Condet

Hiep T. Nguyen, MD

• Assistant Professor of Surgery, Harvard Medical School
• Assistant in Urology, Children? Hospital Boston, Boston,
• Massachusetts

Redevelopment in the near coastal communities treatment medical abbreviation discount 25mcg thyroxine amex, building on the coastline medicine journals impact factor discount 100mcg thyroxine visa, and expansion into wildland areas have implications for hurricane medicine cabinets with mirrors buy thyroxine 125 mcg on line, surge and beach erosion and wildfire risks respectively symptoms low potassium 200mcg thyroxine for sale. Data on the structural characteristics of single family residential homes came from "Exposure and Vulnerability Components of the Florida Public Hurricane Loss Projection Model published in 2005 by Florida International University, also using the Property Appraiser database. Forty seven (47) percent of residential units reside in the unincorporated areas of the county. The southern municipalities of Boca Raton, Delray Beach and Boynton Beach collectively have an estimated 46,348 residential units; the northern municipalities of Palm Beach Gardens and Jupiter have 25,622 units; West Palm Beach in central county has 20,377 units; and the communities of Wellington and Royal Palm Beach have 24,696 units. A breakdown of residential units by type by jurisdiction follows on the next page. Thirteen and a half percent have exterior wall of wood in the form of wood siding, wood frame stucco or board batten. A 2005 study by Florida International University focuses on the roof system, roof to wall connections, wall systems, wall to foundation connections, openings, and in the case of manufactured homes the anchors into the ground as areas requiring further understanding. But vulnerabilities are much more complicated than failures of individual components. When a windstorm causes damage to a structure, it will usually cause different damage modes to different components at the same time. Nevertheless, certain structural designs and materials seem to be more vulnerable than others. Roof Covering Materials One portion of the resistance capacity of the roof system to wind uplift includes the ability of the shingles, tiles, or other roof covering to stay attached to the roof sheathing. The loss of covering, though not vital to the structural integrity of a structure, can contribute significantly to the damage of the contents of the structure and increase insurance losses. A second, more important aspect of the wind uplift resistance capacity of the roof system includes the ability of the sheathing to remain fastened to the trusses. The third subcomponent of the roof system, the trusses or rafters, is less important to the prediction of damage. Individual trusses or rafters will not fail in uplift before massive damage has already occurred from the loss of sheathing. The contribution of the trusses or rafters to the overall capacity of the building occurs in the resistance to the loss of the entire roof as a whole unit. Post disaster studies have found that the roof to wall connection is another vital characteristic of the overall resistance of the home to hurricane force winds Roof Types Different roof types have different capacities to resist strong winds. The majority of roof types for single family houses in Palm Beach County are gable or hip. Gable roofs can be simply described as two pitched roof surfaces connected to vertical surfaces at each end. Hip roofs are gable roofs with gable ends brought together at the same pitch as the rest of the roof. Post disaster surveys have shown that gable roofs tended to suffer more structural damage than hip roofs. Exterior Wall Materials Exterior wall failures are much less commonly cited in post damage reports than roofing system failures. Residential structures in Palm Beach County are predominately of two types, concrete block and wood frame. Damage to masonry walls, especially reinforced concrete walls, is less prevalent than to wood frame walls. Both forms of wall materials are largely dependent on the integrity of the roof system for their survival. Post Disaster Redevelopment Plan Volume 2 24 Number of Stories Obviously two story family buildings differ from single story structures in terms of structural characteristics, number of openings, value, etc. Most one-story buildings have either masonry exterior walls or timber frame, in other words one type of wall material. However, most multi-story buildings have mixed exterior wall material, typically concrete block walls for the first story and timber frame for the second story.

The high-performing acne natural treatment buy thyroxine 150mcg without a prescription, high-poverty schools we studied tend to reflect characteristics of highly entrepreneurial organizations symptoms 6 week pregnancy 150 mcg thyroxine with visa. These schools are succeeding either by working outside of traditional public education structures (charters); or by working around those structures medicine wheel wyoming thyroxine 150mcg discount, internally (in-district charterlikes); or by operating exceptionally well against the system ­ with emphasis on exceptionally medications known to cause nightmares thyroxine 150mcg low cost. A handful of major school districts ­ Chicago, Miami-Dade, New York City, Philadelphia ­ are experimenting with turnaround zones in an effort to establish protected space for these kinds of approaches. With rare exceptions, schools and districts ­ essentially risk-averse, conservative cultures ­ will not undertake the dramatic changes required for successful turnaround on their own. But while states may have the responsibility to ensure equitable intervention across district lines, they clearly do not have the capacity to implement turnaround on the ground at the scale of the need. Their role is to require fundamental, not incremental change; establish operating conditions that support, rather than undermine, the desired changes; add new capacity in highleverage school and district roles and establish turnaround partners; and galvanize local capacity where it is currently trapped in dysfunctional settings. States should pass regulations (as Massachusetts has) or legislation (as Maryland has) that produce sufficient leverage for all district leaders to create the protected space they need for turnaround to be effective. The best regulations change the incentives for local stakeholders, motivating the development of turnaround zones in order to gain their advantages ­ while avoiding "final option" alternatives that would diminish district and union control. That means a collaborative revision of many contractual requirements in districts with unions. Districts, working with turnaround partners and the state, must be able to install new principals if needed; principals must in turn have control over who is working in their buildings, along with the allocation of money, time, and programming (including curriculum and partnerships with social services). Schools must be freed to take on professional norms, including differentiated roles for teachers and differentiated compensation. Decision-making must be freed so that it revolves around the needs of children, not adults. At the same time, each turnaround school cannot be expected to design and manage its own change process; its latitude for decision-making lies within a framework of strong network support and turnaround design parameters established by the state, and carried out by districts and/or turnaround partners. Building Capacity Organizational turnaround in non-education-related fields requires special expertise; school turnaround is no different. It is a two-stage process that calls for fundamental transformation at the start, managed by educators with the necessary training and disposition, with steady, capacity-building improvement to follow. Neither schools and districts, nor states, nor third-party providers have sufficient capacity at present to undertake successful turnaround at scale. Changing Conditions Turnaround requires protected space that dismantles common barriers to reform. Chronically under-performing schools offer a politically defensible opportunity to create such a space. A few entrepreneurial school districts (Chicago, Miami-Dade, New York) have created such condition-changing zones or "carve-outs" for their neediest schools. But others (Philadelphia, Oakland) have needed intervention from the state to mount similar initiatives. Moreover: turnaround represents an opportunity to redesign the ways schools work with outside partners. The fragmentation that characterizes current school/provider relationships needs to be replaced by an integrated approach that aligns outside support around the turnaround plan, organized by a single "systems integrator" partner. Clustering for Support Turnaround has meaningful impact at the level of the school building, but turnaround at scale cannot be accomplished in ones and twos. States and districts should undertake turnaround in clusters organized around identified needs: by school type. Clusters should be small enough to operate effectively as networks, but large enough to be an enterprise ­ i. The Political Realities: Enabling the State Role Turnaround of failing local schools has no natural constituency. Coalitions of support must instead be built at two levels ­ statewide and community-wide. To ensure sustained and sufficient statewide commitment to turnaround reforms and investments, someone (governor, commissioner, business/community leader) or some agency must create an advocacy coalition of political, education, corporate, foundation, university, and nonprofit leaders. To ensure broad commitment to turnaround at the community level, states can blend the leverage of accountability-based sanctions (you risk losing authority over this school if you fail to act) with the "carrot" of resources and conditionchange. Finally: to design and implement turnaround effectively, states must create an appropriate coordinating body or mechanism to lead the work, ideally as a public/private agency linked to the state department of education. The goal of this study was to produce recommendations for states and school districts seeking a flexible, systematic approach to swift and significant transformation in schools (particularly high schools) deemed chronically under-performing under No Child Left Behind or state accountability systems.

Abnormal mucus in the pulmonary tree leads to atelectasis medicine nobel prize 2015 cheap 75mcg thyroxine visa, fibrosis symptoms zinc overdose generic 200mcg thyroxine fast delivery, bronchiectasis medicine list cheap thyroxine 125mcg without prescription, and recurrent pulmonary infections symptoms jaundice buy thyroxine 150mcg without prescription, especially with Staphylococcus aureus and Pseudomonas species. Obstruction of the vas deferens and seminal vesicles in males leads to sterility, while obstruction of the bile duct produces jaundice. Patients with acute pancreatitis typically present with abdominal pain that is associated with increased serum levels of pancreatic enzymes (amylase and lipase). Most cases of acute pancreatitis are associated with either alcohol ingestion or biliary tract disease (gallstones). Alcohol ingestion is the most common cause, and pancreatitis usually follows an episode of heavy drinking. Symptoms of acute pancreatitis include abdominal pain that is localized to the epigastrium and radiates to the back, vomiting, and shock, the latter being the result of hemorrhage and kinins released into the blood. Laboratory confirmation of pancreatic disease involves the finding of elevated serum amylase levels in the first 24 h and rising lipase levels over the next several days. Other pancreatic enzymes, such as trypsin, chymotrypsin, and carboxypeptidases, have not been as useful for diagnosis as have amylase and lipase. Complications seen in patients who survive the acute attack include pancreatic abscess formation, pseudocyst formation, or duodenal obstruction. The major cause of chronic pancreatitis in adults is chronic alcoholism, while in children the major cause is cystic fibrosis. Recurrent attacks of acute pancreatitis also result in the changes of chronic pancreatitis. Hypercalcemia and hyperlipidemia also predispose to chronic pancreatitis (since they are causes of acute pancreatitis), while in as many as 10% of patients, recurrent pancreatitis is associated with pancreas divisum. This condition refers to the finding of the accessory duct being the major excretory duct of the pancreas. Chronic ductal obstruction may be a cause of chronic pancreatitis and may be associated with gallstones, but it is more appropriate to relate gallstones with acute ductal obstruction and resultant acute pancreatitis. Complications of chronic pancreatitis include pancreatic calcifications, pancreatic cysts and pseudocysts, stones within the pancreatic ducts, diabetes, and fat malabsorption, which results in steatorrhea and decreased vitamin K levels. True cysts, wherever they are found in the body, are always lined by some type of epithelium, whether columnar cell, glandular, squamous, or flattened cuboidal cell. The pancreatic pseudocyst is most commonly found against a background of repeated episodes of pancreatitis. Eventual mechanical large duct obstruction by an inflammatory process per se, periductal fibrosis, or an abscess along with inspissated duct fluid from secretions and enzymes leads to the expanding mass. The mass lesion may be located between the stomach and liver, between the stomach and the colon or transverse mesocolon, or in the lesser sac. Pancreatic cancers are highly malignant tumors that account for about 5% of cancer deaths in the U. Their occurrence has increased threefold in the past 40 years, mainly as a result of smoking and exposure to chemical carcinogens. About 20% of pancreatic adenocarcinomas are found in the body and 10% are found in the tail. Tumors located in the tail of the pancreas present late, when therapy is no longer possible. The major symptoms of pancreatic carcinomas in general include weight loss, abdominal pain (usually the first symptom), back pain, and malaise. Surgery for a tumor of the head of the pancreas may involve pancreatoduodenectomy, which is called a Whipple procedure. Pancreatic gastrinomas (tumors of the G cells of the pancreas) secrete gastrin and are a cause of Zollinger-Ellison syndrome. This syndrome consists of intractable gastric hypersecretion, severe peptic ulceration of the duodenum and jejunum, and high serum levels of gastrin. Insulinomas (tumors of cells) are the most common islet cell neoplasm and are usually benign. Glucagonomas (islet cell tumors of the cells) secrete glucagon and are characterized by mild diabetes, anemia, venous thrombosis, severe infections, and a migratory, necrotizing, erythematous skin rash. Symptoms that result from the excess and uncontrolled secretion of insulin include low blood sugar (hypoglycemia) with subsequent hunger, sweating, and nervousness.

Wilson even described examining a patient in his office symptoms 2 order thyroxine 25 mcg on line, with the young house officer McDonald Critchley medications similar to vyvanse discount thyroxine 125mcg free shipping, and that the patient indeed had atonic paralysis medicine hat jobs cheap 25mcg thyroxine free shipping, with loss of tendon reflexes and an extensor plantar response during the attack medicine in balance buy thyroxine 25mcg on-line. A corollary was that consciousness could only be eliminated by lesions that simultaneously damaged both cerebral hemispheres. The nascent field of neurosurgery also began to contribute cases in which loss of consciousness was associated with lesions confined to the upper brainstem or caudal diencephalon. However, the most convincing body of evidence was assembled by Baron Constantin von Economo,19 a Viennese neurologist who recorded his observations during an epidemic of a unique disorder, encephalitis lethargica, that occurred in the years surrounding World War I. Most victims of encephalitis lethargica were very sleepy, spending 20 or more hours per day asleep, and awakening only briefly to eat. When awakened, they could interact in a relatively unimpaired fashion with the examiner, but soon fell asleep if not continuously stimulated. Many of these patients suffered from oculomotor abnormalities, and when they died, they were found to have lesions involving the paramedian reticular formation of the midbrain at the junction with the diencephalon. Other patients during the same epidemic developed prolonged wakefulness, sleeping at most a few hours per day. Von Economo identified the causative lesion in the gray matter surrounding the anterior part of the third ventricle in the hypothalamus and extending laterally into the basal ganglia at that level. Von Economo suggested that there was specific brainstem circuitry that causes arousal or wakefulness of the forebrain, and that the hypothalamus contains circuitry for inhibiting this system to induce sleep. However, it was difficult to test these deductions because naturally occurring lesions in patients, or experimental lesions in animals that damaged the brainstem, almost invariably destroyed important sensory and motor pathways that complicated the interpretation of the results. As long as the only tool for assessing activity of the cerebral hemispheres remained the clinical examination, this problem could not be resolved. He found that after a transection between the medulla and the spinal cord, a preparation that he called the encephale isole, or isolated brain, animals showed a desynchronized (low voltage, fast, i. Bremer concluded that the forebrain fell asleep due to the lack of somatosensory and auditory sensory inputs. Later studies showed that electrical stimulation of the midbrain reticular core could excite forebrain desynchronization. The waves of postsynaptic potentials in the cerebral cortex are now understood to be due to the intrinsic burst firing of neurons in the thalamus, basal forebrain, and the cortex itself, which produce waves of postsynaptic potentials in cortical neurons. When the membrane potential of burst neurons is close to their firing threshold, they fire single action potentials that transmit sensory and other information. However, when burst neurons have been hyperpolarized to membrane potentials far below their usual threshold for firing sodium action potentials, a low-threshold calcium channel is deinactivated. When the low-threshold calcium channel is triggered, calcium entry brings the membrane potential to a plateau that is above the threshold for firing sodium action potentials. As a result, a series of sodium spikes are fired, until sufficient calcium has entered the cell to activate a calcium-activated potassium current. This potassium current then brings the cell back to a hyperpolarized state, terminating the burst of action potentials. This brings the cell above the threshold for firing sodium action potentials, which are fired in a burst, until this is terminated by a calcium-activated potassium current that hyperpolarizes and silences the cell. Thalamic axons on their way to the cerebral cortex, and cortical projections to the thalamus, give off collaterals to the reticular nucleus as they pass through it. Basal forebrain neurons also fire in bursts that are time-locked to cortical rhythms. Periods of forebrain arousal returned after several days if the animals were kept alive. However, it is clear that the slab of tissue from the rostral pons through the caudal midbrain (the mesopontine tegmentum) contains neural structures that are critically important to forebrain arousal, at least in the acute setting. At the time, little was known about the origins of ascending projections from the mesopontine tegmentum to the forebrain, and the arousal effect was attributed to neurons in the reticular formation. However, more recent studies have shown that projections from the mesopontine tegmentum to the forebrain arise from several well-defined populations of neurons. The major source of mesopontine afferents that span the entire thalamus is a collection of cholinergic neurons that form two large clusters, the pedunculopontine and laterodorsal tegmen- tal nuclei. Other neurons in the cholinergic pedunculopontine and laterodorsal tegmental nuclei send axons into the lateral hypothalamus, where they may contact populations of neurons with diffuse cortical projections (see below). Some of them innervate the midline and intralaminar nuclei of the thalamus, and others pass through the lateral hypothalamus to the basal forebrain and prefrontal cortex.

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