Sheer down, screaming, seventy feet he fell, smashing to the earth with an audible thud and crunch, his body rebounding slightly and settling down again. I fail to describe him.
Evaluare pre-transport Recomandare Se recomandã ca medicul care solicitã transportul sã B încadreze solicitarea pe grade de urgenţã în funcţie de prioritãţi . Argumentare Încadrarea corectã a urgenţei medicale duce la reducerea IIa morbiditãţii şi mortalitãţii neonatale .
Standard Medicul solicitant trebuie sã includã în evaluarea C pre-transport a nou-nãscutului: - istoricul perinatal şi al naşterii - examenul clinic la naştere - rezultatul explorãrilor paraclinice efectuate de spitalul solicitant [1,26].
Argumentare Evaluarea completã pre-transport economiseşte timpul Iv echipei de transport . Standard Medicul solicitant trebuie sã evalueze starea nou- C nãscutului permanent pânã la sosirea echipei de transport . Argumentare Practic, niciodatã în timpul transportului starea IV pacienţilor nu se amelioreazã . Standard La sosirea la spitalul solicitant, echipa de transport C trebuie sã evalueze starea clinicã, investigaţiile anamnestice, paraclinice, tratamentele şi informaţiile oferite de monitorizarea nou-nãscutului bolnav .
Argumentare Evaluarea stãrii nou-nãscutului la sosirea echipei de IV transport poate oferi informaţii în plus, necesare îngrijirilor acordate pe durata transportului . Standard Echipa de transport trebuie sã evalueze la sosirea la C spitalul solicitant semnele vitale ale nou-nãscutului care trebuie transferat şi sã le consemneze în fişa de transport .
Argumentare Fişa de transport este un document medico-legal IV [1,72,93,94]. Categorii de nou-nãscuţi care necesitã transport Standard Medicul curant trebuie sã decidã transferul neonatal C conform principiilor regionalizãrii şi ierarhizãrii unitãţilor sanitare anexa 3 [1,72].
Argumentare Eficienţa deciziei de transfer creşte calitatea actului IV medical [72,]. Standard În conformitate cu ierarhizarea unitãţilor sanitare, B pe baza competenţelor de îngrijire a nou-nãscutului, dupã evaluarea clinicã, medicul precizia obstetric dating nrp trebuie sã indice transferul spre unitãţi de rang superior pentru categoriile de nou-nãscuţi enumerate în anexa 3 [72,92].
Argumentare Unitãţile de nivel III au competenţe, personal calificat III şi pot asigura diagnosticul şi tratamentul acestor nou-nãscuţi . It hurt his pride terribly, thus to be outwitted by the small and tender Folk.
He stood on the ground and looked up at us, snarling, lashing his tail, snapping at the stones that fell near to him.
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Once I whizzed down a stone, and just at the right moment he looked up. It caught him full on the end of his nose, and he went straight up in the air, all four feet of him, roaring and caterwauling, what of the hurt and surprise. He was beaten and he knew it.
Recovering his dignity, he stalked out solemnly from under the rain of stones. He stopped in the middle of the open space and looked wistfully and hungrily back at us.
He hated to forego the meal, and we were just so much meat, cornered but inaccessible. This sight of him started us to laughing. We laughed derisively and uproariously, all of us. Now animals do not like mockery.
To be laughed at makes them angry. And in such fashion our laughter affected Saber-Tooth. He turned with a roar and charged the bluff again. This was what we wanted. The fight had become a game, and we took huge delight in pelting him.
But this attack did not last long. He quickly recovered his common sense, and besides, our missiles were shrewd to hurt.
Vividly do I recollect the vision of one bulging eye of his, swollen almost shut by one of the stones we had thrown. And vividly do I retain the picture of him as he stood on the edge of the forest whither he had finally retreated. He was looking back at us, his writhing lips lifted clear of the very roots of his huge fangs, his hair bristling and his tail lashing.
He gave one last snarl and slid from view among the trees. And then such a chattering as went up. We swarmed out of our holes, examining the marks his claws had made on the crumbling rock of the bluff, all of us talking at once.
One of the two Folk who had been caught in the double cave was part-grown, half child and half youth. They had come out proudly from their refuge, and we surrounded them in an admiring crowd. She was a strapping big woman, very hairy, and the thrashing she gave him was a delight to precizia obstetric dating nrp horde. We roared with laughter, holding on to one another or rolling on the ground in our glee.
In spite of the reign of fear under which we lived, the Folk were always great laughers. We had the sense of humor. Our merriment was Gargantuan.
It was never restrained.
There was nothing half way about it. When a thing was funny we were convulsed with appreciation of it, and the simplest, crudest things were funny to us. Oh, we were great laughers, I can tell you. The way we had treated Saber-Tooth was the way we treated all animals that invaded the village. We kept our run-ways and drinking-places to ourselves by making life miserable for the animals that trespassed or strayed upon our immediate territory.
Even the fiercest hunting animals we so bedevilled that they learned to leave our places alone. We were not fighters like them; we were cunning and cowardly, and it was because of our cunning and cowardice, and our inordinate capacity for fear, that we survived in that frightfully hostile environment of the Younger World. Lop-Ear, I figure, was a year older than I. What his past history was he had no way of telling me, but as I never saw anything of his mother I believed him to be an orphan.
After all, fathers did not count in our horde. Marriage was as yet in a rude state, and couples had a way of quarrelling and separating. Modern man, what of his divorce institution, does the same thing legally. But we had no laws. Custom was all we went by, and our custom in this particular matter was rather promiscuous.
Nevertheless, as this narrative will show later on, we betrayed glimmering adumbrations of the monogamy that was later to give power to, and make mighty, such tribes as embraced it. Furthermore, even at the time I was born, there were several faithful couples that lived in the trees in the neighborhood of my mother.
Living in the thick of the horde did not conduce to monogamy. It was for this reason, undoubtedly, that the faithful couples went away and lived by themselves. Through many years these couples stayed together, though when the man or woman died or was eaten the survivor invariably found a new mate. There was one thing that greatly puzzled me during the first days of my residence in the horde. There was a nameless and incommunicable fear that rested upon all.
At first it appeared to be connected wholly with direction. The horde feared the northeast. It lived in perpetual apprehension of that quarter of the compass. And every individual gazed more frequently and with greater alarm in that direction than in any other. When Lop-Ear and I went toward the north-east to eat the stringy-rooted carrots that at that season were at their best, he became unusually timid.
He was content to eat the leavings, the big tough carrots and the little ropy ones, rather than to venture a short distance farther on to where the carrots were as yet untouched. When I so ventured, he scolded me and quarrelled with me. He gave me to understand that in that direction was some horrible danger, but just what the horrible danger was his paucity of language would not permit him to say.
Many a good meal I got in this fashion, while he scolded and chattered vainly at me. I kept very alert, but I could see no danger. I calculated always the distance between myself and dating traverse city nearest tree, and knew that to that haven of refuge I could out-foot the Tawny One, or old Saber-Tooth, did one or the other suddenly appear.
One late afternoon, in the village, a great uproar arose. The horde was precizia obstetric dating nrp with a single emotion, that of fear. The bluff-side swarmed with the Folk, all gazing and pointing into the northeast.
I did not know what it was, but I scrambled all the way up to the safety of my own high little cave before ever I turned around to see. And precizia obstetric dating nrp, across the river, away into the northeast, I saw for the first time the mystery of smoke. It was the biggest animal I had ever seen. I thought it was a monster snake, up-ended, rearing its head high above the trees and swaying back and forth.
And yet, somehow, I seemed to gather from the conduct of the Folk that the smoke precizia obstetric dating nrp was not the danger. They appeared to fear it as the token of something else. What this something else was I was unable to guess. Nor could they tell me. Yet I was soon to know, and I was to know it as a thing more terrible than the Tawny One, than old Saber-Tooth, than the snakes themselves, than which it seemed there could be no things more terrible.
Broken-Tooth was another youngster who lived by himself. His mother lived in the caves, but two more children had come after him and he had been thrust out to shift for himself. We had witnessed the performance during the several preceding days, and it had given us no little glee.
Broken-Tooth did not want to go, and every time his mother left the cave he sneaked back into it.
When she returned and found him there her rages were delightful. Half the horde made a practice of watching for these moments. First, from within the cave, would come her scolding and shrieking.
Then we could hear sounds of the thrashing and the yelling of Broken-Tooth. About this time the two younger children joined in. And finally, like the eruption of a miniature volcano, Broken-Tooth would come flying out. At the end of several days his leaving home was accomplished. He wailed his grief, unheeded, from the centre of the open space, for at least half an hour, and then came to live with Lop-Ear and me.
Our cave was small, but with squeezing there was room for three. I have no recollection of Broken-Tooth spending more than one night with us, so the accident must have happened right away. It came in the middle of the day.
In the morning we had eaten our fill bloodborne password nu funcționează the carrots, and then, made heedless by play, we had ventured on to the big trees just beyond. I cannot understand how Lop-Ear got over his habitual caution, but it must have been the play. We were having a great time playing tree tag. And such tag! We leaped ten or fifteen-foot gaps as a matter of course.
And a twenty or twenty-five foot deliberate drop clear down to the ground was nothing to us. In fact, I am almost afraid to say the great distances we dropped. As we grew older and heavier we found we had to be more cautious in dropping, but at that age our bodies were all strings and springs and we could do anything.
Broken-Tooth displayed remarkable agility in the game. To be truthful, we were afraid to attempt it. From the end of the branch to the ground it must have been seventy feet, and nothing intervened to break a fall. But about twenty feet lower down, and fully fifteen feet out from the perpendicular, was the thick branch of another tree. As we ran out the limb, Broken-Tooth, facing us, would begin teetering. This naturally impeded our progress; but there was more in the teetering than that.
He teetered with his back to the jump he was to make. Just as we nearly reached him he would let go. The teetering branch was like a spring-board. It threw him far out, backward, as he fell. And as he fell he turned around sidewise in the air so as to face the other branch into which he was falling. This branch bent far down under the impact, and sometimes there was an ominous crackling; but it never precizia obstetric dating nrp, and out of the leaves was always to be seen the face of Broken-Tooth grinning triumphantly up at us.
He had gained the end of the branch and begun his teetering, and I was creeping out after him, when suddenly there came a low warning cry from Lop-Ear. I looked down and saw him in the main fork of the tree crouching close against the trunk.
Instinctively I crouched down upon the thick limb. Broken-Tooth stopped teetering, but the branch would not stop, and his body continued bobbing up and down with the rustling leaves. I heard the crackle of a dry twig, and looking down saw my first Fire-Man. He was creeping stealthily along on the ground and peering up into the tree. At first I thought he was a wild animal, because he wore around his waist and over his shoulders a ragged piece of bearskin.
And then I saw his hands and feet, and more clearly his features. He was very much like my kind, except that he was less hairy and that his feet were less like hands than ours. In fact, he and his people, as I was later to know, were far less hairy than we, though we, in turn, were equally less hairy than the L hyosung dating People. It came to me instantly, as I looked at him. This was the terror of the northeast, of which the mystery of smoke was a token.
Yet I was puzzled. Certainly he was nothing; of which to be afraid. Red-Eye or any of our strong men would have been more than a match for him. He was old, too, wizened with precizia obstetric dating nrp, and the hair on his face was gray. Also, he limped badly with one leg.
There was no doubt at all that we could out-run him and out-climb him. He could never catch us, that was certain. But he carried something in his hand that I had never seen before.
It was a bow and arrow. But at that time a bow and arrow had no meaning for me.
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How was I to know that death lurked in that bent piece of wood? But Lop-Ear knew. He had evidently seen the Fire People before and knew something of their ways. The Fire-Man peered up at precizia obstetric dating nrp and circled around the tree. And around the main trunk above the fork Lop-Ear circled too, keeping always the trunk between himself and the Fire-Man.
The latter abruptly reversed his circling. Lop-Ear, caught unawares, also hastily reversed, but did not win the protection of the trunk until after the Fire-Man had twanged the bow. I saw the arrow leap up, miss Lop-Ear, glance against a limb, and fall back to the ground. I danced up and down on my lofty perch with delight.
It was a game! The Fire-Man was throwing things at Lop-Ear as we sometimes threw things at one another. The game continued a little longer, but Lop-Ear did not expose himself a second time. Then the Fire-Man gave it up. I leaned far out over my horizontal limb and chattered down at him.
I wanted to play. I wanted to have him try to hit me with the thing. He saw me, but ignored me, turning his attention to Broken-Tooth, who was still teetering slightly and involuntarily on the end of the branch. The first arrow leaped upward. Broken-Tooth yelled with fright and pain. It had reached its mark. This put a new complexion on the matter.
I no longer cared to play, but crouched trembling close to my limb. A second arrow and a third soared up, missing Broken-Tooth, rustling the leaves as they passed through, arching in their flight and returning to earth.
The Fire-Man stretched his bow again. He shifted his position, walking precizia obstetric dating nrp several steps, then shifted it a second time. The bow-string twanged, the arrow leaped upward, and Broken-Tooth, uttering a terrible scream, fell off the branch. I saw him as he went down, turning over and over, all arms and legs it seemed, the shaft of the arrow projecting from his chest and appearing and disappearing with each revolution of his body. Sheer down, screaming, seventy feet he fell, smashing to the earth with an audible thud and crunch, his body rebounding slightly and settling down again.
Still he lived, for he moved and squirmed, clawing with his hands and feet. I remember the Fire-Man running forward with a stone and hammering him on the head…and then I remember no more. Always, during my childhood, at this stage of the dream, did I wake up screaming with fright—to find, often, my mother or nurse, anxious and startled, by my bedside, passing soothing hands through my hair and telling me that they were there and that there was nothing to fear.
My next dream, in the order of succession, begins always with the flight of Lop-Ear and myself through the forest.
The Fire-Man and Broken-Tooth and the tree of the tragedy are gone.
Lop-Ear and I, in a cautious panic, are fleeing through the trees. In my right leg is a burning pain; and from the flesh, protruding head and shaft from either side, is an arrow of the Fire-Man. Not only did the pull and strain of it pain me severely, but it bothered my movements and made it impossible for me to keep up with Lop-Ear. At last I gave up, crouching in the secure fork of a tree.
Lop-Ear went right on. I called to him—most plaintively, I remember; and he stopped and looked back. Then he returned to me, climbing into the fork and examining the arrow.
He tried to pull it out, but one way the flesh resisted the barbed lead, and the other way it resisted the feathered shaft. Also, it hurt grievously, and I stopped him. For some time we crouched there, Lop-Ear nervous and anxious to be gone, perpetually and apprehensively peering this way and that, and myself whimpering softly and sobbing. Lop-Ear was plainly in a funk, and yet his conduct in remaining by me, in spite of his fear, I take as a foreshadowing of the altruism and comradeship that have helped make man the mightiest of the animals.
Once again Lop-Ear tried to drag the arrow through the flesh, and I angrily stopped him. Then he bent down and began gnawing the shaft of the arrow with his teeth. As he did so he held the arrow firmly in precizia obstetric dating nrp hands so that it would not play about in the wound, and at the same time I held on to him.
I often meditate upon this scene—the two of us, half-grown cubs, in the childhood of the race, and the one mastering his fear, beating down his selfish impulse of flight, in order to stand by and succor the other.
And there rises up before me all that was there foreshadowed, and I see visions of Damon and Pythias, of life-saving crews and Red Cross nurses, of martyrs and leaders of forlorn hopes, of Father Damien, and of the Christ himself, and of all the men of earth, mighty of stature, whose strength may trace back to the elemental loins of Lop-Ear and Big-Tooth and other dim denizens of the Younger Precizia obstetric dating nrp.
When Lop-Ear had chewed off the head of the arrow, the shaft was withdrawn easily enough. I started to go on, but this time it was he that stopped me.
My leg was bleeding profusely.
Some of the smaller veins had doubtless been ruptured. Running out to the end of a branch, Lop-Ear gathered a handful of green leaves. These he stuffed into the wound. They accomplished the purpose, for the bleeding soon stopped. Then we went on together, back to the safety of the caves.
Well do I remember that first winter after I left home.
I have long dreams of sitting shivering in the cold. Lop-Ear and I sit close together, with our arms and legs about each other, blue-faced and with chattering teeth. It got particularly crisp along toward morning. In those chill early hours we slept little, huddling together in numb misery and waiting for the sunrise in order to get warm. When we went outside there was a crackle of frost under foot. One morning we discovered ice on the surface of the quiet water in the eddy where was the drinking-place, and there was a great How-do-you-do about it.
Old Marrow-Bone was the oldest member of the horde, and he had never seen anything like it before. I remember the worried, plaintive look that came into his eyes as he examined the ice.
This plaintive look always came into our eyes when we did not understand a thing, or when we felt the prod of some vague and inexpressible desire.
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Red-Eye, too, when he investigated the ice, looked bleak and plaintive, and stared across the river into the northeast, as though in some way he connected the Fire People with this latest happening. But we found ice only on that one morning, and that was the coldest winter we experienced. I have no memory of other winters when it was so cold.
I have often thought that that cold winter was a fore-runner of the countless cold winters to come, as the ice-sheet from farther north crept down over the face of the land.
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But we never saw that ice-sheet. Many generations must have passed away before the descendants of the horde migrated south, or remained and adapted themselves to the changed conditions. Life was hit or miss and happy-go-lucky with us. Little was ever planned, and less was executed. We ate when we were hungry, drank when we were thirsty, avoided our carnivorous enemies, took shelter in the caves at night, and for the rest just sort of played along through life.
We were very curious, easily amused, and full of tricks and pranks. There was no seriousness about us, except when we were in danger or were angry, in which cases the one was quickly forgotten and the other as quickly got over. We were inconsecutive, illogical, and inconsequential. We had no steadfastness of purpose, and it was here that the Fire People precizia obstetric dating nrp ahead of us. They possessed all these things of which we possessed so little. Occasionally, however, especially in the realm of the emotions, we were capable of long-cherished purpose.
The faithfulness of the monogamic couples I have referred to may be explained as a matter of habit; but my long desire for the Swift One cannot be so explained, any more than can be explained the undying enmity between me and Red-Eye. But dating site rockhampton was our inconsequentiality and stupidity that especially distresses me when I look back upon that life in the long ago.
Once I found a broken gourd which happened to lie right side up and which had been filled with the rain. The water was sweet, and I drank it. I even took the gourd down to the stream and filled it with more water, some of which I drank and some of which I poured over Lop-Ear.
And then I threw the gourd away. It never entered my head to fill the gourd with water and carry it into my cave. Yet often I was thirsty at night, especially after eating wild onions and watercress, and no one ever dared leave the caves at night for a drink. Another time I found a dry; gourd, inside of which the seeds rattled.
I precizia obstetric dating nrp fun with it for a while. But it was a play thing, nothing more. And yet, it was not long after dating queen ayah that the using of gourds for storing water became the general practice of the horde.
But I was not the inventor. The honor was due to old Marrow-Bone, and it is fair to assume that it was the necessity of his great age that brought about the innovation. At any rate, the first member of the horde to use gourds was Marrow-Bone. He kept a supply of drinking-water in his cave, which cave belonged to his son, the Hairless One, who permitted him to occupy a corner of it. We used to see Marrow-Bone filling his gourd at the drinking-place and carrying it carefully up to his cave.
Imitation was strong in the Folk, and first one, and then another and another, procured a gourd and used it in similar fashion, until it was a general practice with all of us so to store water.
Sometimes old Marrow-Bone had sick spells and was unable to leave the cave. Then it was that the Hairless One filled the gourd for him. A little later, the Hairless One deputed the task to Long-Lip, his son.
And after that, even when Marrow-Bone was well again, Long-Lip continued carrying water for him. By and by, except on unusual occasions, the men never carried any water at all, leaving the task to the women and larger children.
Lop-Ear and I were independent. We carried water only for ourselves, and we often mocked the young water-carriers when they were called away from play to fill the gourds.
Progress was slow with us. We played through life, even the adults, much in the same way that children play, and we played precizia obstetric dating nrp none of the other animals played.
What little we learned, was usually in the course of play, and was due to our curiosity and keenness of appreciation. For that matter, the one big invention of the horde, during the time I lived with it, was the use of gourds. At first we stored only water in the gourds—in imitation of old Marrow-Bone. But one day some one of the women—I do not know which one—filled a gourd with black-berries and carried it to her cave.
In no time all the women were carrying berries and nuts and roots in the gourds. The idea, once started, had to go on. Acesta precizeaz standardele, principiile i aspectele fundamentale ale managementului particularizat unui caz clinic concret care trebuie respectate de practicieni indiferent de nivelul unitii sanitare n care activeaz.
Ghidurile clinice de neonatologie sunt mai rigide dect protocoalele clinice, fiind realizate de grupuri tehnice de elaborare respectnd nivelul dovezilor tiinifice i gradele de recomandare. Protocoalele clinice au un grad mai mare de flexibilitate, adaptat nivelului fiecrei uniti sanitare. Scop Scopul acestui ghid este de a standardiza metodele i procedurile utilizate pentru un transport optim  Acest ghid de transport i stabilizare neonatal se adreseaz personalului de specialitate - medici neonatologi i medici de medicin de urgen - dar i medicilor pediatri, obstetricieni, cardiologi i chirurgi pediatri care se confrunt cu problema transferului i transportul nou-nscuilor cu diverse patologii perinatale.
Prezentul ghid este elaborat pentru ndeplinirea urmtoarelor deziderate: - creterea calitii asistenei medicale acte i proceduri medicale profilactice i terapeutice - aducerea n actualitate a unor probleme cu impact asupra sntii nou-nscuilor - stabilirea metodologiei de identificare a grupelor de nou-nscui care necesit transfer - reducerea diferenelor n practica medical, astfel nct transportul s devin mai eficient, sigur i standardizat - ghidul constituie un instrument de consens ntre clinicienii de diferite specialiti i materniti de diferite niveluri - ghidul protejeaz clinicianul din punctul de vedere a malpraxisului - ghidul permite loreal dating coral nagellack documentaiei medicale necesare transportului - ghidul permite oferirea unei baze de informaie pentru analize i comparaii - permite acordul practicii medicale romneti cu principiile medicale internaionale.
Se prevede ca acest ghid s fie adoptat pe plan local, regional i naional. Metodologie de lucru 3. Etapele procesului de elaborare Ca urmare a solicitrii Ministerului Sntii Publice de a sprijini procesul de elaborare a ghidurilor clinice pentru neonatologie, Asociaia de Neonatologie din Romnia a organizat n 28 martie la Bucureti o ntlnire a instituiilor implicate n elaborarea ghidurilor clinice pentru neonatologie. Totuşi, aşa cum s-a aratat în mai multe meta-analize, factorul V Leyden nu pare să fie un factor de risc pentru infarctul miocardic sau accidentul vascular precizia obstetric dating nrp ischemic Mutaţia genetică a protrombinei PT GAcare are ca rezultat nivele crescute de protrombină, se asociază, asemenea factorului V Leiden, cu un risc mare de trombembolism venos, dar nu şi de tromboză arterială În mod similar, deficienţa de antitrombină implică un risc predominent de trombembolie venoasă.
De aceea, ghidurile actuale nu recomandă evaluarea de rutină a deficienţei de antitrombină la pacienţii cu tromboză arterială 1,7. Au fost raportate rare cazuri de tromboză arterială, în mod particular în cazul deficienţei de proteina S; deficienţele acestor proteine reprezintă predominent factori de risc pentru trombembolia venoasă şi, de aceea, nu se recomandă includerea determinării nivelelor plasmatice ale acestor proteine în evaluarea pacienţilor cu tromboză arterială 1,7.
Factorul von Willebrand este o glicoproteină de dimensiuni mari produsă de celulele endoteliale şi, de asemenea, întâlnită şi în interiorul trombocitelor. Subiecţii cu nivele ridicate de factor von Willebrand au risc înalt de modificări trombotice.
Markeri de funcţie endotelială Endoteliul normal, un organ autocrin, paracrin şi endocrin, joacă un rol cheie în protecţia vasculară împotriva aterosclerozei, prin reglarea tonusului vascular, scăderea nivelului de lipide, inflamaţie, creştere vasculară şi trombogeneză.
Factorii de risc convenţionali pot favoriza şi stimula procesul de ateroscleroză prin inducerea disfuncţiei endoteliale, ca urmare a diminuării biodisponibilităţii oxidului nitric NOprincipalul mediator al funcţiilor endoteliale mai sus menţionate precizia obstetric dating nrp Endoteliul disfuncţional îşi poate pierde capacitatea de a-şi exercita efectul protectiv la nivelul sistemului vascular, devenind astfel un important factor în dezvoltarea şi progresia procesului aterosclerotic 43, Acest lucru nu este surprinzător, de vreme ce există dovezi clare ca ateroscleroză implică iniţial infiltrarea LDL-colesterolului prin endoteliul disfuncţional, urmată de oxidarea lui la nivelul intimei arteriale.
Această modificare a LDL-ului conduce la eliberarea de fosfolipide, care potenţează disfuncţia endotelială, cu activarea procesului inflamator şi eliberarea factorilor de creştere, ducând la proliferarea celulelor musculare netede vasculare şi producere de colagen în matrix-ul celular Stresul parietal este indus prin eliberarea manşetei sfigmomano metrului după umflarea acesteia la maxim, timp de 5 minute mini mum 50 mmHg peste presiunea sistolică, cu scopul de a opri fluxul de sânge arterialla nivelul antebraţului.
Se va induce astfel, o stare de flux crescut de scurtă durată la nivelul arterei brahiale hiperemie reactivăcare provoacă eliberarea oxidului nitric cu vasodilataţie secundară, care poate fi vizualizată şi cuantificată prin ultrasonografie de înaltă rezoluţie. Vasodilataţia mediată de flux FMD este exprimată ca modificarea diametrului post-stres parietal, sub forma unui procent din diametrul de bază Deşi această tehnică apreciază numai funcţia vasomotorie a endoteliului, ea este o metodă atrăgătoare, deoarece este non-invazivă şi permite efectuarea de măsurători repetitive Animal dating mult, există date importante care sugerează că disfuncţia endotelială evaluată la nivelul antebraţului reprezintă un marker de evenimente cardiovasculare viitoare Figura 9 Având în vedere faptul că vasodilataţia mediată de flux este în prezent o metodă în plină expansiune, fiind disponibila din punct de vedere comercial pe toate aparatele de ecocardiografie, putem presupune ca evaluarea funcţiei endoteliale va fi un important pas în aprecierea riscului cardiovascular în viitorul apropiat.
Microalbuminuria este un alt marker de funcţie endotelială, ce indică hiperpermeabilitatea endoteliului faţă de aceste macromolecule. Figura 9. Rata de evenimente cardiovasculare totale fatale şi nonfatale şi valorile medii ale creşterii procentuale ale funcţiei endoteliale modificat din Rigiditatea arterială Disfuncţia endotelială şi ateroscleroza incipientă favorizează scăderea elasticităţii arteriale; de aceea, creşterea rigidităţii arteriale este considerată în prezent un marker de ateroscleroză subclinică.
Rigiditatea sau reducerea complianţei arterelor mari modifică timpul de re - flec ta re a undei arteriale. La subiecţii tineri, viteza undei pulsului este mică, şi astfel, unda pulsului reflectată ajunge precizia obstetric dating nrp nivelul aortei după închiderea valvei aortice. De aceea, presiunea sistolică în aortă rămâne nemodificată, iar unda retrogradă creşte presiunea centrală diastolică, cu o creştere a presiunii de pefuzie coronariană; acesta este principalul mecanism fiziologic de creştere a perfuziei coronariene în timpul diastolei.
Astfel, aceasta ajunge la aortă în timpul ejecţiei ventriculului stâng, adăugând un surplus de presiune şi crescând presiunea arterială sistolică centrală, cu scăderea presiunii arteriale diastolice şi, în consecinţă, şi a pefuziei coronariene 45,