Typical patient complaints include postprandial vomiting or bloating 5 medications post mi order secnidazole 1gr free shipping, appetite and weight loss medicine you take at first sign of cold 1gr secnidazole visa, and abdominal distention treatment menopause discount secnidazole 500 mg line. Gastric aspiration after an overnight fast typically yields more than 200 mL of food residue or clear fluid contents medicine to treat uti buy secnidazole 1 gr fast delivery. Conservative measures (as in routine ulcer therapy) are indicated in most cases of obstruction medications with sulfur best secnidazole 1gr. Patients with marked obstruction may require continuous gastric suction with careful monitoring of fluid and electrolyte status oxygenating treatment secnidazole 500mg without prescription. A saline load test may be performed after 72 hrs of continuous suction to test the degree of residual obstruction medications similar to xanax 500 mg secnidazole for sale. Aspiration is performed at least daily for the next few days to monitor for retention and to guide dietary modifications as the patient progresses to a full regular diet medicine guide secnidazole 1 gr otc. Affecting about 10% of patients who have undergone partial gastrectomy, this disorder is characterized by rapid gastric emptying. However, intestinal exposure to hypertonic chyme may play a key role by triggering rapid shifts of fluid from the plasma to the intestinal lumen. The patient may experience weakness, dizziness, anxiety, tachycardia, flushing, sweating, abdominal cramps, nausea, vomiting, and diarrhea. The patient usually is advised to eat six small meals of high protein and fat content and low carbohydrate content. Other postsurgical complications include reflux gastritis, afferent/blind loop syndrome, stomal ulceration, diarrhea, malabsorption, early satiety, and iron-deficiency anemia. Ulcers that fail to heal on a prolonged course of drug treatment should not be confused with ulcers that recur after therapy is stopped. Fasting plasma gastrin concentration should be measured to exclude ZollingerEllison syndrome. Available data indicate that only maximum acid inhibition, with a regimen such as omeprazole (20 mg twice a day) or lansoprazole (30 mg twice a day), offers advantages over continued therapy with standard antiulcer regimens. Despite healing after withdrawal of therapy, 70% of ulcers recur in 1 year, and 90% in 2 years. Similarly, erosive esophagitis will recur in more than 80% of individuals within 1 year after discontinuation of antisecretory therapy. Candidates for long-term maintenance therapy include patients with serious concomitant diseases; four relapses per year; or a combination of risk factors, producing a more severe natural history of peptic disease. Study Questions Directions for questions 16: Each of the questions, statements, or incomplete statements in this section can be correctly answered or completed by one of the suggested answers or phrases. All of the following statements concerning antacid therapy used in the treatment of duodenal or gastric ulcers are correct except which one? As part of a comprehensive management strategy to treat peptic ulcer disease, patients should be encouraged to do all of the following except (A) decrease caffeine ingestion. A gastric ulcer patient requires close follow-up to document complete ulcer healing because (A) perforation into the intestine is common. All of the following provide acid suppression similar to omeprazole 20 mg every day except (A) dexlansoprazole 30 mg every day. Directions for questions 78: the questions and incomplete statements in this section can be correctly answered or completed by one or more of the suggested answers. When administered at the same time, antacids can decrease the therapeutic efficacy of which of the following drugs? A B C D E Sodium bicarbonate Aluminum hydroxide Calcium carbonate Magnesium hydroxide Propantheline 9. Correct statements concerning cigarette smoking and ulcer disease include which of the following? Though all agents are useful in the treatment of Helicobacter pylori, only the combination of rabeprazole with amoxicillin and clarithromycin for 7 days is correct. Antacids have been shown to heal peptic ulcers, and their main use in modern therapy is to control ulcer pain. Antacids should be taken 1 hr and 3 hrs after meals because the meal prolongs the acid-buffering effect of the antacid. If diarrhea becomes a problem with antacid use, an aluminum hydroxide product can be alternated with the antacid mixture; this takes advantage of the constipating property of aluminum. Because calcium carbonate causes acid rebound and constipation, its use should be avoided. Bland food diets are no longer recommended in the treatment of ulcer disease because research indicates that bland or milk-based diets do not accelerate ulcer healing. Studies show that patients can eat almost anything; however, they should avoid foods that aggravate their ulcer symptoms. The ulcer may respond to therapy; however, failure of the ulcer to decrease satisfactorily in size and to heal with therapy may suggest cancer. Doses of omeprazole 20 mg, dexlansoprazole 30 mg, pantoprazole 40 mg, and rabeprazole 20 mg administered once daily provide similar levels of acid suppression. All provide significantly better acid inhibition than ranitidine, even at doses of 150 mg twice a day or more. In addition to causing acid rebound, calcium carbonate, if taken with milk and an alkaline substance for long periods, may cause milk-alkali syndrome. It also may cause adverse effects such as hypercalcemia, alkalosis, azotemia, and nephrocalcinosis. Propantheline, like other anticholinergic agents, may cause dry mouth, blurred vision, urinary retention, and constipation. Clinical studies have shown that smoking increases susceptibility to ulcer disease, impairs spontaneous and drug-induced healing, and increases the risk and rapidity of recurrence of the ulcer. Also, the accelerated emptying of stomach acid into the duodenum may predispose to duodenal ulcer and may decrease healing rates. The mean peak blood concentration of cimetidine and the area under the 4-hr cimetidine blood concentration curve were both reduced significantly when cimetidine was administered at the same time as an antacid. The absorption of ranitidine is also reduced when it is taken concurrently with an aluminummagnesium hydroxide antacid mixture. To avoid this interaction, the antacid should be administered 1 hr before or 2 hrs after the administration of cimetidine or ranitidine. Antacids may reduce mucosal binding of sucralfate, decreasing its therapeutic efficacy. These symptoms are associated with various changes in bowel habits, predominantly diarrhea or constipation, though some cases experience both or alternate between the two. In addition to urgency, bloody stool, and mucus in the stool can also gradually increase. Further, there may be patterns of symptoms, which relate to disease location as well as type (inflammatory, fibrostenotic, or fistulizing for example), which can be useful in determining therapy decisions. Other common presenting complaints are pain, bloating, rectal urgency, and incontinence. Rates for southern Europe, Asia and Central/South America have been reported to be lower than those seen in North America and northern Europe. Rates in southern Europe have recently seen increasing incidence rates compared to historical rates. This difference has been shown to decrease as underdeveloped areas are developed and a more western diet is adopted. Diseases of the Bowel: Inflammatory Bowel Disease and Irritable Bowel Syndrome 909 6. Left-sided colitis: Disease starting at the rectum and extending retrograde to the splenic flexure of the colon. Backwash ileitis: Inflammation of the terminal ileum due to retrograde flow of colonic contents in pancolitis patients 2. There is clear evidence of immune system activation with subsequent infiltration of the tissue by lymphocytes, macrophages, and other cells. The exact trigger of this apparent poorly regulated immune response has yet to be defined. Regardless of cause there appears to be failure of normal suppressor mechanisms with a resultant overly vigorous and abnormally long immune response to a disease trigger. Differential diagnosis includes bacterial, protozoal, and viral pathogens (notably Clostridium difficile, fungal, protozoal, viral, and helminthic pathogens). Other possibly confounding diseases include endometriosis and diverticular disease. With longer disease history, the colon may begin to become featureless and tubular in nature. Inflammation and subsequent injury of tissue known as cryptitis leads to crypt abscess and subsequently focal aphthoid ulceration. The inflammatory process can progress with influx and proliferation of macrophages and other inflammatory cells. Abnormal increases in frequency and amplitude of contractions can lead to functional constipation while diminished motor function of the underlying musculature can lead to diarrhea. Hypersensitivity to normal amounts of intraluminal distention exists, as does a heightened perception of pain in the presence of normal quantity and quality of intestinal gas. Diseases of the Bowel: Inflammatory Bowel Disease and Irritable Bowel Syndrome 911. The caloric density of food intake may increase the magnitude and frequency of myoelectrical activity and gastric motility. The first few days of menstruation can lead to transiently elevated prostaglandin E2, resulting in increased pain and diarrhea. Most patients will present with symptoms related to altered stool frequency, bowel sensation, and abdominal pain. Many patients present with acute symptoms mimicking appendicitis or intestinal obstruction. While not well correlated in controlled trials, stress is often implicated by patients and family members as a contributing factor. A significant number of patients have a history of perianal disease, especially fissures and fistulas, which are sometimes the most prominent or even initial complaint. Patient presentation is highly variable with regard to intensity, location, and duration of pain. They include diarrhea, constipation, mixed, and alternating diarrhea and constipation. While total prevalence numbers remain relatively constant, studies of defined patient populations at various periods show the same number of active patients, but the individual patients may be different. It has been characterized by right lower quadrant pain, diarrhea, and can mimic acute appendicitis. Pain can be colicky and usually precedes defecation and is relieved by defecation. Extensive inflammation can lead to loss of absorptive surfaces with resultant malabsorption and steatorrhea. This malabsorptive state can lead to dietary deficiency, hypoalbuminemia, electrolyte imbalances, coagulopathy, and increased risk of bone fractures. It is not normally used in clinical practice but is extensively used in clinical research. Sigmoidoscopy and colonoscopy are done to visualize the bowel when clinically appropriate to exclude other possible diagnoses. Newer agents (enteric-coated mesalamine, olsalazine, balsalazide) have been developed to allow dosing without the sulfapyridine moiety, which has been implicated in many of the common adverse events and intolerances to sulfasalazine. Sulfasalazine is considered by many to be the first choice due to longer history of use, more convincing clinical trial data, and lower cost. Intolerance of the sulfapyridine moiety of sulfasalazine is common and is implicated in many adverse events associated with sulfasalazine. Sulfasalazine can interfere with the absorption of folic acid, thus it is advisable for such patients to take folic acid supplements. Rarely more serious side effects such as hepatotoxicity or acute or chronic renal injury have been reported. The aminosalicylates may increase risk of toxicity and leukopenia when given in combination with mercaptopurine by decreasing mercaptopurine clearance. Concomitant use of antacids or acid lowering agents may affect release characteristics of some of the formulations. Steroid dependency, when a patient is unable to be tapered completely off of steroids, does occur and should not be confused with maintenance. The rectally delivered topical formulations of steroids are of particular use in left-sided disease. Budesonide (Entocort) is an oral steroid delivered in a controlled release formulation which acts in a topical manner owing to very high first-pass metabolism by the liver. The anti-inflammatory effects are likely due to glucocorticoid suppression of proinflammatory cytokines. Topical delivery and targeted delivery of low bioavailability steroids have been developed to reduce the risk of adverse effects. Consensus on the value of monitoring of metabolite levels during therapy has not been reached. Monitoring complete blood counts 4 weeks after starting therapy and then monthly during Diseases of the Bowel: Inflammatory Bowel Disease and Irritable Bowel Syndrome 917 therapy should be done to monitor for toxicity. Methotrexate is a folate analog and inhibits dihydrofolate reductase with multiple modes of anti-inflammatory effects. Methotrexate is a known teratogen and should be avoided or used with extreme caution in patients of child-bearing age (female and male) and only when all other therapies have been ineffective and the patients understand the risks involved. The most common risks are rash, nausea, pneumonitis or Mycoplasma pneumonia, and elevated serum transaminases. Both cyclosporine and tacrolimus are calcineurin inhibitors and are potent inhibitors of T-lymphocyte activation. Before therapy is initiated, patients should be screened for potential drug interactions, normal renal function, cholesterol levels, blood pressure, and electrolyte status to help avoid toxicity. A steroid taper is also started at 3 to 4 months and should be done over 4 to 8 weeks. Cyclosporine and tacrolimus both have short- and longterm adverse events that can be serious. Patients should be closely monitored for effects on blood pressure, electrolytes, renal function, and cholesterol. Cyclosporine and tacrolimus are substrates of cytochrome P4503A4 and P-glycoprotein enzymes. Significant and harmful alterations in cyclosporine and tacrolimus blood concentrations have been described as a result of concomitant administration of drugs that are also substrates or modifiers of these enzymes. Cyclosporine has been noted to increase methotrexate and methotrexate metabolite concentrations. Natalizumab was made available again in 2006 via a restrictive company administered access program. Place in therapy is yet to be fully elucidated and the benefit must clearly outweigh the risks. A fourth biologic agent, natalizumab (Tysabri), is a humanized monoclonal antibody directed at 4-integrin on the surface of white blood cells. Adalimumab is a recombinant human IgG1 monoclonal antibody with human heavy and light chain variable regions and human IgG1:k constant regions. Dosing and administration (1) Infliximab initial dosing is 5 mg/kg in a three-dose induction regimen of day 0, 2, and 6 weeks. Duration of therapeutic effect appears to be 8 to 10 weeks and dosing every 8 weeks has been advocated following a response to initial dosing. These immunosuppressant drugs have not been shown to improve clinical disease control when given concomitantly with infliximab. Formation of anticertolizumab antibodies has been reported in 8% of certolizumab treated patients. Diseases of the Bowel: Inflammatory Bowel Disease and Irritable Bowel Syndrome 919 c. Risk of such a reaction is greater (22%) with infliximab use than with adalimumab (1%) or certolizumab (rare). Patients should be tested for tuberculosis prior to use of these agents and their use should be avoided or discontinued in the case of active infections. Binding of the 4-integrin protein by natalizumab effectively interrupts normal leukocyte trafficking across endothelial layers to areas of inflammation. More serious adverse effects include increased risk of opportunistic infections and acute hypersensitivity reactions. Patients are to be monitored closely for symptoms so that natalizumab may be discontinued. While few clinical trials and a recent meta-analysis indicate potential benefit, design limitations temper the strength of those findings. Metronidazole has been useful in patients suffering from pouchitis postbowel resection surgery that involves formation of a pouch. Prebiotics are orally administered substances like nondigested carbohydrates with the goal of facilitating growth of commensal gut flora to displace possible antigenic microorganisms. All of these agents should be avoided in serious disease as they may further impair intestinal motility and increase risk of toxic megacolon. Antidepressants and anxiolytics have been used when specific patient symptoms warrant their use as adjuvant therapy. Patients with extensive disease (pancolitis) undergo colectomy more than patients with less extensive (distal) disease and also usually require colectomy sooner than patients with less extensive disease. A small leakproof opening is created in the abdomen wall, and the pouch is periodically drained. A tubular pouch is formed from the small intestine and attached to the preserved sphincters, which allows bowel movements without external bags or appliances.
Importantly symptoms 9 days after ovulation buy secnidazole 500mg on line, hypothermia may increase urine output421 and impair lactate clearance symptoms in dogs generic secnidazole 1gr without a prescription. Myoclonus is most common and occurs in 1825% medications given im order secnidazole 1gr without prescription, the remainder having focal or generalised tonicclonic seizures or a combination of seizure types medicine news cheap 500 mg secnidazole fast delivery. Other motor manifestations could be mistaken for seizures and there are several types of myoclonus medicine 0552 cheap 500mg secnidazole visa, the majority being non-epileptic treatment stye buy secnidazole 500mg low price. Seizures may increase the cerebral metabolic rate437 and have the potential to exacerbate brain injury caused by cardiac arrest: treat with sodium valproate symptoms of appendicitis 1 gr secnidazole with mastercard, levetiracetam symptoms ptsd generic secnidazole 500 mg, phenytoin, benzodiazepines, propofol, or a barbiturate. Temperature control A period of hyperthermia (hyperpyrexia) is common in the first 48 h after cardiac arrest. Animal and human data indicate that mild induced hypothermia is neuroprotective and improves outcome after a period of global cerebral hypoxia-ischaemia. The term targeted temperature management or temperature control is now preferred over the previous term therapeutic hypothermia. Whichever target temperature is selected, active temperature control is required to achieve and maintain the temperature in this range. Early cooling strategies, other than rapid infusion of large volumes of cold intravenous fluid, and cooling during cardiopulmonary resuscitation in the prehospital setting have not been studied adequately. As yet, there are no data indicating that any specific cooling technique increases survival when compared with any other cooling technique; however, internal devices enable more precise temperature control compared with external techniques. A careful clinical neurological examination remains the foundation for prognostication of the comatose patient after cardiac arrest. Suspend sedatives and neuromuscular blocking drugs for long enough to avoid interference with clinical examination. When residual sedation/paralysis is suspected, consider using antidotes to reverse the effects of these drugs. Based on expert opinion, we suggest waiting at least 24 h after the first prognostication assessment and confirming unconsciousness with a Glasgow motor score 34 K. For this reason, we recommend that prognostication should be multimodal whenever possible, even in presence of one of these predictors. Apart from increasing safety, limited evidence also suggests that multimodal prognostication increases sensitivity. Although awakening has been described as late as 25 days after arrest,485487 most survivors will recover consciousness within one week. It should at least include screening for cognitive impairments and for emotional problems, and the provision of information. All decisions concerning organ donation must follow local legal and ethical requirements, as these vary in different settings. Screening for inherited disorders is crucial for primary prevention in relatives as it may enable preventive antiarrhythmic treatment and medical followup. Most experts agree that such a centre must have a cardiac catheterisation laboratory that is immediately accessible 24/7 and the facility to provide targeted temperature management. Basic life support for those with a duty to respond the following sequence is to be followed by those with a duty to respond to paediatric emergencies (usually health professionals). Have a low threshold for suspecting an injury to the neck; if so, try to open the airway by jaw thrust alone. If jaw thrust alone does not enable adequate airway patency, add head tilt a small amount at a time until the airway is open. Look, listen and feel for no more than 10 s before deciding if you have any doubt whether breathing is normal, act as if it is not normal: 5A. If breathing is not normal or absent: · Carefully remove any obvious airway obstruction. Ensure that there is adequate head tilt and chin lift but also that the neck is not over-extended. If you are confident that you can detect signs of life within 10 s · Continue rescue breathing, if necessary, until the child starts breathing effectively on his own · Turn the child on his side (into the recovery position, with caution if there is a history of trauma) if he remains unconscious. The compression should be sufficient to depress the sternum by at least one third of the anterior-posterior diameter of the chest. To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where the lowest ribs join in the middle. Do not interrupt resuscitation until: · the child shows signs of life (starts to wake up, to move, opens eyes and to breathe normally). When to call for assistance It is vital for rescuers to get help as quickly as possible when a child collapses. Although abdominal thrusts have caused injuries in all age groups, the risk is particularly high in infants and very young children. For 18 year old, use attenuated pads if available, as explained in the section on Adult Basic Life Support and Automated External Defibrillation. There are several recovery positions; they all aim to prevent airway obstruction and reduce the likelihood of fluids such as saliva, secretions or vomit from entering into the upper airway. If one is unsuccessful, try the others in rotation until the object is cleared. Do not intervene at this point as this may move the foreign body and worsen the problem. These manoeuvres create an artificial cough, increasing intrathoracic pressure and dislodging the foreign body. If back blows fail to dislodge the object, and the child is still conscious, use chest thrusts for infants or abdominal thrusts for children. Do not attempt blind or repeated finger sweeps these could push the object deeper into the pharynx and cause injury. Assess the effectiveness of each breath: if a breath does not make the chest rise, reposition the head before making the next attempt. Paediatric advanced life support Assessment of the seriously ill or injured child the prevention of cardiopulmonary arrest In children, secondary cardiopulmonary arrests, caused by either respiratory or circulatory failure, are more frequent than primary arrests caused by arrhythmias. The topics of D and E are beyond the remit of these guidelines but are taught in paediatric life support courses. Summoning a paediatric rapid response team or medical emergency team may reduce the risk of respiratory and/or cardiac arrest in hospitalised children outside the intensive care setting but the evidence is limited on this point as the literature tends not to separate out the team response alone from the other systems in place to identify early deterioration. The assessment of a potentially critically ill child starts with the assessment of airway (A) and breathing (B). Even though the primary problem is respiratory, other organ systems will be involved to try to ameliorate the overall physiological disturbance. Circulatory failure is characterised by a mismatch between the metabolic demand by the tissues, and the delivery of oxygen and nutrients by the circulation. The transition from a compensatory state to decompensation may occur in an unpredictable way. This is a guide only and tubes one size larger and smaller should always be available. Uncuffed Premature neonates Full term neonates Infants Child 12 years Child >2 years Gestational age in weeks/10 3. Diagnosing cardiopulmonary arrest Signs of cardiopulmonary arrest include: · · · · Unresponsiveness to pain (coma) Apnoea or gasping respiratory pattern Absent circulation Pallor or deep cyanosis Palpation of a pulse is not reliable as the sole determinant of the need for chest compressions. Establish respiratory monitoring (first line pulse oximetry/peripheral oxygen saturation SpO2). End tidal carbon dioxide monitoring can also be used in non-intubated critically ill patients. Tracheal intubation is the most secure and effective way to establish and maintain the airway. In the conscious child, the judicious use of anaesthetics, sedatives and neuromuscular blocking drugs is essential to avoid multiple intubation attempts or intubation failure. Clinical examination and capnography should be used to ensure that the tracheal tube remains secured and vital signs should be monitored. A correctly sized cuffed tracheal tube is as safe as an uncuffed tube for infants and children (not for neonates) provided attention is paid to its placement, size and cuff inflation pressure. Displaced, misplaced or obstructed tubes occur frequently in the intubated child and are associated with an increased risk of death. A simple guide to deliver an appropriate tidal volume is to achieve normal chest wall rise. Once the airway is protected by tracheal intubation, continue positive pressure ventilation at 10 breaths min-1 without interrupting the chest compressions. Vascular access is essential to enable drugs and fluids to be given, and blood samples obtained. Isotonic crystalloids are recommended as the initial resuscitation fluid for infants and children with any type of circulatory failure. There are varying regimes of combining plasma, platelets and other blood products in delivering massive blood transfusion,588,589 so the regime used should be according to local protocols. Adrenaline (epinephrine) plays a central role in the cardiac arrest treatment algorithms for non-shockable and shockable rhythms. The use of single higher doses of adrenaline (above 10 g kg-1) is not recommended because it does not improve survival or neurological outcome after cardiopulmonary arrest. Atropine is recommended only for bradycardia caused by increased vagal tone or cholinergic drug toxicity. In bradycardia with poor perfusion unresponsive to ventilation and oxygenation, the first line drug is adrenaline, not atropine. Calcium is essential for myocardial function,599 but the routine use of calcium does not improve the outcome from cardiopulmonary arrest. Data from neonates, children and adults indicate that both hyper- and hypo-glycaemia are associated with poor outcome after cardiopulmonary arrest,603 but it is uncertain if this is causative or merely an association. Check blood or plasma glucose concentration and monitor closely in any ill or injured child, including after cardiac arrest. There is no evidence for giving magnesium routinely during cardiopulmonary arrest. There is no evidence for giving sodium bicarbonate routinely during cardiopulmonary arrest. Position the cardiac monitor leads or selfadhesive pads as soon as possible to enable differentiation between a shockable and a non-shockable cardiac rhythm. These rhythms are more likely after sudden collapse in children with heart disease or in adolescents. Most cardiopulmonary arrests in children and adolescents are of respiratory origin. Arrhythmias Unstable arrhythmias Check for signs of life and the central pulse of any child with an arrhythmia; if signs of life are absent, treat as for cardiopulmonary arrest. If the child has signs of life and a central pulse, evaluate the haemodynamic status. There is currently insufficient evidence to support or refute the use of vasopressin or terlipressin as an alternative to , or in combination with, adrenaline in any cardiac arrest rhythm in adults or children. Pad/paddle size for defibrillation Select the largest possible available paddles to provide good contact with the chest wall. Position of the paddles Apply the paddles firmly to the bare chest in the antero-lateral position, one paddle placed below the right clavicle and the other in the left axilla. In Europe we continue to recommend a dose of 4 J kg-1 for initial and subsequent defibrillation. Doses higher than 4 J kg-1 (as much as 9 J kg-1) have defibrillated children effectively with negligible side effects. Give 100% oxygen, and positive pressure ventilation if required, to any child presenting with bradyarrhythmia and circulatory failure. Cardiac pacing (either transvenous or external) is generally not useful during resuscitation. They can also be used in haemodynamically unstable children, but only if they do not delay chemical or electrical cardioversion. It is given by rapid, intravenous injection as close as practicable to the heart, and followed immediately by a bolus of normal saline. Ventricular tachycardia occurs most often in the child with underlying heart disease. There is little evidence to support any additional specific interventions that are different from the routine management of cardiac arrest; however, the use of resuscitative thoracotomy may be considered in children with penetrating injuries. Guidance on the termination of resuscitation attempts is discussed in the chapter on ethics in resuscitation and end-of-life decisions. Preparation A minority of infants require resuscitation at birth, but a few more have problems with this perinatal transition, which, if no support is given, might subsequently result in a need for resuscitation. Of those needing any help, the overwhelming majority will require only assisted lung aeration. A tiny minority may need a brief period of chest compressions in addition to lung aeration. Planned home deliveries Recommendations as to who should attend a planned home delivery vary from country to country, but the decision to undergo a planned home delivery, once agreed with medical and midwifery staff, should not compromise the standard of initial assessment, stabilisation or resuscitation at birth. Ideally, two trained professionals should be present at all home deliveries; one of these must be fully trained and experienced in providing mask ventilation and chest compressions in the newborn. Equipment and environment When a birth takes place in a non-designated delivery area, the recommended minimum set of equipment includes a device for safe assisted lung aeration and subsequent ventilation of an appropriate size for the newborn, warm dry towels and blankets, a sterile instrument for cutting and clamping the umbilical cord and clean gloves for the attendant and assistants. Timing of clamping the umbilical cord A systematic review on delayed cord clamping and cord milking in preterm infants found improved stability in the immediate postnatal period, including higher mean blood pressure and haemoglobin on admission, compared to controls. A similar delay should be applied to preterm babies not requiring immediate resuscitation after birth. Until more evidence is available, infants who are not breathing or crying may require the umbilical cord to be clamped, so that resuscitation measures can commence promptly. Temperature control Naked, wet, newborn babies cannot maintain their body temperature in a room that feels comfortably warm for adults. The association between hypothermia and mortality has been known for more than a century,675 and the admission temperature of newborn non-asphyxiated infants is a strong predictor of mortality at all gestations and in all settings. Initial assessment the Apgar score was not designed to be assembled and ascribed in order to then identify babies in need of resuscitation. If so, evaluate the rate, depth and symmetry of breathing together with any evidence of an abnormal breathing pattern such as gasping or grunting. Heart rate is initially most rapidly and accurately assessed by listening to the apex beat with a stethoscope679 or by using an electrocardiograph. A healthy baby is born blue but starts to become pink within 30 s of the onset of effective breathing. Tone A very floppy baby is likely to be unconscious and will need ventilatory support. Tactile stimulation Drying the baby usually produces enough stimulation to induce effective breathing. If the baby fails to establish spontaneous and effective breaths following a brief period of stimulation, further support will be required. Classification according to initial assessment On the basis of the initial assessment, the baby can be placed into one of three groups: 1. Breathing inadequately or apnoeic, normal or reduced tone, heart rate less than 100 min-1 Dry and wrap. This baby will usually improve with mask inflation but if this does not increase the heart rate adequately, may rarely also require ventilations. Breathing inadequately or apnoeic, floppy, low or undetectable heart rate, often pale suggesting poor perfusion Dry and wrap. Once this has been successfully accomplished the baby may also need chest compressions, and perhaps drugs. Newborn life support Commence newborn life support if initial assessment shows that the baby has failed to establish adequate regular normal breathing, or has a heart rate of less than 100 min-1. Airway Place the baby on his or her back with the head in a neutral position. The supine position for airway management is traditional but side-lying has also been used for assessment and routine delivery room management of term newborns. Meconium Lightly meconium stained liquor is common and does in general not give rise to much difficulty with transition. Intrapartum suctioning and routine intubation and suctioning of vigorous infants born through meconium stained liquor are not recommended. The presence of thick, viscous meconium in a non-vigorous baby is the only indication for initially considering visualising the oropharynx and suctioning material, which might obstruct the airway. Initial breaths and assisted ventilation After initial steps at birth, if breathing efforts are absent or inadequate, lung aeration is the priority and must not be delayed. If the heart rate increases but the baby is not breathing adequately, ventilate at a rate of about 30 breaths min-1 allowing approximately one second for each inflation, until there is adequate spontaneous breathing. Without adequate lung aeration, chest compressions will be ineffective; therefore, confirm lung aeration and ventilation before progressing to circulatory support. Some practitioners will ensure airway control by tracheal intubation, but this requires training and experience. Positive end expiratory pressure All term and preterm babies who remain apnoeic despite initial steps must receive positive pressure ventilation after initial lung inflation. The most effective technique for providing chest compressions is with two thumbs over the lower third of the sternum with the fingers encircling the torso and supporting the back. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it may be appropriate to consider stopping resuscitation. In cases where the heart rate is less than 60 min-1 at birth and does not improve after 10 or 15 min of continuous and apparently adequate resuscitative efforts, the choice is much less clear and firm guidance cannot be given. Withholding resuscitation It is possible to identify conditions associated with high mortality and poor outcome, where withholding resuscitation may be considered reasonable, particularly when there has been the opportunity for discussion with parents. When withdrawing or withholding resuscitation, care should be focused on the comfort and dignity of the baby and family. Use a 3:1 compression to ventilation ratio, aiming to achieve approximately 120 events per minute, i. When delivering chest compressions it would appear sensible to increase the supplementary oxygen concentration towards 100%.
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Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: an observational cohort study. Quality of cardiopulmonary resuscitation before and during transport in out-of-hospital cardiac arrest. Prehospital termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Making decisions to limit treatment in lifelimiting and life-threatening conditions in children: a framework for practice. Arch Dis Child 2015;100:s323 [Suppl 2], Published Online First: 19 February 2015. Sudden unexpected death in infancy: aetiology, pathophysiology, epidemiology and prevention in 2015. Partial do-not-resuscitate orders: a hazard to patient safety and clinical outcomes? An under-recognized benefit of cardiopulmonary resuscitation: organ transplantation. Cardiac arrest in the organ donor does not negatively influence recipient survival after heart transplantation. Utilization of donors who have suffered cardiopulmonary arrest and resuscitation in intestinal transplantation. Adult heart transplantation with distant procurement and ex-vivo preservation of donor hearts after circulatory death: a case series. Improving in-hospital cardiac arrest process and outcomes with performance debriefing. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom national cardiac arrest audit. Development and validation of risk models to predict outcomes following in-hospital cardiac arrest attended by a hospitalbased resuscitation team. Risk-standardizing survival for inhospital cardiac arrest to facilitate hospital comparisons. Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the national registry for cardiopulmonary resuscitation. Impact of resuscitation system errors on survival from in-hospital cardiac arrest. Quality management in resuscitation-towards a European cardiac arrest registry (EuReCa). For information on how accreditation can help your practice provide the best care possible to your patients, visit aahanet. Guidelines keep your hospital staff-from medical director to veterinary assistant-on the cutting edge of veterinary medicine. In addition, guidelines define the role of each staff member, so everyone on the health care team can work together to offer the best-quality medical care. Guidelines are just that-a guide established by experts in a particular area of veterinary medicine. Thank you for helping to advance our shared mission to deliver the best in companion animal medical care. Manufacturers of veterinary-specific products spend resources to have their products reviewed and approved by the U. These products are specifically designed and formulated for dogs and cats and have benefits for their use; they are not human generic products. Use oral fluids for patients with a functioning gastrointestinal system and no significant fluid imbalance. This route is not adequate for replacement therapy in anything other than very mild dehydration. Use intravenous or intra-osseous fluids for patients undergoing anesthesia; for hospitalized patients not eating or drinking normally; and to treat dehydration, shock, hyperthermia or hypotension. Consider starting the anesthetic procedure at 3 mL/kg/hr in cats and 5 mL/kg/hr in dogs. Fluid deficit calculation for dehydration: body weight (kg) x % dehydration = volume in liters to correct. See section on dehydration for more details on determining timeframe for replacement of deficit. In general, the choice of fluid is less important than the fact that it is isotonic. Staffing and monitoring y Provide staff training on assessment of patient fluid status, catheter placement and maintenance, use and maintenance of equipment related to fluid administration, benefits and risks of fluid therapy, and drug/fluid incompatibility. The assessment of patient history, chief complaint, physical exam findings, and indicated additional testing will determine the need for fluid therapy. Therapy must be individualized, tailored to each patient, and constantly re-evaluated and reformulated according to changes in status. Needs may vary according to the existence of either acute or chronic conditions, patient pathology. All patients should be assessed for three types of fluid disturbances: changes in volume, changes in content, and/or changes in distribution. The goals of these guidelines are to assist the clinician in prioritizing goals, selecting appropriate fluids and rates of administration, and assessing patient response to therapy. These guidelines provide recommendations for fluid administration for anesthetized patients and patients with fluid disturbances. Introduction these guidelines will provide practical recommendations for fluid choice, rate, and route of administration. They are organized by general considerations, followed by specific guidelines for perianesthetic fluid therapy and for treatment of patients with alterations in body fluid volume, changes in body fluid content, and abnormal distribution of fluid within the body. Therapy must be individualized and tailored to each patient and constantly re-evaluated and reformulated according to changes in status. Factors to consider include the following: y Acute versus chronic conditions y Patient pathology. General Principles and Patient Assessment the assessment of patient history, chief complaint, and physical exam findings will determine the need for additional testing and fluid therapy. Items of particular importance in evaluating the need for fluids are described in Table 1. Next, develop a treatment plan by first determining the appropriate route of fluid administration. Evidence-based support for specific recommendations has been cited whenever possible and appropriate. Other recommendations are based on practical clinical experience and a consensus of expert opinion. Because each case is different, veterinarians must base their decisions and actions on the best available scientific evidence, in conjunction with their own expertise, knowledge, and experience. These guidelines are supported by a generous educational grant from Abbott Animal Health. Using replacement solutions for short-term maintenance fluid therapy typically does not alter electrolyte balance; however, electrolyte imbalances can occur in patients with renal disease or in those receiving long-term administration of replacement solutions for maintenance. Well-hydrated patients with normal renal function are typically able to excrete excess Na and thus do not develop hypernatremia. Hypokalemia may develop in patients that receive replacement solutions for maintenance fluid therapy if they are either anorexic or have vomiting or diarrhea because the kidneys do not conserve K very well. Alternatively, fluid made up of equal volumes of replacement solution and D5W supplemented with K. Fluids and Anesthesia One of the most common uses of fluid therapy is for patient support during the perianesthetic period. Advantages of providing perianesthetic fluid therapy for healthy animals include the following: y Correction of normal ongoing fluid losses, support of cardiovascular function, and ability to maintain whole body fluid volume during long anesthetic periods y Countering of potential negative physiologic effects associated with the anesthetic agents. Current recommendations are to deliver 10 mL/kg/hr to avoid adverse effects associated with hypervolemia, particularly in cats (due to their smaller blood volume), and all patients anticipated to be under general anesthesia for long periods of time (Table 4). The paradigm of "crystalloid fluids at 10 mL/kg/hr, with higher volumes for anesthesia-induced hypotension" is not evidence-based and should be reassessed. Those high fluid rates may actually lead to worsened outcomes, including increased body weight and lung water; decreased pulmonary function; coagulation deficits; reduced gut motility; reduced tissue oxygenation; increased infection rate; increased body weight; and positive fluid balance, with decreases in packed cell volume, total protein concentration, and body temperature. For example, patients with uremia benefit from preanesthetic fluid administration. Assess excessive anesthetic depth first because it is a common cause of hypotension. Postanesthetic Fluid Therapy Postanesthetic fluid administration varies based on intra-anesthetic complications and comorbid conditions. Patients that may benefit from fluid therapy after anesthesia include geriatric patients and patients with either renal disease or ongoing fluid losses from gastrointestinal disease. Next, determine the fluid type based on replacement and maintenance needs as described in the following sections. Fluid therapy for disease falls into one or more of the following three categories: the need to treat changes in volume, content, and/or distribution. Typically, the goal is to restore normal fluid and electrolyte status as soon as possible (within 24 hr) considering the limitations of comoribund conditions. Once those issues are addressed, the rate, composition, and volume of fluid therapy can be based on ongoing losses and maintenance needs. Replace the deficit as well as normal and abnormal ongoing losses simultaneously. Accurate dosing is essential, particularly in small patients, to prevent volume overload. Monitor for a resolution of the signs that indicated the patient was in need of fluids (Table 1). Patients with a high risk of fluid overload include those with heart disease, renal disease, and patients receiving fluids via gravity flow. Their smaller blood volume, lower metabolic rate, and higher incidence of occult cardiac disease make them less tolerant of high fluid rates. Acute renal failure patients, if oliguric/anuric, may be hypervolemic, and if the patient ispolyuric they may become hypovolemic. Reassessment of response to fluid therapy will help refine the determination of which fluid compartment (intravascular or extravascular) has the deficit or excess. Subcutaneous fluids are best used to prevent losses and are not adequate for replacement therapy in anything other than very mild dehydration Hospitalized patients not eating or drinking normally, anesthetized patients, patients who need rapid and/or large volume fluid administration. Used in patients with a need for rapid and/ or large volume fluid administration, administration of hypertonic fluids and/or monitoring of central venous pressure D5W, 5% dextrose in water. Fluid deficit calculation Body weight (kg) % dehydration = volume (L) to correct General principles for fluid therapy to correct dehydration include the following: y Add the deficit and ongoing losses to maintenance volumes. Replace ongoing losses within 23 hr of the loss, but replace deficit volumes over a longer time period. The typical goal is to restore euhydration within 24 hr (pending limitations of comorbid conditions such as heart disease). Assess for euhydration, and avoid fluid overload through monitoring for improvement. Hypovolemia Hypovolemia refers to a decreased volume of fluid in the vascular system with or without whole body fluid depletion. Hypovolemia and dehydration are not mutually exclusive nor are they always linked. Hypotension may exist separately or along with hypovolemia and dehydration (Figure 1). Hypovolemic patients have signs of decreased tissue perfusion, such as abnormal mentation, mucous membrane color, capillary refill time, pulse quality, pulse rate, and/or cold extremity temperature. Hypovolemia due to decreased oncotic pressure is suspected in patients that have a total protein 35 g/L (3. Treating hypovolemia When intravascular volume expansion without whole blood is needed, use crystalloids, colloids, or both. High K administration rates may lead to cardiac arrest; therefore, do not exceed 0. In general, if 50% of the calculated shock volume of isotonic crystalloid has not caused sufficient improvement, consider either switching to or adding a colloid. The typical hydroxyethyl starch dose for the dog is up to 20 mL/kg/24 hr (divide into 5 mL/kg boluses and reassess). Simultaneously administering crystalloids and colloids y Use this technique when it is necessary to both increase intravascular volume (via colloids) and replenish interstitial deficits (via crystalloids). Administer the crystalloids at 4045 mL/kg in the dog and 2527 mL/kg in the cat, which is equivalent to approximately half the shock dose. Titrate to effect and continually reassess clinical parameters to adjust rate and type of fluid administered (crystalloid and/ or colloid). Using hypertonic saline y To achieve the greatest cardiovascular benefit with the least volume of infused fluids (typically reserved for large patients or very large volume losses). When to administer colloids y When it is difficult to administer sufficient volumes of fluids rapidly enough to resuscitate a patient and/or when achieving the greatest cardiovascular benefit with the least volume of infused fluids is desirable. Preparations vary, and some colloids are longer lasting than crystalloids (up to 24 hr). Direct effects of hypertonic saline last 3060 min in the vascular space before osmotic forces equilibrate between the intra and extravascular space. Once the patient is stabilized, continue with crystalloid therapy to replenish the interstitial fluid loss. Treating hypovolemia due to blood loss the decision of when to use blood products instead of balanced electrolyte solutions is based on the severity of estimated blood loss. Following 15 mL/kg of hemorrhage, even 75 mL/kg of crystalloid will not return blood volume to prehemorrhage levels because crystalloids are highly redistributed. Large volumes may be needed to achieve blood volume restoration goals, and large volumes may be detrimental to patients with normal whole body fluid volume but decreased vascular volume resulting from acute blood loss. Patients with body fluid content changes include those with electrolyte disturbances, blood glucose alterations, anemia, and polycythemia. It is acceptable, and often desirable, to initiate fluid therapy with an isotonic balanced crystalloid solution while awaiting the electrolyte status of the patient. Tailor definitive fluid therapy as the results of diagnostic tests become available. If life-threatening hyperkalemia is either suspected or present (K 6 mmol/L), begin fluid therapy immediately along with medical therapy for hyperkalemia. Volume expansion associated with the fluid administration results in hemodilution and lowering of serum K concentration. The relief of any urinary obstruction results in kaliuresis that offsets the effect of the administered K. The relative alkalinizing effect of the balanced solution promotes the exchange of K with hydrogen ions as the pH increases toward normal. Most K-containing balanced electrolyte solutions contain lower K concentrations than those typically seen in cats with urethral obstruction, so the use of such solutions does not affect blood K in those cats.
Translation like pronoun fails becomes interpretation the treatment 2014 buy secnidazole 500 mg fast delivery, imposition treatment kitty colds discount secnidazole 1 gr with mastercard, the transposition of one body on to an other not one treatment nail fungus order 1gr secnidazole fast delivery, not two: it multiplies with each border crossed or not crossed symptoms constipation secnidazole 500 mg online. There is always friction: meaning not like an object transported and dropped into a new place medications safe for dogs buy secnidazole 500mg visa, but meaning like skin it bears scars medicine zyrtec 1gr secnidazole, rips and tears treatment stye generic secnidazole 500mg visa, hydrated nourished and worn medicine engineering purchase secnidazole 500 mg overnight delivery. Enke edited the collection Transfeminist Perspectives in and beyond Transgender and Gender Studies (2012) and is working on a graphic novel titled ``With Finn and Wing: Growing Up Amphibious in a Nuclear Age. Kang, Tobaron Waxman, the Electronic Disturbance Theater, Chris Vargas, Cayden Mak, and Jacolby Satterwhite, have created works that express dimensions of transgender and gender-nonconforming experience while also transforming the relationship between the aesthetics, politics, and technologies of cultural representation. In their transmedia productions, bodies, images, sounds, materialities, politics, and informatics offer points of social contact and expressive meaning making rather than static representations and theories. These practitioners engage transmedia critically by paying attention to shifting networks of interrelated references, such as masculine and feminine, surface and essence, migrant and citizen; race, region, ethnicity, and nationality; urban, suburban, and rural; post- and nonindustrial; human, animal, plant, and thing. In the War of Desire and Technology at the Close of the Mechanical Age (1996), Stone explains how the act of listening to a public lecture by Stephen Hawking, amplified through microphone, computer, and speakers, can create a communicative intimacy that trespasses the presumed boundaries of the body and internal self. For Stone, communications technology and the gendered body itself are virtual ``prostheses' that provide zones of active social interaction, boundary shifting, and communicated meaning (ibid. In response to the epistemic violence of academic knowledge production, Stone has turned to performance as her primary medium of knowledge transmission, emphasizing the impact of sharing space, time, and physical presence in specific contexts (Stone 2010). This real-time action in performance produced a layered media insurgency that destabilized academic paradigms of knowledge production and ownership. Subversive transmedia exploits, undermines, and overwrites corporate uses of the same term by ``post'-industrial transnational Hollywood. As a commercial concept, transmedia describes contemporary media products that are created through models of production and for models of consumption that differ from mass industrial modes. Transmedia products are hybrids that cross and connect multiple media narrative threads, genres, and forms. They are produced, circulated, and consumed across interconnected media industries and technologies within the United States and transnationally. The hybrid products created through managed transnational media networks promise diverse yet coordinated entertainment experiences for different audiences-and greater profit for media corporations-through multiple avenues of consumption. New Zealand was an outsourced and economically incentivized filming location for Avatar. The location was also a source of labor and an ecological resource (the basis for the virtual world of Pandora) for the film. The interpenetration of media industries and technologies produces phantasmagorias, or simulated sensory connections between products that overload and alienate the senses so that consumption becomes passive (Buck-Morss 1991). A reclaimed transmedia approach recognizes that commercial intoxication relies on sustaining the out-of-world feeling of having been transported across space and time. Becoming aware of our participation in these time-space warps, or ``wormholing dynamics,' can jolt us out of sensory alienation (King 2012). Trans and genderqueer rebels mobilize transmedia to recover the deleted material conditions that have enabled the current technological and economic networking of media. What has been called the ``digital revolution' describes the transformation of late nineteenth- to mid-twentieth-century mass media technologies, including newspapers, magazines, radio, television, and film, by new media technologies that rely on computational devices and the Internet as a backbone for communicative networking (Chun and Keenan 2005). The shift from ``old' to ``new' media has helped to facilitate a broad transition from mass industrial economies based in manufacturing in the global North to a new global economy based on services, leisure, and entertainment. Critical transmedia approaches interrupt corporate and state narratives on the purely democratizing effects of new media and the new ``weightless' political economy that it has created. The ``virtual' network infrastructure does not only rely on conductors (cables, towers, satellites), nodes (connecting points, protocols, Downloaded from read. It also depends on a labor-intensive economy that includes creative work along with cassiterite mining, semiconductor manufacturing, the the production and laying of fiber-optic cables in regions of Africa, Latin America, and Asia (Ekine 2010). Revealing the hidden labor of the transnational bodies found on the integrated circuit is mandatory for a critical understanding of global media networks and commerce. Their/his research focuses on new strategies for transgender, queer, and gender and sexual nonconforming cultural activism at the turn of the twenty-first century, with the transition from cultural politics to cultural economies facilitated by networked media technologies. Lissette Olivares is a PhD candidate in the History of Consciousness Department at the University of California, Santa Cruz, where she investigates the role of new media in social movements from a transnational and transhistorical perspective. Almost any trans person can attest to the existence of it based on personal experiences or the experiences of acquaintances. And there is documented evidence of sexual violence, physical violence, and verbal harassment of trans people, and at least the self-reports of trans people indicate that such behavior often arises from hostile attitudes toward them as trans. However, the exact rates, nature, and extent of violence are difficult to determine, in part because there are no reliable statistics on how many trans people there are and because the various methods for collecting these data have specific limitations (Stotzer 2009). While it is clear transphobia exists, however, it is far from evident what transphobia is. Provisionally, the term can be defined to mean any negative attitudes (hate, contempt, disapproval) directed toward trans people because of their being trans. Transphobia occurs in a broader social context that systematically disadvantages trans people and promotes and rewards antitrans sentiment. It therefore has a kind of rationality to it, grounded in a larger cisgenderist social context (Hopkins 1996). In doing this, I have tried to avoid smuggling an actual account of the underlying nature of transphobia into the definition. If it is defined as ``those who violate gender norms,' or as ``those who are problematically positioned with respect to the gender binary,' then a very general account of the nature of transphobia is immediately forthcoming-namely, transphobia is a hostile response to perceived violations of gender norms and/or to challenges to the gender binary. It is not wise, however, to build a robust account of transphobia into the definition. A trans woman may not view herself as violating norms of gender, and Downloaded from read. Rather, she may see herself as a woman living within the binary and in accordance with norms of womanhood. A robust definition of this type ironically invalidates her gender identity in order to function as an account of transphobia. I therefore prefer to leave trans people undefined and open to the multiple, contested meanings. Consequently, while transphobia is provisionally defined, one of the central components of that definition (trans people) is not only undefined but left open to multiple interpretations. Underlying the attempt to build a robust account of transphobia within the definition of the term is the problematic assumption that there is a singular phenomenon of which there can be a uniform account. Consider that while the pronoun it can be used to deny the personhood of individuals deemed outside the binary categories, the expression really a man disguised as a woman effectively accuses a trans person of pretense by deeming them within one of the binary categories. Both are instances of verbal harassment, and both can function as ``justifications' for physical violence. But that the latter concerns a response to perceived violations of the binary is surely controversial. Whether there is a singular phenomenon here (hostile responses to perceived violations of the binary) is therefore far from clear. For example, Latin American representations of trans people as deceivers may include stronger associations with criminality (Lewis 2010). Indeed transphobia can occur differently in different types of social contexts within a culture. In therapeutic contexts it is not uncommon for trans people to be viewed as mentally ill. The view that ``mental illness' is the paradigmatic stigma elides different forms of stigma applied to trans people for whom access to medico-psycho-therapeutic narratives is irrelevant. And the controversial expectation that there is a single phenomenon is precisely what helps promote treatment of specific kinds of transphobia as somehow exemplary. Finally, the view that transphobia can be separated from other enactments of power (such as sexism, classism, racism) is a nonstarter. This means that not all acts of violence against trans people need be transphobic in nature. A trans woman might be targeted not because of her trans status but because she is simply viewed as a sex worker (Namaste 2005). Moreover, at least in some cases, transphobia may be inseparably blended with misogyny or racism in ways that challenge a single-axis model of power (Juang 2006). Such inseparabilities undermine the attempt to account for transphobia in a way that excludes or marginalizes considerations of sexism, racism, classism, ableism, and so forth. This consideration is important because it questions why certain instances of violence should Downloaded from read. My conclusion, at any rate, is that while we might have a definition of transphobia, the term is not much more than a convenient (and not altogether innocent) placeholder for the real intellectual work that remains to be done. Talia Mae Bettcher is a professor of philosophy at California State University, Los Angeles. Her research is located at the intersections of transgender studies and feminist philosophy. She is currently working on a book about the nature of gendered personhood and its relationship to transphobic violence. Some of her articles include ``Evil Deceivers and Make-Believers: On Transphobic Violence and the Politics of Illusion' (Hypatia, summer 2007) and ``Trapped in the Wrong Theory: Rethinking Trans Oppression and Resistance (Signs, winter 2014). With Ann Garry, she coauthored the Hypatia special issue ``Transgender Studies and Feminism: Theory, Politics, and Gender Realities' (summer 2009). While Hopkins discusses homophobia, not transphobia, his idea is useful in this context. Sex Change, Social Change: Reflections on Identity, Institutions, and Imperialism. Trans-poetic projects often seek to navigate the limits of the (im)possible, writing the ``resistance of the inarticulate, in a language that situates' (edwards 2013: 325) or lending poetic form to ``a body that has been historically illegible' (Shipley 2013: 197). Such projects may engage relations between the textual and the corporeal, between content and form, between ``signifiers and the world they configure' (Holbrook 1999: 753). An example of a trans-poetics relevant to transgender studies is one articulated in feminist translation studies regarding the inevitability and potentiality of error. As translation is imbricated with cultural/political oppressions, silences, repressions, and reiterations, the error produced in the discord between two languages offers clues to the limits of the self: within these errors one encounters and disrupts the boundaries between self and another (author, text, language) (Spivak 1993). In the context of gender performativity, error is also conceived as generative, as the imperfect iteration that allows for the possibility of the ``improper' (Butler 1993). A trans-poetics making use of both of these understandings of error draws on the discord, contingencies, and multiplicities possible in language in order to narrate and subvert cultural and critical attempts to fix gender and sexual boundaries. Rebekah Edwards teaches in the Departments of English and Women, Gender and Sexuality Studies at Mills College and Visual and Critical Studies at the California College of Arts. From the Latin specie -appearance, form, kind-species has long been Ї caught up in racisms, colonialisms, and sexual and gender norms. Trans species challenges these intersecting stories of nature that culture tells itself. Indeed, for many species, heterosexual sex is impossible, as with fungi whose thousands of sexes make of propagation a nonheterosexual flourishing. Trans species also describes connections integral to human processes of being and doing trans. Premarin, a hormonal treatment derived from the urine of pregnant mares and often used for human feminization, involves ``horses kept in cycles of gestation and impregnation so as to collect their urine' (Hayward 2010: 228); this entwining of bodies and violences makes many trans embodiments possible. Eva Hayward describes the ways in which ``a transitioning woman is enfleshing, enfolding elements of her environment within herself. Trans species reveals how these coconstitutive identities and ways of being happen through species differences. Imbricated ontologies and mutually constitutive identities reveal trans species as a mode of connection. Trans species promotes hybrid fruit and rhizomatic extensions that make new becomings possible, becomings that reveal intimacies inconceivable under the genus regime. Trans species is trans making, in that it demonstrates how the illicit tendrils of trans formations weave new webs that join multiple and diverse bodies and beings, making them kin in spite of kind. Harlan Weaver is a visiting research scholar at the Center for Science, Technology, Medicine, and Society at the University of California, Berkeley. Recent publications include ``Becoming in Kind: Race, Gender, and Nation in Cultures of Dog Fighting and Dog Rescue' (American Quarterly, September 2013) and ``Monster Trans: Diffracting Affect, Reading Rage' (Somatechnics, September 2013). It is an adjectival form of xenoestrogen: that is, an estrogen anthropocentrically and racially marked as ``foreign' or ``alien,' which includes those estrogens belonging to plants (phytoestrogens) and fungi (mycoestrogens) as well as various kinds of synthetic estrogens. The xenoestrogenic tangles with the more familiar rootstock of steroidal estrogens-estrone, estradiol, and estriol-that have come to define the female sex hormone. Trans- further concatenates the oversimplified alienations and -phobias connected to xeno- by enacting ``movements-across-into-strangeness' that foster new conjugations, allowing xenoto suggest alternate worldings rather than marking a discontinuous zone of incommensurable and inaccessible difference (King 2012). Trans-ing xeno- unsettles the oversimplified Others necessary for the production of stratification and Downloaded from read. Transxenoestrogenesis, a word with prefixes like nerve endings, recapitulates the syntax of sensate life folding over itself, invaginating itself, to encounter its own materiality. Used in the treatment of postmenopausal and post-hysterectomy symptoms, regulation of the female reproductive cycle, osteoporosis, ovarian failure, prostate cancer, and certain intersex conditions, Premarin also has been used transxenoestrogenically by transwomen following the now antiquated yet nevertheless still employed Standards of Care for hormonal transition issued by the World Professional Association for Transgender Health and its predecessor organization, the Harry Benjamin Gender Dysphoria Association. The manufacture of Premarin remains controversial, because it relies on the forced use, suffering, and dying of horses. Cramped in small stalls, kept indoors for six months of the year, mares are forcibly impregnated so that their urine can be collected for the manufacture of Premarin. Animal rights groups have protested these conditions, influencing policy and compelling changes in industrial practice that have benefited the well-being of horses exploited for Premarin production while not yet winning their liberation. Attending to the roots of conjugate, Donna Haraway notes that the ``yoking together' of ``molecules and species to each other in consequential ways' is fundamentally constitutive of Premarin (2012: 307). The cultivation and exploitation of equines has been built into the biopolitics of transwomen. Thus, historically, human bodies hormonally sex-transitioning from male to female have always been trans-species (``tranimal') bodies (Kelley 2014 [in this issue]). This is a more general state of affairs than commonly recognized, given that estrogens -produced by most vertebrates, some insects, and a number of plants- trans (an active verb, like queer) the boundaries of species, phyla, and kingdoms. For example, phytoestrogens in red clover (Trifolium prantense) affect testosterone levels in grazers, resulting in changes to herd fecundity. Premarin and its many xenoestrogenic kin found in foods, medicines, fertilizers, cosmetics, sanitary products, and other elements of material culture leak into habitats, environments, and ecosystems. They pass through the bodies of human consumers and nonhuman foodstuff animals into urine, milk, vomit, feces, and blood, seeping into septic waters and leeching into fields, fertilizing vegetal and bacterial growth, entering into new biochemical conjugations that make their ways into the bodies of others that, in turn, consume them. Rhetoric aside, polar bears, alligators, frogs, mollusks, fish, and birds are numbered among more than two hundred animal species around the world that are indeed already responding physically to hormone-altering xenoestrogenic pollutants in their environments (Ah-King 2013). Transestrogenic xenogenesis outpaces Darwinian natural and sexual selection and in so doing reinvigorates the promise of transgender politics. Sexual difference-already a ``difference engine' driving change-is monkey-wrenched by toxicity and pollution to propagate different differences rather than difference as usual (Chen 2012; Helmreich and Greenforst 2012). Neither utopic nor dystopic, transxenoestrogenesis invites the realization that bodies are lively and practical responses to environments that change over time, even when those environmental changes involve exposure to carcinogens, neurotoxins, asthmagens, and mutagens, to possibilities of cancer, diabetes, immune system failure, and heart disease. But where danger lies, promise might also be found: in the double binds of biochemistry, some phytoestrogens and mycoestrogens promote heart health and cancer prevention in humans; such is the emergent nature of the conditions of life and death. Transxenoestrogenesis, a purposely unmetabolizable term proposed as a key concept for a twenty-first-century transgender studies, can be characterized as a toxic, expressive, resilient, and ethico-politically problematic form of species symbiosis that undoes sex and embodiment as we know it. As much an environmental concern as a transgender one, transxenoestrogenesis is not a forecast of disaster but rather a reminder that we are already living in ruination. Transgender is noninnocent; xeno- still gives rise to -phobias; estrogens are unavoidable; genesis remains biblical, and Eden is dirty -Adam and Eve are increasingly undone as industrialism continues to release its effluvient progeny into our garden states. Things can get worse, and probably will; but life for earthlings is already precarious. Transxenoestrogenesis names but one form of our shared vulnerability to one another, our bodies open to the planet. Eva Hayward teaches in the College of Design, Architecture, Art, and Planning at the University of Cincinnati. An early version of the ``transgender umbrella' is found in a Human Rights Commission of San Francisco report on the Investigation into the Discrimination against Transgender People (Green 1994), a document drafted to educate city officials adjudicating a ``gender identity' civil rights ordinance. In the two past decades, the umbrella diagram has spread nationally (United States) and internationally to become a widely utilized educational tool. Given that its original purpose was for political advocacy, the image suggests sheltering trans-identified and gender-nonconforming individuals from the hard rain of discrimination. By gathering nonnormative sex and gender terms underneath its canopy, the umbrella visually casts an aggregative categorical imaginary that includes all sex/ual and gender-nonconforming identities and expressions. In so doing, the umbrella implies that all formations of sex and gender are not only possible but also taxonomically containable. While it draws upon the appearance of a ``natural' or ontologically prior grouping, the umbrella is produced through a classificatory imaginary that constitutes the population it purports simply to represent. The aggregating aspect of the transgender umbrella is predicated upon historically shifting understandings of the category transgender. This history is complicated because the term references both a specific identity and a consolidation of various sex- and gender-nonconforming individuals. Without this sense of political collectivity, it would not have been possible to visually render transgender as an umbrella instead of as a continuum of gender-nonconforming identities and behaviors or as a particular mode of being. The umbrella that sorts and classifies all sexual and gender nonconformity underneath a singular canopy is not without controversy. As anthropologist David Valentine argues, the very ``flexibility' of the category transgender constitutes its ``capacity to stand in for an unspecified group of people' and to encompass ``individual identity and simultaneously [to represent] gendered transgressions of many kinds' (2007: 39). Realignments of identities via this particular transgender imaginary can productively differentiate trans-identified people from those who are nontrans gay or queer. However, these same ``flexible' sorting practices sometimes obscure the specific intersections of classed, raced, geographic, and cultural dimensions of personhood. As anthropologist Megan Davidson explains: ``Different constructions of the category transgender, who it includes and excludes, are not simply negotiations of a collective identity but.
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