Order zofran amex

Movement of the thumb upward is likened to femoral anteroversion, and downwards to retroversion. The therapist palpates the greater trochanter of the hip whereas passively rotating the hip via the lower leg, stopping when the trochanter is parallel to the floor. The angle of the lower leg in relation to vertical will present a clinical estimate of femoral anteroversion/retroversion. When the lower leg factors laterally (inside hip rotation), the patient has anteroversion. When the lower leg factors medially (hip external rotation), the patient has retroversion (Table 12-5). Richardson et al27 suggest a three-tiered system consisting of straightforward screening exams, clinical measures, and diagnostic measures to assess neuromuscular control of the local stabilization system. First the clinician palpates the lumbar multifidus in a relaxed state, evaluating bilaterally for atrophy spanning a defined twovertebra phase. In their examine blinded examiners had been asked to determine the "most affected vertebral level of lumbar multifidus using palpation. Palpation may not be helpful in assessment of patients with continual low back ache as a result of generalized atrophy or infiltration of fatty tissue, or each, into the lumbar multifidus can confound findings. Cues for proper muscle motion are the identical as for the "drawing-in check" with the addition of the command "gently swell out your muscle tissue underneath my fingers with out transferring your backbone or pelvis. Hides et al33 report proof supporting abnormal muscle activation in patients following spontaneous resolution of acute low back ache. The topic then actively raises one leg 12 inches from the plinth and notes any replica of posterior back or pelvic ache. The check is performed once more with the therapist simulating the motion of the transversus abdominis by pushing inward from the lateral border of the pelvis or using a pelvic support belt to compress the pelvis within the frontal airplane. A positive check suggests that a patient will reply nicely to local stabilization exercise. This check holds promise as a nontechnological clinical assessment of local stabilization, but further analysis is required to determine reliability (Figure 12-18). Hopefully this expertise will be reasonably priced to all clinicians within the close to future. Clinical Measures of Local Stability Abdominal Drawing-in Test this check is similar to the screening check described earlier with the addition of the usage of pressure biofeedback and positioning the patient in susceptible. Richardson et al27 recommend instructing the patient within the motor skill to be examined by cueing the patient to "draw within the stomach wall" and educating the patient within the corset-like anatomy of the transversus abdominis. It can also be essential to start by instructing the patient within the kneeling-on-all-fours place earlier than precise testing. The patient is cued to "breathe out and in after which, with out breathing in, slowly draw within the stomach so that it lifts up off the pad, maintaining the spinal place steady. According to Richardson et al,27 an accurate isolated transversus abdominis contraction will reduce pressure within the biofeedback unit by 6 to 10 mm Hg because the drawing-in motion of the transversus abdominis strikes the stomach wall away from the pressure bladder. A drop in pressure less than 6 mm or a rise in pressure indicates a "poor" transversus abdominis contraction. If correct recruitment of the transversus abdominis is observed, then muscular endurance is assessed with 10-second isometric holds for up to 10 repetitions. Hodges et al31 examined the connection between laboratory examine of local stabilizers and clinical testing used to assess local stabilization patterns. They reported "good settlement" between topics with a poor capacity to decrease pressure with the drawing-in check and those with delayed transversus abdominis activation within the laboratory. As apply acts evolve and this expertise becomes more reasonably priced, the authors hope to see more widespread use of these methods of local stabilizer assessment. As mentioned earlier, the clinical assessment tools of local stabilizers at present lack proof. Endurance is measured in consecutive seconds the patient can preserve this place. The patient then actively raises one arm and the opposite leg till level with the trunk. As no established norms exist for this check, endurance is measured in consecutive seconds the patient can preserve this place. The analysis into local stabilization already mentioned suggests that extreme activation patterns or activation of global muscle tissue earlier than the local stabilizers is linked to low back, sacroiliac, and groin ache. Established regular values for this check make it enticing for use in quantifying targets. The patient begins in supine hook lying place after which recruits the transversus abdominis and multifidus with a cue of "drawing in. During this movement the quadratus lumborum is energetic to preserve stability within the frontal airplane. The gluteus medius is also energetic, stabilizing the hip within the frontal airplane and mixing with the other hip rotators to stabilize the hip within the transverse airplane. The patient begins lying on his or her facet with the higher physique propped up on an elbow and the highest leg crossed over the underside with each ft touching the plinth. Timing begins when the patient raises his or her physique off the plinth and is supported only by the ft and down forearm. The patient then strikes forward till the pelvis is at the fringe of the plinth but nonetheless supported. The patient is timed for as long as the trunk may be maintained parallel to the floor (Table 12-7). Abdominal Bracing Abdominal bracing exams the endurance of the rectus abdominis to hold the trunk in a flexed place (Figure 12-19). The patient is positioned with a 60-diploma wedge positioned behind the trunk as in a sit-up. Test hip is abducted to midrange, barely extended, and barely externally rotated. Many patients will rotate the pelvis backward to compensate for a weak posterior gluteus medius with the tensor fascia latae Patient is positioned in facet lying with the leg to be examined within the down place. The therapist supports with high leg whereas resisting hip adduction on the medial distal femur of the down leg. Downward pressure is utilized by the therapist against the distal posterior thigh whereas stabilizing the pelvis with the other hand. Therapist applies resistance against distal anterior thigh whereas stabilizing the trunk with one hand on the anterior shoulder. Examiner medially rotates the femur by transferring the lower leg laterally to midrange. Therapist applies pressure in a medial direction against the lateral lower leg whereas stabilizing the hip and pelvis with a hand on the thigh. Therapist strikes the check leg into midrange of external hip rotation by transferring the lower leg medially. Strength is outlined because the maximal quantity of force produced by a muscle motion; in other words, energy is a measure of muscle performance as a mobilizer. Drop Leg Test Clinical Application On the basis of the clinical experience of the authors of this chapter, the hip abduction manual muscle check is often not delicate sufficient to detect weakness within the posterior fibers of the gluteus medius even when performed as described earlier. Instead, they recommend taking the hip passively to the top-ofrange abduction and extension after which asking the patient to hold the leg there. Isometric Manual Muscle Testing Manual muscle exams have been a staple of physical remedy for the reason that epidemic of polio necessitated a speedy and dependable technique of assessing energy with out tools. Table 12-eight describes commonly accepted check positions used to assess trunk and hip mobilzers. However, this grading system is often not delicate sufficient to detect relative weakness seen in sturdy athletes. Conversely, this means any athlete not testing at 5/5 with manual muscle testing has an obvious energy impairment that ought to be addressed. Hand-held dynamometers have been proven to be a dependable and more delicate measure of isometric energy testing and may be employed with the established check positions for manual muscle testing. However, it has just lately come into disfavor because of alleged limitations as a "useful check" and excessive working prices. Most gamers and followers would agree that a faster serve improves performance within the sport of tennis, a useful exercise as outlined by the Nagi model of disability. This begs the query, "How is a dependable measure of rotator cuff energy not a useful check?

8 mg zofran with amex

Drowning is defined as demise throughout the first 24 hours of submersion, which includes demise at the scene. Near-drowning is defined as submersion during which survival is greater than 24 hours, no matter morbidity and mortality. The common pathophysiologic occasions in all drowning incidents are asphyxia and hypoxia. After a submersion incident, most victims will go through a period of struggle and breath-holding, or water will enter the oropharynx and larynx leading to choking and laryngospasm (4,5). This will result in hypoxia and loss of consciousness, followed by asphyxia and demise. Loss of protecting reflexes will occur in most victims, resulting in water aspiration. All organ systems are affected after a submersion damage because of asphyxia, hypoxia and acidosis. Risk elements which were identified as indicators of irreversible neurologic damage and mortality include (2,6): 1) Age less than three years. A classification of submersion victims based on neurologic function was developed by Conn and Baker (7,8). This classification has several advantages: 1) It estimates the magnitude of hypoxic insult. The classification is as follows: Category A: Awake, alert, fully aware, minimal damage. Category B: Blunted, obtunded to stuporous, normal central respiratory drive, purposeful responses to pain. Unarousable, abnormal central respiratory pattern, abnormal motor responses to painful stimuli, seizures may occur. The aim is to improve oxygenation and air flow as rapidly as potential to minimize cerebral hypoxic-ischemic injury. All patients should be transported rapidly to the emergency division for further evaluation and therapy. Initially, important signs and core temperature are obtained, followed by respiratory, cardiovascular and neurologic evaluation. Most patients with a major submersion damage should be admitted to the hospital for remark; nonetheless class A patients, with no different vital accidents, could also be discharged from the emergency division after a period of remark. Although the survival rate has improved with advances in emergency care, prevention is one of the best strategy. Parental supervision of infants and children whereas in and round water is important. Moreover, children and adolescents vulnerable to situations similar to syncope and seizures ought to all the time have a companion. So far, the only environmental preventive strategy that has decreased the variety of submersion accidents in children is the installation of four-sided fencing that isolates the pool from Page - 492 the home. True/False: the American Academy of Pediatrics advocates swimming lessons for all children over two years of age. Which of the following interventions will improve the outcome in a drowning sufferer? He reviews that she has only recently recovered from a cold, however has continued to cough. She often coughs in matches with submit-tussive emesis, will typically flip blue in the face, and makes a "gasping-like" noise when she tries to inhale after a coughing episode. According to her father, the onset of those signs began "after a type of coughing matches this morning". There is an sick contact in the home (a grandfather who has been coughing for the last three months). She is sitting on the exam table, leaning forward, taking quick breaths with some nasal flaring. She has barely asymmetrical chest actions (her right chest wall moves less than her left) and she has decreased breath sounds with hyper-resonance and decreased tactile fremitus on the proper as nicely. Since you think a pneumothorax, your nurse locations the affected person on 2 liters/minute of oxygen through nasal cannula whilst you prepare for medical transport to the Emergency Department. Upon affirmation by the radiologist, she is diagnosed with a right, simple, major spontaneous pneumothorax. Air leak syndromes embody a wide-spectrum of ailments together with pneumomediastinum, pneumothorax, pneumopericardium, pneumoperitoneum, subcutaneous and interstitial emphysema, and pulmonary pseudocyst. Due to the pathophysiology of air leak syndromes, more than one of those disease processes are often current concomitantly. The exact prevalence and incidence of the differing air leak syndromes is difficult to determine. From a research of Minnesota residents between 1959 and 1978, it has been estimated by extrapolating the data, that about 9000 individuals in the United States develop a major spontaneous pneumothorax yearly (1). Pneumothoraces are also found in about 5% of hospitalized asthmatic children and about 10-25% of cystic fibrosis patients older than 10 years old (three). Thoracic air leak syndromes result from a free communication with the environment, both from a pleura defect or from alveolar rupture. The kind of air leak syndrome that develops will depend upon the placement and the nature of the communication. Although air leaks may be brought on spontaneously, nearly all of them are secondary to some kind of trauma (intentional, accidental, mechanical, and iatrogenic). The mechanism of alveolar air leaks begins with constructive intra-alveolar inflation stress causing an increase in the air quantity of the alveolus with a simultaneous decrease in the blood quantity of the adjacent alveolar blood vessels. The distinction between the changes in these respective volumes causes an attenuation of the tissue that tethers the perivascular sheath to the alveolar wall. The escaping air may then dissect along perivascular planes into the mediastinum (pneumomediastinum), into the pericardium (pneumopericardium), into the pleural area (pneumothorax), into the peritoneal cavity (pneumoperitoneum), out of the thorax along subcutaneous tissue planes (subcutaneous emphysema), and/or be confined to the interstitium of the lung (interstitial emphysema) (4). Since pneumothoraces are the most common kind of air leak syndrome, the rest of the dialogue will consider this entity. A pneumothorax is defined because the abnormal presence of air in the pleural area (6). Pneumothoraces are categorized as spontaneous or traumatic and categorised as simple, speaking, or pressure (1,7). Traumatic pneumothoraces could also be attributable to penetrating or blunt trauma, mechanical air flow, central line placement, or poisonous inhalations. This defect may cause paradoxical chest wall motion (collapse during inhalation and expansion during exhalation) together with the sonorous sound of air coming into and exiting the wound. A pressure pneumothorax happens when the progressive accumulation of air causes a shift of the mediastinum to the alternative hemithorax causing a subsequent compression of the contralateral lung and nice vessels (7). Communicating and pressure pneumothoraces may result in the fast onset of hypoxia, acidosis, and shock. Although the cardinal manifestation of a pneumothorax is the sudden onset of chest pain, signs will range relying on the extent of lung collapse, degree of intrapleural stress, rapidity of onset, age, and respiratory reserve of the affected person (4,6). Symptoms that may be current include: tachypnea, dyspnea, tachycardia, and cyanosis. The chest pain may range from a localized sternal pain to an amazing pleuritic pain tough to localize (6). There is normally a decrease in breath sounds, tactile fremitus, and a decrease in thoracic excursion whereas there is an increase in resonance to percussion on the affected aspect. Page - 494 Radiographs will assist to differentiate a pneumothorax from emphysema, an emphysematous bleb, diaphragmatic hernia, compensatory overexpansion, massive pulmonary cavities, contralateral atelectasis, or different cystic formations. A pressure pneumothorax normally leads to cardiopulmonary compromise (shock, bradycardia, hypoxia) requiring quick needle decompression (thoracentesis), which may be achieved by inserting a big bore (sixteen or 18 gauge) needle (smaller gauge needles are passable for premies, newborns and infants) via the second or third interspace (near the apex of the lung) in the midclavicular line. Tube thoracostomy (commonly known as a chest tube) could also be required after the initial decompression if the pneumothorax reaccumulates. A speaking pneumothorax ought to have the defect lined immediately, which helps to convert the situation to a simple pneumothorax. An occlusive dressing using petroleum gauze could also be applied, however this have to be carried out with warning as it can cause the development of a pressure pneumothorax.

order zofran amex

Purchase zofran 8 mg otc

Because the airway can swell quickly, this situation must be handled aggressively and quickly to forestall airway obstruction. Immediate tracheal intubation is indicated if the affected person exhibits signs of laryngeal edema, such as hoarseness, stridor, or a brassy cough. Endotracheal intubation and mechanical air flow are required in the case of respiratory failure. Signs of respiratory failure embody the development of tachypnea, use of accent respiratory muscles, and hypoxemia (three). To precisely estimate the depth of pores and skin damage, devitalized tissue must be debrided, and enormous blisters must be eliminated. In this technique, the physique is divided into eleven Page - 662 areas of nine p.c each. Each higher extremity is 9%, the anterior and posterior parts of each decrease extremity are 9%, the anterior higher and decrease parts of torso are 9% each, the posterior higher and decrease parts of the torso are 9% each, and the neck and head together is 9% to give a complete of ninety nine%. However, it must be taken into consideration that the head is relatively larger and the legs comparatively smaller in surface space for youngsters in contrast with adults. Significant burns of face, hands, genitalia, ft, or across the joints are categorized as severe. Transfer to or session with a burn heart should be thought-about for these patients. If clothing has adhered to the pores and skin, it should be left for removing during the cleaning of the wound (4). To lower ache, the burn could also be cooled with the applying of cooled, sterile, saline-soaked gauze. Removal of necrotic tissue could be accelerated with the usage of enzymatic debriding preparations such as collagenase and papain-urea preparations. Flimsy intact large blisters are more likely to lyse on their very own soon, so these could be debrided as properly. The appearance of the burn on the second day nearly always seems worse with enlarging blisters. Patients suffering wounds deeper than a superficial partial-thickness burn should have their tetanus immunization up to date. This will provide some ache reduction, protect the wound from infection, and take in drainage from the wound. Most deep partial-thickness burns ultimately heal by epithelialization in three-9 weeks. Hair follicles are destroyed in full-thickness wounds stopping epithelialization. Full thickness burns require surgical treatment consisting of eschar excision and pores and skin grafting. Severely injured patients are higher served at a delegated burn heart particularly educated in analgesia and wound care for patients with burns. Transfer to a burn heart should be thought-about in additional extreme burns, main burns to the hands, face, ft, perineum, or advanced electrical burns. If an extremity is concerned, immobilization and elevation could also be helpful to reduce edema. Furthermore, compartment syndrome might develop in an extremity that has sustained a circumferential burn. Patients with circumferential burns of an extremity should be admitted to the hospital for observation of the development of this potentially limb and life threatening situation. Ingestion of fluids could also be insufficient in youngsters because of ache, nervousness, and the effects of narcotics. Extravasation of fluid into unburned tissue in addition to elevated evaporation from the surface of the wound ends in hypovolemia. Fluids must be administered to forestall hypovolemia-induced ischemia, lactic acidosis, and shock. Although sufficient fluid administration is crucial, it is important to avoid over-hydration. Increased hydrostatic pressure and decreased oncotic pressure from protein loss contributes to the fluid shift, and over-hydration might result in elevated wound and complete-physique edema (including pulmonary edema and respiratory compromise). When administering fluid to infants, it is important to appreciate the lack of maturity of their kidneys. Because of an imbalance of maturation of tubular and glomerular features, the osmolar concentrating ability is estimated to be one half of that seen in adults (6). In order to minimize radiant and evaporative warmth loss, the ambient temperature should be kept sufficiently high. Thermiogenesis is completed by catabolism of fats shops requiring large quantities of oxygen. Excessive lactate manufacturing and metabolic acidosis might result from prolonged thermiogenesis. The improve in metabolic expenditure is roughly proportionate to the surface space burned. To lower the loss of muscle mass, about 20% of the calories administered should be from protein. Most youngsters maintain electrical burns by the insertion of a metal object right into a wall outlet or by publicity to frayed electric cords. Intense warmth and deep accidents are produced when the current passes via the tissues. If a child puts a reside electric twine into the oral cavity, the lips could also be burned. Additionally, the burn might extend fully via the lips and oral mucosa to the labial artery. This could be potentially catastrophic if this artery erodes because of sloughing of necrotic tissue. There is a high risk of scar formation related to burn wounds that take more than three weeks to heal. Furthermore, scars might develop in wounds that heal spontaneously with out pores and skin grafting. Children are inclined to scar worse than adults, and patients with dark pores and skin colour, scar worse than patients with gentle pores and skin. Pressure garments worn 24 hours a day, repeatedly for one 12 months after healing, might restrict the development of scarring. Physical and occupational remedy should begin on the day of admission in order to maximize the cosmetic and practical end result. If needed, remedy might continue after discharge for a number of months because the scar tissue varieties and contractures develop. Rehabilitation entails joint positioning, active and passive range of movement workouts, limitation of pressure necrosis, ambulation, and assistance in day by day activity. Rehabilitation programs for burn patients consist not only of bodily support, however emotional support as properly. As the pediatric burn affected person matures and enters into new social conditions, psychological support could also be helpful. What formulation is used to decide the quantity of fluid administered to the pediatric burn affected person throughout the first 24 hrs? Despite following the above fluid formulation, a burn affected person has a continuous urine output via urinary catheter of only 0. Pediatric burns: management of thermal, electrical, and chemical burns and burn-like dermatologic circumstances. Antibiotic ointments such as silver sulfadiazine and bacitracin are indicated for all burns besides superficial burns. Infants 6 months old or younger are more prone to fluid overload due to their lowered glomerular filtration rates. The Parkland formulation is used to estimate the quantity of fluid acceptable for administration in the first 24 hours. No different examination findings are present What are the potential causes for this lesion? An arthropod might bite with the usage of mandibles or inflict a wound from a stinger. In Hawaii, arthropod bites can occur from mosquitoes, flies, fleas, ants, lice, centipedes, beetles, roaches, and spiders.

8 mg zofran with amex

purchase zofran 8 mg otc

Purchase zofran discount

Each idea additionally has a proper logic definition represented by a set of defining relationships to different ideas. The set of qualifying relationships present syntactically correct values that can be offered to a user for postcoordination. Alternatives Qualifier Quality attribute A kind of attribute of a component by which its quality is assessed or measured. A typology is the examine or systematic classification of varieties which have attributes or traits in frequent. Quality metric An agreed method and means for measuring levels of achievement, efficiency or conformance of a component or its Quality attribute(s). Quality goal An agreed degree of achievement, efficiency or conformance of a component for any given Quality attribute. Query predicate A assertion of a condition that determines whether or not candidate instance data should be included in or excluded from a range. R Range A constrained set of values that the Concept Model permits to be utilized to a selected attribute when that attribute is utilized to a concept in a particular area. Note: the vary of permitted values that can be utilized to an attribute is often outlined to embody ideas in one or more branches of the subtype hierarchy. Example: the vary for values of 116676008 Associated morphology is subtypes of 49755003 Morphologically abnormal structure. The original four-byte codes are distinguished from 5-byte codes within the general illustration by prefixing them with a full cease. A Realm may be a nation, a corporation, an expert self-discipline, a specialty, or an individual user. Record companies Functions performed by software that interacts with a document system used to capture data which may embody references to data in a terminology. Note: Record companies are intimately associated to ways by which data is entered, saved and retrieved by a particular utility. Reference data model A excessive-degree generalized model that permits data to be represented and associated constantly inside a particular subject of human endeavor. Note: the Health Level 7 Version three Reference Information Model is probably the most extensively used reference data model in well being care. Different variations of a reference set member could share the identical identifier (id) but have totally different effectiveTimes. Each reference set has an identifier (refsetId) and incorporates one or more reference set members. Each reference set member has its own distinctive identifier (id) which permits it to be versioned utilizing the effectiveTime and energetic fields. Reference terminology A terminology by which every term has a proper pc processable definition that supports meaning based retrieval and aggregation. The nature of the association is indicated by a reference to another idea referred to as the relationship kind. Note: There are currently two launch formats: Release Format 1 and Release Format 2. However, for backward compatibility Release Format 1 files may be generated utilizing a conversion utility and continue to be distributed obtainable during an interim transitional period. The files representing every kind of component contain one model of every component released as much as the time of the snapshot. Note: Most of the information within the metadata hierarchy is simply related to Release Format 2. Alternatives Root metadata code S Situation with specific context A idea that specifically includes a definition the context of use of a clinical discovering or procedure. Example: "Family history of diabetes mellitus" is a situation with specific idea as a result of it defines the context as "household history". Note: A situation with specific context is outlined as a subtype of the situation to which it applies with an attribute associating it with the related clinical discovering or procedure. Alternatives Explicit context Clinical situation Snapshot launch A Release Type by which the release files contain one model of every component released as much as the time of the snapshot. A Snapshot view be provided by a set illustration that matches the content of a Snapshot launch or may be generated as a Dynamic snapshot view by filtering a Full view. It is considered to be probably the most complete, multilingual healthcare terminology in the world. The mixture of the International version with a National Extension is referred to as a National Edition. The International launch refers to a launch of content from the International version at a particular launch date. See additionally International Edition which refers to the identical general content, without specifying a particular launch date. Components and reference set members which are a part of the identical module are share the identical moduleId value. Each component and reference set member is a part of one and just one module as at a given time limit. The organization answerable for a module can move a component and reference set member from that module to another module that the identical organization is answerable for, by making a revised model of the component or reference set member with a unique moduleId that applies from the effectiveTime of the revised model. Note: the National Edition may be made obtainable to licensees at a particular launch date as a part of a National Release. Note: See additionally National Edition which refers to the mixture of a National Extension with the International Release and, where related, any modules from different Extensionson which it depends. Alternatively, a National Release could consist solely of the National Extension launch files for the required launch date. In this case, the National Edition is generated by combining these files with the International Release on which it depends. It consists of the acknowledged subtype Relationships plus the defining Relationships that exist prior to running a Description Logic classifier. Note: the Relationships distributed in the main Relationships files are inferred from the acknowledged Relationships utilizing a Description Logic classifier to guarantee consistency and completeness. Alternatives Stated type Statistical classification A hierarchical organization of terms or concepts that permits aggregation into categories that can be counted and in contrast without double counting. A statistical classification is monohierarchical which means that every node within the hierarchy is a part of one node is the level above. This avoids double counting but means that arbitrary choices must be made where a node is of course associated to multiple mother or father. Example: the figure under illustrates the relationships between the structure, complete and half ideas utilized to a the center. In Release Format 2 the usual approach to symbolize a subset of elements is through the use of a Simple Reference Set 2. In Release Format 1 the term subset has the following particular meaning: � A group of elements. Concepts, Descriptions or Relationships) that share a specified frequent attribute or frequent kind of attribute. Subsets symbolize data that affects the way in which the elements are displayed or in any other case accessible inside a particular realm, specialty, utility or context. This particular meaning arose from the "Subset Mechanism" which has now been changed by Reference Sets. Subsumption test A test to determine whether or not a specified candidate idea or expression is a subtype descendant of another specified idea or expression. Alternatives Subtype test Subtype A specialization of a concept, sharing all of the definitional attributes of the mother or father idea, with extra defining characteristics. Subtype is usually used to refer to the ideas in a hierarchy which are immediately associated to a mother or father idea through the is a relationship. Example: the figure under exhibits an example hierarchy by which idea "E" has three subtype kids (G, H and J). A B D G L S M H N T E J P U C F K R Figure 142: Hierarchy Illustration - Subtype kids Alternatives Subtype kids Child Children Subtype classification A classification hierarchy by which every node is connected to its supertypes. For example, if a concept has four kids, then descendants are these kids plus all of the ideas which are descended from these four kids.

purchase zofran discount

8mg zofran amex

To undergo metastasis they need to dissolve the basement membrane and extracellular matrix so as to reach the bloodstream and subsequently migrate to a new site, the place they reaggregate and reestablish cell-cell and cell-basal lamina interactions. Those aldehydes then interact with each other or with other lysyl facet chains to form collagen cross-hyperlinks. Plasminogen (reply c) is an inactive form of plasmin that occurs in plasma and is transformed to plasmin by organic solvents. Members of that gene family regulate cell division and migration, neurite extension, tumor cell metastasis, and blood coagulation. Intramembranous ossification differs from endochondral ossification during which of the next methods? Action of osteoblasts Light microscopic look of the grownup bone Ultrastructural look of the grownup bone Presence of woven bone early in the ossification process Microenvironment during which ossification happens a hundred and five. A 7-yr-old boy is referred to the endocrine clinic with short stature, rhizomelic shortening of the legs and arms, a disproportionately long trunk, trident palms, midfacial hypoplasia, distinguished forehead (frontal bossing), thoracolumbar gibbus, and megalencephaly. Decreased bone deposition beneath the periosteum Decreased proliferation of osteoblasts in the major ossification middle Decreased proliferation of osteoblasts in the secondary ossification middle Decreased appositional development of chondroblasts in the major ossification middle Decreased interstitial development of chondroblasts in the epiphyses 193 Copyright � 2007 by the McGraw-Hill Companies, Inc. The molecular basis for shock absorption inside articular cartilage is which of the next? A sixteen-yr-old lady presents to the pediatric genetic and endocrine clinic with short stature, Tanner stage 2 of pubertal growth and lack of menstruation. That gene working through particular transcription elements would affect the production of which of the next by the cells delineated by the box in the accompanying photomicrograph. Cyclins Acid phosphatase Alkaline phosphatase Type I collagen Osteocalcin 196 Anatomy, Histology, and Cell Biology 108. A 22-yr-old man presents to the orthopedic clinic after a referral from his major care physician. He has a history of recurrent fractures of the humerus and femur and numerous dental caries and related abcesses. Three years prior to this referral, he was efficiently treated with hyperbaric oxygen and surgery for mandibular and maxillary osteomyelitis. A spine x-ray reveals "sandwich" vertebrae with thickening of the vertebral endplates. The cell type primarily affected on this affected person is shown in the accompanying transmission electron micrograph (A) and labeled as "C" in the mild micrograph (B). The activation and stimulation of these cells is concerned during which of the next? Analysis of synovial fluid reveals synovitis with a white blood cell depend of 2500 (normal lower than 2000/mm3). Physical examination reveals decreased abduction and external rotation of the best and left shoulders. Loss of the proteoglycan matrix and fibrillation in the articular cartilage during the early stages b. Formation of osteophytes at the articular margins and eburnation of enormous weightbearing joints in the later stages d. Heterologous autoantibodies directed in opposition to the synovium 198 Anatomy, Histology, and Cell Biology 110. A 42-yr-old woman who has been a type I diabetic for 30 years falls when she journeys over her vacuum cleaner hose. She tried to break her fall by inserting her hand out to save herself and in the process her wrist is compelled backwards. She arrives in the emergency room and an x-ray of her wrist is shown in the accompanying x-ray. Internal callus External callus Clot Pannus Granulation tissue Specialized Connective Tissues: Bone and Cartilage 199 111. The ache started roughly 6 months ago and is a deep ache that worsens when she stands or walks. X-ray of hips and pelvis reveals osteolytic lesions and regions with excessive osteoblastic activity. The affected person had felt well aside from a rise in fatigue over the past few months. X-rays reveal lytic lesions of the skull and pelvis and a compression fracture of lumbar vertebrae. A potential underlying mechanism for the signs noticed on this case is which of the next? A forty six-yr-old woman presents with ache in the left leg that worsens on weight bearing. In addition, laboratory checks present low ranges of 1, 25-hydroxyvitamin D, calcium, and phosphorus and elevated alkaline phosphatase. A second bone biopsy, which was not decalcified, reveals uncalcified osteoid on all the bone surfaces. Decreased glucocorticoid ranges that result in decreased high quality of the bone deposited b. A newborn lady is born with a small mouth, somewhat widely spaced eyes and low-set ears. Absence of the parafollicular cells Increased numbers of cells in the deep cortex of the lymph nodes Tetany Excess activity of osteoclasts Increased Ca2+ ranges in the blood Specialized Connective Tissues: Bone and Cartilage 201 116. The affected person is hyperparathyroid (parathyroid hormone, 234 pg/mL; normal 10�55 pg/mL) and hypercalcemic (calcium, 12. Serum ranges of 1,25-dihydroxyvitamin D are decreased (10 pg/mL; reference vary, 24�65 pg/mL). He has been receiving massive doses of calcium supplemented with vitamin D to bind the phosphate. The production of calcified gentle tissues is mediated by the constructions shown in the accompanying transmission electron micrograph. Increased secretion of acid phosphatase Inhibition of alkaline phosphatase Accumulation of calcium and phosphate Increased secretion of osteoprotegerin Increased synthesis of type I collagen 202 Anatomy, Histology, and Cell Biology 117. Growth issue Binding of ionic calcium and physiologic hydroxyapatite Formation of the three-dimensional lattice of the matrix Cell attachment Binding of mineral parts to the matrix 118. In the diagram of a joint beneath, the construction labeled C is which of the next? Site of macrophage-like cells that phagocytose particles from the synovial fluid Site of cells that synthesize the synovial fluid Initial site of harm in osteoarthritis Initial site of irritation in rheumatoid arthritis Perichondrium Specialized Connective Tissues: Bone and Cartilage 203 119. Her height has decreased by an inch over the past 5 years and her weight has increased by 12 lb. Which of the next is the most probably mechanism of action for the bisphosphonates? Once the osteosarcoma cells reach the lungs, enter the lung parenchyma, and clonally increase, they produce bone. If a laboratory were designing an efficient therapy to forestall the spread of metastatic osteosarcoma, which of the next approaches would most probably achieve success? A 28-yr-old woman visits your family medicine clinic complaining of loss of sense of odor, nosebleeds, problems with swallowing, and hoarseness. She admits to "informal, social use" of cocaine on a regular basis since her sophomore yr of school when her "boyfriend turned her on to cocaine at a party. There can also be perforation and collapse of the nasal cartilage resulting in a "saddle nostril" deformity. The breakdown of the nasal cartilage releases collagen fibers primarily of which kind? In both cases, bone growth happens by basically the identical process, the synthesis of collagen and other matrix parts by osteoblasts (reply a) and the calcification of the matrix through the action of alkaline phosphatase from osteoblasts. Bone growth happens in two different locations, which differ in the presence or absence of cartilage models of the bones. For instance, in the flat bones of the skull, bone formation happens through the differentiation of osteoprogenitor cells from mesoderm and is accompanied by vascularization. In both endochondral and intramembranous ossification, the primary bone fashioned is woven bone (reply d), also referred to as major bone. Growth in the size of long bones after start (postnatally) happens through cell proliferation of chondroblasts (immature chandrocytes) in the secondary ossification facilities of the epiphyses.

Generic zofran 4mg on line

The adjective for the operative time span from decision for surgical procedure to placement on the operating room desk is. The adjective for the operative time span from placement on the operating room desk until transfer to postanesthesia recovery unit or intensive care unit is. The adjective for the operative time span from admission to postanesthesia is. Cells carry out metabolism, the sum of all of the physical and chemical activities that occur within the physique. The primary categories of natural compounds within the physique are: � Proteins, which embrace the enzymes, some hormones, and structural materials. The primary carbohydrate is the sugar glucose, which circulates within the blood to provide energy for the cells. Some hormones are derived from lipids, and adipose (fat) tissue is designed to retailer lipids. Within the cytoplasm that fills the cell are subunits referred to as organelles, every with a particular perform. Genes control the formation of enzymes, the catalysts needed for metabolic reactions. When a physique cell divides, by the process of mitosis, the chromosomes are doubled and then equally distributed to the two daughter cells. Sex cells (egg and sperm) divide by one other process (meiosis) that halves the chromosomes in preparation for fertilization. Tissues Cells are organized into four primary types of tissues that carry out particular functions. Included are adipose (fat) tissue, cartilage, bone (Chapter 19), and blood (Chapter 10). There are three types of muscle tissue: � Skeletal or voluntary muscle moves the skeleton. It coordinates and controls physique responses by the transmission of electrical impulses. Mucous membranes secrete mucus, a thick fluid that lubricates surfaces and protects underlying tissue. Serous membranes, which secrete a skinny, watery fluid, line physique cavities and canopy organs. Bear in thoughts, nevertheless, that the physique functions as a whole-no system is impartial of the others. In toto means "entire" or "fully," as in referring to a construction or organ removed completely from the physique. Postmortem actually means "after dying," as in referring to an autopsy carried out to determine the cause of dying. Biopsy comes from the Greek word bios, that means "life," plus opsis, that means "imaginative and prescient. Such combined forms that routinely seem as word endings will simply be described and used as suffixes on this book. Exercise four-2 Match the following terms and write the appropriate letter to the left of every quantity: 1. The ending -ose indicates that maltose is a(n). Used as the suffix -some to mean a small physique, as in ribosome, lysosome, chromosome An immature cell that has the capability to develop into any of quite a lot of different cell sorts. The four primary tissue sorts are. The control heart of the cell is the. The number of chromosomes in every human cell aside from the sex cells is. An natural compound that speeds the rate of metabolic reactions is a(n). A cytotoxic substance is damaging or toxic to. The term hydration refers to the relative quantity of. A myxocyte is present in tissue that secretes. The research of form and construction. The formation of cells (use -genesis as an ending). The specimens included several small containers of pink-tinged cloudy fluid labeled pelvic lavage (washing) for cytology, which R. She took all of the tissue specimens to the pathology laboratory for gross and microscopic analysis. A check tube half-crammed with a cloudy gel and a cotton-tipped applicator labeled swab of pelvic fluid for culture and sensitivity and Gram stain was taken to the microbiology laboratory to be streaked on a culture plate and incubated to search for development. Any organisms that grew out could be Gram-stained and tested for sensitivity to antibiotics that could be utilized in remedy. Three phrases that comprise a root that means appeal to, take up: 11. Three phrases with a root that means formation, molding, improvement: 12. In this stance, the terms illustrated in Figure 5-1 and listed in Display 5-1 are used to designate relative place. A frontal plane, additionally referred to as a coronal plane, is made at right angles to the midline and divides the physique into anterior and posterior components. A transverse plane passes horizontally, dividing the physique into superior and inferior components. Body Cavities Internal organs are positioned inside dorsal and ventral cavities. The dorsal cavity contains the brain within the cranial cavity and the spinal cord within the spinal cavity (canal). The uppermost ventral house, the thoracic cavity, is separated from the abdominal cavity by the diaphragm. Positions In addition to the anatomical place, there are different normal positions by which the physique is placed for examination or medical procedures. Vessels are generally named for the organ they supply: the hepatic artery and vein of the liver, the pulmonary artery and vein of the lungs, the renal artery and vein of the kidney. A starting scholar in medical science may be stunned by the huge number of names and terms that he or she is required to be taught. That is, aside from some internal organs such as the liver, spleen, stomach, pancreas, and gut, almost every thing on the best aspect could be discovered on the left as well. The skeleton could be figuratively cut up down the middle, giving equal buildings on both sides of the midline. Abdominal cavity Abdominal pelvic cavity Cranial cavity Dorsal cavity Diaphragm Pelvic cavity Spinal cavity (canal) Thoracic cavity Ventral cavity 1 2 four 5 3 9 6 8 7 1. Epigastric area Hypogastric area Left hypochondriac area Left iliac area Left lumbar area Right hypochondriac area Right iliac area Right lumbar area Umbilical area four 1 7 5 2 8 6 3 9 1. As she fell, two different cyclists collided with her, sending all three crashing to the ground. Other injuries included a cut on her face and on her right arm and an apparent deformity to each her shoulder and knee. After her bleeding was controlled and her injured extremities have been immobilized, she was transported to the nearest emergency division. During transport, the paramedic in charge radioed ahead to provide a prehospital report back to the charge nurse. His report included the following info: occipital and frontal head pain; laceration to right temple, superior and anterior to right ear; lumbar pain; bilateral thoracic pain on inspiration at midclavicular line on right and midaxillary line on the left; dull aching pain of the posterior proximal right thigh; bilateral paresthesia (numbness and tingling) of distal decrease legs circumferentially; varus (knock-knee) adduction deformity of left knee; and posterior displacement deformity of left shoulder.

Purchase discount zofran on line

Simple requirements can be addressed by specifying a price-set consisting of the permitted coded values that can be utilized in a specific field. However, effective illustration of scientific information requires a wealthy information mannequin and an expressive terminology. An inevitable facet-impact of a richer strategy to information illustration is an increase within the interdependencies and overlaps between the knowledge mannequin and the terminology. In order to specify and validate consistent illustration of meaningful scientific information, constraints have to be applied to both the knowledge mannequin and terminology. The constraints on information mannequin and terminology components have to be integrated, or bound together, in ways that guarantee consistency, keep away from ambiguity and decrease the number of different ways during which the same that means may be expressed. A terminology binding is an occasion of a hyperlink between a terminology element and an information mannequin artifact. The information mannequin artifact to which a terminology binding is applied may be a field of a class in a static mannequin or a collection of fields of one or more associated lessons. In any given situation the range of Concepts or expressions which might be useful, related and meaningful is rather more limited. This gives rise to a requirement to represent constraints on the content material or a specific field in a method that may be interpreted and applied by utility software program. The simplest constraint requirements can be met by specifying the record of valid codes. This requirement is addressed by subsets specified utilizing the Reference Set mechanism. The use of postcoordinated expressions adds further dimensions to the requirement for constraints. It may be necessary to specify whether all postcoordinated refinements of idea are permitted or whether some types of refinement are prohibited or required. Requirements for representing expression constraints are intently associated to the necessities for representing question predicates in queries. The requirements for representing postcoordinated expression question predicates are intently associated to the necessities for representing constraints on expressions. While a constraint specifies whether a specific expression is permitted in a specific situation, an expression predicate specifies the range of candidate expressions that match the question. The mannequin is centered around the illustration of concepts and their related relationships and descriptions. These embody totally specified names, preferred phrases and synonyms in each supported language. The ensuing definition may be adequate to distinguish the idea from its parents and siblings within the subtype hierarchy during which case the idea is taken into account to be totally defined. Figure 12 illustrates the abstract logical mannequin of an idea, including the defining Relationships between concepts (represented by the associations labelled sourceId, destinationId and typeId) and the definition status (represented by the definitionStatusId). As initially stated:; � Hand pain is a pain and has finding web site hand construction or 2. Different views of idea definitions range in one or more of the next three dimensions: � � � Flattened or nested; Stated or inferred; Direction and extent of logical transformation these three dimensions are thought-about within the following subsections of this information. To support this view concepts have to be created (and defined) for any value that should be expressed within the definition of another idea. Example: the finding web site for the idea pain in left hand might solely be defined by first creating an idea construction of left hand leading to a definition similar to: pain in left hand has is a pain. The idea construction of left hand might be defined as follows: construction of left hand is a hand construction construction of left hand has laterality left. This avoids the need for creating intermediate concepts but results in more complicated definitions. Example: the finding web site for the idea pain in left hand might be defined without creating the idea construction of left hand by nesting an acceptable definition as follows: pain in left hand is a pain pain in left hand has finding web site (is a hand construction and has laterality left). The solely distinction is the need to create and outline concepts to represent the nested elements within the definition. Inferences are derived by applying a consistent set of logical guidelines to the definition taking account of the definitions of associated concepts. Several semantically identical views may be inferred and these are mentioned within the following section. Logical transformations might range within the extent to which they normalize the definition and the extent of redundancy within the ensuing definition. Different inferred views have properties that optimize various kinds of perform. The excessive factors within the spectrum of attainable idea definition views are: � Comprehensive: � � the set of all defining relationships that may be inferred to be true for an idea based mostly on the stated definition of this concept and the stated definitions of all different instantly or not directly associated concepts. Minimal: � the smallest set of defining relationships that expresses the definition of the idea. Each inferred view is a mix of a specific supertype view (is a relationships) and an attribute view (different defining relationships). The issues in this section exclude the defining traits of an idea. This complete view of supertypes is understood in description logic as a "transitive closure". It includes traversing (transiting) the goal of each is a relationship to search for and follow further is a relationships till all paths through the hierarchy attain the basis idea (closure). This is a extremely redundant expression of the logical abstract mannequin of an idea definition. Instead this may be answered just by checking the transitive closure of " idea M" for the presence of " idea B". Note: Experience means that a pre-computed transitive closure desk out-performs different options and is robust, versatile and easy to implement. Therefore, unless storage capability is significant concern, this strategy is beneficial. Relationships with different supertype ancestors that may be reached by traversing multiple is a relationships are omitted. The rationale for that is that every one the distinguishing options of the "totally defined" concepts (white unshaded in examples) are represented by different defining relationships which is able to show up within the attribute a part of the view. This view can be utilized when testing whether a candidate idea is subsumed by a predicate expression. In this view the definitions of primitive concepts ought to implicitly or explicitly embody a reference to the defined idea itself. Relationships with totally defined supertype ancestors are omitted as are relationships with primitive ancestors which might be also supertypes of considered one of proximate primitive supertypes. This view can be utilized to take a look at if a candidate expression is subsumed by a predicate idea. In addition to the totally different views described in this section, different logical forms may be applied to the values of the relationships. This includes those stated and different inferred by inheritance from stated supertype ancestors. The full type includes all attainable supertype ancestor values of the stated attributes. This signifies that in lots of circumstances it will embody a very massive set of relationships. Taken to its logical excessive this also includes relationships duplication of relationships with relationship types which might be supertypes of those types stated. In an entire view (including supertypes and attributes) this distinction is clear. This includes those stated and others inferred by inheritance from stated supertype ancestors. This view supplies a minimal attribute view which is semantically complete when combined with one of the primitive supertype views. Table 12: Primitive differential attribute views of sample concepts See Figure 17 C. If the primitive supertype view of primitive concepts includes the idea itself. The entries proven above for primitive idea apply solely the place the idea itself is excluded from the proximal primitive supertype view.

EPP (erythropoietic protoporphyria)

Buy zofran visa

Metabolism Upon completion of all actions, the chart should look like this: Normal Rat Baseline Thyroidectomized Rat Hypophysectomized Rat Weight ml O2 utilized in 1 minute ml O2 used per hour Metabolic fee With Thyroxine 249�251 grams 7. The hypophysectomized rat lacks a pituitary gland, thus produced no thyroid stimulating hormone to stimulate thyroxine manufacturing. Because the traditional rat produced thyroxine usually, its metabolic fee was faster than the opposite rats. On the traditional rat, the metabolic fee after thyroxine injection is faster than the baseline metabolic fee. The injected thyroxine compensated for the thyroxine misplaced when the thyroid was removed. On the hypophysectomized rat, the metabolic fee after thyroxine injection is faster than the baseline metabolic fee. The injected thyroxine compensated for the thyroxine misplaced when the pituitary gland was removed. On the traditional rat, the metabolic fee after propylthiouracil injection is slower than the baseline metabolic fee. Propylthiouracil is antagonistic to thyroxine and will are inclined to decrease the results of thyroxine. On the thyroidectomized rat, the metabolic fee after propylthiouracil injection is identical as the baseline metabolic fee. On the hypophysectomized rat, the metabolic fee after propylthiouracil injection is identical as the baseline metabolic fee. Compare the baseline metabolic charges for the thyroidectomized rat and the traditional rat and clarify your outcomes. Compare the baseline metabolic charges for the hypophysectomized rat and the traditional rat and clarify your outcomes. The following questions discuss with Activity 2: Determining the Effect of Thyroxine on Metabolic Rate. Did the results for the thyroidectomized rat indicate hyperthyroidism or hypothyroidism? Describe the impact of administering propylthiouracil on every of the rats, and clarify why it had this impact. Do you assume the drug propylthiouracil is used to deal with hypothyroidism or hyperthyroidism? Hormone Replacement Therapy the following questions discuss with Activity 5: Hormone Replacement Therapy. Explain why ovariectomized rats had been used in this experiment and correlate this to their baseline T rating. Recap your predictions regarding the results of calcitonin and estrogen on bone density and why you made these predictions. What impact did the administration of estrogen injections have on the estrogen-handled rat? What impact did the administration of calcitonin injections have on the calcitonin-handled rat? Insulin and Diabetes the following question refers to Activity 6: Obtaining a Glucose Standard Curve. What is a glucose standard curve, and how can you use this device to decide a concentration of glucose? If college students must work in bigger groups, have them every get keyboard and mouse expertise with the program. The hematocrit degree of the wholesome male dwelling at one mile elevation in Denver is 55. When the blood flowing by way of the kidneys is hypoxic (low oxygen degree), the kidneys reply by producing a hormone, erythropoietin, which stimulates the bone marrow to produce more pink blood cells. If your bone marrow is producing an elevated variety of pink blood cells, your hematocrit is elevated. The pink blood cell count for a person with aplastic anemia could be lower than the pink blood cell count of a wholesome particular person. The menstruating feminine is affected by iron-deficiency anemia, inflicting her pink blood cells to settle. Yes, the pink blood cells of the male with polycythemia contain adequate ranges of hemoglobin molecules. Yes, the pink blood cells of the female Olympic athlete contain adequate ranges of hemoglobin molecules. If the anti-A antibody causes the blood to agglutinate, antigen (agglutinogen) A could be present on the blood cells. Patient #2 has elevated ldl cholesterol, which has been related to elevated threat of cardiovascular disease. List the following values from Chart 1: Hematocrit value for wholesome male dwelling at sea degree in Boston Hematocrit value for wholesome feminine dwelling at sea degree in Boston forty eight 44 Yes 2. Describe the difference between the male and the female hematocrit for a person dwelling in Boston. List the following values from Chart 1: Hematocrit value for wholesome male dwelling in Denver Hematocrit value for wholesome feminine dwelling in Denver 55 53 Both female and male had a higher hematocrit than the female and male 5. Describe how the kidneys reply to a decrease in oxygen and what impact this has on hematocrit. List the following value from Chart 1: Hematocrit for feminine with iron-deficiency anemia 32 A hematocrit of 32 is beneath normal. Erythrocyte Sedimentation Rate the following questions discuss with Activity 2: Erythrocyte Sedimentation Rate. Compare the values in question 18 and clarify how they might be used to monitor coronary heart situations. Describe the ratio of packed cell volume to Hb (hemoglobin) obtained for the wholesome female and male subjects. Describe the ratio of packed cell volume to Hb (hemoglobin) for the female with iron-deficiency anemia. Hemoglobin values improve in patients with polycythemia, congestive coronary heart failure, 27. List which blood samples in this experiment represent people who could donate blood to a person with kind B. Patient four should lower dietary consumption of ldl cholesterol (pink and organ meats, eggs, 38. Low blood ldl cholesterol can be brought on by hyperthyroidism, liver illness, inadequate absorption of nutrients from the gut, and malnutrition. It is helpful to instruct college students in the correct operation of the mouse and menu system as a part of the lab introduction. Encourage college students to attempt to apply the concepts from the simulation to the human as they work by way of the program. If an illustration computer display screen is out there, present college students both main screens of the simulation and describe the essential equipment components. Explain how the simulated pump is much like the left ventricle (or the proper ventricle) of the guts. Point out the fact that the pump operates very like a syringe, with adjustable beginning and ending volumes. It is usually useful to clarify the fundamentals of end diastolic and end systolic volumes and their relationship to the simulated pump. Indicate the analogies between the components of the simulation and the components of the human cardiovascular system. Answers to Activity Questions Vessel Resistance Activity 1: Studying the Effect of Flow Tube Radius on Fluid Flow (pp. Because fluid move is proportional to the fourth power of the radius, will increase/decreases in tube radius cause will increase/decreases in fluid move. We alter blood move in the human physique by rising or lowering the diameter of blood vessels by the contraction or rest of clean muscle tissue in vessel partitions. Anemia would end in fewer pink cells than normal, which would decrease the viscosity of the blood. Blood viscosity would improve in situations of dehydration, resulting in decreased blood move. Obesity would end in decreased blood move as a result of vessels must improve in length in order to serve the elevated amount of adipose tissue in the physique. The length versus move fee plot is linear, whereas the plots for radius, viscosity, and length are all exponential.


  • https://www.forwardhealth.wi.gov/kw/archive/Physician050211.pdf
  • https://www.who.int/patientsafety/montreal-forum-report.pdf
  • https://centerforinquiry.org/wp-content/uploads/sites/33/quackwatch/health_robbers.pdf
  • https://kissingbug.tamu.edu/files/canine-chagas-disease-2.pdf