Geolgical Survey) shore bird any of various species of bird, such as the sandpiper, plover, or snipe, that frequents the shores of coastal or inland waters shore reef a synonym of fringing reef shore species marine fishes that are always found near the shore shoreline the line separating land and water. It fluctuates as water rises and falls Shoreline of Fanning Island in the South Pacific. In areas affected by tidal fluctuations, the shoreline is the interpreted mean high water line. In confined coastal water of diminished tidal influence, the mean water level line may be used. In non-tidal waters, the line represents the land/water interface at the time of survey. In areas where the land is obscured by marsh grass, cypress or similar marine vegetation, the actual shoreline can not be accurately represented. The bottom and any objects in the water above the bottom reflect sound waves back to the towed array. It is typical of population growth rate trends which begin rapidly at an exponential rate but slow as limiting factors are encountered until a limit is approached asymptotically this sigmoid (or s-shaped) curve is characteristic of many growth situations. The Act also provides for the Secretaries of Agriculture and the Interior to develop cooperative plans for conservation and rehabilitation programs on public lands under their jurisdiction. Some coral reefs are affected by this Act siliceous composed of silicon or primarily of silicon sill the lowest point on a submarine ridge or saddle at a relatively shallow depth, separating a basin from an adjacent sea or another basin sill reef. The genetic code is specified by the four nucleotides: adenine, cytosine, thymine, and guanine. It usually exists as a covalently closed circle sinistral left, as opposed to dextral, or right sink a process or place that acts to absorb or remove energy or a substance from a system. Sink populations or species are present only because immigrants compensate for excess deaths in the area. Eventually, sink species will disappear from isolated areas sinkhole a depression formed in an area either by dissolving of the surface limestone or by collapse of underlying cavities sinus one of several air spaces within the skull that are in contact with ambient pressure through nasal passage openings in the posterior pharynx; a sac-like space the sinuses are a group of 4 pairs of air filled spaces in the head. They also trap and filter organic and nonorganic particles from the air, such as bacteria, spores, and dust. In many molluscs, such as octopods and squids, the siphon may be used to forcibly expel water, providing a means of propulsion An octopus rapidly swimming by forcibly expelling water through the tubular siphon projecting from the head. This water current inflates the body, circulates fluids, and provides a volume of water to act as a hydrostatic skeleton siphonophore siphonophores are "colonial jellyfish" which have swimming bells at the top, and tentacles with stinging cells below that help them to catch their prey. Each individual of the colony is specialized for a different function, such as swimming, feeding and reproduction. They are in the phylum Cnidaria, class Hydrozoa and order Siphonophora siphonozooid a specialized polyp found in colonial soft corals, such as sea pens and sea pansies, which functions as as intake for water, which circulates within the colony and helps keep it upright siphuncle a tubelike structure in the body of a shelled cephalopod, such as the chambered nautilus, extending through the partitions of each chamber of the septate shell; the term is also used to describe tubular structures that direct water flow, or as a feeding siphon of several different kinds of invertebrates Sipuncula an animal phylum that contains the peanut or starworms. They are small, non-segmented benthic animals (they are not worms), some of which live in coral crevices, empty mollusk shells or marine worm tubes. Several species bore into coralline rock sister group a taxon thought to be the closest relative of a given taxon, exclusive of the ancestral species of both taxa sister taxa two taxa that are more closely related to each other than either is to a third taxon. The annual density bands are revealed when slices of coral skeleton are X-rayed skeletogenesis the process of skeleton formation in vertebrates and invertebrates skeleton a supportive or protective structure or framework of an animal, a plant, or part of an animal or plant. In animals it is an external (exoskeleton) or internal (endoskeleton) support structure, against which the force of muscles acts. Vertebrates have a skeleton of bone or cartilage; arthropods have one made of chitin; corals have one of calcium carbonate: sponges have a mass of spicules; many other invertebrates use a hydrostatic skeleton, which is an incompressible fluid-filled region of their body. Snappers are found in the tropical and subtropical regions of the Atlantic, Pacific, and Indian oceans. Some ha sneaky male a small, non-dominant male fish which attempts to fertilize eggs by darting suddenly onto the nest site; also called "sneaker" snorkel a breathing device that allows a swimmer to breathe while face down in the water. For example, coral reef management decisions should identify how these essentially ecological decisions effect the coral reef dependent community soft coral common name for species of the anthozoan order Alcyonacea of the subclass Octocorallia. In contrast to the hard or stony corals, most soft corals do not possess a massive external skeleton Beautiful specimen of soft coral soft dorsal a dorsal fin containing only soft rays, or the soft-rayed hind part of the dorsal fin, if both spines and soft rays are present (as in squirrelfish) the spiny dorsal (spd) and soft dorsal (sod) fin of a schoolmaster snapper. Solitary forms remain as a single individual polyp and one corallite solstice either of the two times of the year when the sun is the greatest distance from the celestial equator, occurring about June 22 and December 22 solute the chemical substances dissolved in a solution, such as salts in seawater solution a liquid mixture in which the minor component, the solute, is uniformly distributed within the major component, the solvent solvent the liquid in which a solute is dissolved to form a solution somatic mutation a change in the genetic structure that can occur in any of the cells of the body except the reproductive cells, and therefore is neither inherited nor passed to offspring. Some marine animals, such as whales and dolphins, use echolocation systems similar to active sonar to locate predators and prey Mother and juvenile bottlenose dolphins (Tursiops truncatus). As the molecules are set in motion, they radiate outwards, colliding into other molecules (compression), then move apart farther than their equilibrium distance (rarefaction), travelling in this manner. The receptor translates the mechanical energy of the pressure wave to electrochemical energy of a nervous system, which stimulates a hearing or tactile sensation in the receiving organism; a body of water that is usually broad, elongate, and parallel to the shore between the mainland and one or more islands.
During prelarval ongrowing, special attention should be paid to such risky periods of postembryonic development as transition to branchial respiration and transition to exogenous feeding. Malformations in any of the mentioned systems or functions lead to prelarval mortality. The chronology and peculiarities (stages) of sturgeon prelarval development are described in detail in Dettlaff, Ginsburg and Schmalhausen (1993) (Figure 91). After hatching, they disperse in the water column, making periodic movements up to the water surface and then drifting down to the bottom of the tank. During natural spawning, such a behaviour of sturgeon prelarvae lets them, firstly, avoid siltation and secondly, by running along the current, reach the zones with high concentrations of food organisms. At transition to branchial respiration and at the stage of alimentary system formation (during the so-called period of "swarming"), prelarvae are deposited at the bottom of the tank, forming swarms of different types. If these are located in the zones with poor water supply, mortality induced by oxygen deficiency may occur (oxygen consumption may be several times higher during this period as compared with embryonic development; for Russian sturgeon larvae at 152 d age, the oxygen threshold concentration was reported to range from 1. By this period, the intensity of oxygen consumption has increased several times as compared with that of the embryonic period, while exogenous feeding gradually stabilized during the fry period (Figure 92). It should be noted that prelarval behaviour during the period of their aggregation into "schools" is an indicator of prelarval hatchery quality. During the period of mass "schooling", prelarvae that are swimming outside a "school" in the depth or on the surface of the water, feature, as a rule, various morphological anomalies. The mass mortality of prelarvae at this stage also may be related to the hatchery quality of eggs and unfavourable rearing conditions. Upon reaching these stages, prelarvae with morphological defects such as developmental anomalies of the respiratory organs and/or digestive tract are not capable of further development and die. The overall mortality during the period of endogenous feeding should not be higher than 510 percent (depending on species). Therefore, sampling of prelarvae (3050 live and dead individuals) should be performed every three days to control the development of the larvae and evaluate their quality (Figure 93). The timely replacement of the filter screen at the outlet of the tanks is very important. In the course of prelarval growth, the mesh size of the outlet screen should be gradually increased from 12 mm at prelarval holding and transition to exogenous feeding to 7 mm at rearing of 10 g fry. The development of these receptors reaches a morphologically definite level at the end of this period. During the period of transition to active feeding, gustatory afferentiation plays a key role in the food-seeking behaviour of sturgeons (Devitsina and Gadzhieva, 1996). The proper transition of prelarvae to exogenous feeding requires: · well-developed sensory organs enabling response to the presence or movement of food organisms; and · a mouth apparatus (capable of clenching the mouth; and a throat cavity connected to an esophagus) and digestive glands in the stomach and intestine that have reached a certain level of differentiation (Sytina and Timofeyev, 1973). During the first days post hatch, tripsin appears in the spiral intestine of sturgeon larvae. Stomach formation from the yolk sac is an important biological trait of early sturgeon ontogenesis. At the onset of exogenous feeding, pepsin can be found in the stomach (Sudakova, 1998), allowing utilization of simple proteins only. The increase in rate of successive stomach development is yolk-sac resorption dependent. At the onset of exogenous feeding, the cellular partition that closes the passage from the oral cavity to the gullet in prelarvae resolves and simultaneously the melanin (fecal) plug is extruded from the anal opening. At the moment of initiation of exogenous feeding, prelarvae that have been in a quiescent state exhibit bottom grouping while searching for feed. In conventional hatchery protocol 120 (Dettlaff, Ginsburg and Schmalhausen, 1993), the appearance of single melanin plugs serves as an indicator to initiate first feeding, which should be performed at melanin plug extrusion in 23 percent of larvae. Untimely feeding may cause damage and loss of larvae; this is most characteristic for larvae of carnivorous sturgeon species (beluga and kaluga sturgeons). At the same time, past experience has shown that administration of feed in small doses stimulates the transition to exogenous feeding and significantly increases both survival ability of larvae and growth rates (Mironov, 1994).
Diseases
These disparate observations are not easily reconciled with the suggestion that blinking might be a marker of central dopaminergic activity. In patients with impaired consciousness, the presence of involuntary blinking implies an intact pontine reticular formation; absence suggests structural or metabolic dysfunction of the reticular formation. Care should be taken to avoid generating air currents with the hand movement as this may stimulate the corneal reflex which may simulate the visuopalpebral reflex. It is probable that this reflex requires cortical processing: it is lost in persistent vegetative states. It has been reported that in the evaluation of sensory neuronopathy the finding of an abnormal blink reflex favours a non-paraneoplastic aetiology, since the blink reflex is normal in paraneoplastic sensory neuronopathies. These signs may help to distinguish tardive dyskinesia from chorea, although periodic protrusion of the tongue (flycatcher, trombone tongue) is common to both. The pouting quality of the mouth, unlike that seen with other types of bilateral (neurogenic) facial weakness, has been likened to the face of the tapir (Tapirus sp. Cross Reference Facial paresis Bovine Cough A bovine cough lacks the explosive character of a normal voluntary cough. It may result from injury to the distal part of the vagus nerve, particularly the recurrent laryngeal branches which innervate all the muscles of the larynx (with the exception of cricothyroid) with resultant vocal cord paresis. Because of its longer intrathoracic course, the left recurrent laryngeal nerve is more often involved. A bovine cough may be heard in patients with tumours of the upper lobes of the lung (Pancoast tumour) due to recurrent laryngeal nerve palsy. Bovine cough may also result from any cause of bulbar weakness, such as motor neurone disease, GuillainBarrй syndrome, and bulbar myopathies. Cross References Bulbar palsy; Diplophonia; Signe de rideau Bradykinesia Bradykinesia is a slowness in the initiation and performance of voluntary movements in the absence of weakness and is one of the typical signs of parkinsonian syndromes, in which situation it is often accompanied by difficulty in the initiation of movement (akinesia, hypokinesia) and reduced amplitude of movement (hypometria) which may increase with rapid repetitive movements (fatigue). It may be overcome by reflexive movements or in moments of intense emotion (kinesis paradoxica). Bradykinesia in parkinsonian syndromes reflects dopamine depletion in the basal ganglia. It may be improved by levodopa and dopaminergic agonists, less so by anticholinergic agents. Cross References Abulia; Akinesia; Fatigue; Hypokinesia; Hypometria; Kinesis paradoxica; Parkinsonism; Psychomotor retardation Bradylalia Bradylalia is slowness of speech, typically seen in the frontalsubcortical types of cognitive impairment, with or without extrapyramidal features, or in depression. Cross References Palilalia; Tachylalia Bradyphrenia Bradyphrenia is a slowness of thought, typically seen in the frontalsubcortical types of cognitive impairment. Silent reading may also be impaired (deep dyslexia) as reflected by poor text comprehension; Writing: similarly affected. There is a mild and transient aphasia or anomia which may share some of the characteristics of aphemia/phonetic disintegration. More commonly there is infarction in the perisylvian region affecting the insula and operculum (Brodmann areas 44 and 45), which may include underlying white matter and the basal ganglia (territory of the superior branch of the middle cerebral artery). Passive flexion of the neck to bring the head onto the chest is accompanied by flexion of the thighs and legs. Cross References Blepharospasm; Dystonia Bruit Bruits arise from turbulent blood flow causing arterial wall vibrations which are audible at the body surface with the unassisted ear or with a stethoscope (diaphragm rather than bell, better for detecting higher frequency sounds). They are associated with stenotic vessels or with fistulae where there is arteriovenous shunting of blood. Examination for carotid bruits in asymptomatic individuals is probably best avoided, other than in the clinical trial - 67 - B Brushfield Spots setting, since the optimal management of asymptomatic carotid artery stenosis has yet to be fully defined. Dysfunction of efferent and/or afferent thalamic and striatopallidal tracts has been suggested as the neural substrate. If necessary, a rubber gum shield or bite may be worn in the mouth to protect the teeth. This may be differentiated clinically from bulbar weakness of upper motor neurone origin (pseudobulbar palsy). Recognized causes include Brainstem disorders affecting cranial nerve motor nuclei (intrinsic): Motor neurone disease (which may also cause a pseudobulbar palsy); Poliomyelitis; Glioma; Syringobulbia. A myogenic bulbar palsy may be seen in oculopharyngeal muscular dystrophy, inclusion body myositis, and polymyositis.
The presence or absence of the germinal vesicle may be observed by focusing a light beam on the section surface. A female with oocytes that show 100 percent response in the progesterone and some response in the controls should spawn within 1 week. A 100 percent response in the progesterone and no response in the controls indicate that this female should probably spawn in about 2 weeks. As Van Eenennaam, Bruch and Kroll (2001) noted, the estimates assume that the females are being held at approximately 1315 °C. At warmer temperatures, these time periods should be reduced, while at colder temperatures they may be slightly extended. Females with less than 80 percent response are considered to be questionable candidates for spawning. It should be noted that different incubation media have been tested or used by Williot, 1997. Prior to spawning, holding should be performed at spawning temperatures without any short-term water temperature increase above the optimal value. In this instance the less mature fish should be held at lower spawning temperatures and the gradient of temperature increase should be lower prior the hormonal stimulation. Violation of this requirement causes desynchronization in oocyte maturation resulting in poor hatchery quality of eggs. Duration of prior-to-spawn holding of other female groups (Table 11) is determined on the basis of the sum of effective temperatures of water (expressed in degree-days). The primary requirement for the prespawn holding of males is the preservation of their reproductive quality. Typically, males are spawnable even after short-term exposure to spawning temperatures; therefore, the most effective way to maintain their reproductive quality is to hold them at low temperatures. In the case of extended exposure of males to spawning temperature, they tend to become overripe (especially males of beluga, stellate and sterlet sturgeons); as well, problems with sperm may arise while working with the last lots of females. In the longstanding practice of Azov and Caspian seas sturgeon hatcheries, the readiness of females to spawn was evaluated on the basis of a study of their physiological status. The considerable variability of reproductive indices, which requires individual evaluation, is typical for such fish. Study of the physiological status of breeders allows identification of spawnability using hematological techniques, as well as assessment of adaptive function of lipid metabolism at the final stages of the reproductive cycle. Such females respond positively to hormonal injections only after holding at spawning temperatures (up to 200 od). Riper females with comparatively larger eggs and higher levels of protein in the oocytes migrate in the middle of the spawning run. In this case, hormonal injections should be administered after holding for short duration. Therefore, earlier, as a rule, biopsy examination was not applied for determination of spawnability of breeders captured during the period of spawning run the duration of prior-to-spawn holding of these spawners at hatcheries was determined on the basis of dates of the capture in the wild. Table 12: Recommendation on duration of prespawn holding of broodstock captured during spring spawning run. Species, spawning run period Azov Sea Basin Russian sturgeon Onset of spawning run, captured in sea Mass spawning run, harvesting in sea Onset of spawning run, harvesting in sea Mass spawning run, harvesting in sea Harvesting in river, May 100200 40120 Stellate sturgeon 250400 200300 180220 2035 1020 1015 515 210 Duration of holding o d d the current protocols for in vivo blood sampling intended for individual analysis of the physiological status of fish are noninvasive and comply with modern industrial standards of sturgeon artificial reproduction. These protocols allow the whole hatchery process to be accomplished on a differential basis, taking into account the initial physiological state of the brood fish. It should be mentioned that the mean values of protein and lipid metabolism indices of wild females (Table 13) during the final phases of the reproductive cycle confirm normal development of gonadogenesis. Poststimulation biochemical characteristics of blood exhibit a 1225 percent decrease (from the initial level) in hatchery productive females and a 5070 percent decrease at transition of gonad to flow condition. Indices considerably higher than the mentioned mean values are typical for immature specimens, the duration of prespawn holding of which should be prolonged. Lower diagnostic characters correspond to skinny fish, hatchery utilization of which is not reasonable. To restore reactivity of follicular epithelial cells (in the case of females being held at spawning temperatures), it is recommended to apply intramuscular injections of 72 triiodthyronin (T-3) at a dosage of 20 mg per kg of weight once a day (over a period of 24 d) in the course of prespawning female holding.
This effectively separates the pulmonary venous and systemic venous returns, as in a normal heart; but unlike normal, a ventricle does not pump blood from systemic veins to pulmonary arteries. Some patients develop complications from chronically elevated systemic venous pressure, including pleural, pericardial, and ascitic effusions, liver dysfunction, and protein-losing enteropathy. Many patients who appear well palliated for years after the Fontan procedure develop left ventricular dysfunction of unknown cause and heart failure. It is probably independent of the type of palliation, since ventricular dysfunction develops in patients with BlalockTaussig and other aorticopulmonary shunts. Some speculate that the myocardium is congenitally myopathic in tricuspid atresia patients. Summary Children with tricuspid atresia present with cyanosis and cardiac failure. The electrocardiogram reveals left-axis deviation, right atrial enlargement, and left ventricular enlargement/ hypertrophy. In a few neonates, significant tricuspid regurgitation is present; in these patients, the right ventricle is enlarged. An atrial communication, either foramen ovale or atrial septal defect, allows a right-to-left shunt. The right ventricle frequently communicates with the coronary artery system through myocardial sinusoids. During systole, blood flows from the high-pressure right ventricle into the major coronary artery branches and even as far as the aortic root. During the first year of life, these progressively enlarge and form a way for the right ventricle to decompress. Features of congestive cardiac failure may appear if the atrial communication is small or if left ventricular dysfunction is present. No murmur is usually present; however, in some a soft, continuous murmur of patent ductus arteriosus is found. In neonates with tricuspid regurgitation, a pansystolic murmur is heard along the lower left and right sternal border. Since the right ventricle is hypoplastic, the precordial leads show an rS complex in lead V1 and an R wave in lead V6. This pattern resembles left ventricular hypertrophy and contrasts strikingly with the normal pattern for a newborn. If tricuspid regurgitation and an enlarged right ventricle are present, a pattern of right ventricular hypertrophy is found. The cardiac contour resembles tricuspid atresia by showing prominent right atrial and left ventricular borders. Summary of clinical findings In a cyanotic infant, the combination of X-ray findings of cardiomegaly and reduced pulmonary vascular markings and left ventricular enlargement/hypertrophy on the electrocardiogram suggests the diagnosis of pulmonary atresia. Echocardiogram Cross-sectional echocardiography shows a small, hypertrophied, poorly contracting right ventricle and no motion at the location of the pulmonary valve, which appears plate-like. The tricuspid valve motion may appear so limited by poor flow into the blindly ending right ventricle that, echocardiographically, the diagnosis 6 Congenital heart disease with a right-to-left shunt in children 227 may be confused with tricuspid atresia. In contrast to tricuspid atresia, Doppler usually demonstrates some tricuspid regurgitation. If marked tricuspid valve regurgitation is present, the right ventricle is enlarged. The right ventricular systolic pressure (which can be estimated from the tricuspid regurgitation velocity) is often suprasystemic. The patent ductus, which shows a continuous aorta-to-pulmonary artery shunt, appears long and convoluted, similar to that in tricuspid atresia and tetralogy of Fallot with pulmonary atresia. Left ventricular function may be subnormal, especially if abnormal right ventricle-to-coronary artery connections (sinusoids) are present. Cardiac catheterization the oxygen saturation shows a right-to-left atrial shunt and marked systemic arterial oxygen desaturation because of severe limitation of pulmonary blood flow. The hypoplastic right ventricle, entered with a catheter via the tricuspid valve, reveals high (often suprasystemic) pressure.
She said, `I had this body of expertise which I could just plunk into the completely open area of the spinal cord blood pressure control circuitry. Existing histological methods could show that there were nerve endings near other nerve endings but could not show that there was communication between the nerves through chemical synapsis. The techniques applied in this project demonstrated the communication links between neurons, which then allowed the pathways between the brain and the cardiovascular system to be identified. Professor Chalmers said, `So, what Ida [LlewellynSmith] was able to do was to add the dimension of showing that one of the nerves that you traced from the brain stem down to the spinal cord actually made a synapse with a nerve which was going out to a blood vessel. So it got us down to very precise capacity to establish links between brain pathways and outflows (functional outflows), and the ones which interested us were the ones to blood vessels and/or the heart, because we were interested in blood pressure and the circulation. It was therefore proposed that LlewellynSmith move from the Department of Anatomy and Histology to the cardiovascular neuroscience research team in the Department of Medicine at Flinders, where she could work on blood pressure control circuits in the central nervous system. She wanted a disease focus for her basic research and to link it to solving a well-defined important clinical problem. As indicated earlier, Dr Llewellyn-Smith also wanted to work in a challenging new research niche, where there was little existing knowledge and the potential to have a significant impact. She said, `When I got into the area of central cardiovascular control, there was so little basic knowledge [and so] I really have spent almost 20 years generating very basic information. Professor Chalmers had been a cardiologist who had also moved into basic research. By the late 1980s, he had been working in the area for approximately 20 years and had a very high profile. Up until the case study research project, the cardiovascular research had been mainly focused on the physiological and structural aspects, and understanding of the role of brain chemistry in the control of blood pressure was still very basic. Professor Chalmers was looking for different approaches to investigate the same problem and recognised the power of physiology combined with anatomy to obtain the whole picture. Llewellyn-Smith observed that this was because it was such a new area and already had the support of Chalmers. Llewellyn-Smith said, `I mean I was proposing to do experiments that absolutely nobody else in the world was doing, and it was sufficiently sophisticated. The committee was overwhelmingly supportive of the application and very enthusiastic about the planned research (Grant-in-Aid Assessment Forms, 1987): `This excellent project is likely to yield significant results. There were therefore no major conceptual changes, only some clarifying and fine tuning of the project. In relation to funding, only two variations were apparent between the application and the grant. The grant was made for two years rather than the requested three years, and the funding for equipment was reduced by Aus$8,735 as the committee concluded that (apart from a diamond knife) the equipment required should already be available at Flinders Medical Centre. Another key facilitator was that a lot of the equipment, infrastructure, laboratory space and facilities were made available to Dr Llewellyn-Smith in the Department of Medicine at Flinders University. In reputational terms, Professor Chalmers brought significant capital to the project, while Dr Llewellyn-Smith brought important skills, techniques and a good track record in those skills and techniques. Hall Prize of the Cardiac Society of Australia and New Zealand, and the Volhard Medal of the International Society of Hypertension. It was recognised that Dr Llewellyn-Smith would bring particular skills and techniques in understanding how the spinal cord is involved in blood pressure control. In particular, it was noted in the grant application that Dr Llewellyn-Smith had shown in previous ultrasound studies of the enteric nervous system that a variety of chemically identified types of nerve fibres form synapses on some enteric neurons, indicating the presence of specific connections and the existence of specific pathways. Llewellyn-Smith had also developed a technique for correlating light and electron microscopy to allow the synaptic input of neurons identified using the light microscope to be studied electron microscopically. The correlated light and electron microscopic immunocytochemistry had proved very successful for studying connectivity in the brain. The method that LlewellynSmith had previously developed was to be used in the spinal cord to compare the synaptic inputs from different types of immunocytochemically defined nerve fibres to specific subpopulations of sympathetic preganglionic neurons. As part of the project, there was a need for perfusion (injection of fluid into a blood vessel in order to reach an organ or tissues) of the spinal cord. At the time, Dr Llewellyn-Smith did not have experience in perfusion, but the Flinders Medical Centre, where she was based, was doing perfusion. Another benefit of the institution being hospital based was that it helped provide a clinical focus to the research and easy access to clinicians who were interested in doing research.
Bladderwrack. Loratadine.
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Ba sed o n the h istor y a nd resu lt s from t he exercise t est, t he overa ll clin ica l d iagnosis is likely hyp er t roph ic (obst r uct ive) ca rd iomyopat hy, a genet ic d isorder t h at cla ssica lly present s w it h a systolic mu r mu r aud ible at the left lower ster nal border that increases with Valsalva. T his aor tic stenosistype murmur represents turbulent flow through an obstructed left ventricular outflow tract (ie, subvalvular stenosis). As a result the pressu re is less a long t he sept u m compa red w it h t he rest of t he posterior ventricular wall, resulting in a Venturi effect that " sucks" the anterior leaflet of the mitral valve to the septum (ie, systolic anterior movement of the mitral valve), which results in a midsystolic gradient within the left ventricular chamber. The clinical finding of a systolic murmur that gets louder with Valsalva is due to t he decrea se in venou s ret u r n, t he decrea sed filling of t he left vent ricle, a nd hence a reduction in t he d imension of t he out flow tract, causing an increase in the obstruction and in the intensit y of the murmur. Patients with hyper trophic cardiomyopathy are at increased risk for sudden cardiac death, particularly those who experience blood pressure drops with exercise, have marked left ventricular hypertrophy (> 3 0 m m), h ave a fa m ily h istor y of sudden ca rd iac deat h, ex p er ience syncope or a documented sustained ventricular tachyarrhythmia (vent ricula r tachyca rdia or vent ricu la r fibrillation), or have episodes of nonsusta ined vent ricula r tachyca rdia. T herapy for these patient is generally an implantable cardiover ter defibrillator. Each strip shows a nonsustained episode of a rapid wide complex tachycardia that is ventricular in origin. Each episode term inates sponta neously after a few seconds; t herefore, t his is nonsust a ined vent ricu la r t achyca rdia. H owever, t here a re ma rked changes in Q R S morphology and Q R S axis (); therefore, this is polymorphic ventricular tachycardia. It should be noted that t he Q T inter va l () of the sinu s b eat s is nor m a l at 360 m sec. In t he presence of a nor m a l Q T inter va l t h is is ter med polymor ph ic vent ricu la r t achyca rd ia, a nd t he most com mon etiology is active ischemia. The only three arrhythmias provoked by active ischemia are polymorphic ventricular tachycardia, ventricular flutter (ventricular tachycardia with a rate > 260 bpm), and ventricular fibrillation. Anot her less com mon cause for polymor phic vent ricula r t achyca rdia is fa m ilia l catechola m iner gic polymor ph ic vent r icu la r t achyca rd ia, which is the result of a genetic abnormalit y affecting the r yanodine or calsequestrin 2 gene. Three days later s he again pres ents to the emergency department with complaints of s evere naus ea and vomiting as well as diarrhea. She has attempted to s tay hydrated and to eat but has been unable to due to s evere emes is with intake. She was pres cribed ondans etron for her naus ea and ciprofloxacin for her diarrhea at an outpatient clinic. While in the emergency department, the patient has a syncopal epis ode that is captured on the telemetry s trip below. After the six th Q R S complex there is a n episode of a rapid w ide complex tachyca rdia with Q R S complexes that a re cha nging in mor phology a nd a x is. The episode of polymor ph ic vent ricu la r t achyca rd ia in this case is called " torsade de pointes" or t wisting of points, which is defined a s p olymor ph ic vent r icu la r t achyca rd ia a sso ciat ed w it h Q T prolongation. Given her severe d ia r rhea a nd emesis w it h p o or or a l int a ke, she is likely hypokalemic and hypomagnesemic, which a re t wo major risk factors for acquired Q T prolongation and torsade de pointes. In addition, she has been t a k ing t wo k now n Q T prolonging agent s: a qu inolone a nd met h adone. Initial laboratory as s es s ment reveals acute renal ins ufficiency, hyperkalemia, lactic acidos is, and a blood pH of 7. Rather, there are rapid and irregular waveforms that are completely disorganized and without any distinct morphology. At times the waveforms look more organized (), as in lead V3 for example, and resemble polymorphic ventricular tachycardia. H ow ever, it ca n a lso o ccu r in the set t in g of p r o fo u n d m et a b o lic d ist u rba nces such as acidosis a nd sept ic sho ck, as illust rated in t h is case. Respiratory failure due to aspiration, bronchospasm, sleep apnea, or pulmonary embolism can also result in ventricular fibrillation arrest. The only effective therapy for ventricular fibrillation is prompt electrical defibrillation. Ventricular fibrillation does not revert spontaneously, nor are antiarrhythmic drugs effective for reversion.
Premature infants demonstrate cry expression, grimacing, and knee and leg flexion during total reposition changes. Physiologic alterations in blood pressure, heart rate, and respiratory rhythm and rate occur with touch and handling. Hypoxemia can occur with non-painful or routine caregiving activities such as suctioning, repositioning, taking vital signs, diaper changes, and electrode removal. Those changes can be minimized with some handling techniques, including · Avoid sudden postural changes by slowly turning an infant while containing extremities in a gently tucked, midline position. Use blanket swaddling and hand containment to decrease physiologic and behavioral distress during routine care procedures such as bathing, weighing, and heel lance. Immediately return infants to supportive positioning or swaddling after exams, tests, or procedures to avoid prolonged arousal, fluctuating vital signs, or both. It provides warmth and the sensation of skin against skin (tactile), rhythmic rise and fall of chest (vestibular), scent of mother and breast milk if lactating (olfactory), and quiet parent speech and heartbeat (auditory). Tactile sensation forms the basis for early communication and is a powerful emotional exchange between infants and parents. Handling and positioning techniques promote comfort, minimize stress, and prevent deformities while creating a balance between nurturing care and necessary interventions. Balancing routine or aversive tactile stimulation such as procedures and tests with pleasurable or benign touch is essential. Acuity, maturation, and behavioral responses of each infant change over time requiring continual reassessment of the amount, type, and timing of tactile interventions during the hospital course. Since touch can be disruptive to maturing sleep-wake states, avoid touching a sleeping infant for care or nurturing unless absolutely necessary. Guidelines for Acute Care of the Neonate, Edition 26, 201819 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 4-Environment Positioning · · · · hands to face or in midline tucked body or trunk partial flexion of hips adducted to near midline lower boundary for foot-bracing or complete circumferential boundary that supports position and calms infants. Prolonged immobility and decreased spontaneous movement increase the risk of position-related deformities. Common malpositions include: · · · · · · abduction and external rotation of the hips shoulder retraction scapular adduction neck extension postural arching abnormal molding of the head Each position has advantages and disadvantages. Prone positioning places an infant at risk for flattened posture unless a prone roll is used. It encourages midline Primary goals for positioning are comfort, stability of physiologic systems, and functional posture and movement. Before birth, the uterus provides a flexible, circumferential boundary that facilitates physiologic flexion as the uterine space becomes limited during advancing pregnancy. In time, muscle contractures and repetitive postures can lead to abnormal posture and movement. Therapeutic positioning promotes neurobehavioral organization, musculoskeletal formation, and neuromotor functioning. Although some suggest that side lying may contribute to atelectasis of the dependent lung, no evidence supports this hypothesis. Supine positioning - appears to be the least comfortable and most disorganizing position for preterm infants, with decreased arterial oxygen tension, lung compliance, and tidal volume compared to prone. Dolichocephaly - lateral flattening or narrow, elongated head shape of preterm infants that occurs over time due to their soft, thin skulls. Brachycephaly - flattened occiput, alopecia (bald spot), and deformation of the ipsilateral ear and forehead. Torticollis ("twisted neck") - with limited movement and head tilted to one side due to shortening of the sternocleidomastoid muscle. Gentle, flexible boundaries contain while allowing controlled movements that promote flexorextensor balance without the disorganization or stress of uncontrolled movement. Physical and occupational therapists are available to assist with appropriate positioning. Daily physical activity of low birth weight preterm infants improves bone growth and development.
Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Wheal: Erythematous, well-circumscribed, raised, edematous lesion that appears and disappears quickly B. Crust: Exudative mass consisting of blood, scale, and pus from skin erosions or ruptured vesicles/papules 4. Scar: Formation of new connective tissue after damage to epidermis and cutis, leaving permanent change in skin 6. Pathogenesis: Benign vascular tumor with a phase of rapid proliferation followed by phase of spontaneous involution. Many begin to regress by 6 months, with a rate of 10% complete involution per year. Clinical presentation: Newborns may demonstrate pale macules with threadlike telangiectasias that later develop into hemangiomas. Atypical clinical findings, growth pattern, and equivocal imaging should prompt tissue biopsy to exclude other neoplasms or unusual vascular malformations. Decision to treat should be based on location, size, pattern, age of patient, and risk of complications. Propranolol (Hemangeol)3 (a) Nonselective -adrenergic blocker given orally; should be initiated under careful supervision of a pediatric dermatologist or other practitioner experienced in management. Chapter 8 Dermatology 207 (b) Patients should be clinically screened for cardiac disease. Electrocardiogram and/or echocardiogram are not required but obtained only when indicated. Clinical presentation: Benign vascular tumor, appears as small bright red papule that grows over several weeks to months into sessile or pedunculated papule with a "collarette" or scale. Shave excision or curettage with cautery of base: Recommended for pedunculated lesions. Surgical excision: May be necessary for large or unusual lesions, but recurrence rates are high. Laser therapy: Can be used for small pyogenic granulomas but may require two to three treatments. For More Information Regarding Vascular Tumors and Vascular Malformations, Please See: issva. Clinical presentation: (1) Common warts: Skin-colored, rough, minimally scaly papules and nodules found most commonly on the hands, although can occur anywhere on the body. Trauma on weight-bearing surfaces results in small black dots (petechiae from thrombosed vessels on the surface of the wart). Treatment4: (1) Spontaneous resolution occurs in >75% of warts in otherwise healthy individuals within 3 years. Particularly effective in combination with adhesive tape occlusion; response may take 46 months. Clinical presentation: Dome-shaped, often umbilicated, translucent to white papules that range from 1 mm to 1 cm. Can occur anywhere except palms and soles, most commonly on the trunk and intertriginous areas. Can occur in the genital area and lower abdomen when obtained as a sexually transmitted infection. Treatment: Most spontaneously resolve within a few months and do not require intervention. Etiology: Represent cutaneous reaction patterns triggered by endogenous and environmental factors. Spread by skin-to-skin contact and through fomites; can live for 2 days away from a human host. Female mites burrow under the skin at a rate of 2 mm/day and lay eggs as they tunnel (up to 25 eggs). Clinical presentation: Initial lesion is a small, erythematous papule that is easy to overlook.
If noted, these individuals should be evaluated thoroughly for dyslipidemia and associated vascular, metabolic or cardiovascular disorders. Some of these include: topical application of crushed garlic, castor oil or lemon rind; a "cleansing diet" consisting of only fresh papaya or pineapple and water for three consecutive days; niacin supplements; and exercise and stress reduction techniques. The key to managing patients is recognizing its appearance, and referring for the proper medical workup. Since the management of a discovered systemic disease and its potential complications will rest within the domain of the internist or other specialist, the role of the primary eye care provider is to discover undiagnosed cases and monitor ocular health for the ocular complications. When these cells invade the episclera and sclera scaffolding upon branches of trigeminal nerve they can produce, patchy areas of bluish subconjunctival discoloration. This may be of importance as these patients may have increased risk for glaucoma or exhibit artificially low intraocular pressure measurements. Clinical study of hereditary disorders of connective tissues in a Chilean population: joint hypermobility syndrome and vascular Ehlers-Danlos syndrome. Surgical repair of bilateral full thickness macular holes in a patient with blue sclera secondary to osteogenesis imperfecta. Severe conjunctivochalasis in association with classic type Ehlers-Danlos syndrome. Bevacizumab treatment for subfoveal choroidal neovascularization from causes other than age-related macular degeneration. Presenting signs and clinical diagnosis in individuals referred to rule out Marfan syndrome. Central corneal thickness is lower in osteogenesis imperfecta and negatively correlates with the presence of blue sclera. A new alternative to riboflavin/ultraviolet-a: collagen cross-linking with rose bengal/green light. Dendritic ulcerations with classic terminal end bulbs staining brightly with sodium fluorescein and rose bengal dyes have been reported as part of the syndrome. The mother in such cases should be examined for concurrent gynecological infection. In cases involving serotype-2, concurrent systemic infection or issues where immunosuppression is suspected, consider concurrent use of oral antiviral therapy with dosage based on age and body weight. The medication requires less frequent initial dosing (approximately every three hours while awake) and can be tapered as resolution is seen over seven to 10 days. Additionally, ganciclovir demonstrates greatly reduced corneal toxicity, primarily because it is only taken up by virus-infected cells. The disease is generally self-limiting and can be managed with palliative therapies such as artificial tear drops and ointments along with oral overthe-counter analgesics for any additional discomfort. If a papillomacular rash is present, topical prophylactic antibiotic ointments can be prescribed to prevent secondary cellulitis. Epithelial keratitis concurrently present, with or without subepithelial marginal infiltrates, may be cautiously 11. Delayed type hypersensitivity in the pathogenesis of recurrent herpes stromal keratitis. The impact of the herpetic eye disease studies on the management of herpes simplex virus ocular infections. However, if iritis is present, topical steroid use in the absence of topical antiviral coverage is not advised. In the setting of corneal involvement, topical steroids should not be used without topical antiviral coverage. Factors such as severity, recurrence, other topical medications used, atopic disease or a history of immunosuppression can significantly alter the presentation and risk of corneal involvement. Topical prophylactic antibiotic ointment can be dispensed to prevent secondary eyelid infections in cases where a rash is apparent, and drops can be used in cases where keratopathy is significant. Etiology of acute conjunctivitis due to coxsackievirus A24 variant, human adenovirus, herpes simplex virus, and Chlamydia in Beijing, China. Pediatric herpes simplex of the anterior segment: characteristics, treatment, and outcomes.
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