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Cost Accumulation and Allocation in Management Accounting

Anticoagulant Accumulation/Toxicity

Settler Colonialism and Primitive Accumulation

Intracellular & Extracellular accumulation

Gen path week 8 (necrosis and cellular accumulations)

Accumulations

The American Sleep Disorders Association, in 1990, initiated a 5 year process to develop the widely used International Classification of Sleep Disorders (ICSD). The original ICSD listed 84 sleep disorders, each with descriptive details and specific diagnostic, severity, and duration criteria. The ICSD had 4 major categories: (1) dyssomnias, (2) parasomnias, (3) disorders associated with medical or psychiatric disorders, (4) "proposed" sleep disorders. The ICSD has since been revised twice. The second edition, ICSD-2 was released in 2005 which contains a list of 77 sleep disorders. That new list was broken down into 8 sub-categories: (1) Insomnia; (2) Sleep-related breathing disorder; (3) Hypersomnia not due to a sleep related breathing disorder; (4) Circadian rhythm sleep disorder; (5) Parasomnia; (6) Sleep-related movement disorder; (7) Isolated Symptoms, apparently normal variants, and unresolved issues; and (8) Other sleep disorders. A third edition of the ICSD was released in 2014. The major clinical divisions were unchanged in the third edition from the 2nd version, but there was an addition of variations in the diagnostic criteria for pediatric patients with obstructive sleep apnea, and there was a heading of Developmental Issues added to each section of disorders that have developmentally-specific clinical features in order to aid physicians in diagnosing those patients (specifically 9-CM and 10 CM). Sleep Disorders Categories The ICSD-3 lists about 77 sleep disorders which are divided into the following categories: Insomnia Sleep-related breathing disorder Central Disorders of Hypersomnolence Circadian rhythm sleep disorder Parasomnias Sleep-related movement disorder Some of the above categories have a section for isolated Symptoms, apparently normal variants, and unresolved issues Other sleep disorders There are some other sleep disorders that are divided into two appendices of the ICSD-2 manual. They are as follows: Sleep Related Medical and Neurological Disorders; and ICD-10-CM Coding for Substance-induced Sleep Disorders Study the disorders listed under each of the above categories until you have a good idea of what is included in each. There is a complete list of all the current classified sleep disorders in chapter 27, beginning on page 476 of your Sleep Disorders Medicine, 4th edition textbook. Insomnias Insomnias are disorders that usually produce complaints of not enough sleep, poor quality of sleep. Patient perception can play a role in the complaints. Occasionally, a patient may perceive that they are getting poor quality or not enough sleep even though they may be getting what we think is a normal night’s rest. Insomnias are defined by a repeated difficulty initiating sleep, not sleeping long enough, or poor quality sleep regardless of the amount of sleep time. Primary insomnia would not be due to another sleep disorder. If another sleep disorder such as OSA is causing the insomnia, then we call that secondary insomnia. These disorders may require medical treatment if they are long-lasting. Temporary insomnia due to a stressful situation or life event may correct itself with time. The types of insomnia are covered on pages 476 and 480 of your textbook. Sleep-Related Breathing Disorders These are disorders that involve disordered respiration, or breathing during sleep. These may be obstructive or not. There can be various causes of both. Central apnea syndromes include Cheyenne-Stokes breathing pattern and high-altitude periodic breathing. Cheyenne-Stokes is usually associated with either congestive heart failure or a traumatic brain injury which would actually be called secondary Central Sleep Apnea because it is secondary to another problem. It can also occur due to extreme old age, or a “worn-out” heart (a pacemaker may be needed for this type of patient). You will see patients like this occasionally. Primary Central Sleep Apnea has no apparent cause but still results in an irregular breathing pattern. These patients are not necessarily good candidates for CPAP because their breathing problem may not involve an obstruction. If not, you will likely see an increase in the number or length of central apneas after placing them on CPAP. There are newer PAP technologies that have been developed in recent years that do have some effect on the regulation of these types of patients’ breathing pattern but may show limited success in extending life expectancy. The obstructive type of breathing disorders, on the other hand, do respond well to treatment. These will likely make up the vast majority of patients that you will encounter in the sleep laboratory. Refer to pages 476 and 481 for more detailed examples of these disorders. Central Disorders of Hypersomnolence If you break down the word “hypersomnia” into its root terms as you did in medical terminology, it should be apparent that these disorders involve excessive sleepiness. However, the excessive sleepiness cannot be the result of another class of disorder. If a patient has another such disorder, that disorder must be effectively treated before a diagnosis of hypersomnia not due to a sleep-related breathing disorder can be made. These patients may have nights of uninterrupted sleep, but they still have unintended or unwanted lapses into sleep during the day. There can be many different causes of this; some of which are very interesting. Narcolepsy and Kleine-Levin Syndrome fall into this category along with some neurologic or psychiatric disorders. Circadian Rhythm Sleep Disorder Circadian rhythm sleep disorders are sleep disorders related to the internal clock of the human body resulting in an irregular sleep-wake cycle. Patients with these sleep disorders have circadian rhythms that make it difficult for them to function in society. The three extrinsic circadian rhythm sleep disorders are the time zone change syndrome, shift work sleep disorder, and irregular sleep-wake pattern (secondary circadian rhythm disorders). Three intrinsic circadian rhythm sleep disorders are delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24-hour sleep-wake disorder (primary circadian rhythm disorders). For Circadian Rhythm disorders, refer to page 482 of your textbook. Time Zone Change Syndrome (Jet Lag Syndrome): Jet lag is experienced as a result of eastward or westward jet travel, after crossing several time zones, disrupting synchronization between the body's inner clock and its external cues. Symptoms do not occur after north-south travel. jet lag symptoms consist of difficulty in maintaining sleep, frequent arousals, and excessive daytime somnolence. Delayed Sleep Phase Syndrome: The ICSD-2 defines delayed sleep phase syndrome (DSPS) as a condition in which a patient's major sleep episode is delayed in relation to a desired clock time. This delay causes symptoms of sleep-onset insomnia or difficulty awakening at the desired time. Typically, patients go to sleep late (between 2:00 am and 6:00 am) and awaken during late morning or afternoon hours (between 10:00 am and 2:00 pm). Patients cannot function normally in society due to disturbed sleep schedules. Patients may try hypnotic medications or alcohol in attempts to initiate sleep sooner. DSPS patients may be treated by the use of chronotherapy (intentionally delays sleep onset by 2-3 hours on successive days until the desired bedtime has been achieved) or phototherapy (exposure to bright light on awakening). Advanced Sleep Phase Syndrome: Advanced sleep phase syndrome is characterized by patients going to sleep in the early evening and wake up earlier than desired in the morning (2:00 am-4:00 am). Because the patients have early morning awakenings, they experience sleep disruption and daytime sleepiness if they don't go to sleep at early hours. ASPS is most commonly seen in elderly individuals. Diagnosis is based upon sleep logs and characteristic actigraphic recordings made over several days. Chronotherapy may be used to treat ASPS; however, this therapy is not as successful in ASPS as in DSPS. Bright light exposure in the evening has been successful in delaying sleep onset. Non-24-Hour Sleep-Wake Disorder: Also known as Non-entrained, free running, or hypernychthemeral syndrome, is a disorder characterized by a patient's inability to maintain a regular bedtime and a sleep onset that occurs at irregular hours. Patients display increases in the delay of sleep onset by approximately one hour per sleep-wake cycle, causing an eventual progression of sleep onset through the daytime hours and into the evening. These individuals fail to be entrained or synchronized by usual time cues such as sunlight or social activities. This disorder is extremely rare and is most often associated with blindness. Parasomnia The parasomnias are a class of sleep disorders associated with arousals, partial arousals, and sleep stage transitions. They are dysfunctions (including movements and behaviors) that are associated with sleep, or that occur during sleep. Most parasomnias occur during delta sleep or slow wave sleep, although some can occur during any stage. REM Behavior Disorder, Nightmare Disorder, and Recurrent Isolated Sleep Paralysis are also included in this group although they are all associated with REM sleep. Rem Behavior Disorder (RBD) may involve a very drastic or sometimes violent dream enactment. Approximately 88% of known cases are in males. Elderly patients (over the age of 60) make up a high percentage of known cases (60%). RBD is now considered to be a possible indication of a future neurodegenerative disease such as Parkinson’s. Around 50% of patients with REM parasomnias also have some type of central nervous system disorder, and almost 10% have a psychiatric disorder. The treatment for these disorders is usually limited to securing the environment, but can also include the prescription of clonazepam. Think of parasomnias as things that patients may also do while sleeping, excluding movement disorders (other than RBD) which used to be included in this category as well. Examples would be Night Terrors, Nightmares, Hallucinations, Sleepwalking, or Enuresis (bed-wetting), etc. Parasomnias are covered in your text book on pages 482 - 484. Sleep-Related Movement Disorders Bruxism: Bruxism (teeth grinding) occurs most commonly in individuals between ages 10 and 20 years and is commonly noted in children with mental retardation or cerebral palsy. Bruxism is noted most prominently during NREM stages I and II and REM sleep. Episodes are characterized by stereotypical tooth grinding and are often precipitated by anxiety, stress, and dental disease. Occasionally, familial cases have been described. Usually, no treatment is required, but in extreme cases, dental reconstruction and appliances such as mouth guards may be needed. Periodic Limb Movement Disorder: Periodic limb movement disorder (PLMD, or PLMS for Periodic Limb Movements in Sleep) is a common sleep disorder affecting approximately 34% of people over the age of 60 years. PLMD can be defined as repetitive, involuntary limb movements during sleep. These movements are seen mostly in stage II sleep, and not in REM sleep due to muscle atonia in REM. The criteria for the leg movements to qualify as PLMS, the leg movements must last from 0.5 seconds to 5 seconds in duration each, there must be a gap of 5 to 90 seconds between each one, and there must be a cluster of at least 4 of these movements. Symptoms of PLMS often include frequent EEG arousals, fragmented sleep architecture, daytime sleepiness, and a disturbed bed partner. Treatment of PLMS usually includes medications. However, if the leg movements are related to respiratory events, they usually disappear when the respiratory events are corrected via CPAP, BiPAP, dental appliances, etc. The most common medications used to treat PLMS include Clonazepam, Dopamine Agonists, Anticonvulsants, and Opiates. Restless Legs Syndrome: Restless Legs Syndrome (RLS) is a disorder that causes discomfort in the legs and an irresistible urge to move them. This scenario can occur while the patient is asleep or awake. Patients often describe this discomfort as an itching, crawling, or creeping sensation in their legs. RLS is a common disorder, and affects more than 5% of the total population. Most RLS patients begin having symptoms before the age of 20, and continue to have these symptoms throughout their lives. Most patients with RLS also have PLMS. The most common treatments for these disorders are medications, including benzodiazepines, dopamine, opiates, and alpha-adrenergic blockers. Nocturnal Leg Cramps: Nocturnal leg cramps are intensely painful sensations that are accompanied by muscle tightness occurring during sleep. These spasms usually last for a few seconds but sometimes persist for several minutes. Cramps during sleep are generally associated with awakening. Many normal individuals experience nocturnal leg cramps. Causes remain unknown. Local massage or movement of the limbs usually relieves the cramps. Rhythmic Movement Disorder: Rhythmic movement disorder occurs mostly in infants younger than 18 months of age, is occasionally associated with retardation, and is rarely familial. It is comprised of three characteristic movements: head rolling, headbanging, and body rocking. These episodes are usually not remembered once the person awakens. It affects approximately three times as many males as females. Treatment for rhythmic movement disorder usually includes behavior modification, benzodiazepines, and antidepressants. Rhythmic movement disorder is a benign condition, and usually, the patient outgrows the episodes. Other rhythmic movement disorders can be related to the use of a drug or substance, or to another medical condition. Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues This category includes disorders that are borderline normal or are normal variants. These include such examples as long sleeper, short sleeper, hypnic jerks, and other types of twitching or jerking movements that may only occur at sleep onset or in newborns. You have probably seen someone display a hypnic jerk as they fell asleep, or you may have woken yourself jerking because you felt like you were falling. Things like snoring or sleep-talking could be included in this case if they are not causing symptoms of insomnia or excessive daytime sleepiness but are disturbing to the patient or other people. Other Sleep Disorders A diagnosis in this category gives the physician an option for when the diagnosis may not be clear or too unusual to clearly fit into one of the other categories. This diagnosis may often be used as a temporary diagnosis until the actual cause of the disorder is determined. Environmental Sleep Disorder could be something in the surrounding environment, such as a barking dog, that is disturbing the patient's sleep enough to cause symptoms. Appendix A: Sleep-Related Medical and Neurological Disorders This category includes disorders that sometimes occur unrelated to sleep, but are related to sleep in these cases. Examples are sleep-related epilepsy, headaches, Sleep-related Myocardial Ischemia, or gastroesophageal reflux. Fibromyalgia used to be included in this section. While fibromyalgia is not necessarily a disorder that is only related to sleep, it can cause arousals, or disruptions of the patient's sleep and is a common diagnosis of patients that you will see. Appendix B: Other Psychiatric/Behavioral Disorders Frequently Encountered in the Differential Diagnosis of Sleep Disorders This section includes mood disorders, anxiety disorders, schizophrenia, or any other psychiatric diagnosis that may affect the patient's quality of sleep. Therefore, you will also likely see patients who have been referred by a psychiatrist on occasions. Intrinsic and Extrinsic Sleep Disorders These are terms that were previously used to differentiate between disorders that originated from within the body and those that were caused by something in the outside environment. However, I think that you could still see these terms again, so I think it is a good idea for you to be familiar with this terminology. INTRINSIC DISORDERS Intrinsic disorders include various types of insomnia and restless legs syndrome. Narcolepsy and recurrent hypersomnia are disorders of excessive sleepiness. Hypersomnolence can also be caused by narcolepsy, apnea, sleep disordered breathing, or periodic limb movements in sleep. EXTRINSIC DISORDERS Extrinsic sleep disorders include those that originate or develop from causes outside the body. Some of these dyssomnias found within this category include: conditions of inadequate sleep hygiene, altitude insomnia, food allergy insomnia, nocturnal eating, limit-setting sleep disorder, and sleep-onset association disorder. Sleep apnea is a disorder that commonly afflicts more than 12 million people in the United States. The word apnea is of Greek origin and means "without breath." Patients diagnosed with sleep apnea will literally stop breathing numerous times while they are asleep. The apneas on average can last from ten seconds to longer than a minute. These events can occur hundreds of times during a single night of sleep. Obstructive sleep apnea (OSA) is the most common type of apnea found within the category of sleep disordered breathing. OSA is caused by a complete obstruction of the airway, while partial closure is referred to as a hypopnea. The hypopnea is characterized by slow, shallow breathing. There are three types of apneas: obstructive, central, and mixed. So, sleep disordered breathing may be due to an airway obstruction (OSA), an abnormality in the part of the brain that controls respiration (central sleep apnea), or a combination of both ( mixed sleep apnea). This lesson will concentrate on obstructive sleep apnea. OSA occurs in approximately two percent of women and four percent of men over the age of 35. Check out this video for a good example of an OSA patient: Sleep Apnea - Hard to Watch... (Links open in a new window. Right click on link and choose "open in a new window") Obstructive Sleep Apnea sufferers are not always the ones that you would expect. Check out this video of an Asian woman, especially near the end: Sleep Apnea Causes of Obstructive Sleep Apnea The exact cause of OSA is difficult to pinpoint. The site of obstruction in most patients is the soft palate, extending to the region at the base of the tongue. There are no rigid structures, such as cartilage or bone, in this area to hold the airway open. When a patient is awake, muscles in the region keep the passage open. However, a patient who tests positive for OSA will experience a collapsing of the airway when they are asleep. Thus, the obstruction occurs, and the patient awakens to open the airway. The arousal from sleep lasts only a few seconds, but brief arousals disrupt continuous sleep. When the sleep architecture is fragmented, the patient will be prevented from obtaining SWS and REM sleep ( these stages of sleep are needed by the body to replenish its strength ). Once normal breathing is restored, the person falls asleep only to repeat the cycle throughout the night. Typically, the frequency of waking episodes is somewhere between 10 and 60. A patient with severe OSA may have more than 100 waking episodes in a night of sleep. Often, the OSA patient will complain of nonrestorative sleep and excessive daytime sleepiness. Risk Factors The primary risk factor for OSA is excessive weight gain. The accumulation of fat on the sides of the upper airway causes it to become narrow and predisposed to closure when the muscles relax. Age is another prominent risk factor. Loss of muscle mass is a common occurrence associated with the aging process. If muscle mass decreases in the airway, it may be replaced with fat, leaving the airway narrow and soft. Men have a greater risk for OSA. Male hormones can cause structural changes in the upper airway. Below are other common predisposing factors associated with OSA: Anatomic abnormalities, such as a receding chin Enlarged tonsils and adenoids ( the main causes of OSA in children) Family history of OSA ( However, there has been no medically documented facts stating a generic inheritance pattern ) Use of alcohol and sedative drugs, which relax the musculature in the surrounding upper airway Smoking, which can cause inflammation, swelling, and narrowing of the upper airway Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio syndrome, neuromuscular disorders, Marfan's syndrome, and Down syndrome Nasal and sinus congestion or problems Symptoms of OSA The nightly disruption and fragmentation of normal sleep architecture will cause the patient to experience the feeling of nonrestorative sleep. The most common complaint from someone who suffers from OSA is excessive daytime sleepiness (EDS) . The numerous disruptions and arousals will prevent the patient from obtaining a continuous deep sleep. Thus, the individual could also be prone to automobile accidents, personality changes, decreased memory, impotence, and depression. Patients are rarely aware or recall the frequent awakenings that occur following the obstructive episodes. EDS may be mild, moderate, or severe. Some patients will complain of falling asleep in a non stimulating environment, such as reading a book or a newspaper in a quiet room. Severe OSA patients may complain of falling asleep in a stimulating environment, such as during business meetings, eating, or casual conversation. One of the most dangerous scenarios is patients who suffer from OSA can fall asleep behind the wheel. Patients will often complain of feeling like they have not slept at all no matter of the length of time in bed. The same holds true for napping. Other indicators or symptoms of possible OSA include morning headaches and frequent urination during the night. Physical signs that coincides with characteristics of OSA patients include snoring, witnessed apneic episodes, and obesity. Not every individual who snores will test positive for OSA, but most patients who have OSA will snore with moderate to loud levels. Hypertension is prevalent in patients with OSA, although the exact relationship is unclear. It has been medically proven that treating OSA can significantly lower blood pressure. Complications The most prevalent complication for patients who suffer from OSA is a diminished quality of life due to chronic sleep deprivation and previous described symptoms. Coronary artery disease, cerebral vascular accidents (strokes), and congestive heart failure are being evaluated to define the exact nature of their connection to OSA. Still, it has documented that there is a relation between these complications and OSA. Obstructive sleep apnea aggravates congestive heart failure (CHF) by placing stress on the heart during sleep. Statistics show there is a high prevalence of OSA in patients with CHF. Central sleep apnea may be prominent in patients with CHF. Diagnosis The most universal method for diagnosing OSA is to have the patient undergo a sleep study. The technical name for the procedure is nocturnal polysomnograph. The first priority with any procedure is patient safety. A thorough analysis of the information gathered prior to beginning the test will give the technician an opportunity to determine the reason for testing, to verify all necessary monitoring parameters, and to determine the possible need for ancillary equipment. The technician must be aware of any precautions or special patient needs during testing. An understanding and knowledge of the signs, symptoms, and findings of a variety of sleep disorders and sleep related breathing disorders is necessary to ensure patient safety and recording requirements during polysomnography testing. Various medical problems will be encountered with the patients undergoing a sleep study. Examples of these complications include: asthma, COPD, cardiac arrhythmias, carbon dioxide narcosis, and abnormal breathing. Numerous cardiac arrhythmias may occur and they include: asystole, ventricular tachycardia or fibrillation, bigeminy, trigeminy, multi-focal PVC's, heart blocks, atrial fibrillation, bradycardia, or tachycardia associated with sleep apnea. Some of these cardiac arrhythmias are life threatening and require technician intervention. Others are relatively benign and require only that the technician watch the patient closely. Thus, all polysomnography technicians will be required to be certified in Basic Life Support. The polysomnography testing will include recording of multiple physiological parameters in sleep. These parameters usually include EEG, EKG, eye movements, respiration, muscle tone, body position, body movements, and oxygen saturation. The electroencephalogram (EEG) measures brain electrical activity. The brain activity during different stages of sleep as compared to wake is distinctly different. The electrooculogram (EOG) monitors eye movements and allows the examiner to determine REM sleep and wake. The electromyogram (EMG) monitors muscle tone, and the EMG helps to differentiate REM sleep from wake because the muscles relax to a state of paralysis in REM sleep. The electrocardiogram (EKG or ECG) monitors heart rate and graphs the electrical signal as it is conducted through the heart. Respiratory effort belts are placed around the patient's chest and abdomen to detect and record the rising and falling movements associated with respiration. A pulse oximeter is attached to the finger to record oxygen saturation levels in the blood. Leg leads or electrodes are attached to record leg movements which may determine the patient has periodic limb movement disorder. A thermistor is used to monitor breathing. Obstructive sleep apnea is diagnosed if the patient has an apnea/hypopnea index (AHI) of 5 or greater an hour. The respiratory disturbance index (RDI) is sometimes used in place of the AHI and essentially refers to the same data. However, in the recent past, RDI was an index that also included the number of respiratory effort related arousals(RERAS) per hour in addition to the hypopneas and apneas. Some sleep centers may still do this, but most are currently not scoring the RERAS due to non-coverage of insurance. An RDI from five to ten per hour would be a positive finding for OSA as well. Clinically speaking, an obstructive apnea is defined as a complete cessation of airflow for 10 seconds or more with persistent respiratory effort. An obstructive hypopnea is defined as a partial reduction in airflow of at least 30 percent followed by a drop in SaO2 of at least 3% or an arousal from sleep, or an alternate definition of 50 percent reduction in nasal pressure airflow signal followed by at least a 4% drop in SaO2(desaturation). Medicare still requires the 4% drop in SaO2 for their patients, but the first definition is recommended by the American Academy of Sleep currently. SaO2 refers to the amount of Oxygen in the blood being carried by the red blood cells. This will always drop when a patient stops breathing. The many physiological measurements taken usually enable the physician to diagnose or reasonably exclude OSA. Certain scenarios may prove a more difficult diagnosis. Such as, a patient who may have mild OSA at home, or only after using certain medications or alcohol but does not experience any episodes during the sleep study. Thus, the sleep study results must be interpreted with the entire clinical picture in mind. Another condition, called upper airway resistance syndrome, cannot be seen on polysomnography. This syndrome is characterized by repetitive arousals from sleep that probably result from increasing respiratory effort during narrowing of the upper airway. These patients suffer the same sleep disruption and deprivation as other sleep apnea patients. In such cases, the only alarming indicator that is recorded is the recurrent arousals. Ultimately, patients suffering from upper airway resistance syndrome may not test positive for OSA with standard polysomnography testing. Treatment A patient suffering from OSA has several treatment options that include: weight reduction, positional therapy, positive pressure therapy, surgical options, and oral appliances. Significant weight loss has shown tremendous improvement and possible elimination of OSA. The amount of weight a patient needs to lose to achieve noticeable benefits varies. However, one will not need to achieve "ideal body weight" to see improvement. Positional therapy is a method of treatment used to treat patients whose OSA is related to body positioning during sleep. A OSA patient who sleeps flat on their back, or in supine position, will experience worse symptoms in general. This type of therapy has its limits, but some patients have experienced benefits. Some of the strategic methods include: a sock filled with tennis balls is sewn into their shirt to make it uncomfortable for the sleeper to lie on their back, and positional pillows to assist in sleeping on their side. Positive pressure therapy is one of the most if not the best methods of treatment for obstructive sleep apnea. There are three different types of devices: continuous positive airway pressure (CPAP), autotitration, and bi-level positive airway pressure. CPAP, the more common of the three therapy modes, is the most prescribed method of treatment for OSA. A facial or nasal mask is worn by the patient while they sleep. The mask is connected to the CPAP machine with tubing. Positive air pressure is delivered from the machine to the mask and continues to the upper airways establishing a "pneumatic splint" that prevents collapsing of the airways. Autotitration devices are designed to provide the minimum necessary pressure at any given time and change that pressure as the needs of the patient change. Bi-level positive airway pressure differs from the CPAP by reducing the level of positive pressure upon exhalation. Oral appliances are another avenue a patient can try as a therapeutic device. Generally, there are two categories, mandibular advance devices and tongue-retaining devices. Mandibular advance devices are similar to athletic mouth guards. They differ in the mold for the lower teeth is advanced further forward than the mold for the upper teeth. This will cause the jawbone to remain forward and prevent the collapse of the airway. It is effective in mild cases of OSA, particularly if the patient's OSA is positional. Tongue-retaining devices also resemble an athletic mouth guard. It acts as a suction cup and is placed between the upper and lower teeth. The tongue is positioned forward and obstructions caused by the tongue should be minimized. First described in 1981, CPAP therapy has become the most preferred treatment for patients with OSA. CPAP flow generators or machines maintain a constant, controllable pressure to prevent blockage of the upper airway. The positive air pressure travels through the nostrils by a nasal or facial mask. This airflow holds the soft tissue of the uvula, palate, and pharyngeal tissue in the upper airway in position so the airway remains open while the patient progresses into deeper stages of sleep and REM sleep. The CPAP device can be described as a "pneumatic splint." Variations to the CPAP machine are available to help with compliance. BPAP, Bi-PAP or bi-level positive airway pressure is another option for treatment. Those three are one and the same. They are just different ways that you might see this term. The AASM guidelines uses "BPAP" in their protocol publications. BiPAP is a trademarked term by a company named Respironics. Anyway, most of the problems patients experience with CPAP are caused by having to exhale against a high airway pressure. Because the air pressure required to prevent respiratory obstruction is typically less on expiration than on inspiration, Bi-PAP machines are designed to detect when the patient is inhaling and exhaling and to reduce the pressure to a preset level on exhalation. Patients with severe OSA may require maximum levels of pressure to eliminate the obstructive apnea. Bi-PAP may be the chosen method of treatment with this scenario, and Bi-PAP may be used when the patient has more than one respiratory disorder. Regardless of the mechanism used, the goal of the technician should always be to titrate the machine to the lowest possible pressure to eradicate the sleep apnea. Each individual patient with OSA will present a different scenario for the attending polysomnography technician. The sleep study with positive airway pressure titration will need to achieve the optimal pressure for the specific patient. The sleep study with CPAP/Bi-PAP will show not only when the respiratory events have ceased, but also when the arousals from the respiratory events occur. The ultimate goal for the technician during a titration process is to achieve the minimal optimum pressure to eliminate all obstructive events and snoring during all stages of sleep and all body positions while sleeping. Compliance Mask fitting is an essential element of a patient's success with positive airway pressure therapy since it affects compliance and effectiveness of treatment. The higher pressures used during CPAP/Bi-PAP therapy can cause a significant air leak with the mask. The leak can also emerge from the patient's mouth if they are using a mask that doesn't cover the mouth. This can startle a new CPAP user. The leak can wake the patient from sleep. Thus, the mask stability is tested with higher pressures. Higher pressures may also require tighter head gear to maintain an adequate seal. Adversely, this will contribute to the discomfort from wearing the mask. When selecting a CPAP mask the following factors should be considered: comfort quality of air seal convenience quietness air venting CPAP/Bi-PAP machines are also available with humidity. Nasal congestion and dryness are very common complaints with positive airway pressure therapy. Humidification can also be heated. These features have proven to help with patient compliance. Ultimately, the biggest obstacle with compliance is getting patients to comply with their own treatment. Without the patient's willingness to use it, CPAP will not provide effective therapy. Studies have shown that CPAP compliance varies from approximately 65% to 85%. The bottom line for the patient to experience the benefits and relief of complaints is they must use the machine on a nightly basis. Information regarding the degree to which a patient is compliant with CPAP is essential for assessment of therapeutic impact. If problems persist after implementation of CPAP, the causes could include: delivery of insufficient pressure to maintain upper airway patency during sleep misdiagnosis of the etiology of the individual's symptoms failure to use the device for a sufficient duration on a regular basis Possible Side Effects The principal side effects with CPAP/Bi-PAP use include: contact dermatitis nasal congestion rhinorrhea dry eyes mouth leaks nose bleeds (rare) tympanic membrane rupture (very rare) chest pain aerophagia (the excessive swallowing of air, often resulting in belching) pneumoencephalitis (air in the brain, which is extremely rare, reported in a patient with a chronic cerebral spinal fluid leak) claustrophobia smothering sensation Actions can be taken to counteract some of the side effects. Nasal congestion or dryness often can be reduced or eliminated with nasal sprays or humidification. Rhinorrhea can be eliminated with nasal steroid sprays or ipratropium bromide nasal sprays. Epistaxis (nose bleeds) is usually due to dry mucosa and can be treated with humidification. Skin irritation can be combated with different mask materials. Dry eyes are usually caused by mask leaks and can be eliminated by changing to a better fitting mask. Attempts to reduce claustrophobic complaints have resulted in the patient using nasal pillows or prongs as opposed to the nasal or facial mask. Mouth leaks can be reduced or eliminated by using a chin strap. A small number of patients complain of chest pain or discomfort with CPAP use. This can probably be attributed to increased end-expiratory pressure and the consequent elevation of resting lung volume, which stretches wall muscles and cartilaginous structures. The resulting sensation that is created is due to chest wall pressure that persists through the hours of wakefulness. Any complaints of chest pain should always be taken seriously. However, if the complaint by the patient on CPAP proves to be nondiagnostic, Bi-PAP therapy may prove to be an option since expiratory pressure can be reduced. Sometimes it pays for the technologist to develop some psychological skills in order to convince the patient to use the device. I have found that a patient who doesn't seem to believe they need CPAP tends to change her/his mind when they see the data that shows him not breathing. Keep in mind that your patients can't see themselves sleep. They may also not be aware of all the possible complications of OSA down the road. Another area of concern for OSA patients using CPAP/BPAP devices is the negative effects on arterial blood gases and oxyhemoglobin saturation. Studies have reported severe oxyhemoglobin desaturation during nasal CPAP therapy in a hypercapnic (elevated levels of carbon dioxide in the blood) sleep apnea patients. Studies have also shown significant oxygen desaturations with CPAP administration with supplemental oxygen. The exact cause has yet to be determined. This occurrence may be due to the following factors: worsening hypoventilation related to the added mechanical impedance to ventilation associated with exhalation against increased pressure increased dead-space ventilation a decrease in venous return and cardiac output due to increased intrathoracic pressure during CPAP administration in patients with impaired right or left ventricular function and inadequate filling pressure One more possibility is when the optimal pressure setting has not been reached yet. Therefore, a ten second apnea may have turned into a 90 second hypopnea. The patient may not arouse from sleep as quickly to get a breath since the airway is not completely closing off as it was without therapy. This should improve once enough pressure is added, however. Despite the above scenarios and problematic experiences, CPAP/Bi-PAP administration has been reported to improve awake arterial blood gases in OSA patients with hypercapnia and cor pulmonale. Traditional and Evolving Methods of Initiating CPAP/BPAP Different methods have been established for implementation of positive airway pressure therapy. Traditionally, patients have undergone a technician attended PSG-monitored trial of CPAP. Split-night studies are now conducted more frequently. Home CPAP trials is another avenue that is being investigated. Use of predictive formulas to estimate or establish optimal level for CPAP therapy has been investigated. Each scenario has advantages and disadvantages. CPAP Therapy of Nonapneic SDB There are numerous documentations of patients with congestive heart failure (CHF) suffering from sleep-disordered breathing (SDB). Most often the respiratory events will be central in nature (no effort, brain not sending signal to breathe) resembling Cheyne-Stokes respiration (CSR). CSR is defined as a breathing pattern characterized by regular "crescendo-decrescendo" fluctuations in respiratory rate and tidal volume. The presence of SDB was associated with sleep-fragmentation and increased nocturnal hypoxemia. The conclusions from the findings are stated below: There is a high prevalence of daytime sleepiness in patients with CSR in conjunction with CHF. Patients with CHF who also have CSR have a higher mortality than patients who have CHF without CSR. CSR, AHI (apnea/hypopnea index), and the frequency of arousals were correlated with mortality. Furthermore, research has found CPAP has been noteworthy and effective on breathing in patients with CHF and CSR. The results of several studies showed an increase in cardiac output and stroke volume and a reduction in left ventricular wall tension during application of CPAP. The improvements seen in CHF patients with CSR regarding cardiac function during sleep is believed to carry over to wakefulness. Possible factors contributing to the improvements seen include: sleep-related reduction of left ventricular transmural pressure improved oxygenation during sleep reduced sympathetic nervous system activation during sleep CPAP machines have become a lot more sophisticated during the past decade. One of these updates is the ability of some machines to generate an algorithm that can predict the next breath of these central sleep apnea patients. These machines will adjust how much air is delivered during each breath based on this prediction. This has the effect of making the breathing pattern more consistent. You may see this denoted as Auto-SV, or servo-ventilation. We will talk about this more later, but I just wanted you to be aware that there are more sophisticated machines for patients with CHF and irregular breathing patterns that are not due to obstructions. Effects of Altitude Changes and Alcohol Consumption Older CPAP machines will not adjust to changes in altitude. As altitude increases, the older CPAP devices will deliver progressively lower than prescribed pressure. The more modern devices will detect altitude changes and make the appropriate adjustments. The polysomnography technician would benefit from information regarding a patient relocating from a high altitude location to lower altitude or vice versa if there are complaints of the CPAP therapy being nontherapeutic. Alcohol consumption can present further complications for a patient suffering from OSA. Alcohol suppresses the arousal response. The patient may experience a greater frequency and duration of apneas and hypopneas and increased snoring. Excessive alcohol use also increases sleep fragmentation. Taking a sedative can cause these effects to be imitated or exacerbated. Still, there are reports stating moderate alcohol consumption did not significantly alter the level of pressure required to eliminate the obstructive events. Nonetheless, OSA patients should avoid alcohol

1. Fundamental 1 (Cell adaptation, necrosis, intracellular accumulation)

Immune System Study Guide Function of the Immune System Main Function: The immune system protects the body from harmful invaders (pathogens like bacteria, viruses, fungi, etc.) and detects and eliminates abnormal cells.Detects and destroys foreign invaders . Yngv Memory: The immune system has the ability to "remember" past infections, allowing it to respond more quickly to the same pathogen if encountered again.Maintains a memory of past infections to mount a quicker response if the same pathogen attacks again. Types of Immunity Innate Immunity: The immune system you're born with; provides a quick response to any pathogen. First line of defense: Skin and mucus act as physical barriers. Macrophages: Large white blood cells that "eat" pathogens and activate other immune cells. Histamine & Inflammation: Histamine triggers inflammation to fight infection (redness, heat, swelling, pain). Adaptive Immunity: Develops over time and strengthens with repeated exposure to pathogens. B-cells: Produce antibodies that specifically target pathogens. T-cells: Help destroy infected cells or coordinate the immune response. Memory Cells: "Remember" past infections for faster responses in the future. Innate immunity is something you're born with and provides a quick response to any pathogen. Adaptive immunity develops over time, adapting to new threats. It includes things like antibodies and memory cells. Signs of Inflammation Redness (rubor): Increased blood flow to the affected area. Heat (calor): Blood flow increases temperature at the site. Swelling (tumor): Fluid accumulation and immune cells moving to the area. Pain (dolor): Due to chemicals irritating nerve endings. Loss of Function (functio laesa): Temporary loss of function in the inflamed area. Bacteria vs. Viruses feature bacteria viruses size bigger smaller Can live without a host? yes no Good or bad Some are helpful Always harmful treatment Antibiotics kill them No antibiotics, only vaccines or immune system fights them examples Strep throat Flu, COVID-19 Antibiotic Resistance Occurs when bacteria evolve to resist antibiotics. Reasons for Resistance: Overuse or misuse of antibiotics. Using antibiotics for viral infections. Self-medicating without proper diagnosis. Vaccines What Are They?: Biological preparations that provide immunity against specific diseases. How Do They Work?: Contain weakened or inactivated parts of a pathogen to stimulate an immune response. Importance: Vaccines teach the immune system to recognize pathogens and fight them effectively in the future. They also contribute to herd immunity. Reproductive System Study Guide Male Reproductive System Testes: Produce sperm and the hormone testosterone. Epididymis: Stores sperm until they mature. Vas Deferens: Transports sperm from the testes to the urethra. Prostate Gland & Seminal Vesicles: Produce fluids that nourish and transport sperm. Penis: Delivers sperm into the female reproductive tract during ejaculation. Female Reproductive System Ovaries: Produce eggs (ova) and hormones like estrogen and progesterone. Fallopian Tubes: Transport eggs from the ovaries to the uterus; fertilization typically occurs here. Uterus: Where a fertilized egg implants and develops during pregnancy. Cervix: The lower part of the uterus that connects it to the vagina. Vagina: The passage that receives sperm and also serves as the birth canal. Conception and Pregnancy Conception: Occurs when sperm fertilizes an egg in the fallopian tube, forming a zygote, which then implants in the uterus. Pregnancy: The zygote develops into an embryo and then a fetus in three trimesters: First Trimester (Weeks 1-12): Organ development begins; the heart starts to beat. Second Trimester (Weeks 13-26): Rapid growth; organs mature and gender can be determined. Third Trimester (Weeks 27-Birth): The fetus continues to grow; organs mature, especially the lungs. Factors Affecting Baby Development Environmental factors: Exposure to toxins, pollutants, drugs, or infections. Nutrition: Essential nutrients are crucial for healthy fetal development. Health conditions: Chronic conditions like diabetes or hypertension can affect pregnancy. Types of Contraception Barrier Methods: Condoms (Male & Female): Prevent sperm from reaching the egg and protect against STDs. Pros: Easy to use, no side effects, protects against STDs. Cons: Must be used correctly every time; can break or slip off. Diaphragm with Spermicide: A barrier placed in the vagina to cover the cervix. Pros: Non-hormonal, on-demand use. Cons: Requires fitting, not effective without spermicide. Hormonal Methods: Birth Control Pills: Prevent ovulation through hormones like estrogen and progesterone. Pros: Highly effective, can regulate periods, reduces acne. Cons: Must be taken daily, side effects like nausea or headaches. Patch: Worn on the skin to release hormones. Pros: Easy to use, weekly change. Cons: Visible, may cause skin irritation. Implant: A small device placed under the skin to release hormones. Pros: Long-lasting (up to 3 years), effective. Cons: Requires professional insertion, can cause irregular bleeding. IUD (Intrauterine Device): A device inserted into the uterus to prevent fertilization. Pros: Long-lasting (5-10 years), effective. Cons: Requires professional insertion, may cause cramping. Permanent Methods: Vasectomy (Male): Cutting and sealing the vas deferens to prevent sperm from reaching the urethra. Tubal Ligation (Female): Cutting or sealing the fallopian tubes to prevent eggs from reaching the uterus. Pros: Permanent, highly effective. Cons: Surgical procedures, irreversible, not suitable for those wanting future children. Emergency Contraception: Morning-After Pill: Taken after unprotected sex to prevent pregnancy. Pros: Available over-the-counter, effective within 72 hours. Cons: Not for regular use, may cause side effects. Copper IUD: Can be inserted up to 5 days after unprotected sex to prevent pregnancy. Key Takeaways Immune System: It provides a defense against infections, relying on both innate (immediate) and adaptive (long-term) immunity, with important components like macrophages and memory cells. Vaccines are essential in helping the immune system recognize pathogens and prevent diseases. Reproductive System: Male and female systems work together to ensure conception and pregnancy, with critical stages of fetal development occurring in the three trimesters. Environmental factors and health conditions can impact pregnancy. Contraception Methods: There are various types, each with its pros and cons, including barrier methods, hormonal methods, and permanent methods. Choosing the right method depends on individual needs, effectiveness, and side effects. Histamine & Inflammation: Histamine release can cause redness, warmth, and swelling as part of the body's inflammatory response to infection or injury. Vaccines & Herd Immunity: Vaccines are critical in preventing the spread of infectious diseases by "teaching" the immune system to recognize and fight specific pathogens. Herd immunity occurs when a large portion of a population is vaccinated, making it harder for diseases to spread. Components of the Immune System: Defense against pathogens: The immune system helps protect the body from harmful invaders like bacteria, viruses, fungi, and parasites. Recognition of abnormal cells: It identifies and eliminates cells that are infected or cancerous Key Defense Lines: First Line of Defense: Skin & mucus trap and kill germs. Second Line of Defense: Inflammation and macrophages (eat germs). Third Line of Defense: T-cells destroy infected cells, B-cells make antibodies to target germs

3. Management accounting - Cost accumulation

. The last experimental. So this is going to involve the event relationship to between more variables. And do much changing on manipulating one of the variables theries as you already talked about both designs. And then we record or collect data, what obser the change in the dependent variable that result from our manipulation of the. That's what we're looking at. We're moving and sh and manipulating one and seeing if it causes an effects or change in the other. That's what we're looking for. So have experimental research, we are looking for causation not just correlation. We're not just looking to see due to variables moved together. No, we're actually looking to see if we make a change in one variable, do we see a subsequent change in the other word? If we make another change in that variable, we shift it more, we change it fast. We take it away. Do we need a consequential change in the independent variableag yet, okay, you're able to shift and manipulate the independent variable and consistently see a change of the dependent variables, then you know you have causation, a change in one causes a change in the other. They've already kind of gone over this multiple things, so I will just briefly say this again, but you've got the independent variable dependent variable, the independent ones you what we're going to manipulate and change, whatever. that looks like. um at a very simple level of experimental research, you can have one level of your independent variable, and then nothing, right? You can have your experimental group and your controller. The group that gets the treatment, that group that does not. So that is your very basic experimental research where you just have two groups and one of them is to control groups. But even still, you should see a change in the depependent variable to the group that is receiving treatment and you should see no change for the group that is not receiving treatment, right? That would be causation. Now, of course, you can have multiple levels of the independent variable, we're not gonna get too much into that. In this course, um, but two is kind of the minimal, right? treatment, no truth, and then you can move beyond that. The dependent variable is the one that is being measured. It is hopefully changing. If you see no change in the dependent variable when you're making changes to the independent variable, you've got a big problem, right? That means that your independent variable that you manipulating actually has nothing to do with the behavior that you're trying to observe. It doesn't impact it at all, and you're going to have no results, no adjacent. It's very disappointing. It does happen. and it's disappointing, but not happen. Um, so it is the uh the outcome orependent measure. Now, something I briefly mentioned that I have gone too much into depth, yet are the confounding variables, so the confounding or they're also called you probably heard them called extraneous variables. These are other variables, other than your independent variables. So anything that is not your independent variable can be a confounding variable, and it can cause and change in the dependent variable if you have not accounted for and controls something that has to be at and avoid it at all costs. Let's say let's say we're doing a study and we are trying to decrease the amount of smoking individuals engage. Hi, so we're trying to help them. We're trying to decrease their smoking paper. And our treatment is going to be some sort of meditation and relaxation techniques that they can learn because of that is based on the research that people smoke war when they're experiencing higher levels of stress. So how can we decrease their stress? Let's teach them various coping mechanisms, deb breathing techniques, meditation techniques, other things that they can do to decrease their stress and hopefully have a decrease in theopy behavior. Okay, great. So we implement our treatment. But what if we forgot to ask participants? if any of them had gotten pug onto to the doctor recently and had some maybe vac about their health, if they received some not so great news about their health, could that be a variable that is intacting how much they decide to smoke after that document? Absute, right? The doctors that said, hey, you' lungs are not looking for good, or you've got something precursors to cancer, we're gonna have to run some tests. That type of news could certainly impact someone who's smoking and could result in a change in their smoking behavior, they might leave that doctor's office and go, okay, wow, I really need to stop smoking. But if we didn't ask them that, we don't know. We don't have that information. So, we've moved forward, we implement our procedure and our treatment, and theyreased their smoking and we go, wow, our treatment works really great. Look at all these people that stop smoking. But in fact, all those people went to the doctor got not so great, there was a decided to not smoke, regardless of whether or not you taught them had a meditate break, right? That is a confounding variable that will throw your data because you did not account for it. Whenever we're doing a study like that, on any type of addictive behaviors for illness, if you're doing a medication study, you have to ask all of those questions. You have to get all of that information up front, because those are come down in variables that can change the behavior that you did not account for and you are not manipulating or control. So now we can't make the claim that if we um, you know, give individuals, um different mechanisms to decrease their stress, it will decrease their snow people. We can't make that claim anymore because that's not what caused the meaning. Or at least we don't know for sure that that's what we're doing. So confoundingles are a big bump. we run into these a lot, and I will tell you that when we are designing a research study um when you're working in a lab and you're working with researchers, it is intimidating to bring a research project to the lab. I mean, I did it a lot inad school. We were required to do this. You have to do this when you're doing research, but you bring your research question and your proposal for how you're gonna run your study to the lab. you put it up there and literally everyone in the room writs it apart. Everyone sits there for an hour or two and says, what about this confounding birdle? What about this? Well, this one's gonna throw your data. Well, this one's not gonna work. Well, you have an accountant for this, they rip it apart. It doesn't feel great in the moment. However, that is how you identify all of the compounding variables and you find a way to account. so that you have good data in the end. It's very important piece of research and experimental research specifically. We do want to avoid them at all costs. Okay, so here's another example. Let's say a researcher investigate whether giving students more time to study, reduces their tests anxiety. Okay. What is going to be the dependent variable here? What are we measuring? What are we looking at? We wouldn't want to take it again. Test anxiety. levels of anxiety when you're taking a test, right? That's what we're measure. We're trying to change that, okay? So that's gonna be the behavior that we're looking at. What is the independent variable here? Time to set, the amount of time that you're set, whatever that may be, okay? So the DV is test anxiety or levels of anxiety will take the test whatever you will word that, that's what we're measuring. Am amount of study time is what we're looking at for the independent version. Now, when you're taking a test, there are multiple things that happen that have nothing to do, maybe, with the amount of time you study. Can we reduce test anxiety by making sure that you study at least a minimum amount of time? Yes, we can reduce your test anxiety a little bit. But there are also other factors that if we if I was running this study as an experimental research, not just as like the naturalistic observation in a classroom, like let's just see if we can help. If I was actually running an experimental res research that many things that I have to account for. I need to account for type of tests. What if I get half of my participants, the tests is the morning and half of my participants the test in the afternoon? That's the I founding variable. Maybe the students in the morning are more stressed out because they didn't have time to relax in the morning and get ready for this test that I'm about to do them yet. Right? They're getting ready, they're in traffic, they're driving here, trying to park and so and so forth. Yes, we might run into that in the afternoon, but you still have got more time in the day. to get ready for it. So that's a confounding marriage, time of test. Another confounding variable would be temperature in the room. If it's too cold or too hot, you've got one room that's hotter, one room that's colder. That can impact someone's test anxiety. When you're feeling anxious, if I'm sure everyone has felt that feeling at one point in their life, it doesn't feel great to then also be hot and sweat. It usually makes that anxiety a little bit worse. You start to feel kind ofustrophobic and you're like, I don't know what's going on. I'm getting really hot. I don't feel good, I'm getting kind of dizzy, like, and your anxiety skyrock. right? So, I wanna make sure that the temperature in my room every time participants are taking the test, it has to be exactly the same, or usually within a couple degrees of the temperature. Okay, so these are just a few examples I can go on and on about all of the things that would impact you while you're having an exam that would impact your test anxiety. I need to help for all of those things, and every participant in all of my different groups would all have to have the same things so that I can truly say it was the amount of set. and it wasn't possibly due to during the room, time of the test, the room that they're in, how close they're sitting to each other and so on. and and that and that's part of the roofing unit ofart process, right? If I came to my lab and just said, oh, I'm gonna do this. They're like, well, what else, what else are you controlling for? I'm like, nothing, you know,'ll be fine. They're gonna rivet apart, right? All of those confounding variables that we need to account for. Um, a study involved investigating how manipulating the accuracy with which feedback is delivered, affects a number of work tasks that can be completed by college. So this is essentially, say, a student is doing a work task, and if I give you no feedback on that, as to whether you're doing it track, if I give you feedback that is correct and it matches, I say, yes, that's correct. or if I give you wrong feedbacks. So that's what we're talking about when we were saying a different type of feedback on your ability to complete a task. So, what is the independent variable here? What are we manipulating? Yeah, that's hypo feedback, right? We're gonna change that. It's gonna be different. What's the dependent variable that we're measured? It's the behavior we're looking at here? Yeah. Uh, number of work task. Correct, yes. How many workops did they actually complete? Do they get more done when they're getting positive feedback? Do they get more done when they're getting no feedback at all? You probably don't get more done when they're getting negative. You back would probably be my hypothesis, but we're gonna look at them, right? We're gonna count how many tasks they get done based on the type of feedback that they are given. And then we see how this impact that dependent varies. How does that impact the behavior that they're engaging? So, there will be questions like this on these things. This is like a perfect example. It will be this exact one, I'll change the words I'll change a thing. And I'll ask you these questions. What is the independent? What is the dependent variable? And sometimes I'll put a confounding variable in there and I'll say like, identify the confounding variable. and you'll hopulate pick one of the choices. So very similar to what I've test questions would look like for something like that. But the good to be able to look at examples and pull these things up about. If you're in any type of research class, statistics class, you need to be able to have this very uh, you guys could go over these ones.. I'm not gonna keep going, but you get you get this. All right. So experiments typically involve two groups at a minimum, which I talked about already, but you're gonna have atom minimum, your control group, and your experimental. The control group is a group of participants that does not receive the treatment. No treatment. Okay. Um, you don't change it. You essentially just measure their behavior, but you don't expose them to anything. Um, so work tasks with the feedback, that would be the control group is no feedback, okay? So we just allow the students to complete tasks as they normally would, we do not interject, we do not give the feedback one way or another. We just sort of let them carry on with their day as they normally would and we count how many works how they could. Versus, the experimental group are the ones that are going to receive some type of treatment. Now, as I've said before, minimally, you've got one experiment group and your control but you can have multiple experimental groups and a controll. And so you can have two or three different types of feedback. Those would be your experimental groups, and you can still have a group that received no feedback. if we're looking at study fine with students, you can look at, you know, two hours, four hours, six hours a week. Those are your experimental groups. the other students, you would sort of just allow them to either or you would prevent them from studying at all, or you just would not manipulate the study time for them, you would allow them to study however long they normally do and have them report on. So you would just basically specify that this group did not have a controlled set amount of set, and then they would report on how many hours they affected. versus the other three experimental groups would have a set amount by the time that you're controlled. Okay. Here's a question, a clinical psychologist conducts a study that involves ten people. He thinks he can cure depression by giving his science a particular type of drug. So he prescribes the drugs and finds his 60 days later, all clients show fewer signs of depression, as the psychologist includes he has cured depression. So what's the problem? There's a lot of problems here, but like, what's the main simple problem with what we understand in this particular research research? What has not been done? Yes.... doesn't describe. There is no controller, right? Every single person got the drug. There's no control group. So how do you know that that drug improved their depression? If you do not have a control group, you have no comparison to make, the whole point of having a control group, the whole reason we do it is so that if the drug does work, let's say that the psychologist is correct, this drug works, it cures depression. If you have a controlled group, we have a group of participants who didn't get the dress, what should happen for them? is someone over here? I take a guy? What should happen for people who are naked? Is it control with this? What do you expect? Yes. Yes, they should save the same, right? They're not getting the drugs. So they shouldn't get better. And then the people in the experimental group who are getting the drug if the drug works, they should get better. And you have that comparison. You now you can definitively say, okay, look at all these people that did not get the drug in my control group, they didn't get any better. The symptoms of depression persisted. But look at all of my participants, my experimental your, we saw a significant improvement in depression symptoms. Okay, now maybe you have a plane. But if you give the drugs to every single person, you have nothing to compare. How do you know what your drug is not something else that you're their depression? Maybe a bunch of people were unemployed and during that time that they were given the drug, they got a job. Back didn't improve someone's levels of depression, especially if it's a situational depression. course, there's a depression that is biologically, you know, that's a different type of depression, but there's also situational depression. And if you have an accountant for every single situation that person is in, those are confounding variables that can impact in this case, levels of depression. Do you know how control group, you have nothing to compare. You cannot make this. big problem. can't rule out any other expavation. So that's why minimally we always have to have at least a control group and an experimental group. And as I said, you can have more than that, but the bare minimum requirement, no treatment, treatment, control group, experiment. So when we use, um control groups and experimental groups, individuals are randomly assigned to each group, and I've kind of talked about this a little bit that the need for this in order to make sure that the participants in each group represents the larger population. That's the, right? You're never going to be able to access the entire population. You're not going to be able to access every single person who's ever experienced depression or has symptoms of depression in a drug site. You're going to have to randomly assign participants to certain groups and hope that they represent the larger population of people that experience symptoms of depression, right? So that is the point of random assignment to different conditions. Usually, the experimenter, I mean, ideally, the experimenter doesn't even know who's in which group, in a drug study that is ideal. We call it a double blind assignment where the participant doesn't know if they're getting a drug or not and the experiments or also does't know if they're getting the drug or not. Why? Because bias can be introduced? If they're participant thinks they're getting the drug, um, they can have sort of placebo effects, right? If you've ever heard of that, the placebo effects, or they think they're getting better because they're underlyression, they're getting the drug. researchers can also treat participants differently based on if they know who is getting the drug and who's not, and that will impact the data that they're collecting on that person's behavior. So, ideally, like the perfect scenario, nobody knows what's going on. There's a lab that assigns the drug and puts it in an envelope and assigns names, randomly and they give the envelope to their researcher and there's a red pill and there's a blue pill, but the researcher doesn't know which one is which. One could be trained it, one could be placebo, we don't know, and that's very important, but kind of nobody knows what's going on. until the end. And that's how you get the best data. out of something like this. Now, group should be comparable to each other. um, they should be assigned to the group based on Chancel, essentially. Um, usually we use some sort of computer programming to randomly assign numbers, two people and then randomly assign those numbers into the groups that were trying to produce. This can be very difficult to do. The smaller your participant pool, in fact, the more impossible this gets. So that's why a lot of research studies try to get so many participants and absorbid an amount of participants, um or why you need to run several studies to build your participant pool, before you can make any sort of claim about your data. because the smaller you participant pool gets, the less representative of the population they will be. because you do need to think about things like, um intelligence or um education level personality type socioeconomic status, ethnicity, um, their income, there's so many things that you have to think about and a smaller you participant will gets, the less representative of all of these things it will be. And then we run into the problem that your participants didn't actually represent the larger population, and your data really only applies to that very small group, and it cannot be applied to the larger group, which is always the goal. The goal of research is to collect data with a smaller amount of people, but you hope that you can go and apply those kinds and those results to the larger population. If you are looking for a drug that cares depression, you want those results to be good and to be representative of the larger population so that you can then produce a drug that can be distributed to people who have symptoms of depression and it cures them, right? You don't only want that drug to work for 60 people that you ran the side with, and that's it. and it doesn't work for anyone else. So, random assignment does help with this, but also large participant groups are going to make sure or ensure that you have a representative family of the larger published. Okay. yeah. So some other important things we have to considerable we're running research. and just terms that you should be aware of, so a confederate is someone who is employed by the researcher or is a researcher themselves that is going to participate in the study and pretend to be a participant. So they're gonna essentially take part in the study. um, the participants will not know that that person is a confederate, obviously it's a secret, so this involves some level of deception, usually in the study that we have to present to our review board and make sure that all of that is okay. But when you use a confederate, it's usually because you are conducting a study that people know they're being observed, they're going to change their behavior. So that's why we have confederates. When I was in grad school, a a grad friend of mine, she was in a different lab, and I was helping with her study. She ran this really interesting study on graphic Ed, so people would eat very, very fast. And I'm not just talking like, you know, kind of fast. We're talking like a burrit that big, is gone in one minute or less, like gone. And so, like barely chewing their food, like, wrap it, rapid, you. And as you can expect, there is a lot of health concerns that come first. We had some children who were rabbit eaters in that study. um there was significant choking hazards that had already occurred with some of those personents because they're eating much too fast, too large in bites. Um, but before we could run our study with children, we had to make sure that it was safe and it was not going to impact them too greatly, so we ran it with college students here on campus. Um and when we first started running it, you realized very quickly that they knew they were being observed, and so they were slowing down their eating. They were still eating fast, but it wasn't quite as fast as they had reported in their interviews when we were trying to pull participants. So what did we do? We got conf better. So we had a sticker researcher in there. and we left, so we who were identified as the researchers, we were like, hey, um, we're gonna be back a little later, and we're just we're gonna ask for your report on how fast you ate, but we gotta go. We'll be back later. Maybe pizza in the middle of the room, help yourselves. And then we actually had another researcher in there who was a participant, but she was a confederate. And she had to eat with them, which was difficult because she had to eat very, very quickly, so that they didn't know that she was a confederate. But that is an example of what we would do. Now, she had a time where she had different time on her too, that she was like collecting data for certain people in different sessions, so we could get a truer representation of how fast those people ate and their behavior was a different because they didn't know that they were being observed. So that is a perfect example when we could use the compatory. Um, replication and I've already sort of talked about this before, but we always wanna ask if we can rep replicate the results that have been found. This is extremely important. Scientific understanding is based on the accumulation of knowledge. The more knowledge we have, the more data we have on a on a body of research, the greater our scientific understanding is of that res research, of that behavior, of that phenomenon or theory, or whatever it is that we're investigated, the more research we have, the better we understand it. Replication is foundational to science moving forward. If we adjust did research for the heck of it, just to entertain ourselves to stimulate our reins or whatever research we just want to do, it doesn't help science, it doesn't move us forward at all. We have to publish it and then other scientists, other researchers have to replicate it and move the science forward. It's an extremely important part of research and without it, it really would kind of be pointless to do research at all. The point is to accumulate the knowledge and move the science forward. I've gonna talk about briefly about significant outcomes. If you take a statistical course, they get into this in great detail. But whenever we're looking at data, we're looking for what is called significant outcomes, statistically significant differences. We're not just looking for minimal differences between our groups, between our control group and our experimentsal groups, or even between our different experimental groups, we're looking for significant changes. big changes, changes that make a difference in people's lives. and a difference in their behavior changes, not just very small minuscule differences that maybe we can kind of say, well, there's a slight change. No, there must be a statistically significant dip. Now, of course, that is determined by the statistical analysis that are run. um, or if you're doing a study that's sort of based on kind of like a real world problem, um, things like when we work with children with autism and things like that, um, or any individual with a developmental disability, we're looking for um learning outcomes, so do they make significant jumps in their learning outcomes or their development? E cognitive or physical development, right? So they need to be meaningful differences as, you know, we're not just looking for tinyunicule changes, we're looking for meaningful, statistically significant differences between our groups. Experimental bias is something we always have to be aware of, these are going to be factors that could impact your dependent variable, a bias from the researcher, a bias from the in from the first incipant. Those can impact the data that you get in the way that they be hidden um any expectations that you are the persistent have can surely impact how they are behaving. We always need to account for that and make sure that we're, you know, making sure that doesn't do. Well is a false treatment. I've already kind of mentioned this before, but we typically see this with any sort of drug study um, but it's just the no treatment. They're given a pill that doesn't have any chemical properties to it, so it shouldn't impact their um system.? So if it impacts them in any way? That's what we need when we say alpha seat. And then finally, I've also talked about this already, but double blind means both the experimenter and the person do not know who's receiving treatment and who's not. That is the ideal standard to lose a another one in experiment, nobody knows. And it prevents

06: Intracellular Accumulations

Identifying with one's own nations and support of its interests Idea that Nation (people) should be the state (country) Nation People who share a common culture, language, territory, and government 1848 Revolutions Wanted liberal change, heavily influenced by ideas of Enlightenment -Democratic -Nationalistic Italy was divided into multiple kingdoms and city states Northern Italy to rebel and unite under King Victor Emmanuel of Piedmont Sardinia Constitutional monarchy Giuseppe Garibaldi leads Red Shirt rebels in the south Too radical and southern Italians join with northern Kingdom of Piedmont and Sardinia 1871 Italy Fully United Italy becomes united under Constitutional Monarchy Prussia and Austria emerge as two major German powers Otto Von Bismarck Chancellor of Prussia Unite German people under Prussian leadership Realpolitik Politics based on reality not morals 1871 German Empire created Ottoman empire Ruled by Turks Extremely diverse Culturally Ethnically Religiously Ottoman empire Muhammad Ali fights war with Ottomans Tie results in Egypt being independent Selim III tries to modernize and reform based on enlightenment Janissaries resist Balkans independence Russia supports fellow Slavs, Serbia effectively Independent 1815 Western Europe helps the Greeks (nationalism/racism) Greece Independant 1829 Ottoman empire loses territory in Europe and Africa to independence movements Ottoman empire known as “the sick man of Europe” Topic 5.3 Industrial Revolution Begins Thematic Focus - Economics Systems (ECN) As societies develop, they affect and are affected by the ways that they produce, exchange, and consume goods and services. Learning Objective  1 Explain how economic systems transformed during the period of 1750-1900. Historical Developments Summarize industrialization and its impact. (see 5.3 reading guide) Industrialization, the increased mechanization of production, and the Social! changes that accompanied this shift, had their roots in several influences. Such as Increased agricultural production and greater individual accumulation of capital. I reshaped Society, increasing world population, shitting people from farm to city, and expanding the production and consumption of goods Thematic Focus - Humans and the Environment (ENV) The environment shapes human societies, and as populations grow and change, these populations in turn shape their environments. Learning Objective 2 Explain how environmental factors contributed to industrialization from 1750 to 1900. Historical Developments Britain’s Industrial Advantages • Mineral and colonel resources - used resources for fuel and manufacturing  • Good environment - rives made transportation cheap • Strong fleet- let resources from colonies to be brought to Britain shortly  • Growth- farmers growing more food meant fewer people had to grow their own • End enclosure movement- The government stopped providing farmland which made people move to urban places  Describe the features of the Cottage Industry • It's a pull-out system • Merchants proved cotton to women who spun it into finished cotton at home • Cotton industries gave women independence •  The cotton industry was slow so people demanded faster processes, due to people wanting faster process it led to faster machinery  Explain the development of the factory system and how it relates to specialization of labor.  The factory system used special machinery was also a new way of making products, it increased efficiency and reduced the need for manual labor. It was similar to specialisation of labor the increase efficiency and productivity in production Topic 5.5 Technology of the Industrial Age Thematic Focus - Technology and Innovation (TEC) Human adaptation and innovation have resulted in increased efficiency, comfort, and security, and technological advances have shaped human development and interactions with both intended and unintended consequences Learning Objective 3 Explain how technology shaped economic production over time. Historical Developments A. Explain the impact of the technologies of the first Industrial Revolution. Factory system technology improved systems and grew technologies to be more efficient  Steam engine Powered trains→ Bigger train industry, used for traveling jobs, replacing sails trade and fast communication around the world   Coal Used to heat up stream from the steam engine but causes pollution  B. Explain the impact of the technologies of the Second Industrial Revolution.   Steel Bessmer process mass produces steel from pig iron making railroads Chemicals Led to the development of new materials and product Electricity Has powered machinery, led to an increase in population/efficiency in factories  Oil Was used for cars/mechanic cars, to power cars focused on maximizing product efficiently  C. Explain how technologies impacted trade and migration.  The change increased the rise of maritime trading empires, People were able to shift from farm to city increasing world Production and expanding the production and consumption of goods Topic 5.6 Industrialization: Government’s Role from 1750 to 1900 Thematic Focus - Governance (GOV) A variety of internal and external factors contribute to state formation, expansion, and decline. Governments maintain order through a variety of administrative institutions, policies, and procedures, and governments obtain, retain, and exercise power in different ways and for different purposes. Learning Objective 4 Explain the causes and effects of economic strategies of different states and empires. Historical Developments As the influence of the Industrial Revolution grew, a small number of states and governments promoted their own state-sponsored visions of industrialization.  Answer the following questions to explain the state-sponsored  industrialization of Japan. a. What was the historical situation of Japan in the 1800s?  The emperor was at the highest point of the social hierarchy, but the shogun and daimyo had the power  b. Describe the threat Japan faced from Western powers. The US came with modernized equipment their ships looked intimidating and forced Japan to open trading ports c. What was Japan’s response to the Western threats? Japan created trading ports with the US  and became more modernized  d. Define MEIJI RESTORATION and identify key changes it made.  The emperor wanted to modernize but the Shoguns and daimyo didn’t want to so the emperor won they made Japan modernized by becoming more Westernized and pro-business Topic 5.7 Economic Developments and Innovations in the Industrial Age  Thematic Focus - Economics Systems (ECN) As societies develop, they affect and are affected by the ways that they produce, exchange, and consume goods and services. Learning Objective 9. Explain the development of economic systems, ideologies, and institutions and how they contributed to change in the period from 1750 to 1900. Historical Developments A. Western European countries began abandoning mercantilism and adopting free trade policies. Define the following terms to demonstrate an understanding of the developing economic systems. ADAM SMITH • Wrote “Wealth of Nations”  • Established the idea of private owner ship of industry and business LAISSEZ FAIRE CAPITALISM • Laissez -Faire “Leave Alone” “Hands Off!” ◦ Little to no government involvement in business ◦ Reduce tariffs on trade(don’t penalize imports and exports with tax=free trade) • FREE MARKETS Mercantilism • Government run companies believing ... • fixed amount of wealth • Wealth = amount of silver + Gold you have • Export more than import • Colonies serves as resources STOCK MARKETS capitalism • No limit to earn wealth • supply and  demand should be bought + sold • minimal govt intervention LIMITED-LIABILITY CORPORATIONS Corporation • Business run by lots of people • Stockholders buy parts of companies • corporations made profit  • if Corporations go out of business stockholders only lost the amount they put in the business C. The development of industrial capitalism led to changes in social life. Explain the changes as they relate to -  consumerism Working class and middle class had time to shop and have money from working in the factories standard of living • The working class who worked at the factories lived in the slums which were crowded, unsanitary condition, dirty  leisure time Companies encouraged leisure activities like baseball because it taught hard work, discipline, teamwork, and rule following  Topic 5.8 Reactions to the Industrial Economy from 1750 to 1900 Thematic Focus - Social Interactions and Organization (SIO) The process by which societies group their members and the norms that govern the interactions between these groups and between individuals influence political, economic, and cultural institutions and organization.. Learning Objective 10. Explain the causes and effects of calls for changes in industrial societies from 1750 to 1900. In response to the social and economic changes brought about by industrial capitalism, some governments, organizations, and individuals promoted various types of political, social, educational, and urban reforms A.  Explain how workers organized themselves to improve working conditions, limit hours, and gain higher wages.  Workers rise up and rebeled against the capitalist business owners and they revolted against the upper class B. Discontent with established power structures encouraged the development of various ideologies, including socialism and communism.  Identify the people and key points of each ideology. KARL MARX & FRIEDRICH ENGELS • German journalist • Appalled at the horrible working conditions in the factories • He blamed capitalism • Big business owner dont care about workers- just for profit $$$  SOCIALISM • New governmet ownership of industry  • Resources distributed all • High taxes support government (helthcare,education,safty net) • Goal of classless society  COMMUNISM • Advanced stage of Socialism • Classless society is achieved • Everyone is equal economically, politically, socially therefore… • No government is needed • No $ is needed  •  No need for national borders = world peace C. In response to the expansion of industrializing states, some governments in Asia and Africa, including the Ottoman Empire and Qing China, sought to reform and modernize their economies and militaries. Reform efforts were often resisted by some members of government or established elite groups. Topic 5.9 Society and the Industrial Age Thematic Focus - Social Interactions and Organization (SIO) The process by which societies group their members and the norms that govern the interactions between these groups and between individuals influence political, economic, and cultural institutions and organization. Learning Objective 11. Explain how industrialization caused change in existing social hierarchies and standards of living. Historical Developments A. Because of changing economic systems, new social classes developed during the Industrial Era. Identify and define the 2 new classes.   1. bourgeoisie 2. proletarians B. The Industrial Revolution had a profound impact on the lives of all people. Describe the impacts on the following groups:  Demographic Group Impact Working class • Strict schedules • Low pay • dangerous tasks Family • families had to move to rural to urban • Families lived in slums which were unsanitary  Children • children had to work in factories • Children worked long hours and lower pay • children faced dangerous tasks to do Women • Women had more independence  • Women had shifted from working at home to factories • Early feminism . C. The rapid industrialization and  urbanization led to a variety of environmental challenges. Identify at least 3 environmental problems created by urbanization and the Industrial Revolution.  Air pollution was happening because of factories using coal to for machinery and causing smoke to pollute the air, water pollution was caused by factories dumping toxins into rivers and deforestation because of the population growing in cities natural lands have to be clearing for housing, factories, roads,  Topic 5.10 Continuity and Change in the Industrial Age The final topic in this unit focuses on the skill of argumentation and so provides an opportunity for your students to draw upon the key concepts and historical developments they have studied in this unit. Using evidence relevant to this unit’s key concepts, students should practice the suggested skill for this topic. Learning Objective Explain the extent to which industrialization brought change from 1750 to 1900. Historical Developments • The development of industrial capitalism led to increased standards of living for some, and to continued improvement in manufacturing methods that increased the availability, affordability, and variety of consumer goods. ◦ Railroads, steamships, and the telegraph made exploration, development, and communication possible in interior regions globally, which led to increased trade and migration. • The 18th century marked the beginning of an intense period of revolution and rebellion against existing governments, leading to the establishment of new nation-states around the world. ◦ Enlightenment philosophies applied new ways of understanding and empiricist approaches to both the natural world and human relationships; they also reexamined the role that religion played in public life and emphasized the importance of reason. Philosophers developed new political ideas about the individual, natural rights, and the social contract. ◦ The rise and diffusion of Enlightenment thought that questioned established traditions in all areas of life often preceded revolutions and rebellions against existing governments

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