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The communication plan should be to alert the communities and attempt to establish communication with the dam itself by any means possible buy cheap cialis extra dosage 40mg impotence forum. You may need to assign a courier to make con- tact with the dam if there does not appear to be an open and reliable line of communication discount cialis extra dosage 50 mg with mastercard erectile dysfunction what kind of doctor. Ofcials of both the local communities and the central governments should be contacted at this time to notify them that you are giving the towns along the river notice to evacuate for safety generic 50 mg cialis extra dosage otc erectile dysfunction doctor atlanta. Tis would be a good point in time to notify the governments that you will need additional resources to evacuate the populous, and that there may be a need to send telecommunications engineers to the dam to reestablish communications. The couriers should be mobilized, and any type of telecommunication engineers to get limited communications back up and active are essential to the emergency management plan. In addi- tion, vehicles that can evacuate the population should be highly sought, as well as getting medical resources notifed and mobilized for potential patients. Stage 3 of the Disaster You have now been notifed that the Banqiao Dam has failed. You have also learned that the Shimantan Dam has failed, which is upstream of the Banqiao Dam, and has caused water to come rushing toward the Banqiao Dam (Watkins, 2012). Tese events have now been climaxed with 62 dams that have failed, causing 6 billion m³ of water to be released in total, which has caused a massive wave 6. You must fnd a way to evacuate all of the towns along all of the rivers as quickly as possible through whatever means possible. Any available helicopters for search and rescue will be needed since the food is so powerful and widespread. At this point you must communicate the evacuation order to all towns that could be impacted. In addition, you should contact all medical resources to mobilize them since those resources will now be needed. The government should be contacted to request any assistance in the form of search and rescue personnel and equipment. Structural engi- neers should be contacted to see if anything can be potentially done to block remaining water from escaping dams that have already failed by adding addi- tional barriers to the damaged areas. All search and rescue personnel and equipment should now be mobilized as well as medical resources and engineering support. You should begin to take an inventory of all facilities that can house medical resources as well as housing displaced residents. With such a large population, you will also need to fnd resources for food, water, sanitation, and medicine for those individuals. Stage 4 of the Disaster You have now learned that communications were completely inadequate or had failed completely. You have received word that signal fares were not seen, tele- graphs were never sent or completed in transmission, and several couriers were lost in the rush of water. In addition, other dams have failed or have been bombed by the military to reverse the water fow, communication lines are nonexistent, electricity has been lost over wide parts of the region, transportation lines have 68 ◾ Case Studies in Disaster Response and Emergency Management been completely severed, and you have over a million people who are isolated by foodwaters (Watkins, 2012; Navarro, 2008). After several days it has now been reported that over 200,000 are dead from the food, with several communities wiped from the face of the earth (Navarro, 2008; Watkins, 2012). You will need to get the million or so people out of the isolated area or get some type of transportation line open to them so that food and other supplies can be sent to them before famine occurs.

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Comparison of single and double balloon valvuloplasty in children with aortic stenosis buy cialis extra dosage 60 mg overnight delivery erectile dysfunction caused by hydrocodone. Balloon valvuloplasty for recurrent aortic stenosis after surgical valvotomy in childhood: immediate and follow-up studies order cialis extra dosage 50 mg free shipping impotence hypertension medication. Balloon dilatation of congenital aortic valve stenosis in infants and children: short term and intermediate results cheap cialis extra dosage 40 mg line erectile dysfunction treatment bangladesh. Independent predictors of immediate results of percutaneous balloon aortic valvotomy in children. Effectiveness of balloon valvuloplasty in the young adult with congenital aortic stenosis. Clinical and hemodynamic follow-up after percutaneous aortic valvuloplasty in the elderly. Early restenosis following successful percutaneous balloon valvuloplasty for calcific valvular aortic stenosis. Follow-up results of balloon aortic valvuloplasty in children with special reference to causes of late aortic insufficiency. Aortic valve reinterventions after balloon aortic valvuloplasty for congenital aortic stenosis intermediate and late follow-up. Twenty-five year experience with balloon aortic valvuloplasty for congenital aortic stenosis. Intermediate-term effectiveness of balloon valvuloplasty for congenital aortic stenosis. Surgical valvuloplasty versus balloon aortic dilation for congenital aortic stenosis: are evidence-based outcomes relevant? Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. In a series of 123 consecutive neonates and infants with severe aortic stenosis, balloon valvuloplasty was associated with decreased freedom from reintervention compared to surgical valvuloplasty, though mortality and longterm freedom from valve replacement were similar between groups. Repeat balloon aortic valvuloplasty effectively delays surgical intervention in children with recurrent aortic stenosis. Aortic valve morphology is associated with outcomes following balloon valvuloplasty for congenital aortic stenosis. Balloon dilation of severe aortic stenosis in the fetus: potential for prevention of hypoplastic left heart syndrome: candidate selection, technique, and results of successful intervention. Aortic valvuloplasty in the fetus: technical characteristics of successful balloon dilation. Fetal aortic valve stenosis and the evolution of hypoplastic left heart syndrome: patient selection for fetal intervention. Predictors of technical success and postnatal biventricular outcome after in utero aortic valvuloplasty for aortic stenosis with evolving hypoplastic left heart syndrome. Fetal intervention for critical aortic stenosis: advances, research and postnatal follow-up. Fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome: postnatal outcomes of the first 100 patients. Of 100 patients who underwent fetal aortic valvuloplasty, there were 88 live births, 38 of whom eventually received a biventricular repair. Fetal mortality was 11%, while valvuloplasty was technically successful in 77% of cases. Estimated survival of the entire fetal cohort was 75±5% at 5 years, with improved survival in patients with a technically successful valvuloplasty. Current perspective on aortic valve repair and valve-sparing aortic root replacement. Is there still a place for open surgical valvotomy in the management of aortic stenosis in children?

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If a probe passed through the fenestrations enters the right atrium cheap cialis extra dosage 60mg fast delivery erectile dysfunction dr mercola, the foramen ovale is considered patent trusted cialis extra dosage 40 mg erectile dysfunction. Several small thebesian veins drain directly into the left atrial cavity buy cialis extra dosage 200mg low price erectile dysfunction normal age, particularly along the septum. Comparison of the Atria With regard to the atrial septum, the limbus of the fossa ovalis is a feature of the right atrium, and the ostium secundum is characteristic of the left atrium (Fig. The free wall of the right atrium contains the crista terminalis and pectinate muscles, whereas that of the left atrium does not (Table 6. Although the superior vena cava and the pulmonary veins can anomalously join the contralateral atrium, the inferior vena cava almost invariably joins the morphologic right atrium. Thus, the distinguishing features of a morphologic right atrium are the limbus of the fossa ovalis, connection of the inferior vena cava, and a large pyramidal appendage. The limbus can be detected with four-chamber imaging, and the course of the inferior vena cava and the morphology of the atrial appendage can be assessed by either invasive or noninvasive imaging. Identification of the crista terminalis and pectinate muscles is possible by direct inspection at operation or autopsy but not consistently by imaging procedures. The annulus, leaflets, and commissures form the valvular apparatus, and the chordae tendineae (tendinous cords) and papillary muscles form the tensor apparatus. The annulus of each valve is somewhat saddle shaped rather than being truly planar and represents an ill-defined ring of fibrous tissue from which the leaflets arise. Although the mitral annulus is a continuous ring of collagen, the tricuspid annulus is not and exhibits loose connective tissue at the points of annular discontinuity. Consequently, ventricular dilation leads more readily to annular dilation of the tricuspid valve than of the mitral valve. During the first two decades of life, valvular growth correlates better with age than with body height, weight, or surface area (1). Owing to direct cordal insertions along their leading edges, the free edges have a serrated appearance. Tendinous cords also insert along the ventricular aspect of each leaflet (the valve pocket or undersurface) and thereby support the leaflet during ventricular systole. On the atrial aspect, the closing edge represents an ill-defined junction between the thinner body (or clear zone) and the thicker contact region (or rough zone) of the leaflet. During valve closure, apposing leaflets contact one another along the surfaces between the free and closing edges (Fig. In about 50% of fetuses and infants, blood cysts occur as small (<3 mm) purple nodules along the contact P. The membranous septum is located along its annulus (dashed line), at the anteroseptal commissure (arrow). B: The mitral valve has two leaflets, with papillary muscles beneath each commissure. C, D: In short-axis views, the tricuspid orifice is shaped like a reversed D at the annular level (C) and like a triangle at the midleaflet level (D). As shown in D, the anterior leaflet (arrow) of each valve is a midcavitary structure that divides its ventricle into inflow and outflow regions. A fibrous layer (fibrosa) forms the strong structural backbone of the valve and is continuous from the annulus proximally to the sites of cordal insertion distally. In contrast, the spongy layer (spongiosa) acts as a shock absorber and becomes prominent along the contact regions of each leaflet.

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Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study order 50mg cialis extra dosage amex erectile dysfunction treatment uk. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease cialis extra dosage 40mg visa impotence at 18. Heart rate response during exercise and pregnancy outcome in women with congenital heart disease purchase 100mg cialis extra dosage fast delivery zma impotence. Pregnancy and its outcome in women with and without surgical treatment of congenital heart disease. Risk factors and risk index of cardiac events in pregnant women with heart disease. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Prospective validation and assessment of cardiovascular and offspring risk models for pregnant women with congenital heart disease. Predicting the risks of pregnancy in congenital heart disease: the importance of external validation. Uteroplacental blood flow, cardiac function, and pregnancy outcome in women with congenital heart disease. Impact of pregnancy on the systemic right ventricle after a Mustard operation for transposition of the great arteries. Effect of pregnancy on clinical status and ventricular function in women with heart disease. Risk and predictors for pregnancy-related complications in women with heart disease. Atrial septal defect and pregnancy: a retrospective analysis of obstetrical outcome before and after surgical correction. Comparison of pregnancy outcomes in women with repaired versus unrepaired atrial septal defect. Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects. Non-cardiac complications during pregnancy in women with isolated congenital pulmonary valvar stenosis. Pregnancy outcome in women with congenital heart disease and residual haemodynamic lesions of the right ventricular outflow tract. Pregnancy in women with corrected tetralogy of Fallot: occurrence and predictors of adverse events. Fertility, pregnancy and delivery in women after biventricular repair for double outlet right ventricle. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Comparison of risk of hypertensive complications of pregnancy among women with versus without coarctation of the aorta. Obstetric and neonatal outcome after oocyte donation in 106 women with Turner syndrome: a Nordic cohort study. Increased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome. The immediate and long-term impact of pregnancy on aortic growth rate and mortality in women with Marfan syndrome. The Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. Expert consensus document on management of cardiovascular diseases during pregnancy.

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