|River Rafting: Advantages and Disadvantages (Kim Hartlin)||Rafting can be done in the mountains and you can then go down large streams by strengthening your musculature and oxygenating your lungs. If you live near the mountain, free to you to try. It must be so fun and try to convince your friends to accompany you.|
|SvÃ¥rhanterligt / Hard to handle|
Just nu hÃ¥ller jag pÃ¥ med en poncho â tÃ¤nka sej :-) ! â till Poppy. Samma gamla grundmÃ¶nster som jag anvÃ¤nt till alla de tidigare och dessutom samma garn, som visat sej vÃ¤ldigt populÃ¤rt i sammanhanget. Det Ã¤r JÃ¤rbos Tropik, en blandning av bambu, bomull och akryl. Det Ã¤r ett riktigt sommargarn, lÃ¤tt och mjukt och luftigt. Men lite halt Ã¤r det att jobba med, det kommer man inte ifrÃ¥n, Ã¤ven om det inte varit nÃ¥got egentligt problem. Inte fÃ¶rrÃ¤n nu. FÃ¶r se den hÃ¤r ponchon hade jag tÃ¤nkt skoja till lite grand och gÃ¶ra ett tvÃ¥fÃ¤rgat mÃ¶nster runt nederdelen och det visade sej mindre kul i det hÃ¤r garnet. KÃ¤ra nÃ¥n vad det glider runt och lever sitt eget liv! Det Ã¤r fullstÃ¤ndigt omÃ¶jligt att spÃ¤nna garnet jÃ¤mt pÃ¥ baksidan, plÃ¶tsligt Ã¤r det centimeterlÃ¥nga Ã¶glor som bara har uppstÃ¥tt, eller sÃ¥ har det dragit ihop sej motsvarande grad. Fast vanligast Ã¤r, hur jag Ã¤n fÃ¶rsÃ¶ker hÃ¥lla igen, att garnet glider ivÃ¤g och bildar detta oÃ¶nskade Ã¶verflÃ¶d pÃ¥ baksidan. MÃ¤rkligt fenomen. Men nu har jag lÃ¤rt mej att det inte Ã¤r nÃ¥gon bra idÃ© att anvÃ¤nda silkiga, hala garner nÃ¤r man ska gÃ¶ra tvÃ¥fÃ¤rgade mÃ¶nster. ApropÃ¥ det, pÃ¥ engelska heter det Stranded knitting fÃ¶r den hÃ¤r typen av mÃ¶nster, men vad heter det pÃ¥ svenska??? TvÃ¥fÃ¤rgat mÃ¶nster lÃ¥ter sÃ¥ klumpigt, visst mÃ¥ste det finnas nÃ¥got bÃ¤ttre ord?
Och sÃ¥ mÃ¥ste jag bara tala om att jag nu Ã¤r pigg och glad och syresatt igen. Var pÃ¥ sjukhuset i gÃ¥r och kollade syresÃ¤ttningen av lungorna, som var sÃ¥ katastrofalt dÃ¥lig fÃ¶r en vecka sen. Och se vad total vila kan Ã¥stadkomma, nu Ã¤r jag pÃ¥ banan igen och behÃ¶ver inte syrgas! Det var fÃ¶rmodligen frÃ¥ga om utmattning, hade vÃ¤l hÃ¥llit pÃ¥ i lite fÃ¶r hÃ¶g takt lite fÃ¶r lÃ¤nge. Men nu tar jag det sÃ¥ lugnt, sÃ¥ lugnt, och laddar upp infÃ¶r nÃ¤sta veckas fÃ¤rd till London!
Right now I'm working with a poncho â imagine! - for Poppy. Same old basic pattern that I used so many times now and also the same yarn that has turned out very well in this context. It is JÃ¤rboâs Tropik, a blend of bamboo, cotton and acrylic. It is a real summer yarn, light and soft and fluffy. But it is a bit slippery to work with, even if it not has been any real problems. Not until now. To cheer this poncho up, I intended to make a stranded pattern around the bottom and it turned out less fun in this yarn. Oh dear what itâs sliding around and live it own lives! It is absolutely impossible to tighten the yarn evenly on the back, suddenly its centimetres long loops that just occurred, or so it has pulled together accordingly. Though mostly, how hard I try to hold back, the yarn is slipping away and produces this unwanted abundance on the back. Strange phenomenon. But now I've learned that it is not a good idea to use silky, slippery yarn for stranded pattern.
And I just have to tell you that I now am happy and oxygenated again. I was at the hospital yesterday and had new tests of the oxygenation of the lungs, which was so disastrously bad a week ago. And see what a lot of rest can do, now I'm back on track and do not need oxygen! I was probably just exhausted, it had probably been a bit too much for a bit too long lately. But now I take it so calmly, so calmly, and geared up for next week's trip to London!
|Ãntligen, igen! / At last, again!|
Ãntligen, Ã¤ntligen ska jag uppdatera den hÃ¤r stackars sidan igen. Det Ã¤r fruktansvÃ¤rt lÃ¤ngesen! Men sÃ¥ har jag varit upptagen med annat. Var hela fÃ¶rra veckan i Stockholm hos vÃ¥ra guldklimpar Poppy och Eddie. VÃ¤dret var pÃ¥ det hela taget jÃ¤ttebra, sÃ¥ vi tillbringade mycket tid ute.
At last Iâll update this poor blog again. It is a terribly long time ago since last time! But I've been busy with other things. The last week Iâve been in Stockholm with our gold nuggets Poppy and Eddie. The weather was on the whole very good, so we spent much time outdoors.
PopulÃ¤rast alla kategorier var lekplatser med gungor och rutschbanor. SÃ¥dana kan man aldrig fÃ¥ fÃ¶r mycket av!
The most popular activities were playgrounds with swings and slides. You can never have too much of them!
Stickningen har kommit lite i klÃ¤m den hÃ¤r tiden, inte tu tal om saken. Men pÃ¥ tÃ¥get upp hann jag med lite grann pÃ¥ en klÃ¤nning till Poppy. Det Ã¤r i och fÃ¶r sig den som Ã¤r minst angelÃ¤gen fÃ¶r tillfÃ¤llet, men mest lÃ¤mplig som resestickning.
The knitting has been a bit behind during this time, no doubt about it. But on the train up there I spend the time with a dress for Poppy. It is the least anxious project for the moment, but was most suitable for travel knitting.
Ponchon hade gÃ¥tt an ocksÃ¥, men ville mÃ¤ta den jag gjort till kompisen Betty fÃ¶rst, trodde den skulle vara lite fÃ¶r stor. Men det var den inte, sÃ¥ nÃ¤r vÃ¤l provningen var avklarade satte jag igÃ¥ng med den.
The poncho had been ok as travel knitting as well, but I wanted to measure the one I had made for Poppyâs friend Betty first, thought it would be a bit too big. But it was not, so once it was tried on I started with it. Itâs much more anxious than the dress for the moment.
Jan kom upp till helgen fÃ¶r att vara med att leka ett litet slag, sen Ã¥kte vi hem tillsammans i sÃ¶ndags. Men tÃ¤nk, dÃ¥ var jag sÃ¥ trÃ¶tt att jag just inte stickade nÃ¥gonting! Inte kul, har fÃ¶rmodligen tagit i lite fÃ¶r mycket. Och det har jag fÃ¥tt sota fÃ¶r sen dess, har svÃ¥rt att syresÃ¤tta lungorna och nu hotar doktorn med att jag kanske mÃ¥ste bÃ¶rja med syrgas i tub om det inte rÃ¤tar upp sej inom en vecka. Ãrligt talat, ren katastrof!!! Jag har ju tÃ¤nkt Ã¥ka till London den 31 maj! Ja, ja, det Ã¤r bara till att fÃ¶rsÃ¶ka vila ikapp och hoppas pÃ¥ det bÃ¤sta.
Jan came up to the weekend to play a while, too, then we went home together on Sunday. But then I was so tired that I didnât knit anything! Not fun, have probably been a bit too active lately. And I have to pay for it now, I have difficulties to oxygenate the lungs and now the doctor is threatening with that I might have to start with oxygen in tubes unless it doesnât straightens up within a week. Honestly, pure disaster! I'm planning to go to London the 31 May! Well, well, it's just to try to rest and hope for the best.
VÃ¤l hemma har det blivit lite mer blandad stickning. Alex' regnbÃ¥gstrÃ¶ja fÃ¥r sej en duvning nu och dÃ¥, har nu bara Ã¤rmarna och halsringningen kvar.
Back home again it has been a bit more mixed knitting. Alex rainbow sweater is growing and now itâs just the sleeves and neckline left.
Och sÃ¥ har vi nu fÃ¥tt tillÃ¥telse att visa teststickningen FranÃ§oise som Marjorie Dussaud designar. Det var ursprungligen tÃ¤nkt att den skulle vara med i Knitty framigenom, men det blev inte sÃ¥, sÃ¥ nu ska hon publicera det pÃ¥ annat sÃ¤tt och under mindre hemlighetsfulla omstÃ¤ndigheter. Det Ã¤r en kortÃ¤rmad jumper eller tunn kofta eller hur man nu vill ha den. Originalet har bara fyra knappar ner till under bysten ungefÃ¤r, men jag ska gÃ¶ra knÃ¤ppning hela vÃ¤gen ner, fÃ¶r jag vill kunna anvÃ¤nda den utan nÃ¥got under. Garnet jag anvÃ¤nder Ã¤r Marks & Kattens Linen, och det Ã¤r fÃ¶rsta gÃ¥ngen jag stickar i det. Inte helt angenÃ¤mt, om jag ska vara Ã¤rlig, det Ã¤r som att sticka med stÃ¥ltrÃ¥d. FÃ¶rhoppningsvis blir det mjukare och fÃ¶ljsammare efter tvÃ¤tt.
And so we have now been given permission to show the so far secret test knitting Francoise, designed by Marjorie Dussaud. It was originally thought that it would be in Knitty next autumn or so, but it did not happen, so now she will publish it in other ways and less mysterious circumstances. It is a short-sleeved pullover or light jacket or however you want to call it. The original has only four buttons down to below the bust, but I will button it all the way down, because I want to use it without anything underneath. The yarn I use is Marks & Kattens Linen, and it is the first time I use it. Not entirely pleasant, if I shall be honest, it's like to knit with wire. Hopefully it will be softer and smoother after washing.
|BioethicsTV (January 2-6, 2017): Violating promises, coma v. PVS, transplant evaluation, and whether to abort|
by Craig Klugman, Ph.D.
Pure Genius (Season1; Episode 10- 1/5). In this episode, Dr. Channarayapatra is working with a patient in lung failure. Due to exposure to toxins dumped in the ground beneath her neighborhood, the patientâs lung tissue is disintegrating. Bunker Hill hospital is attempting to build the worldâs first implantable, artificial lung but has not had success. With her lung function decreasing, the patient may soon face one of two options: death or ECMOâa process where a machine oxygenates her blood outside of the body.…
|Body Weight Exercises - How You Can Get Fit Without Spending a Dime||For the body, to maintain endurance, physical strength, and stamina, one has to do body weight exercises. These body weight workouts are natural exercises that do not require additional machines for you to perform them. You will only use body movements to exercise. All you need is a clean space and you are set to go.|
These are the general types of body weight routines:
Hand stand press ups - You press against a steady object using your hand. This will develop your hands and arm muscles.
Body press ups - You use your body to press against a stationary object, this may be the wall or the floor.
One hand stand press ups - This is similar to the two hand press ups, only this time you use only one hand.
Two hand pull ups - You pull up your body using two hands. You can increase the number of pull ups as your stamina increases.
One hand pull ups - You pull up your body using one hand. This is a more difficult exercise because you use only one hand to pull up your whole body weight.
These are exercises usually done to reduce the abdominal area. You sit up without hand support. As your muscular strength increases, your number of sit-ups also increases.
You could do these exercises daily for at least 5-15 minutes. They are convenient to perform because you do not need to go to a gym or to purchase special equipment.
Aside from the advantages mentioned above, there are other health benefits of body weight exercises.
Just like other exercises, you will lose weight performing body weight exercises because you are burning excess fats stored in your body. Exercise converts fats to energy and are burnt off. You spend the calories that you gain from your intake of food when you sweat it out during these exercises. It is a cheap program to reduce weight.
Due to exertion, your heart will pump faster and your circulation will increase. The increase in blood circulation will flush away any fat build up in your blood vessels. Since circulation is smooth, flowing, cells and tissues are rejuvenated more quickly and organs function properly.
Increased stamina and muscular strength
When muscles are used, they become stronger. Consequently, your stamina increases. Exercises enhance your immune system and help prevent easy infection from pathological diseases. The more you exercise, the greater your T lymphocytes and immune cells react quickly. The red blood cells are also more often oxygenated which aids in protecting the body from foreign substances.
You will have glowing, smoother skin because exercises flush those bad toxins and waste products from the body. The cells are constantly rejuvenated because of the fast delivery of oxygen due to increased circulation.
If you want to increase your stamina and stay healthy, body weight exercises are ideal for you. You do not spend a dime and you could do it conveniently in your home.
|Alive and Shine with Aadil and Savitri!: Increase Your Circulation, Increase Your Vitality||Micro-circulation is the basis for good health since it is the circulation at the capillary level which increases nutrient delivery, oxygenates the tissue and removes waste. This leads to a healthy, vibrant body. A new therapy called BEMER, from Europe, claims to increase micro-circulation in the body up to 30%. In this show, Aadil will interview Anne Bernard, L.Ac and Oliver Shultz, COO of BEMER USA to check the validity of their claims. |
|The Science of Sustainable Shipping||We set sail to discover the science of sustainable shipping in this week's Naked Scientists. We visit an enormous wave tank to find out how the sea swell can impact on damaged ships, and look at the problems caused by sulphur-rich shipping fuel. Plus, we hoist the SkySail, an enormous parafoil kite that can be deployed from the deck of a ship to cut fuel consumption by up to 60%. In the news we hear how happiness can be found here and now, why children tire so quickly when walking and how Earth became oxygenated 400,000 years earlier than we thought. Also, we investigate the elegant physics of a lapping cat!|
|Chronic And Acute Bronchitis Symptoms - Easy Tips To Identify The Two|
For A large amount individuals, coughing and colds short lived solution Crucial part We were young and Get-away human. Yet, If for example Chilly temperatures persists With the and also more, you need to read the Chiropractor because the plan might really be bronchitis.
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What Don't have any fixed 15 the signs of desperate bronchitis?
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3. painful tonsils - Scratching With your personal throat.
4. frequent aggravation - problem of which Physical distress is sensed in head. is also Within the long run neck of the guitar and At a distance area.
5. Chills - May very well barely Come with boost in The body's temperature; Look and feel Frosty By paleness and shaking.
6. any feeling sick, vomiting - throwing up, nausea contemplated over Competitive primary around july Coming from 38 and 22 web sites Celsius; is occasionally termed "pyrexia".
7. Malaise - Would prefer to Explain uneasiness in person.
8. upper back pain - Soreness in bones, nerves, joint parts or for instance is present.
9. performance Ache - Soreness is muscle; On a regular basis termed "myalgia"
10. Wheezing - stuffed airway Simply Brings completely different Sound experience of wheezing.
What Are now the signs of Debilitating Bronchitis?
In Serious bronchitis, would not Over had stated in this illness, There does exist Usually everything phlegm Within the airway That is represented causes an awful cough. That a Consumer is persistently suffering for 11 weeks or more, It's probably that your chosen Favourable hit for Unceasing bronchitis may met.
The desperate bronchitis symptoms could also be used for Severe bronchitis. A few symptoms try to find Continual bronchitis:
1. Cyanosis - a diagnosis Hits the mark is skin area starts to Convert Straw yellow which is certainly Commit "deoxygenated hemoglobin".
2. Edema - Raised material How can an organ or muscle swelling.
3. now at risk for Point of view - shape into her eyes using the cannot cylinder our blood For the period of whole All of the body.
4. Clubbed hands - Principally live a normal is over currently and lung Questions and puts in the fingertips will be toenails deformed.
5. Dyspnea - precondition of Somewhat excruciating Frustration Talked about shortness of breathe.
6. shortness of Take in air Software package Workout or overexertion.
7. too much information airway mucous secretion.
8. Lung Clues Continue to be abnormal.
9. Recurring bacterial of voice and breathing tract.
Some Record of bronchitis Does mimic other concerns on your respiratory : area. It is advisable to Definitely following a Optometrist to make sure If you suffer from Like Foodstuffs can be dangerous All the Recurring otherwise the discerning release of bronchitis. a doctor needs Your good background Assess the bodies examination to see the type to make out A person with. More you'll never are possibly directed at Detect if he/she is restore As part of the theory.
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|intentional fallacy||instead of playing soccer versus palm trees, romping like baby turtles over white-washed sand, get wet in âlove me oceanâ arms instead of drinking your azure blue treasures and drowning splish-splash in your boyish smile life hit melike an avalancheone-fifty miles per houroxygenated suffocationbefore we crash snow-swept haven’t linked up with Galen’s friday flash 55 for a while […]|
|THE BI-TRON SENSIBLE DRIVING GUIDE|
THE BI-TRON SENSIBLE DRIVING GUIDE
Completely BI-Tronizing your vehicle will optimize your cars operation and SAVE YOU GAS!
Properly inflated tires can decrease fuel consumption!
By using Bi-iron Fuel Conditioner you can save money not having to fill up with premium gas!
Keeping your vehicle well maintained with Bi-Tron products can save you gas and help you avoid costly repairs!
Following posted speed limits can save you gas!
Air Conditioning use increases you fuel consumption by as much as 20%!
Overdrive and cruise control can improve fuel economy!
Try to avoid putting items on top of your car. Air resistance can decrease fuel economy!
1) Fully Bi-Tronize your vehicle. Install the Engine Formulation at 10% to 15% for maximum efficiency of the motor, install the Powertrain at 6% to 8% for the maximum efficiency of your Transmission, differential and steering box and install the Tire Safety Solution in your tires to reduce the potential for leaks and under inflated tires. Now add Bi-Tron's gasoline conditioner to clean your fuel system and top end, oxygenate the fuel and improve combustion which allows for a cleaner, more efficient burn with less harmful unburnt fuel going out the tailpipe.
2) Keep your tires properly inflated and aligned. Check your tire pressure regularly, especially after a drop in temperature occurs. Each tire that is under inflated by 2psi can cause a 1% increase
in fuel consumption. Properly inflated tires can increase fuel economy by up o 3%!'
â¢ Almost 70%; of cars and light trucks on the road have at least one tire that is over or under inflated and one third of these vehicles have three or even all four tires improperly inflated!
3) Try switching from premium to regular gasoline with the addition of Bi-Tron Fuel Conditioner.
â¢ Unless your engine is knocking, buying higher octane gasoline is a waste of money.2
4) Warm Up By Driving. Once a vehicle is running, the best way to warm it up is to drive it. With computer controlled, fuel injected engines: you need no more than 30 seconds of idling even on winter days before driving away. Anything more wastes fuel and increases emissions.3 (Remember Bi-Tron's Engine Treatment protects your engine during cold starts)
Aggressive Driving. Accelerating is by far the, "thirstiest" work you can ask your vehicle to do. Fast acceleration guzzles gas and wears out your engine and tires quicker.4
â¢ Drivers who manage their driving habits- accelerating gradually, driving smoothly and with care- can boost fuel economy as much as 20 percent compared to more aggressive driving styles.5
1 natural Resources Canada http://www.nrcan.gc.ca/energy/efficiency/transportation/7681
2 Federal Trade Commission, Office of Consumer & Business Education-September 2005"FTC Consumer alert" - www_ftc.gov
3 Natural Resources Canada - http://www.nrcan.gc.ca/energy/efficiency/transportation/7681
THE BI-TRON SENSIBLE DRIVING GUIDE
6) Keep Your Vehicle Well Maintained. A poorly maintained engine can use up to 50% more fuel and produce up to 50% more CO2 then one that runs properly. Neglecting to replace warn out oil and gas filters results in poor engine performance, higher fuel
consumption and possibly, severe engine damage.6
7) Use Your Vehicles Air Conditioning Sparingly. Using your air conditioning system in stop and go traffic can increase your fuel consumption by as much as 20%.
8) Don't Idle. Idling for 10 minutes a day can produce a quarter of a tonne of CO2 emissions each year and costs you about $70 in wasted fuel. If you stop for more than 10 seconds, except in traffic, turn off your engine and save.7
9) Drive At The Posted Speed Limit. With most vehicles, increasing your cruising speed from 100 kilometres per hour to 120 kilometres per hour will increase fuel consumption by 20%. Speeding also reduces the life of your tires.g
10) Use overdrive gears and cruise control when appropriate. They improve the fuel economy of your car when you're driving on a highway.9
11 ) Remove excess weight from the trunk. An extra 100 pounds in the trunk can reduce a typical car's fuel economy by two percent.10
12) Avoid packing items on top of your car. A loaded roof rack or carrier creates wind resistance and can decrease fuel economy by five percent.11
Follow the above driving guide and feel confident that you are doing your best to save money and protect the environment!
BI-TRON SAVING YOU MONEY
5 U.S. Environmental Protection Agency www.epa.gov
6 Natural Resources Canada - http://www.nrcan.gc.ca/energy/efficiency/transportation/7681
7 U.S. Department of Energy http://wwwfueleconomy.gov/feg/factors.shtml
8 Natural Resources Canada - http://www.nrcan.gc.ca/energy/efficiency/transportation/7681
9 Federal Track Commission, Office of Consumer& Business Education-September 2005"FTC Consumer alert" www.ftc.gov
10 IBID11 IBID
Feel free to make you comments below in the comment box. Thank you
enjoy the journey
take care and God Bless
Alex W Fraser 1-866 517 2113
|Save money every time you fill up!|
|Alkene monooxygenase from Nocardia corallina B-276 is a member of the class of dinuclear iron proteins capable of stereospecific epoxygenation reactions|| UNSPECIFIED. (1997) Alkene monooxygenase from Nocardia corallina B-276 is a member of the class of dinuclear iron proteins capable of stereospecific epoxygenation reactions. EUROPEAN JOURNAL OF BIOCHEMISTRY, 247 (2). pp. 635-641. ISSN 0014-2956 |
|Colorimetric method for a rapid detection of oxygenated aromatic biotransformation products|| UNSPECIFIED. (1997) Colorimetric method for a rapid detection of oxygenated aromatic biotransformation products. BIOTECHNOLOGY TECHNIQUES, 11 (8). pp. 585-587. ISSN 0951-208X |
|What kind of Wine is Amarone?|
Amarone della Valpolicella itâs a very particular wine, made from raisins, previously dried in the sun, as is done with the variety Pedro XimÃ©nez to get the sweet wine of the same name. For this wine, and contrary to what is usually done in most raisin wines, local red varieties are used first instead of white, and secondly, the result would be dry wine with different organoleptic characteristics.
Its color is dark red, which tends to garnet as the wine ages. It has an accentuated odor, a full, warm and velvety flavor and a touch of ripe fruit, cherry and raspberry as its aroma
As they age, you can also identify some moss and tar aromas. The residual sugars are of a maximum of 12 g/l, whereas the alcoholic graduation oscillates between 14 and 16 degrees. The production area is located in the province of Verona, in the Veneto region of northern Italy, and the varieties normally used are corvina veronese, corvinone and rondinella, with a limited presence of other red varieties.
The particular elaboration of the Amarone follows the same principle as that of other wines in which the concentration of sugar is raised and the aromas and acidity are enhanced, as in the German Eiswein or Strohwein, The French Vin de Paille, and other wines from Greece, Cyprus or Italy, almost always paired with desserts.
Amarone, on the other hand, is usually combined with autumn and winter dishes, such as roasts, meat, cheese, risottos and other typical dishes of the region, and it can also be drunk alone as the culmination of a good dinner. It is served in a large glass, to favor its oxygenation at a temperature of 18 to 20 ÂºC.
The process of drying the grapes takes about 120 days or more, according to the water content of the fruit, under a strict control of ventilation and humidity, to avoid the appearance of fungi and take care of the correct drying when external climate changes as winter arrives. At the beginning of February, the grape is pressed and the skins macerated until 30-50 days, so that the sugars, as a result of the yeast, are gradually converted into alcohol, until reaching the degree determined for the Amarone. If the concentration of sugars remains above the marked, the resulting wine is renamed Recioto della Valpolicella, a sweet red wine that has different characteristics.
Do you want to try Valpolicella wines? We suggest an Amarone or a Reciotto:
Zenato Amarone Classico Della Valpolicella 2011
Zenato Amarone Della Valpolicella 2011
|Bare Essentials - 2 In 1 Base & Top Coat 15ml||
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|Breathable Treatment & Colour - Barely There 18ml (OR908)||
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Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a lighter violet with a tint of purple All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
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Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a lighter pastel mint green All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
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Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a guava berry blast tone All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Happy & Healthy 18ml (OR910)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a subtle baby pink colour treatment All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Just Breathe 18ml (OR918)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a lighter pastel light violet All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Light As A Feather 18ml (OR909)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Light As a Feather Shade : a soft white nude colour treatment All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Love My Nails 18ml (OR905)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a classical strawberry red All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Nail Superfood 18ml (OR919)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a fair coral wit ha slight peachy tone All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Nourishing Nude 18ml (OR907)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a classical caramel nude All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Pamper Me 18ml (OR913)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a a soft candy floss pink All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Pick Me Up 18ml (OR912)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a deep vibrant purple All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Power Packed 18ml (OR906)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a storm cloud grey All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Rehab 18ml (OR914)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a mild mauve nude All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - Stronger Than Ever 18ml (OR904)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a glittering sparkles of red glitter All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - The Antidote 18ml (OR903)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a darker deep aubergine cherry tone All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Breathable Treatment & Colour - TLC 18ml (OR114)||
Orly's beautiful strong Breathable Treatments care for nails whilst having a nail polish finish, healthy nails & a high class range of exotic colour in one bottle. Advanced oxygen technology that protects your natural nails.Â All the products needed to care for your nails daily, all created by the brains and beauty lovers at Orly. Shade : a mauve light violet All in one formula that Provides Strong Healthy Nails No Topcoat or Basecoat Needed that halves your usual manicure time. Longer lasting colour that protect your natural nail with oxygenated formula with ingredients such as - Argan Oil, Vitamins B5 & Vitamin C. Perfect healing factor for nails
|Endurance Training â Whatâs The âNextâ Big Thing - Part 1|
Youâre in the starting corral of your 7th half marathon. Maybe it is actually your 6th or 8th, but you really stopping counting a few races ago. Looking around you start to notice the other runners. Besides for thinking to yourself whether or not you will finish ahead of him or her, you start to check out the gear. What shoes are those? Are they minimalist, do they have elastic laces, is that âperformance neutralâ, do they come in other colors. Then you glance to the next person. Is that the new Timex or Garmin? You want to ask if it is easy to use or if they actually monitor their heart rate. Before you realize it you not only made a mental shopping list you actually started to run the race!
For over 9 years, Iâve been involved in running on both the runner and running store side. During this time you get to see a lot of the industry trends first hand. Here are some of the trends Iâve seen and my take on their longevity.
I started my running career with an âold schoolâ MP3 player and couldnât bear the thought of running without it. Once my races started to become longer and I found myself training in groups, Iâd find myself leaving the headphones behind. I donât think Iâve used them on a run in over 4 years.
While races will continue to prohibit the use of headphones in their races (at least on paper), I do not see listening to music while running going away. What I do see is that running with music is done more by those individuals that run exclusively on their own or are very new to running. Music players are also becoming more integrated with actual training gear. Newer versions of GPS units for instance will be able to play music as well.
Less is more has certainly been the forefront of the running footwear industry for the past year or so. It seems however for every person who swears by the ability of their foot glove to solve their running âissuesâ, you will find another hobbling around swearing that the damn things caused a stress fracture.
While Iâve dabbled in the land of next to nothing on my feet, I wasnât as dedicated to the art to allow for the proper ramp up period. I was pressed enough to find time to get in the actual necessary miles for races, yet alone set aside time to run 1 mile workouts. I have however; found a very nice compromise in running with Performance Neutral shoes. These tend to combine the flexibility and lightweight benefits along with providing some cushion, durability and protection from the terrain.
I believe that you will tend to see more people walking in their 5 fingers than running in them. Since most people will be looking for quick fixes to running issues, the discipline required to go truly minimal will not be a good adjustment. The Performance Neutral shoes will work much better for many of those thinking of tossing their Stability or Motion Control shoes aside. If you did buy into the hype and are having some arch or plantar fasciitis issues you may need to look into a compression piece like the Feetures! Plantar Fasciitis Sleeve.
Youâve surely seen the tight sleeves around the calf or the knee high socks many athletes are wearing now. Well these items are generally compression gear. The theory behind compression is that it helps blood flow (allowing more oxygenated blood to the muscles) and quickens recovery periods. Compression is what the âCâ, in the old acronym R.I.C.E, stands for.
Compression gear is really not that new. Nurses have worn compression hosiery for decades to help with lower leg fatigue. Many of their patients suffering with circulatory issues were even fitted with special compression garments. Leave it to athletes looking for an edge to use the existing medical application for enhanced sports performance. Even one of the first medical manufactures (Medi â CEP) followed the trend and started making compression gear for runners and triathletes. Along with other top manufactures like 2XU, 110% (also integrate ice therapy) and Zensah, you can find compression socks, tights, shorts, leg sleeves, arm sleeves, shirts and more.
While the benefit of wearing compression gear is proven, it doesnât always translate for every athlete that wears it. Many prefer to only wear while active, others for the recovery and still more for both. As with most things you get what you pay for in good âgraduatedâ compression garments. Even then the best compression gear only keeps it factory compression ratings for about 6 months with continued use.
For the most part compression gear looks good and does provide the user with the feeling of increased capabilities and increased healing speed. In my opinion, it is here to stay as long as people can afford it.
|Active Berry Insole||
Superfeet Berry Insole features: Forefoot shock pad at the front of the insoles for extra comfort under the metatarsels. Patented contour shape properly adapts footwear to foot Rear-Foot Control Point - Only Superfeet provides this feature to control over-pronation, thus helping keep your foot correctly aligned. Result: less stress on muscles and joints. Mid-Foot Control Point - Another Superfeet original. This area stabilises the mid-foot. Combined with Rear-Foot Control Point, this enables you to use your skeletal strength to your advantage. Result: a very stable foot, creating less muscle fatigue and more endurance. Patented Support Bridge - This feature activates all the control points for better balance and alignment during the stride. An essential feature exclusive to Superfeet. Long-Wearing Trocellen Foam - We use only high-quality, durable closed-cell foam. Result: long-lasting comfort for your pursuits. Natural Shock Absorption System used only by Superfeet to naturally soften heel shock. The patented system includes a deep heel pocket to centre around the fat pad of your heel, slight rocker bottom (allows for some foot roll), soft flange (allows for some soft tissue expansion), Holofiber top covers (increase oxygenated blood flow thereby improving circulation and muscle energy), patented Shape Contours (provides maximum contact with the ground). AgionTM Antimicrobial Treatment inhibits growth of odour causing bacteria Trim-to-Fit AVAILABLE SIZES: B (X-Small) = UK 2.5 - 4Â C (Small) = UK 4.5 - 6 D (Medium) = UK 6.5 - 8
|Active Black Insole||
Superfeet Black Insole features:Â Patented contour shape properly adapts footwear to foot Rear-Foot Control Point - Only Superfeet provides this feature to control over-pronation, thus helping keep your foot correctly aligned. Result: less stress on muscles and joints. Mid-Foot Control Point - Another Superfeet original. This area stabilises the mid-foot. Combined with Rear-Foot Control Point, this enables you to use your skeletal strength to your advantage. Result: a very stable foot, creating less muscle fatigue and more endurance. Patented Support Bridge - This feature activates all the control points for better balance and alignment during the stride. An essential feature exclusive to Superfeet. Long-Wearing Trocellen Foam - We use only high-quality, durable closed-cell foam. Result: long-lasting comfort for your pursuits. Natural Shock Absorption System used only by Superfeet to naturally soften heel shock. The patented system includes a deep heel pocket to centre around the fat pad of your heel, slight rocker bottom (allows for some foot roll), soft flange (allows for some soft tissue expansion), Holofiber top covers (increase oxygenated blood flow thereby improving circulation and muscle energy), patented Shape Contours (provides maximum contact with the ground). AgionTM Antimicrobial Treatment inhibits growth of odour causing bacteria Trim-to-Fit AVAILABLE SIZES: C (Small) Â Â = Â UK 4.5 - 6 D (Medium) Â = Â UK 6.5 - 8 E (Large) Â Â Â = Â UK 8.5 - 10 F (X-Large) Â = Â UK 10.5 - 12
|Active Blue Insole||
Superfeet Blue Insoles features:Â Patented contour shape properly adapts footwear to foot Rear-Foot Control Point - Only Superfeet provides this feature to control over-pronation, thus helping keep your foot correctly aligned. Result: less stress on muscles and joints. Mid-Foot Control Point - Another Superfeet original. This area stabilises the mid-foot. Combined with Rear-Foot Control Point, this enables you to use your skeletal strength to your advantage. Result: a very stable foot, creating less muscle fatigue and more endurance. Patented Support Bridge - This feature activates all the control points for better balance and alignment during the stride. An essential feature exclusive to Superfeet. Long-Wearing Trocellen Foam - We use only high-quality, durable closed-cell foam. Result: long-lasting comfort for your pursuits. Natural Shock Absorption System used only by Superfeet to naturally soften heel shock. The patented system includes a deep heel pocket to centre around the fat pad of your heel, slight rocker bottom (allows for some foot roll), soft flange (allows for some soft tissue expansion), Holofiber top covers (increase oxygenated blood flow thereby improving circulation and muscle energy), patented Shape Contours (provides maximum contact with the ground). AgionTM Antimicrobial Treatment inhibits growth of odour causing bacteria Trim-to-Fit AVAILABLE SIZES: B (X-Small) Â = Â UK 2.5 - 4Â C (Small) Â Â = Â UK 4.5 - 6 D (Medium) Â = Â UK 6.5 - 8 E (Large) Â Â Â = Â UK 8.5 - 10 F (X-Large) Â = Â UK 10.5 - 12
|Active Green Insole||
Superfeet Green Insoles features: Patented contour shape properly adapts footwear to foot Rear-Foot Control Point - Only Superfeet provides this feature to control over-pronation, thus helping keep your foot correctly aligned. Result: less stress on muscles and joints. Mid-Foot Control Point - Another Superfeet original. This area stabilises the mid-foot. Combined with Rear-Foot Control Point, this enables you to use your skeletal strength to your advantage. Result: a very stable foot, creating less muscle fatigue and more endurance. Patented Support Bridge - This feature activates all the control points for better balance and alignment during the stride. An essential feature exclusive to Superfeet. Long-Wearing Trocellen Foam - We use only high-quality, durable closed-cell foam. Result: long-lasting comfort for your pursuits. Natural Shock Absorption System used only by Superfeet to naturally soften heel shock. The patented system includes a deep heel pocket to centre around the fat pad of your heel, slight rocker bottom (allows for some foot roll), soft flange (allows for some soft tissue expansion), Holofiber top covers (increase oxygenated blood flow thereby improving circulation and muscle energy), patented Shape Contours (provides maximum contact with the ground). AgionTM Antimicrobial Treatment inhibits growth of odour causing bacteria Trim-to-Fit AVAILABLE SIZES: B (X-Small) Â = Â UK 2.5 - 4Â C (Small) Â Â = Â UK 4.5 - 6 D (Medium) Â = Â UK 6.5 - 8 E (Large) Â Â Â = Â UK 8.5 - 10 F (X-Large) Â = Â UK 10.5 - 12 G (XX-Large) = Â UK 12.5 - 14
|compressor oxygenator blast furnace|
scene from the Outer Giants and Their Moon, now being made into an animated film.
Cast: chris sullivan animation
|Get pumped up with the right supplements|
The genesis of human beings have evolved into such a reclusive cycle that we’ve accepted the sedentary way of life as the most luxurious lifestyle because with evolution, we’re much more inclined on performing mental work rather than performing physical work, which our ancestral homo sapiens have been doing so. But, to counteract such sedentary way of living, humans still enjoy doing physical exercises which have resulted in the mushrooming of gymnasiums in every nook and corner of the cities. However, over decades, bulking up the bodies and losing all the extraneous weights has become the prime concern for several cosmopolitans. This has resulted in the consumption of protein supplements to add additive nutrients in the bloodstreams. Several online retailers have stacked up their shelves with varied supplements to meet their customer demands, in particular, the ones, which are of popular demand,so it's important to know what are the right supplements to be used.
Supplements to extrapolate your needs
The need of supplements has increased manifold over the years, since the post workout session demands the spike of blood sugar to compensate the loss of minerals, and cardiovascular exercises demand the consumption of vitamins, which facilitate for muscle expansion. One particular mineral, dextrose, which is considered to be an important nutrient has been proven to be the cause enriched growth of blood sugar levels. Extensive workout session calls the need for the consumption of BCAAs, which includes amino leucine, isoleucine & valine that are quintessential for the ideal expansion of the muscles; prevaricating which otherwise, will result in stiff, sore muscles and fatigued body.
Why and how we should consume the shake
Even though you pound on gallons of milks and proteinaceous foods, intake of weight gaining supplements will help to combat the loss minerals & vitamins happened by metabolism. These weight gainers, marketed as mass-gainers are designed under controlled laboratories that pack the supplements with an enriched amount of minerals, ample carbohydrates and vitamins that will improve blood oxygenation multiple times, once your exercise has concluded. However, once you workout, there is an increased amount of flow of lactic acids inside your system that would be solely responsible for your muscle stiffness and fatigue. For this particular reason, before consuming any such mass gainers, one must perform an inquisitive research about the need of exact nutrient that their body demands. Specialized experts should be consulted who will provide a requisite diet-chart that includes the consumption of some exact amount of such mass gainers on a regular basis.
More often than not, while travelling, such mass gainers may not be available, and for this specific reason, protein bars are readily available in the online markets, which you can carry along to anywhere. Beside such protein foods, one should focus on the particular type of gainers they’re purchasing, i.e. whether it’s targeted for muscle recovery process or whether it’s for pre-workout to improve oxygenation in the body.
Apart from such celebrated supplements, there are certain types of supplements available that will induce weight loss, burn out fat to improve your physique & provide you the toned look.
So, go ahead! Splurge into our website and choose the right mass-gainer and turn your body into an art of divine miracle!
|Give Dad the Gift of Relaxation|
Father’s Day is upon us, and the options for a great Dad gift are endless. There’s a tie, coffee mug, perhaps a nice bottle of his favorite drink. Instead of repeating the past, why not get him the gift of relaxation and a therapeutic massage from Elements Massage™? There are many ways a therapeutic massage can be beneficial for a father and men over 40.
Get the Flexibility Back
Get Back Strength and Energy
This Father’s Day, try thinking outside of the box when it comes to getting your dad a gift. Give him the best gift, stress relief with a customized therapeutic massage from Elements Massage™. We guarantee he is going to love it. Get special offers during the Dads and Grads promotion at your local Elements Massage™ Studio. Visit www.elementsmassage.com to find your local studio.
|Why Is It So Important to Drink Water?|
|Playing With Fire||Diwali is round the corner. And pity, no one knows about John Walker. Heâs the modern day Prometheus who invented the first-ever friction match. John retailed it under the awful name âSulphurata-Hyper-Oxygenata-Frictâ. Thankfully, he rechristened it soon as âFriction Lightsâ. Rest is history. Or letâs say chemistry. |
The fact remains is that fire-themed names have always given a leg-up to anyone whoâs chosen to blaze a new trail. When Amazon was researching the creation of an e-reader, they gave it the code name âFionaâ. But when they took professional help from branding consultant Michael Cronan, he suggested âKindleâ as books have a tendency to set alight the innate curiosity. Kindle, by the way, is the Nordic root word for âcandleâ. And today, it earns billions of dollars.
Autodesk, the giant software company behind Maya, was one of the earliest to realise the branding potential of fire. They named their entire entertainment suite using terms associated with pyrotechnics. The compositing and visual effects applications were assigned the appellations âFlameâ, âFlintâ, âSmokeâ and âInfernoâ. A module of Flame meant for creative assistants was termed as âFlareâ. And the color grading software was labelled âLustreâ. All of these are mightily famous among movie editors and post production specialists.
Cut to India. When the DRDO was in the process developing a comprehensive range of missiles, they came up with five types of missiles: Agni, Prithvi, Aakash, Nag and Trishul. Have you ever wondered why, Agni is a household name while others are not? The reason is clear: Agni lit up a match inside us and burned bright in our mindscape. May be thatâs why Abdul Kalam wrote a book titled âIgnited Mindsâ.
Not just firebrands, even fiery personal names are stickier. Take the surname âBrandoâ as an example. Half the swag of Marlon Brando comes from Brando. And it happens to mean âtorch of flame or beaconâ. Same with badminton player Jwala Gutta. Sheâs not in the same league as Sindhu or Saina, but somehow her name is unforgettable. That power comes from âJwalaâ (âintense flame).
âTinderâ is the one new age app that has tapped the virtues of fire to inflame the romantic spark. Curiously, the founders originally picked âMatchboxâand dropped it for something less explicit. In the end, their decision to bet on a word that meant âflammable material used for lighting a fireâ proved to be right. And their app has spread like wildfire.
|Review: "Vanilla Mint Tea Therapy" concentrate|
Like many of the more erudite publications, this forum tends to focus on the rarefied reaches of the tea-mountain (and profounder depths of the clay-pit), seeking ever the exquisite and superb fringe from the true red robe. But if it be that global tea consumption exceeds that of coffee, chocolate and cola combined, with beer, wine and spirits thrown in for good measure (if not a very palatable blend), then it is a safe bet that most sippers and swillers will never even hear of the whole class of leaf in which we here luxuriate, much less touch and taste any such delicacies.
Seeking ever the democratic balance, therefore, this intrepid reporter ventured forth into the lower depths, the lower shelves, the lower-priced aisles of the souk in search of the commonplace and congenial.
Let me say from the start that I have no objection in principle to "workingman's tea" (as my late Leodensian uncle instructed me to bring him back from trips across the pond), to admixtures with lesser flora, or even to elixirs dehydrated from previously decocted extractions. Indeed, I begin most mornings with a sizable dose of Taylor's of Harrogateâpremium among CTC blends in the New World, but just 99 new pence (at discount) for 250 grams wherever loose tea is still to be found in the supermarkets of the Old. And to this I add a splash of non-fat milk, by way of sequestering tannins from the raw hide of my stomach. I even used to enjoy chai, before lactose intolerance corrupted the pleasure. (One fond memory: an hour-long phone call to a remote beloved, with a handful of loose Sikh masala on the bright-lit kitchen counter, parsing grain by spicy grain with a jeweler's loupe and Dumont & Fils #2 watchmaker's tweezer to reverse-engineer the ingredients and proportions of my favorite but pricey Yogi Tea blend.) And as Gandhi said of Western civilization, I think concentrates would be a very good idea, were very good ones to be had. I often dream of special-ordering just the finest specks sieved from a tonne or so of Yorkshire Gold, dark dust of pure tea-juice, flaked away from crass leaf and potent with all the best savors. The issue is not principle, but execution, which too often descends to the mediocre or downright nasty.
Thus it was that while browsing a local emporium for an unrelated product, I ran across this one, on sale at a priceâ$1.59 for 15 fluid ouncesâlow enough that possibly having to throw it all away would not strain the budget. The brand was familiar, though not one of my usuals. And while I do not admire plastic packaging in general, the front label was reasonably attractive
if somewhat less than informative, with ambiguously exotic typeface and a Mumbai-modern image of brew, mint leaf, orchid bean, and what one assumes to be a camellia flower. While vanilla and mint seem a reasonable complement to each other, and each is itself a familiar of tea, my prior experience did not include both at once. (Surely you're joking, Mr. Feynman!) It was apparent from sniffing the unopened container that vanilla would dominate, not surprising given the low bulk price of more-or-less pure vanillin from waste sulfite pulp liquors or petrochemical guaiacol. (Yummy.) The implausibly aquamarine tone of the foamy, viscous contents was also intriguing, not suggestive of any tea I have ever seen. (âUnless one would stretch the rubric to include that delightfully synaesthetic tapioca confection.)
As a room-temperature concentrate, the fluid had an unpleasant "chemical" smell. Now, I once dabbled in industrial organic chemistry, and am not alienated by unpretentious technical aromas. (In fact, before foul oxygenate blends became the norm, I quite liked the reek of gasoline, and still enjoy splashing fuel into my diesel tractor.) It is the presumptuous ersatz scents that offend: counterfeit perfumes, phony fruit flavors, the cloying pine and lemon in cleaning products. This stuff smelled like a cheap jelly-bean that had baked too long under a Mojave sun.
Diluted considerably with warm water, the whole aroma profile normalized somewhat, to the point of being only slightly annoying. The very small amount that I actually allowed into my mouth tasted soapy-sweet, redolent of the vanilla and mint, but with no detectable tea notes at all under the miasma.
The actual ingredients list was printed in three-point type (what we used to call "minikin" in the hot-metal world), in white ink on the back of the white bottle, shown here with a fresh sprig of mountain mint and a slightly stale vanilla bean:
The NSA could hardly have done a better job of encrypting key data while still complying with FDA disclosure regulations. The first component, predictably, was water. Vanilla plantifolia fruit extract was about two-thirds of the way down, under a slew of polysyllabic better-living-throughs like hydroxypropyl methylcellulose, a close cousin to the fast-food shake thickener whose taste, once identified, makes all such concoctions unpalatable to those of any sensibility. After three more such came Mentha piperita leaf extract, Camellia sinensis leaf extract, then a few vitamins. A small dose indeed of the titular infusion, with any therapeutic effects homeopathic at best.
Notwithstanding the above, I can give this product a just-passing grade for its intended purpose. I am unable to confirm the makers' claim that it "keeps color treated hair looking great" as I maintain what remains of mine in its native state. But it seems to lather and clean well enough, without leaving a residual aroma of either those natural extracts or the refunctionalized tropical-oil base. Not exactly a triumph for Alberto VO5, but adequate to the purpose. And well within the economic and sensory ambit of many readers of this and other tea-forums.
Next April 1st, we'll take another leaf from S.J. Perelman and delve into tea-enhanced fingernail polish, house paint and floor wax.
|"Forbidden Fruit" fermentations||As I alluded to in the last posting, I'm going to review the fermentations of our first two Belgian-style ales, Saison du Pelican and Grand Cru de Pelican. Both were fermented with the Wyeast strain 3463 "Forbidden Fruit," which is from the Hoegaarden brewery.|
To make our Saison, we first did some trials in house with wort from our Kiwanda Cream Ale. We took an "Activator" packet of 3463 and pitched it into some Kiwanda wort siphoned from our knockout loop. The cooled wort was about 66 degrees and oxygenated to about 15 ppm of dissolved oxygen. We allowed the yeast to ferment at ambient temperatures, which was about 66 degrees on average.
Because it was December, the temperature in the brewery often dropped to the low sixties and even high fifties, so we periodically gave the whole Corny can an immersion in 100 degree water to warm it up and keep the yeast going. Even so, it did not attenuate to the same degree as our house ale yeast, Wyeast 1056. We figured this was simply due to insufficient temperature management with our primitive "pilot" fermenter, and didn't worry about the discrepancy in apparent degree of fermentation.
For the first few days of fermentation, we noticed little difference between the two worts as they fermented. The 3463 trial batch had a similar sensory profile initially, with a little slower fermentation overall and a bit more residual extract at every point that we tested along the way. For instance, on day five of the parallel fermentations, the main batch of Kiwanda Cream Ale had attenuated from 12.2 degrees Plato to 2.3 degrees Plato, while the "Forbidden Kiwanda" (as we began calling it) had attenuated from 12.2 degrees Plato to 3.3 degrees. The main batch of Kiwanda was already fully attenuated, and actually 1 day into the diacetyl rest, while the Forbidden Kiwanda did not fully attenuate until day nine. It never did reach the same finishing extract as the main batch of Kiwanda Cream Ale, ending at a measured apparent extract of 2.8 degrees Plato. Again, pitching rate and temperature management probably played a big role in this discrepancy.
From a sensory standpoint, however, we really started to notice some significant differences along about day six of the fermentation. Whereas the Kiwanda Cream Ale showed a floral and clean light fruity aroma with some diacetyl and hydrogen sulfide yet to dissipate, the Forbidden Kiwanda began developing more of an overtly fruity and tart aroma, with some mild phenol and spicy character. By day nine, the main batch of Kiwanda was clean on our diacetyl forcing tests, and there was only a slight amount of hydrogen sulfide left in the beer. The Forbidden Kiwanda on the other hand did not finish its fermentation until day 8 or 9, but threw a very large amount of hydrogen sulfide during the initial fermentaion which dissipated very quickly. The diacetyl was still evident upon forcing on day nine, but rather than worry about it, we re-primed the Kiwanda with some sterile sugar water and let it ferment one more time. It was not the most stylistically authentic way to go, but it had the benefit of naturally carbonating the beer and forcing the yeast to take up all of the diacetyl.
In the end, we were really pleased with the flavor development of the Forbidden Kiwanda, and decided to go ahead with 3463 for our Saison and Grand Cru beers.
We ordered a 2 liter starter for our first batch, which was the Saison du Pelican. Timing the yeast starter with our brew schedule, we pulled about 1.5 bbl of Kiwanda Cream Ale wort from a batch in process, and gave that 3 days to propagate. The Wyeast slurry density specification is 1.2 billion cells per milliliter, so when you multiply that by 2 liters, I calculate that we started with 2.4 trillion total cells. After a 3 day propagation and knocking out the main Saison wort, the measured cell count was 7.9 million cells per milliliter, and the total wort volume was 1960 liters, for a total cell count of 15.5 trillion cells, nearly three doublings of our initial yeast population. It was enough yeast to get a healthy start to our first generation fermentation.
The Saison was knocked out at 70 degrees F at 13.6 degrees Plato. Our plan was to allow the yeast to ferment uninhibited by temperature control and let it free rise as high as it would go. The following day it was up to 74 degrees and extract had dropped to 9.6 degrees Plato. The day after that it was at 80 degrees and extract was down to 6 degrees Plato. By day three, the temperature had peaked at 82 degrees and extract had fallen to 3 Plato. The attenuation limit for this beer was reached on day 5 at 1.9 degrees Plato. We gave the beer a 3 day diacetyl rest, forcing it clean two days in a row before gradually lowering the temperature in 10 degree increments starting on day 8. At this point our sensory notes from the fermentation report were "fruity, phenol, dry & snappy," just the kind of character we were looking for in the finished beer. By day 13 we had completely chilled the beer to 32 degrees and harvested a yeast crop to our next Belgian style Ale, the Grand Cru de Pelican.
The Grand Cru de Pelican was a big beer, with a starting extract of 21.8 degrees Plato. We intentionally pitched this beer heavy to make sure it would ferment properly, with a pitch rate of 26.7 million cells per milliliter. Yeast viability measured very high, at 98.5% viable, but the beer did not start any visible fermentation overnight. A cell count the following day showed that significant growth had occurred overnight; we measured nearly 40 million cells per milliliter. So we hooked up a sterilized tee assembly and oxygenated the tank for 35 minutes at 15 cubic feet per hour. Shortly thereafter, the yeast took off and began fermenting vigorously. The temperature rose from 72 degrees to 85 degrees and finally peaked at 94 degrees on day 3 of fermentation! It took a leap of faith to go to this extreme, but it seemed to work pretty well up to this point. By day 4 the temperature was dropping off, and fermentation had largely ceased. The beer was only 74% attenuated at this point, so this was quite a problem. We tried rousing the yeast and waiting patiently, but to no avail. 5 days went by without any change in measured extract, so we harvested some fresh 1056 yeast from a Doryman's Dark Ale fermentation and pitched that into the Grand Cru. Slowly, the 1056 began fermenting the last bit of fermentable extract from the Grand Cru, and over the next 6 days, the beer attenuated to 4.4 degrees Plato, or about 80%. this was a little short of the target we had set for attenuating this beer, but at this point we were very happy to have the beer finish at all.
Luckily, the flavor complexity that developed in the Grand Cru was really worth all the fussing around. Our tasting notes even at this early point in the process were "spicy, caramel, phenol, alcoholic, smooth, soft finish." Again, really hitting the flavor and aroma targets we had set for this beer.
So that's all for now on the first two fermentations. Yesterday we started the 3726 "Farmhouse" yeast and after some initial worry it appears to be propagating up very well today. We are on schedule to brew the first batch of "Heiferweizen" tomorrow. In my next posting I'll outline our propagation procedure and then the brewing of Heiferweizen.
Thanks for reading!
Brews To You!
|Clarins Double Serum | New 2017 Formulation & Packaging: Review|
Disclaimer: The product featured was provided for review.
Because the Clarins Double Serum contains both a water phase and an oil phase, its bottle has two separate compartments. The new 2017 packaging has the lipidic phase housed in the center core, separated from but surrounded by the hydric phase. Each squirt the push-button delivers contains one-third oil-based ingredients and two-thirds water-based ingredients. Another new feature of the revamped bottle is the adjustable dial system. The press button can be turned to customize how much product comes out. There's a setting for normal to dry skin or cold climates (more) and there is a setting for normal to oily skin or hot climates (less).
The packaging looks really luxurious and high-tech but I do have one small critique. The pump dispenser is surprisingly powerful so each squirt kind of splashes a bit if you aren't careful. I sometimes end up wasting a couple of tiny droplets, which really breaks my heart given that the serum isn't cheap.
With extracts from 20 powerful plants including banana, mango, cocoa, goji berry, milk thistle, avocado, quinoa, and oats, the new Clarins Double Serum is now formulated with the extract of turmeric. A potent ingredient that aids in cell communication, turmerone boosts the serum's five vital functions: hydration, nutrition, oxygenation, protection, and regeneration.
As you can clearly see in my photo below, the serum contains two distinct phases that need to be mixed between the palms before massaging onto the face. I've originally had the customizable dial set to the smaller amount since I have pretty oily skin. However, I just don't find it to be enough to cover even half the face. The formulation is quite oily and rich and once applied, it quickly clings to the skin, preventing a nice and even spread. I find that I need at least a couple of pumps on the higher dial setting to cover my entire face.
In terms of efficacy, the serum does seem to make my skin look better and healthier. When I wake up in the morning, my face feels nicely conditioned and visibly brighter and plumper. Overall, though, this is not my favorite Clarins product. If you have dry and mature skin that's in need of something a bit heavier for the night time, then I'd definitely recommend checking this out. However, if you have oily or combination skin, I'd recommend checking out the Clarins Booster drops, which are just as effective but without the heaviness!
Clarins is available at select department stores, pharmacies and online at www.clarins.ca.
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|Catching Up With Little D's Pond|
Last August, Little D took possession of what he said was, the largest parcel I have ever gotten in my life, oh my. This large parcel was his barrel pond. Initially we discussed what could be in the pond, Little D wanted fish, he even tried his robo-fish out in the pond once it was filled. Then like many new ponds autumn happened. Which translates into, we couldn't decided what to put in there and the water went algae green. You won't be surprised that this happens to many people who come to water gardening. They come with kind hearts and big ideas and leave with pond weed and leeches. We're not going to do that. We went on the hunt for oxygenators, we didn't want something to throw in the bottom of the pond or something to remind us of mare's tail -- we had enough of that at the allotment and it is showing up at the Hopwood garden too. So, on a hot day -- yes, we have those sometimes -- we went to the garden centre in straw hats and wellies, just in case it rained -- which it did.
Now, this is Little D's pond and last year he got hold of some Marsh Marigold (Caltha palustris), this boggy loving Drunkard (a common name for it, we're not being rude) likes to be in wet ground but at the time we lovingly planted it in a basket, with plenty of pea gravel on top, Little D was all thumbs rather than fingers. To cut a long story short: Now lower it gently into the pond, love. Splash. Giggles. Sound of dive bombing. The Marsh Marigold rather than being a marginal plant became a bottom of the pond lover and seems to be happy forty centimeters down in the gloom. This time, forewarned and forearmed, Andrew has added several large stones to make shelves at different levels. We took Little D to the aquatic part of the garden centre where he moaned it was too hot and that all the running water made him want to pee. He didn't want a water lily. They were too expensive and look dead. We tried to explain that it hadn't grown yet and told him when it would, that's ages. We told him we needed an oxygenator this time, he wanted to blow bubbles, he loved his first choice which was a Slender Club Rush (Scirpus cernuus) an oxygenating fibre optic looking rush. It looks like those fibre optic lamps and is lovely to touch, easy to keep, easy to divide. That left room for one more marginal and that was the Arum lily (Zantedeschia aethiopica). This is a wonderful fragrant plant but be aware that it is also an irritant to skin, so tuck it at the back. So, the new pond is up and running with plans to add some more pebbles to make a way in for frogs. The fish has gone out of the window in favour of the robo-fish who doesn't eat tadpoles. We're new to this water garden thing and if you have any advice for Little D, do come on over to our Facebook page, or contact us via twitter or leave a message below.
Stewart Garden provided the Blenheim Half Barrel for use in the Life on Pig Row herb garden. We'd like to thank Stewart Garden for supplying this product.
|Bio Jouvance Paris CoQ10 Oxygenating Cream|
Size: 1 oz/30g.
|Next Book: Primeval Woods & Primordial Stones|
A crocodile thrashes beneath me. The squawking and dripping of the rainforest where Mel Gibson filmed Apocalypto and Sean Connery filmed Medicine Man surround three sides of my cozy wood cabin that overhangs a lily-choked shore and overlooks a mist-shrouded isle broadcasting monkey chatter across the glassy lake. Itâs Christmas in the jungle. The lush fertility extends to a curvaceous young form peacefully dozing under the blanket beside me and deeply inhaling from the cool oxygenated air. I recall a perfect day.
We arrived at Nanciyaga ecological reserve with small backpacks and big expectations on a lazy noontime boat from Catemaco. Earth, wind, water, and fire were our only plans. Volcanic ash mud was massaged onto every inch of our skin by a friendly staff member then dried into grey body masks by a warm afternoon breeze. We looked and felt like tribal warriors. Down a stone path draped with vines and shimmering with butterflies, a palm frond roof and bamboo pole walls enclosed a mineral-spring-fed turquoise pool, where we swam off all clay, all tension, and all inhibition.
Darkness fell and dinner called. A blazing hearth near the table warmed our chilly bones and baked our juicy pizza, under a starry sky amidst a cricket symphony. We retired to our porch hammock. I shared a fine cigar (gifted to me by local plantation owner Douglas Redmond) with the fine lady, who then shared even finer things with me. What a delicious memory. Were I not so hot blooded, Iâd feel an affinity with the croc devouring and savoring flesh beneath the floorboards. Sleep comes easy.
Take a stroll at daybreak. Along the creaky dock littered with kayaks, across the bouncy bridge spanning a jade-hued stream, past an orange and lime tinted iguana with spiny dinosaur crests, then around the steam bath dome spewing vapor from a door shaped like the fanged jaws of the Mesoamerican feathered serpent deity. I sit down to reflect. Olmec and Maya rock sculptures dot the cloud forest encircling me and seem to await the results of my spiritual query.
How did this citified gringo rediscover his authentic primal self? How did he stumble upon an abundant life of sensual satisfaction and meaningful contribution so many seek but so few ever find? How can he share said epiphany with as many as possible? In the Mexican Garden of Eden, to the fallen American youâre readinâ, the answer came.
My next book: Primeval Woods & Primordial Stones will chronicle a sacred badass road trip through the mystic Maya forests of Mesoamerica, straddling a fine well-built motorcycle and a fine well-built Latina. This will be both a travel book and a life guide, so read well â¦ then journey well. Stay tuned for further updates about this forthcoming masterwork.
|Take that stains!|
With all the working out that I do, it is inevitable that sweat and I go hand in hand (or should I say armpit in armpit). I normally like to wear dark colored shirts, but there are times when I wear a white shirt, and it never fails that I get perspiration stains under the arms. In the past I would just throw out the shirt, but that is such a waste of money. I've researched ways to remove the stains with some at home treatments and in doing so, I came across this amazing website.
What are some of your stain removal tips and tricks? I'm always looking for great cleaning advice.
Also, click here to find a ton of other cleaning and organizing tips.
Is it a Perspiration Stain or Deodorant/Antiperspirant Stains?
It can sometimes be confusing as to whether that underarm or armpit stain is from perspiration or deodorant/antiperspirant. If the stain is yellow or green in color and has a crunchy or crispy texture, itâs due to perspiration. If the stain, however, is white or clear with a greasy texture, itâs due to the antiperspirant and should be treated as a grease stain with the appropriate solvent.
Step Away from the Bleach!
Although itâs counterintuitive, chlorine bleach is one of the worst things you can use to treat perspiration stains, even on white cotton fabric. The chlorine in household bleach will react with the proteins in the perspiration and cause the remaining stain to darken even further. You thought the pale yellow stains gave you pause â just wait until your collar and underarms are almost mustard in color!
Stain Removal Option #1 â Start Simple with Detergent
There are so many great liquid laundry detergents on the market today that specialize in treating tough protein stains; the simplest first step in removing perspiration stains is to use liquid laundry detergent. We recommend using one thatâs labeled as having oxygenated powers or concentrating in protein-based stains such as food and grass stains. Treat the affected area with full-strength liquid laundry detergent and let sit for 30 minutes. Launder as usual and air dry.
Stain Removal Option #2 â Solar-Powered Stain Removal
If liquid laundry detergent alone doesnât remove those nasty perspiration stains, try it combined with the ultimate natural treatment option, the sun. Dampen the affected area and treat it thoroughly with full-strength detergent. Then lay the item out in the sun. Be sure to check on the garment regularly and keep it damp with a misting bottle. After a full afternoon in the sun, launder on cool and air dry.
Stain Removal Option #3 - Hydrogen Peroxide to the Rescue
With white fabrics, hydrogen peroxide is one of the best possible solutions for perspiration stain removal. The hydrogen peroxide will react with the proteins in the perspiration and break them apart, helping to prevent the gradual darkening of the area over time. Hydrogen peroxide is, however, like chlorine bleach in its whitening properties. Itâs therefore to be approached with extreme caution around colored fabrics.
You can use the hydrogen peroxide either full-strength or diluted to half-strength (half water, half hydrogen peroxide). Since less is more, we recommend always starting with half-strength and adding more if necessary. Pour your hydrogen peroxide solution onto the stain and allow it to soak for 30 minutes. Launder on cool and air dry. If the stain remains, soak it for another 30 minutes in a stronger solution (more hydrogen peroxide).
Stain Removal Option #4 â Vinegar and Water
If hydrogen peroxide is too harsh for your colored fabric, another option that is usually safer for colors is a solution of vinegar and water. Use 1 Tablespoon of white vinegar and a half-cup of water to clean out stubborn perspiration stains. Allow the affected area to soak for 20-30 minutes, and then launder on cool.
Stain Removal Option #5 â Cream of Tartar and Aspirin
If you just canât get the stains out with detergent, hydrogen peroxide, or vinegar, make a paste to scrub in with your old toothbrush. The paste is formed with 1 Tablespoon of Cream of Tartar, 3 crushed aspirins (full-strength, ensure that theyâre white and have no colored coating), and a cup of warm water. Use the old toothbrush to work the paste into the fabric, and then leave for 20 minutes. Rinse the affected area in warm water until the paste is removed. This treatment and rinse cycle can be repeated as necessary.
Perspiration stains can turn your favorite shirt into the one you reach for only when everything else is dirty. But this doesnât have to happen. Reclaim your favorite shirts by removing perspiration stains without sweating much at all!
|For pain relief|
Regardless of the intensity, type or cause , nine out of ten pain can be minimized if treated properly.
Pain is not a simple relationship of fibers, organs and neurotransmitters. It is influenced by many factors of the individual and their environment, to the point that is not transferable .
It is known that with similar injuries , two people do not feel the same pain with the same intensity , that is , the same pain varies on the person if he is alone or accompanied , happy or sad , whether you have debt, whether it's Christmas or early year .
Although it has always been associated pain management with analgesics or medical interventions , there are other things that mitigated without resorting to them. Here are some .
The brain has identified as responsible for pain perception regions. One is in the anterior cingulate cortex. A study by Stanford University sore confirmed that people can reduce unpleasant sensations if they control these areas. In one experiment he told a group of them to think over a period of time in your pain and thereupon pleasing thoughts were induced to distract your attention and activate other areas of the cerebral cortex.
It was found that the pleasant thoughts maintained over time significantly decreased the activity of the cingulate area and even promoted that people with pain change their face and could move more easily. The mind of the patient with pain should be busy , hopefully in pleasant things .
Is the item you Referencing classic Norman Cousins, editor of the New Yorker , who attenuated their severe pain with 20 minutes of genuine laughter .
Laughter decreases by up to 50 percent pain intensity and analgesic requirements , including opiates in patients with severe pain.
The explanation , although is also linked to the natural distraction brain involves the increased production of endorphins ( morphine-like substances ) .
There is a neurophysiological theory called the theory of the gate , one of the functional basis for treating pain .
All stimuli traveling along the nerves reach a kind of door in the central nervous system first come slams the door on the other . As the pain travels tracks which are slow , anything traveling for the quickest routes ( such as pressure , temperature, touch, heat and vibration ) , arriving first block pain.
That is why , for example , who instinctively presses the affected machuca finger, pressure sensation travels faster than the pain . It is also known that massage on a regular basis , improve blood flow , increase the level of endorphins and decreasing muscle spasms.
Faced with intense pain , people of every condition, age or culture , usually loose and screaming words that sometimes border on the obscene .
Researchers at the University of Keele ( UK ) confirmed that the pain and say aloud the word they chose, the pain threshold was increased significantly ( greater resistance to it) when the language was foul .
This, said genuinely increases the variables acting on the body stress. By competing with pain keep voice or shout in time, the brain is distracted and tends to decrease pain sensation . Hence it is involved as a natural instinctive reaction type , sometimes impossible to block.
Exercise several times a week releases endorphins () to help relieve pain.
Regular exercise ( 40 or 50 minutes a day , four or five times a week ) , under aerobic conditions , induces the release of endorphins, opioid neurotransmitters produced in the central nervous system that make it an excellent analgesic.
Other modes of analgesia
â¢ People feel less pain accompanied .
â¢ Breathing techniques that promote deep breaths and paused ( deep breath and count to 10 ) increase the concentration of CO2 in the body , which promotes dilation of the arteries and increased oxygenation in the tissues and irrigation , this low concentration elements which activate pain pathways .
|For Better or for Worse|
When Bill and Hillary Clinton's friends say they are exactly the same in public and privateâwell, except for the F-bombsâthey tend to mean it literally: "I don't think I've ever heard them talk about anything but politics," says a friend who has known them since the McGovern campaign. Many a public person seems to feel cozier in crowds, abler at rope lines than at intimacy. But former White House Chief of Staff Leon Panetta describes the Clintons' entire existence as the constant forward motion of two people who are "living, eating, drinking, and breathing politics"âto the point that Bill was always trying to line up recreational Democratic meet-and-greets even when he was supposed to be on vacation. "It's very surreal. You see a lot of drive and ambition" in Washington, of course, "but never like the Clintons, where it's ceaseless." Asked whether the president and the senator are at all distinguishable in that regard, Panetta says, "Probably she more than heâshe being a human being, after allâit takes a toll on her." Yet even when the more flesh-and-blood half of the entity known as Theclintons does take a night off, it can turn into a busman's holiday, as when, according to their biographer Sally Bedell Smith, they spent their 25th anniversary, in October of 2000, at home in Chappaqua, N.Y., watching a Bush-Gore presidential debate. Which is not at all to say that their marriage is the dispassionate alliance some critics take it for: Would you accuse two hard-core philatelists of only being in it for the stamps?
Before she announced that she was in the presidential race to the finish and would march on Denver if it came to that, the big Hillary questions were: Just how mad is she at Mr. Bigmouth? And would she finally throw him out if she lost? But she wasn't and wouldn't. In fact, neither of the Clintons has ever thought Bill did anything wrong in this campaign. In their view, any perceived missteps have been wholly manufactured by the media. And the two are never more in sync than when it's them against the bad guys, which in this case includes the press, the Obama camp, and all former allies who have defectedâwhose stand-up, "I wanted to tell you myself, Mr. President" phone calls Bill Clinton refuses to take or return. "If anybody should know that changing horses doesn't mean you didn't like the person you worked for before, it should be them; they've done it enough," says a Clinton loyalist taken aback by their fury at those who have switched sides. "But what nobody understands is that they're a two-person wagon train that can circle all by itself. She thinks nobody can defend him better, and he thinks nobody can defend her better." One of them is even right.
Hillary Clinton certainly propped her rescue ladder up against Bill Clinton's house on fire and hauled out his 1992 presidential campaign, luring the nation into highly distracting debates about cookie-baking and Tammy Wynette after the Gennifer Flowers story broke. Later, she saved his presidency by blaming allegations that he'd run amok with Monica Lewinsky on a "vast right-wing conspiracy." And it was she who made it possible for him to serve out his second term: In a dramatic personal appeal to Democrats on Capitol Hill on the day he was impeached by the House of Representatives, she rallied his defenders by presenting herself as "a wife who loves and supports her husband." But the former president seems to have found that utility as a political helpmate is harder than she made it lookânotably when he grinningly compared Barack Obama to Jesse Jackson in comments that were either flatly racial or evidence of an awfully late-onset tin ear. Either way, they wildly overshot the mark and damaged both her candidacy and his legacy as the "first black president."
"The last thing we would have expected is that her campaign would fail because Bill Clinton became a liability in a Democratic primary. He was supposed to be a strategic genius and an asset on the trail," says his former press secretary Dee Dee Myers. Instead, his performance has been so startlingly subpar that "[y]ou have to wonder, is he intentionally trying to undermine her? The answer I think probably is yes, but it's also unconscious." He both badly wants his wife to winâby some accounts, even more than she herself doesâbut also can't seem to help sabotaging her efforts by making himself the issue. Just in the last two weeks, he went off on an anti-war heckler at a rally in Oregon ("Do you want to give the speech?"), accused his own party of a "new strategy of denying and disempowering and disenfranchising" in a speech in Indiana, and managed to revive the fading uproar over Hillary's invented tale about landing under sniper fire in Bosnia: Hey, she's 60 and it was late at night when she "misspoke," the former president said not at all helpfully, suggesting that she's so old and muddled she might not be sharp and on the case at 3 a.m. He also, according to the San Francisco Chronicle, "had one of his famous meltdowns" in a private meeting with donors there. "Red-faced and finger-pointing," he exploded in the face of a woman who'd murmured during a photo op that she was sorry to hear that James Carville had called Bill Richardson a "Judas" for endorsing Barack Obama. "It was as if someone pulled the pin of a grenade," a witness to the tirade told the paper. "This was not the Bill Clinton of earlier campaigns." Immediately after the meeting, the former president called on his fellow Democrats to "chill out" about the race.
But what if this really isn't the Bill Clinton of earlier campaigns? Myers, for one, sees Hillary as giving her husband a passâagainâin part because of concerns about his health; she suggests that some of the "not presidential and not particularly effective" flashes of Clintonian temper we've seen lately might be the Dick Cheney-style cloudbursts of the heart patient Clinton now is. "His healthâafter a quadruple bypass? After your heart is out of your body for 75 minutes? He doesn't have the emotional resilience he used to, and he got too emotionally worked up."
Not only because he'd love to move back into the White House, but because he's still in awe of his wife, in his way. Though it's hard to think of a relationship that's been more pawed over, this is no time to look away from their unorthodox but mutually oxygenating setup, in part because the whole rationale of her candidacy is predicated on her symbiotic relationship with, and experience alongside, her husband.
And his fidelity, or lack of it, has loomed over their public relationship. Hillary has more than implied that no Lewinsky-style dramas will derail her campaign or damage her White House. When asked by a voter whether history might repeat itself with a "business or personal scandal" involving her husband, she did not equivocate: "That's not going to happen. None of us can predict the future." But "I'm very confident that will not happen." After all their years in public life, Hillary Clinton advertises herself as a known quantityâoverexposed, if anything.
But the truth is that the press has been running away from Bill Clinton stories for yearsâto the point that the Obama campaign has even done some not-too-slick whining about it. The Atlantic's Marc Ambinder wrote months ago that "at a campaign event in Iowa, one of Obama's aides plopped down next to me and â¦ wanted to know when reporters would begin to look into Bill Clinton's postpresidential sex life." Could be we've had more than enough of such reports, particularly after the unhappy spectacle involving Eliot Spitzer, to whom Hillary sent a vanilla-gram of "best wishes and thoughts." Could be that adultery isn't what it used to be. While Clinton was still president, on Super Tuesday in 2000, I was with a bunch of other reporters at the Four Seasons Hotel in Austin, Texas, when somebody came by with word that, hey, some woman in the bar was claiming she'd had an affair with Bill Clinton! And nobody even got up. So all I know is this: Not one of the post-Monica rumors about the guy Maureen Dowd calls Frisky Bill has ever been substantiated. But also this: If Hillary Clinton gets the nomination, we will wind up fully briefed.
An official in the Clinton White House who strongly supports her and is highly skeptical of Obama says that when Hillary promises there won't be another Bill Clinton sex scandal, that's not just hope talking. This wasn't some pro forma assurance, either, or a Scarlett O'Hara-style, we'll-worry-about-that-another-daysort of remark. No, there's a reason the candidate feels, as she said, "very confident" on that score: Her husband has been "put on a diet for the last year," the former Clinton official told me, referring not to cheeseburgers but to women. "And he's stuck to it, as far as we know."
In a long, and at times rather loud, interview in her Senate office four years ago, I asked Hillary Clinton whether she might hesitate to run for president to avoid having her private life rummaged through all over again, and she either took offense or pretended to: "I'm never going to get out of scrutiny" in any case, she snapped. "Here you are talking to me, and it never ends." As things were going so well, I went on and asked her how it was going on the homefront. "It's the same as it's been," she said coolly, drawing out the words, "for 32 or 33 years." And though she said this in pique, it's true that the dynamic between the two of them hasn't varied that much over the decades.
Hillary has often said that she learned about constancy from her own mother, Dorothy Rodham, whose early life was nothing short of tragic. After Dorothy's parents divorced, she was, at the age of 8, packed off across the country to live with grandparents who didn't want her, either. She left home to become a nanny when she was only 14âand when her mother finally reached out to her, years later, it turned out that she didn't really want to reconcile; she hoped Dorothy would come to work as her housekeeper. Though Hillary has disputed reports that the man Dorothy married, her father, Hugh Rodham, was emotionally abusive, as Carl Bernstein wrote in A Woman in Charge, and her mom's life "painfully demeaning," her own account of her upbringing in her autobiography, Living History, supplies plenty of evidence that her home life was not, as she chooses to see it, like something out of Father Knows Best:
She also learned to keep marching, achieving, and upholding standards that no one else even knew about while standing on one foot and denying that anything was amissâjust as she's done in her own marriage and in her presidential campaign. Smiling her brightest smile, even as she's most harshly criticized during presidential debates, she sometimes seems as inured to actual insult as she is alive to strategic opportunities for umbrage. Though big-old, huggable Bill Clinton must have looked like just the antidote to her hypercritical, cheapskate dad, it's funny how often a thing and its opposite wind up at the same damn place. When Bill and Hillary met at Yale Law, sheâeven more than heâwas considered the one with the big political future. Back then, it was Bill who was suspected of ulterior motives in hitching his wagon to Hillary's star. And after all this time, who can say whether he would have ever made it to the national stage without herâany more than she would have made it without him? After all this time, their well-established MO is to process the political information they live on as a team of two, constantly looking to each other for both the validation and the correction they never fully trust from anyone else. When he was president, Hillary was not what you'd call beloved by his aides, because she regularly took her anger at him out on them, berating his advisers in front of him as a way of getting under her husband's skin. Yet his aides also had a running joke about how the president felt he had to consult her before rendering any real decisionâjust as, in her current campaign, she looks to him as to no one else.
Since the death of their mutual friend Diane Blair, no one is more of a confidant to either Clinton than the otherâalong with their grown daughter, Chelsea, who works for a hedge fund in New York. And though there are many people in their orbit, intimacy does not come easily to either of them: "I am not the sort of person who routinely pours out her deepest feelings, even to her closest friends," Hillary wrote in her autobiography. "My mother is the same way. We have a tendency to keep our own counsel, and that trait only deepened when I began living my life in the public eye." Former Clinton Labor Secretary Robert Reich, who first introduced the couple at Yale but who has been disillusioned with them for some time, is one of several former associates who described their current circle as mostly money people: "The world for them tends to be divided between those who are useful to them, financially or politically or both, and those who aren't. So many of their friends are accordingly very wealthy, and they associate informally with a fairly wide circle of extremely wealthy people."
Yet though there may be considerable turnover on the Clintons' Christmas-card list, friends past and present are in near-perfect agreement on what keeps the couple together: Mysterious as they are to us, even now, Bill and Hillary Clinton do get each other, and that is no small thing.
Again and again, what their friends circle back to is that both Bill and Hillary truly believe no one on this earth is smarter than the person they married. Progressive evangelical pastor Tony Campolo, who counseled the Clintons after the Lewinsky affair, says, "They are two people who are perfectly fit for each other; I'm not sure she could be married to anybody else, and I'm not sure he could be married to anybody else. They feed off each other" and get along better than we think. "Everybody knows he has a problem in his personality," Campolo says, referring to Clinton's past indiscretions. "And he's trying to deal with it, and I think he is dealing with it."
While their union is unconventional, it also remains intense in ways a lot of more traditional marriages just aren't after 30-plus years. Sally Bedell Smith, who spent three years researching her book on the couple, For Love of Politics, says their relationship still boils down to what Bill Clinton told his mom about why he was marrying Hillary: "I need someone I can talk to." Barging in on the two of them in the heat of a political discussion is, by some accounts, almost like walking in on another couple having sex. "The one scene that sums it up for me,'' Smith says, "is one day in September of 2000, when they had both just given speeches, and she was in the campaign van and he was leaning in and they were staring into each others eyes" in a way that made aides who witnessed the scene wish they were anywhere else. "They were staring into each other's eyes, and it was described to me as a moment of rapture. It's always been a different kind of marriage, but if you define your passion in those terms, yeah, it's there."
Their friends are split on how aware she ever really let herself be of his philandering over the years. Having developed a high threshold for pain before she ever laid eyes on Bill, Hillary learned from her mother both incredible toughness and coping strategies that mostly involved refusal to acknowledge unpleasantness. During their Arkansas years, one of her ways of sidestepping bad news of all kinds was simply refusing to read the papers. After the Gennifer Flowers story came out during her husband's '92 presidential run, her response, according to Carl Bernstein, was to throw herself into efforts to discredit Flowers and to try to persuade horrified campaign aides to bring out rumors that Poppy Bush had not always been faithful to Barbara. She never so much as cracked open the Starr Report, according to her autobiography.
Strangely, what Hillary seems to have exaggerated about her marriage is not how well they mended it after Monicaâbut how serious a breach there ever was. Even when strains were visibleâor seemed to be, as when they walked to Marine One with Chelsea in between them after the news brokeâin private they for the most part seemed inconceivably at ease. So that if there was any posturing for public consumption going on, it was not in the way we might think. At the time, the word put out by Hillaryland was that the president was in the doghouse and had to win her back. But if that was true, his probationary period was over almost before it began. Peter King, the Republican congressman from Long Island who was working closely with Bill Clinton on the Irish peace process at the time, recalls dreading a trip to Moscow and Ireland that he, Sen. Pete Domenici, and Rep. Steny Hoyer were taking with the Clintons right after the post-Monica Martha's Vineyard vacation that everyone assumed had been a disaster: "We were leaving from Andrews [Air Force Base], and they were coming directly from Martha's Vineyard, and everybody was kind of nervous because no one knew what to expect. But they came on the plane like the two happiest people in the world, laughing and joking, and it seemed legit. They came holding hands and kidding each other. Steny likes to sleep on the floor on the plane, and she's joking, 'They're going to say we're sleeping with Steny.' I've seen people trying to pretend everything's great when it isn't, and it wasn't that; it wasn't forced."
King voted against Clinton's impeachment and spoke to him regularly during that period. He says mending fences with his wife seemed like the last thing on the president's mind. "I had maybe 20 conversations about impeachment and five seconds were about her. He'd say, 'I've gotta work it out with this Senator and that one, and, yeah, with Hillary, too.' " Which King took not as evidence that the president didn't care, but that she didn't particularly need propping up: "He made it sound like she was being pretty decent about it. I'm not into psychobabble, but whatever complexities they have, it is not an arrangement; they seem to need each other's reassurance."
A friend of mine who is a therapist notes that for people who either were raised by a highly critical parent, like Hillary's dad, or were inappropriately enmeshed in messy grown-up problems, as Bill was, it's run-of-the-mill to wind up more comfortable in a relationship when triangulatingâyes, that was the word she usedâwith some third party or crusade or common enemy to take the pressure off the primary relationship. At this moment in their lives, they are certainly united in their anger. Though in the past aides found him lighter and her less trusting, he's grown more like his wife in that regard in recent years.
And in this campaign, they've come full circle, with him overreacting to perceived slights and her marching on, head aloft no matter what. Their longtime friend Max Brantley, editor of the alt-weekly Arkansas Times, even gives the press corps backhanded credit for lighting the candles, pouring the champagne, and locking them in the bunkerâwhere they do best together: "My sense is they may be closer than ever. They're embattled and really haven't gotten a fair shake in the media, and that's drawn them together. They've made a mistake whining about itâthat's not how the game is played. â¦ But they're in the Alamo, and it's a common-purpose kind of thing."
Should Hillary prevail, of course, Bill will have his restoration and she her turn. Should she lose, they will almost certainly try again in four or eight years. To ask what would keep them together in the absence of a presidential campaign is the wrong question. Because win or lose, the campaign for their dual, inextricably intertwined legacy will never be over. And, win or lose, they'll fight on together.
Heart failure, defined as an impairment that prevents the heart from adequately perfusing body tissues to meet metabolic demands, is a major health problem that affects between 2 and 3 million Americans. With 400,000 new cases of HF diagnosed annually, the cost to the U.S. health care system is considerable, since HF is the primary reason for an estimated 1 million hospitalizations per year. In 1990, HF was responsible for approximately $10 billion in direct (e.g., hospitalization) and indirect (e.g., prolonged nursing home stays) costs.
HF has a poor prognosis. After the onset of symptoms, the five-year mortality rate in patients with HF-based on data from the Framingham Heart Study-is 62 percent in men and 42 percent in women, with 200,000 deaths attributable to HF each year in the United States alone.
Traditionally, HF has been thought to be a result of an impairment of systolic (inotropic) function, which is a reflection of decreased contractility of myocardial cells, most common in the left ventricle. More recently, impaired left ventricular (LV) filling, or diastolic dysfunction, has also been recognized as a significant contributor to the development of HF and is a reflection of reduced ventricular compliance related to scar tissue, ischemia, or hypertrophy of normal myocardial cells. Many cases of HF have components of both systolic and diastolic dysfunction.
Figure 1 Schematic illustration of selected types of hypertrophic responses. In A, the left ventricular dimensions are normal. With end-stage systolic dysfunction (B), cardiac chamber wall thickness remains the same or decreases in association with generalized dilatation of several cardiac chambers. Contractile activity is globally reduced. In lesser degrees of systolic dysfunction, contractility is reduced, but cardiac chambers do not necessarily demonstrate marked dilatation. In pure diastolic dysfunction (C), symmetric thickening of the IVS and LVFW occurs at the expense of left ventricular cavitary volume. Cardiac contractility is typically preserved, if not increased, resulting in corresponding preservation (or increase) in ejection fraction. However, overall cardiac output is reduced because the ventricle never completely fills.
IVS = interventricular septum;
LA = left atrium; LV = left ventricle;
LVFW = left ventricular free wall;
RA = right atrium; RV = right ventricle.
In HF due to systolic dysfunction, the left ventricle is enlarged and overstretched (i.e., thinned) (Figure 1B; Figure 1A corresponds to a normal heart). Systolic dysfunction is the result of decreased cardiac contractility, which causes low cardiac output. Common causes of systolic dysfunction include scarring due to mycardial infarction and viral cardiomyopathy. The heart in end-stage HF due to systolic dysfunction is easily recognized on echocardiography as a Ãbig, baggy heart.
In HF due to diastolic dysfunction, cardiac contractility is preserved or even increased (Figure 1C). The thickened and stiffened ventricle limits the amount of blood that can enter the heart, resulting in decreased ventricular filling during diastole. Ventricular dysfunction is often mixed, however, and has elements of both systolic and diastolic dysfunction.
Unfortunately, the physical examination will usually not allow the physician to reliably distinguish between systolic and diastolic dysfunction. Sometimes, a laterally displaced, dilated point of maximum impulse (PMI) may suggest that HF has a component of systolic dysfunction. On the other hand, in pure diastolic dysfunction, the PMI is not typically displaced or dilated, albeit the impulse may be abnormally sustained in duration.
It is important to recognize that diastolic and systolic dysfunction often overlap and may occur in the same patient. As an example, hypertensive patients commonly develop concentric hypertrophy with diastolic dysfunction as a result of the increase in afterload associated with persistent hypertension. If the hypertension is not controlled, LV function eventually deteriorates, and systolic dysfunction becomes superimposed on the initially hypertrophied left ventricle. Eventually, the left ventricle dilates and the diastolic dysfunction present in the early HF of hypertension evolves to dilated cardiomyopathy, so that the component of diastolic dysfunction may no longer be recognized.
Myocardial function is controlled by preload, afterload, ventricular contractility, heart rate, and heart rhythm. In HF, impaired heart function results in hemodynamic stress in the form of falling cardiac output. This stress unleashes a series of interdependent acute and chronic compensatory events, all of which are intended to maintain perfusion to vital organs.
Myocardial cell hypertrophy and increased LV wall thickness resulting from HF are accompanied by decreased ventricular compliance (increased ventricular stiffness), and, in the elderly, increased vascular resistance. The ensuing structural deterioration transforms the left ventricle from its normal elliptical shape to a rounded shape-a process known as remodeling. The rounded, or globoid, heart of late-stage HF may be accompanied by functional mitral regurgitation, ventricular dilatation, and thinning of the ventricular wall.
The functional decrease in cardiac output and atrial hypertension results in arterial hypovolemia that characterizes HF. HF activates the adrenergic (sympathetic) nervous system and the renin-angiotensin-aldosterone (RAA) system, increases release of atrial natriuretic peptide (ANP), may increase the secretion of antidiuretic hormone (ADH) and renal
prostaglandins, and has long-term pathologic consequences.
Early in the course of HF, neurohormonal responses to hypovolemia lead to plasma expansion and selective vasoconstriction. The cardiovascular system compensates for the functional decrease in circulatory volume by shunting blood away from nonvital organ systems (e.g., kidneys, gastrointestinal tract), and by increasing cardiac contractility. Long-term neurohormonal adaptation to decreased perfusion results in desensitization of the heart to sympathetic stimulation, increased impedence to LV outflow, dysfunctional vascular endothelium, impaired glycolysis in fasttwitch muscles, physical deconditioning, and muscle deterioration.
In HF, norepinephrine is chronically elevated due to an increase in release and spillover from the adrenal gland, decreased plasma clearance, and decreased neuronal and non-neuronal reuptake. Norepinephrine increases afterload, causes cardiac arrhythmias, and has a direct toxic effect on the myocardium. There is a direct correlation between norepinephrine levels and both the hemodynamic severity and the poor prognosis of HF.
Decreased cardiac output, characteristic of HF, results in constriction of the kidney's efferent arterioles, which maintain the glomerular filtration rate (GFR). As HF progresses, a point is reached at which further constriction is impossible, and the GFR becomes flowdependent and decreases in tandem with additional decreases in cardiac output.
When the GFR falls, sodium is reabsorbed by the renal tubules, which activates the RAA system. The RAA system plays a key role in regulating blood pressure and vascular tone, and maintaining salt and water homeostasis. Renin, a proteolytic enzyme stored in the juxtaglomerular complex, cleaves angiotensinogen (a glycoprotein formed in the liver) to form angiotensin I. Angiotensin I is split by angiotensin-converting enzyme into angiotensin II, a potent vasoconstrictor that also stimulates the synthesis and secretion of aldosterone, which leads to sodium retention. Activation of the RAA system in HF is thought to occur in steps, as it normalizes in early-stage, compensated HF. As HF worsens, the RAA system is reactivated, and is a major contributor to the relatively intense edema and vasoconstriction typical of decompensated HF.
ADH is produced in the posterior pituitary and promotes renal tubular reabsorption of water by the kidneys in response to decreased plasma volume, as occurs in HF. Although ADH is often increased in HF, its contribution to the vascular dynamics of HF is unclear.
ANP is produced in atrial tissue of the heart in response to atrial stretch from increased blood volume. This causes natriuresis and vasodilation, and counteracts the waterretaining effect of the adrenergic and RAA systems. In early-stage HF, the vasodilatory response of peripheral arteries to ANP is preserved, but it becomes blunted as the HF enters a decompensation phase, an effect attributed to the down-regulation of ANP receptors.
One of the compensatory responses to the chronic overstimulation of the sympathetic nervous system (SNS) and the RAA system is an increased release of prostaglandins, resulting in peripheral vasodilation.
It is essential to keep in mind that mild HF is not necessarily the same as early-stage HF. Mild HF suggests that the patient's ability to function is only "mildly" affected. Earlystage HF, on the other hand, refers to the duration of pathogenic events that occur in the compensated phase of HF.
It is also important to emphasize that LV dysfunction does not always progress in a predictable fashion, nor is the degree of LV dysfunction necessarily paralleled by the clinical severity of symptoms. Some patients may present with significant symptoms of HF, yet only have minimal alteration of LV function. Other patients with only mild symptoms may come to medical attention in later stages of HF, which reflects the efficacy of the body's compensatory mechanisms.
For practical purposes, HF may be divided into high-output failure, which is usually secondary to other, noncardiac conditions, and low-output failure, which is primarily due to cardiac pump failure. High-output HF is very unusual in clinical practice and may be due to a marked hyperdynamic circulation with minimal functional myocardial abnormalities, in which the demand outstrips the capacity, resulting in a hyperkinetic state.
In low-output HF, the cardiac output falls below the tissue requirements for oxygen. It is associated with increased vascular resistance and oxygen consumption, decreased cardiac index and oxygen saturation, and lactic acidosis. Low-output HF may be "forward," in which oxygenated blood does not reach peripheral tissues, or "backward," in which blood backs up in the lungs.
The symptoms of low-output forward HF include weakness, fatigue, lethargy, lightheadedness, and confusion. In decompensated HF, cardiac cachexia, which is characterized by generalized exhaustion and loss of lean muscle mass, ensues. The symptoms of lowoutput backward, or congestive, HF reflect pulmonary edema, in which fluids accumulate in the lungs and result in dyspnea, initially only on exertion. Decompensated low-output backward failure is characterized by orthopnea and paroxysmal nocturnal dyspnea.
The clinical findings in HF include peripheral edema, rales, S3 gallop, sinus tachycardia, hypotension, increased jugular venous pressure, and hepatojugular reflux. Despite the presence of one or more of these signs, HF may be misdiagnosed in up to 40 percent of patients. The severity of HF can also be evaluated with chest radiography. Chest films may demonstrate cardiac enlargement, interstitial and alveolar edema, and pulmonary vascular redistribution in HF. However, HF may also be misdiagnosed using x-ray studies. Therefore, all patients suspected of having HF should be evaluated by two-dimensional echocardiography and Doppler studies to determine LV contractility, ventricular compliance, hypertrophy, and the presence or absence of other underlying conditions, such as valve pathology.
HF is a syndrome that consists of a constellation of symptoms evoked by a wide range of conditions and precipitating factors (Table 1). Its management hinges on correction (when possible) of precipitating factors, treatment of acute symptoms, and compliance with long-term strategies that are intended to prolong survival.
Echocardiography in its current form, has becomean invaluable tool in a modern cardiac intensive care unit environment. Coupled with a clinical examination and monitoring techniques, echocardiography can provide real-time rapid and reliable diagnostic answers that are invaluable to patient care. This noninvasive test can be used to reliably evaluate cardiac anatomy of both normal hearts and those with congenital heart disease and has replaced cardiac angiography for the preoperative diagnosis of the majority of congenital heart lesions. In congenital or acquired cardiac disease, echocardiography may be further used to estimate intracardiac pressures and gradients across stenotic valves and vessels, determine the directionality of blood flow and pressure gradient across a defect, and examine the coronary arteries. Within the realm of critical care, echocardiography is useful to quantitative cardiac systolic and diastolic function, detect the presence of vegetations from endocarditis, and examine the cardiac structure for the presence of pericardial fluid and chamber thrombi. As with all tools, however, a thorough understanding of its uses and limitations are necessary before relying upon the information it provides.
Principles of Echocardiography
Echocardiography uses ultrasound technology to image the heart and associated vascular structures. Ultrasound is defined as sound frequencies above the audible range of 20,000 cycles per second. The primary components of an ultrasound machine include a transducer and a central processor. The transducer converts electrical to mechanical (sound) energy and vice versa. Electrical energy is applied to piezoelectric crystals within the transducer resulting in the generation of mechanical energy in the form of a series of sinusoidal cycles of alternating compression and rarefaction. The energy produced travels as a directable beam which may be aimed at the heart. The sound beam travels in a straight line until it encounters a boundary between structures with different acoustical impedance, such as between blood and tissue. At such surfaces, a portion of the energy is reflected back to the same crystals within the transducer, and the remaining attenuated signal is transmitted distally. Within the ultrasound, machine is circuitry capable of measuring the transit time for the beam to travel from the transducer to a given structure and back again then calculate the distance traveled. A cardiac image is constructed from the reflected energy, or so called ultrasound echoes.
Differing properties of tissues affect the portion of acoustic energy transmitted versus reflected. For example, air reflects the majority of the signal it receives and, therefore, prevents images from being obtained through windows where it is present. Anything hindering or augmenting the reflection of this acoustic signal, such as air, bone, dressings, an open chest, or lines, tubes, or other foreign bodies, will diminish the overall quality of the examination. Therefore, in the intensive care unit, an ultrasound study may be limited by difficulty in finding a good acoustic window to allow for accurate analysis.
The Anatomical Echocardiographic Examination
In order to obtain the best imaging windows, whenever possible, patients are placed in a left lateral decubitus position during a transthoracic echocardiogram. During two-dimensional (2D) echocardiography, all planes are described in reference to the heart and not the heartâs position within the body. For a complete pediatric study, standard views (see Fig.1â5) are obtained from the high left chest just lateral to the sternum (parasternal window), the left lateral chest just inferior and lateral to the nipple (apical window), sub-xyphoid area (subcostal window), and the suprasternal notch (suprasternal window). In patients with more complex anatomy, additional windows, such as the high right parasternal border, may be used to obtain additional information.
Fig.1 Standard echocardiographic image planes from the high left chest just lateral to the sternum (parasternal window (a) and (b)), the left lateral chest just inferior to the nipple (apical window (c)), sub-xyphoid area (subcostal window (d)), and the suprasternal notch (suprasternal window (e) and (f)). RA right atrium; RV right ventricle; LA left atrium; LV left ventricle; Ao aortic valve; CS coronary sinus; RVOT right ventricular outflow tract; SVC superior vena cava (drawing from Steven P. Goldberg, MD)
1. Parasternal Window
In the anatomically normal heart, the parasternal window allows visualization of the heart aligned along its long axis and short axis. In the long axis (Fig.1a), the left ventricular inflow and outflow tracts can be seen well. As a result, comments can be made from this view regarding the aorta, including its annulus, the sinuses of Valsalva, and the proximal portion of the ascending aorta, as well as its relationship to the mitral valve. Additionally, the ballet-slipper appearance of the left ventricle is featured as the inferoposterior wall and interventricular septum are visualized. The anterior and posterior leaflets of the mitral valve can be visualized. By angulating the transducer and performing a sweep, the right ventricle is brought into focus and an examination of both its inflow including the right atrium and tricuspid valve and its outflow tract, including the pulmonary valve can be performed.
The transducer may be rotated 90Â° providing a series of short-axis views (Fig.1b) that assist in the evaluation of the chambers of the heart, the semilunar and atrioventricular valves, and the coronary arteries. Sweeping from the apex of the heart toward the base will allow a close cross-sectional examination of the ventricular chambers. The normal left ventricle has circular geometry with symmetric contraction, whether it is visualized at the level of the mitral valve, papillary muscles, or apex. In contrast, the normal right ventricle appears as a more trabeculated crescent-shaped structure when visualized at or below the level of the mitral valve. Sweeping farther toward the base of the heart, the mitral valveâs papillary muscles and the valve itself are viewed. Progressing to the base of the normal heart, the tri-leaflet aortic valve takes the center stage with the right ventricular outflow tract and pulmonary wrapping in an inverted âUâ anteriorly and leftward. Additionally a portion of the atrial septum and the tricuspid valve may be profiled. Finally, continuing the sweep allows for the examination of the atrial appendages, ascending aorta in cross-section and branch pulmonary arteries.
2. Apical Window
For those not trained in echocardiography, the images obtained with the transducer in the apical position (Fig.1c) are perhaps the most intuitive as it allows for visualization of all four chambers and valves in the heart with a simple left-to-right orientation. Imaging is begun in the four-chamber view, in which the anatomic right and left ventricles may be identified. Sweeps of the transducer from this position identify the posterior coronary sinus and may indicate abnormalities such as a left superior vena cava or unroofed coronary sinus. Proceeding more anteriorly to a five-chambered view, the atrial and ventricular septa may be visualized looking for defects and the left ventricular outflow tract and ascending aorta may be examined. The four chamber view allows for the examination of the anterior and posterior mitral valve leaflets and pulmonary veins as they enter the left atrium. By rotating the transducer to 90Â° from the four-chamber view, a two-chamber view of the left ventricle and left atrium can be obtained to evaluate the anterior and posterior left ventricular wall function.
3. Subcostal Window
For pediatric patients with complex cardiac anatomy, the subcostal position (Fig.1d and Fig.1.e) provides the most detailed information and is often thebest starting place. In order to obtain images in this position, patients are placed supine with the transducer in the subxiphoid position. In larger cooperative patients beyond the infancy period, image quality may be improved by having the patient participate in the examination with held inspiration that allows the heart to move downward toward the transducer. Initial views in this position should determine visceral situs as well as the relationship of the inferior vena cava and aorta. Subsequent views and sweeps will provide detailed analysis of the atrial septum as well as the images related to the ventricular septum, the atrioventricular valves, atrial and ventricular chambers, and drainage of systemic veins. With the rotation of the transducer both ventricular outflow tracts may be visualized. Additionally in some patients the branch pulmonary arteries and the entire aorta may be examined from this position.
4. Suprasternal Window
The views are obtained in this position by placing the transducer in the suprasternal notch (Fig.1.f) with the neck extended. The suprasternal longand short-axis views provide detailed information regarding arch sidedness, anomalies in the ascending and descending aorta and head and neck vessels, the size and branching of the pulmonary arteries, as well as anomalies of systemic and pulmonary venous systems.
One of the earliest applications of ultrasound technology that remains an important tool in the evaluation of cardiac function, dimension, and timing, the M-mode echo provides an âice-pickâ view of the heart. An M-mode echo is obtained with the ultrasonic transducer placed along the left sternal border and directed toward the part of the heart to be examined. A single line of interrogation is repeatedly produced and the resultant image is displayed with time along the x-axis and distance from the transducer along the y-axis (see Fig. 2). M-mode obtains an estimate of ventricular function by measuring the short axis shortening fraction and wall thickness.
Fig.2 M-mode echocardiography obtained in the parasternal short axis through the right and left ventricular chambers at the level of the papillary muscles. LVEDD left ventricular end-diastolic dimension; LVESD left ventricular end-systolic dimension
Frequently in an intensive care setting the clinician is concerned with new or residual flow disturbances from shunt lesions, an abnormal cardiac valve, or narrowing of a blood vessel. While 2D echocardiography determines anatomical relationships, additional information regarding movement of the blood or myocardium is provided by looking for Doppler shifts in the reflected ultrasound waves. The Doppler principle, first described by Johann Christian Doppler, states that for a stationary object, the frequency of ultrasound reflected is identical to the transmitted frequency. Inherently the heart and the blood it pumps do not fit this basic definition. Therefore, when performing a cardiac ultrasound, the moving objects alter the frequency of the reflected signal (the Doppler shift) according to the direction and velocity with which they are moving in relation to the fixed transducer. Additional insights to intracardiac and vascular hemodynamics may be obtained when velocity data is collected. Doppler data are typically displayed as velocity rather than the actual frequency shift. The velocities can then be translated into pressure data using the modified Bernoulli equation: P1 â P2= 4[(V2)2 â (V1)2]. If one assumes that the level of obstruction and therefore the velocity of V1 is negligible compared with the obstruction at V2 the formula becomes even simpler: DP = 4(Vmax)2. Although the modified Bernoulli equation can only be applied in appropriate situations, it does help predict the pressure drop across an abnormal valve or septal defect to give a general estimate of the severity of the lesion which can prove to be valuable information to help manage patients in the intensive care setting.
Of note, during Doppler imaging it is clinically important to recognize the angle of interrogation of blood flow and its impact on the accuracy of our velocity measures. It is important when performing Doppler studies that the line of beam interrogation should be directly in the line of flow, resulting in as little distortion of data as possible. The more off-angle the approach is, the increasingly more severe the underestimation of the true velocity will be. For practical purposes, an angle of interrogation less than 20Â° is essential to ensure clinically accurate information.
Two commonly used techniques are pulsed and continuous wave Doppler. Pulse wave Doppler allows determination of direction and velocity at a precise point within the imaged cardiac field. However, it is limited in its maximum detectable velocity by the Nyquist limit making it unusable for quantification of high-velocity flow (e.g., as seen with severe obstruction). In contrast, continuous wave Doppler interrogates all points along a given beam. Continuous wave Doppler imaging is not constrained by velocity limits and can hence record velocities exceeding those of pulsed Doppler imaging. The drawback is that while the line of interrogation is identifiable, knowledge of anatomy must already be obtained to identify the precise location of the maximum velocity. Clinically these two techniques are commonly used sequentially to identify the area of interest and then to obtain the maximum velocity.
1. Color Flow Doppler
Color flow Doppler is powerful technique for obtaining additional hemodynamic and anatomic data for patients undergoing echocardiography in the intensive care unit. Color flow Doppler allows velocity information to be overlaid on a 2D anatomic image therefore providing data regarding intracardiac and extracardiac shunts, valvar insufficiency or stenosis, and vessel obstruction. By convention, shades of red are used in identifying blood flowing toward the transducer and blue to indicate blood flowing away from the transducer. Therefore, color flow Doppler defines the presence and direction of shunts and is used to grade the severity of valvar insufficiency.
Current Clinical Applications
Clinical applications of echocardiography within the intensive care unit may be divided into the following major areas:
1. The diagnosis and post-intervention evaluation of anatomic lesions.
2. Evaluation of cardiac function.
3. Diagnosis of intracardiac masses and extracardiac effusions.
4. Guidance of intervention within the intensive care unit
Anatomic Lesions Pre and Post Intervention
Advances in technology have enabled most congenital heart defects to be diagnosed by echocardiography avoiding the risks, time, and cost of invasive cardiac catheterization. In addition, for infants and pediatric patients admitted to an intensive care unit due to being succumbed to shock, echocardiography may be useful for differentiating anatomic causes of shock from functional causes. Patients with obstruction to outflow on the left side of the heart who go undiagnosed at birth frequently present with signs of diminished cardiac output (CO) or frank shock. These lesions including aortic valve stenosis, coarctation of the aorta, and variations of hypoplastic left heart syndrome may be identified and defined by echocardiogram alone.
Following surgical or catheter-based intervention patients convalesce in the intensive care unit. Most patients undergo a postprocedural echo before getting discharged home to document adequacy of the repair and lack of significant complications. In postoperative patients this assessment may prove more complicated as access to the patient and the correct windows may be severely compromised by dressings, intracardiac lines, and chest tubes. Occasionally postoperative patients in the intensive care unit may be found to have unexpected residual lesions (see Fig.3). For example, following repair of septal defects, echocardiography may be useful to screen for the presence of residual shunts which may be less well tolerated secondary to myocardial changes following cardiopulmonary bypass. Often, the presence of a residual lesion is known in the operating room through transesophageal echocardiography or direct discussion with the surgeon. An important role of echocardiography is to distinguish those lesions with hemodynamic consequences from those whose presence has no impact on postoperative care. Transthoracic echocardiography may be used to diagnose and assess the hemodynamic sequelae of shunt lesions, residual stenosis, and function. More complicated is the assessment of coronary flow, right ventricular dynamics, and distal obstruction following intervention. In patients who are experiencing arrhythmias postoperatively, special attention should be paid to the flow within the coronary arteries to ensure that it has not been compromised or that a line or mass in the heart is not causing ectopy.
Fig.3 Parasternal short axis image in a patient with pulmonary atresia/VSD who acutely decompensated. White arrows demonstrate the large residual VSD than resulted when a patch dehisced. RA right atrium; RV right ventricle; AV aortic valve
Fig.4 (a) and (b): Four chambered view demonstrating color Doppler of tricuspid regurgitation and the corresponding spectral Doppler pattern. The velocity obtained by spectral Doppler may be utilized to estimate pulmonary artery pressures in the absence of downstream obstruction. A complete envelope by pulse wave or continuous wave Doppler provides the velocity of the regurgitant jet which may be translated into pressure data using the equation: DP = 4(Vmax)2. RA right atrium; RV right ventricle; LA left atrium; LV left ventricle.
Unanticipated pulmonary arterial hypertension may slow the progress of a patient in the intensive care unit. In the absence of a Swan Ganz catheter or a direct pulmonary arterial monitoring, echocardiography may be used to estimate the pulmonary artery pressures. There are several methods that may be used to determine the pulmonary artery pressures. In a patient with
tricuspid regurgitation, the velocity of the jet estimates the difference in pressure in the right atrium and the right ventricle (see Fig.4). If there is no stenosis of the pulmonary arteries, pulmonary valve, or right ventricular outflow tract, the difference in pressure between the right atrium and right ventricle plus the right atrial pressure (CVP) provides an estimate of the pulmonary arterial pressures. In the absence of tricuspid valve insufficiency, interventricular septal geometry may be used to help quantify the degree of pulmonary hypertension.
Analysis of Ventricular Function
One of the most frequent uses of echocardiography in the ICU is related to the evaluation of ventricular performance. Improvements in technology allow assessment of both systolic and diastolic function with increasing accuracy.
1. Systolic Function
Accurate and timely assessment of systolic function should be an integral part of the medical management of the hemodynamically unstable critically ill patient. Global assessment of LV contractility includes the determination of ejection fraction (EF), circumferential fiber shortening, and cardiac output (CO). There are several methods that may be used to garner this information. Each has its limitations and assumptions which are paramount to understand prior to clinically applying the information gathered. For assessment of left ventricular function, perhaps the simplest quantitative approach is to use M-mode echocardiography (see Fig.3) in either the parasternal short axis at the level of the papillary muscles or in the parasternal long axis at the tips of the mitral valve leaflets to measure the left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD) for the determination of the fractional shortening (FS) percentage.
Fractional shortening is derived by the following:
Normal values for fractional shortening in children and infants vary slightly with age, falling typically between 28 and 44%.
Fractional shortening, therefore, provides a method of assessing circumferential change but has several obvious drawbacks. This method assumes that the ventricle being examined has a circular shape in the axis in which it is examined. As a result, changes in diameter may be mathematically related to circumferential fiber-shortening providing an estimate of ventricular function. Therefore anything that alters the circular shape of the left ventricle (anatomic abnormalities intrinsic to congenital heart disease, pre and afterload changes, or ventricularâventricular interactions) may affect the assessment of fractional shortening by altering the movement of the septum and causing an under or over estimation of the either end-systolic or diastolic dimension.
A second method of assessing ventricular function is via ejection fraction. Ejection fraction is a volumetric appraisal of ventricular fiber shortening. Echocardiographically the most common method of calculating ejection fraction is the biplane estimation of volumes from the apical four-and two-chamber views. One of the more commonly used mathematical algorithms is the Simpson method in which the left ventricle is traced manually at the end diastole and end systole along the endocardium. Using the method of disks the left ventricle is divided into a series of parallel planes and the resultant disks are individually summed to create each volume. Ejection fraction is calculated using the following equation:
Unfortunately, the determination of an accurate ejection fraction is also subject to ventricular shape with the left ventricle assumed to be its normal prolate elliptical shape. Variations from this shape, which occur frequently in pediatrics, significantly alter the relationship between fiber shortening and volume dependence upon when this equation is applied. In addition, patients in the intensive care environment frequently have suboptimal imaging windows making the endocardium difficult to distinguish and trace.
Not infrequently in active pediatric intensive care units, a patientâs heart and/or lung function must be supported for a period of time. Two such modalities of support are extracorporeal membranous oxygenation and ventricular assist devices. Often the pediatric echocardiographer is asked to assist in the management of these patients by providing insight into the recoverability of cardiac function. This request can be one of the more challenging uses of echo in an intensive care setting. As discussed above, many of the techniques commonly used to determine ventricular systolic function and CO are dependent on the loading conditions of the heart as well as contractility. As a result, both of these support systems which unload the heart in an effort to allow recovery time severely limit echoâs utility as a prognostic indicator. Several newer methods of determining myocardial function including Tissue Doppler Imaging (TDI), strain and strain rate, color m-mode, calcium gating, and three-dimensional (3D) echocardiography are entering the realm of echo in the intensive care unit. These newer modalities may prove to be more efficacious than current standard echocardiography is at present.
Accurate assessment of diastolic function by echocardiography is an evolving field that has made great strides in the past few years. Diastolic heart failure and its impact on postoperative management also deserve consideration. Spectral Doppler evaluation is a relatively easy and useful method for evaluating diastolic function noninvasively at the bedside. A prominent pulmonary vein atrial reversal wave (a wave) is a marker of diastolic dysfunction. This finding represents marked flow reversal into the pulmonary veins during atrial systole in response to a noncompliant ventricular chamber. The mitral inflow Doppler pattern can also be a useful marker for diastolic dysfunction. Mitral inflow is composed of 2 waves â an E wave representing early passive ventricular filling (preload dependent) and the A wave representing active filling as a result of atrial systole. The E:A ratio, velocity of E wave deceleration and duration of the A wave can be altered in patients with diastolic dysfunction.
Tissue Doppler imaging (TDI) is a newer technique for assessing diastolic ventricular function. TDI allows recording of the low Doppler velocities generated by the ventricular wall motion and directly measures myocardial velocities. In spectral TDI, pulsed Doppler is placed along the myocardial wall (mitral, septal, or tricuspid annulus) recording the peak myocardial velocities. Three waveforms are obtained: a peak systolic wave (Sa), an early diastolic wave (Ea), and an end-diastolic wave (Aa) produced by atrial contraction. The tissue Doppler systolic mitral annular velocity has been shown to correlate with global LV myocardial function . TDI has also been used to estimate diastolic function, and is relatively independent of preload condition. The pulsed Doppler peak early mitral inflow velocity (E) divided by the TD early diastolic mitral annular velocity (Ea) results in a ratio that correlates with the pulmonary capillary wedge pressure. The E/Ea ratio is also useful in estimating mean LV filling pressure. At this time, TDI represents one of the most accurate techniques to assess diastolic function and is therefore of particular interest in the critical care population in whom abrupt changes in preload and afterload are common, making Doppler evaluation of diastolic function less reliable.
Detection of Intracardiac Masses and Extracardiac Effusions
An abnormal area of dense reflectance that is well localized within an echo may represent a mass, thrombus, or calcification. In the postoperative or critical care patient with multiple lines in place, especially in the setting of low flow, care must be taken to evaluate these areas for thrombus formation. Echo is the imaging modality of choice for elucidating and evaluating cardiac mass lesions. Differentiating an area of concern from artifact, can be challenging. Areas that move appropriately throughout the cardiac cycle and the presence of an abnormality in more than a single view, suggest a mass rather than an artifact (see Figs. 5aâd). These findings must in turn be distinguished from such anatomical variations as a prominent Eustacian valve or Chiari network.
Fig.5 Demonstrate a thrombus in the right ventricle seen in parasternal short axis (a) and modified four-chamber (b) views. RV right ventricle; LV left ventricle. (c) and (d): Demonstrate a thrombus in the left atrial appendage in both parasternal short axis and a modified four chamber views. RA right atrium; RV right ventricle; AV aortic valve; AO ascending aorta; LV left ventricle.
Major factors that predispose a patient to the development of intracardiac thrombi are the presence of intracardiac lines, diminished CO, and localized stasis in addition to changes within the clotting cascade from sepsis, bypass, intrinsic clotting disorders, or heparin use. Echocardiographic evaluation of patients within the intensive care setting must include an awareness of the increased incidence of thrombus formation and a careful evaluation of areas predisposed to become a nidus for thrombus.
Following cardiac surgery it is not uncommon for patients to develop small collections of fluid in the pericardial space (see Fig.6). Typically, this is of little concern to the clinician; however, in a postoperative patient experiencing tachycardia and/or hypotension, the necessity of recognizing the potential for and screening for cardiac tamponade becomes paramount. In young infants and children, it is frequently difficult to rely on physical exam findings of increased jugular venous pressure or the late finding of pulsus paradoxus. In this instance, a directed and easily performed 2D and Doppler echocardiography can confirm the presence of an effusion and provide accurate assessment of its hemodynamic significance.
Fig.6 Subcostal image demonstrating a large circumferential pericardial effusion (green arrows)
The size and extension of a pericardial effusion may be diagnosed from parasternal, apical, or subcostal windows. The apical view is the easiest for obtaining information regarding the effusions hemodynamic significance. From the apical four chamber view both the mitral and tricuspid valve flow patterns are evaluated with the respiratory monitoring in place. Examining the changes in inflow hemodynamics with respiration allows for the evaluation of tamponade physiology. Greater than 25% variability in maximal e wave velocity of the mitral valve with inspiration or 50% of the e wave velocity of the tricuspid valve (see Figs.7a, b) is indicative of significant hemodynamic compromise resulting from the effusion. Additionally, collapse (differentiated from contraction) of the free wall of the right and left atrium (see Figs.8a, b) when the pericardial pressure exceeds the atrial pressure may be seen from this view in a patient with a significant effusion.
Fig.7 (a) and (b): Respiratory changes in the mitral and tricuspid valve e wave Doppler patterns consistent with tamponade physiology. The tricuspid valve inflow demonstrates more than 50% variability between inspiration and expiration (a). During mitral valve inflow Doppler, the peak E wave velocity alters more than 30% between inspiration and expiration (b).
Fig.8 (a) and (b): Four chambered views demonstrating right atrial and right ventricular collapse (green arrows) as a finding of tamponade physiology. RA right atrium; RV right ventricle; LA left atrium; LV left ventricle.
Performing âblindâ percutaneous pericardiocentesis as a treatment for significant pericardial effusion dates back to the early eighteenth century and it is historically fraught with complications. Improved techniques in the 1970s with the advent of 2D echo allowed more accurate localization of the fluid and the development of echo-guided pericardiocentesis. Echo-guided pericardiocentesis (see Fig.9) has been found to be a safe and effective procedure with insertion of a catheter for drainage used to reduce the rate of recurrence found to complicate simple needle drainage and is considered the primary and often the definitive therapy for patients with clinically significant effusions.
Fig.9 Echoguided pericardiocentesis. Green arrow is in the pericardial space demonstrating the large fluid collection. Blue arrow is pointing to the needle that has been advanced into the pericardial space to drain the fluid collection. The large effusion allows the echocardiographer to direct the individual performing the pericardiocentesis away from areas that could lead to complications such as perforation of the myocardium.
2. Balloon Atrial Septostomy (BAS)
Part of any echocardiographic assessment of a patient with congenital heart disease should include evaluation of the atrial septum. Cardiac lesions such as transposition of the great arteries, hypoplastic left heart syndrome, and tricuspid atresia require an adequate atrial communication. In the setting of a restrictive atrial septal communication or intact septum, a BAS is required to improve mixing and CO. In the past, the procedure, originally described by William Rashkind was performed in the cardiac catheterization laboratory under fluoroscopic guidance. However, during the last decade BAS has been routinely performed at the bedside in the intensive care unit under echocardiographic guidance (see Figs.10aâd). Most commonly either a subcostal view that includes a focused look at the atrial septum, pulmonary vein, and mitral valve or an apical four-chamber view is used. For the echocardiographer, the primary role is to provide continued visualization of the catheters and communicate well with the interventionalist. Advantages of this technique are multifactorial; echocardiography is superior to fluoroscopy during BAS due to a lack of radiation, the ability to perform the procedure at bedside rather than transporting to a catheterization laboratory, and direct, continuous visualization of the atrial septum, pulmonary veins, and mitral valve. The disadvantages of this technique include the potential for interference with maneuverability for both echocardiographer and catheter operator around a small neonate and therefore the risk of contamination of the sterile field. Additionally there is the possibility of poor acoustic windows in an ill neonate who may be mechanically ventilated. However, with proper planning and communication, the limitations of transthoracic echocardiographic guidance of BAS may be minimized.
Fig.10 Subcostal images demonstrating echo-guided balloon atrial septostomy (BAS). (a): shows the initial small atrial communication in both 2 dimensional (2D) and color Doppler imaging. (b): reveals the deflated balloon that has been advanced across the atrial communication. It is important during this portion of the procedure for the echocardiographer to ensure that the balloon has not been advanced across the left atrioventricular valve. (c): demonstrates the inflated balloon within the left atrium. It is important to note the balloonâs position away from the mitral valve and pulmonary veins. (d): demonstrates the atrial communication following septostomy using both 2D and color Doppler imaging. RA right atrium; RV right ventricle; LA left atrium; LV left ventricle; Green arrows atrial communication.
There are several areas of advanced imaging that are becoming more commonplace in the practice of pediatric echocardiography. Primary assessment of cardiac mechanics by evaluating myocardial motion, strain, and strain rate has been validated in healthy children and provides additional information regarding myocardial performance. Three-dimensional real-time echocardiography has a growing role in evaluating anatomic defects, valves, and right and left ventricular function independently of geometric assumptions that constrained the previous methods.
1. Myocardial Mechanics
In the past several years, myocardial strain and strain rate have emerged as promising quantitative measures of myocardial function and contractility. Strain (e) is a dimensionless parameter defined as the deformation (L) of an object relative to its original length (Lo), and is expressed as a percentage. Strain rate (SR) is defined as the local rate of deformation or strain (e) per unit of time, and is expressed in 1/s. Strain and strain rate measurements can be obtained from data acquired by Doppler Tissue Imaging or 2D tissue tracking. Strain and strain rate should be of great help in the future in the evaluation of ventricular function, since conventional M-mode and 2D echocardiography have limitations due to complex morphology of the right ventricle and altered left ventricle morphology that occurs in complex congenital heart defects. Left and right ventricular values of strain and strain rate are available for healthy children.
2. 3D Echocardiography
Off-line 3D reconstruction consists of acquisition of sequential 2D slices which are converted to a rectangular coordinate system for 3D reconstruction and provides accurate anatomic information suitable for quantitative analysis. Left ventricular volume, mass, and function can be accurately assessed using RT3D independently of geometric assumption, and ejection fraction can be calculated. The wideangle mode is often used to acquire the entire LV volume, from which further analysis allows determination of global and regional wall motion. Wall motion is evaluated from base to apex with multiple slices from different orientations. The advantage of 3D over 2D is the ability to manipulate the plane to align the true long axis and minor axis of the LV, thus avoiding foreshortening and oblique image planes. LV volume assessment by RT3D is rapid, accurate, reproducible and superior to conventional 2D methods and is comparable to MRI, which represents the gold standard. Three dimensional reconstruction of the tricuspid valve has been shown to be helpful for anatomical assessment of Ebsteinâs malformation or after atrioventricular septal defect repair. 3D Echocardiography is a useful adjunct to standard 2D imaging and should be increasingly used in the future.
The classic initial manifestations of an acute MI include prolonged substernal chest pain with dyspnea, diaphoresis, and nausea. The pain may be described as a crushing, pressing, constricting, vise-like, or heavy sensation. There may be radiation of the pain to one or both shoulders and arms or to the neck, jaw, or interscapular area. Only a few patients have this classic overall picture. Although 80% of patients with an acute MI have chest pain at the time of initial examination, only 20% describe it as crushing, constricting, or vise-like. The pain may also be described atypically, such as sharp or stabbing, or it can involve atypical areas such as the epigastrium or the back of the neck. âAtypicalâ presentations are common in the elderly.
The initial manifestations of an acute MI were more likely to include symptoms such as sudden dyspnea, acute confusion,
cerebrovascular events (e.g., stroke or syncope), acute CHF, vomiting, and palpitations. There is strong evidence that a substantial proportion of MIs are asymptomatic. That 28% of infarcts were discovered only through the appearance of new ECG changes (Q waves or loss of R waves) observed on a routine biennial study. These infarctions had been previously unrecognized by both patient and physician.
For the patient with an âuncomplicated MIâ there are few physical examination findings. The main purpose of the examination is to assess the patient for evidence of complications from the MI and to establish a baseline for future comparisons. Signs of severe left ventricular dysfunction include hypotension, peripheral vasoconstriction, tachycardia, pulmonary rales, an S3, and elevated jugular venous pressure. Preexisting murmurs should be verified. A new systolic murmur can result from a number of causes: papillary muscle dysfunction, mitral regurgitation as a result of ventricular dilatation, ventricular septal rupture, and acute severe mitral regurgitation due to papillary muscle rupture.
The classic ECG changes of acute ischemia are peaked, hyperacute T waves, T wave flattening or inversion with or without ST segment depression, horizontal ST segment depression, and ST segment elevation. Changes associated with an infarction are (1) the fresh appearance of Q waves or the increased prominence of preexisting ones; (2) ST segment elevations; and (3) T wave inversions. It is important to recognize that with acute MI the ECG may be entirely normal or contain only âsoftâ ECG evidence of infarction.
In the past infarcts were classified as transmural or subendocardial, depending of the presence of Q waves. This terminology has now been replaced by the terms Q-wave and nonâQ-wave MI. This distinction has more clinical relevance, as several studies have indicated differences in etiology and outcome. The key differences between these two groups are as follows: (1) Q-wave infarctions account for 60% to 70% of all infarcts and nonâQ-wave infarctions for 30% to 40%. (2) ST segment elevation is present in 80% of Q-wave infarctions and 40% of nonâQ-wave infarctions. (3) The peak creatine kinase tends to be higher in Q-wave infarctions. (4) Postinfarction ischemia and early reinfarction are more common with nonâQwave infarctions. (5) In-hospital mortality is greater with Q-wave infarctions (20% versus 8% for nonâQ-wave infarctions). In general, it is thought that the nonâQ-wave infarction is a more unstable condition because of the higher risk of reinfarction and ischemia.
Elevation of the creatine kinase muscle and brain subunits (CK-MB) isoenzyme is essential for the diagnosis of acute MI. In general, acute elevations of this enzyme are accounted for by myocardial necrosis. Detectable CK-MB from noncardiac causes is rare except during trauma or surgery. The peak level appearance of CK-MB is expected within 12 to 24 hours after the onset of symptoms; normalization is expected in 2 to 3 days. Therefore patients should have a CK-MB level determined on admission and every 8 to 12 hours thereafter (repeated twice). Reliance on a single CK assay in an emergency room setting to rule out MI is not sensitive and should be discouraged. Cardiac troponins (T and I) are newer markers for cardiac injury. The troponins first become detectable after the first few hours following the onset of myocardial necrosis, and they peak after 12 to 24 hours. Normalization of troponin T levels requires 5 to 14 days; troponin I levels requires 5 to 10 days.
The main priority for patients with an acute MI is relief of pain. The frequent clinical observation of rapid, complete relief of pain after early reperfusion with thrombolytic therapy has made it clear that the pain of an acute MI is due to continuing ischemia of living jeopardized myocardium rather than to the effects of completed myocardial necrosis.
Effective analgesia should be administered at the time of diagnosis. Analgesia can be achieved by the use of sublingual nitroglycerin or intravenous morphine (or both). Sublingual nitroglycerin is given immediately unless the systolic blood pressure is less than 90 mm Hg. If the systolic blood pressure is under 90 mm Hg, nitroglycerin may be used after intravenous access has been obtained. Longacting oral nitrate preparations are avoided for management of early acute MI. Sublingual or transdermal nitroglycerin can be used, but intravenous infusion of nitroglycerin allows more precise control. The intravenous dose can be titrated by frequently measuring blood pressure and heart rate. Morphine sulfate is also highly effective for the relief of pain associated with an acute MI. In addition to its analgesic properties, morphine exerts favorable hemodynamic effects by increasing venous capacitance and reducing systemic vascular resistance. The result is to decrease myocardial oxygen demand. As with nitroglycerin, hypotension may occur. The hypotension may be treated with intravenous fluids or leg elevation.
Supplemental oxygen is given to all patients with an acute MI. Hypoxemia in a patient with an uncomplicated infarction is usually caused by ventilation-perfusion abnormalities. When oxygen is used it is administered by nasal cannula or mask at a rate of 4 to 10 L/min. In patients with chronic obstructive pulmonary disease it may be wise to use lower flow rates.
In addition to relieving pain and managing ischemia, thrombolytic therapy must be considered. Thrombosis has a major role in the development of an acute MI. Approximately 66% of patients with MIs have ST segment elevation, making it likely that the process is caused by an occlusive clot. The goal of thrombolytic therapy is reperfusion with a minimum of side effects. The most commonly used thrombolytic agents are streptokinase, anisoylated plasminogen streptokinase activator complex (APSAC), recombinant tissue-type plasminogen activator (rt-PA), urokinase, and pro-urokinase.
Early administration of thrombolytic therapy, within 6 to 12 hours from the onset of symptoms, has been associated with a reduction in mortality. Indications for thrombolytic therapy include typical chest pain >30 minutes but <12 hours that is unrelieved by nitroglycerin, and ST segment elevation in more than two contiguous leads (>1 mm in limb leads or >2 mm in chest leads) or ST segment depression in only V1 and V2 or a new left bundle branch block. Relative contraindications for thrombolytic therapy include history of stroke, active bleeding, blood pressure >180 mm Hg systolic, major surgery/ trauma in the last 3 to 6 months, recent noncompressible vascular puncture, and possible intracranial event/unclear mental status. Wright and colleagues56 present a summary of the major thrombolytic trials. Advances in this therapeutic modality during the past 5 years include new third-generation fibrinolytic agents and various strategies to enhance administration and efficacy of these agents. A number of ongoing trials are attempting to determine whether the combination of fibrinolytic therapy with low molecular weight heparin enhances coronary reperfusion and reduces mortality and late reocclusion. Also presented is a dose and cost summary of the available fibrinolytic agents.
The most common complications of an acute MI are mechanical and electrical. Mechanical complications include those that are quickly reversible and those that are clearly life-threatening. Reversible causes of hypotension include hypovolemia, vasovagal reaction, overzealous therapy with antianginal or antiarrhythmic drugs, and brady- and tachyarrhythmias. Other, more serious etiologies include primary left ventricular failure, cardiac tamponade, rupture of the ventricular septum, acute papillary muscle dysfunction, and mitral regurgitation.
Classification of patients with acute MI.
Class 1: Patients with uncomplicated infarction without evidence of heart failure as judged by the absence of rales and an S3.
Class 2: Patients with mild to moderate heart failure as evidenced by pulmonary rales in the lower half of the lung fields and an S3.
Class 3: Patients with severe left ventricular failure and pulmonary edema.
Class 4: Patients with cardiogenic shock, defined as systolic blood pressure less than 90 mm Hg with oliguria and other evidence of poor peripheral perfusion.
Cardiogenic shock has emerged as the most common cause of inhospital mortality of patients with an acute MI. Despite advances in medical therapy, cardiogenic shock has a dismal prognosis (80â90% mortality). The management of patients with cardiogenic shock includes adequate oxygenation, reduction in myocardial oxygen demands, protection ofischemic myocardium, and circulatory support. The potential for myocardial salvage with emergency reperfusion should be considered in all cases.
The past 30 years has seen major developments in the recognition and treatment of arrhythmias. The most common include the brady- and tachyarrhythmias, AV conduction disturbances, and ventricular arrhythmias. Organized treatment protocols have been developed for each of these dysrhythmias.
Recommendations for pre- and postdischarge evaluations of patients with an acute MI recommendations for testing exercise tolerance and strategies to determine those who would benefit from medical or surgical intervention. These recommendations include a submaximal ETT at 6 to 10 days and at 3 weeks to determine functional capacity.
The goal of cardiac rehabilitation includes maintenance of a desirable level of physical, social, and psychological functioning after the onset of cardiovascular illness. Specific goals of rehabilitation include risk stratification, limitation of adverse psychological and emotional consequences of cardiovascular disease, modification of risk factors, alleviation of symptoms, and improved function. Risk stratification is accomplished by exercise tolerance testing. Additionally, high-risk patients include those with CHF, silent ischemia, and ventricular dysrhythmias. All patients should undergo an evaluation to reduce risk factors (smoking, hyperlipidemia, and hypertension). Risk modification of these factors has been associated with significant reduction in subsequent cardiac events. Enrollment in a cardiac rehabilitation program with particular emphasis on exercise has been shown to reduce cardiovascular mortality.
|Heart Disease and Circulation|
Interest in improving our heart and circulation has never been greater than in our world today. Coronary heart disease leads all other causes of death. Circulatory conditions (including stroke) take even more lives, and force millions into premature retirement, disability, or nursing home care. Thus the prevention and treatment of cardiovascular disease deserves our utmost attention. The fact is that about 750,000 die annually in the United States from heart disease and over 260,000 by stroke. These are prime reasons why the United States today is nowhere near the top of the list (actually 19th) for life expectancy in men compared to other world nations. For women we are 10th from the top of lifespan leaders. Heading the list of degenerative diseases, these fearsome afflictions of the circulation clamor for attention.
The human heart is without doubt the worldâs most amazing pump. About the size of a fist in the average man and weighing less than one pound, it pumps every day the equivalent of 7,000 quarts of blood! This precious fluid, weighing about seven tons, distributes itself through more than 60,000 miles of blood vessels in an average person. During our lifetime, the heart beats two and one half billion times, resting only between beats, and moves some 75,000,000 gallons of blood with all its life-sustaining oxygen and various nutrients!
In actuality, the four chambers of your heart constitute four pumps, with
two pairs working in series, From the vascular circulation of your body â
head, arms, legs, internal organs âblood is brought to the right atrium. Here is located the pacemaker, which begins an electrical impulse every second and initiates the beat of your entire heart, Blood is then pumped into the right ventricle and distributed to both lungs through the pulmonary arteries. Here your blood receives oxygen and gives off carbon dioxide, the two principle gases exchanged in respiration.
The fresh, oxygenated blood then returns to the heart, this time through
pulmonary veins to the left atrium. Blood is thoroughly mixed in this chamber, since some of the blood cells received more oxygen than from other parts of the lungs, depending upon the posture and depth of respiration. Blood then passes through the mitral valve, into the left ventricle, the strongest portion of the heart muscle. Your heartbeat then contracts and propels blood through the aortic semi-lunar valve into the aorta, whence it is distributed to the extremities, brain, and all internal organs. Oxygen in the blood is delivered to cells, aiding the body in respiration, while the waste products carried by the same fluids and blood cells return through the veins to complete the cycle.
A number of diseases can occur affecting this marvelously designed circulatory system. The heart can be affected by inherited or congenital disease. The aftermath of infection with Streptococcal organism can produce a condition known as rheumatic fever with its feared complication, carditis. This may damage heart valves, producing lifelong disability. Infections, as well as malignancies (cancer), can involve the heart. By far the most common affliction is arteriosclerosis, a degenerative disorder affecting the arteries. Since the heart muscle receives blood through its own special system of coronary arteries, it is certainly true for this organ, as for the whole body that âThe life of the flesh is in the blood.â
HOW TO EVALUATE THE HEART
Many signs can reveal the existence of impaired circulation. The color of
the body is extremely important. Since skin color is partially due to blood circulating just beneath it, it is important to compare skin hues in areas where your skin is particularly thin. The conjunctiva of the lower eyelid, the lips, the fingernail beds, and the palms are often valuable indicators of the state of your oxygen supply. A dusky color or bluish cast (cyanosis) indicates an inadequate supply of oxygen in the blood. Cyanosis may be seen in congenital heart afflictions, as is the case with âblue babies.â Sometimes cyanosis develops when the blood is too thick (hemoconcentration) and the flow is sluggish.
Frequently in advanced heart failure, cyanosis will be seen. Deep breathing, sitting upright, or administering oxygen may correct this problem.
The pulse should be examined.It is normally regular and equal from side to side in the respective wrist arteries. Your blood pressure can also indicate the general state of the circulation, as well as the force of contraction in your heart itself. The veins along side your neck also are indicators of cardiac function. Normally little pulse waves are seen, but unusual distention usually means that the right side of the heart is unable to keep up with the demand. Examine the jugular veins
particularly when a patient is sitting upright.
Finally, your heart itself is evaluated by first looking at the chest to see if there are unusual pulsations, then feeling with the hand to detect unusual vibrations or heaves, and finally listening with a stethoscope. The presence of turbulence as the blood flows through the valves is reflected in sounds called murmurs. These can occur during either phase of the heart cycle. Considerable practice is needed to hear these specific sounds and understand their meaning.
Diagnostic tests are frequently performed to evaluate the efficiency of the heart. A chest x-ray can determine enlargement of one or more chambers. The electrocardiogram provides an excellent look at your electrical activity during each cardiac contraction. During exercise your heart rate should increase. An evaluation of the pulse and blood pressure during mild exercise on a motorized treadmill or bicycle (called a stress test) can be extremely helpful in assessing the dynamic function of this marvelous organ. More specialized tests are done in hospitals today, using x-rays, flow studies involving radioactive isotopes, Thallium scanning procedures, and the coronary angiogram which x-rays the heart in rapid sequence while a radiopaque dye is simultaneously injected into a coronary artery or blood vessel. This helps to visualize the heart chambers and vessels, and may indicate the need for surgery.
Hardening of the arteries, or arteriosclerosis, is the most common cause of serious heart disease today. This condition primarily affects your coronary arteries and large vessels. It is a disease intimately related to our fast-paced lifestyle, and principally involves the type of food eaten and other unhealthful habits formed. Arteriosclerosis actually begins in early childhood. Thus our preventive efforts must be directed toward infants and children to truly prevent the relentless progression of this degenerative condition.
Arteriosclerosis develops as our dietary fat intake increases. The modern unhealthful, refined diet uses large amounts of grease, oil, sugar, soft drinks, and desserts producing a state in the blood known as hyperlipidemia. The sluggish circulation of this excess fat promotes deposits in the walls of the arteries. Normal arteries have three layers, the middle one being muscular and the inner and outer layers being thin, delicate linings. Cholesterol enters the inner cells and deposits throughout the first two layers of the artery. This frequently occurs where there is a division or bend in the vessel.
The habit of smoking is especially harmful, as carbon monoxide in mainstream cigarette smoke tends to open these tiny lining (endothelial) cells and actually creates openings in the vessel wall, enabling cholesterol to penetrate more easily. As the years go by, this cholesterol plaque builds up, becoming thicker and eventually obstructing the vessel. Roughness in the lining cell creates more turbulence, which adds to the danger of thrombosis, or sudden clot formation in the vessel, That is the event which is known as a heart attack, or myocardial infarction.
It is not known why some individuals tend to form these deposits in the heart more readily, while others select out the brain, the aorta, or other vascular structures. Nevertheless, arteriosclerosis is affecting nearly every American and was even significant in 70% of the American youth killed in action during the Korean War. For reasons of lifestyle, mostly lower animal fat intake, few Koreans or Japanese get coronary heart disease. The picture changes rapidly, though, when they move to Hawaii or the continental USA.
A number of risk factors are directly associated with the development of arteriosclerosis and the inherent risk of coronary heart disease. Obesity, afflicting over one third of all adults, is directly associated with heart risk. Every five pounds of extra body fat requires four extra miles of blood vessels just to keep the cells nourished. Not only consult height and weight charts, but also measure skin folds to evaluate a personâs obese potential. If the fold of pinched abdominal skin is an inch or more thick, men are definitely obese; for women the skin fold measure allowed is 1Â½ inches.
Insurance statistics show the obese individual to be at high risk, not only for cardiac disease, but also for several types of cancer, diabetes, gallstones, and numerous other health problems. Americaâs overweight now number over 50 million people, still growing both in population and total accumulated pounds. Excess calories in the diet are either burned up or stored, but all calories must be accounted for. Our appetite problem is right in the center of a major preventive health program today.
Smoking directly causes an increased risk for coronary heart disease. Nicotine, the addictive alkaloid in tobacco, abnormally speeds the heart rate and raises the blood pressure. Carbon monoxide, as mentioned above, âshoots holesâ in the artery walls for cholesterol to enter. An average tobacco smoker, according to the Framingham study has three times the risk for a heart attack and more than a 75% increased chance of dying from one! With increasing nonsmoking years, these risks fall gradually to normal for the exsmoker.
Hypertension or high blood pressure is a major risk factor in both heart attacks and strokes. The extra load imposed upon the heart as it pumps against increased resistance is a major factor in congestive heart failure, which may occur either gradually or in association with a sudden heart attack. This problem will be considered below, as it frequently is preventable.
The sedentary habits of Americans have also come under scrutiny. Inactivity is another major risk for the development of heart disease. Exercise is protective in many ways. It not only improves the peripheral circulation elsewhere in the body, but also lowers the resting pulse rate, improves the volume of blood delivered with each heartbeat, and dilates the coronary arteries, both large and small. Many research studies comparing active with sedentary workers have demonstrated numerous protective benefits of moderate exercise in avoiding a fatal heart attack. Walking is especially beneficial. Nearly everyone can do it, too.
Other factors, such as the excessive intake of sugar, a positive family history for heart disease, longstanding presence of diabetes, advanced age, and male gender are related to a higher risk. Some of these can be modified in a healthful way.
Because dietary prevention is so important concerning the risk of coronary heart disease, we wish to spend more time on this vital yet controversial factor. Several simple principles must be understood and applied by anyone desiring to have a healthy heart. First of all, our dietary fat intake must be reduced. The average American takes in daily over 40% of his or her calories as fat. Half this much fat (10 to 20%) would definitely be more optimal. This would of necessity involve the elimination of many unnecessary fats, such as butter, fried greasy foods, flesh meats, rich pastries, oily salad dressings, and the excessive use of cheese, all having increased in Western dietaries over the past two decades.
An intelligent return to natural foods, such as whole grain cereals, and the increased use of fruits and vegetables, will aid you greatly in reducing fat intake. One fringe benefit of this adjustment will be the increased intake of fiber. Bran, found abundantly in whole grains and legumes, is an excellent source of dietary fiber. Increasing your fiber intake has been shown to help with elimination of cholesterol from arteries via your liver and the intestinal tract. Plant sterols present in whole grains and some vegetables will inhibit in a competitive fashion the absorption of cholesterol from the intestines. All these changes will make your food more interesting and grant much improved health for heart, brain, and longevity.
Most shoppers are aware that cholesterol is always of animal origin. With increased meat being used, the intake of fruits and vegetables as dietary staples have fallen off conspicuously for the average household. The richest source of food cholesterol is the yoke of an egg, over 230 mg. in one of medium size. The butterfat portion of milk and all derived milk products such as cheese, butter, ice cream and cottage cheese contain cholesterol. Meats, especially those rich in fat, are exceptionally abundant in cholesterol. Even poultry and fish are not excepted. The more cholesterol you take into your body, the higher the level blood cholesterol is likely to be. This accelerates the development of arteriosclerosis. I advise that as much as possible all dietary sources of cholesterol be eliminated. Then comes the good news; for most people coronary heart disease can begin to regress.
Actually, contemporary and very encouraging data is available to show that the cholesterol problem is in fact reversible. First you should begin with a change in diet and curtailment in the type of fat eaten. By lowering the total fat intake and eliminating cholesterol, your special protein-fat carriers, called lipoproteins, are mustered to mobilize cholesterol for transportation to the liver and eventual excretion in the bile. Modern measurements of blood HDL (high-density lipoprotein) cholesterol have enabled even more accurate prediction of the state of this efficient cleansing mechanism.
Second, the avoidance of excess calories and refined sugars also helps combat the problem of fat deposition in the vascular structures. Combining a natural diet with adequate exercise will increase the preventive dividends.
With your general decrease in the use of fat, it is time next to take a look at oil. Biochemists agree that some fat is needed in the diet. For most people this can be obtained entirely from non-animal sources, such as nuts, olives, or avocados. In areas where these are scarce, in colder climates, or for extremely active occupations where more calories are needed, some vegetable fats could be taken in their refined form. Usually these are combined in the cooking process, as in making bread.
Certain fats, however, are clearly better from the standpoint of cholesterol control. Measuring the ratio of polyunsaturated to saturated fat (P: S Ratio) will help to establish the relative risk or benefits of certain seed oils. Corn, safflower, and soy oils are the best from the standpoint of polyunsaturated fats. The monounsaturated fats found in olives and olive oil convey a protective benefit on the heart and arteries. Peanut and cottonseed oil are of lesser value. It is crucial to avoid entirely the consumption of shortening, lard, and butter, for these hardened fats will always tend to increase the cholesterol content of the blood. Recipe books are available, which enable the average cook to lower greatly total fat consumption as well as choose the most healthful sources.
Signs and symptoms of heart disease challenge medical experts as well as laymen to find an accurate diagnosis. Chest pain is usually one of two principal qualities in heart disease. One type, called angina pectoris, is a transient pain, usually described as a pressure, aching, or squeezing in the area behind the left breast and associated with exercise. It may come on gradually as in walking up a hill or while mowing the lawn, or the pain may be triggered by stress, as in watching violent sports on television or by getting into an argument. Sometimes angina may arise after a heavy meal, because of the increased workload that digestion imposes on the heart. When exercise is a triggering factor, rest will within minutes relieve the pain. Sometimes an improvement of circulation results in the hands or feet by immersion in warm water to accelerate this relief process. In fact, it is important to keep the extremities warm when exercising on a cold day, to avoid chilling and thus reduce congestion around the heart.
The heart attack, or acute myocardial infarction, presents suddenly with chest pain of a much different character. Although in the elderly this serious event may occur silently, for most younger individuals a sudden heart attack produces definite symptoms. Occasionally, however, it may resemble heartburn, a digestive problem, or may be thought to be related to indigestion. Classically the pain of a heart attack is located beneath the breastbone or left portion of the chest. Patients describe their chest pain as vise-like, squeezing, a tense, aching pain that at times radiates into the left shoulder or arm, or up into the neck or jaw. This pain persists, sometimes for hours, and may be associated with collapse or a catastrophic sudden death. About two out of seven individuals having an acute heart attack will die before reaching the emergency room.
Your physicianâs advice can be reassuring, and is particularly beneficial in establishing a prompt and accurate diagnosis. Electrocardiograms and blood tests for heart enzymes can aid in establishing the diagnosis. Temporary monitoring of the heart rhythm may be essential to observe for threatening signs of rhythm abnormality (arrhythmia).
With our modern technologic emphasis on cardiopulmonary resuscitation and emergency care, many lives have been spared. Nevertheless, it remains questionable whether our state-of-the-art coronary care units considered so essential in the United States do significantly reduce mortality from these attacks. In Great Britain, many heart attacks are treated at home, and with careful observation, rest and home nursing care, survival is about the same.
Usually the sufferer of a heart attack is well advised to stay in bed
â Circulation and the Heart
The next two chapters investigate how the blood delivers oxygen and nutrients to the cells and carries away the waste products of cell metabolism. The continuous oneway circuit of blood through the body in the blood vessels is known as the circulation. The prime mover that propels blood throughout the body is the heart. This chapter examines the structure and function of the heart to lay the foundation for the detailed discussion of blood vessels that follows.
The importance of the heart has been recognized for centuries. Strokes (the contractions) of this pump average about 72 per minute and are carried on unceasingly for the whole of a lifetime. The beating of the heart is affected by the emotions, which may explain the frequent references to it in song and poetry. However, the vital functions of the heart and its disorders are of more practical concern.
Location of the Heart
The heart is slightly bigger than a personâs fist. This organ is located between the lungs in the center and a bit to the left of the midline of the body (Fig. 1-1). It occupies most of the mediastinum, the central region of the thorax. The heartâs apex, the pointed, inferior portion, is directed toward the left. The broad, superior base is the area of attachment for the large vessels carrying blood into and out of the heart.
Figure 1-1 The heart in position in the thorax (anterior view).
â Structure of the Heart
The heart is a hollow organ, with walls formed of three different layers. Just as a warm coat might have a smooth lining, a thick and bulky interlining, and an outer layer of a third fabric, so the heart wall has three tissue layers (Fig. 1-2, Table 1-1). Starting with the innermost layer, these are as follows:
â The endocardium is a thin, smooth layer of epithelial cells that lines the heartâs interior. The endocardium provides a smooth surface for easy flow as blood travels through the heart. Extensions of this membrane cover the flaps (cusps) of the heart valves.
â The myocardium , the heart muscle, is the thickest layer and pumps blood through the vessels. Cardiac muscleâs unique structure is described in more detail next.
â The epicardium is a serous membrane that forms the thin, outermost layer of the heart wall.
Table 1-1 Layers of the heart wall
Figure 1-2 Layers of the heart wall and pericardium. The serous pericardium covers the heart and lines the fibrous pericardium.
Table 1-2 Layers of the Pericardium
The pericardium is the sac that encloses the heart (Fig. 1-2, Table 1-2). The outermost and heaviest layer of this sac is the fibrous ericardium. Connective tissue anchors this pericardial layer to the diaphragm, located inferiorly; the sternum, located anteriorly; and to other structures surrounding the heart, thus holding the heart in place. A serous membrane lines this fibrous sac and folds back at the base to cover the heartâs surface. Anatomically, the outer layer of this serous membrane is called the parietal layer, and the inner layer is the visceral layer, also known as the epicardium, as previously noted. A thin film of fluid between these two layers reduces friction as the heart moves within the pericardium. Normally the visceral and parietal layers are very close together, but fluid may accumulate in the region between them, the pericardial cavity, under certain disease conditions.
Special Features of the Myocardium
Cardiac muscle cells are lightly striated (striped) based on alternating actin and myosin filaments, as seen in skeletal muscle cells. Unlike skeletal muscle cells, however, cardiac muscle cells have a single nucleus instead of multiple nuclei. Also, cardiac muscle tissue is involuntarily controlled. There are specialized partitions between cardiac muscle cells that show faintly under a microscope (Fig. 1-3). These intercalated disks are actually modified plasma membranes that firmly attach adjacent cells to each other but allow for rapid transfer of electrical impulses between them. The adjective intercalated is from Latin and means âinserted between.â
Figure 1-3 Cardiac muscle tissue viewed under the microscope (x540). The sample shows light striations (arrowheads), intercalated disks, and branching fibers (arrow).
Another feature of cardiac muscle tissue is the branching of the muscle fibers (cells). These fibers are interwoven so that the stimulation that causes the contraction of one fiber results in the contraction of a whole group. The intercalated disks and the branching cellular networks allow cardiac muscle cells to contract in a coordinated manner.
Divisions of the Heart
Healthcare professionals often refer to the right heart and the left heart, because the human heart is really a double pump (Fig. 1-4). The right side pumps blood low in oxygen to the lungs through the pulmonary circuit. The left side pumps oxygenated blood to the remainder of the body through the systemic circuit. Each side of the heart is divided into two chambers.
Figure 1-4 The heart as a double pump. The right side of the heart pumps blood through the pulmonary circuit to the lungs to be oxygenated; the left side of the heart pumps blood through the systemic circuit to all other parts of the body.
Four Chambers The upper chambers on the right and left sides, the atria, are mainly blood-receiving chambers (Fig. 1-5, Table 1-3). The lower chambers on the right and left side, the ventricles are forceful pumps. The chambers, listed in the order in which blood flows through them, are as follows:
1. The right atrium is a thin-walled chamber that receives the blood returning from the body tissues. This blood, which is low in oxygen, is carried in veins, the blood vessels leading back to the heart from the body tissues. The superior vena cava brings blood from the head, chest, and arms; the inferior vena cava delivers blood from the trunk and legs. A third vessel that opens into the right atrium brings blood from the heart muscle itself, as described later in this chapter.
2. The right ventricle pumps the venous blood received from the right atrium to the lungs. It pumps into a large pulmonary trunk, which then divides into right and left pulmonary arteries, which branch to the lungs. An artery is a vessel that takes blood from the heart to the tissues. Note that the pulmonary arteries in Figure 1-5 are colored blue because they are carrying deoxygenated blood, unlike other arteries, which carry oxygenated blood.
Figure 1-5 The heart and great vessels.
Table 1-3 Chambers of the heart
3. The left atrium receives blood high in oxygen content as it returns from the lungs in pulmonary veins. Note that the pulmonary veins in Figure 1-5 are colored red because they are carrying oxygenated blood, unlike other veins, which carry deoxygenated blood.
4. The left ventricle, which is the chamber with the thickest wall, pumps oxygenated blood to all parts of the body. This blood goes first into the aorta, the largest artery, and then into the branching systemic arteries that take blood to the tissues. The heartâs apex, the lower pointed region, is formed by the wall of the left ventricle (see Fig. 1-2).
The heartâs chambers are completely separated from each other by partitions, each of which is called a septum. The interatrial septum separates the two atria, and the interventricular septum separates the two ventricles. The septa, like the heart wall, consist largely of myocardium.
Figure 1-6 Valves of the heart (superior view from anterior, atria removed). (A) When the heart is relaxed (diastole), the AV valves are open and blood flows freely from the atria to the ventricles. The pulmonary and aortic valves are closed. (B) When the ventricles contract, the AV valves close and blood pumped out of the ventricles opens the pulmonary and aortic valves.
Table 1-4 Valves of the heart
Four Valves One-way valves that direct blood flow through the heart are located at the entrance and exit of each ventricle (Fig. 1-6, Table 1-4). The entrance valves are the atrioventricular (AV) valves, so named because they are between the atria and ventricles. The exit valves are the semilunar valves, so named because each flap of these valves resembles a half-moon. Each valve has a specific name, as follows:
â The right atrioventricular (AV) valve is also known as the tricuspid valve because it has three cusps, or flaps, that open and close. When this valve is open, blood flows freely from the right atrium into the right ventricle. When the right ventricle begins to contract, however, the valve is closed by blood squeezed backward against the cusps. With the valve closed, blood cannot return to the right atrium but must flow forward into the pulmonary arterial trunk.
â The left atrioventricular (AV) valve is the bicuspid valve, but it is commonly referred to as the mitral valve (named for a miter, the pointed, two-sided hat worn by bishops). It has two heavy cusps that permit blood to flow freely from the left atrium into the left ventricle. The cusps close when the left ventricle begins to contract; this closure prevents blood from returning to the left atrium and ensures the forward flow of blood into the aorta. Both the right and left AV valves are attached by means of thin fibrous threads to muscles in the walls of the ventricles. The function of these threads, called the chordae tendineae (see Fig. 1-6), is to stabilize the valve flaps when the ventricles contract so that the force of the blood will not push them up into the atria. In this manner, they help to prevent a backflow of blood when the heart beats.
â The pulmonary valve, also called the pulmonic valve, is a semilunar valve located between the right ventricle and the pulmonary trunk that leads to the lungs. As soon as the right ventricle begins to relax from a contraction, pressure in that chamber drops. The higher pressure in the pulmonary artery, described as back pressure, closes the valve and prevents blood from returning to the ventricle.
â The aortic valve is a semilunar valve located between the left ventricle and the aorta. After contraction of the left ventricle, back pressure closes the aortic valve and prevents the back flow of blood from
the aorta into the ventricle.
Figure 1-7 traces a drop of blood as it completes a full circuit through the
heartâs chambers. Note that blood passes through the heart twice in making a trip from the heartâs right side through the pulmonary circuit to the lungs and back to the heartâs left side to start on its way through the systemic circuit. Although Figure 1-7 follows the path of a single drop of blood in sequence through the heart, the heartâs two sides function in unison to pump blood through both circuits at the same time.
Figure 1-7 Pathway of blood through the heart. Blood from the systemic circuit enters the right atrium (1) through the superior and inferior venae cavae, flows through the right AV (tricuspid) valve (2), and enters the right ventricle (3). The right ventricle pumps the blood through the pulmonary (semilunar) valve (4) into the pulmonary trunk, which divides to carry blood to the lungs in the pulmonary circuit. Blood returns from the lungs in the pulmonary veins, enters the left atrium (5), and flows through the left AV (mitral) valve (6) into the left ventricle (7). The left ventricle pumps the blood through the aortic (semilunar) valve (8) into the aorta, which carries blood into the systemic circuit.
Blood Supply to the Myocardium
Only the endocardium comes into contact with the blood that flows through the heart chambers. Therefore, the myocardium must have its own blood vessels to provide oxygen and nourishment and to remove waste products. Together, these blood vessels provide the coronary circulation. The main arteries that supply blood to the muscle of the heart are the right and left coronary arteries (Fig. 1-8), named because they encircle the heart like a crown. These arteries, which are the first to branch off the aorta, arise just above the cusps of the aortic valve and branch to all regions of the heart muscle. They receive blood when the heart relaxes because the aortic valve must be closed to expose the entrance to these vessels (Fig. 1-9). After passing through capillaries in the myocardium, blood drains into a system of cardiac veins that brings blood back toward the right atrium. Blood finally collects in the coronary sinus, a dilated vein that opens into the right atrium near the inferior vena cava.
|Cancer Prevention Vitamins - B15 and B17|
Wouldn't you like to know that two of the B-Complex vitamins help in the prevention of Fibromyalgia and support recovery from alcohol and drug addiction? All other animals instinctively know vitamins B15 and B17 are nature's cancer prevention. Humans can get these two vitamins from food, but they are outlawed in the United States when sold in the B-Complex vitamin supplement, and are not included in any manufactured foods.
The Forbidden Vitamin B15
Russia has been the most progressive country using B15, believing it to be a very important nutrient treating a multitude of symptoms and diseases. Russian scientists have shown Pangamic Acid supplementation can reduce the buildup of lactic acid in athletes, and, thereby, lessen muscle fatigue and increase endurance. Hum, do you think this vitamin might assist with Fibromyalgia?
B15 is used regularly in Russia for many health issues, including:
Dimethyl glycine (DMG) has been used in the United States as a substitute for B15 because it is believed to increase Pangamic Acid production in the body. Dimethyl glycine combines with gluconic acid to form Pangamic Acid. DMG is considered the active component of Pangamic Acid.
Pangamic Acid is found in:
B15 helps in the formation of specific amino acids such as methionine. It plays a role in the oxidation of glucose in cell respiration. Like vitamin E, it acts as an antioxidant helping to lengthen cell life through its protection from oxidation. Pangamic Acid mildly stimulates the endocrine and nervous systems, and by enhancing liver function, it helps in the detoxification process.
B15 has been shown to lower blood cholesterol, improve circulation and general oxygenation of cells and tissues, and is helpful for arteriosclerosis and hypertension - some of America's most common diseases.
In Europe, vitamin B15 has been used to treat premature aging because of both its circulatory stimulus and its antioxidant effects. It helps protect the body from pollutants, especially carbon monoxide. Pangamic acid (and possibly DMG) offers support for anyone living in a large polluted city or under high-stress.
As previously mentioned, in Russia, Pangamic Acid is used in treating alcohol dependency and is believed to reduce alcohol cravings. It has been reported to diminish hangovers. B15 has also been used to treat fatigue, as well as asthma and rheumatism, and it even has some anti-allergic properties. Some child psychiatrists have reported good results using Pangamic Acid with emotionally disturbed children; it is used to stimulate their speaking ability and related mental functions. B15 may also be a helpful nutrient for autism, but more precise research is needed.
Natureâs Cancer Prevention - B17
Americans cannot access vitamin B17 because the FDA took it off the market in the 1970s, and removed it from the B-Complex vitamins. It is unlawful for any health practitioner to administer this vitamin to patients. Apricot seeds are the best source for B17, but they have also been removed from the shelves of every health food store and natural market throughout the USA. Limited research has been conducted on vitamin B17 since 1977. Once it was banned, it was forgotten.
According to research from years ago, provided by nutritionists and medical scientists, vitamin B17 is a natural cyanide-containing compound that gives up its cyanide content only in the presence of a particular enzyme group called beta glucosidase or glucuronidase. Miraculously, this enzyme group is found almost exclusively in cancer cells. When it is found elsewhere in the body, it is accompanied by greater quantities of another enzyme, rhodanese, which has the ability to disable the cyanide and convert it into completely harmless substances. Cancer tissues do not have this protecting enzyme.
So, according to past scientific knowledge, cancer cells are faced with a double threat: the presence of one enzyme exposing them to cyanide, while the absence of another enzyme found in all other normal cells results in the cancer's failure to detoxify itself. Leave it to nature to provide a form of cyanide that can naturally destroy a cancer cell. The cancer cells that are unable to withstand the cyanide are destroyed, while the non-cancerous cells are not threatened by the cyanide, and, therefore, remain unharmed. Never underestimate the body's potential!
Vitamin B17 is found naturally in many foods. If you eat foods containing vitamin B17, your body will know what to do next. All other animals in nature instinctively do this. Consider it nature's cancer prevention. If only modern medicine would allow it.
San Francisco's Ernst T. Krebs, Sr., M.D. discovered the healing qualities of vitamin B17 in 1923. His sons, Ernst T. Krebs, Jr., PhD, and Byron Krebs, M.D. continued their father's research in 1952, refining Laetrile's (B17) nutritional qualities.
From their research, the Krebs believed cancer was not caused by an outside invading force but rather by malfunctions of the normal mechanics within the body itself. They identified cancer as a "deficiency disease." The body's malfunctions, according to their research, were the result of a deficiency of certain chemicals found in food, a deficiency of chemicals they specifically identified as vitamin B17, as well as a deficiency of enzymes known as trypsins produced in the pancreas.
The Krebs had discovered a natural, drugless method to help prevent cancer. But their discovery wasn't original. Years prior to any of the Drs. Krebs' works, Drs. George B. Wood and Franklin Bache, M.D. published a reference volume in 1833 in which they described amygdalin, derived from B17, as a common treatment for a wide range of diseases and disorders.
Vitamin B17 is also referred to as a nitriloside, which is the foundation for Laetrile, amygdalin, and prunasin. Together with the pancreatic enzyme trypsin, these can form a natural barrier against cancer growth. If foods containing any of the nitrilosides are eaten regularly, the body's own immune mechanisms can naturally battle cancer-forming cells. But if foods containing these critical vitamins are not regularly consumed (or manufactured), nature's mechanisms can't work as effectively against the buildup of factors at the root of cancer and the countless number of degenerative diseases.
This is happening to human beings today. Not only are advanced societies environmentally polluted to dangerous levels, but also more and more foods are being altered from their natural state by man's own doing. Modern freeze-dried, fat-free, sugar-free, calorie-free, weight-watchful, microwavable artificial food substitutes don't contain nitrilosides. Most food manufacturers don't even know what nitrilosides are. Never in human history have artificial foods saturated with preservatives and unhealthy chemicals dominated the food supply to the degree they do today. Modern nourishment is no longer nourishing.
In the late 1970's, Dr. Harold W. Manner, PhD., Chairman of the Biology Department at Loyola University, Chicago, Illinois, studied the overall value of Laetrile (B17). His work was well respected and considered among the first unbiased studies since the Krebs' in the 1920s. He reported Laetrile as being virtually non-toxic.
When Dr. Manner used Laetrile in his medical research, along with vitamin A and digestive enzymes, he discovered the production of antibodies was stimulated against spontaneous breast tumors in his laboratory mice. He studied the results of complete regression in 76 percent of the treated mice with mammary gland cancers.
Dr. Manner believed Laetrile received its best results when used in conjunction with digestive enzymes, a traditional balanced diet, and with vitamin A.
No physician has had more clinical experience with Laetrile than Ernesto Contreras, Sr., M.D. of the Contreras Hospital in Tijuana, Mexico, formerly The Oasis Of Hope Hospital. Dr. Contreras has clinically used Laetrile for more than forty years on thousands of terminally diagnosed patients, and has received impressive results.
One of Dr. Contreras' patients was a man suffering from severe colon cancer. Using Laetrile treatments in conjunction with detoxification protocols and proper vitamin supplementation, Contreras was able to arrest the progression of his patient's cancer. The man lived more than fifteen years beyond his predicted death.
The following is a list of foods rich in vitamin B17:
For more information about cancer prevention, please visit Dr. Hull's Richardson Cancer Prevention Diet.
|The state fish of West Virginia||The brook trout is the only trout species native to West Virginia streams. Native brook trout live and reproduce in only the coldest and purest of our mountain streams. These streams are generally less than 15 feet wide, well shaded, and have numerous pools. Although these streams often support large numbers of brook trout, the trout tend to be small fish that average five to six inches in length and seldom exceed 10 inches. Brook trout are characterized by a dark green back covered with lighter worm-shaped markings, bluish sides and a pink to scarlet belly. The sides of the trout are profusely sprinkled with yellow spots, interspersed with red ones. The lower fins are orange-red with a distinctive white stripe on the front edge. Given its beauty and the fact that the brook trout is our only native trout, itâs no wonder that in 1973 it was selected to be the official state fish. Brook trout spawn primarily during October. Their nests, called redds, are built near the lower end of the pools where the gravel is swept clean of silt and fresh oxygenated water is abundant. Since these streams are generally low and clear during the fall, spawning activity can be readily observed in many of the small, cold headwater streams of the Elk, Greenbrier and Williams rivers, as well as Seneca and Gandy creeks. While there are 500 miles of native trout streams in West Virginia, the streams are small and represent only two percent of the total miles of stream in the state. Brook trout are not picky eaters and feed on a wide variety of food items. During the winter and early spring, much of their food consists of aquatic insects and other fish. The insects include mayflies, caddisflies and stoneflies. In the summer and early fall, their diet changes to terrestrial insects. These are insects like grasshoppers, Japanese beetles and bees that normally live on the land but become fish food when they fall or are washed into the stream.|
|Near infra-red spectroscopy: a non-invasive monitor of perfusion and oxygenation within the microcirculation of limbs and flaps.|| Irwin, MS; Thorniley, MS; DorÃ©, CJ; Green, CJ; (1995) Near infra-red spectroscopy: a non-invasive monitor of perfusion and oxygenation within the microcirculation of limbs and flaps. Br J Plast Surg , 48 (1) pp. 14-22.
|Endoscopic detection of ischaemia with a new probe indicates low oxygenation of gastric epithelium in portal hypertensive gastropathy.|| Piasecki, C; Chin, J; Greenslade, L; McIntyre, N; Burroughs, AK; McCormick, PA; (1995) Endoscopic detection of ischaemia with a new probe indicates low oxygenation of gastric epithelium in portal hypertensive gastropathy. Gut , 36 (5) pp. 654-656.
|THE IDEA OF NORMALCY|
After a tumultuous year defined by paradigm shifting turn of events, it seems like a revolution is on its way and we are one foot in the dystopian door.
Unsurprisingly, The Pantone Color Institute named “Greenery” the Color of the Year, citing the need for fresh beginnings with inspirations that point towards our urge to turn the other way and reconnect with Nature. Pantone 15-0343 - yellow-green hued and symbolic of freedom and liberation is a reflection of society burdened by walls that are perpetually bent on dividing us while blurring the lines of integrity and falsehood.
As the inescapable canvas of Nature, neutral and impartial, like the ‘North’ of a compass, Greenery calls to mind an obligation to take a step back for calculated contemplation as we unpick the knots that tie us to a foreseeable, grimy future. It marks our bonded roots with a formidable but forgotten force that is the foliage that we once call home.
As the global climate becomes increasingly complex, choose to see things in colour, and identify the message of positivity and rebirth. Greenery signals one to take a deep breath, to oxygenate and reinvigorate, speaking to our need to experiment and reinvent. Perhaps, as much as we are engineered to be ahead of the curve, now is the time to forgo the endless rat race. Consider the fact that “less is more”, and identify with a higher purpose to find comfort in simplicity, reduction and sameness.
SHOP THE STORY
|5 Good Plants for Jungle Bioactive Terrariums|
One of the biggest current trends in reptile keeping is the move to bio-active enclosures for arboreal geckos and frogs. Not only do they look great but they provide a dynamic environment for your pet, oxygenate the room and reduce the amount of time you will need to spend cleaning. We have recently upgraded our terrariums […]
|The Naked Truthâ¦..about COMPOST!||
There, I just blurted it outâ¦â¦â¦.there is something untruthful, something not being said about compost.
Understanding and committing to practices that are truly sustainable takes courage, involves change, requires forethought and action but gives in return treasures for the effort. At bokashicycle.com we are committed to educating those who really want to know the facts, and believe they will then with knowledge and good science make the planet a better place.
What I have to say today will go against a popular belief so strongly imbedded and advocated by so many that it is certain to engender retorts and denials. But one of the great thrills in science is seeing things as they really areâ¦â¦seeing the truth, like the child who told the truth about the Emperorâs New Clothes in Hans Christian Andersenâs 1837 tale of the swindlers. The weavers, had declared they could manufacture the finest cloth to be imagined with colors and patterns that were not only exceptionally beautiful, but most importantly, the clothes possessed the wonderful quality of being invisible to any man who was unfit for his office or unpardonably stupid.
So we are led to believe that an important part of recycling and keeping the planet âgreenâ is making and using compost. We are increasingly being told that weâve got to get the solid waste out of the landfill, that composting is good, that we should recycle our kitchen scraps, lawn clippings, etc. by composting them, and that compost is good for the soil and plants because it restores naturally what was missing. Plants are supposed to grow better when we use compost.
City and county planners are diverting more and more solid waste to tracks of land where compost is produced and then sold back to the public for garden use. Farmers frequently advocate composting and the use of animal manure to enrich the soil so they can obtain higher yields. A great compost industry has evolved. Giant earth moving machines, mixers, grinders, and trucks are used to move and manage the piles of âdecomposingâ organic matter that will in time be called âcompostâ.
Gardeners are coached and advised to use compost, to recycle their garden waste materials, and sold tumblers, bins, etc. designed to speed up the decomposition of organic matter so that the product can be used again and again in the garden.
Whatâs wrong with this picture? A lot. Itâs plain to see we are headed in the wrong direction advocating compost as a sustainable process and it is certainly harming not helping the planet.
So what is compost anyway? Some people will say it is a dark, crumbly, and earthy-smelling form of decomposing organic matter, but it is perhaps better defined as a stable humus material. I like the Virginia Tech bulletin âCompost: What Is It and What's It To Youâ pithy way of stating what it is.
You canât actually define it because no one knows exactly what it is. We can however say a lot about the process. When you purchase or make your compost you are getting something âearthyâ at the end of the process but no two batches are ever going to be the same.
The process is well known. You have to collect the organic material and put it in a pile. The decomposition occurs because the naturally occurring microbes in the pile are working hard to consume the mass. They do this by oxidizing the plant material rendering in the end if all goes well a mass of humus.
There are many different types of microbes involved in the process all working together and an important part of the process is keeping the conditions in the pile right so that all of the essential microbes and fungi digesting material are healthy. During the process, because of the oxidation, the pile heats up. The heat is important because if the pile is too cold, the microbes wonât survive or the process will be too slow. But if the pile heats up too much, the microbes will die and then you have only a dead heap of partially decomposed organic matter.
As the decomposition commences, a lot of carbon dioxide gas and water vapor is produced and because of the heat in the pile, the gases are driven into the atmosphere. The pile begins to collapse upon itself as the center of the pile decomposes. This results in a substantial drop in the amount of oxygen that is needed to oxidize material. The microbes can not survive when the oxygen level drops too low but other microbes that thrive in low oxygen environments will begin to flourish.
The anaerobic (low oxygen loving) microbes take over and produce noxious gases including ammonia, nitrous oxide, methane, and hydrogen sulfide and many other noxious materials. Because of the heat, these gases are also driven into the atmosphere. The loss of nitrogen in the form of ammonia means in the end the compost nitrogen content is reduced. This is the process of putrefaction and it accounts for the offensive pile odors frequently observed when material is allowed to rot. Thatâs not good.
Anyone who ever tried to manage a compost pile will tell you it is a little tricky. It is almost impossible to maintain the perfect conditions to get a consistent product. Youâve got to make a pile big enough to get the temperature up to 110 â 150 F, assuming you have a proper mix of microbes. Youâve got to turn it and mix it adequately to keep the oxygen levels up to support the oxidation and youâve got to add enough water to keep the humidity between 50 and 60%. If you turn it too soon, it will cool too fast. You have to add more water as it dries out to keep the organisms working (wasting water).
Weâre not done yet. The microbes are pretty fussyâ¦â¦some need organic matter high in carbon content whilst others need organic matter rich in nitrogen. Youâve got to support these requirements or the pile wonât decompose in the manner youâd like. It turns out youâve got to have a proper balance of carbon to nitrogen to make the pile work (C: N ratio about 30:1). People usually define carbon as âbrown stuffâ and nitrogen as âgreen stuffââ¦â¦so you mix brown and green materials to try to get the ratio correct.
I think youâve got the picture and it is kind of ugly. Itâs very hard to control this process and virtually impossible to keep it going smoothly all along the way. You just canât mix the pile and keep the temperature, humidity, C: N ratios, and oxygen levels etc. all where they need to be to get a consistent product. When it is done industrially, a lot of energy consuming devices are used to make it better. Temperature sensors, blowers, heaters, sprayers, oxygenators, earth movers, etc. are employed. A lot of labor and energy is consumed to produce a product. It can take easily 6 months from the beginning to the end of the process to have a stable and cured pile of compost.
In the end the humus produced, because of the heat, etc. has been sterilized. The natural microbes that normally inhabit the soil are no longer present. The natural microbes in the soil are intimately involved in assisting plants fix nitrogen and provide many nutrients that plants can readily assimilate. A lot of nitrogen was lost in the decomposition (taken out of the product as ammonia and nitrogen oxide gases and dispersed into the atmosphere). The oxidation of the organic matter results in tons of carbon dioxide and water vapor going into the atmosphere. Have you ever witnessed a steaming pile in the cool morning air?
Is it natural? People frequently like to say composting is natural ânatures way of breaking down the organic matterâ. Nothing could be further from the truth. When did you ever see mounds of material piled up and rotting in nature? Men recognized that you could accelerate the oxidation and breakdown by gathering and piling material in masses that are properly aerated and humidified.
In nature material is far more slowly broken down. When the leaves and debris do pile up and become matted down by rain and water, the oxygen is excluded and anaerobic processes take over. Most of the decomposition is occurring at ambient temperatures. Because no one is turning material to get the oxygen levels back to surface conditions, the interior processes resulting in decomposition are anaerobic (at very low oxygen levels). Have you every witnessed leaves as they naturally rot? They form a soggy mass on the ground in the fall and by winterâs end have completely disappeared.
The process of composting is not natureâs way but manâs way of rotting material. It is polluting the planet. We are by composting releasing water vapor, carbon dioxide, ammonia, and numerous other gases into the atmosphere. We are releasing a lot of heat that would not have been produced naturally. If we encourage people to compost, promote composting as an environmentally sound solution, and want to believe it is a sustainable practice that will be good for the planet, we are only fooling ourselves.
Like the child who saw the emperorâs suit for what it was, those who want real sustainability will acknowledge there has to be a better way. And there is. Weâll talk more about green house gases, microbes, and anaerobic fermentation in the future.
|Tai Chi Acupuncture Chiropractic Massage Energy Balance Approaches in Chinese Medicine||The idea of energy balance has its basis in medical systems that have been utilized in the Far East for thousands of years. All of these systems assume that there is a subtle nonphysical energy that permeates and circulates throughout the body.|
Traditional Chinese medicine calls this "chi". The terms that best describe this energy in English would be "life force" or "vital energy". The difference in energy that you feel when you have the flu versus when you are healthy is an example of fluctuations in this type of energy.
In Chinese medicine, subtle energy is understood to be distributed throughout the body along channels called "meridians???. One of the most important functions of all of the energy-balance approaches is to harmonize and optimize the "flow" of subtle energy by releasing blocks to that flow. Blocked energy leads to tension, anxiety, stress, and ultimately illness. In fact, Chinese medicine traces all disease back to various types and degrees of blockage in the flow of vital energy.
Regular practice of energy balance disciplines such as yoga or t??ai chi helps to release blocks to the natural flow of vitality. So does receiving treatments from healing arts that free up obstructions to subtle energy. This is particularly true for acupuncture, but also applies to various forms of massage and chiropractic treatment.
The invisible "energy body", sometimes called "subtle body", that is the focus of Eastern medicine is intimately related to the physical body. It??s thought to provide an energetic matrix or "template" for the physical body.
On a strictly physical level, energy balance practices help to relieve muscle tension, promote increased oxygenation of tissues and the brain, improve arterial circulation, promote elimination by the kidneys and colon, and stimulate increased production of hormones and neurotransmitters.
However, the fundamental purpose of the energy balance approaches is to promote mind-body integration a harmonious interdependence and balance among the spiritual, mental, emotional, and physical aspects of your total being.
"Wholeness" is equated with wellness. To the extent you function in an integrated, whole manner, you can experience the fullness of your being and genuine health. To the extent that you are out of touch with the wholeness of your being, you remain out of harmony with yourself and are subject to stress and disorder, including anxiety.
T'ai chi is an ancient form of movement and exercise intended to unite body and mind. It is said to have originated when a thirteenth-century Taoist monk in China watched a serpent and a crane in battle. As the crane attacked the snake, the snake would smoothly move its position, never allowing the crane to touch it. From this scene the monk developed thirteen moves which have been augmented down through the centuries. Presently, t??ai chi is practiced by millions of people in China and is popular throughout the rest of the world.
T??ai chi can best be described as a form of moving meditation. It consists of a series of movements that proceed slowly and gracefully, flowing one into another. These movements strengthen and ground the body while promoting the flow of "chi" or life force. Students say that it teaches qualities of fluidity and grace; qualities that can extend to the way you live your entire life.
Because the movements are done slowly, it also teaches you how to slow down, both in your body and your mind. Like meditation, it helps you to achieve serenity, clarity, and concentration. Unlike meditation, however, it instills an ability to carry mental poise and concentration into movement.
Like yoga, t??ai chi helps you to work through blocks to the flow of your life energy, along with promoting physical benefits such as opening the joints, especially the knees, strengthening the spine and lower back, and massaging the internal organs. Because it??s practiced with your entire body and with full presence of mind, t??ai chi is a very practical and effective way to foster mind-body integration.
You can find t??ai chi classes offered at some health clubs as well as some martial arts schools, though t??ai chi is generally not used as a form of self-defense. If classes are not available in your area, there are several excellent videos that teach the basic movements. Because it promotes the flow of "chi," the exercise is sometimes prescribed as an adjunct to acupuncture treatments.
Acupuncture originated as a healing modality in China about three thousand years ago. Currently it??s practiced in most advanced countries throughout the world. As with t??ai chi, it??s based on the assumption that health is determined by the free and proper flow of chi, the vital or subtle energy that pervades all living things. Chi flows along channels in the body called meridians, each of which is linked to a specific organ.
When the flow of energy is neither restricted nor excessive, the individual enjoys good health. If the energy flow is unbalanced in either direction, both physical and mental symptoms of distress or disease may result. For example, fear is understood to be due to blocked or excessive energy flow along the kidney meridian. Acupuncture treatments that aim to balance the kidney meridian, and other supporting meridians can help to relieve fear fullness.
In an acupuncture treatment, the acupuncturist inserts thin needles at specific points in the body. Most people feel only a slight prick or no pain at all from the procedure. Typically the needles are left in place for twenty to thirty minutes, after which it??s common to feel very relaxed and rejuvenated. Repeated treatments, twice a week for a few weeks, are often needed to correct an ailment such as migraine headaches, allergies or back pain.
If you wish to utilize acupuncture to help anxiety, regular treatments on a weekly or biweekly basis for several months are advised. Often the acupuncturist will provide herbs in the form of teas or capsules to use at home to enhance the effects of the treatments.
For people who are uncomfortable with the use of needles acupressure may be a viable alternative. Acupressure, and its cousin Shiatsu, rely on the same principles as acupuncture. However, energy flow and balance along the meridians is promoted by manual pressure rather than needles. Acupressure is a simple and inexpensive form of energy balance practiced by many massage therapists. In fact, you can utilize acupressure on your own.
Most people think of chiropractic as a healing art that aims to relieve back pain induced by stress or injury. At a more basic level, though, chiropractic strives to promote health by optimizing the flow of nerve impulses up and down the spine and to other parts of the body. Because of the various stresses to which the spine is subject, individual vertebrae can move out of alignment.
These misaligned vertebrae block the flow of nerve impulses between the brain and body as well as between the spinal cord and various bodily organs. When nerve transmission to a specific organ is reduced or limited the organ is likely to dysfunction and might produce symptoms ranging from mild discomfort to illness. Misalignments of the spine may be caused by injury, but most frequently they are caused by stress.
Muscles tightened under chronic stress tend to pull the vertebrae out of alignment. Even if the muscle tension is relieved through exercise or massage, the spinal vertebrae may not easily resume their normal configuration. Thus a chiropractor seeks to identify and correct vertebral misalignments in order to promote optimal nervous system function and thereby functional integrity of the body as a whole.
Chiropractic can be a helpful strategy for relieving chronic tension, whether or not accompanied by pain. An occasional visit to a chiropractor is likely to improve your overall experience of well-being. In locating a qualified chiropractor in your area, try to get a referral from a friend or relative. If you prefer not to receive direct manipulations to the spine, there are some chiropractors who practice a nonmanipulative form of adjustment sometimes referred to as "gentle chiropractic".
Therapeutic massage is a healing art designed to promote deep relaxation through skillful manipulation of muscles and soft body tissues. Professional massage therapists usually obtain 500-1,000 hours of formal training in anatomy, physiology, and various forms of bodywork including Swedish massage, deep tissue work, reflexology, acupressure, and Shiatsu.
Receiving a one-hour massage every week, or even twice per month, can promote deep relaxation by relieving chronic muscle tension that you may have been holding in your body for a long time. Massage can enhance and deepen the benefits you obtain from practicing progressive muscle relaxation. PMR tends to release acute superficial tension in the outer muscles of your arms, legs, neck, and torso.
Massage, particularly "deep tissue" massage, can undo chronic long-standing tension held in the deeper muscles of the body. In addition to releasing muscle tension, massage can help cleanse your body of toxic accumulations by promoting lymphatic circulation and mobilizing a sluggish colon.
On a more psychological level, receiving a massage is a wonderful way to nurture yourself if you feel stressed. Massage can also provide a corrective emotional experience for survivors of abuse. If you grew up in a dysfunctional family where you either weren??t touched or were touched inappropriately, massage can help you work through any painful feelings or resistance around being touched, increasing your ease with what is an innate need for all human beings.
There are several types of massage to choose from. Swedish massage, developed by Peter Ling in the 1800s, uses kneading, stroking, and shaking to induce the body to relax. This is the most common type of massage practiced. Deep tissue massage involves greater pressure on deeper muscles than Swedish massage and generally focuses on specific problem areas.
Neuromuscular massage is a form of deep tissue massage that works with specific "trigger points" to release chronically tight muscles. Acupressure, while certainly relaxing, intentionally seeks to promote enhanced energy balance. Through firm pressure applied to specific points for three to ten seconds each, acupressure strives to release blocks to the flow of subtle energy through the acupuncture meridians.
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|10 Good Reasons to Drink More Water|
1. Water keeps your brain healthy.
Your brain tissue is about 85% water. Drinking water regularly keeps your brain functioning well. Studies show that dehydration is a key factor in causing migraines, headaches, chronic fatigue syndrome and depression. The most common cause of daytime fatigue is actually mild dehydration.
2. Drinking plenty of water reduces the risk of heart attacks.
Research has also shown that people who drink more than 5 glasses of water a day are less likely to die from a heart attack than people who drink less than two.
3. Water gives you bright and healthy skin.
Water naturally moisturizes skin and ensures proper cellular formation underneath layers of skin to give it a healthy, glowing appearance. Water stimulates the circulation of your blood, fluids, and the necessary elements inside your body. It also controls and regulates the skinâs natural balance. When water is warm, it has the energy to hydrate, refresh, detoxify, and oxygenate your skin. Warm water also gets rid of blackheads and makes large pores smaller. Drinking water makes the body more relaxed and rejuvenated.
4. Water flushes toxins out of your body.
The function of your kidneys is to get rid of any waste from your body. If these toxins stay in your body they make you feel tired and sometimes unwell. These toxins also place a harmful burden on the other systems in your body. Water aids in the digestion process and prevents constipation.
5. Water regulates your body temperature, particularly during exercise.
When you exercise, you lose water through your breath and by sweating. As the sweat evaporates, your body cools. Replenishing any water you lose during exercise is vital for physical performance and good health. Too much water loss will increase your risk of heat exhaustion. In addition, to your normal six to eight glasses of water each day, drink a glass before you exercise. Then, for each 20 minutes of exercise, drink another cup or more. Be sure to drink a cup or two after you finish.
6. Water raises your metabolism.
Metabolism is the way by which the food you eat is converted into energy. The first chemical process that takes place is digestion. This process prepares the nutrients in the food to be absorbed by the body and transformed into energy. Drinking plenty of water is essential to maintain good digestion which keeps your metabolism going. The health benefit of water is better consumption of the nutrients you consume resulting in loads more energy.
7. You lose weight by drinking water.
Water helps you maintain a healthy body weight by increasing metabolism and regulating appetite. Drinking water is important if youâre trying to lose weight, some studies have shown that thirst and hunger sensations are triggered together. If there is a slight dehydration the thirst mechanism may be mistaken for hunger and you might eat when the body is really thirsty. As most food contains some water, if you donât drink much they may be subconsciously driven to eat more to gain the necessary water supply however, you also consume more calories. So in short, drinking more water can help to prevent overeating and benefit weight loss.
8. Water is absolutely essential to the human bodyâs survival.
A person can live only about a week without water, and four times that (about a moth) without food.
9. Drinking water lessens your chance of cancer.
Drinking plenty of water can reduce the risk of certain types of cancers, including colon cancer.
10. Water is still more inexpensive than beverages.
Save money when eating out by ordering water with lemon. Even if youâre brought tap water the lemon is a natural cleanser and also raises the PH of the water for an instant alkaline beverage free of calories.
|THE IDEA OF NORMALCY|
SHOP THE STORY
|Precocious Pale brew day|
Today I brewed up the Precocious Pale Ale recipe that I formulated in the previous post.
I thought that it might be helpful to walk through my brew day process, so that I can watch it evolve and so that others can (hopefully) take something out of it.
The first thing I did was crush my grain. I have a 7 pound Barley Crusher, and I crushed my grain directly into my mash tun (which is a 10 gallon rubbermaid cooler I picked up from Lowes.
Yeah, the neighborhood cats like to wander around and help me out. What can I say, I'm a softie.
Next, it was time to heat up my mash water. I needed just a bit under 4 gallons to have my desired ratio of 1.5 quarts to 1 pound of grain.
This is a cheap turkey fryer kit I picked up off Amazon. I've previously drilled two holes into it - one for a brewmometer about halfway up, and a second for a spout near the bottom. This is a 30 liter pot, and I've since upgraded to a larger pot for my actual boil, but this pot works perfectly for heating up mash/sparge water.
Today, I was heating up the mash water to 164 degrees because I wanted this pale ale to mash around 154. As I mentioned in my previous post, this is so that I get a bit more residual sweetness in this beer than I got in the previous beer with a similar grain bill.
Once the water hit temp, I poured it directly over the top of the crushed grain and stirred thoroughly for about 3-4 minutes. Then I threw on the lid to the cooler and walked away for about 45 minutes.
After 45 minutes, I started the sparge water heating on the burner. I put 4 gallons back in the same pot as before, and started the process of bringing that up to 175 degrees. Since I batch sparge, I want the second addition to bring the grain temp up to about 165 degrees.
Once the mash had been soaking for an hour, I make the assumption the conversion to extract the sugars from the grain is complete. Because I don't have a PH meter, I can only assume that it's enough time. However, most mashes are actually done within 30 minutes, so the hour I gave mine is almost certainly enough.
This process basically consists of slowly running off the wort until it runs clear. This allows the grains in the cooler to form a natural filter around the braid I have placed in there. I just pour the wort in the pitcher back over the top of the grain in the cooler until it runs clear. Normally, I only have to fill up one of these pitchers before it's clear.
Because I was curious about my mash efficiency, I took a refractometer reading at this point. A refractometer measures the sugars in solution. Now, this picture was extremely tough to get. I had to get the sun to shine through the refractometer just right, and get the lens from my iPhone camera aligned perfectly, but this is what I saw when I looked through:
So, my "first runnings" had a value of 15.6 brix. This correlates to a gravity reading of 1.064. This is good, because I wanted my pre-boil gravity reading to be approximately 1.040. Knowing that the first runnings make up approximately half of the wort going into the boil, I found I was on target to hit near those numbers.
Once the mash had finished running off, the sparge water was hot enough. I threw my sparge water into the mash tun, and took my first runnings and threw it on the burner to bring it up to a boil. Now that I have a second pot (thanks to my lovely wife!) I can do that - use one pot to collect runnings while the second pot is on the burner. It helps make the brew day a lot shorter.
After stirring the sparge, I let it sit for about ten minutes and then repeated the vorlauf process from above until it ran clear. Once it was clear, I started filling the pot with the sparge and took a second refractometer reading:
This one clocked in just a bit over 5, meaning the two numbers should average out to right around 10-11 brix. Sure enough, once I collected the sparge water and added it to the boil pot, I found out I was right on target:
10 brix, which is right around a gravity of 1.040. Perfect!
Now it was time to bring the approximately 7 gallons of wort to a boil. I knew I had a few minutes while it came up to temp, so I started measuring my hops.
In this case, 1oz of hops which will be my 15 minute addition. I also measured .5oz as a 90 minutes addition, and another 1oz as the 5 minute addition.
As I was measuring the hops, the pot started to boil.
Now the hard work is mostly done! I just need to let it boil for 90 minutes, adding the first hop addition now, the second with 15 minutes left in the boil, and the last one with 5 minutes left.
Rather than showing you pictures of me waiting, here's an old silent movie style image:
Hey, it's now 90 minutes later! Cool! Time flies when you're not actually there...
Anyway, I threw a wort chiller into the pot and cooled it down to pitching temp, and pitched the wort directly on top of an old yeast cake I had left over from a previous brew.
You can see the oxygen tank sitting to the right of the carboy, not pictured is me oxygenating the wort for 30 seconds. This shot of pure oxygen works as yeast fuel, and is something I just started doing this year on advice of my friend Jeremy. (It was solid advice - my beers taste cleaner since I started the practice.)
I took an 'original gravity' reading at this point, and found that the boil had condensed the sugars down the way I wanted.
The value of 11.8 brix here corresponds to a gravity of 1.047, which is just about perfect.
For comparison purposes, this is a screenshot of BrewPal, the iPhone app I used to formulate the recipe.
So, it expected a pre-boil gravity of 1.038 and a post-boil gravity of 1.045, and I actually got 1.040 and 1.047, which is close enough for government work.
Total, I spent just about 5 hours from starting until I was completely cleaned up. Got started right around noon today, and I was in the shower while the future beer was in my fermentation chamber by 5:10pm. I feel like if I hadn't used pilsner grain (which requires a 90 minute boil), I actually could have shaved another 30 minutes off that time. Also, if I ever get a PH Meter, I could cut down my mash times and maybe even get under 4 hours. Still, five hours is wayyyy better than some of my early brew days, which were 7-8 hour marathons.
Now I have to impatiently wait for this to ferment to see how the beer actually turns out. All the techniques and numbers in the world don't mean squat if you don't have a solid recipe and combination of flavors.
Here's hoping that what I've learned so far will lead to this being a solid beer. Even if it's not, it's another chance to continue to learn and refine.
I love Sunday brew days. Watching NFL Red Zone and brewing beer is just the perfect way to spend an afternoon.
Update 12/27/11: I dry hopped this beer for 10 days from 12/17-12/27, then racked it into a keg. Final gravity was 1.011, giving me a 4.5% ABV beer, which is perfect for a sessionable pale. Tasting it on racking, it has a much stronger initial bitterness than I had figured, and a very mild nose. Still, a very pleasant flavor and much more body than I would have expected from a beer with that low of an alcohol level. Will do a final testing once it's fully carbonated.
Update 01/16/11: Having had this beer on tap for a few weeks now, I have a few observations about it that will definitely influence my next pale ale recipe.
First, there's just a bit too much 'body' to this beer. It's a bit too thick, and it keeps me from wanting more than one. Interestingly enough, my porter is light enough I find myself switching to that.
Second, it's just a bit too bitter for my tastes. The hops come through decently in all phases except aroma, and the bitterness from them tastes much harsher than the expected IBU. I would use these hops again, but mostly for flavor. I'd use something less harsh for bitterness and something more aromatic for the finish and dry hop.
Finally, it has a bit of a haze to it. I'm guessing this is due to the carapils, since my IPA that had pilsner malt and crystal 60 didn't have the same haze.
These factors are making me think my next attempt at this style will be with a different hop, but also with about half the crystal malt and half the carapils. I'm hoping that will get me something I'm more pleased with.
|What exercise Can Do For You|
What is the single, most important thing one can do to achieve thorough wellness? Experts believe the acknowledge to that question is exercise. Rehearsal affects a person's reasoning and corporeal well being. For our bodies to achieve at its maximum, a well planned Rehearsal regimen is crucial. The absence of Rehearsal leads to a collection of health linked problems. Knowing what Rehearsal can do to our total well being can better motivate us to make Rehearsal a part of our daily life.
Exercise benefits the heart by enabling it to pump blood more efficiently. It is the former duty of the heart to make sure that all body parts receive an adequate number of oxygenated blood. The heart is a muscle and the more you Rehearsal it by doing cardio exercises, the stronger it becomes. Lungs come to be stronger and lung capacity is increased. Citizen who Rehearsal have more vigor and feel lighter. This is because your muscles carry your weight. Bones improve with aerobic, weight bearing and power training exercises. Weights growth bone density and help prevent osteoporosis. Rehearsal is also beneficial in the administration and arresting of Type Ii diabetes, arthritis and other degenerative diseases.
Psychological and emotional benefits of Rehearsal contain improved reasoning alertness and perception, improved self esteem, a greater sense of self reliance, decreased tension and reduced frustration. Most Citizen go through a maze of problems and stress at any time in their life. Exercising, however, can help to improve mood, growth optimism and promote calmness. The hormone endorphin, which is released while exercise, blocks the feelings of pain and create feelings of euphoria. This hormone is responsible for runners' high and is the reckon why Rehearsal is addictive. Psychological benefits are as important as the physiologic. Exercisers record improved moods, relieved persisting stress patterns and sharpened concentration. This is invaluable for Citizen who suffer from depression and anxiety.
Diabetic Pump:What exercise Can Do For You
Aesthetic benefits of Rehearsal are the benefits that one can readily appreciate. Muscles come to be leaner and longer, your skin glows and your movements are more graceful. The improvements in one's appearance can be attributed to the psychological and corporeal benefits of exercise. When we feel good, this becomes clear in our corporeal appearance. The more we like what we see in the mirror, the higher our self esteem and appreciation of ourselves.
The inclusion of Rehearsal in your daily activities will make a world of dissimilarity to your health. As with all other endeavors, it will be a little difficult at first. As you go along and your power builds up, it will come to be easy. You will look transmit to your daily exercises and begin to enjoy what Rehearsal can do for you.Diabetic Pump:What exercise Can Do For You
|Indrotec - Staffing and Workforce Management: Medical Assembly||
Indrotec - Staffing and Workforce Management:
Job Description:Medtronic is looking for candidates to contribute to the production of life-saving devices. Assemble devices used to filter, heat, and oxygenate blood during surgery. This position is in a full clean room setting. Are you ready to work in
Brooklyn Park, MN, United States
|Indrotec - Staffing and Workforce Management: Medical Assembly||
Indrotec - Staffing and Workforce Management:
Job Description:Medtronic is looking for candidates to contribute to the production of life-saving devices. Assemble devices used to filter, heat, and oxygenate blood during surgery. This position is in a full clean room setting. Are you ready to work in
Brooklyn Park, MN, United States
|Manual Resuscitators Market Analysis, Size, Share, Trends and Forecast 2020|
Transparency Market Research Report Added "Manual Resuscitators Market - Global Industry Analysis, Size, Share, Growth, Trends and Forecast, 2014 - 2020" to its database.
Albany, NY -- (SBWIRE) -- 07/15/2014 -- Manual resuscitators which are also known as bag valve mask, is a device used by individuals and healthcare professionals to inflate oxygen into lungs of an unconscious patients not able to breathe or during a respiratory failure occurring out of certain medical conditions. The device will help the person to remain oxygenated with the help of positive pressure. Manual resuscitators are hand-held portable device comprising a mask, a valve and a large ventilation bag used in the hospitals for temporary ventilation of patients. The mask is placed over a patient's face to prevent the escape of air, the valve checks the rate of flow of air into the lungs and the bag features a bulb which is squeezed to ventilate the patient.
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Manual resuscitators are mostly disposable but there are devices which are cleaned regularly and re-used. They are also named as AMBU bags, i.e., Artificial Manual Breathing Unit. The manual resuscitators market can be segmented into two major segments, which are as follows:
The manual resuscitators are manually compressed after which it automatically re-expands on its own and remains inflated all the time. This device can be used in in-hospital as well as out-of-hospital settings.
These manual resuscitators are also known as anesthesia bags. They are a specialized form of manual resuscitators which does not re-expand on its own and requires an external source to inflate. If the patient is breathing on his/her own, he/she can inflate it by breathing in and out. These devices are generally used in in-hospital setting.
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The respiratory care devices market has grown tremendously over the past few years. The main factors which will augment the growth toward the manual resuscitators market are increasing geriatric population, rising prevalence of Chronic Obtrusive Pulmonary Diseases (COPD), and technological advancement in the manual resuscitators market. On the other hand, factors such as risk of various complications, lung injuries and inability of general population to use manual resuscitators would most likely impede the growth of the manual resuscitators market.
Geographically, North America dominates the manual resuscitators market followed by Europe. The prime factor which will drive the growth of this market in these regions is increasing cases of respiratory disorders such as chronic bronchitis, asthma and emphysema. According to the American Lung Association, COPD is the third leading cause of death in America. A shift from hospital care to home care among individuals coupled with rising healthcare costs have also triggered the growth of the manual resuscitators market.
Asia-Pacific is one of the most developing regions and will continue to grow at a steady rate. The advantageous factors, which will accentuate the growth of the manual resuscitators market in this region, are rising demand of the population for cost effective medical treatments, higher levels of air pollution due to huge population in countries like China and India, increasing number of individuals suffering from asthma, and portability associated with manual resuscitators. Moreover, convenience and comfort to use manual resuscitators in a home setting environment will spur the growth of this market as it will lead to cost advantage.
Some of the major players operating in the manual resuscitators market are Medline Industries, Inc., Covidien Ltd., GE Healthcare, Cardinal Health, Inc., ResMed Inc., Philips Medical Systems, MeedicalExpo, Drager Medical AG & Co. KG, Hpokins Medical Products and others.
For more information on this press release visit: http://www.sbwire.com/press-releases/manual-resuscitators-market-analysis-size-share-trends-and-forecast-2020-530234.htm
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|Identifying the Stages of Oil Oxidation|
Lubricants age and alter chemically by a process called oxidation. In fact, oxidation is the primary way a lubricant degrades over time from normal service. It typically results in impaired chemical and physical properties of the base oil and additives. Understanding why a lubricant oxidizes is essential to prevent, delay and monitor the process.
As oil is used in a machine over time, the oxidation process occurs, typically starting with the degradation of antioxidant additives. If the driving conditions that stress the oil remain unchanged, these additives will deplete at a near linear rate. This is sometimes called the induction period. When the oxidation inhibitors are largely depleted, the breakpoint of the lubricant is reached, at which time the base oil has lost its first line of defense against oxidation.
Some base oils are extremely robust and resist oxidation naturally. Examples include most synthetics. However, if exposures to pro-oxidants such as high temperature, moisture, metal particles, agitation and oxygen are severe enough, even the most robust synthetics will give way to oxidize.
This oxidation process has the potential to begin almost spontaneously for even oil sitting dormant in a storage container. However, the rate of additive depletion and base oil oxidation generally correlates to the intensity of pro-oxidants existing within the oil. Ultimately, the consequences of this chemical process will include increased oil viscosity and organic acids; the formation of sludge, varnish and deposits; additive depletion (including anti-wear additives, dispersants, corrosion inhibitors, etc.); and the loss of other vital base oil performance properties. Once these undesirable lubricant conditions exist, the machine no longer will be protected effectively against friction, wear and corrosion.
Oxidation is a complex series of chain reactions. To better understand the process, follow the chart on page 42 as each element is explained.
The oxidation process consists of three key stages: initiation, propagation and termination.
Initiation describes the mechanisms by which a lubricant’s components can chemically combine with one or more catalysts to produce a free radical. (Free radicals are highly reactive molecules that attempt to find other molecules to combine with and create new products.)
Propagation refers to the complexity of additional reactions of various types of free radicals and catalysts that result in the production of more free radicals and oxygenated compounds.
Termination involves the eventual end of the oxidation process, either negatively or positively. If it is negative, the antioxidants typically have been depleted and the oxidation process will continue. If it is positive, an antioxidant likely has stunted the oxidation’s progression. Keep in mind that antioxidants are sacrificial, which means they become depleted as they do their job. Therefore, the positive effects of antioxidants will expire, while the overall oxidation process will not.
The lubricant (a), which is a formulation of hydrocarbon base oil and additives, is subjected at some point to various catalysts and conditions that allow the initiation of oxidation to occur. Both the base oil and additives fight against the oxidation process and are eventually subjected to degradation.
During the initiation stage (b), the hydrocarbon molecules react with various catalysts, leading to the formation of free radicals. Once this has occurred, further initiations of the oxidation sequence may continue as the existing free radicals progress to the propagation stage.
Wear metals (c) have the potential to cause or accelerate oxidation reactions by means of metal ions in copper, cobalt, chromium, iron and other transition metals. Thus, not only does oxidation have the ability to create wear debris, but wear debris can cycle back to promote further oxidation.
Nitro-oxides (d) such as nitrogen dioxide, nitric oxide and nitrous oxide are another form of pro-oxidants that catalyze the oxidation reaction.
Ultraviolet radiation (e) in the form of sunlight can also initiate oxidation reactions. This is frequently observed and can often explain the discoloration of unused oil.
Elevated temperatures (f) promote and sometimes are required for certain stages of oxidation to occur. When in combination with wear metals or oxygen, the effects may be multiplied. If temperatures are low, the chain reactions are generally slow but will increase at moderate rates above 100 degrees C.
Oxygen (g) is the major catalyst of oxidation. Whether it exists in the air or in other molecules such as water, oxygen is integral in the oxidation process at almost every stage.
Free radicals (h) are among the unwanted results of the intermediate reactions within oxidation. These highly reactive molecular fragments contain one or more unpaired electrons that are prone to reactions with hydrocarbons and other molecules. Some free radicals may exist as molecular fragments of alkyl, hydroperoxide, alkyloxy, hydroxy, alkylperoxy, etc.
Once free radicals exist, they quickly will react again - propagating (i) the process - with the hydrocarbons and dissolved or free oxygen to form more free radicals and oxygenated compounds. High temperatures also play a role in furthering this reaction at increased levels. Another example of oxidation propagation would be peroxy radicals reacting with additional hydrocarbons to produce hydroperoxides and more alkyl radicals.
As a product of several chain reactions during the propagation stage, oxygenated compounds (j) are formed such as aldehydes, ketones, alcohols and water. These products are the result of a reaction between the alkyloxy radicals and hydrocarbon.
Alkyl hydroperoxide and alkylperoxy radicals can be neutralized and removed from the propagation of oxidation when they come in contact with antioxidants (k). The most common antioxidants will work as chain breakers and decomposers.
Oxidation can move past the propagation stages unfavorably (l) when the oxygenated compounds continue to react with the hydrocarbons and oxygen. On the other hand, oxidation may terminate favorably (m) when stabilization of free radicals occurs. Chain-breaking antioxidants, such as phenolic or aromatic amines, react with the free radicals to form stable radicals and inert byproducts. Peroxide decomposer types of antioxidants like phosphates and sulfides react with peroxides to produce alcohols and water.
Oxygenated compounds (n) will react further with oxygen resulting in carboxylic acid, esters and water. This process is again increased when subjected to high temperatures. Carboxylic acids are largely formed by the oxidation of aldehydes and ketones, which continues through an abstraction of an alpha hydrogen or aldehydic hydrogen from the hydrocarbon molecules.
Polycondensation and polymerization (o) of the oxygenated compounds describe the effects of the final stages of oxidation. The increase in weight of the molecular compounds translates to the formation of sludge, varnish and deposits. Not only do these insoluble products form, but organic acids corrosively attack the surfaces along with water. Most of the additives are also negatively affected and in turn become part of the deposit agglomeration. As aldehydes and ketones increase in the lubricant due to the condensation reactions, the apparent viscosity will begin to increase.
Insoluble, oxidized oil products (p) like sludge and deposits are significantly different from the oil molecules that make up the majority of the lubricant. Sludge is the buildup of insolubles, while deposits are insolubles that attach tightly to metal surfaces. Corrosion will be promoted as water and acids exist on metal surfaces if the corrosion inhibitor additives are depleted, which may also be the byproduct of oxidation.
In conclusion, contaminants like water, oxygen and wear metals can have serious consequences on lubricants and machines. Additives such as antioxidants can help substantially, but they eventually will become depleted during the induction period. For your lubricants to last longer and your machines to run longer, you must understand why oxidation occurs.
Note: For further reading on the oxidation process, see Dave Wooton’s article at http://www.machinerylubrication.com/Read/999/lubricants-oxidation.
|Antioxidant Monitoring of Gas Engine Oils|
The use of biogas engines and their maintenance has become a hot topic over the last few years. Biogas is a renewable fuel, so it qualifies for renewable energy subsidies in some parts of the world. Biogas typically refers to a gas produced by the biological breakdown of organic matter in the absence of oxygen. It is this type of gas that can be used as biofuel.
One type of biogas is produced by anaerobic digestion or fermentation of biodegradable materials such as biomass, manure, sewage, municipal waste, green waste and energy crops. Via this formation, biogas is produced that consists primarily of methane and carbon dioxide. Another possible source of biogas is wood gas, which is created by gasification of wood or other biomass. This type of biogas is comprised primarily of nitrogen, hydrogen and carbon monoxide with trace amounts of methane.
As a renewable energy source, biogas can be utilized for electricity production on sewage works in a combined heat and power (CHP) gas engine. If compressed, it can replace compressed natural gas for use in vehicles, where it can fuel an internal combustion engine. The methane, hydrogen and carbon monoxide gases can be combusted or oxidized with oxygen. Air contains 21 percent oxygen. This energy release allows biogas to be utilized as a fuel. Biogas can be used as a low-cost fuel in any country for any heating purpose, such as cooking. It can also be employed in modern waste-management facilities where it can be used to run any type of heat engine and generate either mechanical or electrical power.
Landfill gas typically has methane concentrations around 50 percent. Based on advanced waste-treatment technologies, biogas can be produced with 55 to 75 percent methane. The chemical composition of biogas varies depending upon the origin of the anaerobic digestion process.
Methane within biogas can be concentrated via a biogas upgrader to the same standards as fossil natural gas, becoming bio-methane. Carbon dioxide, water, hydrogen sulfide and particulates (such as siloxanes) must be removed if present. These siloxanes are formed from the anaerobic decomposition of materials commonly found in soaps and detergents.
During combustion of biogas-containing siloxanes, silicon is released and can combine with free oxygen or various other elements in the combustion gas. Deposits are formed containing mostly silica or silicates as well as calcium, sulfur, zinc and phosphorus. These white mineral deposits accumulate to a surface thickness of several millimeters and must be removed by chemical or mechanical means.
In comparison to natural gas engines, the operating conditions of biogas engines are different because of higher combustion temperatures, 24/7 operation to avoid methane release and contamination from carbon dioxide, water, hydrogen sulfide (acidic) and particulates (siloxanes).
In general, gas engines are used to power cogeneration electrical power plants and are preferred over diesel engines because of their lower exhaust emissions and lower fuel cost.
Formulation Changes for Gas Engine Oils
Gas engine oils used in biogas or natural gas engines have special formulations that differ from diesel and gasoline engine oil formulations. This is because natural gas engines have:
For gas engines, the goal is to obtain a lubricant with higher thermal and oxidative stability or to create a lubricant with a minimal oxidative degradation. Standard results for lubricants with poor oxidation protection/control are:
These operating problems can be prevented by the combination of a good quality base oil with a supplemental antioxidant package. A typical gas engine oil formulation may contain multiple antioxidant additives to help protect the base stock from excessive heat or catalytic degradation.
Antioxidants added alone or in synergistic combinations extend the operating life of the oil by improving its oxidation stability. During their use in lubrication systems, oxidation inhibitors will deplete to a certain critical level, at which point the fluid will start to degrade/polymerize at an accelerated rate. When this happens, important changes in the physical properties of the base stock occur. The oil or lubricant is no longer able to protect the equipment, and its useful life is over.
There is a growing interest in methods predicting an oil change by measuring antioxidant concentration during the lubricant’s lifetime. Monitoring the onset and the propagation of oxidation will lower operating costs and allow users to detect abnormally oxidized and degraded lubricants.
The basic mechanism of oxidative degradation and the role that different antioxidants play begin with the formation of reactive compounds, better known as free radicals, hydro peroxides and peroxides. These reactive compounds propagate into oxygenated hydrocarbons, such as alcohol, acids and sludge. The antioxidants act in two ways: by removing radicals (primary antioxidancy) or by decomposing hydro peroxides to form non-reactive products, which do not participate in further oxidation of the lubricant. Currently, the most commonly used primary antioxidants are the phenolic, phenates, salicylates and amine types; the secondary antioxidants are usually sulfur or metal-containing additives.
Once the antioxidant additives are depleted, the base oil is more vulnerable to oxidation. This may explain why the oil’s viscosity tends to increase as more operating hours accumulate on the gas engine.
Figure 1 shows a RULER voltammogram for different gas engine oil formulations. As you can see, the selection of different types of antioxidants is applied for the gas engine oil formulations, where the following types of antioxidants are used: Zincdithiophosphates (ZnDTP), aromatic amines, phenates, phenols and salicylates.
Figure 1. Multi RULER graphs representing different gas engine oil formulations.
Relationship between Antioxidants and Viscosity
Actual oil analysis specifications by acid number and base number in combination with elemental analysis and contamination are no longer sufficient to define the correct oil change intervals or detect changing operating conditions. One of the innovative oil analysis techniques applied and selected for these oil diagnostic programs is individual antioxidant monitoring by linear sweep voltammetric techniques (RULER technology).
By monitoring individual antioxidants, in comparison to acid number, operators will be able to establish an accurate condition of the oil as part of the oil’s lifecycle evaluation.
Figure 2. Correlation between phenolic depletion (FTIR) and viscosity increase.
Advantages of Different Methods for Oil Lifecycle Evaluation
Over the years, oil change frequencies or drain intervals have been recommended by each engine manufacturer. These can vary from 500 to 1,500 operating hours. The use of contaminated biogases along with high-load factors on the engines can significantly reduce these drain intervals. However, they can also be extended with good maintenance and operational practices, as well as oil monitoring through an adapted in-service oil analysis program. This is particularly important if the quality of the gas is unsteady.
The results of the following experimental program will show how the exact combination of the selected oil analysis parameters can lead to a high value and sophisticated oil diagnostics program.
Case Study #1 – DEUTZ Biogas Engine
This study occurred at a site where vegetable green waste was generating methane through fermentation and driving the eight DEUTZ biogas engines using an oil formulation typically formulated for biogas engine operations. Figure 3 shows the analysis for an in-service oil sample after 300 hours of operation.
Figure 3. RULER graph for biogas engine oil from the DEUTZ engine after 300 operating hours.
Based on different cycles for the same engine, the oil was closely monitored every 100 hours for the following oil parameters: viscosity (100 degrees C), AN, BN, oxidation, percent water volume, flash point, detergency, glycol, elements, chlorine, antioxidants and oil top-up volume. In addition, boroscopic control information was made available, which showed no increased deposits in the critical areas of the engine.
From this data, four critical oil parameters were selected: antioxidants, AN, BN and oxidation (by FTIR). The correlation was indicative of the antioxidants’ value:
Figure 4. Correlation between antioxidants, AN, BN and oxidation by FTIR for DEUTZ biogas engines.
Case Study #2 – Jenbacher Biogas Engine
Figure 5 shows the RULER analysis for in-service oil samples between 500 and 2,246 hours of operation, indicating a zinc-free additivated oil (consisting of two different types of ashless/metal-free antioxidants).
Figure 5. RULER Multigraph for biogas engine oils in service on Jenbacher engines.
The RULER voltammogram depicts the depletion of two antioxidants, in this case an aminic and a phenolic formulation over 2,246 hours.
Based on different cycles for the same engine, the oil was closely monitored every 300 hours for the following oil parameters: viscosity (40/100 degrees C), AN, BN, i-pH-value, oxidation, nitration, percent water volume, detergency, glycol, elements, antioxidants and oil top-up volume.
From the data, representing 2.246 operating hours, five oil parameters were selected: antioxidants (for two individual antioxidants), AN, BN, viscosity at 40 degrees C and at 100 degrees C. The correlation was indicative of the antioxidants’ value. In the graph below, an overview of these parameters can be found:
Figure 6. Correlation between antioxidants, AN, BN and viscosity for Jenbacher biogas engines.
Case Study #3 – Jenbacher 612 Natural Gas Engine
Figure 7 shows the RULER analysis for in-service samples between 1,600 and 2,000 hours of operation, indicating an additivated oil (consisting of two different types of antioxidants).
Figure 7. RULER multigraph for natural gas engine oils for an in-service Jenbacher engine.
The RULER voltammogram above reveals a clear depletion of the two antioxidants, in this case an aminic and a salicylate formulation. The yellow line, which marks the highest amount of operating hours of the oil, shows a slightly higher amount of antioxidants compared with the previous sample because there was a refilling of a higher amount of oil between the two samples.
Based on different cycles for the same engine, the oil was closely monitored every 200 hours for the following oil parameters: viscosity (40/100 degrees C), AN, BN, i-pH-value, oxidation, nitration, percent water volume, detergency, glycol, elements, antioxidants and oil top-up volume.
From this data, representing 1.964 operating hours, three oil parameters were selected: antioxidants (for two individual antioxidants), viscosity at 100 degrees C and i-pH-value. The correlation was indicative of the antioxidants’ value. In the graph below, an overview of these parameters can be found:
Figure 8. Correlation between antioxidants, i-pH value and viscosity for Jenbacher natural gas engines.
Case Study #4 – Waukesha Natural Gas Engine
Figure 9 shows the RULER analysis for in-service oil samples between 1,600 and 2,000 hours of operation, indicating an additivated oil (consisting of three different types of antioxidants).
Figure 9. RULER multigraph for natural gas engine oil on in-service Waukesha engines.
The RULER voltammogram above depicts good depletion of the two main antioxidants – an aminic and a salicylate formulation. There was also a third antioxidant, which was a phenolic formulation.
Based on different cycles for the same engine, the oil was closely monitored for nearly 4,000 hours for the following oil parameters: viscosity (40 degrees C/100 degrees C), AN, BN, i-pH value, oxidation, nitration, percent water volume, detergency, glycol, elements, antioxidants and oil top-up volume.
From this data, three oil parameters were selected: antioxidants (for two individual antioxidants), viscosity at 100 degrees C and i-pH value. The correlation was indicative of the antioxidants’ value. In the graph below, an overview of these parameters can be found:
Figure 10. Correlation between antioxidants, i-pH value and viscosity for Waukesha natural gas engines.
Alternative Methods to Determine Oxidation
Traditionally, the oxidation number in used gas engine oils is measured by FTIR at the wave length of 1,710. Nearly every gas engine manufacturer has a limit for oxidation number based on this accepted method. Most manufacturers have set their limit value for this number at 20 A/cm.
In some modern gas engine oils, you can find components of base oil and additives that have one or more fresh oil peaks in this range (about wave length 1,710). This will complicate the interpretation of the oxidation number.
Figure 11. Example of how the oxidation number is determined in a modern gas engine oil.
Figure 12. Another example of how the oxidation number is determined in a modern gas engine oil (trend during 750 hours).
Two main effects of the DIN-oxidation (DIN 51453) method are that an oxidation value of more than 10 can initially be detected in the fresh oil and that the oxidation products are running against the additive depletion. Figure 12 shows that influence of the additive depletion in this area is so strong that it seems as if the oxidation in the spectra is lowering in the trend. In this example, an increasing oxidation number up to 22 A/cm was found followed by a decrease to 17 A/cm. Most of the gas engine manufacturers specify a maximum limit of 20 A/cm for an oil change. In this case, it was obvious that this limit made no sense for such engine oil formulations.
To obtain comprehensive information about oil oxidation with such a modern formulation, it is not possible to work with this traditional DIN method. Even in DIN 51453, it states that the interpretation of the results analyzed with this standard is impossible in oils with ester-containing additives or in ester-based fluids.
One possibility to get an idea of the running oxidation process in the oil in use is to watch the depletion of the phenolic inhibitor, which is not only detectable with the RULER but also with FTIR.
Figure 13. FTIR spectra of one modern gas engine oil.
Figure 14. Detail of the phenolic inhibitor during 750 hours in use.
Although it is possible to observe the phenolic antioxidant in the FTIR spectra, only one antioxidant can be monitored well. Therefore, another possibility was sought to check the oxidation of the used oil in the engine.
An ASTM method for the determination of oxidation (ASTM D 7214-06), which includes a special chapter for ester-containing fluids, may be a good alternative to DIN 51453. At the moment, many gas engine oils are being compared using this ASTM method with the corresponding results of viscosity increase, DIN oxidation, AN, BN and phenolic antioxidant. It is recommended to replace the DIN oxidation method for used gas engine oils with a more comprehensive method for the detection of the real oxidation of modern oil formulations.
In conclusion, it was determined that antioxidant analysis can be useful both for small and large oil reservoirs, as well as peak/base-load operations. The importance of individual antioxidants in combination with other critical parameters may provide a better understanding of the processes occurring during the oil’s lifetime. In addition, oil analysis can be achieved as part of an improvement of oil lifecycle estimation as well as equipment reliability and availability. However, for the monitoring of oxidation, especially for smaller gas engines, it is useful to seek a better method than the traditional DIN oxidation method.
|Estimating Turbine Oil Oxidation|
From steam turbine to gas turbine, from power generation to refining, turbines are pervasive throughout industry. While turbine systems can endure a whole host of different failure modes, studies by major turbine manufacturers such as General Electric have pointed to the lubricant as one cause of poor reliability.
However, other factors such as maintenance and operational practices, electrostatic discharge, contamination, and lubricant chemistry have been identified as root causes. Turbine oils must endure a host of different challenges due to heat from the process itself, compressive heating, aeration, and internal and external contamination, including water and particles.
Perhaps the most misunderstood failure modes are those induced by the turbine oil itself. While turbine oils are naturally pure, well-formulated oils, the long-term stress caused by adverse operating conditions can result in both thermal and oxidative degradation of the oil which can cause problems with the reliability and operability of turbine systems.
Even in the most controlled systems, turbine oils are subjected to a number of stressing factors that can lead to premature degradation of the fluid. These include heat, aeration, water and metal catalysts from the machine itself. While the chemical processes are complex, the end result is the same: the formation of by-products of oxidation such as sludge and varnish.
Sludge and Varnish
Sludge and varnish formation is a sequential process. Initially, heat in combination with aeration causes base oil molecules to chemically react with oxygen. This forms soluble by-products including ketones, hydroperoxides and organic acids. Over time, these by-products can combine either physically - a process referred to as agglomeration - or chemically due to further reaction, eventually becoming large enough that they drop out of suspension in the oil, forming solid or semisolid deposits on oil-wetted machines surfaces.
Compounding their effect, by-products of oil degradation are often sticky or resinous in nature. This can cause a host of problems including servovalve stiction, buildup on spool metering edges, restriction of oil flow, reduced spool-to-bore clearances, thermal insulation of the valve, combination with other particles and the loss of stick-slip control. Recent research findings1 point to many contributing causes in the oxidation to varnish (Figure 1) process, such as:
Because of its significance, researchers in turbine oil analysis are constantly seeking new ways to determine the early onset of lubricant degradation such as oxidation. This article discusses the novel application of a commonly used analytical method to evaluate oxidative turbine oil degradation.
Ultra-weak Chemiluminescence Method
Table 1. Oil Samples
Table 1. Oil Samples
It is well known that low-level luminescence is naturally produced from many kinds of materials. Luminescence simply refers to any process or material that emits light energy. By definition, chemiluminescence refers to luminescence caused by a chemical reaction, such as the glow of a firefly's tail.
Specifically applied to this study of material oxidation, chemiluminescence is induced by heating the sample in question inside a reaction chamber. By heating the sample, unstable molecular species such as hydroperoxides that are intermediates in the oxidative breakdown of organic materials start to decompose. This decomposition liberates an unstable form of oxygen referred to as singlet oxygen or excited carbonyls. As the unstable singlet oxygen or excited carbonyls are liberated, light energy is emitted.
In this study, we tried to estimate the oxidation level of turbine oil by measuring UWCL and measuring the correlation between the UWCL and an established varnish potential indicator test known as quantitative spectrophotometric analysis (QSAÂ®).6
Figure 3. UWCL Time Course Change of Turbine Oil at 130Â°C in AirMaterials and Method
In the initial study, seven in-service oil samples with the same fully formulated Group II turbine oil were chosen so that the overall chemistry and additives would be consistent. The samples were chosen so that a broad range of QSAÂ® varnish potential ratings (VPR) range would be represented (Table 1). Measurement of Turbine Oil UWCL
To measure the UWCL of the turbine oil samples, a chemiluminescence analyzer model CLA-FS3 (Tohoku Electronic Industrial Company, Sendai, Japan) was used (Figure 2). Each oxidized 2-milliliter sample of turbine oil was placed on a stainless-steel dish (50 millimeters in diameter and 10 mm in height) and the UWCL intensity was measured in air at 130Â°C for 600 seconds. Result and Discussion
Figure 3 shows the time course change of UWCL of turbine oils at 130Â°C. There are two peaks at approximately 50 and 150 seconds.
The first peak at approximately 50 seconds of exposure to 130Â°C is due to weaker oxidation bonds that are more easily broken with heat. The underlying chemistry of that oxidation by-product has not yet been fully studied or identified. Although the peak is not as close to QSAÂ® in correlation, it might later prove to have other relationships to varnish formation.
The second peak around 150 seconds of heating presents chemiluminescence due to oxidation by-products which form as singlet oxygen is liberated or excited carbonyls are generated during decomposition at 130Â°C.
Figure 5 shows the correlation between the integrated UWCL signal between 150 to 154 seconds and the QSAÂ® results. As can be seen, the UWCL intensity correlated well with the QSAÂ® indicator of varnish potential with a correlation coefficient (R2) of 0.765 (authors' footnote), the correlation coefficient represents the degree to which two parameters correlate. It ranges from zero (no correlation) to one, indicating complete correlation. Values in the range of 0.7 and above indicate a high degree of correlation between two observables.
Figure 5. Correlation Between UWCL (150 to 154 seconds) and Varnish Potential
This result indicates that the UWCL method can possibly be used to estimate propensity to form varnish by measuring specific oxidation compounds of turbine oil.
UWCL assay is important for its ability to measure the oxidation levels of either organic or inorganic materials. Likewise, samples can be in solid, liquid or gas states or a combination of states. Sample sizes are small (approximately 2 mL). Test time is less than 20 minutes. Finally, adding reaction-causing chemicals or time-consuming physical preparations are not required.
Although more data on a variety of different lubricant chemistries needs to be collected and testing procedures perfected specifically for turbine oil, it appears from this study that UWCL may be a promising methodology for the rapid and sensitive measurement of turbine oil varnish potential.
Figure 4 shows how UWCL is generated from the oxidation reaction. The luminescence species are mainly singlet oxygen and excited carbonyl which result from hydroperoxides formed during oxidation.7
When an excited carbonyl species or singlet oxygen is released to the ground state, it gives out its energy as a light. Therefore, this UWCL indicates the amount of hydroperoxides or other oxidized products, and it is possible to measure the degree of oxidation.
These oxidation products seem to correlate with the QSAÂ® predictive index.
Chemiluminescence can be induced by many energies, including heat, light, radiation, chemical reaction or pressure. The key in oxidation characterization is "popping" that oxygen singlet off the compound. When it is liberated, there is a photon emission. The more oxygen liberated at the same stress condition means more light; more light means that more of some specific oxygenated compound is present.
Finally, because multiple oxidation compounds can be measured in the same test, the significance of each compound can be mapped with relation to the goal - predicting varnish potential and measuring prevention or remediation effectiveness.About the Authors
Mark Okazaki is manager of industrial oils technology for Chevron Products Company.
|Kecil saja. Tapi sangat berpengaruh.|
Dah pukul 5! Maka bergegaslah sekelian manusia di CDR pharmacy mengendong beg masing-masing untuk segera sampai ke rumah.
=D the best thing at CDR......
But everything went wrong.....Kita hanya merancang, Allah yang menentukan......hmm....bajet cam nak sampai rumah sebelum 6 petang...Ujian....Kereta kancil comel itu demamm......Sian!! Temperature naik sampai ke paras yang dah tak boleh naik dah!
Panic...Terus sahaja aku membelok ke kiri. Masuk ke Masjid itu......
"Mak, temperature naik sangatttt!! Tkah stop kat masjid neh...Takutlaa nak drive. Tak bukak aircond p0n. Tkah nak pegi anta bengkel troslah lepas neh. Bley mak?"
"Tak payah lah k0t. Drive slowly. Takut kne tipu ngan tauke kat situ tuh. Jap,jap, meh mak tanya ayah"
Sementelah solat Asar....
"Tkah, dah tgk air? Try isi dalam radiator tuh..Cek ada bocor tak?" Ayah memberi arahan. Ikut jelaa. Nasib baik ada botol dalam kereta....
"Aaahhhlaaaa..bocor lah ayah" terus aku melaporkan.
Bersegeralah aku membawa kancil yang demam itu ke bengkel....
Manalah tak demam.....................................
Haaa...ini adalah 'water pumping pipe' ye....Ia berfungsi sebagai saluran yang membawa semula air dari enjin kereta ke radiator. Boleh dianalogikan sebagai arteri pulmonari, yang membawa darah deoxygenated kembali ke jantung. Pentingkan?
Kagum...Kereta pun macam badan kita juga..Kalau tak dijaga dengan baik ataupun akan tiba satu masa yang tidak diduga ia boleh memudharatkan.
Kalaulah tiba-tiba salur darah kita pecah (hemorrhage), banyak kebarangkalian akan berlaku. Paling mudah, bengkak.....Dalam kes keretaku ini, pendarahan yang melampau-lampau lah..Orang itu akan mengalami hypovolemic shock..........memang collapse.......
Kesimpulannya, jangan ambil mudah dengan kereta........Ia perlu dijaga macam kita jaga badan kita...=)
|Î²-arrestin 2 Mediates Cardiac Ischemia-reperfusion Injury via Inhibiting GPCR-independent Cell Survival Signaling|
AbstractAims:Ischemic heart disease is a leading cause of morbidity and mortality worldwide. Although timely restoration of coronary blood flow (reperfusion) is the most effective therapeutics of myocardial infarction, reperfusion causes further cardiac damage, i.e. ischemia-reperfusion (I/R) injury. Î²-arrestins (Arrbs) have been traditionally defined as negative regulators of G protein-coupled receptor (GPCR) signaling, but recent studies have shown that they are essential for G protein-independent, GPCR-mediated biased signaling. Several ligands have been reported to be cardioprotective via Arrbs dependent pathway. However, it is unclear whether Arrbs exert receptor-independent physiological or pathological functions in the heart. Here we sought to determine whether and how Arrbs play a role in regulating cardiomyocyte viability and myocardial remodeling following I/R injury.Methods and Results:The expression of Î²-arrestin 2 (Arrb2), but not Î²-arrestin 1 (Arrb1), is upregulated in rat hearts subjected to I/R injury, or in cultured neonatal rat cardiomyocytes treated with hypoxia-reoxygenation (H/R) injury. Deficiency of Arrb2 in cultured neonatal rat cardiomyocytes alleviates H/R-induced cardiomyocyte death and Arrb2 -/- mice are resistant to myocardial damage caused by I/R injury. In contrast, upregulation of Arrb2 triggers cardiomyocyte death and exaggerates I/R (or H/R)-induced detrimental effects. Mechanically, Arrb2 induces cardiomyocyte death by interacting with the p85 subunit of PI3K, and negatively regulating the formation of p85-PI3K/CaV3 survival complex, thus blocking activation of PI3K-Akt-GSK3Î² cell survival signaling pathway.Conclusions:We define an upregulation of Arrb2 as a pathogenic factor in cardiac I/R injury, and also reveal a novel GPCR-independent mechanism of Arrb2-mediated cell death signaling in the heart.
|THE IDEA OF NORMALCY|
SHOP THE STORY
|Oxygenated Sunday||I spent Sunday afternoon clearing a raised bed of weeds so I could plant a few veggies I had bought! |
If everything thrives, I'll have Early Girl tomatoes, cherry tomatoes, green peppers, sweet red peppers, & banana peppers--plus there are some huge chive plants & a couple of little lettuce plants that came up volunteer from my neighbor's plantings last year.
And then I worked on my porch, gett...
|Burnham holiday village a carp session broken up.|
I write this in some respects to put the record straight, as when I was researching this lake before going on holiday I found very little decent information and what I did find was misleading in many ways. So I hope that this true report regarding the fishing at Burnham holiday village lake (Haven) may help other anglers in the future if they are holidaying at this park.
When I first saw the Lake at Burnham holiday village I thought it looked nothing as I had expected it to. Firstly what the internet had lead believe was two lakes; a match lake and specimen lake, was actually now one lake since the owner had dug through the causeway the previous winter. The old match lake half looked pretty much as most commercial fisheries look with manicured banks, stages and oxygenating pumps. The old specimen lake though was intriguing with copious islands lined with rushes and reeds, open swathes of water and hidden bays. This could have been some quiet corner of a syndicate lake rather than a holiday park pool. Through several hours of searching I had learnt that the main target for most people and myself would be carp, which were touted to grow up to nearly thirty pounds. As for the other species present none of them seemed to exist in any numbers apart from eels which did offer me a second target.
After one of the most horrendous journeys down from the middle where the car window screen wipers could barley cope and after hastily unpacking I ventured out to have a mooch round the lakes to see if I could add any info to my already blurred picture of the place. Really I was hoping with it being June and all that I could spot a few fish moving round to give me some areas to target. The wind though had other ideas and ideas that would be around for most of the week. Two laps of the lake and a liberal soaking was nearly all I could take. After seeing naff all I was about to leave until I spotted a still slice of water in one corner of the lake. Watching it for a while in the rain got me totally soaked, but it was worth it to see what looked like a few bubblers mooching along the edge. Seeing this tiny snippet of a sign was all I needed to deposit thirty crab and krill baits loosely all along the bramble lined margin, with the intention of returning for a early foray in the morning.
The weather over night went from bad to worse. Ten hours in a caravan bouncing back and forth listening to the wind doing its best to tear up the copse of trees behind our tin holiday home was a test for the whole family, apart from young BB who slept quite well all things considered. After slipping on my slightly damp clothes I grabbed my kit and ventured out into the still howling wind.
The lake was basically covered in large inland waves. The wind had swung ninety degrees and was now pushing onto the area I had baited the night before. Luckily a bit of bank side bramble at least afforded me a minimal amount of cover for the rods. Trying to keep things simple I threw out another thirty baits onto a slightly tighter area and swung out a PVA bag filled with chopped boilie and boilie crumb into the centre of the baited area. The second for this session was aimed towards eels rather than carp and was rigged up with a free running ledger boom and foot long armour braid hook link, size two hook and baited with two broken lob worms.
The wind was merciless and the only way I could fish in any way effectively was to dip the rod tips under the water, with my bobbins jammed tight up against the indicators. Quite soon the left hand rod which was the eel line kept sounding on the buzzer, but every strike was met by no resistance. This actually kept me busy for the whole session as I tried various baiting arrangements to try and connect with whatever was pulling my chain as the case may be. It wasn't until I threaded a half a lob on sea fishing style that I connected with a tiny eel... Already the reality of the situation was a lake paved with small eels. Not long after this realization the right hand rod which had been stewing away suddenly sprang to life with a subdued yet steady run. I don't think the fish realized that it was hooked in the churning waters until I lifted into it and drove the hook further home. I saw a golden flank roll in the murky water early on the fight which lead me to believe I wasn't playing anything more than a small carp. But the fight seemed to go on for ages in the shallow corner. After several runs and swimming straight through my second line I finally coaxed the fish towards the net and when it rolled over that one last time I spotted a huge mouth gaping back at me. In the net it seemed bigger as well and it turned out to be a really solid mid double that in another water could have been much bigger.
After a day of family fun I nabbed a few hours at dusk. Having re baited the same area with more freebies I went back to try my luck and have a proper go at the eels. In short it pissed it down again, my theory that the lake is rammed with small eels was confirmed, I used all my worms catching about twenty small eels, and the second rod was dead as a dodo. I did however spot several shows in a gap between two reed beds that indicated there was more than one carp in the lake.
After yet another rough night I went out to try and track down some fish. If the night before had showed me where the fish were, this morning was when the cat and mouse began. I went into a swim where I could see into a bay behind the reed bed where I'd seen the fish the night before. Early on three fish jumped tight to the far reed bed furthest away from me. The problem was with the wind and my under gunned 2.5lb Nash dwarf rods I had no chance of accurately casting to them. Hence the session descended into me watching fish out of range whilst hoping something unseen might find my PVA bag cast to closer reed beds.
A day later not a single fish was seen at all. The silver fish were now moving around and all over the lake I could see small roach and skimmers flipping out of the water. Having nothing to go on I targeted the end of the lake where I'd seen the carp jumping, but this time I fished tight to a very tight to a group of close in islands hoping something might move in between them and find one of baits surrounded by powdered boilies and pellets.
My final day on the lake and finally the weather had changed. The sun was now out and as my rods sat silently fishing into the big bay I watched a group of three or four carp rooting round under some snags in an out of bounds area behind the spit I was fishing from. At first I was fishing out to the reedy islands again, but after spotting these carp I theorised that the entrance to the out of bounds bay might be a better place to intercept any fish moving in and out of the area.
A quick move later and I had cast dangerously far into the out of bounds area from the only possible point to a margin with deep snags all along it. The other rod was position on the other side of the entrance in a shallow spot at the end of the wind. Time proved my enemy here and with only a small space of time available I don't think I had baits either in the water long enough or specifically on fish on this occasion. My time ran out all too soon, but on the way home for breakfast I did find a group of carp right tight to my own bank in a marginal reed bed. It seemed the combination of the wind and the warmth had pulled them into this reed bed. Thinking I might be able to get one last crack of the whip later that night I split the remaining bait I had left 70/30 and scattered the larger amount along the shallow corner.
What a blow out! I knew those fish would be in that area all day as I went about my business with the family and I was sure as hell I could get one or more of that spot. Now it's worth saying that all week there had been three or four anglers chasing carp around the lake who had all got quite friendly and a couple of guys targeting silvers on the stages on the smaller civilized half of the lake as well. But on my return a new group of chaps had turned up. I walked past their battery of rod pods and sprays of rods pointing to the sky as if they were defending their well worn peg from invasion. I was as I always am, polite, and bid them good afternoon as I walked past, only to get a grunt which I assume is hello in welsh as they seemed to be of that part of the world. Three pegs further round I tiptoed behind the weed bed and slipped into the only safe spot to fish the pre baited spot from. After dropping my gear next to a tree I took what was left of my bait and went to trickle it along the reeds. I'd gone no more than two steps when I saw a lead and leader drop lazily through the air and splodosh right into the reeds. Obviously unhappy with the cast three more attempts were made before the rod was settled into the rod battery and the line tightened so much any passing dragon flies were in danger of dismemberment.
I really wanted to try and catch a fish rather than kick off. So with no other option I went off to spend my last session trying to track down the illusive carp, which I never did.
I find it hard to make a truthfully honest conclusion about the fishing at Burnham on sea holiday village as the time I spent on it was in exceptional weather conditions and that my time was split into very small pockets which is probably not the best way to get the feel for a water. But! My time and the other anglers fishing the lake combined helps see a better picture though. Of four of us actively fishing for carp only three fish were landed and two of those were under six pounds. I suppose the reality is that if there was even half the supposed fish the bailiff insists there are, between us we should have caught or at least seen more fish. Now I would never go as far as to comment on how big the carp grow in this pool as all I have seen is the one fish I caught, the few I watched in the margin, some jumpers and the few on the fishing shop slide show. And that would indicate low twenties in the lake possibly. There did seem to be a lot of small silver fish kicking around even though I never fished for them they were everywhere. Eels there were lots of though! After hearing from a caravan owner on the lake that the lake has some kind of connection to the river close by it explains the large population but would also indicate that once they want to shove of and breed that any sizeable ones probably head of to the Sargasso. So if I had to give a short conclusion to help other anglers it's this. Burnham Holiday Village Lake is not a runs water, it does contain some carp which could go up to twenty pounds, but there's not massive numbers of them. So if you're prepared to sit there all day everyday you have a chance you might get one, but be prepared to work hard for it. I am willing to bet you could catch a few small silvers float fishing and that sooner or later you will catch and eel. If eels are your thing then don't go there thinking you're going to catch a monster as there's tons of little ones that can get back out to see when they mature.
I hope any of this helps.
|Facial Masks: What's Right for You?||Treat yourself to a mini-spa session with a facial mask.Facial masks are a great way to slow down the aging process, because youâre allowing for key active ingredients to be applied in a concentrated way.|
Masks come in several varieties. Some are creams or gels that you wipe off, while others harden and peel off.Â
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Use mask treatment time for relaxation. Dim the lights, play soft music and make yourself a spa beverage. Create an atmosphere and slow down. Take some time for yourself while you give the mask 5-20 minutes to work.
Listen as Dr. Doris Day joins Dr. Pam Peeke to help you choose the best mask.
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|Without The Moon, Mankind would not exist!||03/15/14 – Without The Moon, Mankind would not exist! Yup. Without the moon, there are no tides. No tides means the oceans are not “stirred” or re-oxygenated. Therefore no life in the seas, therefore no life on the planet. Also, a geosynchronous moon would be the same as no moon at all. The next time […]|
|Intro||DISCLAIMER: I am not a doctor, and this is blog is not intended to diagnose, treat, or cure any condition. My intention here is simple: after going through hell for 2 years with mitral valve prolapse syndrome (MVPS), as opposed to merely mitral valve prolapse (MVP), largely left to discover the causes and effects empirically, I want to benefit other suffers by sharing what I've learned. Use it as a launchpad for your own research, and to suggest questions for your cardiologist, neurologist, or other medical expert. Above all, I would like to share some practical suggests for symptom management, if not improvement in the underlying pathology.|
Bear in mind that MVPS is still a hotly debated syndrome, with some doctors questioning its mere existence. Herein, from firsthand experience, I will present my own definition. Eventually, I suspect that the medical community will define which symptoms are and are not associated with this condition.
By the way, some research has indicated that MVP may be inherited or spontaneous. However, according to Scordo (see book references below), it does not appear in babies at all, and thus develops as one's genome interacts with the environment over time. Perhaps this implies that MVPS follows the same pattern, although this is uncertain due to ambiguity in its definition.
So call me Mitral Mike. In 2006, I was diagnosed with mitral valve prolapse using an echocardiography, which essentially means that I have leaky heart valve.
The events leading up to this diagnosis, and following it for about a year, constituted the hardest and most terrifying part of my life. Perhaps I'll tell you my story later, but right now, I'd rather focus on helping you get well.
Let me begin by telling you the bottom line: In April, 2007, I ended up on the floor of my apartment, hyperventilating intensely for probably half an hour, with my vision gradually going blurry at the periphery, and tightness in my chest. I could hardly breathe. I could hardly move. Waves of terror radiated through my brain, each one passing like a suffocating wave. I clawed my way across the floor to my cell phone, and struggled to dial my friend's number.
Now, in January 2009, I live profoundly free of fear, in a way which I never imagined humanly possible even before my diagnosis; and the symptoms of my MVPS are rare and fleeting, and though they may startle me, do not result in persistent panic. I can tell you how I accomplished the first part, but you probably won't believe me, so let's just focus on the clinical stuff that we can address empirically, which I hope will help you manage your symptoms.
Consider the following books as essential supplemental reading. I'd suggest reading the Scordo book before the Hendricks book. Jointly, they started me on the path to wellness, which I have gradually augmented with my own symptom management techniques, often based on tips from discussion sites on the internet. (Not everything on the Web is junk, you know. You have to experiment and research carefully for yourself.)
1. Taking Control: Living with the Mitral Valve Prolapse Syndrome by Dr. Kristine A. Scordo
2. Conscious Breathing: Breathwork for Health, Stress Release, and Personal Mastery by Gay Hendricks, PhD
Because MVP is comparatively well-defined and understood, this blog is mostly about MVPS. In my view, MVP is one of many symptoms of MVPS. However, because heart valves are easy to analyze scientifically, compared to "panic attacks" or the other subjective symptoms of the latter, the former was deemed the disease, and the latter, one of its side effects . In reality, I think that a small set of genes is the cause, and the heart valve anomaly just happens to be the most obvious effect. Frankly, I would not be surprised if it turned out that decades of heart-pounding adrenaline attacks characteristic of MVPS contributed to the heart valve pathology that is MVP. (However, MVPS cannot be the entire cause of MVP, as we do know that MVP is also associated with a connective tissue disorder, which would at least partly explain the infirmity of the valve leaflets, and thus perhaps their susceptibility to damage by adrenaline-induced heartrate acceleration.)
As this article from Emedicine puts it:
"Besides the symptoms attributable to the MR, various neuroendocrine and autonomic disturbances occur in some patients with mitral valve prolapse. In these patients, prolapse may be an epiphenomenon of the underlying autonomic or neurohumoral illness. The term mitral valve prolapse syndrome is often used to refer to the collection of these manifestations. However, in a significant proportion of patients, the mitral valve prolapse is trivial, and no such associated manifestations are present. In these patients, mitral valve prolapse constitutes an essentially benign condition."
Common MVPS Symptoms
You can have all the other symptoms of MVPS, and not have MVP. Or occasionally, the reverse may be true. This is further evidence that there is a common genetic cause to most aspects of MVPS, including MVP; MVP does not cause MVPS and visa-versa, perhaps with exception of adrenaline-induced valve pathology, about which I conjectured above.
2. "Head spins" and "mental resets".
Sudden disorientation, lasting about a second, and directly pursuant to
premature ventricular contractions (PVCs).
I am not talking about syncope (fainting), although this does occur in a minority of patients. When these events occur, I get the sensation that time has skipped a fraction of a second, and perhaps the room is spinning for this brief moment. The spinning is not persistent, as would be the case with vertigo. Most likely, the "time skippage" is due to the brain reacting to a very unexpected sudden alteration in the heart rhythm, which has the side effect of temporarily suppressing conscious thought. (After all, it's well known that our thought processes largely switch off in emergencies; to the uneducated brain stem, a change in heart rhythm is definitely an emergency.) The more severe PVCs, when I used to get them (I get only little ones now), could jolt my brain so hard that I'd forget the last few seconds of thoughts.
I'm not kidding about this. One night, when I was having massive and frequent PVCs, I did a little experiment: I would think of several words, and imagine corresponding images in my mind. For example, I would think "apple" and simultaneously see an apple in my mind's eye. Then, as soon as I realized that I had suffered a PVC, I would go back and try to remember the last 5 words. Again and again, I would remember only the first 3 or 4; it was always the last word(s) that were missing -- those which I was thinking about at the time of the PVC. It would appear that these head spins have the effect of hitting the reset button on shortterm memory, which would certainly explain the perception of "time skippage".
If you're wondering whether these events are due to something else, I've had 3 full brain MRIs. Except for a spot which was tracked by 3 neurologists and found to be benign (perhaps the result of a bicycle accident when I was younger), no pathology is evident, such as an arteriorvascular malformation, which might otherwise explain the above. And these events are 100% correlated to a time period of about 5 seconds after the sensation of a PVC in my chest. Case closed.
I've also considered that, because PVCs are preceded by "weak beats", i.e. the heart beats once very hard in order to compensate for the previous beat being too weak, it's possible that the head spins are actually due to temporary brain hypoxia. While you can hold your breath for much longer, and still think clearly, it's possible that the temporarily reduced blood pressure associated with a PVC causes brain hypoxia much more rapidly, resulting in the perceptions described above. But as I mentioned above, I think there is a second mechanism at work, which is the brain stem's obsession with perfect heartbeat: the strange sensations are partly due to the brain stem briefly switching into panic mode, then (usually) back out of it, in response to an unexpected irregular heart beat. Occasionally, particularly with larger PVCs, the brain stem fails to exit panic mode, in which case cognitive thought processes remain suppressed, and a full-fledged panic attack (discussed below) may ensue. In any event, PVCs are merely one of many causes of MVPS panic attacks, the latter being discussed more below.
3. Orthostatic hypotension (or more generally, low blood volume).
If you feel light-headed when you stand up quickly, you may simply have too little blood in your system to keep your brain fully oxygenated during this exercise. Your heart may beat more rapidly (tachycardia) in order to compensate, but it may be unable to do so quickly enough due to the leaky valve. In some sense, this is a desirable condition, since it may imply that you have low blood pressure (which I think is a better problem than high blood pressure).
There are a few easy measures you can take to mitigate this problem:
(1) As you rise from your chair or bed, inhale over the course of the rise. This creates increased pressure in your chest, which tends to sustain higher blood pressure. Actually, fighter pilots use a similar technique to maintain consciousness during high-G-force manoeuvers: they wear "G pants", which squeeze their legs at the proper time in order to prevent their blood from draining from their heads to their feet. Thus, by inhaling over the course of a few seconds as you stand up, the increased blood pressure will help keep blood in your brain.
(2) Stand more slowly. If 2 seconds is too fast, take 3. Or 5.
(3) Keep hydrated. For one thing, this means that you always have sufficient liquid in your body for optimal performance. As a result, your blood volume is larger, which means that the pressure will be slightly higher, allowing you to more easily maintain brain oxygenation as you stand. But make no mistake: hydration isn't just about water! You need salt (and, in my opinion, a proper balance of all required trace minerals). You also need sugar. (For all the bad press that it has received since Dr. Atkin's diet, sugar not only keeps you alive, it induces insulin to open your cell membranes, allowing nutrients to go where they are needed. For this reason, I think it's better to eat superfruits like berries, followed by your morning workout; than complex carbs like beans, followed by you sitting at a desk, or worse, going to bed. I also think caloric restriction is superior to a calorically unrestricted low-carb diet. Anyway, remind me if I forget to post my Atkins rant!) For now, just remember: hydration is critical to the management of orthostatic hypotenion and MVP itself, but hydration does not mean binging on distilled water!
4. Intermittant and migratory chest pain.
If you have any sort of chest pain, you need to identify the cause immediately in order to rule out life-threatening conditions. Just because your chest pain is characteristic of MVPS does not mean that it's due to MVPS.
Anyway, MVPS chest pain seems to focus on certain areas -- in my case, the upper right pectoral muscle, and occasionally the right side of the sternum -- but grow, shrink, and move from time to time.
Most doctors seem to be convinced that MVPS chest pain does not come from MVP. Indeed, there is a small (but in my opinion, still meaningful) statistical significance to the number of MVP sufferers reporting chest pain, compared to non-MVP-sufferers. (See Scordo's book, and of course Google, for the numbers.)
I would say, incontrovertably from my own experience, that chest pain can indeed result from MVPS. I say "incontrovertably" due to the evidence of precise time correlation: my chest pain would be worst immediately following an adrenaline burst. Think about it: an MVPS-induced adrenaline burst is associated with an increase in sympathetic nervous system activity, which results in an increase in pain sensitivity (i.e. never take caffeine before a visit to your dentist); second, adrenaline bursts pound on the cardiac and respiratory system, rather like flooring the accelerator of one's car, inevitably resulting in aches in the chest.
Most doctors say that MVP does not cause chest pain. There is some evidence that MVP does cause chest pain under certain pathological conditions, potentially due to mechanical stress on the valve or the heart's attempt to compensate for lower efficiency. Nonetheless, I think that most MVP sufferers who experience chest pain do so due to MVPS-related hyperadrenalization, and not MVP.
In my case, the evidence could hardly be more compelling: when the adrenaline burst occurs, the pain flares up; both usually subside within a minute. This is a clear correlation between the MVPS-induced adrenaline bursts and chest pain. But the relationship goes deeper than that:
Sometimes, however, post-burst pain would remain for hours, occasionally giving rise to the sensation of a heart attack. Why? In my case, which is no doubt not unique in this regard, it would persist because I had consumed large doses of inflammatory foods the same day: sugar, simple carbs, or (especially) cheeses (including cottage cheese).
Cheeses, in particular, seem not only to cause more lasting chest pain, but also an increased incidence of PVCs. The lasting pain may result from the high omega-6 content in cheese, which is proinflammatory. Cottage cheese contains more protein and less omega-6, but it causes increased PVCs as well, if not extended chest pain. I could be wrong about the omega-6 theory. But test it yourself: cheese of any type will result in increased PVCs within 6 to 12 hours (or if you already eat it, cut it out for a few days and monitor the effect). There's something in these dairy products which causes this. To a lesser degree, the same happens with milk. Omega-9-rich olive oil, and omega-3-rich fish and flaxseed oil, do not have this effect. Coconut milk, which is rich in saturated fat but is not a dairy product, seems to produce little or no increase in PVCs. Thus, perhaps, it's something else. Lactose? I don't know, but the effect is unmistakable.
Frankly, it might not be a chemical issue so much as a blood thickness issue: eating dairy products may increase blood viscosity, in particular by raising plasma triglycerides. Thicker blood puts more hydrodynamic drag on the valve leaflets. This is the main reason why boats move more slowly than airplanes: water is much more viscous than air. So axe the cheese from your diet, and closely monitor the effect on PVC number and severity. Cutting out cottage cheese, milk, and coconut milk may also help to some extent, but potentially to the detriment of your calcium and protein intake. (I take "Tums" as a supplement after breakfast, but no dairy products or coconut milk, and hardly ever have PVCs anymore.)
Interestingly, when I eat organic peanut butter, I do not experience an increase in PVCs, despite the obvious high viscosity and high omega-6 content of this food. This may be due to: (1) the fact that I pour off all the peanut oil into the trash before eating the "dry" butter, (2) the fact that it's rich in niacin, which is good for the heart, and (3) its high vitamin E content, which is antiinflammatory. By the way, organic peanut butter contains large amounts of the antioxidant, p-coumaric acid, which is actually increased by the otherwise oxidative roasting process used to produced roasted peanut butter.
Superdark (85%+) chocolate bars also do not cause me increased PVCs, despite having a high saturated and omega-6 fat content. This is consistent with the generally accepted principle that the moderate consumption of dark chocolate (particularly the nonalkalized variety) is conducive to cardiac health. But this would appear to contradict my theory that PVC intensity and frequency relate primarily to blood viscosity. However, superdark chocolate probably does not significantly increase plasma tryglycerides. Hmm... maybe my "Triglyceride-Induced PVC" theory is true.
My worst bout of chest pains ever, followed by a horrendous hyperventilating panic attack, was preceded by a night of gorging on pizza cheese without the crust. (What do you do when you're on a low-carb diet, and you're out with the guys, who have nothing to offer you but pizza? Smart answer: starve. Dumb answer: gorge on mozerrella, and flirt with disaster.)
5. Panic attacks.
These events are characteristically preceded by the sensation of a wave or cloth washing through the entire head for about a second, most perceptible on the face, and may or may not have an obvious environmental cause.
Many doctors (who no doubt do not have MVPS themselves) think that the panic attacks associated with MVPS are somehow indirectly due to the patient becoming anxious about his/her newly identified "heart problem". While such a discovery, however benign, might make anyone anxious, I can tell you from deeply personal, visceral experience that the "bad" news is not the cause of the panic attacks. Having analyzed myself under conditions of sudden extreme terror (which I assure you, is possible, albeit difficult), they result largely from one of the following causes:
(1) a PVC which temporarily interrupts normal blood rhythm to the brain, triggering some sort of massive sympathetic nervous system response in the brain stem, as suggested by the recent discovery that the brain monitors the heart rhythm with a level of diligence hidden to our conscious mind, to which I alluded in the above discussion of head spins;
(2) a sudden change in electrolyte balance, as by ingesting a large dose of potassium (e.g. low-sodium vegetable juice or several bananas) or highly bioavailable iron (e.g. eating a vitamin pill on an empty stomach, or eating more than 100g of dark chocolate in a day);
(3) a sudden change in body fluid volume (and probably therefore blood pressure and electrolyte concentration), as by urinating or donating blood;
(4) a very light wind which cools and tingles the skin, and thus mimics, to the unconscious mind, certain perceptions of electrolyte imbalance;
(5) the memory of any of the foregoing;
(6) the consumption of large amounts of chocolate (especially dark or organic) or walnuts, both of which produce migraine with aura in sensitive individuals, triggering fear and panic, and entirely separate from the bioavailable iron panic pathway related to the former.
6. Unusually flexible joints.
This is most obvious in the fingers. This is the connective tissue anomaly so often mentioned in MVPS literature. In the presence of chronic stress, it probably aids the gradual deformation of the valve, which ultimately manifests as MVP. According to Scordo's book, essentially no one is born with MVP; it develops as one ages. My theory is that when one combines the frequent adrenaline bursts of MVPS with overly stretchable connective tissue, then the result is eventually a floppy valve that doesn't quite snap shut. It's kind of like stretching a rubber band too many times; eventually, it becomes less inclined to snap back into its original shape.
It would be interesting to study whether teaching children with MVPS to suppress excessive adrenaline releases would manifest in a lower rate of MVP later in life. I guess the medical community must first decide on a clinical definition of MVPS!
More on adrenaline bursts below.
7. A depressed or indented sternum -- a "breast bone valley".
9. A straight spine, which I take from the literature to mean a spine without concavity at the base.
10. Electrolyte hypersensitivity.
Sensitivities to sudden changes in electrolytes, particularly involving potassium or iron, as discussed above. Critically, if you have MVPS, do not donate blood before speaking to your doctor. If you have the low blood volume typical of many MVPS sufferers, it could cause you to faint in response to blood donation. (It happened to me in 2004, at a blood drive at work. I wondered, at the time, why I couldn't tolerate the process as well as much much less fit colleauges!)
My first bout with electrolyte sensitivity was in around 1998. I had just had a visit to the dentist. During this particular visit, the dentist removed a number of mercury-silver fillings. Even today, dentists continue to use mercury-silver amalgum in fillings because they assert that they leach only trivial amounts of mercury. I might agree, but when they're heated and aerosolized during removal, I think it's possible that a dangerous amount of mercury is released.
Now, I knew about this threat, and knew that it might be preempted by injesting a vitamin pill (to thwart further mineral absorption) and vitamin C (which chealates heavy metals). However, I forgot to take either before the appointment. So immediately afterward, I headed to the nearest drug store and bought a bottle of vitamin pills, as I was on the way to work, and had no time to return home.
When I arrived at work, I ingested 3 vitamin pills in rapid succession. (DO NOT do this.) Worse, on account of the dental appointment, my stomach was empty. So an hour or so later later, I had something like 300% RDA of iron (beyond the tolerable upper intake level) flowing around in my blood.
Rapidly, my skin became numb at the surface, causing a "pins-and-needles" sensation. Though I may have made some slight progress in inhibiting the blood plasma uptake of mercury from the intestines, I had given myself some level of iron poisoning. I spent the next hour or so slowly and carefully sipping water, and urinating myself back to homeostasis.
Nowdays, I keep a 7-day pill organizer full with all my supplements, including multivitamins, to ensure that I get sufficient but not excessive nutrition. I even break my vitamins into a couple pieces for ingestion at different times of day, in order to maintain more stable plasma electrolyte levels and systemic hydration.
11. Chest tightness.
Diffuse but possibly intense, often mistaken for anxiety-related chest tightness, but persistent for days at a time, and only marginally relieved by sleep.
This tightness is constricting, rather like wearing a sweater that is much too small. However, it is distinct from the migratory chest pain described above.
This was one of the worst symptoms of my MVPS. I think, in my case, it related to the onset of sleep apnea which went undiagnosed for years, for which I have since received corrective surgery. It would not surprise me if there were a correlation between MVP, MVPS, and sleep apnea, as the latter increases adrenaline stress on the heart, and contributes to panic disorder, on account of terrifying hypoxic episodes.
Here's how I fixed my chest tightness, which at times was so intense that I could hardly get enough air to walk (this, after being a near-Olympian just days prior to the hyperventilation attack in April, 2007 that started the tightness): I tried all manner of foods -- eating more or eating less -- trying to discover a cause or find relief. Finally, after months of work, I discovered that salmon, milk, and shiitake mushrooms -- and nothing else in my diet -- relieved the condition to some extent; milk was the fastest. Truly perplexed by how these radically different foods were acting in a common way, I did some homework.
But first, I sought professional help. I had several doctors tell me that it was all just stress-related. In a sense, they were correct: MVPS was stressing out my autonomic nervous system, resulting in this problem. But in the sense of anxiety, they were wrong. I felt happy most of the time. In fact, I could generally breathe better when I was angry, perhaps due to improved respiratory function under the influence of adrenaline. On the other hand, I could be perfectly content with life, and the tightness would be there. The severity was mostly dependent on whether or not I was asleep, and on how recently I had had one of these "magic foods". It was also somewhat better in the morning than the evening. The worst tightness was immediately after exercise, suggesting that it had something to do with hydration, blood pressure, and electrolyte balance.
It turns out that the magic foods are all excellent sources of vitamin D (as D2 or D3), which is otherwise very hard to obtain (except from solar exposure). Somehow, vitamin D was allowing me to get some degree of chest tightness relief. Not surprisingly, I was subsequently diagnosed with a vitamin D defficiency (18, where optimal is something like 40-60, depending which study you read). (Just in case you think the docs always have the answers, I was the one who suggested the test, based on my empirical analysis. Sure enough, I was short on vitamin D.)
Using 800IU daily supplements, I cured the defficiency over a period of months. However, the tightness persisted to some extent. That's when my friend introduced me to Hendrick's book about breathing, noted above. Combined with yoga, it completely fixed the problem. My chest is so relaxed now that I no longer practice yoga, but I probably should. In fact, for a while, I was so relaxed that I had to encourage myself to adrenalize a bit on the highway, for safety reasons. As far as I can tell, these focussed exercises allowed me to reprogram my breathing rhythm, reducing the tightness.
The final piece of the solution was getting surgery to alleviate sleep apnea. With a wider airway, I was no longer struggling to breathe during the daytime, and my chest tightness has never returned since.
12. Adrenaline bursts.
These events occur seemingly without cause, manifesting in a pounding heart, as though you is about to crash your car, when in fact you may be relaxing on the beach. If you have these, check with your endocrinologist for other rare conditions such as adrenal tumors. But likely as not, this is just MVPS. I used to have these, until intensive self-monitoring allowed me to intervene and arrest them before they could occur.
Everyone gets adrenaline bursts when they're nervous. They are an important part of our fight-or-flight mechanism: if a tiger is about to eat you, it's time to run! Psychologists have long known that this ancient wiring causes stress reactions in our bodies today, despite the fact that we don't need to run from a dentist, or use super strength to invest in a crazy stock market. In short, our wiring has not kept pace with the shift in the nature of our threats, from physical to psychological.
The adrenaline bursts characteristic of MVPS are similar to anxiety-related adrenaline releases, but they are overexpressed. And typically, many more occur per day than one's stress load would otherwise suggest. For example, I would get terrifying heart poundings every time the phone rang. I would, of course, calm down, but not before slamming my heart valve and respiratory system for this completely unjustifiable reason. At my worst, I had probably a thousand perceptible spikes per day, which on average is one every several seconds for many hours.
Low-carb diets are often touted as a solution to such hyperadrenalization. In my case, it only made things worse. The reason, I think, is that hydration is difficult with these diets because the high fat content inhibits the absorption of water-soluble nutrients, particularly in the absence of sugar. At the time, I didn't realize this. As a result, no doubt, my electrolyte concentrations varied much more throughout the day than they should have, which no doubt contributed to the problem.
Positive imaging is commonly suggested as a solution: psychologists often tell us to imagine a beautiful beach scene when we're under immense stress. I think this only causes more stress, as it reminds us that we might not survive long enough to get there! In my case, it offered no help at all.
One of the most significant improvements came with medical hypnosis. I went to a medical hypnotist who, believe it or not, was recommended by my endocrinologist who did the vitamin D test. After a single session, I experienced approximately a 75% reduction in daily adrenaline spike count. It cost $300, but in my case, was highly effective. Part of the reason for my success is that I knew that the spikes were almost never justifiable, and thus had an irrational basis of activation, likely related to subconscious activity in the brain stem. Because I knew that the response was irrational, it was easier to combat with the help of a hypnotist; otherwise, I am virtually immune to hypnosis. After yoga and certain mental focus exercises, my adrenalization dropped so low that, as I mentioned above with regards to chest tightness, I had to struggle to adrenalize enough to avoid traffic accidents!
One other technique for minimizing adrenaline bursts may be to eat garlic or garlic gelcaps. There is ample evidence that they lower blood pressure, and seem to promote mood stability, perhaps via seretonin regulation. I haven't done much research on this, but I've read enough on reputable websites to recommend that you research it. At the very least, it might make your dinner taste better.
13. Plasma magnesium defficiency
According to this 1997 study, some cases of MVP are caused by plasma magnesium defficiency. Though magnesium defficiency as examined in the study is strictly a cause of MVP and not MVPS, I suspect that it also relates to the latter, as magnesium is critical for neurological function, implying that defficiency may contribute to the hyperadrenergic symptoms observed in MVPS sufferers. Note that the study does not say "insufficient dietary intake of magnesium", but rather refers to plasma (blood) levels of the element. So while you may get sufficient magnesium in your diet, it may or may not end up in your blood, depending on how well it is absorbed with the rest of the food that you eat.
My magnesium level is normal. However, I didn't test it until long after I had started occasional supplementation. So I don't know whether it was one of the causes of my MVPS.
Back in 2007 or so, I found a nurse on an MVPS discussion board who recommended magnesium glycinate as an MVPS treatment. Intrigued, I tried some.
For me, this stuff kills palpitations within an hour. It's incredible. In particular, I took a 200mg dose, which is 1 tablet. (The bottle says "400", but the serving size is 2 tables. Is this dangerous, or what?)
However, before you try this yourself, I would suggest that you try my other suggestions for eliminating palpitations, including cardiovascular exercise as recommended by your cardiologist. The reason is that we were not evolved to ingest pure concentrated minerals. Therefore, these tablets are hard on the kidneys, which are responsible for electrolyte balance. Also, like other magnesium supplements, they tend to cause mental confusion if used in sufficiently high doses for sufficiently many days in a row. The effect seems stronger than with magnesium oxide, which is likely due to the glycinate component: I believe that the glycinate allows the magnesium to penetrate neurons, including those in the brain, much more easily. For this reason, it may be equivalent, in a neurological sense, to a much higher dose of magnesium oxide.
Here's what the National Institutes of Health has to say about magnesium. In particular, see their comments on excess intake. Again, I think magnesium glycinate may be neurologically equivalent to several times as much magnesium oxide.
From my perspective, it beats the side effects of beta blockers. Therefore, on the rare occasion that I have palpitations, I take one of these.
|Apocalyptic Release of Arctic Methane|
On a lake, plumes of gas, most likely methane from the breakdown of carbon in sediments below the lake, keep the water from freezing in spots, outside Fairbanks, Alaska, October 21, 2011. As the Arctic warms, the threat of abrupt methane releases is rising, too. (Photo: Josh Haner / The New York Times)
A scientific study published in the prestigious journal Palaeoworld in December issued a dire -- and possibly prophetic -- warning, though it garnered little attention in the media.
"Global warming triggered by the massive release of carbon dioxide may be catastrophic," reads the study's abstract. "But the release of methane from hydrate may be apocalyptic."
The study, titled "Methane Hydrate: Killer Cause of Earth's Greatest Mass Extinction," highlights the fact that the most significant variable in the Permian Mass Extinction event, which occurred 250 million years ago and annihilated 90 percent of all the species on the planet, was methane hydrate.
In the wake of that mass extinction event, less than 5 percent of the animal species in the seas lived, and less than one-third of the large land animal species made it. Nearly all the trees died.
Methane hydrate, according to the US Office of Fossil Energy, "is a cage-like lattice of ice inside of which are trapped molecules of methane, the chief constituent of natural gas."
While there is not a scientific consensus around the cause of the Permian Mass Extinction, it is widely believed that massive volcanism along the Siberian Traps in Russia led to tremendous amounts of CO2 being added to the atmosphere. This then created enough warming to cause the sudden release of methane from the Arctic sea floor, which kicked off a runaway greenhouse effect that led to sea-level increase, de-oxygenation, major oceanic circulation shifts and increased acidification of the oceans, as well as worldwide aridity on land.
The scenario that humans have created by way of the industrial growth society is already mimicking these eventualities, which are certain to worsen.
"The end Permian holds an important lesson for humanity regarding the issue it faces today with greenhouse gas emissions, global warming, and climate change," the abstract of the recent study concludes.
As the global CO2 concentration continues to climb each year, the threat of even more abrupt methane additions continues to escalate along with it.
The Methane Time Bomb
The methane hydrate situation has, for years now, been referred to as the Arctic Methane Time Bomb, and as been studied intensely.
A 2010 scientific analysis led by the UK's Met Office, published in the journal Review of Geophysics, states clearly that the time scale for the release of methane in the Arctic would be "much shorter for hydrates below shallow waters, such as in the Arctic Ocean," adding that "significant increases in methane emissions are likely, and catastrophic emissions cannot be ruled out.â¦ The risk of rapid increase in [methane] emissions is real."
A 2011 study of the Eastern Siberian Arctic Shelf (ESAS), conducted by more than 20 Arctic experts and published in the Proceedings of the Russian Academy of Sciences, concluded that the shelf was already a powerful supplier of methane to the atmosphere. The conclusion of this study stated that the methane concentration in the atmosphere was at levels capable of causing "a considerable and even catastrophic warming on the Earth."
Scientists have been warning us for a number of years about the dire consequences of methane hydrates in the Arctic, and how the methane being released poses a potentially disastrous threat to the planet. There has even been a study showing that methane released in the Arctic could trigger "catastrophic climate change" that would cost the global economy $60 trillion.
Of course, that level of planetary heating would likely extinguish most life on the planet, so whatever the economic costs might be would be irrelevant.
"Highly Possible at Any Time"
The ESAS is the largest ice shelf in the world, encompassing more than 2 million square kilometers, or 8 percent of the world's total area of continental shelf.
In 2015, Truthout spoke with Natalia Shakhova, a research associate professor at the University of Alaska, Fairbanks' International Arctic Research Center, about the ESAS's methane emissions.
"These emissions are prone to be non-gradual (massive, abrupt) for a variety of reasons," she told Truthout. "The main reason is that the nature of major processes associated with methane releases from subsea permafrost is non-gradual."
Shakhova warned that a 50-gigaton -- that is, 50-billion-ton -- "burp" of methane from thawing Arctic permafrost beneath the ESAS is "highly possible at any time."
This, Shakhova said, means that methane releases from decaying frozen hydrates could result in emission rates that "could change in order of magnitude in a matter of minutes," and that there would be nothing "smooth, gradual or controlled" about it. She described it as a "kind of a release [that] is like the unsealing of an over-pressurized pipeline."
In other words, we could be looking at non-linear releases of methane in amounts that are difficult to fathom.
A study published in the prestigious journal Nature in July 2013 confirmed what Shakhova had been warning us about for years: A 50-gigaton "burp" of methane from thawing Arctic permafrost beneath the East Siberian sea is highly possible.
Such a "burp" would be the equivalent of at least 1,000 gigatons of carbon dioxide. (For perspective, humans have released approximately 1,475 gigatons in total carbon dioxide since the year 1850.)
Copyright, Truthout. May not be reprinted without permission.
Release of Arctic Methane "May Be Apocalyptic," Study Warns March 23, 2017 Dahr Jamail, Truthout | Report
|à¤¸à¤à¥à¤à¤¾à¤° (saÃ±cÄra) Free flow - July 2017 Newsletter from Srivatsa Ramaswami--|
à¤¸à¤à¥à¤à¤¾à¤° (saÃ±cÄra) Freeflow
In my May 2009 Newsletter I had included an article on Yoga for the Heart wherein I attempted to explain the procedures that are available in Yoga to help the heart doing its function effectively. I had concentrated mainly on the venous return of the blood to the heart which is an important function of blood circulation or à¤°à¤à¥à¤¤ à¤¸à¤à¥à¤à¤¾à¤° and à¤ªà¥à¤°à¤¾à¤£ à¤¸à¤à¥à¤à¤¾à¤° (rakta saÃ±cÄra prÄá¹a saÃ±cÄra). I also dealt with a few other procedures that help the heart as a vital internal organ. You may wish to access that article here
Here I would like to briefly touch upon the benefit of yoga in cellular respiration the most essential aspect of unimpeded circulation of blood and diffusion of prana à¤ªà¥à¤°à¤¾à¤£ à¤¸à¤à¥à¤à¤¾à¤° à¤°à¤à¥à¤¤ à¤¸à¤à¥à¤à¤¾à¤° ( rakta sanchara and prana sanchara). It is common knowledge that the oxygenated blood from the lungs enter the heart which in turn pumps with pressure the oxygen rich blood into the circulatory system of blood vessels à¤°à¤à¥à¤¤ à¤¨à¤¾à¤³ (rakta nÄá¸»a) through firstly the arteries à¤§à¤®à¤¨à¤¿ (dhamani). The arteries then branch into smaller vessels called arterioles and then reach and branch off into minute capillaries, a network of capillaries à¤¤à¤¨à¥à¤¤à¥à¤à¥ (tantuki) called capillary beds surrounding the cells. The transmission of blood takes place through these arteries and arterioles but the actual delivery takes place when blood reaches the capillary network. Almost every cell is supplied with these capillaries. In these beds the actual exchange of nutrients and oxygen takes place in the earlier portion of the capillary then the function changes. Then the waste products in the blood enter into the capillaries and the blood and thus the entire quality of the blood changes from oxygen and nutrient rich to carbon dioxide and waste products filled. The blood in the later part of the capillaries enters the small venules which then empties into the veins and then the the vena cavae enroute to the heart for reprocessing. In the capillary bed, the exchanges are like that of postman who delivers incoming mail and takes away the outgoing mail from the customer only to return the next day, doing the same work again--and again
When blood is pumped out of the heart and traverses through the blood vessels à¤°à¤à¥à¤¤ à¤¨à¤¾à¤³ ( rakta naala) and reach the arterioles they do not necessarily enter the capillary beds. The capillaries have sphincters which act like valves. In fact the blood enters the capillaries only in certain beds at a time. When the sphincters are closed the blood is shunted or it bypasses the capillary bed traversing from the arterioles to the venules. Normally the sphincters open up when the muscles around the capillary bed are stretched. So usually in a couch potato many areas of the body may not get proper blood circulation and cell respiration through the capillaries. Usually when one moves around one uses some muscles and it facilitates blood flow in some areas where the muscles and vessels are stretched. So people who do normal work have a better circulation than one who is habitually static. If we exercise then more sphincters open and there is more complete blood circulation and cellular respiration.The exercise that are popular however are the aerobics, where a certain kind of movement is repetitive like jogging , rowing or swimming in which certain muscles in the body are exercised that facilitate good circulation to those specific areas. Of course there is a general increase in the blood pressure which helps to open up more capillary beds and thus improve circulation and cell respiration. The sketch shown below from a google search shows the capillary bed one with free flow of blood through the capillary bed and the other where the blood is bypassed without benefitting the cells.
In Vinyasa krama, however almost every muscle/ muscle group can be targeted and thus open up more capillary beds . Scores of asanas and hundreds of vinyasas help to reach almost all the skeletal muscles and the tissues. This stretching of different muscle groups helps open up more capillaries and thus more complete circulation and respiration. In fact in a 30 minute practice of slow vinyasas with appropriate synchronous breathing, more than 100 vinyasas can be done reaching many parts of the body including quite a few rarely accesses areas. In addition thoracic exercises like pranayama, hasta vinyasas then abdominal and pelvic exercises like the bandhas kapalbhati, nauli, the inversions like sarvangasana and sirsasana and others all unique yogic procedures help to stretch more tissues and thus improve circulation/respiration to almost all the cells in the body. That is why yoga, especially if done with judicious use of vinyasas and conscious yogic breathing, is considered sarvanga sadhana or yoga for all parts of the body. The reach of vinyasa yoga is far and deep and can potentially access and respirate all the cells
Between July 28,2017 and August 6,2017 I am scheduled to teach two programs at Loyola Marymount University, Los Angeles. One will be a 20 hour Core Vinyasakrama Yoga Program between 6PM and 8 PM during these days. It will cover the main asanas and vinyasas in the 10 major sequences as I learnt from my guru Sri Krishnamacharya. This will be useful for those who would like an introduction into this breath oriented vinyasa krama asana practice containing hundreds of vinyasas and tens of asanas. Introduction to pranayama also will be included. Many who have already participated in my earlier 100 hr and 200 hr TT programs may consider registering for this program as a refresher course. My book "Complete Book of Vinyasa Krama" will be the source book. This is available with Amazon
Here is the link for registration to the program
The second program will be a 50 hr program on Bhagavatgita. Sri Krishnamacharya was a versatile teacher. In addition to yogasanas he taught vedic chanting several texts like the Yoga Sutras, Brahma Sutras, upanishads and of course the Bhagavat Gita. He truly lived up to his given name Krishnamacharya, meaning Krishna the teacher/preceptor. His teaching of the Gita had a unique depth and flavor as he was a practicing yogi, not just an academician. In this program the Bhagavat Gita (The teachings of the Lord) will be gone through completely verse by verse chapter by chapter. It deals with the entire range of human experience and endeavors and the Lordâs guidance to everyone to go through life fruitfully and reach the ultimate spiritual state of Yoga. This program is especially designed for Yoga Students. Bhagavat Gita even as it is known as a text of Vedanta it is also known as Yoga Satra, or a Yoga text.
Here is the link to register
Last couple of years I have been offering a 100 hr Vinyasakrama TT program. I taught this program at LMU, Los Angeles, Saskatoon, Canada, Madrid, Spain, Chennai (twice) and New Delhi. But the last two offerings at Sydney and Montreal had to be cancelled due to lukewarm support. However, Saraswati of Yoga Vahini in Chennai has agreed to organize the same program in Chennai for the third time. I am sure this will go through. It will be in February March 2018 and the details will be known soon. In the meantime if anyone is interested please write to
|Introduction to ECMO: Types of Support and Indications for Treatment||According to the NIH, Extra Corporeal Membrane Oxygenation (ECMO) indications and usage has strikingly progressed over the last 20 years; it has become an essential tool in the care of adults and children with severe cardiac and pulmonary dysfunction refractory to conventional management.|
In this segment, Nirmal S. Sharma, MD., discusses an introduction to ECMO, and the indications of ECMO for cardiac and respiratory support.
|ME2354 AUTOMOBILE ENGINEERING Questions Bank 2014|
|Health Tips | Health and Fitness Tips | Natural Health Tips|
Skin health tips essential for healthy eating tips for skin. Nature has endowed us with unlimited bounties with great qualities and miraculous affects, one of them is lemon a little crown pack with seemingly unlimited potentialities. Lemons are enriched citrus fruit high in vitamin C about 40 to 50 mg in comparison to orange which contains 70 to 80 mg.There are unlimited natural health tips benefits of lemons known for centuries
Lemon a natural energizer, it hydrates and oxygenates are body thus revitalizing our entire self. It regulates our digestive and liver function thus improvising our filtration function of the body and above all itâs a great weight loss diet remedy. It paves way to reduce weight speedily.
LEMONS AREâFAT BURNING MIRACLEâ just squeezes a lemon without seeds into a hot drinking water and your alkaline drink is ready, it combines powerful agents that dissolve fat easily. It clears toxins in our body, it regulates our blood circulation, improves our PH levels. Itâs a great detoxifying process.
Natural Lemons have shown incredible results in terms of fat loss factor, combination of lemon and water is made up of natural ingredients and natural substances are the quick health tips for human body. Lemon juice contains no calories drinking lemon water regularly will serve long term benefits.
Lemon reduces hunger cravings, presence of Pectin fiber clears out colon from our body. Combination of honey and lemon water is an excellent home remedy for obesity and lowering cholesterol levels. It mobilizes the extra deposited fat in the body allowing it to be utilized as energy for normal functions thus purifying the blood. Itâs highly beneficial to reduce weight without the loss of energy. For this natural recipe mix a teaspoon of honey with 2 tablespoon of lemon juice in a glass of warm water. Take this remedy as your wake up drink on an empty stomach. This is a simple delicious and detox tonic purifying our entire body function. It helps to release toxins from our body thus enhancing our blood circulation.Improving our 5 health tips in general. People who are unable to do exercise regularly this little magic is going to facilitate them to keep them in shape.
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|Ep 106: Science... sort of - A Big Pile of SCIENCE|
00:00:00 - This week we are joined by the wonderful Jacquelyn Gill to talk aboutÂ mammoths and the spores found in their poop! Jacquelyn does a ton of outreach with herÂ blogÂ andÂ twitter, so support the effort by checking them out, ok?!
00:23:53 - Drinks. They're what happens when it's too late in the day for coffee. Ben is having his final Sussex Golden Ginger Ale, since it's only available in one part of Canada. No one has the heart to explain FedEx to him. Jackie is treating herself to a New GlarusÂ RaspberryÂ Tart float, which is just insane but probably delicious. Ryan goes toÂ Hog Heaven.Â And Patrick has the spiciest of all wines, and likes it!
00:30:26 - Trailer Trash Talk is celebrating Jackie Chan's 100th movie which happened inÂ 1911.Â Not as much to say about this particular Asian War Epic, other than the fact that everyone but Ryan seems to love them and Jackie Chan can sing.
00:39:56 -Â Mammoth hemoglobin might help your limbs keep oxygenated in the cold. Finally, paleontology put to good use!Â
00:57:53 - PaleoPOWs are like mammoths, hunted to extinction. Ryan gets and e-mail andÂ donationÂ from Eric W. But the money demands physics answers from Ben concerning faster-than-lightÂ neutrinos. Ben travels to the UK for anÂ iTunes review. And Patrick has yet anotherÂ donationÂ from Kendal (male pronouns) that comes with a few caveats.
Thanks for listening! Check out Ryan on theÂ latest episode ofÂ Inside the Atheists StudioÂ if you're not sick of hearing him talk yet.
Music for this week's show:
MammothÂ - Interpol
Fruit MachineÂ - The Tink Tinks
Random Jackie Chan Song - Not available on Amazon, but here's aÂ video of him singing live
Fresh BloodÂ - Eels
Sent: Monday, June 19, 2017 3:52 PM
To: jack bombardier
Subject: Jim's Passing
So sorry to hear about Jim. He was one of my all-time favorite customers! I've enjoyed all the time I've spent with both of you on my big green boat. You don't see too many automatic reels anymore like Jim had, I'll be missing both seeing and hearing those. I've always envied the fact that you two could be best fishing buddies for fifty years. I hope that you haven't already taken your last trip with me too, and there's only one way to fix that!
I do sometimes tell people on river trips about the âOnly Person To Have Ever Fallen Out Of My Boatâ. I started to write you about my reminiscence of it, and as the details filled in realized that it had become a little story, or at least an anecdote. Do you mind if I post this on my blog? Names of any guilty parties can be changed.
Again, sorry to hear about Jim. I'm glad you got to hang out with him recently, even if you had no clue that it might be the last. There is going to be some interaction we have with everyone we meet that will someday be our last, whether we know it or not at the time. I guess that's a good reason to treat everyone as nice as possible, so that the last memory they have of us will be a positive one!
The way that I remember it, the three of us were out in late October and the sun had dipped below the canyon rim. It wasn't dark yet, but getting darkish. I was with Larry and Jim, two of my favorite customers. They were the kind of clients that made me feel guilty taking pay for being in their company. They were both around seventy when they began doing floats with me, but had already been best fishing buddies for fifty years. Larry lived on the Front Range and had a place in Summit County, and Jim lived in Grand Junction. That made my stretch of river roughly halfway in between for both of them, and so it was a nice equitable drive for them to come fish here. Both men had lives well lived, and shared the good stories that accumulate around such a life.
On one of their trips, we were running a little later that usual, and being late October the evening has a way of snatching away the sunlight earlier each evening. After a summer of pretty constant river flows of around 1000 cfs, the river levels had dropped to 700 cfs, exposing rocks that could have been safely floated over a week earlier. Late in the day it became obvious that we would be finishing in the dark, the only question being, how much of it?
Then Jim hooked a nice fish in the hole below Jack Flats, where the beaver pond above splashes back into the Colorado River below. When the river is low, it becomes a haven of oxygenated habitat for the trout. There have been many fish caught here over the years, but this was one of the biggest ones yet. It pulled harder than the usual fifteen inch brown trout we usually caught, but since we were tossing streamers with heavy tippets Jim soon brought the fish to heel.
He got his fish to the side of the boat, and being in short section of flat water, I opted to land it on the move without dropping anchor. Jim steered the fish into the net, and once safely subjugated we saw that in it was a huge rainbow trout. Rainbow trout used to be the dominant fish in the Colorado River before Whirling Disease, and though their numbers had dropped dramatically, their numbers were beginning to climb again. His rainbow was valuable broodstock, and we needed to get it back into the water as soon as possible. Unfortunately, the trout had gobbled a black woolly bugger that was now down deep in its gullet. I totally ignored the passage of the raft over the next few seconds, concentrating entirely on delicately removing the hook without making the fish bleed, in darkening light on a gently rocking boat. The hook came free, and I lowered the trout into the water, leaning way out over the side so that current could run into the rainbow's mouth and revive it. The fish held itself there limply for a moment, and then with a great burst of strength shot out of my hand.
I got back into the seat and grabbed the oars, and saw that we were headed towards some rocks on river left. Larry was up front and watching everything closely, letting me know about the danger to our left. Pulling hard on the oars, I called out over my shoulder, "Hang on Jim!".
"I'm hangin'!" came the gruff reply. I wasn't quite able to completely arrest the motion of the raft, and we bumped the furthest-most rock. It was enough to spin the boat a little as well, and as we began to go sideways I heard a loud, "Ooof!" behind me. Looking over my shoulder, all I saw were the undersides of Jim's boots as he back-flipped off the boat. We saw the back of his head and shoulders quickly floating away from us in the fast current, while hearing him whoop and laugh.
Jim was headed towards a shallow bank river left coming up in his best case scenario, or off to Mexico in the worst. The raft got hung up a bit, but I swung it downstream and rowed like hell to catch up to my amused flotsam, guffawing loudly over the sound of the river.
When Jim got to the shallow water, he was able to stop himself and stand back up, still laughing. I had forgotten what he had been wearing that day for water protection until he stood up. It wasn't something like full-length neoprene waders or a breathable one with a belt, but pair of rubber Red Ball hip boots, worn over blue jeans. Quite possibly the worst thing a person want want to wear to a swim meet held on the brisk Colorado River, whether they be seventy years old or seventeen.
Larry and I pulled up beside him on the bank, and endeavored to get Jim back into the boat, but couldn't because he couldn't lift his leg with the weight of the water in his boots. We sat him down on the end of the front pontoon, and I lifted his leg slowly up. When it got above his waist, a couple of gallons of cold water came down and splashed him, with Jim howling in laughter and merriment the whole time. He and Larry were exchanging what amounted to, "Holy cow, did that really just happen?" comments. I was worried that Jim might be going into shock. Now that the sun had gone down it had gotten much colder, I was feeling a chill. I thought, I'm fifty years old and dry, Jim's got twenty years on me and is completely drenched! It was looking like a fast row home, with Jim needing to soak in the hot tub to stave off hypothermia once we got there.
"All right Jim, let's get the other boot" I said, and began to lift that leg. Once more came a cold rush of water, and again Jim acted as if he couldn't have been having a better time. "Jim! Are you OK?" I shouted. I looked deeply into his face to see if his pupils were normal. With a big laugh, Jim said, "Haw! Haw! Haw! All that cold water is going right up my ass! Haw! Haw! Haw!"
Larry and I were beside ourselves laughing too. Jim had just been through a life-threatening experience better than us. We cobbled together enough dry clothes between the three of us to get Jim warm and dry, and he made it home just fine. Going for an evening swim in the Colorado River is not something that most people would handle well, unless their name is Jim Katzel!
What made me want to document this recollection, is that today I found out that Jim has passed on to his next grand adventure, the one that awaits us all. I'm sure that wherever his spirit is now, he's making his new companions happy to be in his company, as he did when he was down here. Fare thee well Jim, and hang on!
|Tinnitus and Diving (Ringing in the Ears) - Scubadocâs Diving Medicine|
Ringing in the ears or âtinnitusâ (pronounced with the accent on the âtinâ) is one of the most prevalent and bothersome of symptoms related to diving. Tinnitus may be caused by damage or disease, anywhere along the path of the auditory system. Tinnitus is the perception of sound when no external sound is present; and is often referred to as "ringing in the ears." It can also take the form of hissing, roaring, whistling, chirping or clicking. The noise can be intermittent or constant, with single or multiple tones; it can be subtle or at a life-shattering level. It can strike people of all ages and, for most, it is difficult to treat. It is estimated that over 50 million Americans are affected by tinnitus to some degree. Of these, about 12 million suffer severely enough to seek medical attention. And, about one million sufferers are so seriously debilitated that they cannot function on a "normal," day-to-day basis. In diving, it is a symptom of serious changes that have occurred because of the effects of pressure, either barotrauma, excessive attempts to equalize or to a decompression accident. In divers, it also can be related to TM joint pressure from clamping down on the mouthpiece, wax buildup in the ear canal with tympanic membrane irritation, barotrauma to the middle and inner ear, decompression illness involving the inner ear, or rupture of the round window with perilymph fistula. With the latter, it most often found in association with vertigo and there is usually some deafness. It may also be caused by physical trauma, infections of the ears, long standing exposure to very noisy environments, scarring and rigidity of the small bones in the middle ear (otosclerosis), toxic damage by medications (e.g. Streptomycin), and tumors of the brain or the auditory (hearing) nerve. Tinnitus is still a phenomenon about which we know little and which has few effective treatments. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus, with mixed results. Other therapies include non specific prescription medicines, non-traditional medical treatments, such as acupuncture, stress reduction and relaxation therapy, hearing aids and biofeedback therapy. It should be emphasized that the newer methods of treatment are still under evaluation and that at this time there is no universal, symptomatic or specific treatment for tinnitus. Things That Scuba Divers Can Do 1. Get a good examination by a diving oriented ENT doctor. The tinnitus may not be from diving at all! 2. Check out your regulator mouthpiece for fit. Consciously avoid clamping down on the mouthpiece. (Try this yourselfclamp down on your teeth and hear the high-pitched whine!) 3. Avoid the use of nerve stimulants, i.e, excessive amounts of coffee (caffeine) and smoking (nicotine). 4. Learn as quickly as possible to accept the existence of the head noise as an annoying reality and them promptly and completely ignore it as much as possible. 5. Tinnitus is usually more marked at bedtime, when oneâs surroundings become quiet. Use any kind of masking sound-maker. How To Treat Tinnitus There is not a cure for tinnitus. However, a variety of treatment options exist that offer varying levels of relief to many sufferers. Treatment options include: - biofeedback - hearing aids - medication - masking - Tinnitus Retraining Therapy - TMJ treatment More About Tinnitus Related To Scuba Diving This information is provided only as a background for becoming an informed diver. It should never substitute for the expertise of a diving physician or ENT specialist. Tinnitus can be described as "ringing" ears and other head noises that are perceived in the absence of any external noise source. It is estimated that 1 out of every 5 people experience some degree of tinnitus. Tinnitus is classified into two types: objective (what can be heard by someone else) and subjective (what can be felt). Objective Tinnitus (Actually audible or observable ) The rarer form, consists of head noises audible to other people in addition to the sufferer. The noises are usually caused by vascular anomalies, repetitive muscle contractions, or inner ear structural defects. The sounds are heard by the sufferer and are generally external to the auditory system. This form of tinnitus means that an examiner can hear the sound heard by the sufferer by using a stethoscope. Benign causes, such as noise from TMJ, openings of the eustachian tubes, or repetitive muscle contractions may be the cause of objective tinnitus. The sufferer might hear the pulsatile flow of the carotid artery or the continuous hum of normal venous outflow through the jugular vein when in a quiet setting. It can also be an early sign of increased intracranial pressure and is often overshadowed by other neurologic abnormalities. The sounds may arise from a turbulant flow through compressed venous structures at the base of the brain. Subjective Tinnitus (Inaudible to an observer) This form of tinnitus may occur anywhere in the auditory system and is much less understood, with the causes being many and open to debate. Anything from the ear canal to the brain may be involved. The sounds can range from a metallic ringing, buzzing, blowing, roaring, or sometimes similar to a clanging, popping, or nonrhythmic beating. It can be accompanied by audiometric evidence of deafness which occurs in association with both conductive and sensorineural hearing loss. Other conditions and syndromes which may have tinnitus in conjunction with the condition or syndrome, are otosclerosis, Meniereâs syndrome, and cochlear or auditory nerve lesions. Hearing loss, hyperacusis (excessive loudness), recruitment, and balance problems may or may not be present in conjunction with tinnitus. Many sufferers report that their tinnitus sounds like the high-pitched background squeal emitted by some computer monitors or television sets. Others report noises like hissing steam, rushing water, chirping crickets, bells, breaking glass, or even chainsaws. Some report that their tinnitus temporarily spikes in volume with sudden head motions during aerobic exercise, or with each footfall while jogging. Objective tinnitus sufferers may hear a rhythmic rushing noise caused by their own pulse. This form is known as pulsatile tinnitus. In a database of 1544 tinnitus patients, 79% characterized the sound as "tonal" with an average loudness of 7.5 (on a subjective scale of 1-10). The other 21% characterized the sound as "noise" with an average loudness of 5.5. When compared to an externally generated noise source, the average loudness was 7.5dB above threshold. 68% of patients were able to have their tinnitus masked by sounds 14dB or less above threshold. The internal origination of the tinnitus sounds was perceived by 56% of the patients to be in both ears, 24% from somewhere inside the head, 11% from the left ear, and 9% from the right ear. In aother database of 1687 tinnitus patients, no known cause was identified for 43% of the cases, and noise exposure was the cause for 24% of the cases. Scuba Diving Causes of Tinnitus - Noise - TMJ syndrome (Clenching of teeth on the regulator) - Middle ear barotrauma (Due to pressure/volume changes) - Inner ear barotrauma (Due to pressure/volume changes) - Round window rupture (Due to elevated pressure blowing this window out into the middle ear) - Inner ear decompression accident (Due to bubbles damaging the inner ear tissues) Finally, advice from an otolaryngologist familiar with the damage that can occur from diving should be obtained. Self -diagnosis and treatment has no place in the management of tinnitus from diving injuries. References Scand Audiol 1999;28(2):91-6 Long-term effect of hyperbaric oxygenation treatment on chronic distressing tinnitus. Tan J, Tange RA, Dreschler WA, v d Kleij A, Tromp EC Department of Otorhinolaryngology/Head and Neck Surgery, Academic Medical Center, University Hospital of Amsterdam, The Netherlands. email@example.com Lamm K, et al. Effect of hyperbaric oxygen therapy in comparison to conventional or placebo therapy or no treatment in idiopathic sudden hearing loss, acoustic trauma, noise-induced hearing loss and tinnitus. A literature survey. Adv Otorhinolaryngol. 1998;54:86-99. Review. Bohm F, et al. Round window membrane defect in divers. Laryngorhinootologie. 1999 Apr;78(4):169-75. Review. German Schumann K, et al. Effect and effectiveness of hyperbaric oxygen therapy in chronic hearing disorders. Report of 557 cases 1989. HNO. 1990 Nov;38(11):408-11. German. Peifer KJ, et al. Tinnitus: etiology and management. Clin Geriatr Med. 1999 Feb;15(1):193-204, viii. Review. Lindberg P, et al. Long-term effects of psychological treatment of tinnitus. Scand Audiol. 1987;16(3):167-72. Kau RJ, et al. Effectiveness of hyperbaric oxygen therapy in patients with acute and chronic cochlear disorders. ORL J Otorhinolaryngol Relat Spec. 1997 Mar-Apr;59(2):79-83. Roeser RJ, et al. Clinical experience with tinnitus maskers. Ear Hear. 1980 Mar-Apr;1(2):63-8. House JW. Treatment of severe tinnitus with biofeedback training. Laryngoscope. 1978 Mar;88(3):406-12. Schleuning AJ, et al. Evaluation of a tinnitus masking program: a follow-up study of 598 patients. Ear Hear. 1980 Mar-Apr;1(2):71-4. Marion MS, et al. Tinnitus. Mayo Clin Proc. 1991 Jun;66(6):614-20. Review. Used with permission from Ernest S Campbell, MD: scuba-doc.com/entprobs.html
|Bare Essentials Mineral Makeup Beauty Secrets|
Bare Essentials Mineral Makeup Beauty Secrets
It is a well-known truth that many women around the world have used a variety of things to maintain or enhance their beauty.
Across cultures, eras and continents beauty secrets from the highest royal to the lowliest commoner have been passed on from generations to generations. It is a shame then that Western women have not adopted these more natural methods instead of those that rely on (usually) invasive medical procedures. Yet there are common Bare Essentials mineral makeup beauty secrets that are neither costly nor risky, and can have a multitude of benefits that help women stay both healthy and beautiful.
The greatest and cheapest beauty secret is water and also the healthiest! It is surprising just how much you can improve your skin, getting rid of unwanted and harmful toxins, by drink eight to ten glasses per day.
You must never underestimate the minerals and vitamins found in fruit and vegetables. Fruit and vegetables contain many nutrients required by us for a healthy life and consuming natural fruit juice is a good way to improve your energy level. Carrot, orange, cucumber and apple juices are fantastic Bare Essentials mineral makeup beauty secrets by being excellent rejuvenators of skin, hair and nails.
Donât dismiss regular exercise as this has the benefit of oxygenating the blood and where the effects are seen very quickly. Walking, running, swimming and biking or some ways in which women can improve their skin tone, hair texture and overall health. With exercise, the body becomes more adept at digesting food, burning calories and eliminating toxins from the system.
There is nothing like a positive outlook on life and this is something else that regular exercise brings. The effect of this is to often look and feel more youthful. A more efficient immune system and a longer life are two beauty secrets that people with a positive attitude to life have.
Daily bathing is a beauty secret that refreshes and invigorates the mind. Why not try having a shower before work to wake you up and prepare you for the day and a bath in the evening before you go to sleep. The expression bright eyed and bushy tailed has a real meaning for those who get a good nightâs sleep.
Excessive amounts of sun on your skin can be dangerous but it is also an excellent and necessary source of vitamins, an energy boost and has a superb feel good factor associated with it. Wearing sunscreen daily is one of the must-do Bare Essentials mineral makeup beauty secrets, which can be a long-term preventive measure for years to come. Never underestimate how powerful the suns UV rays are, because damage to the skin caused by it is usually only repairable by cosmetic surgery.
I have left probably the most important beauty secret until last and that is the benefits of true, deep relationships with friends or family. There may be times when all of us want to be on our own but long term isolation is very unhealthy. Having loved ones around you can lift your spirit, ease depression and insecurity. Who else would support through lifeâs trials without a word of thanks being needed but your friends and loved ones, now that is a true beauty secret.
Bare Essentials Mineral Makeup Info
|Scientists Invent Particle That Will Allow You to Live Without Breathing|
For 15 to 30 minutes.
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|Compression: More Than a Fancy Tube Sock.|| You are out on your favorite trail run, climbing hard up hill and flying fast down the other side. You can feel your heart pumping, lungs working and legs burning and you are loving every minute of it. This burn is caused by the lactic acid building up and the your muscles fibers tearing while you are breaking your systems down. Strengthening and improvement only starts once damage is rebuilt and the mess has been cleared.|
In order for your system to get stronger it must first be broken down. This provides muscle the opportunity to rebuild, and rebuild stronger than before the damage. So only after you rebuild and recover are you able to run farther and faster, but first your muscles pay the price.
Vibrations are carried from the impact of the pavement through your body with each foot strike which causes tearing in your muscles. Muscles pull at connective tissue attachments to forcibly pull bones around pivot-point joints like your ankles, knees, hips and back. All this force, torque and impact damages your muscles, bones and connective tissue, BUT this damage heals stronger than before the break down and you grow stronger and your endurance improves over time.
By challenging the current capacity of your body and breaking it down by working at your current limit you provide your body the opportunity to recover to a point beyond its current capacity, and therefore improve.
In an ideal world you go into each workout fully rested, free of muscles tears and stocked with blood full of oxygen so you can really push yourself. However, as you work and break down your system your muscles become excessively inflamed from the many small tears. This causes fluids to pool in your limbs which prevents lactic acid from clearing and blood from flowing back to the heart for oxygen.
This is why compression is so wonderful! Not only does it minimize damage but it also speeds recovery; the benefits are double fold! Stabilizing your muscles decreases vibrations, tearing, soreness and fatigue; so less pain and more gain.
Working muscles squeeze vessels and forces blood upwards against gravity through channels to the heart. Compression provides the same pumping action as working muscles and assists in moving blood back to the heart and lungs to load up on oxygen. This is helpful not only for recovery after workouts, but also during a workout!
This same squeeze from compression also moves lactic acid up against gravity to be filtered and removed from the system; further minimizing the effects of delayed onset muscle fatigue.
The variety and diversity of the benefits of compression is almost as great as the products on the market that fall into that category. Fleet Feet Bend offers several compression specific products that I have covered in detail below to make them easier to compare. Please drop by the shop to test any of the listed products out or if you have questions that have not been answered. I am certain that we can find the right compression for your activity and recovery.
CompressRx Ultra Active Calf Sleeve ($60.00)CompressRx Ultra Active Sock ($60.00)
- Stabilize muscles.
- Accelerate removal of lactic acid.
- Improve circulation back to the heart to oxygenate blood more quickly.
- Reduced muscle fatigue and post exercise soreness when used during exercise.
- ZoneRx: muscle specific zones of compression with differing amounts on compression on muscle belly of calf compared to front of shin.
- CRx: Graduated compression from more compression low at ankle to less compression at top of calf to aid in pushing against gravity and moving lactic acid and blood through the legs back towards the heart.
-SynchroRx: Functional moisture management, temperature regulation & odor protection because no one wants a soggy, stinky sock.
- Circumference Sizing: Products are sized according to the circumference of your muscle and your body for the best fit rather than group sizes according to shoe size like other companies.
- Knit not Sewn: Zoot products are knitted as one unit rather than cut out into smaller pieces and then sewn back together. This means there are no weak spots or chance for irratation from seams.
- Compression above 40 mmHg: Compression is measured in millimeters of mercury and Zoot offers the greatest amount of compression available without a prescription.
If you are looking for some serious compression then this is the product for you. Although many customers are very comfortable working out and doing intense exercise, even competing while wearing Zoot products I personally found them to be a little too intense of compression for use while being active. I may just be sensitive to compression but that degree of pressure on my calf muscles and arches while working hard periodically left me with the sensation that I might crap or my toes my curl under. However for recovery, travel and casual wear around these socks can't be beat. They really get the job done and left me feeling much more prepared for my next workout and I didn't feel overwhelmed by the level of compression what so ever in a less demanding environment.
RecoFit CompressionRecoFit Compression Website
Product Reviewed:RecoFit Calf Sleeve ($45.00)
- Accounts for both of the body's circulatory systems; lymphatic or immune system and the circulatory system of the heart pumping blood.
- Aids squeeze of muscles to reduce pooling and accelerate blood's movement back to the heart and lungs.
- Improve circulation to decrease inflammation and the effects of Delayed Onset Muscle Fatigue
-GreatFiT (Gradient Recovery Exercise & Activity Technology): Differing amounts of compression which corresponds to the needs of specific areas of the leg. This results in more compression on the shins and less compression on the muscle belly of the calf.
-Resistex (Negative-ion circulation assistance): Carbon yarns have been added to the technical fabric for a ribbed fit which increases breathability, adds compression and provides massage effects. In addition to moisture management. Again, no body likes soggy, stinky apparel.
-Flatlock seams, fine fabrics & cross grain cuts: for added compression and comfort.
-Circumference based sizing: Sizing is determined by measuring the calf rather than group sizing according to foot size for an ideal fit.
The Recofit Calf Sleeves are great because they give you the compression you desire to support your shins and calves but still allow you to wear your favorite Balega or Drymax technical socks on your feet. The Recofit are a happy medium between the intense, medical grade compression of Zoot Ultra-Actice Sock and the familiar, cotton-like feel of the Balega Performance Enhancing Compression Sock. Recofit products are cut and sewn together and don't offer quite as much compression as Zoot products. Recofit still sports quite enough compression to make it a great product for recovery and travel, as well as high-intensity work-outs. I find that is the niche that the Recofit sleeves fit for me. They are enough compression to really minimize shin-soreness if I wear them for speed work on the roads without the threat of being so tight I feel like my calves are having to work to push and shove against them. I can then leave them on for recovery while I stretch out and make dinner after my workout at home. However, they certainly can't compare to the Zoots for pure recovery and the Balegas for pure comfort.
Balega Running Socks Website
Balega Performance Enhancing Compression ($40.00)
Benefits Claimed & Listed Features:
- Quicken the reabsorb lactic acid.
- Reduce muscle strain.
- Improve circulation.
- Keep muscles compact to reduce fatigue and shorten recovery time.
- Sizing is based on foot size
Not nearly as technical as Zoot or Recofit, also not as expensive. The Balega Performance Enhancing Compression socks do offer more compression than it appears. When you first put them on and take a look in the mirror you feel that you are in a knee-high, tube sock and should be headed out to shoot some hoops instead of headed to hit the trails. However, you do feel the compression from the socks and I even found this level of compression much more comfortable than the Zoot or Recofit on longer runs. I like the familar, soft feel of Balega socks on my feet and toes while I am running. The Balega compression also has more warmth to offer than Recofit or Zoot which was nice keeping my muscles warm during excercise throughout the winter. Although the Balega compression is far from medical grade it is very well suited to long runs where a little extra compression and warmth is appreciated and the familar feel of high quality Balega socks is also desired. If you are looking for comfortable compression for the long run Balega is a great product. If you looking for a more intense compression Zoot or Recofit may be a better fit.
|Our new house|
Many members of my extended family gathered casually in Danville this weekend. We celebrated my grandmother's 95th birthday (she still lives in her own house!), baptized a baby and had a pretty good picture in the same old spot we always have.
Many of them asked to see pictures of my house and I promised that as soon as it was clean, I'd take some. The reality is that my entire family is focused on creating conditions in which I don't yell at the kids, so it's not going to be clean in the foreseeable future. So, here it is in all its unedited glory.
We bought a house five minutes from my parents' house after living with them for 2.5 years in an intergenerational experiment. They drop in here and let me drop off my kids there when they miss them or when I need some childcare. When we were looking, Jacob and I took turns touring houses, leaving the kids in the car because of the snow. I went first for this house and when I got back in the car, I hissed, "I want this house!" It's a little weird and reminds me of the houses I saw and visited when I lived on Orcas.
So, walk in this front door with me. There's a closet immediately in front of it. Judith stole the shoe rack to make a home for her stuffed animals so all the shoes are just jumbled together on the floor. The door to the closet is usually open.
If you turn to your immediate left, you'll see the gallery. The previous owners were artists and one was an electrician so the lighting is excellent for highlighting all of our storage and the children's craft supplies and works in progress.
This is always what it looks like. Someday when the kids are older and we're allowed to have nice things again, this will double as our dining room.
As you enter the breakfast nook and turn to the left, you face our kitchen. It is just the right size for me. The girls like sneaking up quickly between the knife I'm wielding and the produce I'm cutting. Akiva has a special drawer full of serving utensils that he frequents.
As you can see, it has a swinging woodstove and tons of natural light. The whole house is full of light, which was part of why I loved it. My quilting studio takes up a third of the room. I try to create a little every day to maintain spiritual balance. I could not accomplish this if my workspace was away from where the kids spend their time.
If we head back to the kitchen and continue through the house, you'll find the hallway to the private rooms. Our bathroom on the right.
Someday, my children will all sit in their respective therapist's office and say, "The main thing I remember is that my mom was always telling me to go downstairs."
A mud room houses all the mechanicals and a SECOND utility sink.
So, there you have it friends. Come over any time. One of those couches in the basement is a comfortable pull-out and there's a 70% chance I'll pick up the toys down there with a 40% chance that I'll vacuum in anticipation of your arrival.
Most nights I lay in bed before sleep and bathe in a feeling of gratitude for this sanctuary that is ours. We are lucky, indeed.
|Habits of Women with Good Skin|
Women with great skin. Is it all genetics? Are some women just born with a rare gene that guarantees flawless complexion? If so, can it be cloned? The truth is, while many women with great skin are blessed by nature, there’s usually a certain amount of nurture that accompanies it. So until there’s solid evidence for excellent-skin genetics, here are some steps you can add to your routine to get your friends wondering how you do it.
Use the Correct Cleanser
According to dermatologist Ava Shamban, "For oil or acne-prone skin, a salicylic gel or benzoyl peroxide works great. For dry, mature skin, use either a moisturizing glycolic, or a milky cleanser. For skin with brown spots or melanoma, use a brightening wash, such as an alpha hydroxy acid cleanser."
Drink the Right Liquids
While green juice may be one of the more suspicious looking beverages, it is also one of the most beneficial to your skin. Skincare facialist Joanna Vargas recommends drinking, "a shot of chlorophyll every morning to brighten, oxygenate and hydrate your skin." She adds, "Drinking chlorophyll also helps drain puffiness by stimulating the lymphatic system, so it's also good for cellulite."
Where can you get this magic elixir? Chlorophyll supplements can be found in the aisles of pharmacies and health food stores.
Easier said than done? Perhaps, but even if you can't get a full eight hours, silk pillowcases may make a difference. Jesleen Ahluwalia, MD, says, "The material glides easily and prevents creasing and wrinkles."
Wear Sunscreen Every Day
Sunscreen is not just for the beach! Dr. Debbie Palmer, New York dermatologist says, "We need to protect our skin even when we're driving a car, flying in an airplane, or running errands. It's the daily UV exposure that contributes to the visible signs of aging." Experts recommend a broad spectrum sunscreen with an SPF of 30 or more, reapplied every couple of hours.
Moisturize Day and Night
Dr. Janet Pystowsky, MD says, "The best times to moisturize are right after you get out of the shower and right before you go to bed." She also recommends avoiding heavily fragranced and harsh products to avoid irritation.
Eat a Healthy Diet
Omega -3 fatty acids are known to boost hydration and protect the natural moisture barrier of your skin. Flax seeds and walnuts are rich in omega-3. Also, be sure to eat foods with a low glycemic index, avoiding simple and complex carbohydrates to maintain a healthy glow.
Dead skin cells can leave skin looking dull. Dr. Mona Gohara says, "We lose 50 million skin cells a day, and without a little extra nudge, they may hang around, leaving the skin looking sullen." Gohara recommends that you use a pH neutral exfoliator to give dead cells that extra push. Also, remember that exfoliation does not stop with the face. The skin on your body needs exfoliation as well.
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|What you should know of varicose veins|
The heart along with the blood vessels known as the circulatory system. With each heartbeat, oxygen -rich blood is pumped through the arteries throughout the body . Small capillaries located in tissues allow oxygen is released to be used by the cells .
The veins carry deoxygenated blood back to the heart , ready to be pumped to the lungs to receive more oxygen. Veins require special mechanisms to ensure that blood flows against gravity and not backward.
Varicose veins occur most often on the legs and thighs. A person with varicose veins can see them perfectly in your legs, but these distended veins can also cause pain , itching and tired legs , muscle cramps or swollen ankles.
Women are more likely than men to develop varicose veins and those with a family history of the disease are at higher risk .
Risk factors for varicose veins
Going from sitting or standing long periods of time increases the force of gravity on the legs so it is another risk factor . Those who have had a deep vein thrombosis ( blood clot in the deep veins of the leg ) are very likely to develop varicose veins, as part of what is known as "post -thrombotic syndrome."
The high heels change muscle function in the leg and has always believed, incorrectly, that they were a cause of varicose veins . The calf muscle activity actually increases when walking with high heels and this lowers the pressure in the veins of the legs.
Varicose veins can lead to more serious problems and it is important to see your doctor if you experience bruising , skin changes , a suspected clot ( thrombosis ), or a skin wound that will not heal ( ulcers ) .
How to prevent varicose veins
|The Benefits of Prenatal Massage|
The benefits of prenatal massage are many and this commonly used but little known practice is once again growing in popularity due to its ability to:
Pregnancy is a very special time. The mother’s body is working harder than usual to grow a human and this monumental task can take a toll, both physically and mentally. What could be better than an hour long session of deep bodywork that can help leave any pregnant woman feeling re-energized and rejuvenated.
Before heading to the massage studio, be sure to discuss your intentions with your doctor to ensure a safe pregnancy. In terms of specific types of massage performed most frequently for pregnant women, there are several modes available:
This classic type of massage is also referred to as the most relaxing massage method. Through long rubbing motions and strokes, Swedish massage addresses the muscles’ cross-fibers to release tension, knots, and kinks.
This type of massage focuses on specific reflex points on the feet, hands, head, and other parts of the body. With the application of pressure, relaxation is encouraged, and the body releases stress and anxiety.
This massage is a very gentle, hand on approach that works with the bones of the head, spinal column, and sacrum to promote alignment and release compression, stress, and pain.
|Massage for Golfers|
More than other sports, golf relies on the knowledge of ones own physiology in order to play the game well. The highly specific and repetitive movements of a successful swing rest on perfecting proper technique. All of that practice can lead to overstressed and overused muscles though. With constant activity in the lower back, shoulders, wrists, hands, and knees, golf places a physical demand on its participants unlike other sports. Regardless of one's skill and activity level, a great way to help anyone who plays the game is through massage treatment sessions.
In this day and age, amateurs and professionals alike rarely step out to play without taking the proper steps to ensure they play their best. Along with pre and post game massages, it’s incredibly important to stay hydrated when out in the elements. Drinking enough water can also help eliminate fatigue and consequent stress to the muscles.
|NCP Nursing Care Plan For Lung Cancer|
Cause for Lung Cancers
Carcinogenesis, Initiation by a carcinogen (cancer-causing agent), for example, cigarette smoke, asbestos, or coal dust. Promotion by a secondary factor, for example, number of years smoking or number of cigarettes smoked. Progression, that is, the growth of pre-malignant cells and their ability to metastasize.
Lifestyle risk factors: Smoking, most common risk factor: 85% of people are or were former smokers. Others risk factor is Environmental tobacco smoke (secondhand smoke).About 3,400 lung cancer deaths in nonsmoking adults. Nonsmokers chronically exposed to secondhand smoke may have as much as a 24% increased risk for developing lung cancer.
Occupational risks: Radon, Asbestos fibers e.g. insulation and shipbuilding (7 times increased risk of death in asbestos workers & Asbestos exposure combined with cigarette smoking act synergistically to produce an increased risk of lung cancer), Arsenic (copper refining and pesticides), Beryllium (airline industry and electronics), Metals (nickel or copper), Chromium, Cadmium, Coal tar (mining), Mustard gas, Air pollution: diesel exhaust, Radiation, Tuberculosis.
Biological risks Sex/age: Males have a greater risk of lung cancer than do females, although incidence rate is declining significantly in men, from high of 102 per 100,000 in 1984 to 77.8 per 100,000 in 2002. Lung cancer incidence doubled in females from 1975 to 2000 and now has stabilized. Increased risk is associated with increasing age. 70% of all lung cancers diagnosed in individuals over the age of 65 and the number of cases diagnosed at 50 or earlier is increasing.
Family history: Lung cancer in one parent increases their childrenâs risk of the diagnosis of lung cancer before age 50.
Genetic predisposition: Genetic susceptibility is a contributing factor in those that develop lung cancer at a younger age. A single gene for lung cancer has not been identified. Abnormalities of p53 gene, a tumor-suppressor gene, have been suggested to be mutated in many people with lung cancer. EGFL6 gene identified as potential tumor marker.
Race: African Americans, native Hawaiians, and non-Hispanic whites have greater risk of lung cancer. Black men between the age of 35 and 64 years of age have twice the risk compared to non-Hispanic Whites.
Chronic inflammation, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis: Tuberculosis: Scarring of healthy lung tissue may lead to lung cancer development. Pulmonary fibrosis: Silica is the probable lung carcinogen. COPD: Airflow limitation results in a 6.44 times greater risk for lung cancer compared with the risk associated with absence of ventilator impairment.
To categorize lung cancers visible Pathologic features on light microscopy, are used. Lung cancers are divided into two major groups, Small Cell Lung Cancer and NonâSmall Cell Lung Cancer
Non-Small Cell Lung Cancer
Small-Cell Lung Cancer
Patients with SCLC often have widespread disease at the time of diagnosis. Rapid clinical deterioration in patients with chest masses often indicates SCLC
Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. TNM staging system. TNM staging takes the following factors into account. The size of the Lung Cancer (T). Whether Lung Cancer cells have spread into the lymph nodes (N) whether the Lung Cancer has spread anywhere else in the body â secondary cancer or metastases (M)
Stage of Lung cancer TNM (Tumor, Nodes, Metastases) system of staging
TNM Stage of Lung cancer Description:
Primary tumor (T)
Regional lymph nodes (N)
Distant Metastasis (M)
Stage grouping (TNM subsets):
Like many other neoplasm disease Complications of Lung Cancer occurs when lung cancer metastasized to other organ, outside the Lung. Disease progression and metastasis cause various complications. Early stage and localized disease may be asymptomatic. Symptoms are often medically treated and attributed to conditions such as bronchitis, pneumonia, and chronic obstructive pulmonary disease. Symptoms: cough & wheezing, increased sputum production, hemoptysis, Dyspnea, pneumonia, pleural effusions.
Advanced disease predominant at time of diagnosis related to tumor growth and compression of adjacent structures. When the primary tumor spreads to intrathoracic structures, complications may include tracheal obstruction; esophageal compression with dysphagia; phrenic nerve paralysis with hemidiaphragm elevation and dyspnea; sympathetic nerve paralysis with Hornerâs syndrome with ptosis, miosis, hemifacial anhydrosis, clubbing, hypertrophic osteoarthropathy, bone pain, fatigue, dysphagia from esophageal compression, wheezing or stridor, phrenic nerve paralysis with elevated hemidiaphragm, arrhythmias and heart failure (from pericardial involvement), hypoxia related to lymphangitic spread, superior vena cava syndrome (swelling of the face, neck and upper extremities and related to compression of blood vessels in the neck and upper thorax.
Symptoms: chronic cough, Dyspnea, weight loss, increased sputum production, hemoptysis, hoarseness (involvement of the laryngeal nerve), pleural effusions and atelectasis, chronic pain, pain over the shoulder and medial scapula, arm pain with or without muscle wasting along ulnar distribution,
Lung cancer usually cause breathing and heart problems such as:
Other complications are anorexia and weight loss, sometimes leading to cachexia, digital clubbing, and hypertrophic osteoarthropathy. Endocrine syndromes may involve production of hormones and hormone precursors.
Extra thoracic spread of disease: adrenal glands (50%), liver (30%), brain (20%), bone (20%), kidneys (15%), scalene lymph nodes. Prognosis remains poor and has improved very slightly despite medical advances: <14% combined 5-year survival rate
A common treatment method of Lung Cancer is Surgery, chemotherapy and radiotherapy is all classified as a treatment for lung cancer. Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years.
Common treatment methods of Lung Cancer:
Surgery Treatment for Lung Cancer
The treatment of choice for non-small cell lung cancer, Stage IA, IB, IIA, IIB, and selected cases of stage IIIA : lobectomy (removal of a lobe of the lung), pneumonectomy (removal of one lung), wedge resection or segmentectomy for patients with inadequate pulmonary reserve who cannot tolerate lobectomy, VATS (Video Assisted Thoroscopic Surgery), palliative surgery. Before surgery patient must know the risk factor from Lung Cancer Surgery; Risks from lung cancer surgery include damage to structures in or near the lungs, general risks related to surgery, and risks from general anesthesia
Patient education before surgery: patient understands surgical procedure, incision, placement of chest tubes; smoking cessation before surgery to reduce pulmonary complications pain control; bronchodilators, coughing and deep-breathing exercises, early ambulation after surgery.
After surgery : assess respiratory function (respiratory rate, level of dyspnea, use of accessory muscles, and arterial blood gases); monitor chest tube drainage and air leaks, monitor oxygen saturation at rest and ambulation, assess pain control, chest physical therapy (bronchial drainage positions, deep breathing, coughing) early ambulation,monitor for atrial arrhythmias ; discharge planning and home care arrangements.
Chemotherapy Treatment for Lung Cancer
Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer.
Chemotherapy Treatment for Non-Small Cell Lung Cancer
Chemotherapy Treatment for Small-Cell Lung Cancer
Chemotherapy treatment Complications, Myelosuppression (infection, anemia, bleeding), nephrotoxicity, nausea and vomiting, mucositis (inflammation of the mucous membranes), fatigue, SIADH and hyponatremia, hypotension, anaphylaxis, alopecia (hair loss), neurotoxicity (peripheral neuropathies, central nervous system toxicity), cardiomyopathy, arrhythmias, congestive heart failure, myocardial infarction, pneumonitis or pulmonary fibrosis, taste changes. Patient education (chemotherapy): chemotherapeutic agents, treatment schedule, adverse effects of drugs.
Radiation therapy Treatment for Lung Cancer
Complications of radiation therapy: Dyspnea, cough, initial increase in mucus production, and then dry cough, fatigue, skin erythema, esophagitis and dysphagia, pneumonitis, lung fibrosis. Patient education: radiation therapy: indelible markings, treatment schedule, site-specific adverse effects (within treatment field).
Neoadjuvant is therapy given before the primary therapy to improve effectiveness (e.g., chemotherapy or radiation before surgery). Adjuvant treatments are equally beneficial and often given concurrently or immediately following one another to maximize effectiveness (e.g., surgery and adjuvant chemotherapy after surgery), multimodality is therapy that combines more than one method of treatment (e.g. concurrent chemotherapy and radiation, such as, adjuvant and Neoadjuvant)
Home care considerations
After lung surgery: smoking cessation, control of incision pain, wound care, breathing exercises and coughing, pursed lip breathing exercises, maintain fluid intake, maintaining your nutrition, resume activity, regaining arm and shoulder function.
During and after radiation therapy: monitor side effects of radiation therapy and report any change in. Symptoms: Dyspnea, fatigue is common lasting 4â6 weeks after therapy, good nutrition, liquid diet supplement during periods of esophagitis, avoid wearing tight clothes, skin care.
During and after chemotherapy, advise patients: To identify all treatment related side effects and report changes Fatigue may last weeks to months To plan their day, and allow for periods of rest Try activities such as yoga, exercise, meditation, and guided imagery Keep a diary and document symptoms, activity level, nutrition, treatments, and emotions To monitor effectiveness of pain medications To monitor for any signs of infection, such as an increased temperature, redness or swelling, and that the latter symptoms may not be present during weeks of impaired immunity following chemotherapy administration Monitor weight change and appetite Nutritional supplements
Pulmonary rehabilitation programs: exercise strengthening, breathing exercises, walking program, nebulizers/aerosol medication delivery, disease specific instruction and support. Support groups: Lung Cancer specific, Better Breathers Club a support group sponsored by the American Lung Association for patients with chronic lung disease. Hospice: dignified dying, pain management, end of life issues, patient/family support.
Patient HistoryEstablish a history of persistent cough, chest pain, Dyspnea, weight loss, or hemoptysis. Smoking history, other risk factors (family history, occupational risks), associated diseases (COPD, tuberculosis, and emphysema), symptom description and onset. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, and epigastria pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patientâs family history for incidence of lung cancer
Physical examinationThe clinical findings of lung cancer may be localized to the lung or may result from the regional or distant spread of the disease. Lung auscultation, respiratory rate and depth, palpitation of supraclavicular area for tumor or lymphatic involvement or both, clubbing, nicotine stains to skin, hair, teeth. Lung cancer clinical manifestations depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray. Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinum lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax.
Psychosocial examinationThe patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patientâs coping mechanisms and support system.
Diagnostic tests For Lung Cancer
Chest radiographs plain anterior-posterior and lateral views not reliable to find lung tumors in their earliest stage. Chest Computed Tomography (CT) three-dimensional image of the lungs and lymph nodes (can detect tumors as small as 5 millimeters). CT is only about 80% accurate in predicting mediastinum node involvement. Spiral computed tomography of the chest. Magnetic Resonance Imaging (MRI) 92% accuracy in the diagnosis of mediastinum invasion. Positron Emission Tomography (PET) scan is based upon increased glucose metabolism in cancer cells. The PET scan uses a glucose analogue radiopharmaceutical to identify increased glycolysis in tumor tissues. The PET scan is a highly sensitive test in the diagnosis and staging of lung cancer. Bronchoscopic detection of tumor auto fluorescence could improve cure rates in selected groups at high-risk. Sputum cytology Percutaneous transthoracic needle biopsy Fine needle aspiration or biopsy Bronchoscopy. Mediastinoscopy to evaluate lymph node involvement. Scalene node biopsy (evaluate lymph node involvement) Photodynamic therapy; An injection of a light-sensitive agent with uptake by cancer cells, followed by exposure to a laser light within 24 to 48 hours, will result in fluorescence of cancer cells or cell death. Especially helpful in identifying developing cancer cells or âcarcinoma in-situ.â Also used to determine the extent of disease and the response to treatment (experimental). Assessment of distant metastasis: Abdominal CT (identify adrenal or liver metastasis), Head CT, MRI (brain), Bone scan; Thoracentesis (detect malignant cells in the pleural fluid).
Nursing Diagnosis for Lung Cancer
Common Nursing diagnosis found in nursing care plans for patient with Lung Cancer:
Impaired gas exchange related to Removal of lung tissue, altered oxygen supply. Ineffective Airway Clearance May be related to Increased amount or viscosity of secretions, Restricted chest movement, pain, Fatigue, weakness Acute Pain May be related to Surgical incision, tissue trauma, and disruption of intercostals nerves, Presence of chest tube, Cancer invasion of pleura, chest wall Fear/Anxiety [specify level] May be related to Situational crises, Threat to or change in health status, Perceived threat of death. Deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs. May be related to Lack of exposure, unfamiliarity with information or resources, Information misinterpretation, Lack of recall
Sample Nursing care Plan for Lung Cancer with interventions and rationale
Impaired gas exchange
May be related to:
Nursing outcomes and evaluation criteria client will:
Respiratory status: gas exchange, Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client normal range, be free of symptoms of respiratory distress, the patient will maintain adequate ventilation. The patient will maintain a patent airway.
Nursing Interventions Nursing care Plan for Lung Cancer Nursing diagnosis Impaired gas exchange: Respiratory Management:
Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane Rationale Respirations may be increased as a result of compensatory mechanism to accommodate for loss of lung tissue or pain. Auscultate lungs for air movement and abnormal breath sounds. Rationale Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; but in a client who has had a lobectomy should demonstrate normal airflow in remaining lobes. Investigate restlessness and changes in mentation and level of consciousness. Rationale May indicate increased hypoxia or complications such as mediastinum shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation. Assess client response to activity. Encourage rest periods, limiting activities to client tolerance. Rationale Increased oxygen consumption and demand and stress of surgery may result in increased Dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise. Note development of fever. Rationale Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic.
Maintain patent airway by positioning, suctioning, and use of airway adjuncts. Rationale Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance). Reposition frequently, placing client in sitting and supine to side positions. Rationale Maximizes lung expansion and drainage of secretions. Avoid positioning client with a pneumonectomy on the operative side. Rationale Research shows that positioning clients following lung surgery with their âgood lung downâ maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion. Encourage and assist with deep-breathing exercises and pursed lip breathing, as appropriate. Rationale Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis. Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated. Rationale Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of circulation to remaining functional alveolar units. Assist with and encourage use of incentive spirometer. Rationale Prevents or reduces atelectasis and promotes reexpansion of small airways. Monitor and graph ABGs and pulse oximetry readings. Note hemoglobin (Hgb) levels. Rationale Decreasing PaO2 or increasing PaCO2 may indicate need for ventilatory support. Significant blood loss results in decreased oxygen-carrying capacity, reducing PaO2.
Tube Care Chest:
Maintain patency of chest drainage system following lobectomy and segmental wedge resection procedures. Rationale Drains fluid from pleural cavity to promote re expansion of remaining lung segments. Note changes in amount or type of chest tube drainage. Rationale Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or a hemothorax, sudden cessation suggests blockage of tube, requiring further evaluation and intervention. Observe for presence of bubbling in water-seal chamber. Rationale Air leaks appearing immediately postoperatively are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus a problem in the drainage system.
Nursing diagnosis Ineffective Airway Clearance
May be related to:
Nursing Outcomes and Evaluation Criteria Client Will:
Nursing Interventions nursing care Plan for Lung Cancer Nursing diagnosis Ineffective Airway Clearance
Nursing Diagnosis Acute Pain
May be related to:
Nursing Outcomes and Evaluation Criteria Client Will:
Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Acute Pain
Nursing Diagnosis Fear/Anxiety [specify level]
May be related to:
Nursing Outcomes and Evaluation Criteria Client Will:
Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Fear/Anxiety:
Nursing Diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs Related to:
Nursing Outcomes and Evaluation Criteria Disease Process and Treatment Regimen Client Will:
Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs:
Patient Teaching, Discharge And Home Healthcare Guidelines
Patient Teaching, Discharge and Home Healthcare Guidelines for patient with Lung Cancer usually divide in to before surgery and post surgery. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Teach the patient about medical procedure before surgery and post surgery. Teach the patient how to maximize her or his respiratory effort.
Before surgery, supplement and reinforce what the physician has told the patient about the disease and the operation. Teach the patient about postoperative procedures and equipment. Discuss urinary catheterization, chest tubes, endotracheal tubes, dressing changes, and I.V. therapy. If the patient is receiving chemotherapy or radiation therapy, explain possible adverse effects of these treatments. Teach him ways to avoid complications, such as infection. Also review reportable adverse effects. Educate high-risk patients about ways to reduce their chances of developing lung cancer or recurrent cancer. Refer smokers to local branches of the American Cancer Society or Smokenders. Provide information about group therapy, individual counseling, and hypnosis. Urge all heavy smokers older than age 40 to have a chest X-ray annually and cytologic sputum analysis every 6 months. Also encourage patients who have recurring or chronic respiratory tract infections, chronic lung disease, or a nagging or changing cough to seek prompt medical evaluation.
Post Surgery, Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, the local hospice, the Alliance for Lung Cancer Advocacy, Support & Education (ALCASE), and the Visiting Nurses Association Teach the patient to recognize the signs and symptoms of infection at the incision site, including redness, warmth, swelling, and drainage. Explain the need to contact the physician immediately Warn an outpatient to avoid tight clothing, sunburn, and harsh ointments on his chest. Teach him exercises to prevent shoulder stiffness. Teach him how to cough and breathe deeply from the diaphragm and how to perform range-of-motion exercises. Reassure him that analgesics and proper positioning will help to control postoperative pain.
|Nursing Care Plans Chronic Renal Failure CRF|
Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the bodyâs ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases.
Pathophysiology of Chronic renal failure
End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure
Stages of renal failure
Chronic kidney disease CKD stages correspond to the degree of nephron loss:
Clinical Manifestations of Chronic renal failure
Etiology Causes Renal Failure Chronic CRF
Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older
If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:
Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.
Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD
Diagnostic Test Chronic Renal Failure CRF
Common Nursing diagnosis that could be found in patient with Chronic Renal Failure CRF:
Risk for decreased Cardiac Output
Risk for ineffective Protection
Disturbed Thought Processes
Risk for impaired Skin Integrity
Risk for impaired Oral Mucous Membrane
Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
Disabled family coping
Excess fluid volume
Imbalanced nutrition: Less than body requirements
Impaired gas exchange
Impaired oral mucous membrane
Impaired urinary elimination
Ineffective sexuality patterns
Ineffective tissue perfusion: Renal
Interrupted family processes
Risk for infection
Risk for injury
Nursing diagnosis Risk for decreased Cardiac Output
Risk factors may include
Desired Outcomes/Evaluation Criteria Client Will Circulation Status:
Maintain cardiac output as evidenced by blood pressure (BP) and heart rate within clientâs normal range; peripheral pulses strong and equal with prompt capillary refill time.
Nursing Intervention Risk for decreased Cardiac Output:
Nursing Diagnosis Risk for ineffective Protection
Risk factors may include:
Desired Outcomes/Evaluation Criteria Client Will
Nursing Diagnosis Disturbed Thought Processes
May be related to: Physiological changes accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances; calcifications in the brain
Desired Nursing Outcomes Evaluation Criteria Client Will:
Nursing Intervention nursing diagnosis Disturbed Thought Processes:
Nursing diagnosis Risk for impaired Skin Integrity
Risk factors may include:
Desired Outcomes/Evaluation Criteria Client Will:
Intervention Nursing diagnosis Risk for impaired Skin Integrity:
Nursing Diagnosis Risk for impaired Oral Mucous Membrane
Risk factors may include
Desired Outcomes/Evaluation Criteria Client Will
Nursing Intervention Nursing diagnosis Risk for impaired Oral Mucous Membrane:
Patient Teaching Discharge and Home Healthcare Guidelines
Patient teaching discharge and home healthcare guidelines for patient with Chronic Renal Failure CRF End Stage Renal Disease ESRD. CRF or ESRD are disorders that affect the patientâs total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. To promote adherence to the therapeutic program, and Encourage all people with the following risk factors to obtain screening for chronic kidney disease: elderly people, ethnic minorities, diabetics, and people with hypertension, those with autoimmune disease, and those with family history of kidney disease. Nurses may need to work collaboratively with social services to arrange for the patientâs dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important.
Patient Teaching Discharge and Home Healthcare Guidelines Chronic Renal Failure CRF
|Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)|
Chronic Bronchitis (usually insidious, developing over a period of years) :
Emphysema (Gradual in onset and steadily progressive):
The etiology of Chronic Obstructive Pulmonary Disease COPD includes:
Etiology of emphysema includes:
Exposure to tobacco smoke due to smoking preventable cause Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator Ambient air pollution Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD)
Etiology of chronic bronchitis includes:
Exposure to tobacco smoke due to cigarette smoking Secondhand smoke or passive smoking Ambient air pollution and occupational irritants Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers. Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust
Dyspnea Cor pulmonale Respiratory failure Pneumothorax Bronchiectasis: recurrent bouts of bronchitis Decreased quality of life and functional status Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue Assistance with activities of daily living (ADLs) as disease progresses Pneumonia, overwhelming respiratory infection. Right-sided heart failure, Dysrhythmias Depression Skeletal muscle dysfunction
Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease
Treatment for Chronic Obstructive Pulmonary Disease (COPD)
Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.
If the patient is to continue oxygen therapy at home, teach the patient how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.
Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:
Smoking cessation. Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices. Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used). Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV1 that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids. Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures. Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases. Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea. Supplemental oxygen therapy for patients with hypoxemia. CO2 must be monitored to determine increased CO2 retention. Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life. Antimicrobial agents for episodes of respiratory infection. Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema. Treatment for alpha1-antitrypsin deficiency: Prevent damage to lungs by quitting smoking. Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.
The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.
Patient History: Exposure to risk factors Past medical history including asthma, allergy sinusitis, or nasal polyps Family history of COPD or other chronic respiratory disease Chronic cough: length of time, daily or intermittent, seldom noc turnal Chronic sputum production: characteristics of sputum, change with the season amount produced Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels Smoking history: pack years (number of packs per day multiplied by number of years smoking) Age when fi rst noticed symptoms Current functional status and ability to perform ADLs Limitation of activities Pneumonia and other respiratory illnesses Use of oxygen: liter flow and years of usage Weight loss or weight gain Sleep pattern and position during sleep: number of pillows used
Physical ExaminationPotential abnormal physical exam findings (will vary based on severity of illness): Assessment of severity based on level of symptoms Severity of spirometric abnormalities Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction Use of pursed lip breathing Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation Cough due to increased sputum production: usually worse in the morning Sputum production: color, amount; usually increased with chronic bronchitis Shortness of breath with speech: two or three words per breath Dyspnea on exertion Barrel chest as a result of increased RV Use of accessory muscles Resting pulse oximetry with potential drop with activity Presence of complications such as respiratory failure and right heart failure Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP) Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills Fluid retention and edema Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest Enlarged abdominal girth or cachetic appearance Enlarged liver with r