used merely to identify different categories of the qualitative variable under consideration. Qualitative variables are sometimes called indicator variables, and when there are only two categories, they are sometimes called dichotomous variables. The following are some examples of qualitative variables and the dummy variables used to quantify them: Qualitative Variable Dummy Variable & Sex (male, female): 1 for male x1 ¼ : 0 for female & Place of residence (urban, rural, suburban): 1 for urban x1 ¼ : 0 for rural and suburban & 1 for rural x2 ¼ : 0 for urban and suburban & Smoking status [current smoker, ex-smoker 1 for current smoker x1 ¼ : (has not smoked for 5 years or less), ex-smoker 0 for otherwise (has not smoked for more than 5 years), never smoked]: & 1 for ex-smoker 5 years x2 ¼ : 0 otherwise & 1 for ex-smoker > 5 years x3 ¼ : 0 otherwise 11. This rule is applicable for any multiple regression containing an intercept constant. The variable sex, with two categories, can be quantified by the use of only one dummy variable, while three dummy variables are required to quantify the variable smoking status, which has four categories. The following examples illustrate some of the uses of qualitative variables in multiple regression. In the first example we assume that there is no interaction between the independent variables. Since the assumption of no interaction is not realistic in many instances, we illustrate, in the second example, the analysis that is appropriate when interaction between variables is accounted for. There are two independent variables: length of gestation (weeks), which is quantitative, and smoking status of mother (smoke), a qualitative variable. Grams Weeks Smoke 21 2183 42 1 71 2070 37 0 22 3204 38 0 72 3345 40 0 23 3005 36 0 73 3600 40 0 24 3090 40 1 74 3232 41 0 25 3430 39 0 75 3657 38 1 26 3119 40 0 76 3487 39 0 27 3912 39 0 77 2948 38 0 28 3572 40 0 78 2722 40 0 29 3884 41 0 79 3771 40 0 30 3090 38 0 80 3799 45 0 31 2977 42 0 81 1871 33 0 32 3799 37 0 82 3260 39 0 33 4054 40 0 83 3969 38 0 34 3430 38 1 84 3771 40 0 35 3459 41 0 85 3600 40 0 36 3827 39 0 86 2693 35 1 37 3147 44 1 87 3062 45 0 38 3289 38 0 88 2693 36 0 39 3629 36 0 89 3033 41 0 40 3657 36 0 90 3856 42 0 41 3175 41 1 91 4111 40 0 42 3232 43 1 92 3799 39 0 43 3175 36 0 93 3147 38 0 44 3657 40 1 94 2920 36 0 45 3600 39 0 95 4054 40 0 46 3572 40 0 96 2296 36 0 47 709 25 0 97 3402 38 0 48 624 25 0 98 1871 33 1 49 2778 36 0 99 4167 41 0 50 3572 35 0 100 3402 37 1 Source: John P. Solution: For the analysi s, we quant ify smoking status by means of a dummy variable that is coded 1 if the mother is a smoker and 0 if she is a nonsmoker. The scatter diagram suggests that, in general, longer periods of gestation are associated with larger birth weights. To obtain additional insight into the nature of these data, we may enter them into a computer and employ an appropriate program to perform further analyses. For example, we enter the observations y1¼ 3147, x11¼ 40, x21¼ 0, for the first case; Y2¼ 2977, x12¼ 41, x22¼ 0 for the second case; and so on.

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Chapter 9 Atrial Flutter and Fibrillation Atrial fibrillation and its cousin generic speman 60pills without a prescription man health women news p90x results, atrial flutter (typical and atypical) order speman with american express prostate cancer xgeva, are the most common arrhythmias with which we must deal clinically discount plavix, yet they are the group of arrhythmias about which we know the least. For the past decade, experimental data as well as clinical electrophysiology studies have allowed a better, but still incomplete, understanding of these arrhythmias. It appears that they represent a heterogeneous group of disorders that are markedly influenced by the functional and anatomic structures of the right and left atrium as well as the autonomic nervous system. Atrial fibrillation and flutter frequently coexist and can appear spontaneously or can be induced in the same patient. The clinical and electrophysiologic definitions of atrial fibrillation and flutter are hard to decipher. More recently, atrial fibrillation has been divided into paroxysmal (self-terminating within 7 days), persistent (lasting greater than 1 week or requiring electrical or pharmacologic cardioversion), and permanent (failed cardioversion or not 1 attempted). Others have tried to categorize atrial fibrillation by assumed mechanisms, such as a focal atrial fibrillation, vagally mediated atrial fibrillation, sympathetically mediated atrial fibrillation, etc. Atrial fibrillation has also been classified based on whether or not it appears as an isolated electrical phenomenon (lone atrial fibrillation) or whether it is associated with some form of organic disease. The fact that there are so many definitions attests to our lack of total understanding of this arrhythmia. Typical flutter is a term now used to describe both “classic” counterclockwise flutter in which the inferior leads demonstrate a sawtooth-like undulating baseline with positive flutter waves in lead V and negative flutter waves in V , and clockwise flutter, which has1 6 positive, notched flutter waves in the inferior leads and in V and negative flutter waves in V. Both of these6 1 patterns are currently believed to be due to reentry with opposite directions of activation (counterclockwise and clockwise) in the same anatomic circuit. The term “atypical” flutter is currently applied to any macrorentrant atrial tachycardia that is different from these two. It is therefore necessary to distinguish a reentrant mechanism from an automatic mechanism to diagnose “atrial flutter” versus atrial tachycardia when tachycardia rates are 250 to 320 beats per minute (bpm) in the absence of drugs. I prefer to use the terms macrorentrant and focal atrial tachycardia; the term “flutter” is too often misused and incorrect. The term typical flutter should be used to describe macroreentrant, tricuspid-caval isthmus-dependent atrial tachycardia. Given all these variables, this chapter will discuss the role of electrophysiology studies in evaluating these arrhythmias. Programmed atrial stimulation and endocardial activation mapping techniques have been used to (a) analyze the electrophysiologic substrates of atrial conduction, refractoriness, and ectopic atrial impulse formation that may be responsible for the initiation of either macroreentrant atrial tachycardia (i. Additional benefits of an electrophysiologic study are the ability to determine the nature of P. Electrophysiologic and Anatomic Substrates of Macroreentrant Atrial Tachycardia (Typical and Atypical Atrial Flutter) and Fibrillation Atrial fibrillation occurs in many disease states, but can occur in the absence of disease, that is, lone atrial fibrillation. Microscopic abnormalities can be found in patients with and without atrial fibrillation which may be part of normal aging.