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If it occurs before age 2, there may be hypopigmentation of the iris on the affected side. Orbital metastases can result in periorbital ecchymoses, resulting in a "raccoon eyes" appearance. Megalencephaly is a disorder of brain growth, usually accompanied by macrocephaly. An increase in growth rate with crossing of percentiles is of more concern than the case of a child with a large head growing at a normal rate. Causes of obstructive (noncommunicating) hydrocephalus include aqueductal stenosis, neonatal meningitis, subarachnoid hemorrhage in a premature infant, intrauterine viral infections, vein of Galen malformation, and posterior fossa lesions or malformations (tumors, Chiari malformation, Dandy-Walker syndrome). Subarachnoid hemorrhage in a premature infant can also cause nonobstructive (communicating) hydrocephalus. These include lysosomal diseases (Tay-Sachs disease, gangliosidosis, mucopolysaccharidoses), maple syrup urine disease, and leukodystrophies. Plain long bone radiographs may be indicated for evaluation of skeletal dysplasia or trauma. Chapter 187 14 Part I u Head,Neck,andEyes 12 Skull deformational malformations occur as the result of an alteration of the normal forces (in utero, perinatal, or postnatal) acting upon the growing cranium. Positional skull deformity, or plagiocephaly (skull asymmetry), is the most common type of deformational malformation. Its incidence has increased because of the recommendations to place infants on their backs while sleeping. Plagiocephaly is a benign condition that must be distinguished from true cranial suture synostosis. In plagiocephaly, sutures are open, and a frontal and temporal prominence occurs on the same side as the flat occiput. Molding can occur with breech presentation or as the neonate passes though the birth canal; it resolves within a few weeks. It is often not noticed in the newborn and is diagnosed when the infant develops better head control. Imaging studies are rarely necessary and should only be considered in refractory cases or children born with congenital deformities. Symmetric occipital flattening that is believed to be positional does not require imaging. The condition may occur as a primary isolated disorder, which is most common, or as part of a syndrome. Common associated disorders include Crouzon, Apert, and Pfeiffer syndromes, congenital hyperthyroidism, and adrenal hyperplasia. It should be distinguished from true bulging, such as occurs in hydrocephalic infants. Examination of the fontanel should be performed while the infant is in a sitting position. As long as head growth is normal and sutural ridging is absent, early closure is not a concern. Silver nitrate is more likely to produce this condition than other agents used for prophylaxis. The most common causes in the United States are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Moraxella catarrhalis. Gonococcal conjunctivitis typically appears as a fulminant purulent conjunctivitis in the first 2 to 6 days of life. Chlamydial conjunctivitis is more likely beyond the first 6 days of life and is often associated with a pneumonitis. These clinical findings are not specific, however, and prompt evaluation and treatment are always indicated to avoid serious sequelae. In limbal vernal conjunctivitis, a ring of swollen conjunctiva surrounds the limbus of the cornea. Bacterial conjunctivitis is more likely to have purulent discharge than viral conjunctivitis, although significant overlap in the clinical presentation of the two etiologies does occur. Nontypable Haemophilus influenzae, pneumococci, staphylococci, and streptococci are common agents.

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After pelvic fixation and repair of the laserations, the patient was extubated after neuromuscular block reversed by sugammadex and transfered to intensive care unit. After 1 month later he was suffering from infection at his sacral decubitis and still he was immobile. His treatment is proceeding at the yard of Clinical Bacteriology and Infection Diseases. Results: Morbid obesity has been associ- ated with increased mortality after trauma. This may result from difficult airway control, and higher number of pelvic injuries that occurs in morbidly obese trauma patients. Videolaryngoscopy reduces the number of failed intubation attempts by improving the glottic view while also reducing laryngeal/airway trauma. Morbid obesity is not a risk factor for mortality in critically ill trauma patients. There many types of injuries but most of them were unintentional injuries (n=53; 86. The most common complications were acute kidney injury (45%), pulmonary complications (34. Discussion: Major trauma resulting from road traffic accidents is a leading cause of intensive care utilization and mortality was correlated with complications. Preemptive transplantation cannot be performed for all patients due to the limited number of donors. The aim of this study was to evaluate the perioperative effects of dialysis before renal transplantation. Materials and Methods: In this study, 666 patients who underwent kidney transplantation at our center were investigated retrospectively. Preoperative, intraoperative, and postoperative comparisons were carried out between groups. Results: There was no difference in terms of intraoperative blood transfusion, crystalloid and colloid requirement, inotropic-vasopressor agent administration and hemodynamic parameters between the pretransplant dialysis and preemptive transplant patients. It was observed that dialysis requirement, delayed graft function, and acute rejection development were significantly higher during the postoperative period in patients who underwent dialysis before transplantation. In non-preemptive patients, the decrease of serum creatinine levels at the first postoperative month was more prominent when compared to preemptive patients; however, that difference disappeared on the first year followup. No significant difference was found for serum albumin levels and proteinuria alterations of the patients in long-term follow-up. Additionally, patient and graft survival comparisons between nonpreemptive and preemptive transplant patients on 3 years follow-up revealed no significant difference. Discussion: In conclusion, preemptive transplantation treatment is suggested to be considered as the first treatment option for end-stage renal failure patients since patients with preemptive transplantation appear to have less metabolic function impairment, complication risk, and more successful outcomes in terms of cost-effectiveness. It is an autosomal recessive inherited disorder with an incidence of 1 in 25 000 live birth. General anesthesia is required for surgical treatment of complications of mucociliary dyskinesia of respiratory tract. We presented a case of 20 year old girl underwent general anesthesia for surgical treatment of recurrent nasal polyposis and chronic paranasal sinusitis. Materials and Methods: A twenty year old girl with complaints of recurrent nasal obstruction and secretion, headache, and mucopurulent productive cough was planned to nasal polypectomy and functional endoscopic sinus surgery under general anesthesia. Nasal polypectomy and sinus drainage were performed four times until came to our institute. She has bilateral bronchiectasis, situs inversus and bronchial asthma, paranasal sinusitis, bilateral nasal polyposis and alergy for amoxicillin, pollen and fungi. Antihistaminic (loratadine) inhaled bronchodilator and corticosteroid (salbutamol, fluticasone) were used by the patient. Midazolam 1 mg were used for sedation and cefazolin 2 gr was used for infection prophylaxsis preoperatively.

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However, biodiversity underpins a much wider range of services, many of which are currently undervalued. The bacteria and microbes that transform waste into usable products, insects that pollinate crops and flowers, coral reefs and mangroves that protect coastlines, and the biologically-rich landscapes and seascapes that provide enjoyment are only a few. Although much more remains to be understood about the relationships between biodiversity and ecosystem services, it is well established that if the products and services that are provided by biodiversity are not managed effectively, future options will become ever more restricted, for rich and poor people alike. However, poor people tend to be the most directly affected by the deterioration or loss of ecosystem services, as they are the most dependent on local ecosystems, and often live in places most vulnerable to ecosystem change. Ecosystems are being transformed, and, in some cases, irreversibly degraded, a large number of species have gone extinct in recent history or are threatened with extinction, reductions in populations are widespread and genetic diversity is widely considered to be in decline. Reducing the rate of loss of biodiversity, and ensuring that decisions made incorporate the full values of goods-and-services provided by biodiversity will contribute substantially towards achieving sustainable development as described in the report of the World Commission on Environment and Development (Brundtland Commission report). It is particularly important for the livelihoods of the rural poor, and for regulating local environmental conditions. Functioning ecosystems are crucial as buffers against extreme climate events, as carbon sinks, and as filters for waterborne and airborne pollutants. From the use of genetic resources to harnessing other ecosystem services, agriculture throughout the world is dependent on biodiversity. Agriculture is also the largest driver of genetic erosion, species loss and conversion of natural habitats. Meeting increasing global food needs will require one or both of two approaches: intensification and extensification. Intensification is based on higher or more efficient use of inputs, such as more efficient breeds and crops, agrochemicals, energy and water. Extensification requires converting increasing additional areas of land to cultivation. Both approaches have the potential to dramatically and negatively affect biodiversity. In addition, the loss of diversity in agricultural ecosystems may undermine the ecosystem services necessary to sustain agriculture, such as pollination and soil nutrient cycling. Many of the factors leading to the accelerating loss of biodiversity are linked to the increasing use of energy by society. Dependence on and growing requirements for energy are resulting in significant changes in species and ecosystems, as a result of the search for energy sources and of current energy use patterns. The consequences can be seen at all levels: locally, where the availability of traditional biomass energy is under threat, nationally, where energy prices affect government policies, and globally, where climate change driven by fossil-fuel use is changing species ranges and behaviour. The latter is likely to have very significant consequences for livelihoods, including changing patterns of human infectious disease distribution, and increased opportunities for invasive alien species. Changes to the environment have altered disease patterns and human exposure to disease outbreaks. In addition, current patterns of farming, based on high resource inputs (such as water and fertilizers) and agricultural intensification, are putting great strains on ecosystems, contributing to nutritional imbalances and reduced access to wild foods. Human societies everywhere have depended on biodiversity for cultural identity, spirituality, inspiration, aesthetic enjoyment and recreation. Culture can also play a key role in the conservation and sustainable use of biodiversity. Biodiversity loss continues because current policies and economic systems do not incorporate the values of biodiversity effectively in either the political or the market systems, and many current policies are not fully implemented. Although many losses of biodiversity, including the degradation of ecosystems, are slow or gradual, they can lead to sudden and dramatic declines in the capacity of biodiversity to contribute to human wellbeing. Modern societies can continue to develop without further loss of biodiversity only if market and policy failures are rectified. These failures include perverse production subsidies, undervaluation of biological resources, failure to internalize environmental costs into prices and failure to appreciate global values at the local level. Reducing the rate of biodiversity loss by 2010 or beyond will require multiple and mutually supportive policies of conservation, sustainable use and the effective recognition of value for the benefits derived from the wide variety of life on Earth. Some such policies are already in place at local, national and international scales, but their full implementation remains elusive.

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The presence of congenital anomalies may identify syndromes associated with amenorrhea. Galactorrhea is often associated with amenorrhea; acne, hirsutism, and other signs of possible virilization should be identified. A careful examination of the reproductive tract is useful in identifying anatomic defects and assessing sexual maturity. External genitalia appear female, but the vagina is shallow and testes are intraabdominal. At puberty, breasts develop owing to gonadal estrogens; axillary and pubic hair is absent. It is caused by suppression of gonadotropinreleasing hormone pulsatile secretion and is most commonly associated with chronic illness associated with undernutrition (Crohn disease, celiac disease), stress, excessive exercise, or weight loss and with eating disorders. The female athlete triad consists of disordered eating, amenorrhea, and low bone mass. A history of cyclic pain may be present, and a midline lower abdominal mass (hematocolpos/hematometra) may be palpated. Gonadal function and secondary sexual development are normal, but urinary tract and skeletal anomalies may be present. Stigmata of Turner syndrome include short stature, pigmented nevi, high-arched palate, low hairline, shield chest, ptosis, cutis laxa, pterygium colli, shortened fourth metacarpals, cubitus valgus, heart murmurs, nail changes, and deformed ears. Other associated conditions include myasthenia gravis, idiopathic thrombocytopenic purpura, rheumatoid arthritis, vitiligo, and autoimmune hemolytic anemia. Menstrual cycles should revert to normal within 6 months of stopping birth control pills and by 12 months after the last injection of medroxyprogesterone (Depo-Provera). Chapter 69 142 Part V u GenitourinarySystem 8 Adolescent girls with hyperprolactinemia may present with amenorrhea or delayed puberty and often with galactorrhea. Galactorrhea with normal or mildly elevated prolactin levels may be secondary to nipple stimulation and chest wall irritation or trauma. Hyperprolactinemia may be due to drugs including antipsychotics, methyldopa, amitriptyline, benzodiazepines, cocaine, and metoclopramide. The amount of bleeding is roughly proportional to the amount and duration of prior estrogen exposure. Estrogen status may also be confirmed by vaginal smear or the presence of abundant watery cervical mucus. For a progestin challenge, a 5- to 10-day course of oral medroxyprogesterone acetate or a single dose of intramuscular progesterone is given. Rarely, it may be that the uterus cannot bleed secondary to uterine scarring caused by prior dilatation and curettage or severe uterine infections (Asherman syndrome). Periodic menstrual bleeding occurring more frequently than every 21 days, greater than every 45 days, or lasting longer than 7 days requires evaluation. Variations in menstrual cycles may include menorrhagia (normal intervals, excessive flow and duration of bleeding), metrorrhagia (irregular intervals), polymenorrhea (intervals # 21 days), oligomenorrhea (,6 menses/yr), and intermenstrual bleeding. In girls who have reached menarche, a detailed menstrual history including date of menarche and menstrual pattern should be obtained. A sexual history (sexually transmitted disease, sexual partners) is important, as well as any use of hormonal contraception. Exposure to medications, including exogenous estrogens, anticoagulants, and platelet inhibitors, may be a cause of bleeding. An examination of external genitalia must be done (vaginal digital exam if possible) to identify anatomic abnormalities, and a pelvic examination performed when indicated for sexually active patients. The foreign object may be visualized in the kneechest position, but if not, examination using anesthesia may be required. The most common organisms obtained on culture are group A streptococci, Shigella, and mixed organisms. The presence of gonococci, Chlamydia, or Trichomonas should prompt evaluation for sexual abuse.

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China regards landfills as the main treatment option, while India strongly avoids them. The Chinese policies also support incineration, an option that is prohibited by law in the Philippines. The national policies and strategies of China and Thailand also stress these elements of waste management, although not to the same degree. However, all of the countries seem to share a lack of capacity to enforce the laws in order to meet the objectives. The laws require local actors to reform their solid waste management systems to meet high environmental standards, but local governments generally lack the necessary financial capacity and technical knowledge. There are few initiatives from central governments to help local actors meet the requirements stated in the laws. Composting concerns several governmental departments and there is a clear need for effective coordination. Waste regulation is typically handled by the Ministry of Environment, but sustainable composting, where the product is used for soil improvement, needs support also from other government bodies such as the Ministry of Agriculture. To expand composting it is important not only to stimulate the production of compost but also to promote increased use among farmers. An inter-ministerial body may be needed to coordinate supply oriented and demand oriented policies. Subsidies to mineral fertilisers are a particular obstacle to increased use of compost and other organic fertilisers. If governments want to promote the beneficial use of compost, these subsidies must be reduced or extended to cover organic fertilisers. Other forms of financial support from national governments could include tax reductions or exemptions for compost and composting equipment. The demand for organic food is growing, both in the countries studied and in their export markets. However, despite this trend, many composting initiatives face difficulties in finding markets for their products. The producers of compost and the potential buyers seem to have difficulty in finding each other. Here, national governments can play a role in improving the compost market by reducing transaction costs. Official quality standards for various grades of compost, quality control systems and labelling schemes can be important policy tools. Avoiding contamination of compost is a prerequisite for its sale and safe usage, and experience shows that this requires careful segregation at source. Since many composting initiatives are operating on a small-scale, they typically have very limited capacity to search for potential buyers. Likewise, many organic farmers have difficulties in finding reliable suppliers of fertilisers. Especially for such small and medium-sized actors, databases where buyers and sellers can get in contact can be helpful. To facilitate such initiatives, local governments need to develop their waste management plans in dialogue with citizens. Therefore, stakeholder involvement in local waste management planning should be required in the national waste legislation. The cases also represent different types of cities or towns; Bangkok and Dhaka are national capitals and mega-cities, Nonthaburi and Surabaya are large cities, while Phitsanulok and San Fernando are both small towns. The composting initiatives in Dhaka and Surabaya have gained international recognition as good examples, while San Fernando in the Philippines is a less well known case with an interesting model for cooperation between the local government and community groups.

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Sensations (S) are related to the physical stimulus (P) as S = Pn, where n could be less than 1 but occasionally greater than 1 (Stevens, 1975). Excellent books and papers deal with behavioral assessment of time in animals (Church and Gibbon, 1982; Killeen and Weiss, 1987; Staddon and Higa, 1999) and humans (Vierordt, 1868; Allan, 1979; Gibbon et al. A System of Rhythms 125 argue that psychological time corresponds to real time, at least at the milliseconds to seconds scale. The psychophysical observations also indicate that there is not a certain point in this time continuum where timing is most accurate. In other words, time perception does not have a characteristic time scale; it is scale-free. The progressively longer time required for recalling items from short-term memory after the initial fast recall of the first items may also reflect properties of systems with pink noise. Longer times allow propagation of activity to an ever-increasing population of neurons. However, information passing through spatially divergent neuronal networks is progressively more vulnerable to interference from other network effects (technically referred to as noise or "leakage"), therefore information deteriorates over time. Sensory stimuli, such as flashes of light, evoke progressively longer latency, longer duration, lower amplitude, and more variable responses at successive stages of sensory pathways. The most vulnerable components are the long-latency responses recorded from higher level associational areas, whereas the short-latency components, reflecting activity of early processing, are quite resistant to habituation. When the source and intensity of the auditory conditioning signal were changed, the latency and amplitude of the early evoked 31. However, several investigators argue in favor of a characteristic "tempo" in both music (beat) and speech. Control behavioral experiments showed that the monkeys indeed counted from 1 to 5. When plotted on a logarithmic scale, the tuning curves of "number neurons" could be fitted by a Gaussian with a fixed variance across the range of numbers tested. The increasing magnitude of neuronal pool necessary for identifying higher numerosity can explain the scaling. These "sensory" potentials are localized to the primary sensory cortical areas of the appropriate modality. Localization of the components is more difficult with scalp recordings, and they are collectively referred to as "cognitive" components. A later, N450 (450 milliseconds) component is believed to reflect semantic encoding (Kutas and Hillyard, 1980). It is important to note that these evoked components reflect averaged waveforms of hundreds of repetitions. The single events can often be equally or better described as combinations of various oscillators. However, the amplitude and shape of longer latency responses were essentially independent of the location and intensity of the signal source and were, instead, invariant concomitants of the significance of the signal, as verified by the overt behavior of the cats. Indeed, this assumption appears to be the case, at least to a certain minimum spatial scale. Power spectra of long epochs of electrical fields, representing membrane voltage fluctuations of perhaps a few hundred neurons in the depth of the cortex when recorded by a microelectrode (micrometer range) or millions of neurons recorded by scalp electrodes (10 centimeters), are essentially identical. In other words, the long-term temporal structure of the macroscopic neuronal signal, reflecting the collective behavior of neurons that give rise to it, is macroscopically by and large similar in virtually all cortical structures and in brains of various mammalian species. In essence, the claim is that a collective pattern recorded from a small portion of the cortex looks like the pattern recorded from the whole. Even the power spectrum of synaptically isolated neurons, generating intrinsic (channel) noise, has a 1/f form (DeFelice, 1981; White et al.

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The cellular-synaptic mechanisms of these spikes are identical to the gamma oscillations, and only their isolated appearance and large amplitude distinguish them from the more regular, multiwave gamma rhythm. This feature alone makes the sharp waves eligible for affecting neocortical targets. Its recruitment dynamics are delicately controlled by the various classes of interneurons. For the potential role of axonal gap junctions between axons of pyramidal cells in the ripple event, see computational models in Traub and Bibbig (2000) and Traub et al. Understanding the content, of course, is a general requirement for understanding any macroscopic field pattern and requires large-scale recording of neurons. Since this strategy proved valuable for revealing the relationship between single-level behavior and theta oscillations (Cycle 12), I follow a similar line of reasoning here for sharp waves. Modification of Self-Organized Hippocampal Patterns by Experience In principle, neuronal activity during sharp waves can be useful in two fundamentally different ways. First, the participating neurons can discharge independently and randomly, thereby erasing or equalizing synaptic modifications brought about by specific activity in the waking brain. The expected result is a fresh tabula rasa of the hippocampal autoassociator, every morning ready to be filled with the excitements of the new day. This hypothetical erasure mechanism, of course, should also apply to immobility, drinking, and eating following exploratory learning, because sharp waves are present during such consummatory behaviors, as well. Alternatively, the neuronal pathways used and modified in the waking brain can be repeatedly replayed during nontheta behaviors but now with the temporal dynamics of the sharp waves. First, neuronal representations of a single episode could be replayed multiple times, assisting with the consolidation process. Second, the molecular mechanisms underlying synaptic plasticity occur in multiple stages, involving transient local synaptic modification, signaling to the nucleus, gene transcription, and eventually incorporation of a newly synthesized protein into the synapse that brought about the cascade in the first place. The selective and repeated activation of the same neurons and synapses by the sharp-wave events could be indispensable in this protracted course because the molecular traffic would still be guided by 26. Because many more neurons are active during the sharp-wave event than in a single theta cycle or at any other comparable time window, representations that occurred at intervals longer than hundreds of milliseconds in the waking brain can be brought together into the temporal scale of synaptic plasticity. Furthermore, recently acquired information can be combined with retrieved previous knowledge, again in the critical temporal window of plasticity. From this perspective, sharp waves may be the means of internally organized hippocamponeocortical transfer of neuronal information. Beneath all that turbulence, sharp waves retain and replay the information embedded in the synaptic network that gives rise to the event. A small fraction of pyramidal cells participate in as many as 40 percent of successive events, whereas the majority remain silent or contribute only occasionally. Since this unequal distribution of active neurons is largely similar to the differential firing patterns of hippocampal pyramidal cells in the waking animal, an important issue is whether the firing patterns in theta and sharp waves correlate with each other. Using large-scale recordings of multiple single neurons, Matthew Wilson and Bruce McNaughton at the University of Arizona in Tucson were the first to demonstrate such a relationship. Using a well-learned behavioral task in rats, they reported that pyramidal cells with overlapping place fields preserved their pairwise temporal correlations during subsequent sleep, whereas place cells, which did not overlap spatially or temporally, rarely showed correlated firing during sleep. Several other experiments in various laboratories have confirmed the now well-accepted observation that, in an unchanging environment, the firing rates and temporal correlations of neurons are preserved in multiple sleep/wake/sleep cycles and that most of the correlated discharge occurs during sharp waves. Frey and Morris (1997) advanced a "synaptic tag" hypothesis for guiding this process. The activated synapse would trigger local protein synthesis and create a short-lived synaptic tag, which in turn would attract the products of gene expression, shipped globally throughout the cell. The sharpwave replay mechanism could replace the tagging mechanism or the two processes could work in parallel to ensure input specificity of synaptic modification.

References:

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  • http://media.corporate-ir.net/media_files/IROL/25/254026/Voyager%20Company%20Overview%20June%202019%206.18.19.pdf