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Aerosols (liquid droplets or solid particles dispersed in a gas) such as fog can scatter a beam of light depression symptoms pregnancy cheap bupron sr 150 mg on line. Properties Water is the most abundant (and important depression symptoms ppt order bupron sr now, besides oxygen) substance on Earth depression us purchase bupron sr 150mg overnight delivery. Water is an excellent solvent and has a high boiling point anxiety before bed buy generic bupron sr 150 mg online, high surface tension, high heat of vaporization, and low vapor pressure. High Heat Capacity and High Heat of Vaporization Heat capacity is the amount of energy required to raise the temperature of a substance by 1° Celsius. The specific heat capacity is the energy required to raise the temperature of 1 g of a substance by 1°C. Water has a high heat capacity, absorbing and releasing large amounts of heat before changing its own temperature. It thus allows the body to maintain a steady temperature even when internal and/or external conditions would otherwise increase body temperature. Specific heat of vaporization is the heat required to evaporate 1 gram of a liquid. During perspiration, water evaporates from the skin, and large amounts of heat are lost. Reactivity Water is not reactive with most compounds, so it can serve to transport substances in the body. It takes part in most metabolic transformations (hydrolysis and dehydration reactions). You Should Review I I I I I I I I I the characteristics of solutions and the properties of true solutions the types of solutions and how they compare saturated solutions supersaturated solutions dilute solutions concentrated solutions how water dissolves ionic compounds how water dissolves covalent compounds hydrates Questions 51. Which of the following properties of water is not dependent on the polar nature of water? How many grams of sugar are needed to make 500 ml of a 5% (weight/volume) solution of sugar? Which of the following types of bonds forms when a hydrogen atom binds to a highly electronegative atom and also partially binds to another atom? You need 20 ml of stock solution; you would then fill the container with water to the 100 ml mark (80 ml H2O). Equilibrium Equilibrium is reached when two opposing reactions occur at the same rate. Equilibrium Constant the equilibrium constant, K, for a reaction describes the concentrations of reactants and products for a chemical reaction at equilibrium. For a balanced chemical equation, wA + xBґyC + zD, the equilibrium constant is written as: K= [C] y [D]z w x [A] [B] = x (solute needed) 500 ml (final volume) where [A], [B], [C], and [D] are concentrations of reactants and products and w, x, y, and z are the coefficients used to balance the chemical equation. If one of the reactants or products is a solid, it is not included in the equilibrium expression. Activation Energy Activation energy is the minimum amount of energy required for reactants to be transformed into products. Hydrogen atoms are capable of forming a partial bond between a highly electronegative atom and another atom. Endothermic versus Exothermic Reactions Endothermic reactions are reactions that consume energy in order to take place. Reversible Reactions A double arrow (Ё) designates reversible (twoЖ way) chemical reactions. If arrows differ in length, the longer arrow indicates the major (faster) direction in which the reaction proceeds. For example, increasing the concentration of compounds on the right side of a chemical equation will shift the equilibrium to the left. Energy R Energy released P Reaction Progress You Should Review I Reaction diagram for an exothermic reaction 5. Temperature Rates of reactions increase with temperature, as more collisions between particles occur at higher temperatures. Particle Size Smaller particles react faster, as they collide often at any given temperature and concentration. Concentration A high concentration of reacting particles increases the rate of chemical reactions between them. Catalysis Catalysts speed the reaction rate by lowering the activation energy of the reaction. When the reaction is finished, both reactants and products are present in equal amounts. The fact that a reaction is complete does not mean that both reactants and products are present in equal amounts. Definitions Acids are proton donors (according to the Brшnsted Theory) or electron acceptors (according to the Lewis Theory). Acids release protons (H+) and form anionic conjugate bases (negatively charged ions).
Placement of a bedside commode and providing access to depression kanji order bupron sr 150mg overnight delivery alternate urine receptacles may be appropriate in some situations bipolar depression evaluation cheap 150mg bupron sr visa. Behavioral Interventions for Urinary Incontinence Procedure Types of Incontinence Patient-dependent Pelvic muscle (Kegel) exercises Stress and urge Bladder training Stress and urge Bladder retraining Acute treatment of bipolar depression an update order bupron sr 150 mg line. Use of education depression symptoms more common in adults cheap 150 mg bupron sr free shipping, bladder records, pelvic muscle, and other behavioral techniques. Progressive lengthening or shortening of intervoiding interval, with intermittent catheterization used in patients recovering from overdistention injuries with persistent retention. Purposeful postponement of urination following urge for a predetermined period of time. Requires trained therapist, adequate cognitive and physical functioning, and motivation. Offer opportunity to toilet every 2 h during the day; toilet only on request; social reinforcement; routine offering of fluids. Medications should be used in conjunction with continued nonpharmacologic interventions. The chemical differences in the antimuscarinic medications include molecular size, polarity, and specificity for the M3 receptor. Multiple studies have demonstrated relative equivalence in efficacy as compared with placebo for oxybutynin and tolterodine, but these agents differ in tolerability, formulation availability, and to a limited extent cost (discussed later). Oxybutynin chloride, one of the older and more thoroughly studied agents is a small, lipophilic molecule specific for the M1 and M3 receptors. It is available as an immediate-release tablet, an extended-release tablet, and a transdermal patch. The efficacy is relatively equivalent for all formulations, but the tolerability and cost are increased with the extended-release and transdermal Chapter 32 / Urinary Incontinence 353 Table 32-4. Management of Reversible Conditions That Contribute to Urinary Incontinence Condition Conditions affecting the lower urinary tract Urinary tract infection (symptomatic) Atrophic urethritis/vaginitis Pregnancy/vaginal delivery/episiotomy Postprostatectomy Stool impaction Management Adverse drug effects Increased urine production Metabolic (hyperglycemia, hypercalcemia) Excess fluid intake Volume overload Venous insufficiency with edema Antimicrobial therapy Estrogen (topical) Behavioral intervention Avoid surgical therapy postpartum as condition may be self-limiting Behavioral intervention Avoid further surgery until certain that the condition will not resolve Disimpaction Appropriate use of stool softeners and laxatives High-fiber dietary intake Greater mobility Adequate fluid intake Discontinuation or change of therapy if clinically appropriate Dosage reduction or modification. Adjust dose for hepatic impairment No cognitive impairment noted in clinical studies. For example, ketoconazole, a strong inhibitor, may warrant a dose decrease for tolterodine. However, dose adjustment is recommended in case of renal impairment and also in patients older than 75 years. Drugs that could cause accumulation of darifenacin, such as ketoconazole, should be coadministered cautiously. If compliance is likely to be a problem, the transdermal-patch formulation or any once-daily formulation may be more appropriate. Pharmacologic Options for Stress Urinary Incontinence Drug Estrogen (topical) Women only Dose 0. Atonic detrusor is treated with catheterization while the treatment of obstruction may be managed with -1 adrenergic antagonists. This condition may be successfully treated with -1 adrenergic antagonists and/or 5- -reductase inhibitors. Table 32-7 provides a summary of individual agents that are used for chronic retention of urine. These agents must be used cautiously in individuals with preexisting hypertension and avoided in individuals suffering from chronic retention of urine. Other agents, such as Ro 1151240, a selective -1A/1I-adrenergic agonist, are also in the investigational pipeline. Prazosin, doxazosin, terazosin, tamsulosin, and alfuzosin are all available on the market. It is usually reserved for individuals who fail or cannot tolerate less-invasive therapeutic options, including pharmacotherapy. Referral to a surgeon should be considered for patients in whom the quality of life can be improved with successful intervention, regardless of age, but risks of the surgery should always be considered as well. The standardisation of terminology of lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Effectiveness of anticholinergic drugs compared with placebo in the treatment of overactive bladder: Systematic review. Antimuscarinic agents: Implications and concerns in the management of overactive bladder in the elderly. An evidence-based approach to the evaluation and management of stress incontinence in women. The search, limited to human subjects and English language journals, included the National Guideline Clearinghouse, PubMed, and the Cochrane database. Osteoporosis is the most common human bone disease that is often recognized only after a patient experiences a fracture. Characterized by low bone mass and increased bone porosity, osteoporosis leads to reduced bone strength and an increased risk of bone fracture. Although the disease can affect any bone, most typical fracture sites include the hip, spine, wrist, and ribs.
Some patients develop complications from chronically elevated systemic venous pressure depression hotline chat purchase bupron sr discount, including pleural anxiety over health purchase bupron sr overnight delivery, pericardial depression symptoms emedicine discount generic bupron sr uk, and ascitic effusions depression symptoms loss of interest generic 150 mg bupron sr with amex, 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. Right atrial angiography shows a right-to-left shunt at the atrial level and resembles tricuspid atresia. Left ventriculography usually distinguishes this anomaly because the ventricular septal defect and right ventricular outflow areas are not visualized in pulmonary atresia; instead, the aorta is opacified and, subsequently, the pulmonary artery opacifies by a patent ductus arteriosus. This allows the determination of the distance between the right ventricle cavity and the main pulmonary artery (filled from the ductus with a separate injection). Abnormal connections, called sinusoids, between the right ventricular cavity and coronary arteries may fill from the right ventricle. They represent a poor prognostic sign, since myocardial function may depend on retrograde perfusion, and limit operative efforts to return the right ventricular pressure to normal.
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Because the systemic and pulmonary circulations are connected at the great vessel level definition depression bei kindern buy generic bupron sr 150 mg on-line, systemic blood flow may fall with a decrease in pulmonary vascular resistance; therefore worldwide depression definition buy generic bupron sr line, oxygen administration is avoided once the diagnosis has been made because of its effect on lowering pulmonary vascular resistance depression definition oxford bupron sr 150mg overnight delivery. Corrective operations are not available for infants with hypoplastic left heart syndrome depression symptoms racing thoughts purchase bupron sr 150mg mastercard. Palliative operations include the Norwood procedure, which essentially converts the physiology from aortic atresia to pulmonary atresia by using the native pulmonary trunk as a neoaorta (Figure 8. Controlled pulmonary blood flow is supplied to the disconnected branch pulmonary arteries from a systemic artery through a prosthetic, usually Gore-Tex, shunt. An alternative (Sano shunt) inserts a valveless prosthetic tube between the right ventricle and pulmonary artery to maintain pulmonary blood flow. Infants palliated with a Norwood procedure have a univentricular heart and later may be candidates for cavopulmonary anastomosis (Glenn and Fontan) operations. The long-term prognosis for children who have survived either of these two operative approaches is unknown. Summary Hypoplastic left heart syndrome is a common cause of shock and congestive heart failure in the neonate. Although palliative options, including Norwood operation and transplantation, exist, mortality is higher than for most other cardiac malformations. Coarctation of the aorta (see Chapter 5), either isolated or coexisting with other cardiac malformations, is another common cause of congestive cardiac failure in neonates. Clinical diagnosis is difficult because the low cardiac output from congestive failure minimizes the blood pressure difference between the arms and legs. Following treatment with inotropes, a blood pressure differential may develop as the cardiac output increases. Much less frequently, aortic and pulmonary stenosis may lead to congestive cardiac failure early in life. The aortic arch may be interrupted distal to the left subclavian artery origin (type A) or between the left carotid artery and the 256 Pediatric cardiology Figure 8. As the ductus undergoes normal closure, flow to the lower body is markedly reduced. All patients with interrupted aortic arch as neonates have a clinical presentation similar to coarctation of the aorta, characterized by signs and symptoms of low cardiac output and shock. Neonates have a difference in oxygen saturation between the upper (normal saturation) and lower extremities (lower saturation) because the right ventricle supplies all the lower body cardiac output via the ductus. As the ductus arteriosus narrows, decreased lower extremity pulses become apparent, a finding similar to that in neonates with coarctation. With interruption occurring between the origin of the left carotid artery and the left subclavian artery (type B), only the right-upper extremity pulses may be palpable, whereas in 8 Unique cardiac conditions in newborn infants 257 neonates with interruption distal to the left subclavian artery (type A), pulses in both upper extremities may feel equal. This stage is characterized by nonspecific signs of shock, including poor perfusion, cyanosis, listlessness, and marked tachypnea. The electrocardiogram shows findings similar to those of coarctation, including right ventricular enlargement/hypertrophy. As with coarctation, temporary palliation is accomplished by maintaining ductal patency with prostaglandin. The ascending aorta, which is small, courses cephalad and does not curve posteriorly to become the aortic arch, as in a normal neonate. The ductus arteriosus, which is large, curves posteriorly to join the thoracic descending aorta so seamlessly that the ductus itself may be mistaken for the aortic arch. Unlike a normal aortic arch, the brachiocephalic arteries cannot be seen arising from the ductus. As in coarctation, the ductal shunt is predominantly right to left (from pulmonary artery to descending aorta) because the right ventricle is the sole source of blood flow to the lower body. Oxygen data show a left-to-right shunt at ventricular level and a right-to-left shunt via the ductus arteriosus, with normal saturation in the ascending aorta and its branches and decreased saturation in the descending aorta, corresponding to the level of right ventricular saturation. Left ventriculography demonstrates the location of the arch interruption, the origin and courses of the aortic branches, and the degree of left ventricular outflow tract hypoplasia; the last effect is better demonstrated by echocardiography. If the left ventricular outflow tract is of an inadequate size or is severely obstructed, a palliative operation, similar to a Norwood operation, can be done. Summary Interrupted aortic arch is a form of left heart obstruction that presents in neonates in a manner similar to coarctation of the aorta; it is highly associated with DiGeorge syndrome. The success of operative repair depends on the degree of left ventricular outflow tract hypoplasia and on whether associated noncardiac anomalies are present. Volume overload Volume overload placed on either ventricle may lead to neonatal cardiac failure, and may result from rare lesions such as valvular insufficiency, or arteriovenous malformations. The arteriovenous fistula is associated with low systemic arterial resistance and an increased volume of blood flow through the shunt. The increased flow through the right side of the heart leads to profound cardiac symptoms early in life.
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