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Boccaccio#8217;s Decameron Essay Sample. Boccaccio#8217;s The Decameron is today acknowledged as a masterpiece of medieval literature, and its influence can be seen in the work of to kill bird other great writers such as Chaucer and Shakespeare. Yet, the intellectual elite of legal his time rejected his masterpiece when it was first published, overlooking his wit and ingenuity and choosing instead to decry his lack of to kill bird atticus etiquette and political correctness. Clearly, he was prepared against just such attacks, for How is Rural-Urban the Provision of Care for Older People in Urban, throughout his work he cleverly weaves in bird atticus, his defense against would-be detractors, using the narrative frames of boston matric himself in both the first and atticus, the third person points of view. In the the steps of mitosis, Prologue, Boccaccio the author makes plain his ostensible purpose for writing having survived a bout of lovesickness thanks to the encouragement of a mocking bird atticus his friends, he now hopes to movies provide women afflicted by to kill a mocking quotes the same curse a diversion from cake case their melancholy in the form of stories. This lovesickness is quickly juxtaposed with the image of the dreadfulness of the Black Death in the author#8217;s Introduction.

Here, he sets the to kill atticus, background of his tale in stupa at sanchi, a time of which horrors would still be very much alive in the memories of his readers, and hence framing the extenuating circumstances for the ribaldry and impiousness that is to to kill a mocking bird follow. The Steps! Indeed, #8220;in the bird quotes, face of so much affliction and principles, misery, all respect for the laws of to kill bird quotes atticus God and man had virtually broken down and schizophrenia, been extinguished#8221;, and out of quotes necessity, standards of boston matric sexual propriety had also fallen (Boccaccio 7-9). A Mocking Bird Atticus! After establishing that his story is taking place in a time unlike any other, Boccaccio proceeds to distance himself from his sordid tales by making it as divorced from stupa at sanchi reality as possible, to reduce their impact upon to kill bird atticus, the reader. Having portrayed the dystopia that was Florence at the time, he proceeds to magically create a utopia for his chosen band of cake case men and women, a garden villa replete with servants, beautiful meadows, and excellent mind. The contrast could hardly have been greater. Immediately, the a mocking bird, reader understands that the stories should not be taken too seriously. Having constructed the stupa at sanchi, backdrop for his work, Boccaccio proceeds to add several narrative layers to further reduce his culpability.

He introduces the a mocking atticus, female protagonists by saying how, #8220;one Tuesday morning (or so I was told by a person whose word can be trusted) seven young ladies were to be found#8230;#8221; (Boccaccio 13). Marketing Positioning Statement Examples! This alludes to bird quotes atticus the fact that the stories he is about to recount were passed on legal principles to him by to kill a mocking bird atticus someone else. This puts two layers between him and how does telescope work, the contents of bird his work the storytellers themselves and the unknown messenger. Within the stories themselves, he occasionally inserts other stories, and the combined effect of positioning statement these various narrative layers is to create further distance between himself and to kill a mocking, any responsibility for his controversial tales. With that, Boccaccio proceeds to narrate the first of of mitosis his hundred tales.

The story of Ser Cepperello is especially important as Boccaccio uses it to bird atticus introduce the theme of about appearance versus reality that runs through the atticus, rest of the cake case, book what seems to be the truth may be in to kill, fact far from it. The story of a wicked man who achieves sainthood may seem blasphemous at first, but Boccaccio tempers it by making it clear that, despite Ser Cepperello#8217;s ungodliness in life, he still managed to boston matric perform his duties as a saint in death, increasing the faith of the people, being a beacon of hope for them, and granting the prayers of those who pray through him. To Kill Bird Quotes Atticus! The entire tale in schizophrenia, itself is a mocking bird atticus meant to Rural-Urban Migration for Older be a subtle lesson for how we should read the rest of the book. Boccaccio is a mocking bird atticus encouraging us to read with our eyes open to the fact that while the subject matter may be lewd and unseemly, we should strive to detach ourselves from cake case it and seek to a mocking enjoy the contents of the stupa at sanchi, book without letting it influence us in any unbecoming way. Bird Atticus! In this sense we should emulate the positioning examples, two brothers in the tale, who hidden behind a wooden partition have a good laugh at to kill bird atticus, the #8216;confessions#8217; of the legal, soon-to-be Saint Ciapelletto, knowing full well that everything he was saying was a lie. Our own morals are our partition from the fiction, and to kill a mocking bird quotes, if we choose to marketing erect them there is bird quotes nothing Boccaccio#8217;s stories can do to us. Rather, the onus is on him to provide a good delivery of cake case his stories, so the lovelorn women reading The Decameron will be sufficiently entertained. On that point, Boccaccio#8217;s self-defense moves on to kill quotes to a new level. Principles! The first story of Day Six is meant to illustrate to a mocking the reader what exactly he thinks about storytelling. Movies About! He likens it to the gentlemanly arts of swordplay and riding. He shows how it is neither the content nor details of a story that matter, but rather how it is a mocking bird told.

In this, he answers the stupa at sanchi, critics who accused him of plagiarizing ideas from other well-known tales at that time or fault his recollection. The knight in the story possessed a tale which was #8220;in itself#8230;indeed excellent#8221; (Boccaccio 447), but due to his poor delivery he makes a mess of his tale, and to kill a mocking, his unfortunate listener Madame Oretta is positioning examples comically portrayed as falling ill, testament to a mocking the harm that a badly spun yarn can cause. The crux of the the steps of mitosis, entire story, however, lies in her timely comment to the knight which saves her from further agony. She says to him, #8220;Sir, you have taken me riding on a horse that trots very jerkily. Pray be good enough to set me down.#8221; (Boccaccio 447). The sexual reference here is unmistakable. To Kill Bird Quotes Atticus! Boccaccio is equating the stupa at sanchi, art of to kill a mocking quotes atticus storytelling to positioning statement examples that of to kill bird lovemaking.

In that light, would not the young, unmarried women to stupa at sanchi whom he is to kill a mocking bird quotes addressing the positioning examples, book be able to savor that sensual pleasure vicariously by to kill a mocking quotes atticus reading his stories? Bawdry though they might be, if the stories fulfill the function of helping to satiate the the steps, reader#8217;s appetite for sex and prevent worse sins like fornication, perhaps the Church should not be so opposed to to kill atticus it. Indeed, rather then simply defending himself we now see Boccaccio actually promoting his work as a positive influence! However, there have been instances in the book where even Boccaccio has to admit that he has carried things too far, and a timely intervention is necessary to allay the doubts of the reader. The best example of this is Boccaccio#8217;s introduction to Day Four. Previously, the lusty Dioneo had told a story particularly raunchy and boston matric, sacrilegious. He had spun a tale of how a holy man had taught a nai??ve young girl how to #8216;put the to kill bird quotes atticus, Devil back in stupa at sanchi, Hell#8217; an euphemism for to kill a mocking bird, sexual intercourse. The story perverts the for Older People in Urban China, entire notion of service to the Lord and even seems to reward sexual licentiousness by illustrating how the a mocking, young girl managed to marketing statement survive a fire which wiped out her entire household and to kill a mocking bird atticus, got married happily in boston matric, the end. But worst of all is the a mocking bird quotes, reference to the resurrection of Christ which Dioneo uses to play on boston matric the holy man#8217;s act of to kill bird atticus getting an positioning erection.

In fact, for bird atticus, over five hundred years English translators refused to translate this portion of the text as it was deemed too blasphemous (Boccaccio 825). Little wonder then, that the Boccaccio has to devote the marketing positioning statement, beginning of the next story to to kill a mocking bird explain himself. The introduction to boston matric Day Four is to kill bird atticus famous for its so-called hundred and first story, that of how does a refracting telescope Filippo and his attempts to raise his son to be innocent and virtuous by to kill a mocking bird quotes atticus ensuring he has no exposure to the world at large. However, it is all in vain, as his son is immediately attracted to women upon seeing them even though he does not even know what they are. It is significant that this is the schizophrenia, only story in which Boccaccio himself narrates, without the safety of the bird quotes atticus, layered narrative to Rural-Urban Migration Shaping of Care for Older China shield him. This is perhaps because this story contains another central theme of his defense that sexual needs are perfectly natural and people should have no need to control them. In fact, they cannot be suppressed and this justifies in part the sexual nature of his stories, for to quotes censor them would be akin to movies about schizophrenia going against nature. Interestingly Boccaccio does not complete the to kill a mocking bird atticus, story, as he probably knows that were he to do so it would likely just become one of the many stories in statement examples, the collection, instead of to kill a mocking quotes atticus setting it apart. As a result, its significance is made clear.

The introduction to boston matric Day Four in fact marks the beginning of a shift towards a more somber mood as well, with the reign of the lovelorn Filostrato who decrees the day#8217;s subject matter to be those whose love ended in unhappiness. Boccaccio saves his strongest defense for his epilogue, where he ties in to kill a mocking bird atticus, all the various threads of his arguments into the steps of mitosis one coherent whole. To Kill A Mocking Bird! He recalls the Black Death that plagued Florence, by principles reminding the to kill a mocking bird quotes, reader that it was a time when #8220;even the most respectable people saw nothing unseemly in positioning examples, wearing their breeches over their heads if they thought their lives might thereby be preserved#8221; (Boccaccio 799). He presents the to kill quotes atticus, different narrative layers as if he had no hand in stupa at sanchi, the stories at all, #8221; I could only transcribe the stories as they were actually told#8230;even if one could assume that I was the inventor as well as the scribe of these stories (which was not the case)#8230;#8221; (Boccaccio 800). Last but not least, he emphasizes that once the to kill a mocking bird quotes atticus, storyteller has fulfilled his duty to entertain, the story is merely what the marketing positioning examples, listener wishes to make out of it, for #8220;like all other things in the world, stories, whatever their nature, may be harmful or useful, depending upon the listener#8221; (Boccaccio 799). Ultimately, the critical reader must heed what Boccaccio has written in the Prologue, and to kill, #8220;learn to the steps recognize what should be avoided and likewise what should be pursued#8221; (Boccaccio 3). A Mocking Quotes! His stories #8220;will not run after anyone demanding to stupa at sanchi be read#8221; (Boccaccio 800). The reader who has read this far has no right to be outraged by his lack of modesty, for a mocking bird, he has always had the option of turning away. Principles! By delighting in quotes, the tales enough to cake case read the to kill a mocking quotes atticus, entire book to its conclusion, the boston matric, reader has become complicit in the crime.

Boccaccio has negated his responsibility to a mocking atticus uphold morality due to the sheer nature of his job as a storyteller. The clergy and others who would have had reason to condemn the book have been caught wrong-footed and cast in boston matric, a bad light by the genius of Boccaccio once again only this time, it is happening in to kill a mocking bird quotes atticus, real life. Boccaccio, Giovanni. Boston Matric! The Decameron. A Mocking Atticus! Trans. G.H. McWilliam. Penguin Books, 1995.

Is this the perfect essay for of mitosis, you? Save time and to kill bird quotes atticus, order Boccaccio#8217;s Decameron. essay editing for only $13.9 per page. Stupa At Sanchi! Top grades and bird quotes atticus, quality guaranteed! Relevant essay suggestions for Boccaccio#8217;s Decameron. The Decameron, a collection of principles 100 short stories by to kill a mocking bird quotes atticus Italian author Giovanni Boccaccio. The allegorical work is telescope best known for tales of love in all its forms from to kill a mocking bird atticus erotic#8230; “The Decameron” by Giovanni Boccaccio. Plague as Dehumanization of Florentine Society It is necessary to movies about outline that “The Decameron” by Boccaccio is one of the best remarkable and touching portraying of the plague in the#8230; Malgudi Days is a very special book, but it also may well be a book for special tastes.

A collection of thirty-two stories, most of to kill a mocking bird atticus which have been selected from#8230; Canterbury Tales Lines 796-799 Of The Prologue. INTRODUCTION Geoffrey Chaucer wrote The Canterbury Tales, an anthology of stories in how does a refracting telescope work, a framework story, between 1387 and 1400. To Kill A Mocking Bird Quotes! It is the How is Rural-Urban of Care, story of thirty people who travel as pilgrims#8230; Canterbury Tales an ancient writer Geoffrey Chaucer. Canterbury Tales are stories written and to kill a mocking bird quotes atticus, told by an ancient writer called Geoffrey Chaucer. Chaucer was telling a story of boston matric a set of bird quotes thirty men who were traveling to of mitosis Canterbury#8230; Is the a mocking bird atticus, Climax of the Migration the Provision for Older People, Miller#8217;s Tale Simply?

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?Olivia Mirek Period 2 2/13/15 The Enduring Spirit through Inevitable Struggle In The Old Man and to kill a mocking the Sea by Ernest Hemingway, the endurance of . the one’s spirit through constant suffering demonstrates that the success and Rural-Urban Migration the Provision of Care for Older People China the importance of the human soul are determined by perseverance, rather than the physical losses and gains in life. Although Santiago is unable to to kill atticus bring the marlin back to land as a whole, the relentless demonstration of his worthiness through his fight with a noble opponent shows. Ernest Hemingway , Fish , Life 1404 Words | 4 Pages.

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Resume Format Guide - Reverse-Chronological, Functional, Combination Styles. By Resume Genius. Making a perfect resume needs more than just error-free spelling and to kill grammar. How Does Telescope Work. A resume must be framed and formatted to present you in the best way possible, a process that requires combining creativity, composition, and to kill a mocking quotes marketing. Therefore, we’ve written this resume format guide to be a comprehensive resource to those looking to format their own resumes.

We provide writing tips, expert advice, and sample images covering every resume format for your convenience. Looking for more resume samples? Click the link below. How to Choose the Best Resume Format. Use the chart below to get a quick idea of which resume format will be best for presenting your unique job experience. As you may have seen above, job seekers have three options when it comes to formatting their resume: Chronological, Functional, and about schizophrenia Combination . Each resume format has their own set of advantages and disadvantages for different kinds of job seekers, so be sure to choose wisely. Check out the in-depth writing guides below to get every bit of information needed to create the best resume for you: To get inspiration and an idea of what your resume can look like, we’ve created three huge libraries of resume format examples . The links below are separated by a mocking atticus resume style and include industry-specific samples. Visit each library and How is Rural-Urban Migration of Care for Older in Urban China find your industry.

As the name suggests, a reverse chronological resume presents your work experience information from newest (most relevant) to oldest (least relevant). This means the resume will begin with your most recent job, and end with your oldest experience. This structure allows you to present yourself in terms of to kill bird, your promotions and upward career mobility , and marketing positioning statement examples is therefore particularly useful for entry to mid level applicants looking to boost their careers. I should use a reverse chronological resume format if… I want to demonstrate a vertical career progression.

I want to apply to to kill bird atticus, a job in a similar field. I don’t have large work experience gaps. I shouldn’t use a reverse chronological style if… I have multiple gaps in my employment history. I am considering working in a new industry I frequently change jobs. To learn more about what should be in included in a reverse-chronological resume, click here. The functional resume format frames the candidate in terms of the skills and boston matric abilities he/she believes are most relevant to the job opening . Unlike the quotes reverse chronological resume, the functional resume ignores when and where the candidate learned or performed those skills . The candidate and simply lists them at the top of the resume in movies schizophrenia, order of a mocking quotes, most relevant to least relevant skills. Legal Principles. Even the “least relevant” skill should still be relevant to the job you are applying for. To Kill A Mocking Quotes. “Least relevant” here really means “the least relevant of your most relevant skills.”

Warning: Many human resources professionals have negative impressions of functional resumes precisely because they do not reveal chronological information, making it seem like the candidate is hiding something. By using the functional format, job candidates can achieve three big goals: provide evidence that they are strong candidates for the job, and hide work experience gaps (if they haven’t been working for periods of Rural-Urban Migration Shaping People in Urban China, time.) help hiring managers quickly locate specific skills that are required for a particular position, which is beneficial. I should use a functional resume format if… I have unusually large gaps in my employment history.

I am in the midst of a big career change into a new industry. I want to promote a specific skill set. I shouldn’t use a functional style if: I want to highlight my upward career mobility. I am a student or entry-level candidate that lacks experience. I lack relevant or transferable skills. To learn more about to kill bird, what should be in included in of mitosis, a functional resume, click here. A combination resume is literally a combination of the reverse-chronological and functional resume formats. Combination resumes will often begin with a professional profile or summary of qualifications that includes skills, abilities, and to kill quotes achievements relevant to the job opening. Of Mitosis. (This is the functional part.) This introductory section is then followed by your reverse-chronological professional experience, education, and additional sections. (This is the reverse-chronological part.)

I should use a combination resume format if… I want to showcase a relevant and well-developed skill set. To Kill A Mocking Atticus. I want to movies about, transfer to a different industry. I am a master at what I do. I shouldn’t use a combination resume format if… I am a student or entry level candidate. I want to emphasize my educational experience. I lack relevant qualifications and skills. To learn more about to kill atticus, what should be in included in a combination resume format, click here. If you have any specific questions not answered in this guide please feel free to marketing positioning, post them in the comments at to kill a mocking quotes atticus, the bottom of the page and of mitosis one of our Senior Resume Experts will be glad to answer them for you!

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If I apply a admin. job but I only have relevant experience several years ago, and now in school learning social service. How can I make my resume? Emphasize old skills and transferable skills from a mocking atticus, social service in a combination or functional resume. How Does Work. Good luck on the job hunt! Yes, if you have several impressive awards/honors then they can definitely be place above your professional experience. To Kill A Mocking Bird Quotes Atticus. Good luck on principles, the job hunt! We suggest using a combination format. To Kill A Mocking Quotes. Best of luck on the job hunt! We suggest that you stick with the traditional reverse-chronological format.

Good luck! I did a career shift recently to teaching after having a graduate degree and 10 years experience in planning and development. I have recently completed a graduate degree in education and have 2 years of teaching experience in a preschool setting and trying to now make the positioning statement examples shift to elementary age. Do you think I should use a combination resume? A combination resume should work for your situation. To Kill A Mocking Bird Quotes. Check out our combination format writing guide for more info: https://resumegenius.com/resume-formats/combination-resume-samples. For a chronological resume, if I completed an internship with a past employer — while simultaneously being employed by them — does the internship go above or below the primary employment experience? (E.g., I worked at HSBV from 8/2013 – 12/2015, with my internship — also at HSBV — from 1/2015 – 5/2015, so right in the middle of my employment with them. Schizophrenia. Should the to kill a mocking bird quotes atticus internship be listed before, or after?) You should list you internship after your employment. Good luck! I have what I perceive to be a unique situation (I understand everyone thinks they are different).

I am an army veteran of nearly 7 years and now I am studying to get my BS is Homeland Security. I joined the work army at 19 in a mocking bird quotes atticus, 2006 and the steps of mitosis got out in 2013. From 2013 until January of this year, I have been trying to make my own way as an bird quotes atticus, entrepreneur. I was largely unsuccessful and in marketing positioning statement, order to stay on top of a mocking quotes, my bills I ended up taking odd jobs during the day while working as a bouncer at various bars and boston matric clubs at night. I am currently looking for to kill a mocking bird, an internship as part of my degree program so i need to create a resume. I thought a functional resume would be ideal so as to blur the past 3 years. Boston Matric. However, I understand from this article that students should use a chronological resume. I need to know how firm that rule is. Also, if anyone has any specific guidance for my resume I am very willing to to kill a mocking bird quotes atticus, accept advice.

Thanks. In your situation, we would suggest using a functional format. This will allow you to of mitosis, focus on your skills that are relevant to the internship you are applying for. Good luck on the job hunt and thank you for your service! Okay so I am a third year college student looking for to kill a mocking atticus, a part-time job that fits my class schedule and isn’t in the fast-food industry to help me pay rent next year. I have never had to write a resume for boston matric, any of my other jobs so I’m at a loss as to what to do. I am applying as an entry-level applicant but I also didn’t work during my freshman year and about half of quotes atticus, my sophomore year. Therefore I’m not really sure how to approach this and I really need this job. Please help! Thanks! Good luck on the job hunt!

Consider adding a ‘Publications’ section to include your research and writing experience. Good luck on the job hunt. Several positions require a chronological resume be included. I am over 40, most recent position was over 5 yrs ago as a Seasonal Tax Professional with HR Block. Recently received my AA degree. I do not include employment start – end dates on my resume for many reasons but I am not trying to look like someone who can not or will not follow directions either.

Please share your thoughts. Hi I used to be a pediatric nurse for movies schizophrenia, two years till moved to this country on to kill quotes atticus, 2012 and have been working at Walmart since then, recently got my RN license and want to start working as a nurse…what type would you recommend me? In your case, we suggest using a functional resume. Best of luck on the job hunt! Hi, I am presently working as Project Manager in construction company and the steps before this I worked as Operations Manager in to kill bird quotes, a different company. Now I want to apply for a job (Title : Plant Manager). The Steps Of Mitosis. I am confused which format I should choose to post for this job opportunity. Please recommend. We suggest sticking with the traditional reverse-chronological format. Best of luck!

Detailing all 18 years of your experience might be overdoing it. With three pages, there is likely some redundant information that you could cut. However, if you truly feel that all of your content is relevant and a mocking quotes atticus of interest to the employer, then stick with what you have. Best of legal, luck on to kill quotes atticus, the job hunt! I am now trying to rejoin the movies schizophrenia full-time workforce after almost a 17 year absence. Prior to marriage mother hood I was a very successful Director of to kill a mocking, Public relations for a well known beauty company in NYC (1990-1996). After that I joined a small firm on Long Island as their first ever Director of PR and advertising (1997-1999). Then babies came. Boston Matric. 6 years later I joined a local firm as their Director of Operations (office manager) from to kill atticus, 2006-2009.

Then my family and I moved to Switzerland and just returned after 7 years. I was a teacher of marketing examples, English as a Second Language. To Kill A Mocking Quotes. I am looking for boston matric, work in almost any capacity: From Communications manager to administrative assistant. I am struggling with how to present my resume. To Kill A Mocking Quotes. I’ve been letting my cover letters explain the the steps history and why I would be a good fit for to kill a mocking bird, any given position, but I’m sure my resume is legal holding me back. A Mocking Bird. Any ideas.

Thanks in Rural-Urban for Older People, advance! If you’re looking to to kill quotes atticus, get back into communications or office management, then it might be better to use a functional format. This will allow you to emphasize your skills instead of the dates of your work experience. As far as explaining work gaps in your cover letter, check out this how-to guide: https://resumegenius.com/cover-letters-the-how-to-guide/cover-letter-red-flags-solutions. While I was in high school I did my internship at the steps, for State Farm. After I graduated I was offered a job there and to kill a mocking quotes stayed there for 2 years. I have recently worked at work, the National Instituted of Health for a year. I currently want to go back to quotes, finding an office job or something related and need help deciding what type of resume I should use?

Based on the info you’ve given us, a ‘Chronological’ format would still be appropriate. How Does A Refracting Work. Best of luck! If the bird quotes atticus the position you are applying for how does a refracting work, is also an administrative job, then stick with the traditional Reverse-Chronological resume format. Good luck on the job hunt! Glad you liked it! Hi there! This is great. I was just wondering, if I’ve been at the same position for 3 years (2014-present) but did a second job for 6 months in 2015 that I would like to list, would I put that first (since technically 2015 is more recent than 2014)?

Or would I list that after my current position, since I’m still presently in this role? Thanks! List your current position first. Best of luck! A combination or functional resume would be suitable. To Kill A Mocking Atticus. Best of luck!

It sounds like a functional format would be a good choice. Good luck on the job hunt! Hi there Elizabeth, You have a bit of flexibility with the resume format, but when in doubt go with reverse-chronological. Because you’re lacking in transferable skills, I’d recommend working on your resume objective to get your application started on the steps of mitosis, the right foot. https://resumegenius.com/how-to-write-a-resume/career-objective-writing-guide. Also consider the a mocking quotes soft skills you’ve built during your time working in a call center.

Many of these could potentially be transferable. https://resumegenius.com/how-to-write-a-resume/skills-section-writing-guide. Good luck with your job application! Yes, a combination resume is perfectly suited to of mitosis, someone of your experience, even with the career change. Good luck making the a mocking bird quotes atticus shift back into principles, your previous field! If you are aiming for a new industry, you can’t go wrong with the classic “reverse-chronological” resume format. Good luck landing your fellowship! Share Resume Format Guide – Reverse-Chronological, Functional, #038; Combination Styles

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1988 Dbq Apush Essays and to kill a mocking bird atticus, Research Papers. APUSH DBQ Lexus Weigand 3/3/14 From 1875 to principles, 1900, there was a new kind of city in America, one that was based on . industry, and industry needs workers. The factories needed hundreds of workers to run machinery and other processes in manufacturing, but these workers were not treated properly and they wanted to do something to improve the way that they were treated. The organized labor, although it showed some minor successes, was overall very unsuccessful in improving the position of to kill quotes atticus workers. History of the United States , Homestead Strike , Industrial unionism 962 Words | 3 Pages. ?Jack Magill APUSH /Period 4 18 November 2014 The Jacksonian Rule The 1820’s in the United States saw a presidential election won on a . “corrupt bargain”, a Yankee Misfit in boston matric, office, and the end of the era of Good Feelings; the United States was desperate for a fresh new face to take office and restore power to the people. Andrew Jackson and his comrades did what they believed in, what they thought was necessary to a mocking atticus, uphold the use of the constitution to guide the administration and telescope, give power to the.

Andrew Jackson , Federal government of the United States , Georgia 1423 Words | 5 Pages. DBQ #1 When first founded, The New England and Chesapeake colonies were both very similar because of to kill a mocking bird quotes their English heritage and their . mission to survive in the new world in which they had landed. Throughout the the steps of mitosis 1600’s the immigrants of the quotes atticus two regions longed for a new and better life escaping religious persecution, poverty, and political tyranny. How Is Shaping The Provision For Older People China. Although their initial goals were the same, the two regions evolved into to kill a mocking, two very different and unique societies by the 1700’s based off of a refracting work their social. Massachusetts , Massachusetts Bay Colony , New England 1402 Words | 4 Pages. Quotes. DBQ - New England VS the Chesapeake Colonies Although New England and the Chesapeake region were both settled by marketing examples, people of English origin, by . 1700 the to kill bird quotes regions had evolved into two distinct societies. There were social, political, and economic differences between the two regions. The main reason as to why this development occurred was that the Chesapeake concentrated on obtaining wealth whereas New England had strong religious beliefs. With different goals in legal, mind, the two regions separated due.

England , Government , Greater London 902 Words | 3 Pages. The 1988 Gin DBQ During the mid to bird, late 18th century, England went through many difficult times one of which revolved about . the the steps English Parliaments decision to pass the Gin Act of a mocking quotes atticus 1751 that restricted the How is Shaping the Provision for Older People China sale of gin. This act did this in three ways, first by not letting distillers sell to unlicensed merchants, second by to kill quotes, restricting the retailers by only those with a significant amount of How is Migration of Care for Older People in Urban land sell gin, and thirdly by charging high fees to all those still able to sell gin. This reasonable decision. Beer Street and Gin Lane , Evil , Gin 1419 Words | 4 Pages.

Carson Mayes DBQ APUSH During the election of 1800, Jefferson ran for the Democratic-Republic party. His philosophy on quotes atticus, . Examples. government had always been to bird quotes, have a strict interpretation of the Constitution along with the strong belief in state rights over a strong central government that his opposing Federalist party wanted. His beliefs on a frugal and limited government, reduced army and navy, and the repeal of taxes were all issues that helped maintain his philosophy of government as well as. Alexander Hamilton , Alien and Sedition Acts , Federalism 880 Words | 3 Pages. Ollie Cunningham APUSH per. 5 October 31, 2010 Civil War and Reconstruction DBQ The United States Civil War was one of . America’s darkest hours of movies schizophrenia nationhood, but resulted in new rights and liberties for African Americans and quotes, revolutionized the United States for how does work the better.

The war resulted in the freedom of black slaves, and called for a complex reunification procedure to rejoin the depleted South and the high spirited North. Constitutional and social developments during the Civil War and. Abraham Lincoln , American Civil War , Democratic Party 842 Words | 3 Pages. 2003 AP US DBQ The Progressive Era was a twenty year period, between 1900 and 1920, of much change in the U.S. Many Americans would begin . to stand up for what they believed was right. This would lead to a number of reforms to help improve American life. Laws passed under Presidents Roosevelt, Taft, and to kill bird quotes atticus, Wilson, would dramatically change this country all the way into the present time.

As industry became a large part of urban America, many citizens were oppressed. Unfair and unsanitary conditions. Telescope Work. African American , Democracy , Franklin D. Roosevelt 973 Words | 3 Pages. ? APUSH Document-Based Question #3 British rule over its American colonies was selfish and unfair. A Mocking Bird Quotes. They were over three thousand miles away, . ruling from boston matric afar. Britain used the colonies to get ahead economically and didn’t care what happened to the colonies. They taxed the colonists and passed laws that the colonists believed infringed on to kill, their human rights of freedom. Many people believe that the Revolutionary War was a result of social and How is Rural-Urban of Care in Urban, political differences and controversies. However, the.

American Revolutionary War , British Empire , Colonialism 736 Words | 3 Pages. 990 DBQ Jackson’s followers were common men who believed in the rights for the lower and working classes, strict interpretation of the . constitution,and democracy instead of a republic. To Kill A Mocking Quotes Atticus. Many of his followers were inspired when Jackson rose from little education and social opportunity and movies about schizophrenia, took President, and they knew he would protect their rights and fight for to kill bird quotes the “Common man ,” instead of the elite. Supporters and followers of Andrew Jackson believed they were the guardians of the Constitution. Democracy , Second Bank of the United States , Social class 789 Words | 3 Pages. How Does A Refracting Telescope Work. 2002 AP DBQ In the quotes atticus years following the War of 1812, the principles “Era of to kill bird Good Feelings” evolved between the years 1815 and boston matric, 1825. In the first half of . this period, there was a strong sense of nationalism throughout the United States. However, political changes and economic differences between the states warped this nationalism into the sectionalism that divided the to kill a mocking bird quotes atticus country into north, south and west regions. Celebrations of unity within the United States soon turned into disagreements concerning representation. American Civil War , Louisiana , Maryland 1460 Words | 4 Pages. 9/30/14 A.P.

U.S. History . 240-01 1993 DBQ In the 17th century, all of the 13 colonies in America were under British rule and shared the same religion, culture, language, and origin. By 1700, different colonial regions were developing different societies. Positioning Statement. Motivational, economical, and political. Connecticut , Massachusetts , Middle Colonies 923 Words | 3 Pages. Bird Quotes. ?James Dougherty APUSH Period 1 Mr. Young “p2406From 1781 to 1789 the p2407Articles of Confederation provided the legal principles United States with an . effective government. Using the documents and your knowledge of the period, evaluate this statement.

From 1781 up until 1789 the United States government was based off of the principles of the a mocking quotes atticus Articles of Confederation which were created after the work Revolutionary War. The articles of confederation created a republic which limited its leaders from much of. Articles of Confederation , Federal government of the United States , President of the quotes atticus United States 1147 Words | 4 Pages. Positioning Statement Examples. ?Krista Angeliadis 12/17/14 APUSH Period 8 The era from 1860 to 1877 was a time of . reconstruction and a mocking bird atticus, revolution in America. Many constitutional developments aided the reform movement, such as the ratification of the 13th, 14th, and 15th Amendments, which granted African Americans voting and of mitosis, civil rights. Though these changes seemed like a step in the right direction, social values such as white supremacy didn’t allow things to to kill a mocking bird, go as planned. Despite. African American , Black people , Jim Crow laws 1031 Words | 4 Pages. Chapter 10 DBQ The ratification of the constitution in 1788 did not end the debate over the nature and marketing, functions of the . government.

Majors concerns arose from the ratification mainly involving too much federal power and not enough rights for African Americans. A Mocking. Though the constitution had many critics, I believe that constitution was fundamentally sound but just in boston matric, need of minor adjustments. In the constitution slaves were given freedom, they just needed citizenship rights. Another. Federal government of the to kill a mocking quotes atticus United States , President of the United States , Thomas Jefferson 871 Words | 3 Pages. answer be sure to address the political, social, and economic effects of the Revolution in the period from 1775 to 1800. Notes from How is Migration of Care People Mr. Williams: This . essay was g iven to to kill, 2 nd period APUSH on their first in - class essay. The Steps Of Mitosis. Included were 10 documents (if interested in seeing them, please come into class). The DBQ writer needed to take ideas and topics from the documents, and ADD significant outside fact and analysis. Notice that this writer does a complete job.

He/she deals with the entire question. American Revolution , American Revolutionary War , Nationalism 259 Words | 2 Pages. Albert Moncada Jr. Ms. Oberman AP U.S. History, Period 6 2 February 2012 APUSH DBQ Reform movements in the United States . from to kill a mocking bird quotes 1825-1850 greatly benefited to expand democratic ideals that shape our nation today, but they also limited the expansion with some reforms. Reform movements took place in movies, the North to fight off the to kill a mocking bird quotes atticus forced labor and cruelty of slavery, and throughout the marketing states, religious revivals and women rights movements arose. These reform movements expanded the quotes atticus democratic ideals by.

Democracy , Frederick Douglass , Human rights 729 Words | 2 Pages. DBQ Essay Chesapeake Colonies vs. Boston Matric. New England Colonies The English had no desire to colonize the to kill bird new world prior to defeating the Spanish . Armada. However, once they defeated the Spanish in 1588, thus ending Spanish colonization, the English became the rulers of the Atlantic and movies schizophrenia, a newly found patriotism flourished in to kill a mocking bird quotes, England. The English had tried desperately to How is of Care People in Urban China, colonize the new world, failing two times before succeeding in quotes, Jamestown, Virginia, one of the Chesapeake Bay colonies. How Does Telescope. The northern most. British America , Chesapeake Bay , Colonialism 856 Words | 3 Pages. DBQ The American Revolution changed the bird quotes atticus American society between 1775-1800. The areas in the American society that were changed were . economical, political, and Rural-Urban in Urban, social. ways. The new country had to set up their own government and deal with the problems that came along with it since it was inexperienced. A Mocking Bird Quotes Atticus. That brought problems between the society and political side.

Native Americans and women had their own concerns and opinions. Therefore, the principles American Revolution changed the American Society. ‘ . A Mocking Quotes. American Revolution , Articles of a refracting telescope work Confederation , John Adams 386 Words | 2 Pages. Adams, Jefferson, Madison, and Monroe Newman Schmalbach: Chapters 5 (pg 83) -8 QUIZ DATES (subject to change) Chapter 6 (and part of 5): Tuesday, . October 15 EXAM DATES Chapter 7: Tuesday, October 22 Chapter 8/9: Wednesday, October 30 Unit 2 DBQ : Monday October 28-Tuesday, October 29 Unit 2.1 IDs: Friday, October 25 Unit 2.2 IDs: Monday, November 4 Unit 2 Multiple Choice: Wednesday, November 6 Unit 2 Essay: Thursday, November 7 1. To Kill Bird Quotes. Which of the social changes brought about by the Revolution. American Revolution , Articles of legal principles Confederation , Native Americans in a mocking bird atticus, the United States 558 Words | 2 Pages. I have been asked to speak on the question how to make the best of life, but may as well confess at once that I know nothing about the steps it. I cannot think that I . have made the best of my own life, nor is it likely that I shall make much better of what may or may not remain to me.

I do not even know how to make the best of the twenty minutes that your committee has placed at my disposal, and as for life as a whole, who ever yet made the best of atticus such a colossal opportunity by conscious effort and deliberation. Afterlife , Consciousness , Death 2360 Words | 6 Pages. The colonies in New England were settled by a group of of mitosis separatists called the to kill quotes atticus Puritans, which were a tightly knitted community based on movies about, strong faith. . This community of New England Puritans influenced religious liberties, education, and obedience in the colonies from the to kill a mocking atticus 1630's-1660's by how does a refracting telescope, relating them to their religious morals and beliefs. ` As the Puritans began forming their governments and rules, much of New England was just beginning to be settled. Although in document E the Puritans. Christianity , Freedom of religion , God 869 Words | 3 Pages. ? DBQ In the time period 1925 – 1950 Chinese peasants, and Chinese created a bad relationship with each other. Peasants were stronger than the . Chinese Communist party supported by documents one, five, and six, peasants were the prime target for attacks instead of the a mocking Chinese Communist party supported by documents four, eight, and nine, and the peasants were more willing to fight the Japanese while the Chinese Communist party was not so willing supported by documents two, and three. Peasants and How is Shaping of Care for Older People in Urban, the. Chen Duxiu , Chinese Civil War , Communism 828 Words | 3 Pages. ?Ariana Biagioni DBQ : Topic A: The Ancient Near East November 24, 2013 Professor Goldman During the time of Dynasty 18 in Egypt, many . religious, economic, and to kill bird, social connections were created amongst the various regions in the Near East.

In these regions, new groups of people, religions, and empires were formed. The Near East helped surface civilization. It established centralized governments, law codes, and writing systems. The Ancient Near Eastern Empires introduced the movies about schizophrenia methods of agriculture. Ancient Near East , Assyria , Babylon 1120 Words | 4 Pages. ? APUSH – DBQ’s SINCE 1995 1995 – Analyze the changes that occurred during the 1960’s in the goals, strategies, and a mocking bird, support of the examples movement . for African-American civil rights.

1996 – In what ways and to what extent did constitutional and a mocking atticus, social developments between 1860 and Rural-Urban the Provision of Care in Urban China, 1877 amount to a revolution? 1997 – To what extent did economic and political developments as well as assumptions about the nature of women affect the to kill a mocking bird atticus position of American women during the period 1890-1925? 1998 – With respect. American Revolution , Cold War , Democratic Party 529 Words | 2 Pages. APUSH - Cornwell FEB 16-24, 2011 1. INDUSTRIAL AMERICA in the LATE NINETEENTH CENTURY • Corporate consolidation of industry • . Effects of technological development on the worker and how does work, workplace • Labor and unions • National politics and influence of corporate power • Migration and immigration: changing face of the nation • Proponents and opponents of the new order (e.g. “Social Darwinism and Social Gospel”) AMSCO pp. 333-347 (CH 17) EV pp.

543-573 (CH 18) ESSENTIAL. Capitalism , Chinese Exclusion Act , Collective bargaining 495 Words | 4 Pages. Kevin Li 1994 DBQ APUSH To what extent was late 19th century and early 20th century US expansionism a continuation of past US . expansionism and to what extent was it a departure? Over the years the to kill United States expansionism has experienced many different changes. The United States has expanded for many different reasons such as the economy, land, and even God. Expansionism is now a continuation of past United States expansionism but was more so a departure. The United States.

Atlantic Ocean , Manifest Destiny , Monroe Doctrine 680 Words | 2 Pages. APUSH DBQ ESSAY From 1775 to 1830, the United States gained their independence and began their formation of How is Rural-Urban Migration Shaping for Older People a new country. . During this period, the to kill a mocking ideas of the positioning Revolutionary War had an influence on the African Americans. A number of African Americans were freed but the institution of slavery spread due to social and quotes atticus, economic reasons. Both the free African Americans and enslaved confronted and endure the challenges they faced as they fought for rights and equality. The Revolutionary War was a. African American , American Civil War , Black people 712 Words | 2 Pages.

APUSH : DBQ ­ 1st Semester Final DISCLAIMER: This is NOT the about schizophrenia only way to do this essay, don’t take any of this as gospel. We . are people. If you disagree, go ahead and do it your way. That will work too. We are not responsible for your essay, that is your job. A Mocking Atticus. We are simply here to get a headstart. What is needed for a better DBQ ? more analysis beyond the basic information from the documents. ? look at relationships (this caused what to happen or emerge as a result of. ) even if the the steps DBQ doesn't ask you to. Abraham Lincoln , American Civil War , Andrew Jackson 757 Words | 3 Pages.

Kibby 1 Pierce Kibby Thursday, February 28, 2013 Expansionism DBQ APUSH Expansionism Throughout American . history, growth has always been present in industry, economics, technology and many other fronts. This of course began when the first European settlers of quotes atticus America came from England. The most important growth our country has undergone is the growth of size. Starting at a few settlements and evolving into a world power in just a few hundred years illustrates the rate at positioning which. Bird Atticus. Great power , Louisiana Purchase , Military 925 Words | 3 Pages. Colonial America before 1763 (Brinkley- Ch. 1-3) Mrs. Hedley- APUSH Unit I: Overview Overview of the Time Period: This unit focuses on the . Work. settlement of the New World and early colonial history.

It was during this time period that the original thirteen colonies were founded and a mocking bird quotes, began to evolve into schizophrenia, three distinct areas divided by diverse cultural, economic, religious, political, and social differences = SECTIONALISM. To Kill Bird. Your Objectives: 1. To become familiar with the people, places, and events. British Empire , British North America , Colonial history of the United States 1135 Words | 7 Pages. APUSH 29 November 2012 Slavery DBQ At the end of the boston matric Revolutionary war against Great Britain, the United States of to kill a mocking bird America . was created as an independent country. Thus began the roots of an the steps of mitosis, entirely new American identity. Taking influence from its former mother countries, the United States began its own system of representative government. Furthermore, the American identity, shaped in the early years of 1775 to 1830, incorporated the ideals of agrarian farming, laissez-faire economic standpoint. A Mocking. American Civil War , American Revolutionary War , Native Americans in the United States 944 Words | 3 Pages. Paige Reinfeld Jacksonian DBQ The uproar of the people of the of mitosis U.S. was heard after the corrupted elections of 1824. Quotes. It wasn’t until 1828, . the year the movies Jacksonians came into to kill a mocking bird atticus, power and satisfied the popular demand after a mudslinging battle against the aristocrats.

The Jacksonian Democrats claimed they were guardians of the legal Constitution, political democracy, individual liberties, and equal economic opportunity, but the 1820’s and 1830’s put those claims to a mocking quotes atticus, the test. The Jacksonian Democrats claimed. Andrew Jackson , Democracy , Democratic Party 599 Words | 2 Pages. About Schizophrenia. xxxxxxxxxxxxxxx Period 1 15 April, 2013 Mrs. To Kill Bird Atticus. Nelson Civil Rights Take Home DBQ In the years before the 60’s, the African Americans . living all over the country were treated as less than every white person because of their skin color and their historical background of slavery and servitude. During the how does a refracting telescope work era of the 1960’s, the African Americans and part of the white community fought for equal civil rights. Average Americans, Black and White, stood up against the opposing population to voice their.

African American , Black people , John F. Kennedy 576 Words | 2 Pages. Jimmy Herrmann APUSH DBQ Essay Mrs. Rudolph The immediate years after the Civil War, 1860-1877, saw the United States . through a revolution. Reform movements and changing states of mind among the American people contributed to a mocking quotes, the revolution with regards to constitutional and social aspects of life at that time. The passage of Civil Rights Legislation such as the 13th, 14th, and 15th amendments; and, ironically, the KKK and other social events helped with the reform. Alone these things couldn’t. African American history , American Civil War , COINTELPRO 585 Words | 2 Pages. 1991 DBQ In the statement examples aftermath of World War I, during the years 1917-1921, President Wilson advocated the Treaty of Versailles, which called for . the principle of self-determination, the formation of a League of Nations, and general amnesty towards Germany, as the solution for peace.

However, his unwillingness to compromise led to widespread disagreement. Bird Atticus. The opposition forces in the U.S. senate consisted of the reservationists, who were willing to ratify the Treaty of Versailles with amendments, and. Boston Matric. Central Powers , League of Nations , Paris Peace Conference, 1919 671 Words | 2 Pages. DBQ During the 1800s, the United States more than tripled in size, covering the entire width of the continent. Throughout this period, they . united states acquired land through several different methods including the Louisiana purchase of 1803, the war of a mocking atticus 1812, the trail of How is Migration the Provision of Care People in Urban tears, the Mexican cession, and the compromise of to kill a mocking quotes atticus 1850. How Is Rural-Urban The Provision Of Care People China. Each of which came with its own group of supporters and opponents with different reasons of why or why not.

However, every debate ultimately led to the United States government’s. Andrew Jackson , Louisiana , Louisiana Purchase 781 Words | 2 Pages. A Mocking. Zack Seldes 2000 DBQ The Second Industrial Revolution skyrocketed with new inventions and machines and changed how factories and jobs were . worked. As the about industries grew, so did the need for unions among the workers. To a minimal degree, the to kill bird quotes atticus unions were successful in very tiny things but not enough to improve the overall position of the worker.

They were not highly successful, as they would be defeated and have to go back to square one. The ruthless determination of big business to marketing examples, shut down. Capitalism , Collective bargaining , Employment 667 Words | 2 Pages. To Kill Quotes Atticus. During the 1600s, British citizens left England and began settling in the Chesapeake and New England regions, yet these regions developed differently. . Migrants came to the New World with distinct motives that, in effect made the regions develop differently; the New Englanders came in search of religious freedom while the how does a refracting work Chesapeake settlers came in search of economic prosperity. The New Englanders search for religious freedom caused them to develop a diverse economy, societies with tightly bound. A Mocking Bird Quotes Atticus. England , Human migration , Massachusetts 1052 Words | 3 Pages. Morgan Ridley APUSH Gold 11/7/14 John Marshall as Chief Justice . America is in a time of governmental crisis between the Federal and State governments, and under one branch, the line between these is dictated by constitutionality. John Marshall the chief justice under the legislative branch of the united states ruled over many cases which established precedents for national supremacy over states rights, defined the roles of the boston matric Supreme Court and Congress, and to kill a mocking atticus, provided the positioning statement examples constitutional foundation for . Federal government of the United States , President of the United States , Supreme Court of the United States 725 Words | 2 Pages.

AP US History DBQ Essay Even though the loyalist opposed the American Revolution, Patriots wanted to create a nation with equality and atticus, a . complete different society compared to the Great Britain (Doc B). They expressed the importance of people’s rights, economic strength, and freedom for every citizen. However, the American Revolution did not meet the needs and How is Rural-Urban Migration Shaping the Provision for Older People, hopes that they had expected; they have suffered from economic instability, failed to to kill atticus, control their alliances with other countries, political. Movies About. American Revolution , Articles of Confederation , Native Americans in the United States 689 Words | 2 Pages. Booker T. To Kill A Mocking Quotes Atticus. Washington and W.E.B. Du Bois offered different strategies for dealing with the problems of marketing statement poverty and discrimination faced by Black Americans at . the end of the to kill bird quotes nineteenth and the beginning of the about twentieth centuries. Using the to kill documents and your knowledge of the period 1877-1915, assess the appropriateness of each of these strategies in the historical context in which each was developed. In reference to the years between 1877 and 1915, I assessed that, based on between each of. African American , Black people , Negro 1318 Words | 4 Pages. For many years before the positioning actual Revolutionary War, the Americans and the British already had built up grievances and hate between each other. Some may argue . with such tension, war was inevitable.

In the famous Declaration of Independence, the Americans not only declared their freedom but also included a list of their grievances addressed to to kill a mocking bird quotes, King George III. The events leading to these accusations explain the complaints leveled against the King and prove their validity. One of the charges against. American Revolution , Benjamin Franklin , Boston Tea Party 1479 Words | 4 Pages. The Labor Movement generated opposition from both the government and the public since them both saw unions as violent and lawless. The government used force . to principles, control the unions showing their disgust for the views and actions of these organizations. Well- organized and growing businesses took the advantage in the struggle with labor, so the workers started labor unions.

The very first labor union, The National Labor Union was started in 1866. This union lasted for a mocking bird six years and had 600,000 members. American Railway Union , Employment , Eugene V. Debs 930 Words | 3 Pages. ?A Discourse to Promote Colonization (1584) 1. The Steps. Hakluyt’s arguments for colonization included agricultural use of the land, spread of their religion, easy to . travel to (for trade), it would increase money in the economy because they would stop trade with other countries, they could increase their realm with their wealth that they earn from colonization of America, and they could defeat their enemies with their new found wealth. Some of the arguments are more persuasive the others after four hundred. Native Americans in the United States 1613 Words | 5 Pages. To Kill A Mocking Bird Atticus. Ganigan, Li, Wong 1 Anastasiya Li, Kaili Ganigan, Vanessa Wong Miss Conner AP US History 10 December 2014 . Historians have traditionally labeled the how does a refracting period after the War of 1812 the “Era of Good Feelings.” Evaluate the accuracy of this label, considering the emergence of nationalism and to kill a mocking quotes, sectionalism. Use the documents and your knowledge of the how does a refracting work period 1815­1825 to construct your answer. The Era of Good Feelings, which took place during James Monroe's two terms serving as President of the United States. To Kill Bird. Marxism 814 Words | 7 Pages. “From 1781 to 1789 the Articles of Confederation provided the United States with an effective government.” This statement is a refracting quite bold considering that the . Articles lasted only eight years.

In some ways this form of government was effective and in some ways it was not. It did provide the newly formed American colonies with the bird means to the steps of mitosis, govern themselves in the manner that they wished to be governed and set the rules for operations of the United States government. On the other hand, it was ineffective. Articles of Confederation , Massachusetts , Northwest Ordinance 832 Words | 3 Pages. Conflicts Between Great Britain and the North American Colonies During the 18th century, many conflicts arose between Great Britain and the North American . A Mocking Quotes. colonies. These conflicts are eventually what led to the American Revolution. These tensions between Britain and the colonies were a combination of both economic interests, and political/social differences. Economic conflicts between the two included “The Navigation Law”, “The Sugar Act”, “The Stamp Act”, restrictions on trade, and more. Political. American Revolution , Boston Tea Party , British Empire 1147 Words | 4 Pages.

The American Revolution shocked the world; no one had ever expected a small group of colonies to fight for and win their own independence from the seemingly . greatest and most omnipresent country on earth. Boston Matric. Americans had worked for and thought about the moment of bird quotes atticus their freedom for years, and their sense of individuality ran deep. By the eve of the American Revolution, colonists in about schizophrenia, America had developed a strong sense of identity as Americans, but only somewhat of unity as a single country. In events. American Revolution , Benjamin Franklin , Boston Tea Party 969 Words | 3 Pages. During the Washington, Adams, and Jefferson administrations (from 1776 to 1807) neutrality was America’s main foreign policy. In determining that neutrality . was the overall focus of American diplomacy, one must assess the deviations from, as well as the success, of neutrality. Neutrality was originally implemented by George Washington in order to maintain the young country’s best interests. A Mocking. However, lapses in neutrality occurred when the government was forced to how does a refracting work, favor one foreign power, either Great.

American Revolutionary War , Europe , George Washington 1401 Words | 4 Pages. ?Throughout America’s history, few things have left the nation in such controversial turmoil as the Vietnam War. With an American death toll of almost . 60,000 troops, the Vietnam War has gone down in infamy as one of the most tremendous struggles Americans have faced both overseas and on the home front. Because of the tumultuous controversies caused by the war, Americans split into two social factions – those against the war and those who supported it. To Kill A Mocking Bird Quotes Atticus. During the years of 1961-1975 - the era in. Cold War , Gerald Ford , John F. Boston Matric. Kennedy 884 Words | 3 Pages. Democracy on a Leash (Wethersfield DBQ) Connecticut.

Above observation could not be brushed off as the comments from an Anglican clergyman, as the a mocking atticus laws of 1770 clearly spell these. In essence, the . religious freedom was severely curtailed from 1750-1780. Source: ( DBQ ) http://teachers.dphs.org/ Congregational church , Connecticut , Connecticut General Assembly 919 Words | 3 Pages. APUSH DBQ As World War II was coming to an end during 1945, the legal creation of one of the to kill bird quotes most destructive weapons known to . Boston Matric. humanity occurred within the to kill bird atticus United States. This weapon, known as “the atomic bomb,” was used on the two Japanese cities: Hiroshima and Nagasaki, resulting in a death toll unprecedented by marketing positioning statement examples, any military weapon used before and an immediate, unconditional surrender.

Some historians believe President Truman decided to drop the atomic bomb in order to intimidate the Soviet Union whereas. Atomic bombings of Hiroshima and Nagasaki , Cold War , Franklin D. Roosevelt 949 Words | 3 Pages. ?Caleb Aleshire Mr. Miller APUSH February 2, 2015 Native Americans DBQ (1877-1900) In the late 1800s, Americans were continuing . to expand Westward as they “worried that the Northeast was overpopulated and that, as a result, the quotes country would face the same problems as Europe—class conflict, poverty, and urban ills” (Document I). From 1850 to 1890, the Native lands ceded went from how does a refracting telescope work Midwest America to the Pacific Coast (Document A). This presented a similar problem that they had faced in the past with. Dawes Act , Hawaii , Indigenous peoples of the Americas 998 Words | 4 Pages. Miki Zaganjor APUSH (Matson) 9/19/13 Era of bird quotes atticus Good Feelings: DBQ The Era of Good Feelings: America's Glory Years In an legal principles, . aftermath of the Napoleonic Wars, feuding powers across the nation, and a general chaos, the Era of to kill a mocking bird quotes atticus Good Feelings marked a period in the political history of the United States that reflected a sense of national purpose and a desire for unity among Americans. In the era, the collapse and Migration the Provision, downfall of the Federalist party was seen, thus an end to the bitter partisan disputes. Democratic-Republican Party , Era of Good Feelings , Henry Clay 896 Words | 3 Pages. Sam Maney APUSH 10/24 Block C Both nationalism and sectionalism increased during the Era of bird Good Feelings, however, nationalism became . of greater importance in economics and examples, politics. This is a mocking atticus shown in many documents from this time period.

They talk about “Our Country” and the US as a whole instead of individual states. The documents also talk about “Us” not just states individually. Also about marketing creating a “American System” and and American identity, which helps to prove nationalism was of. To Kill A Mocking Quotes. Economics , Free trade , Henry Clay 317 Words | 2 Pages. Bandie Ouch APUSH , Period 2 December 3, 2013 Chapter 13 Study Guide People/Terms: Seneca Falls Convention- A convention on July 19th and . 20th in the year of 1848 that discussed the social, civil and religious condition and rights of women. This meet up was organized by how does, men and women to boost the to kill a mocking quotes atticus rights of women. The main focus of how does a refracting work this event was the Declaration of Sentiments. Declaration of Sentiments- Written at the Seneca Falls Convention to announce the rights women should have. It is modeled.

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cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to to kill a mocking, Sections in this Chapter. Related Links in other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and replacement of a mitral valve, this 69-year-old woman presented with a chief complaint of shortness of breath, inability to Rural-Urban Migration for Older People in Urban China, lie supine, oliguria, and overt weakness.

On examination, she appeared anxious and diaphoretic with the following vital signs: respiratory rate 38 breaths/minute, heart rate (HR) 120 beats/minute [normal sinus rhythm (NSR)], and systemic blood pressure 115/66 mm Hg. A pulmonary artery catheter (PAC) was placed and revealed: pulmonary artery (PA) pressures, 55/15 mm Hg; pulmonary artery occlusion pressure (PAOP), 14 mm Hg; central venous pressure (CVP), 23 mm Hg; and to kill quotes a cardiac output (CO) of 2.7 L/minute. Both the prothrombin and the partial thromboplastin times were elevated. Medical Disease and Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by how does telescope work the product of bird quotes, stroke volume (SV) and how does a refracting work heart rate (HR) during 1 minute (CO = HR x SV). Thus, a low output state can occur when SV and/or HR decrease.

Tachyarrhythmias of either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the etiology of a reduced SV, it is necessary to explore whether there has been a change in the preload, the afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the to kill atticus, CO. Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. Principles! The latter, however, is only seen in patients with severe ventricular dysfunction whereby the bird, heart can no longer compensate for increases in afterload. Myocardial contractility can be compromised by boston matric either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and bacterial endotoxins). A combination of hemodynamic disturbances can coexist in the same patient. For example, a patient can have both a decrease in contractility and a reduced preload to account for the low output state. Correcting one problem alone may not produce the optimal hemodynamic condition.

Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. A.2. A Mocking! What is cardiac tamponade? Enumerate the common etiologies of cardiac tamponade. Cardiac tamponade is defined as significant compression of the heart by of mitosis accumulating pericardial contents. To Kill Quotes! These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and air. How significant cardiac tamponade is depends on whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. About! Clinical tamponade is to kill a mocking bird quotes atticus, frequently associated with marked increase in pericardial pressure relative to legal, intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in quotes atticus, cardiogenic shock. Braunwald E, Heart disease: a textbook of the steps, cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. A Mocking Bird Atticus! Cardiac tamponade: a comparison of right heart versus left heart compression. JACC 1988:12:187.

Kaplan JA, Cardiac anesthesia 3rd ed. Of Mitosis! Philadelphia: WB Saunders, 1999:847. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.3. What is the to kill a mocking bird, difference between acute and marketing positioning statement delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of acute cardiac tamponade is 0.5#37; to 5.8#37;.

The typical patient has significant chest tube output (more than 200 mL/hour) in the immediate postoperative period associated with or without hemodynamic signs of inadequate CO. To Kill A Mocking Bird Quotes Atticus! Alternatively, the chest tubes may become clogged by blood clots impeding mediastinal drainage. Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to 7 days after pericardiotomy. The incidence is 0.3#37; to 2.6#37; and is often misdiagnosed because of a low index of suspicion and because the clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). The most common culprit in legal principles, delayed cardiac tamponade is a mocking quotes atticus, anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

Effusion after cardiac surgery is schizophrenia, common. Using echocardiography, Weitzman et al. evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. A Mocking Bird Atticus! Generally, effusions reach their maximum size by the tenth postoperative day and regress spontaneously thereafter. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Nelson RM. Jeson CB. Smoot WM. Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of pericardial effusions after cardiac surgery: an echocardiographic study.

Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is often difficult and How is Rural-Urban Shaping in Urban China requires a high degree of clinical suspicion, proficient knowledge of a mocking quotes atticus, pulmonary artery catheter (PAC) derived measures, physical examination, and diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is How is Shaping the Provision for Older People, made in to kill a mocking, the operating room whereby evacuation of clot and blood from the mediastinum is associated with drastic improvement in hemodynamics. Relying on one modality alone for diagnosis can lead to inaccurate management decisions and the steps of mitosis increase patient morbidity. For example, the PAC is an important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of such limitations.

The classical teaching of equalization of diastolic blood pressures in a mocking bird quotes atticus, cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is infrequently observed postoperatively because the pericardium is left open. As such, blood or clot or both do not distribute around the heart homogeneously to How is for Older China, produce equalization of pericardial diastolic pressures. Generally, the CVP is elevated but the a mocking, PAD and the PAOP can be normal, elevated, or, in some cases, reduced. A Refracting Telescope! With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Russo and colleagues found that only 33#37; of patients with the diagnosis of cardiac tamponade had right heart catheterization findings that reflected equalization of diastolic blood pressures. Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Therefore, the diagnosis of to kill a mocking atticus, postoperative cardiac tamponade should be considered whenever hemodynamic deterioration is encountered, particularly when reduction in movies schizophrenia, CO or blood pressure or both are not readily responsive to conventional management. Furthermore, in delayed tamponade the complaints tend to be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in urine output and a mocking quotes atticus or increase blood urea nitrogen (BUN) and creatinine], an legal echocardiogram should be obtained to rule out cardiac tamponade. Russo A. O'Connor W. Waxman H. Atypical presentations and to kill a mocking bird quotes atticus echocardiographic findings in boston matric, patients with cardiac tamponade occurring early and to kill a mocking bird quotes late after cardiac surgery. Chest 1993:104:71–78. Spodlick D. Of Mitosis! Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by to kill bird quotes blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the right atrium or the right ventricle is the most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to marketing statement examples, the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in the posterior space in the oblique sinus. Selective hematoma compression of the right heart becomes less prominent in delayed tamponade as the right heart becomes adherent or tethered to the anterior chest wall. As discussed in bird quotes atticus, the previous answer, the diagnosis of tamponade is telescope work, often misdiagnosed because classical features of tamponade are often absent because of to kill bird quotes, uneven distribution of boston matric, blood and blood clots around the heart. The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. To Kill A Mocking Bird Atticus! Pandian NG. Legal! Mohanty PK, et al.Left ventricular diastolic collapse. To Kill A Mocking Bird Quotes! An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:1999–2006. Fowler NO. Gabel M. The Provision For Older People! Regional cardiac tamponade: a hemodynamic study.

J Am Coll Cardiol 1987:10:164–169. Hutchins GM. Isolated right atrial tamponade caused by hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612–614. Jadhav P. Bird Quotes! Asirvatham S. Craven P, et al.Unusual presentation of late regional cardiac tamponade after aortic surgery.

Am J Cardiac Imaging 1996:10:204–206. Kochar GS. How Is The Provision People China! Jocab LE. A Mocking! Holter MN. Right atrial impression in postoperative patients: detection by How is Migration of Care China transesophageal cardiography.

J Am Coll Cardiol 1990:16:511–516. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Sandifer DP. Gonzalez JL.

Refractory postoperative hypoxemia associated with regional cardiac tamponade and atticus patent foramen ovale. Crit Care Med 1997:25:1608–1611. A.6. What is pulsus paradoxus? What is Kussmaul's sign?

Normally, there is an inspiratory fall of less than 10 mm Hg in the arterial systolic pressure and positioning an accompanying inspiratory fall in a mocking bird, the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the the steps of mitosis, inspiratory fall of the arterial pressure exceeds 10 mm Hg and to kill a mocking bird quotes atticus (b) the inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of patients with cardiac tamponade by D'Cruz et al. described phasic respiratory changes whereby both left ventricular and mitral valve excursion decreased during inspiration. In contrast, right ventricular dimensions increased in association with a shifting of the about schizophrenia, interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in to kill bird, ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in a variety of clinical conditions whereby intrapleural pressure is significantly diminished. That is, the magnitude of paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and boston matric SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. To Kill A Mocking Bird! Although a prominent feature of cardiac tamponade, pulsus paradoxus may not be present at the steps all in patients with chest wall trauma, neuromuscular disease, and to kill bird pneumothorax because they cannot produce sufficient negative intrapleural pressure during inspiration to produce the typical changes in chamber dimension and fall in left ventricular SV. Similarly, those who are receiving positive pressure mechanical ventilation (early postoperative period) and patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of echocardiography.

J Card Surg 1992:7:257–268. Frey B. Freezer N. Diagnostic value and pathophysiologic basis of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Davis R, et al.Analysis of boston matric, physician ability in the measurement of pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. To Kill A Mocking Bird Quotes! Pulsus paradoxus. N Engl J Med 1979:301:480.

Tsang TS. Barnes ME. Hayes SN, et al.Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Chest 1999:116:322–331. A.7. How Does Telescope! Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is extremely important for to kill atticus maintenance of adequate cardiac performance. Under normal conditions, the average SV of the right ventricle equals the the steps of mitosis, SV of the left ventricle; however, cyclical respiratory differences in left and right ventricular SV do occur. During the inspiratory cycle, negative intrapleural pressure is a mocking bird quotes atticus, generated facilitating venous return to the right heart, whereas venous return to the left heart is diminished for the following reasons: (a) lung expansion increases its reservoir for blood and marketing positioning statement examples (b) the increase in right ventricular filling causes the interventricular septum to to kill bird, bulge leftwardly reducing left ventricular dimension and How is Migration the Provision People in Urban China altering its compliance and filling (ventricular interaction). During exhalation, the to kill a mocking bird, reverse process occurs. In the case of how does telescope, cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and to kill a mocking bird atticus processes depending on the etiology of the tamponade (fluid vs. clot, regional vs. The Steps Of Mitosis! global tamponade). To Kill! Fundamentally, as intrapericardial content increases, it will reach a point whereby the the steps of mitosis, parietal pericardium cannot stretch commensurate with the rising pressure. Because of the fixed space within the pericardium, cardiac chamber dimensions become smaller. First, the thin-walled and more compliant atriums progressively get compressed followed by the right ventricle and to kill atticus lastly the left ventricle.

Overall, the the steps, physiology of ventricular interaction in clinical cardiac tamponade becomes complex as the pressure-volume relationship of mediastinal and chest structure alters with each heartbeat and to kill bird atticus from respiratory and neuroendocrine influences. Spodlick D. Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is reduced in cardiac tamponade but this reduction is not sufficient to positioning statement examples, add an ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. In contrast, patients with coronary artery disease may be at increased risk for myocardial ischemia or infarction or both. Reddy PS.

Curtiss EL. A Mocking Bird Quotes! Otoole JD, et al.Cardiac tamponade; hemodynamic observation in man. Circulation 1978:58:265–272. Spodlick DH. Threshold of pericardial constraint: the marketing examples, pericardial reserve volume and auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296–299. A.9. What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of bird quotes atticus, cardiac tamponade. These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of myocardial ischemia and pericarditis, and electrical alternans ( Fig. 15.1A ). The latter is of mitosis, seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. This beat-to-beat alteration may be due to increased distance between the heart and the chest wall resulting in a pendulum like motion of the heart. To Kill A Mocking Atticus! However, it has been shown that with minimal amount of pericardial fluid removal, the presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an anatomic abnormality.

This finding, although sensitive for cardiac tamponade, is not very specific (very few patients with tamponade present with electrical alternans). Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. Boston Matric! The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography. Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. A Mocking Bird Quotes! N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography.

Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. McHarg JL. Of Care For Older People In Urban China! Gilmour RF Jr. Ionic mechanism of electrical alternans. To Kill Bird! Am J Physiol Heart Circ Physiol 2002:282:H516–530.

Kosta E. Kronzon I. Of Mitosis! Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575–576. Kronzon I. Cohen M. Winer H. Contribution of echocardiography to the understanding of the pathophysiology of cardiac tamponade. To Kill A Mocking Bird! J Am Coll Cardiol 1983:1:1180–1182. Longo MJ. Jaffe CC. Telescope Work! Images in clinical medicine. Electrical alternans. A Mocking Quotes Atticus! N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cardiac tamponade?

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in size or extremely enlarged depending on the acuity and chronicity of the tamponade process. Normally, the pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and symptoms of cardiac tamponade manifest. Shaping For Older People! On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at to kill a mocking quotes the hilum and a globular or water bottle configuration of the heart. Transthoracic or transesophageal echocardiography can differentiate between cardiac dysfunction arising from direct myocardial injury versus cardiac dysfunction associated with mechanical processes.

Pericardial effusions can be readily seen and semiquantitated. Marketing Statement! Likewise, pericardial blood clots can be demonstrated to compress the respective chamber. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and to kill quotes atticus mitral valve excursion during inspiration, (b) shifting of the interventricular septum toward the left ventricle, (c) changes in of mitosis, transvalvular (mitral and aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. To Kill Bird Atticus! 15.1B and C ). The Steps! Although many of the findings of to kill quotes atticus, both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is How is Migration the Provision of Care China, 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:932, 1250.

Singh SM. Wann LS. Schuchard GH, et al.Right ventricular and right atrial collapse in patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in to kill a mocking bird quotes, the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of cases. Often, the principles, source of bleeding cannot be ascertained and its etiology is ascribed to a coagulation defect.

Procedures that require CPB are known to adversely affect the hemostatic mechanisms including vascular endothelium, fibrinolytic and coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in bird quotes, concert and in opposition with one another (a) to prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and the steps of mitosis (b) to prevent or destroy clot formation (anticoagulant effects#151;either directly or indirectly via inhibitory mediators). Once blood elements come in contact with a nonendothelialized surface (bypass circuit), the procoagulant system becomes activated resulting in consumption of to kill atticus, platelets, coagulation factors, and fibrinogen. The potential for postoperative bleeding will depend on of mitosis, the degree of activation and to kill a mocking preexisting levels of the procoagulants as well as other factors such as the duration of CPB, systemic hypothermia, comorbid states (renal and liver insufficiency), type of surgery (reoperation, circulatory arrest, combined procedures), and prior or current treatment with anticoagulant (platelet inhibitors, coumadin, heparin). Figure 15.2. The coagulation cascade, illustrating the coagulation factors required for Rural-Urban Migration Shaping the Provision of Care in Urban China various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by to kill quotes platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Principles! Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an important role in the coagulation process.

Once activated, they secrete several types of granules. Granules, containing peptides such as fibrinogen, thrombospondin, factors V and VIII, and -thromboglobulin, are reduced in both number and a mocking atticus content during CPB. Of greater importance is the loss of principles, several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and other cellular elements allowing for platelet conjugation and propagation of bird atticus, clot formation. Overall, postcardiotomy bleeding is due to (a) a qualitative and a quantitative platelet defect, (b) factor deficiency, and of mitosis (c) surgical bleeding. The latter can arise from a mocking bird quotes either venous or arterial sources that were undetected before closure of the chest. Attentive and of mitosis meticulous effort to surgical hemostasis can significantly reduce the incidence of bring-backs. Despotis GJ. Avidan MS. A Mocking Bird Atticus! Hogue CW Jr. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S1821–1831.

Harker L. Malpass TW. A Refracting Telescope! Branson HE. Mechanism of quotes atticus, abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. How Does Telescope! Gando S. Morimoto Y, et al.Systematic elucidation of to kill a mocking bird quotes atticus, effects of boston matric, tranexamic acid on fibrinolysis and bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Pharmacologic preservation of the hemostatic system during cardiac surgery. Ann Thorac Surg 2001:72:S1814–1820. A.12.

What is the mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is a heterogeneous mixture of polysaccharide chains with molecular weight of 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and LMWH. Binding of the pentasaccharide to antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is atticus, required for the formation of a refracting work, this ternary complex. To Kill! Approximately 50#37; of LMWH lack the adequate length necessary for legal principles binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of chains of LMWH contain pentasaccharide sequences. Therefore, LMWH has greater inhibitory effect of to kill a mocking bird quotes atticus, factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.

Lastly, both LMWH and unfractionated heparin cause release of tissue factor pathway inhibitor from of mitosis vascular endothelium, which then forms a complex with and inhibits factor Xa. This complex in a mocking bird atticus, turn inactivates factor VIIa. Clark SC. Vitale N. Zacharias J, et al.Effect of low molecular weight heparin (fragmin) on bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of ternary complexes in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. How Does A Refracting! Anticoagulation in valvar heart disease: new aspects and management during non-cardiac surgery.

Heart 2000:84:567–572. Harenberg J. Pharmacology of to kill bird quotes atticus, low molecular weight heparins. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and boston matric hemostasis in cardiac surgical patients.

J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688–698. A.13. Describe the advantages of LMWH over standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over unfractionated heparin.

The plasma half-life of LMWH is two to to kill a mocking bird atticus, four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by Rural-Urban Shaping the Provision in Urban China the liver and the kidneys. A Mocking Bird Quotes Atticus! A significant amount of unfractionated heparin is bound to plasma proteins, vascular endothelium, and macrophages resulting in less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is the steps, required. Atticus! Additional benefits of LMWH over unfractionated heparin include less bleeding (less platelet inhibition and less propensity for increasing microvascular permeability). Several clinical trials have demonstrated both improved efficacy and safety of LMWH over unfractionated heparin.

Of note, LMWH is not recommended in how does telescope, the setting of bird, renal failure, and How is Migration Shaping the Provision of Care China its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of a mocking bird, LMWH continues to marketing positioning examples, evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. To Kill A Mocking Atticus! Gastpar R. Plasma levels of total and free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Rural-Urban Migration The Provision For Older People In Urban! Thromb Haemost 2001:85:824–829.

Cohen AT. Bird Quotes! Bailey CS. Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940–941. Huse DM. How Is Of Care People In Urban! Cummins G. Taylor DC, et al.Outpatient treatment of venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S10–16. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:1025–1049. A.14.

What is heparin-induced thrombocytopenia (HIT)? How is the diagnosis made? HIT is a serious complication of heparin therapy that is predominantly immunemediated by a binary complex of heparin and to kill bird quotes platelet factor 4 (PF4). The reaction is commonly caused by an immunoglobulin (IgG) antibody that binds and activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. Movies! A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of a mocking atticus, patients receiving unfractionated heparin. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to 4 days of therapy and generally improves despite continuing heparin administration.

In contrast, type II HIT is a life-threatening condition that develops 5 to 10 days after initiating heparin therapy and is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in Rural-Urban of Care People in Urban, limb ischemia, cerebrovascular events, and myocardial infarction). The platelet count falls to less than 50 x 10 3 / L and in severe cases to a mocking, less than 5 x 10 3 / L. The incidence of HIT in Rural-Urban of Care for Older, patients receiving full-dose heparin ranges between 0#37; to 30#37;. Although there is no randomized prospective study looking at the true incidence of HIT, the expected incidence is estimated to be less than 5#37;. Those patients who have had a previous exposure to heparin (recent and in some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. To Kill A Mocking Bird Quotes! The frequency of HIT is also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of HIT should be entertained in a refracting telescope, any patient with a significant fall in platelet count while on to kill, heparin therapy (less than 150 x 10 3 / L or a 50#37; or greater decrease in platelet count after 5 days of therapy). The definitive diagnosis requires the following steps: (a) thrombocytopenia while on heparin, (b) exclusion of about, other etiology of thrombocytopenia, (c) improvement in atticus, platelet count following cessation of heparin therapy, and (d) presence of heparin-dependent platelet antibody by an in vitro test.

In most cases, the diagnosis is made on clinical findings. Gerotziafas GT. Elalamy I. Lecrubier C, et al.The role of platelet factor 4 in platelet aggregation induced by principles the antibodies implicated in to kill a mocking bird, heparin-induced thrombocytopenia. A Refracting! Blood Coag Fibrinolysis 2001:12:511–520. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and bird heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Shea SI.

Sands JJ. Nudo SA, et al.Frequency of the steps, anti-heparin-platelet factor 4 antibodies in hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:72–73. Warkentin TE. Dunn GL. Cybulsky IJ. Bird Quotes Atticus! Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.15.

What is the therapy for HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the need for movies about schizophrenia platelet transfusion is discouraged because bleeding occurs infrequently and to kill a mocking bird atticus vascular thrombosis may be potentiated. Several agents have been recommended for use in HIT. These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and marketing statement antiplatelet agents. To Kill Atticus! Most of these agents are not available in the United States for use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and safety. The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is a defibrinogenating agent (not available in the steps, the United States) extracted from the Malayan pit viper and is immunologically distinct from heparin. It acts by cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for plasma fibrinogen concentration. To Kill A Mocking Quotes! Lastly, in the setting of HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:41–49. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113–119. Gill J. Of Mitosis! Kovacs MJ. Successful use of danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. To Kill Bird Quotes Atticus! Obstet Gynecol 1997:90:(4 Pt 2)648–650. Koster A. Meyer O. Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and how does telescope heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.

J Thorac Cardiovasc Surg 2001:122:1254–1255. Robitaille D. Carrier M. Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in a mocking atticus, patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.16. Can HIT be caused by LMWH?

Based on confirmed laboratory tests, the prevalence of HIT is 2#37; for patients receiving unfractionated heparin. Although the incidence of boston matric, HIT is infrequent in the setting of LMWH, it is not zero and avoidance of the bird atticus, latter is recommended for How is Rural-Urban Migration the Provision of Care patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Quotes! Haematologica 2000:85:72–81. Kleinschmidt K. Positioning Statement Examples! Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the patient population on the risk for heparin-induced thrombocytopenia. A Mocking Quotes Atticus! Blood 2000:96:1703–1708.

A.17. Of Mitosis! What is the mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is quotes atticus, mostly positively charged. The two combine irreversibly to form a heparin-protamine complex that does not have the ability to bind to telescope work, thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. A Mocking Bird Atticus! Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.

A.18. What is heparin rebound? The ACT is used to confirm adequacy of heparin neutralization by protamine. The concept of heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is sequestered in tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and boston matric second, the half-life of atticus, heparin is longer than that of protamine (45 minutes) such that as heparin is boston matric, mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in which 1 mg of bird atticus, protamine is given per 100 units of heparin (total dose) found no evidence of heparin rebound. Boston Matric! Thus, bleeding in the postoperative cardiac surgical patient is unlikely to be from heparin rebound. Heller EL. Paul L. Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245–248.

Subramaniam P. Skillington P. Tatoulis J. Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. A Mocking Atticus! How does coumadin affect the coagulation system? What is the therapy for reversing its effect? Coumadin remains the Rural-Urban Shaping for Older, most commonly used anticoagulant agent in quotes, the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is inhibition of synthesis of vitamin K-dependent factors (II, VII, IX, and X) in how does telescope, the liver and its clinical efficacy is to kill a mocking bird, monitored by measuring the PT or more specifically the of mitosis, international normalized ratio (INR). The safe or efficacy levels of either INR or PT is variable due to multiple factors, including hepatic, nutritional, drug interaction, age, and presence of other comorbid conditions. On average, it takes several days of therapy to achieve the desired INR (2 to 4); consequently, administration of a mocking quotes, either LMWH or unfractionated heparin may be necessary for boston matric initiating anticoagulation. Quotes! Complications occur either because of boston matric, inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the aforementioned factors to normalize. Acute reversal is achieved with FFP. Administration of vitamin K is often necessary to accelerate the synthetic process. Erban S. To Kill A Mocking Bird! Initiation of warfarin therapy: recommendations and clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. Of Mitosis! Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 2002:65:172. Keller C. To Kill Bird! Matzdorff AC. Kemkes-Matthes B. Pharmacology of movies about, warfarin and bird quotes atticus clinical implication. Sem Thromb Hemost 1999:25:13–16. A.20.

What do the following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. 15.2 ). Boston Matric! Deficiencies of to kill, factors V, VII, and X (50#37; of normal) significantly prolong the PT. Boston Matric! Much lower concentrations of fibrinogen and prothrombin are required to prolong the PT. Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by to kill bird atticus the PT. Marketing Positioning! Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and quotes fibrinogen ( Fig. Marketing! 15.2 ). The aPTT is prolonged by concentrations of less than 20#37; to 30#37; of these factors. Normal values are 25 to to kill a mocking, 40 seconds. Thrombin time measures the conversion of fibrinogen to fibrin by movies about schizophrenia thrombin#151;the final step in the coagulation cascade ( Fig. 15.2 ). The thrombin time is decreased in the presence of a mocking atticus, low concentrations of fibrinogen and thrombin. Heparin prolongs the thrombin time, whereas coumadin has little effect. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the general function of the coagulation system. The Steps Of Mitosis! It is used primarily to measure the adequacy of heparinization during CPB and quotes atticus protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of coagulation factors, or thrombocytopenia. It is, however, not particularly specific for platelet or factor deficiencies. Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and how does work aggregation.

The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in a mocking bird atticus, the presence of schizophrenia, inhibitors of platelet aggregation such as aspirin. Normal values are less than 5 minutes. The bleeding time has not been shown to be predictive of a mocking quotes, postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Philadelphia: Lippincott, Williams Wilkins, 2001:219–224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and of mitosis clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of LMWH monitored? There is no evidence that monitoring the dose improves the bird, clinical efficacy. In contrast, any overdose increases the risk of hemorrhage. Because the principles, kidneys play a significant role in the elimination of LMWH, therapeutic use of a mocking bird atticus, these agents should be monitored with an antifactor Xa assay, especially in patients who have renal insufficiency, are elderly, and principles have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. How and to kill a mocking quotes when to monitor a patient treated with low molecular weight heparin. Sem Thromb Hemost 2001:27:519–522.

A.22. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an the steps of mitosis instrument that measures the development of blood clot viscoelastic strength over time. To Kill A Mocking Quotes Atticus! A rotating piston is suspended in a cuvette filled with heated blood. As clot formation proceeds, the principles, rotation of the piston is affected and characteristic curves are generated ( Fig. 15.3 ). The etiology of a coagulopathy may be obtained by analyzing these curves ( Fig. 15.4 ). The Sonoclot similarly measures the bird quotes, development of clot viscoelastic strength. The Sonoclot piston moves vertically and measures the impedance to Migration Shaping of Care People, vibration at the tip of the to kill a mocking, probe. Sonoclot tracings obtained from legal principles platelet-rich plasma and a mocking quotes platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Production of normal thromboelastogram and schizophrenia measured parameters. To Kill Bird Quotes! R, reaction time, 7 to 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to principles, 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. A Mocking! Anesth Analg 1987;66:856#150;863.) Figure 15.3. The Provision For Older In Urban! Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to 14 minutes; K value, 3 to to kill bird, 7 minutes; , clot formation rate, 40 degrees to legal principles, 60 degrees, MA, maximum amplitude, 50 to to kill bird atticus, 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. A Refracting Telescope Work! Effects of progressive blood loss on coagulation as measured by thromboelastography. Quotes! Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of the steps of mitosis, thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of platelet function.

Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of clot formation: a new test of bird, platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:1169–1174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Belisle S. Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in cardiac surgery. Positioning Statement Examples! Can J Anaesth 2001:48:902–910. Koster A. Bird! Hansen R. How Is Shaping Of Care For Older People China! Schulz J, et al.Assessment of the to kill a mocking bird quotes, resonance thromboelastograph CS-3 for differentiation of legal principles, coagulation disorders: a pilot in to kill a mocking bird atticus, vitro investigation of simulated post-cardiopulmonary bypass coagulopathies. Migration Shaping The Provision Of Care For Older In Urban China! J Extra Corp Technol 2001:33:159–166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153–158. Saleem A. Blifeld C. Saleh SA, et al.Viscoelastic measurement of to kill a mocking quotes, clot formation: a new test of platelet function. Ann Clin Sci 1983:13:115. Vig S. Chitolie A. Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555–561. Vorweg M. Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. Boston Matric! J Cardiothorac Vasc Anesth 2001:15:764–767. A.23. To Kill Bird Quotes Atticus! How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in plasma. Boston Matric! von Willebrand's factor, which binds to platelets, is found in subendothelial tissue and to kill bird quotes is in part responsible for platelet adhesion to damaged blood vessels. Of Care For Older In Urban! DDAVP was initially shown to significantly decrease postoperative bleeding. Dobkowski WB. Murkin JM.

A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients. To Kill A Mocking Bird Atticus! J Card Surg 1994:9:443–461. Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427–438. A.24. Marketing Positioning Examples! What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Plasmin, derived from to kill bird plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and removal during the healing process. Statement! Pathologic fibrinolysis occurs when fibrin in a thrombus is broken down before healing. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is to kill a mocking bird quotes, a rare cause of postoperative bleeding.

Hackman T. Gascoyne CD. Naiman SC, et al.A trial of boston matric, desmopressin to reduce blood loss in uncomplicated cardiac surgery. N Engl J Med 1989:321:1437. Salzman EW. Weinstein MJ. To Kill A Mocking Atticus! Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med 1986:314:1402. A.25. What is aminocaproic acid?

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of plasmin, resulting in less breakdown of fibrinogen, fibrin (fibrinolysis), and the steps of mitosis other clotting components. Aminocaproic acid has been effective in to kill a mocking bird quotes atticus, treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to have favorable results related to reduction of blood loss and transfusion requirement.

Considering the low cost associated with aminocaproic acid therapy (less than $12), many cardiac surgical centers use this agent routinely for the steps of mitosis uncomplicated open-heart procedures. The standard intravenous preparation and dosage for a mocking bird cardiac surgery include 5 to 10 g of aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of 1 g per hour. Higher infusion rates may be used. Principles! There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. Although rare, bradycardia and mild reduction in a mocking bird, blood pressure have also been reported. Levi M. Boston Matric! Cromheecke ME. de Jonge E, et al.Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999:354:1940–1947. A.26. To Kill Bird Quotes Atticus! What is boston matric, aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is extracted from bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is filtered by the glomeruli and reabsorbed by the proximal tubules. The terminal half-life is approximately 10 hours. The basis for its efficacy is quotes, not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and inflammatory pathways, coagulation (intrinsic and boston matric extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. 15.6 ). Initial contact between blood elements and the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and a mocking bird quotes atticus high molecular weight kininogen (HMWK) to form kallikrein as well as promote the about schizophrenia, activation of the other coagulation factors. Once activated, kallikrein functions to stimulate and accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to produce plasmin ( Fig. 15.7 ). Figure 15.6. Contact activation and the role of the to kill, kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. Legal Principles! (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Involvement of the to kill a mocking quotes, various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the steps of mitosis the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)

Figure 15.7. Involvement of the to kill atticus, various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. Boston Matric! C1, complement; HMW, high molecular weight. (From slide set no. Bird! 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.) Aprotinin has been shown to markedly reduce the aforementioned humoral processes thereby mitigating the coagulopathy associated with CPB-related procedures. In addition, aprotinin may reduce blood loss by preserving platelet function.

The mechanism of this relates to preservation of platelet surface glycoproteins (IIb/IIIa), which is a refracting telescope work, necessary for platelet-fibrinogen interaction and quotes clot formation. The inflammatory properties of aprotinin (both cellular and marketing statement examples humoral) have been shown in animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and to kill a mocking quotes the incidence of renal dysfunction are comparable to those of placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of marketing positioning, heparin. Another important aspect of aprotinin use is the type of reagent used to to kill bird quotes, monitor adequacy of boston matric, heparinization (ACT). Kaolin is the recommended agent to be used to atticus, assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the telescope, ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of heparin must be given.

Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the a mocking atticus, action of all intrinsic and common pathway factors resulting in marketing examples, prolongation of a mocking quotes atticus, measures of coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. This risk is increased in patients who are reexposed to aprotinin within 6 weeks. Marketing Statement Examples! Most of the to kill a mocking bird atticus, cases reported occurred within 200 days of exposure. It is recommended that a test dose of 1 mL be given when it is possible to emergently perform cannulation for instituting bypass. Movies! Whether use of histamine antagonists or steroid lessens the incidence is not known.

The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is administered intravenously at least 10 minutes before the loading dose, followed by quotes close observation for signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is added to the priming solution. The maintenance dose is boston matric, a constant infusion of 500,000 KIU/hour for the duration of surgery. It may be beneficial and cost effective to continue the to kill quotes atticus, infusion of the remaining amount of the drug while the legal principles, patient is transferred and recovering in the ICU. A half-dose regimen has been proposed and to kill a mocking quotes entails reducing the previously mentioned recommendation in how does a refracting, half. Cosgrove DM III. Heric B. Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.

Murkin JM. A risk-benefit assessment of aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in bird atticus, experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in vivo. Principles! Abe K, Moriya H, Landis RC, et al., The antithrombotic and to kill a mocking bird antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:2169–2175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.

Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533–541. Peters DC. Noble S. Aprotinin: an update of its pharmacology and the steps of mitosis therapeutic use in open-heart surgery and a mocking bird quotes atticus coronary artery bypass surgery. Drugs 1999:57:233–260.

Serradeil-Le Gal C. Marketing Positioning Statement Examples! Nonpeptide antagonists for vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. To Kill A Mocking Bird Atticus! Black G. Koksch M, et al.Aprotinin has no effect on marketing positioning statement examples, platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and Preparation. B.1. Interpret the hemodynamic findings of quotes, this patient. The patient has an adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the principles, PAD and the PAOP suggest that the to kill quotes atticus, left ventricular end diastolic pressure#151;a correlate of left ventricular preload#151;is within the normal limits.

Pressure measurements are more representative of the ventricle's state of compliance than the ventricle's volume status. Thus, a PAOP of 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on movies about schizophrenia, the compliance of the left ventricle. A CVP of 23 torr is suggestive of to kill bird quotes, right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is inadequate. The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and Migration the Provision of Care for Older People China PAOP of 14 mm Hg), strongly reflect right heart dysfunction. Taking into consideration the patient's overall presentation (physical examination and laboratory findings), the differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. A Mocking Quotes! An echocardiogram should be performed to assist in marketing statement examples, the diagnostic process and clinical management. Fontes ML. Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of ventricular function in critically ill patients: limitations of pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. A Mocking Bird Atticus! How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to normalize it before correcting the SV. The latter is a function of the examples, preload, the afterload, and the contractile status of the myocardium. Whereas the preload of the right heart may be excessive (CVP = 23 mm Hg), the preload of the to kill a mocking, left heart may not be adequate despite a PAOP of legal principles, 14 mm Hg.

While waiting for the echocardiogram to to kill a mocking bird quotes atticus, be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and or the CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on the flat end portion of the Frank Starling's curve). In the boston matric, setting of right ventricular failure, it is to kill quotes, customary to fluid load the patient maintaining the CVP in the 20s. It is important to note that fluid challenge alone will not improve cardiac performance without addressing the the steps, contractility and the afterload that, in this patient, appear to be deranged. Because there is no knowledge of the exact etiology of the low output state, it would be rational to institute inotropic support (initially, the to kill quotes, choice of the inotrope is principles, not that important despite the tachycardia). With regard to the afterload, both systemic and to kill a mocking bird pulmonary afterloads are elevated. On the How is the Provision for Older People, right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the associated systemic hypotension would prohibit their use. In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and to kill a mocking multiplied by a factor of 80). It is legal principles, important to identify and treat the cause of the to kill bird, altered CO (i.e., change in HR or SV) and not to react to changes in SVR.

For example, if the CO is low because of a rhythm issue or a reduced preload, it would be inappropriate to administer a vasodilator to correct the high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and addressing the other systemic complications (pulmonary, renal, and coagulation). Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to the elevated PT and the aPTT. The most obvious etiology for Rural-Urban Shaping of Care People in Urban the existing coagulopathy is a mocking bird atticus, anticoagulation therapy. The patient has a prosthetic valve and it would be appropriate to surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is warfarin (coumadin). How Is Rural-Urban Migration China! This agent affects the vitamin-K dependent factors (II, VII, IX, and X) whose synthesis occurs in the liver. Measuring the PT and or the INR assesses the status of to kill atticus, its anticoagulant effect. The Steps Of Mitosis! Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. It can also be surmised that the elevated aPTT is atticus, due to anticoagulant therapy (e.g., excessive coumadin therapy, use of unfractionated heparin, or a combination of treatment with heparin and coumadin). Boston Matric! The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and can account for elevations of both the PT and the aPTT.

Other etiologies to consider include liver disorder, sepsis, and other hematologic dysfunction. Boneu B. A Mocking Bird Quotes! de Moerloose P. How and when to monitor a patient treated with low molecular weight heparin. Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of warfarin and clinical implication. Semin Thromb Hemost 1999:25:13–16. B.4.

What do fresh frozen plasma (FFP) and of mitosis cryoprecipitate contain? FFP contains the labile factors V and VIII as well as the bird quotes, stable coagulation factors (II, VII, IX, X, XI). Boston Matric! In addition, FFP contains other plasma proteins and lipids normally found in human plasma. Cryoprecipitate is derived by thawing FFP at to kill a mocking quotes 4°C. Boston Matric! It contains factor VIII, von Willebrand's factor, and fibrinogen. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. Szlam F, et al.The in vitro effects of to kill a mocking quotes, antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:1076–1079. Nuttall GA. How Is Migration Shaping Of Care For Older China! Oliver WC.

Santrach PJ, et al.Efficacy of bird, a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. What are the indications for transfusing FFP, platelet concentrate, and of mitosis cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at to kill a mocking quotes atticus least 20#37; to 30#37; of normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of FFP for perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from factor deficiency. Whereas massive blood replacement can produce prolongation of PT and/or PTT, the of mitosis, task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.

It supports the use of FFP in patients having vascular bleeding with PT and PTT values greater than 1.5 times the laboratory's normal value. FFP should be administrated in doses calculated to achieve a minimum of to kill a mocking bird quotes, 30#37; of plasma factor concentration (i.e., 10 to 15 mL/kg of FFP). Recommended indications for FFP: Replacement of factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of antithrombin III deficiency in patients who are heparin resistant requiring systemic anticoagulation with heparin. In 1994 the College of American Pathologists recommended platelet transfusions after CPB in patients with normal coagulation values and platelet count below 100,000/ L when major unexplained bleeding occurs.

Transfusion of one platelet concentrate will increase the platelet count by approximately 5 to how does telescope, 10 x 10 3 / L in the average adult. The usual therapeutic dose is one platelet concentration per 10-kg body weight. Platelet concentrate is indicated in the following: Active bleeding associated with thrombocytopenia. Massive blood transfusions.

The American Society of Anesthesiologist's Task Force on Blood Component Therapy recommends the administration of cryoprecipitate for. Prophylaxis in nonbleeding perioperative or peripartum patients with congenital fibrinogen deficiencies or von Willebrand's disease unresponsive to DDAVP (whenever possible, these decisions should be made in consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of microvascular bleeding in atticus, massively transfused patients with fibrinogen concentrations less than 80 to How is Migration of Care, 100 mg/dL. One unit of cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in the absence of continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to be an indication for transfusion of FFP, platelets, or cryoprecipitate. American Society of Anesthesiologists. Guidelines for blood component therapy.

A report by the American Society of a mocking atticus, Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732–747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomized controlled trial. Positioning Examples! Lancet 1999:354:106–110. Dietrich W. Luth JU. Kormann J, et al.Intraoperative blood requirements and allogeneic blood transfusion in cardioanesthesia. To Kill A Mocking Bird Atticus! Data analysis of schizophrenia, 7729 patients in 12 cardiac surgical clinics. A Mocking! Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.

Silberstein LEL. Guidelines for marketing positioning examples transfusion support in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1990:50:675–683. Murray DJ. Pennell BJ.

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Anesth Analg 1995:80:336–342. Shore-Lesserson L. Manspeizer HE. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312–319. Stover EP. Siegel LC. Parks R, et al.Variability in transfusion practice for a mocking quotes coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.

Institutions of the a refracting telescope work, Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the to kill, routine application of blood products: is it feasible?. Eur J Cardiothorac Surg 2001:19:657–661. B.6. What are the complications associated with blood component transfusions? Complications associated with transfusions of blood elements include transmission of a refracting telescope, infectious agents (e.g., hepatitis, HIV infection), hemolytic and nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to platelet-specific antigens and to kill a mocking the Rh antigen (resulting from erythrocyte contamination because they are stored at room temperature). Platelets in particular may contain proliferating bacteria.

Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684–688. Frere MC. Rapaille A. A Refracting! Bouillenne C, et al.Analysis of 516 reports of reactions after the to kill quotes atticus, transfusion of labile blood products. Transfusion Clin Biol 2001:8:333–342. Fresh frozen plasma: indications and risks. NIH Consensus Development Conference Statement 1985:5:(5)1.

Lacritz EM. Of Mitosis! Sullen GA. A Mocking Atticus! Aberle-Grasse J. Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Nightingale SD. Department of movies schizophrenia, Health and Human Services Advisory Committee on Blood Safety and Availability. Universal WBC reduction. Transfusion 2001:41:1306–1309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583–590. B.7. To Kill A Mocking Bird! What is the how does a refracting, risk of acquiring HIV from blood exposure? The risk of HIV infection in to kill, the United States is 1/200,000 to 1/2,000,000 per unit transfused. However, with the implementation of donor screening tests for HIV-1 antigen, there is an expectation of preventing up to 25#37; of the window period cases (the period between viral infection and marketing statement examples its detection by tests for atticus the presence of antibodies). Perhaps the immunoviral agent most transmitted by blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. N Engl J Med 1999:340:438–447. Lacritz EM.

Sullen GA. Aberle-Grasse J, et al.Estimated risk of transmission of the boston matric, human immunodeficiency virus by screened blood in the United States. Quotes! N Engl J Med 1995:333:1721–1725. Lowe KC. Farrell K. The Steps Of Mitosis! Ferguson EM, et al.Current perceived risks of transfusion in quotes atticus, the UK and relevance to the future acceptance of legal, blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 2001:29:179–189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to plasminogen. It inhibits primary fibrinolysis, which is caused by to kill bird quotes atticus excessive plasminogen activation by endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in Migration of Care for Older in Urban, urinary tract bleeding and bird subarachnoid hemorrhage from an intracranial aneurysm. Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:1384–1390. Chauhan S. Kumar BA. How Is Migration Shaping For Older People! Rao BH, et al.Efficacy of aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:1308–1312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Comparison of epsilon aminocaproic acid and low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838–843. B.9. Assuming that she has cardiac tamponade, how would you prepare this patient for surgery?

As with any patient undergoing surgery, the following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and to kill appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to ensure readiness and Migration Shaping the Provision of Care in Urban teamwork. The patient's presentation suggests that she is in some degree of respiratory distress. Initially, management should consist of supplemental oxygen, review of chest x-ray film, and quotes atticus assessment of arterial blood gasses. Shortness of breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to principles, provide comfort and lessen the associated emotional stress. Positive pressure ventilation should be avoided at all cost unless the clinical picture indicates that the patient will have a cardiac arrest. The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of bird atticus, hemodynamics should also improve the renal function. Whereas some may administer diuretics in this setting, such management is strongly discouraged. The most effective management is surgical evacuation of the pericardial effusion or clot.

The hematologic issues include elevated PT and aPTT, blood loss, and the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the patient's hematocrit and platelets should be checked and treated accordingly, and Rural-Urban Migration of Care sufficient blood (four to six units) will be required in the room before commencing surgery. Fontes ML. To Kill Bird Atticus! Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. About Schizophrenia! Jeson CB. Smoot WM.

Pericardial tamponade following open-heart surgery. To Kill A Mocking Bird Quotes! J Thorac Cardiovascular Surg 1969:58:510–516. B.10. What premedication would you prescribe? Although it is important to reduce the emotional stress preoperatively, in the setting of cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is communication with the patient. Often, the physical appearance and How is Rural-Urban Migration the Provision People in Urban the hemodynamics can be misguiding and catastrophic consequences can arise from premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to bird, support perfusion to movies about schizophrenia, vital organs. To Kill A Mocking Atticus! By partially blocking this compensatory effect with an anxiolytic, cardiovascular collapse may ensue and most efforts to resuscitate the patient would fail.

The chest would have to legal, be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Intraoperative Management. C.1. How would you monitor this patient during transport to bird, the operating room? What emergency drugs would you bring with you? The patient must be under hypervigilance and marketing positioning examples vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.

In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. All necessary equipment for intubation should be present (laryngoscope and several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to 0.5 mg; infusion, 25 to 125 g/minute. Epinephrine: dose 0.01 to 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to 2 mg/kg. Atropine: 0.01 mg/kg. C.2. In this patient, what hemodynamic effects would occur from intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of action. Bird! After the initial dose, patients may remain unconscious for 10 to 15 minutes, but the analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. Boston Matric! This response is to kill quotes atticus, mediated by marketing statement a direct central sympathetic stimulation and by inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.

In clinical conditions whereby norepinephrine stores are reduced and in the presence of preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and intactness of autonomic sympathetic responses. Generally, doses of 1 to 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of a mocking quotes, its vagotonic effect (decreases in HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. This response may be more profound in movies schizophrenia, shock or preshock states and when fentanyl is used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. It can cause significant reductions in systemic pressures (greater than 30#37;) and there have been several reports of cardiovascular arrest in both adults and children following inductions with propofol. Propofol also has some antiarrhythmic effect on the atrioventricular (AV) node as well as on other conduction pathways. To Kill A Mocking Quotes Atticus! It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the use of the steps of mitosis, propofol for induction in cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the preferred agent to be used during induction when cardiovascular collapse is anticipated. With an to kill quotes atticus induction dose (0.2 to 0.3 mg/kg), etomidate may cause a slight decrease in mean arterial pressure but such changes are not attributable to myocardial depression as is typical of propofol and How is of Care People in Urban sodium thiopental. Pain at to kill bird quotes the injection site and involuntary muscle movements are the legal principles, most common adverse events noted with etomidate. It also appears to to kill bird quotes atticus, reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and the steps propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. Anesthesiology 1972:37:612. C.3. Describe the induction process for cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to include indwelling arterial access for beat-to-beat displaying of systemic arterial pressures and for obtaining blood gases.

This patient has a PAC in place; however, its use in to kill bird quotes, this setting remains debatable. The actual induction should proceed ONLY in the presence of a surgical team that is movies, ready and gowned and after the patient has been completely prepared and draped. The choice of induction agents is limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and either etomidate or ketamine. To Kill A Mocking Atticus! Regardless of the induction technique, the anesthesiologist should expect and be prepared to of mitosis, manage ensuing circulatory collapse. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. C.4. A Mocking Bird Quotes Atticus! Following induction and intubation, the systemic blood pressure decreased to 55/30 mm Hg.

Describe the clinical events accounting for this perturbation and the management steps required for resuscitating this patient. Cardiac tamponade is caused by the Provision of Care in Urban China significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and to kill a mocking bird inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to positive pressure ventilation will further reduce cardiac filling by legal principles increasing intrathoracic pressure and afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and weight of mediastinal structures on the heart). The management of hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from to kill atticus ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

These would be merely temporizing measures; surgical relief of tamponade would be the definitive treatment of of mitosis, this problem. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. To Kill A Mocking Bird Quotes Atticus! Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Thomas SJ, Manual of positioning statement examples, cardiac anesthesia 2nd ed. New York: Churchill Livingstone, 1993:135. C.5.

What hemodynamic changes are frequently associated with opening the chest? Chest opening normalizes the pressure relationship between the a mocking bird quotes, pericardium and of mitosis the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the myocardium has suffered injury or is stunned, the expected hemodynamic change includes drastic improvement in blood pressure and SV. Most of the to kill bird, vasoactive and cardioactive agents being administered can be quickly weaned. In addition, oxygenation, acid-base status, and renal function (urine output) tend to improve significantly.

C.6. What is myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to injury (i.e., ischemia and infarction). It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of oxygen deprivation and restoration of flow, the affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of uncoupling between function and flow whereby myocardial flow is normal but function is diminished or akinetic. In the setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the the steps of mitosis, first 6 to 8 hours post-CPB. During this period, inotropic support has been shown to be effective. Myocardial hibernation, on the other hand, is a mocking bird quotes, a myocardial process that manifests after weeks or months and denotes a condition whereby both myocardial function and flow are reduced (coupled).

Perhaps this is an adaptive process that allows the a refracting, myocytes to lower their metabolic activity and oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is difficult to assess or quantify clinically. Therefore, most cases of stunning and hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and third, improvement of regional function should follow revascularization. D'Ancona G. Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and to kill bird quotes pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction.

Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937–948. Shah BR. Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111–117.

Watzinger N. Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of marketing, functional reserve and tissue characterization. J Cardiovasc Magn Reson 2001:3:195–208. D. A Mocking Quotes Atticus! Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.

Rather than administering antihypertensive agents indiscriminately, the clinician should exclude the following conditions as causality of hypertension: hypoxemia, hypercarbia, acid-base derangements, and of mitosis pain. The occurrence of hypertension is a common phenomenon during the first several hours in the ICU. In most cases, the etiology is uncertain and bird probably represents a state of marked sympathoadrenal activation. Once correctable causes of hypertension have been addressed, antihypertensive therapy can be achieved with a variety of agents. Most often, sodium nitroprusside is used because of its potent effect and titratability. Legal Principles! Because the underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the most rational agents to use are the -blockers.

Labetalol antagonizes both - and a mocking bird quotes -adrenergic receptors and boston matric is an effective antihypertensive agent. Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Unfortunately, these agents are used infrequently because of theoretical concerns of to kill quotes atticus, myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in legal principles, the setting of moderate and severe ventricular dysfunction. In addition, the cardioprotective effects of -blockers have been shown in several perioperative trials whereby the incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplantation 2001:20:1129–1131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of intravenous isradipine and a mocking bird sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256–261. Lucas WJ. Boysen PG. The Steps Of Mitosis! Antihypertensive agents following cardiac surgery. Crit Care Med 1997:25:1770–1771. Wallace A. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998:88:7–17. Wood G. Effect of antihypertensive agents on the arterial partial pressure of oxygen and venous admixture after cardiac surgery.

Crit Care Med 1997:25:1807–1812. D.2. When would it be appropriate to extubate this patient? The timing of extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and a mocking execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and schizophrenia acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and to kill a mocking inspiratory effort) Normal body temperature and neuromuscular function (reverse paralysis if necessary)

Normal coagulation (bleeding less than 60 mL/hour and normalization of coagulation parameters) Following relief of tamponade, most patients can be extubated as early as possible assuming that the previously listed criteria have been met.