Christopher T. Bowe, MD, FACEP

• Associate Residency Program Director, Assistant Professor, Emergency
• Medicine, Department of Emergency Medicine, Maine Medical Center,
• Portland, ME, USA

Mapleson C: Expiratory valve impotence kidney stones kamagra oral jelly 100 mg buy visa, supply of fresh gases erectile dysfunction age 16 cheap kamagra oral jelly 100 mg buy line, and a reservoir bag are all close to the facemask; there is no corrugated tube erectile dysfunction juice drink buy kamagra oral jelly on line. Mapleson D: Supply of fresh gases is close to the facemask separated by corrugated tube from the reservoir bag and expiratory valve erectile dysfunction herbs a natural treatment for ed order cheap kamagra oral jelly on-line. Mapleson F: Supply of fresh gases is close to face mask erectile dysfunction at age 20 kamagra oral jelly 100 mg order without a prescription, which is separated by a corrugated tube from a reservoir bag with an expiratory port, but no expiratory valve. The relative positioning of the fresh gas inlet is a key differentiating factor in determining the Mapleson classification and system performance. The end products of this reaction include heat (the heat of neutralization), water, and calcium carbonate. It consists primarily of calcium hydroxide (80%) along with sodium hydroxide, water, and a small amount of potassium hydroxide. It possesses greater inertness than soda lime, resulting in less degradation of the volatile anesthetics. Increasing the hardness of soda lime by adding silica minimizes the risk of inhalation of sodium hydroxide dust and decreases resistance of gas flow. Higher concentrations of sevoflurane, prolonged exposure, and low-flow anesthetic technique appear to increase the formation of compound A. The E-cylinders are used as a secondary gas supply in case the central gas supply fails. Both gas supplies use redundant safety mechanisms, including color coding of gases and non-interchangeable inlet connection systems. Most anesthesia machines use pressure from the oxygen supply to drive their mechanical components, such as the ventilator bellows, gas flush valves, and so on. Pressure regulator valves are used to reduce the pressure from the secondary E-cylinder supply to 45 to 47 psi before the gases enter the machine. This pressure, slightly lower than the pipeline supply, allows preferential use of the pipeline supply if an E-cylinder is accidentally left open. All machines also have an oxygen supply low-pressure sensor that activates an alarm when inlet O2 pressure drops below a threshold value, usually 20 to 30 psi. In the United States, E-cylinders are color coded as follows: oxygen = green; nitrous oxide = blue; carbon dioxide = gray; medical air = yellow; helium = brown; and nitrogen = black. The international coding system is slightly different with oxygen = white and air = black and white. Gas lines located between the gas inlet and the flow control valve-flowmeter apparatus are subject to higher pressures and are therefore considered the high-pressure system. Gas lines located between the flow control valve­flowmeter apparatus and the common gas outlet are considered the low-pressure system. This safety feature helps ensure that some oxygen enters the breathing circuit even if the operator forgets to turn on the oxygen flow. When the knob of the flow-control valve is turned, a needle valve is disengaged from its seat, allowing gas to flow through the valve. Touch- and color-coded control knobs make it more difficult to turn the wrong gas off or on. Analog flowmeters, also known as constant-pressure variable-orifice flowmeters, use an indicator ball, bobbin, or float that is supported by the flow of gas through a tube with a tapered bore that is calibrated to each particular gas. Electronic flowmeters take similar measurements and perform calculations to report flow rates in a digital display. If a leak develops within or downstream from the oxygen flowmeter, a hypoxic gas mixture could be delivered to the patient. To reduce this risk, oxygen flowmeters are always positioned downstream to all other flowmeters. The oxygen flowmeter is positioned farthest to the right, downstream to the other gases; this arrangement helps to prevent hypoxia if leakage were to occur from a flowmeter positioned upstream. Vapor pressure is the pressure exerted on the walls of a container by the gaseous phase when a solution is at equilibrium between gas and liquid at a given temperature. This physical property describes the tendency of a substance to leave the liquid phase to enter the gaseous phase. The word volatile is a relative term that refers to substances that have high vapor pressures at normal working temperatures. Vaporizers have concentration-calibrated dials that precisely add volatile anesthetic agents to the combined gas flow. All modern vaporizers are volatile agent specific and temperature corrected, capable of delivering a constant concentration of agent regardless of temperature changes or flow through the vaporizer. As vaporization proceeds, the temperature of the remaining liquid anesthetic drops and vapor pressure decreases unless heat is readily available to enter the system. In this system, a portion of the total gas flow from the machine enters the vaporizer and is diverted into two streams. These two streams are mixed before exiting the vaporizer to enter the common gas pipeline. Temperature compensation within the vaporizer is achieved by a strip composed of two different metals welded together. The metals within this strip expand and contract differently in response to temperature changes. With changes in temperature, differential contraction of these metals causes the strip to bend in a calibrated fashion, allowing more or less gas to pass through the vaporizer. In this manner, the concentration of volatile anesthetic delivered by the vaporizer remains stable over a wide range of temperatures. Desflurane requires an electronic vaporizer; it is the most commonly encountered electronic vaporizer. The vapor pressure of desflurane is so high that at sea level, its boiling point approaches room temperature. Because desflurane vaporizes so extensively, a tremendously high fresh gas flow would be necessary to dilute the carrier gas to clinically relevant concentrations. Unlike a variable-bypass vaporizer, no fresh gas flows through the desflurane sump. Rather, pure desflurane vapor joins the fresh gas mixture before exiting the vaporizer. The amount of desflurane vapor released from the sump depends on the concentration selected by turning the control dial and the fresh gas flow rate. Three types of oxygen analyzers are available: polarographic (Clark electrode), galvanic (fuel cell), and paramagnetic. The first two types use electrochemical sensors that contain cathode and anode electrodes embedded in an electrolyte gel separated from the sample gas by an oxygen-permeable membrane. As oxygen reacts with the electrodes, a current is generated that is proportional to the oxygen partial pressure in the sample gas. Paramagnetic analyzers use a magnetic field that attracts O2 much more than other gases. In this manner, O2 levels can be analyzed quickly enough to distinguish between inspired and expired O2 concentrations. Paramagnetic devices are more expensive but are self-calibrating and have no consumable parts. The sensor should be placed into the inspiratory or expiratory limb of the breathing circuit but not into the fresh gas line. Some machines contain an additional spirometer that measures inspiratory tidal volumes. The flow of gas across vanes within the spirometer causes their rotation, which is measured electronically, photoelectrically, or mechanically, and is converted to a tidal volume. A hot-wire spirometer uses a fine platinum wire that is electrically heated at a constant temperature inside the gas flow. The cooling effect of increasing gas flow on the wire electrode causes a change in electrical resistance, which can be converted to a tidal volume. One gas stream flows over a chamber containing volatile anesthetic, which is carried to the outlet of the vaporizer. These two streams are mixed prior to exiting the vaporizer to enter the common gas pipeline. By controlling the ratio of these streams, the concentration of volatile anesthetic delivered into the system can be controlled. Pollution of the operating room environment with anesthetic gases may pose a health hazard to operating room personnel. There are two types of scavenging systems: a closed interface and an open interface. An open interface is open to the outside atmosphere and usually requires no pressure relief valves. A closed interface is closed to the outside atmosphere and requires negative and positive pressure relief valves that protect the patient from the negative pressure of the vacuum system and positive pressure from an obstruction in the disposal tubing. In active scavenging, a reservoir chamber accepts waste gas overflow when the capacity of the vacuum is exceeded. The vacuum control valve on an active system should be adjusted to allow the evacuation of 10 to 15 L of waste gas per minute. Clinical considerations: Adequate oxygen delivery to vital organs must be maintained during anesthesia. Arterial blood pressure is used as a measure of organ blood flow because instruments that monitor specific organ perfusion and oxygenation are complex, expensive, and often unreliable. In: Clinical Monitoring: Practical Applications in Anesthesia and Critical Care Medicine. The cuff bladder should extend at least halfway around the extremity, and the cuff width should be 20% to 50% greater than the diameter of the extremity. The cuff pressure is released 2 to 3 mm Hg per heartbeat until the pulse is again palpable. Korotkoff sounds may be difficult to hear during episodes of hypotension or peripheral vasoconstriction. Doppler probe: the Doppler Effect is the shift in sound wave frequency when a source moves relative to an observer. A Doppler probe transmits an ultrasonic beam that is reflected by underlying tissue. The probe should be positioned directly above an artery so that the beam passes through the vessel wall. Measurements may be unreliable during arrhythmias and when on cardiopulmonary bypass. Contraindications: Catheterization should be avoided in arteries of extremities with inadequate collateral blood flow or suspicion of vascular insufficiency. Selection of Artery for Cannulation Radial artery: Commonly cannulated because of its superficial location and collateral blood flow. Inadequate collateral flow occurs in 5% of patients because of incomplete palmar arches. Ulnar collateral circulation adequacy can be assessed via the Allen test, palpation, Doppler probe, plethysmography, or pulse oximetry. Normally not considered because of a risk of hand blood flow compromise, especially if the ipsilateral radial artery has been punctured. Brachial artery: Large and easily identifiable in the antecubital fossa and has less waveform distortion because of its proximity to the aorta. Femoral artery: Provides excellent access but is prone to pseudoaneurysm and atheroma formation. The femoral site has been associated with an increased incidence of infections complications and arterial thrombosis, as well as aseptic necrosis of the femoral head in children. Dorsalis pedis and posterior tibial arteries: the most distorted waveforms because of its distance from the aorta. Axillary artery: Surrounded by the axillary region of the brachial plexus, and thus nerve damage can result from a hematoma or traumatic cannulation. Flushing of the left axillary artery can easily result in transmission of air or thrombi to the cerebral circulation. Alternatively, the needle is lowered to a 30° angle and advanced 1-2 mm to ensure the catheter tip is in the vessel lumen. Factors associated with increased rate of complications: Prolonged cannulation, hyperlipidemia, repeated insertion attempts, female gender, extracorporeal circulation, and the use of vasopressors. Complication risk is minimized by the following: When the ratio of catheter to artery size is small, heparinized saline is continuously infused through the catheter at a rate of 2 to 3 mL/h, flushing of the catheter is limited, and meticulous attention is paid to aseptic technique. The transduced waveform depends on the dynamic characteristics of the catheter­tubing­transducer system. Tubing, stopcocks, and air all can lead to overdamping, which will underestimate the systolic pressure. Improve system dynamics: Low-compliance tubing, minimize tubing and stopcocks, remove air bubbles. Transducers convert the mechanical energy of the arterial pressure wave to an electrical signal, and their accuracy depends on correct calibration and zeroing procedures. Motion or electrocautery artifacts can result in misleading arterial waveform readings. The rate of upstroke indicates contractility, and the rate of downstroke indicates peripheral vascular resistance. Lead V5-anterior and lateral wall ischemia: Lies at the fifth intercostal space at the anterior axillary line. A true V5 requires at least five lead wires; a modified V5 can be monitored by three leads. Electrocardiography: Clinical Considerations Artifacts are a major problem because of the small voltage potentials being measured. Patient or lead-wire movement, use of electrocautery, 60-cycle interference, and faulty electrodes can simulate arrhythmias. Contraindications: Tumors, clots or tricuspid valve vegetations that could be dislodged during cannulation. Internal jugular vein cannulation is relatively contraindicated in patients who have had an ipsilateral carotid endarterectomy. Central Venous Catheterization: Techniques and Complications Placement: A catheter is placed in a vein so that its tip lies at the junction of the superior vena cava and the right atrium.

The activities of the basal nuclei are initiated by information received from the sensory cortex erectile dysfunction pills generic purchase 100 mg kamagra oral jelly, the thalamus erectile dysfunction 38 years old order kamagra oral jelly 100 mg amex, and the brainstem erectile dysfunction 40 cheap kamagra oral jelly 100 mg mastercard. When examined by his local medical practitioner erectile dysfunction australian doctor purchase 100 mg kamagra oral jelly with amex, he is found to have complete paralysis of the entire right side of the face erectile dysfunction drug overdose kamagra oral jelly 100 mg with visa. The physician tells the pa- tient that he has suffered a mild stroke, and he is admit- ted to the hospital. The original physician grouped together the facial paralysis, the slurred speech, and the hypertension and, in the absence of other findings, made the incorrect diagnosis of cerebral hemorrhage. A lesion of the corticonuclear fibers on one side of the brain will cause paralysis only of the muscles of the lower part of the opposite side of the face. This patient has complete paralysis of the entire right side of the face, which could only be caused by a lesion of the lower motor neuron. The correct diagnosis was Bell palsy, an inflammation of the connective tissue sheath of the facial nerve, which temporarily interfered with the functions of the axons of the right facial nerve. This case provides a good example of how knowledge of the central connec- tions of a cranial nerve enables a physician to make the correct diagnosis. The cranial nerves are commonly damaged by trauma or disease, and testing for their integrity forms part of every physical examination. The oculomotor, trochlear, abducens, accessory, and hypoglossal nerves are entirely motor. The trigeminal, facial, glossopharyngeal, and vagus nerves are both sensory and motor nerves. The letter symbols commonly used to indicate the functional components of each cranial nerve are shown in Table 11-1. The cranial nerves have central motor and/or sensory nuclei within the brain and peripheral nerve fibers that emerge from the brain and exit from the skull to reach their effector or sensory organs. The different components of the cranial nerves, their functions, and the openings in the skull through which the nerves leave the cranial cavity are summarized in Table 11-2. Cranial Nerve Motor Nuclei the motor nuclei of the cranial nerves receive impulses from the cerebral cortex through the corticonuclear 323 mebooksfree. These fibers originate from the pyramidal cells in the inferior part of the precentral gyrus (area 4) and from the adjacent part of the postcen- tral gyrus. The corticonuclear fibers descend through the corona radiata and the genu of the internal capsule. They pass through the midbrain just medial to the corticospinal fibers in the basis pedunculi and end by synapsing either directly with the lower motor neurons within the cranial nerve nuclei or indirectly through the internuncial neurons. The corticonuclear fibers thus constitute the first-order neuron of the descending pathway, the internuncial neuron constitutes the secondorder neuron, and the lower motor neuron constitutes the brain. Such a nerve cell is, therefore, equivalent to the motor cells in the anterior gray columns of the spinal cord. The majority of the corticonuclear fibers to the motor cranial nerve nuclei cross the median plane before reaching the nuclei. Bilateral connections are present for all the cranial motor nuclei except for part of the facial nucleus that supplies the muscles of the lower part of the face and a part of the hypoglossal nucleus that supplies the genioglossus muscle. The general visceral motor nuclei form the cranial outflow of the parasympathetic portion of the autonomic nervous system. They are the Edinger-Westphal nucleus of the oculomotor nerve, the superior salivatory and lacrimal nuclei of the facial nerve, the inferior salivatory nucleus of the glossopharyngeal nerve, and the dorsal motor nucleus of the vagus. These nuclei receive numerous afferent fibers, including descending pathways from the hypothalamus. The somatic motor and branchiomotor nerve fibers of a cranial nerve are the axons of nerve cells situated within Sensory nuclei of the cranial nerves include somatic and visceral afferent nuclei. The sensory or afferent parts of a cranial nerve are the axons of nerve cells outside the brain and are situated in ganglia on the nerve trunks (equivalent to posterior root ganglion of a spinal nerve) or may be situated in a sensory organ, such as the nose, eye, or ear. The central processes of these cells enter the brain and terminate by synapsing with cells forming the sensory nuclei. Each receptor cell consists of a small bipolar nerve cell with Granular cell Synaptic glomerulus Tufted cell where they synapse. The nerve cells of these nuclei form the third-order neuron, and their axons terminate in the cerebral cortex. From the coarse peripheral process, a number of short cilia arise, the olfactory hairs, which project into the mucus covering the surface of the mucous membrane. These projecting hairs react to odors in the air and stimulate the olfactory cells. Bundles of these nerve fibers pass through the openings of the cribriform plate of the ethmoid bone to enter the olfactory bulb. The fibers of the optic nerve are myelinated, but the sheaths are formed from oligodendrocytes rather than Schwann cells, since the optic nerve is comparable to a tract within the central nervous system. The optic nerve leaves the orbital cavity through the optic canal and unites with the optic nerve of the opposite side to form the optic chiasma. Optic Chiasma the optic chiasma is situated at the junction of the anterior wall and floor of the third ventricle. In the chiasma, the fibers from the nasal (medial) half of each retina, including the nasal half of the macula, cross the midline and enter the optic tract of the opposite side, while the fibers from the temporal (lateral) half of each retina, including the temporal half of the macula, pass posteriorly in the optic tract of the same side. Olfactory Bulb this ovoid structure possesses several types of nerve cells, the largest of which is the mitral cell. The incoming olfactory nerve fibers synapse with the dendrites of the mitral cells and form rounded areas known as synaptic glomeruli. Smaller nerve cells, called tufted cells and granular cells, also synapse with the mitral cells. The olfactory bulb, in addition, receives axons from the contralateral olfactory bulb through the olfactory tract. Olfactory Tract this narrow band of white matter runs from the posterior end of the olfactory bulb beneath the inferior surface of the frontal lobe of the brain. It consists of the axons of the mitral and tufted cells of the bulb and some centrifugal fibers from the opposite olfactory bulb. As the olfactory tract reaches the anterior perforated substance, it divides into medial and lateral Optic Tract the optic tract emerges from the optic chiasma and passes posterolaterally around the cerebral peduncle. Most of the fibers now terminate by synapsing with nerve cells in the lateral geniculate body, which is a small projection from the posterior part of the thalamus. A few of the fibers pass to the pretectal nucleus and the superior colliculus of the midbrain and are concerned with light reflexes. The lateral stria carries the axons to the olfactory area of the cerebral cortex, namely, the Lateral Geniculate Body the lateral geniculate body is a small, oval swelling projecting from the pulvinar of the thalamus. It consists of six layers of cells, on which synapse the axons from the optic tract. The axons of the nerve cells within the geniculate body leave it to form the optic radiation. The medial olfactory stria carries the fibers that cross the median plane in the anterior commissure to pass to the olfactory bulb of the opposite side. The periamygdaloid and prepiriform areas of the cerebral cortex are often known as the primary olfactory cortex. The entorhinal area (area 28) of the parahippocampal gyrus, which receives numerous connections from the primary olfactory cortex, is called the secondary olfactory cortex. These areas of the cortex are responsible for the appreciation of olfactory sensations. Note that in contrast to all other sensory pathways, the olfactory afferent pathway has only two neurons and reaches the cerebral cortex without synapsing in one of the thalamic nuclei. The primary olfactory cortex sends nerve fibers to many other centers within the brain to establish connections for emotional and autonomic responses to Optic Radiation the fibers of the optic radiation are the axons of the nerve cells of the lateral geniculate body. The tract passes posteriorly through the retrolenticular part of the internal capsule and terminates in the visual cortex (area 17), which occupies the upper and lower lips of the calcarine sulcus on the medial surface of the cerebral hemisphere. The visual association cortex (areas 18 and 19) is responsible for recognition of objects and perception of color. They converge on Four neurons conduct visual impulses to the visual cortex: (1) rods and cones, which are specialized receptor neurons in the retina; (2) bipolar neurons, which connect the rods and cones to the ganglion cells; (3) ganglion mebooksfree. In binocular vision, the right and left fields of vision are projected on portions of both retinae. The image of an object in the right field of vision is projected on the nasal half of the right retina and the temporal half of the left retina. In the optic chiasma, the axons from these two retinal halves are combined to form the left optic tract. The lateral geniculate body neurons now project the complete right field of vision on the visual cortex of the left hemisphere and the left visual field on the visual cortex of the right hemisphere. The lower retinal quadrants (upper field of vision) project on the lower wall of the calcarine sulcus, while the upper retinal quadrants (lower field of vision) project on the upper wall of the sulcus. Note also that the macula lutea is represented on the posterior part of area 17, and the periphery of the retina is represented anteriorly. Visual Reflexes Several unique neuronal pathways exert involuntary control over our vision for optimal visual function, protection, and cognitive processing. The constriction of the pupil on which the light is shone is called the direct light reflex; mebooksfree. The afferent impulses travel through the optic nerve, optic chiasma, and optic tract. Here, a small number of fibers leave the optic tract and synapse on nerve cells in the pretectal nucleus, which lies close to the superior colliculus. The impulses are passed by axons of the pretectal nerve cells to the parasympathetic nuclei (Edinger-Westphal nuclei) of the third cranial nerve on both sides. Here, the fibers synapse and the parasympathetic nerves travel through the third cranial nerve to the ciliary ganglion in the orbit. Finally, postganglionic parasympathetic fibers pass through the short ciliary nerves to the eyeball and the constrictor pupillae muscle of the iris. The fibers that cross the median plane do so close to the cerebral aqueduct in the posterior commissure. When the eyes are directed from a distant to a near object, contraction of the medial recti brings about convergence of the ocular axes; the lens thickens to increase its refractive power by contraction of the ciliary muscle; and the pupils constrict to restrict the light waves to the thickest central part of the lens. From here, cortical fibers descend through the internal capsule to the oculomotor nuclei in the midbrain. Some of the descending cortical fibers synapse with the parasympathetic nuclei (Edinger-Westphal nuclei) of the third cranial nerve on both sides. Here, the fibers synapse, and the parasympathetic nerves travel through the third cranial nerve to the ciliary ganglion in the orbit. The facial nerve and its branches supply the orbicularis oculi muscle, which causes closure of the eyelids. Afferent impulses from the the automatic scanning movements of the eyes and head that are made when reading, the automatic movement of the eyes, head, and neck toward the source of Main sensory nucleus of trigeminal nerve I. The visual impulses follow the optic nerves, optic chiasma, and optic tracts to the superior colliculi. Here, the impulses are relayed to the tectospinal and tectobulbar (tectonuclear) tracts and to the neurons of the anterior gray columns of the spinal cord and cranial motor nuclei. Oculomotor Nerve Course the oculomotor nerve emerges on the anterior surface of the midbrain. It then continues into the middle cranial fossa in the lateral wall of the cavernous sinus. The afferent sensory fibers are believed to have connections with the efferent preganglionic sympathetic neurons in the lateral gray columns of the first and second thoracic segments of the spinal cord. The white rami communicantes of these segments pass to the sympathetic trunk, and the preganglionic fibers ascend to the superior cervical sympathetic ganglion. The postganglionic fibers pass through the internal carotid plexus, long ciliary nerves, and short ciliary nerves to the dilator pupillae muscle of the iris. Oculomotor Nerve Nuclei the oculomotor nerve has two motor nuclei: (1) the main motor nucleus and (2) the accessory parasympathetic nucleus. The main oculomotor nucleus is situated in the anterior part of the gray matter that surrounds the cerebral aqueduct of the midbrain. The nucleus consists of groups of nerve cells that supply all the extrinsic muscles of the eye except the superior oblique and the lateral rectus. The outgoing nerve fibers pass anteriorly through the red nucleus and emerge on the anterior surface of the midbrain in the interpeduncular fossa. The main oculomotor nucleus receives corticonuclear fibers from both cerebral hemispheres. It also supplies, through its branch to the ciliary ganglion and the short ciliary nerves, parasympathetic nerve fibers to the following intrinsic muscles: the constrictor pupillae of the iris and ciliary muscles. Therefore, the oculomotor nerve is entirely motor and is responsible for lifting the upper eyelid; turning the eye upward, downward, and medially; constricting the pupil; and accommodating the eye. Trochlear Nerve Nucleus the trochlear nucleus is situated in the anterior part of the gray matter that surrounds the cerebral aqueduct of the midbrain. It lies inferior to the oculomotor nucleus at the level of the inferior colliculus. The nerve fibers, after leaving the nucleus, pass posteriorly around the central gray matter to reach the posterior surface of the midbrain. The trochlear nucleus receives corticonuclear fibers from both cerebral hemispheres. It also receives fibers from the medial longitudinal fasciculus, by which it is connected to the nuclei of the third, sixth, information from the visual cortex. It also receives fibers from the medial longitudinal fasciculus, by which it is connected to the nuclei of the fourth, sixth, and eighth cranial nerves. Trochlear Nerve Course the trochlear nerve, the most slender of the cranial and eighth cranial nerves. The accessory parasympathetic nucleus (Edinger- Westphal nucleus) is situated posterior to the main oculomotor nucleus. The axons of the nerve cells, which are preganglionic, accompany the other oculomotor fibers to the orbit. Here, they synapse in the ciliary ganglion, and postganglionic fibers pass through the short ciliary nerves to the constrictor pupillae of the iris and the ciliary muscles.

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Syndromes

• Chest x-ray
• Liver failure
• Being near the droplets or secretions from someone who sneezes, coughs, or has a runny nose
• Poor weight gain
• Chronic kidney disease
• Chest x-ray
• Neurological losses are treated according to the type and severity of function loss.
• Loss of muscle control in the lower legs and feet
• Significant scratching
• Children: 44 to 120

References

• Ciejek EM, Nordstrom JL, Tsai MJ, et al: Ribonucleic acid precursors are associated with the chick oviduct nuclear matrix, Biochemistry 21:4945n4953, 1982.
• Hsu YS, Hwu WL, Huang SF, et al. Niemann-Pick disease type C (a cellular cholesterol lipidosis) treated by bone marrow transplantation. Bone Marrow Transplant 1999;24:103.
• Nakeeb A, Pitt HA, Sohn TA, et al. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg. 1996;224(4):463-473.
• Stavem K, Aaser E, Sandvik L, Bjornholt JV, Erikssen G, Thaulow E, et al. Lung function, smoking and mortality in a 26 year followup of healthy middle aged males. Eur Respir J 2005; 25(4):618-25.
• O'Donoghue M, Boden WE, Braunwald E, et al: Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: A meta-analysis. JAMA 2008;300:71-80.
• Tran DT, Newton EK, Mount VA, Lee JS, Wells GA, Perry JJ. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2015;(10):CD002788.
• Vandoninck V, van Balken MR, Finazzi Agro E, et al: Percutaneous tibial nerve stimulation in the treatment of overactive bladder: urodynamic data, Neurourol Urodyn 22(3):227n232, 2003.