Chas G Newstead BSc FRCP

• Consultant renal physician
• St James? University Hospital
• Honorary senior lecturer
• University of Leeds, Leeds, UK

Fluid and other electrolyte disturbances are often treated with hemodialysis sleep aid for 3 year old order 100 mg modafinil with amex, peritoneal dialysis sleep aid that works order modafinil 100 mg mastercard, or other continuous renal replacement therapies sleep aid chemical buy 200 mg modafinil amex. Bed rest may be indicated to reduce exertion and the metabolic rate during the most acute stage of the disorder insomnia unspecified generic modafinil 200 mg otc. Fever and infection insomnia 4 weeks post hysterectomy generic modafinil 200 mg free shipping, both of which increase the metabolic rate and catabolism insomnia articles quality 100 mg modafinil, are prevented or treated promptly. Drowsiness and lethargy may prevent the patient from moving and turning without encouragement and assistance. It has also decreased the need for dialysis in patients with oliguric acute tubular necrosis in a multisite clinical trial of patients. Patients with nonoliguric acute tubular necrosis did not benefit (Lewis, Salem, Chertow et al. If respiratory problems develop, appropriate ventilatory measures must be instituted. The elevated serum phosphate level may be controlled with phosphate-binding agents (aluminum hydroxide). These agents help prevent a continuing rise in serum phosphate levels by decreasing the absorption of phosphate from the intestinal tract. If the patient gains or does not lose weight or develops hypertension, fluid retention should be suspected. Dietary proteins are limited to about 1 g/kg during the oliguric phase to minimize protein breakdown and to prevent accumulation of toxic end products. Caloric requirements are met with high-carbohydrate meals because carbohydrates have a proteinsparing effect (ie, in a high-carbohydrate diet, protein is not used for meeting energy requirements but is "spared" for growth and tissue healing). Foods and fluids containing potassium or phosphorus (bananas, citrus fruits and juices, coffee) are restricted. Potassium intake is usually restricted to 40 to 60 mEq/day, and sodium is usually restricted to 2 g/day. Blood chemistry evaluations are made to determine the amounts of sodium, potassium, and water needed for replacement, along with assessment for overhydration or underhydration. After the diuretic phase, the patient is placed on a high-protein, high-calorie diet and is encouraged to resume activities gradually. Massaging bony prominences, turning the patient frequently, and bathing the patient with cool water are often comforting and prevent skin breakdown. The patient and family need assistance, explanation, and support during this time. The purpose and rationale of the treatments are explained to the patient and family by the physician. High levels of anxiety and fear, however, may necessitate repeated explanation and clarification by the nurse. The family members may initially be afraid to touch and talk to the patient during the procedure but should be encouraged and assisted to do so. The rate of decline in renal function and progression of chronic renal failure is related to the underlying disorder, the urinary excretion of protein, and the presence of hypertension. The disease tends to progress more rapidly in patients who excrete significant amounts of protein or have elevated blood pressure than in those without these conditions. Clinical Manifestations Because virtually every body system is affected by the uremia of chronic renal failure, patients exhibit a number of signs and symptoms. Strict fluid volume control has been found to normalize hypertension in patients receiving peritoneal dialysis (Gunal, Duman, Ozkahya et al. Environmental and occupational agents that have been implicated in chronic renal failure include lead, cadmium, mercury, and chromium. Dialysis or kidney transplantation eventually becomes necessary for patient survival. Dialysis is an effective means of correcting metabolic toxicities at any age, although the mortality rate in infants and young children is greater than adults in the presence of other, nonrenal diseases and in the presence of anuria or oliguria (Wood et al. Chart 45-7 Stages of Chronic Renal Disease Stage 1 Reduced renal reserve, characterized by a 40% to 75% loss of nephron function. The patient usually does not have symptoms because the remaining nephrons are able to carry out the normal functions of the kidney. At this point, the serum creatinine and blood urea nitrogen rise, the kidney loses its ability to concentrate urine and anemia develops. All of the normal regulatory, excretory, and hormonal functions of the kidney are severely impaired. Pathophysiology As renal function declines, the end products of protein metabolism (which are normally excreted in urine) accumulate in the blood. Neurologic changes, including altered levels of consciousness, inability to concentrate, muscle twitching, and seizures, have been observed. The precise mechanisms for many of these diverse signs and symptoms have not been identified. It is generally thought, however, that the accumulation of uremic waste products is the probable cause. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure, and hypertension. Hypertension may also result from activation of the renin­angiotensin­aldosterone axis and the concomitant increased aldosterone secretion. Other patients have a tendency to lose salt and run the risk of developing hypotension and hypovolemia. Episodes of vomiting and diarrhea may produce sodium and water depletion, which worsens the uremic state. Serum creatinine is the more sensitive indicator of renal function because of its constant production in the body. In renal failure, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath. Serum calcium and phosphate levels have a reciprocal relationship in the body: as one rises, the other decreases. With decreased filtration through the glomerulus of the kidney, there is an increase in the serum phosphate level and a reciprocal or corresponding decrease in the serum calcium level. The decreased serum calcium level causes increased secretion of parathormone from the parathyroid glands. In renal failure, however, the body does not respond normally to the increased secretion of parathormone; as a result, calcium leaves the bone, often producing bone changes and bone disease. In addition, the active metabolite of vitamin D (1,25-dihydroxycholecalciferol) normally manufactured by the kidney decreases as renal failure progresses. Uremic bone disease, often called renal osteodystrophy, develops from the complex changes in calcium, phosphate, and parathormone balance (Barnas, Schmidt, Seidl et al. This medication also binds dietary phosphorus in the intestinal tract and permits the use of smaller doses of antacids. Both calcium carbonate and phosphorusbinding antacids must be administered with food to be effective. Hypertension is managed by intravascular volume control and a variety of antihypertensive agents. Heart failure and pulmonary edema may also require treatment with fluid restriction, low-sodium diets, diuretic agents, inotropic agents such as digitalis or dobutamine, and dialysis. The metabolic acidosis of chronic renal failure usually produces no symptoms and requires no treatment; however, sodium bicarbonate supplements or dialysis may be needed to correct the acidosis if it causes symptoms (Tonelli et al. Neurologic abnormalities may occur, so the patient must be observed for early evidence of slight twitching, headache, delirium, or seizure activity. If seizures occur, the onset of the seizure is recorded along with the type, duration, and general effect on the patient. Intravenous diazepam (Valium) or phenytoin (Dilantin) is usually administered to control seizures. Anemia associated with chronic renal failure is treated with recombinant human erythropoietin (Epogen). Anemic patients (hematocrit less than 30%) present with nonspecific symptoms, such as malaise, general fatigability, and decreased activity tolerance. Epogen therapy is initiated to achieve a hematocrit of 33% to 38%, which generally alleviates the symptoms of anemia. It may take 2 to 6 weeks for the hematocrit to rise; therefore, Epogen is not indicated for patients who need immediate correction of severe anemia. Adverse effects seen with Epogen therapy include hypertension (especially during early stages of treatment), increased clotting of vascular access sites, seizures, and depletion of body iron stores (Fink et al. The patient receiving Epogen may experience influenza-like symptoms with initiation of therapy; these tend to subside with repeated doses. Management involves adjustment of heparin to prevent clotting of the dialysis lines during hemodialysis treatments, frequent monitoring of hematocrit, and periodic assessment of serum iron and transferrin levels. Because adequate stores of iron are necessary for an adequate response to erythropoietin, supplementary iron may be prescribed. Hypertension that cannot be controlled is a contraindication to recombinant erythropoietin therapy. Patients who have received Epogen have reported decreased levels of fatigue, an increased feeling of well-being, better tolerance of dialysis, higher energy levels, and improved exercise tolerance. Additionally, this therapy has decreased the need for transfusion and its associated risks, including bloodborne infectious disease, antibody formation, and iron overload (Fink et al. Management is accomplished primarily with medications and diet therapy, although dialysis may also be needed to decrease the level of uremic waste products in the blood (Fink et al. At the same time, adequate caloric intake and vitamin supplementation must be ensured. Protein is restricted because urea, uric acid, and organic acids-the breakdown products of dietary and tissue proteins-accumulate rapidly in the blood when there is impaired renal clearance. High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. Vitamin supplementation is necessary because a protein-restricted diet does not provide the necessary complement of vitamins. Additionally, the patient on dialysis may lose water-soluble vitamins from the blood during the dialysis treatment. Occasionally, Kayexalate, a cation-exchange resin, administered orally, may be needed. The patient with increasing symptoms of chronic renal failure is referred to a dialysis and transplantation center early in the course of progressive renal disease. Dialysis is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment. Management of Patients With Urinary Disorders 1329 and evaluation criteria, are presented in more detail in the Plan of Nursing Care. A nutritional referral and explanations of nutritional needs are helpful because of the numerous dietary changes required. The patient is taught how to check the vascular access device for patency and how to take precautions, such as avoiding venipunctures and blood pressure measurements on the arm with the access device. Additionally, the patient and family require considerable assistance and support in dealing with the need for dialysis and its long-term implications. For instance, they need to know what problems to report to the health care provider, including the following: · Worsening signs and symptoms of renal failure (nausea, · vomiting, change in usual urine output [if any], ammonia odor on breath) Signs and symptoms of hyperkalemia (muscle weakness, diarrhea, abdominal cramps) Signs and symptoms of access problems (clotted fistula or graft, infection) Nursing Management the patient with chronic renal failure requires astute nursing care to avoid the complications of reduced renal function and the stresses and anxieties of dealing with a life-threatening illness. The dialysis nurses also provide ongoing education and support at each treatment visit. The importance of follow-up examinations and treatment is stressed to the patient and family because of changing physical status, renal function, and dialysis requirements. The home care nurse also assesses the patient for further deterioration of renal function and signs and symptoms of complications resulting from the primary renal disorder, the resulting renal failure, and effects of treatment strategies (eg, dialysis, medications, dietary restrictions). Many patients need ongoing education and reinforcement on the multiple dietary restrictions required, including fluid, sodium, potassium, and protein restriction. Reminders about the need for health promotion activities and health screening are an important part of nursing care for the patient with renal failure. Gerontologic Considerations Changes in kidney function with normal aging increase the susceptibility of elderly patients to kidney dysfunction and renal failure. Because alterations in renal blood flow, glomerular filtration, and renal clearance increase the risk for medication-associated changes in renal function, precautions are indicated with all (text continues on page 00) · Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water · Imbalanced nutrition: less than body requirements related · to anorexia, nausea and vomiting, dietary restrictions, and altered oral mucous membranes Deficient knowledge regarding condition and treatment regimen Activity intolerance related to fatigue, anemia, retention of waste products, and dialysis procedure Low self-esteem related to dependency, role changes, changes in body image, and sexual dysfunction Nursing care is directed toward assessing fluid status and identifying potential sources of imbalance, implementing a dietary program to ensure proper nutritional intake within the limits of the treatment regimen, and promoting positive feelings by encouraging increased self-care and greater independence. A great deal of emotional support is needed by the patient and family because of the numerous changes experienced. Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions. Fluid restriction will be determined on basis of weight, urine output, and response to therapy. Encourage high-calorie, low-protein, low-sodium, and low-potassium snacks between meals. Baseline data allow for monitoring of changes and evaluating effectiveness of interventions. Information about other factors that may be altered or eliminated to promote adequate dietary intake is provided. Complete proteins are provided for positive nitrogen balance needed for growth and healing. Reduces source of restricted foods and proteins and provides calories for energy, sparing protein for tissue growth and healing. Alter schedule of medications so that they are not given immediately before meals. Explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels. Provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium. Ingestion of medications just before meals may produce anorexia and feeling of fullness. Promotes patient understanding of relationships between diet and urea and creatinine levels to renal disease.

Institute care according to protocol at first indication of potential skin breakdown sleep aid up up info discount 200 mg modafinil otc. Encourage patient to express concerns about care at home; explore with patient possible solutions to problems insomnia new haven order 200 mg modafinil mastercard. Lack of knowledge and poor preparation for care at home contribute to patient anxiety insomnia 58 order modafinil 100mg overnight delivery, insecurity sleep aid i can take with lorazepam 100mg modafinil with visa, and nonadherence to therapeutic regimen insomnia uk modafinil 200 mg on line. One method of correction for a fracture of the femur in the distal third is two-wire skeletal traction sleep aid melatonin buy modafinil 200mg amex. The patient presents with pain, deformity, obvious hematoma, and considerable edema. Frequently, these fractures are open and involve severe soft tissue damage because there is little subcutaneous tissue in the area. If nerve function is impaired, the patient is unable to dorsiflex the great toe and has diminished sensation in the first web space. Tibial artery damage is assessed by evaluating pulses, skin temperature, and color and by testing the capillary refill response. Symptoms include pain unrelieved by medications and increasing with plantar flexion, tense and tender muscle lateral to tibial crest, and paresthesia. Hip, foot, and knee exercises are encouraged within the limits of the immobilizing device. Partial weight bearing is begun when prescribed and is progressed as the fracture heals in 4 to 8 weeks. Distal fractures with extensive soft tissue damage heal slowly and may require bone grafting. The development of compartment syndrome requires prompt recognition and resolution to prevent permanent functional deficit. Other complications include delayed union, infection, impaired wound edge healing due to limited soft tissue, and loosening of the internal fixation hardware. Because these fractures produce painful respiration, the patient tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to pneumonia and atelectasis results. To help the patient cough and take deep breaths, the nurse may splint the chest with her hands. Occasionally, the physician administers intercostal nerve blocks to relieve pain and to permit productive coughing. Chest strapping to immobilize the rib fracture is not used, because decreased chest expansion may result in pneumonia and atelectasis. The pain associated with rib fracture diminishes significantly in 3 or 4 days, and the fracture heals within 6 weeks. In addition to pneumonia and atelectasis, complications may include a flail chest, pneumothorax, and hemothorax. Medical Management Most closed tibial fractures are treated with closed reduction and initial immobilization in a long leg walking cast or a patellar tendon­bearing cast. As with other lower extremity fractures, the leg should be elevated to control edema. The cast is changed to a short leg cast or brace in 3 to 4 weeks, which allows for knee motion. At times it is difficult to maintain reduction, and percutaneous pins may be placed in the bone and held in position by an external fixator. Fractures generally result from indirect trauma caused by excessive loading, sudden muscle contraction, or excessive motion beyond physiologic limits. Stable spinal fractures are caused by flexion, extension, lateral bending, or vertical loading. The anterior structural column (vertebral bodies and disks) or the posterior structural column (neural arch, articular processes, ligaments) has been disrupted. Unstable fractures occur with fracture-dislocations and exhibit disruption of both anterior and posterior structural columns. The patient with a spinal fracture presents with acute tenderness, swelling, paravertebral muscle spasm, and change in the normal curves or in the gap between spinous processes. Immobilization is essential until initial assessments have determined whether there is any spinal cord injury and whether the fracture is stable or unstable. If spinal cord injury with neurologic deficit does occur, it usually requires immediate surgery (laminectomy with spinal fusion) to decompress the spinal cord. Management of Patients With Musculoskeletal Trauma 2103 Levels of Amputation Amputation is performed at the most distal point that will heal successfully. The site of amputation is determined by two factors: circulation in the part, and functional usefulness (ie, meets the requirements for the use of the prosthesis). The circulatory status of the extremity is evaluated through physical examination and specific studies. Doppler flowmetry, segmental blood pressure determinations, and transcutaneous partial pressure of oxygen (PaO2) are valuable diagnostic aids. The amputation of toes and portions of the foot causes minor changes in gait and balance. A Syme amputation (modified ankle disarticulation amputation) is performed most frequently for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight-bearing. Below-knee amputations are preferred to above-knee amputations because of the importance of the knee joint and the energy requirements for walking. Knee disarticulations are most successful with young, active patients who are able to develop precise control of the prosthesis. When above-knee amputations are performed, all possible length is preserved, muscles are stabilized and shaped, and hip contractures are prevented for maximum ambulatory potential. Most people who have a hip disarticulation amputation must rely on a wheelchair for mobility. Upper extremity amputations are performed to preserve the maximum functional length. Initially, a guillotine amputation is performed to remove the necrotic and infected tissue. Medical Management Stable spinal fractures are treated conservatively with limited bed rest. The head of the bed is elevated less than 30 degrees until the acute pain subsides (several days). The patient is monitored for a transient paralytic ileus caused by associated retroperitoneal hemorrhage. A spinal brace or plastic thoracolumbar orthosis may be applied for support during progressive ambulation and resumption of activities. The patient with an unstable fracture is treated with bed rest, possibly with the use of a special turning device (eg, Stryker frame) to maintain spinal alignment. Neurologic status is monitored closely during the preoperative and postoperative periods. Within 24 hours after fracture, open reduction, decompression, and fixation with spinal fusion and instrument stabilization are usually accomplished. Postoperatively, the patient may be cared for on the turning device or in a bed with a firm mattress. Progressive ambulation is begun a few days after surgery, with the patient using a body brace orthosis. Patient teaching emphasizes good posture, good body mechanics, and, after healing is sufficient, back-strengthening exercises. The risk for infection increases with contaminated wounds after traumatic amputation. Joint contracture is caused by positioning and a protective flexion withdrawal pattern associated with pain and muscle imbalance. Amputation of a lower extremity is often made necessary by progressive peripheral vascular disease (often a sequela of diabetes mellitus), fulminating gas gangrene, trauma (crushing injuries, burns, frostbite, electrical burns), congenital deformities, chronic osteomyelitis, or malignant tumor. Of all these causes, peripheral vascular disease accounts for most amputations of lower extremities. Medical Management the objective of treatment is to achieve healing of the amputation wound, the result being a nontender residual limb (stump) with healthy skin for prosthesis use. Healing is enhanced by gentle handling of the residual limb, control of residual limb edema through rigid or soft compression dressings, and use of aseptic technique in wound care to avoid infection. A closed rigid cast dressing is frequently used to provide uniform compression, to support soft tissues, to control pain, and to prevent joint contractures. Immediately after surgery, a sterilized residual limb sock is applied to the residual limb. The residual limb is wrapped with elastic plaster-of-paris bandages while firm, even pressure is maintained. For the patient with a lower extremity amputation, the plaster cast may be equipped to attach a temporary prosthetic extension (pylon) and an artificial foot. This rigid dressing technique is used as a means of creating a socket for immediate postoperative prosthetic fitting. Early minimal weight bearing on the residual limb with a rigid cast dressing and a pylon attached produces little discomfort. Elevated body temperature, severe pain, or a loose-fitting cast may necessitate earlier replacement. A removable rigid dressing may be placed over a soft dressing to control edema, to prevent joint flexion contracture, and to protect the residual limb from unintentional trauma during transfer activities. This rigid dressing is removed several days after surgery for wound inspection and is then replaced to control edema. A soft dressing with or without compression may be used if there is significant wound drainage and frequent inspection of the residual limb (stump) is desired. Stump (wound) hematomas are controlled with wound drainage devices to minimize infection. Rehabilitation Patients who require amputation because of severe trauma are usually, but not always, young and healthy, heal rapidly, and participate in a vigorous rehabilitation program. Because the amputation is the result of an injury, the patient needs psychological support in accepting the sudden change in body image and in dealing with the stresses of hospitalization, long-term rehabilitation, and modification of lifestyle. Patients who undergo amputation need support as they grieve the loss, and they need time to work through their feelings about their permanent loss and change in body image. Their reactions are unpredictable and can include anger, bitterness, and hostility. The multidisciplinary rehabilitation team (patient, nurse, physician, social worker, psychologist, prosthetist, vocational rehabilitation worker) helps the patient achieve the highest possible level of function and participation in life activities. Prosthetic clinics and amputee support groups facilitate this rehabilitation process. Vocational counseling and job retraining may be necessary to help patients return to work. Knowing the full options and capabilities available with the various prosthetic devices can give the patient a sense of control over the disability. If the patient has experienced a traumatic amputation, the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaffected extremity. If infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage. For wound healing, a balanced diet with adequate protein and vitamins is essential. Any concurrent health problems (eg, dehydration, anemia, cardiac insufficiency, chronic respiratory problems, diabetes mellitus) need to be identified and treated so that the patient is in the best possible condition to withstand the trauma of surgery. The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may influence management and wound healing. An adequate support system and professional counseling can help the patient cope in the aftermath of amputation surgery. The major goals of the patient may include relief of pain, absence of altered sensory perceptions, wound healing, acceptance of altered body image, resolution of the grieving process, independence in self-care, restoration of physical mobility, and absence of complications. Pain may be incisional or may be caused by inflammation, infection, pressure on a bony prominence, or hematoma. The patient describes pain or unusual sensations, such as numbness, tingling, or muscle cramps, as well as a feeling that the extremity is present, crushed, cramped, or twisted in an abnormal position. When a patient describes phantom pains or sensations, the nurse acknowledges these feelings and helps the patient modify these perceptions. In addition, beta-blockers may relieve dull, burning discomfort; antiseizure medications control stabbing and cramping pain; and tricyclic antidepressants are used to improve mood and coping ability. Whenever the dressing is changed, aseptic technique is required to prevent wound infection and possible osteomyelitis. If this is not done, excessive edema will develop in a short time, resulting in a delay in rehabilitation. The nurse notifies the surgeon if a cast dressing comes off, so that another cast can be applied. The nurse instructs the patient and family in wrapping the residual limb with elastic dressings. After the incision is healed, the nurse teaches the patient to care for the residual limb. The nurse who has established a trusting relationship with the patient is better able to communicate acceptance of the patient who has experienced an amputation. The nurse encourages the patient to look at, feel, and then care for the residual limb.

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The patient is informed that this is a noninvasive test insomnia 08 electro remix generic modafinil 100mg free shipping, that a hand-held transducer will be placed over the neck and orbits of the eyes sleep aid knock out buy modafinil 200 mg amex, and that some type of water-soluble jelly is used on the transducer insomnia 7 year old child 100mg modafinil with mastercard. It is obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue sleep aid music order modafinil 200 mg online. Tumors sleep aid that works buy discount modafinil 200 mg line, brain abscesses sleep aid us buy modafinil 100 mg online, blood clots, and infection may cause abnormal patterns in electrical activity. Electrodes are applied to the scalp to record the electrical activity in various regions of the brain. The amplified activity of the neurons between any two of these electrodes is recorded on continuously moving paper; this record is called the encephalogram. The patient may be asked to hyperventilate for 3 to 4 minutes and then look at a bright, flashing light for photic stimulation. These activation procedures are performed to evoke abnormal electrical discharges, such as seizure potentials. If the epileptogenic area is inaccessible to conventional scalp electrodes, nasopharyngeal electrodes may be used. It is used to identify patients who may benefit from surgical excision of epileptogenic foci. Evoked changes are detected with the aid of computerized devices that extract the signal, display it on an oscilloscope, and store the data on magnetic tape or disk. These studies are based on the concept that any insult or dysfunction that can alter neuronal metabolism or disturb membrane function may change evoked responses in brain waves. In neurologic diagnosis, they reflect conduction times in the peripheral nervous system. In clinical practice, the visual, auditory, and somatosensory systems are most often tested. In visual evoked responses, the patient looks at a visual stimulus (flashing lights, a checkerboard pattern on a screen). The transit time from the retina to the occipital area is measured using computer-averaging methods. Auditory evoked responses or brain stem evoked responses are measured by applying an auditory stimulus (a repetitive auditory click) and measuring the transit time up the brain stem into the cortex. In somatosensory evoked responses, the peripheral nerves are stimulated (electrical stimulation through skin electrodes) and the transit time up the spinal cord to the cortex is measured and recorded from scalp electrodes. This test is used to detect a deficit in spinal cord conduction and to monitor spinal cord function during operative procedures. Because myelinated fibers conduct impulses at a higher rate of speed, nerves with an intact myelin sheath record the highest velocity. Demyelination of nerve fibers leads to a decrease in speed of conduction, as found in Guillain-Barrй syndrome, multiple sclerosis, and polyneuropathies. Nursing Interventions There is no specific patient preparation other than to explain the procedure and to reassure the patient and encourage him or her to relax. The patient is advised to remain perfectly still throughout the recording to prevent artifacts (signals not generated by the brain) that interfere with the recording and interpretation of the test. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. The meal is not omitted, however, because an altered blood glucose level can also cause changes in the brain wave patterns. Sedation is not advisable as it may lower the seizure threshold in patients with a seizure disorder and alter brain wave activity in all patients. Patients with seizures do not stop taking their antiseizure medication prior to testing. The electrical potentials are shown on an oscilloscope and amplified by a loudspeaker so that both the sound and appearance of the waves can be analyzed and compared simultaneously. They help to distinguish weakness due to neuropathy (functional or pathologic changes in the peripheral nervous system) from weakness due to other causes. Nursing Interventions the procedure is explained and the patient is warned to expect a sensation similar to that of an intramuscular injection as the needle is inserted into the muscle. Surface or needle electrodes are placed on the skin over the nerve to stimulate the nerve fibers. This is the most common complication, occurring in 15% to 30% of patients (Connolly, 1999). It is particularly severe on sitting or standing but lessens or disappears when the patient lies down. The fluid continues to escape into the tissues by way of the needle track from the spinal canal. Both traction and pain are lessened and the leakage is reduced when the patient lies down. Post­lumbar puncture headache may be avoided if a smallgauge needle is used and if the patient remains prone after the procedure. When a large volume of fluid (more than 20 mL) is removed, the patient is positioned prone for 2 hours, then flat in a side-lying position for 2 to 3 hours, and then supine or prone for 6 more hours. The postpuncture headache is usually managed by bed rest, analgesic agents, and hydration (Connolly, 1999). Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the epidural space, usually at the site of the previous spinal puncture. The needle is usually inserted into the subarachnoid space between the third and fourth or fourth and fifth lumbar vertebrae. Because the spinal cord divides into a sheaf of nerves at the first lumbar vertebra, insertion of the needle below the level of the third lumbar vertebra prevents puncture of the spinal cord. A successful lumbar puncture requires that the patient be relaxed; an anxious patient is tense, and this may increase the pressure reading. The increase in pressure caused by the compression is noted; then the pressure is released and pressure readings are made at 10-second intervals. A slow rise and fall in pressure indicates a partial block due to a lesion compressing the spinal subarachnoid pathways. Other Complications of Lumbar Puncture Herniation of the intracranial contents, spinal epidural abscess, spinal epidural hematoma, and meningitis are rare but serious complications of lumbar puncture. Other complications include temporary voiding problems, slight elevation of temperature, backache or spasms, and stiffness of the neck. Therefore, the patient and family must receive clear verbal and written instructions about precautions to take after the procedure, complications to watch for, and steps to take if complications occur. Because many patients undergoing neurologic diagnostic studies are elderly or have neurologic deficits, provisions must be made to ensure that transportation and postprocedure care and monitoring are available. Usually, specimens are obtained for cell count, culture, and glucose and protein testing. The specimens should be sent to the laboratory immediately because changes will take place and alter Chapter 60 Assessment of Neurologic Function 1847 Chart 60-4 Guidelines for Assisting with a Lumbar Puncture A needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar interface to withdraw spinal fluid. Explain the procedure to the patient and describe sensations that are likely during the procedure (ie, a sensation of cold as the site is cleansed with solution, a needle prick when local anesthetic is injected). Determine whether the patient has any questions or misconceptions about the procedure; reassure the patient that the needle will not enter the spinal cord or cause paralysis. The patient is positioned on one side at the edge of the bed or examining table with back toward the physician; the thighs and legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae, for easier entry into the subarachnoid space. The physician cleanses the puncture site with an antiseptic solution and drapes the site. Local anesthetic is injected to numb the puncture site, and then a spinal needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar interspace. The nurse assists the patient to maintain the position to avoid sudden movement, which can produce a traumatic (bloody) tap. The patient is encouraged to relax and is instructed to breathe normally, because hyperventilation may lower an elevated pressure. Monitor the patient for complications of lumbar puncture; notify physician if complications occur. Continuing Care Contacting the patient and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. During these phone calls, teaching is reinforced and the patient and family are reminded to make and keep follow-up appointments. Patients, family members, and health care providers are focused on the immediate needs, issues, or deficits that necessitated the diagnostic testing. This is also a good time to remind them of the need for and importance of continuing health promotion and screening practices and make referrals to appropriate health care providers. What nursing observations and assessments are indicated because of the occurrence of these two disorders? Describe the procedure, its duration, and preparation for this test, including medication/diet restrictions, if any. What explanation can you give to the patient and his wife regarding the difference between the two procedures? What additional information will help prepare the patient to undergo this procedure? Neurotransmitters of the brain: Serotonin noradrenaline, norepinephrine, and dopamine. Using transcranial Doppler sonography to augment the neurology examination after aneurysmal subarachnoid hemorrhage. Nursing documentation versus standardized assessment of cognitive status in hospitalized medical patients. Describe the special nursing needs of patients with varied neurologic dysfunction. Use the nursing process as a framework for care of the patient with altered level of consciousness. Identify the early and late clinical manifestations of increased intracranial pressure. Use the nursing process as a framework for care of the patient with increased intracranial pressure. Describe the needs of the patient undergoing intracranial or transsphenoidal surgery. Use the nursing process as a framework for care of the patient undergoing intracranial/transsphenoidal surgery. Use the nursing process to develop a plan of care for the patient experiencing seizures. Some of the topics in this chapter, such as headaches and seizures, may be symptoms of dysfunction in another body system. Conversely, headaches and seizures can be quite serious symptoms of a severe disruption of the neurologic system. These disorders can also be diagnosed at times as "idiopathic," or without an identifiable cause. The commonality in these disorders is not in the diagnosis or the medical treatment; it is in the behaviors and needs of the patient and the manner in which nurses can best support the patient through these episodes. Yet this system is vulnerable, and its optimal function depends on several key factors. First, the neurologic system relies on its own structural integrity for support and homeostasis. Examples of structural disruption include head injury, brain tumor, intracranial hemorrhage, infection, and stroke. Further expansion places pressure on vital centers, which can cause permanent neurologic deficits or lead to brain death. It requires the body to deliver the essential elements of oxygen and glucose and to filter out substrates toxic to the neurons. Some conditions can be treated and neurologic impairments can be reversed; others result in permanent deficits. Although neuroscience nursing is a specialty requiring an understanding of neuroanatomy, neurophysiology, neurodiagnostic testing, critical care nursing, and rehabilitation nursing, nurses in all settings care for patients with neurologic disorders. The nurse also collaborates with other members of the health care team to provide essential care, offer a variety of solutions to problems, help patients and families gain control of their lives, and explore the educational and supportive resources available in the community. The goals are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. Coma is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years). Akinetic mutism is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes. The cause may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis). The underlying causes of neurologic dysfunction are disruption in the cells of the nervous system, neurotransmitters, or brain anatomy (see Chap. A disruption in the basic functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and other mechanisms such as antibodies disrupting chemical transmission at receptor sites. The two hemispheres of the cerebrum must communicate, via an intact corpus callosum, and the lobes of the brain (frontal, parietal, temporal, and occipital) must communicate and coordinate their specific functions (see Chap. Additional anatomic structures of importance are the cerebellum and the brain stem. The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement. The brain stem contains areas that control the heart, respiration, and blood pressure. If the patient is comatose, with localized signs such as abnormal pupillary and motor responses, it is assumed that neurologic disease is present until proven otherwise.

See acetone insomnia oxford ohio generic modafinil 100mg with visa, replacements; resin emulsifiers/cleaners cleaners insomnia nursing diagnosis buy 100mg modafinil mastercard, water-based: Aquaclean insomnia wiki buy 200mg modafinil mastercard, 33:20; disposal guides fear of insomnia modafinil 200mg on line, 31:68; Thermaclean insomnia hours discount 200 mg modafinil with mastercard, 31:68 insomnia 7 weeks pregnant modafinil 200mg with mastercard. See also emulsifiers Clean Seas: Barnaclean electronic antifouling system, 46:50 clear finishes. See paints/coatings, exterior; resins; varnish Clearwater Electric Boats: electric glide boats/coastal cruisers, 43:17 cleats: installation/hurricane damage, 30:8; installation/location/safety, 42:88; stainless deck cleat/chock with universal deck mount/Schaefer Marine/New Found Professional BoatBuilder Metals, 95:6; fixed and flush Nomen cleat, 95:6 Clement, Eugene P. See fabrics, marine/upholstery; fabrics, specialty; fiberglass fabrics/reinforcements entries cloth, laminating. See fabrics, specialty (laminating); fiberglass fabrics/reinforcements clothing, work/protective: air-cooling vest, 29:58; fabric/static/dust and, 22:12; footwear, 3:19; for foundrywork, 42:46; for welding work, 85:4; in hot weather, 29:58, 33:46; protective suits, 3:19, 4:58, 23:54, 33:46, 64:5. Thornycroft, 85:76 Coastal Prop Technology: Prop Scan, 42:74 Coastal Zone Management Act: non-pointsource pollution regulation, 18:64, 27:8 CoastDesign: Autoplate/Autoship/Autoyacht software, 8:35, 17:58 Coast Guard, U. See also antifouling paints/coatings; electrochromic coatings; epoxy paint; gelcoat; linear polyurethane paints; paint; paints/coatings, exterior; paints/finishes, interior; varnishes/varnishing; etc. Cobalt Boats: builder/construction profile, 28:32, 60:104; closed-molding shop, 90:84, 113:28; cored construction/knitted reinforcements, 29:38; deck plugs/tooling, 28:10, 60:104; hull-to-deck joints, 60:104; safety-related design, 15:50; ventilation system/plant layout, 28:32, 35; 113:28; Xycon skincoat, 28:60 Professional BoatBuilder cobalt naphthenate: introduction of, 38:30; promoter for vinyl ester resin, 6:16, 35:4, 44:30 Coble, Paul Valen: on keel fasteners/galling, 38:20; obit, 149:10; profile of, 88:46; propeller nut installation protocal, 149:10; surveyor tricks, 149:10 Coble, Paul Valen, author: "Respect Where Respect Is Due," 14:64 Cobra Cable Ties, 74:16, 76:10 Cockburn, Conrad: on navigating a Sea of Standards and scantling standards, 155:4 Cockerell, Sir Christopher: hovercraft inventor obituary, 61:10 Cockey, David: on seated eye height comparison to overall height of male and female U. See also dashboards; seats/seating; wheelhouse cockpit soles: encapsulated plywood vs. See also fabric impregnators; vacuumbagging; wood laminates Cole, Jack: Rule 1162 compliance/Skipjack Boats, 25:8 Cole, Stephen A. See also accidents, boat/marine color, hull: and gelcoat blistering, 15:13; and heat distortion/print-through, 2:6, 14:45, 14:55, 45:76, 64:22, 99:104; and postcuring, 14:45, 14:55, 64:22; seasonal freeze-thaw cycling of/data logger testing, 109:170. See also catamarans, power; dive boat; excursion boat market; ferries; fishing boats, commercial, construction commuter: Long Island Sound, 58:13; planemultihull hybrid/Xtreme Xplorer, 57:15; prototype Commuter 36/Magic/Reuel Parker, 130:20; superyacht/Vitters Shipyard, 58:13. See also outsourcing; systems; specific items of equipment composite boats: Custom Composite Technologies, 103:54; hybrid composite sandwich boat/Symphony Boat Co. Composite Design Technologies: FiberSim stitching software, 57:88 Composite Engineering, Inc. See also blistering, gelcoat/osmotic, testing/diagnosis; surveying techniques/tools/equipment composites testing, lab/standardized: applications/methodology/interpreting results, 4:22, 4:27, 6:5, 8:4, 8:28, 34:42, 48:16, 106:62; builder education/composites engineering, 58:104; burnout test/glass-to-resin ratios, 51:85, 125:62; Carderock naval research facility, 42:39; classification/scantlings standards, 48:8; computer analysis vs. See also anti-seize lubricants/compounds; buffing compound; epoxy compound; fairing compound; fillers; polyester compound; sealant; silicone caulk; thread-locking compounds compounds (polishes) for gelcoat restoration: types/applications, 15:44. See also gelcoat finishes Compozitex: print blocker, 7:50, 7:62 compressed-air (pneumatic) tools/systems: equipment/applications/shop techniques, 33:58, 33:64; for spray systems/hotweather, 33:36. See also computer softweare, hydrodynamics/performance prediction; performance prediction computer software, relational database program: Alpha 4, 50:59; for tracking production/materials/labor, 50:59; Windows Access 95, 50:59 computer software, spreadsheets (flat-file database): for design analysis, 49:8, 64:52; limitations vs. See stoves, galley Cool Corporation: Supercool refrigeration subassemblies, 7:64 coolant recovery bottles: in sea trial tests, 145:56 coolers, air. See air coolers cooling systems: Gridcooler keel coolers, 2:70;intercooler, aftercooler, and reduction-gear coolers, 111:66; keel coolers for metal hulls/dual heat exchanger cooling, 111: 16; outdoor airconditioning/Misters Unlimited, 89:8; R. See antifouling paints/coatings, copperbased (non-tributyltin) copper/copper alloys: galvanic corrosion, 32:36, 32:39, 33:28, 52:18, 82:40, 105:96, 107:4 CopperClad: antifoulant, 2:12, 7:42, 7:48 Copper Coat: antifoulant, 1:68 Copperlok: antifouling coating, 8:4 copper sheathing, applications: adhesives with, 9:5; copper alloy (Mariner 706), 7:42, 7:48, 9:5, 23:4; copper/nickel foil, 7:42 cordless tools. See tools, power, hand-held core bonding, materials/techniques: balsa core, 9:36, 33:46, 45:54, 45:68, 70:92, 71:38, 91:96, 94:48, 99:4, 120:18, 150:4; bedding, 51:22, 51:29, 73:40; bond inspection/surveying/testing, 33:46, 45:76, 48:16, 82:104, 100:80; bondline venting/bleeder/flat-panel fabrication, 45:68, 94:48; co-curing/panel warping/flatpanel fabrication, 45:68; contour-cut cores vs. Airex, 35:58, 51:6, 51:22, 52:30, 53:4, 56:5; Bead & Cove Planking System/foamcored one-offs, 35:58; for bow ramp in Advanced Composite Riverine Craft, 146:24; vs. See core bonding; fiberglass construction, cored/sandwich cored panel penetration: repairs to , 97:130, 99:44 cored/sandwich construction. See composite flat-panel construction; fiberglass construction, cored/sandwich Corel 45: one-design racer, 61:66 Coremat: print-through control, 7:50, 7:62; weight savings, 3:27 core materials: for bottom panels, 51:22, 51:24, 51:26, 51:29, 53:4, 54:62, 55:5, 56:5, 57:7, 70:92; brittle vs. See also corrosion, stray-current; blistering, carbon fiber/galvanic corrosion, stray-current: aluminum foil experiment/Dick Troberg, 105:96; 107:4; bonding system protection for, 138:18; causes/prevention, 32:36, 33:28, 41:21, 65:38, 82:80; galvanic isolators and, 30:38, 31:4, 33:4, 41:21, 43:5 corrosion test meter: vs. See upholstery/cushions Custom Composite Technologies (Maine): profile of, 103:54 custom/semi-custom/one-off construction: 1990s retrospective, 60:27; accessories/hardware/ancillary equipment, 14:26, 14:32, 64:11; advanced-composites racing catamaran/Cogito, 39:30; Aluminewman (aluminum custom cockpit), 17:19; aluminum vs. See also blister repairs; delamination; hurricanes/major storms; insurance, boat/marine; repair techniques; surveying techniques/tools/equipment; surveyors/surveying, profession/judgment damage, minor: composite repairs assessment, 82:22 damping materials. See Taylor, David, Model Basin Davidson, Ken: model testing/performance prediction, 60:66 Davidson, Laurie (New Zealand boat designer): 71:70 Davies, Richard: on surveying and ethics/judgment, 110:4 Davies, Roger: on trailering/point loading, 60:5 Davis, Arch, author: "Mold Alternatives for One-Offs," 10:42; "Strip-building in DuraKore," 15:34; "Training Down Under," 20:25 Davis, Jr. Davis, Lincoln: vintage outboard engines, 92:68 Davis Yachts: Carson "Buddy" Davis, Jr. See nonskid deck coatings/coverings deck hardware/fittings, installation/bonding: acrylic adhesive/X-Serts for, 18:4; chocks, 30:8; cleats, 30:8; for carbon fiber laminates/galvanic blistering, 57:30; for cored laminates, 15:21, 32:44, 34:52, 36:78; epoxy-potted fasteners, 15:21, 32:44, 36:78; hurricane damage and, 30:8; loading/cored construction, 52:40; 3M 5200 sealant for, 15:21, 28:27, 29:4 deck hardware/fittings, manufacture: inhouse vs. See also hardware, marine; rigging, stainless steel deck hardware/fittings, used: salvaging/recycling/Sailorman, 60:82 deckhouse: sliding-top, 54:18. See also core bonding, materials/techniques; secondary bonding Delcam: software for multiaxis turning equipment, 106:10 DeLillo, Michael: on Lee Dana/Bertram Yacht, 43:5 Delta International Machinery Corp. Blount and Associates, 102:4; 109:5, 100; 113:4; sea trials, 110:50, 111:4; speed/length ratio, 126:38; trim tabs, 111:4; vs. Moonraker, 126:38; and Virgin Atlantic Challenger Blue Riband Award, 135:26 Det Norske Veritas: advanced-composites research, 47:57; safety standards/testing cored composites, 34:42, 34:45, 63:38, 68:32, 142:40; type-approved materials/data and scantlings standards, 142:40 Detroit Diesel Corp. Bonsink Trading Company fairing putty machine, 120:38; pre-preg temperature and cure cycle monitoring, 132:24; profile of, 77:70; in-house composites skills, 132:24 DeWalt Industrial Tool Co. See saw blades Diamond Machining Technology: flat-file sharpener, 19:59; whetstone sharpener, 1:68 Diamond Saw Works: Sterling saw blades, 12:60 Diana Yacht Design: megayacht construction/market, 12:50 diaphragm pumps. See pumps, diaphragm Diaship: megayacht construction/market, 12:50 DiaTrim Tools Ltd. See also painting supplies Drott Manufacturing: Marine Travelift acquisition, 57:133 Drum (monohull): 62:46 drums, resin/gelcoat/chemical: Barrel Harness, 8:54; containers for (Enviropac), 9:56; Drumroll leak-control system, 26:54; storage/inert-gas cap, 15:13 dryers, air. See air dryers dryers, hot-air: for drying water-saturated flotation foam, 37:48 dry ice: use for cleaning and removal of contaminats/Cold Jet, 141:6 dry storage. Duramold: hot-molding process/Spruce Goose wood airplane/Howard Hughes, 151:6 DuRant, Suzi, author: "Prop Re-Pitching Made Easier," 119:6 Dura-Skrim: fiber reinforced polyethylene covers and tarps, 155:4. See also Hall, Thomas Duratec: for plug/high-temp tooling, 59:76; polyester epoxy bondcoat, 49:59, 51:6; sanding/fairing, 59:76; vinyl ester primer, 34:21, 42:59 Duroboat: interlocked aluminum boats, 4:42 durometers. See Barcol hardness tester; Shore tester Dusseldorf Boat Show, 115:128 dust, fiberglass: controlling, 28:38, 29:4, 84:10, 129:8; definition, 28:39; Dustron booth/J & J Marine, 104:78; and secondary bonding, 20:32; static electricity and, 22:12, 48:86 dust, wood: controlling/Blovac air gun, 8:54; controlling/Bad Dust Containment Systems, 129:8; exposure limits/1989, 1:30. See also vacuum cleaners/systems; ventilation systems, shop dust collectors, for air-driven sanders and cutters: AirWall, 13:70; Dust Muzzle, 19:59, 66:5; Festo/Diatrim, 5:26; pollution control, 29:4; Powermatic Artisan 73, 18:54; Sand Trap 73505, 20:56; sources, 87:10; Vacuum Sanding Systems, 20:56 dust control: sanders, 84:10, 87:10; throughthe-pad vacuum sanding/Hutchings Manufacturing Co. Choate, 126:56; at Gold Coast Yachts, 124:42; at Huckins Yacht Corporation, 121:62; James Betts, 129:38; at Keefe Kaplan Maritime, 121:62; marketing/advertising, 7:72, Professional BoatBuilder E 11:34, 117:54; R&D/product development, 45:120; 117:54, 127:4; "Refresh, Not Refit"/ Knight & Carver Yacht Yard, 127:42; retrofitting molds/San Juan powerboat/San Juan Composites, 121:62; at Stingray Boats, 127:30; at Trinity Yachts, 121:62; at Westport Shipyard/Pacific Mariner, 121:62; at Willis Marine, 121:62 economics, impact on marine industry: mid1970s devaluation/embargo (American Marine), 19:28; 1980s/90s recession, 7:72, 9:13, 11:34, 13:26, 15:80, 16:4, 19:28, 45:120, 138:3, 139:74; luxury/sales/use taxes, 4:9, 12:2, 12:50, 16:4, 18:64, 20:64, 25:3, 37:66; postrecession composite boatbuilding, 123:26, 151:68; and profit margins/pleasure boat market, 21:4, 32:64, 123:72. See also battery cables; cable sheathing; cable ties; grounding; wire/cable, marine electrical fires. See corrosion, galvanic electrochromic coatings: on "smart" composites, 46:45 Professional BoatBuilder electrochromatic glass, 131:54. See resin emulsifiers/cleaners Encompix: materials requirements planning system software, 96: 52 Endeavor Catamaran Corp. See design/engineering considerations/parameters; designer/naval architect/engineer, profession/responsibility Professional BoatBuilder engineering consultants. See enginecontrol systems, electronic; engines, computer applications; engines, marine, diesel; engines, marine, gas Engine Management Systems, Inc. See also engine-control systems; instruments/instrument panel; noise/vibration control; performance prediction; propeller shaft/drive shaft; propulsion/drive systems; speed, estimating engines, marine, drive systems. See also enginecontrol systems; engine mounts; propulsion/drive systems engines, marine, inboard: bonding systems, 33:28; ceramic pistons, 92:68; cooling systems/ventilation/installation, 37:26; flooding/salvaging, 43:44; fuel efficiency, 17:44, 92:68; noise/vibration control (engine mounts), 34:22, 34:26, 34:27, 35:58; twin-screw rudder installation, 45:96, 54:62; wet exhausts, 43:44, 89:66 Professional BoatBuilder engines, marine, installation/layout: bedding/alignment, 29:14; accessibility, 108:4, 109:6; bed/support/stringers, 37:26; engineroom design/layout, 25:42, 37:26, 37:30, 37:34, 46:16, 59:44; forward location, 51:96; installing a hatch cut-out for accessing engine, 106:34, 36; and propeller-shaft stuffing box, 29:14; weight reduction in, 64:52. See also engine mounts; noise pollution; noise/vibration control; soundproofing insulation engines, marine, outboard: acoustic/performance testing, 52:43; grounding/bonding systems, 23:4, 33:28; high-performance propellers for, 48:86; Honda fuel-injected, 22:56; Mariner/specwar, 52:43; mufflers/silencers/boat-noise control, 43:75 engines, marine, steam: Titanic, 53:12 engines, marine, turbine: horsepower ratings/speed prediction, 59:56; power vs. See also putties, syntactic Equipment Engineering: Paint Pig, 8:54 Equipment Sales Co. See also ferries; passenger vessels Exeltech: inverter supplier, 25:34, 25:40 exhaust hose: double-clamping, 51:6; fiberglass, 43:44, 46:5; standards/quality, 49:16, 51:6; wet-exhaust system/standards/installation, 43:44, 46:5, 49:16 exhaust system. See engine exhausts; engine exhaust system, dry; engine exhaust system, wet; mufflers/silencers Exley, Chris: on sportfishermen tower pod, 104:4 exotherms: "bucket effect," 108:100; exothermic reaction/cross-linking/catalyst ratios, 1:6, 50:46, 108:100; "the hot hut" fireproof disposal site/Viking Yachts, 131:54; monitoring/photo-curing resins, 18:17; resin shrinkage/open- vs. See coextrusion Exxon Valdez, 127:104 A, A B C D E G H I J K L M N O P Q R S T U V W X Y Z fabric, polyester. See fiberglass fabrics/reinforcements fabrics, marine/upholstery: design mock-ups, 9:28; Nautolex vinyls, 6:52; photorealistic studies, 40:48; performance boat seats/Outerlimits Offshore Powerboats, 133:84; Stamoid Super Light, 34:28, 34:32; Sunbrella, 32:15; UltraSuede, 3:60, 6:34, 6:39. See Peel Ply/peel ply fabrics, sailcloth: Vectran, 41:58 fabrics, self-adhesive: Saerfix, 129:8 fabrics, specialty (laminating). See putties, fairing Professional BoatBuilder fairing problems, prevention of: 67:49 fairing software. See also putties, fairing fairing tools: foam pad, 60:27; PowerBoard, 24:62; 3M Hookit Rigid Fairing Board, 102:14 Fairline: hull-design software, 7:18, 8:35, 17:58, 79:8; Version 2. Faro Arm, computerized measuring device: 78:94; 81:42 Farr, Bruce (designer): cored Kevlar/S-glass laminate/Baltic 60 yacht, 85:46; Millennium 65, 59:10, 71:70; profile, 61:66; and computer modeling technology, 61:66 Farr Yacht Design: and Young America hull failure, 65:66; boat design for Oracle Racing Inc. See also specific fastener types; nails; rivets/riveting; screws entries fasteners, acrylic-adhesive-mounted: Click Bonds/X-Serts (adhesives/applications/installation), 18:4, 32:52 fasteners, nuts: Nylok elastic stopnuts/keel fasteners, 38:20; Southco captive nuts/electronics, 41:62 fasteners, removal, tools for: Drill-Out bolt/stud extractor, 46:65; Fuller plug cutter/wood screws, 23:20; Invis magnetic field device for fastening and detaching parts/panels, 79:10; Pivex pivot driver, 44:54; T & L extractor/wood screws, 24:58 fasteners, stainless steel: bolt head markings, 118:52; corrosion of, 15:23, 32:36, 32:41, 38:20, 39:4, 127:84; corrosion prevention/potting in epoxy, 15:21, 32:21, 32:44, 36:78; graphite lubricant for, 39:4; keelbolts/installation, 15:23, 38:20, 39:4, 40:4; keelbolt fasteners/backing plates for, 127:84; and pressure-treated lumber, 91:20; selftapping screw penetrations and water intrusion, 97:130; stopnuts for, 38:20; thread-locking compounds, 38:20, 39:4, 40:4; titanium, 40:4, 57:30. See also core bonding, materials/techniques; delamination; surveying techniques/tools/equipment, nondestructive fiberglass construction, cored/sandwich, flatpanel: applications/techniques, 2:42, 45:54, 45:68, 48:4, 54:44, 54:62, 91:178; corrugated cores, 91:178; fabric Professional BoatBuilder impregnator applications, 5:34, 54:44; knitted heavyweight reinforcements, 29:38; for megayachts, 2:42 fiberglass construction, cored/sandwich, repairs: hull-drying techniques, 9:36; patching techniques/materials, 36:34, 108:100, 111:82, 113:4; plate glass tests for skincoats, 111:82; Sea Ray Boats, 96:16. Kevlar/carbon fiber, 28:18, 45:54, 56:64, 58:36; epoxycompatible, 37:48, 42:62; fiber orientation/strength/thickness, 28:18, 29:38, 31:68, 34:42, 45:54, 47:66, 51:85, 51:88, 53:20, 55:5, 71:38, 106:112. Kevlar/carbon fiber, 28:18, 56:64, 58:36; pre-cut laminate material kits, 142:40; for reducing print-through, 34:18, 34:21, 50:46; storage/blister prevention, 15:13; strength/breakage/stress concentrations, 13:3, 13:36; for thermoplastics, 11:20; thickness/resin content, 51:85, 55:26; use of peel-ply between steps of multiplepacket laminates, 107:70; VectorFusion fabrics, 114:10; for vinyl ester resins, 42:62; weighing fabrics/quality assurance procedures, 142:40; wetout/backwetting/blister prevention, 15:13, 119:58. See also fiberglass fabrics/reinforcements, taping and tabbing fiberoptic borescope: for non-destructive surveying/visual inspection, 35:42, 35:50; rentals/sources, 35:42, 35:50 Professional BoatBuilder fiberoptics: BritePak Fiber Tubing, 34:28; for interior lighting, 34:28, 34:32; sensors/"smart" composites, 46:45 fiber orientation. See also microspheres/microballoons; resin thixotropes fillets/filleting: inside corners/chines, strakes, steps, and transom corners, 58:79. See plastic film film, prismatic/light: Scotch Brand Parallel Light Film, 34:28, 34:32 film, vacuum. See also electrical systems; wiring, marine first aid: burn dressings/supplies, 8:54. See deck hardware/fittings; rigging, stainless steel Fitz, Frank, 143:3 Fitzgerald, John, author: "The Case for the Customer Service Rep," 148:38 Fitzgerald, Mark: designer/model testing, 55:32; prototype for Fitzgerald 36 design, 71:6 Fitzgerald, Mark, author: "The Case for Classifying and Standardizing Product Specs," 49:96; "Patrol Yacht," 51:96 Flacksenhae, John J. See stabilizer system Florida Board of Professional Engineers: professional engineer (p. Lucie County manufacturer incentive program, 32:48; sales tax/10 to 90, 37:66; subcontractors in boatyard, 54:5. See flotation foam; foam, syntactic; foam cores; polyurethane foam; soybased form, 143:52; urethane flotation foam foam, closed-cell: Ductile, 10:52; for icebox insulation/R value of, 90:64; Softlite/ionomer plastic, 40:66; SeaDek, 125:20; use in Hy-Lite Powerboat construction, 66:11 foam, syntactic. See also bulkheads/compartments; oilcanning/deflection framing jig: four-way Bessey K clamps, 5:58 franchises: choice of law provisions and franchise statute, 150:20; dealer-builder relationship, 150:20; license and community of interest, 150:20 Franklin, Ian (New Zealand boatbuilder): profile, 71:73 Franzen, Iver C. See R-12 refrigerant (Freon) Frers, German (Argentina): Swab sailboats, 84:52 freshwater systems: systems technician training/certification, 57:99. See heaters/heating systems, boatshop furniture, interior: design updates/weightsaving techniques, 6:39, 34:28, 92:76; divinycell foam-cored/Gunboat International boat, 144:58; Lazzara Yachts/American Quality Furniture Co. See instruments/instrument panel; navigation instruments/systems gauges, strain: used in "smart" composites, 46:45Geer, Abbot M. See tooling gelcoat gelcoat, weathered/deteriorated, causes/caveats/restoration: chalking, 13:70, 15:44, 15:49, 103:26; cleaning/cleaners, 15:44; compounding/polishing/finishes, 15:44, 15:49; fading, 15:44, 15:49, 18:33; 64:112; shrink-wrapping and, 18:33; yellowing, 15:49, 64:112 gelcoat blistering. See blistering, gelcoat/osmotic; blister repairs gelcoat cleaners: types/applications, 15:34, 15:44 gelcoat finishes: Awlgrip, 15:44, 19:12, 19:20; compounds (polish/rouge), 15:44; copolymer wax, 15:44; Crystal TopCoat, 15:44; polishing paste, 20:56 Gelcoat Peeler Ltd. See also catalyst; exotherms; resins, exotherms/curing cycles Gem Products: Gemlux electrochemical polishing process/stainless steel, 49:79 GenCorp Polymer Products: Nautolex marine vinyls, 6:52 General Automotive Specialty Co. Raymond Hunt Associates, 139:18; power catamaran/F-26b Tigercat, 45:120 Grainger, W. See resin (gram) scale Granata, Peter: deck design/plug construction, 28:10; interior design/Cobalt, 28:32; on product safety/liability, 15:50; on retrofit program, 18:4; runabout design/Marine Design Resource Alliance, 51:11 Granata, Peter, author: "Beating the LookAlike, Perform-Alike Syndrome," 17:8 Granata Design. Kurt: on seaworthiness, 34:55 grid systems, structural: molded integral, 46:28, 46:35, 46:37, 48:4, 58:54, 143:10 Griffin, Nancy, author: "Marine Trade Associations," 4:9 Griffon Hovercraft Ltd: passenger-carrying hovercraft, 96:52 Grimes, Paul: on bonding fastenings, 18:4 Grimnes, Martin: on heavyweight reinforcements, 18:54 Grimnes, Martin, author: "Fast Forward," 54:112 grinders, disc: for blister repair, 16:42; Cyclone, 14:57; Fein angle grinder, 36:78; Festo (DiaTrim) air-driven, 5:26; Makita, 15:44, 27:70; Mini Angle Grinder, 21:60; Tercoo/rubber disc tipped with tungsten carbide studs, 141:30 grinders/polishers, discs for: aluminum oxide, 26:54; diamond abrasive, 12:60, 20:56, 25:59; Rx-Cut depressed-center, 40:66 grinding laminates: carbon-fiber, 28:18; dust control/air quality, 28:38, 28:48; Kevlar, 28:18; moisture/blister detection, 23:42; secondary bond lines/repairs, 19:46, Professional BoatBuilder 19:48, 20:32, 20:37, 25:25, 39:19, 39:27, 42:5 grinding pads: lubricant for, 37:36 Grinnacle Import Export Pte. Herreshoff, 54:3, 54:82; Sonny Hines, 54:3, 54:62 Hall, Eric: rig/spar design innovations, 6:20, 47:44 Hall, Frank, Boat Yard: advanced-composite repairs, 43:54; fire protection, 44:18 Hall, J. Raymond Hunt Associates, 81:90 handholds: in control station, 48:66, 48:79; design/occupant protection, 34:13; placement of, 50:20 handicapped-accessible yacht: John Anderson/Tim Nolan design, 57:15 hand layup. Luke, 14:26, 14:32; mounting, marine Professional BoatBuilder hardware, 139:96; quality control, 34:72, 54:79; Rybovich, 14:26, 14:32; stainless steel/corrosion, 54:70, 54:70, 139:96; stainless steel/electrochemical polishing process, 49:79; watertight deck hatch latch, 150:72. Hawley, Chuck: on ozone-clean marine refrigeration/service, 26:17 hawsepipes: anchor-stowage systems, 22:28, 22:29; cutting and choosing fittings, 105:26; hawseholes, 106:4; water intrusion and structural failures of, 105:26; Hayash, Edward: on strength testing of cored laminates, 8:4 Hayden, Sterling: on saloons, 57:15 Hanes, H. See also chemical sensitivities/allergies; spills, fuel/chemical, cleanup/containment kits Professional BoatBuilder hazardous waste. See also liners Healey, Bill: builder profile/Viking Yacht, 46:16, 46:26 Healey, Bob: builder profile/Viking Yacht, 46:16 health, occupational. See also temperature, of boatshop heat-cured composites: oven/temperaturecontrol system for, 39:30. Luke, 14:26, 14:32; Professional BoatBuilder systems technician training/certification, 57:99 heaters/heating systems, boatshop: bellyband, 15:13; for blister repairs, 17:11; catalytic heaters/blister repairs, 8:54, 16:42, 17:11; for gelcoat, 11:42; heat recovery/ventilation system, 2:67; HeatTriever air-rotation system, 5:26; infrared/blister repairs, 17:11; infrared/thermoforming plastics, 10:34; kerosene, 19:25; Master Mark Boat Heater, 6:52; for painting/aluminum boats, 37:42; for painting/repair tent, 19:25; for post-curing epoxy, 14:45, 42:52, 136:22; for resin drums, 15:13; and secondary bonding, 20:32; shop-built post-cure heater panel/Brooklin Boat Yard, 136:22. See also ovens/autoclaves; temperature, of boatshop Heat-Triever Systems: air-rotation and heating system, 5:26 Hebert, Paul: Corsair Marine/production efficiency, 29:22 Hebert, Susan: on gelcoat maintenance/restoration, 15:44 Heesen Yachts (The Netherlands): enviable order book, 125:8; superyacht with Fast Displacement Hull Form/van Oossanen & Associates, 134:6 Helgerson, David A: on designer Dave Martin and the "Sparkman & Stephens school" of naval architecture, 107:4 Heli-Coil: Drill-Out bolt/stud extractor, 46:65 Helix Mooring Systems: screw anchors, 30:8, 30:16, 38:4 Hella Inc. Hellyar-Brook, Roger, author: "Thirty-Eight Weeks (Marine Systems Technician course)," 57:99 Hellyar-Brook, Roger: and Landing School curriculum, 75:112 helm. Kern: on expanding epoxy foam, 140:4; on potted fastenings, 15:21; on market downturn, 12:4; on post-curing epoxy, 14:45; on water permeation/osmosis, 15:60. See also System Three Resins Hendrickson, Ray: on dragging hose/cable, 30:4 Hendrickson, Ray, author: "Tents Make Storage-Shed Space More Usable," 19:25 Henwood, William: on boatbuilding/boat handling skills, 34:5 Herex foam: cross-linked/high-density, 23:54, 74:68 Herion Inc. En Ferries," 122:12; "Rhinophoto," 132:6; "Low Impact for a Tall Ship,"157:14 Hines, Sonny: on cored bottoms, 51:22; profile, 54:3, 54:56, 54:62 Hines-Farley Offshore Yachts: closing of, 145:12; cored bottoms, 51:22; Double Dog sportfishermen, 101:38; longest and fastest 63 Sportfishermen extension build, 145:12; "number one sportfishing boat" by Robb Report, 65:11; profile, 54:3, 54:56, 54:62 hinges: stainless steel/electrochemical polishing process, 49:79 Hinterhoeller, George: and C&C Yachts, 92:48 Hinterhoeller Yachts: Niagara 35/Niagara 42/Mark Ellis designs, 138:32, 139:74; Nonsuch series/free-standing rigs, 55:46 Hitachi Power Tools: electronically controlled routers, 1:68 Hi-Tech Hose, Inc. Hoechst Celanese: Marco method, 32:28, 26:44, 38:30; Trevira polyester fabric, 7:50, 7:62, 22:8, 22:20, 32:4 hoists.

See Pregnancy Mauritania nutrition sleep aid list buy cheap modafinil 100mg on line, 62 Mauritius family planning in insomnia green day modafinil 200mg sale, 107-8 vital statistics in sleep aid for teenagers order modafinil 100mg fast delivery, 84 sleep aid unisom order 100 mg modafinil otc, 284 Measles childhood mortality insomnia quotes funny purchase modafinil 100 mg with mastercard, 290-1 See also Children; Tropical infectious diseases Medical distance and female health care sleep aid taking cvs by storm modafinil 200 mg overnight delivery, 28-9 risk factors, 92-3 1 Menopause, 20, 113-4 mental health and, 137 See also Life span Mental health, 10 gender and, 136-7, 138-40, 144, 146-7 See also Psychiatric tests; Schizophrenia Micronutrient deficiencies, 64-7 passim environmental health, 197 gender and, 68 obstetric complications and, 114 schistosomiasis and, 213 See also Body-mass index; Iodine-deficiency disorder; Iron-deficiency anemia; Protein-energy malnutrition; Vitamin deficiency Midwives. See cancers Nervous system disorders, 10 See also Cerebrovascular diseases; Cognitive development; Collagen diseases; Demyelinating diseases; Epilepsies; Headache syndromes; Lupus; Toxic disorders Neurotoxicity. See Pregnancy Occupational and environmental health, 11, 183-99 passim See also Agriculture; Chemicals; Formal (economic) sector; Informal (economic) sector; Injuries Onchocerciasis and lymphatic filariasis, 192, 200-1, 225-8 See also Tropical infectious diseases Oral Contraceptives. See Contraceptives; Family planning Orphanhood method mortality and, 284-5 See also Demographic data Outcomes study, 142-3 See also Mental health; World Health Organization Ovarian cancer, 160-1 See also Cancers Self-Reporting Questionnaire, 140 Puerperium. See Nutrition; United Nations Administrative Committee on Coordination/A System of National Accounts Reproduction. See Mental health; Psychiatric tests; World Health Organization Schistosomiasis, 192, 200, 212-5 See also Tropical infectious diseases Schizophrenia, 142-3, 149 See also Mental health; Psychiatric tests Self-Reporting Questionnaire. See Psychiatric tests Senegal malnutrition and reproduction, 73 mental health in, 140 surveys, 285 Service sector. Aldinger, Ronnie Blecher-Gonen, Fan Zhang, Malte Spielmann, James Palis, Dan Doherty, Frank J. S1 to S27 Captions for Tables S1 to S16 References Other Supplementary Material for this manuscript includes the following: (available at science. The filtered nuclei were then transferred to a new 15 ml tube (Falcon) and pelleted by centrifuge at 500xg for 5 min at 4°C and washed once with 1 ml ice-cold cell lysis buffer. The samples were split to 5 tubes with 100 ul in each tube and flash frozen in liquid nitrogen. Gestational age, reported as the number of weeks post-fertilization, was estimated from fetal foot length. Dried tissue was placed on a heavy-duty foil or in cryotube, snap frozen in liquid nitrogen, and then stored at -80°C. Nuclei isolation and fixation of frozen fetal tissues On the day of pulverization, we pre-cooled pre-labeled tubes and a hammer on dry ice with a cloth towel between the dry ice and metal. We created a "padding" by taking an 18" x 18" heavy duty foil, folded in half twice creating a rectangle and then folded twice to create a square. The frozen tissue was placed inside the foil "padding" then inside a pre-chilled 4 mm plastic bag to prevent tissue from falling out onto the dry ice in case the foil ruptured. Using the prechilled hammer, we manually pulverized the tissue inside the packet with 3 to 5 impacts, avoiding a grinding motion. When necessary, we re-chilled the sample to avoid thawing and repeated the procedure until we generated small, uniform fragments. The samples were split into two tubes with 250 µl in each tube and flash frozen in liquid nitrogen. For human cell extraction in renal and digestive organs (kidney, pancreas, intestine, and stomach) and paraformaldehyde fixation, we followed the procedure described in (13). Immunohistochemistry Fetal tissues were fixed in formalin and embedded in paraffin. Sections of 4-5 m thickness were cut and placed on Superfrost Plus slides (12-550-17, FisherBrand). For Immunohistochemistry, sections were subjected to heat mediated antigen retrieval (pH6. Filtered nuclei were spun down at 500xg for 5 min and resuspended in nuclei wash buffer. Nuclei from each sample were then distributed into several individual wells in four 96-well plates. The links between well id and tissue id were recorded for downstream data processing. Reverse transcription was carried out by incubating plates by gradient temperature (4°C 2 minutes, 10°C 2 minutes, 20°C 2 minutes, 30°C 2 minutes, 40°C 2 minutes, 50°C 2 minutes and 55°C 10 minutes). Amplification was carried out using the following program: 72°C for 5 min, 98°C for 30 sec, 12-16 cycles of (98°C for 10 sec, 66°C for 30 sec, 72°C for 1 min) and a final 72°C for 5 min. Cells were pelleted and resuspended in 500ul nuclease free water including 1% SuperRnaseIn. For mixed-species experiment, the percentage of uniquely mapping reads for genomes of each species was calculated. For multi-mapped reads, reads were assigned to the closest gene, except in cases where another intersected gene fell within 100 bp to the end of the closest gene, in which case the read was discarded. Clustering analysis of pseudobulk transcriptomes was done with Monocle 3/alpha (11). Briefly, an aggregated gene expression matrix was constructed as described above for human fetal organs from each individual. Cell filtering, clustering and marker gene identification For the detection of potential doublet cells, we first split the dataset into subsets for each organ and individual, and then applied the scrublet/v0. For detection of doublet-derived subclusters for cells from each organ, we used an iterative clustering strategy as shown before (11). Briefly, gene count mapping to sex chromosomes were removed before clustering and dimensionality reduction. The top 1,000 genes with the highest variance were selected and the digital gene expression matrix was renormalized after gene filtering. The data was log transformed after adding a pseudocount, and scaled to unit variance and zero mean. We then cluster the cells into sub-groups using the Louvain algorithm implemented as scanpy. Subclusters with a detected doublet ratio (by Scrublet) over 15% were annotated as doublet-derived subclusters. For data visualization, cells labeled as doublets (by Scrublet) or from doublet-derived subclusters were filtered out. Genes expressed in less than 10 cells and cells expressing less than 100 genes were further filtered out. The downstream dimension reduction and clustering analysis were done by Monocle 3/alpha (11). Cell clusters were identified using the Louvain algorithm implemented in 7 Monocle 3 (louvain res = 1e-04). Clusters were assigned to known cell types based on cell type-specific markers (Table S3). We found the above Scrublet and iterative clustering based approach is limited in marking cell doublets between abundant cell clusters and rare cell clusters. To further remove such doublet cells, we took the cell clusters identified by Monocle 3 and first computed differentially expressed genes across cell clusters (within-organ) with the differentialGeneTest() function of Monocle 3. We then selected a gene set combining the top ten gene markers for each cell cluster (ordered by q-value and fold expression difference between first and second ranked cell cluster). Subclusters showing low expression of target cell cluster specific markers and enriched expression of non-target cell cluster specific markers were annotated as doublets derived subclusters and filtered out in visualization and downstream analysis. Differentially expressed genes across cell types (within-organ) were re-computed with the differentialGeneTest() function of Monocle 3 after removing all doublets or cells from doublet-derived subclusters. Adjudication of the 15 initially unannotated cell types As noted in the main text, our first round of annotation was performed on a tissue-bytissue basis by comparing observed cell types to those expected from prior knowledge of the same tissue. In general, we recovered all or nearly all main cell types identified by previous atlasing efforts directed at the same organs, despite differences with respect to species, stage of development and/or technology. In addition, we identified 15 cell types that we did not at least initially expect to observe in a given tissue. We labeled these based on the top enriched differentially expressed gene markers within that tissue. Unsurprisingly, the initially unannotated cell types were rarer than annotated cell types (median 0. We have grouped them into 8 to which we have assigned preliminary annotations based on these additional analyses, 4 that would be better characterized as subtypes of other cell 8 types, and 3 that have high specificity scores but remain ambiguous. Of note, although observed in at least two samples of each organ, their abundance was highly variable. We believe that these cells correspond to hepatoblasts that are potentially circulating. We infer they correspond to trophoblasts that have entered fetal circulation and are present in sufficient numbers in at least the fetal adrenal gland and fetal lung, which were two of the most deeply sampled organs, to cluster independently of other cell types. In the companion single cell atlas of chromatin accessibility, a corresponding placental cluster was identified, and shown by two methods to be dominated by maternally derived cells (12). On cell type correlation analysis with the corresponding mouse tissue, they are strongly matched to labyrinth trophoblasts. Glycodelin produced by the maternal endometrium is a key regulator of fetomaternal tolerance during pregnancy (202). Notably, in the global analysis these cells cluster separately from all other neurons. Although this most likely reflects contamination of that sample with a fragment of brain during dissection, it is notable that other neuronal cell types were not identified within the same tissue sample. These cells are not uniformly distributed across the 8 cerebral tissues sampled, but are clearly observed in 5 of these tissue samples. This could reflect contamination, but of note we did not observe other cerebellar cell types in those same tissue samples. Differentially expressed genes across cell types were identified with the differentialGeneTest() function of Monocle 3. For clustering analysis of blood cell across 15 organs, we extracted all blood cells corresponding to annotated clusters of myeloid cells, lymphoid cells, thymocytes, megakaryocytes, microglia, antigen presenting cells, erythroblasts, and hematopoietic stem/progenitor cells. Cell clusters were identified using the Louvain algorithm implemented in Monocle 3 (louvain res = 1e-04). We then applied a similar analysis strategy as above for clustering analysis of endothelial or epithelial cells across organs. For endothelial cells, we first extracted cells corresponding to annotated clusters of vascular endothelial cells, lymphatic endothelial cells and endocardial cells across organs. Cell clusters were identified using the Louvain algorithm implemented in Monocle 3 (louvain res = 1e-04), and then annotated based on the tissue origin of endothelial cells. For epithelial 12 cells, we first extracted cells from the epithelial cell cluster in. Intra-dataset cross-validation analysis For cells from each organ, we randomly sampled up to 2,000 cells from each main cell type. As control, we randomly permuted the cell type labels, followed by the same analysis pipeline. For cell type specificity analysis across all organs, we applied the same analysis strategy to the full dataset after sampling up to 2,000 cells of each main cell type. Sub-clustering analysis For each main cell type (with over 1,000 cells) in each organ, we applied Harmony/v1. Cell clusters were identified using the Louvain algorithm implemented in Seurat/v3. We then applied the intra-dataset cross-validation approach to evaluate the specificity of sub-clusters within each main cell type. For every sub-cluster pair, A and B, we computed the number of A cells mislabeled as B cells in cross-validation analysis with the true dataset (mislabeled cell number: n) or the permuted dataset (mislabeled cell number: m). A large n value suggests the two sub-clusters are not well separated by the full transcriptome. We thus iteratively merged similar sub-cluster pairs (n > m), and identified a total of 657 subtypes across 15 organs. The intra-dataset cross validation approach was applied to evaluating subtype specificity within each main cell type in each organ. To improve accuracy and specificity, we selected cell type-specific genes for each target cell type by: 1) ranking genes based on the expression fold-change between the target cell type vs. We combine the two values by: = + 14 and find reflects the matching of cell types between two data sets with high specificity. For each cell type in dataset A, all cell types in dataset B are ranked by and the top cell type (with > 0. We then applied the same integrative analysis strategy to extracted human and mouse cells from the hematopoietic, endothelial and epithelial trajectories. For the co-embedded human and mouse hematopoietic cells, we annotated each mouse cell based on its k nearest neighbours of human cells. Differentially expressed genes across mouse hematopoietic cells were computed with the differentialGeneTest() function of Monocle 3/alpha. Differentially expressed genes across the three branches were computed with the differentialGeneTest() function of Monocle 3/alpha. We then clustered cells with k means clustering (k = 10) and computed the average development time for each cluster. The progenitor cell group was annotated based on the lowest average development time and appeared at the center of the three branches. Each cell was assigned a pseudotime value based on its distance from the progenitor cells. Using the Garnett models trained on this human cell atlas for cell type classification the R package Garnett for Monocle 3 (version 0. Models were trained on the entirety of each tissue dataset with the exception of cerebrum, where 100,000 cells were randomly sampled for training for computational efficiency. The model was applied using the function classify cells with the same parameters as above. When compared cell type assignments to those provided by the authors, we considered the following cell types to be equivalent: acinar, Acinar cells; ductal, Ductal cells; endothelial, Endothelial cells; mast, Myeloid cells; macrophage, Myeloid cells; schwann, Glia; alpha, Pancreatic Alpha cells; beta, Pancreatic Beta cells; delta, Pancreatic Delta cells; activated stellate, Pancreatic stellate cells; quiescent stellate, Pancreatic stellate cells; t cell, T cells. Most trajectory analysis was done with Monocle3 with setup instructions and tutorial available at cole-trapnell-lab. We do not observe a clear correspondence between the differentiation trajectories and estimated post-conceptual age. Semi-supervised classification with Garnett agrees with manual annotations and can be used for automatic classification of other datasets.

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References

• Rossi F, De Castro R, Ceccarelli PL, et al: Anterior sagittal transanorectal approach to the posterior urethra in the pediatric age group, J Urol 160(3 Pt 2):1173n1177, 1998.
• Konstantinov IE, Karamlou T, Blackstone EH, et al. Truncus arteriosus associated with interrupted aortic arch in 50 neonates: a Congenital Heart Surgeons Society study. Ann Thorac Surg. 2006;81:214-22.
• Kim SY, Kim SM, Chang H, et al. Long-term outcomes of ethanol injection therapy for locally recurrent papillary thyroid cancer. Eur Arch Otorhinolaryngol 2017;274(9):3497-3501.
• Prayson RA. Diagnostic challenges in the evaluation of chronic epilepsyrelated surgical neuropathology. Am J Surg Pathol 2010; 34(5):e1-13.
• Danobeitia JS, Djamali A, Fernandez LA. The role of complement in the pathogenesis of renal ischemia-reperfusion injury and fibrosis. Fibrogen Tissue Rep. 2014;7:16.
• Cheng DCH, Karski J, Peniston C, et al: Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: A prospective randomized controlled trial, J Thorac Cardiovasc Surg 112:755, 1996.
• Frank I, Blute ML, Cheville JC, et al: An outcome prediction model for patients with clear cell renal cell carcinoma treated with radical nephrectomy based on tumor stage, size, grade and necrosis: the SSIGN score, J Urol 168(6):2395n2400, 2002.
• Dong YF, Soung do Y, Schwarz EM, O'Keefe RJ, Drissi H. Wnt induction of chondrocyte hypertrophy through the Runx2 transcription factor. J Cell Physiol 2006; 208(1):77-86.