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Magnetic resonance-based assessment of global coronary flow and flow reserve and its relation to left ventricular functional parameters: a comparison with positron emission tomography. Faster flow quantification using sensitivity encoding for velocity-encoded cine magnetic resonance imaging: in vitro and in vivo validation. Effects of exercise and respiration on blood flow in total cavopulmonary connection: a real-time magnetic resonance flow study. In vivo evaluation of Fontan pathway flow dynamics by multidimensional phase-velocity magnetic resonance imaging. Accurate noninvasive quantitation of blood flow, cross-sectional lumen vessel area and wall shear stress by three-dimensional paraboloid modeling of magnetic resonance imaging velocity data. Normal three-dimensional pulmonary artery flow determined by phase contrast magnetic resonance imaging. Magnetic resonance imaging evaluation of myocardial perfusion and viability in congenital and acquired pediatric heart disease. 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You need to start by communicating with the frst responders that are available and call up any volunteers that may be needed since many of your frefghters are already engaged in fghting blazes elsewhere generic 100 mg clomid with mastercard women's health center warner robins ga. In addition purchase clomid visa women's health clinic calgary ne, you need to start alerting residents to the danger of the fre that is sweeping through the city and prepare to evacuate residents in areas that are known to be at risk from the fre. Once the area of the fre has been identifed, several diferent initiatives can be tried to contain the fre. If water is available, it can be hosed on wooden structures in an attempt to prevent the fames from spreading. If water is not available, some wooden structures could be knocked down as a fre break in an efort to prevent the fames from spreading to another area of the city. Once it has been established where the fre is and how the fre is spreading, any available frefghters can be directed to tackle frst those blocks that are already on fre. Volunteers can be used to alert residents and help any evacuation process that would be required if the fre starts to spread to other neighborhoods. Medical personnel and medical assets also need to be mobilized for any incoming casualties. Stage 2 of the Disaster The fre has just jumped the river that divides your city and is currently burning on both sides of the river as well as engulfng several boats. Your citizens still do not appear to be too concerned about their well-being (Sheahan and Upton, 1871). Tis disaster will tax the resources of the city since the fre is now out of control on both sides of the river, several ships are on fre, and others are endangered. You need to start having your volunteers go door to door to get citizens to evacuate out of areas that are in the path of the fre. Since you have a river available, you may be able to route some of the water from the river into areas of your city to give you additional fre breaks as well as cut down the number of areas to which the fre can spread. With the fre on both sides of the river, it would probably be a calculated move to get some engineers and con- struction workers to channel water from the river to both sides of the city to limit the blaze. Stage 3 of the Disaster You have made calls to neighboring cities but your calls are not heeded by any of them (Sheahan, 1871). Since receiving assistance from other entities does not appear to be forthcoming, what will you do with the resources that you currently have under your control? Your displaced persons will need shelter, food, and water, so you will need to start mobilizing resources to gather assets that can provide those essentials to your citizens. At this point in the disaster you realize that you are on your own since no neighboring communities seem to be forthcoming with help. It would be a wise idea to continue to con- tact other cities and state government ofcials to acquire additional resources. With the fre spreading, you need to continue to gather intelligence on how many resources are available and how much of your city is on fre. Without having adequate intelligence, it is hard to dole out resources appropriately to contend with the blaze. You need to attempt to evacuate the people in certain sectors that positively can- not be saved. In addition, you need to start thinking about a strategic plan concerning which parts of the city can be saved so that you can funnel more resources to those areas. Stage 4 of the Disaster Your city’s water supply has just been cut of (Sheahan, 1871). Remember that water is just as critical for human survival as it is for fghting the fre. Tis would be a good point in the disaster to put your engineers and construction workers to work on rerouting the water lines so that your displaced persons have water to drink and your frefghters have water to put on the blaze. If the fre chief is not taking a leadership role, fnd someone in the fre department that is competent and willing to take charge. With no leadership, the fre department will become disillusioned and morale will begin to fail. In addition, attempt to funnel in any volunteers that can be found to help alleviate the manpower shortage in the fre department. Stage 5 of the Disaster Your frefghters are now out of water and have given up; you have a mass of citizens that are panicking and running across the bridge, jumping in the lake, and diving into the river (Sheahan, 1871). How do you regain control of the situation and what should you to do to evacuate the remaining endangered citizens successfully? Any frst responders that are avail- able should be sent to alleviate the pressure of a potential riot breaking out along the waterfront. Any ships that have not been damaged could be sum- moned to ferry displaced persons away from the city to safety. For the rest of the residents, you need to develop a means of safe passage for them out of the city. The biggest communication need at this point is to show the public that you are a leader and you are in charge. Try to keep the public as calm as possible and assure them that help is coming and that a safe passage will be opened for those that are not evacuated by way of the river. Any police that are available should be mobilized to assist in evacuation of citizens. Additionally, land transportation and any ships that are seaworthy should be mobilized to evacuate the citizens from the burning city. You decide that as mayor a declaration of martial law should be issued (Sheahan, 1871). What are the advantages and disadvantages to having an arrangement between the civilian government and the military? If assistance becomes available that appears to ofer resources that could help the situation, take advantage of the resource. The military has resources that can help get food and shelter to displaced citizens as well as getting citizens evacuated to safety. In addition, the military can provide a stabilizing presence that will instill some conf- dence in your citizens as well as provide support in manpower to your police and fre departments. You should begin to repair infrastructure to your city, which will allow citizens whose homes are still intact to return home. Stage 7 of the Disaster The fre has now died down due to a light rain that is falling and the wind has sub- sided as well. Your city now has 34 blocks reduced to absolute rubble (roughly a third of the city) (Long, 2008). The areas destroyed include your downtown areas, business district, upscale residences, and several harbor areas (Sheahan, 1871). You now have an additional problem on your hand—90,000 of your 300,000 residents are homeless (Jeter, 1997). As the chief administrator, what should your frst priorities be in the aftermath of the disaster? A high priority is to build temporary shel- ter and develop the logistics to provide food, water, and medicine to your displaced persons. The repairing of infrastructure should be completed by engineers and construction workers, and then the salvaging and clearing of ships from the river area so that supplies can arrive to support your citizens. Shelter, water, food, and medical resources for your displaced persons represent resources that could be provided by surrounding cities and organizations.

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In contrast to furosemide buy clomid with mastercard breast cancer grade 0, bumetanide is partially metabolized in the liver with approximately 50% excreted unchanged in the urine discount clomid 100 mg online menstruation quality. Thus, the dosage may need to be reduced in patients with clinically significant hepatic and/or renal dysfunction. The indications and potential complications are similar to those described for furosemide. Thiazide Diuretics Thiazides inhibit sodium and chloride transport in the distal convoluted tubule of the nephron. Thiazide diuretics have been available for many years and there is broad experience with these agents. Hydrochlorothiazide and chlorothiazide are the primary drugs in this class used in children with cardiovascular disease. They are close structural analogs with similar mechanism of action, diuretic efficacy, and side effects. Following oral administration, a diuretic effect is generally noted within 60 minutes and may persist as long as 12 to 24 hours. A thiazide diuretic is generally used for outpatient management of a chronically congested circulatory state, but may also be useful in the inpatient setting for patients with more advanced heart failure. In this situation, they may be used in combination with a loop diuretic and/or a potassium sparing agent. Adverse effects of thiazides include hypokalemia, hyperuricemia, and hypercalcemia. Nonrenal effects of thiazide diuretics that have been described in older patients and adults include carbohydrate intolerance and adverse effects on plasma cholesterol and triglycerides. The extent and implications of potential disturbances in cholesterol, lipoproteins, and triglycerides have not been determined in young children. Metolazone Metolazone is a sulfonamide derivative that blocks sodium reabsorption in the distal and proximal convoluted tubule. It exhibits several thiazide properties although it does not have a classic thiazide structure. In general, metolazone is reserved for short-term treatment of edematous states that are resistant to conventional therapy with loop diuretics or thiazides. The combination of metolazone and furosemide can be synergistic and promote marked diuresis (with associated electrolyte loss). The major adverse effects of metolazone include significant volume depletion and severe electrolyte disturbances. Potassium Sparing Diuretics Spironolactone is the prodrug of canrenone and therefore, bioactivation is required for drug action. The drug competitively inhibits aldosterone at the distal tubule and thus, reduces potassium loss in the urine. The diuretic effect of spironolactone is relatively weak compared with the loop or thiazide diuretics. In most cases, it is used in combination with either furosemide or hydrochlorothiazide predominantly for its potassium sparing effects. The major adverse effect of spironolactone is hyperkalemia which in most patients, is not a significant problem in the absence of excessive potassium intake (e. Similarly, if co- administration of a potassium supplement is necessary, serum potassium levels should be monitored carefully. Vasodilators Several vasodilators are available that encompass a broad spectrum of mechanisms, primary sites of action, efficacy, and toxicity (69,74,75). The major indications for the use of vasodilators in children with heart disease are impaired ventricular function, pulmonary hypertension, aortic valve regurgitation, and systemic hypertension. The selection of a specific drug depends upon the primary goal of therapy, underlying or associated conditions, and whether or not the treatment is acute or chronic in nature. One approach to classifying vasodilators groups the drug classes according to their major mechanism of action (Table 82. Knowledge of the mechanism of action of a given drug provides a framework for understanding the pharmacology and therapeutic applications. Another method is to group drugs according to their predominant site of action (predominately venous, arteriolar, or balanced; Table 82. Depending on the therapeutic goals, one may select an agent that has predominant effects on venous capacitance, arteriolar resistance, or both. Nitric Oxide Modifying Drugs Relaxation of vascular smooth muscle by drugs in this class is mediated by nitric oxide. Nitroglycerin Nitroglycerin relaxes smooth muscle in the cardiovascular, respiratory, and gastrointestinal systems. At the usual therapeutic concentrations, the predominant site of action is the venous vascular bed. Nitroglycerin therefore acts principally to increase venous capacitance, promoting a reduction in atrial and ventricular filling pressures. Nitroglycerin has been largely replaced by other agents, but is sometimes administered after cardiac surgery. At low doses there is little effect on systemic vascular resistance, systemic arterial pressure, or heart rate. However, higher doses can produce arteriolar dilation with hypotension and reflex tachycardia. Nitroglycerin is rapidly metabolized in the liver and must be given by continuous infusion. Nitroglycerin is a potent vasodilator that must be used with appropriate hemodynamic monitoring. Patients with decreased intravascular volume (low preload) may respond adversely to nitroglycerin because a further decline in filling pressure may significantly reduce cardiac output. Overdose causes hypotension and tachycardia, which respond quickly to a reduction in dose or cessation of the infusion. Nitroprusside Nitroprusside is an extremely potent vasodilator that reduces systemic and pulmonary vascular resistance and increases venous capacitance. It is used for treating hypertensive emergencies consequent to its potency, rapid onset of action, and titratable effects. Nitroprusside is occasionally administered to pediatric cardiac surgical patients in the immediate postoperative period. In addition, it may be effective acutely in children with left ventricular dysfunction and low cardiac output. With proper monitoring and dosing, nitroprusside appears to be safe and effective in neonates. While the precise relationships between cyanide or thiocyanate concentrations in plasma or red blood cells and clinical toxicity are not entirely clear, potential toxicity should be considered in patients with renal dysfunction who are receiving prolonged infusions of nitroprusside. Because of the rapid onset of action and rapid metabolism, the desired hemodynamic effect can be achieved by careful dose titration. The major adverse effects of nitroprusside are a direct extension of its powerful vasodilator activity. Careful hemodynamic monitoring is imperative in order to avoid significant hypotension.