Often super levitra 80mg sale erectile dysfunction fact sheet, lower eyelid laxity size trusted super levitra 80mg impotence by age, the laser power per unit of area decreases, facilitating can be associated with epiphora, which is usually related to careful and precise dissection of fat bags in a blood-free internal canthal insufficiency. When laxity is severe, a typical field, thanks to the laser energy coagulation effect. This situation is accompanied by watering signs of skin aging or pigmentation, laser resurfacing can be eyes due to difficulties in tear transit to the lacrimal duct practiced in a single pass to obtain skin tightening [15 ]. With these set- due to excessive skin removal, ignoring canthal tendon laxity tings and one or two passes, good results are achieved in and its necessary adequate repositioning. The incision extends to the orbital rim, and cient, and a partial section of the tendon may be necessary. In the case of the lower eyelid, the canthal tendon is band from the lower lid is cut with the laser, parallel to the attached to the fibers of the tarsus. Two dissec- fibers of the orbit are directed and held by the tendon, which tion levels are carried out: one external, including skin and Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1137 a c b d e F i g. This condition, when using laser resurfacing for skin skin has been tightened without worsening the scleral appearance 1138 M. The lower eyelids present an excellent the excess skin of the upper lids has been excised with the aid of the Co2 aesthetic outcome with adequate skin tension eliminate excess skin [17 ]. At the end of surgery, the lateral canthus should be checked for its correct position, which should be approxi- mately 2 mm over the horizontal level of the medial canthus, so that normal tear drainage can be recovered by the lacrimal punctum. To finish, the skin which continues the lateral can- thus is closed in two layers with 6-0 Vicryl™ (Fig. Anatomical aging changes are noticed in the symmetry and lateral canthi of both eyes. The lacrimal duct should be at a lower level than the Blepharoplasty lateral canthus. In the right eye, there is a mild ectro- well-established surgical procedure with benefits over the pion, and in the left eye, epiphora causes a constant weeping of the eye. When it comes to Fat bags are in the lower lids; however, the upper lid keeps its anatomi- cal design quite well. Complementary with pulses of 30 ms at the same power, deepithelization of brow elevation enhances this surgery, improving the surgical the tarsal internal level is performed to eliminate the con- outcome [19 ]. B ut, when dealing with eyebrow elevation, fixation of the Once this preliminary process is finalized, the length of soft tissue related to the forehead is still one of the least the tarsal band is checked to obtain a desirable tension and is controllable and least predictable stages of the surgery, espe- then attached to the orbit. Next, the tarsal band is sectioned, cially when eyebrow tail lifting is to be carried out [20 ]. In the right eye, the external canthal tendon was shortened by the exposure of bilateral sclera with slight epiphora and constant eye plication to raise the external canthus. In the lower eyelid, fat bags have been repositioned, Evident upper eyelid skin laxity and dermatochalasis which reduce his with the aim of giving volume and to avoid the sinking of the eye. The presence of fat bags in the lower eyelid and cutane- festoons were eliminated by excision and skin lifting. Excellent aes- gery, a good aesthetic result in the upper eyelid with removal of thetic rejuvenation results with high patient satisfaction mally invasive procedure with reduced surgical time. The Endotine™ surgical reabsorbable material lasts for a period of around 8–10 months, leaving fibrosis that anchors the eyebrow tail in its new elevated position. The implant is designed with three hooks which when in place, suspend the eyebrow. Surgery is done under local anesthe- sia, and the device is placed via the upper blepharoplasty incision. A blunt instrument is used to elevate the periosteum, sepa- rating it from the bone surface; then, the implant is placed fixing it directly to the bony part. Fixation is performed by introducing the implant pin into a surgically drilled, made-to-measure hole. The base of the implants main- tains good contact and adapts to the frontal bone, and eye- brows are elevated and engaged with the hooks incorporated in the absorbable device (Fig. The whole intervention is under local anesthe- days, to hold the implants in place (Fig. Trelles In only one surgical procedure, upper blepharoplasty and nicely rejuvenate the periorbital appearance (Fig. Low eyebrow elevation can be done, simplifying surgical aes- eyebrow position is corrected thanks to the Endotine™ thetic eyebrow lifting, avoiding specific procedures neces- implants which are also well indicated for those patients pre- sary for this surgery, as in the case of frontal or endoscopic senting moderate ptosis and for those who refuse to undergo lifting [22]. The combination of upper blepharoplasty and conventional surgery to lift the forehead (Fig. We use this treatment in various ses- sions, following our reported experience to enhance the condi- tion of stretch marks and improving skin appearance [25]. Striae distensae are a very common cutaneous lesion for which treatment remains a challenge. In the early stages, striae appear pink to red (striae rubra) b ut over time become atrophic and white (striae alba). Both stages of stretch marks represent a distension (distensae) of tissue fibers [26 ]. Histologies show that striae distensae are similar to scars with a thin flat epidermis, attenuation of the rete ridges, fray- ing and separation with loss of parallel orientation of colla- gen bundles, and dilated vessels [27 ]. Tissue changes are as a consequence of body weight changes, corticosteroid ther- apy, Cushing’s syndrome, infections, and hormonal factors such as puberty and pregnancy [28]. The patient is wearing the tape on the frontal area to exert pressure and keep forehead presenting this skin disorder. Eyebrow tails have been raised giving the whole face a better aesthetic appearance Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1141 b Fig. The skin’s texture has improved and stretch marks are less noticeable include glycolic and ascorbic acids and also two to three ses- marks are outlined using a pixel-based algorithm with computer- sions of 585 nm pulsed dye laser to decrease redness in the generated data, thanks to an operator-based edge detection pro- lesion and to stimulate collagen. The before and after condition of stretch marks in beneficial effects against stretch marks [29, 30 ]. However, the total disappearance of stretch marks is clinical improvement and collagen remodeling, as occurs in not expected, rather an improvement in the appearance of the the case of atrophic facial scars and fine wrinkles [31 ]. Favorable broadband pulsed light (Nova Plus; Nova Light, Switzerland) changes to skin condition are noticed from the third session and, in combination with light chemical peels and 585 nm pulsed according to our controls, maintained for 3–6 months. So, it is dye laser sessions helps against the multifactorial origin of advisable to recommend that patients undergo one or two main- stretch marks. As we have communicated, this treatment tenance sessions every 6 months to sustain the results achieved. Therefore, a combination of chemical We carry out four treatment sessions with an 800– peels and sessions of 585 nm flash pulsed dye laser enhances 1,800 nm band width at a fluence of 31 J/cm2. By adding these treatments, the microcontours of stretch light are delivered in a chopped mode as a series of mini marks are improved. Particularly, we find that the use of 20 % pulses to avoid skin burning and to safely build up a solid glycolic and 10 % ascorbic acid is an effective complement thermal deposit in tissue.

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The majority (78%) demonstrated no change in the leading edge of the prolapse between the first and the last visit generic 80mg super levitra with amex prostate cancer erectile dysfunction statistics, following which 63% still continued observation [32] purchase super levitra 80 mg line erectile dysfunction vitamin deficiency. Prevention can be classified as primary (interventions in asymptomatic individuals to reduce known risk factors for the development of a disease) or secondary (to detect symptoms at an early stage and to intervene to stop further development or to improve the prognosis of the condition). To stop recurrence of an illness or preventing it becoming chronic is tertiary prevention. There are known predisposing factors such as age, obesity, family history, parity/vaginal childbirth, and surgery. Identification of individuals at risk might help with implementing preventative measures. Although the prevalence of incontinence is increased in the elderly, the two do not necessarily have a cause-and-effect relationship; other pathological processes associated with aging might be responsible. Likewise, management of other risk factors such as chronic cough, smoking, and adjusting medication that has an adverse effect on the bladder could help incontinence (e. Regular toileting, easy access to toilets, restricting fluids (especially caffeine), and prevention of urinary tract infection, e. Menopause and Hormone Replacement Therapy There is a definite aging process in the lower urinary tract, resulting in atrophic change and poor urethral function. Urgency 126 Urgency is a distressing symptom for the older patient with restricted mobility, causing panic and anxiety on the sensation of bladder fullness. Often, patients void more frequently to prevent urgency incontinence, which can have the opposite effect, by reducing bladder capacity and worsening the symptoms. There is evidence that patients with urgency incontinence (more than once a week) are at increased risk of falls and bone fracture than in those without [48]. One study in morbidly obese women undergoing surgically induced weight loss showed subjective and urodynamic improvement in incontinence 1 year after surgery [55]. A randomized trial in 338 overweight and obese women found that a mean weight loss of 8% in the intervention group (vs. Familial and Genetic Factors Identification of risk groups is important and family history might be relevant. A small study in four pairs of postmenopausal identical twins with different parity status, i. Childbirth Vaginal birth probably has an important role in the pathogenesis of pelvic floor dysfunction. However, not all women develop pelvic floor problems following vaginal birth, suggesting that identifying “at- risk” groups might provide an opportunity for prevention [68]. Primigravidae with excessive bladder- neck mobility antenatally (a possible marker for weak pelvic floor collagen) appear to be at higher risk 127 of postpartum stress incontinence [69], itself a risk factor for long-term incontinence [10]. Antenatal and prepregnancy incontinence [11,13] family history of incontinence in pregnancy, obesity [53], and persistent postnatal incontinence [70] also appear to be important risk factors. However, this assumption might not be correct; pregnancy itself might also be responsible [76]. Identifying women at risk before or early in a first pregnancy might enable preventative measures to be introduced. Prevention Cesarean Section Identification of risk groups might help with prevention, but what this intervention should be is a matter of debate. Results from these studies provide evidence for patient counseling and careful planning of mode of delivery to prevent pelvic floor dysfunction. Various models for scoring risk factors have been proposed and are being validated to provide estimates of postpartum pelvic floor pathologies to facilitate decision making and prevention of pelvic floor trauma [84,85]. It seemed that the more intensive the program, the greater the treatment effect [86]. Longer-term studies with 6 and 8 years follow-up [93,94] and one review [95] have shown that the initial beneficial effect does not persist, probably due to poor compliance. However, the incontinence in those women was not severe enough to require surgery. For example, there is conflicting evidence regarding prolonged second stage of labor, birth weight, epidural, episiotomy, and mode of delivery. A Cochrane review has shown an increased association of maternal perineal trauma with forceps delivery [96]. The review also suggested a significantly more third- or fourth-degree tears (with or without episiotomy), vaginal trauma, and flatus incontinence with forceps [96]. However, as with all studies assessing episiotomy, the technique and angle are poorly described (see later). It would appear that prevention by changing obstetric practice is not possible with the current state of knowledge. However, it might be worthwhile considering earlier delivery (by cesarean section) in short stature primigravidae who have obstructed labor before full dilatation to prevent pelvic floor injury [28]. Despite repair, 30%–50% of affected women suffer from anal incontinence [102–104], and 40% will opt for a future elective cesarean section to avoid worsening of symptoms from a further vaginal birth [105,106]. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years; instrumental delivery (forceps and ventouse), especially without episiotomy; Asian ethnicity; a more affluent socioeconomic status; higher birth weight; and shoulder dystocia. The authors concluded that changes in risk factors were unlikely explanations for the observed increase and that this was likely due to better training and recognition. For example, the “overlap repair” for complete tears seems to be associated with a lower incidence of fecal urgency and deterioration of anal incontinence symptoms compared with “end-to-end” repair [110]. This is ongoing via excellent courses run throughout the world (Sultan A and Thakar R, personal communication). For example, fewer third- and fourth-degree tears have been seen following mediolateral episiotomy [111,112], whereas the risk is increased by midline episiotomy [113]. Standard obstetrics textbooks state that a mediolateral episiotomy should be performed at an angle of at least 40°, with most suggesting an angle of between 45° and 60°. However, two studies found that most doctors and midwives perform mediolateral episiotomies at a much lesser angulation [115,116]. A recent Cochrane review also failed to demonstrate any benefit of cesarean section in the prevention of anal incontinence and recommended that preservation of anal continence should not be used as a criterion for choosing elective primary cesarean delivery [122]. However, it might not be the particular instrument that is important, but the indications for the assisted delivery (e. For these women, secondary prevention might be achieved by elective cesarean section. Large retrospective studies using an anatomical rather than a physiological outcome, i. However, these findings have not been replicated by other equally large retrospective studies [131,132]. Further prospective long-term studies are required before elective cesarean section can be recommended for prevention in asymptomatic women. Many of these are due to congenital abnormalities and distortion of structures caused by disease [135]. Preoperative intravenous urography, intraoperative cystoscopy, and the use of ureteric catheters in potentially difficult cases might help prevent trauma to the urinary tract. In a systematic review, women over the age of 60 years who had undergone hysterectomy had a higher odds ratio compared with women less than 60 years [136].

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Micturition and the mind: Psychological factors in the aetiology and treatment of urinary disorders in women order super levitra 80 mg line erectile dysfunction freedom book. Consequences from these events directly and indirectly affect patients and their families and surgeons and their colleagues throughout the world wherever such events happen to occur order generic super levitra on line erectile dysfunction nutrition. Information about inpatient procedures is more readily available, but the quality and scope varies by location. Furthermore, data available from developed countries indicated that about half of surgical adverse events were deemed to have been preventable. Information is uneven and less readily available regarding outpatient surgery procedures performed worldwide. Global analysis as of February 2014 reported that the site of surgery has shifted over the past few decades from the inpatient to outpatient settings [2]. Outpatient surgical procedures in the United States has definitely increased, comprising about one-third of all surgical procedures in 2000 to more than half by the end of 2010 [3]. This trend is expected to continue albeit on a slower trajectory due to continued growth in the aging population and the proportion with high medical case complexity necessitating an inpatient surgery venue. Healthy patients deemed at low risk for adverse events are typically selected for outpatient procedures. However, more complex patients may be selected for outpatient surgery as less invasive techniques become available and economic factors, including changes in cost and reimbursement for health-care services, drive provision of services away from hospital inpatient settings. Similarly, the precise number of female urology and urogynecology inpatient operative procedures performed worldwide is not known. Where data are available, the rates of specific female urology and urogynecology surgical procedures appear to be on the rise. They projected that both the overall and age-adjusted rates would continue to increase over time since about 20% of the U. The exact number of female urology and urogynecology outpatient surgical procedures that are performed worldwide is also not known but appears to be growing. In the United States, Boyles and colleagues [6] found that female urinary incontinence procedures performed in the outpatient setting doubled between 1994 and 1996. Interest has been growing over the past decade to better define the role of surgical care among other global health priorities and its role in addressing the global burden of disease [9]. Given the volume of surgery estimated to take place 143 worldwide and the shift in the site of surgery from inpatient to outpatient settings, it would behoove surgeons of all specialties to understand how multiple factors can contribute to error such as factors related to cognition, fund of knowledge, clinical judgment, diagnostic problem-solving, and decision- making; technical skills, communication, and teamwork; supervision and documentation; administrative; and clinical systems and environment. It is imperative that surgeons of all specialties develop and master techniques for mitigating or preventing errors, resulting in adverse surgical events and patient harm across the continuum of surgical care. Fortunately, multiple efforts are underway worldwide to make healthcare safer for patients and clinicians [8,10,11]. This chapter will provide an overview of medical errors and adverse events and address multiple efforts aimed at preventing their occurrence or mitigating their effects in the surgical setting. Specific clinical approaches for improving quality and safety of patient care such as prophylaxis for infection and deep venous thrombosis and the prevention of retained objects and safe introduction of new technology will be covered elsewhere. Their care should be free from hazards that increase the likelihood of adverse events or harm. These researchers reviewed medical records of hospitalized patients to estimate the rate of adverse events and negligence occurring in the states of New York, Colorado, and Utah. The landmark study involving Colorado and Utah showed that operative adverse events accounted for 44. Bleeding, infections, and deep venous thrombosis were the next most common surgical adverse events identified. Overall, surgical technique–related complications, infection, and bleeding accounted for about half of all surgical adverse events. A more recent analysis in 2013 by James [16] examined information from four separate studies published during 2008–2011 about preventable adverse events in hospitalized patients. Each of these studies employed the Global Trigger Tool [17] as the core method used by trained health-care professionals to extract data from medical records and determine if an adverse event may have harmed a patient. He concluded that a lower limit of 210,000 deaths per year of hospitalized patients was associated with preventable harm, and the true number may be upwards of 400,000 deaths per year. He noted that nonlethal but serious harm was 10- to 20-fold more common than lethal preventable adverse events. Based on James’ analysis and preliminary data on deaths in the United States for 2011 [18], deaths due to preventable adverse events would more likely be the third leading cause of death in 2011 compared to the eighth leading cause of death in the United States in 1997. Around the world, the year 2000 was pivotal in the call to action to improve safety of patient care and decrease medical errors. In their landmark report, An Organisation with a Memory, they stated that preventable errors are the result of human error whether intentional or not. The launch of patient safety initiatives in Australia occurred around this same time. Lessons learned from the Australian incident monitoring study of the 1980s [20,21] did much to inform their efforts to improve patient safety in their country. Similar awareness and patient safety initiatives began in New Zealand around 2001 [22]. Canada released a multifaceted action plan to improve patient safety, Building a Safer System, in 2002 [23]. Successful efforts in such endeavors led to the formation of the World Health Alliance 144 for Patient Safety in 2004, and the Global Patient Safety Challenge to Safe Surgery Saves Lives —improving the safety of surgery around the globe [24]. Fundamental to the global call to action to improve patient safety is the understanding that “to err is human” [25]. James Reason asserted in 1990 that errors are inevitable and an acceptable price to pay in coping with difficult, complex tasks [25]. In his landmark book, Human Error, he described a framework for human error, highlighting the relationship between various aspects of human cognition and error. His framework differentiated three error types—“skills-based slips and lapses, rule-based mistakes and knowledge-based mistakes” [26]. He stressed that understanding the differences between these error types helps to identify suitable means by which to intervene and address them. To that end, James Reason promoted two main approaches by which to deal with the problem of human error: the person approach and the systems approach [27]. The person approach embodies the long-standing tradition of targeting and blaming individuals for errors. The systems approach scrutinizes how and why defenses fail and designs ways to trap or minimize the effect of errors via measures that address the person, the team, the workplace, and the institution as a whole. The health-care industry is highly complex, and some 24-hour-a-day services are more vulnerable to error than others such as intensive care settings, the operating theater, emergency departments, and labor and delivery units. Examples of such organizations include naval aircraft carriers, nuclear power plants, offshore oil platforms, and air traffic control systems. Weick and Sutcliffe assert that “good management of the unexpected is mindful management of the unexpected” [31]. Preoccupation with failure involves anticipating and recognizing where failure can occur and taking measures to prevent it.

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Whereas the action potential for skeletal muscle and nerves is caused by the abrupt opening of fast sodium channels in the cell membrane discount 80 mg super levitra visa erectile dysfunction hiv, in cardiac muscle order super levitra from india erectile dysfunction causes weed, it is due to the opening of both fast sodium channels (the spike) and slower calcium chan- nels (the plateau). Depolarization is also accompanied by a transient decrease in potassium permeability. Subsequent restoration of normal potassium permeability and closure of sodium and calcium channels eventually restore the membrane potential to normal. The slow influx of sodium, which results in a less negative, resting membrane potential (−50 to −60 mV), has three important consequences: constant inactivation of fast sodium channels, an action potential with a threshold of −40 mV that is primarily caused by ion movement across the slow calcium channels, and regular spontaneous depolarizations. During each cycle, intracellular leakage of sodium causes the cell membrane to become progressively less negative; when the threshold potential is reached, calcium channels open, potassium permeability decreases, and an action potential develops. Bupivacaine, the most cardiotoxic local anesthetic, binds inactivated fast sodium channels and dissociates from them slowly. It can cause pro- found sinus bradycardia and sinus node arrest as well as malignant ventricular arrhythmias. These proteins are fixed in position within each cell during both contraction and relaxation. Dystrophin, a large intracellular protein, connects actin to the cell membrane (sarcolemma). Cell shortening occurs when actin and myosin are allowed to fully interact and slide over one another. Whereas troponin is attached to actin at regular intervals, tropomyosin lies within the center of the actin −7 −5 structure. An increase in intracellular calcium concentration (from about 10 to 10 mol/L) promotes con- traction as calcium ions bind troponin C. The resulting conformational change in these regulatory proteins exposes the active sites on actin that allow interaction with myosin bridges (points of overlapping). The force of contraction is directly dependent on the magnitude of the initial calcium influx. Acetylcholine acts on specific cardiac muscarinic receptors (M ) to produce negative chronotropic, dromotropic, and inotropic effects. Cardiac sympathetic fibers originate in the thoracic spinal cord (T1–T4) and travel to the heart initially through the cervical ganglia (stellate) and then as the cardiac nerves. Norepinephrine release causes positive chronotropic, dromotropic, and inotropic effects primarily through activation of β -adrenergic receptors. Patients with reduced ventricular compliance are most affected by loss of a normally timed atrial systole. The x descent is the decline in pres- sure between the c and v waves and is thought to be caused by a pulling down of the atrium by ventricular contraction. The notch in the aortic pressure tracing is referred to as the incisura and represents transient backflow of blood into the left ventricle just before aortic valve closure. Ventricular preload is end-diastolic volume, which is dependent on ventricular filling. In the absence of pulmonary or right ventricular dysfunction, venous return is also the major determinant of left ventricular preload. Afterload depends on ventricular wall tension during systole and arterial impedance to ejection. The larger the ventricular radius, the greater the wall tension required to develop the same ventricular pressure, but an increase in wall thickness reduces ventricular wall tension. Contractility is related to the rate of myocardial muscle shortening, which in turn depends on the intracel- lular calcium concentration during systole. Norepinephrine, sympathomimetic drugs, and secretion of epi- nephrine from the adrenal glands increase contractility via β -receptor activation. These phenomena are likely caused by both an intrinsic response of vascular smooth muscle to stretch and the accumulation of vasodilatory metabolic + + byproducts. Sympathetic-induced vasoconstriction (via α -adrenergic receptors) can 1 be potent in skeletal muscle, kidneys, the gut, and the skin; it is least active in the brain and heart. The most important vasodilatory fibers are those to skeletal muscle, mediating an increase in blood flow (via β -adrenergic receptors) in response to exercise. Vasodepressor (vasovagal) syncope, which can occur after 2 intense emotional strain associated with high sympathetic tone, results from reflex activation of both vagal and sympathetic vasodilator fibers. Vascular tone and autonomic influences on the heart are controlled by vasomotor centers in the reticular formation of the medulla and lower pons. They are also responsible for the adrenal secretion of catechol- amines as well as the enhancement of cardiac automaticity and contractility. Decreases in arterial blood pressure enhance sympa- thetic tone, increase adrenal secretion of epinephrine, and suppress vagal activity. The resulting systemic vasoconstriction, elevation in heart rate, and enhanced cardiac contractility increase blood pressure. Peripheral baroreceptors are located at the bifurcation of the common carotid arteries and the aortic arch. Elevations in blood pressure increase baroreceptor discharge, inhibiting systemic vasoconstriction and enhancing vagal tone (barorecep- tor reflex). Long-term control: The effects of renal mechanisms occur hours after sustained changes in arterial pres- sure. After perfusing the myocar- dium, blood returns to the right atrium via the coronary sinus and anterior cardiac veins. Thus, coronary perfusion pressure is usually determined by the difference between aortic pressure and ventricu- lar pressure, and the left ventricle is perfused almost entirely during diastole. Increases in heart rate also decrease coronary perfusion because of disproportionately greater reduction in diastolic time as heart rate increases. Sympathetic stimulation of the coronaries increases myocardial blood flow because of increased metabolic demand and a predominance of β -receptor activation. The endo- cardium is most vulnerable to ischemia during decreases in coronary perfusion pressure. Whereas vasodilation caused by desflurane is primarily autonomically mediated, sevoflurane appears to lack coronary vasodilating properties. Volatile agents reduce myocardial oxygen requirements and are protective against reperfusion injury. Systolic heart failure occurs when the heart is unable to pump a sufficient amount of blood to meet the body’s metabolic requirements. Clinical manifestations usually reflect the effects of the low cardiac output on tissues (e. Left ventricular failure most commonly results from primary myocardial dysfunction (usually from coro- nary artery disease) but may also result from valvular dysfunction, arrhythmias, or pericardial disease. In patients with diastolic heart failure, the impaired heart relaxes poorly and produces increased left ven- tricular end-diastolic pressures. These pressures are transmitted to the left atrium and pulmonary vascula- ture, resulting in symptoms of congestion.

N. Merdarion. University of Massachusetts at Dartmouth.