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(Picea glauca) Medium to large reaching 80 feet. Shade-tolerant but prefers sun. Clay, sand and loam soils with moisture conditions from moist to dry, best in well-drained sandy loams. Drought resistant. Straight stemmed, narrow crowned. Native. RETURN & REFUND POLICY Due to the nature of the stock and variables in handling and planting, the Conservation District cannot guarantee survival of plant stock or accept returns/offer refunds It is unlawful for trees, shrubs and other plants purchased to be resold with the roots attached (per PA 189 of 1931, as amended). The District is not liable for any direct, indirect, special incidental or consequential damages (included but not limited to economic losses and lost profits) incurred or claimed by the customer.

Traumatic Injuries to the Mouth Injuries to the mouth can cause teeth to be pushed back into their sockets. Dr. Waldron or your general dentist may reposition and stabilize your tooth. Root canal treatment is usually started within a few weeks of the injury and a medication, such as calcium hydroxide, will be placed inside the tooth. Eventually, a permanent root canal filling will be implanted. Sometimes a tooth may be pushed partially out of the socket. Again, your endodontist or general dentist may reposition and stabilize your tooth. If the pulp remains healthy, then no other treatment is necessary. Yet, if the pulp becomes damaged or infected, root canal treatment will be required. If left untreated, many different complications can arise. These complications can include but are not limited to: Infection of the tooth, root system or surrounding tissue, inadequate hygiene due to an inability to properly clean the dislodged tooth and the gums, and loss of the tooth. If an injury causes a tooth to be completely knocked out of your mouth, it is important that you are treated immediately! If this happens to you, keep the tooth moist. If possible, put it back into the socket. A tooth can be saved if it remains moist. You can even put the tooth in milk or a glass of water (add a pinch of salt.) Dr. Waldron may start root canal treatment based upon the stage of root development. The length of time the tooth was out of your mouth and the way the tooth was stored, may influence the type of treatment you receive. Tooth Injuries in Children An injured immature tooth may need one of the following procedures to improve the chances of saving the tooth: This procedure encourages the root to continue development as the pulp is healed. Soft tissue is covered with medication to encourage growth. The tip of the root (apex) will continue to close as the child gets older. In turn, the walls of the root canal will thicken. If the pulp heals, no additional treatment will be necessary. The more mature the root becomes, the better the chance to save the tooth. In this case, the unhealthy pulp is removed. The doctor places medication into the root to help a hard tissue form near the root tip. This hardened tissue provides a barrier for the root canal filling. At this point, the root canal walls will not continue to develop, making the tooth susceptible to fractures. So it is important to have the tooth properly restored by your dentist.

Frizz is an offshoot of having dry hair. Dryness lifts the hair cuticle when then starts to absorb moisture from the atmosphere and swells up. Certain bad maintenance habits can also contribute to frizz and these include washing with harsh shampoos, washing hair too often, using heat tools too often, towel drying. Noticeably all these are related to the imbalance in moisture, heat, hydration and friction. Yes, the fibres on towels strip the hair of too much hydration it go from washing, which is why using a cotton shirt is recommended as an alternative. Frizz can occur on all hair types but curly to coily hair is particularly susceptible to this mangled mess because curly hair tends to be drier. Curly to coily hair can also be damaged by using incorrect hairbrushes that cause breakage of the cuticle which leaves hair susceptible to frizz. Switching to a wide tooth comb that supports the natural curl shape of hair instead of bore bristled brushes that force against it can make a big difference. Combining these tips with the right products will give you an advantage in preventing future frizz. Products with sealant properties will be the most beneficial because they will limit the amount of humidity that hair cuticle can absorb, thus work better to prevent frizz in the first place. Here are the best products to tame frizzy hair in 2021, curated by our beauty pros: This colour safe shampoo contains an exclusive Brazilian Super-Nutrient Complex that adds protein strength to hair while keeping unwanted humidity out. It cleanses hair while only maintaining the amount of moisture needed for health and shine, which makes it a perfect anti-frizz formula for hair that’s been styled using a blow dryer. Luxurious rose tinted elixir is the ultimate answer to unruly frizz prevention and control even in 80% humidity. With the infusion of Imperial Tea Extract, Camelia and Marula Oil, it’s smoothens hair strands from frizz, leaving it silky radiant and more manageable. It can be applied to either dry or wet hair as a leave-in treatment and worked throughout the hair. You’ll appreciate its beautiful scent and the lightweight, non-greasy liquid formula. Kevin Murphy’s reconstructing treatment doubles as a post-wash conditioner to nourish frizzy hair and thereby prevent the dryness that causes frizz. It renews frazzled hair from root top tip with the help of amino acids and enzymes to repair damage and smoothen out your locks. For the best results, apply to freshly washed hair and allow the product to absorb for a few minutes before rinsing it out. Control frizz with a premium caviar extract anti-frizz nourishing oil. It’s lightweight yet rich enough to penetrate thick and curly hair. It tackles frizz by supplying hair with the nourishment needed for dry hair. Watch how it will add elasticity and mobility to overtaxed brittle hair. The Climate shied Complex technology contained inside limits the humidity absorption rate of hair to keep it smooth. Apply to freshly washed damp hair before styling. This anti-humidity milk has the anti-frizz property Morpho-Keratin to coat hair fibres and solidity for smoother hair. It’s an excellent choice to keep frequently heat styled hair moist and nutrient rich. It gives “undisciplined” hair a large dose of hydration to tame it and smooth frizz and flyaway hairs without weighing hair down. Apply as a leave in conditioner to wet or damp hair before using heat styling tools. Protecting your hair from frizzing up encompasses protecting it from dryness and atmospheric humidity. Using hydrating products that give hair the moisture it needs ensure hair cuticles won’t need to absorb from the air. Alternatively for high porosity hair sensitive to too much saturation, products that seal the cuticle layer on the scalp to prevent it from humidity do the job just as well. Dry hair and thus frizz prevention doesn’t just include hydrating hair, it also includes limiting sun and heat exposure, using a shirt instead of a towel to dry hair after washing it and sleeping on satin pillowcases to prevent friction. Getting into the proper maintenance habits to care for hair is also essential to combat frizz. Such habits include using the proper brush for your hair texture and not over-combing hair. Luckily as we’ve displayed above, if frizz has already become an issue, it’s one that can be solved within frequent usage of the right products. High humidity does not have to ruin your hairstyle for any longer. *All products available in UAE only *Disclaimer: Products are recommended and not meant to treat diagnose or cure any condition. Consult nearest salon stylist for professional help.

posted August 09, 2019 Baked Potatoes on the Grill These Baked Potatoes on the Grill are the best baked potatoes you’ll ever have. They’re fluffy, soft, and cooked to complete BBQ perfection. The secret is in the process. By seasoning well, grilling them in foil, and finishing them on direct heat, these potatoes stay moist on the inside, and crispy on the outside. BBQ Baked Potato There are a handful of methods for making BBQ baked potatoes, and I’ve tried them all. Unfortunately, they always come up short. One method involves wrapping the baked potato in foil then grilling hot. While this does result in a cooked potato, this method gives you no BBQ flavor at all. So why cook them on the grill in the first place? Other methods dry out the potatoes, so they aren’t fluffy or moist. To remedy this complete and utter travesty, I’ve created my own method for making baked potatoes on the grill! To get the perfect BBQ baked potatoes, they are first wrapped in foil and grilled at 350 degrees F for 60 minutes and then cooked unwrapped over direct heat. With this method, you get a slow rise in temperature, but the foil keeps the heat in to evenly cook the potatoes. After the first hour, peel off the foil and put them on the direct heat to crisp the skin and give the potato some good BBQ flavor. This final step is crucial to get that crispy, crunchy skin that will taste as good, if not better, than the fluffy insides. Grilled Baked Potatoes in Foil When grilling baked potatoes, I recommend wrapping them in heavy duty foil before placing them on the grill. Cooking your grilled baked potatoes in foil helps the potatoes slowly rise in temperature and allows each potato to evenly cook. I cannot place enough emphasis on using a good heavy duty foil while grilling these potatoes. Heavy duty foil doesn’t split or rip while wrapping or cooking, so you don’t run the risk of anything seeping out while your food is on the grill. If you don’t have any heavy duty foil on hand, you can lay out 2 layers of regular foil to increase the strength. How to Grill Baked Potatoes I love cooking baked potatoes on the grill. Sure, the oven does the job, but by cooking on the grill over indirect heat and then finishing them hot and fast, they come out tasting better than ever. Follow these 5 steps to get perfectly grilled baked potatoes every time: - Prep the grill and potatoes. Preheat your grill to 350-400 degrees F for two-zone cooking (one side with indirect heat, one side with direct heat). Rinse and scrub the potatoes to clean them and remove excess dirt. - Wrap the taters. Lay out 1 piece of 18″ heavy duty aluminum foil for each potato. Drizzle each washed potato with olive oil and season well with salt and pepper. Wrap each potato tightly with foil. - Grill those potatoes! Place the wrapped potatoes on the indirect side of the grill, close the lid, and cook for 1 hour. Rotate the potatoes at the 30-minute mark, so that the potatoes that were close to the direct heat get rotated away (and the potatoes that were farthest from the direct heat are now closer). - Remove the foil and grill hot. After grilling for 60 minutes, remove the potatoes from the foil using heat-resistant gloves or tongs. Take care to not burn yourself; these taters will be hot! Place the unwrapped potatoes on the direct side of the grill and cook them for 1-2 minutes per side (4-5 minutes total). - Cut, fluff, and serve hot. Remove your potatoes from the grill. Split them open, fluff the insides, and serve with your choice of toppings. (Try my Brisket Chili, it’s delicious with potatoes!). How Long to Grill Baked Potatoes It takes approximately 1 hour to fully grill baked potatoes with your grill temperature set at 450-500 degrees F. I recommend cooking the potatoes wrapped in heavy duty foil for the first 60 minutes, then unwrapping them and placing them on direct heat for 4-5 minutes to crisp the skin. Make sure to keep track of the internal temperature of your potatoes while they are cooking. Grill temperatures can vary, and your potatoes might need a little less or more time to get to that perfectly soft texture. Baked Potato Internal Temp The optimal internal temperature for a baked potato is 210 degrees F. Using a reliable meat thermometer, aim for your grilled baked potatoes to reach between 205-215 degrees F. When your potato is in this sweet zone, you can guarantee it is evenly cooked throughout, and it will be fluffy and light. Bring on the butter and sour cream! More Potato Recipes Potatoes are an amazing side for BBQ. When trying to decide what sides to cook with your meat, I say go for the potatoes! Try out these other great potato recipes from Hey Grill Hey: Baked Potatoes on the Grill Recipe Baked Potatoes on the Grill - 4 large russet baking potatoes - 2 Tablespoons olive oil - 2 teaspoons salt - 2 teaspoons black pepper - Preheat the grill. Preheat your grill to 350-400 degrees F for 2-zone cooking. - Clean the potatoes. Rinse baked potatoes and scrub to remove any excess dirt. - Wrap the potatoes in foil. Lay out 4 large pieces of 18" heavy duty aluminum foil (or lay out 2 layers of regular foil). Set 1 washed potato onto a piece of foil. Drizzle with olive oil, and season with salt and pepper. Wrap tightly with foil. Repeat with the remaining potatoes. - Bake the potatoes on the grill. Place wrapped potatoes on the indirect side of the grill, making sure the potatoes aren't touching each other so the heat can surround all sides of the potato. Close the lid and cook for 60 minutes. Rotate once at the 30-minute mark, so any potatoes that were close to the direct heat can be shifted away so they all cook evenly. - Move potatoes to direct heat. After 60 minutes, remove potatoes from the foil using tongs or heat-resistant gloves (be careful not to burn yourself!), and place the potatoes on the direct side of the grill. - Finish baking the potatoes. Cook for 1-2 minutes per side (4-5 minutes total) on direct heat. A perfectly cooked baked potato will have an internal temperature of 210 degrees F, so aim for your potatoes to be between 205-215 degrees F. - Serve hot. Remove the baked potatoes to your serving platter, split your potatoes open with a knife, fluff the insides with a fork, and top with salt and pepper and any additional toppings you prefer. BBQ Must Haves Join the Grill Squad The Grill Squad is our exclusive membership program that will transform bland cookouts into booming barbecues that you'll remember for a lifetime. The technique and skills you learn will bring your backyard cookouts to a new level. For the cost of a full brisket, you'll get annual access to an exclusive BBQ community, Pitmaster Classes, discounts, and much much more!

Biting, chewing, licking, and digging are all your French Bulldogs canine instinct. So no matter what you do, these may not go away entirely. These behaviors are not worrying if your Frenchie does them from time to time. They are a source of comfort and entertainment for your furry companion. But when they do this more than usual, there may be an underlying cause. This is a stressful experience for both you and your Frenchie. And if untreated, these behavioral issues can have dreadful outcomes. Do French Bulldogs Bite? French Bulldog puppies go through a “teething phase” where they want to bite on anything. This teething phase is a normal part of their growth where their baby teeth will fall out for adult teeth to grow. They will start teething when they are 3 months and will end at around 6 months of age, sometimes longer. Biting is also a part of a Frenchie puppy’s play where they learn bite inhibitions. Puppies will bite each other and sill stop when they hear the other puppy cry. With this, they will find out how hard to bite until they start to hurt others. Trained Frenchie adults will grow out of this biting stage. If they do not, you can train them to stop the biting. But if your Frenchie suddenly became a biter, destroying items in your house, there may be a problem. French Bulldogs with separation anxiety bite and chew on anything out of distress. If you suspect that your Frenchie has separation anxiety, there are many ways you can help. With love and effort, they can overcome this issue. Are French Bulldogs Known for Biting People? Although their muscular appearance can look intimidating, Frenchies are a non-aggressive breed. They have an even temperament and without any underlying issues, it is not common for them to bite. Frenchies without any issues may bite or nip out of fear. This is a normal reaction for dogs when they feel backed into a corner. Especially for female Frenchies who are usually docile, but are prone to mood swings. During playtime, your Frenchie may bite you sometimes. But this does not come from a place of aggression, it is part of their play. This is why Frenchies always need a chew toy for them to gnaw on. Do French Bulldogs Bite Strangers? French Bulldogs have a friendly nature and generally do well with strangers! Frenchies may even play with them which includes nibbling on them, but this is not out of aggression. Sometimes, Frenchies can be aggressive with strangers. This happens when they were not socialized as puppies. So when seeing (or smelling) unfamiliar people, they may react out of fear and bite. Socialization is best done when your Frenchie is still young. But it’s still possible to do this with an adult Frenchie, it just takes a little more time and effort. A well-socialized Frenchie will grow up to be very friendly. This is great for them because they love to be the center of attention, even if it is from strangers. They will happily greet strangers and may even cozy up to them without a problem. Do French Bulldogs Bite Their Owners? There are times when your Frenchie will bite you when you are playing with them. But this should not hurt you, they would have learned biting inhibition when they were young. If biting is a concern to you during playtime, try not to play with your Frenchie using your hands. Make use of toys instead and there is a great variety of toys that they enjoy. One of those toys is a chew toy. Since Frenchies love to chew, they can easily destroy one. So make sure that the chew toy you get is durable. Make sure not to get a flimsy one. They may swallow broken parts and can choke on them. Or these broken pieces may get stuck between their teeth. Why Does My French Bulldog Bite Me? The common reason why Frenchies bite you is that they are teething or they are playing with you. These are normal and are not a cause for concern. But there are other reasons for biting that are worrying. If your Frenchie is biting out of the ordinary, it may be because of the following: Lack of Socialization This is the most common cause of behavioral issues in French Bulldogs, including biting. Unsocialized Frenchies are prone to manifesting aggression when they are in fear. This makes them unreliable since anything can make them scared and they can snap at any time. Other than strangers and other dogs, even the smallest stuff can scare them. This includes traveling, vacuums, and even day-to-day situations. This pushes them to be fear biters and may even bite their fur parents. This condition can manifest itself in many ways: destructive behavior, escaping, and stress. Stress can bring out aggressive behaviors in Frenchies. And sometimes, this aggression can lead to them lashing out and biting you. The good thing is that separation anxiety is treatable. Self-Defense and Territorial Issues Frenchies will do what they can to protect themselves and their territory. Their territory includes their belongings and even you, their owner. And they believe the best way to defend is by biting. This can be a big issue if not addressed. Untrained Frenchies will bite unnecessarily, without any real threat. One of the reasons why Frenchies love playtime is because they get to spend time with you! Out of excitement, they will jump on you and may bite you. But this is not a hostile act, play aggression is part of how they play. When they are in pain, French Bulldogs may change their behavior. If they are usually cuddly, now, want to be alone. So if you get too close for their liking, they might bite you. This is more common for rescued Frenchies, where they may have had a difficult upbringing. But any Frenchie can suffer from trauma, no matter what their background is. Some experiences that can be traumatic for your Frenchie are: - Fights with other animals - Medication side effects - Illnesses or Diseases How well you treat your Frenchie will reflect in how they act towards you. Some actions can make your Frenchie aggressive, causing biting problems. This includes the following: - Starving Them - Throwing Things at Them - Unnecessary Shouting How Strong Is a French Bulldog Bite? French Bulldogs have a bite force pressure that is about 180 to 230 PSI (pounds per square inch). Although their ancestors are well-known to have strong bites, Frenchies are not as forceful as theirs. Bite force PSI is difficult to measure accurately. There are many factors to consider, including the following: - Location of the Bite: Dogs bite with more pressure using their molars. If they bite with their front teeth, it would not be as strong. - Their Size: Larger dogs will be able to chomp down much harder than smaller dog breeds. - The shape of Their Head: Dogs with wider heads, like Bulldogs, have stronger bites. Narrow-headed breeds will not be able to grip as hard. - Their Personality: Non-aggressive breeds tend to have gentler bites. Frenchies who are well-socialized are friendly and may hold back when they do bite. - How They Feel: Dogs will only bite at full force when they are in danger or provoked. So when testing out their bite forces, they may not show their full strength. The average bite force of dogs sits around 230 to 250 PSI, and a French Bulldog’s PSI is lower than that. This can be because they are not aggressive, to begin with. But keep in mind that they are a medium to small breed, so their bites would not be as strong. How Do You Stop a French Bulldog From Biting? To stop biting issues, you first need to figure out what is causing your Frenchie’s biting problem. They may be aggressive because of underlying medical problems and in this case, they need to see a vet. This can also be due to separation anxiety, which also needs a different treatment. It can also be because your Frenchie fears something: a specific noise, objects in your home, to name a few. Sometimes, there may even be no evident trigger. Whatever the reason may be, you should fix this biting problem before it escalates. Here are some ways you can do this: First, you need to figure out your Frenchie’s trigger. Once you have, you need to expose your Frenchie to this to help them face their fear. You must not remove the trigger until they calm down. Once they have, you can now remove it. You may need to keep on repeating this for a few weeks until they do not react aggressively anymore. The goal of this exercise is for your Frenchie to understand that these triggers aren’t a threat to them. This way, they will behave the next time they see or hear something. No matter their age, Frenchies tend to be puppies at heart. They can become overexcited with almost anything: a new toy, treats, or even a playmate. And overexcitement is one of the reasons why your Frenchie may bite. Obedience training is a need for any dog and they should at least undergo the basics. This is a lifelong process that needs continuous behavioral corrections, including biting. Keep in mind that negative reinforcement is not good for correcting their behavior. Use positive reinforcement to teach your Frenchie that biting is bad instead. They will be able to understand this much better. Aversive training is another thing that you can go for, this is one of the most common methods. This training stops your Frenchie’s bad behavior by making it uncomfortable or distasteful to them. You can use a bitter spray that is safe for dogs on anything that they bite on. Some gloves work the same way, which can help if your Frenchie likes to bite your hand. But aversive training makes use of positive punishment and negative reinforcement. It may not be the best method and may cause your Frenchie to become stressed or fear you. There are also other training methods that you can try. No matter what you go for, make sure that you are consistent and firm with training your Frenchie. Also, don’t forget to reward your Frenchie for their great work! Teaching Them How to Accept Hands Frenchies should learn not to bite any hand that goes near their mouths or heads. A simple trick to do this is by giving them a treat and then taking it out of their mouths immediately. What this does is help them understand that biting is not good no matter what the reason is. Teaching Them That People Aren’t a Threat When they see many unfamiliar faces, your Frenchie may panic and act out. Teaching them to ignore people will prevent them from becoming aggressive towards strangers. When your Frenchie goes into defensive mode, reward him with treats and pats and have him go into a “time out”. This method uses positive reinforcement, which many vets recommend. This method is not to discipline your Frenchie. It is teaching them to sit down and remain calm while they watch people. And when your Frenchie barks at people, tap their noses and remind them to calm down. The goal is to help them calm down and teach them that these strangers are not a threat. Letting Them Know They Are Not Threatening There are certain actions your Frenchie will do to try and become threatening to you. Some of them are the following: - Howling or Growling at You - Biting or Licking Their Lips - Putting Their Paw on Your Face - Biting on a Wound If your Frenchie does these, let them know that you are not threatened by them. This will help to curb the likelihood of them trying to bite you, to begin with. Don’t Play Using Your Hands Teach your Frenchie what they can and can’t bite. Play aggression, where they bite and chew, is part of their play. If you are using your hands to play, they won’t know that biting your hand is not good. Using toys when playing helps them understand that these are the only objects they can bite on. Chew toys and tug of war toys are perfect for these. Do French Bulldog Puppies Bite? Frenchie puppies bite and nibble as part of their play. Puppies will bite each other to learn bite inhibition. This will teach them self-control and help them figure out how hard to bite before it hurts others. A Frenchie puppy that bites does not mean that they are aggressive. As puppies, this is a part of their learning process. When they grow up, the biting should go away. Why Does My French Bulldog Puppy Bite Me? Puppies will go through a teething process, where their baby teeth will fall off and adult teeth grow out. This is an uncomfortable and sometimes painful process for them, which is why they may bite and nip. This is normal for Frenchie puppies and should not pose any concern. Sometimes, the teething process can bring out destructive behaviors in your pup. Puppies can chew on furniture, shoes, and other items, to comfort themselves. If you have this issue, it is best to give them teething or chewing toys. There are also cooling teething toys that work well to soothe their gums. When Do French Bulldogs Stop Biting? Your Frenchie puppy’s teething process will start at 3 months old and end at about 7 to 8 months old. Some Frenchies take more time, it depends on how fast their adult teeth have completely grown. You will know if your Frenchie is teething with these signs: - Excessive Chewing: They will munch on anything they can get their paws on. Chewing helps to relieve their discomfort. - Drooling: Puppies will salivate a lot when they are teething, which shouldn’t be a reason for you to panic. - Loose Baby Teeth: You may find their small teeth around the house, especially on their toys. - Inflamed Gums: Their gums will look red and angry. Especially when their baby teeth have fallen off. Sometimes, it may bleed. - Blood on Their Toys: Don’t worry if you see some blood on stuff they chewed on. This is blood from their gums and is a normal part of the teething process. The teething process can be a rollercoaster ride for you and your pup. So learning more about it will help you know what to expect. As early as 2 to 3 weeks old, your Frenchie’s baby teeth will start to show. First, their front teeth will come through. Followed by their canine teeth. And finally, their premolars. They will have a total of 28 baby teeth, which will start to fall out when they are 3 months of age. At around 8 months old, all 42 adult teeth will have grown out. The reason why they have more teeth as adults is that puppies don’t grow their molars. These molars will only grow when the baby teeth fall off. How Do I Get My French Bulldog Puppy to Stop Biting? Since your Frenchie puppy is learning bite inhibition, you can use that to your advantage. As puppies, they learn to stop biting when the other puppy cries or squeals. So whenever they bite you, you can imitate this and squeal. This will signal your Frenchie to stop biting because they think you’re hurt. You can also use verbal commands like “Stop”. Sometimes, Frenchie puppies will ask for comfort after doing these methods. No matter how tempted you are, don’t give in to this. You should ignore them for a few minutes before cuddling them. Giving in right away will not help with the biting problem since it sends them mixed signals. Be firm with this and the biting problem should go away. Some dog trainers also take extra steps with those methods. After you squeal, place your thumb under your pup’s tongue with a finger under their chin. Do this for 10 seconds and let go. Not every dog owner will like doing this, and most of the time, you don’t need to do this. Some use this trick as a fallback and not the main way to stop the nipping. That technique is often used since it is quite effective. But there are other ways you can stop your puppy’s biting problems. Below are other methods that you can try. - Play With Toys: It is not a good idea to play with your hands. They might think that biting your hand is okay and they might do this until they are adults. - Don’t Play Back: When they bite you, do not reciprocate their energy by reacting playfully. This encourages them to bite more since they think you are playing. - Use Bitter Sprays: These sprays have a taste that Frenchies don’t like. If you use this on your hands, they will become discouraged to bite. Apart from these methods, you should also train your Frenchie. Basic obedience training is a must to help you discipline them when they misbehave. Additionally, start socializing them as puppies. While their biting problem may be temporary, it can also be brought into adulthood. A biting puppy may not be intimidating, an adult Frenchie’s can be dangerous. Although they do not have the strongest bites, they still have powerful bites. No matter what you do, do not resort to physical punishment. This will make your Frenchie fear you and can lead to more biting problems out of aggression. Remember, positive reinforcement is always best. Are French Bulldogs Chewers? All dog breeds have chewing habits, including French Bulldogs! And when they are puppies, they may chew more. Chewing habits in puppies are most likely because of the teething process. But adult Frenchies also love to chew, especially on their favorite toys. Sometimes, this can be a cause for concern if your Frenchie is an adult. If they’re chewing more than usual, there may be an underlying issue. And they can get pretty destructive if this is not addressed. Below are some reasons why your adult Frenchie has a chewing problem: A Frenchie who lacks physical and mental stimulation will chew on anything. They may chew on your shoes, wires, or anything to keep themselves occupied. The good news is that certain toys distract them and keep them occupied for hours! Here are some you can try: - Chew Toys: Best for Frenchies who tend to destroy furniture and shoes. Chew toys will help them with their chewing urges. - Interactive Feeding Toys: Since Frenchies are food motivated, take advantage of it! They may never stop playing with this until they get food out. - Regular Balls: Even a soccer ball can keep your Frenchie occupied. They will enjoy pushing it around with their little noses, especially outdoors. This is the root cause of a lot of behavioral issues in French Bulldogs. With this condition, they become restless and stressed. So they may resort to chewing on anything they set their eyes on. Believe it or not, Frenchies may let you know when they get upset. They can be self-centered sometimes and when they don’t get what they want, they will react like a toddler. And one way they do this is by chewing on anything they can. Some medical problems can cause your Frenchie to chew more than usual. Frenchies are not the healthiest of dog breeds, so watch out for the following: - Allergies: Environmental allergens and food allergies can cause your Frenchie to itch. Other than scratching their skin, they may chew on their skin to relieve the itch. - Pododermatitis: This condition causes your Frenchie to have inflamed paws. So they lick and chew their feet for relief. Injuries, infections, and even unknown reasons can cause this. - Fleas and Parasites: Bites from these can trigger a severe allergic reaction. Other than chewing, your Frenchie can lick, bite, and scratch excessively. Will French Bulldogs Chew Furniture? French Bulldogs have destructive tendencies, both as adults and as puppies. And one of their destructive behaviors is to chew on furniture. This is more common with puppies since they are going through the teething stage. Adult Frenchies still love to chew, but at this point, they should have learned what they can chew. This should be their toys and nothing else. The most common reason why Frenchies chew on furniture is due to separation anxiety. This is a disorder that stresses out your Frenchie when they are away from you for some time. Behavioral issues come out whenever you are not around, including destroying your furniture. Many Frenchies develop this because they were bred to be companion dogs. So they need to be around you most of the time for them to be happy. But if you work a nine-to-five job, this can be hard to avoid. Don’t lose hope though, there are many ways to teach your Frenchie to spend time alone. In general, as long as you keep them occupied while you’re away, they should do well alone. A variety of toys will do the trick. You can even take them out for a walk before going to work so that they can nap all day. Some Frenchie owners even get another Frenchie. Two Frenchies in a household decrease their risk of developing separation anxiety. They can keep each other entertained while you’re away. If you can’t get another dog yet, then doggy daycare is a good option. Your Frenchie can get socialized in the process, which is a bonus. But what if you’re a fur parent who isn’t away a lot? If your Frenchie has chewing problems despite this, there may be a medical issue with them. Many medical conditions can cause this. It’s best to talk to your vet about this to pin down the exact reason. Why Is My French Bulldog Chewing His Paws? Occasional paw chewing is normal. But if your Frenchie has been doing it a lot, the culprit is usually allergies. Frenchies are allergic to environmental allergens and food. Knowing what your companion is allergic to will help prevent a lot of issues. Not only paw chewing but also itchy and inflamed skin. Frenchies can be allergic to the following: - Grass or Weeds - Mold Spores - Dust and Dust Mites - Cleaning Agents - Certain Prescription Drugs These allergens can cause inflammation in your Frenchie’s paws. In an attempt for relief, they will lick and chew on their paws. But it’s not only allergies that cause excessive paw chewing. Here are other reasons why your Frenchie chews their paws: - Something’s Stuck: You should always check your Frenchie’s paws daily, especially after walks. A foreign object stuck in their paws is painful. If it’s not removed, it can cause an infection. - Yeast Infection: This one is due to an unhealthy diet. A yeast infection can make your Frenchie chew on their paws. - Insect Bites: Itchy bites are not only uncomfortable, but they also make their paws swollen. Your vet can prescribe your Frenchie with a topical cream and antihistamines. - Burnt Paws: If you are walking your Frenchie on a hot day, the hot pavement will hurt their paws. They chew and lick their paws to cool them off. - Separation Anxiety: A restless Frenchie has many self-soothing behaviors. This includes excessive paw licking and chewing. - Phobia: While fear can bring out aggression, it can also bring out their anxiety. Certain noises or strangers can cause excessive chewing in Frenchies. What Can I Give My French Bulldog to Chew? It is great that there are many chew toy choices for Frenchies. Chewing problems can be annoying and potentially destructive. Other than your furniture, they can chew on dangerous items like electrical wires. Your Frenchie should chew on toys instead, which is safer. There are a variety of chew toys you can choose from below: - Dumbbell Chew Toys: These are usually made of rubber to withstand a Frenchie’s strong bite. Some of them have bristles that can soothe their gums and can double as a toothbrush. - Treat Chew Toys: These have pouches where you can put your Frenchie’s favorite treats in. This acts as a reward for them whenever they play with this. Positive reinforcement like this will encourage them to chew on this more. - Tug of War Chew Toys: A ball and a rope in one toy, two things a Frenchie likes to bite on. This toy intrigues Frenchies because they cannot separate the two. This is great for both mental and physical stimulation. - Interactive Feeder Toys: These functions like the treat chew toys, using positive reinforcement. Whenever they squeeze this toy, treats go out. - Beeping Chew Toys: Whenever your Frenchie chews on this toy, it releases a beeping sound. This is also a great toy to keep them occupied. - Toothbrush Chew Toys: If your Frenchie dislikes toothbrushing, this is a good alternative. These have rubber or silicone bristles to clean their teeth and jaws. These toys above do more for your Frenchie other than to help with their chewing problem. Usually, they are hit two birds with one stone! Here are the benefits to giving your Frenchie a chew toy: Eases the Teething Process During this stage, your Frenchie puppy’s teeth are going to swell and may also bleed. This is a painful process for them, which makes them find comfort in chewing on anything. Chew toys, especially cooling ones, help to soothe them. It will also help any loose baby tooth to fall off, speeding up the teething process. Removes Tartar and Plaque A lot of chew toys have bristles or embossed patterns that brush their teeth. Tartar and plaque buildup can lead to infections that can cause your Frenchie’s teeth to fall out. They only have two sets of teeth in their lifetime, so taking care of their teeth should be a priority. Teaches Them to Spend Time Alone A way to combat separation anxiety is for Frenchies to learn how to spend their time alone. Chew toys, along with other toys, keep them distracted while you are away. Improves Their Intelligence Chew toys that have pockets for treats work like a puzzle for Frenchies too. These get their brains working to figure out how to get a treat out. Food motivates Frenchies, so they will work hard to get their favorite treats! At What Age Do French Bulldogs Stop Chewing? Your Frenchie’s relentless chewing will end at around 8 months. At this age, they are through with the teething process and they already have all their adult teeth. But this will not completely stop your Frenchie from munching on something. Chewing habits are normal for any dog and are necessary to keep a strong jaw and a clean set of teeth. Excessive chewing and destructive behavior are what should concern you. Most of the time, it is due to lack of stimulation which has many possible remedies. Sometimes, it can be due to a health problem that needs medical intervention. How Do You Stop a French Bulldog From Chewing? Fixing a Frenchie’s chewing problem depends on what caused it and there are 3 common causes for this. This includes boredom, separation anxiety, and medical issues. The wrong approach will not stop the issue and may leave you frustrated. If it is due to boredom, a variety of toys may help. If you suspect that it is separation anxiety, you need to tackle this disorder as a whole. But chewing problems can be due to medical conditions, too, and with those, a vet should be able to help you out. For bored Frenchies, a variety of toys will keep them busy. Chew toys work well, but puzzle toys are great for distracting them too. Especially ones that let them work to reward them with treats. Chewing problems is one of the behavioral issues that separation anxiety can cause. If you only tackle one symptom, the chewing issue may not completely go away. For separation anxiety, you need to teach your Frenchie to become more independent. Spending time alone while you are away should not make them feel stressed. Here are a few ways you can do that: - Create a Routine: A daily routine will help your Frenchie know what to expect. You do your morning rituals, your Frenchie plays alone for a few hours, and you go home. - Get a Dog Sitter: If you work long hours, have someone keep your Frenchie company. A pet sitter may not even be necessary. You can ask a neighbor to walk or watch over your Frenchie too. - Doggy Daycare: Sometimes, Frenchies may want the company of another canine friend. Doggy daycares help your Frenchie to form bonds with other furry friends. This socializes them and keeps them distracted while you are away. - Burn Excess Energy: You can walk your Frenchie before you go to work so that he will nap while you are gone. - Get Another Dog: Another dog can keep your Frenchie entertained too. They can play and exercise in your absence, which is great for keeping your Frenchie fit too. There are many other ways to help a Frenchie who has separation anxiety, these are only a few of them. Addressing your Frenchie’s anxiety issues should stop the chewing problem. Chewing is a soothing mechanism for Frenchies who have health issues. These conditions cause them discomfort and sometimes pain. If this is causing the chewing problem, medical intervention is what they need. This can be due to allergies, fleas or parasites, or pododermatitis. And it may be hard to pinpoint which one is causing the chewing problem at home. Allergies may be the hardest one to diagnose since a lot of allergens can trigger chewing. Consulting your vet will help you narrow down this list. They will also provide the proper treatment for your loving companion. Do French Bulldogs Lick More Than Other Dogs? Friendlier breeds like the French Bulldog tend to lick more than other breeds. Since Frenchies are companion dogs, they love showing affection towards their owners. And sometimes, it can be by licking your face, hands, or feet. Most of the time, Frenchies see their owners as their parents or the leader of their pack. After all, you are the one taking care of them. Licking is a canine instinct to show their respect for you. Other than their humans, Frenchies also like to lick themselves. They do this to groom themselves, clean a wound, and get rid of dead skin. Occasional licking is normal and part of their routine. But if your Frenchie is a compulsive licker, there may be an underlying problem. They can excessively lick their paws, skin, and genitals. This can be due to separation anxiety, allergies, and even canine compulsive disorder. The latter is a form of obsessive-compulsive disorder (OCD) in dogs. Why Does My French Bulldog Lick Humans So Much? Most of the time, the reason why your Frenchie licks you is that they want to tell you that they love you. Licking is a universal sign of affection for dogs and Frenchies have a lot of love packed in their small bodies. But there are other motives behind their affectionate kisses. Another reason is that people taste good for them. Human skin tastes salty, that’s why they enjoy licking people. And after you have eaten, you may have some food residue on your face. Sometimes, Frenchies will try their best to get near your face and lick you all over. If your Frenchie has a very friendly personality, they may also greet other people by licking! What Does It Mean When a French Bulldog Licks You? Dogs are communicators and one of the ways your Frenchie does this is by licking you. Sloppy dog kisses are usually to show love for you. But there may also be other reasons why they lick. Decoding your Frenchie’s licks can be hard. So below are other possible reasons for this behavior, to help you out. They’re Grooming You Grooming you is one of the ways they show you love. As a puppy, your Frenchie experienced this from their mother. And now they are doing this act of endearment towards you. They will usually lick your face to groom you. But this can be any patch of your skin that they can reach. It can be your hands or feet, as long as they get to lick you. Your Skin Tastes Good The salty taste of human skin is enticing to Frenchies. Other than that, if you have traces of food on your face, they will also lick your face. They Admire You Frenchies are pack dogs and for them, you are the leader of the pack. So they lick you to show you respect and ask for your approval. They Want to Say Something Learning your Frenchie’s body language is important because this can mean anything. They can be asking for food, water, or playtime. Sometimes, they will lick you to get your attention because they feel lonely or bored. You can differentiate these licks from the usual doggy licks. If they are trying to ask you for something, the licks are usually more intense. They’re Trying to Calm You Down Your Frenchie can sense whenever you are in distress. So in an attempt to comfort you, they will give you doggy kisses on the face, hands, or feet. A study published in 2012 shows how capable dogs are in showing empathy towards humans. The researchers found that whenever someone cries, dogs try to comfort their humans. These dogs would nuzzle, sniff, and even lick people to calm them down. Even if you are not crying, your Frenchie can read your body language and facial reactions. Their licking is their way to remind you to relax a little. It Feels Good Whenever your Frenchie licks you, the sensory stimulation increases their oxytocin levels. Oxytocin is the “love hormone”, linked to higher levels of social interaction. Higher levels of oxytocin also release dopamine and promote feelings of pleasure. These reactions make your Frenchie feel more relaxed and comfortable. Why Does My French Bulldog Lick My Face? Sloppy Frenchie licks are a sign of affection towards you. This affection can be the regular dog kiss, an attempt to groom you, or showing you respect. Licking is part of any dog’s instinctive behavior. One of the reasons is that their mothers groom their puppies by licking them. They are extending their “tradition” towards you with the tender canine act of licking you. Although sometimes the reason can be silly like licking food remnants off of your face. It can also be because they like salty human skin. Why Does My French Bulldog Lick My Hand? Your face is not the only part of your body that your Frenchie licks to show affection. While that is the common reason, licking your hand can also mean that they are being submissive. When your Frenchie regards you as their leader, they show their obedience when they lick you. This is a canine behavior that dogs got from their ancestors, wild wolves. Whenever their pack leader comes home, they lick the leader out of respect. So your Frenchie is doing the same thing. Why Do French Bulldogs Lick Your Feet? Feet are enticing to French Bulldogs since they hold a lot of biological information. Frenchies learn about the world using their mouths and noses. So through your feet, they are learning about you. Your feet are chock-full of scents that tell your Frenchie about your activities. Their sense of smell is so much better than ours. Your feet tell them where you have been and what you have been doing. Other than that, your feet have pheromones, your unique smell. Mix those in with salty feet sweat and your feet become more irresistible to your Frenchie. So with your Frenchie’s fascination towards feet, they can’t help themselves but lick it. Dogs have a sensory organ called Jacobson’s organ. With this organ, they can smell and taste at the same time. Apart from your feet being interesting to them, below are other reasons they lick your feet. Seeking Your Attention Feet are ticklish parts of the body so your Frenchie enjoys the reaction they get out of licking it. Frenchies are people pleasers so whenever you laugh or smile, they think they are doing a good job. They misunderstand your playful reaction. But this encourages them to keep doing this. So if feet licking is something you would like to stop, you have to discourage them nicely. Like with your hands, your Frenchie also likes to lick your feet to show their obedience. There is no stopping your Frenchie from showing their respect towards you. So if they cannot access your hand, they will make do with your feet. Regular Dog Kisses Sometimes, your feet are more accessible for you Frenchie than your face or hands. They do not choose where to kiss you, any patch of your skin will do for them! Feet Are Gross Your feet are in contact with the floor most of the time. It can collect dirt, soil, and other nasty stuff. And sometimes, feet can get fungal infections too. While these may be unpleasant for us, dogs love this gross stuff. They even roll around in garbage and sometimes eat their poop. Feet Are Meaty Food-loving Frenchies may find that your fleshy feet are like chicken breasts. It does not help that your feet are moist and salty, a delicious treat for them. But they do know that your feet are not food and that you will not appreciate them biting on you. So they do the next best thing: they lick your feet instead. It’s Their Strategy In general, feet are harder for you to defend since you cannot see your Frenchie approaching them. Your Frenchie may want to give you kisses and they know that they can sneak one on your feet much better. Shorter breeds like Frenchies tend to do this a lot. While your hands and feet are harder for them to get to, your feet are always within their reach. Why Do French Bulldogs Lick the Floor? The typical reason why they lick floors is to search for food crumbs that fell. Or they may be investigating a scent that they have picked up on. While these two are the common causes, there are other reasons for this and they are worrying. Knowing these will help you take action immediately to help your companion. Excessive licking of surfaces (ELS) is not limited to floors. Your Frenchie can lick on carpets, cabinets, and any other surfaces. And this condition can be due to many health problems. Boredom or Anxiety In an attempt to keep themselves occupied, Frenchies may resort to licking the floor. And if they are anxious, this helps to soothe themselves. While this is not considered destructive behavior, you should not ignore this. Frenchies are allergic to cleaning agents, molds, and dust. All these can be present on the floor and can cause an allergic reaction. Or worse, they may ingest or inhale something toxic to them. This includes human medication, bleach, and pesticides. Even if you have pet-proofed your house, you should still watch out for excessive floor licking. This can turn into obsessive behavior pretty quickly, which is hard to treat. This is the most common health issue in dogs that causes excessive floor licking. It can take many forms such as the following: - Chronic Pancreatitis - Irritable Bowel Syndrome (IBS) - Delayed Gastric Emptying Only a trip to the vet can help you figure out which one causes ELS in your Frenchie. If you do not seek medical intervention, these can lead to severe consequences. The good news is that with the proper treatment, this will go away. Dental and Mouth Issues A Frenchie who has this problem is in pain, so licking the floor is a way for them to ease this. Other than excessive licking, they can show other symptoms. They can drool more, struggle to chew, and have bad breath. There is a wide range of medical conditions that cause this. This includes the following: - Dental Disease (gum disease and infected, chipped, or loose teeth) - Foreign Objects Stuck in Their Mouth - Oral Tumors - Stomach Ulcers - Traumatic Injuries in the Mouth Any of these can trigger your Frenchie to lick floors. If you suspect that this is because of teeth and mouth problems, you must consult with your vet. Frenchies with Pica will lick or eat anything that is not food. It can be soil, carpets, plastic, and anything else with an interesting texture to them. This condition has a long list of possible causes. Even boredom or separation anxiety can push your Frenchie to develop pica. Pica is a serious condition that is dangerous when untreated. Some of the things that they eat may be harmful or toxic when ingested. This condition causes your Frenchie to have an abnormal and excessive appetite. There are many possible causes to this and can be regular boredom or them not eating the right portions. Other reasons are more serious health issues, including diabetes mellitus and hyperthyroidism. Sometimes, Frenchies perform repetitive behaviors to ease their stress and anxiety. Excessive floor licking may be one of them and they do this to the extent that interferes with their daily life. If you suspect you Frenchie has this, they may present other behaviors too. Constant pacing, tail chasing, and overgrooming are a few of them. Although this is not a common reason for floor licking, you should always consider this. There are a few brain problems that can cause excessive floor licking. Older Frenchies are prone to canine cognitive dysfunction. This is like dementia in humans so they experience changes in brain function due to brain aging. Other neurological disorders include hydrocephalus, brain tumors, and seizures. You must consult with your vet to rule out any problems with the brain. A diagnostic test for this includes X-rays, CT, MRI, and spinal fluid analysis. It can get expensive, but neurological disorders can have severe consequences if untreated. Why Do French Bulldogs Lick Their Paws? Paw licking is normal for any dog, but breeds of bulldogs do this more since they are prone to skin problems. Occasional paw licking is nothing to worry about. Your Frenchie may be cleaning their paws. But if they are doing it more than normal, they may have some problems. Figuring out what that problem is is a process of elimination that may take time. To help you with this, here are possible reasons why your Frenchie licks their paws: Something may be stuck in your Frenchie’s paws so they are licking it to get the object out. So whenever you take them outdoors, always inspect all their paws afterward. If left untreated, the foreign object may cause an infection. Check your Frenchie’s paws if there are any wounds, which can be due to foreign objects getting stuck. If there aren’t any, you should take a look at their toenails. Long toenails can make walking painful for your Frenchie. Sometimes, they may break and can bleed. This is very painful for your Frenchies since their toes have a lot of nerve endings. Your Frenchie’s paws may come in contact with substances that cause their paws to be swollen. With seasonal changes, some of these substances can become more prevalent. During the summer, watch out for pesticides and fertilizers. Walking your Frenchie on hot pavements can burn their paws. During the winter, chemicals to melt ice, including salt, can cause paw irritation. A cold pavement can also do this. So if you plan to walk your Frenchie outdoors during winter, make sure they are wearing socks. An overgrowth of yeast can make your Frenchie’s feet itchy. This yeast infection can also affect their ears. Yeast infections can also produce a musty odor, so it may be easier to figure out if this caused the paw licking. Insect Bites and Stings Bites from insects not only irritate your Frenchie’s paws but also cause discomfort. Antihistamines can help to calm this down, but make sure to talk to your vet first. The wrong medication dosage can harm your Frenchie. Unfortunately, Frenchies are allergic to a lot of things that can cause skin problems. When this happens, Frenchies start to lick themselves more than usual. Here are some allergens to watch out for: - Flea Saliva: The bites themselves are uncomfortable for your Frenchie. But flea saliva is what triggers an allergic response that makes their skin itchy. - Environmental Allergens: Your Frenchie can itch when they come in contact with these. Watch out for dirt, mold, pollen, and others. - Food Allergens: Grains are a common allergen and it is present in a lot of kibble brands. Your Frenchie may also have an intolerance to certain meat like beef, chicken, and fish. Some medical conditions like Cushing’s disease make your Frenchie’s skin itchy. But licking due to other conditions like arthritis is a way for your Frenchie to relieve their pain. Do French Bulldogs Like to Dig Holes? Digging brings joy to a lot of dogs, even French Bulldogs, that is why they like to do it. It is part of their many instinctual behaviors, along with sniffing and barking. Frenchies were even used to find and dig buried items in the dirt. This instinct may still be present in your Frenchie’s DNA. While their ancestors used digging for work or survival, Frenchies may do it for fun! Why Does My French Bulldog Dig So Much? Most of the time, the reason why your Frenchie digs a hole is that it is a pleasurable activity for them. But since this behavior is from their ancestors, other reasons may be instinctual. Unfortunately, lack of stimulation causes a lot of behavioral issues. Since digging holes makes Frenchies happy, they may dig to keep themselves entertained. Burying Their Treasure Frenchies have a territorial nature and if you have other dogs, they will hide their toys or bones. Even if you do not have other pets they may still do it out of instinct. The curious Frenchie always keep their eyes peeled for anything interesting. With their strong sense of smell, they will dig holes to find their treasure. And they may not stop until they can show something to you, even if it is a small rock. Stressful situations can make your Frenchie go into fight-or-flight mode. Digging is one of their many outlets for release to escape from these situations. Frenchies who are not spayed or neutered may dig around when they are in heat. Males and females may have different reasons for this, though. Female Frenchies dig because of their strong nesting instinct. Even more, if they are pregnant. But if you see them digging near a fence, they may be looking for a mate. Male Frenchies are the same. When they catch a whiff of a female Frenchie’s scent, they will dig around to escape and look for her. Reasons for trying to escape can be as silly as them trying to get to the barbecue party that they smell. But if your Frenchie has separation anxiety, they may be escaping home to try and look for you. Brachycephalic breeds like French Bulldogs do not do well in the heat. On a hot day, it is hard for them to cool down since they have narrow nostrils and elongated soft palates. If they have no access to a puddle or air conditioning, they make do and cool themselves down in a hole. Why Does My French Bulldog Dig at the Floor? Like licking, Frenchie may dig floors because they want to get the food crumb that they found. Food is not the only thing that causes this, they might have found an interesting smell. So they use their paws to investigate a bit more. But these are not the only reasons for the digging. If you want to get to the bottom of this, below are other possible causes. Scratching on the floor is one of the ways Frenchies show their excitement. You may notice this whenever it is time to take them out on a walk or when they have a new toy. This is another way for them to release their extra energy. It can also be because they want to get to something but cannot. If they are looking out the window and another dog passes by, they start to bark and dig in place. Fluffing Their Bedding Frenchies dig around wherever they want to make a more comfortable space for them. When they dig, they try to make a cooler resting spot. So when you see your Frenchie dig and turn around a few times, they want to nap a bit. Digging brings your Frenchie pleasure, even if it is on the floor. When anxious or bored, they keep themselves occupied. Digging helps them to release some pent up energy Getting Your Attention Frenchies love that they can grab your attention by digging. They may have realized this whenever you check up on them whenever they do this. So they may use this attention-seeking behavior to communicate with you and get some love. Why Does My French Bulldog Dig at My Legs? Digging at your legs is one of the many ways your Frenchie tries to communicate with you. This act is usually out of affection and sometimes they are trying to tell you something. Decoding this doggy language can be tricky. So below are some reasons for this act, to help you out. They’re Asking for Love Your Frenchie may come up to you to let you know they want some love. This companion breed loves two things in the world: food and its owners! So the next time your Frenchie does this, you might want to give them some cuddles. A Frenchie who rummaged through garbage may touch your leg with a guilty look on their face. This is an act of submission to let you know that they are sorry. They Need Something When their doggy bowl is low on water and food, your Frenchie will put their paw on your leg to remind you. While it can be hard to say no to cute faces, make sure not to give in too much. Constant food begging can be a problem without you realizing it. They’re Calming You Down Your Frenchie can read your emotions like a book. They can sense the slightest change in your mood and facial expressions. When you are feeling upset or stressed, your Frenchie may paw at you to comfort you. Whenever you pet them, they associate this with feelings of affection. So they pet you back when you are sad to let you know that they also love you. They Want Playtime You will know they are asking to play if they paw at your leg while wagging their tails and jumping around. Sometimes, they may also give you their favorite toy. Should I Let My French Bulldog Dig? Occasional digging is okay since it is a natural behavior for dogs. Digging is a source of your Frenchie’s entertainment and comfort. So this instinctual act may never completely go away, especially since it is in their DNA. What should worry you is when the digging becomes excessive. Digging has risks that can have serious consequences. The risks involved are the following: - Escaping Home: If your Frenchie makes a successful escape, they may be in danger. They may get stuck somewhere or worse, they could get hit by a car. - Nail Trauma: Excessive digging puts a lot of stress on their nails. This can cause broken, bleeding nails that are very painful for them. This pain can also affect how they walk. - Damaging Your Yard: Your determined Frenchie can dig many holes in your yard. This unpleasant sight can cause any owner distress. Another bad news is that fixing your yard may also cause you money. - Tripping in Holes: If you already have a few holes in your hard, you and your Frenchie are at risk of tripping in them. An increased risk of accidents may mean more trips to the vet. - Getting Infections: There are a lot of bacteria and parasites present in the soil. Your Frenchie is prone to catching these the more they dig. Now that you know these risks, it is best to try and limit your Frenchie’s digging behavior. If you want to create a safe digging spot for your Frenchie, consider getting them a sandbox. Getting a sandbox is also an opening for you to spend more time with your furry companion. Use your Frenchie’s digging instincts to your advantage, you can hide toys and treats in the sandbox to encourage it to use them. How to Stop French Bulldogs From Digging There are many methods you can use to prevent your Frenchie from digging. But the best way to put a stop to this is to release your Frenchie’s excess energy. Talking them out on walks is a good start for this. Frenchies have low energy levels so a brisk walk will do for them. A tired Frenchie will not have time to dig if they are busy sleeping. Sometimes, it is better to use various methods at the same time. Here are some that you can try: - Keep Them Indoors: This may not stop them from digging indoors. But keeping them inside keeps them away from bacteria and parasites in the soil. - Distract Them: Digging is fun for your Frenchie. So why not entertain them with toys instead? An assortment of toys will make sure that they don’t get bored easily. - Training: Your Frenchie can learn that digging whenever and wherever is not good. Be firm and use keywords like “No” to make the digging stop. - Dog House: Sometimes, Frenchies dig to create their shelter. You can give them their safe space outdoors so they won’t have to create one. - Create a Digging Spot: You can fence off a part of your yard where your Frenchie can dig to their heart’s content. This spot should be visible to you at all times so you can check in on them. - Get a Sandbox: This can be an alternative digging spot for your Frenchie. It is safer since you know what’s in the sandbox.

Tonight, I spent a wonderful evening bottling pickled onions. However the story doesn’t start there. It began yesterday when Amy noticed that some of my home-grown brown onions (that I have been drying for far too long) were beginning to re-shoot. Oh, no I thought. I better do something with them before they all are ruined. So, after lunch Amy and I began to peel 2 kg of small brown onions. Amy was tasked with peeling as much of the dry skin off with her hands, and I top and tailed the onion and removed the first moist layer. It took us about two hours of teary goodness and our clothes smelled like sulphur when we were finished and the kitchen compost bin was full with brown skins. I then placed the onions into a large stainless steel bowl, dissolved a quarter of a cup of non-ionised salt into 4 litres of cold water and poured it over the onions to cover. I left them overnight before the next step. So back to the beginning of my post. After dinner tonight, I washed out 8 jars in hot soapy water and scrubbed clean with a bottle brush. I then rinsed with cold water and put the jars on a baking tray upside down and into the oven still wet at 120C for 15 minutes to sterilize. Whilst the jars are in the oven, I prepared the pickling solution. I poured 1 litre of white vinegar into a saucepan, added half a cup of white sugar and 1 tablespoon of pickling spices to the pan. You can pick up pickling spices in the spice rack of most supermarkets. For those who can’t find some, as I couldn’t last year, here is a simple mixture of spices that will suffice. 1 tspn Coriander seeds 1 tspn Cloves, whole half tspn Fennel seeds half tspn Peppercorns quarter tspn Mustard seeds Once the sugar is dissolved, I brought it to the boil and then simmered for 15 minutes. I then strained the liquid, discarded the spices and let it cool down to room temperature. While I was waiting for the liquid to cool, I drained and rinsed the onions in cold water. I then removed the sterilised jars from the oven and put them on a clean tea towel to cool down as well. Careful because they are very hot! Now, don’t forget to sterilise the lids of the jars. You can’t put them in the oven, because the plastic in the lid melts and doesn’t seal properly, so you have to let them sit in boiling water for the same time you have the jars in the oven. Make sure they are extremely clean before sterilizing them. I use a large fowlers-vacola jar to do this. Once the jars are cool to touch, add into each jar 1 dried Birdseye chilli, some peppercorns and a bay leaf. Then I packed the onions into each jar. I found that I only had enough onions for 5 jars so I placed the others aside. I used a bit of artistic flare and arranged them so that you can see the chilli and the bay leaves in the jars once packed. Then, when and only when the pickling liquid is cool (a hot liquid kills the crunchiness of the finished product), I poured it into each jar to just cover the onions. To finish off, I secured each lid tightly, and below is the finished product. Homemade pickled onions. I grew the Birdseye chillies two years ago, and dried them for storage. I use them in cooking and pickling. Boy are they hot. Anyway, the Pickled Onions will be ready to eat in three months. Refrigerate before you open them because it adds to the crunch. Great with cold ham, some cheese and crackers. I reckon that this lot will go down just divinely with some Wenslydale I have lying around somewhere and that will be ready about the same time! A match made in heaven.

Spicy Potato Stir fry / urulla kizhaghu Mezhukku puratti is a simple and tasty Kerala style vegetable preparation. Back home, in my school college days it is one of my favourite lunch box side dish. Yes! It is a perfect and desirable side dish for me with boiled rice and chamandhi or sambar or moru curry or rasam 🙂 . Those days we close friends used to share and enjoy our lunch box dishes each other with lots of fun, jokes, film stories, gossip 😉 , new fashions and trend. Oh God! My tongue still recalls the divine and delicious dishes that were prepared by my friend’s mothers which include Hindu, Muslims and Christian preparations. When there have any religious festivals like Onam, Christmas and Ramadan , after the holidays we have a great feast . Hmm.. I am really miss all those special moments 🙁 but I have no regrets too because I enjoyed a lot those days and still remember each moments like yesterday. Yeah! It is a life time memory for me 🙂 Sometimes we never know a true value of moment until it becomes a ‘memory’.Recall your school days and go back into the past, it’s a special and fresh feeling 🙂 Have a nice day guys 🙂 Here is my school time favourite (even now) 😉 🙂 recipe. Hope you also like and enjoy it as much as I do 🙂 |Recipe Type||Side Dish/Kerala (India)| |Cooking and Preparation Time||20 to 30 Minutes| |Serve to||5 to 6| Ingredients For Kerala Style Spicy Potato Stir fry/ urulla kizhaghu Mezhukku puratti |Potato||4 Numbers (Medium Size)||Skinned and diced evenly| |Big Onion||1 Big or 2 Small/medium size||Skinned and chopped| |Red dry Chilly||2 numbers||Cut into small pieces| |Oil||2 to3 Tablespoon||I used coconut oil here| |Mustard Seeds||¼ Teaspoon| |Turmeric Powder||¼ Tablespoon| |Chilly Powder||¾ Tablespoon||Adjust as per your taste| |Salt||As per your Taste| |Water||Require for cooking potato dices (approximately ¼ Cup)| Method For Kerala Spicy Potato Stir fry/ urulla kizhaghu Mezhukku puratti • Place diced potato in a non-stick pan. Add water (not much, approximately ¼ Cup), salt and 1 table spoon oil (adding oil prevent from sticking the dices each other as well as the bottom of the pan). • Cover the pan and cook in a low/medium heat. • When half cooked, add ¼ tablespoon turmeric powder and mix well. • Cover and cook until the potato done with moist texture (Do not overcook potato). Turn off the heat, keep aside. • Heat remaining oil in another non-stick frying pan. Pop mustard seeds. • Add onion, red dry chilly and curry leaves. Sauté well. • When its light brown in colour, lower the heat and add ¾ tablespoon red chilly powder. Sauté next 2 minutes. • Add cooked potato dices. Sauté and mix well, make sure all masala’s well coated with potato dices. • Cover and cook it 2 to 3 minutes in a lower flame for all potato dices well absorb all masala’s. • Uncover the pan, increase the flame. Stir potato continuously (sprinkle some oil if required) until very dry and fry in texture. • Turn off the heat, taste and add salt if required. • Serve spicy potato stir fry with boiled rice and enjoy 🙂 More Stir fry recipes please click HERE

Is Boric Acid Good For Nail Fungus If you are looking for a natural way to get rid of your nail fungus, boric acid might be the answer. This substance has been used for years in fighting off fungus and bacteria that causes bad breath and body odor. It also is an effective treatment for athletes foot, jock itch, ringworm and other skin infections among many other things. But does it work on nail fungi? Here are some of the facts about this natural remedy: Boric Acid is made up of boron as well as sulfur which give it its antifungal properties- so yes! Boric acid can help with nail fungus but please consult your doctor first before trying any home remedies or over the counter treatments if you have diabetes or kidney problems. One way you can control the growth of your nail fungus or even get rid of it completely is by using boric acid as a topical treatment. The substance seeps into the skin on your feet and under your nails where the fungi live. Its one of the most effective treatments available because it contains ingredients that kill bacteria and remove moisture from the area which allows for healthy nail growth. reason why I recommend using this home remedy is because it has been shown that boric acid for toenail fungus actually improves the thickness of nails in some users while traditional topical treatments dont even have any effect on them! Its also not toxic Everything You Need To Know About Boric Acid Treatments For a yeast infection, you can shop for premade boric acid suppositories at drug stores or online, or make your own with boric acid powder and gelatin capsules . Possible side effects for its use in yeast infections include burning, discharge, or redness. However, you should steer away from this product if you are pregnant or have an open wound. For best results, it’s advised to insert a new capsule every day for one to two weeks until symptoms have cleared. Boric acid can be used for other purposes apart from yeast infections, most notably for athlete’s foot, ear infections, or minor wounds according to MedicineNet. To use BA for athlete’s foot, sprinkle some boric acid powder in your socks or stockings as it can help clear mild infections, ease itchiness, and neutralize odors, too. As Dr. Axe explains, the acid modifies the pH of the skin, which can help remove dead skin that feeds the fungus. MedicineNet recommends also diluting boric acid as a treatment for diaper rash, insect bites, and more, while also touting its benefits in treating foot odor. Moreover, the website describes boric acid’s usefulness in treating ear infections but maintains it should not be used in children. Use boric acid mixed with distilled water for minor cuts or burns, but utilize it sparingly. Boric acid is a powerful multi-purpose solution, but should still be used with proper research and advice from a medical professional. Can You Use Cold Laser Shower For Toe Fungus Boric Acid For Toenail Fungus Over The Counter For Thick Toenail Fungus Laser Toe Fungus Encino How To Destroy Toenail Fungus. Treatments For Skin Fungus Infections How To Treat Toe Fungus Vinegar. Using Oregano Oil For Toe Nail Fungus Can Candida Overgrowth Cause Nail Fungus. Clear Touch By Radiancy Nail Fungus Reviews Can Toenail Fungus Affect Your Leg. Any Side Effets Wth The Drug Ltraconazole That Kils Fungus Will It Kill Nail Fungus Foot Fungus Burning Sensation. Is Organic Vinegar Good For Nail Fu Fungus Can You Put Nail Polish On Nails With Fungus Dr Wu Chang Toenail Fungus Treatment Review. Eat This For Breakfast To Destroy Nail Fungus Metaphysical Cause Of Toenail Fungus. Also Check: Is Cancer A Fungus Or A Virus Recommended Reading: How Do You Treat White Toenail Fungus Don’t Use Boric Acid Until You Read This If you’re curious about giving boric acid a shot, it’s safe to say you’re not alone the antiviral and antifungal treatment has been used for centuries, making it suitable for a wide variety of uses . Although boric acid is most commonly used for chronic yeast infections, according to Dr. Axe, it can also be used to treat athlete’s foot and acne. If you’re ready to give it a try, there are just a few things you should know first. Boric acid is derived from boron, which occurs in certain minerals, volcanic waters, or hot springs . It is a wide-ranging natural antifungal that can be used to treat infections, as well as natural pest control against insects . Its antibiotic properties make it helpful against fungal and bacterial infections. Boric acid can also be found in antiseptics, astringents, skin lotions, and some eyewash products. If you’re planning on using boric acid for a chronic or recurrent yeast infection, you should know it has been used as a treatment for over 100 years and some experts now recommend vaginal boric acid suppositories for infections that resist traditional medicines . It can treat both the Candida albicans and Candida glabrata yeast strains by inserting capsules directly into the vagina. This treatment is much less expensive than other over-the-counter medications. Who Apple Cider Vinegar Will Not Work For If you are diabetic, chances are that your toenail fungus infection is as a result of diabetes and not a fungus per se. People who are diabetic often have the fungus infection known as onychomycosis. This infection affects their toenail. If you are in the class of these people, using ACV will amount to a total waste of your time. You May Like: How To Get Rid Of Toe Nail Fungus Fast Pain In Fungus Nail Foot Fungus Pain In Toe Tools For Fungus Toenail Debridement Can Tea Tree Get Rid Of Fungus On Skin Does Baking Soda Help In Treating Toenail Fungus. Is Toenail Fungus Laser Treatment Eligible For Hsa Reimbursement Instant Toenail Fungus Cure. Does Clotrimazole Cure Toenail Fungus Foods That Kill Fungus On The Skin. Cure Toe Nail Fungus Topical Clear Small Spots On Skin Fungus. How To Kill Toe Fungus In Shower What Internal Homeopathic Remedy Is Good For Toenail Fungus. Laser Treatment For Nail Fungus Rockland County The Toughest Ovtc Toe Fungus Medicine Toe Fungus Terbafine. Toenail Fungus Pomona Who Do I See About Toenail Fungus. What Are The Key Ingredients In Emuaidmax EmuaidMAX is made from a high quality, medical grade ingredients such as: - Tea Tree Oil - Olea Europaea Fruit Oil - And more! Best of all, the formula does not contain any artificial preservatives, chemicals, alcohol, petrochemicals, or fragrances. This means the formula is made without anything artificial or damaging to the skin, so you dont have to worry about any nasty chemicals entering your body. to view a full list of ingredients from the manufacturer. EmuaidMAX is FDA-registered, and it is a high-quality treatment that utilizes the highest concentrations of natural ingredients to treat an incredible variety of ailments. These natural oils have been used by indigenous cultures for centuries to treat all sorts of skin and nail conditions everything from athletes foot to ear infections, boils, eczema, psoriasis, and more. Also Check: How Do You Get Dip Nails Off Recommended Reading: Is Bleach Good For Nail Fungus How Fungi Infect The Nail Onchomycosis, or toenail fungal infection, is an invasion by a microscopic organism that thrives in warm, damp environments. Fungal spores are in the air, and they will grow if they land on a receptive surface like your toenail. They feed off the nail tissues, burrowing into the skin under the nail. Over time the nail thickens and may lift off the nail bed as fungal debris accumulates. Once your nail is raised off the nail bed, it wont reattach, and a new nail wont grow from that part of the nail bed. However, your nail will continue to grow from the root at the base. Model Construction And Group Intervention Mice were randomly divided into N , M , and B groups . Chlorpromazine solution 0.2 mL was injected intramuscularly for anesthesia, hair on the back was shaved, and two injection sites were randomly selected. The mycelium suspension 1.5 × 109 cells/0.1 mL was injected into the M and B groups, and the control group was treated with SWIF. Six mice were randomly selected to observe the clinical manifestations. Fungal fluorescence microscopy and colony count were used to determine whether the mouse skin CA infection model was successfully constructed. On the fifth day after inoculation, 12 mice in each group were anesthetized by the above methods. Each mouse in group B was hydropathic compressed with six layers of sterile gauze and 3% boric acid solution for 30 min, once every 12 h. Group M was treated with SWIF, while the blank group was fed normally without treatment. Recommended Reading: Is White Vinegar Good For Toenail Fungus Complications: What If The Infection Is Left Untreated If the nail fungus spreads deeper into the nail bed, it will cause the nail to thicken and turn green, yellow, brown, or black. As the infection progresses, the infected nail becomes brittle and pieces of it will start to break off from the toe or finger completely. Should the condition be left untreated, it can spread to other nails or cause skin around the infected nail to become inflamed. In more advanced stages, a foul smell may develop and white or yellow patches may be seen on the exposed nail bed. Over time, severe fungal nail infections can cause permanent damage to the nail root or nail bed. It can be quite embarrassing to have this condition since this is an infection thats hard to hide. People with Onychomycosis may also find it difficult or painful to wear shoes, walk, or stand for long periods of time if their toenails have been infected severely. Recommended Reading: How To Get Rid Of Severe Nail Fungus Use Povidone Iodine To Treat Your Nail Fungus Reply Back To This Thread When Your Fungus Goes Away So That People Know Its Real Please upvote this. Use Povidone Iodine Prep solution to safely and effectively get rid of toe fungus. This stuff works like magic ad is cheap! My gf tells me that Its what surgeons and nurses use religiously in the hospital before doing any incision or surgery. It kills everything that can live on your skin and apparently even nail fungus. Best part is it gets sticky once dry and stays on your nail for the entire day, continuously killing the fungus. No need to constantly reapply it. It works like magic, Id say it took less then a month and the fungus is gone baby gone. You can get a bottle off amazon or whatever for around 10$. I have no affiliation with iodine and suspect this cure isnt perpetuated because this stuff is dirt cheap and cant be easily monitized. Edit 1: Its non toxic and can be beneficial to your body, I believe your thyroid or something loves iodine. Im not a professional MD but I no it worked for me! Finally while tending to some cuts on my hand with my iodine solution and resting. I got the idea to put a few drops of this iodine on top of my toe. I saw results the next time I took my shoes off. I kept doing it daily for a few weeks and the toe fungus is gone Recommended Reading: How To Rid Toenail Fungus Risk Factors Of Toenail Fungus Anyone can have a toenail infection, but there are certain risk factors that make a person more prone to having a fungal nail infection. A few of them are as follows. - Aging is a predominant risk factor for having toenail fungus. As we grow old, the quality of our blood vessels goes down. The blood supply to the peripheral parts like the toenail gets disturbed hence there is an increased chance of having a fungal nail infection. Aging also causes one to have more exposure and slower growing nails. - Perspiring heavily provides the fungus with an ideal setting for its growth and invasion. - Male gender is more prone to have toenail fungus especially if there is a family history of toenail fungus as well. - If you are working in humid and moist environments, especially in a setting where your hands are wet most of the time for instance, bar tending or housekeeping. - Wearing socks and shoes hinders the ventilation of foot skin and sometimes the material of the socks is such that they dont absorb perspiration. - Contagious If you live with someone who has toenail fungus, you are also likely to have it. - Walking barefoot in damp places like swimming pools, gyms and shower rooms. - A history of athletes foot. - A history of a minor skin or nail injury and certain skin conditions like psoriasis. - Having chronic diseases like diabetes, peripheral vascular diseases, weak immunity and certain syndromes for instance Downs syndrome. Case Study Of Baking Soda And Toenail Fungus Believing anything without a proof is not possible. That is why we are here to help you get the real results. As I was also suspicious of the use of baking soda for toenail fungus, although it has properties to fix the fungus, I asked one of my physician friends who works in a hospital to recommend it to a patient. After careful research and consultation with researchers fellows, we allowed two patients to apply baking soda mixed with apple cider vinegar to treat toenail fungus. And below is the image of how it was looking that time. For the first 5 weeks, the people under observation applied the baking soda paste with apple cider vinegar thrice a day. Their skin got really dry, around the toenail. They experienced a burning sensation initially, but it was recovered by using a mix of oregano and tea tree oil too. After the 7th week as there was no further improvement only the skin around the nail fungus was becoming rough. As it is obvious, these home remedies gonna take a lot of time to fix the fungus completely. The results were coming good, but very slow, also some other symptoms that were not so damaging, but dont look good too like the rough skin around the nail and irritation. So, the doctors including me, prescribed them the probiotic supplement named Urgent fungus destroyer from the Phytage labs to add in. This was to aid the external or topical treatment for toenail fungus. And below are the results that the above patient got. Recommended Reading: Does Baking Soda Help With Toenail Fungus Colorless Iodine Can Strengthen Nails Kill Fungus: Heloise Dear Heloise: While looking for colorless iodine, I came across your column. Ive never heard that iodine strengthens nails, but I will tell you from a lifetime of use, it can kill nail fungus infections. It works better if you can use a dropper rather than the brush. Toenails grow very slowly and the area should remain exposed as much as possible . Its a long process and depends on how far under the nail the fungus resides. A minimum of six months to get clear. Monika H., Yonkers, New York Dear Monika: I have long touted decolorized iodine to strengthen weak and brittle nails. Use every day for one week, and then once a week for maintenance. Im glad to hear that white iodine also works for fungus on nails, but always check with your medical provider or pharmacist. Look for decolorized iodine at the pharmacy or online. Heloise Dear Heloise: I see some girls store their leather handbags in plastic dust covers. This is a no-no for me. Leather needs to breathe. I store my bags in plain white pillowcases. I attach a picture of the bag on the outside, so I know whats inside. Gia in New Mexico Dear Gia: Great storage idea! I love reusing old pillowcases, and picture labeling makes a lot of sense. Heloise Dear Heloise: With all the recent downtime, Ive been making a point of doing the many things Ive been meaning to do! Deep cleaning the house is an obvious goal, but I deep cleaned my car and garage also! Baking Soda With Borax Powder Or Boric Acid Boric acid or borax powder has fungicidal properties which kill off the onychomycosis and athletes foot, so using baking soda for foot fungus also works. Beware that borax powder is banned in some countries, so you will have to check if the product is available before trying the treatment. - Mix enough amounts of BS, borax powder, and water. - Combine the ingredients well to make a thick paste. - Simply the affected finger and gently rub the mixture on them. - After few minutes, rinse off with water and pat dry. - Repeat the process 2 times a day for quick results. Recommended Reading: What Kills Fungus On Scalp What Is The White Hard Stuff Under My Toenails Nail psoriasis sometimes causes too much keratin to grow under the nail. This overgrowth is called subungual hyperkeratosis. People with hyperkeratosis may notice a white, chalky substance under the nail. When this occurs in the toenails, the pressure of shoes pushing down on the nails might cause pain. Read Also: What Spice Helps Toenail Fungus How To Use Them A person interested in trying a blend of essential oils can buy the oils online or from a health food store. Mix the oil with a carrier oil before applying the mixture to the affected nails. Ozonized oils are oils infused with ozone gas. Examples of oils that are available in ozonized form include sunflower oil and olive oil. According to , ozonized oils show positive effects similar to a traditional medication called terbinafine cream in treating one type of fungus. In this study, the researchers used rabbits to test the effectiveness of the treatment. Another study carried out on 400 people tested how ozonized oils affected fungal infections. In this 2011 study , researchers used ozonized sunflower oil to treat toenail fungus. Their results indicated that ozonized oils cured up to 90.5 percent of the total infections with only a 2.8 percent relapse rate after 1 year. The researchers concluded the ozonized sunflower oil works more effectively than ketoconazole cream, which is an antifungal medication. Also Check: Does Dollar General Have Nail Polish Don’t Miss: Is Seborrheic Dermatitis A Fungus

Eye Exams for Contact Lenses Contact lenses are a great alternative to wearing eyeglasses. An often unknown fact is that not all patients wear contact lenses as their primary source of vision correction. Each patient is different, with some patients wearing contact lenses only on weekends, special occasions or just for sports. That is the beauty of contact lens wear, the flexibility it gives each individual patient and their lifestyle. If you decide to opt for contact lens wear, it is very important that the lenses fit properly and comfortably and that you understand contact lens safety and hygiene. A contact lens exam will include both a comprehensive eye exam to check your overall eye health, your general vision prescription and then a contact lens consultation and measurement to determine the proper lens fit. The Importance of a Comprehensive Eye Exam Whether or not you have vision problems, it is important to have your eyes checked regularly to ensure they are healthy and that there are no signs of a developing eye condition. A comprehensive eye exam will check the general health of your eyes as well as the quality of your vision. During this exam the eye doctor will determine your prescription for eyeglasses, however this prescription alone is not sufficient for contact lenses. The doctor may also check for any eye health issues that could interfere with the comfort and success of contact lens wear. Hard To Fit Contact Lens Patients Even if you’ve been told you can’t wear contact lenses, we may be able to help. Specialty contacts are available for patients with dry eyes, severe astigmatism and more. The Contact Lens Consultation The contact lens industry is always developing new innovations to make contacts more comfortable, convenient and accessible. Therefore, one of the initial steps in a contact lens consultation is to discuss with your eye doctor some lifestyle and health considerations that could impact the type of contacts that suit you best. Some of the options to consider are whether you would prefer daily disposables or monthly disposable lenses, as well as soft versus rigid gas permeable (GP) lenses. If you have any particular eye conditions, such as astigmatism or dry eye syndrome, your eye doctor might have specific recommendations for the right type or brand for your optimal comfort and vision needs. Now is the time to tell your eye doctor if you would like to consider colored contact lenses as well. If you are over 40 and experience problems seeing small print, for which you need bifocals to see close objects, your eye doctor may recommend multifocal lenses or a combination of multifocal and monovision lenses to correct your unique vision needs. Contact Lens Fitting One size does not fit all when it comes to contact lenses. Your eye doctor will need to take some measurements to properly fit your contact lenses. Contact lenses that do not fit properly could cause discomfort, blurry vision or even damage the eye. Here are some of the measurements your eye doctor will take for a contact lens fitting: In order to assure that the fitting curve of the lens properly fits the curve of your eye, your doctor will measure the curvature of the cornea or front surface of the eye. The curvature is measured with an instrument called a keratometer to determine the appropriate curve for your contact lenses. If you have astigmatism, the curvature of your cornea is not perfectly round and therefore a “toric” lens, which is designed specifically for an eye with astigmatism, would be fit to provide the best vision and lens fit. In certain cases your eye doctor may decide to measure your cornea in greater detail with a mapping of the corneal surface called corneal topography. Pupil or Iris Size Your eye doctor may measure the size of your pupil or your iris (the colored area of your eye) with an instrument called a biomicroscope or slit lamp or manually with a ruler or card. This measurement is especially important if you are considering specialized lenses such as Gas Permeable (GP) contacts. Tear Film Evaluation One of the most common problems affecting contact lens wear is dry eyes. If the lenses are not kept adequately hydrated and moist, they will become uncomfortable and your eyes will feel dry, irritated and itchy. Particularly if you have dry eye syndrome, your doctor will want to make sure that you have a sufficient tear film to keep the lenses moist and comfortable, otherwise, contact lenses may not be a suitable vision option. A tear film evaluation is performed by the doctor by putting a drop of liquid dye on your eye and then viewing your tears with a slit lamp or by placing a special strip of paper under the lid to absorb the tears to see how much moisture is produced. If your tear film is weak, your eye doctor may recommend certain types of contact lenses that are more successful in maintaining moisture. Contact Lens Trial and Prescription After deciding which pair of lenses could work best with your eyes, the eye doctor may have you try on a pair of lenses to confirm the fit and comfort before finalizing and ordering your lenses. The doctor or assistant would insert the lenses and keep them in for 15-20 minutes before the doctor exams the fit, movement and tearing in your eye. If after the fitting, the lenses appear to be a good fit, your eye doctor will order the lenses for you. Your eye doctor will also provide care and hygiene instructions including how to insert and remove your lenses, how long to wear them and how to store them if relevant. Your eye doctor may request that you schedule a follow-up appointment to check that your contact lenses are fitting properly and that your eyes are adjusting properly. If you are experiencing discomfort or dryness in your eyes you should visit your eye doctor as soon as possible. Your eye doctor may decide to try a different lens, a different contact lens disinfecting solution or to try an adjustment in your wearing schedule. Contact us today to schedule your contact lens exam and fitting.

Image source – Pixabay Petunia is one of the most commonly grown ornamental flowering plants. From containers to flower beds, these plants can be grown in a variety of conditions. There are 20 different species of petunias that are popular around the world. It is an annual that is easy to nurture even for gardeners who have newly ventured into gardening. Companion plants for various reasons Plant pairings are done based on various parameters. Companion planting trends have emerged recently as they offer a host of benefits for all the plants grown in the group. This method involves picking plants of different varieties to be grown close to each other. Petunia companion plant combination tips - Growing petunias close to vegetable crops is a common practice. This is mainly because these vibrant flowers can attract pollinators and improve yields. But there are also other flowering plants that can be grown close to petunia beds in order to make them look prettier. Some of them grow in harmony with your petunia batch without depleting the soil nutrients. There are others that can help in keeping a check on the plant diseases that are common in petunias. Whatever be the reason for which you are hunting for petunia companion plants, here are the most popular choices to consider. - You can grow petunias close to almost all types of flowering plants. This plant has a reputation for keeping a variety of garden insects away. If you have a vegetable garden, then you ought to be careful about leafhoppers and hornworms. These can damage the foliage and bring down the yield. Petunia can be raised close to these plants as a pest-repellent which also looks pretty. - While this insect-repelling nature of petunia is well-known, another fact to remember is that this is a plant that requires full sunlight. They also thrive in soil that is not soggy. Any flowering plant that can grow well in well-lit garden spaces would be able to grow well with petunias. It should also be a plant that doesn’t need to be constantly moist. - Petunias cannot tolerate dry soil for a long time. So, it is not a good companion to be grown close to your succulent or cacti bed. - Make sure that you do not grow this plant close to feeble stemmed flowering plants. It can creep on supports or even cover the ground when you grow them in containers close to the ground. So, it might end up invading the space of other delicate plants. Best petunia companion plants The following are petunia companion plants that can be chosen for gardens and containers as well. For garden beds, it is about creating height differences. You should know about the thriller, spiller, and filler strategy while choosing plants for combining in containers. Thriller plants are the primary focus and they are characterized by vertical growth. Fillers fill the space and grow bushy in the gaps. Spillers trail in the pot and create a continuation effect. Petunias fall in the fillers category. You can therefore choose plants that are thrillers or spillers for the best results with petunias. 1. Red salvia: Gardeners who are looking for flowering plants to grow as garden borders love to work with this combination. Red salvia and petunias of lighter colors like white and yellow are classic pairs. This is another plant favored by gardeners looking to attract pollinators. Both petunias and red salvia offer a treat for hummingbirds. The height of this plant and the dense growth of the petunia plants are perfect combinations. In fact, this plant is chosen as a companion mainly for that extra height it gives to your borders with the leggy flower stalks. This one blossoms elegantly in places that receive full sun and so does petunia. If it is for containers, then this would be the thriller plant for your petunias. A soil pH level in the range of 5.5 to 6.5 is beneficial to red salvia plants. For petunias, you would have to maintain the pH levels in the range of 6.0 to 7.5. Hit the sweet spot and maintain the pH level in your flower bed between 6.0 to 6.5 and both petunias and red salvia plants would thrive. Daisies are other petunia companion plants that are chosen as they have very similar water requirements like petunias. Upright stalks in the daisies make them wonderful companions for petunias. You also can tap into the variety of colors available with both these plant varieties and make some wonderful color combinations in your garden. This is also a plant that you can combine with petunia arrangements grown in containers. Daisies have very similar soil pH needs as petunias. So, you would not have to worry about rotating the soil nutrients in the bed when you grow both these plants together. Lantana and petunia combinations are particularly popular in container gardening. These can both be grown comfortably in partially shady porches without any compromise in blooms. This is a plant that can reach a height of 6 feet when grown in the garden as a perennial. It contrasts the trailing nature of the petunias and creates a cascading appearance for the flower bed. It thrives in well-drained soil much like your petunia plants. It can grow well even in acidic soil and can withstand pH levels in the range of 5.5 to 8.5. A petunia bed would therefore be a favorable place for your lantana plants. Another upright plant popular in the list of petunia companion plants is the snapdragon. Yellow snapdragons can be paired easily with purple and even red petunias. The black petunia variant is another killer combination to choose along with a light snapdragon variant. With its soil pH requirement in the range 5.5 to 6.2, you do not need additional preparation of the bed before planting this in petunia beds. Medium fertile soils are sufficient for vibrant blooms similar to petunias. Full sun can result in bright blooms in the snapdragon plant. You will have both petunias and snapdragons blooming in summer. Bold and beautiful flowers on tall stems make the asters great companions for low-growing petunia plants. Aster, like petunias, would not tolerate water-logging in soil. Without letting the plant dry out for a long time between watering schedules, you can easily keep the soil moist. It would be important to add a well-drained potting mix for growing aster and petunia pairs in pots. Soil pH should be maintained in the range of 5.5 to 7.5 for aster plants to grow and bloom as expected. This makes it easy to grow this in combination with petunias in the same container. You can also pick this one as a pair for low hanging baskets. In this case, you can go with trailing variants of petunias like wave petunias. You would have the petunia elegantly spilling from the basket while the aster grows upright. This flowering plant prefers similar growing conditions like that of petunias. If you need a perennial that perfectly complements the short-lived petunia plantation, then candytuft is a popular choice. The bunches of candytuft flowers make great contrasts to dark color petunia variants. These grow to similar heights like petunias. They are perfect when grown on flower beds rather than in containers. This is another warmth-loving plant that doesn’t stand soggy soils. Good drainage promotes better root growth and increases the life of this plant. Maintain the pH level between 6 and 7.5 for the best results. A versatile combination to grow with your petunia would be the lobelia. Though it is often grown as a perennial it can also be nurtured as an annual in your petunia pots. The bush growth of the petunia in the container can be perfectly complemented with the trailing growth of lobelia. For companion planting in containers, trailing lobelia makes a good choice. It coordinates well with petunias of various types. This plant carries blooms that are as bright as petunias. But the flowers of lobelia are slightly smaller. This helps in creating a nice balance in the appearance when the plants are both in full bloom. It starts blooming right when spring begins. When you pick a sunny spot for your petunia-lobelia container, you can be assured of bright and healthy flowers. Even moisture with good drainage can keep the plant growing healthily. pH levels in the range of 6.0 to 7.5 can provide the right medium for the plant to grow and develop a healthy root system. Like petunias, this is another flowering plant that shows visible improvement in blooms upon providing organic plant fertilizers regularly. Depending on the arrangement of your petunia plants you can trim this down to encourage bushy growth. While economically using up whatever garden space you have, you would also be able to aesthetically accent your petunia plants with these other flowering plants. With these plant combinations, you can easily build the prettiest flower bed in your garden in no time.

Pumpkin Spice Scones Make these. Seriously. They are incredible. I thought I had found my favorite scone recipe previously (and those are really good), but these are better. They are moist and sweet and full of wonderful pumpkin flavor. And the icing? Don’t leave it off, because it takes the scone from good, to something that I want to eat for breakfast every morning. It’s like the gooey topping of a cinnamon roll. Mike loved these as well. He no longer claims to dislike scones or pumpkin, that’s how good these are. He rated them a 4 and asked me to make them again this weekend, although without the nuts. 🙂 Pumpkin Spice Scones 2 cups Flour ⅓ cups Brown Sugar, Tightly Packed 2 teaspoons Baking Powder ½ teaspoons Salt 1 teaspoon Cinnamon ½ teaspoons Ginger Powder ½ teaspoons Nutmeg 1 stick Unsalted Butter, Frozen ½ cups Pumpkin Puree ½ cups Heavy Cream 1 cup Powdered Sugar ½ teaspoons Cinnamon ¼ teaspoons Ginger Powder 2 teaspoons Corn Syrup 1 teaspoon Vanilla Heavy Cream (Enough To Let Icing Reach Consistency Of Honey) ½ cups Toasted, Chopped Walnuts (optional) Mix first 8 ingredients with a fork and add the frozen butter stick by grating it on a cheese grater over the flour mixture. (Note: work quickly, holding the frozen butter in its wrapper and a paper towel to keep it from melting.) Mix butter curls into the flour mixture with a fork. In a small bowl, mix the pumpkin and cream and pour into the flour/butter mixture. Fold with a wooden spoon just until flour is moistened, then turn out onto a lightly floured board and gently knead over a couple of times. Pat into a circle about 1 inch thick and cut into 8 sections like pie slices. Separate scones onto a cookie sheet and place them in the freezer for 30 minutes. (Or make these ahead and place them in the fridge overnight.) Bake at 400F for about 25 minutes till just firm and golden around the edges. Let cool to room temperature. For the Icing: Mix the first 5 icing ingredients (powdered sugar, cinnamon, ginger powder, corn syrup, vanilla). Add heavy cream in small amounts at a time, stirring often, until icing reaches the consistency of honey. With a large soup spoon, spoon the icing over the cooled scones and sprinkle toasted walnuts over the top. Let the icing set a bit before putting the scones away in an airtight container. from Tasty Kitchen

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Monday night I stepped outside into a winter wind. Low in the WSW, I saw Venus accompanying a crescent moon. With her fiery light, she has long fascinated mankind. The Egyptians, the Arabs, the Greeks, and the Romans all knew her well. Down through the ages Venus’ brilliance has spawned many myths, but she is most revered as the goddess-of-love. One of the best descriptions of her temperament comes from 17th century astrologer Lilly. “She is a Feminine Planet, temperately Cold and Moist, Nocturnal, the less Fortune, author of Mirth and Joy; of the elements, the Air and Water are Venereal; In the Humors, Phlegm with Blood, with Spirit and Genital seed.” Even today her mythological status is alive and well, but let us not forget that Venus also help us crack the universe. Through a primitive telescope, in 1610 Galileo saw that the phases of Venus were inconsistent with a geocentric solar system. It was a discovery that shone a light on Copernicus, while dooming the Ptolemaic system to the dustbins of history.

Salted Caramel Whoopie Pies Has there ever been anything so smooth and rich that your eyes widen at the mere suggestion? Well, this one does it for us! It's rich chocolate cakes with a sprinkling of sea salt (just to remind you of the difference between sweet and salty!) and then filled to overflowing with the richest home made caramel that you can imagine. If you could only be here to enjoy the process of making this delectable treat! Our chocolate cakes are deep and fully chocolate but moist and tender. We pack them with so much chocolate they just can't hold anymore! They are almost a brownie! The caramel filling is made of sugar, heavy cream and butter, that's it...it's so yummy we want to eat it with a spoon, but that's another story! This very rich caramel is mixed with our homemade marshmallow and more butter to make sure it melts in your mouth! In our minds, there just isn't anything that tops this one! Chocolate cakes with a sprinkling of sea salt and rich caramel cream, YES, please! Here are the ingredients: Chocolate cake ingredients: sugar, cage free eggs, butter (cream and salt), flour (unbleached hard wheat flour, malted barley flour, niacin, reduced iron, thiamin mononitrate, riboflavin, folic acid), cream cheese (pasteurized nonfat milk and milkfat, cheese culture, whey protein concentrate, salt, guar gum, carob bean gum), cocoa, baking powder (sodium acid pyrophosphate, sodium bicarbonate, corn starch and monocalcium phosphate), vanilla, salt. Caramel Filling Ingredients: sugar, butter (cream and salt), water, cream, cage free egg whites, modified corn starch, tapioca flour, vanilla, sea salt.

Cissus vitiginea L., Sp. Pl. 117 1753. (Syn: Cissus angulata Lam.; Cissus vitifolia Salisb. (ambiguous synonym); Vitis linnaei Wall.; Vitis linnaei Wight & Arn.; Vitis vitiginea (L.) Kuntze); Sri Lanka, S-India (Orissa, Maharashtra, Andhra Pradesh, Karnataka, Tamil Nadu, Kerala), Thailand, Maldives, Bangladesh as per Catalogue of Life; Common name: South Indian Treebine • Malayalam: nerinnampuli • Sanskrit: amlavetasah • Tamil: cempirantai, mutainari • Telugu: Adavidraaksha, అడవిగుమ్మడి Adavi Gummadi Climbing, foetid shrubs; bark blackish to reddish; branchlets densely pubescent, swollen at nodes; tendril simple, bifid or branched. Leaves simple, 5-angular or deeply lobed, 4-8 x 4-7.5 cm, ovate-orbicular, base truncate to cordate, margin irregularly dentate, apex acute or obtuse, pubescent, basally 3-nerved; petiole to 6 cm long; stipules c. 2.5 mm long, triangular, pubescent. Flowers in axillary or leaf-opposed umbellate cymes; peduncle to 5 cm long. Calyx c. 2 mm long, cupular, pubescent. Petals 4, yellow; c. 2.5 mm long ovate, obtuse, recurved. Stamens 4; filaments green; anthers rotund, yellow. Disk more or less 4-lobed, yellow. Berry c.1 cm long, ovoid to obovoid, purplish-blue, pendulous. Seed 1, c. 7 mm long, ovoid. Flowering and fruiting: May-December Dry and moist deciduous forests, also in the plains India and Sri Lanka (Attributions- Dr. N Sasidharan (Dr. B P Pal Fellow), Kerala Forest Research Institute, Peechi from India Biodiversity Portal) plant ID – efloraofindia | Google Groups : (mixed thread): 2 correct images as above. Found in Velneshwar in Konkan in the month of April. one more ID please. It is a Vitaceae Member. Based on the curved pedicels, i think the 3rd set of pictures belong to Cissus vitigenia (Vitaceae). But need leaf characters to confirm the id. Cissus vitiginea — Please check id for GE-10Dec2012: I think this is Cissus vitiginea. Plant was found growing in dry wasteland in Chennai outskirts. Flowering and fruiting in November. All parts, except perhaps flowers and fruits, were pubescent or densely so. Please check the id Yes …, I agree with the id Cissus vitiginea. 02082017BHAR2 : 4 posts by 3 authors. Attachments (3) Found in Vandalur forest. Chennai. Vitaceae sp.. Check for Cissus vitiginea.. Thanks, …, for id. To me also appear close to images at Cissus vitiginea I think it is from family vitaceae Could be a species of Cissus Appears close to images at Cissus vitiginea L. vitiginea only … This plant is In Tirupathi hills.Please tell me the ID : 4 posts by 3 authors. 2 images. It is Cissus vitigenea Vitaceae member ID Please : 5 posts by 3 authors. Attachments (3) Vitaceae member ID Please Cissus species in eFloraofindia (with details/ keys from published papers/ regional floras/ FRLHT/ FOI/ Biotik/ efloras/ books etc., where ever available on net) This Species in TN state As a non botanist member what I could apprehend about this species is- This can lead to Cissus vitiginea L. (you my check “bud” pic at http://www.plantekey.com/plants/vitaceae/cissus-vitiginea), ignoring Ampelocissus tomentosa (Roth.) Planch. Please wait for botanist members.. Id.Shrilanka.4 Jan 2020. : 3 posts by 2 authors. Attachments (1) Id pl. tree. It is Cissus vitiginea Check for Cissus species (Cissus vitiginea ??????) Yes, appears close to images at Cissus vitiginea L. Check if it is same or something else: I think same. Catalogue of Life The Plant List Ver 1.1 Flowers of India FRLHT GBIF Flora of Karnataka The Linnean Collections Flickr India Biodiversity Portal Flora of the Nilgiris RPRC Flora of Eastern Ghats: Hill Ranges of South East India, Volume 1 By T. Pullaiah, D. Muralidhar Rao, K. Sri Ramamurthy (Description) Flora of Eastern Karnataka – Google Books An updated review on Cissus vitiginea L. (Family: Vitaceae … (pdf)

Rocky Mountain Foothill Limber Pine - Juniper Woodland Provisional State Rank This ecological system occurs in foothill and lower montane zones in the northern Rocky Mountains and island mountain ranges of Montana and on escarpments extending out to the western Great Plains grasslands. Elevation ranges from 1,219 to 2,286 meters (4,000-7,500 feet), occasionally higher in southwestern Montana. At higher elevations, it is limited to sites with thin soils on rock outcrops. Some of the most ecologically interesting examples occur along and within the mountains of the Rocky Mountain Front where it occurs most commonly on west and north facing aspects. At lower elevations, it can occur on all aspects and on relatively level terrain. Fire is infrequent and spotty because rocky substrates inhibit growth of the continuous canopy that would be needed to spread. This system occurs on sites that are characterized by extreme winter weather and droughty summer conditions. It is typically dominated by limber pine (Pinus flexilis) or Rocky Mountain juniper (Juniperus scopulorum). This systemis usually found below continuous forests of Douglas-fir (Pseudotsuga menziesii), or rarely, ponderosa pine (Pinus ponderosa) or lodgepole pine (Pinus contorta) in the foothills. Rocky Mountain juniper stands often occur in complex transitional zones or grow on exposed or severe sites within other forest systems. These juniper stands can exhibit a savanna-like character in southwestern Montana. In the system as a whole, because sites are so marginal for tree growth, limber pine mortality from abiotic and biotic stresses may be high. East of the Continental Divide, limber pine can occur at the upper tree line, with whitebark pine (Pinus albicaulis) in Glacier National Park and the Sweetgrass Hills. The climtate characteristic of these systems is marked by a relatively small amount of precipitation, with the wettest months during the growing season, very low humidity, and wide annual and diurnal temperature ranges. Winter conditions may be very cold but relatively dry, and often include rapid fluctuations in temperature associated with chinook winds. In Montana, limber pine and Rocky Mountain juniper stands are found mainly on calcareous substrates. Soils have a high rock component (generally over 50% cover) and are coarse- to fine-textured, often gravelly. Slopes are moderately steep to steep. Forest and woodland, aridic, sandy, shallow soils, organic A horizon less than 10 cm, Pinus flexilis, Juniperus scopulorum This system occurs in foothill and lower montane zones in the northern Rocky Mountain Front and foothills, within the island ranges, and on escarpments extending out into the western Great Plains. This system is well represented in the Gravelly Range and Beaverhead Range, and the greater Yellowstone ecosystem and the Pryor Range in the southern portion of the state. It ranges from southern Alberta to central Colorado and east into North and South Dakota. Ecological System Distribution Approximately 714 square kilometers are classified as Rocky Mountain Foothill Limber Pine - Juniper Woodland in the 2017 Montana Land Cover layers. Grid on map is based on USGS 7.5 minute quadrangle map boundaries. Montana Counties of Occurrence Beaverhead, Big Horn, Blaine, Broadwater, Carbon, Carter, Cascade, Chouteau, Custer, Dawson, Deer Lodge, Fallon, Fergus, Flathead, Gallatin, Glacier, Golden Valley, Granite, Hill, Jefferson, Judith Basin, Lewis and Clark, Liberty, Madison, Mccone, Meagher, Musselshell, Park, Phillips, Pondera, Powder River, Powell, Prairie, Ravalli, Rosebud, Sanders, Silver Bow, Stillwater, Sweet Grass, Teton, Toole, Valley, Wheatland, Wibaux, Yellowstone The systems is usually found below continuous forests of Douglas-fir (Pseudotsuga menziesii) or lodgepole pine (Pinus contorta) in the foothills,and can occur in large stands well within the zone of continuous forests in the northern Rocky Mountains. Along the Northern Rocky Mountain Front, this system is found on west and north facing aspects in the foothills and within the mountains. At lower elevations, it can occur on all aspects and on relatively level terrain. Rocky Mountain juniper stands are often found in complex transitional zones or growing on exposed or severe sites within other forest systems. Climate is characterized by a relatively small amount of precipitation, with the wettest months during the growing season, very low humidity, and wide annual and diurnal temperature ranges. Winter conditions may be very cold but relatively dry, and often include rapid fluctuations in temperature associated with chinook winds. In Montana, this system occurs grows mainly on limestone substrates, where roots follow the pattern of fractured and weathered rock (Burns and Honkala, 1990). Soils have a high rock component (typically over 50% cover) and are coarse- to fine-textured, often gravelly and calcareous. Soils are generally poorly developed, shallow, have low moisture holding capacity and are easily erodable, so in some occurrences, little topsoil is present. Although the system can be seen on gently rolling terrain, limestone cliffs, and exposed bluffs, it is most often found on rocky ridges and steep rocky slopes, and can survive in extremely windswept areas at both lower and upper tree line. Slopes are typically moderately steep to steep. Elevation ranges from 1,219-2,286 meters (4,000-7,500 feet) (Pfister et al, 1977). In the Beaverhead Mountain range, it occurs at higher elevations (Cooper et al, 1999). Vegetation is characterized by an open-tree canopy or patchy woodland that is dominated by either limber pine or Rocky Mountain juniper. In the Pryor Mountains Utah juniper (Juniperus osteosperma) is sometimes seen at its northernmost extent within this system. Douglas-fir regularly occurs, but ponderosa pine and lodgepole pine are comparatively rare within these forests. Prolonged drought and white pine blister rust (Cronartium rubicola) have decimated limber pine along the Rocky Mountain Front (and elsewhere), resulting in a skeleton woodland with scattered Douglas-firs as the only living trees. At the northern end of its range in Montana, limber pine is mostly associated with common juniper (Juniperus communis) and creeping juniper (Juniperus horizontalis), whereas in the southern end of its range, it is associated with Rocky Mountain juniper. A sparse to moderately dense short-shrub layer is usually present. Within north-central and northwestern Montana, the most common shrubs include bearberry (Arctostaphylos uva-ursi), creeping juniper, shrubby cinquefoil (Dasiphora fruticosa ssp. floribunda),and Canadian buffaloberry (Shepherdia canadensis). Other shrubs that may be present in west-central and southern Montana includebig sagebrush (Artemisia tridentata), black sagebrush (Artemisia nova), curl-leaf mountain mahogany (Cercocarpus ledifolius), rubber rabbitbrush (Ericameria nauseosa), skunkbush sumac (Rhus trilobata), Woods’ rose (Rosa woodsii), common snowberry (Symphoricarpos albus), or western snowberry (Symphoricarpos occidentalis). Herbaceous layers are generally sparse, but range to moderately dense; they are typically dominated by perennial graminoids such as blue grama (Bouteloua gracilis), Idaho fescue (Festuca idahoensis), rough fescue (Festuca campestris), poverty oatgrass (Danthonia intermedia), spike fescue (Leucopoa kingii), needle and thread (Hesperostipa comata), prairie junegrass (Koeleria macrantha), Indian ricegrass (Oryzopsis hymenoides), Sandberg’s bluegrass (Poa secunda), or blue bunch wheatgrass (Pseudoroegneria spicata). Common forbs include yarrow (Achillea millefolium), fringed sage (Artemisia frigida), arrowleaf balsamroot (Balsamorhiza sagittata), prairiesmoke (Geum triflorum), hymenopappus (Hymenopappus species), four-nerve daisy (Hymenoxys species), dotted gayfeather (Liatris punctata), stone seed (Lithospermum ruderale), silver lupine (Lupinus argenteus), pricklypear (Opuntia species), crazyweed (Oxytropis species), and cushion plants such as draba (Draba species), phlox (Phlox species), Rocky Mountain douglasia (Douglasia montana) and Howard’s alpine forget-me-not (Eritrichium howardii). This system often occurs in complex ecotones on severe sites within other forest systems. It often intergrades with Rocky Mountain Dry-Mesic Montane Mixed Conifer, Rocky Mountain Lower Montane, Foothill and Valley Grassland, Mountain Mahogany Woodland and Shrubland, and Montane Sagebrush Steppe. National Vegetation Classification Switch to Full NVC View Adapted from US National Vegetation Classification A0540 Pinus flexilis Rocky Mountain Woodland Alliance CEGL000805 Pinus flexilis - Festuca idahoensis Woodland CEGL000806 Pinus flexilis - Festuca campestris Woodland CEGL000807 Pinus flexilis - Juniperus communis Woodland CEGL000810 Pinus flexilis - Leucopoa kingii Woodland CEGL000815 Pinus flexilis Scree Woodland A2035 Pinus flexilis Intermountain Basins Forest & Woodland Alliance CEGL000804 Pinus flexilis - Cercocarpus ledifolius Woodland A3202 Krascheninnikovia lanata Steppe & Dwarf-shrubland Alliance CEGL001325 Krascheninnikovia lanata - Phlox spp. Dwarf-shrubland A3210 Juniperus scopulorum - Juniperus virginiana Woodland Alliance CEGL000747 Juniperus scopulorum - Piptatherum micranthum Woodland A3424 Pinus flexilis / Shrub Understory Central Rocky Mountain Woodland Alliance CEGL000808 Pinus flexilis - Juniperus osteosperma Woodland CEGL000809 Pinus flexilis - Juniperus scopulorum Woodland A3425 Pinus flexilis / Grass Understory Central Rocky Mountain Woodland Alliance CEGL000813 Pinus flexilis - Pseudoroegneria spicata Woodland A3426 Juniperus osteosperma - Juniperus scopulorum / Shrub Understory Central Rocky Mountain Woodland Alliance CEGL000734 Juniperus osteosperma - Cercocarpus ledifolius Woodland CEGL000742 Juniperus scopulorum - Artemisia nova Woodland CEGL000743 Juniperus scopulorum - Artemisia tridentata Woodland CEGL000744 Juniperus scopulorum - Cercocarpus ledifolius Woodland CEGL000745 Juniperus scopulorum - Cercocarpus montanus Woodland A3427 Juniperus osteosperma - Juniperus scopulorum / Grass Understory Central Rocky Mountain Woodland Alliance CEGL000748 Juniperus scopulorum - Pseudoroegneria spicata Woodland A3496 Juniperus osteosperma / Shrub Understory Woodland Alliance CEGL000730 Juniperus osteosperma - Artemisia tridentata Woodland A3497 Juniperus osteosperma / Herbaceous Understory Open Woodland Alliance CEGL000738 Juniperus osteosperma - Pseudoroegneria spicata Open Woodland *Disclaimer: Alliances and Associations have not yet been finalized in the National Vegetation Classification (NVC) standard. A complete version of the NVC for Montana can be found here Major disturbances in this system include fire, soil erosion from over-used range, and biotic vectors. Clark's nutcrackers have co-adapted an important mutualism with limber pine, and are the primary harvester and disperser of its seeds. These woodlands often originate with and are likely maintained by fire. Regeneration on burns is largely from germination of seedlings from Clark's nutcracker seed caches. Fire can easily kill young limber pine and Rocky Mountain juniper because of their thin bark (Fischer and Clayton, 1983), however, fuel loads in this system are generally light due to open rocky terrain, and fires do not generate severe damage or considerably alter vegetation composition. In comparison with upper treeline limber pine communities, foothill populations are thought to experience greater disturbance frequency (Schuster et al., 1995), and fire return intervals vary between 50 and 400 years (U.S. Department of Agriculture, 2012). Over time limber pine woodlands have shifted both up- and down-slope in response to changing climate and drought, and are considered to be particularly sensitive to future change (Means 2010). This system occurs on dry, rocky sites that are typified by extreme winter weather and droughty summer conditions that offer marginal conditions for tree growth. Consequently, mortality from abiotic and biotic stressors is high in some areas. Limber pine is highly susceptible to white pine blister rust (Cronartium ribicola), the pine needle pathogen (Dothistroma septospora), and mountain pine beetles (Dendroctonus ponderosae). It can also be heavily infected or killed by limber pine dwarf-mistletoe (Arceuthobium cyanocarpum), particularly in south-central and southwestern Montana (Jackson et al., 2010), and is susceptible to infestation by cone beetles (Conophthorus contortae), the ponderosa pine cone worm (Dioryctria auranticella), and the western conifer seed bug (Leptoglossus occidentalis). Resistance to blister rust and mountain pine beetle is lower for limber pine than for other North American pines affected by these biotic agents (Hoff and McDonald 1993; Means 2010), and drought can exacerbate vulnerability to pine beetle attack (Jackson et al., 2010). The most significant damage due to biotic factors appears to occur at locations on the Lewis and Clark National Forest along the northern Rocky Mountain Front, the Gravelly range and sections of the Yellowstone ecosystem in southwestern Montana. Large numbers of trees have very thin crowns and poor terminal growth, and severe mortality is occurring in some areas. Under natural conditions, Rocky Mountain juniper seedlings become established on moist sites in partial shade (Burns and Honkala 1990). Stands found in southwestern Montana may exhibit a savanna-like character due to the inability of Rocky Mountain juniper to establish on drier micro-sites. Rocky Mountain juniper is generally shallow rooted, and forest health can be negatively affected by heavy grazing, especially on exposed sites with erodible soils. Although Rocky Mountain juniper is relatively resistant to disease and tolerant of insects, several insect pests do attack this species including cedar flathead borers (Chrysobothris spp.) and bark beetles (Phloeosinus spp.) (Scher, 2002). Additionally, mistletoes (Phoradendron spp.), a blight caused by Cercospora sequoia, and cedar apple rust (Gymnosporangium juniper virgiananae) can be especially problematic (Burns and Honkala 1990). In the absence of natural fire, periodic low to moderate intensity prescribed burns can be implemented during late fall months to maintain and enhance limber pine regeneration, although results may be variable due to insufficient ground fuels and rocky terrain typical of this system. Fire may kill young trees of limber pine and Rocky Mountain juniper because of their thin bark. Thinning may also be used in particularly dense stands to reduce spread of mountain pine beetles (Bureau of Land Management, 2011). In light of blister rust prevalence, stands can be managed to maintain limber pine forest composition, and to diversify age structure to include regeneration, thereby encouraging natural selection of rust resistant individuals (Jackson et al., 2010). On sites with slopes and forage that support domestic livestock, use can be monitored to maintain soil integrity. Reintroduction of prescribed fire fosters limber pine restoration because it provides open sites and exposed mineral soils that are suitable for Clark's nutcracker to cache seeds, and for seedlings to establish. Augmenting natural limber pine regeneration with seed sources that exhibit some resistance to blister rust or, in some cases, with nursery stock, will be necessary in areas where seed sources are absent or greatly reduced. Blister rust-resistant or tolerant trees can be identified in previously infected stands, or by screening for an identified resistance gene (Schoettle and Sniezko 2007; Schoettle et al. 2014). Direct seeding may be the most practical restoration method on most sites, however seed-transfer guidelines should be considered when the seed source is a considerable distance from the seeding site (Schoettle and Sniezko 2007). Germination will take place during the first growing season after fall caching or direct seeding. Because this system is characterized by shallow soils, outplanting of nursery stock may be limited to microsites with deeper soil pockets. Out-planted seedling survival has been shown to be higher when seedlings are planted on microsites with some cover, when seedlings are planted in clumps rather than singly, and when competition from surrounding vegetation is minimized (Asebrook et al. 2011). Seedling health was marginally improved in burned areas compared to unburned areas within an experimental area in Waterton Lakes National Park, Alberta (Asebrook et al., 2006). Species Associated with this Ecological System - Details on Creation and Suggested Uses and Limitations How Associations Were Made We associated the use and habitat quality (common or occasional) of each of the 82 ecological systems mapped in Montana for vertebrate animal species that regularly breed, overwinter, or migrate through the state by: - Using personal observations and reviewing literature that summarize the breeding, overwintering, or migratory habitat requirements of each species (Dobkin 1992, Hart et al. 1998, Hutto and Young 1999, Maxell 2000, Foresman 2012, Adams 2003, and Werner et al. 2004); - Evaluating structural characteristics and distribution of each ecological system relative to the species' range and habitat requirements; - Examining the observation records for each species in the state-wide point observation database associated with each ecological system; - Calculating the percentage of observations associated with each ecological system relative to the percent of Montana covered by each ecological system to get a measure of "observations versus availability of habitat". Species that breed in Montana were only evaluated for breeding habitat use, species that only overwinter in Montana were only evaluated for overwintering habitat use, and species that only migrate through Montana were only evaluated for migratory habitat use. In general, species were listed as associated with an ecological system if structural characteristics of used habitat documented in the literature were present in the ecological system or large numbers of point observations were associated with the ecological system. However, species were not listed as associated with an ecological system if there was no support in the literature for use of structural characteristics in an ecological system, even if point observations were associated with that system. Common versus occasional association with an ecological system was assigned based on the degree to which the structural characteristics of an ecological system matched the preferred structural habitat characteristics for each species as represented in scientific literature. The percentage of observations associated with each ecological system relative to the percent of Montana covered by each ecological system was also used to guide assignment of common versus occasional association. If you have any questions or comments on species associations with ecological systems, please contact the Montana Natural Heritage Program's Senior Zoologist. Suggested Uses and Limitations Species associations with ecological systems should be used to generate potential lists of species that may occupy broader landscapes for the purposes of landscape-level planning. These potential lists of species should not be used in place of documented occurrences of species (this information can be requested at: mtnhp.org/requests ) or systematic surveys for species and evaluations of habitat at a local site level by trained biologists. Users of this information should be aware that the land cover data used to generate species associations is based on imagery from the late 1990s and early 2000s and was only intended to be used at broader landscape scales. Land cover mapping accuracy is particularly problematic when the systems occur as small patches or where the land cover types have been altered over the past decade. Thus, particular caution should be used when using the associations in assessments of smaller areas (e.g., evaluations of public land survey sections). Finally, although a species may be associated with a particular ecological system within its known geographic range, portions of that ecological system may occur outside of the species' known geographic range. - Adams, R.A. 2003. Bats of the Rocky Mountain West; natural history, ecology, and conservation. Boulder, CO: University Press of Colorado. 289 p. - Dobkin, D. S. 1992. Neotropical migrant land birds in the Northern Rockies and Great Plains. USDA Forest Service, Northern Region. Publication No. R1-93-34. Missoula, MT. - Foresman, K.R. 2012. Mammals of Montana. Second edition. Mountain Press Publishing, Missoula, Montana. 429 pp. - Hart, M.M., W.A. Williams, P.C. Thornton, K.P. McLaughlin, C.M. Tobalske, B.A. Maxell, D.P. Hendricks, C.R. Peterson, and R.L. Redmond. 1998. Montana atlas of terrestrial vertebrates. Montana Cooperative Wildlife Research Unit, University of Montana, Missoula, MT. 1302 p. - Hutto, R.L. and J.S. Young. 1999. Habitat relationships of landbirds in the Northern Region, USDA Forest Service, Rocky Mountain Research Station RMRS-GTR-32. 72 p. - Maxell, B.A. 2000. Management of Montana's amphibians: a review of factors that may present a risk to population viability and accounts on the identification, distribution, taxonomy, habitat use, natural history, and the status and conservation of individual species. Report to U.S. Forest Service Region 1. Missoula, MT: Wildlife Biology Program, University of Montana. 161 p. - Werner, J.K., B.A. Maxell, P. Hendricks, and D. Flath. 2004. Amphibians and reptiles of Montana. Missoula, MT: Mountain Press Publishing Company. 262 p. - Native Species Commonly Associated with this Ecological System - Native Species Occasionally Associated with this Ecological System Original Concept Authors Montana Version Authors - Classification and Map Identifiers Cowardin Wetland Classification: National Land Cover Dataset: |Element Global ID ||CES306.955, Rocky Mountain Foothill Limber Pine - Juniper Woodland 42: Evergreen Forest 4236: Rocky Mountain Foothill Limber Pine - Juniper Woodland - Literature Cited AboveLegend: View Online Publication - Asebrook, J.M., J. Lapp, and T. Carolin. 2011. Whitebark and limber pine restoration and monitoring in Glacier National Park. Pp. 335-337 In: Proceedings of the high five symposium on the future of high-elevation, five-needle white pines in western North America, Keane, R.E., Tomback, D.F., Murray, M.P., and Smith, C.M. Missoula, MT: USDA Forest Service, Rocky Mountain Research Station. RMRS-P-63. - Bureau of Land Management (BLM). 2011 Whitebark and Limber Pine (Five Needle Pine) Management Guidelines for Wyoming BLM. In: FY 2011 Memorandums. Wyoming: U.S. Department of the Interior, Bureau of Land Management. - Fischer, W.C. and B.D. Clayton. 1983. Fire ecology of Montana. Forest habitat types east of the continental divide. USDA, Forest Service Gen. Tech. Rpt. INT-141. - Hoff, R.J. and G.I. McDonald. 1993. Variation of virulence of white pine blister rust. European journal of forest pathology 23(2):103-109. - Jackson, M., A. Gannon, H. Kearns, K. Kendall. 2010. Current Status of Limber Pine in Montana. Report 10-06. Missoula, MT: U.S. Department of Agriculture, Forest Service, Northern Region. 14 p. - Means, R.E. 2010. Synthesis of lower treeline limber pine (Pinus flexilis) woodland knowledge, research needs, and management considerations. Pp. 29-36 In: Proceedings of the high five symposium on the future of high-elevation, five-needle white pines in western North America, Keane, R.E., Tomback, D.F., Murray, M.P., and Smith, C.M. Missoula, MT: USDA Forest Service, Rocky Mountain Research Station. RMRS-P-63. - Pfister, R. D., B. L. Kovalchik, S. F. Arno, and R. C. Presby. 1977. Forest habitat types of Montana. USDA Forest Service. General Technical Report INT-34. Intermountain Forest and Range Experiment Station, Ogden, UT. 174 pp. - Scher, J.S. 2002. Juniperus scopulorum. In: Fire Effects Information System, [Online]. U.S. Department of Agriculture, Forest Service, Rocky Mountain Research Station, Fire Sciences Laboratory. - Schoettle, A.W. and R.A. Sniezko. 2007. Proactive intervention to sustain high-elevation pine ecosystems threatened by white pine blister rust. Journal of Forest Research 12(5):327-336. - Schoettle, A.W., R.A. Sniezko, R.A., A. Kegley, and K.S. Burns. 2014. White pine blister rust resistance in limber pine: evidence for a major gene. Phytopathology 104(2):163-173. - Schuster, W.S., J.B. Mitton, D.K. Yamaguchi, and C.A. Woodhouse. 1995. A comparison of limber pine (Pinus flexilis) ages at lower and upper treeline sites east of the Continental Divide in Colorado. American Midland Naturalist 133(1):101-111. - U.S. Department of Agriculture, Forest Service, Missoula Fire Sciences Laboratory. 2012. Information from LANDFIRE on Fire Regimes of Limber Pine Communities. In: Fire Effects Information System. Missoula, MT: USDA Forest Service, Rocky Mountain Research - Additional ReferencesLegend: View Online Publication Do you know of a citation we're missing? - Asebrook, J.M. 2006. Revegetation Monitoring Reports: Glacier National Park. West Glacier, MT: Research Reports, Glacier National Park. - Burns, R. M., and B. H. Honkala, technical coordinators. 1990a. Silvics of North America: Volume 1. Conifers. USDA Forest Service. Agriculture Handbook 654. Washington, DC. 675 pp. - Cooper, S.V., C. Jean, and B.L. Heidel. 1999. Plant associations and related botanical inventory of the Beaverhead Mountains Section, Montana. Unpublished report to the Bureau of Land Management. Montana Natural Heritage Program, Helena. 235 pp.

My criteria for planning a road trip is pretty simple: Are there friends along the way that I can impose upon? - Does my Roadside America app approve of this route? - Are there amusement parks in the vicinity? I’ve wanted to go to Indiana Beach (fun fact: not actually a beach) for awhile now, and it seemed logical to combine this with a long overdue visit to Michigan to hang out with Bill, Jessi and Tammy and also meet up with some other ladies I have been Internet friends with for YEARS. (More on that later!) We had to drive through actual farmlands to get to Monticello, Indiana, at which point a man of about 100 years of age collected $7 from us and told us where to park. Which was “anywhere in the wide open, empty parking lot.” We got there right when the park opened, and not only was it a ghost town, but none of the rides were running. We roamed around for awhile, getting turned away from the Hoosier Hurricane and wasting time at the shooting gallery. Also, the humidity was so bad that it felt like Hell with the lid on; my face took on the sebaceous sheen of a glazed Christmas ham in no time. It was disgusting. But not so disgusting that I would consider visiting the dilapidated water park portion of Indiana Beach, which was included in regular admission because the lazy river wasn’t running. God only knows why not. No thanks, dirty pastel water slides. God only knows what kind of fungi you’re getting ready to launch into my vagina. (I have phobias, OK?) Chooch killed some time at the shooting gallery, while I paced around, waiting for the adjacent Frankenstein’s Castle to open their dumb doors already. I refuse to partake in the shooting galleries at amusement parks because HENRY won’t teach me how to aim. So I almost never hit anything. And then I pout, which morphs into an inevitable Hulk Rage later on. Fuck you, Henry. Lame Henry didn’t get the ride-all-day wristband because he’s too old to have fun at amusement parks now. But he sure does enjoy the ones with free general admission so that he can walk around and complain for nothing. I promise you, we broke up at least 87 times that day. The main (OK, the only) reason Indiana Beach made my list is their staggering collection of THREE dark rides. Two of them, The Den of Lost Thieves and the most-anticipated House of Frankenstein were basically the last rides to open that day. But oh, were they worth the wait. The Den of Lost Thieves is a shooting ride, which I generally do not enjoy. Kennywood took out a great dark ride, the Goldrusher, and replaced it with a modern shooter-type dark ride and the only thing remarkable about it is how incredibly boring it is. I would gladly bypass this one every time we visit Kennywood, but Chooch always drags me on it. I hate waiting in line for it too! You wait and wait and wait only to get put in this holding room, like a foyer, where they force you to watch some animated portrait on a wall telling you the story of Ghostwood Estate and then the door opens and it’s a fucking free-for-all. Everyone pushes their way through so even if you were the first one in line before entering that room, chances are you’ll take a fanny pack to the groin and wind up 17 people back. So when I realized that the Den of Lost Thieves was also a shooting ride, I was like, “Damn, we drive 8 hours for this?” But it turned out to be FANTASTIC! Old, musty and full of old-school scares. I loved the shit out of this ride. Especially since I got more points than Chooch. Another dark ride in the park doubled as a coaster! It was called the Lost Coaster of Something I Forget Who Knows. There was no one in line when Chooch and I walked past, so I shoved all of my belongings into Henry’s chest and bolted for it. “Um…it’s gonna take a few minutes,” the older, orange-shirted ride operator said. “It got stuck, and I’m waiting for someone to push it back out.” Oh OK, no big deal, you guys. Rides get stuck like all of the time, right? And probably not back-to-back times, right? He said something about the cars not being “properly weighted” and I was like, “Oh well if you’re looking for all of the weight, you’ve come to the right thunder thighs.” Four more people joined us right as a mechanic came grunting out of the fake cave, pushing the double mine cars in front of him. The ride operator seemed confident that we had enough bodies to successfully propel the mine cars from start to finish, so we loaded up with me and Chooch and some lady and little girl in one car, and a guy and kid in the one behind us. Awkward thing about this ride: four people fit in a car, but the seats face each other, so unless you’re with three of your homies, you get to stare at strangers for the next two minutes and I hate that you guys. Looking at people who are looking at me, it’s just…ew. Not for me. This ride was pretty thrilling and volatile, just like a relationship with me! All of the ups and downs and whiplash and violent shoves. Will you need a PFA? Maybe! And then…nothing. It just stopped, right in the middle of the dark cave. “Is it supposed to do this?” I asked the people in the car with us. “I DON’T THINK SO BUT THE STEEL HAWG GETS STUCK ALL THE TIME,” answered the little girl in an octave only little girls can manage. ****Mental note to be wary of the Steel Hawg. (Which never opened that day anyway, so moot point.) Anyway, guess what guys? We were stuck! I think this may have been my first time ever getting stuck on a ride, too, so thanks Indiana Beach! That’s a cherry I sure needed popped. As if it wasn’t hot enough that day, now we were stuck inside some muggy faux-cavern, in a near-enclosed car, with no rescue in sight. I had sweat rolling into my eyes and mouth, I could feel it dripping from the backs of my knees, my whole person was slick with the moist essence of PANIC. And I had these strangers staring at me and I had nothing to say other than nervous laughter and then the kid in the car behind us started to cry and his dad was mouthing off about how this was such BULLshit and Chooch kept meowing and I was like, “WHY IS NO ONE TRYING TO COMMUNICATE WITH US OVER AN INTERCOM OR MORSE CODE OR CROP CIRCLE?!” And then finally, after a good FIVE MINUTES OF NOTHING, that same disgruntled mechanic came trudging up the track behind us, shouted an answer to a garbled voice over his walkie talkie, fumbled with some switches in the breaker box next to us, and then said “Enjoy your ride” just as the motor kicked in and we went STRAIGHT DOWN A HILL. Oh that’s right, we were stuck on the zenith of a hill and had no idea because it was so dark in there. So…that was definitely a thrill. Meanwhile, Henry had been dreaming of buying a taco all day. That’s what he’s thinking about in this picture, as a matter of fact. Indiana Beach has a taco stand that was apparently featured on the Food Network for some reason. I love me a good taco, but I knew that Indiana Beach was for sure not going to have a meatless option. So Chooch and I decided to get pizza and then Henry was going to get his coveted taco afterward. Except that Chooch only ate one slice of his personal pizza and Henry acted like a motherfucking martyr and ate the rest of it. Like, who cares? Sometimes I think he does this shit on purpose, like he’s some Leftover Scraps Hero. OK, you ate three small slices of crappy pizza, good for you. Oh, you ate the rest of Chooch’s waffle for breakfast? Well, FUCK Henry. Thanks for taking one for the team. Shit. I knew all of his moaning and groaning over this would eventually paint a bigger picture, and I was right: Now that he had eaten Chooch’s pizza, he was “too full” to get a taco, and that was ALL THAT HE WANTED, you guys. A fucking taco, but now Chooch and I had ruined his life by having the audacity to get pizza for our own lunches. Last time I checked, no one was forcing pizza down Henry’s enlarged hatch. I kept coaxing him to get a taco, but he was being such a bitch about it. He was acting offended almost, like he was on a porn diet and I was trying to get him to succumb to peer pressure by showing photos of naked broads going to town on tacos. So bizarre. Maybe he’s trying to fit back into his SERVICE costume? Wistful thoughts over the taco stain on his shirt that could have been. Dreaming of brushing a taco with his moustache bristles to the tune of a Selena song. He had his chance right here! Going, going…. Gone. This was right after he said, “I DON’T WANT ONE NOW. JUST FORGET IT.” Oh wow, someone’s come down with a case of the Erins. Not buying a taco. Yeah Henry. Don’t forget. Bitchbaby motherfucker. (I think Mexico might find it hard to believe that the world’s best tacos are in Indiana.)

Padded dog collars are comfortable, soft and strong Contrasting stitching adds a “wow” factor - Soft lining on the inside, sturdy bridle leather on the outside - Stainless steel or brass hardware for the extra-special touch or for dogs with sensitivities to nickel Burgundy leather dog collars with Red, Blue, Pink, or Tan padded lining and brass hardware Black leather dog collars with Red, Blue, Pink, or Tan padded lining and stainless steel hardware 1″ width x 18″, 20″, 22″, 24″, and 26″ lengths 3/4" width x 14" and 16" lengths Padded Handle Leather Leash BUCKLED DOG COLLAR SIZING Even though your new dog collar is adjustable, it is important to measure your dog carefully for his comfort and your peace of mind. You will not want the collar so loose that is slips over the dog’s head or so tight that he can’t breathe properly. Keep in mind that our measurements are from the center bar of the buckle to the farthest hole and that you will be able to adjust the collar down from there. Please also take into account that each collar will have 4″ of adjustment. Given the example of an 18″ dog collar, an 18″ collar will adjust from 14″ to 18″. - If you are satisfied with the fit of your dog’s current collar, measure that collar from the center bar of the buckle to the farthest hole. Our collars are sized according to this measurement, not to the over-all length of the collar which varies by manufacturer - If you don’t have a tape measure, your can measure your dog’s neck or chest with a string then measure the string with a flat ruler. - A rule of thumb is to leave an allowance for two fingers to fit between the collar and the dog for a comfortable fit. The collar should not be so tight that it will cause discomfort or so loose that it slides over the dog’s head. 14" adjusts 10″ – 14″ 16" adjusts 12″ – 16″ 18″ adjusts 14″ – 18″ 20″ adjusts 16″ – 20″ 22″ adjusts 18″ – 22″ 24″ adjusts 20″ – 24″ 26″ adjusts 22″ – 26″ 30″ adjusts 26″ – 30″ 34″ adjusts 30″ – 34″ BRIDLE LEATHER CARE INSTRUCTIONS Quality full grain bridle leathers are some of the most durable leathers available. Proper care will ensure that our products meet your expectations. If wet or soiled, leather should be allowed to air dry. Never dry your collar or leash in direct heat! Once dry, gently clean using a damp cloth. You may then want to treat your collar or leash with a light coating of a product such as a neutral colored Leather Balm applied according to instructions on the label. Alternatively, you may wish to apply Leather BriteTM conditioner to nourish and help repel dirt and oils. FINISHED LEATHER CARE INSTRUCTIONS Full finished leathers are made from full grain natural vegetable tanned leather and coated with a protective coating designed to meet high performance standards (i.e., light fastness, flexibility, wear characteristics, and anti-soiling properties). Clean only with a mild soap and water solution using a slightly moist cloth or non-abrasive sponge. Never use harsh solvent-based cleaners. Applying Leather BriteTM conditioner will nourish and help repel dirt, extending the life of your collar and leash.

- New product - New product (350 g) net (€24.29/kg) This cake is made with the finest ingredients: candied fruit, wheat flour, whole eggs. It contains more than 39% fruit. The raisins are macerated overnight in pure Caribbean rum specially selected for this recipe. The macerated raisins are combined with Amarena cherries, citron and candied orange peel. The traditional method of preparation, baking for a long time in wooden moulds, results in a moist cake that develops all the flavours of the candied fruit and the ingredients that make up the dough. Presented pre-sliced, this pure butter cake with candied fruit is perfect for dessert or tea time. What’s more, it is easy to take with you on a picnic. INGREDIENTS: 24% raisins macerated in rum, 22% candied fruits (12% Provençal Amarena cherries, orange and citron peel, glucose-fructose syrup, sugar, colouring agent : anthocyanin, flavouring, acidity regulator : citric acid, preservatives (potassium sorbate, sulphur dioxide (SULFITES))), WHEAT flour (GLUTEN), sugar, 9% concentrated BUTTER (MILK), whole EGGs, EGGs yolks, salt, baking powder (sodium hydrogen carbonate and disodium diphosphate), natural vanilla and orange extract. MAY CONTAIN TRACES OF NUTS, HAZELNUTS, PISTACHIOS and ALMONDS. Possible presence of cherry stones and grape stalks. From 50€ of purchase Credit card, Paypal For any order From 70€ of purchase Albert Ménès gift wrapping Naturally-sourced spices, processed and packaged in our French kitchens We favour products with no artificial colours or preservatives Deli products, grown and produced by small producer and small to medium sized companies on a human scale A range inspired by the world of gastronomy regularly updated with new recipes

If you love cream cheese the way I do, these are the muffins for you. If I wasn’t baking muffins every Monday, I would’ve baked a triple batch and frozen them until I ran out. Then I’d bake them again. These muffins are delicious. Rich cream cheese enveloped in a moist cake-like batter with a hint of cinnamon. Need I say more? - 21/2 cups Flour - 11/2 tbsp Baking Powder - ⅔ cups Caster Sugar - Finely grated rind of 2 medium oranges - ½ tsp Salt - 2 Eggs - 250ml Milk - 85g Butter, melted - For the Filling - 175g half-fat soft cheese - 3 tbsp Caster Sugar - 6 small strawberries - Preheat the oven to 200oc/Gas 6/fan oven 180oc. - Line a muffin tin with 12 paper cases. Sift the flour and baking powder into a large bowl, then stir in the sugar, ornage rind and salt. - Beat the eggs and milk together in a jug or bowl, then stir in the butter and gently mix into the dry ingredients to make a loose, slightly lumpy mixture. Do not overmix or the muffins will be tough. - Mix together the soft cheese and sugar for the filling. Half-fill the paper cases with the muffin mixture, then push half a strawberry into each. Top with a teaspoon of sweet cheese, then spoon over the remaining muffin mixture to cover and fill the muffin cases. - Bake for 15 minutes until well risen and golden on top. Remove from the tin and allow to cool completely on a wire rack. Muffin Monday: Round Up There are 10 fabulous versions of Cheesecake Muffins. Click below on the pictures to view.

🙂 Tuesday brings us another #Blogbattle and its One Year Anniversary!! Woo-Hoo!! Time sure does fly when you’re having fun!! #BlogBattle is a weekly short story challenge using a single word for inspiration. Hosted by the talented Rachael Ritchey. Feel free to join in, or click here to read the current week’s stories and vote for your favorites. With this weeks word, I just had to take a trip to the Hair Salon to check up on my dear friends favorite characters, Nita and Michael 😉 Happy Reading!! This week’s word: Hair Locks of Love Nita walks into her hair salon carrying a bag of Double Chocolate Chunk Brownies, and two Venti Iced Smoked Butterscotch Lattes. Without a word, she places one of the cups in front of Michael along with the bag of brownies, and turns to hang up her coat. She hears a slight gasp and a rustle of the bag as Michael opens it to reveal its contents. “Buttercup, you didn’t.” Michael proclaims as he takes a sip of his latte. “Yep, I sure did.” She replies with a smile. “Oh, my, gawd, I have died and gone to heaven, this is absolutely delish. What’s the occasion?” He asks with a hint of skepticism. “Can’t I treat my partner to breakfast?” Nita replies. Michael just gives her a look, and continues eating his brownie. “What?” He’s not buying it, she continues. “OoooKaaay…so, I have this friend.” Michael swallows his brownie with exaggeration, to prevent himself from choking, “That never ends well.” He says flatly. “I’m serious Michael, just hear me out.” “OK, OK Cupcake…proceed.” “My friend Kat just moved here from the small town she grew up in. She is staying with her cousin for awhile, since there are more opportunities for her here to find a job in marketing. She has never been away from home, and she lived a very sheltered life. She was raised in a very strict church, where she couldn’t wear jeans, couldn’t wear any make-up, and she has never cut her hair.” With eyes wide, he asks, “How were you two even friends?” Nita shrugs, “We just were. Even though I didn’t agree, I respected their beliefs, and never tried to change her. Now her beliefs are different, so slowly she has been making some changes with her clothes, and makeup, but the hair is the last to go. She is ready to step out and get a new look. Plus she wants to donate her hair to Locks of Love*. So. This is where you come in, I want you to work your magic on her.” “Oh Honey Bun, why didn’t you say that in the first place, you know how I do. Question is, why aren’t you doing it?” Another shrug, “I think you are what she needs to get through this, it’s a big step. Plus I’m still close with her family, I don’t want to be the one to do it I guess.” “She’s not going to get all hysterical on me is she?” Michael questions with apprehension. “No, no. Nothing like that. You just know how to make women feel beautiful, and that is what she needs right now.” Mocking him she adds, “You know how you do.” “I am all that and a bag of chips my Little Frappacino,” Michael says with a single snap of his finger. “She’ll be in this afternoon, I penciled her in. Her name is Katherine, but I call her Kat.” “This afternoon? What if I had said no?” “That’s what the brownies and Iced Smoked Butterscotch Latte were for.” Nita says as she waggles her eyebrows “You. Little. Minx. Mmmmm….these brownies though.” Michael says as he takes another bite, and his eyes roll to the back of his head while he closes his eyes. ~ ♦ ~ Nita greets Kat with a great big hug. She takes her coat, and then walks her over to Michael’s station. “Michael this is Kat, Kat, Michael.” Nita makes the introduction as Kat sits down. Kat quietly responds as she holds out her hand, “Nice to meet you Michael.” “The pleasure is all mine Kat.” Michael shakes her hand with both of his. “Would you just look at all this gorgeous hair?” Michael exclaims as he combs his fingers through it, looking directly at her in the mirror, with his megawatt smile. “Just think Sunshine, how happy you’ll make one cute little Angel Face when she receives her new hair-do from Locks of Love.” With that Kat smiles and visibly relaxes in Michael’s chair. Oh, yeah, he was definitely the right person for the job. Nita walks away with a smile on her face knowing that her long time friend is in good hands. Michael and Kat discuss what she would like, and he suggests what he knows will look good on her. Before Michael gets started, Nita documents this event with photos. She takes a before picture, and a picture as Michael cuts the portion that will be donated. They agree that Kat will not see the progress until it is complete. Michael keeps her distracted through the whole process keeping her talking and laughing. Kat was genuinely enjoying herself, and Nita was happy to see the Kat she knew all too well. As Michael is finishing up, Nita walks past him. Doing all she can to contain her excitement, yet wanting him to see her approval, she lays her hand on his upper arm and gives it a squeeze. He looks into her moist eyes, and gives her a knowing wink. Michael removes the cape, and adds some finishing touches. Nita takes Kat’s hand and asks if she is ready. With an enthusiastic nod, they turn her chair around so that she is facing the mirror. Her eyes open wide, as she raises her hand to her mouth in shock. Not fully recognizing the person looking back at her, yet thinking she is really pretty. Kat moves her head back and forth as her hair sways with the movement. She runs her fingers through her shoulder length hair, in awe at the golden highlights and just how shiny and soft it is. “Kat, you look gorgeous!!” Nita says as she squeezes her shoulders. “What do you think?” “I….I…I don’t know what to say.” Kat stutters as her shock gives way to elation. “I’ve rendered a woman speechless…my work is done here.” Michael says with a dramatic bow. Laughing, Kat gets up from the chair, reaches out to hug him and says, “Thank you Michael, thank you so much.” “Awww Kit Kat, you are so very welcome.” He steps back and rests his hands on her shoulders, looks directly in her eyes and says, “Always remember. You, do you Boo. Always do you.” He says with a wink as he smooths his hands over her hair. © 2016 Carrie Ann *Locks of Love is a public non-profit organization that provides hairpieces to financially disadvantaged children in the United States and Canada under age 21 suffering from long-term medical hair loss from any diagnosis. You can find more information here.

Guest Blog by Ron Smith We’ve all heard the adage: work smarter, not harder. It makes good sense, so here are eight woodworking tips to make your shop work easier and more efficient: 1 – Sanding made easier Sanding woodwork by hand may seem like a chore, but with special tools and high-quality sandpaper, you’ll get excellent results that often outshine a power sander. Besides, it’s quieter, doesn’t produce clouds of dust, and may get into places power sanders can’t. Use a sanding block for faster, more efficient results. It distributes sanding pressure more evenly and maintains a flatter surface than merely folding a piece of sandpaper. Also, change sandpaper often. Sand with the grain of the wood, especially for the final grits. To remove deep scratches and stains, angle across the grain up to about 45º for the first sanding. Before moving to the next finer grit, sand with the grain to remove all cross-grain scratches. For sanding painted surfaces, buy clog-resistant sandpaper. The paint will build up slower than on standard sandpaper. 2 – Avoid drywall screws for woodworking When screwing two pieces of wood together, use the traditional wood screw over the drywall screw for better results. A drywall screw is threaded the full length. Since the top threads tend to grip the first board it enters, this can force two pieces of wood apart slightly because you have threads in both boards. The top part of a wood screw, on the other hand, has a smooth shank that won’t grip the first board. This makes it easier to clamp two pieces of wood together. There’s another reason to avoid drywall screws: The hardened, brittle steel shafts of drywall screws will often break during installation, especially when screwed into hardwoods. Removing them from a finished material is nearly impossible and getting them out damages the surface. Wood screws are made of thicker, softer metal, so they’re break-resistant. Wood screws do, however, require you drill: - A pilot hole for the threads - A wider counterbore hole the length of the non-threaded shaft - A countersink hole for setting the head However, you can easily handle all three drilling chores by buying a set of three countersinking bits. They handle most common screw sizes. 3 – Know your wood’s moisture content When building with wood, you must know the correct moisture content of each piece of wood. Too dry, and the finished product may swell or crack. Too moist, and the end product may shrink or warp. It’s no wonder experts say incorrect moisture causes 80% of all woodworking problems. Therefore, it’s critical to know the moisture content of each piece of wood before it is used. For instance, if you’re planning an inlay job using two different species of wood, you’ll need to know the moisture content of each type so that your inlay glue joints stay intact. A failsafe way to avoid a ruined project is to use a moisture meter. Wagner Meters is one provider for both professionals and hobbyists a variety of highly accurate, professional-grade moisture meters. Use a free wood moisture app To help solve your moisture problems easily and quickly, Wagner offers you the FREE Wood H2O mobile app. This handy app calculates equilibrium moisture content (EMC), troubleshoots many common wood moisture problems, and accesses helpful resources. Download your FREE mobile app here. 4 – Prevent excess glue stains To eliminate stains caused by oozing glue along joints, clamp the pieces together without glue. Apply masking tape over the joint and then cut it with a utility knife. Next, separate the pieces, apply the glue, and clamp them together again. The glue will ooze onto the tape, not the wood. Remove the tape before the glue dries. 5 – Measure with a drafting square Make accurate measuring and marking layouts on boards faster and easier with a drafting square – available at any art supply store. When you need an accurate square in the 2- to 3-foot range, drafting squares beat the cumbersome drywall squares for accuracy and eliminate the hassle of hooking up a carpenter square. 6 – Keep a clean, orderly workspace Achieving efficiency in your shop can sometimes be as simple as clearing clutter from your work area. A disorderly work area can hinder your productivity. Another tip: Only keep out items that you use daily. Everything else should be put in designated areas so they’re quickly retrievable when needed. 7 – Keep a well-lit shop Pay special attention to lighting. You should have consistent and ample illumination on all work areas so you can work from any angle without casting shadows. This ensures safety and productivity. - Overhead lighting - Focused lighting - On-tool lights Painting walls and the ceiling white can help diffuse the light. 8 – Keep your blades sharp Dull tools such as chisels, blades, planes, scrapers and gouges don’t cut cleanly. They tear at the wood fibers resulting in a fuzzy, uneven, unprofessional look. Tools that have been chipped or nicked require grinding. A bench grinder, wet grinder, or even a belt sander can be used. Avoid letting your tool get too hot when using a bench grinder or belt sander to prevent it from losing temper. Dipping it in a pan of cool water every few seconds will help. After grinding, proceed to honing using either a flat wet stone or oil stone. A wet stone is preferred when doing fine woodworking. The final step is polishing using a fine wet stone, a stropping wheel or leather. Tools with sharper blades make woodworking easier, more efficient, and safer. Achieving efficiency in your shop won’t just improve your productivity and help you work faster and easier, it’ll also make you feel accomplished and more satisfied. Special Thanks to Wagner Meters for Providing This Blog.

So when a reader requested Gluten-Free, Allergy-Free Meatballs or Meatloaf, there was no question as to which I’d choose. I knew I’d be going for the diminutive meatballs. There wasn’t even really a question of how to make them allergen-free. I often use cornflakes in place of wheat bread crumbs in chopped meat recipes, as it binds, without being boggy. And Ener-G egg replacer does a fantastic job of replacing the traditional egg.* If you can’t eat corn, substitute brown rice bread crumbs instead. And don’t worry; you won’t miss the lack of Parmesan cheese in this one tiny bit. The biggest question was actually, “To fry or not to fry?” A running debate with meatballs. When I make turkey meatballs, I usually cook them in sauce, essentially boiling the meatballs. But for beef, I decided on a compromise: I fried them just long enough to seal the shape, and bump up that succulent flavor, but not so long as to dry them out. Then, I finished them off by cooking them in sauce, for a tender, moist, perfect batch of meatballs. (Gluten-Free, Egg-Free, Dairy-Free, Kid-Friendly) Makes 6 Servings Each little meatball is a mouthful of heaven. Eat them on their own with some gfree garlic bread, or over your gfree pasta of choice. I use 85% lean beef in this recipe, so they don’t dry out, but you can use whatever is best for you. - 1 1/2 cups unsweetened cornflakes (or other flaked cereal of choice, or 1/2 cup gluten-free bread crumbs) - 1 lb ground beef (85% lean) - 3 Tablespoons minced parsley - 2 cloves garlic, minced fine - 2 Tablespoons simple tomato sauce (be sure it’s smooth, not chunky, or in a pinch, you can use ketchup) - 1/2 teaspoon salt - 1/4 teaspoon pepper - 1 1/2 teaspoons Ener-G egg replacer mixed with 2 Tablespoons rice milk - 1 Tablespoon + 1 1/2 teaspoons rice milk - 2 Tablespoons Olive Oil - 4 cups simple/basic tomato sauce 1. Put cornflakes in cuisinart, and pulse until you have reduced cornflake crumbs to 1/2 a cup. 2. Combine ground beef, parsley, garlic, tomato sauce, salt, pepper, egg replacer, and rice milk in a large mixing bowl. Mix well, using your hands to thoroughly combine. (take off your rings first!) Once well mixed, add cornflake crumbs and mix in well. 3. Using a 1 Tablespoon cookie scoop or regular tablespoon, scoop out balls, setting them aside on a plate. You should have enough to make about 30 balls. Once you’ve scooped them all, wet your hands slightly with cool water, and roll balls till smooth, wetting your hands as often as needed. 4. Heat olive oil over medium-high heat in a deep heavy pan. Cook the meatballs in two batches, 4-5 minutes each, till brown, shaking the pan a few times. Remove meatballs from pan and set aside. 5. Add simple red sauce to pan, bring to a boil, and then reduce to a simmer. Add meatballs back to pan, and cook over low heat, loosely covered, at a simmer 30 minutes. Serve! *If you are looking for a meatball recipe without Ener-G egg replacer, I have a great turkey meatball recipe in The Whole Foods Allergy Cookbook. Allergy-Free Meatballs © 2011 by Cybele Pascal (Please note that all my recipes are completely free of all top allergens (wheat, dairy, soy, eggs, peanuts, tree nuts, sesame, fish, shellfish, and gluten), so as many people as possible can enjoy them. Additionally, all the ingredients are available at Whole Foods, and online at Amazon.com. If you have trouble finding something, let me know and I’ll help you find it.) SAFETY NOTE: Because each person’s food sensitivity and reaction is unique, ranging from mild intolerance to life-threatening and severe food allergies, it is up to the consumer to monitor ingredients and manufacturing conditions. If manufacturing conditions, potential cross contact between foods, and ingredient derivatives pose a risk for you, please re-read all food labels and call the manufacturer to confirm potential allergen concerns before consumption. Ingredients and manufacturing practices can change overnight and without warning.

Caveat: This post only has one picture and it’s pretty dismal as I accidentally deleted the rest of the pictures on my phone. So, you may need to put on your imagination caps a bit for this one. My apologies. Regardless, this cake was super delicious and perfect for Mother’s Day coming up. This recipe is for the cake only which I could have eaten plain with a little powdered sugar on top. I just made a traditional coconut icing which was tasty but the cake is the real star here. The completely ridiculous thing is that the one picture I DO have showcases the icing, not the cake! Oy vey. Trust me when I tell you the cake is moist and delicious, light and airy with a nice coconut flavor. This recipe uses a full can of coconut milk which makes it super tasty. Traditionally I make a tiered coconut cake, so this sheet pan version was a nice change, and would be great for a large group. - 2 cups white sugar - 1 cup butter, softened - 4 eggs, separated - 1 cup unsweetened shredded coconut - 2 cups all-purpose flour - 2 tablespoons baking powder - 1 teaspoon salt - 1 (14 oz.) can coconut milk Preheat oven to 350 degrees. Grease a 13 x 9 cake pan. Beat sugar, butter and egg yolks together with a mixer in a bowl until smooth and creamy. Add in shredded coconut and combine. Whisk together flour, baking powder and salt in another bowl. Beat together the creamed butter mixture, alternating with the coconut milk, into the flour batter until everything is combined nicely. Beat egg whites in a glass or metal bowl until soft peaks form. The peaks should be soft mounds as opposed to shark peaks. Gently fold egg whites into the cake batter and pour everything into your prepared cake pan. Bake in the oven until a toothpick comes out clean. My parents oven where I was making this run hots so it only took about 25 minutes. It may be closer to 40 or 45 for you. I’d check every 5 minutes after 25 minutes for your oven. It seemed to bake very quickly! That’s it! A simple, delicious cake that stands out for the lovely coconut flavors of shredded coconut and coconut milk. Feel free to frost with your favorite frosting. Tip: I took a bunch of sweetened shredded coconut and mixed it with some butter in a pan on the stove to get those browned delicious bits of coconut flakes you see on top of the icing. Just be sure to set the browned buttery coconut on paper towels to absorb the leftover butter before scattering on top of the cake. It makes it! Definitely a winner in my book! If you love coconut cake, I’d encourage you to try this! Happy eating!

Learn the history of sour cream coffee cake, and try a traditional recipe for this beloved baked treat from food historian Gil Marks. Perfectly moist streusel-filled bundt cake drizzled with icing. Serve with coffee or tea for a sweet afternoon indulgence! Coffeecakes are baked goods, generally sturdy and informal, that commonly accompany hot beverages. They, of course, can be enjoyed without the benefit of coffee or tea. Yet eating a piece of simple cake with a hot beverage provides textual and flavor contrasts that enhance each item, making for a more substantial and pleasurable experience. Thus cakes and pastries were a fundamental part of the menu of coffeehouses from their onset. The words coffee and tea were first mentioned in English in 1598 in a translation of the travels of Dutch navigator Jan Huyghen Van Linschoten. Actual coffee was only introduced to Europe (outside of the Ottoman Empire) by way of Venice in 1615 and reached England in 1630 (23 years after the founding of Jamestown), several decades before the arrival there of tea in 1652. The first coffeehouse outside the Ottoman Empire opened in Livorno, Italy in 1632; the first in England was in Oxford in 1650. Subsequently, coffee cultivation spread outside its native Ethiopia, while the cost of sugar in Europe plummeted due to the influx of Caribbean cane. As a result by the end of the 18th century, the masses of Europe partook of coffee on a daily basis and it replaced beer there as the most widely consumed beverage. Meanwhile, the Dutch brought tea to North America in 1650 and coffee in 1670. Initially, tea proved more popular. The first coffeehouse in America, the London Coffee House, opened in 1676 in Boston. American coffeehouses served as one of the primary locations for revolutionary activities, including purportedly planning the Boston Tea Party. After the War of 1812, less expensive and high quality coffee began flowing in from South America. Beginning in the 1840s, tumultuous economic and social conditions in Germany led to decades of mass immigration to America, the newcomers (along with Scandinavians) bringing their foods, traditions, love of coffee, and some common Teutonic expressions, including kaffeekuchen (yeast coffeecakes), blitzkuchen (“lightening,” quicker cakes made without yeast), krummelkuchen (crumb cake), kaffeehaus (coffeehouse), kaffeeklatsch (coffee chat), and streusel (from streuen, “to scatter/strew”). Demographic changes generally take several decades or even generations to engender local culinary and cultural transformations. By the mid-19th century, coffee replaced tea and hard cider as the American drink of choice and German-style kuchen increasingly supplanted British baked goods as American coffeecakes. The British began referring to various baked goods served with popular hot beverages by the names “tea cakes” and “coffee cakes” akin to the initial “chocolate cakes,” which accompanied, but did not contain, chocolate. English tea and coffee cakes were typically unleavened cookies, scones, and crumpets (akin to what Americans call English muffins), or sweet yeast buns. In this vein, the “Tea Cakes” in The Cook and Housekeeper’s Complete and Universal Dictionary by Mary Eaton (England, 1822) were unleavened sugar cookies, while her “Coffee Cakes” consisted of small sweet yeast cookies. The latter usage eventually disappeared in England. On the other hand, the term “coffee cake,” denoting the beverage accompaniment, slowly spread to America, such as in The Family Physician by Samuel B. Emmons (Boston, 1844). It was not, however, until after the Civil War when the impact of German coffee traditions grew more pronounced that the term referring to the beverage accompaniment became commonplace in America. More typically, Americans initially used it to indicate a chemically-leavened butter cake incorporating brewed coffee into the batter, such as the “Coffee Cake” in the July 1860 issue of The Genesee Farmer (Rochester, NY) and the “Connecticut Coffee Cake” in Jennie June’s American Cookery Book by Jane Cunningham Croly (New York, 1870). As late as the 1918 edition of The Boston Cooking School Cook Book, Fannie Farmer employed “Coffee Cake” and “Rich Coffee Cake” in the “Cake” section to denote batters containing coffee, while her “German Coffee Bread” (a streusel-topped yeast cake) and “Coffee Cakes (Brioche)” in the “Bread and Bread Making” section entailed yeast-raised sweet breads popular with hot coffee. The “Coffee Cake” in The Godey’s Lady Book Receipts and Household Hints by Sarah Frost (Philadelphia, 1870), manifesting a lingering British influence, entailed simple sweet yeast cakes with raisins. Reflecting the linguistic and gastronomic changes afoot in America at that time was Aunt Babette’s Cook Book by Bertha Kramer (Cincinnati, 1889), the author from a German-Jewish background. In the generic “Cake” section, Kramer provided a recipe for “English Coffeecake,” entailing a coffee-flavored butter cake leavened with soda. In addition, there was a separate section entitled “Coffeecakes,” encompassing an assortment of German yeast-raised kuchen and pastries enjoyed with coffee. Pointedly, the recipes in the “Cake” section were leavened with chemicals, while all of the baked goods in her “Coffeecakes” section were raised with yeast. Kramer referred to one of these yeast cakes (topped with chopped almonds, cinnamon, and sugar) as “Kaffee Kuchen” and three others as “Coffeecake.” Hood’s Practical Cook’s Book by C.I. Hood & Co. (Lowell, MA, 1897), a sarsaparilla and medicine producer, included “German Coffeecakes,” consisting of a sweet yeast bread pressed out and sprinkled with chopped almonds, cinnamon, and sugar, and noting: “The greater part of the sweetness should be on the top.” A different Teutonic topping proved even more popular – streusel – a simple pastry of flour, sugar, butter, and sometimes spice. Since it has no liquid, streusel can contain a higher amount of sugar and butter than other pastries, which makes it tender and sweet. The larger the proportion of flour, the crumblier the texture, while a higher proportion of sugar results in crisper and more granular chunks. Streuselkuchen began appearing in Pennsylvanian manuscripts in the 1860s and soon in small German bakeries in the Northeast and Midwest. The “Streusel Coffee Cake” in A Book of Cooking and Pastry by C.F. Pfau (Quincy, IL, 1887), the first record of the word streusel in an American cookbook, was a traditional yeast-raised treat rolled out and topped with streusel. Meanwhile, the nature of American cakes and coffeecakes (the kind accompanying hot coffee) was changing corresponding to the popularization of commercial baking soda and baking powder. Chemically-leavened coffeecakes, a distinctively American innovation, are much easier and quicker to prepare. They fall in between quick breads and butter cakes. In general, coffeecake batter is more liquidy than quick breads as well as contains a bit more sugar and fat (either butter or oil), but less so than butter cakes. The final product is lighter, moister, and has a finer crumb than quick breads, but less sweet and intense than butter cakes. Coffeecakes are able to be prepared either like quick breads -— stirring together the liquid and dry ingredients -— or creamed like butter cakes. The creaming method produces a fine crumb. Whereas butter cakes are commonly frosted and quick breads tend to stand alone, coffeecakes are usually single-layered and lightly gilded with a glaze, streusel, or cinnamon-sugar topping or a combination of these -— almost never a frosting. In the early 1800s, as Americans increasingly leavened baked goods with pearlash and later baking soda, they discovered that clabber (naturally fermented raw milk) and clabbered cream (which rises to the top of clabber during fermentation — commonly referred to then as “sour cream,” but not the same as modern cultured sour cream) provided acid to activate the alkali as well as enhanced the flavor and texture of the final product. Eliza Leslie in Seventy-Five Receipts for Pastry, Cakes, and Sweetmeats (Boston, 1828), in a recipe for “Cream Cakes,” early biscuits leavened with pearlash and baked in “muffin-rings,” noted: “For these cakes, sour cream is better than sweet.” The December 1837 issue of “The Family Magazine” (Cincinnati) copied Leslie’s recipe with an added explanation: “The pearlash will remove the acidity, and the batter will be improved in lightness.” Following World War I, pasteurization in America became widespread and practically eliminated various old-fashioned homemade naturally-fermented dairy products. In cakes, instead of old-fashioned clabber and clabbered cream, Americans shifted to using commercial cultured sour cream (made by adding a bacterial culture to pasteurized light cream and heating at 71.6°F to achieve the desired level of lactic acid and medium sharp flavor). As with other commercial products, sour cream was initially sold in bulk and scooped out of barrels. Eventually, producers began packaging it in reusable 16-ounce glass jars. After supermarkets introduced refrigerated cases and innovation led to sour cream prepackaged in small plastic containers, this venerable Eastern European necessity became a standard of the mainstream American kitchen and ingredient in various baked goods. Sour cream coffeecake, sometimes called Russian coffeecake, emerged as one of the most delicious and popular of all coffeecakes. An early record of “Sour Cream Coffee Cake,” already topped with streusel, was in Streamlined Cooking: New and Delightful Recipes for Canned, Packaged and Frosted Foods by Irma Rombauer (Indianapolis, 1939), the author noted for being on top of and furthering contemporary food trends. This recipe subsequently appeared for the first time in her classic The Joy of Cooking in the 1941 edition. Soon some cooks moreover began to sprinkle part of the streusel in the center of the batter as well as on top, spreading the wealth and flavor. This dense coffeecake is not overly sweet or posh — proving ideal for breakfast, brunch, snacks, and other informal occasions — while the ample streusel makes it rich and impressive enough for a dinner dessert and any time of the day — even without coffee. The lactic acid in sour cream results in a tender crumb and also keeps the cake fresh longer. The fat contributes flavor and moistness. The slight tang of the sour cream and the warmth of the cinnamon-accented streusel perfectly underscore the velvety, buttery cake. The batter is rather thick in order to support the heavy streusel. An optional topping of cream cheese or fruit filling or mixing in various additions enhances the sensory experience and provides variety. Coffeecake can be made in almost any type of pan, but many people prefer a Bundt. In some families, sour cream coffeecake became a Sunday brunch standard and even a Christmas, New Year’s, and Mother’s Day tradition. In 1959, the layered streusel version of sour cream coffeecake became de rigor in school cafeterias in Los Angeles. In the early 1970s, sour cream coffeecake made from packaged cake mix and baked in a Bundt pan was given a then contemporary name, Sock-It-to-Me Cake. April 7 is National Coffeecake Day – as good occasion as any to enjoy this justifiably popular treat. We are a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for us to earn fees by linking to Amazon.com and affiliated sites. As an Amazon Associate I earn from qualifying purchases. Sour Cream Coffeecake - 1 cup granulated sugar or packed light brown sugar, or ½ cup each (7 ounces/200 grams) - 1 cup all-purpose flour (4.25 ounces/120 grams) - 2 tsp ground cinnamon - 1/8 tsp salt - 1/2 - 1 tsp ground nutmeg or cloves (optional) - 1/2 cup unsalted butter, melted (65 to 67°F) (1 stick/4 ounces/120 grams) - 1/2 - 1 cup coarsely chopped pecans, walnuts, grated coconut, or chocolate chips, or any combination (optional) - 2 cups all-purpose flour, or 1 2/3 cups sifted cake flour and ½ cup all-purpose flour, sifted (8.5 ounces/245 grams) - 1 tsp double-acting baking powder - 1 tsp baking soda - 1/2 tsp salt - 1/2 cup unsalted butter, softened (65 to 67°F) (1 stick/4 ounces/115 grams) - 1 cup granulated sugar, or ½ cup granulated sugar and ½ cup packed light brown sugar (7 ounces/200 grams) - 3 large eggs (scant 2/3 cup/5.25 ounces/150 grams) - 1 cup sour cream (8.5 ounces/245 grams) - 1 1/2 tsp vanilla extract, 1 teaspoon lemon extract, or 1 teaspoon orange extract (or 1 teaspoon vanilla and ½ teaspoon almond extract) - 1 tsp finely grated lemon or orange zest (optional) Glaze Ingredients (optional) - 1 cup confectioners' sugar (4 ounces/115 grams) - 1/2 tsp vanilla or almond extract - 2 tbsp milk, water, maple syrup, or strong brewed coffee To make the streusel - In a medium bowl, combine the sugar, flour, cinnamon, salt, and, if using, nutmeg. Stir in the butter to resemble coarse crumbs. If using, add the nuts. To make the batter - Preheat the oven to 350°F (325°F for a convection oven or if using a glass pan). Grease one 9-inch (9 cups) Bundt or tube pan, 9-inch square pan, 10- by 8-inch baking pan, or 9-inch springform pan.Combine the flour, baking powder, baking soda, and salt in a mixing bowl. - In a separate large bowl, beat the butter on low speed until smooth, about 2 minutes. - Increase the speed to medium, gradually add the sugar, and beat until light and fluffy, about 4 minutes. - Beat in the eggs, one at a time. - Blend in the sour cream, vanilla, and, if using, zest. - Stir in the flour mixture. - Spread a little more than half of the batter in the prepared pan. - Sprinkle with half of the streusel. - Carefully cover streusel with the remaining batter. - Top with the remaining streusel and bake until the cake is golden and a tester inserted in the center comes out clean, 50 to 60 minutes for a Bundt pan; 30 to 40 minutes for a 9-inch square pan; or 45 to 55 minutes for a springform pan; increase baking times slightly if using a fruit or cheese filling. - Set on a wire rack and let cool in the pan for at least 20 minutes, then remove the cake to a wire rack and let cool completely. The cake tastes even better when allowed to mellow overnight. Wrap the cooled cake in plastic and store at room temperature for up to 4 days or in the freezer for up to 2 months. To make the optional glaze - Combine all the glaze ingredients, gradually stirring in enough liquid until smooth and of pouring consistency. - Drizzle over the cake and let stand until set. THK Note: we put the icing into a resealable bag, snipped off a corner with scissors, and drizzled a crosshatch pattern on the top of the cake. tried this recipe? Let us know in the comments!

Somewhere in my memory, I remember eating such a delicious and savory casserole as this. It was like Thanksgiving in a pan. Just prior to this recipe, one week, to be exact, I thought I had found it. I was so excited that I got too carried away and made all of what you see below. Unfortunately, it was in vain. The ingredients were certainly there. Countless brushes and tubes of paint, like ingredients, does not a great artist, or cook, make. |Boring. Bland. Not much taste.| After some thought, I re-interpreted what I thought were the mistakes of the recipe and added different-but-similar ingredients. Voila! I created this recipe. I loved it. Add a bit of cranberry "anything" on the side, a bit of sweet potato or mashed, and it's Thanksgiving any time of the month. And without all the fuss. I can't imagine anyone turning his nose at this simple, everyday feast. As casseroles go, this certainly fits the definition. Comforting. Easy. All-in-one. Generally inexpensive. Little cleanup. If, however, you are one not inclined to be limited by definitions and, say, verge on the side of complexity, even a tad, you are still in luck. Feel free to include simple ingredients, such as some chopped onion and celery in a bit of butter with pork sausage to add to the stuffing mixture. Trust me, it's worth cleaning that extra pan. And don't forget this recipe around Thanksgiving. Leftover turkey will work quite well. Oh, and it is kid-friendly! |I love Bell's--if only for the box! Seriously,| I can't imagine a better poultry seasoning. Some do's and don'ts: Do not crisp the stuffing mixture. You want it moist, so keep a loose sheet of foil on top. Do not over-dilute the Alfredo sauce. Do not skip the extra Parmesan cheese, even if it's out of that famed "no-no" green can. Do strive to keep an even ratio between the chicken layer and the stuffing layer. Too much chicken and you lose the great flavors of the stuffing. Of course, one could be bad and just double the stuffing layer. And, yes, I have thought about it. Decisions such as those, on a casserole level, are usually decided by one's budget. This is more of a process than a recipe. It results in a 11 x 7 pan of cozy deliciousness. Oh, and it freezes well, so you may want to make two. - 3 cups chopped/chunked rotisserie chicken (save the skin and finely chop) - 1, 15-ounce jar mushroom Alfredo sauce (I use Bertolli) - 2 tablespoons sour cream (use at least two but no more than four) - 2 tablespoons milk or cream - Bell's Seasoning (my personal favorite) or poultry seasoning - Dried, whole thyme - Parmesan cheese (I use shaved) - 1 box chicken stuffing mix (I use Stove Top) Lightly grease an 11 x 7-inch pan or dish. In a medium bowl, toss the chicken with a bit of the Bell's or poultry seasoning. Add about a tablespoon or so of the Parmesan. Spread in the bottom of your casserole dish. |I sprinkled on some shavings of Parmesan cheese.| In the same now-empty bowl, combine the Alfredo sauce, sour cream and milk or cream. Mix. You still want it a bit thick, but not too liquid -like. It should be a bit thinner that mushroom soup from a can. Spread on top of the chicken. You could also add more Parmesan cheese -- or cheddar or whatever you have on hand to use up. |Keep the sauce a bit thick, not too thin.| Wipe out sauce bowl. Empty contents of stuffing mix into the bowl. Add some Parmesan to your taste. I like to add a bit more Bell's and dried thyme flakes. Add wet ingredients. Cover and allow to sit several minutes to thicken. Spread by tablespoons on top of the chicken/sauce mixture. |I sprinkled on a bit of whole dried thyme. Thyme and chicken are great partners. Always use less, not more.| Bake in a 350-degree oven for about 30 minutes. Tent loosely with tin foil. Remember, all the ingredients are basically already cooked. You just want to warm everything through until bubbly. Cool ten minutes before serving. Makes great leftovers--if there are any. Note: Stove Top Stuffing mix and jarred Alfredo sauces are often on sale or BOGO. That's when I stock up. |March in North Carolina. My cat, Boo,| is concentrating on a mole's progress ...

The Hobby Of Collecting Decorative Plastic Stamps - This topic is empty. 2022-08-24 at 21:01 #2137gudrunoliva31Guest Pigment inks are the best and straightforward technique for for you to add color to your rubber stamped images. No person be without doubt the colors you use will match all your stamped elements with it. Ink can be applied a selection of ways. Experience will assist choose your favorite method. Ink a make-up applicator, and then mist it lightly with water and พลาสติกกันกระแทก color because if you were using a paint clear. You may also use the corner of a make up sponge dabbed in the ink, and color globe rubber stamped image making use of it dry or moist diverse results. If you are fascinated about learning different cultures and countries, you’ll need should definitely try out stamp gallery. Some of the samples of these stamps are is actually known as Asian notary stamps. If in order to high gloss or semi-gloss wall paint currently dealing with your wall, prime with water primer starting. All other paint types need no pre-preparation. The ink inside material pads can be permanent once it is bound. Leave your try to dry to acquire day, after that, somewhat like silk painting, use an iron to press your unit. The iron wants regarding on a hot setting to therefore press your creation within the wrong hand side. Once in order to everything ready, all you might need to do is to decide on realize of pattern you need to have cut for the rubber stamp, and start to draw your pattern on the eraser having a sharpie note down. You need to probably practice a notepad first to make sure you don’t make any mistakes. To make sure in which you don’t draw a pattern that ends up being larger than the eraser you have, start with drawing the external boundaries of the shape you are aiming relating to. Hand stamped cards are a fantastic place start off. Just take a Drink. Start with Stamps, Ink and Paper. Acquire a slip of ribbon perhaps a punched layer for an outstanding first bank card. The third way to add color a few stamped image is as well as then choose one of ink other than black or brown. You may ink the general image and stamp it on your paper craft ideas. With this done, you are ready to begin filling the actual world spaces with fun coloring techniques.

There is no other way to describe the past 4 weeks for me. A whirlwind. A blur. In 4 weeks I have spent close to 50 hours on my ass driving or passengering. I’ve gone to British Columbia and back. I’ve gone to Bismarck and back. I’ve done several drives to Missoula and back. UB and Loki did the big trips with me, charming every soul they met along the way. Well, maybe not the new neighbor dogs in Bismarck just yet but they seem like nice dogs themselves. I spent days in 3 time zones, attended 2 days of the Montana veterinary medical conference, played in a fun golf tournament as a last-minute sub and didn’t totally embarrass myself, made a Canada Day video with 2 of our ferrets that is worth friending me on facebook just to see and I even made my first birdie playing with Alistair here in Seeley Lake. We hosted friends from Australia on their own blirlwind vacation and did all-things-Montana in one day. Tanya’s Big Breakfast Exploring the back forest in Steve, our Ranger. Canoeing on and swimming in Salmon Lake. More pool. More wine. More vodka. Steak supper at the coolest steakhouse around. Maybe a bit more wine. And a great bonfire with toasted marshmallows to cap off the busiest of days. The very next day was the trek to Bismarck with UB and Loki. As we crossed the state line the smoke from fires up in Canada’s Northwest Territory filled the skies. The fires in Canada are pretty bad this year, owing to some drought-like conditions in the northern regions. We are faring a bit better in Montana thanks to the late heavy rains we had in the spring. Nobody in Montana complains much about late snow and rain. Or, they might, but they don’t mean it. We lived through the nation’s worst fire the first summer we moved here. Where highways had tanks and National Guardsmen letting people in to check their homes and then get back out of the evacuation zone. Where the smell of smoke permeated our homes, our clothes, our pets, our cars. Where everything important was packed in bags and cat and dog crates lined every hallway in case we had to leave in an instant… we take fire season and its rules pretty seriously. Back in Bismarck I got to help tend our lovely little garden that my husband diligently plans each year. The soil is amazing. Its rich and moist and almost black. It is life in a tangible form. Something to be said about 10-year-old topsoil thanks to our beautiful herd there. We dined at some of our favorite restaurants and once again marveled at the growth and vibrancy of the capital city of one of the busiest states in the nation. A new supermarket and impressive-looking high school are going up close to our farm in addition to a Bed, Bath & Beyond and rumors of a Costco. Loki was exhausted after a couple of days of remembering things with her nose and ears. She ran around with a confidence ill-suited to a blind dog but UB, Gampy and I made sure to keep her in check. The first step in my need for dental crowns occurred. I haven’t had dental work done since I was a kid so it was a bit strange but it went well. My rubber tongue and slippery cheeks went away in time for us to hit the East 40 steakhouse that night. Its odd to think that I’m at an age now where I might have things in my body that are fake. Like these 2 temporary crowns. They are the only fake things about me. The only things that my DNA didn’t code for- things I didn’t begin my journey with. Granted, I’m missing my tonsils but its not like they put fake ones in their place. When did the warranty on my body start running out? I didn’t have much time to ponder this as we were busy attending a beautiful outdoor wedding on the 12th of July. It was a pretty hip, relaxed ceremony. The pastor told the congregation we all sounded like a “bunch of white people”. He was right so we chimed in with musical quotes he threw at us and all cheered as if we were at a hockey game. Rebecca was radiant. I’ve known her since she was a little girl. Her parents were part of the team that introduced Alistair and I back in 1994. I coached young Rebecca and she was my Tinkerbell one season and we’ve watched her grow up into an outstanding young woman. She seems to have found an equally cool partner in Ben. It all came full-circle because the 12th of July is the day that Alistair and I eloped 18 years ago in Watford City. He was on call but they let him turn the pager off for 2 hours. We got a couple of bouquets made for Whitney and I, arranged for our friend, Gretchen to take the kids for a couple of hours afterwards, called a friend in from the rodeo where her husband was the emcee and her daughter was barrel racing and we eloped. 18 years is something. I can’t quite believe its been that long. Its been a crazy, fun, amazing, hilarious, love-filled journey. I wasn’t a veterinarian then. We didn’t play golf back then. We had 2 cats, 1 dog and 1 ferret, as well as about 10 horses, not to mention 2 young kids. It was wonderful to share our special, private day with Rebecca and Ben and their families. Rebecca’s parents now have Star and Maggie and we quickly visited them, too. Star was Alistair’s Arabian stallion when I first met him. Maggie is Star’s Pinto grand-daughter. Full circle, once again. I’m not a nostalgic person by nature but having this time right now and the most amazing of house/pet sitters in Lynn and Jessi and Carson, I was able to reconnect with special people. Connecting in ways that facebook doesn’t allow… like a real hug from a real friend. Merielle, Anna, Susan, Uncle Pete, Aunty Wendy, Brad, Janet, Rebecca, Dallas, Anne, Luba, Mom, Dad and Nan…. special people who shared their parents, partners and pets with me…. Edna, Mike, Angel, Chelsea, Chelsea’s mom, Porter, Peaches, Michael, Donna, Calypso, Ben, Cal, Bax and Tabitha. But I’m back home and back on the golf course and I’ve watched Alistair leave once more for Bismarck. By plane this time. Which is as unnerving as watching him drive down the driveway. For 7 years I’ve watched him leave, knowing I’ll see him again in 2 weeks. But you never really know, right? A passenger plane is shot down over the Ukraine and nobody is talking about it. You never know. The fact we appreciate the fleetingness of time, particularly as medical doctors, is maybe why we put so much attention on living in the Now. We go to Hawaii, we get golf memberships, we buy Steve and Norman to make our adventures that much more fun. We enjoy big breakfasts and wonderful suppers and wine and scotch in the hot tub in the evening. We play with the animals and laugh and sing and make videos with them. We get outside to ride, canoe, bonfire, hike or play golf as much as we can because you never really know. Maybe that’s part of why we’re still able to laugh and love after 20 years together. My marriage. My adventures. My life. My blirlwind.

The geographical and historical dictionary of America and the West Indies [volume 1] C H A Luis de Cabrera, to make an cfl’ecliial discovery of this nation, but he did not succeed. In 1662 the innermost part of this country was penetrated by Fatlier Geronimo Montemayor, of the extinguished company of Jesuits. He discovered a nation of Indians, whose manners corresponded with this ; but he did not succeed in establishing missions, for want of labourers, and from other obstacles which arose. Ceuadas, a very abundant river of the same province and kingdom, from which the above settlement borrowed its title. It rises from the lake of Coraycocha, Avhich is in the desert mountain or "pararno of Tioloma. It runs n. and passing by the former settlement, becomes united witli another river, formed by two streams flowing down fronrthe paramo of Lalangiiso, and from the waste waters of the lake Colta ; it then passes through the settlement of Pungala, its course inclining slightly to the e. and at a league’s distance from the settlement of Puni, is entered by the Riobamba near the Cubigies, another river which flows down from the mountain of Chimborazo, and following its course to the«. for some distance, turns to the c.as soon as it reaches the w. of the mountain of Tungaragua, and at last empties itself into the Maranon ; rvhen it passes through the settlement of Penipe, it flows in so large a body that it can be passed only by means of a bridge, which is built there of reeds ; and before it reaches the ba/ios or baths, it collects the Avaters of the Tacunga, Ambato, and other rivers, Avhich flowing doAvn from the one and the other cordillera, have their rise in the s. summit of Eiinisa, and in the s. part of Ruminambi and Cotopasci. CEUALLOS, Morro de los, an island of the river Taquari, formed by this dividing itself into two arms to enter the river Paraguay, in the province and government of this name. C H A 351 runs from w. to e. being navigable by small vessels till it enters the S. sea. CHACALTANGUIS, a settlement and head settlement of the district of the alcaldia mayor of Cozamaloapan in Nueva Espana, is of a moist temperature, and situate on the shore of the large river Alvarado. It contains seven families of Spaniards, 18 of Mulattoes and Negroes, and 75 of Popolucos Indians. Within its district are 19 engines or mills for making refined sugar ; and its territory produces maize and cotton in abundance ; is three leagues to the e. of its capital. CHACALTONGO , Natividad de, a settlement and head settlement of the district of the alcaldia mayor of Tepozcolula, is of a cold temperature, and surrounded by eight wards within its district ; in all of which there are 160 families of Indians, who cultivate much maize and wheat ; is seven leagues between the e. and s. of its capital. (CHACAPOYAS. See Chachapoyas.) CHACARACUIAN, a settlement of the proprovince and government of Cumaná in the kingdom of Tierra Firme ; situate in the middle of the serrania of that province. It is under the care of the Catalanian Capuchin fathers ; and, according to Cruz, on the coast of the sea of Paria.

Stranding is an event in which one or more marine mammals arrive to the coast line, whether dead or alive, showing an inability to return to deep waters in which they can move. Discover how to help them! The causes of this happening can be natural (due to depredation such as injuries from bites or attacks, adverse environmental conditions or diseases) or anthropogenic (pollution, harassment, fishing gear, among others). In Mexico, the Federal Environmental Protection Agency (PROFEPA) is the coordinating body responsible for decision-making, the choice of methods, specialists or application of specific measures. Here are the actions you can carry out if you find a stranded dolphin or other cetacean in need of your help. Steps to help a stranded dolphin - Report the situation to PROFEPA to the number 01-800-PROFEPA (770 3372). - Provide as much information as possible: contact, location, time of sighting, number of stranded animals, weather conditions and a description of the animal. - DO NOT HANDLE OR MOVE THE ORGANISMS UNTIL THE TEAM OF EXPERTS ISSUES INSTRUCTIONS, once their physical and/or health conditions are assessed. - Remove any objects that may hurt them and avoid clusters of persons around the organisms. - Protect the organisms physically from wind and sunlight. Staying calm will contribute to the tranquility of the animal. - If conditions allow it, keep their skin fresh and moist with a light cloth; avoid covering the blowhole and fins (do not throw water directly). Maintain their position on their belly and dig holes around their pectoral fins so they may rest without having to bear their full weight.

Getting Going With Worms If the wiggly, slimy image of worms is the only thing keeping you from composting with these garden powerhouses, think again. Worms are nice housemates. Give them a simple bin, paper, and table scraps, and they’ll thank you with gifts of poo that you and your garden will love. We‘re familiar with the basics of caring for a dog or cat. Those pets need shelter, exercise, nourishment and a place to use the bathroom. You use food bowls, leashes, and litter boxes. But when welcoming worm pals into your home, ehh…. we don’t really have a clue. Garden author Sharon Lovejoy says not to worry. Caring for your composting worms is not so complicated. It’s nature doing nature’s work. Give your worms a cool and damp environment and they will thrive. Worms are beneficial pets. Their castings supercharge soil. Castings, created by the breakdown of organic material, are crazy nutrient rich. Beyond adding nutrients that your plants utilize as fertilizer, worm compost is full of life – beneficial microorganisms - that your soil can use to create more plant food. Worm composting is inexpensive and requires less maintenance than a compost pile since no turning is required. All composting helps to reduce the amount of trash sent to the landfill while reducing the need to buy fertilizer. Gardeners with small spaces can find a place for a worm bin when a compost pile is not an option. Lovejoy says worms are a great way to interest children in composting and nature. Kids love worm watching and handling. Loop them in to help with feeding and separating the worms from the compost. All worms are not created equal – for composting. Like choosing the right type of dog to bring home to your family, you’ll want the right worm. Don’t take in strays. Worms dug up from your garden won’t survive in a worm bin. Hands down, the best worm for composting is the red wiggler or Eisenia fetida. Red wigglers can eat! And they’re happy homebodies. They thrive in bins; contentedly making worm babies while turning your trash into rich nutrient filled compost. Worms can be ordered from several websites. Worm composting is simple says Lovejoy. “They eat. They poop. They eat. They poop. And then they reproduce,” she said. Before inviting them to stay, you’ll need a snug home for your worms. They dig plastic or wood domiciles. And instead of granite countertops, house shopping worms, make good drainage a top priority. In fact, any commercially available worm bin or homemade bin with good drainage, will make worms happy campers as long as their bedding is shallow and moist not wet, and they’re not overfed. Once you have a bin and worms, set-up housekeeping. When your worms first arrive, make sure their packing material is still slightly moist. To prepare their bed, lay several layers of newspaper or cardboard at the bottom of the bin. Lightly wet the paper. Add crumpled-up shredded paper – including junk mail that isn’t glossy – to about half the area of your bin. Spray the paper with water to make it moist but not saturated. Keep it fluffy so your worms have enough air. Under a bright light, gently spill your worms into the bedding. Worms like the night life and will bury down into the bedding to avoid light. Once they’ve moved in, sprinkle the bedding with a small amount of soil or dried leaves. This helps them break down waste. The move will stress your worms. Wait several days before giving them any food. Worms will eat most anything. Scraps of vegetables and fruit, cereals and starches, eggshells and coffee grounds are particularly good worm food. Avoid meat and dairy products as well as very acidic food. The biggest mistake made is overfeeding worms. Drainage and air circulation will keep the compost fresh smelling and not sour. In this scenario, the compost is working aerobically. Too much food and water can cause compaction and create anaerobic break down of food, which can make your worms sick. Lovejoy says to guard against too much liquid by keeping dry cardboard or newspaper on top of the worms under the lid. This will help absorb extra moisture. Worms can take a little neglect and continue creating life-giving gifts for your garden. “What could be a better pet?” ask Lovejoy, “ You don’t even have to walk them.”

We include products we think are useful for our readers. If you buy through links on this page, we may earn a small commission. Here’s our process. Most people do not give the area behind their ears much attention. However, some people may notice a smell that originates there. Sometimes, poor hygiene can cause the smell, but minor infections are also a common cause. Because people cannot see the area behind their ears, they may not think to wash it or check for skin irritation or signs of infection. Many relatively minor issues can cause a smell behind the ears. These include: - seborrheic dermatitis, a type of eczema - poor hygiene - piercing infections - yeast infections - cut or injury infections In most cases, a smell behind the ears is not a sign of a serious problem. Finding the right treatment and paying a little more attention to the area can usually clear it up. There are also many effective methods of prevention, which we also discuss in this article. It can affect any area of the body, including the back of the ears. In some cases, fungi that live on the skin cause seborrheic dermatitis. The condition does not usually cause a bad smell. However, the scaly, oily flakes it produces can trap sweat and odor. Also, the condition can sometimes be painful, which may cause people to avoid thoroughly washing behind their ears. Using antifungal treatments can usually clear symptoms. Many people with seborrheic dermatitis on the skin also have this condition on the scalp, so it may be helpful to wash the scalp with antifungal shampoo. Many antifungal shampoos are available to purchase online. The area of skin directly behind the ears can very easily trap sweat and oils. The back of the ear can trap residue from skin and hair care products. Having long hair may also make it easier to trap oil and other residues. The area behind the ears is also impossible to see without a mirror, so most people do not pay much attention to it. They may not wash the area very much or pay close enough attention when they do. So, if the area does not hurt and just smells bad, the most simple solution is to thoroughly wash with warm water and soap. An ear piercing is an open wound until it fully heals. For this reason, it is easy for bacteria to enter the wound. Bacteria can also infect healed ear piercings, especially if the piercing is unclean. Cleaning the ears and earring posts with either rubbing alcohol or a special ear piercing solution might help. Ear piercing solution is available to purchase online. If the infection is painful, if there is a fever or swollen lymph nodes, or if home treatment does not work, see a doctor. As with other infections, those of ear piercings can travel to other areas of the body, potentially becoming very serious. People should see a doctor if the infection is in the cartilage of the ear. These infections can be more difficult to treat and may require stronger antibiotics. Yeast tends to grow in warm and moist areas. As a result, people who sweat a lot or those who do not regularly clean the area behind their ears may develop a yeast infection. Yeast infections tend to itch and may produce a beer- or bread-like smell. Rarely, a person may develop a serious yeast infection that doctors call invasive candidiasis. This occurs when yeast gets into the bloodstream and spreads through the body. When this happens, a person may develop signs of a yeast infection in several areas of the body. Most yeast infections respond well to over-the-counter antifungal remedies. If the infection is severe, if a person with a weak immune system develops the yeast infection, or if home remedies do not work, a doctor can prescribe a pill or cream to clear the infection. Sometimes, yeast or other fungi infect the inside of the ear, usually in the outermost part. Doctors call this otomycosis. This infection may become invasive, spreading deep into the ear or even into the bone. Infected injuries sometimes smell unpleasant. It is possible not to notice an injury behind the ear, such as a cut, scrape, or pimple, until it becomes infected. If there is swelling, pain, or discharge, the infection probably requires antibiotics. If the pain is minor, try cleaning the injury with soap and water and applying a triple antibiotic ointment. See a doctor if symptoms do not go away in 1–2 days. If there is a fever or intense pain, or if the injury is very flushed, seek immediate medical attention. Preventing a bad smell behind the ear is typically as simple as keeping the area clean. Good hygiene may also help prevent infections and skin irritation. People can try the following strategies to prevent developing a smell behind the ears: - Wash behind the ears during every bath or shower. People with sensitive skin or eczema should use sensitive skin soap, which is available online. - Wipe the area behind the ears with a warm, wet washcloth after intense physical activity. - Keep ear piercings clean. Twist and rotate the piercings in a circle several times each day. Do not take new posts out until at least 6 weeks after piercing. Children who are too young to clean their ears must receive adult help. - Gently exfoliate the area behind the ears once or twice per week. This prevents dead skin from building up. An exfoliating wash or rough washcloth can help with this task. People with skin conditions should discuss exfoliation with a doctor before trying it. - Do not ignore a bad smell, even if there is no pain. A bad smell may be a warning sign of an infection or other problem, so it is best to see a doctor. Noticing a bad smell behind the ears can be alarming. Finding the right treatment can help remove the smell as well as resolve the underlying cause. In many cases, treatment is a simple matter of taking the time to wash this often neglected area. Even when an infection or other serious issue is the cause, a doctor can usually prescribe a quick-acting treatment. Discussing unusual smells in the body may feel uncomfortable, but people should not hesitate to seek help from a healthcare professional. They can offer reassurance that the problem is common and a quick path to relief.

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A particularly fine variety Easy for all to grow Awarded an RHS Award of Garden Merit Height Up to 45cm (17.7in) Spread Up to 30cm (11.8in) Sun or semi shade 2 Options From£2.99 2 Options From£2.49 A particularly fine variety producing long, smooth, white-skinned, tapering roots of uniform size. Parsnip 'Albion' has a delicious sweet flavour and good texture, with lifted roots storing well without discolouring. This RHS AGM variety makes a useful crop for the organic gardener, having been specially bred for its resistance to canker. Height and spread: 45cm (18"). 1 packet (300 parsnip seeds) (37213) Direct sow parsnip seeds outdoors from mid spring to early summer, as soon as the ground is workable. Avoid sowing in cold or wet soils. Grow parsnips in a sunny position in stone-free, well prepared ground that has been deeply cultivated. Parsnips prefer a fertile, light, well drained soil. Sow parsnip seeds thinly at a depth of 2cm ( 3/4in) in drills 30cm (12") apart. Germination is slow and may take up to 28 days. When large enough to handle, thin out the seedlings within each row to 7cm (3in) apart or 10cm (4") apart if larger roots are required. Water well to encourage germination. Once germinated, parsnips should be watered only when necessary to keep the soil moist. Keep beds weed free at all times. Harvest parsnips from late autumn through to January, as and when required. However, their flavour will be improved if they are left in the ground until exposed to frost. Alternatively lift and store parsnips in boxes of barely moist soil, peat or sand, and store in a cool place. Roots can be stored like this for up to 4 months. Loosen the soil around the roots with a fork before lifting them to avoid damaging the roots. Seeds and garden supplies will normally be delivered within the time period stated against each product as detailed above. Plants, bulbs, corms, tubers, shrubs, trees, potatoes, etc. are delivered at the appropriate time for planting or potting on. Delivery times will be stated on the product page above, or in your order acknowledgement page and email. Orders for packets of seed incur a delivery charge of £2.99. Orders which include any other products will incur a delivery charge of £6.99. Where an order includes both packets of seeds and other products, a maximum delivery charge of £7.99 will apply - regardless of the number of items ordered. Large items may incur a higher delivery charge - this will be displayed in your shopping basket. Please see our Delivery page for further details, and more information on different charges that may apply to certain destinations. For more information on how we send your plants please visit our Helpful Guide on plant sizes.

UC Cooperative Extension Ventura County 669 County Square Dr. Suite 100 Ventura CA 93003 Monday - Friday from 9 a.m. to 4 p.m. Please phone ahead as staff schedules vary due to COVID-19. We are also available via phone and email. Click here for our office directory: Contact/Staff Info Answers to frequently asked questions about Citrus U.C. Cooperative Extension Recognizing freeze-damaged citrusBen FaberFarm AdvisorU.C. Cooperative ExtensionVentura County Citrus leaves appear wilted or flaccid during periods of low temperature. This is a natural protective response to freezing temperatures and does not mean the leaves have been frozen. Leaves will be firm and brittle and often curled when frozen. Leaves become flaccid after thawing, and if the injury is not too great, they gradually regain turgor and recover, leaving however, dark flecks on the leaves. Seriously frozen leaves collapse, dry out, and remain on the tree. Foliage form recent flushes are most susceptible to this damage. If twigs or wood have been seriously damaged, the frozen leaves may remain on the tree for several weeks. If the twigs and wood have not been damaged severely, the leaves are rapidly shed. Trees losing their leaves rapidly is often a good sign and is not, as many growers believe a sign of extensive damage. Cold damage to the twigs appears as water soaking or discoloration. In older branches and trunks it appears as splitting or loosening of bark where the cambium has been killed. Bark may curl and dry with many small cracks. Dead patches of bark may occur in various locations on limbs and trunk. Sensitivity to frost is dependent upon many variables. In general, mandarins are the most cold hardy followed by sweet orange and grapefruit. Lemons are very frost sensitive with Eureka decidedly more sensitive than Lisbon. Limes are the least cold hardy. Healthy trees are more tolerant than stressed ones. The rootstock also imparts sensitivity onto the scion. Injury to the foliage and to young trees may be immediately recognizable but the true extent of the damage to larger branches, trunks, and rootstocks may not appear for on to four months following the freeze. No attempt should be made to prune or even assess damage from the frost until spring when new growth appears. Rehabilitation of freeze-damaged citrus The only treatment that should be done rapidly after a freeze is whitewashing. Often the most severe damage following a freeze results from sunburn of exposed twigs and branches after defoliation. Temperatures do not have to be extremely high to cause sunburn. A white latex paint that has been diluted with water so that it can be sprayed is the easiest way to whitewash. The whitewash needs to be white on the tree, so don’t add too much water. Pruning should be carried out to prevent secondary pathogens and wood decay organisms from slowing tree recovery. Again, however, there should be no rush to prune. Premature pruning, at the very least, may have to be repeated and, at the worst, it can slow tree rehabilitation. It should be remembered that when pruning, all cuts should be made into living wood. Try to cut flush with existing branches at crotches. Do not leave branch stubs or uneven surfaces. Tools should be disinfected in bleach or other fungicide before moving on to the next tree. Irrigate carefully! Remember that when leaves are lost, obviously evaporation from leaves is greatly reduced, and, therefore the amount of water required is also greatly reduced. A frost-damaged tree will use the same amount of water as a much younger or smaller tree. Over irrigation will not result in rapid recovery. Instead, it may induce root damage and encourage growth of root rotting organisms. Irrigation should be less frequent, and smaller amounts of water should be applied until trees have regained their normal foliage development. Fertilization of freeze-damaged trees should be carefully considered. There is no evidence to indicate that frozen trees respond to any special fertilizer that is supposed to stimulate growth. If trees are severely injured-with large limbs or even parts of the trunk killed-nitrogen fertilizer applications should be greatly reduced, until the structure and balance of the tree become re-established. Trees should be watched for evidence of deficiencies of minor elements. Deficiencies of zinc, manganese, copper, and iron are most likely to develop. For citrus, these materials should be applied as sprays, and they should be used as often as symptoms are observed. Two or more applications may be required the first year. Heat and its importance in citrus Heat affects different types and varieties of citrus differently. Heat determines when fruit ripens and how sweet it will be. Grapefruit has one of the highest heat requirements of all citrus. Grown along the coast it will be sour, but in the Central Valley it can be decidedly sweet. A Pixie mandarin along the coast will be 6-8 weeks later in ripening than the Valley and will hang on the tree much longer. Acid fruits like lemon and Bearss lime have low heat requirements and are well adapted to the coast. The everblooming characteristics of lemons and limes are accentuated along the coast where there may be continuous cropping with lemon blooms year round. High temperatures can have a negative effect on citrus. Coastal citrus may suddenly drop fruit when temperatures swing from the cool 60’s to the 90’s as often happens with Santa Ana conditions. Sudden warm weather can cause fruit to split, induce flower and leaf drop, and cause sudden burn to both the fruit and tree. These problems are compounded by dry soil moisture and problems can be reduced if there is adequate moisture present during the heat wave. In hot environments, some citrus like navels produce less fruit. You callem tangerines, but they are mandarins Seediness and citrus Seediness in citrus is often unpredictable. Officially, a fruit can have up to 5 seeds and still be considered seedless. Some varieties such as ‘Washington’ navel, ‘Pixie’ mandarin and ‘Armstrong’ satsuma are consistently seedless. Some varieties, such as the Valencias are consistanly seedy. Others,such as ‘Clementin’ and ‘W. Murcott’ mandarin only produce seed if a pollinizer nearby. The fruit number and size may be reduced without seeds, though. There is no precise list of compatible pollinizers and varieties may perform differently depending on the region and the weather that year. In the spring time the trees are alive with bee pollinators (notice the difference, the tree is a pollinizer and the insect is the pollinator). What size plant to buy The longer the plant has been in the container, the longer it takes the plant to adjust to the bull soil after it has been planted. The smaller the plant is that goes in the ground that can survive, the more rapid the growth. A 5 gallon container grown lemon will have outgrown the 15 gallon container in three years. This has been shown consistently with all manner of container grown plant……..and they are cheaper. Leaving a citrus unpruned is not as critical as it is for deciduous trees. They form a blob with leaves extending to the ground. Pruning however, improves air circulation (reduces fruit disease), increases fruit size, reduces alternate bearing (especially in mandarins), reduces limb breakage and controls trees size. Light pruning to open up the centers in late winter at flowering is the best time. It helps even out flowering, allows for regrowth during the summer, avoids spread of disease to cuts during the rainy season and reduces the likelihood of sunburn which can be a problem when done in the summer time. Late fall/winter pruning stimulates growth that can easily freeze. Severe pruning can rejuvenate an overgrown tree, but expect yield reduction. Also expect to whitewash the tree (dilute latex paint), to reduce sun burn. All citrus is sold as grafted trees. The tree is a combination of a rootstock (used because it consistently propagates well for the nursery) and the scion (a known variety that consistently reproduces the same fruit). Early on and even later the rootstock growth (suckers) may be more vigorous than the scion and out grow it. Rootstock growth is often more thorny than the scion. Know where the graft union in on your tree. It can usually be seen as a diagonal scar between 6 and 12 inches from the soil. Remove all shoot growth below the graft. Remove suckers as soon as they are observed. There are many different rootstocks available to growers. A certain rootstock will be chosen because it has greater nematode resistance, salt resistance, disease resistance etc. The retail nursery typically sells whatever rootstock the wholesale nursery propagates. Wholesale nurseries do not all use the same rootstocks, but use those that they feel grow best for them. In some cases, a retail nursery may be able to special order a rootstock for a special situation. You can always ask. There is one choice that the buyer can make, though, whether it is dwarfing or not. The ‘Flying Dragon’ rootstock creates small tree, under 6 feet and it is very slow growing. It especially lends itself to container culture. Container grown citrus Citrus grows well in containers, especially if you choose varieties like ‘Meyer’ lemon which is a less aggressive tree or use ‘Flying Dragon’ dwarfing rootstock on one of the other citrus varieties. There is a long history of orangeries in Europe, where full sized trees were grown outside in containers in the warm weather and then moved into large greenhouses when it got cold. Half barrels and terra cotta pots can be used, but if a large container is used and you want to be able move it, put the container on some wheels first. Fill the container with a good quality potting mix and plant your tree. Containers dry out much faster the soil grown trees, so stay on top of the irrigation. When irrigating, make sure water comes out of the bottom of the pot to avoid salt accumulation in the root zone. Prune as necessary to keep the canopy in balance with the pot or pot up to the next size. Asian citrus psyllid and greening disease Currently in much of the southeast there is a pest-disease complex. A small insect about the size of an aphid can carry a bacteria that causes fruit to be distorted and bitter, causes a mottled color of the leaves and eventually kills the tree in five to eight years. This disease is in Louisiana, Florida, the Caribbean, Mexico and Brazil. Massive amounts of energy and pesticides are being used to keep in under control. The psyllid is now in California along the California border, but the psyllid at this point is not carrying the bacterial pathogen. The insect is being monitored and tested for the bacteria at this time and it is hoped that control practices in that area and in Mexico will prevent the introduction of psyllids carrying the bacteria. Growing citrus in a lawn Trees don’t belong in lawns. In California we irrigate. Do you irrigate to the needs of the lawn or to the tree? Frequently, lawns are irrigated by timers, putting a short burst of water on. Trees like a deep watering. Shallow watering leads to an accumulation of salts in the tree’s root zone and salt burn results. If possible, keep a 6 foot turf free area around the trunk. And best of all irrigate the tree separately from the turf and make sure the lawn sprinklers do not wet the trunk which can lead to crown rot in the tree. Budding and grafting of avocado and citrus By: Pam Elam It is often tempting, after eating a particularly good orange or avocado, to plant the seed and grow our own tree full of these delicious fruit. Trees grown from these seed, however, may produce fruit that are not edible at all, or the trees may not bear fruit for many years. The best way to produce good-quality fruit is to grow seedlings from them and then attach, by budding or grafting, material from trees that are known to be good producers. Budding and grafting can also be used to change or add varieties to mature citrus or avocado trees, a process known as top working. This publication is a brief introduction to budding and grafting for the home gardener. For more information, consult the materials listed at the end of this publication or contact your local Cooperative Extension office. The best time of year to start citrus or avocado seedlings is in early spring. To germinate citrus or avocado seed, plant them in a shallow container such as a nursery flat or a pan with drainage holes in well-drained commercial potting mix. Plant the seed two to three times deeper than their length. For example, a citrus seed about ¼ inch (6 mm) long should be planted about ½ to ¾ inch (12 to 18 mm) deep. Keep the seed in a warm place-between 70° and 80°F (21° to 27°C)-and keep the soil moist. Covering the nursery flats with clear glass or plastic will help maintain the proper humidity. Avocado seed can also be germinated by suspending them in water. Place toothpicks horizontally into the seed near the top. Suspend the wide end of the seed in a small container of water with the toothpicks resting on the edge of the container. Place it in indirect light and refresh the water at least weekly. After germination (usually 12 to 15 days), replant the seedlings into a larger container of good-quality commercial potting mix. (If all danger of frost has passed, the seedlings may be planted directly into the ground where you want the tree to grow instead of replanted into containers.) Good choices for containers include a cardboard milk carton cut horizontally in half or a one-gallon can. Punch drain holes in the bottom of the container. The seedling will be ready for budding or grafting when it has grown to 24 to 30 inches (60 to 75 cm) tall. Keys to Budding and Grafting Budding and grafting are vegetative propagation techniques in which a single bud or stem (scion) of a desired plant (cultivar) is attached to a rootstock plant. In budding, a single bud with its accompanying bark (often referred to as budwood) is used as the scion. In grafting, part of a stem or branch is used as the scion. One of the most important keys to successful budding and grafting is properly positioning the scion on the rootstock. In order for the scion and rootstock to grow together, the thin greenish plant layer (cambium) just under the bark of the scion and rootstock must be aligned so that they touch each other. If they do not touch each other, the bud or graft will fail. Within 10 to 15 days, a successful bud or graft forms a hard whitish tissue (callus) where the two cambium layers grow together. Always use sharp cutting or grafting instruments and make clean, even cuts. Options include a budding knife, a sharp kitchen knife, or a single-sided razor blade. Do not allow the cut surfaces of the scion or rootstock to dry out. Immerse cut scions in a pail of water, wrap them in plastic, or graft them immediately after cutting. Also, remove any leaves from scions after cutting to help keep the scions from losing water. Keep the scions in a cool place during the work. When to Bud or Graft Budding and grafting are best done in the spring or fall when the bark is easily separated from the wood. It should be timed to be early enough so that warm weather will help ensure a good bud union, yet late enough so that the bud will not begin to grow and callus will not grow over the bud itself. Citrus budded or grafted in the fall must be protected from frost. Avocados are best grafted in the spring when the bark is easily separated from the wood. Budding is the standard method used to propagate citrus. Aside from being the easiest method, it allows a large number of plants to be propagated from a small amount of scion wood and is suitable for trees, rootstocks, or branches from 1 /4 to 1 inch (0.6 to 2.5 cm) in diameter. Budwood should be taken only from high-producing, disease-free trees (see Warning at end of this article). The best citrus budwood is located just below the most recent flush of new growth; the best avocado budwood is located near the terminal end of shoots that have fully matured, leathery leaves. How to make a T-bud T-budding (see fig. 1) is generally the best budding method for citrus and avocados. To make a T-bud, make a T-shaped cut on the rootstock about 8 to 12 inches (20 to 30 cm) above the ground (fig. 1A). The vertical part of the T should be about 1 inch (2.5 cm) long and the horizontal part about one-third of the distance around the rootstock. Twist the knife gently to open flaps of bark. Avoid cutting through any buds on the bark of the rootstock. On the scion (fig. 1B), cut a selected bud beginning about 1 /2 inch (1.2 cm) below the bud and ending about 3 /4 to 1 inch (1.9 to 2.5 cm) beyond the bud. Make a horizontal cut about 3 /4 inch (1.9 cm) above the bud down through the bark and into the wood. Gently remove the shield-shaped piece for budding (fig. 1C). Slip the budwood down into the T-shaped cut under the two flaps of bark until the horizontal cuts of the bud match up with the horizontal cut of the T (fig. 1D). After inserting the budwood into the rootstock, wrap the bud and rootstock with budding rubber (fig. 1E). Budding rubber is available from agricultural supply or hardware stores; if budding rubber is unavailable, use wide rubber bands, green tie tape, or stretchy tape. Leave the bud exposed while wrapping. Do not coat the area with grafting wax or sealant. The best grafting technique for small-diameter 1/4 to 1 /2 inch [0.6 to 1.2 cm]) rootstocks is whip grafting. Whip grafting should be done in the fall or spring. Although whip grafts use more scion wood than budding does, they allow the grafted plant to develop more rapidly. To make a whip graft (fig. 3), select as a scion hard and mature green wood. First make a long, sloping cut about 1 to 2½ inches (2.5 to 6.2 cm) long on the rootstock (fig. 3A). Make a matching cut on the scion. Cut a "tongue" on both the scion and rootstock by slicing downward into the wood (figs. 3B-3C). The tongues should allow the scion and rootstock to lock together. Fit the scion to the rootstock (fig. 3D) and secure with budding rubber (fig. 3E). Apply grafting wax to seal the union. To prevent sunburn, new whip grafts should be protected from the sun until they heal. After the scion has begun to grow, remove any growth from the rootstock. If necessary, support new shoots by staking. The best grafting technique for large-diameter trees or branches is bark grafting (fig. 4). To make a bark graft, first cut off the rootstock (the trunk or branch to be grafted) just above a crotch where smaller branches sprout out. If possible, try to retain one branch of the original plant as a nurse branch. The nurse branch will provide the scion nutrition and support from wind (the nurse branch will eventually be removed). Cut vertical slits 21/2 to 3 1/2 inches (6.2 to 8.7 cm) long through the bark of the remaining freshly cut rootstock stubs down to the wood. These slits should be spaced 3 to 5 inches (7.5 to 12.5 cm) apart. Cut the scions 5 to 6 inches (12.5 to 15 cm) long with 4 to 6 buds per scion (figs. 4A-4C). If scions are cut longer than this, they may dry out before healing. When cutting the scions, make a sloping cut about 3 inches (7.5 cm) long at the base of the scion. Using a grafting knife or other very sharp knife, lift the bark on one side of the slit. Insert the scion into the slit with the long-cut surface of the scion facing the wood of the rootstock and push it down into the slit (fig. 4D). Make sure that the scion fits snugly into the slits in the bark and that the cambiums are properly aligned. Secure citrus scions by nailing them in place with thin flathead nails or tying them with strong cord or tree tape. Secure avocado scions with plastic nursery tape. Coat all cut surfaces thoroughly, including the tops of the scions, with grafting wax or pruning paint. To protect the graft from sunburn, paint it with white interior water-based paint, either undiluted or mixed 50/50 with water. Paint the entire area around the graft union, including the scions, waxed areas, and the exposed trunk below the graft union. Inspect the grafts frequently and re-wax them if they begin to crack or dry out. Once the scions begin to grow well, remove all but one scion per branch. Early on, however, prune the scions that will be removed to reduce their vigor but do not prune the scion that will be kept. The one scion you keep will eventually become a main scaffold branch. Any nurse branches should also be removed after all the scions are growing well. Top working is the process of changing fruit varieties on a mature tree. Most citrus and avocado are top worked by bark grafting (see above). Top working should be done in the spring or fall.

Camping with some friends near Cherokee, NC, we were discussing lunch, at breakfast. (Come on – you know you’ve done it, too. I heard a great quote about this point, this week, “Why don’t we go get lunch and talk about dinner?”). Looking for options, the one couple among us with any bars of phone signal, suggested Haywood Smokehouse, in Dillsboro – a Texas-style barbecue house with three NC locations, based in Waynesville. They started talking it up and I explained that they had me at “barbecue”… One of the first things that we noticed, sitting at the table, was the menu of sauces. I immediately went hunting and gathering for bottles and began the “shake-the-bottle-drip-some-on-your-finger” process to see what I’d like. I think, at the table, we tried most all of these. The SOB, with habanero and jalapeño, was too hot for me – and I do like hot stuff. But I did REALLY like the japple- a mix of apples and jalapeño, which I thought was very good on the brisket. I ordered a combo plate: Brisket, pulled pork, green beans and mac-n-cheese. The meats were smoked as they should be – without sauce – and had great flavor. The brisket was moist and tender, with an 1/8″ smoke ring, and the pork had a good bit of smoke on it as well. The green beans were cooked with some ham, but weren’t cooked long enough to get really soft. The mac-n-cheese was fairly good – not soupy but cheesy enough. This was a definite win. I’d try one of the other locations if I was in their areas. 2021 Update: Camping with the same couples, two years later, I ended up with almost the same plate: pulled pork, brisket, mac-n-cheese and fries. (I looked back and saw my note about the green beans). Just as tasty as I recalled. They no longer have the Japple sauce on the menu, so I tried the Georgia Fire on my brisket. The yellow -mustard based sauce, with quite a kick, really complemented the beef.

Today’s adventure involved a road trip to Auburn, Alabama, for barbecue with a group of friends. We have these folks that we camp with – three couples in metro Atlanta, one in south Alabama and one in South Carolina. Eight of us (it was a little far for the South Carolinians, so they weren’t part of this adventure) were preparing to gather (after a successful meet up at Rodney Scott’s in Birmingam) over the holidays and one of the couples suggested Bow & Arrow. Owned by chef David Bancroft, of Acre (which we visited in 2016), Bow & Arrow has been open for about 18 months and is his interpretation of the Texas smokehouses of his childhood, placed in a contemporary South Alabama context. Before eating, I went around back, to see what I could see. The first thing that I found was these two big Southern Pride smokers. This was off to a good start. But one thing, that wasn’t terribly promising, were the fixed business hours. A place that has to guarantee that they’ll be open until nine, every night, almost has to over prepare their meats. Which means that some will be left over for the next day. And that means that some of the meats that you’re eating today, may have been smoked yesterday. Anyhow, as we walked into the ordering line, the first thing that we saw (past the tortilla making machine) was the meat warmer, below. On this carousel of warming meats, the proteins are kept warm waiting for serving. Immediately to the right of this carousel is where you make your selection. In the picture below, he’s cutting the meats in the forefront and weighing them on a scale off-left of the photo. Working your way down the line, you make your additional selections, pay and find a spot to sit. There apearred to be a couple of choices you make that aren’t right from the line – someone behind us ordered the tacos and they gave her a number and said they would bring those to the table. One of us chose a two meat plate with lean brisket, turkey, house-made tortillas, hash brown casserole, slaw and deviled-egg potato salad. To start with, on this platter, the hashbrown casserole was absolutely awful. I tried it, too, and it tasted like nothing that had ever had potatoes in it. Another couple at the table felt the same way and took their order back, along with us, and exchanged it for something else. The slaw had both mayonnaise and vinegar in it and was well received, as was the potato salad. My beloved made tacos from both the brisket and the turkey, seasoning them with the Alabama white sauce from the condiment bar. The meats both looked moist and smoked well. I could confirm the brisket, as I had some also, but we’ll have to take my wife’s (and Mark’s) word for it, on the turkey. They both enjoyed it. My main platter was a three meat plate with ribs, moist brisket and pulled pork with creamed corn, mac-n-cheese and house-made Texas toast. The mac-n-cheese and creamed corn were both fine, but neither was anything to write home about. The ribs were very meaty and had just the right amount of tug when you pulled the meat off the bone. They had a rib sauce, on the table, that was very good on the ribs. I’m not sure quite how to describe that sauce – tomato-based with a little heat and “tang” to it. Nice smoke ring on the ribs, too. The brisket (which I ordered moist) was very good, with a solid smoke ring and good flavor. They had a Texas Red sauce that went well with this (although there was also a mustard-based sauce that got good reviews, at the table). The pork was smoked well, also. I enjoyed the white sauce on the pork. A little closer view of the meats – you can see the smoke ring, very clearly. I, as is my wont, over-ordered – a side of jalapeno-cheddar sausage to go with my plate below. And a smoked chicken potpie made with home-made biscuits. This tray did, also, contain the desserts – one of which (the eclair) was not mine. So I didn’t, technically, eat full two platters of food for lunch. But close. Overall, the meats were very good – these folks have a really good handle on how to smoke meats. The sides were okay. The desserts were good (banana pudding) and exceptional (Memaw’s eclaire – which Monica, who helped us before ordering, said was the best thing on the menu and didn’t lie about). Apparently, it was like a banana pudding with a thin layer of chocolate gnoche. Several times, riding down the road since, my beloved has said, “If I was ever on the Best Thing I Ever Ate”, it would be that eclair in Auburn.” High praise, indeed.

How To Get Rid Of Acne Scabs Fast Pimple scabs form when you keep picking the pimples and bumps on your face. Scabbing is a stage of healing wounds. The best way to heal the wounds is to avoid touching, squeezing and scratching acne spots and bumps. But it is never simple given the pimples can be itchy or painful. - Popped acne scabs can start to bleed or ooze. - A yellow fluid is likely an infection on the pimples. - Redness is also a sign of serious irritation. - If you continue to pop and pick the acne spots, your pimple scabs wont heal or go away. So, before you try to get rid of acne scabs, it is important to know what is causing them. What About Lasers For Dark Skin While lasers are a great option for treating acne scars, it’s important you do your research and ask the right questionsespecially if you have darker skin. “When considering laser treatments I always recommend having a consultation first,” says Davis. “See if the right laser for your skin type is available, who will be the operator behind the laser, how much experience they have in skin of color, and request to see before and after images.” Cheek Acne Treatment #: Adjust Your Diet If youre wondering how to clear cheek acne, making these changes to your diet may be helpful: 1. Eliminate Indigestion: Indigestion is a sign that your body is struggling to process foods properly. You may lack water, fiber or gut bacteria to digest food. This can cause inflammation, risk of food allergies, and difficulty processing sugar which will spike insulin and can contribute to excess sebum production, which can lead to acne flare ups. Hydrate, eat more fiber, and try eating probiotics like yogurt or kombucha to eliminate indigestion. 2. Reduce Sugar Intake: Decrease your intake of sugar sweets, processed carbohydrates, and sugary beverages. Replace with non-sweetened beverages and whole foods. If you love sweets, try curbing the cravings with yummy blueberries or strawberries. 3. Incorporate Leafy Greens: Essential vitamins and minerals are critical to skin health. Substances such as Vitamin E or Omega-3 fatty acids contribute to the production of skin tissues and the elimination of inflammation. The right balance of nutrition can be found in natural vegetables and greens and can make your skin vibrant and acne-free. 4. Consider Taking a Supplement: This can help correct vitamin and mineral deficiencies that can lead to skin issues but it can also help abolish aggravators, calm, and nourish the skin. Recommended Reading: How To Get Rid Of Acne On Face Overnight What Causes Acne On The Chin Acne on the chin, as we said earlier, is no different than acne on other parts of your face and body, therefore the main cause for chin breakouts are clogged pores. The pore is an opening to a hair follicle and attached inside the top of the follicle are sebaceous glands which are tiny oil-producing glands we have all over the body except on the palms of the hands, soles of the feet, and lips. Pores can become clogged with excess oil, dead skin cells, and white blood cells. When the pore becomes clogged, this creates a perfect, airless environment for the bacteria to thrive and cause acne. But besides that, some of the most common things that can trigger excess oil production that will then lead to a clog can also be underlying conditions, hormonal changes, using bad skincare products, poor hygiene, bad diet, etc. Lets mention a few of these and explain how they could possibly affect you. Moisturize With Aloe Vera Aloe vera is a tropical plant whose leaves produce a clear gel. The gel is often added to lotions, creams, ointments, and soaps. Its commonly used to treat abrasions, rashes, burns, and other skin conditions. When applied to the skin, aloe vera gel can help heal wounds, treat burns, and fight inflammation . Aloe vera contains salicylic acid and sulfur, which are both used extensively in the treatment of acne. Research has found that applying salicylic acid to the skin reduces acne ( While research shows promise, the anti-acne benefits of aloe vera itself require further scientific research. Recommended Reading: Will Aloe Vera Help Acne Why Do Acne Scars Happen Scarring occurs as a result of injury to the skin and excess oil production, bacteria, and inflammation. Zeichner explains, Inflammation in the skin tells our pigment producing cells to become overactive, explaining why pimples leave behind dark spots. The hyperpigmentation that remains isnt permanent, but it can be uncomfortable for some people. It can also present differently, depending on your complexion. is more common in patients who have darker skin tones, he adds. Whereas, fair skinned patients are often left with pink or red spots in areas where there used to be pimples. This post-inflammatory erythema heals on its own over several weeks. Although most superficial breakouts heal on their own without leaving a significant mark, there are others that leave a more noticeable scar behind. This is why its advised to avoid picking pimples. It can lead to more injury to the skin, which can lead to a greater chance of a scar, Garshick says. Read Also: What Is The Cause Of Chest Acne Dermatological Procedures To Improve Or Remove Acne Scars But while certain measures can help prevent new scarring, what are your options for minimizing the appearance of existing scars? Common procedures to remove or improve acne scars include: Dermabrasion This effective scar removal treatment uses a high-speed brush or other instrument to resurface your skin and remove or reduce the depth of scars. It can take up to three weeks for skin to heal. Microdermabrasion For this less-intensive type of dermabrasion, a dermatologist or aesthetician uses a handheld device to remove surface skin. More than one treatment may be required, but theres no downtime, according to the AAD. Chemical peel During a chemical peel, a chemical solution is applied to the skin. It removes the outer layer of your skin, resulting in a smoother, more even appearance. You may experience redness and peeling for three to seven days after the procedure, notes the American Society for Dermatologic Surgery . Laser Your dermatologist can use a laser resurfacing treatment to remove the outer layer of your skin, contour areas of acne scars, or lighten redness around healed acne lesions. Healing may take between 3 and 10 days. Recommended Reading: How To Remove Acne Scars Naturally So How Do I Get Rid Of Acne Scars At Home 1. Use a retinoid. While retinoids can help prevent acne scars, they’re also a great option for treating them if you’re already dealing with them. Using a retinoid in your skin care routine will stimulate collagen production to fill concave scars and soften the edges. All of this will improve skins overall texture. For her patients, Dr. Henry likes Epiduo Forte, a prescription medication that combines a retinoid with benzoyl peroxide to fight acne and improve skin tone and texture. But if you’re looking for an over-the-counter retinoid option, she recommends one with between 0.5 and 1 percent retinol, like PCA’s. Dr. Zeichner is also a fan of retinoids, and recommends Differin Gel to help boost cell turnover which results in a more even skin tone, texture, and pigmentation. However, if you have sensitive skin and tend to react to active ingredients, like benzoyl peroxide, salicylic acid, and retinoids, then it’s best to avoid products with those ingredients, says Dr. King. “For post-inflammatory hyperpigmentation in sensitive skin types, I would recommend avoiding any products that are irritating the skin enough to cause inflammation and potentially additional post-inflammatory hyperpigmentation because this will be counterproductive,” she adds. 2. Up your exfoliation game. 3. Glow with vitamin C. How To Get Rid Of Pimple Scabs Keeping the wounded pimples soft and moist can really help them heal overnight or fast enough. The natural healing process can take a little more time, but it may make the bumps go away without leaving black spots on your face. Another basic rule for faster healing is not to scratch or pull off the crusty parts. This will cause further wounding. Here are other ways to get rid of acne scabs fast and naturally. Try these home remedies. Recommended Reading: How To Clear Up Chin Acne Why Are Some People More Prone To Scars Than Others The realisation that some people barely suffer from scarring is a hard pill to swallow. Unfortunately, it’s got nothing to do with luck and everything to do with your genes. “Acne scarring often depends on our genetics. Individuals with deeper skin tones are at a higher risk of hyperpigmentation due to their larger melanocytes, which produce more melanin. If you have a predisposition to having acne, you are also more likely to scar.” The Best Acne Products For Back Acne Treatment The best acne products for stubborn acne on your back contain acne medication or natural acne treatment ingredients that kill bacteria, cleanse pores and nurture clear skin. The Body Shop offers a soap-free body wash gentle enough to use on the whole body, with antibacterial tea tree oil for acne treatment. If you’ve wondered how to get rid of blackheads on your back, where they can be especially stubborn, give this affordable back acne treatment a try. The Body Shop tea tree skin clearing body wash, from $13, Neutrogena’s acne treatment body wash contains the acne medication salicylic acid to fight back acne breakouts and prevent body breakouts. Use a small amount on a clean, soft cloth or body sponge to create a rich lather, then rinse clear. Neutrogena Body Clear acne body wash, $6 for Amazon Prime members, Target.com Those who prefer a bar soap over a liquid body wash can still benefit from acne-fighting salicylic acid with the Clinique Acne Solutions Cleansing Bar. This mild soap unclogs pores and removes excess oil without drying out skin. Clinique Acne Solutions cleansing bar for face & body, $23, Don’t Miss: Is Murad Good For Acne Dont Try To Pop It Seriously Cystic zits literally cannot be popped, since the problem is so deep within your skin. Trying to manipulate or squeeze the cyst will only push the inflammation out further, leading to more severe scarring and a possible infection, says Shari Marchbein, MD, a dermatologist in New York City. Even if it has the tiniest of whiteheads on top, dont trust itthat sh*t is deep, and youll never get it out. You will always make it worse. & 3 Hypertrophic And Keloidal Scars Whereas atrophic scars create skin indentations, hypertrophic and keloidal scars cause a raised skin growth. Both form when the body overproduces collagen to the point that the scar raises out of the skin. Even for dermatologists, it can be difficult to determine whether a raised scar is a hypertrophic scar or a keloid. However, a 2020 study published in the British Journal of Dermatology distinguished the differences between the two types of acne scars as such: - grow larger than the borders of the original wound - dont grow smaller on their own - have very thick bands of connective tissue in their inner layer Though all sorts of skin types can develop hypertrophic and keloidal scars, Dr. Green points out that people with darker skin are more susceptible to developing keloids. Dont Miss: What Helps Remove Acne Scars Don’t Miss: How To Remove Dark Acne Scars Do Not Pick Pimples And Acne Zits Disturbing acne zits and crusts is a sure way of getting them to turn into wounds. Picking and popping them affects their healing time, making them take a lot longer to go away. Even if you have scars that wont go away, ensure that you exercise restraint to prevent them from getting infected and scabbing over. Your fingernails may have bacteria and other microbes. If you keep touching the itchy bumps and pimples, you may end up with an infection on your face. - Allow the initial blood clot on your pimples to remain and form into a crust. It will protect your wounds and help them heal faster. - Eat a balanced diet to help your wounds heal faster. - Vitamin D, C and E in your diet can help your acne scabs heal faster. If your zits are itchy, try applying a natural antihistamine to help relieve and soothe the itchiness. This will help you avoid popping and picking them. Cell Phone Use And Touching Nobody ever thinks of this, however, this may very well be the trigger of the acne around your mouth and chin. Bacteria that are stuck onto your phone screen can easily be transmitted onto your skin, especially if you rest your cell phone on your chin while you talk. Additionally, I often catch myself resting my chin in my hand while reading, listening to someone, watching TV, and even while using my phone, and I never once realized that this may be triggering my chin acne. Once I started becoming more aware of it, my acne did really lessen its appearance on my chin, so I was sure that resting my chin in my hands couldve had some negative effect on my chin breakouts. Recommended Reading: Why Do I Have So Much Back Acne Powerful Home Remedies For Acne Acne is one of the most common skin conditions in the world, affecting an estimated 85% of young adults . Conventional acne treatments like salicylic acid, niacinamide, or benzoyl peroxide are proven to be the most effective acne solutions, but they can be expensive and have undesirable side effects, such as dryness, redness, and irritation. This has prompted many people to look into remedies to cure acne naturally at home. In fact, one study found that 77% of acne patients had tried alternative acne treatments . Many home remedies lack scientific backing, and further research on their effectiveness is needed. If youre looking for alternative treatments, though, there are still options you can try. This article explores 13 popular home remedies for acne. What Type Of Scarring Do You Have Gross says there are four different types of acne scars one can get: ice pick, rolling, boxcar and hypertrophic. Once you figure out what type you’re dealing with, it’s easier to choose the most effective treatment to getting rid of those scars. You May Like: What Does Acne Prone Skin Mean Shop Our Favorite Vitamin C Face Products “At-home microneedling can be effective, however you can achieve faster results with medical-grade options,” says Martino. To improve the texture of your skin at home, look for a face roller that uses surgical grade stainless steel like Gold Roll CIT. 5. Don’t skimp on sunscreen. The most important acne scar treatment in your arsenal is actually SPF. Sunscreens help tremendously with reducing hyperpigmentation associated with scars, says Dr. Henry. Bonus: It also prevents your acne scar from getting any darker. 6. It might sound weird, but try to avoid coconut oil. Some people like this ingredient to soothe inflammation, but on the face it can do the opposite. Coconut oil can actually clog pores and cause scars, says Dr. Henry. Dermabrasion For Cystic Acne Scars Treatment Dermabrasion refers to the process of sloughing the top layer of the skin using a wire brush. With this method, deep scars may require more than one session for their visibility to be significantly reduced. For lighter scars, microdermabrasion may be more appropriate. It applies the same technique but instead of a wire brush the sloughing is done using small crystals. The results in this one are less pronounced than those achieved through dermabrasion Read Also: How To Heal Acne Scabs Fast Its Never Too Late To Treat Those Scars Although its not possible to get rid of your acne scars quickly, its never too late to treat them. Teenage patients may have to wait until their early 20s before undergoing treatment to make sure theres little risk of future acne flare-ups. While theres no real way to get rid of acne scars naturally and at home, there are a few things you can do to reduce your risk of getting acne scars: - Quit smoking or dont start smoking. - Keep your hands off of your face. Resist the urge to pick or squeeze your pimples. - Treat your acne as soon as possible to reduce the chance of scars. Scarring can happen at any age, no matter if youre a teenager and your hormones are changing or youre an adult. Sometimes when adults lose weight or lose elasticity in their skin as they age, scarring from years past becomes more evident. Occasionally, we will actually remove a pitted scar that we know wont heal well with standard treatment using a technique called punch excision, she says. This is where the whole scar and hair follicle are removed prior to resurfacing. Another treatment that may be helpful before any of the lasers or peels is called subcision, a procedure that involves releasing a scar thats bound to the muscle or deeper tissues so that it can move freely again. Both of these techniques are used with deeper scars to bring them to the surface to enhance their response to the laser, chemical peel or microneedling.

Topics on this page Regular Exams and Cleanings Regular exams are an important part of maintaining your oral health. During your regular exam, we will: - Check for any problems that you may not see or feel - Look for cavities or any other signs of tooth decay - Inspect your teeth and gums for gingivitis and signs of periodontal disease - Perform a thorough teeth cleaning Your regular exam will take about 45 minutes. Each regular exam includes a detailed teeth cleaning, in which we will clean, polish, and rinse your teeth to remove any tartar and plaque that have built up on the tooth's surface. Visiting our office every six months gives you the chance to talk to the doctor about any questions you may have about your oral health. Regular exams are offered by appointment only, so please contact our practice today to schedule your next dental exam and teeth cleaning. Bonding is a conservative way to repair slightly chipped, discolored, or crooked teeth. During dental bonding, a white filling is placed onto your tooth to improve its appearance. The filling “bonds” with your tooth, and because it comes in a variety of tooth-colored shades, it closely matches the appearance of your natural teeth. Tooth bonding can also be used for tooth fillings instead of silver amalgam. Many patients prefer bonded fillings because the white color is much less noticeable than silver. Bonded fillings can be used on front or back teeth, depending on the location and extent of tooth decay. Bonding is less expensive than other cosmetic treatments and can usually be completed in one visit to our office. However, bonding can stain and is easier to break than other cosmetic treatments, such as porcelain veneers. If it does break or chip, tell your doctor. The bonding can generally be easily patched or repaired in one visit. A bridge may be used to replace missing teeth, help maintain the shape of your face, and alleviate stress on your bite. A bridge replaces missing teeth with artificial teeth, looks great, and literally bridges the gap where one or more teeth may have been. Your bridge can be made from gold, alloys, porcelain, or a combination of these materials and is bonded onto surrounding teeth for support. The success of any bridge depends on its foundation — the other teeth, gums, or bone to which it is attached. Therefore, it’s very important to keep your existing teeth, gums, and jaw healthy and strong. Crowns are a restorative procedure used to improve your tooth’s shape or to strengthen a tooth. Crowns are most often used for teeth that are broken, worn, or have portions destroyed by tooth decay. A crown is a “cap” cemented onto an existing tooth that usually covers the portion of your tooth above the gum line. In effect, the crown becomes your tooth’s new outer surface. Crowns can be made of porcelain, metal, or both. Porcelain crowns are most often preferred because they mimic the translucency of natural teeth and are very strong. Crowns or onlays (partial crowns) are needed when there is insufficient tooth strength remaining to hold a filling. Unlike fillings, which apply the restorative material directly into your mouth, a crown is fabricated away from your mouth. Your crown is created in a lab from your unique tooth impression, which allows a dental laboratory technician to examine all aspects of your bite and jaw movements. Your crown is then sculpted just for you so that your bite and jaw movements function normally once the crown is placed. Dentures are natural-looking replacement teeth that are removable. There are two types of dentures: full and partial. Full dentures are given to patients when all of the natural teeth have been removed. Partial dentures are attached to a metal frame that is connected to your natural teeth and are used to fill in where permanent teeth have been removed. Just like natural teeth, dentures need to be properly cared for. Use a gentle cleanser to brush your dentures, always keep them moist when they’re not in use, and be sure to keep your tongue and gums clean as well. There are times when it is necessary to remove a tooth. Sometimes a baby tooth has misshapen or long roots that prevent it from falling out as it should, and the tooth must be removed to make way for the permanent tooth to erupt. At other times, a tooth may have so much decay that it puts the surrounding teeth at risk of decay, so your doctor may recommend removal and replacement with a bridge or implant. Infection, orthodontic correction, or problems with a wisdom tooth can also require removal of a tooth. When it is determined that a tooth needs to be removed, your dentist may extract the tooth during a regular checkup or may request another visit for this procedure. The root of each tooth is encased within your jawbone in a “tooth socket,” and your tooth is held in that socket by a ligament. In order to extract a tooth, your dentist must expand the socket and separate the tooth from the ligament holding it in place. While this procedure is typically very quick, it is important to share with your doctor any concerns or preferences for sedation. Once a tooth has been removed, neighboring teeth may shift, causing problems with chewing or with your jaw joint function. To avoid these complications, your dentist may recommend that you replace the extracted tooth. Traditional dental restoratives, or fillings, are most often made of silver amalgam. The strength and durability of this traditional dental material makes it useful for situations where restored teeth must withstand extreme forces that result from chewing, often in the back of the mouth. Newer dental fillings include ceramic and plastic compounds that mimic the appearance of natural teeth. These compounds, often called composite resins, are usually used on the front teeth where a natural appearance is important, but they can also be used on the back teeth depending on the location and extent of the tooth decay. There are two different kinds of fillings: direct and indirect. Direct fillings are fillings placed into a prepared cavity in a single visit. They include silver amalgam, glass ionomers, resin ionomers, and composite (resin) fillings. Indirect fillings generally require two or more visits. They include inlays, onlays, and veneers. They are used when a tooth has too much damage to support a filling but not enough to necessitate a crown. Fluoride is effective in preventing cavities and tooth decay and in preventing plaque from building up and hardening on the tooth’s surface. A fluoride treatment in your dentist’s office takes just a few minutes. After the treatment, patients may be asked not to rinse, eat, or drink for at least 30 minutes in order to allow the teeth to absorb the fluoride. Depending on your oral health or your doctor’s recommendation, you may be required to have a fluoride treatment every three, six, or 12 months. If you are missing teeth, it is crucial to replace them. Without all your teeth, chewing and eating can destabilize your bite and cause you discomfort. When teeth are missing, your mouth can shift and even cause your face to look older. Implants are a great way to replace your missing teeth, and if properly maintained, can last a lifetime! An implant is a new tooth made of metal and porcelain that looks just like your natural tooth. It’s composed of two main parts: one part is the titanium implant body that takes the place of the missing root, and the second part is the tooth-colored crown that is cemented on top of the implant. With implant treatment, you can smile confidently knowing no one will ever suspect you have a replacement tooth. In addition to tooth replacement, implants may be used to anchor dentures, especially lower dentures that tend to shift when you talk or chew. For patients with removable partial dentures, implants can replace missing teeth so you have a more natural-looking smile. Whether you wear braces or not, protecting your smile while playing sports is essential. Mouthguards help protect your teeth and gums from injury. If you participate in any kind of full-contact sport, the American Dental Association recommends that you wear a mouthguard. Choosing the right mouthguard is essential. There are three basic types of mouthguards: the pre-made mouthguard, the “boil-and-bite” fitted mouthguard, and a custom-made mouthguard from your dentist. When you choose a mouthguard, be sure to pick one that is tear-resistant, comfortable and well-fitted for your mouth, easy to keep clean, and does not prevent you from breathing properly. Your dentist can show you how to wear a mouthguard properly and how to choose the right mouthguard to protect your smile. If you often wake up with jaw pain, earaches, or headaches, or if you find yourself clenching or grinding your teeth, you may have a common condition called “bruxism.” Many people do not even know that they grind their teeth, as it often occurs when one is sleeping. If not corrected, bruxism can lead to broken teeth, cracked teeth, or even tooth loss. There is an easy, non-invasive treatment for bruxism: nightguards. Nightguards are an easy way to prevent the wear and damage that teeth-grinding causes over time. Custom-made by your dentist from soft material to fit your teeth, a nightguard is inserted over your top or bottom arch and prevents contact with the opposing teeth. In the past, if you had a tooth with a diseased nerve, you'd probably lose that tooth. Today, with a special dental procedure called “root canal treatment,” your tooth can be saved. When a tooth is cracked or has a deep cavity, bacteria can enter the pulp tissue and germs can cause an infection inside the tooth. If left untreated, an abscess may form. If the infected tissue is not removed, pain and swelling can result. This can not only injure your jawbones, but it is also detrimental to your overall health. Root canal treatment involves one to three visits. During treatment, your general dentist or endodontist (a dentist who specializes in problems with the nerves of the teeth) removes the affected tissue. Next, the interior of the tooth will be cleaned and sealed. Finally, the tooth is filled with a dental composite. If your tooth has extensive decay, your doctor may suggest placing a crown to strengthen and protect the tooth from breaking. As long as you continue to care for your teeth and gums with regular brushing, flossing, and checkups, your restored tooth can last a lifetime. Sometimes brushing is not enough, especially when it comes to those hard-to-reach spots in your mouth. It is difficult for your toothbrush to get in-between the small cracks and grooves on your teeth. If left alone, those tiny areas can develop tooth decay. Sealants give your teeth extra protection against decay and help prevent cavities. Dental sealants are plastic resins that bond and harden in the deep grooves on your tooth’s surface. When a tooth is sealed, the tiny grooves become smooth and are less likely to harbor plaque. With sealants, brushing your teeth becomes easier and more effective against tooth decay. Sealants are typically applied to children’s teeth as a preventive measure against tooth decay after the permanent teeth have erupted. However, adults can also receive sealants on healthy teeth. It is more common to seal “permanent” teeth rather than “baby” teeth, but every patient has unique needs, and your dentist will recommend sealants on a case-by-case basis. Sealants last from three to five years, but it is fairly common to see adults with sealants still intact from their childhood. A dental sealant only provides protection when it is fully intact, so if your sealants come off, let your dentist know, and schedule an appointment for your teeth to be re-sealed. You no longer need to hide your smile because of gaps, chips, stains, or misshapen teeth. With veneers, you can easily correct your teeth’s imperfections to help you have a more confident, beautiful smile. Veneers are natural in appearance, and they are a perfect option for patients wanting to make minor adjustments to the look and feel of their smile. Veneers are thin, custom-made shells made from tooth-colored materials (such as porcelain), and they are designed to cover the front side of your teeth. To prepare for veneers, your doctor will create a unique model of your teeth. This model is sent to the dental technician to create your veneers. Before placing your new veneer, your doctor may need to conservatively prepare your tooth to achieve the desired aesthetic result. When your veneers are placed, you’ll be pleased to see that they look like your natural teeth. While veneers are stain-resistant, your doctor may recommend that you avoid coffee, tea, red wine, and tobacco to maintain the beauty of your new smile. Wisdom teeth are types of molars found in the very back of your mouth. They usually appear in the late teens or early twenties, but may become impacted (fail to erupt) due to lack of room in the jaw or angle of entry. When a wisdom tooth is impacted, it may need to be removed. If it is not removed, you may develop gum tenderness, swelling, or even severe pain. Impacted wisdom teeth that are partially or fully erupted tend to be quite difficult to clean and are susceptible to tooth decay, recurring infections, and even gum disease. Wisdom teeth are typically removed in the late teens or early twenties because there is a greater chance that the teeth's roots have not fully formed and the bone surrounding the teeth is less dense. These two factors can make extraction easier as well as shorten the recovery time. In order to remove a wisdom tooth, your dentist first needs to numb the area around the tooth with a local anesthetic. Since the impacted tooth may still be under the gums and imbedded in your jaw bone, your dentist will need to remove a portion of the covering bone to extract the tooth. In order to minimize the amount of bone that is removed with the tooth, your dentist will often “section” your wisdom tooth so that each piece can be removed through a small opening in the bone. Once your wisdom teeth have been extracted, the healing process begins. Depending on the degree of difficulty related to the extraction, healing time varies. Your dentist will share with you what to expect and provide instructions for a comfortable, efficient healing process.

I went to a park today with my son to hike the nature trails. We arrived just before the peak viewing of the solar eclipse began in our area and saw some people setting up photography equipment in the parking lot. As we did not have safety glasses we continued on to explore the trails and enjoy the coolness of the woods. We were content just to be enjoying the outdoors, spending time together and hunting for treasures amid the mossy trails. For us, the woods have always been one of our favorite places to hike and enjoy God’s amazing creation. The woods are enchanting, with its own unique climate, cool and moist, with its very own symphony of sounds created by the creatures which dwell there. As we walked and pointed out various finds to each other we passed by an older gentleman who stopped us to inquire if we had viewed the eclipse. When we responded that we had not, he kindly informed us that we are actually able to get a wonderful view from within the woods. That the tiny holes in the canopy of leaves above act like a natural pinhole camera and for the next several minutes the shadows created by the sun would be reflected in a crescent shape instead of the normal round. And sure enough, all around we were surrounded by half moon beams of light. We just happened to be in the right place at the right time. How wonderful of the Lord to put someone on our path to share that with us. While admiring the beauty of the creation on Earth, we got to enjoy a facet of the creation within the heavens. God’s account of creation in Genesis is so beautifully detailed and perfectly reflects God’s heart. Each day is recorded as the magnificence of His earth and the fullness therein comes to fruition. It’s so cool how He made all of it before man, then man, His ultimate creation, was placed right in the middle of it. The earth and its fullness were given to him to simply enjoy and as he cared for it, to reap all of its benefits. It’s awesome to realize that God’s heart has always been: FAMILY! He longed for children to share His creation with. It’s truly amazing to think that God walked and talked with them the same way we would enjoy spending time with our family. What’s even MORE amazing is that His heart has never changed! He STILL desires to walk and talk with us and gets pleasure from watching us, His children, reign on earth and enjoy all the benefits of His creation. I like to think as we were all so occupied with looking UP today, He was looking DOWN upon us and pleased that every day that passes on Earth we are that much closer to joining Him in heaven to reign for all eternity.

Choking among the elderly is extremely common and can lead to death if not addressed immediately. This is why caregivers are strongly encouraged to learn the Heimlich Maneuver and CPR. Why are seniors so prone to choking? Aging adults have decreased saliva due to the aging process of the salivary glands. Saliva is needed to swallow and digest food. Additionally, many elderly may not chew well due to loose or missing teeth. Some may have swallowing problems following a stroke or accident. It is at these times when the dietician and medical staff may consult and change the consistency of the resident's diet. The top foods and liquids that cause choking are: - Hot Dogs - Chicken with bones - Peanut Butter - Pizza with heavy cheese - Hard candy - White bread Depending on diagnostic studies called "swallow studies", the consistency of the diet can be altered to accommodate the resident's swallow reflexes. If a resident appears to have difficulty with the consistency of a diet, caregivers should change the food and liquid and immediately. The following are the consistencies commonly regulated by dieticians: - Whole consistency - Assistance is usually only needed for cutting. - Cut-up food consistency - All food must be cut up no larger than 1/2 inch all around. - Chopped food - All food must be cut up by hand to 1/4 inch. No finger foods. - Ground food consistency - All food must be ground in a machine to a cottage cheese consistency and must be moist. - Puréed food consistency - All food is prepared to a smooth consistency by grinding and pureeing it. Appearance is pudding like. The following are liquid consistencies: - Thin and non-restrictive - Action depends on the resident's needs, but action may not be required. However, thickening agents may be required. - Juices - Nectars and pulpy liquid may require thickening agent - Honey - Caregivers should be cautious due to honey's sticky nature. - Pudding - These liquids are easily fed on a spoon and generally have low choking risks. Caretakers are encouraged to not hurry when assisting with meals since the elderly become overwhelmed and may choke as a result of the stress.

You cannot create a Lecturio account without granting permission to use your email address. Based on our terms and conditions it is not possible to create a Lecturio account without an email address. Lecturio requires a valid email address in order to inform you about important changes and updates (e.g., of our terms and conditions, the status of your course access, etc.). by Zach Davis, Stuart Enoch, PhD, Noor Sash, PhD u.a. Everything you ever wanted to know about medicine – in one package! Lecturio’s “Medicine Flat Rate” includes all current and prospective medical courses. It will provide you with invaluable guidance and comprehensive support for your study and training – not only for medical students, but also for nurses and non-medical practitioners. You will get access to an impressive variety of lectures held by renowned experts, such as the editor-in-chief of The American Journal of Medicine, Prof. Joseph Alpert. Our team of highly qualified medical professionals will guide you through the following main topics: NCLEX-RN Review Course The courses “Basic and Further Science”, “Internal Medicine” and “Specialties” will be added soon. The apophysis is a secondary ossification center found on non-weight-bearing segments of bones. It is the site of ligament or tendon insertion and is involved in the peripheral growth of bones. These secondary growth centers are generally open during childhood and do not close until early adulthood. Chronic apophyseal injury (traction apophysitis) almost always happens in adolescent athletes during periods of growth. Types of chronic apophyseal injury include Sever disease (posterior calcaneal apophysitis), Osgood-Schlatter disease (tibial tuberosity apophysitis), little league elbow (medial epicondyle apophysitis), and Sinding-Larsen-Johansson syndrome (inferior patella apophysitis). Diagnosis is generally made clinically. Chronic apophyseal injuries are generally treated with a conservative approach and rarely require surgical intervention. The spleen is the largest ductless gland and largest single lymphatic organ in the human body. The main functions of the spleen are immunologic surveillance and red blood cell breakdown. The spleen can be affected by diseases of different origins, such as inflammatory, congenital, infectious, neoplastic, and vascular diseases. Ultrasonography (US) is usually used as the 1st-line imaging modality due to its easy accessibility and lack of ionizing radiation, but CT and MRI with contrast can also be helpful. Contrasted imaging modalities can delineate lesions and help differentiate disorders. The mediastinum is the central part of the chest cavity containing many vital structures, such as the heart, great vessels, trachea, thoracic esophagus, lymph nodes, multiple nerves, sympathetic chains, and thoracic spine. Mediastinal pathology (e.g., masses) can be noted on conventional radiographs as part of evaluating chest-related symptoms, or it can be incidentally detected. To elucidate the characteristics of the mediastinal abnormality, further imaging studies are warranted. Common additional modalities are CT and MRI. Cranial nerve palsy is a congenital or acquired dysfunction of 1 or more cranial nerves that will, in turn, lead to focal neurologic abnormalities in movement or autonomic dysfunction of its territory. Head/neck trauma, mass effect, infectious processes, and ischemia/infarction are among the many etiologies for these dysfunctions. Diagnosis is initially clinical and supported by diagnostic aids. Management includes both symptomatic measures and interventions aimed at correcting the underlying cause. Informed consent (IC) is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. The patient's well-being and autonomy are the 2 key fundamental moral values that are preserved by IC. Medical care decisions requiring IC range from the choice to undergo a defined medical or surgical treatment to participation in a research study. The IC represents shared decision-making between the patient and their caregiver and is thus mandatory for both clinical care and enrollment in research studies. Informed consent is usually documented in a signed written form. Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Surface receptors are bound to the cell membrane, receive signals from their surrounding environment, and transmit those signals into the cell, often via the generation of 2nd messengers (like cyclic adenosine monophosphate (cAMP)) or through phosphorylation cascades. There are multiple different subclasses of surface receptors, and 3 of the most important classes include ligand-gated ion channel receptors, enzyme-linked receptors (the most common of which are receptor tyrosine kinases (RTKs)), and G-protein-coupled receptors (GPCRs). Intracellular receptors, on the other hand, are located within the cytoplasm and often act as transcription factors, directly interacting with DNA and affecting gene expression. Diagnostic modalities such as chest X-rays provide static images of the thoracic cavity, including the lungs and airways. While providing a wealth of anatomical information necessary for the diagnosis of pulmonary disease, chest X-rays do not give much information about the individual's respiratory function. Pulmonary function tests are a group of diagnostic procedures yielding useful, quantifiable information about the rate of the flow of air through the individual's airways, lung capacity, and the efficiency of gas exchange in relation to time. The most commonly utilized tests include spirometry (before and after bronchodilator use), lung volumes, and quantitation of diffusing capacity for carbon monoxide (CO). The tests can be influenced by the individual's effort/fatigue, disease state, or anatomical malformation. Nerve tissue consists of 2 principal types of cells: neurons and supporting cells. The neuron is the structural and functional/electrically excitable unit of the nervous system that receives, processes, and transmits electrical signals to and from other parts of the nervous system via its cell processes. There are multiple types of neurons that are classified based on their anatomic structure and function as sensory neurons, motor neurons, and interneurons. The functional components of a neuron include dendrites (to receive signals), a cell body (to drive cellular activities), an axon (to conduct impulses to target cells), and synaptic junctions (specialized junctions between neurons that facilitate the transmission of impulses between neurons; they are also found between axons and effector/target cells, such as muscle and gland cells). Supporting cells are called neuroglial cells and are located close to the neurons; however, these cells do not conduct electrical signals. The CNS consists of 4 types of glial cells: oligodendrocytes, astrocytes, microglia, and ependymal cells, each having a different function. In the PNS, the supporting cells are called peripheral neuroglia and include Schwann cells, satellite cells, and various other cells having specific structures and functions. Schwann cells surround the processes of nerve cells and isolate them from adjacent cells and the extracellular matrix by producing a lipid-rich myelin sheath, ensuring the rapid conduction of nerve impulses. Satellite cells are similar to Schwann cells, but they surround the nerve cell bodies. In the CNS, oligodendrocytes produce and maintain the myelin sheath. A nerve is composed of a collection of bundles (or fascicles) of nerve fibers. Within the CNS, the brain and spinal cord tissue can be classified as gray or white matter, depending on the tissue composition. White matter is most notably composed of myelinated nerve fibers, whereas gray matter is made up of neuronal cell bodies. Invasive mechanical ventilation (IMV) is an advanced airway modality used for individuals with immediate or impending respiratory failure and/or in preparation for surgery. The IMV technique involves positive pressure ventilation delivered to the lungs through an endotracheal tube via a ventilator. The ventilator can be set to specific modes that determine how the machine assists with breathing. The modes are tailored to the individual's needs. The mode refers to the characteristics of mechanical ventilation and mainly includes trigger (how inspiration begins), cycle (how inspiration ends), and limit (when inspiration should be aborted). The most commonly used mode is assist-control ventilation, which is usually followed by pressure-support ventilation for weaning. Careful consideration should be exercised while planning extubation, as IMV is associated with complications. In the pediatric population, imaging often plays a critical diagnostic role, especially in diagnosing congenital anomalies. In children, CT scans are avoided if at all possible due to the high risk of radiation exposure. In addition, both CT and (especially) MRI require children to hold still for significant periods of time and often require sedation to complete the study. For these reasons, plain radiography (often with contrast), fluoroscopy, and ultrasound are the imaging modalities of choice for most suspected cases involving GI pathology. Some conditions that can be diagnosed using imaging include hypertrophic pyloric stenosis, necrotizing enterocolitis, midgut malrotation with or without volvulus, intestinal atresia intussusception, appendicitis, Hirschsprung disease, mesenteric lymphadenitis, and obstructions of the biliary tree. Chest abnormalities are a common presenting pathology of the pediatric population. Imaging modalities such as chest X-rays are the initial diagnostic test of choice used in urgent/emergent pediatric cases. Imaging modalities aid in differentiating the causes of respiratory distress in infants and finding the underlying infectious, traumatic, or congenital disorder. Computed tomography (CT) is a useful adjunctive modality in the pediatric population when conventional radiography fails to adequately characterize pathology. Given the common occurrence with many cardiac or vascular anomalies, specific protocols are necessary to highlight potentially abnormal anatomical structures. Pediatric chest imaging is a multimodality process at most centers used to help answer clinical questions and adequately care for individuals. Imaging of the intestines is typically performed utilizing a multimodal approach, with clinical suspicion being the primary indicator for which study should be completed and in what order. There are also many differences between outpatient imaging versus emergency or inpatient imaging of the intestines. Imaging varies widely based on the patient's history, symptoms, and physical exam findings. The patient's age will also play a factor in the modality chosen. For example, appendicitis is typically 1st evaluated via ultrasound in the pediatric population versus CT in adults. Surgical complications are conditions, disorders, or adverse events that occur following surgical procedures. The most common general surgical complications include bleeding, infections, injury to the surrounding organs, venous thromboembolic events, and complications from anesthesia. In addition, patients may also experience a variety of cardiac, pulmonary, renal/urologic, and CNS complications, especially if the patient is elderly and/or has underlying medical comorbidities. The clinician should be aware of all of these potential complications and their presenting symptoms in order to quickly identify and treat them. Some of the most common signs and symptoms suggestive of a potential complication include tachycardia, hypoxia, fever, pain, and mental status changes. Congenital infections are acquired in utero or during passage through the birth canal at birth and can be associated with significant morbidity and mortality for the infant. The TORCH infections are a group of congenital infections grouped due to their similar presentation. The acronym TORCH arises from the names of the infectious agents that cause the diseases included in this group: toxoplasmosis, other agents (syphilis, varicella zoster virus (VZV), parvovirus B19, and HIV), rubella, CMV, and herpes simplex. The primary goals of antepartum testing and monitoring are to assess fetal well-being, identify treatable situations that may cause complications, and evaluate for chromosomal abnormalities. Antepartum tests for aneuploidy are typically performed in the 1st and 2nd trimesters. These tests are divided into screening tests (which include cell-free DNA testing, serum analyte testing, and nuchal translucency measurements), and diagnostic tests, which provide a definitive diagnosis of aneuploidy and include chorionic villus sampling (CVS) and amniocentesis. Antepartum monitoring is done in the 2nd and 3rd trimesters to evaluate fetal well-being and assess the risk of fetal death. Antepartum monitoring tests include continuous cardiotocography (i.e., fetal heart rate tracings), the non-stress and contraction stress tests (NST and CST, respectively), the fetal biophysical profile (BPP), and umbilical artery Doppler studies. In the human brain, information is transmitted in the form of bioelectrical impulses and chemical signaling molecules. These molecules, called neurotransmitters, are protein molecules used by neurons to emit a specific signal. The signals are picked up in the plasma membrane of adjacent neurons by receptors, which are complexes of protein subunits responsible for sensing relevant stimuli and setting in motion the cellular machinery required to produce the desired response. Cancer immunotherapy is a rapidly advancing medical therapy that takes advantage of the immune system to contain or eliminate cancer cells. Currently, immunotherapies have been incorporated into treatment regimens for different types of cancer. Various therapeutic approaches exist, including using cytokines, vaccines, oncolytic viruses, T-cell manipulation or cellular adoptive immunotherapy, or antibodies to immune checkpoint molecules. These therapies provide new options for advanced cancers, including melanoma, renal cell carcinoma, prostate adenocarcinoma, lung cancer, urothelial carcinoma, Hodgkin lymphoma, and refractory B-cell ALL. With the immune system involved, these agents carry serious and potentially fulminant adverse effects and toxicities. Homeostasis is the steady state of equilibrium. Similarly, in biochemistry, energy homeostasis is the balance point between energy supplied and energy dissipated (i.e., a constant energy state) that the human body seeks to maintain for optimal performance. The hypothalamus plays a central role in regulating energy homeostasis. Inefficient energy homeostasis is thought to be a major factor in the obesity epidemic. Many models have been proposed to explain and further understand the mechanism of energy homeostasis. The prenatal period begins with the formation of the embryo and continues through the development of the fetus, terminating with birth. Neonatal physiology during prenatal life differs significantly from that during postnatal life. Before birth, nutrient, gas exchange, and elimination of waste products occur via the placenta. The fetus receives oxygenated blood via the umbilical vein, and deoxygenated blood is removed via the umbilical arteries. The 3 shunts that help redirect the fetal circulation are the ductus venosus, foramen ovale, and ductus arteriosus. These shunts close after birth, leaving behind vestigial remnants. Postnatally, the fetal circulatory system and organ systems adapt to the extrauterine environment. Placental blood supply is cut off, causing the neonate to make adaptive changes. Estrogen and progesterone are the sex hormones produced by the ovaries in premenopausal women. These agents are responsible for developing and maintaining female sex organs and secondary sexual characteristics. Estrogen and progesterone are used to treat hypogonadism (primary ovarian insufficiency), menopausal symptoms, and gender dysphoria in transgender women. Risks and side effects include uterine bleeding, predisposition to cancer, breast tenderness, hyperpigmentation, migraines, hypertension, and mood changes. Contraindications are estrogen-dependent neoplasms, thromboembolic disorders, and liver disease. Immunoassays are plate-based techniques that can detect and quantify many types of molecules through antibody-antigen reactions. An immunoassay typically involves an analyte, a targeted antibody, and labels. Classification of immunoassays is based on the type of label utilized, which includes enzymes (ELISA), light-emitting molecules/tracers (e.g., chemiluminescence and fluorescence immunoassays), and radioactive isotopes (radioimmunoassays). These specialized immunoassays are relatively sensitive, specific, inexpensive, and rapid, and are widely used in a clinical setting. Immunoassays are used in the diagnosis of infectious diseases, identification of tumor markers, allergy testing, and monitoring drug levels. Blotting techniques involve the separation (via electrophoresis) and transfer of DNA, RNA, or proteins onto a blotting membrane. This separation is generally followed by complexing of the target with a labeled molecule for detection. Southern blotting is used to evaluate for specific DNA sequences and may be used in identification of genetic mutations and in forensics. Northern blotting focuses on RNA sequences and is helpful in assessing gene expression. Western blotting identifies proteins and antibodies and has applications in diagnosing infectious diseases, protein abnormalities (such as prion disease), and autoimmune conditions. Although these tests have good specificity, they have significant disadvantages owing to their expense, labor-intensiveness, and slow turnaround time. An abnormal amount of lipid in blood is called dyslipidemia, which includes abnormal levels of cholesterol, triglycerides, and/or lipoproteins. Dyslipidemia may be primary (familial) or secondary (acquired). Both primary and secondary causes can lead to the development of premature cardiovascular (atherosclerosis) disease. Familial causes are classified according to the Fredrickson system, which looks into the pathology and the lipids that are elevated. Certain types do not increase the risk of premature atherosclerotic disease but still impact overall cardiac risk and chance of cardiovascular events in the future. Screening, early diagnosis, and strict control and management are the keys to prevention of cardiovascular events. Pelvic organ prolapse (POP) is a general term that refers to herniation of 1 or more pelvic organs (e.g., bladder, uterus, rectum) into the vaginal canal, and potentially all the way through the introitus. Weakness and insufficiency of the pelvic floor may result in POP. The major risk factors include parity, vaginal delivery, age, obesity, and conditions characterized by increased abdominal pressure. Affected individuals typically present with vaginal pressure and the sensation of a vaginal bulge, often with associated urinary and defecatory urges. Diagnosis is clinical and management is based on the subject's desires and symptoms. Classification of POP is using either the POP-Q staging system or the Baden-Walker grading system. Conservative approaches include vaginal pessaries, pelvic muscle strengthening exercises, and reducing modifiable risk factors. Surgical repair is an option for individuals with more severe symptoms. Proteins have an extensive range of functions in the body. Structural proteins help maintain the physical integrity of cells and allow movement of substances within cells. Catalytic proteins are enzymes, which are critical in almost all biologic functions (e.g., metabolism, coagulation, digestion). Communication, signaling, and regulatory proteins are critical in coordinating responses throughout the organism, and include receptors, hormones, neurotransmitters, intracellular signaling molecules (such as kinases and G-proteins), and transcription factors. Additionally, proteins are involved in transportation of substances through the bloodstream, as well as across cell membranes. Proteins also play a critical role in the immune system. The ankle is a hinged synovial joint formed between the articular surfaces of the distal tibia, distal fibula, and talus. The ankle primarily allows plantar flexion and dorsiflexion of the foot. The subtalar joint and the other tarsal bones create many synergistic articulations, allowing for a wide range of motion (ROM)–plantar flexion, dorsiflexion, eversion, inversion, abduction, and adduction. The movements are generated by large muscle groups that originate in the leg and insert as well as act upon the bones of the foot and tarsus. There is a global consensus that quality health care should be safe, effective, and patient-centered, yet adverse events during hospital care cause death and disability worldwide. Almost half of these adverse events are preventable in high-income countries, and that proportion is even higher in low- and middle-income countries. The growing complexity of health care systems has been linked to an increase in medical errors resulting in health-care-related adverse events. The term "error" has negative connotations, and the goal of patient safety measures is to prevent adverse events by following accepted practice at a system or individual level. Sentinel events that result in unexpected mortality or major harm to a patient signal the need for investigation and response. Types of medical errors include adverse drug events, incorrect or delayed diagnosis, and errors during procedures and surgeries. The science and culture of patient safety are based on the premise that human error will occur and that we can build systems that prevent and reduce these occurrences. This culture provides a framework for balanced accountability of the individual and the organization in designing workplace systems that are safe and reliable. Many strategies have been implemented to prevent and address medical errors that affect patient safety. The primary functions of the GI tract include the digestion of food and the absorption of nutrients. Multiple organs in the GI system secrete various substances into the lumen to assist in digestion and/or the regulation of GI function. The majority of digestive secretions come from the salivary glands, stomach, pancreas, and gallbladder, although the intestines secrete fluids and mucus too, which are critical in protecting their inner walls. The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons that allow for flexibility as well as dynamic and static support. The foot has 3 primary arches and multiple ligaments that are essential to its structure. The arches are important in absorbing weight during standing, walking, and running and the ability to adapt to uneven terrain during locomotion. Proteins are 1 of the 3 primary macronutrients in the body and are synthesized from individual building blocks called amino acids (AAs). Amino acids are bound together by peptide bonds, which link the amino end of one AA to the carboxy end of the next AA, generating a protein's primary structure. The strand of AAs then undergoes additional folding, ultimately generating complex 3-dimensional structures. Proteins have a wide variety of functions, including catalytic, structural, regulatory, transport, storage, and immunologic functions. They are digested by proteases and peptidases secreted by the stomach and pancreas and absorbed as individual AAs in the small intestines through specialized transporters. There are countless medical conditions related to protein abnormalities, including abnormalities related to enzymes, receptors, membrane channels, hormones, accumulation of proteins, and autoimmune disorders. Pharmacokinetics is the science that analyzes how the human body interacts with a drug. Pharmacokinetics examines how the drug is absorbed, distributed, metabolized, and excreted by the body. Pharmacodynamics is the science that studies the biochemical and physiologic effects of a drug and its organ-specific mechanism of action, including effects on the cellular level. Another way to describe the difference between the 2 disciplines is to say that pharmacokinetics is "what the body does to the drug," whereas pharmacodynamics is "what the drug does to the body." When prescribing medications, physicians must take into account both the drug's pharmacodynamics and its pharmacokinetics to determine the correct dosage and to ensure the appropriate effect. Cholestasis in neonates and young infants is conjugated hyperbilirubinemia in the 1st 3 months of life due to impaired bile excretion. Biliary tract malformations involving the gallbladder and bile duct are grouped into cystic and noncystic obliterative cholangiopathies, the most common of which is biliary atresia. Less common causes include the genetic Alagille syndrome, infectious causes, and metabolic disorders. Clinical presentation is with obstructive jaundice. Ultrasonography and MRCP are useful diagnostic tools, and a prenatal diagnosis is sometimes made with ultrasonography. Cystic causes frequently require surgery to correct the defect and allow for normal child growth. Liver transplantation may be needed in cases of biliary atresia with portal hypertension. Volume status is a balance between water and solutes, the majority of which is Na. Volume depletion (also known as hypovolemia) refers to a loss of both water and Na, whereas dehydration refers only to a loss of water. Dehydration is primarily caused by decreased water intake and presents with increased thirst and can progress to altered mental status and low blood pressure if severe. Volume depletion can be caused by GI losses, renal losses, bleeding, poor oral Na intake, or third spacing of fluids. The clinical presentation has relatively nonspecific symptoms but will ultimately cause low blood pressure if severe. The diagnosis of these imbalances is based on lab findings in addition to clinical symptoms and signs, which can be subtle and unreliable. Management requires differentiation between these 2 conditions. The treatment is to administer fluids with tonicity similar to those lost; isotonic fluids are used for volume depletion, and hypotonic fluids are used for dehydration. The hepatobiliary system is composed of the liver, gallbladder, and bile ducts (within the liver and external to the liver). The liver produces bile, which is a fluid made of cholesterol, phospholipids, conjugated bilirubin, bile salts, electrolytes, and water. Bile, which assists in digestion and helps eliminate waste products, is stored in the gallbladder. The hepatobiliary system can be affected by infections, cysts, solid masses, ischemia, and mechanical flow obstruction, which mandate the presence of reliable imaging tests to determine the etiology. The methods that evaluate structural changes in the liver and biliary tract include ultrasonography, CT scan, and MRI (including magnetic resonance cholangiopancreatography). Additionally, cholescintigraphy, a functional imaging study, helps identify gallbladder pathology by tracking the biliary pathway. Examination of the lower limbs involves assessment of the hips, knees, ankles, and feet to evaluate for signs of pathology. The examination includes inspection, palpation, assessment of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis. Noninvasive ventilation (NIV) is an advanced respiratory support that does not require an artificial, invasive airway. This technique is commonly used during acute respiratory failure. The most common forms of NIV are noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC). In acute respiratory failure, NIV is frequently used to prevent intubation for invasive mechanical ventilation, if there are no contraindications. There are more established contraindications to NIPPV in comparison to HFNC, but NIPPV has demonstrated clear mortality benefit in chronic obstructive pulmonary disease and congestive heart failure exacerbations. Imaging of the internal female reproductive organs (including the uterus, ovaries, and fallopian tubes) is indicated to diagnose common gynecologic complaints, most commonly in cases of abnormal bleeding, pelvic pain, and to evaluate masses, congenital anomalies, and infertility. Ultrasound is almost always the 1st-line imaging modality of choice, whereas MRI is typically reserved for complicated or indeterminate cases as a follow-up. Computed tomography is almost never used for primary gynecologic assessments. Fallopian tubes are not visible on either ultrasound or MRI if they are normal. The best way to assess tubal patency is by using hysterosalpingography, a fluoroscopic exam in which a dye is injected into the uterine cavity, followed by the study of its flow through the fallopian tubes. The renal system is composed of 2 kidneys, 2 ureters, a bladder, and a urethra. These structures function to filter blood and excrete urine, which contains waste products of metabolism. Varying conditions such as infections, cysts, solid masses, ischemia, and mechanical obstruction can affect the renal system. Evaluation of diseases rely on imaging methods such as radiography, ultrasonography, CT, and MRI. Some of these are also used to guide tissue sampling (e.g., renal biopsy). Female breasts, made of glandular, adipose, and connective tissue, are hormone-sensitive organs that undergo changes along with the menstrual cycle and during pregnancy. Breasts may be affected by various diseases, in which different imaging methods are important to arrive at the correct diagnosis and management. Mammography is used for breast cancer screening and diagnostic evaluation of various breast-related symptoms. Ultrasonography is rarely used for screening, but it is typically used for diagnostic workup and during procedures (e.g., breast biopsy). MRI of the breasts is used as a supplementary screening tool for those at high risk for developing breast cancer. Additionally, in individuals with breast implants, inconclusive mammographic and/or breast ultrasound findings, and diagnosed breast cancer needing evaluation pretreatment and posttreatment, MRI is an important breast radiologic tool. Chromosomal testing can be accomplished using several techniques, all of which can identify chromosomal abnormalities. Karyotyping is the staining, organization, and visualization of chromosomes, which can help identify aneuploidy and major structural changes. Karyotyping is not sensitive in identifying small abnormalities and is a labor-intensive process. Chromosomal microarray analysis is a comparative technique that utilizes fluorescence to identify and quantify specific genetic sequences and is much more sensitive in identifying copy number variants, such as microdeletions or microduplications. However, chromosomal microarray analysis is not useful in identifying certain variations such as balanced translocations. Fluorescence in situ hybridization utilizes fluorescent probes to identify and locate specific genes on chromosomes. Compared with karyotyping, FISH is much more sensitive and specific in determining several abnormalities (except for point mutations) but is limited by the currently available gene probes. Function of the GI system is highly regulated through neural and hormonal signaling. Much of this regulation comes from the ANS. Parasympathetic stimulation is excitatory, triggering digestive secretions, an increase in GI blood flow, and movement of material through the tract, while sympathetic stimulation is inhibitory and has the opposite effects. The GI tract also has its own enteric nervous system, which controls numerous local GI reflexes. For example, the presence of a particular nutrient may be detected by chemoreceptors and may trigger release of a particular digestive enzyme, which is coordinated entirely by the enteric nervous system (without input from the brain). In addition, there are numerous hormones and paracrine signaling molecules released by GI organs that similarly affect GI function. The primary functions of the GI tract are digestion and absorption, which require coordinated contractions of the smooth muscles present in the GI tract. Peristaltic waves, segmentation contractions, and the migrating motor complex are all important contraction patterns that help to mix contents, get them in contact with the intestinal walls (where they are further digested by brush-border enzymes and absorbed into the enterocytes), and propel material down the tract at appropriate times and in appropriate amounts. An airway, breathing, and circulation (ABC) assessment is the mainstay for evaluating and treating critically ill individuals. The airway assessment helps identify individuals with potential obstruction of the airway, which may benefit from airway management techniques to ensure adequate ventilation and oxygenation. Measures to relieve and prevent soft-tissue obstruction in an unconscious individual can include special positioning maneuvers and airway adjuncts (such as oropharyngeal or nasopharyngeal airways). By relieving obstruction, assisted breathing with a bag-mask is more effective. Endotracheal intubation provides a more definitive way to ensure airway patency and protection. Congestive heart failure (CHF) is a progressive syndrome characterized by the failure of the heart to maintain the metabolic demands of the body either due to systolic or diastolic dysfunction. Treatment of CHF is centered around lifestyle modifications (salt and fluid restriction, smoking cessation, and weight loss) and pharmacologic management. Acute worsening of heart failure is often secondary to other medical conditions and is managed with aggressive diuresis and interventions to support cardiac and ventilatory functions. Angina is defined as chest pain or discomfort resulting from myocardial ischemia. Therapy for angina is targeted at limiting platelet aggregation and adhesion (with antiplatelet agents), reducing O2 demand (with beta-blockers), reducing preload (with nitrates), and preventing the progression of atherosclerotic disease (using statin therapy), along with the management of comorbidities. Non-Hodgkin lymphomas (NHLs) are a diverse group of hematologic malignancies that are clonal proliferative disorders of mature or progenitor B cells, T cells, or natural killer (NK) cells. Most pediatric cases are aggressive and high-grade (but curable); in adults, low-grade subtypes are more common. Like Hodgkin lymphoma, which has distinct pathologic features and treatments, NHL often presents with constitutional signs of fever, night sweats, and weight loss. Clinical features include lymphadenopathy and hepatosplenomegaly, but some individuals present with extranodal involvement and abnormal lab findings. B-cell NHLs include diffuse large B-cell lymphoma, follicular lymphoma, Burkitt lymphoma, mantle cell lymphoma, and marginal zone lymphoma. T-cell NHLs include adult T-cell lymphoma and mycosis fungoides. Diagnosis is made by lymph node biopsy, bone marrow biopsy, or both. Management is with chemotherapy or targeted drugs. Radiation therapy is used in adults but not in children, and stem cell transplantation is used for patients with aggressive disease. Immune responses against pathogens are divided into the innate and adaptive immune response systems. The adaptive immune response, also called the acquired immune system, consists of 2 main mechanisms: the humoral- and cellular-mediated immune responses. Humoral immunity is mediated through B cells (producing antibodies), whereas cell-mediated immunity involves T cells, and this response is activated when the innate immune system fails to control an infection. As the 2nd line of defense, the adaptive immune system is slower and responds over a longer period of time, but the effect generally leads to specific immunological memory. The 2 important characteristics of adaptive response are specificity (with antigen recognition) and memory (immune response mounted with reinfection). Gender dysphoria, formerly known as gender identity disorder, is the emotional discomfort felt by a patient because of the incongruence between their experienced gender and the gender they were assigned at birth (continuous inner conflict between gender identity and sexual identity). The 1st signs of cross-gender behaviors begin around age 3, the time when gender identity is established. Management involves a multidisciplinary approach (medical and psychological) to best support the patient. Glycogen storage disorders (GSDs) are genetic defects leading to disorders of carbohydrate metabolism. The disorders are caused by pathogenic variants in genes that affect enzymes involved in glycogen breakdown. Deficiency of 1 of these enzymes may occur in the liver or muscles and can cause hypoglycemia and/or abnormal glycogen deposition in tissues. Presentations vary from being fatal in the neonatal period to having their initial presentation with symptoms in adulthood. There are at least 14 types of GSDs, and the 4 most common and significant are von Gierke disease, Pompe disease, Cori disease, and McArdle disease. Diagnosis is clinical; detection of glycogen in tissues is by biopsy and confirmed by DNA analysis. Management aims to treat or avoid hypoglycemia, hyperuricemia, hyperlipidemia (HLD), and lactic acidosis. No cure is currently available, but genetic therapies are being tested. Digestion refers to the process of the mechanical and chemical breakdown of food into smaller particles, which can then be absorbed and utilized by the body. Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Carbohydrates, proteins, lipids, and micronutrients are digested and absorbed differently and require several enzymes and transport proteins to complete the process. Diagnostic procedures in gynecology are useful in identifying the presence of disease, determining the progression of disease, and monitoring the response of the organs to treatment. The major diagnostic procedures include speculum examinations, sonography (ultrasound), colposcopy, cervical biopsy and endocervical curettage, loop electrosurgical excision procedures, vulvar biopsy, endometrial biopsy, hysteroscopy, and hysterosalpingography (HSG). All of these procedures can be performed in the office setting or in a radiology suite, though in certain situations they are performed in the OR if more sedation or increased monitoring is required. Physical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation (e.g., the evaluation of a palpable breast mass or skin/nipple changes). A female genitourinary exam is performed either as a preventative screening exam or a problem-focused exam to evaluate complaints such as itching, pain, lesions, or infection. The investigation includes inspection, palpation, speculum exam, and bimanual exam. In combination with the subject’s history, the clinician uses exam findings to diagnose genital and pelvic conditions or to screen for cervical cancer (Pap smear). Genitourinary examination is an integral part of the male physical examination that provides important information on the normal development in infants and children. Genitourinary examination is used for preventative health exams in adult men and is also a part of problem-focused exams performed to evaluate complaints such as pain, infection, skin lesions, or lumps in the genital or inguinal areas. In subjects with urologic emergencies, such as testicular torsion, an accurate exam leading to prompt treatment can be the defining factor in maintaining fertility. Other significant conditions found on the genitourinary exam are STIs, Peyronie disease, and masses that may need further evaluation to confirm malignancy. Examination of the upper limbs is the portion of physical examination involving the assessment of the shoulder, elbow, forearm, wrist, and hand to evaluate for signs of pathology. The examination includes inspection, palpation, tests of range of movement, and provocative maneuvers. A good history should be taken and concurrently used with the exam findings to obtain a presumptive diagnosis. A neurological exam is a systematic assessment of cognitive, sensory, and motor responses to identify pathologies of the nervous system. A neurological exam allows for the localization of neurologic lesions to narrow the differential diagnosis and focus on subsequent laboratory and imaging examinations. The exam should include assessments of the subject's mental status, speech, cranial nerves, motor system, deep tendon reflexes, sensation, balance, and coordination. Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. From there, the DNA can be visualized with analysis techniques such as gel electrophoresis. The speed, inexpensiveness, ease of use, and high sensitivity and specificity make this technique highly useful for the basic and biomedical sciences, and it has become instrumental in many applications, including forensic analysis, diagnosis of infectious diseases, and diagnosis and screening of genetic abnormalities. Fatty acid metabolism includes the processes of either breaking down fatty acids to generate energy (catabolic) or creating fatty acids for storage or use (anabolic). Besides being a source of energy, fatty acids can also be utilized for cellular membranes or signaling molecules. Synthesis and beta oxidation are almost the reverse of each other, and special reactions are required for variations (unsaturated fatty acids, very-long-chain fatty acids (VLCFAs)). Synthesis occurs in the cell cytoplasm, while oxidation occurs in mitochondria. Shuttling across membranes within a cell requires additional processes, such as the citrate and carnitine shuttles. In certain physiologic states, an increase in fatty acid oxidation can lead to the production of ketone bodies, which can also be utilized as an energy source, particularly in the brain and muscles. Smooth muscle is primarily found in the walls of hollow structures and some visceral organs, including the walls of the vasculature, GI, respiratory, and genitourinary tracts. Smooth muscle contracts more slowly and is regulated differently than skeletal muscle. Smooth muscle can be stimulated by nerve impulses, hormones, metabolic factors (like pH, CO2 or O2 levels), its own intrinsic pacemaker ability, or even mechanical stretch. Whatever the stimulus is, it results in an increase in sarcoplasmic Ca levels. This Ca results in a phosphorylation of myosin, which activates it, allowing the myosin to interact with the actin. In smooth muscle, the actin is attached to cytoskeletal proteins located throughout the sarcoplasm and cell membrane known as dense bodies. Therefore, when the myosin pulls on the actin, the actin pulls on the dense bodies, causing the entire cell to “scrunch†up and contract. The cardiac cycle describes 1 complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. The cycle is frequently represented in a graph known as a pressure-volume loop, which shows how intraventricular volumes and pressures are related to one another throughout the cardiac cycle. The posterior abdominal wall is a complex musculoskeletal structure that houses the abdominal aorta, the inferior vena cava, as well as important retroperitoneal organs, like the kidneys, renal glands, pancreas, and duodenum. This vital anatomical structure consists of the posterior abdominal muscles, their respective fascia, lumbar vertebrae, and the pelvic girdle. The structure is supported by 12th thoracic rib, lumbar vertebrae, and pelvic rim. A physician’s diagnostic and therapeutic tool kit must include a variety of basic procedures that can be performed in the outpatient setting. These procedures include emergency intervention of the airway; drainage of fluid from the abdomen, joints, and spinal canal; and incision and drainage of abscesses. Although these procedures may be of reduced complexity, there are still inherent risks associated with invasive procedures, and these risks must be reduced through consistent aseptic and procedural techniques. Examination of the skin is a fundamental part of the standard physical exam. This exam consists of a thorough inspection of the skin of the entire body. The assessment focuses on identifying abnormal signs on the skin, such as the scalp, orifices, nails, and mucosal surfaces. Dermatologic findings can represent localized processes or may be a sign of systemic disease. Doctors routinely prescribe medications and should, therefore, be comfortable with basic calculations used to determine the optimal dosage. A dosing regimen is the manner in which a drug is administered to an individual, and describes the dose and frequency of the medication to be administered. Accuracy in dosing and the frequency of drug administration is necessary to achieve the desired effect while avoiding side effects and toxicity. In a clinical setting, both the prescribing doctor and pharmacist should review the optimal dose. Several medical conditions, including kidney and liver diseases and hypersensitivity, require dose adjustments to achieve the desired therapeutic effect. Purines and pyrimidines are heterocyclic aromatic compounds, which, along with sugar and phosphate groups, form the important components of nucleotides. Purines include adenine and guanine, while pyrimidines include thymine (in DNA), uracil (in RNA), and cytosine. Purine nucleotide synthesis follows a series of reactions using carbon donors, amino acids (e.g., glutamine, aspartate), and bicarbonate. The de novo pathway generates inosine monophosphate (IMP), which is the precursor of adenosine monophosphate (AMP) and guanosine monophosphate (GMP). Purine synthesis is regulated in the 1st 2 steps. Synthesis of pyrimidine nucleotides also follows different reactions, producing uridine monophosphate (UMP), which is converted to uridine triphosphate (UTP) and cytidine triphosphate (CTP). For thymine, a part of deoxyribonucleotides, ribonucleoside reductase is required to reduce the ribose moiety. Degradation of nucleotides result in xanthine then uric acid production in purines, while pyrimidines produce the amino acids, β-alanine, and β-aminobutyrate. Lipids are a diverse group of hydrophobic organic molecules, which include fats, oils, sterols, and waxes. Fatty acids are integral building blocks of lipids, and can be classified as unsaturated or saturated based on the presence/absence of carbon-carbon double bonds within their nonpolar chains. Eicosanoids are a family of cell-signaling molecules with important physiologic properties derived from the fatty acid, arachadonic acid. In addition, combining fatty acids with different bases, including glycerol, phosphate, and shingosine, results in different lipids with varied functions within the human body. Glycerolipids (triacylglycerols) are important for energy storage and thermal insulation. Glycerophospholipids and sphingolipids are essential constituents of cellular plasma membranes. Another group of lipids is based off of isoprenoids, which are the building blocks of sterols (such as cholesterol). Altered levels of lipids (both an overabundance or deficiency) can result in many potential disease processes. There are many etiologies of peripheral nerve injuries in the cervicothoracic region. The injuries commonly involve the phrenic nerve, the suprascapular nerve, the dorsal scapular nerve, the long thoracic nerve, or the thoracodorsal nerve. The nerves arise from the cervical plexus and brachial plexus. Causes of injury vary and may include trauma, compression, nerve entrapment, stretch or traction from repetitive movement, infection, surgical injury, or metabolic causes. Clinical presentation depends upon the motor and sensory innervation of the affected nerves. Diagnosis is mostly clinical but may also be confirmed with imaging or electrodiagnostic studies. Depending on the specific injury, management may be either surgical or conservative (physical therapy and avoidance of precipitating movements). Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent hyperglycemia due to impaired insulin secretion (type 1 DM), insulin resistance (type 2 DM), or both (latent autoimmune diabetes in adults (LADA)). The goal of diabetes management is to prevent chronic serious and potentially disabling complications due to damage to various organs. Adequate long-term control of blood glucose is crucial in the prevention of complications. Macrovascular complications include heart disease, stroke, peripheral vascular disease, and CKD in various stages, including end-stage renal disease that requires dialysis. Microvascular disease can cause retinopathy, neuropathy, or symptomatic cardiac disease, which are not seen during stress testing or angiogram that are used to diagnose large vessel diseases. The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. The transition point is known as the squamocolumnar junction, which is the site of most cervical cancers. These organs are supplied by the uterine and ovarian arteries and innervated by the autonomic nervous system. Urologic cancer is a broad term that involves cancer of the male and female urinary tracts and male reproductive organs. Risk factors for urologic cancer are smoking; exposure to chemicals such as benzidine and beta-naphthylamine, and arsenic; genetic predisposition; and chronic irritation of the urinary system. Clinical presentation includes painless hematuria, flank and/or suprapubic pain, dysuria, and unexplained significant weight loss. The gold standard for diagnosis is endoscopy of the urologic structures (cystoscopy, cystourethroscopy, ureteropyeloscopy) with biopsy. Additional studies include radiologic imaging, which gives information about the tumor invasion and spread of the disease to other sites or organs. Management includes surgery, chemotherapy, radiotherapy, and supportive treatment, depending on the location, extent, and histology. Skeletal muscle is striated muscle containing organized contractile structures known as sarcomeres that are made up of overlapping myofilaments: actin and myosin. When a nerve impulse arrives from a motor neuron, the signal triggers an action potential (AP) in the sarcolemma (muscle cell membrane), resulting in the release of Ca ions from the sarcoplasmic reticulum (SR) within the muscle cell. The Ca causes a conformational change in regulator proteins (troponin and tropomyosin), exposing myosin-binding sites on the actin filaments. Using ATP energy, the myosin heads pull the myosin along the actin, shortening the sarcomere and resulting in muscle contraction. The ATP can be produced via anaerobic and aerobic mechanisms, and the primary source of ATP energy in a muscle fiber determines its functional characteristics. A complex system of coordinated electrical circuitry within the heart governs cardiac muscle activity. The heart generates its own electrical impulses within its pacemaker cells. The signal then travels through specialized myocytes, which act as electrical wiring, distributing the signal throughout the heart. Once the signal “leaves†the specialized conduction system, it passes to each myocyte through channels called gap junctions (which connect myocytes to each other) and causes them to contract. An electrical impulse is created by the opening and closing of ion channels, allowing the flow of charged particles across the myocardial cell membrane. The flow of charged particles changes the voltage across the membrane and opens up additional voltage-gated channels, allowing the signal to propagate throughout the heart. The human eye is a sensory organ whose primary function is vision. They eye has a spheroidal shape and is structured in 3 layers: a supporting outer fibrous layer, a middle vascular layer, and an inner neural layer. The eye can also be subdivided into 3 compartments: the anterior, posterior, and vitreous chambers. Surrounding the eyeball itself are the extraocular muscles, the lacrimal apparatus, various nerves and vessels, and the bony structure of the orbit. Light travels through the compartments of the eye to focus on the retina, which is the location where photoreceptors convert the stimulus into a neural impulse that is carried by the optic nerve to the brain. Spinal cord injuries are complex injuries that involve damage to the neural tissue within the spinal canal. Spinal cord injuries are commonly the result of trauma. Clinical presentation varies depending on the site of injury and on whether the injury is complete or incomplete. Diagnosis is by clinical exam and imaging. Management is 2-fold, with immediate supportive care and stabilization of spine followed by long-term rehabilitation with physiotherapy and treatment of complications. Spinal cord injuries are associated with multisystem complications. During exercise, the metabolic demands of the body increase, and changes in the cardiovascular system are required to maintain adequate perfusion. During isometric contraction, blood flow is decreased to the contracting muscle due to direct compression of the arteries. Once the contraction ends, vasoactive metabolites cause significant vasodilation, resulting in an increase in blood flow to the muscle known as active hyperemia. During endurance exercise, repetitive, coordinated movements over a sustained period result in an increase in HR, stroke volume, cardiac output, and systolic blood pressure primarily via sympathetic stimulation and effects of the skeletal muscle pump. Diastolic blood pressure usually decreases slightly due to significant vasodilation in the skeletal muscle vascular beds, resulting in a decrease in systemic vascular resistance. Circulation is the movement of blood throughout the body through one continuous circuit of blood vessels. Different organs have unique functions and, therefore, have different requirements, circulatory patterns, and regulatory mechanisms. Several of the most vital organs (including the brain, heart, and kidneys) have autoregulatory properties, meaning that they are able to maintain a relatively constant blood flow despite fluctuations in mean arterial pressure (MAP). In other cases, locally produced factors (such as adenosine, CO2, or NO) can produce local vasoconstriction or vasodilation, regulating blood flow under specific physiologic conditions. Mean arterial pressure (MAP) is the average systemic pressure in the arteries. The MAP is tightly regulated to help maintain appropriate perfusion and is primarily determined by the cardiac output (CO) and the systemic vascular resistance (SVR). Cardiac output is determined by the HR and the stroke volume (the volume of blood ejected by the heart each beat). The HR is primarily regulated by the effects of the ANS on the sinoatrial node in the heart, while stroke volume is determined by the preload, afterload, and inotropy (or contractile strength) of each heartbeat. The SVR is regulated by a number of factors, including the ANS, the arterial baroreflex, circulating catecholamines, the RAAS, and several other hormones. The adult human body is made up of 60% water and is divided into extracellular and intracellular fluid compartments. Extracellular fluid is present outside the cells and makes up â…“ of the total body water. Intracellular fluid is present inside the cells and makes up â…” of the total body water. Intracellular and extracellular fluids are separated into compartments by semipermeable membranes, and the transport of fluid and ions is maintained by channels in the cell membrane. Each compartment contains different concentrations of ions and osmolar molecules. The relative charge and osmolarity are maintained rigorously by the transport of water and substances between compartments. Hypernatremia, hyponatremia, and edema are the clinical conditions arising from disturbances in the maintenance of osmolarity of the body fluid compartments. Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular resistance is directly related to the diameter of the vessel (smaller vessels have higher resistance). Mean arterial pressure (MAP) is the average systemic arterial pressure and is directly related to cardiac output (CO) and systemic vascular resistance (SVR). The SVR and MAP are affected by the vascular anatomy as well as a number of local and neurohumoral factors. Ethics is the field of study dealing with moral principles. Since the beginning, ethics has guided the practice of medicine. The core set of directives are based on the assumptions that all human life has intrinsic value and must be preserved, and all actions of the physician must be congruent with curing disease and in the best interest of the individual. Medical research also operates under these assumptions when seeking better alternatives of care to benefit individuals. Cholesterol is an important lipid molecule that is used for many biologic functions. Cholesterol can either be synthesized from endogenous acetyl-CoA or absorbed from food in the GI tract. Because cholesterol is lipophilic, it must be transported through the bloodstream via lipoproteins, where it can be picked up by hepatocytes or peripheral tissues. There, cholesterol can be stored, used in cellular membranes, or used as a precursor for steroid hormones. The human body cannot degrade cholesterol’s ring structure, so the only mechanism for potential excretion is through the production of bile acids. Glycogen is a branched polymer and the storage form of carbohydrates in the human body. Major sites of storage are the liver and skeletal muscles. Glycogen is the main source of energy during fasting or in between meals. Glycogen provides energy for up to 18 hours, after which energy requirements are met by fatty acid oxidation. The 2 metabolic pathways of glycogen are glycogenesis (glycogen synthesis) and glycogenolysis (glycogen breakdown). The key regulatory enzymes in these processes are glycogen synthase (in glycogenesis) and glycogen phosphorylase (in glycogenolysis). These pathways proceed depending on the energy needs of the cells, generally modulated by hormonal and allosteric regulators. Abnormal accumulation of glycogen occurs with enzyme deficiencies causing different types of glycogen storage disorders. Signaling pathways are complex systems in which a single extracellular signal can elicit multiple intracellular events, some of which may also be triggered by other signaling pathways or may themselves trigger other intracellular events. "Second messengers" is a term used to refer to a diverse group of small molecules or ions that transmit the extracellular signal initiated by a ligand binding to a cell surface receptor to effector proteins inside the cell. In the resting state, small amounts of second messengers exist in a cell; however, their production can rapidly ramp up once a signal has been received. Once released inside the cell, second messengers bind to their target proteins and alter their properties (activity, localization, availability of reaction sites, stability, etc.), causing a change in the cell’s homeostasis and thus transmitting the message. The glyoxylate cycle is an anabolic pathway that is considered a variation of the tricarboxylic acid (TCA) cycle. The TCA cycle occurs in plants, bacteria, and fungi, and acetyl-CoA is converted into succinate. The glyoxylate cycle was thought not to occur in animals due to the absence of the enzymes isocitrate lyase and malate synthase; however, this hypothesis is being explored. The glyoxylate cycle occurs in glyoxysomes, which are specialized peroxisomes. There are no decarboxylation reactions in the glyoxylate cycle. The glyoxylate cycle allows cells to utilize 2 carbon units of acetate, and convert them into 4 carbon units, succinate, for energy production and biosynthesis. Additionally, each turn of the cycle produces a molecule of FADH2 and NADH. Heme is an iron-containing porphyrin (which is made of 4 pyrrole groups), synthesized mostly in the bone marrow and the liver. Heme is a component of many crucial substances, including cytochromes, myoglobin, and hemoglobin. Biologic functions include the transportation of gases (e.g., O2), and electron transfer. Biosynthesis of heme is an 8-step process initiated by the synthesis of aminolevulinic acid. Iron availability affects heme production, as the last step involves insertion of ferrous ion. Iron is obtained from the diet and from the breakdown of heme-containing products. In the process of catabolism, heme is converted into bile pigments, out of which bilirubin is excreted. Mutations involving the enzymes in heme synthesis lead to a group of disorders known as porphyrias, and a defect in the catabolism of heme causes hyperbilirubinemias. Spasmolytics are skeletal muscle relaxants that reduce forceful, involuntary muscle contractions. Spasmolytics have several mechanisms and can either act centrally to inhibit somatic motor neuron signals, or peripherally to prevent Ca+2 release from the sarcoplasmic reticulum. Spasmolytics are often used as temporary adjunctive treatment to alleviate muscle spasms or musculoskeletal pain. Spasmolytics may also be used in the management of spasticity due to upper motor neuron disorders. Most medications readily cross the blood–brain barrier; thus, CNS depression is a common side effect. It is also important to be aware of dependence and withdrawal symptoms (particularly with CNS depressants and GABA agonists). Cardiac mechanics refers to how the heart muscle pumps blood and the factors that affect the heart's pumping function. Stroke volume (the volume of blood pumped out during each contraction) is affected by 3 key factors: preload, afterload, and inotropy (also known as contractility). Preload is how much the ventricle has stretched by the end of diastole (and thus how much blood has filled the ventricles). Afterload is the pressures in the aorta that ventricular contraction must overcome in order to open the aortic valve and eject blood into the aorta. Inotropy is the strength of the muscle contraction itself (independent of the preload), which is primarily related to how much intracellular Ca2+ is present. Body temperature can be divided into external temperature, which involves the skin, and core temperature, which involves the CNS and viscera. While external temperature can be variable, the core temperature is maintained within a narrow range of 36.5–37.5ºC (97.7–99.5ºF). Although the reasons are unknown, it has been hypothesized that a narrow temperature range is maintained for the metabolic rate needed for the functioning and optimization of cellular processes. Regulation of the core temperature is one of the most critical functions of the nervous system and is achieved by physiologic and behavioral feedback and feed-forward mechanisms that are mainly regulated by the hypothalamus. Any change in body temperature or environmental temperature triggers responses that lead to the quick and efficient resetting of homeostasis. Fatty acid oxidation disorders (FAODs) are a group of genetic conditions caused by disruptions in beta-oxidation or the carnitine transport pathway. These disruptions lead to an inability to metabolize fatty acids. All FAOD types are autosomal recessive. Because of the inability of the body to break down fatty acids, these fats accumulate in the liver and other internal organs. The clinical presentations of each disorder vary, but they commonly include hypoglycemia, cardiomyopathy, encephalopathy, seizures, myopathy, and liver dysfunction. Screening of newborns can detect these diseases, and DNA sequencing is usually performed to confirm the diagnosis. Management includes dietary changes or substrate supplementation. During the 4th week of gestation, limb buds form on the sides of the developing embryo. The tips of these buds condense into the apical ectodermal ridge (AER). The AER continues the elongation of the limb buds and maintains its growth by continuously producing fibroblast growth factor 8 (FGF8). As the AER grows away from the body, tissues differentiate. After the cartilage models are formed in the developing limbs, arteries invade central and peripheral areas, giving rise to primary and secondary centers of ossification. The process of endochondral ossification is completed when those centers meet and the epiphyseal plate is no longer present. Vascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass). Surgical intervention is either open or endovascular. Vascular interventions require a multidisciplinary approach, including vascular surgeons, interventional radiologists, anesthesiologists (or anesthetists), nurses, physiotherapists, and occupational therapists. Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Common interventions treat ischemic and valvular heart disease as well as disorders of the great vessels. Acute disseminated encephalomyelitis (ADEM) is an immune-mediated, inflammatory, monophasic, demyelinating condition that affects the white matter of the brain and spinal cord. As a rapidly progressive post-infectious encephalomyelitis, ADEM is characterized by demyelination in the brain and spinal cord as a result of inflammation following infection or immunization. Neuromuscular blockers are skeletal muscle relaxant medications that block muscle contraction through a couple of mechanisms. Depolarizing neuromuscular blockers bind to nicotinic cholinergic receptors (nAChRs), locking the ion channel open. This results in an initial, persistent depolarization, followed by receptor desensitization to result in muscle relaxation and paralysis. Nondepolarizing neuromuscular blockers also bind to these same receptors; however, they act by keeping the channel closed to prevent depolarization. These agents are often used as an adjunct to general anesthesia during surgery, and to facilitate endotracheal intubation. Since these medications also work on muscles associated with breathing, respiratory support should be employed. It is also important that adequate sedation is also given, since these agents do not have a sedative effect. Common adverse effects include anaphylaxis, bradycardia, hypotension, and prolonged paralysis. Physicians should also be aware of the potential for muscle fasciculations and hyperkalemia with succinylcholine. Mineralocorticoids are a drug class within the corticosteroid family and fludrocortisone is the primary medication within this class. Fludrocortisone is a fluorinated analog of cortisone. The fluorine moiety protects the drug from isoenzyme inactivation in the kidney, allowing it to exert its mineralocorticoid effect. The mechanism of action of mineralocorticoids mimics that of aldosterone. By acting on the mineralocorticoid receptors, fludrocortisone induces the expression of proteins responsible for Na+ reabsorption and K+ excretion by renal tubule cells, which results in Na+ and water retention. Mineralocorticoids are used in the management of diseases characterized by insufficient (or absent) aldosterone activity, such as adrenal insufficiency and congenital adrenal hyperplasia. Adverse effects are related to both mineralocorticoid and glucocorticoid effects and include hypertension, edema, decompensated heart failure, hyperpigmentation, hypokalemia, Cushing syndrome, hyperglycemia, and hypothalamic-pituitary-adrenal axis suppression. Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. These medications are also used for conditions requiring physiologic glucocorticoid replacement. Despite their extensive use, glucocorticoids can produce many and varied adverse effects and should be used judiciously. Because of their immunosuppressive effect, these medications may predispose individuals to infection and should be avoided in those with uncontrolled infections. In addition, long-term therapy can lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, so discontinuation of therapy should be done carefully to avoid adrenal insufficiency. Spinal disk herniation (also known as herniated nucleus pulposus) describes the expulsion of the nucleus pulposus through a perforation in the annulus fibrosus of the intervertebral disk. Spinal disk herniation is an important pain syndrome with the potential for neurologic impairment and is most commonly caused by degenerative disk disease. Clinical presentation depends on the presence or absence of spinal cord or nerve root compression and the downstream neurologic sequelae (e.g., radicular pain, muscle weakness, sensory deficit, reflex deficit). Diagnosis is initially clinical and can be confirmed with diagnostic imaging (e.g., MRI). Management can range from conservative to surgical, depending on the situation. A tachyarrhythmia is a rapid heart rhythm, regular or irregular, with a rate > 100 beats/min. Tachyarrhythmia may or may not be accompanied by symptoms of hemodynamic change. Pathologic tachyarrhythmias resulting in hemodynamic instability can be caused by intrinsic cardiac abnormalities, systemic diseases, or medication toxicity. Supraventricular arrhythmias are called narrow-complex tachycardias and originate in the sinoatrial (SA) node, atrial myocardium, or atrioventricular (AV) node. Ventricular arrhythmias originate below the AV node and are characterized by a wide QRS complex. Diagnosis is made by physical exam and ECG. Management is directed toward the type of tachyarrhythmia present and its underlying cause. The membrane potential is the difference in electric charge between the interior and the exterior of a cell. All living cells maintain a potential difference across the membrane thanks to the insulating properties of their plasma membranes (PMs) and the selective transport of ions across this membrane by transporters. There are 3 types of potential: resting membrane potential, equilibrium potential, and action potential. Membrane potential helps to generate action potential, and these action potentials act as carry-and-relay signals to the CNS and brain for performing a specific movement or action. The abdominal organs are derived primarily from endoderm, which forms the primitive gut tube. The gut tube is divided into 3 regions: foregut, midgut, and hindgut. The foregut gives rise to the lining of the GI tract from the esophagus to the upper duodenum, as well as the liver, gallbladder, and pancreas. The midgut gives rise to the GI tract lining between the midduodenum and midtransverse colon. The hindgut gives rise to the GI tract lining from the midtransverse colon through the upper anal canal. The mesoderm gives rise to the muscles of the GI tract wall, connective tissue (including the mesenteries and omenta), and the vasculature. The ectoderm gives rise to the nerve tissue and the lining of the lower anal canal. The branchial arches, also known as pharyngeal or visceral arches, are embryonic structures seen in the development of vertebrates that serve as precursors for many structures of the face, neck, and head. These arches are composed of a central core of mesoderm, which is covered externally by ectoderm and internally by endoderm. Indentations between arches are known as the pharyngeal clefts, or grooves, externally and the pharyngeal pouches internally. Each pharyngeal arch contains cartilage and muscular components, which are supplied by a cranial nerve (derived from neural crest cells), and an artery, known as a pharyngeal aortic arch. Some of these aortic arches go on to form the great vessels near the heart. Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles (benevolence, autonomy, nonmaleficence, and distributive justice). In the 20th century, bioethics began to explore the moral relationship between humans and their world. Both gastrulation and neurulation are critical events that occur during the 3rd week of embryonic development. Gastrulation is the process by which the bilaminar disc differentiates into a trilaminar disc, made up of the 3 primary germ layers: the ectoderm, mesoderm, and endoderm. During this process, a structure called the notochord is formed in the midline in the mesodermal layer; the notochord is critical in inducing neurulation. Neurulation is the process by which some of the ectoderm in the trilaminar embryo develops into the neural tube and neural crest cells, which will go on to form all of the neural tissue in the body. This process is completed by the end of the 3rd week. The psychiatric assessment is the equivalent of a physical exam, tailored to evaluate a patient for psychiatric pathologies. While the psychiatric assessment has a mostly standardized approach, the interviewer can tailor it based on the presenting symptoms of the patient. The psychiatric assessment is designed to systematically assess for various features of psychiatric illnesses and involves both direct questioning and passive observation. The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip†bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. The pelvic ring joints include the pubic symphysis anteriorly and the sacroiliac joints posteriorly. The hip bones are made up of 3 fused bones: the pubis, ischium, and ilium. The pelvic cavity houses various GI, urinary, and reproductive structures, which are supported by the muscles and connective tissue of the pelvic floor. The female pelvis, making accommodations for childbirth, is generally wider and larger than the male pelvis. Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Pain symptoms are seen every day, by every physician, in every clinic and hospital in the world. Understanding pain physiology is the cornerstone to understanding how to treat it and to providing the individual with their first sigh of relief as definitive management is undertaken. Veins transport deoxygenated blood and waste products from capillaries in the periphery back to the heart. Veins are capacitance vessels, meaning that they can stretch significantly, increasing the volume of fluid they can hold without significantly increasing their pressure. Veins respond to stimulation from the ANS, as arteries do, but to less of an extent. The effects of either venoconstriction or venodilation, however, impact venous capacitance. As veins constrict, capacitance goes down, forcing more blood back to the heart (i.e., increasing venous return), which in turn affects the amount of blood that can be pumped out of the heart on the next heartbeat. Thus, changes in venous capacitance can significantly affect cardiac output (CO). These effects can be plotted on graphs known as venous function curves. The anterior abdominal wall is anatomically delineated as a hexagonal area defined superiorly by the xiphoid process, laterally by the midaxillary lines, and inferiorly by the pubic symphysis. From the superficial to deep order, the anterior abdominal wall consists of the skin, subcutaneous tissue, muscle, transversalis fascia, and peritoneum. The lateral abdominal muscles include the external and internal obliques and the transversus abdominis. Anterior abdominal muscles include the rectus abdominis and pyramidalis muscles. The abdominal wall is primarily supplied by epigastric arteries and innervated by thoracoabdominal nerves. Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver function tests assess the levels of various hepatic proteins and enzymes to determine the state of liver metabolic activity, homeostasis, bile metabolism, and protein synthesis capacity. The standard hepatic panel includes the levels of total protein, bilirubin, albumin, ALT, AST, AST/ALT ratio, and alkaline phosphatase (ALP). The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. The bladder acts as a reservoir for urine until micturition is appropriate. Regulation of micturition relies on the CNS and the spinal cord. The salivary glands are exocrine glands positioned in and around the oral cavity. These glands are responsible for secreting saliva into the mouth, which aids in digestion. Saliva helps keep the oral mucosa lubricated, and it provides antimicrobial protection. There are 3 major paired salivary glands: the sublingual, submandibular, and parotid glands. There are also hundreds of minor salivary glands found in patches around the oral cavity. The muscles of the neck can be divided into 3 groups: anterior, lateral, and posterior neck muscles. Each of the groups is subdivided according to function and the precise location of the muscles. The muscles of the neck are mainly responsible for the movements of the head (i.e., extension, flexion, lateral flexion-extension, and rotation), but the deep muscles also contribute to more intricate functions (i.e., speaking and swallowing). Sickle cell disease (SCD) is a group of genetic disorders in which an abnormal Hb molecule (HbS) transforms RBCs into sickle-shaped cells, resulting in chronic anemia, vasoocclusive episodes, pain, and organ damage. Sickle cell trait, which is the heterozygous condition, is the only 1 of the group that is generally benign and rarely associated with serious SCD-like complications. Triggers such as stress and hypoxia can induce or worsen the sickling of RBCs. Individuals with SCD are susceptible to infection, infarction of various organs, and bone marrow aplasia; lung involvement in acute chest syndrome can be rapidly fatal. Sickle cells can usually be seen on the peripheral blood smear, but Hb electrophoresis is needed for diagnosis. The management of painful episodes consists of IV fluids and analgesics, and in severe episodes, exchange transfusions may be required. Survival is improved by vaccination against bacterial infections, prophylactic antibiotics, and aggressive treatment of infections. The pentose phosphate pathway (also known as the hexose monophosphate (HMP) shunt)) is an important physiological process that can occur in 2 phases: oxidative and nonoxidative. The oxidative phase utilizes glucose-6-phosphate to produce nicotinamide adenine dinucleotide phosphate (NADPH) and ribulose-5-phosphate (which can be converted to ribose-5-phosphate). The nonoxidative phase is a collection of several reversible reactions in which the intermediates are connected to several other pathways, including nucleotide synthesis, aromatic amino acid synthesis, and glycolysis. Congenital malformations or teratogenic birth defects are developmental disorders that arise before birth during the embryonic or fetal period. The rate of incidence for children born alive is approximately 3%. The cause may be genetic or contingent on external influences or teratogens. Teratogens are environmental factors that result in permanent structural or functional malformations, or the death of the embryo or fetus. Teratogens include infections, certain medications, drugs, and radiation. The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. The prostate consists of multiple lobes and is made up of glandular and fibromuscular tissue. The glandular tissue has ducts that empty into the prostatic portion of the urethra, and the fibromuscular tissue encircles the urethra. The inguinal region, or the groin, is located in the RLQ and LLQ of the anterior abdominal wall, bordered by the thigh inferiorly, the pubis medially, and the iliac crest superolaterally. The inguinal canal is a tubular structure that runs in a straight line from the anterior superior iliac spine to the pubic tubercle. The canal contains the spermatic cord in men and the round ligament in women. This region is clinically relevant, as it is the site for the most common type of hernias, such as indirect and direct inguinal hernias. Patients with hernias will present with a unilateral bulge in the groin that may be associated with pain. In symptomatic or high-risk cases, hernias can be repaired surgically. The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels including the superior vena cava, inferior vena cava, pulmonary arteries, pulmonary veins, and aorta. The mediastinum extends from the upper thoracic aperture to the diaphragm and is bordered by the lungs. The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. The thalamus consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. The thalamus is divided into anterior, medial, and lateral parts, each containing groups of nuclei that function as relay centers for sensory impulses and for the modulation of motor responses via interconnections with the basal ganglia. The brain stem is a stalk-like structure that connects the cerebrum with the spinal cord and consists of the midbrain, pons, and medulla oblongata. The brain stem contains many nerves, pathways, reflex centers, and nuclei and serves as a major relay station for sensory, motor, and autonomic information. All cranial nerves, except I and II, originate from the brain stem. The brain stem also plays a critical role in the control of cardiovascular and respiratory function, consciousness, and the sleep-wake cycle. Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall laterally by the suspensory ligament of the ovary and to the uterus medially by the utero-ovarian ligament. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes), which are expelled and then “captured†by the uterine tubes. The primary blood supply to the ovary is provided by the ovarian artery, a direct branch of the abdominal aorta; the ovarian artery anastomoses with the ascending branch of the uterine artery, providing excellent collateral blood flow. The cerebellum, Latin for "little brain", is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Three paired peduncles link the cerebellum to the brainstem and diencephalon. Much like the cerebral cortex, the cerebellum has a cortex of gray matter on the surface. The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Blood flows through the heart in 1 direction, moving from the right side of the heart, through the lungs, and then returning to the left side of the heart, where it is pumped out to the rest of the body. As blood moves through the heart, 4 important valves prevent backflow. The heart muscle itself is supplied by the coronary arteries. The heart also has its own conduction system, triggering its own rhythmic contractions. Juvenile idiopathic arthritis (JIA), formerly known as juvenile rheumatoid arthritis, is a heterogeneous group of inflammatory diseases characterized by inflammation of 1 or more joints and is the most common pediatric rheumatic disease. Juvenile idiopathic arthritis is classified according to its clinical presentation, and diagnosis is made with examination findings as well as confirmatory lab testing showing evidence of inflammation and characteristic X-ray findings. Treatment is directed at preventing loss of function and controlling or limiting joint damage, with a variable prognosis depending on the type. Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. These medications are used in the management of a wide range of diseases, most notably in the treatment of overactive bladder, irritable bowel syndrome, chronic obstructive pulmonary disease (COPD), and allergic rhinitis. Atropine specifically is used in emergency medicine in the advanced cardiac life support (ACLS) protocol for severe bradycardia and as an antidote to organophosphate poisoning with insecticides or chemical warfare agents. Atropine is also used in anesthesiology as an antisialagogue or to reverse neuromuscular blocking agents. The term “anticholinergic†is often used to describe the adverse effects of drugs with anticholinergic properties (e.g., tricyclic antidepressants); these include dry mouth, constipation, blurred vision, and orthostatic hypotension. Antiemetics are medications used to treat and/or prevent nausea and vomiting. These drugs act on different target receptors. The main classes include benzodiazepines, corticosteroids, atypical antipsychotics, cannabinoids, and antagonists of the following receptors: serotonin, dopamine, and muscarinic and neurokinin receptors. Anticholinergics and antihistamines are useful in the treatment of vestibular causes of nausea. Serotonin and neurokinin antagonists are effective in the management of chemotherapy-induced nausea and vomiting. Antiemetics should be used with caution, though, because of their adverse effects. Serotonin antagonists and some dopamine antagonists cause QT-interval prolongation. Dopamine antagonists are associated with extrapyramidal symptoms. Additionally, many agents cause sedation and have anticholinergic effects, which can aggravate underlying diseases. The cerebral cortex is the largest and most developed part of the human brain and CNS. Occupying the upper part of the cranial cavity, the cerebral cortex has 4 lobes and is divided into 2 hemispheres that are joined centrally by the corpus callosum. The cortex contains gyri that are separated by sulci. The cerebral cortex provides the neural substrate for the conscious experience of sensory stimuli. The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. The interconnections between the bones, cartilage, and muscles allow for the rhythmic expansion and reduction of the chest wall during breathing, which facilitates changes in intrathoracic pressure to allow expansion of the lungs during inspiration. The extrinsic muscles have 2 bony attachments; the intrinsic muscles only attach to the thoracic skeleton. Premenstrual dysphoric disorder (PMDD) refers to a group of mood, somatic, and behavioral symptoms that follow a cyclical pattern experienced by some women prior to menstruation. Unlike premenstrual syndrome (PMS), PMDD is characterized by significant distress and/or functional impairment. Diagnosis is made clinically with history and physical exam. Management is 2-fold: via lifestyle modification and pharmacotherapy with serotonin reuptake inhibitors or oral contraceptives. Basal ganglia are a group of subcortical nuclear agglomerations involved in movement, and are located deep to the cerebral hemispheres. Basal ganglia include the striatum (caudate nucleus and putamen), globus pallidus, substantia nigra, and subthalamic nucleus. The components intricately synapse onto each other to promote or antagonize movement. Nephritic syndrome is a broad category of glomerular diseases characterized by glomerular hematuria, variable loss of renal function, and hypertension. These features are in contrast to those of nephrotic syndrome, which includes glomerular diseases characterized by severe proteinuria, although there is sometimes overlap of > 1 glomerular disease in the same individual. The clinical presentations of nephritic syndrome are highly varied, from asymptomatic with urinary abnormalities to life-threatening critical illness. Diagnosis is suggested by hematuria, mild-to-moderate proteinuria, and certain serologies (e.g., ANCA); kidney biopsy is necessary in most cases. Management varies as widely as the clinical presentations, from watchful waiting in mild cases to immunosuppression and plasmapheresis in aggressive disease. The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. The spinal cord is divided into cervical, thoracic, lumbar, and sacral regions, though because the spinal cord is shorter than the vertebral column, these regions do not line up with their corresponding vertebral levels. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Like the brain, the spinal cord is surrounded by 3 layers of connective tissue, collectively known as the meninges; these layers are the dura mater, arachnoid mater, and pia mater. The spinal cord is supplied by 1 anterior and 2 posterior spinal arteries. Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. The primary etiologies of nephrotic syndrome are minimal change disease, membranous nephropathy, and focal segmental glomerulosclerosis. The clinical presentation of nephrotic syndrome includes proteinuria (> 3.5 g/day), hypoalbuminemia (< 3 g/dL), and peripheral edema. Other frequently observed clinical findings are hyperlipidemia and thrombotic disease. Diagnosis is suggested by the clinical findings, and kidney biopsy is necessary in most cases. Management varies with the etiology and usually involves glucocorticoids or other immunosuppressant drugs. Renal tubular acidosis (RTA) is an imbalance in physiologic pH caused by the kidney’s inability to acidify urine to maintain blood pH at physiologic levels. Renal tubular acidos3s exist in multiple types, including distal RTA (type 1), proximal RTA (type 2), and hyperkalemic RTA (type 4). Depending on the type of RTA, various mechanisms cause dysfunction of renal acid–base handling, resulting in a non–anion-gap metabolic acidosis. All RTAs present clinically with some degree of metabolic acidosis; however, distal RTA and proximal RTA also have hypokalemia, while hyperkalemic RTA does not. Diagnosis is primarily through the history and laboratory analysis, including measurement of serum and urine anion gaps. Treatment involves the correction of chronic metabolic acidosis with alkali to prevent its long-term catabolic effects on bone and muscles, as well as addressing any underlying causes leading to the RTA. Polyneuropathy is any disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system. There are numerous etiologies of polyneuropathy, most of which are systemic and the most common of which is diabetic neuropathy. The clinical presentation varies by etiology as well as classification of the polyneuropathy, but generally manifests as sensorimotor disturbances (pain, paresthesia, numbness, weakness, and loss of coordination and balance), which have a gradual onset and progressive course. Distal nerves are affected most commonly, but the disease process may progress proximally with time or progression of the underlying etiologic disease entity. Diagnosis is made clinically, but laboratory studies, electrodiagnostic testing, and/or nerve biopsy may be required in some cases. Management varies depending on the etiology. Complex regional pain syndrome (CRPS) is a chronic regional neuropathic pain condition characterized by excruciating pain (out of proportion to apparent tissue damage or inciting trauma), paresthesia, allodynia, temperature abnormalities, skin discoloration, edema, reduced range of motion, and bone demineralization. This syndrome is most often associated with an inciting traumatic event (e.g., fracture, surgery, burn) and predominantly affects the limb(s). Diagnosis is clinical, but it is supported by imaging and electrodiagnostic testing. Treatment centers around multidisciplinary pain management and maintenance of function. Distal radius fractures are one of the most common fractures encountered in practice and are often associated with falling onto an outstretched hand. These fractures are most frequently seen in older individuals, especially women. In this population, these fractures are related to an increase in falls due to gait instability with aging and associated osteoporosis. In younger individuals, distal radius fractures are usually related to high-energy trauma. Individuals often present with pain and a dinner fork deformity of the distal forearm. Diagnosis is clinical and confirmed with x-rays of the wrist. Treatment can be operative or nonoperative depending on the age of the individual, articular involvement, and degree of displacement or angulation. Antiestrogens are medications decreasing the estrogenic effects in the body. The antiestrogens include selective estrogen receptor modulators (SERMs), selective estrogen receptor downregulators (SERDs), aromatase inhibitors, and several others, which include medications suppressing the gonadotropins or counteracting the effects of estrogen. Antiestrogens are most commonly used in the treatment of breast cancer but also treat precocious puberty, gynecomastia, anovulatory infertility, and several gynecologic complaints. Adverse effects include hot flashes, venous thromboembolic events, bone mineral density loss, and ischemic cardiovascular events. Antiestrogens are contraindicated in individuals with known hypersensitivity reactions and pregnancy. Fetal growth restriction (FGR), also known as intrauterine fetal growth restriction (IUGR), is an estimated fetal weight (EFW) or abdominal circumference < 10th percentile for gestational age. The term small for gestational age (SGA) is sometimes erroneously used interchangeably with FGR. However, SGA refers to babies born with a birth weight < 10th percentile for gestational age. Defining FGR is challenging because each fetus has a different growth potential that may not be accounted for. The most commonly recognized classifications for FGR are symmetrical or asymmetrical. Symmetrical FGR occurs when all parts of the fetus are equally small and is typically the result of a complication early in pregnancy. Asymmetrical FGR occurs when there is disproportionately lagging growth in different body parts; most commonly, the fetus will have a normal size head and a small body. The causes of FGR can be broadly grouped into maternal, fetal, and placental. Fetal growth restriction is diagnosed by ultrasonography and confirmed by weight at birth. Management is often targeted to the underlying etiology, if known. Depending on the etiology, these fetuses may be at increased risk for complications such as preterm birth, intrauterine fetal death, and neurologic sequelae. Close surveillance and delivery planning by a skilled provider is crucial. Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding has many benefits for the mother and baby, including a decreased risk of infections, GI distress, and atopic disease for the infant; and a decreased risk of anemia, cardiovascular disease, and breast and ovarian cancer for the mother. True contraindications to breastfeeding exist but are quite rare. Important clinical conditions associated with breastfeeding include engorgement, mastitis, galactocele, breast abscess, and infant jaundice. Fever is defined as a higher-than-normal body temperature. In modern medicine, fever is defined as a temperature > 38°C (100.4°F). It is a common symptom in the pediatric population as an isolated symptom or accompanied by other findings that can help narrow the differential diagnosis. Fever is most commonly the body’s response to infectious processes; however, it can also be seen in other pathologic processes. In neonates and very young infants, the clinical presentation lacks specificity, so more diagnostic aids are deployed to rule out severe bacterial infection (SBI) and to begin treatment according to age and clinical evolution. Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Common neurosurgery cases treat tumors, masses, herniations, various types of hemorrhages, and radicular pain. Although neurosurgery is a surgical specialty, neurosurgeons must be very competent in neurology, critical care, trauma care, and radiology. Instances of traumatic force applied to the chest are seen in 10% of the cases of pediatric trauma, usually in the context of motor vehicle accidents and falls. Chest trauma rarely occurs in isolation and is often associated with polytrauma. The 2 major mechanisms involve blunt and penetrating forces. Pneumothorax, hemothorax, flail chest, and lung contusions are the most common injuries. Treatment of affected children is very similar to that of adults, but unique pediatric pathoanatomy dictates important differences in approach and management. Androgens are naturally occurring steroid hormones responsible for development and maintenance of the male sex characteristics, including penile, scrotal, and clitoral growth, development of sexual hair, deepening of the voice, and musculoskeletal growth. Androgens are primarily given to treat hypogonadism, gender dysphoria in transgender men, and low testosterone in older men (controversial). Antiandrogenic drugs decrease the effect of androgens. Classes include androgen receptor blockers, 5α-reductase inhibitors, and androgen synthesis inhibitors. Both men and women may use antiandrogens, which treat advanced prostate cancer, benign prostatic hyperplasia (BPH), alopecia, and hirsutism. Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. In effect, there is an increased concentration of neurotransmitters in the synapse. Histaminic, muscarinic, and adrenergic receptors are also blocked, leading to a wide array of side effects. For decades, TCAs have been utilized for depression and are considered alternative antidepressant options to selective serotonin reuptake inhibitors (SSRIs). Full effects take a latent period of around 2–3 weeks. Overdose can lead to cardiac toxicity, seizures, and coma. Other uses include treatment for anxiety disorders, chronic pain syndrome, and nocturnal enuresis. Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. General anesthesia is induced via the administration of gaseous or injectable agents before surgical procedures or other medical interventions. On the other end of the spectrum is local anesthesia, which is achieved via the use of topical agents or the local administration of injectable anesthetics to the area of concern. The use of anesthetics has been well documented in history, but the practice of modern anesthesiology only began by the end of the 18th century. Pharmacological treatment of pulmonary hypertension (PH) (characterized by an elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure) includes various classes of drugs. These medications fall into the following drug categories: phosphodiesterase type-5 (PDE-5) inhibitors, soluble guanylate cyclase (sGC) stimulants, prostacyclin receptor agonists, endothelin receptor antagonists, and calcium channel blockers (CCBs). Via differing pathways, the overall effect of the medications is vascular smooth muscle relaxation and vasodilation resulting in a fall in pulmonary arterial pressure. Contraindications, adverse events, and drug interactions are dependent on the class of drugs. Neuropathy is a nerve pathology presenting with sensory, motor, or autonomic impairment secondary to dysfunction of the affected nerve. The peripheral nerves (outside the brain and spinal cord), are derived from several plexuses, with the brachial and lumbosacral plexuses supplying the major innervation to the extremities. Mononeuropathy (affecting a single nerve) and plexopathy (affecting the plexus) can occur from trauma, compression, and systemic diseases. The clinical presentation varies according to location, type of nerves affected, and cause of the damage. Diagnosis requires a thorough physical examination, and diagnostic tests include laboratory tests, imaging and a confirmatory nerve conduction study, and electromyography. Management depends on the etiology but centers around physical therapy, supportive care, and treatment of underlying issues. Brain aneurysms, also known as intracranial or cerebral aneurysms, are dilations of the arteries along points of weakness in the brain. The majority of the aneurysms are berry (saccular) in nature and located within the anterior circulation of the circle of Willis. Unruptured aneurysms are typically asymptomatic, unless the aneurysm compresses surrounding structures. The majority of these aneurysms are detected on rupture and presentation of a subarachnoid hemorrhage (SAH). Rarely, they may be detected incidentally on brain imaging done for other reasons. Diagnosing an aneurysm is done via imaging with CTA or MRA. Management depends on the size, risk of rupture, risk of intervention complications, and individual preference. This may include risk factor modifications, surveillance with serial imaging, and interventional measures (such as surgical clipping or endovascular coiling). Ruptured aneurysms carry a high morbidity and mortality rate. Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus is the most virulent species; S. epidermidis and S. saprophyticus are less virulent but are also clinically significant. Infection can cause a wide array of disease, including cellulitis, abscesses, endocarditis, osteomyelitis, and medical device infections. Toxins formed by S. aureus can cause gastroenteritis, SSSS, and toxic shock syndrome (TSS). Antibiotic management varies based on the type of infection, severity, and sensitivity data. Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Chromosomal mutations occur when an abnormal number of chromosomes is inherited. Point mutations occur when a nucleotide is swapped for another nucleotide and can be missense, nonsense, or silent mutations. Frameshift mutations occur when a nucleotide is added or deleted, and expansion mutations occur when a given trinucleotide sequence is repeated along the chromosome. Genetic mutations are the basis for most inherited diseases. Common disorders caused by DNA mutations include sickle cell disease, Huntington disease, and Tay-Sachs disease. Gregor Mendel (1822–1884), the "father of genetics", was an Augustine monk and mathematician who performed cross-breeding experiments with peas and beans from a monastery garden. Based on the experiments, Mendel deduced hereditary factors may be passed from the parental generation to the filial generation. From the deductions, the father of genetics formed Mendel's laws of heredity: the law of segregation, the law of independent assortment, and the law of dominance. Mendel's laws described the inheritance of uncoupled autosomal genes based on statistical predictions. The gene traits follow the laws of mendelian inheritance. Transplantation is a procedure that involves the removal of an organ or living tissue and placing it into a different part of the body or into a different person. Organ transplantations have become the therapeutic option of choice for many individuals with end-stage organ failure. Transplantation can offer the individual a definitive treatment for a given disease entity. Over the past 50 years, organ transplantation has become established worldwide, with ever-improving results, conferring an immense benefit to hundreds of thousands of individuals. Both solid organs and bone marrow–derived hematopoietic cells can be successfully transplanted for a number of different indications. Tolerance of the transplanted organ by the immune system of the host is achieved through the use of immunosuppressive and immunomodulating strategies. The main complications of transplantation are organ rejection or graft failure; however, chronic immunosuppression also carries the risk of serious complications, including potentially life-threatening infections. The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. The epithelium is classified according to the cells (squamous, cuboidal, columnar), the number of layers, and other unique characteristics either due to function (transitional epithelium allowing distention) or appearance (pseudostratified epithelium giving a false impression of multiple layers). The surface epithelium has multiple functions, which include protection, secretion, filtration, and sensory reception. The urogenital system is derived from intermediate mesoderm. The intermediate mesoderm differentiates into nephrogenic cords (which will go on to form the urinary system) and an adjacent area known as the gonadal ridge (which will go on to form the gonads). The nephrogenic cords elongate in a caudal direction and sequentially develop 3 different structures: the pronephros (rudimentary and nonfunctional), the mesonephros (forms the primitive urinary system), and the metanephros (forms the permanent kidney). Concurrently, the genital system develops in close association with the urinary system. Genital development depends on chromosomal sex, which determines whether the primitive gonads differentiate into testes or ovaries. The gonads then secrete certain hormones, which direct further development of both the internal and external genital structures. The ANS is a component of the peripheral nervous system that uses both afferent (sensory) and efferent (effector) neurons, which control the functioning of the internal organs and involuntary processes via connections with the CNS. The ANS consists of the sympathetic and parasympathetic nervous systems. The efferent nerve fibers that terminate in the endocrine, vascular, and visceral structures coordinate the inner workings of the body in response to several afferent inputs. The sympathetic and parasympathetic neural circuits coordinate stress responses and relaxation responses, respectively. The enteric nervous system regulates visceral organ function. A balance between these systems results in homeostasis, whereas an imbalance leads to pathological conditions. The neck is considered to be quadrangular. This shape is the basis to study various components of the neck and their relations. The boundaries of the quadrangular shape include the mandible, upper border of the clavicle, midline of the neck, and anterior margin of the trapezius. The quadrangular shape is divided into an anterior and posterior triangle by the sternocleidomastoid muscle (SCM). The anterior and posterior triangles are the 2 primary subdivisions and are delineated by easily recognized anatomic structures. Each triangle houses muscles, nerves, vasculature, lymphatics, and adipose tissue. Second-generation antipsychotics (SGAs) are also called atypical antipsychotics. Medications in this class include aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone. The SGAs act primarily by antagonizing dopamine (D2) and serotonin (5-hydroxytryptamine 2 (5-HT2)) receptors. Clinical indications include the treatment of schizophrenia, bipolar disorder, and treatment-resistant depression. In comparison to 1st-generation antipsychotics (FGAs), the SGAs cause fewer extrapyramidal symptoms but more metabolic adverse effects. Immunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response. There are multiple targets in the immune system, as well as varied mechanisms in inhibiting inappropriate immune activity. Biologic agents are medications derived from living organisms that target particular components of the immune system. The targets can be tumor necrosis factor (TNF), interleukins (ILs), or B- or T-cell activity. Calcineurin inhibitors halt the activity of calcineurin, a phosphatase involved in T-cell activation. Corticosteroids interfere with the cell cycle of inflammatory cells and modify the activity of other immune components. mTOR inhibitors are proliferation signal inhibitors, reducing immune-cell proliferation. Some immunosuppressants, such as cytotoxic agents, have antineoplastic activity; these are used in rheumatoid arthritis, as prophylaxis for transplant rejection, and for malignant diseases. Le Fort fractures are a group midface fracture patterns classified into 3 types: Le Fort I, II, and III. Le Fort fractures represent 10%–20% of all facial fractures and can be caused by any significant blunt trauma to the face, most commonly from motor vehicle accidents. Clinical presentation includes severe facial bleeding and edema and mobility of different bone segments, depending on the type in question. Diagnosis is clinical, supported by imaging techniques. Initial management centers around stabilization of the individual and control of bleeding. Definitive management is surgical. Long-term management concerns preservation and rehabilitation of facial function. Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. Risk factors for infection include conditions or agents that may lead to an immunocompromised state, disruption of the normal flora, and/or disturbance of the mucosal barrier. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). The diagnosis is made by identifying Candida on KOH preparation, cultures, or tissue biopsy. Treatment depends on the extent and site of infection, and includes topical or systemic antifungal medications Mendelian inheritance is defined as a pattern of segregation of genes, originating from any 1 of the parents, into gametes. Autosomal inheritance is a key component of Mendelian inheritance. Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. As such, autosomal diseases are inherited at equal rates among both genders. Autosomal recessive diseases are only expressed when 2 copies of the recessive allele are inherited, whereas autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Inborn errors of metabolism are classically autosomal recessive, whereas inherited structural abnormalities are classically inherited in an autosomal-dominant manner. There are 2 types of sex chromosomes in humans: X and Y. Chromosomal sex is male when a Y chromosome is present (e.g., 46,XY or 47,XXY) and female when the Y chromosome is absent (e.g., 46,XX or 45,X0). Male phenotypes develop when a specific gene, called the SRY gene (usually found on the Y chromosome), is present, stimulating differentiation of the gonads into testes. The testes then produce testosterone (triggering development of the penis and scrotum externally and the ejaculatory system internally) and antimüllerian hormone (AMH), which causes regression of the müllerian ducts. Without the SRY gene, ovaries develop; without testosterone, external female genitalia develop; and without AMH, the müllerian ducts persist and differentiate into the fallopian tubes, uterus, and upper vagina. The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. The skin is composed of surface epithelium, exocrine components, connective tissue, muscles, and nerves. The primary role of the skin is to serve as a protective barrier between the internal body and the external environment; it also protects the body from excessive fluid loss. Before the developing blastocyst reaches the uterine wall, it needs to undergo several stages of differentiation. After a continuous process of cleavage and compaction, the morula gives rise to the trophoblast and embryoblast, which are the primary components of the blastocyst. Uterine fluid passes through the zona pellucida to form the blastocyst cavity. When the blastocyst reaches the endometrium, implantation begins by the trophoblast dividing into the cytotrophoblast and syncytiotrophoblast, with the syncytiotrophoblast primarily being responsible for invading the endometrium. The embryoblast divides into the epiblast and hypoblast, which are responsible for creating the amniotic cavity and yolk sac, respectively. The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. The kidneys also play a major role in homeostatic processes, including electrolyte concentration, blood pressure, and acid–base regulation. Grossly, they consist of an outer cortex and inner medulla. Microscopic functional units known as nephrons filter the blood through a structure called the glomerulus, and this filtrate is then modified and concentrated as it moves through a complex tubular system. The renal arteries supply the kidneys via a central opening, known as the renal hilum, on its medial side; large renal veins empty directly into the vena cava. Labor is defined as regular, effective uterine contractions resulting in cervical changes that culminate in expulsion of the fetus and products of conception. Complications may arise during childbirth that necessitate prompt recognition and management by the delivering team. Four important complications/topics related to the moments surrounding delivery include episiotomy and lacerations, operative vaginal deliveries (forceps and vacuum-assisted deliveries), shoulder dystocia, and amniotic fluid embolism. Targeted therapy exerts antineoplastic activity against cancer cells by interfering with unique properties found in tumors or malignancies. The types of drugs can be small molecules, which are able to enter cells, or monoclonal antibodies, which have targets outside of or on the surface of cells. Among the areas in malignant cells that are blocked or inhibited by targeted therapy are signal pathways (as seen in protein kinase inhibitors), which lead to decreased proliferation and subsequent tumor cell apoptosis. Other means of reducing cancer cells is by eliminating the capacity for DNA repair (seen in poly(ADP-ribose) polymerase inhibitors), blocking the ligand-receptor binding (growth factor inhibitors), and increasing immune activity against the neoplasm (immunotherapies). These agents are used in multiple types of cancer and in combination with traditional chemotherapeutic agents. Thrombolytics, also known as fibrinolytics, include recombinant tissue plasminogen activator (TPa) (i.e., alteplase, reteplase, and tenecteplase), urokinase, and streptokinase. The agents promote the breakdown of a blood clot by converting plasminogen to plasmin, which then degrades fibrin. Thrombolytics are particularly helpful for conditions related to vascular obstruction by a blood clot (e.g., acute STEMI, pulmonary embolism (PE), deep venous thrombosis (DVT), and acute ischemic stroke). Efficacy declines the longer tissue ischemia persists; therefore, timing of therapy is particularly important in myocardial infarction and stroke. Life-threatening bleeding and allergic reactions are potentially serious complications. Weighing the risks and benefits of thrombolytics and evaluating individuals for contraindications/bleeding risk before initiating therapy is important. Gout medications include antiinflammatory and urate-lowering medications. Colchicine is an antiinflammatory medication that can be used for acute gout flares. The urate-lowering drug classes include the xanthine oxidase inhibitors, uricosuric agents, and uricases. These medications are beneficial for the prevention of gout exacerbations and work through a variety of mechanisms. Xanthine oxidase inhibitors are the most commonly used urate-lowering therapy; these work by inhibiting the enzyme necessary for the conversion of purines to uric acid. Uricosuric agents reduce reabsorption of uric acid by the proximal tubule, thereby increasing renal excretion. Lastly, the urases are recombinant enzymes that metabolize uric acid to allantoin. In addition to gout, urate-lowering treatment can also be used for other indications, such as the prevention of tumor lysis syndrome and uric acid nephrolithiasis. Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Additionally, with the ability to block muscarinic receptors, anticholinergic effects are also observed with this class of drugs. The 1st-generation H1 antagonists include chlorpheniramine, diphenhydramine, dimenhydrinate, and meclizine. Second-generation antihistamines generally do not cause drowsiness as these agents do not cross the blood-brain barrier. Examples of 2nd-generation antihistamines include loratadine, desloratadine, and cetirizine. Due to their antihistaminic activity, H1 antagonists are prescribed to treat allergy symptoms. Moreover, 1st-generation antihistamines are also used to treat motion sickness, nausea, and vomiting. H2 antagonists (blockers) target the H2 receptor, reducing gastric acid production and secretion. Thus, the general indications of H2 blockers include treatment of GERD and gastric and duodenal ulcers. Peripheral nerve damage affecting the upper extremities is a common occupational injury and also occurs in individuals who participate in recreational sports. Injuries can affect the axillary, musculocutaneous, median, ulnar, or radial nerves. The most common causes of these injuries are overuse, compression or entrapment, or nerve trauma; degenerative or demyelinating disorders; radiation therapy; and mass lesions. Clinical presentation is with motor and/or sensory deficits. Diagnosis is made clinically and based on electrodiagnostic and imaging studies. Treatment in most cases is conservative, although surgical intervention may occasionally be necessary. Brown-Séquard syndrome (BSS) is a rare neurologic injury that causes hemisection of the spinal cord, resulting in weakness and paralysis of one side of the body and sensory loss on the opposite side. This syndrome is most often due to trauma, but it may also occur with disc herniation, hematoma, or tumor. Clinical presentation is consistent with ipsilateral damage to the corticospinal tracts and posterior columns (weakness, loss of proprioception, and vibration sensation) below the level of the lesion, and contralateral anterior column symptoms owing to the unilateral involvement of the spinothalamic tract (loss of pain and temperature sensation). Diagnosis is confirmed with MRI. Management depends on the etiology and site of injury, and timely intervention is associated with a favorable prognosis and recovery. The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force, and its contraction leads to flattening of the dome of the diaphragm. This flattening increases the volume of the thoracic cavity and allows the lungs to expand during inspiration. The molecule DNA is the repository of heritable genetic information. In humans, DNA is contained in 23 chromosome pairs within the nucleus. The molecule provides the basic template for replication of genetic information, RNA transcription, and protein biosynthesis to promote cellular function and survival. Membranoproliferative glomerulonephritis (MPGN) is also known as mesangiocapillary glomerulonephritis. Membranoproliferative glomerulonephritis is a pattern of glomerular injury characterized by mesangial hypercellularity, endocapillary proliferation, and thickening of the glomerular basement membrane (double contour formation). The changes are due to the deposition of Igs, complement factors, or both, in the glomerular mesangium and along the glomerular capillary walls. The pathogenic variants include immune complex/monoclonal Ig-mediated (e.g., from infections, autoimmune diseases) and complement-mediated MPGN. In rare cases, MPGN is not associated with Igs and the complement system, such as in the case of endothelial injury. With multiple etiologies, the presentation and clinical course vary. Presenting features can be asymptomatic proteinuria and hematuria, nephrotic syndrome, nephritic syndrome, or chronic renal failure. Definitive diagnosis requires renal biopsy, although additional laboratory and imaging tests may point to the associated disease. Treatment is based on the underlying cause. Steroids, immunosuppressants, and kidney transplantation are among the commonly used treatment modalities. Anticonvulsant drugs are pharmacological agents used for seizure control and/or to prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action, including ion-channel (Na+, calcium) blocking and inhibition of GABA reuptake. Second-generation anticonvulsants exert their effects via these mechanisms and are associated with good efficacy, fewer toxic effects, and better tolerability, and generally do not require blood level monitoring. Medications in this class include felbamate, gabapentin, pregabalin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, zonisamide, and lacosamide. Anticonvulsant drugs are indicated for focal seizures, generalized tonic-clonic seizures, myoclonic seizures, and Lennox-Gastaut syndrome. Some anticonvulsants are also indicated in conditions unrelated to seizures (e.g., bipolar disorder). The most common adverse effects include dizziness, headache, and somnolence. Cell junctions are proteinaceous structures that physically hold 2 surfaces (cell-to-cell or cell-to-matrix) together. Cell junctions aid in communication and structural support and act as a barrier. They are classified as occluding (tight junctions), anchoring (adherens, desmosomes and hemidesmosomes), and communicating (gap junctions). Type II hypersensitivity has been noticed with autoantibody production against the components of anchoring junctions, resulting in pathology such as pemphigus vulgaris and bullous pemphigoid. The vitreous body is a transparent, gelatinous substance that is present in the space between the lens and the retina, providing structural stability and maintaining the shape of the eye. Some conditions that can affect the vitreous body are posterior vitreous detachment, vitreous hemorrhage, synchysis scintillans, asteroid hyalosis, and persistent fetal vasculature. The conditions can be asymptomatic or present with floaters in the field of vision, photopsia, and decreased visual acuity. Funduscopy and slit-lamp microscopy are commonly used in the diagnosis of these diseases. Treatment methods depend on the condition and severity, but may include observation, vision correction, and surgery. Intravenous anesthetics have been used in modern anesthesia practice since the 20th century. Modern anesthesia began with inhaled anesthetics; however, intravenous agents were adopted because injected or infused doses could be more closely controlled with little wasted medication. Several groups of agents are currently available (e.g., barbiturates, benzodiazepines, and dissociatives), but the most widely used are fentanyl, midazolam, and propofol. Child and adolescent care is the area of healthcare dedicated to individuals who are beyond the immediate neonatal age through adulthood. These individuals do not present a uniform group, but are a series of patient populations, each with evolving healthcare needs (both preventive and pathologic) unique to them. Appropriate care aims to ensure optimal overall health to promote the physical, emotional, and social well-being of these often-challenging populations. Primary care physicians are usually responsible for child and adolescent care. Well-child visits are scheduled yearly for this purpose. These visits are an opportunity to obtain a detailed clinical history, monitor physiologic and psychologic development, assess growth parameters, and perform a thorough physical examination. Age-specific screenings, counseling, and vaccinations should also be completed at these times. Phosphodiesterase (PDE) inhibitors are a group of drugs that act by inhibiting PDE enzymes. Phosphodiesterase inhibitors have various mechanisms of action depending on the subtype of PDE targeted, but their main action is increasing the amount of intracellular cAMP or cGMP, which in turn results in physiologic effects such as reducing inflammation, promoting smooth muscle relaxation, and vasodilation. Phosphodiesterase inhibitors are indicated in a wide variety of medical conditions, such as intermittent claudication, decompensated heart failure, chronic obstructive pulmonary disease, psoriasis, atopic dermatitis, erectile dysfunction, pulmonary artery hypertension, and benign prostatic hypertrophy. Contraindications, adverse effects, and warnings are category- and drug-dependent. Antidepressants encompass several classes of medications and are used to treat individuals with depression, anxiety, and other psychiatric conditions, as well as to manage chronic pain and menopausal symptoms. Bupropion is an atypical antidepressant that acts by increasing neurotransmitter levels and alleviates the symptoms of depression. Brexanolone is a neurosteroid mainly used for the management of postpartum depression. Monoamine oxidase inhibitors are a class of antidepressants that inhibit the activity of monoamine oxidase (MAO), thereby increasing the amount of monoamine neurotransmitters (particularly serotonin, norepinephrine, and dopamine). The increase of these neurotransmitters can help in alleviating the symptoms of depression. Selective inhibitors of MAO type B can also be used for the treatment of Parkinson disease. Other uses include for bulimia nervosa and panic disorder. The major adverse effects include serotonin syndrome and hypertensive crisis. Special care should be taken to avoid other serotonergic medications and tyramine-containing foods. Cholinomimetic drugs, also known as parasympathomimetics or cholinergic agonists, increase acetylcholine (ACh), which acts on cholinergic muscarinic and nicotinic receptors. Other cholinomimetic drugs result in a net cholinergic effect by inhibiting the cholinesterase enzyme. Muscarinic receptors are found in the CNS and are part of the parasympathetic nervous system, which responds to cholinomimetics. Nicotinic receptors are found in the CNS at the neuromuscular junction. Physiologic effects on muscarinic receptors include bronchoconstriction, lacrimation, and bradycardia. Physiologic effects on nicotinic receptors include vasoconstriction, tachycardia, and elevated blood pressure. Cholinergic activation of muscarinic receptors on vascular endothelial cells cause an increase in nitric oxide, which diffuses to the adjacent vascular smooth muscle cells, resulting in smooth muscle relaxation/vasodilation and a paradoxical effect of the cholinomimetics on bronchial smooth muscle (constriction) and vascular smooth muscle (relaxation). Clinical uses of cholinomimetic agents include treatment of dementia, glaucoma, and as an aid for smoking cessation. The primary adverse effect of cholinergic drugs is overstimulation of the parasympathetic nervous system. Symptoms result from excessive levels of ACh in synapses, glands, smooth muscles, and motor endplates. The testicles, also known as the testes or the male gonads, are a pair of egg-shaped glands suspended within the scrotum. The testicles have multiple layers: an outer tunica vaginalis, an intermediate tunica albuginea, and an innermost tunica vasculosa. The testicles are composed of testicular lobules (contain interstitial tissue) and seminiferous tubules (produce spermatozoa). Blood supply to the testicles is primarily provided by the testicular artery. Venous drainage is through testicular veins. The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. The shape and size of the breasts change during a woman’s life and menstrual cycles. Breasts are supplied by the axillary, internal thoracic, and intercostal arteries, and they are innervated by branches of the cervical plexus. The ear is a sensory organ responsible for the sense of hearing and balance. Anatomically, the ear can be divided into 3 parts: the outer ear, the middle ear, and the inner ear. The outer ear consists of the auricle and ear canal. The middle ear houses the tympanic structures and ossicles, which are responsible for the detection and initial transmission of sound. Finally, the inner ear contains the bony labyrinth, along with other structures essential for spatial orientation, hearing, and balance. The auditory and vestibular pathways are anatomically related but discrete pathways that permit conscious perception of and reaction to sound and spatial orientation. Stimulation of specialized hair cells in the cochlea and vestibular apparatus excite and send signals through partitions of the vestibulocochlear nerve (CN VIII) to the brainstem, where they synapse on various targets, send and receive other projections, and ultimately contribute to spatial orientation and perception of sound. Class 3 antiarrhythmics are drugs that block cardiac tissue K channels. The medications in this class include amiodarone, dronedarone, sotalol, ibutilide, dofetilide, and bretylium. The main mechanism of action includes blocking the cardiac K channels to prolong repolarization. However, some medications in this class also exert effects on Na channels, calcium channels, and adrenergic receptors. Indications vary among the medications, but include both atrial and ventricular arrhythmias. Because these medications prolong the QT interval, torsades de pointes is a potential complication of therapy. Hematopoietic growth factors are a family of glycoproteins responsible for the proliferation and differentiation of hematopoietic progenitor cells in the bone marrow. Pharmacologic erythropoietin, thrombopoietin, granulocyte colony-stimulating factor (G-CSF), and granulocyte macrophage colony-stimulating factor (GM-CSF) are used in certain cases in which normal hematopoiesis is impaired owing to treatment (e.g., chemotherapy) or underlying disease (e.g., aplastic anemia). Commonly, erythropoiesis-stimulating agents (ESAs) are given as part of the treatment of chemotherapy-induced anemia and anemia secondary to CKD. G-CSF and GM-CSF are administered to treat chemotherapy-induced neutropenia. Thrombopoiesis-stimulating agents are used in the prevention or treatment of thrombocytopenia. Non-insulinotropic diabetes medications are used to treat type 2 diabetes by methods other than increasing insulin secretion. This group of medications includes the biguanides, thiazolidinediones, alpha-glucosidase inhibitors, sodium–glucose transport protein 2 inhibitors, and amylin analogs. Mechanisms of action vary, but they can include increasing peripheral insulin sensitivity, reducing glucagon release, inhibiting gluconeogenesis, slowing glucose absorption, and increasing satiety. Metformin is the initial medication of choice; others may be used as an alternative monotherapy or as adjunctive therapy. Most of these medications are not associated with severe hypoglycemia, except for amylin analogs or when medications are used in conjunction with other hypoglycemic agents. Antimetabolite chemotherapy agents belong to the cell-cycle–specific drugs, which act on a specific phase of the cell cycle. Cancer cells more rapidly divide (or cycle) than normal cells, making them an easy target for chemotherapy. The different cell-cycle phases include G1, S, G2, and M. Antimetabolites target the S phase, when DNA replication occurs, thus inhibiting DNA synthesis of tumor cells. In this group, the drugs include antifolates (which block folic acid activity, an essential component of DNA and RNA precursors), pyrimidine and purine analogs (which interfere with the process of DNA synthesis), and ribonucleotide reductase inhibitors (which reduce production of deoxyribonucleotides). Cell-cycle–specific chemotherapy drugs cannot differentiate healthy from cancerous cells, thus adverse effects are seen. Myelosuppression is a common finding during treatment. Alkylating agents are cell cycle–independent antineoplastic drugs that work primarily by binding alkyl groups to various parts of DNA. The overall action produces cross-linking of DNA, leading to inhibition of DNA replication and DNA damage. The general effect is cancer (CA) cell death. The subgroups of drugs are nitrogen mustards, nitrosoureas, alkyl sulfonates, triazines, ethylenimines, and methylmelamines. Platinum coordination complexes belong to the group of alkylating agents by producing the same effect, but their mechanism is via formation of covalent metal adducts with DNA. Myelosuppression and toxicity to organ systems such as the kidneys, liver, and lungs are common adverse reactions. Microtubule and topoisomerase inhibitors target cellular structures and processes to inhibit cancer cell proliferation. Microtubule inhibitors act on the cytoskeleton, while topoisomerase inhibitors act on an enzyme that is important in DNA replication and transcription. The microtubule system, along with microfilaments and intermediate filaments, form the cellular cytoskeleton. These components are essential for cell division, movement, and signaling. Taxanes and vinca alkaloids interfere with microtubule function, and thus in effect, inhibit mitosis. Topoisomerase assists DNA replication by creating double- and single-stranded breaks to relieve supercoils. Inhibiting the enzyme causes termination of DNA replication and DNA damage. There are multiple chemotherapeutic agents in each class that commonly produce myelosuppression as an adverse effect. There are multiple different types of malignancies that can affect the vulva. The most common histologic type is squamous cell carcinoma (SCC), which accounts for approximately 75%–85% of all vulvar cancers. Other types include melanoma, basal cell carcinoma, sarcoma, malignancy of the Bartholin glands, and Paget disease of the vulva (an adenocarcinoma). Squamous cell carcinoma is typically associated with either high-risk HPV infection or lichen sclerosus. Vulvar cancer presents as vulvar lesions that can have a variety of appearances, which may include warty or nodular masses, scaly plaques, pigmented lesions, and ulcers; pruritus is also common. Diagnosis usually requires a biopsy, and management is primarily with surgical excision. Unfortunately, lymph node metastasis occurs early in the natural history of the disease and is associated with a poor prognosis. Insulinotropic diabetes medications treat type 2 diabetes mellitus by increasing insulin secretion, which results in decreased glucose levels. The group of medications includes sulfonylureas, meglitinides, glucagon-like peptide-1 (GLP-1) receptor agonists, and DPP-4 inhibitors. The agents are usually used in combination with other therapies for diabetes management. Sulfonylureas and meglitinides are associated with weight gain, while GLP-1 agonists may provide the added benefit of weight loss. Other side effects vary between the drug classes. None of the medications should be used in the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Labor has 3 stages: the 1st stage starts with the onset of regular contractions, the 2nd stage starts with full cervical dilation, and the 3rd stage starts immediately after fetal delivery and ends with delivery of the placenta. The primary factors required for labor to progress normally are the three Ps: power (uterine contractions), passenger (the fetus), and passage (the maternal pelvis). Labor may become abnormally protracted and require augmentation, usually with oxytocin, to prevent maternal and fetal complications. Primary vaginal cancers are malignant tumors that originate from cells in the vagina. Squamous cell carcinoma (SCC) is by far the most common (80%–85%); other histologic types include adenocarcinomas, sarcomas (including sarcoma botryoides, typically seen in children), and melanomas. Vaginal SCC is most commonly associated with HPV infections, while clear cell adenocarcinomas are associated with in utero exposure to diethylstilbestrol (DES). Individuals typically present with vaginal bleeding and/or an irregular mass or lesion on exam; other symptoms may include abnormal discharge, pain, and urinary or defecatory symptoms. A biopsy is required for diagnosis. Staging is based on tumor size, extent of local invasion, and metastasis. Management may be surgical for stage I disease, but surgery is typically avoided in advanced disease, which is instead managed with radiation and chemotherapy. Endometrial hyperplasia (EH) is the abnormal growth of the uterine endometrium. This abnormal growth may be due to estrogen stimulation or genetic mutations leading to uncontrolled proliferation. Endometrial carcinoma (EC) is the most common gynecologic malignancy in the developed world, and it has several histologic types. Endometrioid carcinoma (known as type 1 EC) typically develops from atypical endometrial hyperplasia, is hormonally responsive, and carries a favorable prognosis. Other histologic types are known as type 2 EC; they tend to present at more advanced stages, are not hormonally responsive, and carry a far worse prognosis. Women with both EH and EC tend to present with postmenopausal or irregular menstrual bleeding. Diagnosis is histologic. Management most often involves progestin therapy, surgery, and adjuvant radiation therapy (for advanced disease). Spontaneous abortion, also known as miscarriage, is the loss of a pregnancy before 20 weeks' gestation. However, the layperson use of the term “abortion” is often intended to refer to induced termination of a pregnancy, whereas “miscarriage” is preferred for spontaneous loss. Most spontaneous abortions occur within the 1st 12 weeks of gestation and can be caused by several factors such as infection, trauma, and genetic and autoimmune causes. There are different types of spontaneous abortions, including threatened, inevitable, incomplete, complete, and missed abortions. Spontaneous abortions are diagnosed based on history, physical examination, and ultrasound findings. Management options include expectant, medical, or surgical therapy. Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. There are several forms of insulin, and they differ in their time of onset, peak effect, and duration. Insulin can be classified as fast acting, short acting, intermediate acting, or long acting. A combination of classes can be used to maintain glucose control throughout the day. Common adverse effects include hypoglycemia, weight gain after initiation of an insulin regimen, and local injection site changes. Multiple pregnancy, or multifetal gestation, is a pregnancy with more than 1 fetus. Multiple pregnancy with more than 2 fetuses is referred to as a higher-order multiple pregnancy and the most common type of multiple pregnancy is a twin pregnancy. Due to advanced maternal age and evolving assisted reproductive technology, the rates of multiple pregnancies have steadily increased over the past 3 decades. However, rates have slowly plateaued with the increase of the single embryo transfer. The perinatal mortality and morbidity rates of twin pregnancies are 3–7x higher than singleton pregnancies primarily because of higher rates of preterm delivery. Multiple pregnancies also carry a higher risk of obstetric complications such as congenital anomalies, preeclampsia, and gestational diabetes. Multiple pregnancies are classified as high-risk and require astute obstetric care. Infant care is provided primarily by the child’s parents or other caregiver. A physician can greatly impact the quality of this care during the regularly scheduled outpatient visits, also known as well-child visits. During these visits, the physician has an opportunity to perform a comprehensive assessment of the child’s health, gauge caregivers’ apprehension about their role, and evaluate the overall growth environment of the child. Routine visits should be scheduled at regular intervals, with additional visits for acute concerns. The physician should conduct a history and physical examination; assess growth, development, and nutritional status; encourage administration of vaccinations; and provide anticipatory guidance and counseling to parents or caregivers, making sure to address any questions and concerns and to foster optimal development and support. Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). By far, EOCs are the most common, tend to present in postmenopausal women with advanced disease, and carry a poor prognosis. On the other hand, OGCTs and SCSTs frequently affect younger women, tend to present earlier, and carry a better prognosis. Affected individuals are frequently asymptomatic, although they may present with nonspecific symptoms such as fatigue, increasing abdominal girth, GI symptoms, and pelvic pain. Moreover, if the tumor secretes hormones, abnormal bleeding may be a presenting symptom. Diagnosis is suspected based on imaging studies and confirmed with histologic examination. Treatment is primarily surgical and often with adjuvant chemotherapy. Geriatric care includes the prevention and diagnosis of diseases, as well as the management of diseases, disabilities, and other health concerns in individuals ≥ 65 years of age. Special consideration is given when addressing multiple aspects that are specific to aging. Preventive measures such as vaccinations as well as cancer and disease screening are essential in this age group because of the high risk for infections and developing cancer and chronic diseases. A majority of older individuals have at least 1 chronic medical condition, which increases the likelihood of polypharmacy and adverse drug reactions. Vision, hearing, cognitive function, gait, and balance are among the functions that decline in the geriatric population. These disease- and age-related factors affect the activities of daily living. Assessing the financial and social resources of the elderly is also important, given the direct impact of these factors on their health. A multidisciplinary approach involving various professionals in the healthcare field is important in achieving comprehensive care for the elderly. Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. A thorough understanding of pertinent anatomy, appropriate physical examination, and common problems of the knee joint are essential for diagnosis and proper management of knee pain. Exercise-based therapy is often the 1st-line management of many knee disorders, but surgical intervention is warranted for specific diagnoses. There are several benign vulvar diseases, but some of the most common are Bartholin cyst and abscess, lichen sclerosus, and lichen simplex chronicus. Bartholin cysts are formed due to an obstruction in the excretory duct that causes retention of their secretions (lubricating mucus). Bartholin cysts present as nontender fluctuant masses at the 4 and/or 8 o'clock positions in the labia. If a Bartholin cyst becomes infected, it can develop into an extremely painful abscess. Lichen sclerosus is a chronic dermatologic condition that causes progressive thinning and fibrosis of the vulvar, perineal, and perianal skin, and presents classically with itching and white plaques. Lichen simplex chronicus is a thickening of the vulvar skin due to chronic itching or rubbing, which often occurs in the setting of atopic or contact dermatitis. Hormonal contraceptives (HCs) contain synthetic analogs of the reproductive hormones estrogen and progesterone, which may be used either in combination or in progestin-only formulations for contraception. These formulations act synergistically to produce antiovulatory effects and can also affect the endometrial lining (typically decreasing bleeding and pain associated with menstruation), which is why they are also used to treat a variety of gynecologic issues. Available formulations include oral contraceptive pills (combined and progestin-only), transdermal patches, vaginal rings, progestin injections, subdermal implants, and intrauterine devices. Common adverse effects include nausea, headaches, mood changes, and irregular bleeding. Importantly, estrogens increase the risk of venous thromboembolism (VTE) and are contraindicated in individuals at risk for VTE. Other important contraindications include pregnancy, liver disease, and breast cancer. Cannabinoids are a class of compounds interacting with cannabinoid receptors. The 3 types of cannabinoids are phytocannabinoids (naturally derived from flora), endocannabinoids (endogenous), and synthetic cannabinoids (artificially produced). Endocannabinoids are endogenous neuropeptide neurotransmitters found in the human nervous system. Cannabinoids have a psychotropic effect, which leads to frequent recreational use, but the unique effects of cannabinoids on the CNS also provide pharmacological indications. Prescription cannabinoids treat pain, nausea, vomiting, and seizure disorders and also serve as appetite stimulants. Multitrauma occurs when 2 or more traumatic injuries occur in at least 2 areas of the body. A systematic management approach is necessary for individuals who have undergone trauma to maximize outcomes and reduce the risk of undiscovered injuries. Assessment of multitrauma starts with a primary survey followed by the A-B-C-D-E scheme, involving securing of the airway (A), and evaluating breathing (B), circulation (C), recognition of neurologic deficits or disability (D), and exposure to environmental control (E). Once the primary survey is completed, a secondary survey is performed to obtain pertinent history and nature of the trauma based on a thorough examination and diagnostic studies. The A-B-C-D-E approach is crucial for the overall stabilization, treatment, and identification of any missed injuries. Cerebellar disorders are a specific set of neurologic signs and symptoms caused by local or systemic conditions that affect the cerebellum; the classic sign is ataxia, in addition to several other motor abnormalities that affect coordination. The causes of cerebellar disorders range from acute alcohol intoxication to inherited conditions. Clinical presentation is with incoordination of voluntary muscle movement, affected ocular movements, speech, gait, balance, and muscle tone. The diagnosis is initially made clinically and then followed by imaging studies to determine the etiology; management depends on the specific etiology. Antitumor antibiotics, also known as antineoplastic antibiotics, are the product of soil microbes, Streptomyces bacteria. The commonly used types of antitumor antibiotics—bleomycin, dactinomycin, and anthracyclines—have a wide spectrum of activity against hematologic malignancies and solid tumors. Bleomycin differs from the rest of the drugs owing to its cell cycle–specific action during the G2 phase. Mechanisms of actions of these drugs include free radical damage to DNA, topoisomerase II inhibition, binding of DNA via intercalation, and alteration of cell membrane fluidity and transport of ions. Important adverse effects include cardiotoxicity (acute and chronic) and myelosuppression. Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo is a clinical diagnosis, differentiated through history and physical examination findings, most notably nystagmus. Further testing may be required in malignant cases. Management depends on the etiology but certain maneuvers such as the Epley maneuver can be diagnostic and therapeutic. Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Diagnostic evaluation relies on history, physical examination (including otoscopic and tuning fork examinations), and audiology testing. Management is directed toward the underlying cause of the hearing loss to choose the appropriate course of treatment. Ménière disease is a condition characterized by episodes of vertigo, tinnitus, and hearing loss, likely caused by endolymphatic hydrops of the labyrinthine system in the inner ear. The risk factors include a family history of Ménière disease, preexisting autoimmune disorders, allergies, and trauma to the head or ear. A diagnosis is made clinically, by audiometry, by vestibular testing, and occasionally by imaging. Management can be by diet and lifestyle modification, vasodilators, diuretics, antihistamines, benzodiazepines, antiemetics, glucocorticoids, surgical intervention, or hearing aids. Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Risk factors that cause a predisposition to CTS include obesity, female sex, pregnancy, diabetes, inflammatory conditions, genetic predisposition, and occupational factors. A clinical diagnosis may be made on the basis of history and physical examination and confirmed with electrodiagnostic testing. Conservative management includes splinting and physical therapy; more severe cases may require surgical correction. Anticonvulsant drugs are pharmacological agents used to achieve seizure control and/or prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action including ion-channel (Na+ and Ca+2) blocking and GABA reuptake inhibition. Phenobarbital, phenytoin, carbamazepine, valproic acid, and ethosuximide are the 1st-generation antiseizure drugs. Anticonvulsant drugs generally have complicated pharmacokinetics, multiple drug interactions, and narrow therapeutic ranges compared with new-generation drugs. The brachial plexus is a network of nerves that originate from the lower cervical and upper thoracic nerve roots. The causes of brachial plexopathies include traumatic injuries, birth-related injuries, iatrogenic procedures, neoplastic processes, and previous treatment with radiation. Patients present with sensory and motor deficits related to the site of the lesion and the nerves involved. Diagnosis is made based on clinical findings, imaging, and electrodiagnostic studies. Treatment is related to the underlying cause and may be medical or surgical. The term “persistent vegetative state,” also called unresponsive wakefulness, describes the condition of individuals with severe anoxic brain injury who have progressed to a state of wakefulness without any meaningful response to their environment. A persistent vegetative state is distinguished from a coma in that individuals in a persistent vegetative state have intermittent sleep–wake cycles. The individual's eyes may be open and there may be some yawning, grunting, or other vocalizations. In both cases, the individual is alive, but the brain does not function fully. Persistent vegetative state is most commonly associated with anoxic brain injury due to cardiac arrest, trauma, metabolic causes, or infections. Diagnosis is made by fulfilling specific diagnostic criteria. Treatment is controversial and ethically challenging. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months, while recovery from a nontraumatic persistent vegetative state after 3 months is exceedingly rare. Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Typical GBS is characterized by acute monophasic neuromuscular paralysis, which is symmetric and ascending in progression. If the paralysis reaches the respiratory muscles, GBS can progress into respiratory failure, which requires prolonged hospitalization. Management is mostly supportive and may require either plasma exchange or IV immunoglobulin. Trigeminal neuralgia (TN) is an often chronic and recurring pain syndrome involving the sensory distribution of the trigeminal nerve (cranial nerve (CN) V). The pain is typically unilateral and described as an acute, sharp, electric-shock–like pain involving the maxillary or mandibular areas and often associated with spasm of facial muscles. Trigeminal neuralgia occurs in multiple, short-acting episodes. Most cases are usually due to vascular compression of the trigeminal nerve, although secondary causes can be from aneurysms, neuromas, or other neurologic disorders. A detailed history is the hallmark for diagnosis. Neuroimaging with MRI is useful to determine the exact pathology involving the trigeminal nerve root. The 1st line of therapy is pharmacologic (carbamazepine). Other treatment options include botulinum toxin injections or surgical procedures in refractory cases. Antiadrenergic agents are drugs that block the activity of catecholamines, primarily norepinephrine (NE). There are 2 major types of adrenergic receptors–alpha and beta receptors—and there are several subtypes of each. Antiadrenergic drugs can be classified according to their specificity for the different receptors, with the major classes including selective beta-1 receptor blockers, nonselective beta-blockers, mixed alpha- and beta-blockers, selective alpha-1 receptor blockers, and nonselective alpha-blockers. There are many beta receptors in the heart, so these medications are primarily used for cardiac indications, including MI, angina, heart failure (HF) (stable), and hypertension (as an alternative agent). Alpha receptors are prominent in smooth muscle, especially in the vasculature. Alpha-blockers cause significant vasodilation and are indicated in hypertension and benign prostatic hyperplasia (BPH). Significant adverse effects are possible. Dystonia is a hyperkinetic movement disorder characterized by the involuntary contraction of muscles, resulting in abnormal postures or twisting and repetitive movements. Dystonia can present in various ways as may affect many different skeletal muscle groups. Dystonia may be inherited, acquired, or idiopathic. The diagnosis is made clinically, and genetic testing is recommended in individuals with a family history of dystonia. Management is with botulinum toxin or other drugs that target the various neurotransmitters involved in the pathogenesis of dystonia. Posterior cord syndrome (PCS) is an incomplete spinal cord syndrome affecting the dorsal columns, the corticospinal tracts (CSTs), and descending autonomic tracts to the bladder. Posterior cord syndrome is rare but has a diverse range of etiologies, including demyelinating disorders, degenerative spinal conditions, neoplastic causes, vascular abnormalities, and hereditary neurodegenerative disorders. Clinical symptoms include gait ataxia, paresthesias with loss of position and vibration sense, and urinary incontinence. The diagnosis is made clinically and with neuroimaging. Management addresses treatment of the underlying cause. Ataxia-telangiectasia, also known as Louis-Bar syndrome, is a neurocutaneous syndrome, which involves multiple systems but mainly affects the neurological system. Ataxia-telangiectasia is an autosomal recessive genetic disorder caused by a mutation in the ATM gene (ATM serine/threonine kinase or the ataxia-telangiectasia mutated gene). Ataxia-telangiectasia presents with progressive ataxia, telangiectasias, extrapyramidal symptoms, dermatological manifestations, immune dysfunction, and progressive pulmonary disease. Diagnosis is based on clinical presentation and confirmed with neuroimaging and genetic testing. Management is supportive with symptom management. Prognosis is poor secondary to numerous complications. Sympathomimetic drugs, also known as adrenergic agonists, mimic the action of the stimulators (α, β, or dopamine receptors) of the sympathetic autonomic nervous system. Sympathomimetic drugs are classified based on the type of receptors the drugs act on (some agents act on several receptors but 1 is predominate). Clinical uses of sympathomimetics include the treatment of hypotension, asthma, and anaphylaxis. The primary drugs used as IV vasopressors in the hospital are dopamine and norepinephrine. Dobutamine is given IV as an inotrope. Albuterol is used via nebulizer or metered-dose inhaler for asthma. Sympathomimetics may produce a wide range of adverse effects, which generally resemble excessive stimulation of the sympathetic nervous system. The effects may include palpitations, tachycardia, and/or arrhythmias due to stimulation of cardiac β receptors. Neurofibromatosis type 2 is a neurocutaneous disorder that can arise from mutations in the NF2 gene located in chromosome 22 and may be inherited in an autosomal dominant fashion or occur from de novo mutations. The main clinical features are bilateral vestibular schwannomas, intracranial/spinal meningioma, and intramedullary and extramedullary spinal tumors. Other features can include eye lesions such as cataracts, skin lesions, and peripheral neuropathy. Diagnosis is made clinically from history and examination and confirmed with MRI, molecular testing, and histopathology. Tumor surveillance and follow-up with screening of at-risk family members is recommended. Management includes surgical interventions, radiation therapy, and/or monoclonal antibody therapy with bevacizumab. Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants are used in beverages and as over-the-counter medications, prescription medications, and drugs of abuse. Caffeine and nicotine are commonly used psychostimulants. Amphetamines are used in a clinical setting for specific indications, but are more often used illegally as drugs of abuse along with cocaine. Each agent has its idiosyncrasies with respect to effects, withdrawal, and overdose. Neurofibromatosis type 1 (NF1), also known as phakomatosis, is a neurocutaneous disorder that is most commonly of autosomal dominant inheritance due to mutations in the NF1 gene. Neurofibromatosis type 1 presents a range of clinical manifestations with the most prominent features being various pigmented skin lesions called café au lait macules (CALMs), benign nerve-sheath tumors called neurofibromas, freckling of the inguinal and axillary regions, and iris hamartomas, referred to as Lisch nodules. At least half of the individuals with NF1 have learning disabilities. Neurofibromatosis type 1 may also cause osteodysplasia and malignant transformation of tumors. The diagnosis is based on the typical clinical presentation and can be confirmed with genetic testing. Management depends on the clinical presentation and may vary from surgical removal to chemotherapy/radiotherapy for tumors, occupational therapy and PT for motor impairments, treatment with growth hormone, and bracing in the case of bone abnormalities. Inhaled anesthetics are chemical compounds, which can induce and maintain general anesthesia when delivered by inhalation. Inhaled anesthetics can be divided into 2 groups: volatile anesthetics and gases. Volatile anesthetics include halothane, isoflurane, desflurane, and sevoflurane. Nitrous oxide (N2O) is the most common of the anesthetic gases; cyclopropane and xenon are less commonly used. While the exact mechanism of action of the inhaled anesthetics is unknown, the drugs are believed to have variable effects on GABA, glycine, glutamate, and NMDA receptors in the CNS. Inhaled anesthetics have been used for medical purposes for the last 200 years. Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a clinical disorder that presents with symptoms due to increased intracranial pressure (ICP; ≥ 20 mm Hg) or CSF pressure (> 250 mm H2O), with no structural changes or other attributable causes. The condition is most commonly observed in obese women and after intake of certain drugs, such as growth hormones, tetracycline antibiotics, and high dosages of vitamin A. Classic manifestations include headache, vision loss or visual-field defects, and papilledema. Diagnosis is made by clinical exam, imaging, and lumbar puncture. Management is aimed at decreasing ICP and includes medication, therapeutic CSF removal, and shunting. Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope is not a distinct disease entity; rather, it is a symptom of another pathologic process, whether it be transient or a more established disease process. Syncope may be accompanied by other symptoms, such as light-headedness, sweating, palpitations, nausea, feeling warm or cold, and visual blurring. Workup includes a detailed history and physical examination, electrocardiography, echocardiography, provocative testing (tilt-table test), or imaging of the suspected culprit vasculature. In many cases, a definite etiology is not found. Management is based on the underlying cause and can include physical countermaneuvers, stopping offending drugs, volume resuscitation, blood transfusion, and/or cardiac or vascular interventions. Anthelmintic drugs are used to treat infections caused by parasitic helminths. Helminths include both flatworms (flukes and tapeworms) and roundworms. Anthelmintic medications are categorized on the basis of the class of helminths they are used for. Nematicidal agents include the benzimidazoles (albendazole, mebendazole, and triclabendazole), diethylcarbamazine, ivermectin, and pyrantel pamoate. Praziquantel is a trematocidal and cestodicidal agent. The mechanisms of action of the anthelmintic drugs vary, but many work by disrupting the normal function of the organism, inducing paralysis, and/or causing death. Most of these drugs are well absorbed, which can allow for treatment of systemic infections. Pyrantel pamoate, on the other hand, is poorly absorbed and is better suited to treating luminal nematodes. The benzimidazoles’ absorption is changed by the presence of food, which allows for some control in treating luminal or invasive infections (such as cysticercosis). Adverse effects of anthelmintics vary, but all classes of these drugs are associated with GI side effects. Amebicides are drugs toxic to amoebas such as Entamoeba histolytica (the causative organism of amebiasis). Parasites enter the GI tract where trophozoites can penetrate the intestinal wall and cause an invasive infection. Amebicides are classified based on where the drug is most effective: intestinal lumen or tissues. Intestinal-lumen amebicides include iodoquinol and paromomycin. Tissue amebicides include the nitroimidazole drug class (e.g., metronidazole, tinidazole). Treatment of symptomatic disease usually requires a combination of both classes. Antiresorptive drugs are used to treat osteoporosis. Bisphosphonates are generally used as 1st-line therapy, but other options are available for individuals who fail or cannot tolerate therapy. The drug classes include exogenous hormone therapy (teriparatide, calcitonin, estrogen, and vitamin D), selective estrogen receptor modulators, and RANKL inhibitors. Most of these drugs inhibit osteoclast activity to decrease bone resorption. A notable exception is teriparatide, which stimulates osteoblast activity to promote bone formation. Adverse effects vary greatly among drug classes. Antiviral agents against human herpesviruses (HHVs) include acyclovir, cidofovir, and foscarnet. Human herpesviruses are DNA viruses in the Herpesviridae family. Herpes simplex virus (HSV), varicella-zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), and HHV-8 belong to the Herpesviridae family. Antivirals against the group generally act via inhibition of DNA polymerase. Acyclovir (the prototypical nucleoside analog) requires viral kinase for phosphorylation to become a triphosphate, which is incorporated in viral DNA. Cidofovir requires phosphorylation by host cellular kinase, which allows cidofovir to have activity against mutated viruses and become deficient in viral kinase. Foscarnet (a pyrophosphate analog) does not require phosphorylation. Nephrotoxicity is a shared adverse effect in the agents. Acyclovir can also cause obstructive crystalline nephropathy and foscarnet carries a risk of electrolyte abnormalities and seizures. The nephrotoxic effect of cidofovir can be reduced with IV saline and probenecid. Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased ICP can lead to brain herniation and death if not treated promptly. Clinical presentation includes headache, drowsiness or altered level of consciousness, and papilledema. Diagnosis is suspected based on the clinical presentation and confirmed with urgent brain imaging. Immediate management includes measures to decrease ICP, medications including diuretics, and surgery. Glandular epithelia, composed of epithelial tissue, are specialized structures that play a role in the production and release of enzymes, hormones, sweat, oil, and mucus in organisms. The secretion and release of these substances are prompted by either external or internal stimuli. Products of glandular epithelia are released either into ducts leading to the surface of the epithelium or into the blood. The 2 types of glands are exocrine and endocrine glands. The classification is based on the number and location of secreting cells and the type of secretions, among other factors. Antivirals for hepatitis B include the nucleoside/nucleotide analogs, also known as nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs). Because of their similar chemical structure to nucleosides and nucleotides, NRTIs are able to integrate into viral DNA during the replication process. This process inhibits the function of viral RNA-dependent DNA polymerase, resulting in chain termination. All of these medications are administered orally and are excreted by the kidneys. Indications include chronic hepatitis B infection, and some (such as lamivudine) are also used for HIV. Adverse effects include GI symptoms, evidence of mitochondrial toxicity (such as lactic acidosis), and rebound infection upon discontinuation. Intracerebral hemorrhage (ICH) refers to a spontaneous or traumatic bleed into the brain parenchyma and is the 2nd-most common cause of cerebrovascular accidents (CVAs), commonly known as stroke, after ischemic CVAs. Trauma, hypertension, vasculopathy, vascular malformations, tumors, coagulopathy, and hemorrhagic conversion of ischemic stroke may all be causative factors. Clinical presentation may vary depending on the size and location of the hemorrhage and may range from headache, neurologic signs and symptoms, and altered level of consciousness to coma. Treatment includes stabilization, stopping or reversing of anticoagulation, blood pressure control, monitoring in a neurologic ICU, and possible neurosurgical intervention. Intracerebral hemorrhage is associated with significant morbidity and mortality. Diarrheagenic Escherichia coli is a strain of pathogenic bacteria that can cause intestinal infection. Transmission is often through the fecal–oral route via the consumption of contaminated food or water. Pathogenesis varies based on the strain, but it can include toxin production, invasion of the mucosal surface, and adhesion with alteration of enterocyte structure. Noninvasive disease tends to present with watery diarrhea, while invasive infections cause bloody diarrhea. The diagnosis can be established with PCR. Management generally consists of supportive therapy (fluids and electrolytes). Antibiotics are reserved for severe or persistent infections and are contraindicated with enterohemorrhagic E. coli because of the risk of hemolytic uremic syndrome. Bone, while seemingly inert, is an active, growing, and changing part of the human body, in addition to being the body's primary calcium reservoir. In the correct homeostatic conditions, bone can remodel in response to damage, stress, or hormonal signaling (parathyroid hormone and calcitonin). Osteocytes located deep in the bone sense damage and signal bone-lining cells that will begin the process of remodeling. This process is vital not only for damage repair but also to adapt to a new environment and conditions. Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Crystalloids and colloids have different general compositions, which affect distributions through the body’s fluid compartments and guide clinical use. Crystalloid solutions are typically used for patients who are hypovolemic, dehydrated, or have ongoing fluid losses. Colloidal solutions may be used in cases of low oncotic pressure. Providers should choose fluid types based on the clinical scenario and best available evidence. All recipients of IVFs should be closely monitored to determine the goal and status of the fluid therapy. Epidural hemorrhage (EDH) is an event characterized by bleeding into the epidural space between the dural layers of the meninges and the skull. The primary mechanism triggering bleeding is trauma (i.e., closed head injury), which causes arterial injury, most commonly middle meningeal artery injury. Epidural hemorrhage presents acutely, usually immediately (seconds to hours) following head trauma, with an altered level of consciousness that may span from a momentary loss of consciousness to coma. Diagnosis is based on clinical suspicion following head trauma and is confirmed with neuroimaging (i.e., noncontrast head CT). Management includes stabilization, stopping (possibly, the reversal) of all anticoagulants, monitoring in a neurologic ICU, and neurosurgical intervention. To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. An ectopic pregnancy occurs if the zygote does not reach the uterus before the zona pellucida degrades. Subdural hemorrhage (SDH) is bleeding into the space between the dural and arachnoid meningeal layers surrounding the brain. The most common mechanism triggering the bleeding event is trauma (e.g., closed head injury) causing a tearing injury to the extracerebral “bridging” veins, but rupture of small arteries within this space or intracranial hypotension may also be causative. Acute SDH presents, immediately following head trauma, with an altered level of consciousness that may span from a momentary loss of consciousness to coma, which makes it a potentially life-threatening condition. Chronic SDH may also occur, presenting with a more gradual neurologic deterioration. Diagnosis is based on clinical suspicion following head trauma and confirmed with neuroimaging (e.g., noncontrast head CT). Management includes stabilization, stopping (possibly reversing) all anticoagulants, monitoring in a neurologic ICU, and neurosurgical intervention. Hyponatremia is defined as a decreased serum sodium (sNa+) concentration less than 135 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled via antidiuretic hormone (ADH) release from the hypothalamus and by the thirst mechanism. The basic pathophysiology of all etiologies of hyponatremia is an abnormal increase in total body water (TBW), which dilutes the total body sodium (TBNa+) concentration. The clinical presentation varies greatly, from asymptomatic to subtle cognitive deficits, seizures, and death. Management is guided by etiology, acuity, and duration of symptoms, usually involving oral fluid restriction or administration of IV fluids that contain Na. Sodium must be replaced slowly, as overly rapid correction of hyponatremia can lead to irreversible neurologic complications and death, known as the osmotic demyelination syndrome (ODS). Rapidly progressive glomerulonephritis (RPGN) is a syndrome of severe glomerular disease with progressive loss of kidney function within weeks to months. Rapidly progressive glomerulonephritis is associated with nephrotic syndrome and is a manifestation of different diseases. Histologically, crescents (the proliferation of epithelial cells and the infiltration of monocytes/macrophages in the Bowman space) are found in the glomeruli and arise from immunologic injury. The major mechanisms of immunologic injury are classified into anti-glomerular basement membrane (anti-GBM) disease, pauci-immune crescentic glomerulonephritis, and immune complex-mediated injury. Rapidly progressive glomerulonephritis can manifest with hematuria, proteinuria, and varying degrees of edema and hypertension. Diagnosis is by presentation, laboratory tests, imaging, and renal biopsy. Prompt treatment is essential because RPGN can develop into end-stage renal disease within a short period of time. Modalities include corticosteroids, cyclophosphamide or other immunosuppressants, and plasmapheresis (depending on the underlying disease). Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. The most classic symptom is a sudden-onset (thunderclap) headache along with neck stiffness, vomiting, a decreased level of consciousness, and seizure. As with any stroke, focal neurologic deficits are commonly present, and rapid neurologic deterioration may ensue without prompt diagnosis and intervention. An SAH should be suspected in any person presenting with thunderclap headache and neurologic symptoms, and the diagnosis can be confirmed with neuroimaging or lumbar puncture (LP). Treatment consists of reversal of anticoagulation, control of blood pressure, and neurosurgical intervention to contain the bleed and/or relieve elevated intracranial pressure (ICP). Even with prompt neurosurgical intervention, SAH carries a high mortality rate. Gametogenesis is the development of gametes from primordial germ cells. This process differs between the sexes. In males, spermatogenesis produces spermatozoa. In females, oogenesis results in an ovum. The process starts with the migration of primordial germ cells from the yolk sac to the gonadal ridge. Oogenesis starts during the embryonic and fetal periods, whereas spermatogenesis starts at puberty. However, the phases of gametogenesis are similar, with germ cells progressing through mitosis, meiosis I, meiosis II, and maturation. This process results in gametes that are haploid, with 23 chromosomes. Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. The major cellular response involves neutrophils and macrophages to phagocytose and lyse the injurious organism or repair necrosed tissue after injury. Inflammation can be pathologic if it is prolonged or when normal processes create an excessive response (such as with atherosclerosis). There are multiple mediators of inflammation that overlap with innate immunity when they respond to injurious stimuli. Inflammation can become chronic, resulting in the formation of granulomas, tissue damage, and the loss of organ function. Paraneoplastic syndromes are a heterogeneous group of disorders caused by an abnormal immune response to a neoplasm. The substances produced are not due to the direct effect of the tumor, such as metastasis, mass effect, or invasion. Antibodies, hormones, cytokines, and other substances are generated and affect multiple organ systems. About 10% of cases of cancer are affected by paraneoplastic syndromes. The common cancers that present with paraneoplastic syndromes include cancer of the lung, breast, ovaries, kidney, liver, and stomach and lymphomas. The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th‒11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. The spleen can also activate immune responses, produce antibodies, and function as a reservoir for platelet storage. There are 2 primary types of splenic tissue: red pulp, which contains dense fibrovascular networks for filtering the blood, and white pulp, which is primarily made up of lymphoid tissue surrounding the larger vessels. The spleen has a relatively weak capsule; thus, it can rupture more easily than other abdominal organs and lead to life-threatening hemorrhage. Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Most individuals are asymptomatic until complications arise, including esophageal varices, portal hypertensive gastropathy, ascites, and hypersplenism. The diagnosis is clinical, but it can be supported by ultrasound findings (and hepatic venous pressure gradient measurement in unclear cases). Management requires treating the underlying etiology and managing the complications. This can include nonselective beta blockers to prevent bleeding from varices, diuretics and sodium restriction for ascites, and transjugular intrahepatic portosystemic shunt for refractory complications. Cystoisospora and Cyclospora are genera within the Coccidia subclass of protozoans. These single-celled, obligate intracellular parasites cause intestinal infections in humans. Humans are the only host for these species, and they are both transmitted through the fecal–oral route. The symptoms of cystoisosporiasis and cyclosporiasis are watery diarrhea, abdominal pain, and fever. Severe cystoisosporiasis can occur in immunocompromised individuals, particularly those with HIV/AIDS, and can lead to malabsorption, weight loss, and dehydration. Both diseases are self-limited in immunocompetent individuals, though cyclosporiasis has a longer course. Diagnosis is made by identifying the oocysts in stool samples. Antimicrobial therapy, such as trimethoprim–sulfamethoxazole, can be used (particularly in immunocompromised individuals). The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). The peritoneum supports and suspends the organs within the abdominal cavity and provides an important conduit for the neurovasculature supplying these organs. There are several peritoneal folds, known as mesenteries, omenta, and ligaments. The greater and lesser omenta divide the peritoneal cavity into greater and lesser sacs, which are important anatomic spaces within the cavity. Organs located behind the posterior parietal peritoneum are known as retroperitoneal, while organs that protrude into the cavity and are fully covered by visceral peritoneum are known as intraperitoneal. Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). Hepatitis C virus is an RNA virus and a member of the genus Hepacivirus and the family Flaviviridae. The infection can be transmitted through infectious blood or body fluids and may be transmitted during childbirth or through IV drug use or sexual intercourse. Hepatitis C virus can cause both acute and chronic hepatitis, ranging from a mild to a serious, lifelong illness including liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis C infection is diagnosed by testing for the presence of HCV antibodies and HCV RNA. Management is supportive but includes direct antiviral agents (DAAs) if infection does not resolve spontaneously. Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition is almost always associated with an underlying disease process, which can be classified into 4 categories: decreased nutrient intake, decreased absorption of micronutrients and macronutrients, increased nutrient loss, and increased energy expenditure. The clinical presentation of marasmus varies based on severity, duration of caloric restriction, and vitamin/mineral deficiencies. The clinical presentation of kwashiorkor includes peripheral pitting edema, muscle atrophy, and abdominal distention. Anthropometry is essential in the diagnosis of malnutrition. The 3-step approach to treat malnutrition includes resuscitation, rehabilitation, and relapse prevention. Hepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Hepatitis B virus is transmitted by exposure to infectious blood or body fluids. Examples of types of exposure include sexual intercourse, IV drug use, and childbirth. The virus can cause potentially life-threatening liver disease. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Management of acute hepatitis is typically supportive. Administration of antivirals or liver transplantation may be necessary in fulminant and chronic cases. The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal incontinence can occur if this function is disturbed. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Peristaltic waves within the rectal muscularis, involuntary relaxation of the internal anal sphincter (controlled by the ANS), and voluntary relaxation of the external anal sphincter (controlled by the cerebral cortex) are essential for defecation to occur. The rich plexus of veins surrounding the anal canal can develop into hemorrhoids if dilated. Mitochondria are located in a cell’s cytoplasm and contain circular DNA, called mitochondrial DNA (mtDNA). This DNA exists separately from a cell’s nuclear genome and is inherited solely through the maternal lineage—nonmendelian inheritance. Genetic mutations in mtDNA give rise to various rare diseases such as Leber hereditary optic neuropathy (LHON) and myoclonic epilepsy with ragged red fibers (MERRF). The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Proteins generate energy through redox reactions that create the proton gradient. The complete aerobic catabolism of 1 molecule of glucose yields between 36 and 38 ATPs, mostly through energy obtained as the reduced coenzymes NADH and FADH2 are conveyed through the electron transport system. Three of the 4 respiratory complexes that make up the mitochondrial respiratory chain, as well as ATP synthase, are embedded in the inner mitochondrial membrane. Coenzyme Q and cytochrome c transfer electrons between complexes, which will ultimately meet oxygen and generate H2O. Urea cycle disorders (UCDs) are caused by genetic defects and result in deficiencies of enzymes and transporters of the urea cycle. As a result of the defects, individuals are unable to rid the body of nitrogen waste. Common symptoms include vomiting, lethargy, seizures, and respiratory alkalosis. Most defects are autosomal recessive and definitive diagnosis is by molecular genetic testing. Treatment aims to reduce ammonia concentration in plasma. In less severe cases, acute episodes can be prevented through dietary restriction of protein. Untreated disease may lead to seizures, coma, or death. Olfaction represents an ancient, evolutionarily critical physiologic system. Humans have the ability to detect and discriminate at least 10,000 different odorants. The sense of smell, or olfaction, begins in a small area on the roof of the nasal cavity, which is covered in specialized mucosa. From there, the olfactory nerve transmits the sensory perception of smell via the olfactory pathway. This pathway is composed of the olfactory cells and bulb, the tractus and striae olfactoriae, and the primary olfactory cortex and amygdala. Olfaction is responsible for the detection of hazards, pheromones, and food. The limbic system is a neuronal network that mediates emotion and motivation, while also playing a role in learning and memory. The extended neural network is vital to numerous basic psychological functions and plays an invaluable role in processing and responding to environmental stimuli. The palate is the structure that forms the roof of the mouth and floor of the nasal cavity. This structure is divided into soft and hard palates. The palate is formed between weeks 7 and 10 of gestation, and deformities of this structure (cleft palate) are usually relevant because of its role in feeding, especially in infants. The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. The muscles of the pharynx receive innervation from the vagus and glossopharyngeal nerve to propel food from the oral cavity into the esophagus. Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). The third heart sound (S3) may be physiologic (e.g., athletes) or pathologic (e.g., congestive heart failure), and is related to abnormally rapid deceleration of early diastolic left ventricular inflow. The fourth heart sound (S4) is associated with contraction of the atria into partially-filled and non-compliant (stiff) ventricles. S4 is a pathologic sign in the young, but may be found in older individuals due to an age-related decrease in ventricular compliance. Additional sounds include murmurs (physiologic and pathologic), clicks, and snaps. These sounds are heard in individuals with structural abnormalities of the heart such as septal defects, valvular stenosis, and mitral regurgitation. The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. There are 12 cranial bones that contribute to the structure of the nose's walls and nasal conchae. Genital herpes infections are common sexually transmitted infections caused by herpes simplex virus (HSV) type 1 or 2. Herpes simplex virus type 1 is more commonly associated with non-genital herpes, while HSV-2 is more commonly associated with genital herpes. Primary infection often presents with systemic, prodromal symptoms followed by clusters of painful, fluid-filled vesicles on an erythematous base, dysuria, and painful lymphadenopathy. Primary infection can also be asymptomatic. Herpes infections are unique in that the virus is able to remain dormant in the neuronal ganglia, which allows for recurrent infections. Recurrent outbreaks are usually less severe than the initial infection. Treatment is with antiviral therapy, primarily acyclovir. Pseudomembranous colitis is a bacterial disease of the colon caused by Clostridium difficile. Pseudomembranous colitis is characterized by mucosal inflammation and is acquired due to antimicrobial use and the consequent disruption of the normal colonic microbiota. C. difficile infections account for the most commonly diagnosed hospital-acquired diarrheal illnesses. C. difficile infections can range from asymptomatic colonization to diarrhea and progress to fulminant colitis with systemic sepsis in severe cases. The diagnosis is established based on stool studies. Management of pseudomembranous colitis is mainly using antibiotics. Fecal transplant is considered in a few cases, whereas surgical intervention is required in severe cases. Perforated viscus or GI perforation represents a condition in which the integrity of the GI wall is lost with subsequent leakage of enteric contents into the peritoneal cavity, resulting in peritonitis. The causes of perforated viscus include trauma, bowel ischemia, infections, or ulcerative conditions, all of which ultimately lead to a full-thickness disruption of the intestinal wall. Perforated viscus presents as sudden onset of abdominal pain, distention, nausea, vomiting, obstipation, and symptoms of peritonitis. Diagnosis relies on the medical history as well as imaging studies, including abdominal and pelvic CT scan and X-ray. Treatment includes bowel rest, the use of a nasogastric tube, antibiotics to avoid severe infections or sepsis, analgesics, and surgical repair. Fungi belong to the eukaryote domain and, like plants, have cell walls and vacuoles, exhibit cytoplasmic streaming, and are immobile. Almost all fungi, however, have cell walls composed of chitin and not cellulose. Fungi do not carry out photosynthesis but obtain their substrates for metabolism as saprophytes (obtain their food from dead matter). Mycosis is an infection caused by fungi. Pituitary adenomas are tumors that develop within the anterior lobe of the pituitary gland. They are classified by size (either micro- or macroadenomas) and by their ability to secrete hormones. Non-functioning or non-secretory adenomas do not secrete hormones but can compress surrounding pituitary tissue, leading to hypopituitarism. Secretory adenomas secrete various hormones depending on the cell type from which they evolved, leading to hyperpituitarism. Rhinitis refers to inflammation of the nasal mucosa. The condition is classified into allergic, nonallergic, and infectious rhinitis. Allergic rhinitis is due to a type I hypersensitivity reaction. Non-allergic rhinitis is due to increased blood flow to the nasal mucosa. Infectious rhinitis is caused by an upper respiratory tract infection. All 3 types present with nasal congestion, rhinorrhea, and sneezing. Diagnosis is mainly clinical. Management includes antihistamines, decongestants, and immunotherapy. Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria can also manifest as cutaneous disease leading to nonspecific skin lesions. In advanced stages, diphtheria can damage the heart, kidneys, and nervous system. It is diagnosed via a culture of pharyngeal swabs and treated with antibiotic therapy and the diphtheria antitoxin. Pleuritis, also known as pleurisy, is an inflammation of the visceral and parietal layers of the pleural membranes of the lungs. The condition can be primary or secondary and results in sudden, sharp, and intense chest pain on inhalation and exhalation. Etiologies include infection, trauma, cardiac ischemia, and lung cancer. The most common primary infectious cause is a viral infection, and underlying lung infections account for the majority of secondary infectious causes. Management consists of pain control and the treatment of the underlying condition. Sinusitis refers to inflammation of the mucosal lining of the paranasal sinuses. The condition usually occurs concurrently with inflammation of the nasal mucosa (rhinitis), a condition known as rhinosinusitis. Acute sinusitis is due to an upper respiratory infection caused by a viral, bacterial, or fungal agent. Viral etiologies are the most common cause. Sinusitis presents with facial pain over the affected sinus and purulent rhinorrhea. Diagnosis is usually clinical and management is supportive, although it may require antibiotics. Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Extravascular destruction of RBCs is affected by macrophages of the liver, spleen, bone marrow, and lymph nodes. Other than the site of destruction, HA can also be classified according to the type of RBC defect that causes their destruction. If the RBC has an intrinsic and usually inherited defect such as a hemoglobinopathy, a membrane defect, or a metabolic defect, its destruction is called intracorpuscular hemolysis. If the RBC is normal but is damaged by an external force such as an antibody, mechanical trauma, or a pathogen, then its destruction is classified as extracorpuscular hemolysis, which is almost always an acquired disorder. Gestational trophoblastic diseases are a spectrum of placental disorders resulting from abnormal placental trophoblastic growth. These disorders range from benign molar pregnancies (complete and partial moles) to neoplastic conditions such as invasive moles and choriocarcinoma. Diagnosis is confirmed by elevated serum beta human chorionic gonadotropin (hCG) and ultrasound findings, which are dependent on the disorder. Treatment is primarily through dilation and curettage and/or methotrexate. Enzyme inhibitors bind to enzymes and decrease their activity. Enzyme activators bind to enzymes and increase their activity. Molecules that decrease the catalytic activity of enzymes can come in various forms, including reversible or irreversible inhibition. Reversible inhibition can be competitive, non-competitive, or uncompetitive. Enzyme kinetics describes the sequence of enzyme-catalyzed reactions with a dependence on various parameters such as temperature, pH, and substrate concentration. The reaction rate is measured and the effects of varying the conditions of the reaction are investigated. Amino acids (AAs) can be acquired through the breakdown of intracellular or ingested dietary proteins. Amino acids can enter 3 metabolic routes within the body. They can 1) be recycled to synthesize new proteins; 2) combine with cofactors and substances to create amino acid derivatives; or 3) be catabolized into their functional groups and carbon skeletons. This process releases ammonium, which moves into the urea cycle and produces intermediates for energetic metabolic pathways. Laryngitis is an inflammation of the larynx most commonly due to infection or trauma that can be either acute or chronic. In this condition, the 2 folds of mucous membranes that make up the vocal cords become inflamed and irritated. The inflammation results in a distortion of the voice produced, resulting in a hoarse sound that may lead to an inability to produce any sound (aphonia) in severe cases. In the presence of an infectious cause, patients often also present with rhinorrhea, cough, and mild sore throat. Pharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness. Determining the causative agent based on symptoms alone is difficult. Thus, a throat swab is often performed to rule out a bacterial cause. The mainstay of treatment is symptomatic and supportive, with bacterial causes requiring antibiotics. Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Treatment is directed at the removal of excess fluid and decreasing oxygen demand of the heart. Prognosis depends on the underlying cause, compliance with medical therapy, and presence of comorbidities. Ventricular fibrillation (VF or V-fib) is a type of ventricular tachyarrhythmia (> 300/min) often preceded by ventricular tachycardia. In this arrhythmia, the ventricle beats rapidly and sporadically. The ventricular contraction is uncoordinated, leading to a decrease in cardiac output and immediate hemodynamic collapse. Ventricular fibrillation is most commonly caused by underlying ischemic heart disease. It leads to death within minutes unless advanced cardiac life support measures are started immediately. Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease of unknown etiology. It leads to a necrotizing granulomatous inflammation of small and medium-sized blood vessels of the nose, sinuses, throat, lungs, and kidneys. Early stages of GPA often present with localized manifestations such as infections of the upper respiratory tract, skin lesions, and/or constitutional symptoms. Later stages can present with renal failure and severe respiratory disease. Early diagnosis and treatment of granulomatosis with polyangiitis (which involves the administration of corticosteroids and immunosuppressive agents such as methotrexate) may lead to a full remission but without treatment, the condition has a high mortality rate. Epidemiologists use specific measures of morbidity and mortality to characterize the degree to which illness and disease are present in a population and in how much this affects the population’s health and death rate. Common variable immune deficiency (CVID), also known as humoral immunodeficiency, is a disorder of the immune system characterized by reduced serum levels of immunoglobulins G, A, and M. The underlying causes of CVID are largely unknown. Patients with this condition are prone to infections in the gastrointestinal tract and the upper and lower respiratory tracts. CVID is also associated with a higher risk of developing autoimmune disorders, granulomatous diseases, and malignancy. Personality disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders, which can be behaviorally described as dramatic, erratic, and threatening/disturbing. Personality disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders, which can be behaviorally described as anxious and apprehensive. X-linked agammaglobulinemia, also known as Bruton's agammaglobulinemia or Bruton's disease, is a rare, recessive genetic disorder characterized by the improper development of B cells, leading to a lack of mature B cells capable of responding to stimulation by cell-mediated immune responses or certain antigen-presenting cells. X-linked agammaglobulinemia is more likely to be found in males than females and is due to mutations in the Bruton’s tyrosine kinase gene on the X chromosome. The result of this mutation is a complete or near-complete lack of all antibodies. Presentation includes recurrent bacterial infections after the first few months of life. Management consists of IV immunoglobulins and prophylactic use of antibiotics. Malignant mesothelioma (usually referred to as simply "mesothelioma") is the malignant growth of mesothelial cells, most commonly affecting the pleura. The majority of cases are associated with occupational exposure to asbestos that occurred > 20 years before clinical onset, which includes dyspnea, chest pain, coughing, fatigue, and weight loss. Chest computed tomography (CT) scan shows multifocal pleural thickening and pleural effusion. Pleural biopsy is required for confirmation and to rule out metastases from lung or breast cancer. Treatment is rarely effective, with an average survival time of < 1 year. Selective immunoglobulin A (IgA) deficiency is the most common type of primary immunodeficiency. The condition is a hypogammaglobulinemia characterized by a lack or reduced levels of IgA. This antibody mainly resides in the mucous membranes of the mouth, airways, and digestive tract. The exact cause is unknown. The disease is usually asymptomatic, although some patients can present with recurrent respiratory and gastrointestinal infections as well as autoimmune and malignant disorders. Diagnosis is made with a measure of exceptionally low IgA levels in the serum in the presence of normal IgG and IgM levels. 46,XX gonadal dysgenesis is a disorder present in individuals who are phenotypic females with normal karyotypes of 46,XX and who have streak gonads with no functional ovarian tissue. It is also called “pure gonadal dysgenesis” to differentiate these patients from those who present with the phenotype of Turner's syndrome (webbed neck, short stature, widely spaced nipples). Patients present with a normal development during childhood, primary amenorrhea, infertility, and a lack of secondary sexual characteristics. Management includes hormone replacement therapy and prophylactic gonadectomy. Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Etiologies often involve the liver and can be prehepatic, intrahepatic, or posthepatic. Other symptoms of hyperbilirubinemia include pruritus, pale stools, and darkened urine. The diagnosis is made based on liver function tests and imaging. Management is focused on treatment of the underlying condition. IPEX (immune dysregulation, polyendocrinopathy, enteropathy, X-linked) syndrome is a rare congenital T-cell deficiency associated with transcription factor FOXP3 dysfunction. This factor regulates the development of a regulatory T cell line and dysfunctions usually result in autoimmunity. The condition manifests as autoimmune enteropathy, eczematous dermatitis, nail dystrophy, autoimmune endocrinopathies, and autoimmune skin conditions. The only form of management for IPEX is bone marrow transplantation. Long QT syndrome (LQTS) is a disorder of ventricular myocardial repolarization that produces QT prolongation on electrocardiogram (ECG). Long QT syndrome is associated with an increased risk of developing life-threatening cardiac arrhythmias, specifically torsades de pointes. The condition may be congenital or acquired. Congenital LQTS is attributed to genetic mutations affecting cardiac ion channels. Acquired LQTS usually results from drug therapy and/or electrolyte abnormalities. Patients can be asymptomatic or present with palpitations, syncope, seizures, and even sudden cardiac death. Diagnosis is established with ECG along with medical and family history, laboratory workup, and other cardiac tests. Treatment is determined by etiology. Acquired LQTS requires removal of the offending drug and correction of electrolyte abnormalities. Congenital LQTS management involves avoidance of triggers of arrhythmia, intake of beta-blockers, and placement of an implantable cardioverter-defibrillator (ICD). Autosomal dominant hyper-IgE syndrome (AD-HIES), also known as Job's syndrome, is a rare form of primary immunodeficiency disorder that affects various organs systems in addition to the immune system. Some cases of AD-HIES are caused by mutations in the STAT3 gene, resulting in abnormal neutrophil chemotaxis. In other cases, the cause is unknown. Patients with AD-HIES experience recurrent pneumonia, skin infections, rashes, blisters, and abscesses. Cri du chat is the French term for "cat-cry" or "call of the cat." The term refers to the cat-like cry of a pediatric patient with cri-du-chat syndrome. The condition is a rare genetic disorder caused by deletion mutations on chromosome 5. Cri-du-chat syndrome is more common in females than in males. Aside from the characteristic cry, the condition also presents with dysphagia, low birth weight, poor growth, and severe cognitive, speech, and motor disabilities. Crohn's disease is a chronic, recurrent condition that causes patchy transmural inflammation that can involve any part of the gastrointestinal tract. It is a type of inflammatory bowel disease (IBD) along with ulcerative colitis (UC). The terminal ileum and proximal colon are usually affected. Crohn's disease typically presents with intermittent, non-bloody diarrhea and crampy abdominal pain. Extraintestinal manifestations may include calcium oxalate renal stones, gallstones, erythema nodosum, and arthritis. Diagnosis is established via endoscopy with biopsy that shows transmural inflammation, characteristic “cobblestone” mucosa, and noncaseating granulomas. Management is with corticosteroids, azathioprine, antibiotics, and anti-TNF agents (infliximab and adalimumab). Complications include malabsorption, malnutrition, intestinal obstruction or fistula, and an increased risk of colon cancer. Severe combined immunodeficiency (SCID), also called “bubble boy disease,” is a rare genetic disorder in which the development of functional B and T cells is disturbed due to several genetic mutations that result in reduced or absent immune function. It is the most severe form of primary immunodeficiency and is characterized by dysfunction in both humoral and cell-mediated immune responses. Multiple mutations can result in heterogeneous types of SCID. Patients present with severe and recurrent infections within the first months of life. Management includes IV immunoglobulins and bone marrow transplantation. If left untreated, SCID is usually fatal within the 1st year of life. 5-alpha-reductase deficiency is an autosomal recessive intersex or “disorder of sex development” (DSD) condition caused by a loss-of-function mutation in a gene on chromosome 2. The affected subjects have a 46,XY karyotype, bilateral testes, and normal testosterone production but have impaired virilization during embryogenesis due to defective conversion of testosterone to dihydrotestosterone (DHT), which is a significantly more potent androgen. This leads to male pseudohermaphroditism or ambiguous genitalia in males. Also known as pseudovaginal perineoscrotal hypospadias, these patients present with a clitoris-like phallus, cryptorchidism, bifid scrotum, and a rudimentary prostate. No Müllerian structures are present. Seborrheic dermatitis is a common chronic, relapsing skin disorder that presents as erythematous plaques with greasy, yellow scales in susceptible areas (scalp, face, and trunk). Seborrheic dermatitis has a biphasic incidence, occurring in two peaks: first in infants, then in adolescence and early adulthood. Although the exact etiology is unknown, pathologic mechanisms have been observed involving the sebaceous glands and Malassezia on the skin. Topical medications are used for acute exacerbation or maintenance treatment. These options aim to inhibit skin colonization (antifungal agents), reduce inflammation (steroids, calcineurin inhibitors), and loosen scales and crusts (keratolytic agents). Severe and refractory seborrheic dermatitis may warrant the use of systemic antifungal medications. Type II hypersensitivity, also known as antibody-mediated cytotoxic hypersensitivity, is caused by immunoglobulin G (IgG) and IgM antibodies directed against antigens on cells or extracellular materials. The reaction leads to cytotoxic processes involving antibodies and the complement system. Interference with the normal cellular operation generating either stimulatory or inhibitory dysfunction is another mechanism that occurs. The inciting antigen can be intrinsic or part of the host cell. Extrinsic antigens such as blood products or medications can provoke a similar reaction. For diagnosis, laboratory tests and invasive procedures are utilized, depending on the system affected. Management of resulting disease ranges from supportive care to antibiotics, immunosuppressive medications, and surgery. By refraction, the light that enters the eye is focused onto a particular point of the retina. The main refractive components of the eye are the cornea and the lens. When the corneal curvature, the refractive power of the lens, does not match the size of the eye, ametropia or a refractive error occurs. The types of refractive errors include myopia (nearsightedness), hyperopia (farsightedness), and astigmatism (which can occur in both myopia and hyperopia). The use of a proper refractive device helps correct the visual impairment. Laser in situ keratomileusis (LASIK) is the most common corrective surgical procedure. Friedreich's ataxia is an autosomal recessive disorder characterized by progressive spinocerebellar degeneration. It presents in the 1st to 2nd decades of life with progressive gait ataxia, weakness, tremor, dysarthria, dysphagia, hypertrophic cardiomyopathy, and/or diabetes. Patients eventually become bedridden. Diagnosis is confirmed by genetic testing showing trinucleotide repeat expansion in the FXN gene. Treatment is supportive and most patients die of heart disease in the 4th or 5th decade of life. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Chronic pain lasts > 3 months and may exist in the absence of tissue damage or after healing would have been expected to occur. Pain management involves a combination of addressing underlying causes and using a systematic approach tailored to the clinical scenario. Type III hypersensitivity, also known as immune complex-mediated hypersensitivity, occurs when antibodies and antigens form immune complexes (ICs) in circulation and deposit in susceptible tissues. The complement system triggers the immune response, leading to leukocyte recruitment and tissue injury. There is no single clinical syndrome for this hypersensitivity. Symptoms reflect the impairment of multiple organ systems based on sites of IC deposition. Diagnostic workup depends largely on the history and includes laboratory tests, imaging, and biopsy of the affected organ. Treatment consists of removal or avoidance of offending agents and, in severe conditions, glucocorticoids or immunosuppressive therapy. Neonatal polycythemia is a hematocrit (HCT) that is 2 standard deviations above the average values for gestation and postnatal age. Neonatal polycythemia can develop from increased fetal hematopoiesis (secondary to placental insufficiency, maternal endocrinopathies, genetic disorders, etc.) or passive erythrocyte transfusion (placental-, feto-, or maternal-fetal transfusion). Patients may be asymptomatic or present with plethora, cardiorespiratory distress, and other symptoms. Continuous monitoring of vital signs and metabolic derangements is important. Treatment includes partial exchange transfusion. The elimination disorders that most commonly occur in childhood are enuresis (urinary incontinence) and encopresis (fecal incontinence in inappropriate situations). Enuresis is usually diagnosed when children > 5 years of age continue to wet the bed. Enuresis can occur both in the daytime (diurnal) and at night (nocturnal). The incidence of nocturnal enuresis spontaneously resolves at a rate of approximately 15% per year. Management of nocturnal enuresis primarily consists of behavior and lifestyle modifications but can include desmopressin. Encopresis is most often secondary to underlying constipation, although emotional stressors may also be involved. Management is primarily through treating constipation. Type IV hypersensitivity reaction, or delayed-type hypersensitivity, is a cell-mediated response to antigen exposure. The reaction involves T cells, not antibodies, and develops over several days. Presensitized T cells initiate the immune defense, leading to tissue damage. A cytokine-mediated process is activated by T-helper cells while cytotoxic T cells directly release cytotoxins to infected or dysfunctional cells, causing cell lysis. Clinical manifestations depend on the system involved, so diagnostic tests rely on history and findings. Treatment includes controlling the effects of the immune response with glucocorticoids and immunosuppressive therapy while managing the associated disease complications. Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. The typical presentation of blepharitis includes eyelid edema with itching and redness, crusts and scales around the eyelashes, and gritty sensation. Diagnosis is clinical, with a slit-lamp examination providing details of the structural changes affecting the eye. The mainstay of treatment is eyelid hygiene using warm compresses and eyelid scrubs. In moderate-to-severe cases, topical and oral antibiotics are utilized. Topical glucocorticoids also help improve symptoms but require an ophthalmology evaluation due to potential adverse effects. Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Diagnosis is clinical. Management requires treating the underlying disease, managing complications, and, if required, liver transplantation. Thoracic aortic aneurysm (TAA) is the abnormal dilation of a segment of the thoracic aorta, usually the ascending aorta. Most TAAs are due to degenerative aortic disorders, commonly in patients > 65 years of age. Genetic TAAs account for 20% of cases and are frequently found in younger patients. Most TAAs are asymptomatic (incidentally found in imaging) but could present with symptoms from its effects on surrounding structures. Aortic rupture is a life-threatening emergency. Among diagnostic imaging studies, computed tomography (CT) angiography is the most widely utilized. In asymptomatic cases, aortic expansion is monitored. Operative repair is recommended for symptomatic TAAs and increasing aortic diameter (criteria varies with location and underlying condition). Precocious puberty (PP) is the appearance of secondary sexual characteristics due to elevated sex hormones before the age of 6–8 in girls and 9 in boys. Excess hormone secretion may occur only at the level of the sex hormone or may involve the whole hypothalamic-pituitary-gonadal axis. Measurement of sex hormone levels, as well as X-rays to evaluate skeletal maturity, are used to diagnose and characterize PP. Correcting the hormonal excess at its root cause can appropriately delay the onset of puberty. A primary goal of treatment is the preservation of normal height potential. Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Uveitis can be caused by an infection or systemic disease, but in some cases the cause is idiopathic. Patients present with blurred vision, eye redness, and pain (frequently in anterior uveitis) or reduced vision and floaters (in intermediate and posterior uveitis). Diagnosis is by dilated funduscopy and slit-lamp examination. Treatment for anterior uveitis is topical steroids, while uveitis in deeper locations requires an injection. Uveitis from infections and systemic disorders requires etiology-directed therapy. Benign breast epithelial lesions are grouped histologically as nonproliferative, proliferative without atypia, and atypical hyperplasia. The classifications are based on subsequent cancer risk in either breast. The nonproliferative type carries no risk, while fibroadenoma, the most common benign tumor, is a proliferative breast lesion (i.e., has a slight increase in malignancy risk). Because atypical hyperplasia shares some features with breast carcinoma in situ, future cancer potential is increased. Management ranges from frequent monitoring to surgical excision, depending on certain factors, including the inherent risk of the pathologic diagnosis. Other breast disorders without malignant possibility are associated with underlying infection or systemic disease, so treatment differs. Benign breast diseases are common but present diversely. It is important to distinguish between them to determine the likelihood of cancer and the best course of treatment. Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Frequently, there is peripheral vision loss that eventually leads to loss of central vision. The 2 main types of glaucoma are open-angle and angle-closure. Overproduction or reduced excretion of the aqueous humor leads to open-angle glaucoma. Onset of symptoms is gradual. Angle-closure glaucoma results from blockage in the angle (of the iris and cornea), preventing drainage of the aqueous fluid. Diagnosis involves IOP determination (tonometry) and angle visualization with slit lamp (gonioscopy). Treatment includes topical medications that reduce IOP, and eye surgery. Cor pulmonale is right ventricular (RV) dysfunction caused by lung disease that results in pulmonary artery hypertension. The most common cause of cor pulmonale is chronic obstructive pulmonary disease. Dyspnea is the usual presenting symptom. Clinical findings include signs of right-sided heart failure and hypoxemia. While right cardiac catheterization is the gold standard test, most patients are diagnosed clinically and through the use of noninvasive testing. Echocardiography shows RV enlargement and elevated pulmonary arterial systolic pressure. Management is first focused on the underlying disease. Oxygen therapy improves disease progression, while diuretics reduce RV filling pressure. Lung transplantation is an option for those refractory to therapy. A cataract is a condition defined as painless clouding or opacity of the lens. It causes visual impairment, as the lens provides part of the eye’s refractive power. Although all age groups can be affected, the age-related or senile type of cataract is the most common. Aside from age, there are multiple risk factors, including systemic diseases, medications, or trauma. Patients present with blurry vision, glare sensitivity, and color vision change. Ophthalmologic inspection often shows darkening of or opacities in the red reflex. Slit-lamp examination will show the extent and location of the cataract. The treatment is surgery, which is indicated when loss of vision function interferes with daily function. Hyperbilirubinemia of the newborn is a broad term that refers to various conditions that can cause accumulation of bilirubin during the first few days after birth. The condition is often noted because of visible yellowing of the skin and sclera secondary to bilirubin deposition. Because hyperbilirubinemia arises from physiological processes that accompany birth, it is usually an expected finding. However, hyperbilirubinemia in the neonate can also have pathological etiologies, including breastfeeding-related, blood group isoimmunization, metabolic disorders, and infection. Regardless of etiology, the primary goal of therapy in neonatal jaundice is to prevent the neurotoxic effect of indirect bilirubin, mainly kernicterus. When indicated, treatment mainly includes phototherapy and exchange transfusion. Age-related macular degeneration (AMD) is visual impairment due to changes in the macula, the area responsible for high-acuity vision. It is marked by central vision loss with peripheral vision relatively spared. Risk factors include advanced age, smoking, family history, and cardiovascular disease. The 2 types of AMD are exudative (wet) or non-exudative (dry). The difference between these 2 types is the presence of choroidal neovascularization in wet AMD, which manifests as visual distortion or loss. The more frequently occurring dry AMD is usually asymptomatic but in a minority of cases leads to vision loss. There is no treatment for early dry AMD but Age-Related Eye Disease Study 2 (AREDS 2) supplements are recommended for advanced disease. Inhibitors of vascular endothelial growth factor are used for wet AMD. Dacryocystitis is inflammation of the lacrimal sac due to nasolacrimal duct obstruction and the subsequent stasis of tears. The condition can have an acute or chronic onset. Acute dacryocystitis presents within hours or days with redness, swelling, tenderness, and excessive tearing. The chronic type has a gradual course, often manifesting with epiphora. By etiology, dacryocystitis can be congenital or acquired. Nasolacrimal duct obstruction affects 6% of newborns. Acquired cases occur due to trauma, systemic diseases, or tumors. Diagnosis is made clinically. In some cases, laboratory tests and imaging help determine abnormal structures and underlying disease. Initial treatment includes conservative measures such as Crigler massage, warm compresses, and antibiotics, if indicated. If these fail, surgical options are tried. The embryological development of craniofacial structures is an intricate sequential process involving tissue growth and directed cell apoptosis. Disruption of any step in this process may result in the formation of a cleft lip alone or in combination with a cleft palate. As the most common craniofacial malformation of the newborn, the diagnosis of a cleft is clinical and usually apparent at birth. The type and severity of the defect cause various degrees of difficulty with speech development, feeding, swallowing, tooth eruption, and cosmetic issues. Ultimate correction is through surgical repair. A cataract is a condition defined as painless clouding or opacity of the lens. Cataracts cause visual impairment, as the lens provides part of the eye’s refractive power. The condition is one of the most common causes of pediatric blindness. Cataracts can be present from birth (congenital) or can develop after infancy (acquired). Genetic mutations, systemic diseases, trauma, and medications can lead to cataract development. Children present with an abnormal red reflex, leukocoria, or decreased visual acuity. An ophthalmologic examination reveals the morphology and location of the cataract. Management depends on age of presentation and visual defects. When opacity is of a certain size or is causing visual impairment, strabismus, and nystagmus, cataract surgery is recommended. Anorectal atresia refers to a spectrum of congenital anorectal malformations with an unclear etiology. These anomalies range from a simple imperforate anus in an otherwise normal anorectal region to complex anomalies involving the urogenital system. Anorectal atresia is sometimes seen as an isolated finding, but it may also occur as part of a multi-organ syndrome. Diagnosis is often made during initial newborn examination or after a delay in passage of meconium for over 24 hours after birth. Prognosis varies based on complexity. Treatment is primarily surgical. Congenital diaphragmatic hernias are embryologically derived defects in the diaphragm through which abdominal structures can pass into the chest cavity. The presence of intestines and intra-abdominal organs in the chest interferes with embryonic development of the lungs, which is the major cause of pathology postnatally. Prenatal diagnosis is commonly made by ultrasound during pregnancy followed by confirmation on chest X-ray after birth. Immediate respiratory resuscitation at birth with endotracheal intubation and mechanical ventilation are required. Surgical repair is the only curative option. Prognosis varies, but children with diaphragmatic hernias usually suffer from lifelong pulmonary complications. Anal fistulas are abnormal communications between the anorectal lumen and another body structure, often to the skin. Anal fistulas often occur due to extension of anal abscesses but are also associated with specific diseases such as Crohn's disease. Symptoms include pain or irritation around the anus; abnormal discharge or purulent drainage; and swelling, redness, or fever if an abscess is present. Management is primarily surgical, with fistulotomy, but can include antibiotics if infection is present. Treatment is surgical. Complications after surgery include recurrence and incontinence. Retinal detachment is the separation of the neurosensory retina from the retinal pigmented epithelium and choroid. Rhegmatogenous retinal detachment, the most common type, stems from a break in the retina, allowing fluid to accumulate in the subretinal space. In the setting of an intact retina, detachment occurs when the vitreous pulls on the retina (traction) or when an underlying condition leads to increased leakage of fluid (exudative). Symptoms of photopsia, floaters, and visual defects can present over hours or gradually over weeks. Retinal detachment with visual loss is an emergency. Once macular detachment occurs, visual prognosis is poor. Symptomatic rhegmatogenous retinal detachment with intact central acuity warrants urgent surgery. For non-rhegmatogenous retinal detachments, treatment is directed toward the primary process. A population pyramid graphically illustrates the age and gender distribution of a given population. The shape of the pyramid conveys details about life expectancy, birth, fertility, and mortality rates. Additional data that can be extrapolated from a population pyramid include the effects of historical events, economic development, and future demographic trends. This information helps direct plans for the subsequent social and economic needs of a given population. In order to cope with their environment, cells undergo structural and functional changes. These cellular adaptations are reversible responses that allow cells to survive and continue to adequately function. Adaptive processes consist of increased cellular size and function (hypertrophy), increase in cell number (hyperplasia), decrease in cell size and metabolic activity (atrophy), or a change in the phenotype of the cells (metaplasia). If the stress or stimulus is removed, the cell can return to its original state. However, when the limits of the adaptive responses are exceeded, cellular function is adversely affected, leading to cellular injury. A retinal vessel occlusion is a blockage in a major artery or vein of the retina. Depending on the location, the occlusion can be classified as central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), central retinal vein occlusion (CRVO), or branch retinal vein occlusion (BRVO). Typically, a retinal vessel occlusion is a thromboembolic event. Risk factors include hypertension, diabetes mellitus, and cardiac valvular disease. Central retinal artery occlusion is characterized by sudden, unilateral, painless loss of vision and/or transient vision loss (amaurosis fugax). Treatment options are limited in all cases and usually ineffective. When the macula is involved, prognosis is especially poor, leading to permanent vision loss. A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. Diagnosis is based on history and physical exam findings. Most chalazia will resolve with conservative management. A patent foramen ovale (PFO) is an abnormal communication between the atria that persists after birth. The condition results from incomplete closure of the foramen ovale. Small, isolated, and asymptomatic PFOs are a common incidental finding on echocardiography and require no treatment. Larger PFOs and PFOs associated with paradoxical thromboembolic stroke or other cardiac anomalies may require treatment with anticoagulation. Surgical or percutaneous closure may be indicated in select cases. Substances can accumulate in the cytoplasm, nucleus, or organelles as a result of an intrinsic cellular dysfunction or metabolic abnormalities. Commonly seen substances are pigments, calcium, iron, fat, cholesterol, and glycogen. These substances are produced by the cell and can increase in amount when there is inadequate removal of the substance or failure of metabolite degradation. Defective protein folding, packaging, and transport, both genetic and acquired, also produce substance accumulation. In some instances, deposition is from an external source, such as coal dust. The cell does not have an inherent mechanism of elimination, so material builds up in the exposed site. The cubital fossa is the region anterior to the elbow joint. The cubital fossa is seen as the triangular depression between the brachioradialis and pronator teres muscles. Except for the ulnar nerve, which runs posteriorly, most of the major neurovascular structures transition from the arm to the forearm via the cubital fossa. The 4 important structures of the cubital fossa (from lateral to medial) are the radial nerve, tendon of the biceps brachii muscle, brachial artery, and median nerve. Omphalocele is a congenital anterior abdominal wall defect in which the intestines are covered by peritoneum and amniotic membranes. The condition results from the failure of the midgut to return to the abdominal cavity by 10 weeks' gestation. Omphalocele is frequently associated with genetic syndromes and chromosomal abnormalities. Prenatal diagnosis can be made by prenatal ultrasound, maternal blood elevated ⍺-fetoprotein, and fetal chromosomal analysis. Treatment includes immediate hemodynamic stabilization followed by primary or staged surgical repair. Neural tube defects (NTDs) are the 2nd-most common type of congenital birth defects. Neural tube defects can range from asymptomatic (closed NTD) to very severe malformations of the spine or brain (open NTD). Neural tube defects are caused by the failure of the neural tube to close properly during the 3rd and 4th week of embryological development. The most common type of open NTD is meningomyelocele, which involves both the meninges and neural tissue. The etiologies of NTD are multifactorial, ranging from maternal nutrition to genetic determinants. Prenatal diagnosis by ultrasound and maternal α-fetoprotein level is common. Management of open NTDs is mainly surgical. A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. The condition presents as a painful, localized, erythematous mass in the anterior (external hordeolum) or posterior (internal hordeolum) lamella of the eyelid. A hordeolum usually resolves spontaneously and can be managed with warm compresses, massage, and lid hygiene. In certain cases of significant swelling, topical antibiotics with steroids may be needed. If there is no resolution, incision, and drainage are performed. The menstrual cycle is the cyclic pattern of hormonal and tissular activity that prepares a suitable uterine environment for the fertilization and implantation of an ovum. The menstrual cycle involves both an endometrial and ovarian cycle that are dependent on one another for proper functioning. There are 2 phases of the ovarian cycle (follicular and luteal) and 3 phases of the endometrial cycle (desquamation or menses, proliferative, and secretory). The menstrual cycle is regulated by the hypothalamic-pituitary-ovarian axis via follicle-stimulating hormone (FSH) and luteinizing hormone (LH). A woman’s 1st menstrual cycle is referred to as menarche, and cycles continue until menopause. Atrioventricular septal defects (AVSDs) are a category of congenital defects of the endocardial cushion and atrioventricular valves (AVVs) resulting in abnormal interatrial and/or interventricular communication. Severe forms present early during infancy with failure to thrive and recurrent pneumonia, and require early surgical correction to avoid pulmonary hypertension. Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Patients often present with progressive abdominal distention and weight gain. Abdominal exam may reveal shifting dullness and a positive fluid wave. Diagnosis is established with an ultrasound, and etiologies can be distinguished by ascitic fluid analysis from paracentesis. Treatment involves dietary sodium restriction, diuretics, and treatment of the underlying cause. Psoriasis is a common T-cell–mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Plaques are well-circumscribed and salmon-colored, with silvery scales. Plaques commonly appear on the scalp and extensor surfaces of the extremities. Diagnosis is clinical. Treatment options are determined by the percentage of body surface area (BSA) affected and include topical corticosteroids, retinoids, calcineurin inhibitors, disease-modifying antirheumatic drugs (DMARDs), biologics, and phototherapy. Ethanol is a chemical compound that is produced in small amounts within the small intestine and is also ingested from alcoholic drinks. Ethanol's digestion involves a complex catabolic pathway that mainly takes place in the liver. Ethanol is turned into acetaldehyde, then to acetate, and finally into acetyl-CoA, which becomes a substrate for the citric acid cycle and produces energy. Excessive ethanol intake can have pathologic metabolic consequences including alcoholism, liver disease, and cancer. Chronic pancreatitis is due to persistent inflammation, fibrosis, and irreversible cell damage to the pancreas, resulting in a loss of endocrine and exocrine gland function. The most common etiologies are alcohol abuse and pancreatic duct obstruction. Patients often present with recurrent epigastric abdominal pain, nausea, and features of malabsorption syndrome (diarrhea, steatorrhea, and weight loss). Characteristic computed tomography (CT) findings include pancreatic atrophy, dilated pancreatic ducts, and pancreatic calcifications. Therapy focuses on alcohol cessation, diet changes, pain management, and treatment of pancreatic insufficiency. Hypertension has many adverse effects on the eye, of which retinopathy is the most common presentation. Hypertensive retinopathy consists of retinal vascular changes that develop as a direct effect of elevated blood pressure. In acute increases of blood pressure, autoregulation results in retinal arteriolar narrowing. In chronic hypertension, structural changes consistent with arteriosclerosis affect the retinal vasculature. Endothelial wall damage ensues and various signs appear including hemorrhages, cotton-wool spots, and exudates. In severe cases of uncontrolled hypertension, papilledema is seen. Management is focused on controlling hypertension. Patients with severe hypertensive retinopathy have an increased risk for coronary artery disease and stroke; therefore, detection and treatment of underlying hypertension are important. Actinic keratosis (AK) is a precancerous skin lesion that affects sun-exposed areas. The condition presents as small, non-tender macules/papules with a characteristic sandpaper-like texture that can become erythematous scaly plaques. Actinic keratosis is usually diagnosed clinically but suspicious features warrant a biopsy to rule out invasive squamous cell carcinoma. The majority of AK lesions remain non-malignant, but it is difficult to distinguish those that will resolve from those that will become cancerous. Actinic keratosis has multiple types of treatment, including cryotherapy, shave removal, excision, topical medications, and photodynamic therapy. Lesions with features that are suggestive of cancer warrant removal and pathologic evaluation. The development of the brain, spinal cord, and face involve several complex processes that occur simultaneously to achieve correct organ development. Beginning with neurulation, the neural tube and neural crest cells form the central and peripheral nervous systems. Beginning at the 4th week, the face begins to develop as well, and through the creation of frontonasal, medial, lateral, and mandibular prominence, recognizable facial features can be observed from the 14th week onward. The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. The afferent pathway for visual function starts from the retina and moves through the optic tracts and lateral geniculate nuclei, terminating in the visual cortex. Light stimulus is conducted by the parasympathetic system to the midbrain, while psychosensory reaction is processed by the sympathetic system. Efferent pathways produce the appropriate response: miosis and mydriasis from the parasympathetic and sympathetic innervations, respectively. Pupillary disorders result from defects in areas of the visual afferent and efferent pathways. Presentation varies with pupillary size along with response to light and medication. Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Mild TR may be asymptomatic or present with systemic venous congestion due to increased right atrial and venous pressures. Echocardiography can establish the diagnosis. Treatment focuses on heart failure management, and surgery is reserved for severe disease. Listeria spp. are motile, flagellated, gram-positive, facultative intracellular bacilli. The major pathogenic species is Listeria monocytogenes. Listeria are part of the normal gastrointestinal flora of domestic mammals and poultry and are transmitted to humans through the ingestion of contaminated food, especially unpasteurized dairy products. Listeria can also infect the fetus in utero or neonates during vaginal birth. Healthy individuals exposed to L. monocytogenes usually do not become ill if the inoculum is small, or may develop only self-limiting gastroenteritis. Immunocompromised or elderly individuals, neonates, and pregnant women can develop invasive disease, including meningitis and bacteremia. Treatment of invasive listeriosis includes ampicillin and gentamicin. Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Mild TS may be asymptomatic or present with systemic venous congestion due to increased right atrial and venous pressures. Echocardiography can establish the diagnosis. Treatment focuses on heart failure management, and surgery is reserved for severe disease. Nonalcoholic fatty liver disease is a spectrum of liver pathology that arises due to accumulation of triglycerides in hepatocytes. Risk factors include diabetes mellitus, insulin resistance, obesity, and hypertension, among others. Nonalcoholic fatty liver disease ranges from fatty liver or hepatic steatosis but can lead to nonalcoholic steatohepatitis (NASH), which features fatty deposits and inflammation. Progressive liver injury and fibrosis irreversibly develop into cirrhosis and, possibly, primary liver cancer. Patients are usually asymptomatic but may present with hepatomegaly and right upper quadrant discomfort. Although liver biopsy is the diagnostic gold standard, the diagnosis can also be established by clinical history, imaging, and laboratory tests. The mainstay of management is lifestyle modifications (weight loss and exercise) with control of associated comorbidities. Renal artery stenosis (RAS) is the narrowing of one or both renal arteries, usually caused by atherosclerotic disease or by fibromuscular dysplasia. If the stenosis is severe enough, the stenosis causes decreased renal blood flow, which activates the renin-angiotensin-aldosterone system (RAAS) and leads to renovascular hypertension (RVH), which only accounts for a small fraction of all cases of hypertension. Renovascular hypertension can be associated with abdominal bruits, renal insufficiency, or progressive renal atrophy. Diagnosis is by clinical presentation followed by imaging studies, including duplex ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), and sometimes catheter-based angiography. Revascularization is usually reserved for cases in which medical therapy has failed. Valvular disorders can arise from the pulmonary valve, located between the right ventricle (RV) and the pulmonary artery (PA). Valvular disorders are diagnosed by echocardiography. Pulmonic regurgitation (PR) is the backflow of blood through the valve. Prior cardiac surgeries can lead to PR. Graham-Steell murmur, a high-pitched decrescendo murmur at the left sternal border, is a hallmark finding. Pulmonic regurgitation results in RV volume overload, from which RV failure eventually develops. Severe PR is also treated with surgical valve replacement. Stevens-Johnson syndrome (SJS) is a cutaneous, immune-mediated hypersensitivity reaction that is commonly triggered by medications, including antiepileptics and antibiotics. The condition runs on a spectrum with toxic epidermal necrolysis (TEN) based on the amount of body surface area (BSA) involved. Stevens-Johnson syndrome is characterized by keratinocyte necrosis and separation of the epidermis from the dermis. Patients will present with a flu-like prodrome, followed by cutaneous bullae and sloughing on the face, thorax, and mucous membranes. Stevens-Johnson syndrome is considered a medical emergency, and management is largely supportive. Withdrawal of the causative agent is required. Monitoring for, and treating, superinfection is essential due to the high risk of associated death in these patients. Valvular disorders can arise from the pulmonary valve, located between the right ventricle (RV) and the pulmonary artery (PA). Valvular disorders are diagnosed by echocardiography. Pulmonary stenosis (PS) is valvular narrowing causing RV outflow tract obstruction. Patients are often asymptomatic unless they have other congenital cardiac anomalies or severe PS. Symptoms (exertional dyspnea, chest pain, and syncope) are due to RV failure. Severe PS is treated surgically. Takotsubo cardiomyopathy (also known as stress cardiomyopathy, or “broken heart syndrome”) is a type of non-ischemic cardiomyopathy in which there is transient regional systolic dysfunction of the left ventricle. Patients present with symptoms of acute coronary syndrome, including chest pressure and shortness of breath. Electrocardiogram (ECG) may show ST-segment elevations. Coronary angiography can help in differentiating this condition from myocardial infarction. Echocardiogram can confirm the diagnosis by demonstrating characteristic apical wall motion abnormalities. Management includes the removal of inciting stressors and beta blockers. Neisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. These pathogens have many virulence factors, including fimbriae, lipooligosaccharide envelope proteins, a polysaccharide capsule (unique to N. meningitidis), and IgA protease. Gonococcal infections are sexually or perinatally transmitted and include gonorrhea, pelvic inflammatory disease, septic arthritis, and neonatal conjunctivitis. Meningococcal infections are transmitted via respiratory and oral secretions. They most commonly cause meningococcemia with petechial hemorrhages and meningitis. The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. The muscles of the hand are classified as extrinsic (forearm-based) or intrinsic (hand-based) depending on the location of the muscle belly. These muscles are also grouped by area or type: thenar, hypothenar, lumbricals, and interossei. Budd-Chiari syndrome is a condition resulting from the interruption of the normal outflow of blood from the liver. The primary type arises from a venous process (affecting the hepatic veins or inferior vena cava) such as thrombosis, but can also be from a lesion compressing or invading the veins (secondary type). The patient typically presents with hepatomegaly, ascites, and abdominal discomfort. Onset is often subacute or chronic. Diagnosis is confirmed by Doppler ultrasound. Treatment involves addressing the underlying condition that caused the venous occlusion. Further management involves prevention of further clotting (anticoagulation), restoration of blood flow, and decompressing the liver. Liver transplantation is considered if initial treatment fails and/or the patient has decompensated liver cirrhosis. The cell undergoes a variety of changes in response to injury, which may or may not lead to cell death. Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. The principal targets of cell injury are the cell membranes, mitochondria, protein synthesis machinery, and DNA. Multiple cellular abnormalities resulting from the damage result in cell death. The 2 main types of cell death are necrosis and apoptosis. Necrosis is an uncontrolled cell death characterized by inflammatory changes in a pathologic condition. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects. Primary biliary cholangitis (PBC) is a chronic disease resulting in autoimmune destruction of the intrahepatic bile ducts. The typical presentation is that of a middle-aged woman with pruritus, fatigue, and right upper quadrant abdominal pain. Elevated liver enzymes and antimitochondrial antibodies (AMAs) establish the diagnosis. Medical management is limited to using ursodeoxycholic acid, a disease-modifying agent. Definitive treatment is liver transplantation, which is performed in late stages (cirrhosis). Altitude sickness refers to a spectrum of symptoms caused by physiological changes in the human body at altitudes above 2,500 m. Altitude sickness includes acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). Hypobaric hypoxia is a common pathophysiologic trigger. Acute mountain sickness and HACE represent 2 extremes of a neurologic disorder, from benign to life-threatening. High-altitude pulmonary edema is primarily a pulmonary problem, not necessarily preceded by AMS or HACE. The risk of altitude sickness can be reduced by gradual ascent and other precautionary measures, including medications. The symptoms of altitude sickness can be reduced with hyperbaric oxygen therapy. A femoral hernia is an uncommon type of groin hernia in which intra-abdominal contents herniate under the inguinal ligament and through the femoral ring into the femoral canal. More common in adults than in children, femoral hernias usually present with swelling that protrudes into the femoral triangle (inferiorly to the inguinal ligament and medial to the femoral vein). Although uncommon, femoral hernias are frequently associated with complications, secondary to the small size of the canal, leading to hernia incarceration and/or strangulation. Acute cholangitis is a life-threatening condition characterized by fever, jaundice, and abdominal pain which develops as a result of stasis and infection of the biliary tract. Septic shock, liver abscess, and multi-organ dysfunction are potential serious complications. The diagnosis is confirmed with ultrasound showing dilation of the common bile duct (CBD) or gallstones, elevated liver function tests, and leukocytosis. Treatment includes hemodynamic stabilization, broad-spectrum antibiotics, urgent biliary drainage, and cholecystectomy to prevent recurrence. Decompression sickness (DCS), known informally as “the bends,” is a condition caused by compression and decompression of gases contained in the body during descent and rapid ascent while diving. Clinical presentation of DCS may be nonspecific and variable, with a time of onset that can vary from immediately to 12 hours after surfacing. Diagnosis is made clinically. Management is early supportive therapy and hyperbaric recompression treatment carried out in a specialized facility. Atrioventricular (AV) block is a bradyarrhythmia caused by delay, or interruption, in the electrical conduction between the atria and the ventricles. Atrioventricular block occurs due to either anatomic or functional impairment, and is classified into 3 types. The 1st-degree block is due to delayed conduction through the AV node. The 2nd-degree block is characterized by progressive conduction delay or intermittently blocked conduction. The 3rd-degree block involves total interruption in conduction between the atria and ventricles, causing complete AV dissociation. Patients may be asymptomatic or may present with syncope, chest pain, dyspnea, and bradycardia depending on the severity of the block. Electrocardiography (ECG) establishes the diagnosis, and treatment is based on the type of block and hemodynamic stability of the patient. Acute pancreatitis is an inflammatory disease of the pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain, serum amylase and lipase 3 times the upper limit of normal, or characteristic radiology findings. Ranson’s criteria is commonly used to assess the severity. Management includes aggressive intravenous (IV) hydration, analgesia, nutritional support, and treatment of the underlying cause. Congenital renal abnormalities arise from embryologic/genetic defects and cause a variety of isolated or syndromic renal disorders, including renal agenesis, dysgenesis, and ectopia. Congenital renal abnormalities are generally identified prenatally and represent approximately ⅓ of all prenatal anomalies. Because of the fetal kidney’s role in the production of amniotic fluid, oligohydramnios detected on prenatal ultrasounds often prompts the workup that identifies congenital renal anomalies. Unilateral renal involvement in the presence of a functioning contralateral kidney may only be an incidental finding later in life. In many cases, treatment is supportive. Complement component 3 (C3) deficiency is the absence, reduction, or dysfunction of complement factor C3 and its fragments, C3a and C3b. Complement factors are key components of the innate immune system. Reduced levels of C3b increase the probability of developing infections with encapsulated organisms (e.g., Pneumococcus, Haemophilus influenza, Neisseria meningitidis), especially respiratory infections, due to reduced opsonization. Individuals with C3 deficiencies are also more susceptible to type III hypersensitivity reactions because a reduced clearance of antigen-antibody C3b complexes from the circulation causes an increased risk of hypersensitivity reactions. Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Diagnostic testing with stool analysis or culture is not always required, but can help determine the etiology in certain circumstances. The majority of cases of gastroenteritis are self-limited; therefore, the only required treatment is supportive therapy (fluids). However, antibiotics are indicated in severe cases. The most common benign liver tumors include hepatic hemangiomas, focal nodular hyperplasia, and hepatic adenomas. These tumors are mostly asymptomatic and/or found incidentally on abdominal imaging. While these tumors are benign, large lesions can cause symptoms such as upper abdominal pain, or produce complications such as bleeding. Malignant potential is a concern for hepatic adenoma, depending on risk factors. The diagnosis is based on imaging studies, with characteristic findings defining the tumor. Biopsy generally is reserved for equivocal cases. Management is observation for most small, asymptomatic, and non-growing tumors. However, high-risk factors, symptoms, increasing tumor size, and complications dictate the need for surgical intervention. Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC), is the most common inherited colon cancer syndrome, and carries a significantly increased risk for endometrial cancer and other malignancies. Lynch syndrome has an autosomal dominant inheritance pattern involving pathogenic variants in one of the mismatch repair (MMR) genes or epithelial cell adhesion molecule (EpCAM). Diagnosis is made by genetic testing of the index patient and their family members. Management consists of an earlier screening of individuals with defective MMR genes, as well as total colectomy if colorectal neoplasia is discovered. Prophylactic hysterectomy plus salpingo-oophorectomy are recommended for women beyond reproductive age. Treacher Collins syndrome is a rare genetic condition with autosomal dominant inheritance. Treacher Collins syndrome is also referred to as mandibulofacial dysostosis or Franceschetti syndrome and is characterized by significant craniofacial deformities and conductive hearing loss. Treacher Collins syndrome is strictly a physical disease and does not affect cognition or other spheres of development. Diagnosis is confirmed with genetic testing. Management of the airway, feeding ability, and hearing loss are the primary concerns in the first few years of life. Ultimately, facial reconstructive surgery is needed. Life expectancy is normal. Hereditary angioedema (HAE), also known as C1 esterase inhibitor (C1-INH) deficiency, is an autosomal dominant disorder characterized by recurrent episodes of severe swelling (angioedema). Hereditary angioedema commonly affects the limbs, face, intestinal tract, and upper airway. Swelling in the airway can restrict breathing and lead to a life-threatening airway obstruction. Hereditary angioedema has 3 subtypes distinguished by their underlying etiologies and levels of C1 inhibitor in the blood. Management includes treatment with danazol, kallikrein inhibitors, and C1-INHs. Hereditary angioedema is self-limiting, but may be fatal if the airway becomes compromised. Small bowel obstruction (SBO) is an interruption of the flow of the intraluminal contents through the small intestine, and is classified as mechanical (due to physical blockage) or functional (due to disruption of normal motility). The most common cause of SBO in the Western countries is post-surgical adhesions. Small bowel obstruction typically presents with nausea, vomiting, abdominal pain, distention, constipation, and/or obstipation. The diagnosis is established via imaging. Up to 80% of all cases will resolve with supportive management (bowel rest, intravenous (IV) hydration, and nasogastric decompression). However, surgery is required for persistent or complicated cases. The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting and are specialized for bearing weight and maintaining the horizontal balance of the pelvis. Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory, medium-sized angiopathy due to fibroplasia of the vessel wall. The condition leads to complications related to arterial stenosis, aneurysm, or dissection. The clinical presentation can differ depending on which arteries are affected, but may include secondary hypertension from renal artery stenosis (RAS), neurologic deficits from cerebrovascular involvement, claudication due to limb involvement, and intestinal angina from mesenteric artery disease. The diagnosis is confirmed with imaging, such as computed tomography with angiography. Treatment includes lifestyle modifications, antihypertensive therapy for RAS patients, and potential revascularization. Klinefelter syndrome is a chromosomal aneuploidy characterized by the presence of 1 or more extra X chromosomes in a male karyotype, most commonly leading to karyotype 47,XXY. Klinefelter syndrome is associated with decreased levels of testosterone and is the most common cause of congenital hypogonadism. Symptoms are often not noticed until adolescence or adulthood. Individuals with this condition tend to present as tall, phenotypic men with small testes, decreased body hair, gynecomastia, and infertility. Treatment consists of life-long testosterone replacement therapy. Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Common causes of functional dysphagia include achalasia, scleroderma, and diffuse esophageal spasm (DES). Mechanical causes of dysphagia include esophageal rings, webs, strictures, and cancer. Oropharyngeal dysphagia may be due to structural abnormalities or abnormal neuromuscular function and coordination. The diagnostic workup depends on the patient’s presenting symptoms, but may include manometry, barium esophagram, or direct visualization with nasopharyngeal laryngoscopy or endoscopy. Treatment varies depending on the underlying cause. Actinomyces is an anaerobic, gram-positive, branching, filamentous rod. Actinomyces israelii is the most common species involved in human disease. The organism is commonly found as part of the normal flora in the oral cavity, gastrointestinal tract, and reproductive tract. The disease is caused when the organism is displaced even by minor trauma or procedure, allowing the organism to move beyond the mucosal barrier. Reaching areas of low oxygen leads to the organism's multiplication. Actinomyces is associated with cervicofacial infection, which forms draining sinus tracts. Actinomyces can also affect the thoracic, abdominal, and pelvic areas. Drainage or infected tissue may have the characteristic yellow sulfur granules associated with Actinomyces. Management is with long-term penicillin and surgery, if needed. Nocardia is a branching, filamentous, gram-positive bacilli. It is partially acid fast due to the presence of mycolic acids in the cell wall. Nocardia is a ubiquitous soil organism that most commonly affects immunocompromised patients. Nocardia is transmitted via inhalation of aerosolized bacteria or less commonly, via direct contact with wounds. Nocardia causes opportunistic infections, primarily pulmonary infections (pneumonia, abscess, or cavitary lesions), which may spread to form brain abscesses. In immunocompetent patients, Nocardia can cause a cutaneous infection. Treatment for nocardiosis is with trimethoprim–sulfamethoxazole and/or surgical intervention as indicated. Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas has a sweet, grape-like odor. The most clinically relevant species is Pseudomonas aeruginosa (P. aeruginosa), which has a wide array of clinical manifestations from benign diseases, such as swimmer’s ear and “hot tub” folliculitis, to disseminated bacteremia and osteomyelitis. Risk factors for infections include: neutropenia, cystic fibrosis, asplenia, burn injuries, and indwelling catheters/endotracheal intubation. Management is primarily with piperacillin/tazobactam. Large bowel obstruction is an interruption in the normal flow of intestinal contents through the colon and rectum. This obstruction may be mechanical (due to the actual physical occlusion of the lumen) or functional (due to a loss of normal peristalsis, also known as pseudo-obstruction). Malignancy and volvulus are the most common causes of mechanical large bowel obstruction. Typical symptoms include intermittent lower abdominal pain, abdominal distention, and obstipation. Diagnosis is established with imaging. Mechanical large bowel obstruction requires surgery in most cases. Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. The replication cycle differs between viruses that infect bacteria (bacteriophages) and viruses that infect eukaryotic cells. Bacteriophages have either a lytic or lysogenic replication cycle, while eukaryotic viruses have a defined 6-step replication process. A Meckel’s diverticulum is a persistent remnant of the omphalomesenteric (vitelline) duct. A Meckel’s diverticulum is usually located in the antimesenteric border of the ileum. The mucosal lining of the diverticulum may contain heterotopic mucosa (most commonly gastric). Though frequently asymptomatic, a Meckel’s diverticulum can cause ulceration and present with lower gastrointestinal (GI) bleeding. Other complications include diverticulitis or small bowel obstruction (SBO). A Meckel’s scan can detect the diverticulum in hemodynamically stable patients. For those with active bleeding, arteriography is the diagnostic option. The treatment for a symptomatic Meckel’s diverticulum is surgery. Brucellosis (also known as undulant fever, Mediterranean fever, or Malta fever) is a zoonotic infection that spreads predominantly through ingestion of unpasteurized dairy products or direct contact with infected animal products. Clinical manifestations include fever, arthralgias, malaise, lymphadenopathy, and hepatosplenomegaly. The clinical manifestations, exposure history, serology, and culture data are used in the diagnosis. Treatment involves a combination of antibiotics, including doxycycline, rifampin, and aminoglycosides. Preventative measures include avoiding unpasteurized dairy products, vaccinating livestock, and using caution around animals. The primary visual pathway consists of a relay system, beginning at the retina, whose ganglion cell axons form the optic nerve. The optic nerve fibers from each eye hemidecussate in the optic chiasm (OC), with nasal fibers joining the temporal fibers of the contralateral nerve. The nasal fibers continue as the optic tract on each side, synapsing with the lateral geniculate nucleus (LGN) of the thalamus. Signals are then transmitted to the primary visual cortex of the occipital lobe. The right and left visual fields are processed by opposite hemispheres. Lesions along the pathway result in vision loss or visual field deficits. Based on the type of presentation, the location of the lesion in the pathway can be ascertained. Colorectal cancer (CRC) is the 2nd-leading cause of cancer-related death in the United States. Almost all cases of CRC are adenocarcinoma and the majority of lesions come from the malignant transformation of an adenomatous polyp. As most CRCs are asymptomatic, screening is essential in detecting early disease. Screening is recommended to start at the age of 45 years, utilizing various screening tools available with colonoscopy, flexible sigmoidoscopy, and fecal tests among them. For high-risk individuals, earlier and more frequent screening is recommended. Other stool-based strategies and visualization tests are also available for CRC screening. Giardiasis is caused by Giardia lamblia (G. lamblia), a flagellated protozoan that can infect the intestinal tract. Giardia transmission occurs most commonly through consumption of cysts in contaminated water or through the fecal-oral route. Excystation occurs in the gastrointestinal (GI) tract, and trophozoites attach to the intestinal wall villi and cause malabsorption. The hallmark symptom of giardiasis is foul-smelling steatorrhea. Patients who develop chronic infections may experience weight loss, failure to thrive, and vitamin deficiencies as a result of malabsorption. The diagnosis is made through detection of Giardia organisms, antigens, or deoxyribonucleic acid (DNA) in the stool. Management includes supportive treatment and antimicrobial therapy with metronidazole, tinidazole, or nitazoxanide. Prevention measures include proper handwashing and water treatment. Mycoplasma is a species of pleomorphic bacteria that lack a cell wall, which makes them difficult to target with conventional antibiotics (particularly penicillins and other beta-lactam antibiotics that target cell wall synthesis) and causes them to not gram stain well. Mycoplasma bacteria commonly target the respiratory and urogenital epithelium. Mycoplasma pneumoniae (M. pneumoniae), the causative agent of atypical or “walking” pneumonia, is the most clinically relevant species. Antibiotics, particularly macrolides, are the most effective mode of therapy. Anthrax is an infection caused by the bacterium Bacillus anthracis, which usually targets the skin, lungs, or intestines. Anthrax is a zoonotic disease and is usually transmitted to humans from animals or through animal products. The Bacillus spores can persist in soil for a long time. The Bacillus spores have also been used as a biological weapon. Symptoms depend on which organ system is affected. The skin forms small blisters with surrounding swelling that often turn into a painless ulcer with a black center. Inhalational exposure causes severe fulminant pneumonia. Intestinal exposure causes mucosal ulcers, bloody diarrhea, abdominal pain, nausea, and vomiting. Diagnosis is established with cultures, tissue examination, and polymerase chain reaction (PCR). Management involves antibiotics, antitoxins, and frequently hospital/critical care admission. Mortality from systemic disease remains high. Delayed puberty (DP) is defined as the lack of testicular growth in boys past the age of 14 and the lack of thelarche in girls past the age of 13. Delayed puberty affects up to 5% of healthy boys and girls, and half of all cases are due to constitutional growth delay. Classified as central or gonadal, delayed puberty has multiple etiologies, expressed as a lack of development of secondary sexual characteristics. Diagnosis is made by clinical criteria and confirmed through laboratory testing. Management involves sex-steroid replacement therapy when indicated. Shigella is a genus of gram-negative, non-lactose-fermenting facultative intracellular bacilli. Infection spreads most commonly via person-to-person contact or through contaminated food and water. Humans are the only known reservoir. Because it is resistant to acid, Shigella spp. survive transit through the stomach; thus, only a small amount of inoculum is needed to cause disease. Shigellosis (Shigella dysentery) results in fever, abdominal pain, and bloody diarrhea, which are effects of the toxins and epithelial-cell invasion of the organism. In the majority of cases, symptoms resolve within a few days. However, complications of dehydration, hemolytic uremic syndrome, toxic megacolon, or reactive arthritis can arise. Treatment is primarily using fluid and electrolyte replacement and antibiotics. Cardiac myxoma is the most common of the primary tumors of the adult heart, all of which are very rare. Cardiac myxoma is a benign neoplasm that arises from primitive multipotent mesenchymal cells. Most occur sporadically, but some are a part of some familial syndromes. All 4 chambers may give rise to myxoma, but 90% originate and grow in the atria, with a left-to-right ratio of approximately 4:1. Diagnosis is made by echocardiography, cardiac magnetic resonance imaging (MRI), or cardiac computed tomography (CT). Complete surgical excision is required because of the substantial risk of embolization and cardiovascular complications, including sudden death. Leptospira is a spiral or question mark–shaped, gram-negative spirochete with hook-shaped ends. The disease, leptospirosis, is a zoonosis, infecting animals. Rodents are the most important reservoir. Bacteria shed in the urine of rodents and other animals can be transmitted to humans via contaminated water. The major clinical species is Leptospira interrogans, which causes a mild flu-like illness in a majority of cases. The manifestations are biphasic, with Leptospira found in the blood initially. In the immune phase, the bacteria disappear from the bloodstream and can be detected in the urine. In about 10% of infections, icterohemorrhagic leptospirosis develops, manifesting as hemorrhage, renal failure, and jaundice. Bacterial culture takes weeks, so other diagnostic tests such as serology and dark field microscopy are used. Treatment is primarily with penicillin. The human immunodeficiency virus (HIV) is a species of Lentivirus, a genus of the family Retroviridae, which causes HIV infections and acquired immunodeficiency syndrome (AIDS). The virus has high genetic variability and is divided into 2 major types, HIV type 1 (HIV-1) and HIV type 2 (HIV-2). The human immunodeficiency virus is a single-stranded, positive-sense, enveloped RNA virus, which targets and destroys WBCs, leading to frequent opportunistic infections and, eventually, death. Cervical cancer is the 3rd most common gynecologic cancer. More than 90% of cervical cancer cases are associated with high-risk human papillomavirus (hrHPV), which is transmitted by sexual contact. Cervical cancer can be prevented by early detection and treatment of precancerous lesions caused by hrHPV. The methods of detection are cervical cytology and HPV testing. Screening is recommended by the age of 21 and is generally repeated every 3 years up to the age of 29 in an average-risk individual. By age 30, HPV testing with cytology is obtained. Since the screening program was initiated, there has been a 75% decline in the incidence of and mortality from cervical cancer. Bacteroides is a genus of opportunistic, anaerobic, gram-negative bacilli. Bacteroides fragilis is the most common species involved in human disease and is part of the normal flora of the large intestine. Infection most commonly occurs when the colon wall is breached and bacteria enter the peritoneal cavity, which can cause intra-abdominal infections and intra-abdominal abscess formation. Management involves antibiotics and abscess drainage. Gas gangrene, also known as clostridial myonecrosis, is a life-threatening muscle and soft tissue infection that usually develops after traumatic inoculation with Clostridium perfringens (C. perfringens), but can also develop spontaneously in association with other Clostridium species. Sudden, severe muscle pain classically develops shortly after the injury. Skin color changes (red/purple to black), tenderness, bullae formation, and crepitus are also present and progress rapidly. Most of the time, diagnosis is established clinically. Once the diagnosis is suspected, intravenous (IV) antibiotic therapy should be started and emergent surgical debridement should be performed. Chiari malformations (CMs) are a group of central nervous system (CNS) conditions characterized by the underdevelopment of the posterior cranial fossa with subsequent protrusion of neural structures through the foramen magnum. There are 4 types of CM, with type I being the most common. Headaches are the most common symptom. Diagnosis is made by clinical findings and confirmed by magnetic resonance imaging (MRI). Treatment is surgical, based on decompression of the posterior fossa and restoration of CNS flow. Prognosis depends on the type of malformation. Penetrating chest injuries (PCIs) are caused by an object puncturing the chest wall. Penetrating chest injuries can be high velocity, such as with gunshot wounds (GSWs); medium velocity, such as with pellet gunshots; or low velocity, such as with stab wounds. Penetrating chest injuries have a higher mortality rate than blunt chest injuries but are less common. Performing the standardized trauma evaluation (primary and secondary surveys), as well as ordering proper imaging, is critical to determining the diagnosis and aiding in management decisions. The majority of PCIs do not require major surgery and can be managed by observation or tube thoracostomy, although surgical repair of injuries may be needed. Transposition of the great vessels (TGV) is a cyanotic congenital heart disease characterized by “switching” of the great arteries. There are 2 presentations: the dextro (D)- and levo (L)-looped forms. The L-looped form is rare and congenitally corrected, as the ventricles are also switched. The D-looped form accounts for 3% of all cases of congenital heart disease. The condition occurs within the neonatal phase of life with cyanosis that is unresponsive to oxygen therapy. Diagnosis is confirmed by echocardiogram and a chest X-ray showing the classic “egg on a string” pattern. Treatment is primarily surgical, and the prognosis for surgically corrected cases is good. Foreign body aspiration can lead to choking and death by obstructing airflow at the larynx or trachea. Foreign bodies may also become lodged deeper in the bronchi; this may not affect breathing but can cause infection or erosion of bronchial walls. Foreign bodies (FBs) are more frequently aspirated by children, who may present with coughing or wheezing. As FBs are rarely visible on X-ray, other modalities of imaging, such as computed tomography or flexible bronchoscopy, must be employed when prompted by symptoms and clinical suspicion. The relative frequency with which various objects are aspirated varies based on patient demographics. Prompt removal of the FB is the definitive treatment. Campylobacter ("curved bacteria") is a genus of thermophilic, S-shaped, gram-negative bacilli. There are many species of Campylobacter, with C. jejuni and C. coli most commonly implicated in human disease. The mode of transmission is primarily through the consumption of undercooked food contaminated with Campylobacter. Infection is most often associated with self-limiting gastroenteritis and is also a major cause of bloody diarrhea, especially in children. Two associated complications of Campylobacter gastroenteritis are Guillain-Barré syndrome and reactive arthritis. Vibrio is a genus of comma-shaped, gram-negative bacilli. It is halophilic, acid labile, and commonly isolated on thiosulfate-citrate-bile-sucrose (TCBS) agar. There are 3 clinically relevant species. Vibrio cholerae (V. cholerae) is found in brackish and marine waters. Vibrio cholerae is associated with cholera, which causes severe, secretory “rice-water” diarrhea. The other 2 species are Vibrio vulnificus (V. vulnificus) and Vibrio parahaemolyticus (V. parahaemolyticus), which are transmitted through raw or undercooked shellfish and are associated with wound infections, septicemia, and diarrhea. Legionella is a facultative intracellular, gram-negative bacilli. Legionella does not grow on common culture media because it requires certain supplementation (cysteine and iron). Legionella can be isolated on a buffered charcoal yeast extract (BCYE) medium. The habitat for Legionella is aquatic systems including human-constructed reservoirs, such as cooling towers and hot water tanks. Transmission occurs primarily through inhalation of aerosolized water droplets, causing pulmonary infection. Legionella pneumophila (L. pneumophila) accounts for the majority of human infections. The clinical presentation includes Legionnaires’ disease, atypical pneumonia, and Pontiac fever. Diagnosis is by culture, urine antigen test, and/or polymerase chain reaction (PCR). Fluoroquinolones and macrolides are the main treatments. Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Management includes oxygen supplementation, pain control, ventilation if respiratory failure presents, and possible surgery. Severe traumatic intrathoracic injuries, such as pulmonary contusions, pneumothorax, and cardiac injuries, are often seen in conjunction with flail chest. Atrial septal defects (ASDs) are benign acyanotic congenital heart defects characterized by an opening in the interatrial septum that causes blood to flow from the left atrium (LA) to the right atrium (RA) (left-to-right shunt). Atrial septal defects account for approximately 15% of all cases of congenital heart disease (CHD), making ASDs the 2nd most common CHD. There are 4 types of ASD based on the location of the defect along the atrial septum, but the most common is the ostium secundum defect. Atrial septal defects are usually detected during a routine physical examination and confirmed by an echocardiogram. In infancy, most small ASDs close spontaneously by 2 years of age. Only patients that are symptomatic require surgical closure. In general, most patients with ASD can expect a good overall outcome. Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Upper airway obstruction (UAO) and central airway obstruction (CAO) refers to a mechanical blockage of the large airways and are potentially life-threatening events, which need to be recognized and managed promptly. Aromatase deficiency is a very rare genetic condition with autosomal recessive inheritance. Aromatase deficiency is characterized by congenital estrogen deprivation with increased levels of testosterone due to decreased levels of the aromatase enzyme. Affected females present with abnormal development of the external genitalia, virilization, primary amenorrhea, and tall stature. Males usually develop symptoms later in life, including hyperinsulinemia and lipid metabolism disorders. Individuals affected by aromatase deficiency have an increased risk of developing osteoporosis. Treatment involves hormone replacement therapy. Bordetella is a genus of obligate aerobic, Gram-negative coccobacilli. They are highly fastidious and difficult to isolate. The most important pathologic species is Bordetella pertussis (B. pertussis), which is commonly isolated on Bordet-Gengou agar. Bordetella pertussis is highly infectious via respiratory droplets and is only known to infect humans, causing the clinical syndrome of pertussis. Pertussis is characterized by 3 distinct phases: catarral, paroxysmal, and convalescent. Pertussis is rare in developed countries due to widespread use of the diphtheria, tetanus, and acellular pertussis (DTaP) combined vaccine. Antiphospholipid syndrome (APLS) is an acquired autoimmune disorder characterized by the persistent presence of antiphospholipid antibodies, which create a hypercoagulable state. These antibodies are most commonly discovered during a workup for a thrombotic event or recurrent pregnancy loss, which are the 2 most common clinical manifestations of APLS. Patients with APLS are at risk for both arterial and venous thrombosis, and after a thrombotic event, patients are managed with long-term anticoagulation therapy. Corynebacteria are gram-positive, club-shaped bacilli. Corynebacteria are commonly isolated on tellurite or Loeffler's media and have characteristic metachromatic granules. The major pathogenic species is Corynebacterium diphtheriae, which causes diphtheria—a severe upper respiratory infection. The characteristic findings of diphtheria include pharyngeal pseudomembranes (grayish tonsillar exudates), severe pharyngitis, and “bull’s neck” lymphadenopathy. Treatment is primarily through passive immunization with antitoxin and antibiotics. Prevention is via the diphtheria toxoid vaccine. Reactive arthritis is a seronegative autoimmune spondyloarthropathy that occurs in response to a previous gastrointestinal (GI) or genitourinary (GU) infection. The pathophysiology of this disease is unclear, but a significant proportion of affected patients are positive for HLA-B27. The disease manifests as asymmetric oligoarthritis (particularly of large joints in the lower extremities), enthesopathy, dactylitis, and/or sacroiliitis. Ocular, mucocutaneous, GI, GU, and cardiac manifestations may also occur. The diagnosis is clinical, and efforts should be made to rule out alternative diagnoses. Management focuses on controlling symptoms, typically with nonsteroidal anti-inflammatory drugs. An active infection should also be treated, particularly Chlamydia trachomatis. Splenic rupture is a medical emergency that carries a significant risk of hypovolemic shock and death. Injury to the spleen accounts for nearly half of all injuries to intra-abdominal organs. The most common reason for a rupture of the spleen is blunt abdominal trauma, specifically, motor vehicle accidents. For individuals with splenomegaly, however, even minimal trauma may result in splenic injury or rupture. Patients often present with LUQ abdominal pain; however, pain may be referred to the left shoulder. Patients are at risk for hemodynamic instability due to blood loss. The diagnosis is generally made with CT imaging, and management, ranging from observation to splenectomy, depends on the patient’s hemodynamic stability. Clostridia species comprise a group of spore-forming, obligate anaerobic, gram-positive bacilli. Major pathogenic species include Clostridium perfringens (C. perfringens), which is associated with gas gangrene; Clostridioides difficile, which is associated with pseudomembranous colitis; C. tetani, which causes tetanus; and C. botulinum, which causes botulism. Clostridium perfringens (C. perfringens), Clostridioides difficile, C. tetani, and C. botulinum have broad-spectrum invasiveness and clinical manifestations that are summarized below. Note that Clostridium difficile has been reclassified as Clostridioides difficile. However, exams will likely not have the updated genus for several years. Yersinia is a genus of bacteria characterized as gram-negative bacilli that are facultative anaerobic with bipolar staining. There are 2 enteropathogenic species that cause yersiniosis, Y. enterocolitica and Y. pseudotuberculosis. Infections are manifested as pseudoappendicitis or mesenteric lymphadenitis, and enterocolitis. The bacteria are transmitted through consumption of contaminated food products or water. Manifestations include fever, abdominal pain, and/or diarrhea. The gastrointestinal illness is usually self-limiting. Antibiotics are given for severe infection and in immunocompromised patients. The plague is a bacterial infection caused by Yersinia pestis (Y. pestis), which primarily infects rodents. The disease is transmitted to humans via a fleabite. Inhalation of infectious droplets and handling infected animals or laboratory specimens are other means of transmission. The plague has 3 forms: bubonic (most common form), septicemic, and pneumonic. Bubonic plague results in swollen and tender lymph nodes called buboes in the inguinal area. Pneumonic and septicemic plague can arise as the primary presentation, but also can result from hematogenous spread from the bubonic disease. Diagnosis includes clinical history and findings, culture, polymerase chain reaction (PCR), and serology. The mortality rate is high, so prompt diagnosis and treatment with antibiotics are necessary. Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Patients present with localized knee pain, tenderness, and swelling at the proximal anterior tibia. Diagnosis is clinical and treatment is focused on symptomatic relief. Osgood-Schlatter disease is a self-limiting condition that resolves with skeletal maturity. Ebstein's anomaly (EA) is a cyanotic congenital heart disease (CHD) characterized by the downward displacement of the septal and posterior leaflets of the tricuspid valve (TV). Ebstein's anomaly accounts for less than 1% of all cases of CHD. Maternal use of lithium is a common cause of EA. Clinical presentation varies, with the most common symptom being cyanosis. The age of presentation varies from in utero to adulthood and is proportional to the severity of the TV displacement, most cases present during adolescence. Ebstein's anomaly presents with multiple comorbidities, especially Wolff-Parkinson-White syndrome. The diagnosis is confirmed by echocardiography and definitive treatment is surgical. Patients who are managed appropriately still have a reduced life expectancy. Bacillus are aerobic, spore-forming, gram-positive bacilli. Two pathogenic species are Bacillus anthracis (B. anthracis) and B. cereus. Bacillus anthracis has a unique polypeptide capsule composed of D-glutamate and is associated with cutaneous, gastrointestinal, and pulmonary anthrax. Importantly, B. anthracis is classified as a bioterrorism agent. Bacillus cereus is associated with 2 forms of food poisoning, diarrheal and emetic, both of which are self-limited and require only supportive care. Proteus spp. are gram-negative, facultatively anaerobic bacilli. Different types of infection result from Proteus, but the urinary tract is the most common site. The majority of cases are caused by Proteus mirabilis (P. mirabilis). The bacteria are part of the normal intestinal flora and are also found in the environment. Proteus spp. exhibit a characteristic swarming motility and strong urease activity, which enable initiation of infection. Hydrolysis of urea by urease leads to alkaline urine with an ammonia-like odor. With the elevated pH in the urine, struvite renal stones form, which eventually can cause obstruction and renal failure. Treatment is with antibiotics (e.g., trimethoprim-sulfamethoxazole) for the infection and surgical removal of the stones, if present. Toxic shock syndrome (TSS) is an acute, multi-systemic disease caused by the toxin-producing bacteria, Staphylococcus aureus and Streptococcus pyogenes. Staphylococcal TSS is more common and associated with tampons and nasal packing. Streptococcal TSS is commonly due to invasive group A streptococcal (GAS) infections, such as bacteremia and necrotizing fasciitis, and has a higher mortality rate. Patients present with fever, tachycardia, hypotension, an erythematous rash, and evidence of multi-system organ dysfunction. The diagnosis is based on clinical, laboratory, and culture data. Management involves intravenous fluid (IVF) resuscitation, antibiotics, vasopressor support, and identification and management of the potential infectious source. Slipped capital femoral epiphysis (SCFE) is an orthopedic disorder of early adolescence characterized by the pathologic “slipping” or displacement of the femoral head, or epiphysis, on the femoral neck. Considered a type I Salter-Harris growth plate fracture, SCFE affects boys twice as often as girls. Thought to be due to a combination of biomechanical and endocrine factors, diagnosis is made with hip X-rays and treatment ranges from conservative to surgical. Prognosis depends on the severity of the slip or displacement. Injuries due to cold weather are common among children and athletes who are involved in sports played in cold conditions. There are multiple cold-related injuries, with frostbite being the most common. Frostbite is a direct freezing injury to the peripheral tissues and occurs when the skin temperature drops below 0℃ (32°F). Common sites of frostbite include the nose, ears, fingers, and toes. Clinical signs include skin pallor, anesthesia, blistering, and tissue necrosis. The main treatment is rapid rewarming. Compartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space. Long bone fractures are the most common cause, with the leg and forearm compartments frequently affected. Patients present with pain out of proportion to the injury and may also have pallor, pulselessness, paresthesia, poikilothermia, and paralysis (the 6 Ps of compartment syndrome). Diagnosis is clinical but compartment pressure measurement can be used. Management is an emergency fasciotomy. Failure to diagnose and manage the condition results in limb loss. Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Symptoms of CO poisoning include headache, nausea, weakness, chest pain, shortness of breath, seizures, coma, and even death. Oxygen therapy is key to the management of CO poisoning. Scleroderma (systemic sclerosis) is an autoimmune condition characterized by diffuse collagen deposition and fibrosis. The clinical presentation varies from limited skin involvement to diffuse involvement of internal organs. Diagnosis is established by a combination of physical findings and serology. There is no curative treatment. Management options are limited and include immunosuppressive medications as well as specific organ- or symptom-directed drugs. The overall 5-year survival of patients with scleroderma is about 80%. Erythema infectiosum is a rash illness caused by parvovirus B19. Erythema infectiosum is also known as fifth disease, being 5th in the historical list of rash-causing childhood infectious diseases: measles (1st), scarlet fever (2nd), rubella (3rd), Dukes' disease (4th), and roseola (6th). Transmission is through respiratory secretions. Diagnosis is generally clinical, suspected in patients presenting with an erythematous malar rash with circumoral pallor (“slapped cheek”). A rash over the trunk and extremities occurs afterward. The illness is self-limited and has no specific therapy. Complications can occur, however, due to the viral tropism for erythrocyte precursors. Patients with hemoglobinopathies can experience aplastic crisis, while the immunocompromised may have chronic infection producing pure red cell aplasia. Benign prostatic hyperplasia (BPH) is a condition indicating an increase in the number of stromal and epithelial cells within the prostate gland (transition zone). Benign prostatic hyperplasia is common in men > 50 years of age and may greatly affect their quality of life. The development of BPH involves modifiable and non-modifiable risk factors, which lead to anatomic obstruction and downstream effects on other organ systems. Clinically, patients present with a combination of obstructive and bladder storage symptoms. Diagnosis is made by determining the severity of voiding symptoms through a variety of non-invasive (voiding diary, history, physical examination) and invasive (cystoscopy, urodynamics, transrectal ultrasound imaging) tools. Treatment is multimodal with medical and surgical components (prostatectomy) utilized in combination. Rickettsiae are a diverse collection of obligate intracellular, gram-negative bacteria that have a tropism for vascular endothelial cells. The vectors for transmission vary by species but include ticks, fleas, mites, and lice. The most clinically relevant pathogens are R. rickettsii, which causes Rocky Mountain spotted fever; R. prowazekii, which causes epidemic (louse-borne) typhus; R. typhi, which causes endemic typhus; and R. akari, which causes rickettsialpox. All of these diseases are a form of inflammatory vasculitis and commonly present with fever, headache, and rash. Treatment is with doxycycline. Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae (the most important pathogenic species) is commonly associated with lobar aspiration pneumonia in patients with alcohol-use disorder. It also causes nosocomial infections, such as hospital-acquired pneumonia and urinary tract infections, as well as tissue-destructing abscesses (liver, lung, spleen). Treatment is with cephalosporins for sensitive strains. However, many Klebsiella species have plasmids that confer multidrug resistance. Leishmania species are obligate intracellular parasites that are transmitted by an infected sandfly. The disease is endemic to Asia, the Middle East, Africa, the Mediterranean, and South and Central America. Clinical presentation varies, dependent on the pathogenicity of the species and the host’s immune response. The mildest form is cutaneous leishmaniasis (CL), characterized by painless skin ulcers. The mucocutaneous type involves more tissue destruction, causing deformities. Visceral leishmaniasis (VL), the most severe form, presents with hepatosplenomegaly, anemia, thrombocytopenia, and fever. Management is based on the clinical severity and patient's immune status. Some cutaneous lesions spontaneously resolve or require local therapy. Systemic treatment (amphotericin B), however, is needed for VL. The apophysis is a secondary ossification center found on non-weight-bearing segments of bones. The apophysis is also the site of ligament or tendon insertion and is involved in the peripheral growth of the bone. These secondary growth centers are generally open in late childhood and may not close until early adulthood. With overuse, the apophysis may become inflamed and painful, becoming vulnerable to tearing and avulsion. An acute apophyseal avulsion fracture occurs when a portion of the apophysis is pulled off by the ligament, usually secondary to explosive movements and eccentric muscular contractions. Apophyseal avulsion fractures are primarily treated conservatively, but may require surgical repair if the avulsed fragment is large or significantly displaced. Borrelia are gram-negative microaerophilic spirochetes. Owing to their small size, they are not easily seen on Gram stain but can be visualized using dark-field microscopy, Giemsa, or Wright stain. Spirochetes are motile and move in a characteristic spinning fashion due to axial filaments in the periplasmic space. The ability of Borrelia to express different repertoires of surface proteins allows for bacterial transmission and evasion of the host immune system. Borrelia utilizes Ixodes ticks, Ornithodoros ticks, and the human body louse as vectors, and the resulting diseases include Lyme disease and relapsing fever. The bones of growing children exhibit unique characteristics, which, combined with the unique mechanisms of injury seen in children, result in fracture patterns differing significantly from those common in adults. The greenstick fracture is an incomplete fracture usually seen in long bones. The bone is typically bent, and the fracture extends only partway through the bone. Greenstick fractures are at high risk for refracture and should be completely immobilized. Greenstick fractures rarely require reduction but should be managed cautiously to prevent malunion or angulation deformities. A patient with a greenstick fracture should be referred for orthopedic follow-up. A “toddler’s fracture” is a spiral or oblique fracture of the distal tibia in toddlers resulting from a low-energy trauma with a rotational/twisting component. These fractures are often seen in children who are learning to walk and who do not have a specific history of trauma. The child can sometimes present with a painful limp or refusal to bear weight on the affected limb. Management comprises analgesia and immobilizing the injured leg for several weeks. Antiretroviral therapy (ART) targets the replication cycle of the human immunodeficiency virus (HIV) and is classified based on the viral enzyme or mechanism that is inhibited. The goal of therapy is to suppress viral replication to reach the outcome of undetected viral load. Currently, reverse transcriptase, protease, integrase, and entry inhibitors are used in combined ART (cART) regimens. Combination therapy (3-drug regimen) is used to prevent drug resistance and cross-resistance, which develop through genetic mutations. Rocky Mountain spotted fever (RMSF) is a bacterial infection caused by the obligate intracellular parasite Rickettsia rickettsii. Transmission occurs through an arthropod vector, most commonly the American dog tick (Dermacentor variabilis). Rocky Mountain spotted fever is prevalent in the southeastern United States. Early signs and symptoms of RMSF are nonspecific and include a high fever, severe headache, and rash. The rash is characteristic in that it begins peripherally and moves centrally, and also appears on the hands and soles. A high clinical suspicion is required for diagnosis, and empiric treatment with doxycycline is recommended within 5 days of symptoms onset. The bones of growing children exhibit unique characteristics. These characteristics, combined with the unique mechanisms of injury seen in children, result in fracture patterns that differ significantly from those that are common in adults. When axial loads are applied, particularly to long bones in children, compressive forces may result in buckling of the bone without disruption of the periosteum. These fractures are called buckle or torus fractures and are considered generally stable, requiring only immobilization. A gastrinoma is a tumor that secretes excessive levels of the hormone gastrin and is responsible for Zollinger-Ellison syndrome (ZES). Gastrinomas are frequently associated with multiple endocrine neoplasia 1 (MEN 1) and can arise from the pancreas, stomach, duodenum, jejunum, and/or even from the lymph nodes. Gastrinoma tumors are often malignant and frequently metastasize to the liver, lymph nodes, and bone. Zollinger-Ellison syndrome (ZES) is characterized by high gastrin levels, elevated gastric acid production, peptic ulcers, gastroesophageal reflux, and diarrhea. Diagnosis is based on fasting serum gastrin levels. Management consists of surgical resection of the gastrinoma and/or symptomatic management for unresectable disease. Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Clinical symptoms range from stridor, respiratory distress, and/or dysphagia in neonates, to asymptomatic forms, noted incidentally in adults. Diagnosis is confirmed through X-ray and echocardiography, but may be further defined with a computed tomographic (CT) scan. Definitive treatment is surgical, and the prognosis is excellent as clinical recovery is immediate. Salmonellae are gram-negative bacilli of the family Enterobacteriaceae. Salmonellae are flagellated, non-lactose-fermenting, and hydrogen sulfide-producing microbes. Salmonella enterica, the most common disease-causing species in humans, is further classified based on serotype as typhoidal (S. typhi and paratyphi) and nontyphoidal (S. enteritidis and typhimurium). Transmission occurs through the fecal-oral route and consumption of contaminated foods and water. Bacteria penetrate the intestinal cells through microfold cells of Peyer’s patches and cause abdominal symptoms. Pathogens can also disrupt sodium and chloride transport in the intestine (causing diarrhea) and invade the bloodstream (causing sepsis and nonintestinal infection). Major clinical presentations include typhoid or enteric fever, foodborne enterocolitis, and bacteremia. Antibiotic treatment is considered in severe illness and chronic carrier states. Relapsing fever is a vector-borne disease caused by multiple species of the spirochete Borrelia. There are 2 major forms of relapsing fever: tick-borne relapsing fever (caused by multiple species, such as B. hermsii, B. miyamotoi, and B. turicatae) and louse-borne relapsing fever (caused by B. recurrentis). Patients go through recurrent stages of fever, crisis phase, and afebrile periods. Severe manifestations can include myocarditis, ARDS, and meningitis. Diagnosis is based on the clinical history and visualization of spirochetes on a thick and thin blood smear obtained during a febrile episode. Management of relapsing fever is with antibiotics, such as doxycycline, penicillin, or ceftriaxone. Patients should be monitored closely for Jarisch-Herxheimer reaction. Hashimoto's thyroiditis, or chronic lymphocytic thyroiditis, is the most common cause of hypothyroidism in iodine-sufficient regions. The condition is an autoimmune disorder leading to destruction of the thyroid cells and thyroid failure. The gradual clinical course of Hashimoto's thyroiditis starts with a transient hyperthyroid state (“hashitoxicosis”) followed by subclinical hypothyroidism. Eventually, progression to overt hypothyroidism occurs, which is permanent. Patients may have a painless goiter, but in later stages, the gland is atrophic. Diagnosis is by laboratory tests showing elevated thyroid-stimulating hormone (TSH), low free thyroxine (T4), and positive antibodies against thyroglobulin and thyroid peroxidase. In uncertain cases, imaging is required. Radioactive iodine uptake will show low iodine uptake and ultrasound demonstrates diffuse symmetric enlargement. Biopsy shows lymphocytic infiltration with Hurthle cells. Treatment is lifelong thyroid hormone replacement. An abscess is a collection of pus in the dermis or subcutaneous tissue. Abscesses are one of the commonly encountered skin and soft tissue infections. Although abscesses may occur spontaneously, predisposing factors such as abrasions and punctures are often identified. A patient with a skin abscess usually presents with a localized, fluctuant, tender mass that appears red and warm. Incision and drainage are the mainstay of management, but antibiotics can be used depending on the size of the abscess as well as the patient’s risk factors for severe infection. Graves' disease is an autoimmune disorder characterized by the presence of circulating antibodies against the thyroid-stimulating hormone (TSH) receptors, thereby causing the thyroid gland to hyperfunction. Clinical features include hyperthyroidism (of which Graves' disease is the most common cause), orbitopathy, goiter, and dermopathy/pretibial myxedema. Manifestations reflect the muti-systemic effects of a hyperactive thyroid, including heat intolerance, sweating, palpitations, tremors, pretibial myxedema, and exophthalmos. Diagnosis is by thyroid laboratory tests showing a low TSH, elevated thyroid hormones (thyroxine (T4) and triiodothyronine (T3)) and thyrotropin-receptor antibodies (particularly the thyroid-stimulating immunoglobulins subtype). If initial tests are nondiagnostic, radioactive iodine uptake (increased uptake) and thyroid ultrasound (diffuse thyroid enlargement) provide diagnostic information. Treatment options include thionamides, radioiodine ablation, and surgery. Chlamydial infections are a group of infectious diseases caused by bacteria belonging to the Chlamydiaceae family. The 3 species that can infect humans are Chlamydia trachomatis, C. pneumoniae, and C. psittaci. The most common infection is an STI caused by C. trachomatis, which affects the genitourinary tract. Chlamydia is the most common sexually transmitted bacterial infection in the United States. Other species of Chlamydia mainly cause respiratory infections. Diagnosis is based on nucleic acid amplification tests. Management is with antibiotics. Untreated chlamydial infections may have serious consequences, including sterility, ectopic pregnancies, spontaneous abortions, and chronic pelvic inflammatory disease. Tricuspid valve atresia (TVA) is a congenital heart defect (CHD) causing an absent or rudimentary tricuspid valve (TV) associated with an interatrial or ventricular septal defect. Patients present with cyanosis at birth due to blood mixing between the right atrium (RA) and right ventricle (RV). Diagnosis can be made in utero or confirmed after birth with an echocardiogram. Definitive management involves a staged surgical procedure beginning in the neonatal period. Total anomalous pulmonary venous return (TAPVR) is a cyanotic congenital heart defect wherein the pulmonary veins drain into anatomical sites other than the left atrium. The most common sub-type is the supra cardiac form, where the drainage is into the superior vena cava. Patients are usually cyanotic from birth and present with respiratory and heart failure right after birth. On examination there is a fixed, wide split-second heart sound, and a chest X-ray might reveal the “snowman” sign. Diagnosis is confirmed by an echocardiogram, which can be prenatal. All patients require surgery for survival and medical management is used to bridge the gap to surgery. Serotonin syndrome is a life-threatening condition caused by large increases in serotonergic activity. This condition can be triggered by taking excessive doses of certain serotonergic medications or taking these medications in combination with other drugs that increase their activity. Hallmarks of this condition are autonomic hyperactivity, neuromuscular instability, and altered mental status. Management involves discontinuation of all serotonergic agents, sedation with benzodiazepine, and cyproheptadine (a serotonin antagonist) if supportive measures fail. Primate erythroparvovirus 1 (generally referred to as parvovirus B19, B19 virus, or sometimes erythrovirus B19) ranks among the smallest DNA viruses. Parvovirus B19 is of the family Parvoviridae and genus Erythrovirus. In immunocompetent humans, parvovirus B19 classically results in erythema infectiosum (5th disease) or “slapped cheek syndrome.” Other manifestations vary with the immunologic and hematologic status of the host due to the viral tropism for erythrocyte precursors. Diagnosis is primarily clinical and management is generally supportive. A volvulus is the twisting or axial rotation of a portion of the bowel around its mesentery. The most common site of volvulus in adults is the colon; most frequently the sigmoid volvulus. Patients typically present with symptoms of bowel obstruction such as abdominal pain, distension, vomiting, and constipation/obstipation. In severe cases, signs of bowel ischemia and gangrene (tachycardia, hypotension, hematochezia, and peritonitis) may also be present. Clinical suspicion prompts imaging to confirm the diagnosis and surgery is the definitive treatment. For stable patients with sigmoid volvulus, surgery may be preceded by endoscopic detorsion. However, immediate surgery is required for colon perforation or ischemia. Polymyositis (PM) is an autoimmune inflammatory myopathy caused by T cell-mediated muscle injury. The etiology of PM is unclear, but there are several genetic and environmental associations. Polymyositis is most common in middle-aged women and rarely affects children. Patients present with progressive and symmetric proximal muscle weakness and constitutional symptoms. Complications may arise from respiratory, cardiac, or GI involvement. Diagnosis is based on clinical presentation and laboratory studies and confirmed using muscle biopsy. Management is with systemic glucocorticoids, immunosuppressants, and physiotherapy. All patients should undergo cancer screening because there is a strong association with malignancy. A VIPoma is a rare neuroendocrine tumor arising primarily in the pancreas that releases large amounts of vasoactive intestinal polypeptide (VIP). This process leads to chronic watery diarrhea with concomitant hypokalemia and dehydration, as well as wheezing and flushing (known as Verner-Morrison or WDHA (chronic Watery Diarrhea, Hypokalemia, Achlorhydria) syndrome). Most tumors arise sporadically, but some are associated with MEN 1. Diagnosis is established by measuring serum VIP levels. Treatment consists of medical management of symptoms and complete surgical removal of the tumor when possible. IgA nephropathy (Berger's disease) is a renal disease characterized by IgA deposition in the mesangium. It is the most common cause of primary glomerulonephritis in most developed countries. Patients frequently present in the second and third decades of life and, historically, with a preceding upper respiratory or GI infection. Common presenting features are gross hematuria or asymptomatic, microscopic hematuria on urinalysis. The course is often benign, with the definitive diagnostic procedure, renal biopsy, performed only in cases of severe, progressive renal disease. Treatment depends on the severity of proteinuria, renal function, and pathologic changes. ACE inhibitors or angiotensin-receptor blockers (ARBs) are given to reduce disease progression. Persistent proteinuria and increasing creatinine are indications for immunosuppressive therapy that includes glucocorticoids and, possibly, cytotoxic agents. Sick sinus syndrome (SSS), also known as sinus node dysfunction, is characterized by degeneration of the sinoatrial (SA) node, the heart’s primary pacemaker. Patients with SSS may be asymptomatic or may present with tachycardia or bradycardia. In cases of bradycardia, patients can experience fatigue, light-headedness, and syncope. Diagnosis is made by physical exam and ECG. Management can include a pacemaker. Supracondylar fractures are the most common elbow fractures in the pediatric population. The most common mechanism of injury involves a fall on an outstretched hand, resulting in a fracture of the distal humerus. Patients frequently present with pain, visible deformity, and limited range of motion of the injured elbow. This fracture often requires immediate orthopedic consultation secondary to the displacement of the fracture and the frequency of concomitant neurovascular injury. Subclavian steal syndrome occurs when narrowing/occlusion of the subclavian artery proximal to the origin of the vertebral artery causes a reversal of blood flow in the ipsilateral vertebral artery to continue perfusing the ipsilateral arm. The most common cause is atherosclerosis. Symptoms are rare, but when they occur are usually triggered by physical exertion of the arm and subsequent hypoperfusion of the arm or brain. Patients may present with claudication, pain, pallor, paresthesias, and weakened pulse in the affected extremity. Patients may also present with transient neurologic disturbances concerning for a stroke. Diagnosis is made by clinical findings and imaging (ultrasound, CT, MRI). In addition to appropriate management of atherosclerosis, symptomatic patients may need angioplasty/stenting or surgical revascularization. Prostate cancer is one of the most common cancers affecting men. In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of death is 2.5%. Prostate cancer is a slow-growing cancer that takes years, or even decades, to develop into advanced disease. Several men with prostate cancer are asymptomatic. Late-stage cancer can present with bone pain, urinary symptoms, and/or weight loss. Most cases of prostate cancer are identified based on diagnostic tests to determine prostate-specific antigen (PSA) levels and are confirmed based on image-guided transrectal biopsy. Management of prostate cancer depends on age, life expectancy, comorbidities, risk stratification, and preferences of the patient. Management options include active surveillance, androgen deprivation therapy, radiotherapy, chemotherapy, and radical prostatectomy. Uterine leiomyomas (or uterine fibroids) are benign tumors arising from smooth muscle cells in the uterine myometrium. Leiomyosarcomas, however, are malignant tumors, arising de novo (not from fibroids). With a lifetime risk of > 70% for both African American and Caucasian women, fibroids are common. Conversely, leiomyosarcomas are rare. Leiomyosarcomas may present similarly to uterine fibroids making preoperative diagnosis challenging. Both conditions present with abnormal bleeding, pelvic pain, and/or bulk symptoms. A fibroid is identified as a hypoechoic, well-circumscribed, round mass on pelvic ultrasound. A leiomyosarcoma is usually diagnosed on a postoperative specimen. Depending on patient symptoms and preference, treatment for leiomyoma may include surgical resection or medical options to reduce bleeding and/or bulk. Management of leiomyosarcoma, which carries a poor prognosis, may include adjuvant chemotherapy based on stage. A glucagonoma is a glucagon-secreting neuroendocrine tumor that originates from the α-cells in the pancreatic islets. Most glucagonomas are malignant, and many of them are part of the autosomal dominant condition known as multiple endocrine neoplasia syndrome type 1 (MEN 1). Elevated levels of glucagon lead to increased gluconeogenesis and glycogenolysis, resulting in an increase in free glucose in the bloodstream and the depletion of fat and amino acid stores. Patients often present with diabetes, a characteristic rash called necrolytic migratory erythema, weight loss, anemia, deep vein thrombosis, and neuropsychiatric symptoms. Laboratory findings demonstrate an elevated glucagon level, and imaging shows a pancreatic mass. Management is usually supportive and includes glucagon inhibition with octreotide (a somatostatin analog). Surgical resection is attempted if disease is localized, though this is frequently palliative. Chemotherapy and targeted molecular agents are also used in advanced disease. Rosacea is a chronic inflammatory disease of the skin that is associated with capillary hyperreactivity. This condition is predominantly seen in middle-aged women, and is more common in fair-skinned patients. Patients may have facial erythema, flushing, telangiectasia, papules, pustules, phymatous changes, and ocular manifestations. The diagnosis is clinical. Management includes avoidance of triggers, gentle skincare, topical (and/or oral) antibiotics, and laser (or surgical) therapies. Dilated cardiomyopathy (DCM) is the most common type of non-ischemic cardiomyopathy and a common cause of heart failure (HF). The cause may be idiopathic, familial, or secondary to a variety of underlying conditions. The disease is characterized by the enlargement of 1 or both ventricles and reduced systolic function. Patients typically present with symptoms of HF such as shortness of breath, fatigue, weakness, and peripheral edema. Blood tests, ECG, X-rays, echocardiography, and other cardiac studies and procedures are typically done to obtain the diagnosis. Treatment includes medications used to reduce volume overload (e.g., diuretics) and manage HF (e.g., beta-blockers). Devices such as pacemakers and cardioverter-defibrillators may also be needed. In severe cases, a heart transplant is required. Complications include thromboembolic events and sudden cardiac death. Becker muscular dystrophy (BMD) is an X-linked recessive genetic disorder that is caused by a mutation in the DMD gene. Abnormal, partially functional muscle dystrophin protein is produced, which leads to progressive muscle weakness and the eventual loss of ambulation. The clinical course is highly variable, but symptoms generally occur by adolescence. The diagnosis is based on muscle enzymes, genetic testing, and muscle biopsy (if necessary). Management of BMD is supportive and aimed at slowing disease progression and complications. Dilated cardiomyopathy is the leading cause of death. A thyroid nodule is a disordered growth of thyroid cells that produces a mass in the thyroid gland. Most thyroid nodules are benign and detected either by the patient or by the clinician on examination. In other cases, a thyroid nodule is found in radiologic imaging incidentally. Ruling out of malignancy is important. Workup includes thyroid-stimulating hormone (TSH) and thyroid ultrasound followed by radioactive iodine (RAI) uptake scan or thyroid scan if initial tests suggest the presence of hyperthyroidism. Fine-needle aspiration biopsy (FNAB) is recommended in patients with suspicious ultrasound findings, "cold" nodules (iodine uptake < surrounding tissue) on thyroid scan, large nodules (generally > 1.5 cm), or risk factors for malignancy. Management is dictated by pathology findings and can range from periodic ultrasound monitoring to surgery. Nephritic syndrome is a renal condition with signs and symptoms produced by inflammation of the glomeruli (glomerulonephritis) and increased permeability of the glomerular barriers. Defining features include hematuria, proteinuria (but below nephrotic range), RBC casts with dysmorphic RBCs on urine microscopy, and increased serum creatinine. Causes can be genetic, autoimmune, idiopathic, or post-infectious. The most common cause is acute post-streptococcal glomerulonephritis. General clinical findings include edema, hypertension, and oliguria. Diagnosis is made based on history, physical exam, and laboratory data. A renal biopsy is sometimes necessary to establish the underlying cause. There can be a combined nephritic-nephrotic picture, especially in the chronic presentation. Treatment and prognosis depend on cause and severity. Lentigo maligna is melanoma in situ, a precancerous lesion that may progress to an invasive melanoma (specifically lentigo maligna melanoma subtype). This condition typically occurs in sun-damaged areas (e.g., face and neck) of elderly patients. Lentigo maligna presents as a brown macule with color variegation and asymmetrical borders that grow slowly. The lesion should be biopsied to confirm a diagnosis and surgical excision with a safety margin is the 1st-line treatment. Dermatomyositis (DM) is an autoimmune and inflammatory myopathy. Although the etiology of DM is unclear, it has several genetic and environmental associations. Dermatomyositis is common in women around the age of 50 years. Patients present with symmetrical, proximal weakness, characteristic skin manifestations, and systemic symptoms. Diagnosis is based on clinical presentation and laboratory studies and confirmed on the basis of muscle biopsy. Myositis-specific antibodies, including anti-Mi-2, are specific markers in DM. Management is with systemic glucocorticoids, immunosuppressants, and physiotherapy. As there is a strong association of DM with malignancy, all patients should undergo cancer screening. Opioid use disorder (OUD) is a substance use disorder characterized by pathologic consumption of opioids. Opioids are central nervous system depressants that are used medically as potent analgesics. However, they are often misused for their euphoric effects. Features of opioid intoxication include respiratory depression, drowsiness, and pinpoint pupils. Intoxication can be managed with administration of naloxone. If discontinued, patients may develop withdrawal symptoms such as irritability, piloerection, and stomach cramps. Withdrawal may be managed by methadone or buprenorphine. Chronic OUD is managed with psychotherapy as well as medications. Prognosis is poor without adequate management and prevention of relapse and overdose. Alport syndrome, also called hereditary nephritis, is a genetic disorder caused by a mutation in the genes encoding for the alpha chains of type IV collagen, resulting in the production of abnormal type IV collagen strands. Patients present with glomerulonephritis, hypertension, edema, hematuria, and proteinuria, as well as with ocular (cataract, retinopathy) and auditory (sensorineural hearing loss) findings. Diagnosis is established with urinalysis, urine microscopy, and a renal function panel. A renal biopsy showing characteristic glomerular basement membrane splitting may be used to confirm the diagnosis. Treatment for Alport syndrome is focused on limiting disease progression with angiotensin receptor blockers and angiotensin-converting enzyme inhibitors. Hearing aids are used for hearing loss associated with Alport syndrome. Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. The borders are not clearly delineated. The lower extremities are the most frequent site of infection, but cellulitis can occur anywhere on the body. Diagnosis is usually clinical, and management involves oral and/or parenteral antibiotics. Coverage for MRSA may be added, depending on the presence of risk factors. Chorioamnionitis, commonly referred to as intraamniotic infection (IAI), is a common obstetric complication involving infection and inflammation of the fetal membranes, amniotic fluid, placenta, or the fetus itself. Chorioamnionitis is typically caused by a polymicrobial infection that ascends from the lower genitourinary tract. Primary risk factors include prolonged rupture of membranes and prolonged labor. Chorioamnionitis is diagnosed by clinical findings, including maternal fever. Chorioamnionitis is managed with antibiotics, and by ensuring continued labor progress (or initiating progress) toward delivery. Chorioamnionitis typically resolves soon after delivery. Significant maternal and fetal complications are possible, warranting prompt diagnosis and treatment. Rashes are a group of diseases that cause abnormal coloration and texture to the skin. The etiologies are numerous but can include irritation, allergens, infections, or inflammatory conditions. Rashes that present in only 1 area of the body are called localized rashes. Generalized rashes occur diffusely throughout the body. Rashes can be classified by their distribution, configuration, and morphology. The diagnosis is often clinical and based on the patient’s history and physical exam findings. Management is dependent on identifying the correct condition and varies depending on the etiology. Cocaine use disorder is a substance use disorder defined by pathologic consumption of the recreational drug cocaine. Cocaine is an indirect sympathomimetic that blocks the reuptake of dopamine, serotonin, and norepinephrine from the synaptic cleft. This process causes stimulant effects on the body and mind such as euphoria, increased energy, irritability, psychosis, decreased appetite, and weight loss. Cocaine overdose can cause death secondary to cardiac arrhythmia, myocardial infarction, seizure, or respiratory depression. Prognosis is poor as there is no approved pharmacological treatment, but psychosocial interventions have been associated with improved outcome. Strongyloidiasis is a common parasitic disease caused by infection with the roundworm Strongyloides stercoralis. Transmission occurs through skin penetration, most commonly from walking barefoot. Strongyloides has a unique life cycle that can be entirely completed in the human host, migrating from the skin to the pulmonary system and then to the GI system. Symptoms include cutaneous irritation, constipation, diarrhea, dry cough, and wheezing, depending on where the parasite is in its life cycle. Effective eradication of the parasite can be obtained with anthelmintic medications, usually ivermectin. Adenomyosis is a benign uterine condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Adenomyosis is a common condition, affecting 20%–35% of women, and typically presents with heavy menstrual bleeding and dysmenorrhea. Diagnosis is often made with pelvic imaging. Usually, transvaginal ultrasound is adequate, though MRI can be helpful in indeterminate cases. Management is based on the patient’s preference regarding future childbearing and may include hysterectomy (definitive treatment), other surgical options, or medical hormonal suppression (usually with progestins). Endometrial polyps are pedunculated or sessile projections of the endometrium that result from overgrowth of endometrial glands and stroma around a central vascular stalk. Endometrial polyps are a few millimeters to a few centimeters in size, can occur anywhere within the uterine cavity, and, while usually benign, can be malignant, particularly in postmenopausal women. Endometrial polyps present with abnormal uterine or postmenopausal bleeding, although many are asymptomatic and discovered incidentally. Endometrial polyps are best diagnosed with a saline-infusion sonogram, and are usually treated with hysteroscopic resection. Carotid artery stenosis is a chronic atherosclerotic disease resulting in narrowing of the common and internal carotid arteries. Common risk factors include family history, advanced age, hyperlipidemia, smoking, and diabetes mellitus. Patients may present with or without symptoms of decreased cerebral perfusion. Carotid artery stenosis is commonly diagnosed via ultrasound. Management includes lifestyle modifications to control progression of atherosclerosis. Treatment is with statins, anti-hypertensive and antiplatelet agents, and, in some cases, surgical revascularization. The most serious complication of carotid artery stenosis is stroke. Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition due to either a congenital or an acquired deficiency of ADAMTS-13, a metalloproteinase that cleaves multimers of von Willebrand factor (VWF). The large multimers then aggregate excessive platelets resulting in microvascular thrombosis and an increase in consumption of platelets. Clinical presentation can consist of thrombocytopenia, hemolytic anemia, hematuria, gastrointestinal symptoms, neurological symptoms, and renal involvement. Diagnosis is established based on a combination of clinical symptoms and laboratory tests. Thrombotic thrombocytopenic purpura is a medical emergency and almost always fatal if appropriate treatment is not initiated promptly. Emergency management includes plasma exchange and immunosuppressive therapies. Osteosarcoma is a primary malignant tumor of the bone characterized by the production of osteoid or immature bone by the tumor cells. The disease is most common in children and young adults and most frequently affects growth plates of the long bones, although it can involve any bone. Osteosarcoma can present with pain, swelling, and palpable mass, and sometimes with a pathologic fracture. Diagnosis is established with imaging studies and biopsy. Treatment involves systemic chemotherapy and surgical resection. Long-term survival can be expected with appropriate treatment in the absence of macrometastatic disease. Secondary amenorrhea is defined as the absence of menses for 3 months in a woman with previously regular menstrual cycles or for 6 months in a woman with previously irregular cycles. Etiologies involve either disruptions to the hypothalamic–pituitary–ovarian (HPO) axis or acquired obstructions in the uterus or outflow tract. The most common cause of secondary amenorrhea is pregnancy. The most common pathologic etiologies include functional hypothalamic amenorrhea, polycystic ovary syndrome, hyperprolactinemia, premature ovarian insufficiency, and Asherman's syndrome. The diagnosis is made with a thorough history and physical examination, measurement of hormone levels, a pregnancy test, and imaging with pelvic ultrasonography. A progestin and/or combined estrogen–progestin challenge can help further identify the location of the abnormality. Management depends on the underlying etiology, clinical presentation, and patient desires regarding fertility. Treatment can include lifestyle, medical, and surgical management options. Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis, which is why appendectomies are usually carried out in an urgent fashion. It is one of the most commonly performed emergent abdominal procedures. It can be associated with a number of postoperative complications; however, the majority of patients do very well and recover quickly. Acne vulgaris, also known as acne, is a common disorder of the pilosebaceous units in adolescents and young adults. The condition occurs due to follicular hyperkeratinization, excess sebum production, follicular colonization by Cutibacterium acnes, and inflammation. Acne can present as open or closed comedones, papules, pustules, nodules, or cysts. The diagnosis is based on clinical exam. Management depends on the severity, but includes skin care techniques, topical therapies, antibiotics, and retinoids. Amyloidosis is a disease caused by abnormal extracellular tissue deposition of fibrils composed of various misfolded low-molecular-weight protein subunits. These proteins are frequently byproducts of other pathological processes (e.g., multiple myeloma). These misfolded proteins can become deposited in different tissues, interfere with normal organ functions, and cause tissue-specific diseases (e.g., renal amyloidosis causes proteinuria). Diagnosis is established clinically and confirmed with tissue biopsy. Treatment should be directed toward the underlying cause and the reduction of amyloid deposition. Basal cell carcinoma is the most common skin malignancy. This cancer arises from the basal layer of the epidermis. The lesions most commonly appear on the face as pearly nodules, often with telangiectatic blood vessels and ulceration in elderly individuals. Diagnosis is established by tissue biopsy. Despite having low metastatic potential, basal cell carcinoma should be treated adequately because it is locally aggressive and destructive to tissues. Complete surgical excision is the main treatment method. Long-term prognosis is excellent with adequate management. Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy is known for its historical stigma and psychosocial effects on infected persons, prompting the World Health Organization (WHO) to pursue a disease elimination plan that led to significant reduction in the prevalence of leprosy. The diagnosis of leprosy is established clinically and supported with skin biopsy. It is treated with long-term multidrug antibiotic combinations. Untreated leprosy leads to disability and permanent damage to the skin, nerves, limbs, and eyes. Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm birth may also be initiated by the provider for a variety of maternal or fetal indications. Diagnosis involves assessments to detect cervical change and monitoring for regular uterine contractions. Management depends on gestational age, but typically includes administration of corticosteroids (to improve fetal lung maturity), magnesium sulfate (for fetal neuroprotection against cerebral palsy), group B streptococcus (GBS) prophylaxis, and 48 hours of tocolytics to help patients complete a full course of steroids. Chancroid is a highly transmissible STD caused by Haemophilus ducreyi. The disease presents with painful ulcer(s) on the genital tract (termed chancroid or “soft chancre”). Up to 50% of patients will develop painful inguinal lymphadenopathy. Furthermore, of that percentage, 25% may develop complications of the suppurative lymph nodes. Given the growth of H. ducreyi on a special medium (often not readily available), chancroid is diagnosed based upon clinical appearance and tests to rule out both syphilis and herpes (the most common causes of genital ulcers). Although the disease can resolve spontaneously, antibiotics (azithromycin or ceftriaxone) are the treatment of choice. Treatment should involve both patients and their sexual contacts. Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. It presents with lockjaw, neck stiffness, opisthotonus, rigid abdomen and severe painful muscle spasms. Diagnosis is made on clinical grounds, as it is rarely possible to isolate the infectious agent from the wound. It is treated with antibiotic therapy and the human tetanus antitoxin. Untreated tetanus can lead to respiratory failure and cardiovascular complications and can be fatal. With appropriate treatment, however, most patients will recover. Staphylococcal scalded skin syndrome (SSSS), also known as Ritter disease and staphylococcal epidermal necrolysis, is a toxin-mediated condition caused by Staphylococcus aureus. The exfoliative toxin produced disseminates and cleaves desmoglein 1 in the epidermis, causing separation and detachment of the skin. SSSS most commonly affects young children. Prodromal symptoms precede diffuse cutaneous erythema, tenderness, bullae formation, and superficial desquamation. The mucous membranes are spared. The diagnosis is made clinically and can be confirmed with culture data (targeting possible primary infection sites) and biopsy. However, cultures of bullae are not useful. Antibiotics and supportive care should be initiated as soon as the diagnosis is suspected. A brief resolved unexplained event (BRUE) is defined as a reported, sudden, brief (< 1 minute) event in a child < 1 year of age, which is resolved at the time of presentation. The definition includes ≥ 1 finding of either change in color (cyanosis or pallor), breathing pattern (absent, decreased, or irregular), muscle tone (hypertonia or hypotonia), or level of consciousness. The findings are based on a report given by a parent or caregiver. Adopted by the American Academy of Pediatrics in 2016, the new term was to replace the previously used terms “apparent life-threatening event” (ALTE) and “near sudden infant death syndrome”. The change in terminology was to better define an unexplained event after a thorough evaluation, stratify high- and low-risk groups, identify those needing further evaluation, and avoid unnecessary testing and admissions. Importantly, BRUE can be diagnosed only if there is no other explanation for the episode after a careful history and physical examination. An embolus is an intravascular solid, liquid, or gaseous material that is carried by the blood to a site distant from its point of origin. Emboli of all types warrant immediate medical attention. The majority of emboli dislodge from a thrombus, forming a thromboembolus. Other less common nonthrombotic types of emboli are cholesterol, fat, air, amniotic fluid, and tumor emboli. The cause of the embolus depends on the type, as does the clinical presentation, diagnosis, and management of each embolic condition. Due to their effects on circulation, all emboli have the potential to result in end-organ failure and death. Hypoaldosteronism is a hormonal disorder characterized by low levels of aldosterone. These low levels can be caused by decreased aldosterone production or a peripheral resistance to aldosterone. When hypoaldosteronism occurs as a result of an acquired decrease in renin production, the condition is more commonly referred to as renal tubular acidosis (RTA) type 4. Patients are usually older, with underlying renal disease (e.g., diabetic nephropathy). Hypoaldosteronism usually presents as hyperkalemia with a mild hyperchloremic metabolic acidosis (normal anion gap). Most patients are asymptomatic and routine lab evaluation demonstrates hyperkalemia, prompting a further workup. The condition is diagnosed using serum and urine tests that demonstrate reduced aldosterone levels and a reduced transtubular potassium gradient, among other characteristic findings. Patients are managed based on their underlying etiology. Pulmonary hypoplasia is the lack of normal fetal development of the pulmonary parenchyma. The condition is characterized by a decreased number of alveoli and bronchial generations. Oligohydramnios is a notable cause, but conditions that restrict lung development or lead to fetal lung compression can also result in pulmonary hypoplasia. A diagnosis of pulmonary hypoplasia can be suspected on prenatal ultrasound. Findings include reduced amniotic fluid, congenital abnormalities, and characteristic anatomical measurements. A more complete picture at birth points to the diagnosis based on clinical findings (respiratory distress, typical anomalies) and further evaluation (reduced lung volume on imaging). Treatment is focused on antenatal lung maturity and postnatal ventilatory support, with subsequent correction of associated causes and defects. Survival depends on the degree of lung underdevelopment. Mycobacterium is a genus of the family Mycobacteriaceae in the phylum Actinobacteria. Mycobacteria comprise more than 150 species of facultative intracellular bacilli that are mostly obligate aerobes. Mycobacteria are responsible for multiple human infections including serious diseases, such as tuberculosis (M. tuberculosis), leprosy (M. leprae), and M. avium complex infections. While lungs are the most common site of infection, mycobacteria can colonize and infect other organ systems including the lymph nodes, skin, sinuses, eyes, ears, bones, CNS, and urinary tract. Restrictive cardiomyopathy (RCM) is a fairly uncommon condition characterized by progressive stiffening of the cardiac muscle, which causes impaired relaxation and refilling of the heart during diastole, resulting in diastolic dysfunction and eventual heart failure. It most often occurs secondary to scarring, damage, and/or infiltration of the heart muscle, with amyloidosis being the most common cause. Infrequently, it may be idiopathic or inherited. Signs and symptoms include shortness of breath, low exercise tolerance, fatigue, and peripheral edema. Diagnosis is made through clinical suspicion and confirmed through ECG, X-ray, echocardiography, and cardiac MRI. Treatment includes medications for heart failure, implantable devices such as pacemakers and cardioverter–defibrillators, and heart transplantation in refractory cases. Ehrlichiosis and anaplasmosis are tick-borne bacterial infections. The most common causative species include Ehrlichia chaffeensis and Anaplasma phagocytophilum, which infect and multiply within monocytes and granulocytes, respectively. The clinical presentation can vary widely, but often includes fever, malaise, headache, myalgia, and arthralgias. A maculopapular or petechial rash occurs in some patients. Gastrointestinal, neurologic, and respiratory symptoms are also possible. The diagnosis is based on clinical suspicion and confirmed PCR or antibody testing. Management is with doxycycline. Babesiosis is an infection caused by a protozoa belonging to the genus, Babesia. The most common Babesia seen in the United States is B. microti, which is transmitted by the Ixodes tick. The protozoa thrive and replicate within host erythrocytes. Lysis of erythrocytes and the body’s immune response result in clinical symptoms. Patients usually present with a flu-like illness and jaundice. In severe cases, organ damage may occur. The diagnosis is confirmed by the visual presence of parasites within RBCs, which are often noted to be in a “Maltese Cross” configuration. Serological testing and PCR are also used in the diagnosis. Azithromycin and atovaquone are often used in management. Coinfection with Borrelia and Anaplasma is common. Post-transcriptional modifications (PTMs) are processes that facilitate the generation of mature, functional RNA. These rapidly responsive regulatory mechanisms allow different proteins to be produced from one gene and act as regulators of the phenotype and proliferation rate. These modifications also play a role in some forms of cancer and neurodegenerative diseases. The pre-messenger RNA (mRNA), called heterogeneous nuclear RNA (hnRNA), is modified by adding a 5’ 7-methylguanosine cap and a 3’ poly-A (polyadenylate) tail for stability and protection. Moreover, hnRNA that contains introns (noncoding sequences) among the expressed sequences or exons undergo splicing. This process removes introns to produce a mature mRNA carrying the coding sequence for translation. Alternative splicing, on the other hand, also excludes the introns, but varying combinations of exons are linked, producing different proteins from the original mRNA. In RNA editing, the mRNA sequence is altered and differs from the transcribed DNA template. Transfer RNA and ribosomal RNA start from longer precursor molecules and go through steps that include methylation, trimming, and addition of nucleotides. Caustic agents are acidic or alkaline substances that damage tissues severely if ingested. Alkali ingestion typically damages the esophagus via liquefactive necrosis, whereas acids cause more severe gastric injury leading to coagulative necrosis. Ingestion of large volumes and high concentrations of caustic agents can lead to severe and extensive injuries. Additionally, aspiration affects the laryngeal and tracheobronchial structures. Signs and symptoms include oral pain, burns, dysphagia, vomiting, and abdominal pain. Severe injuries can present with shock, abdominal rigidity, respiratory distress, and/or altered mental status. Diagnosis is based on laboratory tests, abdominal and chest imaging, and endoscopy within 24 hours (if without contraindications) to determine the extent of damage. Management involves stabilizing the cardiorespiratory status, decontamination, and supportive therapy. Severe injury may require surgery. Cannabis use disorder (CUD) is characterized by the pathologic consumption of cannabis, which is the most commonly used illicit substance worldwide. While cannabis has some beneficial medical uses, it also has the potential to cause intoxication characterized by psychosis or cognitive impairment, especially in chronic use. Unlike most other substances, withdrawal symptoms are mild. There is currently no strong evidence for long-term benefits of pharmacologic or psychosocial interventions in the management of cannabis use disorder. Other factors such as underlying mood or personality disorders or comorbidity with other substance use disorders are associated with a poor prognosis. Amphetamine use disorder (AUD) is a condition characterized by pathologic use of psychostimulants. Amphetamines produce their effect by increasing the release and blocking the reuptake of neurotransmitters (dopamine, norepinephrine, serotonin). Medically, they are used for the treatment of ADHD and narcolepsy. Methamphetamines and so-called designer drugs have no clinical use. Intoxication results in euphoria, pupillary dilation, hypertension, skin excoriation, paranoia, and severe aggression. Fatal complications can arise from myocardial infarction and coma. The prognosis for AUD is poor, as there is no FDA-approved pharmacotherapy, but psychosocial interventions have been associated with improved outcomes. In the context of acute or chronic kidney failure, renal function may diminish to a point at which it is no longer able to adequately support life. When this happens, renal replacement therapy is indicated. Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Hyperaldosteronism is defined as the increased secretion of aldosterone from the zona glomerulosa of the adrenal cortex. Hyperaldosteronism may be primary (resulting from autonomous secretion), or secondary (resulting from physiological secretion due to stimulation of the RAAS). Classically, hyperaldosteronism presents with hypertension, hypokalemia, and metabolic alkalosis, although recent studies have suggested that hypokalemia is less common than originally thought in primary hyperaldosteronism. Patients with hypertension who are treatment resistant and/or associated with hyperkalemia should be screened for hyperaldosteronism by determining their plasma aldosterone concentration and plasma renin activity. Confirmatory tests and an abdominal CT scan are required to conclusively diagnose primary hyperaldosteronism. Management involves the use of aldosterone receptor antagonists and surgical excision of any aldosterone-secreting tumors. Lactose intolerance (LI) describes a constellation of symptoms due to lactase deficiency (LD), the enzyme located in the brush border of the adsorptive cells in the small intestine. Lactose is the disaccharide present in milk and requires hydrolysis by lactase to break it down into its 2 absorbable constituents, glucose and galactose. Lactose intolerance typically presents with bloating, abdominal cramping, diarrhea, and flatulence. The diagnosis of LI can be suspected clinically based on symptoms after consumption of a lactose-containing meal. The most commonly used test for confirmation of the diagnosis is the lactose hydrogen breath test. The treatment goal is to eliminate symptoms while maintaining sufficient intake of calcium and vitamin D. Alternative diagnoses to LI should always be sought, as many people wrongly attribute their symptoms to LI. The kidneys are primarily in charge of the maintenance of water and solute homeostasis through the processes of filtration, reabsorption, secretion, and excretion. Glomerular filtration is the process of converting the systemic blood supply into a filtrate, which will ultimately become the urine. Complex regulatory processes ensure that only the appropriate substances in the systemic blood are lost in the urine and that the urine flow is satisfactorily balanced to maintain adequate systemic volume status. Abnormalities of the glomerulus can cause several clinically important conditions. Bariatric surgery refers to a group of invasive procedures used to surgically reduce the size of the stomach to produce early satiety, decrease food intake (restrictive type) and/or alter digestion, and artificially induce malabsorption of nutrients (malabsorptive type). The ultimate goal of bariatric surgery is drastic weight loss. Bariatric surgery is currently the only modality that provides significant long-term weight loss in morbidly obese individuals and cures or significantly improves obesity-related complications. The 2 modalities currently in wide use are the Roux-en-Y gastric bypass and sleeve gastrectomy. Extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (also called MALToma, MALT lymphoma, and pseudolymphoma) is a group of non-Hodgkin’s lymphomas that have historically been grouped together because they appear to arise from postgerminal center marginal zone B cells and share a similar immunophenotype. MALT lymphoma is thought to arise in the setting of chronic immune stimulation, which is usually due to bacterial, viral, or autoimmune stimuli. MALT lymphomas present with symptoms due to localized involvement of glandular epithelial tissues in the specific site where they develop. Diagnosis of MALT lymphoma is made by morphologic, immunophenotypic, and genetic analysis of biopsy samples. Helicobacter pylori–positive gastric MALT lymphoma is treated with H. pylori eradication therapy, and H. pylori–negative gastric MALT lymphoma is treated with radiation therapy. Nongastric MALT lymphoma is treated based on the involved area and extent of disease. MALT lymphoma patients have a good prognosis, with a median survival of > 10 years. Hyperparathyroidism is a condition associated with elevated blood levels of parathyroid hormone (PTH). Depending on the pathogenesis of this condition, hyperparathyroidism can be defined as primary, secondary or tertiary. Primary hyperparathyroidism is an inherent disease of parathyroid glands associated with abnormal secretion of PTH. Secondary hyperparathyroidism results from abnormalities of calcium metabolism, which, if left untreated, can progress to tertiary hyperparathyroidism, which is associated with hypertrophy of the parathyroid gland and oversecretion of PTH even if the primary cause is eliminated. Diagnosis is based on biochemical parameters, which include serum PTH, calcium, and phosphate levels as well as urinary calcium. Management relies mostly on surgical parathyroidectomy for primary and tertiary hyperparathyroidism. Management of secondary hyperparathyroidism is focused on treatment of the underlying disease. Seborrheic keratosis (SK) is the most common benign epithelial cutaneous neoplasm. The condition consists of immature keratinocytes. Seborrheic keratosis is the most common benign skin tumor in middle-aged and elderly adults and presents as a sharply demarcated, exophytic, skin lesion that may be tan or black and has a “stuck-on” appearance. Pruritus or pain can occur if these lesions become secondarily inflamed by trauma, especially if they are within the skin folds. Genetics are thought to play a role, but the pathogenesis is uncertain. The most common mutations involve two oncogenes: fibroblast growth factor receptor 3 (FGFR3) and PIK3CA. There is a familial predisposition to develop a high number of seborrheic keratoses. Treatment is not necessary, as this is a benign condition, but cryotherapy, curettage or electrodesiccation can be performed for discomfort or cosmetic concerns. Thyroiditis is a catchall term used to describe a variety of conditions that have inflammation of the thyroid gland in common. It includes pathologies that cause an acute illness with severe thyroid pain (e.g., subacute thyroiditis and infectious thyroiditis) as well as conditions in which there is no clinically evident inflammation and the manifestations primarily reflect thyroid dysfunction or a goiter (e.g., painless thyroiditis and fibrous Riedel’s thyroiditis). The etiology of thyroiditis is varied and includes autoimmune inflammation (most common), bacterial or viral infection, and drug-induced reactions. The inflammation of the thyroid leads to a sequential pathologic process that can result in signs and symptoms of hyperthyroidism followed by signs and symptoms of hypothyroidism. The resulting damage can be temporary or permanent, and the treatment depends on the underlying cause. Bronchiolitis obliterans is an obstructive lung disease triggered by a bronchiolar injury, which leads to inflammatory fibrosis and narrowing of the distal bronchioles. The triggering bronchiolar injury is often due to inhalation of a noxious substance, infection, or drug toxicity. Bronchiolitis obliterans is also associated with rheumatic disease and is an important complication to recognize following a lung or hematopoietic stem-cell transplant. Following bronchiolar injury, there is an abnormal fibroproliferation within the bronchioles, which results in small-airway obstruction. Patients present with a persistent progressive cough and dyspnea. Diagnosis is usually made based on pulmonary function tests (showing a non-reversible obstructive pattern, air trapping, and decreased gas exchange) and high-resolution CT (showing air trapping and bronchial-wall thickening). Management involves supportive care, bronchodilators, glucocorticoids, and/or macrolide antibiotics. Immunosuppressive therapy is usually increased in patients who have undergone transplantation, and retransplantation may be required if the condition worsens. Potassium is the main intracellular cation in all cells and is distributed unevenly between the intracellular fluid (98%) and extracellular fluid (2%). This large disparity is necessary for maintaining the resting membrane potential of cells, and explains why K+ balance is tightly regulated. The GI tract secretes 5%–10% of the absorbed K+ daily; however, the kidneys are responsible for 90%–95% of the overall K+ regulation. While most of the K+ is reabsorbed in the proximal tubules, the majority of regulation occurs in the principal and α-intercalated cells of the collecting ducts. The most important regulatory mechanisms include aldosterone, plasma K+ concentration, distal urinary flow rate, and the distal delivery of Na+ and water. Hyperkalemia and hypokalemia can result when K+ regulation is abnormal. Dog and cat bites can cause superficial and deep tissue destruction, as well as serious wound infections. Dog bites occur more frequently in men and children and often cause crushing or tearing trauma. Cat bites are more frequent in adult women and result in puncture wounds. Because puncture wounds allow inoculation of bacteria into the deep tissues, cat bites are more frequently associated with infection. The diagnosis is clinical, and cultures should be obtained if the wound appears infected. Management requires fastidious wound care and antibiotics for high-risk or infected wounds. Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Mumps is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the subfamily Rublavirinae. The mumps virus is contagious and spreads only among humans by respiratory droplets or direct contact transmission from an infected person or fomite. Mumps is typically a disease of childhood, which manifests initially with fever, muscle pain, headache, poor appetite, and a general feeling of malaise, and is classically followed by parotitis. Complications include meningitis, pancreatitis, permanent deafness, and testicular inflammation, which can result in infertility. Mumps is managed with supportive care and is preventable by vaccination. Hydrogen cyanide is an extremely poisonous, colorless, flammable liquid used in multiple industries and includes rubber, plastic, and household paints. Exposure to cyanide can occur via inhalation, dermal contact, or intestinal ingestion. Cyanide poisoning is a common complication of closed-space fires since cyanide is a byproduct of plastics combustion. Symptoms develop within seconds to minutes and involve cardiovascular, respiratory, and neurological changes. Management includes sodium thiosulfate, nitrites, and hydroxocobalamin. If not recognized and treated promptly, cyanide poisoning is frequently lethal. Osteochondritis dissecans (OCD) is an orthopedic disorder characterized by the detachment of a focal segment of subchondral bone and cartilage as a result of focal aseptic necrosis. This can occur at any age, but it is most commonly seen in adolescents who participate in competitive sports. Patients can be asymptomatic or may present with joint pain, stiffness, and swelling that is worse with activity. The diagnosis can be made with imaging. Management depends on the severity, but can include restricted weight-bearing activity, physical therapy, or surgery. Primary ciliary dyskinesia (PCD), also known as immotile-cilia syndrome, is an autosomal recessive disorder leading to an impairment that affects mucociliary clearance. Primary ciliary dyskinesia is caused by defective ciliary function in the airways and is characterized by the loss of oscillation (immotility), abnormal oscillation (dyskinesia), or absence of cilia (aplasia). In most cases, PCD commonly presents with recurrent infections of the upper and lower respiratory tract. Clinical features include bronchiectasis, chronic rhinosinusitis, and situs inversus. There is no gold standard diagnostic test for PCD, as several tests are used in the diagnosis. Treatment is individualized, and the primary goal is to remove trapped mucus and treat infections. Patients with PCD usually have a regular lifespan. A cell is a complex unit that performs several complex functions. An organelle is a specialized subunit within a cell that fulfills a specific role or function. Organelles are enclosed within their own lipid bilayers or are unbound by membranes. If a cell is viewed as an organism, the organelles are an equivalent of the cell’s internal organs. Cell organelles carry out various functions from maintaining the shape of the cell to reproduction, movement, protein synthesis, energy production, and the transport of substances in and out of the cell. Intestinal hookworm infections that affect humans are caused mainly by Necator americanus and Ancylostoma duodenale. Millions of people are infected around the world, mainly in tropical regions, where warm and moist environments facilitate larva survival in the soil. Transmission is via dermal penetration by the larvae. From entry, the parasite undergoes a transpulmonary passage, reaching the trachea and pharynx, where it is swallowed. In the small intestine, worms mature and attach to the duodenum. Diarrhea, nausea, and vomiting are GI symptoms. Blood loss (leading to anemia) and subsequent malnutrition are complications. Diagnosis is by stool microscopy showing the hookworm eggs and by PCR. Management targets prevention through proper sanitation and regular deworming of high-risk groups. Treatment involves the use of anti-parasitic medications, with iron supplements for anemia. Short bowel syndrome is a malabsorptive condition most commonly associated with extensive intestinal resection for etiologies such as Crohn's disease, bowel obstruction, trauma, radiation therapy, and vascular insufficiency. The short length of bowel results in insufficient surface area for fluid and electrolyte absorption. Patients typically present with diarrhea, electrolyte abnormalities, and dehydration. Management options include antimotility agents, antisecretory agents, and total parenteral nutrition for patients who cannot maintain themselves with oral intake. Last-resort options include surgical intestinal lengthening procedures and small bowel transplant. Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder affecting the neuromuscular junction and has a strong association with small cell lung carcinoma. Lambert-Eaton myasthenic syndrome affects the voltage-gated calcium channels at the presynaptic membrane. Presentation includes proximal muscle weakness and symptoms of autonomic dysfunction such as dry mouth and sluggish pupillary reflexes. Diagnosis includes nerve conduction studies/electromyography (EMG) and serum detection of antibodies. Management is mainly symptomatic with the use of potassium channel blockers and immunosuppressants. Prognosis is good for nonparaneoplastic LEMS but usually poor for paraneoplastic LEMS secondary to underlying malignancy. Hypocoagulable conditions, also known as bleeding disorders or bleeding diatheses, are a diverse group of diseases that result in abnormal hemostasis. Hemostasis is the innate, stepwise process resulting in bleeding cessation from a damaged blood vessel. Physiologic hemostasis is dependent on the integrity of endothelial cells and subendothelial matrix, platelets, and coagulation factors. The hypocoagulable states result from abnormalities in one or more of these contributors, resulting in ineffective thrombosis and bleeding. Trichinellosis is an illness caused by infection with Trichinella. The most common causative parasite is Trichinella spiralis, which is usually found in pigs and transmitted to humans through the ingestion of undercooked meat. Once ingested, the parasite grows and matures within the intestinal walls. The adult forms mate, and the larvae produced spread through the bloodstream, reaching striated muscles. Symptoms occur during larval migration. Patients may have GI symptoms within a few weeks after consumption of the infected meat, and systemic symptoms such as fever, chills, myalgia, and periorbital edema may follow. Diagnosis can be made by serologic examination and confirmed by the presence of cysts or larvae in a muscle biopsy. Mild infections are self-limited, but systemic disease is managed with antiparasitic medications and corticosteroids. Infection can be prevented by proper meat handling and cooking techniques. Basic surgical intervention in the thoracic cavity has the primary goal of alleviating any malady that mechanically affects the function of the heart and lungs, which can be secondary to underlying pathologies or, most commonly, trauma. Interventions such as tube thoracostomy and thoracentesis are performed to evacuate fluid, blood, or air that is occupying the thoracic cavity in order to restore thoracic negative pressure. When direct intervention to the heart and mediastinum is required, an emergency thoracotomy is performed. Once the immediate mechanical problems are addressed, more advanced reparative surgery involving heart, lungs, or mediastinal structures can then be performed as necessary. The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Between both layers, there is a well-lubricated potential space called the pleural cavity, which eases the respiratory movements of the lungs and helps avoid friction. Edwards syndrome, or trisomy 18, is a genetic syndrome caused by the presence of an extra chromosome 18. The extra chromosome is either from 3 full copies of chromosome 18 or an additional segment of chromosome 18. As the 2nd most common trisomy, Edwards syndrome is seen in 1 out of every 5,500 live births and increases with maternal age. Many cases are detected prenatally with maternal screening and ultrasound findings. Abnormalities include intrauterine growth restriction (IUGR), overlapping fingers, typical craniofacial features, rocker-bottom feet, and congenital heart defects. Trisomy 18 frequently results in fetal loss. For term pregnancies, most deaths occur during the 1st 6 months of life. Delivery in a specialized center is recommended for full-term pregnancies and intervention is based on associated abnormalities. Q fever is a bacterial zoonotic infection caused by Coxiella burnetii. Transmission occurs primarily through the inhalation of contaminated aerosols and exposure to infected animal products. The clinical presentation can vary and often result in mild disease with flu-like symptoms. Other manifestations include pneumonia, hepatitis, endocarditis, and aseptic meningitis. In a small percentage of patients, the disease can become chronic. A high degree of suspicion is required to make the diagnosis, which is aided using serology and PCR. Antibiotics are the mainstay of management. The respiratory system is responsible for eliminating the volatile acid carbon dioxide (CO2), which is produced via aerobic metabolism. The body produces approximately 15,000 mmol of CO2 daily, which is the majority of daily acid production; the remainder of the daily acid load (only about 70 mmol of nonvolatile acids) is excreted through the kidneys. In the setting of hypoventilation, this acid load is not adequately blown off, and respiratory acidosis occurs. Renal compensation occurs after 3–5 days, as the kidneys attempt to increase the serum bicarbonate levels. Patients are often asymptomatic, or they may present with neuropsychiatric manifestations or mild dyspnea. Diagnosis is made with arterial blood gas measurement. Management involves treating the underlying etiology, stabilizing the patient, and avoiding respiratory sedatives. "The respiratory system is responsible for eliminating the volatile acid carbon dioxide (CO2), which is produced via aerobic metabolism. The body produces approximately 15,000 mmol of CO2 daily, which is the majority of daily acid production; the remainder of the daily acid load (only about 70 mmol of nonvolatile acids) is excreted through the kidneys. When hypoventilation occurs, excess carbon dioxide is blown off and respiratory alkalosis develops. The kidneys respond by decreasing serum bicarbonate (HCO3–) through increased HCO3– excretion or decreased excretion of H+. Patients present with an increased respiratory rate, dyspnea, light-headedness and potentially psychologic symptoms. Diagnosis involves a thorough history, an exam, and an arterial blood gas measurement. Management focuses on addressing the underlying abnormalities, stabilizing patients in acute distress, and potentially a small dose of short-acting benzodiazepines. The identification and classification of skin lesions in a patient are important steps in the diagnosis of any skin disorder. Primary lesions represent the initial presentation of the disease process. Secondary lesions develop from irritated or manipulated primary lesions, and/or disease progression. Along with history, a comprehensive examination of the skin, appendages, and mucous membranes is required to differentiate between conditions. The key features noted during examination include the type, morphology, size, color, shape, arrangement, and distribution of the presenting lesions. At times, diagnostic procedures may be necessary. Magnetic resonance imaging is a technique that utilizes magnetic fields and radiofrequency pulses to produce highly detailed images of the human anatomy. Magnetic resonance imaging can detect minute changes, reliably delineate lesions, and characterize vascular malformations. Soft tissues, such as abnormalities affecting non-bony structures, can be evaluated using MRI. Images can be obtained in most planes (commonly used are sagittal, coronal, and axial). Contrary to CT, MRI does not expose patients to ionizing radiation. There are some limitations of this imaging modality: MRI is expensive, time consuming, and not readily available in some centers. Additionally, patients with ferromagnetic implants or devices cannot be exposed to the MRI equipment, which has magnets. Contrast studies may result in renal complications; thus, the determination of renal function is necessary before using certain contrast agents. A pyogenic liver abscess is a polymicrobial infection arising from contiguous or hematogenous spread. Pyogenic liver abscess is the most common type of visceral abscess. Patients may present with a triad of fever, malaise, and RUQ pain. Laboratory analysis can be informative with elevated WBC and abnormal liver function tests, and imaging may reveal solitary or multiple lesions on ultrasound or CT scan. On contrast imaging, the lesions generally appear well defined with rim enhancement. Diagnosis requires aspiration with Gram stain and culture and, in some cases, a drainage catheter may be placed. A combination of drainage and IV antibiotic therapy is the primary method of treatment. Surgical drainage or resection is utilized in specific cases. Carotid and vertebral artery dissections occur when the integrity of the arterial wall structure fails, usually abruptly, resulting in intramural hematoma formation and a false lumen between the tunica media and the intimal or adventitial layers. This may result in aneurysm, stenosis, or occlusion. Patients typically present with unilateral head or neck pain and/or stroke-like symptoms. Minor trauma or neck manipulation are common preceding events. Dissections require imaging to confirm and are treated with medical and sometimes surgical management. Complications can include cerebrovascular stroke and, in severe cases, death. The collective term “bronchial tree” refers to the bronchi and all of their subsequent branches. The bronchi are the airways of the lower respiratory tract. At the level of the 3rd or 4th thoracic vertebra, the trachea bifurcates into the left and right main bronchi. The right main bronchus is shorter and more vertical in direction than the left. Both of these bronchi continue to divide into secondary or lobar bronchi that bifurcate further and further in order to sufficiently spread the respiratory air completely into the left and right pulmonary lobes. The terminal segment of each bronchus contains millions of alveoli, the site of gas exchange. Trisomy 13, or Patau syndrome, is a genetic syndrome caused by the presence of 3 copies of chromosome 13. As the 3rd most common trisomy, Patau syndrome has an incidence of 1 in 10,000 live births and is more common in women. Most cases of Patau syndrome are diagnosed prenatally by maternal screening and ultrasound. More than half of the pregnancies result in spontaneous abortions. If pregnancy reaches term, it is recommended that a specialized center handle delivery and neonatal care. In the neonate, findings include craniofacial and cardiac malformations, severe intellectual disability, and greatly reduced life expectancy. Most babies do not survive beyond 3 months. With no treatment available and a null expectancy of survival, the family is given supportive management and resources to navigate through the natural course of the disease. Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Over 90% of cholecystectomies are now completed laparoscopically because of the procedure’s enhanced recovery time and decreased postoperative pain. Cholecystectomy has a low-risk profile, but the most dreaded complications include vascular and biliary ductal injuries.

DWK Life Sciences DURAN™ Desiccator Base, with flat flange, without outlet, suitable for all types of lids The desiccator base is used to hold the desiccant and the substance to be dried. The lower part is covered with the matching lid. Brand: DWK Life Sciences 247706108 Additional Details : Weight : 3.23200kg The DURAN™ desiccator is a vacuum-suitable laboratory vessel with a ground lid, which is used for storing moisture-sensitive substances and for drying moist products. Separated by a sieve plate (made of metal or porcelain), a drying agent is introduced into the lower part of the desiccator base, which binds the moisture of the substance to be dried, placed on the sieve plate. To accelerate the drying process, a vacuum can be connected if necessary, as the liquid evaporates faster due to a lower pressure in the desiccator. The vacuum is applied via a shut-off valve connection. To facilitate loosening of the lid, the surface grinding of the desiccator must be well greased, since after evacuation the lid is pressed onto the lower part. All DURAN™ desiccators are vacuum-resistant, i.e. they can be used up to the technically maximum possible vacuum. - Tight closure due to standard ground joint - Suitable for all types of lids - Without outlet - With flat flange |Borosilicate Glass 3.3| |Ideal for removing moisture from solids; Storage of moisture-sensitive materials over long periods; For applications requiring vacuum desiccation; Drying of materials; Safe working under vacuum|

STELLENBOSCH HILLS is about to move your lockdown me-time to a whole new level. The winery that made wine pairing fun by thinking “out of the box” has now re-invented the concept, putting pizzazz all back inside – for your enjoyment at home. No need to wait for Stellenbosch Hills’ celebrated Biltong & Wine and Popcorn & Polkadraai to start up again. Simply email-and-collect to get these innovative wine and snack pairings for savouring at your own pad. Even better: why not buy one for a friend? The boxes are great for nibble-and-sip on chilly winter days or Skype and Zoom gatherings with mates. The Biltong & Wine box includes all the favourites. There’s a mixed case of wine containing Polkadraai Pinotage/Merlot; 1707 Reserve White; 1707 Reserve Red; Stellenbosch Hills Shiraz; Stellenbosch Hills Cabernet Sauvignon; and, Stellenbosch Hills Merlot. Packed for two, each box also has six variations in separately bagged pairs of biltong and droëwors. There’s springbok, kudu, moist beef and smoked biltong as well as beef and ostrich droëwors. Should you want to add biltong and droëwors for friends in your tasting party, an additional six portions are available at only R50/person extra. The box also contains tasting notes. The total cost is just R600. The Popcorn & Polkadraai box contains four wines from the easy-drinking Polkadraai range: the Sauvignon Blanc Brut; Chenin Blanc/ Sauvignon Blanc; Rosé; and, Pinotage/ Merlot. The popcorn comes in four flavours that were composed by the awesome Guzzle & Wolf Gourmet Popcorn Company and each is packed for a duo of munch-lovers. There’s coconut and chia seeds; salted caramel; cinnamon and pretzel; and, dark chocolate. Here too, tasting notes are provided. At R300 for all this, it’s another great bargain. Get extra popcorn for just R40/person. To order, send an email to [email protected] or call 021 881 3828. Please note that boxes are only available by collection from the winery’s tasting room on the corner of the R310 and Vlottenburg Road, from Mondays to Thursdays between 9am and 5pm.

Learn How to Grow Unlimited Tomato from Cuttings and clone several varieties of your favorite veggie in containers or garden for free! Have you tried cloning vegetables at home? You can start with Solanum lycopersicum, which grows in almost every condition. Learn How to Grow Unlimited Tomato from Cuttings and cultivate a season-long harvest in simple steps! Avoid these mistakes while growing Tomatoes for the best harvest Why Grow Tomatoes from Cuttings? Tomatoes are fast growers and can easily be grown from seeds, but propagating the plant from cuttings will help you clone a similar variety without waiting for weeks to get a proper fruiting plant. Gardeners often end up thinning the seedlings whose roots are intertwined with each other. In such a case, growing the plant from cuttings becomes a valid and helpful option. Check out the best tomatoes for hanging baskets here Propagating Tomatoes from Cuttings is Easy As compared to growing tomatoes from seeds, propagating from cuttings is a fuss-free process, where you save a lot of time. The biggest advantage is, you can take cuttings from the plant that grows the juiciest and tastiest tomatoes and the upcoming plant would have similar features, meaning you will have the same plant growing the sweeter and tastier tomatoes! Learn some brilliant hacks to grow tomatoes from seeds here How to Grow Unlimited Tomato from Cuttings? Growing tomato from cuttings is a pretty straightforward process and can give you unlimited harvest throughout the year! - Get 4-6 inches cutting from a healthy plant, preferably with new leaves. Use clean and sterilized scissors for the process. - Snip away the lower leaves and the flower buds if any—this will direct all the energy to grow new roots. - Fill a pot with a soil mix and tuck the cutting gently into the soil. - Keep the medium slightly moist all the time. - Place the pot at a location with bright indirect light. - In a week or two, the cutting will develop new roots. - You can then transplant the cutting to a larger pot or in a raised bed of your vegetable garden with all the necessary conditions to help it thrive. You can grow unlimited tomatoes this way from just one plant, as the plant tends to develop new stems every time you cut one. These are the best Tomato varieties to grow How to Increase the Sucess Rate While Growing Tomato from Cuttings To ensure you have the maximum chances of success, keep the following points in mind: - Dip the end of a cutting in a rooting hormone before planting. It will increase the propagation rate–here are the best DIY rooting hormone recipes. - Take cuttings from a healthy plant that is producing lush foliage and plump, juicy fruits. - Go for suckers, the point where a branch meets the main stem (the axil) for propagation. This way, you will be able to remove suckers while propagating them as new plants. Splitting tomatoes? Check out the solutions here Requirements of Growing Tomato Plants The ideal temperature range for a propagating tomato plant is 55-85 F, or 13-30 C. Tomatoes are not frost tolerant, hence cannot take temperatures below 35 F or 1 C. Organic matter is important for growing healthy tomatoes since it improves drainage and supply nutrients steadily. Make sure you add plenty of compost and aged cow or chicken manure at the time of planting that is a must for excellent growth. Also, these plants grow best in slightly acidic to neutral soil with a pH of 6-7. Tomatoes thrive and produce plentiful fruits in 6-8 hours of sun per day. Avoid growing them in a shaded location or where they get only 1-2 hours of direct light. Also, rotate the plant regularly if you are growing them in pots, as it will help every part to get sun exposure. Avoid placing immature tomato seedlings outside in the full sun. Before you pick a feed, it will be a good idea to do a little testing of the soil. If the soil is balanced or high in nitrogen, go for a 5-10-5 or 5-10-10 feed. If the soil is low in nitrogen, then use a balanced fertilizer like 8-8-8 or 10-10-10. Use it once in 3-4 weeks, after diluting to half of its strength. You can also go for specialized fertilizers that are meant for tomatoes, like Espoma. Bone meal, soy meal, blood meal, and well-rotted manure work wonders for the plant too. Tomatoes don’t grow well in a dry growing medium—water the plant when the soil surface feels dry to touch. Also, while watering, make sure that it’s not spilling on the leaves as it can cause blight and other fungal diseases. 6. Pests and Diseases Tomatoes are prone to several pests and diseases such as mealybugs, mites, aphids, blossom end rot, and beetles. Spray the plant with an insecticidal soap solution or neem to keep the invaders at bay by following an organic approach.

And yes, with only about 303 calories and 14 grams of fat total, this steakhouse-worthy entree can be part of a healthy diet. Broiling filet mignon is a good and fast solution to get a crispy and perfectly cooked steak. If you’d like to take a different approach, try seasoning your filet mignon with fresh herbs, garlic, and lemon zest. Filets mignon are considered the king of steaks. Filet mignon can be seared ahead of time on a grill or using a pan. This pan seared filet mignon recipe takes a total of 5 minutes to make, with 3 minutes resting time on the cast iron skillet. If you accidentally took the temperature too far, you will still need to allow the filet mignon to rest before cutting into them. Can't find any recipes or guidelines for timing and heat. Here's a collection of the best renditions to make your next celebration even more festive. Always allow filet mignon to sit for five minutes before serving to ensure that the flavors have time to settle, and then you may slice the meat and serve as desired. Grilling is probably one of the most overlooked cooking methods for a roast, which usually ends up baked or as a pot roast, but grilling can – and should – be one method you consider. return to recipes 0 from 0 votes Print Grilled Montreal Beef Tenderloin Filet Mignon Course Main Course Prep Time 10 minutes Cook Time 55 minutes Total Time 1 hour 5 minutes Servings 16 Ingredients 3 tablespoons McCormick® Grill Mates® Montreal Steak Seasoning 2 tablespoons Parsley Flakes 1 tablespoon Rosemary Leaves 3 tablespoons olive oil Try… Filet Mignon Recipe. Pellet Grill Filet Mignon Recipe. This dish is simply luxurious: grilled beef tenderloin smothered in a vibrant herb butter served on top of a garlicky slab of whole-grain toast. Perfect Grilled Filet Mignon is not only possible, but it is also simple too. 135F is absolute maximum for Filet Mignon. Cooking filet mignon on the grill is really simple, but I’ll be honest with you, I swore off grilling filet mignon a few years ago when I discovered the stove top to oven method.. It’s simply the best way to cook a perfectly even and juicy steak. The filet mignon cut, which comes from the spine area of cattle, offers a juicy and tender cut of meat for steak lovers. It’s slow cooked in SMOKE mode over apple wood, shifted into SEAR mode for a quick reverse sear and finished with blue cheese butter. We know, we know—filet mignon is soooo 90's. If you’re wondering how to cook a New York strip roast, or any other pork or beef roast, on the grill, you’re in luck because Chicago Steak Company has you covered. Our tender and delicious filet mignon are marinated in a garlic-herb oil mixture and placed on the grill. But we don't care. Whether you reserve it for special occasions or break it out to make an ordinary day special, you can’t go wrong with grilled Filet Mignon. Place the steaks on the grill grates over indirect heat, close the lid, and cook until the steaks are 10 degrees away from your target temperature , flipping once halfway through (Rare = 115 degrees F, Medium Rare = 125, Medium = 135, Medium Well = 145, Well = 150 degrees F). Grilled, broiled or roasted, this cut of meat provides a maximum of flavor with a minimal amount of fat content. Filet mignon is a flavorful, buttery cut of steak that’s one of the most popular—and expensive—steaks you can buy. Want to do a whole roast filet mignon (from Costco) for the 4th on gas grill with rotisserie. The easiest and best way to cook filet mignon is on stove top, using a cast iron skillet. Whether you are cooking the best Valentine’s Day dinner you’ve ever had, or just surprising your loved one with a special steak, grilling filet mignon is one of the best dinners you can ever prepare. Generally, a filet will be about 2-3 inches in diameter. But how can you cook a perfect filet mignon on your home grill? Simply seasoned and wrapped in bacon, this Pellet Grill Filet Mignon is so buttery tender, you can practically cut it with a fork. I bounce between these two and can’t choose a favorite. Filet mignon is a tender, boneless strip of meat and is a popular menu item at steakhouses everywhere. If your certified Angus beef filets are closer to an inch or 1 ½ inches thick, they probably won’t need any more than 4 to 5 mins. Filet Mignon. ... Roast beef is a classic main dish for holidays, family get-togethers, and elegant dinners alike. A slice of about 1 ½ inch thick or a bit less will weight about 8 ounces and is an excellent serving size. When removing the filets from the grill, it is best to place them on warm plates. We recommend 120-125F internal temp. Since it does very little work or weight-bearing, it is extremely tender. 1:00 - Prep 0:15 / Cook 0:45. Pull the filet mignon pan out of the oven a few degrees before they've reached their final temperature and allow them to rest in the pan for at least 5 minutes prior to serving. Though the taste is saltier and more distinctively piggish, a pork filet mignon is another, much-cheaper alternative. If you like, make extra herb butter to top chicken, fish or even a grilled pork chop. If using the grill, preheat to the highest temperature or make sure the charcoal coals are red in color. There are a lot of different ways to prepare filet mignon, but my favorite is on the smoker (surprise! https://www.noreciperequired.com/.../how-grill-perfect-filet-mignon Filet Mignon is a slice of the beef tenderloin, which is the psoas muscle of the cow. Grill the filet mignon. Intermediate. Using pork and filet mignon in the same sentence might at first evoke the image of crispy bacon wrapped around the tenderest piece of steak from a cow, with the filet mignon sliced from the prized tenderloin roast. filet mignon steaks, about 6 ounces-each; olive oil; coarse salt or sea salt and fresh ground black pepper; What is the Best Way to Cook Filet Mignon? Filet Mignon is one of the leanest cuts of steak you can buy. Filet Mignon Cook Time on the Grill. How to Grill Filet Mignon. About a 5 lb roast. Follow the simple recipe below for a perfect, mouth-watering steak. I’m sure everyone has a favorite way to prepare and enjoy filet mignon. of grilling on each side. Quite possibly one of the most tender, juicy and delicious steaks, it’s even better when slathered with roasted garlic and chive butter. grilled filet mignon steak - grilling filet mignon - Weber Grills Tips & Techniques BlogGrill your filets over direct high heat with the lid closed as much as possible for 6-8 minutes, turning once; Move the filets over to indirect heat for an additional 4-6 minutes or until your desired degree of doneness. cooked medium rare (120- 125degrees) . Here are a couple of the center cut filets fresh off the grill….yep, I’m going to talk about rest time again… at least 5 minutes. Filet mignon is a small, high-quality cut of meat acquired from the end of the tenderloin section, and is translated from the French as "dainty fillet." Filet mignon is a versatile and very delicious steak to try. This guide to cooking roast beef will help you create a flavorful, moist, and tender roast. Grilling filet mignon obviously does not have to cause anxiety in anyone. Filet mignon, translated from the French as a “dainty” fillet, is undoubtedly the most tender cut of steak available, while thanks to its marbling, offers the perfect mild beef aroma.When done right, it is the perfect dish for any special occasion, but the prospect of preparing it can be daunting. While there are several ways you can prepare and cook it, broiling it is probably the best option is you don't have a grill or don't like using one. A fresh filet mignon has the best taste, but it is possible to cook this cut of meat frozen or thawed. Prized for its tender, rich texture with the right amount of fat for full flavor, yet not overly fatty, filet mignon is often referred to as the "King of steaks" by many chefs and steak lovers. https://www.thespruceeats.com/easy-grilled-filet-mignon-3572631 Avoid the overpriced, stuffy steakhouse and cook it at home instead. The steaks are cut from the smaller end of the beef tenderloin and packs some major beefy flavor. It'll always be one of our favorite cuts of meat. Grilling filet mignon usually won’t take any more than 15 minutes to do, even if they’re super thick cuts, like our Premium Angus Beef Filet Mignon. They are perfect for special occasions. Prep: Preheat your grill to HIGH heat. ... No grill required!

The F.N. Sharp Guide to Different Cuts of Beef There are numerous different cuts of beef, and it can sometimes be confusing to understand which cut should be used for certain recipes and how to break down large portions of beef for easy use. In this guide to beef cuts, we will briefly explain the different portions and how a sharp chef’s knife and a sharp boning knife can help you process steaks, ribs, roasts and other sections of beef. How to Break Down Different Beef Cuts Before we begin,, it’s important to understand how a cow is divided into quarters. First, the cow is split down the middle from the tail to the neck. This creates the two halves from which the hindquarter and the forequarter are cut. These quarters are located exactly as their name describes – the hindquarter is the rear of the cow and the forequarter includes the shoulder and everything in front of the 13th rib. In most cases, the hindquarter and forequarter are broken down by a butcher before sale, then the local grocer or consumer will break them down into the more common beef cuts. The Beef Forequarter The front quarter breaks down into four primary, or primal, cuts. These primal cuts include the brisket, chuck, foreshank and rib. Using a boning knife or a sharp chef’s knife, these primals can be broken down further into cuts you may be more familiar with. The brisket breaks down to the brisket point and the brisket plate. These cuts can be tough, so they are usually used for dishes that are marinated, braised, or smoked for hours to break down the tough connective tissue. The brisket is almost exclusively used when cooking corned beef and is a staple in the BBQ community, especially in competitive barbecue circles. Most ground beef comes from the chuck. The chuck contains a high amount of connective tissues, making it an ideal candidate for grinding meat for burgers, tacos, and other recipes that call for ground beef. It’s also commonly broken down into smaller cubes that can be used for stews and, when cleaned properly, can be used for pot roast and other marinated dishes. How to Season Beef and Other Meats: The Meat Seasoning Guide The foreshank is one primal that requires no further production after it has been removed from the forequarter. This incredibly tough primal best serves its purpose as a base for beef stock and soups. The meat can be cleaned off of the bone using a sharp boning knife and the tough tissue can be cut away to produce beef for stews. The rib portion is separated into the short-rib and the seven-bone rib. Short ribs are located in between the seven-bone rib and the brisket in a section known as the short plate. There are a few variations as to how they are broken down, but using a boning knife to cut in-between the bones creates useable portions that are often seared before braising at a low temperature until the meat is tender. While most of the cuts on the forequarter require braising or marinating before cooking, the seven-bone rib is an exception. From this primal we derive the rib roast, also referred to in restaurants as prime rib. This cut is often slow cooked and has a good fat content that keeps it juicy and moist during the cooking process (check out this great prime rib recipe plus some tips for how to carve it). The bones can be cut off with a flexible boning knife, and it is often broken down into rib-eye steaks for grilling. Try the Ribeye with This Recipe: Masterchef-Worthy Steak & Hash The Beef Hindquarter Finally, we have the hindquarter which includes the flank, long loin, sirloin tip and hip. The flank requires no further processing once removed from the hindquarter. It is commonly marinated for grilling over a flame and is often ground rather than used as chuck when lean beef is required. The long loin is broken down into two sections: the sirloin butt and the short loin. These are the cuts where most steaks come from. As its name implies, the sirloin butt produces sirloin steaks. This sub-primal takes a little extra preparation and a sharp chef’s knife to produce grillable steaks. The sirloin butt is encased in a layer of fat and is split by tough tissue that must be removed before it can be broken down any further. Once all of this tissue and fat has been cleaned away, sirloin steaks can be cut in any shape and size desired. Try Sirloin Steak with This Recipe: Quick and Easy Beef Stroganoff The short loin produces most cuts of steak. Some of the cuts that come from this portion include the porterhouse, T-bone, tenderloin and striploin. The porterhouse and T-bone are essentially the same steak with the exception that the porterhouse is cut from the larger end of the short loin. Sink Your Teeth Into a T-Bone With This Recipe: T-Bone Steak & Potatoes With Espagnole Sauce The tenderloin derives its name from the richness of its meat. It is one of the highest quality cuts of beef, and its cost in restaurants and butcher shops reflects this. Using a very sharp and flexible boning knife will help remove the thin layer of tissue that covers this sub-primal cut. The strip loin is cut into steaks that are commonly sold as New York strip steaks. Only about three-quarters of the strip loin is used for steaks since one end has tough tissue running through the center, making it incredibly tough to chew. This portion can be cut away and ground, or completely removed so the meat can be used for stews or ground beef. The remaining three-quarters are easily cut into strip steaks with a long chef’s knife. The sirloin tip requires some cleaning to remove fat, and it is often sold as a sirloin roast. This cut should not be confused with the sirloin butt from the short loin. It is often tough and steaks cut from this need to be marinated to inject moisture. From the hip, we come up with the round cuts. The inside round and the outside round are commonly sold as roasts. Portions of the hip that are left over once the rounds are removed can be salvaged for ground beef and stew meat. More on Steak: How to Choose the Best Cuts Using the Right Tools When it comes to slicing through meat and bones, make sure your knives are sharp. Not only will this reduce any added blunt force, but will also prevent you from tearing through the meat so your cuts come out nice and clean. The chef’s knife and the boning knife are both great tools for breaking down beef cuts, so be sure these two knives are included in your kitchen knife set – and don't forget the steak knives for the finished product, like a perfectly cooked steak! Knife Knowledge 101: 6 Types of Knives to Keep in Your Kitchen

AN INTRODUCTION TO DRY FASTING by Esmée La Fleur A dry fast is an absolute, true fast in which you abstain from both food and water. This is the type of fast that was practiced by Moses (Exodus 34:28 & Deuteronomy 9:18, both times for 40 days), Ezra (Ezra 10:6, length undisclosed), the Nation of Israel (Esther 4:16, 3 days), Elijah (1 Kings 19:8, 40 days), the Ninevites and their animals (Jonah 3:7-10), most likely Jonah himself when he spent 3 days in the belly of the whale (Jonah 1:17), the Apostle Paul (Acts: 9:9, 3 days), and Jesus Christ (Matt 4:2, 40 days). More than likely, dry fasting has been practiced by many cultures and religious traditions throughout history. Dry fasting has been practiced by the Russians for a very long time. There is quite a bit of literature available on dry fasting in the Russian language. However, none of these writings has been professionally translated. I was first introduced to the concept of dry fast by Tanya Zavasta (a native Russian speaker) in her book Quantum Eating. I found the information fascinating, but did not really know where to go with it. Then I discovered the web community forum The Fasting Connection where I met Milena Albert (a native Russian speaker) who had been practicing dry fasting and was in contact with Dr. Sergei Filonov, a Russian medical doctor who has been conducting dry fasts with his patients for 20 years. Then, I was referred to a Google translation of his 400 page book Dry Medical Fasting: Myths & Reality. While the translation leaves much to be desired (being computer generated), enough of the essence comes through to make it a very worthwhile read for anyone who in interested in embarking on this path. There are two kinds of dry fasts: hard and soft. With a hard dry fast, the faster does not allow any water to touch their body, i.e. no washing dishes, no taking baths or shower, no brushing teeth, etc. With a softer dry fast, the faster can allow their body to come in contact with water. When you go on a dry fast, the pours of your skin develop a greater capacity to absorb water through the skin and in a good clean environment will readily absorb moisture from the air. It is for this reason that Dr. Filonov highly recommends undertaking a long dry fast in the mountains where the air if fresh, moist, and pure. He encourages many of his patients to sleep outside next to a stream of running water during their long dry fasts. While several of our Biblical forefathers fasted for 40 days, the longest dry fast on record in modern times is 18 days. However, most modern practitioners of dry fasting do not recommend dry fasting for longer than 12 days. Dr. Filonov always recommends doing several water fasts before ever attempting a dry fast. Then he recommends that a person start with very short dry fasts, 36-hours once a week. After doing this for a while, then a person can gradually do longer dry fasts of 2, 3, and 4 days. Finally, to affect deep cleansing of the tissues and healing of serious chronic illnesses, he recommends a protocol known as a “fractionated” dry fast in which the person does a dry fast for 5-7 days, re-hydrates for 3 days, then does a second dry fast for 9-11 days. He has found this method to be extremely safe over time. In order to achieve permanent healing results, a person must traverse two separate “acidotic” crises, the first between 3-5 days and the second between 9-11 days. So, by breaking up the fast, the “fractionated” method allows the person to go through the first crisis during the first fast and the second crisis during the second fast, thus reducing the stress on the body from too many toxins needing to be eliminated at one time. It should be noted that Dr. Filonov never recommend doing a dry fast for longer than 5 days without supervision. The problem with this is that there is are no medical doctors with experience in dry fasting in the United States. So, we are pretty much on our own if we want to use this method of healing. Another method of dry fasting that Dr. Filonov has found to be extremely safe and beneficial is a protocol he calls “cascade” dry fasting in which the person begins by fasting 1 day and eating 1 day alternately. Then, he has the person fast 2 days and eat 2 days alternately, then fast 3 day and eat 3 days alternately, then fast 4 days and eat 4 days alternately, then fast 5 days and eat 5 days alternately. With this protocol the person is literally fasting one half of every month. In his book, Dr. Filonov says he personally knows a medical doctor who cured himself of a blood cancer by doing 5/5 protocol for a full year. There was an interesting book published a few years ago called The Alternate Day Diet by Dr. James Johnson which advocates eating every other day for weight management and health maintenance. Although he did not have his patients fast completely on alternate days, but had them restrict their calories to 20% of metabolic requirements, his patient have experienced remarkable benefits and many have overcome severe inflammatory illnesses such as asthma (no longer needing medication). I don’t agree with his protocol of feeding on alternate days, and he even says that the results would be far greater if his patients did not eat anything on alternate days, but he feels that no one would be willing to fast every other day (perhaps he underestimates his patients?). His patients consume as much water as they desire. I have communicated with a young man through The Fasting Connection who has suffered from severe irritable bowel syndrome (IBS) for a number of years. He decided to start water fasting every other day and has experienced remarkable improvements. After four months of doing this, he says that his IBS symptoms are 70% less than they were prior to instituting alternate day fasting. He has not changed his diet which he tells me is far from optimal. I wonder if he would get even better results if he dry fasted? In a dry fast, the body does not eliminate toxins in the same manner as it does during a water fast. Instead of removing toxins through the normal channels of elimination, skin, liver, kidneys, urine, and bowels, it actually turns each cell into a tiny incinerator and burns the toxins up inside of the cell. One thing I have noticed since I started dry fasting is that I have almost no body odor or bad breath during a dry fast, while I always experienced this during a water fast. Each day of a dry fast is said to be equivalent to 3 days of a water fast in terms of detoxification, so you accomplish much more in a shorter time. The good thing about this is that a person does not need to take a long absence from their normal life, so it costs less both for the fast itself (if you are going to a facility to be supervised) and for the time taken off from work. Also, you lose less muscle mass and more body fat with dry fasting, than you do with water fasting, and the recovery time is quicker. Returning to normal function after a 10 day dry fast is much faster than after a 30 day water fast. Nevertheless, a person should plan for a re-building time of twice the length of the dry fast. So, for example, if you do a 7 day dry fast, you should plan for a 2 week recovery period. After my first 4 day dry fast, I had so much energy on day 2 of re-feeding that I decided to go dig up a garden bed I wanted to plant and ended up pulling a muscle in my forearm because I was not properly re-hydrated. It took a week to heal and I learned my lesson. Do not overestimate your capabilities after a dry fast and make sure you give your body sufficient time to recover before engaging in any strenuous physical activity. How you exit a dry fast is extremely important. If you do it incorrectly, you can definitely harm yourself. In his book, Dr. Filonov says to drink two liters of pure water very slowly, holding each sip in your mouth as long as possible, over a two hour period. Then he says to continue drinking water for the next 12 hours a little bit at a time. After that you can start to reintroduce other foods and liquids. Dr. Filonov is not a practitioner of a Zero Carb diet, so he recommends making a fruit compote out of dried figs, prunes, apricots, and raisins (all unsulfured and organic) cooked in water to soften before eating, as well as vegetable soup, fish broth, and raw milk kefir. The way I would come off a dry fast is to rehydrate with water as Dr. Filonov recommends and then introduce bone broth. After that, I would begin eating meat again. My preference is for raw ground beef, but rare steak would be my next choice. The key is to not over eat. Just make sure to hydrate yourself well with plain water before trying to eat anything solid. Dry fasting itself is not a “cure,” but it provides the right conditions to allow the body to activate all of its own, God-given, healing powers. Dr. Filonov has seen many illnesses heal through dry fasting; below is a list of the ones he mentions in his book: irritable bowel syndrome non-insulin dependent diabetes inflammation**Please note: There are a number of conditions for which dry fasting is contraindicated; namely, malignant tumors or blood conditions, tuberculosis, hyperthyroidism and other endocrine diseases, cirrhosis of the liver, heart arrhythmia, circulatory failure degrees II & III, underweight, pregnancy and lactation, being younger than 14 or older than 70 years of age. And, as always, is best to check with a qualified medical practioner before deciding to embark upon fast of any kind.

With a little extra time and effort, you can use cuttings to propagate plants and herbs for the next season. This technique can save you from buying seed packs, since you can essentially recycle the original plant to expand your garden or indoor plant collection. If you love fresh herbs, cuttings can increase your supply. Plus, you can give successful cuttings to friends to expand their garden, and they can repay you with cuttings of their own. Once you master the technique, the possibilities are endless. How to Propagate Plants from Cuttings - Start this process in the early morning when the plants contain the most moisture. - Cut a healthy stem off the main plant, just below a leaf node. The cutting should be about 3–6 inches, and take multiple cuttings since only some will successfully propagate. Use a sharp and clean blade and cut at an angle that’ll give the largest surface area for budding roots. - Cut away any foliage from the bottom area of the cutting, leaving about half or two-thirds of the stem bare. - Place the cuttings in a jar of water until the plant forms new roots, which may take a few weeks or months, depending on the plant. Keep in a sunny area out of direct sunlight. Ensure the water is good quality, such as filtered or spring, or tap if the water is drinkable in your area. Do not use distilled water or water high in chlorine. Ideally, change the water every day, but every other day should suffice. - Once the roots grow, plant the stem into a planter or outside. - Alternatively, skip the water. Dip the end of the cutting in a rooting hormone and plant them directly into soil. Don’t use standard potting soil; a lighter substrate would more effectively help the cutting propagate, such as seed starting mix soils. Ensure the soil stays moist as the roots develop. - Once the roots have developed, transfer the cutting into a pot or plant it outside. These guidelines are for all of the herbs and plants in the following list. However, some have slightly different needs, so use the above instructions along with the tips detailed under the plant name. 12 Herbs and Plants to Grow From Cuttings Basil is a good plant for beginners to try to grow from cuttings. However, don’t cut from a basil plant that has flowered or gone to seed; choose a young plant. The cutting should be at least three or four inches long. Remove almost all of the leaves except for a few at the top, which you should trim to one-third of their size. When you place the stem in water, keep it in a bright, well-ventilated area but avoid direct sunlight and cold drafts. You can also skip the water stage and place the cutting into a seed starting mix soil. The roots should develop after two or three weeks. Thyme has a woody stem so it needs to root in soil instead of water. So cut the thyme around a node where the leaves grow. Remove the lower leaves before planting the cutting into damp soil away from direct sunlight. Take lavender cuttings during the summer, which is when they tend to root. The new growth cuttings should be three to four inches, cut just below the bump of a leaf node. Take off the leaves from the bottom half of the stem and remove the skin from one side of the bottom part of the stem. Plant directly into a container with seed starting mix soil; you can dip it into rooting hormone beforehand but this step is optional. Plant the cutting about two inches deep into the soil and cover them in plastic to create a greenhouse effect. Ensure the soil stays moist until the roots grow. Oregano is a little tricky to propagate from cuttings but it can be done. Cut three to five inches of stems from a young plant, ensure the cuts are made at a 45-degree angle. Remove all leaves except for three or four leaf sets at the top. Oregano can be slow to grow roots, so you may want to add a natural rooting hormone to the water. Keep the jar in a bright area with indirect sunlight. After at least four weeks, the plant should develop roots ready for transplanting. Mint is another good beginner’s herb when it comes to cuttings. It can develop roots in water or soil in just one or two weeks. However, these plants can be invasive. So when you transport the cuttings with roots, you may want to use a planter that will contain it. If you plant it into the ground, ensure it has deep borders around it to keep it from spreading to unwanted areas.

After our last column, a friend pointed out that she didn’t have trouble getting melons to pollinate. Her problem was with blights and mildew. It’s true that melons are a bit difficult to grow because of their susceptibility to molds and certain insects, especially when you’re trying to grow them in cooler, damp climates. Any trouble growing melons is well worth it once they reach the table. The cantaloupes, watermelons and other melons now coming into our stores from warmer climates just don’t hold a candle to a juicy, sweet, homegrown melon. Finding the proper natural or organic cures for these melon problems can be difficult. Mulching is great for issues caused by uneven watering. But mulch can provide places for pests including squash bugs and cucumber beetles to lay eggs. These pesky critters not only consume melon plants but spread disease and wilt. Melon leaves can be burned by insecticidal soap and liquid copper sprays, two common, organic-approved solutions for bugs and mildew. They should only be used in the most diluted form possible. Other problem solvers — like using row covers to shield plants from insects — are great ideas until you need the help of pollinators. Any successful melon growing regimen begins even before you start them in your garden. Got bugs? At Planet Natural we offer a large selection of organic pest control solutions that are guaranteed SAFE and effective. Also, visit our Pest Problem Solver for pest pictures, descriptions and a complete list of earth-friendly remedies. I’ve moved around enough and started new gardens to know one thing is true: the first year is the easiest to grow melons. After that, problems start to mount. So the first rule, one especially helpful in avoiding blight and mildew, is to rotate your melon crop as best possible. Growing melons in warm dry areas of the country is easier than growing them where it’s cool and moist. Good drainage is important as well as is even, careful watering. Over watering gives molds and mildew encouragement they don’t need. Water at the base of plants as best you can and avoid getting leaves damp. Watering at the beginning of the day gives moisture time to evaporate off plants. The cucumber beetle is your enemy. They’re fairly well distributed around the country, we’ve even spotted them — they’re kind of attractive — as far north as our Montana garden. The damage they do to leaves may be minimal but their role in spreading wilt can be disastrous. Use insect traps to detect their appearance in large melon patches. A good visual inspection every few days will suffice if you only have a plant or three. Avoid touching the leaves. You, like the beetle, are capable of spreading mold, wilt and other spores. You can deter cucumber beetles from breeding by using black plastic as a mulch. This prevents the eggs from getting into the soil that they need to hatch and keeps the larvae from getting out of the ground. It also helps warm melon plants in the early season. If you have an infestation you may have little choice but to spray with a pyrethrin mix. Having gangs of preying mantis patrolling your melons may help you avoid getting to that point. Here’s a thorough discussion on organic control of cucumber beetles. Aphids will also go after melon leaves and vines. Releasing ladybugs at the first site of them may help but could be too late if you have problems with mildew. Like beetles, aphids spread disease. With either aphids or beetle infestations, you can use a very weak insecticidal soap spray to take care of them. But make sure you dilute it almost to the point where it doesn’t feel soapy. And spray early in the day to allow it to evaporate before it gets hot. What to do if you spot mildew, mosaic, blight or wilt? Applying copper spray is best but again requires dilution. If the problems have spread widely, there’s nothing to do but destroy the vines. Remove them carefully and stuff immediately into a bag so as not to spread spores or bacteria. Then take them far away from your garden. Burning them? Good idea, but only if it’s legal. And be sure to plant next year as far away from the affected area as you can get. The original insecticidal soap! Concentrated formula makes 6 gallons of spray.Read more Floating Row Cover Floating row covers let in sun, water and air... but keep bugs out! Protects to 26°F.Read more Yellow Sticky Traps Use to attract and capture whiteflies, thrips, fungus gnats, flea beetles & more!Read more Safer® Insect Killer Effective against aphids, caterpillars, potato beetles, flea beetles and more!$9.95Read more

Japanese Silver Grass Gracillimus Maiden Grass features dainty plumes of pink flowers rising above the foliage from late summer to early fall. The violet seed heads are carried on showy plumes displayed in abundance from mid fall to late winter. Its grassy leaves are green in color. As an added bonus, the foliage turns a gorgeous tan in the fall. The khaki (brownish-green) stems can be quite attractive. Gracillimus Maiden Grass is an herbaceous perennial grass with an upright spreading habit of growth. Its relatively fine texture sets it apart from other garden plants with less refined foliage. This plant will require occasional maintenance and upkeep, and is best cleaned up in early spring before it resumes active growth for the season. It has no significant negative characteristics. Gracillimus Maiden Grass is recommended for the following landscape applications; - Vertical Accent - Mass Planting - General Garden Use Gracillimus Maiden Grass will grow to be about 4 feet tall at maturity extending to 6 feet tall with the flowers, with a spread of 4 feet. It tends to be leggy, with a typical clearance of 1 foot from the ground, and should be underplanted with lower-growing perennials. It grows at a medium rate, and under ideal conditions can be expected to live for approximately 20 years. As an herbaceous perennial, this plant will usually die back to the crown each winter, and will regrow from the base each spring. Be careful not to disturb the crown in late winter when it may not be readily seen! This plant does best in full sun to partial shade. It prefers to grow in average to moist conditions, and shouldn't be allowed to dry out. It is not particular as to soil type or pH. It is highly tolerant of urban pollution and will even thrive in inner city environments. This is a selected variety of a species not originally from North America. It can be propagated by division; however, as a cultivated variety, be aware that it may be subject to certain restrictions or prohibitions on propagation.

ENDUIT ANTI HUMIDITÉ ENDUIT ANTI HUMIDITÉ allows the treatment of moist walls and slows the appearance of moisture from the inside and outside of the substracte. Destination: Indoor/Outdoor use - Very low COV - Very easy to apply PREPARATION & APPLICATION: Surface Preparation: (Referred to the D.T.U. 59.1 requirements): The surface must be well prepared, perfectly dry, dust-free, with no humidity and salt stains. Application Tools: Stainless Knife Dilution: 20% to 30% of water Application method: Eliminate non-adherent parts. Apply one coat of ODAPRIM or PIGMAPRIM as primer. After 3 hours of drying, Apply two coats of ENDUIT ANTI HUMIDITE H200. To achieve good efficiency, apply at least 2mm of thickness Spreading-rate: 0.5 to 0.8 Kg/sqm ( Depending on the surface state and the thickness applied) Drying: Touch dry: 1h re-coatable: 12 h Cleaning of equipments: With water, immediately after use Binder: Special binder Appearance of the film: Mat Storage: One year in the closed paint can, as delivered. Store inside in conditions avoiding extremes of temperatures and protect from frost. the support must be hard, cohesive, clean, sound and dry. It is not advisable to apply below 5°C (41°F) temperature and above 85 % relative humidity level. NM03-3-009 Category IV Class 4b Health & Safety: This product is not classified as dangerous. For more details, consult the safety data sheet. Estimated quantity: 0. Estimated total cost *: 0 Dhs TTC. * the estimate of the price concerns only the selected product, and to have it as finishing it is necessary to apply other products of preparation. This estimate may change depending on the condition of the substrate and the chosen paint system. * the estimate of the quantity of paint required is given in units (kg or liter), and the purchase is made according to the available footages for each product.

Have you ever sealed or painted a piece of art only to discover that it does not seem quite right? Or do you lack the materials necessary to glaze and fire your ceramic artwork? I got an email recently from a nice lady called Mary inquiring about cold techniques on clay. Additionally, for those unfamiliar with the word, cold processes are a really sophisticated way of describing acrylic paint. Additionally, I refer to cold procedures as “room temperature glazes.” Fortunately, Christine Federighi was one of my first creative inspirations and teachers. Chris was a gifted artist and painter, but she was not a purist. She used acrylic paint and oil paints rather than ceramic glazes to paint her ceramic sculpture. And for a long period, she did exactly the same thing. This month, I’d like to talk about using acrylic paint to decorate ceramics. Here are five recommendations to assist you in achieving outstanding achievements. 1. To save money on acrylic paint, prep your ceramic pieces first using spray acrylic paint. Ceramic pottery that has been fired is EXTREMELY porous. Want to put this information to the test? If you have a bisque fired (non-glazed) cup, fill it halfway with water. Allow it to sit overnight in a sink, ideally your kitchen sink. What you’ll notice is that water will permeate the structure from the inside out. It is porous, similar to an aquifer. With this knowledge, you’ll appreciate the importance of priming. I suggest using gesso or flat spray acrylic paint. This priming coat will assist in sealing the surface and preventing the acrylic paint from being absorbed so rapidly. If you make a mistake or are dissatisfied with the results, just re-spray and retry. 2. Acrylics are flexible, quick-drying paints that may be used in thin washes similar to watercolors or directly from the tube similar to oils. Unlike watercolors, once acrylics dry, they are permanent and may be painted over without disrupting previously applied washes. And, unlike oil paint, they are easy to clean and dry rapidly. Make your acrylic paint moist to keep them workable. Typically, I work with a white plate as a palette. And while I’m at work teaching a painting class, I use paper plates since they’re easily disposed of. If your acrylic paint dries, you may re-wet the ceramic plate, and the acrylic paint will easily glide off a glazed surface. Want to extend the life of your acrylic paint? Simply mist the acrylic paint with water, throw it in a zip lock bag, and refrigerate. As long as the acrylic paint is wet, no material will be wasted. 3. Do not squirt gallons of acrylic paint and water into your brush as you begin painting. Rather than that, be frugal. Before touching the brush to do your work, tap it on a cloth or paper towel. Add water only if your brush becomes completely dry. Until you develop an intuitive sense for your brush and acrylic paint, adding additional acrylic paint and water can exacerbate difficulties such as drips and blotches. 4. Looking for an effective technique to practice painting skin tones? Take out an old magazine and look for a photograph of a person. On your palette, combine colors and try to mirror the tone of the ad as closely as possible. Apply dabs of acrylic paint on the paper and see how close you can come to the true color of the area. The majority of skin tones may be created by combining white, red, yellow, and brown. When white is added to a color, tints are generated; when black is added, shades are created. Impressionist artists such as Monet and Renoir recognized that no shadow is completely black; all shadows have color. Rather than going for the tube of black, why not combine complementary hues (colors that are diametrically opposed on the color wheel) instead? Alternatively, one of my favorite ways to get a deep blackish tone is to combine Burnt Umber and Ultramarine Blue. Develop the practice of mixing colors and avoid painting directly from the tube. You can read about Beginner tips on acrylic paint by visiting https://creativephotoconnect.com/beginner-tips-on-acrylic-paint/ Finally, experiment. Want to improve your color mixing abilities? Practice! Anyone can improve at any job just by doing it. Take those mags and attempt to match the colors as described before. Alternatively, purchase a notebook and fill it with notes and color experimentation. Overpaint your previous drawings to see if it inspires anything fresh. A nice approach to practice mixing colors is to lay a dab of one hue on the left side of a page and another on the right. Pull the color on the left to the right with your brush, and the color on the right to the left with your brush, until you get a beautiful mix of the two hues. Keep in mind to have fun while you’re doing it. Acrylic Paint Buyer’s Guide & Frequently Asked Questions Throughout our investigation, we discovered a few common queries, most notably about the intended applications of acrylic paint and some of the accompanying equipment that you should use with them: Can my acrylic paint be used as body paint? No. While the acrylic paint on our list are non-toxic and unlikely to cause allergic responses, body paint often has a different binder that is readily washable. Furthermore, acrylic paint gets harder as it dries. However, body paint remains workable and does not fracture as easily as typical acrylic. Should I prepare the surface before painting using acrylic paint? Yes! We strongly suggest priming all surfaces with gesso before to applying acrylic. Gesso makes it simpler for the paint brush to adhere to the surface, while also minimizing paint waste. If you’re really committed to saving money, get gesso and apply it before to painting — you’ll be surprised at how much acrylic paint you save by not absorbing it into the surface. Acrylic paints may be used on a variety of different surfaces. The adaptability of acrylic paint is one of their most appealing features. Whether you want to paint in the classic sense (on canvas or wood panel) or just want to add a pop of color to your crafts, this medium may be used almost anyplace. If you’re not cautious, acrylic might end up costing more money. In contrast to an oil painting, which may be modified for days after application, acrylic paint can dry within an hour. This means that not only do things become permanent quite rapidly, but you may also ruin your paint brushes if you’re not cautious. To preserve the life of your acrylic brushes, you must be careful about cleaning them correctly. Additionally, you should probably consider adding the following art supplies: To get the most out of your new acrylic paint, here are a few other necessary painting tools to consider adding to your shopping basket before checking out: Palette knives are crucial for mixing acrylic paint and achieving uniform color output. Artists also employ these instruments, which come in a range of forms and sizes, to produce stunning paintings straight on the canvas. You can read about 7 Simple Mixing Tips to Improve Your Tracks and Avoid Complications by clicking here. Article Provided by car hanging decor Acrylic paint is very flexible, simple to work with, and the ideal introduction to painting for anybody new to the medium. Having been formed in the early twentieth century, it is, in some respects, the infant of the art world (historically speaking). And, like all newcomers, it has encountered some resistance. It is often overlooked by experts and amateurs in favor of centuries-old oil paint. This is unfortunate since it is a reasonably affordable procedure that can be performed quickly – although with caution – at home. Additionally, it’s an excellent alternative for older youngsters looking to go from poster paints to something more serious. Visit https://bondiartsupplies.com/collections/acrylic-paints to check more about acrylic paint. We’ll walk you through what to anticipate if this is your first time using acrylic paint – the benefits and drawbacks to consider, as well as what you’ll need to get started. Continue reading to discover how to apply acrylic paint with our comprehensive beginner’s guide to acrylic painting. If you’re fascinated about paint but aren’t quite ready to commit, why not try the current trend in paint by numbers? We’ve compiled a list of our favorite paint-by-number kits for grownups for you to try out. What is acrylic paint and how does it work? Acrylic paint is similar to other types of paint in that it is composed of pigment suspended in a binder. These pigment molecules are suspended in an oil-based solution in oil paints; in acrylics, they are suspended in an acrylic polymer. That is as scientific as we will get: the critical distinction is that acrylic paints may be combined with water, but oil paints need turpentine and other oil-based solvents. Acrylic drying time is also critical. Whereas a coat of oil paint may take several hours to many months to cure, an acrylic paint layer may dry in 5 to 20 minutes, depending on the thickness. How to properly apply acrylic paint Acrylic paint is a very flexible media that can be used at any thickness: you may dilute it with water to create a wash or use it straight from the tube. (As with oils, acrylic works best with a ‘fat-over-lean’ ratio, which implies that each subsequent layer should be thicker.) Along with brushes, you may apply it using a palette knife in delightful, pleasant thick dollops. Indeed, if you want to paint in thick, textured layers, acrylic is an excellent option, since its short drying time allows you can swiftly add layer upon layer. However, if you wish to paint pictures with smooth color gradients – such as a sunset – you may discover that the fast-drying qualities of acrylic prohibit you from attaining the seamless transitions you need. With acrylic paint, you may avoid one of the difficulties encountered by oil painters: overworking a surface covered in still-wet paint to the point that the colors get churned and muddy. Acrylics shine best when applied in discrete, broken strokes of color (which is why we’re willing to wager that the impressionists would have used acrylics in the eighteenth century, had they been accessible). Acrylic pouring is becoming a more popular at-home pastime — and one that is especially enjoyable to undertake with children. This technique involves pouring very viscous acrylics over a surface and letting them to dry in luscious, marbled patterns. This is a lot of fun and produces eye-catching results quickly – but you’ll need to invest in some pouring media to get the paint to behave properly. You can read about Are ‘Open’ Acrylic paint Worth It? by clicking here. What are some of the benefits of acrylic paint? Acrylic’s main advantage is its short drying period, which makes it ideal for novices. Additionally, the fact that it is water-mixable eliminates the need for harmful, odorous chemicals found in oils. It’s also child-friendly, however, smaller children should be watched and clad in overalls. Due to the fact that acrylic does not rehydrate with water, it is very hard to remove from carpets and clothing. While it is often possible to remove fallen splotches of acrylic off non-porous surfaces, we do not recommend taking this chance. Finally, because of its flexibility when dry, it may be applied to almost anything – and we mean practically anything. Canvases, boards, scrapwood, and old furniture all work well for acrylic painting as long as the surface is dust-free and prepared (more on that later). What are some of the drawbacks using acrylic paint? Acrylic’s primary shortcoming is also its drying time, which has garnered the medium much scorn throughout the years. Almost every newbie to acrylic painting will find themselves dissatisfied at some time when they send a brush through claggy sections of half-dried acrylic paint. Brushes, therefore, are often one of the first victims of acrylic painting. They are often abandoned, coated with paint, and subsequently found to have dried, hardened, and worthless. This is why it is necessary to keep all unused brushes immersed in a jar of water. Additionally, unlike oils, acrylics dry significantly deeper in color, which you must account for when blending your colors. If this all seems a little precarious, it is often the case for beginning acrylic painters. However, with enough practice, you will begin to recall all of these details. Acrylic paint: necessary things to note Do you have a rag? This will quickly become your closest friend: you’ll use it for everything from removing extra paint from brushes to wiping away errors on your painting. Two vintage jars? Fill them each halfway with water; one will be used to clean your brushes and the other to dilute your colors. And we’re presuming you’re already dressed in an apron rather than your Sunday finery. Paint in acrylic If you’re new to painting in general, you should begin with between four and 10 colors. Acrylic paint manufacturers provide dozens upon dozens of various colors, and although it may be tempting to purchase them all, you will not learn to mix colors in this manner, and you will be overwhelmed by the sheer variety. At the absolute least, you may begin with white and the three primary colors (red, yellow, and blue), but black, green, and a couple of earth tones will almost certainly be useful as well. Prepare to wade through a sea of white. A 60ml tube of acrylic paint costs between £2.50 and £7 — the price varies significantly depending on whether you’re purchasing student- or professional-grade paints. The more expensive the paint, the richer the pigments and the more vivid the color. Additionally, it will be more lightfast, which means it will fade less over time. Artist acrylic paint is available in a broad variety of colors on today’s market. Making the decision on which acrylic paint to purchase might be difficult for a beginner painter. Here are some suggestions to assist you to select what to purchase, as well as some information on the composition of acrylic paint. In light of my previous experience as an acrylic painter, most of this article will be devoted to acrylic paint; nonetheless, the essential ideas apply to all media. Acrylic paint is well-known for its ability to dry quickly in the traditional meaning of the word (often within minutes). Other collections, such as Golden Open and Artelier Interactive, on the other hand, are intended to be used over and over again. Indeed, the Artelier series was the first to design acrylic paint that could be manipulated for up to 24 hours after they were applied to a surface. After they have dried, there is little doubt that ranges such as the ones I have described will remain “open” and usable for a longer period of time than normal acrylics, and that they will also be able to be reworked. Painting using artist acrylic paint has a number of benefits for certain painters, particularly those who often combine colors on the canvas or who want to reflect on their work and make alterations after it has been completed. While using a stay-wet palette, novices will have the easiest time avoiding their acrylic paint from drying out on the palette, which will save them time and frustration in the long run. As a result, my recommendation for the foreseeable future is to keep the ‘open’ ranges in mind. Allow yourself to taste one or two tubes and compare them to the standard sets you’ve prepared for yourself. The fact that you saved money on the task does not mean that your painting strategy was a waste of time. If you feel they will offer you a significant advantage, you may choose to accumulate a collection of them over time (or purchase them in bulk) when your financial resources enable you to. When it comes to acrylic paint, the landscape is constantly shifting, and it’s easy to become disoriented about which paint perform which functions and to quickly come to regret purchasing a new item simply because it has an appealing name or a “must-have” feature that you didn’t realize you needed. For the time being, I recommend that you start with a few conventional acrylic paints to make things easier on yourself. Click here to read about the advent of acrylic dispersion primers. While you may get one or two colors that you do not like, they will always be useful, even if just for practice or if you wish to acrylic paint in monochrome to improve your tonal value skills. What Should You Spend Your Hard-Earned Money On? In order to choose which colors to purchase, consider the following: A black and white camera and some paper are all that is required for most starting painters since they do not have a lot of money to invest in their equipment. You may experiment with different shades of grey and even create some black-and-white paintings to get a feel for working with a variety of value contrasts and to gain confidence in your abilities. As you go, use more colors such as cadmium yellow, permanent rose, ultramarine blue, and burnt umber into your design as you go. If you have the financial means to do so, I would suggest starting with a simple set such as this one. As you get more skilled with acrylic paint, you may decide to supplement your stock of basic colors with more costly professional paint to supplement your collection of basic colors. Suggestions from Retailers The majority of prominent firms now offer their products straight via Amazon, which is a convenient option if you are unable to visit a physical location. Additionally, there are a small number of specialized online art dealers that give an extraordinary degree of service and diversity to their customers online. If you live in a city with a variety of art stores, though, make a point of visiting them on a regular basis. The experience of physically seeing and handling the goods you’re considering purchasing may be worth the trip in and of itself, and you may be able to negotiate a price that is similar to that of online retailers as well. As previously said, there are several types of artist acrylic paint available on the market today. Making the decision on which acrylic paint to purchase might be difficult for a beginner painter. Here are some suggestions to assist you to select what to purchase, as well as some information on the composition of acrylic paint. In light of my previous experience as an acrylic painter, most of this article will be devoted to acrylic paint; nonetheless, the essential ideas apply to all media. Acrylic paint does not need the expenditure of a big number of money. Numerous brands are available to choose from, many of which are almost identical in terms of quality and value, particularly at the entry-level and starter set price points. As previously said, start with a limited selection of classic colors to get a sense of how things will work out. A direct result of this activity will be a greater awareness of the colors that may emerge from a relatively limited number of mixtures that you will get used to creating. Avoiding the temptation to incorporate the contents of approximately thirty separate tubes into each painting because you believe that you must demonstrate that the tubes were worth the money spent on them in the first place will save you money, but more importantly, your paintings will have a genuine sense of balance and harmony. The quickest and most straightforward method of determining the kind of acrylic paint to purchase is to examine the painting style you want to use. Do you favor powerful brushstrokes and plenty of texture, or do you prefer subtle color washes to build up the color in your painting? Which style do you prefer? Consider purchasing a few tubes of each kind and doing an experiment with them. You will eventually establish your own distinct style and brand of acrylic paint that will be recognized by others. If you have any questions or comments, please feel free to post them in the section provided below. I’d be pleased to get your message. Check out How to decorate ceramics with acrylic paint

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You might have seen footage online of sheds that were built out of pallets. It could be simpler to construct a shed from pallets, as it is not building… Using screws could lead to more humidity, which may ultimately lead to rot or mold progress over time, particularly on wood flooring. You’ll normally use fewer screws than you’ll nails, as nails must be six inches aside while screws only have to be eight inches aside. The foundation should be level for the shed to be built and put in correctly. Check and follow the producer’s directions, as most embody the data on constructing the right foundation for his or her shed. Select one that will function well for you, fit within your finances, and is in the style you like. An outdoor shed is something you may see and use in your yard for many years. Interlocking vented deck tiles are proof against common chemical substances, making it hard for stains to stick on or corrode the tiles. Rubbermaid 7 Foot X 7 Foot Storage Shed It looks like a utilitarian shed, which it is, but has a strong basic construction and will last for years. To maintain your garden hoses in tip-top form, you must retailer them in a safe reel, such as the Suncast Swivel Smart Trak Hose Hideaway. Polyethylene – This sturdy plastic is usually made in a UV-resistant mix which helps it stay durable and retain its shade higher over time. When you determine a shed you want, think about upgrading to our premium plans and revel in the advantages of in-depth instructions and simple-to-grasp step-by-step instructions. Premium plans present intensive detail, together with a full supply list and all the instruments required to construct the shed. They also name each piece and give a lot detailed data to help first-time DIYers. The 128 sq. foot of floor area makes it easy to move around inside, and there’s sufficient room to add cabinets for holding pots or bags of soil.

What is a pediatric dental emergency? Emergency dentistry is available to patients who have experienced a dental injury or accident, or are in severe dental pain and discomfort. The goal of emergency dental care is to get patients out of pain quickly and back to optimal oral health as soon as possible. Between contact sports and exploring their worlds, children can have an accident at any time. That’s why pediatric dentists will often leave openings in their schedules for same-day emergency appointments, so they can address your child’s needs as soon as possible. Did you know… More than 5 million teeth are knocked out every year in both children and adults. What to do for your child when they’re experiencing a dental emergency Keep Calm So They Stay Calm It’s easy to panic and feel anxious when your child injures their mouth. But try your best to stay calm and collected. Panicking will only stress your child, so keep a clear head, assess the severity of the situation, and get things under control. Try To Control Any Bleeding If your child’s mouth is bleeding, use clean gauze, cotton balls, or paper towels to absorb the blood, and apply gentle but firm pressure to control the bleeding. Be aware that oral injuries can bleed quite heavily, but if you apply pressure to the area, or your child gently bites down on some gauze, the bleeding should slow within a few minutes. Take Steps To Reduce Swelling & Pain You can have your child take over-the-counter medication like Tylenol or Motrin to help with pain and inflammation. Applying an ice pack externally to the cheek near the affected area can also help numb the site and reduce swelling. Make sure you call us right away to schedule an emergency appointment with your child’s pediatric dentist. We can help you determine the severity of the situation and whether or not your child needs to be seen immediately. The importance of prompt emergency care Cut Or bite On Cheek, Lip, Or Tongue maxillary frenum tear Did you know… Putting a knocked out tooth in milk, not water, can preserve the root while you head to your emergency appointment. Have questions about emergency dentistry? Find answers here. What should I do if my child knocks out a tooth? Knocked-out baby teeth are not usually replaced, even if they’re lost prematurely. If it’s a baby tooth, your child will need to come into our office to have their mouth examined and cleaned to prevent infection, and to get a “space maintainer.” This prosthetic will maintain the proper gap between their teeth, preventing the adjacent teeth from shifting toward the now-empty socket. For an adult tooth, though, you need to get help immediately. Recover the tooth, rinse it, and put it in a container of cold milk to keep it moist. Then, come to our office immediately. Don't spend too much time treating pain or bleeding. Your child’s tooth must be re-attached within 1-2 hours for it to be saved, so time is of the essence. Our Ardsley dentists can treat your child’s pain when they get to our office. What should I do if my child’s dental work falls out? Collect the filling, crown, or other piece of dental work and place it in a plastic baggie. Then, call us for a same-day appointment, and make sure to bring your child’s dental work in with you. It may be possible to reattach a crown instead of completely replacing it. What should I do about a severe toothache? A severe toothache could indicate that your child has a deep cavity or an infected tooth. You should schedule a consultation at our office right away, as these are both serious dental emergencies that will only get worse without proper treatment. What should I do if my child has chipped, broken or cracked a tooth? First, treat their discomfort and bleeding. Then, contact us for a same-day appointment. Even minor tooth damage can cause hairline fractures and these fractures could lead to infections and other complications. After consulting with your child’s dentist, they can determine the best treatment for restoring the damaged tooth, and ensure your child’s smile remains healthy and strong. What should I do if my child has a loose tooth? If a baby tooth has come loose and it’s not due to an oral injury, you don’t have to do anything. Baby teeth are meant to fall out eventually, so this is natural. However, if one of their teeth becomes loose and is bleeding after an oral injury, it may not be ready to fall out yet. The best thing to do is to get a consultation with your child’s dentist to have their mouth examined, and determine whether the tooth can be saved or if it should be replaced with a space maintainer. Did you know… Losing a baby tooth too early can be a dental emergency.

Crepey skin is a result of your skin losing its elasticity and collagen. When that happens, your skin begins to sag and starts to look crinkled. So to treat and prevent your skin from becoming this way, it’s important to use the best body lotions for crepey skin. Now I’m not saying that crepey skin is synonymous with wrinkles. The process of wrinkling is, more often than not, associated with sun damage, genetics, and facial movements. As for crepey skin, it has a lot to do with just sun damage. The sun, after all, tends to break down the natural elasticity of your skin. But, fortunately, there are products to reduce the visibility of unwanted crepey skin. What is Crepey Skin? Much like crepe paper, crepey skin looks thin and finely wrinkled. It feels loose and saggy. Crepey skin and wrinkles are almost one and the same thing. But the former impacts larger areas. On top of that, crepey skin feels visibly thinner and more fragile. The most common areas being the upper part of your inner arms. Along with your neck because here the skin tends to be very sensitive and thin. Therefore, more susceptible to becoming crepey. Crepey skin on the legs is also very common. Especially above the knees and near the skin creases. These areas have skin that stretches quite a lot. So, with that, the likelihood of the surface becoming thin and prone to wrinkles increases. Causes of Crepey Skin Genetics and skin type play a major role when it comes to determining whether or not your skin is going to turn crepey. But the harmful UV rays of the sun are also one of the most common causes. UV radiation exposure from the sun or tanning beds has proven to cause serious damage. Natural and artificial UV rays break down your skin’s elastin fibers. And when that happens, skin starts to stretch and then go back to the normal state. Elastin fibers have the ability to heal, no doubt. However, long-term UV radiation exposure hinders the natural repairing capacity of the fibers. Another common cause of crepey skin is light complexion. If you’re fair-skinned, then it’s likely that your skin might turn crepey. Fair skin is also more susceptible to wrinkling and developing skin damage. Some other not-so-common but possible causes include: The lack of proper nutrition. The lack of natural moisture and hydration present in your skin. Medication like prednisone. The cycle of weight gain and loss. What is the Best Treatment for Crepey skin? No doubt, treatments that involve the use of ingredients such as glycolic acid, salicylic acid, hyaluronic acid, and lactic acid work the most effectively. These alpha and beta hydroxy acids offer moisturizing and healing properties. So body lotions with any of these ingredients is a good solution for crepey skin appearance. For a stronger treatment method, your safest option would be over-the-counter products. More often than not, these have retinol (Vitamin A derivative), which works like magic. Then there are laser treatment methods such as ultrasound, pulsed light, and radiofrequency. What such a method does is re-structure collagen within your skin. It also improves skin elasticity. Most commonly used on areas like the face and neck. Some dermatologists also recommend injecting fillers for making crepey skin look smooth and plump. Best Lotions for Crepey Skin: Top 18 Picks Top Pick - Gold Bond Ultimate Strength & Resilience Skin Therapy Lotion The Gold Bond Lotion for crepey skin is all the rage because it’s got a special combination of three vitamins and seven plumping moisturizers along with lipids and proteins for replenishing moisture. That’s a whole lot, isn’t it? The moisturizing properties of the lotion last for as long as 24 hours. The formula gets absorbed quickly without leaving any greasy feeling. It offers a fresh and clean scent. Speaking of which, there are no artificial fragrances. It’s a hypoallergenic, dermatologist-tested, and non-comedogenic product. The product comes from a brand that manufactures some of the best lotions for delivering soothing relief in the case of eczema, psoriasis, and excessively dry skin. For both adults and babies! Runner-Up Pick - Medix 5.5 Retinol Cream What’s so unique about Medix 5.5? That the cream contains a perfect blend of natural antioxidants and anti-aging ingredients. The primary anti-aging component is retinol, which is Vitamin A. It works just like magic potion when it comes to decreasing the appearance of fine lines, wrinkles, and dark spots. Retinol also corrects skin elasticity and tone. Then there’s the natural version of ferulic acid. It’s a potent antioxidant that reverses sun damage on the skin. In charge of hydrating and nourishing crepey skin are botanimoist AMS and chamomile. They boost your skin’s hydration level by 88-percent. Moreover, there’s black tea, aloe vera, shea butter, and other natural extracts like rosemary, sunflower, and apple. So you never have to worry about hydration with this one. And to make matters even skin-friendlier, the cream is cruelty-free and vegan. Best Budget Pick - Mediix 5.5 Argan Oil Cream As for this Medix cream, it’s got argan oil. And what that does is, in its purest form, softens, moisturizes, and hydrates the skin. Argan oil is very effective when it comes to protecting the elasticity of your skin by minimizing the visibility of blemishes, fine lines, and wrinkles. The most surprising part is the inclusion of coffee bean. Along with aloe vera and lotus extract, coffee bean provides instant hydration. But lotus extract, in particular, is incredibly useful in the sense that it contains Vitamin B, Vitamin C, and even plenty of antioxidants. This too has botanimoist AMS for boosting hydration by 88-percent. And this too is cruelty-free and vegan. TreeActiv Crepey Skin Repair Treatment Collagen boosters in the form of the best body lotion for crepey skin on arms and legs are not that difficult to stumble upon anymore. One such exceptional option is this TreeActiv formulation. It revitalizes crinkly, sagging, dull, and/or dry skin by reversing the visible signs and spots of aging. Powerful, safe, and effective ingredients like hyaluronic acid, alpha hydroxy acids, Vitamin E, essential fatty acids, and antioxidants are used. The combination of minerals, vitamins, and potent essential oils brings into the picture more protection, firmness, and hydration. And every single ingredient is organic. It’s the perfect anti-aging cream for skin nourishment. Diva Stuff Crepey Skin Body & Face Cream The product title includes the words “crepey skin” and it’s also indicative of the fact that the cream is suitable for your face and body. And it’s genuinely capable of treating loose, damaged, or aging skin. Thanks to the inclusion of hyaluronic acid. The thing about alpha hydroxy acids like hyaluronic acid is that they reveal fresher and younger skin. Diva Skin also decided to add honey to this for skin rejuvenation. On top of that, there’s coconut oil, macadamia nut oil, argan oil, and olive oil with excellent nourishing, moisturizing, and hydration properties. Many women use the cream as a sort of spot treatment, especially below the eyes. It works great on the décolletage and neck as well. Even if you have skin sensitivities! Victoria’s Body Shoppe Tighten Up Crepey Skin Moisturizing Cream The label of this moisturizing cream states that it tightens, firms, and smoothens crepey skin on the face, chest, neck, and body. Women who achieve their goals of weight loss are more likely to benefit from a cream like this. It has the ability to firm up excess loose skin like no other. Plus, the moisturizing cream smells of delicious vanilla. It’s got a blend of high-grade, skin-restoring ingredients, organic elements, and plant extracts. They boost the production of collagen and improve elasticity. This unique, healthy combination activates cell regeneration for tightness and smoothness. After all, the active ingredients penetrate deep into the cells of your sagging skin. Voibella Beauty Best Neck & Chest Firming Cream Here comes a lotion you can apply on your neck in case you have crepey skin there. The neck is a very common area which displays the first signs of aging. But you can slow down the aging process in that region simply by using this neck and chest firming cream. The anti-aging ingredients here are 100% organic and natural. There are peptides and Vitamin C for supporting elastic and collagen production. Then there’s retinol too for the much-needed cell turnover. Even jojoba oil is included to make sure your skin receives all the hydration and suppleness it demands. This neck and chest cream is also equipped with green tea and Vitamin E for antioxidants. So you can expect skin repair along with a drastic reduction in the visibility of your wrinkles and fine lines. No matter your skin type! PH Factor 5.5 Retinol Cream Now here’s an ideal retinol cream for acne-prone skin. The actual 5.5 pH factor of this formulation is perfect in the sense that it fights off bacteria in the most natural manner. And when bacteria are eliminated, so are breakouts. What the retinol ingredient does is create a strong barrier on your skin to hold in all the moisture. And to keep potential pollutants at bay. Even ferulic acid in here works to the best of its abilities for improving the sagging, crepey look. And keeping the skin feeling smooth and hydrated. It’s an advanced formula containing botanimoist AMS that increases the hydration levels of your skin by as much as 88-percent. It’s also infused with aloe vera, shea butter, black tea, and chamomile for improving the overall appearance and health of the skin. Skin Nation Super Sexy Firming Cream Body Lotion If you want just one particular reason to use this firming body lotion, then let that reason be apple fruit extracts. Because what apple fruit extracts do is provide your skin with potent antioxidants and Vitamin C that neutralize skin-damaging free radicals. Therefore, they tone, tighten, and firm crepey, aging skin. You should also know that apple fruit extracts contain the natural version of alpha hydroxy acid for gentle exfoliation of the dead skin cells. The formula is full of rich, luxurious oils plus butter for delivering the perfect heavy-duty yet non-greasy dose of moisturizer. It’s the perfect remedy for preventing premature aging in my opinion. Crepe Erase Intensive Body Repair Treatment Crepey and dry skin seems like a bad combination, doesn’t it? But if you have it, the best you can do is treat the common skin condition. Simply by opting for this Crepe Erase treatment. What the special formula offers is TruFirm. It’s a blend of plant extracts that boost elastin and collagen production to restore the natural texture of your skin. The cream is ultra-rich in terms of botanicals that target crepey and dry skin. What’s the most enticing is the inclusion of seven different super hydrators. These include shea butter, beeswax, Vitamin E, coconut oil, cocoa butter, cassava, and olive oil. The formula gets absorbed quickly to work its magic. The outcome of which is healthy elastin and collagen production and total skin replenishment and nourishment. Adamia Therapeutic Repair Lotion Many women are slightly wary about buying a therapeutic repair lotion for crepey skin. And that’s because there are many poor-quality and ineffective products out there manufactured by brands that only want to make money. So it’s a huge relief to come across a brand like Adamia. It ranks as the best over the counter lotion for crepey skin for many reasons. The one unique ingredient added to this repair formula is Promega-7. This includes rich Omega-7 and pure macadamia oil. To be honest, it’s the most effective and soothing moisturizer for distressed skin. The lotion is fragrance-free, paraben-free, hypoallergenic, cruelty-free, soy-free, dermatologist-tested, and more. It’s also non-greasy with exceptional absorption capacities. That means suitable for restoring life into oily, sensitive, and dry skin. Vichy Ideal Body Skin Firming Lotion The renowned skincare brand Vichy offers the most suitable lotion for skin that has become crepey on legs, hands, arms, and face. It’s an extremely nourishing body balm with excellent skin-firming properties. There’s apricot kernel oil, rosehip oil, sunflower oil, and jojoba oil for more radiant, smoother, and firmer skin. As for skin hydration, hyaluronic acid does that best. This particular commonly used skincare ingredient can hold water a thousand times more than its weight. Moreover, the botanical oils go a long way when it comes to smoothing and moisturizing your crepey, damaged skin. But the one thing that shines the brightest, in this case, is mineralizing water. It comes from Auvergne and the water contains 15 rich minerals that strengthen your skin’s natural moisture barrier. By far, it’s the perfect choice for those looking for a combination of face cream and moisturizer. And that too for sensitive skin! Hempz Herbal Body Moisturizer What I’m currently reviewing is an everyday body lotion that ranks as the superior option when compared to just about any lotion formulated for treating crepey skin on the face and body. It has such a wonderful capacity to reduce wrinkles and fine lines that you didn’t even think was possible to do in the first place. The ingredients included in this daily formula perform the task of eliminating dehydrated skin. The natural extracts are ginseng, shea butter, hemp seed oil, amino acids, fatty acids, minerals, and vitamins. The moisturizer is a gluten-free and paraben-free skincare product. It’s also packed with algae extract and polypeptides. Simply put, the formula is age-defying, no doubt. The chances of spotting noticeable differences in the appearance of crepey skin are very likely. Advanced Clinicals Crepey Skin Wrinkle Smoothing Cream Can you expect this anti-wrinkle cream to boost collagen production? YES. Can you expect it to minimize the visibility of wrinkles on your face, neck, chest, and the rest of the body? YES. Can you expect this moisturizing formula to provide so much skin hydration that it doesn’t become crinkly and crepey? Once again, YES. So what makes all this possible? The inclusion of shea butter and olive oil. These two ingredients work on all types of skin. But what’s extraordinary here is the presence of AquaSpheres. It has the capacity to increase the hydration level of your skin by 88-percent. The AquaSpheres is nothing but a blend of hyaluronic acid and collagen. There’s borage oil and poppy oil as well. Nothing works better than this to make your skin look vibrant and lifted. CeraVe Moisturizing Cream Prepare your skin for the best daily face and body moisturizer. CeraVe for crepey skin offers 24-hour hydration. It has the power to restore your skin’s natural protective barrier with the help of essential ceramides. Let me point out that this moisturizing cream works best on dry skin. The formulation includes hyaluronic acid for maximum moisture retention. The cream’s MVE technology replenishes ceramides to deliver long-term moisturization. And how do I know it’s suitable for sensitive skin too? The cream is gentle and non-irritating, thus hypoallergenic. It’s also non-comedogenic by the way. I highly recommend it not only for crepey skin but also for the treatment of eczema. Advanced Clinicals Anti-Aging Hyaluronic Acid Cream The previous Advanced Clinicals Smoothing Cream has AquaSpheres while this one works wonders as a lotion perfect for dealing with crepey skin on the hands. But that doesn’t mean you cannot apply it on your face, neck, chest, arms, and legs. Feel free to do so because this anti-aging formula works great as a daily day face cream, hand lotion, and body moisturizer. The formula receives its potency from Vitamin E, squalene, and borage oil that restore your skin. And the soothing action is performed by aloe vera. Even the current option is infused with hyaluronic acid for locking in all the moisture. It’s a total must-have product for those dealing with signs of early aging or skin damage. No B.S. Body Moisturizer No B.S. here stands for No Bad Stuff. And that’s exactly what you get if you decide to buy this body moisturizer. Only good stuff like shea butter, rosehip oil, lavender oil, and green tea. Shea butter quenches the thirst of dry, dehydrated skin. It makes your face and body shine with moisturization and makes your skin feel soft too. As for rosehip and lavender oil, they combine with green tea to provide a dose of antioxidants for skin protection. The formula is lightweight if you’re worried about the texture making your skin look oily or greasy in any way. This body moisturizer, just so you know, is cruelty-free. On top of that, the brand collaborates with animal shelters for improving their quality of life. Zenith City Originals Best Organic Ultra Repair Skin Cream The last pick on the list is the best organic option. This is an ideal anti-aging repair cream. The dense texture doesn’t take too long to become crystal clear while it’s melting into the skin for rehydration and protection. The cream leaves your skin feeling supple and soft. The level of moisture it allows your skin to hold is pretty commendable. At the same time, your pores don’t feel clogged. Organic acai berries packed with antioxidants, organic shea butter equipped with natural fatty acids and vitamins, and organic aloe vera for hydration and healing. All of these ingredients are certainly capable of treating and preventing crepey skin. How to Deal with Crepey Skin on Arms, Legs, and Neck? Since these are the most sensitive areas, let me discuss how to get rid of crepey skin... Crepey Skin on Arms Crepey Skin on Arm Your upper arms are likely to develop crepey skin. So, at such times, what works best is moisturizing the skin to improve its appearance. This means choosing a body lotion equipped with hyaluronic acid, glycolic acid, salicylic acid, and lactic acid. Crepey Skin on Neck Crepey Skin on Neck You can control the appearance of the skin on your neck by applying Vitamin C. It’s an excellent ingredient when it comes to moisturizing the skin thoroughly. Plus, it helps with counterbalancing the effects of aging as well. Crepey Skin on Legs Crepey Skin on Leg For preventing and treating crepey skin on legs, you need a body lotion that boosts your skin’s collagen production. Even hyaluronic acid, glycolic acid, salicylic acid, and lactic acid work very effectively at such times. How to Choose the Best Body Lotion for Crepey Skin Listed below are the few things to look out for when looking you’re buying products for crepey skin: Now that we’ve established that lack of moisture can worsen the condition, it’s important to choose a product with moisturizing and hydrating ingredients. Look for ingredients such as glycerin, aloe, hyaluronic acid, retinol, etc. as they add hydration and keep the skin moist throughout the day. Collagen breakdown is linked with loss of elasticity. Therefore, always go for products that boost collagen production. If the lotion or cream contains collagen as one of its ingredients, then that’s really good. It’s a great way to boost collagen and improve elasticity. Additionally, make sure that the product doesn’t contain toxic ingredients. What exfoliants do is, at least the gentle, skin-friendly ones like glycolic acid and lactic acid, eliminate dead skin cells. That means they encourage the production of new, fresh skin cells. When combined with moisturizing elements, these exfoliants have the ability to reduce and prevent crepey skin. It’s a very simple explanation here. There are free radicals in the body that cause premature aging and skin damage. And the best way to combat these free radicals is with the help of antioxidants. So make sure the body lotion contains antioxidant-rich Vitamins like C and E. Even green tea extract is loaded with healthy, skin-repairing antioxidants that also minimize skin irritation. The price of a product can greatly influence purchasing decisions. Don’t get too excited and buy something you can’t afford. A low-priced product can offer great value if it has the right ingredient and effective formula. Always do your research, look for reviews, study the notable qualities of a product, and make an informed decision. That being said, we’ve reviewed some low-priced items above that can do the trick if you’re on a budget. What is the Best Home Remedy for Crepey Skin? The most common treatment methods for crepey skin are as follows Exfoliation - Exfoliating your skin at least twice a week using a scrub made of olive oil and sugar. When you exfoliate, you’re getting rid of dead skin cells. And that goes a long way when it comes to treating crepey skin, aging spots, excessive dryness, etc. Dry Brushing - Dry brushing the skin is a natural technique for minimizing the appearance of crepey skin and even cellulite. Castor Oil - Did you know that castor oil offers plenty of skin and hair benefits? Such as treating wrinkles, preventing stretch marks, nourishing dry skin, promoting hair growth, and more. Coffee Facial - For a coffee facial at home, all you need is some organic coffee and honey. Think of it as your very own homemade skin-firming mask. Sunscreen - Another form of treatment, often neglected, is applying sunscreen. With sunscreen, you can minimize the damage caused by natural UV rays. So your skin becomes less prone to wrinkles, fine lines, spots, discoloration, and the crepey effect. Go for SPF 30 or higher for the best results. Frequently Asked Questions About Crepey Skin Q. Is Hyaluronic Acid A Good Solution for Crepey Skin? Many skincare products are infused with this hydrating ingredient for a reason. It makes your skin look smooth and plump, no doubt. And that is why it’s a very effective ingredient for treating crepey skin as well. With aging, the skin’s ability to produce moisture reduces naturally. So, at such times, hyaluronic acid’s hydration properties go a long way. Q. Does Vaseline Work for Treating Crepey Skin? Vaseline is petroleum jelly, right? And that means an excellent moisturizer. So a thin coating of Vaseline keeps your crepey skin moisturized. Therefore, making it look healthier, smoother, and youthful. Q. What Do Dermatologists Recommend for Crepey Skin? Laser treatment methods such as ultrasound, pulsed light, or radiofrequency. These deal with the condition from within. The device used for treatment heats small areas of your skin. And this heat creates energy that improves collagen and skin elasticity. Then there’s another form of treatment dermatologists adopt. Injecting fillers into the skin. It's a non-invasive treatment method that creates a volumizing impact on your crepey skin. Q. Can You Reverse the Effects of Crepey Skin? You need to understand that, as you age, your skin’s natural ability to produce oil and moisture deteriorates. And with these natural protective barriers becoming weaker, it’s only logical for your skin to become more prone to damage. But the good news here is that you can incorporate habits and products that boost your skin’s moisture or hydration levels. Once you start using such products and prioritizing skincare, then it’s highly unlikely for crepey skin to develop. However, once crepey skin develops, you can only do so much to reduce its appearance. It’s not that crepey skin looks unattractive. After all, aging is a very natural process, and so it should be beautiful too. But the point I’m trying to make here is why not treat the condition when you have that option at your disposal! There are many products that help with crepey skin. Much like the 18 body lotions I’ve reviewed in this article for you. Almost every one of them has got natural and effective ingredients for healing, nourishing, hydrating, and moisturizing your skin. No matter how old you are!

This soothing gel contains aloe vera leaf extract giving a refreshing feel with no stickiness making the skin moist. The soothing gel can be applied to the face and body in multi-areas providing a calm and moisturizing effect to sensitive skin from the inside and out as it keeps the skin to become healthy. How to Use For morning and night time, apply a small amount on the palm of your hand and smoothly apply to the skin. For dry and sensitive skin, please apply from time to time for it to absorb. Aloe Barbadensis Leaf Extract, Arginine, Bamboo Leaf Extract, Cabomer, D-Sorbitol, Disodium EDTA, Ethanol, FRAGRANCE, GLYCERIN, Hexanediol, Hydroxyethylcellulose, Phenoxyethanol, Polysorbate 80, FRAGRANCE

Starting a fire in adverse weather, whether is rain or wind or both is a very important survival skill every outdoors aficionado must possess. The ability of igniting a fire when things are less than perfect is a fine art which must be learned and practiced until mastery is achieved. The thing is, nature doesn’t care much about our best laid plans, mice and men alike and an emergency never comes alone. I mean, when confronted with a survival situation, you’d at least expect fine weather, cool breezes and sunshine. In reality, your survival in an emergency situation will become much more complicated than initially thought and I would dare to say nine times out of ten, as you’ll end up not only lost in the woods or wherever, but you’ll also have to deal with rain, cold and high winds. Emergencies almost always bring bad weather with them, it’s almost like a 2 for the price of 1 deal. And that’s fine as long you’re prepared both physically and mentally. However, in critical times, your survival may depend on your ability to light a fire under rain and/or wind and any hardcore survivalist, even Bear Grylls will tell you that you should always carry at least 2 primary and 2 secondary tools for starting a fire. The idea is that a regular fire starter may not always provide you with the best results, especially if it’s raining and it gets wet. Also, if it’s windy and rainy, your chances of igniting a fire with just one match are pretty slim. If it’s freezing cold, your BIC lighter (which uses butane) may not work at all. Basically, starting a fire when it’s windy, cold and rainy is one of the worst situations imaginable, other than starting a fire under water, which is a skill only Chuck Norris masters (he uses phosphorus by the way). I think I have already told you a dozen times in my previous articles about the holy trinity of survival, which includes fire as a means of providing you with (cooked) food, (safe) water and shelter (warmth, protection from wild animals etc), but also about the importance of location. But do you know which survival essential is the first most important? 1. Find an Adequate Location for Making the Fire Everything in life is location, as Van Helsing used to say back in the day, and the same mantra is true when it comes to making a fire. The first thing to look for is an adequate location for making a fire in harsh weather conditions. The idea is to provide your fire with as much protection possible from both wind and rain if possible. And if you’re not in the middle of a frozen desert with no snow around, that’s not impossible. Shelter means three basic things: - shelter from the wind - shelter from the rain - shelter from the ground water. 2. Shelter the Fire Ideally, you should shelter your fire on more than one side (upwind). Build a Windbreak You can protect your fire by building a C shaped windbreak with the open side downwind. You can build a windbreak using wood, rocks, snow, dirt, just use your imagination. To shelter your fire from the rain when outdoors is the hardest job, but it can be achieved. Make the Fire Under a Tree But pay attention! The easiest way is to make your fire under a tree, as evergreens can be regarded as a natural tent of sorts. All you have to do is to pick a big one and make your fire under the lowest branches. Making a fire under a tree may not seem like the best idea, as there are inherent risks attached, like setting the tree on fire, but if you’re paying attention and keeping your fire under control, the chances of such an event happening are minor. You can minimize the risks further by building a good fire pit with no combustible materials around the fire. Build a Fire Pit The third requirement is how to protect the fire from ground earth, with the previous two taken care of by now. The easiest method is to use rocks for building a fire pit on a spot where the ground is raised from the floor. Or you can do that yourself, i.e. you can build a little mound and on top of the mound you’ll put a layer of rocks, thus preventing your fire from staying directly on the wet ground and also making sure any running water will be drained ASAP. 3. Tinder, Kindling and Fuel So much for location folks, let’s move on to the next issue and I will start with an axiom: if you don’t have the Bear Grylls flame-thrower with you, starting a fire using wet wood is basically impossible and a no-go under any circumstances. You’ll waste your time and your gear, bet on a dead horse and the whole palaver. Video first seen on CommonSenseOutdoors. However, there are ways, as Gandalf used to say, but ideally, you should try to find something dry for starting your fire. As a general rule of thumb, a fire gets started in 3 stages: tinder, kindling and fuel. The tinder is a combustible material which is very easy to ignite, i.e. it will catch fire quick and easy. The kindling can be improvised using pieces of finger-thick wood that will be lit from the kindle. The rest is pretty straight forward, as far as your kindle gets ignited you’ll start the main fuel and you’ll have a fire burning in no time. Two of the best survival-tinder (fire starters actually) which can be used for igniting a fire in adverse conditions (even with wet wood) are cotton balls soaked in petroleum jelly and dryer lint mixed with paraffin. These will burn for at least 2-3 minutes, thus providing you with plenty of time to get your fire started. I’ve already written an article about this issue. As an interesting factoid, even in the midst of a rainstorm, you can almost surely find dried branches under the bottom of big/old pine trees. Another great place to look for dry combustible is the underside of uprooted (or dead) trees. Video first seen on IA Woodsman. How to Make the Best Fire Starter for Wet Wood The best fire-starter for wet wood can be home-made using black powder (gunpowder) and nail polish remover (the one that contains acetone). The acetone will be the solvent for the gunpowder. The idea is to make something that burns slow and as hot as possible and the gunpowder/acetone mix is by far the best in this regard. Making the mix is fairly easy, as you’ll start with a small quantity of gunpowder the size of a golf ball put inside a ceramic/glass bowl. Start adding nail polish remover so that the mound of gunpowder is totally covered then mix it together slowly and thoroughly (always wear rubber gloves). Once the stuff inside the ball gets in a putty-state, you can pour off the extra nail polish and then start kneading the putty, just like when making bread. i.e. folding it over time and time again. The purpose of the kneading is to create layers inside your fire-starter. In this way, the burn rate is more controlled. The more layers, the better your fire-starter will be. The finished putty can be stored in an airtight container, but keep in mind that you’ll want to use your putty when it’s still moist. If dried, it burns too fast. This fire-starter burns at 3000 degrees Fahrenheit and a golf-ball sized piece will burn for more than 3 minutes. Basically, you can set anything on fire with this baby and even dry out damp wood in the worst conditions imaginable. One final thing, it would always be nice to use fire accelerants, like gasoline (or alcohol, paint thinner etc), for starting a fire in rain or wind. If you have your car around, the better, as you can siphon out some gasoline from the tank and start a fire even with damp wood in a jiffy. Okay, you’ll not receive those extra bonus style points, but that’s okay. You’ll always have the peace of mind knowing that no matter where you go and no matter how bad the weather is you’ll be able to start a fire and safely cook food and boil some water. Click the banner below to grab this offer! This article has been written by Chris Black for Survivopedia.

Frequently Asked Questions Here we have collected your most commonly asked questions about Eco Femme pads and compiled our answers for you. For questions regarding our online shop, delivery, shipping timing, or your order status, view our online shop information. Can’t find the answer you are looking for? Do contact us! We are happy to answer you. NEW: To Find all the answers to your questions about Eco Bébé, click here. Cloth pads are just like disposables, except you can wash and reuse them several times, therefore saving money and creating less waste. For the environment and to save money. In our blog you can find more information on this. Women have been using cloth for thousands of years before you. Which doesn’t mean it is old fashioned or even outdated. In fact it is all the opposite, absolutely up-to-date: eco-friendly, health beneficial and cost convenient. You quickly incorporate the routine of using, changing, soaking, washing, drying and reusing. Many users have reported benefits of feeling emotionally more connected to themselves and their cycle. The plain uni-coloured fabric is worn facing your body and the patterned leakproof side faces your underwear. The buttons are fastened around your underwear. Our pads have wings which fold around your underwear and are fasted with a press button below. We recommend wearing well fitting underwear whilst using our pads to ensure the pad fits snugly against your body. Cloth pads can be washed easily by hand or in the washing machine. The secret is to first soak the pads in cold water for 30 minutes before washing in up to a maximum of 40 degrees Celsius. Most of the blood comes out in the soaking process. After that, it’s just like washing your clothes. Pull your wet pad into shape to prevent shrinkage then dry on the washing line in full sunlight for best results or tumble dry on low heat. Check out the product demonstration video below to see how it’s done. Our pads are made of organic cotton. The top of the pad is made of soft flannel cotton. The inside of the pad is made of ultra-absorbent cotton flannel (the number of layers differs according to the pad model). The back of the pad is made with a PUL (polyurethane laminate) leakproof layer. This is a personal matter and the answer would depend on the user, but we have very good feedback regarding the comfort of our pads. The comfort of cotton against your skin and between your thighs rather than plastic, less feeling of wetness, less skin irritation, less smell, and our customers love their softness! The back of the pad is made of a leakproof PUL (polyurethane laminate) layer. Beyond that, using cloth pads is just like using disposables. Whether disposable or reusable, a pad needs to be changed in time before it leaks, according to your personal flow. The blood doesn’t stay on the top flannel. The liquid gets absorbed into the inner cotton layers. If your body expels clots during your period, you will find these on top of your pad. If your pad starts to feel wet it means it’s time to change it with a fresh one, just as with any other product. In fact many users report feeling less wetness and more comfort with cotton against their body as compared to sticky plastic pads. You should change your pad about as often as you would change a disposable pad, every 4 to 6 hours, as needed, depending on your flow. You will easily learn when it’s time to change. As with all new garments, especially underwear, you should wash new pads prior to using them. And there is another reason for this: New cloth pads are similar to new towels; after the first few washes cotton absorbency will increase, which is exactly their job to do! We have observed, to increase the absorbency of new pads, wash them 2-3 times with soap, soak them overnight or machine wash, and it will help so the liquid gets absorbed into the inner layers of the pad. Initial shrinkage is also normal to natural cotton material in the first few washes. We have added a few centimeters to each new pad to compensate for this. And we suggest that after washing, you pull your wet pad into shape before hanging it to dry, just as you do with other cotton clothing. We suggest a minimum of 4 pads to change, wash and dry. Most women have an average of 6-8 pads. A few factors influence the number of pads that you need. Factor 1 is the intensity of your personal flow. Factor 2 is the frequency you wash your pads. Factor 3 is the time needed to dry. If the climate where you live allows fast drying you need fewer pads. You need enough dry pads readily available. To become confident using the pads, as well as discover how often your personal flow makes you need to change, you might like to begin by using the pads at home. Before going to work / school you can put clean pads in our attractive travel pouch. You can discretely carry it to the bathroom when you need to change. Soiled pads can be stored by folding the two ends towards the middle, fastening the buttoned flaps and placing them in the carry pouch. This is a clean way to carry them home to be washed at your convenience. You will find out your own washing routine. You can make it your habit to wash your pads one by one after every use, or collect used pads and wash them all at once when your period is over. Do whatever works best for you. Experiment and create a routine that suits you. If you are travelling comfortably, staying at a hotel room or youth hostel, you can manage using your cloth pads just as you do in your home town when you are in a regular daily routine being out at work/ school. You can use our attractive travel pouch to carry your fresh and used pads. Soiled pads can be stored by folding the two ends towards the middle and fastening them with the buttoned flaps to wash them at your convenience. And if anyone does see your drying pads in your youth hostel dorm, it might serve as a great opportunity to open an inspiring conversation about reusable menstrual products to spread the word! If you are travelling more basic and you do not have your ‘own’ place or the time to wash and dry your pads we can be more pragmatic. For those who are comfortable with an internal product we recommend to use a menstrual cup. This makes travelling on your menstruation easy as you only need to rinse it and you can reuse it immediately. For those who prefer pads and feel they just really can’t wash a reusable pad, we recommend an eco-friendly disposable brand of organic cotton with biodegradable leakproofing made out of for example corn starch instead of plastic, but to switch back to reusable whenever possible as even eco-friendly disposable products induce more burden to our environment and health in their production, shipping and disposing. The secret is to first soak the pads in cold water for 30 minutes before washing. This ensures the pads to remain stain free. This is so, because blood contains protein, which rinses easily in cold water, while warm water coagulates protein, making it set in the fabric. When wet, squeeze the water out of your pad. If the water is transparent, it means that the blood has been washed out of the inner layers of your pad. Yes, cloth pads are perfectly safe and hygienic to wear when they are washed well, dried in direct sunlight and stored properly. Cloth has been used by millions of women across the world to manage menstruation for generations. The real question is not whether cloth is hygienic, but whether it is cared for hygienically. Are panties inherently unhygienic? Issues related to cloth pads are linked to unhygienic practices such as poor washing or drying, rather than the cloth itself. Learn more in our full care instructions. Soaking used pads in cold water prior to washing in warm water, is to ensure the pads remain stain free. Blood is washed out easily when initially rinsed in cold water. After that you can wash the pad in warm water. However, harmful bacteria can develop when the pads stay moist. It is not so much the washing but the drying of your clean pads that matters! Dry your pad in a tumble dryer or in direct sunlight (best as UV kills germs) and you’ll be sure that it is safe to use! We have found that washing cloth pads doesn’t take much more water than washing underwear or any other cloth of the same size. Especially if you use a washing machine, after the initial cold water rinse, you can just add the pads to your regular laundry machine load. If a women do not have access to reasonably clean water or enough water to wash their clothes, then maybe washable cloth pads are not the solution. We have found that most regions in rural India do have the resources to continue their traditional practice of using washable cloth for menstruation, and more importantly draw attention on the eco-dangerous alternative: Just consider that a disposable plastic pad will in turn again contaminate the water in the environment as it takes up to 800 years to decompose, or even when burnt the fumes will come back down with the rain. Our decision to use a layer of PUL (polyurethane laminate) is the trade off we have made in order to make our pads functional. We needed a leakproof solution for women to be confident using cloth pads. PUL is an international standard used in reusable cloth diapers and other reusable cloth pads while being the best option to minimize waste at present. The ‘pantyliner pack without PUL’ is our option without PUL. One of our cloth pads is the equivalent of approximately 75 disposable pads so it is a much more eco-friendly option than disposable pads. Our Vibrant range pads’ top layers are dyed with colours, that are in line within the organic standards used per international regulations. The inner layers are unbleached and undyed. Our Natural Organic range is fully certified organic. This range is unbleached and undyed, in natural cream colour. The answer is ‘Yes’. And here are the details: When we started Eco Femme production in 2012, we decided there was a need to make cloth pads affordable for women with limited means of income. This informed our choice to start with conventional cotton. We then set out to find ways to offer our product in organic quality. We wanted to stay within our values of providing a product that is healthy for our bodies and our environment. And it turned out to be feasible! From January 2016 all the cotton flannel in our Vibrant Range was switched to organic cotton, except the striped backing fabric. Since late 2017 the striped fabric is also of organic cotton. In July 2017 we launched our undyed Natural Range with organic certification from GOTS : Global Organic Textile Standard and in 2018 we received certification for our coloured Vibrant Range. Eco Femme is also in the process for vegan PETA certification: People for the Ethical Treatment of Animals. The leakproof layer of PUL (polyurethane laminate) will last for approx 75 washes. So Eco Femme washable cloth pads can last 3 to 5 years, depending on how frequently you use them and if you care for them properly. For example: Do not use a brush to wash the pads, so the quality of the fabric is well maintained, and stick to the rinse-in-cold-water-first-rule to keep them clean. When you feel your pad is no longer working well, recycle it as much as you can. Remove the press buttons (you can hammer them to open), separate the PUL layer (polyurethane laminate) from the remaining cotton layers. The cotton can be recycled with other waste fabric or composted as it is made from organic cotton. The PUL layer can sometimes be removed from the cotton to which it has been fused. In that case the cloth can be recycled and the PUL layer can be added to the plastic waste. If not, the PUL with the fused cloth are “mixed waste”, which generally gets burned or landfilled by the municipality. The press buttons are made of metal and can be given for metal recycling. When you feel that repeated use in ‘hard water’ areas, your pads might have become a little stiff you can do the following: To help keep your pads soft, soak them in water adding a little baking soda, vinegar or a squirt of lemon juice and a drop of essential oil (another idea is to wash the pads in water where neem leaves have soaked over night). Then when drying, scrunch the pad a little before it is fully dry then pull it into shape. This should help to keep your pads nice stay nice and soft. To make your own natural laundry conditioner, visit this link. This is possible when your vaginal secretions of blood and discharge become more acidic in pH. The natural vaginal flora is acidic in a healthy state but can become more acidic at times, for example towards the end of menstruation where there is more vaginal discharge along with the period blood. This is not necessarily a concern, but can also be a healthy sign of natural cleansing of the body! So in fact, not all women experience this discolouration of the pads. We use eco-friendly dyes and have found that this can happen in those colors that have colour red in their spectrum: red, pink, purple – not the blue. The red colour is sensitive to acidity. We have been doing research on the dyes, while being firm to stay with eco-friendly and healthy dyes. In India, women have traditionally used scrap cloth from old saris or towels, folded and held in place by underwear or a string “belt.” These cloth scraps are generally used for 2 to 3 months, then burned or buried. To this day, most – an estimated 74% – Indian women are still practicing this traditional method of managing menstruation. Some women improvise using locally available materials such as sand, ash, rice husk, plastic and paper – with such practices hygiene is a concern. As Indians have more disposable income, there is a trend toward the use of commercially available disposable sanitary napkins, but even better, as awareness is growing in the past few years, a trend for cloth pads and menstrual cups! - Firstly, cloth pads are not a cheap product to manufacture – the raw material costs (pure cotton and leakproofing), stitching charges and overheads associated with pad production make a cost price below Rs100 difficult to achieve. - The next problem then becomes selling the pad due to the stiff competition with disposable pads which are seen as more cost effective, convenient, and also seem cheaper (although in the long run cloth pads are actually cost saving). - Lastly, women often have a hard time to understand and appreciate the up front cost for cloth pads – explaining this requires a serious time investment and makes cloth pads a rather “hard sell”. Eco Femme has developed a cross subsidy model, where we sell the cloth pads for a premium price to a high end market which enables us to cross subsidise for economically disadvantaged women at a price they are comfortable to pay (usually about Rs. 50). Check the programme page for more information. We often have volunteers working with us and find it to be a wonderfully enriching experience for all involved. As of August 2018, we are unable to take new volunteer applications but will do so again when we have an opening. At our office we strive to create a welcoming, fun, caring, and creative atmosphere in which to work productively and be together. Our weekly team meetings start with sharing something a team member has found inspirational and beautiful over the past week, and we always love to have a good laugh, too! We are always happy to welcome visitors, groups of students, and interested individuals to our Open House hour and to arrange information sessions to learn more about our work. In this way we try to always keep an open door, as we are often pleasantly surprised at how just the right person walks through at just the right time! While we are each focused on our specific areas of work, we also value learning together as a team about each person’s work and related global movements, news articles, documentaries, books, and resources of interest. This helps us create a balanced work environment with structure that allows us to meet our goals and grow as a business and the fluidity to bring our full selves to our work and receive fulfillment in return. When you work or volunteer with Eco Femme, you are included in the team and much more – you are welcomed into a supportive community and invited to share your gifts. You can share the articles from our blog to give information, such as, that a woman produces 150kg of sanitary waste in her lifetime, or that chemicals from plastic pads and tampons can be found in the blood stream. You can connect and share our work on Facebook, Twitter and Instagram. And if you are enthusiastic, we can send you some flyers to distribute and you can join our ambassador network. Help us to spread the word and join the #ClothPadRevolution! Eco Femme is a registered unit under Auroville Export Trust which operates as part of the Auroville Foundation under section 20(4) of the Auroville Foundation Act, 1988. All accounts of units/trusts under Auroville Foundation are consolidated and one single income tax return is filed under one PAN: AAATA0037B. All trusts are recognised as non-profit, non-governmental organisations. Auroville has FCRA recognition making it eligible to receive foreign donations. The executives of Eco Femme are Kathy Walkling and Jessamijn Miedema who are responsible for ensuring fiscal accountability. Eco Femme maintains rigorous book keeping and accounting of each transaction and can provide detailed reporting on expenditure against donations. Our accounts are audited annually by a representative of the Comptroller and Auditor General of the Government of India. As a social enterprise, Eco Femme’s commercial activities selling premium priced cloth washable pads, generate a surplus – 33% is contributed towards Auroville as part of our social commitment to the community while the remaining surplus is ploughed back into the organisation. Firstly, we question the need for laboratory testing as it typically focuses on the sterility of menstrual products when the real issue is safety. In reality, menstrual products are not intended to be sterile (this is also the standpoint of the global assocation EDANA in their Guidelines for Testing Feminine Hygiene Products, Dec 2018), nor are vaginas which rely on many bacteria to promote vaginal health. As well as being impractical, an emphasis on ideas around sterile menstrual products plays into unhelpful attitudes claiming that menstrual blood is “dirty” or “unhygienic”. Any critical examination of menstrual products should be based on safety, where safety relates to materials and appropriate use such as thorough washing and drying. Eco Femme cloth pads are made from GOTS (Global Organic Trade Standard) certified cotton flannel. In our personal experience, and from the experiences of many other women, cloth pads are safe to use when cared for properly. We do not believe in discounting these experiences. In this context, emphasis on clinical or laboratory testing simply for the sake of testing, when there have been no issues, risks perpetuating a menstrual culture that alienates women from their lived experiences and common sense. One last note on laboratory testing regarding cloth pads, as this is a not uncommon question. It is curious that the onus lies with cloth pad producers, when cloth is widely accepted as a known and safe material, especially so with organic certification. Compare this with disposable pads, where manufacturers are not legally required to disclose the ingredients. In 2014, US organisation Women’s Voices for the Earth commissioned laboratory The short answer is ‘no’. Fabric softener or conditioner can damage the PUL (leakproof) layer of your pads as well as actually reducing the absorbency of the cotton. To keep your pads soft, we recommend adding a tablespoon of vinegar to your soaking water and to scrunch your pads a little before they are totally dry to help loosen the fabric.

As we saw in Water Usage and Conservation – Analysis, showers turned out to be the largest water usage activity we do while boondocking. Showers consume fresh water and generate grey water creating problems with tank capacity. When trying to conserve water, how one takes a shower is important. Where you take the shower can also be a factor in managing grey waste water tanks. Each RV we have owned over the years has had both inside and outside showers. Exploring different bathing methods could provide additional shower alternatives. The slide-in truck camper has a wet bath as shown above. A wet bath puts the toilet, sink and shower into the same space so that spray from the shower will make the entire bathroom wet. The shower head is located inside the wet bath on the wall shared with the wardrobe closet. The shower curtain slides in the door opening directly across from the bathroom sink. In the above drawing, the bathroom door is closed. A dry bath is where the shower curtain closes in the space where the bathtub or shower are. No spray from the shower should be reaching the floor outside the tub, the toilet or the bathroom sink. This is the normal type of bathroom you would find in a typical US house. Shower heads in RVs generally have a valve on the shower head to turn on or off the water flow. In the picture above, the left shower head is off and the right shower head is on. The shower head is detachable from the wall with a hose that runs to the top of the sink’s faucet. A pull lever on the sink (between the hot and cold water knobs and in front of the hose) diverts water to the shower head. This setup is similar to a residential bathtub and shower combo except that instead of the tub faucet having a knob to pull to make the water divert to the shower, it is the sink faucet with the knob. The basic premise behind Navy Showers is to turn off the water after the hair and body are wet. Next, the hair and body are soaped up (water is still off) and scrubbed. After scrubbing, the water is only turned on long enough to rinse the body clean of soap. My preferred way to shower is to just turn on the water and let it run continuously until I’m done with my shower. My dad, a 22 year Navy veteran from way back called these water wasting showers “Hollywood Showers.” While staying in Davis Mountains State Park (Davis Mountains State Park Recap), I did Hollywood Showers six mornings and kept track of my water usage. My average over six days was 9 gallons per Hollywood Shower compared to an average of 2.8 gallons per Navy Shower (Water Usage and Conservation – Analysis) done during a previous trip. My Navy and Hollywood Showers from the studies I did always included shaving. In a residential setting, I leave the hot water on full when I shave making it easier to rinse the stubble and shaving cream from the razor. However, especially during cold weather, the camper’s 6 gallon water heater has trouble keeping up with hot water demand. Running the water continuously for 5 minutes may not be such a good idea. My solution for shaving is to partially fill the wet bath sink. When the razor blade needs clearing I just shake the blade in the water until all the junk comes off. Afterwards, the sink water stays hot long enough for me to use the water for another purpose – getting my washcloth soaped up and ready for scrubbing. In totally remote areas where there are few people, waste water tank space can be saved by using the outside shower. Like the wet bath shower, the outside shower also has a valve on the shower head to turn the flow on or off. Our previous boondocking locations lacked the privacy necessary for outside nudity so we haven’t done any outside bathing. Bathing Without Water Last year, while at Big Bend National Park (Big Bend National Park 11/2017 Day 1), we were staying in the Rio Grande Village Campground. I quickly tired of the showers there and decided to try something new and different. Early last year I had a surgical procedure done. The surgery center provided me with antibacterial antiseptic wipes to use instead of showering. The surgery center said bathing this way reduces infections. I had never used wipes like these before and was surprised at how clean they made me feel. I bought a few packs of No Rinse Bathing Wipes from Amazon before our Big Bend Trip to try out. The packs come with 8 washcloth sized moist towelettes. I scrubbed with each towelette until almost dry before switching to another one. I found that I could clean my whole body with only 4 towelettes if I wasn’t too dirty. After bathing with the towelettes for 3 days, I discovered that I couldn’t stand my dirty hair and scalp. The towelettes don’t replace shampoo. What worked best for me was to shower and wash my hair on day three. On days one and two, the towelettes work just fine. Based on my experience with the no rinse bathing wipes, I would use them again. Hope to see you on the road ahead!

I have been doing a lot of travelling lately and have been noticing a few things that I take on every single trip whether I’m driving, flying or simply staying away from home. Coincidentally the items all end up in my carry-on. I tend to travel with a carry-on suit case and one bag (usually a back pack) so for that reason everything ends up in my carry-on, but if I were checking a bag I could put some of these items in the checked bag as I don’t need them all during the travel from point a to point b. My eyes are very sensitive to light so I wear sunglasses year round. My Ray Ban tortoise wayfarers are always my first choice for travel because the tint is perfect for even a cloudy day. Having a pair in your bag always comes in handy! Rechargeable Battery Pack Not surprisingly to most of you I use my phone quite a bit and therefore the battery tends to drain before the end of the day (especially on work trips where I am checking emails etc. all day and then out for dinner before calling home later in the evening). I never go on a trip without an extra battery pack. Oh, and of course I always have my phone charger handy in case there is an opportunity to get charged up in an airport, in the car or using the USB port on many Air Canada flights. Yes, baby wipes. I use them as make up removers before I go to bed and they come in handy while away from home. Monat Rejuveniqe Oil This stuff is simply the only thing that keeps my face “normal” while travelling. I tend to get dry skin from all the different air conditioning in planes and hotels; I use a few drops of this oil on my face every morning after washing my face and it keeps my skin from drying out. Not to mention is helps with dark circles under your eyes (just a little added bonus). Lululemon Rulu Scarf Also known as the best scarf ever! Wear it as a scarf, transform it into a shall, open it up completely to be a blanket. It’s the best travel companion hands down. Tip: This scarf is usually a better price on the lululemon website if you’re planning to purchase 🙂 I get blisters all.the.time. having bandaids on hand has saved my feet more times than I can count. I often wear them before I ever get a blister as preventive maintenance as well. Headphones in a tiny case Most people bring headphones, but this little case is the real gem. It’s the perfect size, keeps your headphones tidy and even has a little mirror inside. Not only are wristlets the easiest thing to bring to receptions or dinners they are also a handy way to have critical items out of your back pack or other bags and handy to buy a coffee, show your ID, check Instagram, etc. It also doesn’t take up a lot of room to add back into your bag when you’re ready to store the items. Back to the air conditioning in planes and hotels… I don’t know about you buy I tend to always need a tissue when travelling. Don’t risk it, get a small pack to keep in your bag. Dior Lip Glow Hands down the best lip product I have ever purchased. I am currently on my fourth tube of this stuff – it keeps your lips moist and helps with chapped lips while also bringing out the natural shade of your lips. It will look a little different on everyone because of that but you can’t go wrong with the original version in 001 pink. What items do you always travel with?! I’d love to hear from you and appreciate you sharing this post if you found it helpful. Safe Travels 🙂 My shoes for that: Michael Kors Flats SHOP THIS POST

A Slice of this Soft and Sweet Chocolate Chip Apple Bread with Fresh Apple Bits, Chocolate chips and Toasted Walnuts Makes for a Wonderful Morning Treat or Snack Throughout the Day! Apples, the fruit with its greatest moment of attention in the Fall and is generally overshadowed any other time of the year by Spring berries and Summer stone fruits. Though today, they’re going to shine! There are countless of apple recipes here on URBAN BAKES. Such as this apple tart mixed in a warm bourbon cider sauce or the tiniest chocolate drizzled caramel apples cutely decorated above a cake and of course the all-time fan favorite, cinnamon apple, as seen in this twist bread. Want to go more savory? I got you covered in these biscuits too! With so many apple recipes created in my kitchen, it’s no wonder they have become a staple in my home. My furbabies are just as guilty of enjoying them as well. With a few slices each day in which I sometimes join in with creamy peanut butter. So you’re probably wondering why I’m showing an apple recipe now. Truth be told, I’ve been a little preoccupied at my other workplace which has left me with little time to get creative. Coincidentally however, I noticed a little more attention towards an old post: Chocolate Apple Bread. Have you seen this bread?! It was made seven years ago with THE MOST unappealing images. Shot with a 4S iPhone, I must have saved the images small and expanded them which made them extremely pixelated. But what’s a little more embarrassing is that I decided to use red chocolate chips to bring out the illusion of “pieces of red apples.” I mean, who was I kidding? LOL Although I despise the images, I still like to keep them as a small reminder of how far I’ve come in food photography. I forget about these old posts and like the lemon cupcakes and brownies recently re-created from older versions, I felt it was time to do the same for this recipe. After all, this bread is quite amazing! The images do not give this bread justice in how moist and tender the inside crumb is truly like. Every so often, you take a bite and get a small pocket of the natural juice surrounding the apple chunks and bits of chocolate. Most breads have a dry consistency with more of a bland flavor. But this quick bread is similar to a banana or pumpkin bread where it’s more on the sweeter side. And the crumb topping! Oh. My. Goodness. This is the best part! A good bite will give you a satisfying light but solid crunch to the soft and sweet interior. Eat this bread warm with a slather of salted butter and you will be craving this not just for breakfast to kickstart your morning but even to snack on throughout the day. Just be careful, it’s addicting! Did you enjoy this recipe? Consider rating and commenting below. I love to see your feedback and help answer any questions you may have. Don’t forget to check below for related recipes.Print A Slice of this Soft and Sweet Quick Bread with Apple Chunks, Bits of Chocolate and Toasted Walnuts Makes for a Wonderful Morning Treat or Snack Throughout the Day! - 1/3 cup (45 grams) toasted walnuts, finely chopped - 2 tablespoons (25 grams) mini chocolate chips - 2 tablespoons (25 grams) granulated sugar - 1 tablespoon (14 grams) unsalted butter, softened - 1/4 teaspoon (2 grams) ground cinnamon - 2 cups (250 grams) all-purpose flour - 1/2 teaspoon (4 grams) salt - 1/2 teaspoon (3 grams) baking powder - 1/2 teaspoon (3 grams) baking soda - 1/2 teaspoon (5 grams) ground cinnamon - 1/4 teaspoon (2 grams) ground nutmeg - 1/2 cup (113 grams) unsalted butter, softened - 1 cup (200 grams) granulated sugar - 2 large eggs (100 grams) - 2 tablespoons (30 ml) buttermilk - 1 teaspoon (5 ml) pure vanilla extract - 1 1/2 cups (180 grams) apples, chopped - 1/2 cup (100 grams) toasted walnuts, chopped - 1/4 cup (50 grams) chocolate chips - Heat oven to 350 degrees Fahrenheit (175 degrees Celsius). Line a 8 1/2 x 4 1/2 inch loaf pan with aluminum foil leaving excess foil to hang over two opposite sides for easy removal. Grease and flour bottom and sides of pan or use a baking spray with flour; set aside. - In a small bowl, mix all crumb topping ingredients together: sugar, cinnamon and walnuts; set aside. In a medium bowl whisk flour, salt, baking powder, baking soda, cinnamon, and nutmeg; set aside. - In a large bowl using an electric mixer on medium speed, cream butter and sugar until light in color and fluffy. Add eggs, buttermilk and vanilla; mix until just combined. On low speed, gradually mix in flour mixture. Stir in apples, walnuts and semi-sweet chocolate chips. Pour batter into prepared loaf pan. Sprinkle the top with crumb topping. - Bake for 50 to 60 minutes or until a wooden skewer inserted into the center comes out clean. Allow bread to cool in pan for 10 minutes before grabbing the foil overhang to remove to a wire rack for further cooling. Slice loaf warm or at room temperature. Serve with butter or jam. ENJOY! - Prep Time: 20 minutes - Cook Time: 1 hour - Cuisine: American

Somewhere at the bottom of my purse is a small drawstring bag that holds something precious: a number of small pewter hearts. These little charms — part of Mexican folk religion — are called milagros, the Spanish word for miracles. Each milagro represents a particular prayer, and much like our own prayers, milagros come in all shapes and sizes. For example, if your abuelito (grandpa) is lame, you might get a milagro in the shape of a leg or a crutch. A cow-shaped charm might symbolize someone’s prayer that a beloved milk cow recover from illness. A heart-shaped milagro suggests a prayer for the heart, either literally or figuratively — it might represent a prayer for someone recovering from a heart attack, or perhaps a prayer that a relationship be repaired or that an unmarried child find a spouse. As someone who is intrigued by meaning and metaphor, the heart shape offers me many possibilities. For a friend who had lost his father, the milagro became a prayer of consolation. For a crying teenager, it was a reminder that she was truly loved. For the stranger confiding in me during a plane trip, it was a symbol that God knows the deepest desires of our hearts. I once gave out milagros at the end of a retreat I facilitated for board members — those milagros became the heart of service. Over the past ten years, I’ve given close to six thousand of these little hearts … one by one by one. While these prayers are offered for others, I must confess that they are also meant for me. It is my constant prayer that I experience myself in the heart of God in each moment. Every time I place a milagro in someone’s hand, the reality of that connection becomes a little bit clearer. Sometimes, when I am feeling a bit lost, I take one out and hold it in my hand. The slight coolness feels good. Looking at the milagro’s surface, I see that it is rough, worn, imperfect — a lot like me. And just like that tiny heart in my hand, my presence also can be a prayer. It never fails that when I give someone a milagro, a connection is made. The person’s eyes might light up or grow moist with tears. He or she might grab my hand or give me a hug. Invariably, the people to whom I give a milagro hold their little heart close and promise to keep it in a special place. They need not worry; they are that special place. Funny, isn’t it, the impact these little hearts have?

An intraoral scanner is a handheld device used to directly create a digital impression of the oral cavity. Light source from the scanner is projected onto the scan objects, such as full dental arches, and then a 3D model processed by the scanning software will be displayed in real-time on a touch screen. Mask is a covering worn over the mouth and nose in order to reduce the transmission of infectious agents or to prevent the inhalation of pollutants and other harmful substances. A scar repair sheet is a soft silicone self-adhesive occlusive sheet. It is designed for the management of hypertrophic and keloid scars and the prevention of hypertrophic or keloid scarring after surgery on closed wounds. The sheet should be cut down to the size of the scar; multiple sheets can be used for larger scars. The adhesive side should be placed downwards onto the scar. Adhesive bandage tape can be used if the sheet doesn’t stick. They should remain over the scar for a minimum of twelve hours a day. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots. If you have varicose veins, spider veins, or have just had surgery, your health care provider may prescribe compression stockings. An alginate dressing is a wound dressing that contains alginate fibers derived from seaweed. These dressings are used in the management of wounds that are producing a great deal of exudate, such as deep sores. These dressings are made primarily of seaweed derivatives, and the fibers are spun into ropes or sheets. As the alginate absorbs fluid, it is converted to a gel that provides moisture to the wound bed. Alginates always require a secondary dressing to keep them in place. Hydrocolloid dressings provide a moist and insulating healing environment that protects uninfected wounds while allowing the body's own enzymes to help heal wounds. These dressings are unique because they don't have to be changed as often as some other wound dressings and are easy to apply. The silicone foam dressing offers extreme absorbency, great fit and promotes fast healing for most wound types and stages. This self-adhesive foam dressing helps create a conducive environment for healing by keeping the wound moist and preventing bacteria contamination/activity. A dental microscope is an important tool that allows for better visualization through magnification of objects. In dentistry, microscopes enhance precision which not only enhances the quality of the dentists’ work but also helps ensure the long-term dental health of the patient. For dentists, some of the primary goals include micro-invasive surgeries, minimizing risks and reducing the overall healing time. A microscope is an instrument that can be used to observe small objects, even cells. The image of an object is magnified through at least one lens in the microscope. This lens bends light toward the eye and makes an object appear larger than it actually is. The microscope may provide a dynamic image (as with conventional optical instruments) or one that is static (as with conventional scanning electron microscopes). Dental 3D printers feature light or laser that polymerizes a liquid with the computer-guided precision required to produce small objects with intricate details. The dental 3D printing workflow has four steps. The first step is to scan – collect a digital impression with an intraoral scanner. Send the scans to a lab or to a design station. The second step is to design – import the digital scan into design software (CAD) and design. The third step is to print – once designing is complete, import the file to print preparation software for printer setup. The last step is to prepare – wash, dry, and post-cure printed parts.

This article was co-authored by Maggie Moran. Maggie Moran is a Professional Gardener in Pennsylvania. wikiHow marks an article as reader-approved once it receives enough positive feedback. This article received 25 testimonials and 95% of readers who voted found it helpful, earning it our reader-approved status. This article has been viewed 1,390,034 times. Vermicomposting, or worm composting, allows you to compost your food waste rapidly, while producing high quality compost soil and fertilizing liquid. Best of all, it's self-contained and nearly odorless. Part 1 of 3:Making a Home for Your Worms 1Obtain a worm bin. The worm bin is basically the home for the worms, and the place where they digest the organic material you will give them. Worm bins can be purchased from many online vendors, or from your local gardening or farm supply store. 2If you don't want to buy a worm bin, you can also build one on your own. Use rubber storage totes, galvanized tubs, wood, or plastic. X Trustworthy Source United States Environmental Protection Agency Independent U.S. government agency responsible for promoting safe environmental practices Go to source - Material: Rubber is cheap, easy to use and durable. Galvanized tubs are somewhat costly but will last forever. Wood will eventually be eaten, and plastic cracks easily, but either will do in a pinch. Some people prefer wooden compost worm bins because they may breathe better and absorb excess moisture, which can be hazardous to the worms. Just don't use chemically-treated wood, which may be dangerous to worms or leach harmful chemicals into your compost. 5 gallon (18.9 L) plastic buckets now for sale by most hardware stores can be used - especially if you live in an apartment. Clean the 5 gallon (18.9 L) buckets thoroughly with soap and let them sit for a day or so filled with clean water before using as a worm bin. - Ventilation: Your bin should be well-ventilated, with several 1/8 inch (3mm) holes 4 inches (100mm) from the bottom (otherwise the worms will stay at the bottom of the bin and you may drown your worms). For example, you can build a worm bin out of a large plastic tub with several dozen small holes drilled out on the bottom and sides. Untreated wooden bins are naturally ventilated because of structure of wood. - Size: The larger you make the container, the more worms it can sustain. Estimate 1 pound (0.45kg) of worms for every square foot of surface area. The maximum productive depth for your bin is 24 inches (61cm) deep because composting worms will not go further down than that. - Cover: The bin should have a cover to prevent light from getting in and to prevent the compost from drying out. Choose or make a lid that can be removed if your compost is too wet. Use a canvas tarp, doubled over and bungee-corded on, or kept in place with wood. Burlap sacks also work well, and can be watered directly. 3Use four old car tires for a makeshift home. To make a four-tire wormery, create a base from old bricks or flagstones (must be flat and with as few cracks as possible). - Place a layer of heavy newspaper on top of the bricks. Stuff four old tires with newspapers. - Pile the tires on top of each other, with the first tire on the Sunday newspaper. Put some scrunched up paper or cardboard in the bottom to soak up any excess liquid. - Fill the entire wormery with organic material (semi-composted is best). Add the composting worms (tiger or brandling species are best). - Use a piece of board weighed down with bricks as a lid. The lid must be big enough to stop rain getting in. - Harvest a tire's worth of fertilizer roughly every 8 weeks (during warm months). 4Place the worm bin in a cool area to protect it from excessive heat. If you're keeping your worm bin outside, consider placing it in the shade, under a tree, in the garage or shed, or along the side of the house. - Try keeping the outdoor temperature in the bin between 30 and 70 degrees Fahrenheit, along with at least 4 inches of moist bedding in the bin. This should be an ideal home for your compost-zapping worms. Part 2 of 3:Building Your Ecosystem 1Prepare the bedding for your worms. The bedding is the natural habitat of the worm that you're trying to replicate in your compost bin. Fill your bin with thin strips of unbleached corrugated cardboard or shredded newspaper, straw, dry grass, or some similar material. This provides a source of fiber to the worms and keeps the bin well-ventilated. Sprinkle a handful of dirt on top, and thoroughly moisten. Allow the water to soak in for at least a day before adding worms. X Research source - Over time, the bedding will be turned into nutrient-rich compost material by the worms. When you harvest the composted soil, you'll have to introduce new bedding into the worm bin again. - Canadian peat moss, sawdust, (rinsed) horse manure, and coconut pith fiber are also great for composting. - Avoid putting pine, redwood, bay or eucalyptus leaves into your bedding. Most brown leaves are acceptable in vermicompost, but eucalyptus leaves in particular act as an insecticide and will kill off your worms. 2Choose which worms you want. There are several varieties of worms that that are bred and sold commercially for vermicomposting; just digging up earthworms from your backyard is not recommended. X Research source The Internet or local gardening club is your best bet for finding a worm vendor near you. A pound of worms is all that is recommended. - The worms most often used, Eisenia fetida (Red Wigglers), are about 4 inches long, mainly red along the body with a yellow tail. These worms have a healthy appetite and reproduce quickly. They are capable of eating more than half their own weight in food every day. - Another variety to consider are Eisenia hortensis, known as "European night crawlers." They do not reproduce quite as fast as the red wigglers, but grow to be larger, eat coarser paper and cardboard better, and seem to be heartier. They are also better fishing worms when they do reach full size. - However, as with any non-native species, it is important not to allow European night crawlers to reach the wild. Their voracious appetites and reproductive rates (especially among the red wigglers) have been known to upset the delicate balance of the hardwood forests by consuming the leaf litter too quickly. This event leaves too little leaf litter to slowly incubate the hard shelled nuts and leads to excessive erosion as well as negatively affecting the pH of the soil. So, do your best to keep them confined! X Research source of worms to start. Horticulturalist Maggie Moran advises, "It is ideal to start with between 1 and 3 pounds (0.45 and 1.36 kg) of worms, depending on the size of the bin. On average it takes 5–7 pounds (2.3–3.2 kg) of food each week to sustain a worm bin."|}} Part 3 of 3:Maintaining and Harvesting Your Compost 1Feed your worms digestible amounts regularly. The bedding of your compost bin is a great start, but the worms need a steady diet of food scraps in order to stay healthy and produce compost. Feed your worms at least once a week in the beginning, but only a small small amount. As the worms reproduce and grow in numbers, try to feed them at least a quart of food scraps per square foot of surface area each week. X Research source - Worms eat fruit and vegetable scraps; bread and other grains; tea leaves; coffee grounds; and egg shells. Worms eat basically what humans eat, except they are much less picky! - If you can process your scraps before you introduce them into the compost bin, you'll find that your worms will eat them quicker. Worms go through smaller-sized food more quickly than they can larger-sized or whole food. In this respect, they are also like humans. - Mix the scraps into the bedding when you feed the worms. This will cut down on fruit flies and will give the worms more opportunities to eat. Don't just leave the scraps on top of the compost heap. 2Maintain your bin. Keeping your bin elevated off the ground, using bricks, cinder blocks, or whatever is convenient will help speed composting and keep your worms happy. Worms are capable of escaping almost anything, but if you keep your worms fed and properly damp, they should not try to escape. A light in the same area will ensure your worms stay put. - Sprinkle the surface with water every other day. You want your bedding to have the dampness of a wrung-out sponge. - Add more cardboard, shredded newspaper, hay, or other fibrous material once a month, or as needed. Your worms will reduce everything in your bin quickly. You will start with a full bin of compost or paper/cardboard, and soon it will be half full. This is the time to add fibrous material. 3Pay attention to some composting "dont's". Composting bins are not difficult to maintain, but they do need to be looked after. Here are some things that you shouldn't do if you want a healthy, hearty ecosystem. X Research source - Don't feed your worms too much. If your compost bin starts to smell, it could be because you are feeding your worms more than they can process. When this happens, the bedding can also heat up, killing off the worms. - Don't feed your worms any combination of the following. These foods are difficult for the worms to digest: - Excessive citrus — no more than 1/5 of the total worm food - Meats or fish - Fats or excessively oily scraps - Dairy products (eggshells are fine) - Cat or dog feces - Twigs and branches 4Harvest the compost once it's ready. After 3-6 months, you should have a fair amount of worm compost stored up in your bin. Now it's time to harvest. Keep in mind that you might not be able to save every worm when harvesting the compost. That's okay; by and large, your worms have multiplied, and there should be plenty to continue composting. - Put on rubber gloves, and move any large un-composted vegetable matter to one side. Then, with your gloved hands, gently scoop a section of worms and compost mixture onto a brightly lit piece of newspaper or plastic wrap. Scrape off the compost in layers. Wait a while giving the worms time to burrow into the center of the mound. Eventually you will end up with a pile of compost next to a pile of worms. After harvesting, you should replace the bedding and then return the worms to the bin, do whatever you want with the compost, and repeat. - If you prefer a hands-off technique, simply push the contents of the bin all to one side and add fresh food, water, dirt, and bedding to the empty space. The worms will slowly migrate over on their own. This requires much more patience, of course. It could take up to a few months for the worms to fully migrate to the scraps-side of the compost bin. Did you know you can get expert answers for this article? Unlock expert answers by supporting wikiHow QuestionHow long does it take for a worm to reproduce? QuestionHow many worms do you need to start a worm bin? QuestionHow much money can you make selling worms? Calcium carbonate works well to solve most problems. Be sure to use calcium carbonate (e.g., powdered limestone) and not quicklime (calcium oxide). Shredded paper, egg cartons, cereal boxes, and pizza boxes all make excellent bedding (avoid glossy paper). Always soak household paper waste bedding for at least 12 hours before adding it to the bin, and thoroughly squeeze out the water first. Don't shred junk mail envelopes unless you remove the plastic windows! Worms won't eat plastic, and picking hundreds of shredded plastic window panes out of otherwise beautiful compost is a vermiculturist's nightmare. A balanced diet makes for a healthy bin, healthy worms and a great finished product. - Large amounts of green feeds (grass, alfalfa, etc.) heat up quickly and should be added lightly. - Fresh (un-composted) cow manure contains harmful pathogens and should not be used. It will also heat the bin to deadly levels and kill your worms. - Go easy on the citrus rinds. You can add them, but remember that they're acidic. If possible, add only a little at a time with plenty of other matter. - Powdered limestone will create carbon dioxide in your bins and suffocate your worms if the bins are not well ventilated. Use sparingly only if absolutely necessary and stir your bin every few days following adding. - If cool temperatures are an issue in your area, move outdoor bins into a garage or shed during winter. If bringing your worm bin indoors during the winter is not possible, add a small heating pad as follows: push the matter away from one side, place the pad up against that side, then backfill onto the pad. Run the wire out to an extension, plug it in and leave the pad set on low - or medium in particularly cold weather. This will prevent freezing in winter. - Don't allow your worm bin to heat up past 90 degrees. X Research source You will cook your worms -- something no one should smell. - ↑ https://www.epa.gov/recycle/how-create-and-maintain-indoor-worm-composting-bin - ↑ http://compost.css.cornell.edu/worms/steps.html - ↑ http://www.homecompostingmadeeasy.com/wormcomposting.html - ↑ https://www.dnr.state.mn.us/invasives/terrestrialanimals/earthworms/index.html - ↑ http://compost.css.cornell.edu/worms/steps.html - ↑ http://www.homecompostingmadeeasy.com/wormcomposting.html - ↑ https://aggie-horticulture.tamu.edu/archives/parsons/publications/worm/worm.html About This Article To make your own worm compost system, build or purchase a worm bin and fill it with organic, semi-composted material and bedding for the worms. Place the worm bin in a cool, shady spot and add the composting worms, then add in fruit and vegetable peels, bread crusts, coffee grounds, and other food scraps at least once a week. Sprinkle the surface of the compost bin with water every other day. For advice from our horticulture reviewer on what you shouldn’t put into your bin, like meat or large amounts of citrus, keep reading! Reader Success Stories "I thought I could use regular earthworms. Now I know I need to find some red wigglers or night crawlers. I hear that grits, which we eat down here in the South, is what worms really like. The right amount of moisture and aeration were interesting, too."..." more

Ways to use the Malen Nach Zahlen Program to coloration Your Materials? Will you color? Can you paint by phone numbers? If not, we now have good news for you personally! Artwork is a superb interest, and it’s never been simpler to color on another levels with all the fresh paint by phone numbers phenomenon. This article will reveal to you six artistic techniques that color by quantity has brought off in today’s community. Below are 6 imaginative fresh paint by numbers concepts: 1.Choose your chosen paintbrush established or make yourself with stuff you have throughout the house like chopsticks, yarn, toothpicks, and so forth. This may be carried out any colour mixture and would even create a really cool gift idea! They’ll always bear in mind after they received some thing so exclusive. 2.Use painting pens as opposed to standard brushes if you’re at ease with pulling than artwork. The fresh paint pencils usually come in more colors than fresh paint by number, but the two can be combined. 3.Use your chosen pastels or crayons and layering them on the top of paint by amounts to make a mixed press masterpiece that is uniquely your own! This would make a very exclusive present idea for everyone who loves pulling and piece of art. 4.Painting some paint by numbers (malen nach zahlen) with watercolors, acrylics, tempera painting, as well as chalkboard painting if you’re feeling particularly adventurous. You might utilize this as the chance to try out new techniques like cracking away with the papers when it’s moist, so you can find amazing effects throughout your art! 5.Use dark watercolor color over white colored painting by variety color for a awesome watercolor result. 6.Get paint by amounts on your garments such as color splotches, paint drips, plus more! Fresh paint is common, so it may be placed on any surface, therefore you might make an ensemble that’s truly one-of-a-sort (even though some spots come to mind). The fresh paint by numbers package is a wonderful way to get creative and color all on your own!

Tuesday, 19 September 2017 A Tale Of An Empty Bottle Of DRC 1964 Richebourg - OR - How I Turned Into Rudy Kurniawan For One Day If you haven´t already, and have a couple of days over, you just have to read the 167 pages long thread about Rudy Kurniawan on the Wineberserkers forum - Rudy Kurniawan & global wine auction fraud thread. I have read every page and post since the start on the 4th of February 2012. The whole affair with Rudy that ended (?) with his 10 year prison sentence has also been captured on film with the movie Sour Grapes (a must see!) One detail that has fascinated me is - how did Rudy "make" these old Burgundies? There have been some "recipes" circulating on the net, but I thought I would give it a go myself... The original 1964 Richebourg. Drunk at my 40 year bash and performed nicely although I thought it to be a tad warm but with rich, deep, hedonistic fruit. I scored it 92p then. My blend was better, see below... The set up. I bought a bottle of 2014 Sta. Rita Hills Pinot Noir from Brewer-Clifton. Why? See the pic below from Sour Grapes (evidence from the Rudy trial) - Richebourg and Brewer-Clifton standing side by side, Rudy had something going on there... I first opened a generic Burgundy from 1964 from my stash but that one was clearly over the hill, so I grabbed a bottle of 1976 Vosne-Romanée Les Malconsort, Clos Frantin. With the two bottles of Pinot I started out making a DRC 1964 Richebourg. I toyed with a couple of different blends before I came to the conclusion that approximately 80% Vosne-Romanée and 20% Brewer-Clifton was the ideal blend. It still tasted like a mature Burgundy but it had a firmer backbone and a lovely sweetness in the background. The result. Halfway in our Barolo Boys dinner I presented an interlude between the flights. No other information was given. The unanimous verdict was that of a high quality Burgundy with some age, the guesses landed in the 80´s. I then presented the bottle... A hint of disappointment - a 64 DRC Richebourg should have, or anticipated being, even greater, but there were not any disbelief that it was the real thing. Then I presented me as Rudy Kurniawan. Shows over. We then tried the three wines side by side, the Clos Frantin, the Brewer-Clifton and my blend, and the result was again unanimous, the blend was the finest wine. "1964 Richebourg, DRC" - Barolista style A mature, deep, spicy nose with dried wild strawberries, moist forest floor, coffee grounds and a touch of mint. Deep, fine and a with a very fine sweetness. The taste is mature, multi layered and warm with notes of sweet/sour raspberries, licorice, beet root and autumn leaves. Very long and finely structured. A fine mouthfeel. Really fine. I can see a new career for myself... 93p (tasted 2017/08)

What are Polygala Tenuifolia 20:1 Extract Capsules (Yuan Zhi) Polygala tenuifolia is a perennial purple flowering plant that grows in Asia in various environments but is more commonly found growing in moist soil. Polygala can be found growing in a variety of climates but can mostly be found in grasslands, shrub forests, or prairies. Although it may seem fairly unknown, Polygala tenuifolia root has been widely used in Traditional Chinese practices and is known as Yuan Zhi or Chinese Senega. Polygala is believed to support overall cognitive function when consumed orally. Written anecdotal evidence from users report that Yuan Zhi’s calming and stimulating effects support focus and cognition without the negative drawbacks such as jitters or other feelings of overstimulation like when taking large amounts of caffeine. In fact, modern research has discovered that Yuan Zhi has adaptogen-like properties that make it a great supplement to promote healthy stress levels while simultaneously supporting optimal cognitive function. Yet, more organized research is needed to solidify this evidence. Polygala Yuan Zhi Benefits and Uses - May help support cognitive function - May help promote feelings of well being - May help support healthy stress levels - May help promote respiratory health - May help support neuroplasticity - May help promote sleep quality Polygala and The Brain Most plant extracts usually have one to two primary effects. Polygala however, has a wide range of effects, making it a unique and versatile plant extract. Regular Polygala users report experiencing a stimulating yet calm sensation when taking a Polygala supplement. This is particularly unique since this sort of feeling is typically achieved with a pairing of 2 or more supplements or what some call a ‘supplement stack’, such as Caffeine and L-Theanine. Even though it is quite stimulating, Polygala tenuifolia may also help support sleep quality. Some people say that the calming effects appear to outlast the stimulating effects which is good for those looking for balanced stimulation. The Polygala sleep promoting effects are believed to be associated with Polygala’s tenuifolin content. Tenuifolin a bioactive compound found in Polygala tenuifolia root extracts. Human studies also appear to suggest that Polygala tenuifolia may help promote spatial awareness and organization. A few studies on Polygala found that taking a Polygala tenuifolia extract may help support neuroplasticity. Neuroplasticity is the process by which our brains can adapt, grow, and change, which is a critical process for various cognitive functions since they are dependent on sufficient levels of neuroplasticity. Neuroplasticity is the foundation of memory and memories, as our memory and memories are believed to be stored by neuron connections that are physically changing. These changes are dependent on neuroplasticity. Two of the largest regulators for neuroplasticity are brain derived neurotrophic factor (BDNF) and nerve growth factor (NGF). Research has discovered that an increase in either NGF or BDNF may result in a notable increase in neuroplasticity. Many people believe Polygala tenuifolia elevates both NGF and BDNF levels. Increasing BDNF and NGF levels suggests that Polygala tenuifolia may help promote overall brain health as well as cognitive function. Polygala Tenuifolia Dosage As a dietary supplement, take one 100mg Polygala tenuifolia 20:1 Extract capsule one to three times daily. Polygala Tenuifolia Capsule Reviews For more insight, read the Polygala tenuifolia reviews and experiences below. Where to Buy Polygala Tenuifolia Capsules Nootropics Depot offers 90ct. or 180ct. jars of high quality Polygala tenuifolia 20:1 Extract Capsules (Dual Water/Ethanol Extraction). Nootropics Depot’s Polygala tenuifolia capsules have been lab-tested and verified for both product purity and identity. Attention: These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Healthy Home Upgrade If replacing your tile or installing a new vanity is a bathroom renovation that’s beyond your budget, you can afford one truly luxurious upgrade: transforming your bathroom into a tropical paradise. Low-light bathrooms with small or frosted windows pose no problems for many of these houseplants. What’s more, the high humidity in an average bathroom makes it the perfect environment for many tropical varieties. House plants are also nature's air purifiers—who knew that improving your decorating scheme also had health benefits? Hardworking spider plants prefer medium light to work their magic—that is, removing impurities like formaldehyde and carbon monoxide from the air. Water a spider plant once or twice a week, and you'll be rewarded with new buds that you can repot or gift to friends. This most Zen-like plant can grow in almost any light—even without any soil! Just place your bamboo to root in a container filled with a few inches of pebbles, then fill halfway with water, watering occasionally. If you're feeling fancy, spend a few more bucks for the variety with twisted stalks. Cast Iron Plant Popularized in the Victorian era, there's still a lot to love about the so-called cast-iron plant, or aspidistra elatior. For one, it's super hardy and can tolerate neglect, overwatering, and extreme temperatures. For best results, let the soil of this shade-loving plant dry between waterings. Dracaena, or dragon plants, come in a few varieties, but all of them are at risk of brown and dry leaf tips in low-humidity households. That's just one reason to consider this tropical plant for your bath. The natural humidity of the bathroom will keep it—and your space—looking fresh and flawless. Some gardeners find orchids a bit finicky, but in the right environment, they can flourish. Set yours on a bathroom windowsill. The indirect sunlight will nourish the plant while the high humidity mirrors the environment where orchids naturally bloom. Ferns naturally grow in the filtered light and high humidity conditions of tropical forests. Luckily, the average bathroom can simulate this environment perfectly (if a fern starts yellowing, misting it will help). The Boston fern is a bushier, wild-looking variety with feathery fronds that removes toxins, including formaldehyde, from the air. Keep its soil moist and the bathroom humidity up, and your fern should flourish. Related: 6 Common Houseplant Pests—and How to Get Rid of Them If given the opportunity, ivy can climb and scale walls, trellises, or, in this case, the metal pipes framing a tub. Hang it high by the window to save space and let sunlight filter through the leaves. One type of ivy, English ivy, may actually remove mold spores from its environment. Related: 10 Great Ways to Grow Your Walls Green This succulent is a perfect choice for a sunny bathroom window sill. Not only does it bring life to the room, but it also doubles as a medicine cabinet unto itself. After washing a cut or burn at the sink, split open an aloe leaf and apply the gel to your skin; it helps heal abrasions naturally. Sansevieria, also known as "mother-in-law’s tongue," is one of the most low-maintenance plants you can grow, which makes it the perfect choice for a bathroom. Low-light snake plants filter out formaldehyde, which is common in cleaning products, toilet paper, tissues—and even some cosmetics. Bird’s Nest Fern Easily identified by its fronds that radiate from a central knot or rosette, bird’s nest fern is a perfect bathroom plant because it grows well in areas with more than average humidity. Since it can tolerate varying levels of light, it’s appropriate for bathrooms in which the amount of light changes—if, say, you keep the shades drawn for part of the day. The less light the bird’s nest fern gets, the slower it grows. It will remain countertop (or bathroom shelf) size if your bathroom isn’t too bright, but could grow up to 2 feet tall if it gets bright to medium-bright indirect light. You don't have to have a green thumb to grow these indoor plants: As their name suggests, it doesn’t take much to keep air plants alive, just air and water. These bathroom plants prefer bright light, as long as it’s indirect light, and they like humid environments. Since air plants don’t need soil, you can get creative about the type of vessel to keep them in: Try a glass vase, seashell, or wall-mounted baskets. If you have the money to hire a handyman for every household woe, go ahead. But if you want to hang on to your cash and exercise some self-sufficiency, check out these clever products that solve a million and one little problems around the house. Go now!

A Foundation of Integrity: Over Forty Years of Exceptional Sea Salt Since our founding in 1976, Celtic Sea Salt has grown into a worldwide brand, recommended for both unique taste and unique health benefits. Our roots remain at the center of our growth. While many claim to be the original, we have had over forty years to perfect our craft, and the resulting products embody our dedication. More Information... Each of our salts comes from a unique place! Here is a list of our Celtic Sea Salt® salts and their source. Light Grey Celtic, Fine Ground Celtic, Flower of the Ocean: FRANCE Celtic Pink Sea Salt, Fossil River: SPAIN Gourmet Kosher: GUATEMALA Celtic Kosher Coarse and Fine: COLIMA MEXICO Makai Pure: HAWAII USA Rare Body Bath Coarse and Fine: VARIOUS Here is a list of our salts and their respective harvesting methods: Light Grey Celtic- Hand harvested using method invented by the Celts who settled this region of France. Seawater at high tide is trapped in estuaries until it evaporates to a brine, in which it is guided by the salt farmer through a series of clay-lined beds until by the end it is crystallizing. The farmer uses wooden rakes to pull the sunken crystals imparted with the grey color from the bed of the harvesting ponds. With little more done than natural draining, the yield is a moist, natural crystal salt with the brine, or “bitterns” still intact. Fine Ground Celtic- This salt comes from the Light Grey Celtic, just low-temperature dried and crushed for convenience. Great for baking and as a transition salt (looks the closest to regular salt) Gourmet Kosher- Hand harvested by salt farmers from lined beds where seawater is piped in and allowed to evaporate. As the crystals form they are kept in motion, yielding a beautiful, tiny, delicate crystal. Makai Pure- Greenhouse harvested salt. The seawater is taken from deep ocean currents where there is higher salinity, which yields a high-mineral salt with beautiful natural chunks and flakes. Kosher Celtic- Naturally harvested from salt ponds where the seawater is naturally filtered up through the ground. This is the most moist salt we have. Also for its price the highest minerals. Even the fine ground variety is very moist, full of the mineral-rich brine. Flower of the Ocean- This is the “cream of the crop” of salts. By skimming the crystals off of the surface of the brine, only the most delicate crystals are caught before they sink to become the Light Grey Celtic salt. Flower of the Ocean is a culinary treasure, known as a “finishing salt” or an “expediting salt” to be pinched on food right before serving. No need for a grinder with this salt, as the crystals are easily crushed between the fingers. Unrefined salts like ours have no more than trace amounts of Iodine, not enough to satisfy your daily recommended amount. Try our Gourmet Seaweed Seasoning for a great tasting seasoning that includes natural Iodine! Here are more of our Iodine options Celtic Sea Salt Iodine. We strive to ensure that the salt you get from us is just salt as Mother Nature intended. Our producers test at the source and we do annual 3rd party testing. We test for pollutants like mercury, lead, and aluminum. We also test for radiation, petroleum, and micro-plastics.

Majestic: Quality in the Details Majestic: Quality in the Details A true kitchen centerpiece that is sure to demand attention, these exceptional bespoke ranges will compliment any kitchen. The unique style of the Majestic Series stands out above the rest. ILVE offers the ability to create a customised and individual look. Brass Burner with Nanotechnological Coating Brass Burner with Nanotechnological Coating Brass is a noble material that guarantees excellent durability and the non-stick nanotechnological coating facilitates easy cleaning. Dual Gas Burners Dual Gas Burners Efficient Gas Supply provides up to 20,000 BTU burner power. The Majestic Oven is so Easy to Use The Majestic Oven is so Easy to Use Simple 4.3" TFT full touch screen, with intuitive and straightforward graphics provides easy commands for selecting thermostat, timer and automatic programmer for cooking start and finish timers. Accurate Electronic Temperature Control Accurate Electronic Temperature Control Minimal temperature fluctuation for optimal cooking; temperature spikes, uniform cooking, energy saving. Temperature is adjustable from 85°F for perfect leavening. Continuous Cast Iron Grates Continuous Cast Iron Grates Continuous cast-iron grates let you slide pots easily on and off heat, or from one burner to another. Fast Pre-Heat ILVE ovens maintain a European standard A+ energy rating, thats why ILVE ovens are equipped with a fast pre-heat mode to assist your oven to reach cooking temperature quicker and more efficiently. Sealed Oven ILVE freestanding cookers have a sealed oven cavity that traps moisture in the oven cavity ensuring that your meats remain moist and succulent! This also assists in less meat shrinkage whilst cooking. Digital Clock and Timer Digital Clock and Timer The clock and timer are digital, making it easy to view. Made in Italy Made in Italy Italians are renowned the world over for their passion for design. Combined with exquisite craftsmanship this has produced some of the most desirable products and iconic brands. That same passion and craftsmanship is what drove our founders Eugenio Illoti and Evelino Berno to create their rst commercial cooker way back in 1952. Dual Triple Ring Burner (1): 15,500 BTU each Total Capacity: 3.5 cu. ft. 220 - 240 Volts Warranty: 2 Year Limited Warranty Unpack the Range So now that you have lightened the weight of the range, follow the directions below: Remove the range from pallet and place it on the floor

Model No.: Leisuwash 360 Magic Application: Automotive Beauty Shop Cleaning Process: Cold Water Cleaning Certification: UR, UL, CE, CSA Feature: Sudsing / Foaming Name: Laser Automatic Car Wash Equipment Cost Material: 304 Stainless Steel Function: Car Wash / Polishing / Waxing / Drying Warranty: 3 Years Install Size: 7500*3800*3350 Detection System: Smart Three-Dimensional Monitoring System Central Processor: Industrial PLC Embedded Central Processor + Dual-core System Power Supply: 3 Phase 380v/50Hz (Or Customized) Packaging: Wooden case special for export Productivity: 100 sets/month Place of Origin: Hangzhou,China Supply Ability: 100 sets/month Certificate: ISO / CE HS Code: 8424899990 Laser automatic car wash equipment cost A touchless car wash forgoes brushes and uses high water pressure plus chemicals to clean the vehicle which minimizes the chance of surface damage to the vehicle. The newest LeisuWash inbay automatic car wash raises the standard for touchless car wash equipment. With Revenue Enhancement and Total Cost of Ownership improvements being the main focus, this vehicle wash system delivers the industry`s best Return on Investment. Smart 360™ Technology enables the car wash system to be responsive to the dynamic conditions in the wash bay and allows it to [think for itself", increasing up-time and optimizing the wash process. Substantially faster wash speeds lead to increases in vehicle throughput and shorter lines that will make your customers happy. Simplified machine design and lower energy and utility usages reduce operating costs leading to a more profitable car wash operation. 1.360 ° Smart Rotating Arm 2.Various Car Wash Liquid Spraying 3.High Pressure Chassis Wash & Car Body Wash 4.Magic Color Shampoo, Overglow high-gloss System 5.LED With Voice Guidance 6.Multi Language, Different Wash Mode For Choice 7.Embedded Fast Air Drying |Main Machine Size||L3500*W1200*H90mm||Max Car Wash Size||L5900mm*W2900mm*H2050mm| |Water Pump Size||1200*700*600mm||Rotary Motor Power||0.75Kw Servo Drive System| |Chemical Mixing System Size||800*450*1400mm||Chemical Mixing System Motor Power||1.5kw| |Rail Length||7500mm||Wash Speed||28s/car| |Weight&Packing||2600kg 11m³||Wash Liquid Spraying||28s/car| |Machine Install Dimensions||L7600*W3850*H3350mm||Waxing||30s/car| 1.High pressure pre-wash for under chassis and wheels. Equipped with a unique chassis and fan hub flush function, 80bar high pressure water can effectively remove dirt on chassis, body sides and wheels. 2.Smart 360 rotate arm, spray various washing chemicals with high-precision proportioning technology. 100% accurate measurement with adjustable ratio. only 20~50ml pre-soak comsumption for washing one car through high precision chemical mixing system, save material and cost efficiently. 3.Smart 360 rotate arm, Flush car body 360° with high pressure water. Complete 360° rotating within 28 seconds, water saving 50%, electricity saving 60%, automatic detect the length and width of the vehicle, up to 80bar high pressure water can easily remove the dirt. 4.Magic color Shampoo Thick foam makes cleaning maintenance component fuller contact with dirt, thereby improving the efficiency of decontamination, making the paint colors more moist, bright lights. 5.Soft water with crystal wax coat Soft water can make magic crystal coating color shampoo and wax completely adsorbed body surface, forming a multi-layered interaction strength protective film, car paint become more glorious and beautiful with durable paint protection. Crystal coating of wax can be generated in the paint surface layer polymer, the water softener fused into a hard protective film, with superior protection of car paint, and features anti-acid rain, pollution, UV erosion. 6.Unique embedded fast drying system. Leisuwash 360 Configuring three 5.5kw and one 4kw motors embedded in the washing machine, control the airflow by four cylindrical outlet, the first task is to split a bunch of wind air, reducing wind drag subsequent to follow airflow to dry the surface of the car body, Leisuwash 360 optimize the characteristics of wind speed, other traditional type of fan is to improve the speed, but wind has been minimized when arrive the car body, and in fact the high-speed airflow is the best dried solution. *LED with voice guidance *Automatic clean rearview mirror *Faulty record with data report * Automatic standby service * Multi control mode ( could operate wash system through touch panel, magnetic card, payment station button, remote controller ) Leisu360 installation 3D drawing: Happy Customers All Over The World: Packaging & Shipping: Leisuwash 360 Vehicle Wash System Demonstration Video: Hangzhou Leisu Cleaning Equipment Co.,Ltd Contact Person: Merlin Lee Address: 86# Hongda Road,Xiaoshan District,Hangzhou City, Zhejiang province,China,Hangzhou,Zhejiang

The universe keeps telling us to watch baseball, and it’s about time that we listen. This time we’re talking about Japanese baseball.... That booty is doing the work! Netzer appears to be doubling down on his thoughts. How much longer will major league baseball stay in the closet? When baseball players Joey Gallo and Nomar Mazara celebrate home runs, they don’t mess around. Or do they? Jason Wood, a Major League Baseball agent at CSE Talent, has been accused of covertly photographing athletes while they showered. Unless you live under a dark, moist rock, you know that Tampa Bay Ray’s Chris Archer is extremely popular with fans. When...

Ok…you know I can be fickle when it comes to my love for cake. I love this one and that one and that other one over there and easily vacillate between fruit and chocolate and spice and cream as my favorite. But today…on this wintry, rainy day in January when Nashville is preparing for twenty degree temps, this is my FAVORITE cake of all time and it fits the bill perfectly! It’s sweet, but not too sweet…it’s perfectly moist…it’s complex without being complicated and it is just SIMPLY BEAUTIFUL! So gather your seven ingredients (yes…only 7!) and get to baking! Don’t forget to have a cup of coffee, a fire or favorite blanket and a good book at the ready! XO CHOCOLATE APRICOT MARBLE CAKE (Adapted from Scandinavian Baking by Trine Hahnemann) - 1 cup butter (I always use salted butter) - 1 1/4 cups sugar - 4 eggs - 1 7/8 all-purpose flour - 1/2 tsp baking soda - 1/4 tsp salt - 1 3/4 oz best dark chocolate, at least 60% cocoa solids; finely chopped (I used Lindt Excellence with Sea Salt) - 2 Tbsp cocoa powder - 2 oz organic dried apricots, chopped Preheat the oven to 350 degrees Cream the butter and sugar with an electric mixer until light and fluffy (3 – 4 minutes). Add the eggs one at a time, beating well after each addition. Sift in the flour and mix again, just until a smooth dough forms. Halve the batter and put each half in a bowl (I left half in my standing mixer for the chocolate). Add the chocolate and cocoa to one bowl and mix well. Mix the dried apricots into the batter in the other bowl (I mixed this half by hand). Butter or spray a loaf pan. (I also use four mini loaf pans.) Pour the chocolate batter into the prepared pan and spread it out evenly, then pour over the apricot batter and spread that evenly, too. Take a spoon and dip it into the batter, going right to the bottom of the pan and pulling up to make a swirl inside the cake. Repeat three times in different places in the pan. Bake one hour (or for mini loaf pans, bake 30 – 35 minutes). Insert a toothpick into the middle of the cake; it should emerge clean. If not, bake 5 minutes more, then check again. Let cool in the pan. Serve morning, noon or night!

REHABILITATION TECHNICIAN - REHAB-OUTPATIENT THERAPY Status: Full Time Shift: days, Mon - Fri, including rotating weekends and holidays Under supervision of the department professional, the technician performs general non-technical duties; assists the department professional in transferring, lifting, positioning, and treating patients in all areas in the hospital system including but not limited to: Acute care, Home Health, Outpatient, CMR, and Senior Care. Maintains treatment areas and performs upkeep on all equipment and supplies. 1. High school graduate required. One to two years of college preferred with some experience in patient care and working knowledge of medical terminology.2. Manual or Physical Skill Required:Well coordinated and in good physical condition.3. Physical Effort Required:Intermittent exertion in positioning, lifting, transferring patients, equipment or other materials. Walking and standing predominant although some stooping, kneeling and reaching are required.Strength: MediumPush: FrequentlyPull: FrequentlyCarry: FrequentlyLift: FrequentlySit: OccasionallyStand: ConstantlyWalk: Constantly 1. Administer and assist with such treatments including, but not limited to, exercise, gait training, massage, whirlpool, hot packs, ultrasound, paraffin, ice packs, transfer training, electrical stimulation and traction under the supervision of a department professional.2. Prepare any written documentation required by the department as directed by the department professional.3. Provide care and maintenance of department equipment and supplies.4. Maintain appointment books, logs, charge records and schedules as necessary for the daily operations of the department.5. Prepare treatment areas for incoming patients, transport patients to the Rehabilitation Services Department, and prepare patients and equipment for treatments.6. Maintain and distribute appropriate supplies including linens, bandages, cleaning supplies and assistive devices7. Provide general assistance to department professional as directed, including preparation of hydrotherapy equipment and moist heat pads used in treatment.8. Maintain cleanliness of department, treatment areas and equipment according to posted technician cleaning schedules.9. Perform clerical duties such as writing patient charges, answering telephones, and other related duties as directed.10. Serves as backup bus driver.11. Serves as courier between Rehab Services Department and physicians.12. Assist the exercise specialist with the Wellness Program as directed.13. Comply with department policies, procedures, objectives, and safety, environmental, infection control and quality assurance programs.14. Participate in educational programs, in-service meetings and attend other meetings that are required.15. Meet the needs of patients in the waiting area and the treatment rooms in an appropriate and safe manner.16. Perform other duties as directed by the supervisor.17. Communicate at an appropriate level necessary for interaction with all hospital personnel.18. Follow North Oaks Health System’s Compliance Programs and Federal and State Regulatory guidelines.19. Assist the professional in the aquatic facility as directed.20. Assist with completing tech duties for work area (daily, weekly, monthly and quarterly).

Having lived in Brisbane for a good 6 months now, I was, naturally, missing Melbourne a little. Luckily I had two of the best cures to hand last weekend; a visit from a good friend (Mel) and the recipe for a favourite childhood treat. My Grandmother’s raspberry slice is delicious, easy to make and keeps well. She still makes it fairly regularly and I will admit to enjoying it as much now as I did on weekend visits to Ararat as a child. So, I gave her a ring, had a chat and got the recipe from her (thanks Grandma!) in time for Mel’s visit. It is very 50’s-era Australian and therefore contains only ingredients you are likely to have in your pantry/fridge. I hope you enjoy it as much as I do. - 225g plain flour - 113g butter (softened, at room temperature) - 90g white sugar - a tablespoon or two of milk (if required) - Good raspberry jam (about 1/2 a cup, adjust to suit your tin) - 90g desiccated coconut - 2 eggs - 90g white sugar Firstly, grease and line a slice tin (30 x 20 x 3cm approximately) and pre-heat your oven to 175° (fan-forced). Press the dough out into the slice tin, with great patience! I was warned that this is the most trying step in making the slice and indeed it was. You might notice that our base here was quite wet; my Grandmother gave me the recipe in imperial measurements and I converted them (incorrectly!) to metric. Next time I make this I will update with a picture of the base as it should be. When you have the base covering the tin, spread the jam over the base, generously, but take care to avoid creating holes or craters in the base. If you are lucky enough to have a great home-made raspberry jam to use here (thanks Mel!) it will make this slice even better. Setting the base aside momentarily, in a clean bowl, beat the eggs until light and frothy, then add the coconut and mix and finally add the sugar. This will be a very wet mixture; simply pour over the top of the jam Now pop the slice carefully in the oven and leave to bake for 15 – 20 minutes until golden brown on top. A skewer in the middle should come out clean (except for a little jam). Leave to cool in the pan completely before removing. It will smell amazing and fill your house with the aroma of domestic-bliss however refrain from trying the slice until it is cool. The flavours are much richer at room temperature than when it is straight out of the oven. It is a bit unique in this way. Despite my mis-calculation with the conversions, the slice came out as delicious and moist as ever – to my mind a sign of a great recipe. I suppose you could make it with other jams but certainly I would avoid fresh fruit here, it would be too wet for the base. As I said earlier, it keeps really well in an air-tight container and is something easily whipped up with things you already have in your kitchen. Next to melting moments, these were the quintessential treats of my childhood and I would highly recommend them for any morning tea (at work or home!), general consumption around the house and even a cake stall at school. Thanks again to my Grandmother, Pat, for sharing her recipe with me – and my blog readers!

Original WWII Japanese Army Officer P-1944 Rinji Seikishi Shin-Gunto Katana Sword by YOSHIMICHI - Dated 1945 Original Item: Only One Available. Purchased recently at a large military auction, this is a very nice late war style mid grade Japanese officer Katana, with an arsenal-made blade. It is in the standard 1944 pattern fittings, offically known as the 臨時正式 (Rinji Seikishi) or "Special Contingency" version of the Type 98 Shin-Gunto (九八式軍刀 kyūhachi-shiki guntō) setting. These fittings, while often called the P-1944, were in fact designed in 1938, but didn't really see much use until 1940. They were designed to be more robust than the regular Type 98 fittings, as well as less expensive and time consuming to produce. However the standard Type 98 fittings continued to be produced concurrently until almost the end of the war. A Shin-Guntō (新軍刀, new military sword) is a weapon and symbol of rank used by the Imperial Japanese Army between the years of 1935 and 1945. These are not made as carefully or to as high of a standard as the earlier blades, which makes them a very economical way to get into Japanese sword collecting. This is a very nice example, and appears to have seen very little use in combat. It is signed and dated 1945 on the blade tang by the smith who made it, YOSHIMICHI. The katana itself measures 37 1/4 inches overall, with a 26 inch arsenal-made blade. The blade is most likely not traditionally made, as it does not show any lamination lines or grain, and does not have the correct polish for a hand-made blade. It has a standard bright finish to it, with a faux hamon (temper line). Condition is very good, showing only light wear, and a few areas of light staining. There are some dents and nicks in the blade, so it does look to have seen some level of service. One side of the tang bears the Mei, or signature, of the smith it was made by: 吉 道, which is read as YOSHI MICHI. This smith's real name was 小島 幸七 - Kojima Koushichi, and their name appears in the Seki Tanrensho Booklet printed in 1939. Yoshimichi was active during the Showa Period and worked at Seki arsenal in Gifu, Mino Province (美濃国), and look to have made mostly arsenal forged blades. We have confirmed the signature with other examples of his work. There is also a 岐 GIFU arsenal cherry blossom stamp about 1/2" above the upper peg hole to the left. There are also the painted characters 五 四 九 四 - 5 4 9 4 on the tang, but they do not appear to match to anything. The other side of the tang bears the date when the blade was produced, in the standard long form indicating years into the current emperor's reign: 昭 和 二 十 年 六 月. This would be read: SHOWA (current reigning emperor) Ni-Juu Nen (20th year of reign - 1944) Ju-gatsu (6th Month - June). The tang of the blade (nakago) is the typical futsu (普通 normal) shape of the period, with a naagari (asymmetrically rounded) tip and the usual file marks (yasuri-me), which help the tang stay secure in the handle. The two drilled hole tang is also typical of this period's arsenal forged blades. The blade mountings are the typical Pattern 1944 era Army style. Round iron tsuba (cross guard) with no decorations, a brass habaki (blade collar), with an iron fuchi (grip collar). There are two seppa (spacers) surrounding the tsuba, both properly inlet for the scabbard lock, which is present and fully functional. The tsuka (handle) has magnetic Imperial Army cherry blossom menuki (grip decoration), and an unadorned black Kabuto-Gane (Pommel Cap). The Tsuka (handle) has an excellent faux stingray (Sa-Me) grip panels, covered with complete Ito (cloth binding), which is in very good condition, but not wrapped traditionally, which is typical on the P1944 Setting. The grip wrapping was also lacquered, intended to help protect ig from the moist environment on the islands in the South Pacific. There are two mekugi retaining pegs, which look to be original. The scabbard for this katana is in very good condition, with the correct original light brown paint and late war blacked steel fittings. It matches and locks into the handle, and is of the correct 1944 pattern style. It shows only light wear, and was also lacquered like the grip to protect it. A great chance to pick up a real Japanese WWII Shin-Gunto with a signed and dated blade, ready to display! Blade Length: 26" Blade Style: Katana Overall length: 37 1/4“ Scabbard Length: 28 1/4" It has been over one thousand years ago that the art of making swords appeared in Japan. The swordsmiths of the time may not have known it but they were creating a legendary sword. The Samurai sword has seen combat in many battlefields. From the early days of the Samurai warrior to the fierce battles in the South Pacific during WWII. Each hand-made Samurai sword is unique because it is forged from steel stock. A tremendous amount of work is dedicated to creating these pieces. They were an instrument of war as much as a beautiful artifact to adorn a room. The Samurai sword has grown to be one of the most highly desired military antiques. - This product is available for international shipping. - Eligible for all payments - Visa, Mastercard, Discover, AMEX, Paypal, Amazon & Sezzle

Once a stain has occurred on your silk shirt, act quickly to remove it and do not let it settle into the silk. Use a soft cotton cloth moist with water to dab the stain out of the silk. Continue by making a cleaning solution that is one part water mixed with either one part lemon juice or one part vinegar, and continue dabbing the stain. For grease and oil stains, use an absorbent powder such as baking soda, cornstarch, or talcum power. Apply the powder to the stain and place a heavy object, such as a book, on top of it overnight so that the powder can absorb as much of the stain as possible. This is: How to Get Stains Out of a Silk Shirt (Complete Guide) This article will give you detailed instructions on how to get a variety of different stains out of your silk shirt. You may also be interested in learning how to properly wash and iron your silk shirt. Our step-by-step guides provide you with everything you need to know in order to care for and maintain your silk shirts. How to Get Stains Out of a Silk Shirt Use the methods and instructions below to quickly and effectively get stains out of silk shirts. It is extremely important that you act quickly immediately after a stain has occurred on your silk shirt. The quicker you begin to treat the stain, the more likely it is that you will be able to remove it. Wet stains on silk are much easier to remove than dry stains, so act as quickly as possible! Test for Colorfastness To avoid accidentally removing the color from your shirt while attempting to clean the stain, you must first test the silk for colorfastness. Test for colorfastness by following the steps outlined below. - Dampen a white cloth or towel with water. - Blot/dab the cloth on an inconspicuous or hidden part of your silk shirt. - If you see color transferring from the shirt to the wet towel, then you should refrain from attempting to remove the stain from the fabric. - If your silk garment is in fact bleeding color then it would be best to take it to your local dry cleaner. If your garment does not bleed color, then continue with the at home stain removal methods. Dab the Stain To begin the extraction, use a clean damp cloth to dab the stain. Use an absorbent textile such as a paper towel or a cotton cloth to draw out and extract as much of the stain as possible. Dab or blot the cloth onto the stain, and be sure to avoid any rubbing motion. Tip: Use cold water to dampen to cloth and dab the stain. Do not use hot water. Use a Water Based Cleaning Solution If you still cannot get the stain out, make a water based cleaning solution to strengthen your efforts. Follow these 4 simple steps to make a water based cleaning solution that is highly effective in getting stains out of silk shirts. - Mix one part of lukewarm water (no hotter than 25°C/77°F) with one part lemon juice or white vinegar. - Dab the mixture on a soft white cloth and apply the solution to a small and inconspicuous spot on your shirt in order to make sure the solution doesn't have any negative effects. - Once you are sure the mixture is safe, continue to apply it to the cloth and begin to dab the stain you wish to remove. - Once you have thoroughly dabbed the stained area, proceed to hand wash the shirt to finish the job. How to Get Oil and Grease Stains out of a Silk Shirt Removing oil and grease stains from a silk shirt can sound like an impossible task, but luckily, by using an absorbent powder such as baking soda or talcum powder we can give ourselves a pretty good chance of removing the stain completely. Use an Absorbent Powder If you happen to get an oil or grease stain on silk clothing you will likely need to apply an absorbent powder on top of it in order to remove it. To remove oil and grease stains on silk you can apply talcum powder, baking soda, or cornstarch to the stained area and allow it to sit overnight. Talcum powder is the most effective, however all 3 options work well to remove oil and grease stains from silk shirts. - Apply the Talcum Powder directly to the stained area. - Completely cover the stain with Talcum Powder - Cover the stain and powder with a clean, dry cloth. - Place a heavy object, such as a book, on top of the cloth so that the Talcum Powder can absorb as much of the stain as possible. - Let the talcum powder sit on the stain overnight and brush the powder off of the stain the next morning. - If any oil remains you can try to repeat the process once more. - Once the stain has been removed proceed to wash or dry clean your shirt as directed by the care label. - If the stain remains, you may want to head over to your local dry cleaner to ask for assistance. How to Get Sweat Stains Out of a Silk Shirt Deodorant and sweat stains often end up on the armpits of silk shirts and blouses. Follow the steps below to get sweat stains out of silk shirts. - Mix 1 part lukewarm water with 1 part white vinegar or 1 part lemon juice. - Fill a spray bottle with the cleaning solution from step 1. - Spray the cleaning solution on to the sweat stains. - Let the shirt sit for 3 to 5 minutes. - Finish by hand washing or dry cleaning, as per the shirt's care label. How to Get Stains Out of Silk FAQ How do I get a stain out of silk clothing? Use a water based cleaning solution to gently dab the stain out of the silk clothing. Mix one part lukewarm water with one part white vinegar or one part lemon juice, and apply it to a soft cloth. Use the cloth to dab the stain. If this doesn't work, use an absorbent powder such as baking soda or talcum powder, and cover the stain and allow it to sit overnight. Does silk stain easily? Silk is a delicate and absorbent fabric that takes stains as easily as other natural fibers. Natural fibers such as wool, cotton, linen, and silk, are more absorbent than synthetic fibers, which means they have the ability to take on stains. How do you clean a 100% silk shirt? Start by checking the shirt's care label to see if the shirt can be washed at home, or if it must be dry cleaned. To wash the shirt at home, fill a container with lukewarm water and add a few drops of silk laundry detergent. Submerge the shirt in the water and let it soak for 3 minutes.Use your hands to agitate and clean the shirt in the water. Rinse the shirt under cold water until the soap is completely removed, and then gently roll in an absorbent towel to remove excess water. Hang or flat dry in a cool place away from direct sunlight. Does stain remover work on silk? Silk requires a water based cleaning solution such as water mixed with white vinegar or lemon juice in order to help remove stains. Store bought stain removers may not be appropriate for delicate fabrics such as silk. Never use bleach on silk. You may also apply an absorbent powder such as baking soda or talcum powder to the stain, and then leave it on the stain overnight so that it can extract it from the fabric.

By Bruce Stambaugh The cool morning’s haze hung in the low, sweeping valley, kissing everything animate and inanimate with thousands of moist droplets. The sun, just now slipping above the distant hillsides, began to undo the dew. An Amish church bench wagon stood alone, a silvery silent phantom in the dampened alfalfa field. A week earlier the wagon likely went unnoticed. It had been brought there to supply some of the seating for the hundreds of guests who attended a very special wedding. The bride, a good friend and neighbor, was the happiest, most excited young woman about to be married that I had ever met. Only a year earlier this same 34 year-old had adamantly proclaimed to my wife that she would never get married. Life events change things above and beyond our poor power to anticipate or comprehend them. We can only accept them. Months earlier, the groom was suddenly a young widower with six children, teenager to toddlers. When the life of a wife and mother is taken at 34, a huge, horrible hole is created. Now, through a series of miraculous happenings, the modest, stalwart man was about to take a new bride. It clearly was a bittersweet wedding. In fact, the bride used that as the theme in the invitations, throughout the preparations and the wedding itself. She went out of her way to include the children and their grandparents in this transition. If ever there was a model for the positive blending of families, this wedding was it. There were tears of joy for the new couple, for the young children who would once again have a mother, and for the new groom, who would no longer have to worry about how to care for his family while holding down a fulltime job. Step by step, it all came together. Even the minister had to wipe away a tear or two as he preached his sermon in his native Pennsylvania Dutch. During his animated sermon, he spoke reverently to the children, all dressed in matching gold shirts and dresses. He shared personally and passionately with the bride and groom on the incomparable commitment they were making. In the Amish community, weddings and the meal that follows are a crowning celebration. They are a commitment for a lifetime to each other and the community. Surrounded by hundreds of family and friends, my friend followed her heart, and filled that family’s aching emptiness. The reception was held across the narrow township road from the bride’s parent’s home. A large white tent had been erected to accommodate the reception goers. Usually the wedding party sits in the eck, or corner, while the guests enjoy their meal at long decorated tables. This was no ordinary Amish wedding. The guests were afforded a glimpse of how life would be in this newly established household. Centered at the back of the tent was a huge, antique dining room table. Around it sat the bride, the groom and his six children. The bride fed one toddler while the groom fed another. This marvelous couple had only been married a few minutes, and already they were modeling the family way. I had to wipe away a few tears of my own. Just as the joy of this marriage warmed the spirits of the wedding guests, the strengthening sun quickly melted away the dewdrops around the church wagon. It was an honor and a blessing to have witnessed both. © Bruce Stambaugh 2013

Restaurant Los Angeles - Visit any restaurant Los Angeles offers and you’ll impress your friends and family. To get more out of any restaurant, Los Angeles has beautiful scenic and historical landmarks to visit after dinner. Chinese Restaurants Los Angeles - Whether you like your fare conventional, trendy, or with a twist, You’ll find it in L.A.’s Chinese Restaurants. Los Angeles, The Great Chow Mein Dragon of the West, awaits your visit! Italian Restaurant Los Angeles - Tender veal parmesan, moist grilled salmon, clams or mussels enhanced by flavorful tomato and garlic sauces, juicy steaks… all these and more can be found on the menus of many an Italian restaurant, Los Angeles. Italian Restaurant San Francisco - Friendly service, relaxed, interesting atmosphere, and great food are things I look for in an Italian restaurant. San Francisco has many, but the best are the independent ones owned by local Italians... Restaurant San Jose California - Restaurant, San Jose, California offers beautiful scenic and historical landmarks to visit after dinner. A nice stroll near the water, under palm trees and among the crowds can be just the way to end a perfect evening. Restaurant Oakland Style: Exquisite Good, Tasty Salads, Rich Desserts - Restaurant Oakland Style fine dining features exquisite seafood dishes, meat entrees, and vegetarian specials, creative and tasty salads and desserts to die for. Restaurant Sacramento - Just like the news of Sacramento’s gold spread like a wildfire through the world in the middle 1800s, today, the news is spreading fast that the restaurant Sacramento dining style and experience can’t be beat. Restaurant Denver - A certain culinary sophistication has trickled into this former cowtown, and it's reflected in the menu at any given restaurant. Denver offers dining diversity. Restaurant Seattle - Sometimes called Seattle’s most beautiful restaurant, Canlis is a restaurant Seattle you won’t soon forget. Restaurant Phoenix - If you take some time to scope out the nightlife, see a local band, or eat in a restaurant, Phoenix will reveal its subtle niceties to you. Restaurant Tucson - When you get hungry and want a great restaurant, Tucson will not disappoint you. Here's a sampling of some of the best. Restaurant Albuquerque - If you’re looking for a great restaurant, Albuquerque is sure to have something that suits your taste buds. Restaurant Houston - This is not a city that just wants one type of restaurant, Houston is a melting pot of so many different people and cultures that pretty much anything that is tasty will succeed here! Restaurant Dallas - Everything from the five star restaurants to the fast food restaurant, Dallas has a great variety of those and everything in between! Restaurant Austin: Tasty, Fun, Hip, and Trendy Places to Eat - Even the street tells you are in the states capital. 10010 Capital of Texas is the address for the restaurant Austin called North by Northwest Austin. Restaurant Atlanta - From the wonderful seafood dishes right down to the great low fat salads, the tastes, blends and amazing flavors available in the restaurant Atlanta, Georgia diners, cafes and bistros are what keep people coming back day in and day out. Restaurant Miami - Whether it’s breathtaking views of the Florida Everglades or awe-inspiring glimpses at the Atlantic Ocean, you can find a great view from your restaurant. Miami is a beautiful area. Restaurant Tampa - It doesn’t matter what type of restaurant, Tampa will have what you are looking for. Midwestern United States Restaurant Kansas City Style - The Restaurant Kansas City Style experience is sure to make memories and a lasting impression on travelers passing through this town. Restaurant Cincinatti - Many a hot restaurant Cincinnati offers have menus online – so you can check out exactly what the restaurant serves and get the ideal restaurant experience. Restaurant Cleveland Ohio - Whatever you’re looking for in a restaurant, Cleveland, Ohio has it – from upscale lakefront dining along lake Eerie and microbreweries to small vegetarian restaurants and fun family franchises. Restaurant Dayton - An additional bonus of looking up a restaurant Dayton has online is that you’ll know what to wear -- you can find out just how upscale or casual that particular Dayton restaurant is before you case a caviar place in jeans. Restaurant Minneapolis - Rossi’s Steakhouse, a fantastic downtown restaurant Minneapolis, specializes in great steaks. It also features a tavern and jazz room to add to your dining experience. Eastern and Northeastern United States Restaurant Baltimore - A Dress up or dress down restaurant, Baltimore has both and everything in between! Restaurant Boston - Once a regular stop for Jay Leno, the Paramount is a restaurant Boston that’s sure to please the budget minded diner. Restaurant Philadelphia - You want a different kind of restaurant. Philadelphia actually provides a rich source of different menus. Restaurant Philadelphia II - One type of cuisine you must try while you are in one of restaurant Philadelphia is the famous Philly Cheese Steak. Restaurant Pittsburgh - It doesn’t matter if it’s a Chinese, Indian, Italian, Greek, or just an American restaurant, Pittsburgh will have what you’re looking for! Restaurant Washington DC - Capital Lounge is a restaurant Washington DC known for its 25 cent Wednesday night taco specials. It’s a Capital Hill favorite – greasy but good. All information herein provided is for educational use only and not meant to substitute for the advice of appropriate local experts and authorities. 1999-2034, Pulse Media International, Brian Carter, MSci, LAc, Editor

Home tools Buyer's Guides from tech enthusiast who loves technology and clever solutions for better living. Best bath mat for tub 2018 – [Buyer’s Guide]Last Updated September 1, 2022 Best bath mat for tub of 2018 Check them out and decide which one suits you the best to splurge upon. Like choosing clothes or cosmetics, choosing bath mat for tub should be based on your purpose, favorite style, and financial condition. After carefully examining the reviews and ratings of the people who have used them earlier this listicle has been made. Welcome to my website! If you plan to buy bath mat for tub and looking for some recommendations, you have come to the right place. Test Results and Ratings Why did this bath mat for tub win the first place? I really enjoy the design. It is compact, comfortable and reliable. And it looks amazing! I don’t know anything about other models from this brand, but I am fully satisfied with this product. The material is stylish, but it smells for the first couple of days. I am very happy with the purchase. It is definitely worth its money. The product is top-notch! №2 – Shower Mat by Vive – Square Bath Mats with Drain Hole – Non Slip Suction Cup Pad for Shower Stalls &… Why did this bath mat for tub come in second place? This is a pretty decent product that perfectly fitted the interior of our office. Managers explained me all the details about the product range, price, and delivery. I recommend you to consider buying this model, it definitely worth its money. The material is pretty strong and easy to wash if needed. Why did this bath mat for tub take third place? It is inconvenient to use due to the size. I am going to get something different next time. We are very pleased with the purchase — the product is great! This price is appropriate since the product is very well built. It doesn’t squeaks nor bents. Looks great in my apartment. bath mat for tub Buyer’s Guide The Momentum Home Modern Bath Premium Bathroom Rug with Non-slip Backing absorbs water as effectively as our main pick and dries a little more quickly, but between the synthetic fibers and the nonskid coating brushed on the back, we believe it’s likely to be less durable over the long term. The chenille-style fibers are plusher and thicker than those of our pick, which feels nice but can be an obstruction to a swinging bathroom door. This rug also costs less than our pick, but it’s more limited in color and size options, and the warranty is not as good. How we picked and tested Woven rugs are probably the most universally appealing, since they’re comfortable underfoot, made to absorb well, and easy to clean. Because there are so many styles and preferences for different types of rugs and mats, we split our review into three categories: woven, memory foam, and wooden (bamboo or teak usually). Woven rugs are probably the most universally appealing, since they’re comfortable underfoot, made to absorb well, and easy to clean. We wanted to test both cotton and synthetic versions, because they each have distinct advantages (and disadvantages). Cotton tends to absorb better but takes longer to dry. Synthetics, often made of polyesters or nylon, don’t absorb quite as well—synthetic fibers tend to repel moisture because of their hydrophobic tendencies—but dry much faster. At the higher quality levels, cotton can cost more and last longer. We considered rugs with a variety of pile heights (the length of the fibers that stick up) but tried to focus on those that were about an inch or less thick and looked like they’d fit under a door (although that’s pretty hard to determine just from specs and pictures online). Woven bath rugs can sometimes have a grandma-ish style; we avoided those, focusing on designs that looked more modern. Memory foam appeals to some people because it gives underfoot and dries quickly. We found that the best memory-foam rugs are roughly ½ inch thick. If the foam is thicker than that, it feels swampy underfoot, whereas if it’s thinner you lose that pampering effect of stepping onto the foam. The foam itself is encased by fabric, usually polyester microfiber, which dries quickly and feels especially soft against the skin. We preferred foam rugs with rectangular embossing, which helped water stay pooled on the rug. (Designs with straight embossed lines tend to let water run off the sides of the rug.) A binding that securely attaches all the way around and doesn’t unravel or fray makes the rug more durable. We dismissed any rugs or mats that lacked a nonskid backing. Rubberized backs are far safer than a slippery rug moving around your bathroom floor. For the woven and foam rugs, we preferred rugs with a thick latex or rubberized backing over rugs with a thin, painted-on coating; although a thick backing can make drying take longer, it’s less likely to come off in the wash. We looked for wood mats with nonskid nubs or feet. Flaws but not dealbreakers Besides the price, which we realize might be high for some people, the only real drawback of the Lands’ End Supima Non-skid Bath Rug is that in our tests it dried slower than some competitors, particularly the synthetic rugs. Depending on the humidity and circulation in your bathroom, though, this rug should have no problem drying at a similar pace to a medium-weight terrycloth bath towel. We suspect that this Lands’ End rug dries slower because of its cotton top and its thick latex backing, which probably retains moisture better than a thinner nonslip coating. Gorilla grip Rectangle bath mat The Gorilla grip rectangle bath mat is a unique option with 2gorilla suction cups that ensures it will stick to the surface at all times. This is the best bathtub mat for smooth floors and not tiled or textured floor. It is quite big in size 35” by 16” covering a wide area on the floor. The mat was designed with holes that allow circulation of water preventing mold growth beneath. It is mildew and anti-bacterial resistance and a safe option in any home. It is quite easy to maintain been machine washable. NTTR non-slip bath mat With over 200 suction cups, the NTTR bath mat is one of the best bath mats in the market in preventing accidentals falls in the bathroom. The mat is made of high-quality environmentally safe materials that are non-toxic. It is extra-long, durable and ideal for daily use. It is machine washable and safe from mold, bacterial and mildew. InterDesign Pebblz Bath mat Do you want your bathroom to appear polished and stylish? The InterDesign Pebblz Bath mat is everything you need to a beautiful bathroom. Made from polished and textured pebbles, the mat looks a stunning beauty in your bathroom adding the much-needed glamor. The mat has suction cups on the bottom that keep it firmly grounded. You can cut and trim the pebbles if you want to change the appearance. It is a perfect choice that adheres to the floor well and drains water well. Yimobra bathtub and shower mat The Yimobra is one number one bath mat in the market currently with tons of features that make it an absolute value for money. It is long enough and covers a larger portion of the bathroom floor. It has over 100 suction cups that ensure it sticks to the floor firmly. It is made of high-quality materials that are BPA free, and allergen free. It is a durable and high-quality mat that can be used in various places like hospitals gyms, saunas, and spas. It is a great pick that you must try right away. As our little babies begin to grow and become more independent, the tasks that we once helped them with will soon become their own responsibility. One of the most important places at home to be aware of dangers is the bathroom so that we can teach our kids about safety around water. According to Parents magazine, the bathroom is full of hazards for your child that many people are unaware of. The tub and shower are a risk for young children due to their slippery nature, so a quality non-slip bath mat is the best protection you can give your children. Modern bath mats can be literal lifesavers, preventing from slips, slides and trips that can do serious damage to your little ones. Check out our buyer’s guide for bath mat sets that will prove both practical and personable in your bathroom. Baths Mats for All Ages Not only are bath mats for kids, but there are lots of other styles of bath mats on the markets. Hospitals, assisted living homes, hotels, and gyms are just some of the places where you might find modern bath mats that prevent slips and trips. The elderly in particular are prone to slipping in the bathroom, with rates of bathroom injuries for over 85s significantly higher than other adults. Parents might like their own unique bath mats for use in their ensuite to ensure their own safety, or perhaps one of the fun bath maths to add a bit of personality into your bathroom at home. Epica Anti Slip Bath Mat for Tub This is one of the finest one that you can get. Made of extra sturdy rubber construction, the non-slip grip is something that will make you love this. Designed with a mildew resistant formula, this is one of the few bath mats that was designed with increased comfort in mind. Exceptionally resistant to wear and tear, this is a bathtub mat that has an injection molded rubber that is of the utmost standard of safety and quality. This is the perfect mat that you need to secure your bathroom. Let’s get straight to the point here. The Simple Deluxe Anti-Bacterial Anti-Slip-Resistant Blue bath mat is not just a great product at a great price, but it is something that will make your life easier, happier and just plain better. Composed of a BPA-free, high-quality, machine washable, anti-slip material, this particular piece provides 30% more coverage than just about any other bathmat. Plus, it works on just about any surface. Non Skid Bath Mat The IKEA TOFTBO Microfiber is an all-around great bath mat. It is extremely absorbent, is designed with no-slip safety in mind and will help to make your bath or shower time that much better. If you are in need of a great shower safety tool at a great price, then this is the bath mat that you are looking for. Children don’t bathe or shower like adults do. It is no secret that, because of their playful nature, they tend to get into trouble, especially when bathing or showering in a slippery setting. Your bathtub floor can get pretty dangerous pretty fast when there is nothing to provide adherence to the surface. This is why the Maiyuan is the item you need and that is for several reasons. If we are talking about safety, quality and durability, then the Bathtub Mat for Kids by Maiyuan is the item to go for. It is reliable, comfortable, it provides a powerful grip to the slippery surface of your bathtub and it is easy to clean – a great addition to anyone’s bathroom. On top of that, your kid will love it. Hоw tо Clеаn Bаthtub Mаt Washing уоur bathtub mat іѕ very іmроrtаnt. Hygiene is аlwауѕ a big concern аnd dіrtу mats gіvе bacteria chance to grоw. Furthеrmоrе, nеvеr ѕhаrе your mat. Shаrіng уоur mаt wіth someone саn rеѕult іn аn unwаntеd fungаl оr bacterial infection. Using soap or bath bombs can саuѕе it tо bесоmе dirty. Most реорlе simply wash thеіr bathtub mаtѕ thеmѕеlvеѕ аnd hаng thеm іn thе sun tо drу. Others рrеfеr to send thеіr mats tо the cleaners. Mоѕt sticky mаtѕ аrе mаdе of rubber аnd therefore, ԛuіtе еаѕу tо сlеаn. And here is why they are so appreciated The only downside that some customers have complained about was the fact that, in some cases, the mat was either shorter or narrower than they needed. Which is hardly a design fault and more like the customers’ lack of awareness when purchasing it. Mats are not just for adults Bathing a baby or a toddler can sometimes be more difficult than most people would like to believe. The bathtub’s slippery surface, combined with children’s loose temperament can lead to a lot of problems in some situations. This is why a quality mat is more than welcome in all of the homes that have children. They also work just as great for bathing babies. Since you won’t have to worry about them slipping because of the wet surface, you can now concentrate on what you are actually doing. Making over a busy family bathroom? A glass bath shower screen is a smart and practical choice. Designed to fix to the wall and over your bath, it’s easier to clean than a shower curtain, and will provide more of a sense of light and space, even the smallest room. We’ve picked out our favourite bathtub shower screens below. Scroll down, and you’ll also find a handy buyer’s guide. By submitting your information, you agree to the Terms & Conditions and Privacy & Cookies Policy. Please keep me up to date with special offers and news from Ideal Home and other brands within the Time Inc. UK Group by email. You can unsubscribe at any time. We’d also like to send you special offers and news just by email from other carefully selected companies we think you might like. Your personal details will not be shared with those companies – we send the emails and you can unsubscribe at any time. Please tick here if you are happy to receive these messages. Video Of The Week A quick wipe after each shower with an appropriate cleaner should keep it sparkling. Opting for a special wipe-clean or anti-calcium surface will keep it looking better for longer. This is a see-through coating over the top of the glass. It helps to reduce water spots from limescale and mineral deposits and helps to prevent bacteria and mould growth. Othway Bathroom Bathmat Othway bathroom bath mat will fit most of the bathtub sizes. It can even fit in the shower stall floor. Another great feature of this bath mat is that it has pebbles in the shape of cobblestone at the bottom for comfort. It will provide comfort for your feet as they will massage you while having a shower, and it will make them dry after every shower. Another great fact is that the Othway stands behind their product quality, and they will return your money in the case if you are not satisfied. You will have 60 days money-back guarantee and 1months worry-free guarantee. Gorilla Grip Bathroom Bathmat Like the previous bathtub mat, it will fit most of the bathtubs and even shower stall floors. The exact size of this bath mat is 35-inch by 16-inch. Gorilla Grip stands behind their product and they say that the bath mat will still be non-slippery in any place on any smooth surface thanks to their invention of 32suction cups. It has small holes inside the mat to allow the water to circulate, and it prevents the mold from happening underneath. Like the previous bath mat, it is anti-bacterial, BPA free and non-toxic. A design is beautiful as it features crystal clear color which will suit every bathroom design. Becozier Bath Mat Becozier provides safety for a family from toddler to senior. It has more than 150 powerful suction cups which are designed to prevent the mat from slipping even when the water is fully engaged. One of the features is that this anti-bacterial, like all the other bath mats. It has pebbles gaps which let the water run smoothly and has a healthy circulation, which prevents the mold from happening at the bottom. NTTR Extra Long Bath Mat NTTR produces one of the longest bathtub mats. It’s extra long so it can fit even the biggest bath tubs out there. Dimension of this extra long bath mat is 16” x 39”. It’s made out of 100% non-toxic plastic and It has a great flow of water so there isn’t moist created. This bath mat, as every other mat, has 200 suction cups which provides effective slip resistance. It’s not only safe, but it’s enjoyable as well. Suction cups massage your feet while you are having a shower. It’s available in two different colors which will fit perfectly with any bathroom design and interior. Also, I have to mention that you will be able to use this bath mat in shower as well as in bathtub. It’s available on Online, and the price is really nothing comparing to the safety this mat provides. Langria Bath Mats Langria bath mats are made out of memory foam which absorbs the water, and they dry themselves fast. Non-slip backing surface will make sure it stays in the place and provides non-slippery safety. They look so nice in my opinion, that they can be used for different purposes as well. They can be used in the kitchen as a rug, or even as a doormat. Thanks to the little gaps which allow the water flow as it helps to avoid the water from staying inside the mats. Up to 80% of falls in the home are in the bathroom. Walking and attempting to use towel bars, sink tops or other objects to support balance. Install grab bars. Grab bars are best suited for elders with good upper-body strength who are able to hold onto grab bars while moving or standing. All grab bars should be slip-resistant (‘grip’ surface bars are better than those bars with high gloss finish), color contrasted from the wall for visibility, and securely fixed to the studs of the wall for adequate support (“bolted on” bars are preferable to suction cup bars, which could easily slip away when body weight is applied). Where’s the best place to install grab bars? Look where the elder normally holds onto when entering or exiting the shower and place the grab bars there. The trick is not to change one’s behavior (which is difficult to do) but to make behavior safer. Use a shower chair. A shower chair can provide stability for an elder with difficulty balancing and a rest place for those who have difficulty standing for long periods of time. A good shower chair has rubber tips on the legs to prevent sliding. When used with a hand-held shower head, an elder can remain seated while bathing. Use a tub-attached grab bar. If an elder uses a tub to bathe, they need to step over the tub’s high sides whenever they get in and out. Clamp on” safety bars are designed for steel bath tubs and can’t be easily tightened onto newer fiberglass or acrylic tubs without cracking the tub. A tension pole can serve as an alternative. A rubber non-slip mat. A mat or non-slip adhesive strips applied to the bathtub and shower floor surface provides stable footing. Sometimes elders with decreased vision and poor depth perception view bathtub surfaces as “bottomless pits” and become fearful when entering. Placing a mat or strips on the tub/shower floor can eliminate this problem by providing visual cuing. These can be placed on the top of sink edges to guard against hand slippage if these surfaces are used for balance support. Use a raised toilet seat. Elders may have difficulty lowering themselves down to sit on a low toilet seat and rising to a standing position safely (due to lack of arm and leg strength and balance). A raised toilet seat (raises toilet seat height by 3-inches) reduces the amount of squatting and the distance that has to be covered to sit on the toilet. Grab bars on the raised seat itself provide added safety. Bedside commodes are beneficial if toilets are difficult for an individual to use. Elders who have a difficult time traveling to the bathroom because of the location of the bathroom also benefit from bedside commodes. Install a telephone in the bathroom. Having a phone nearby in the event of a fall and/or injury ensures that the elder gets help quickly. This may be life-saving for an elder who lives alone. As an alternative, a medical alert system (that’s waterproof) can be used. Is the pathway from the bedroom to the bathroom dark? A poorly-lit pathway can easily cause a fall. Use nightlights to create a well-lit path to the bathroom. Having nightlights in the bathroom helps as well. No matter how pleasing to the eye or nice-looking a bath mat is, you should take into consideration how it can fit perfectly between your sink, toilet bowl, and bathtub or shower area. You should not get a bath mat that is too small that it does not cover a wide amount of space nor too big that it curls on the sides and runs against other bathroom items. To identify the right size of bath mat, measure your bathroom’s dimensions and don’t simply rely on your memory or your assumptions. Measuring your bathroom is especially helpful if you are going to do your shopping online. Design and color The design and color of your bath mat are entirely up to you. Most of the time, homeowners choose the design and color of their bath mats from the overall design of their bathroom. Still, you should pick one that will not look dirty after only a few days of use. While white or light-colored fabric bath mats look clean and fresh, they can easily look soiled after a number of people have stepped on them. A good tip to follow with design and color is by looking at some pictures of bathrooms and toilets to see how other homeowners choose their bath mats. If you do not have a number of fabric bath mats to alternate with each one or have the time to wash them after a few days, stick to picking a design and color that can last you for a week before washing. While we may have the common belief that bath mats can be tossed in the washer for cleaning, not all can be cleaned through this process. Move frequently-worn clothing to places where it’s easiest to access. Avoid putting things on high shelves, the closet floor, or in drawers that are hard to open. Expert Tip: Cleaning out unworn clothes (or putting them in a storage area) helps create more space for easier access. Move frequently-used items down from high shelves and up from low shelves. Put them within easy arm’s reach. One third of all falls in the elderly population involve hazards at home. Factors include: poor lighting, loose carpets and lack of safety equipment. Install at least one stairway handrail that extends beyond the first and last steps. Make sure rugs, including those on stairs, are tacked to the floor. Remove loose throw rugs. Avoid clutter. Remove any furniture that is not needed. All remaining furniture should be stable and without sharp corners, to minimize the effects of a fall. Change the location of furniture, so that your elderly parent can hold on to something as they move around the house. Do not have electrical cords trailing across the floor. Have additional base plugs installed so long cords are not necessary. Grab bars provide extra stability and assistance during transfers. They are typically installed in areas where a senior may need something to hold on to for added balance. Bathrooms are a common location for grab bars, since they can help seniors sit down and get up from the toilet and enter and exit the bathtub or shower safely. When getting in and out of the tub, transfer benches provide stability and help the caregiver get the elderly seniors in and out of the tub safely, without injuring the elderly person or the caregiver. Install anti-slip mats on the bath tub or shower floor. The hard rubber material prevents the elderly person from slipping and provides stability. You can also throw in your washing machine! Wash on cold with gentle detergent (no bleach), and air dry. Canes and walkers help seniors feel steady on their feet. Make sure the mobility device you choose is the correct height for your elderly parent, and has rubber tip or other traction on the bottom, for safety. Get the kids out of the bath After bathing and drying your baby, you do need to clean up the bathroom. One of the things that you also need to clean is the baby bath mat. Do not leave it to let it dry on its own. The bottom part of bath mat for babies have air gaps that are wet. Because of the higher moisture, this now becomes conducive to the growth of molds and mildew. It is best to wash it and after rinsing, hang it to let it dry. Regarding the moisture, if that is becoming a concern for you, then check out our previous post on the best dehumidifiers for your home. The portable ones are excellent for use in the bathroom. First of all thanks for reading my article to the end! I hope you find my reviews listed here useful and that it allows you to make a proper comparison of what is best to fit your needs and budget. Don’t be afraid to try more than one product if your first pick doesn’t do the trick. Most important, have fun and choose your bath mat for tub wisely! Good luck! So, TOP3 of bath mat for tub - №1 — Bathtub Mat by Vive – Non Slip Shower Safety Matting – Rectangle for Bath - №2 — Shower Mat by Vive – Square Bath Mats with Drain Hole – Non Slip Suction Cup Pad for Shower Stalls &… - №3 — The Original GORILLA GRIP

The enameled cast iron Square Grill Pan, 9.5", brings the delicious flavor of outdoor grilling conveniently indoors. The interior surface is finished with a black satin enamel that eliminates the need for the traditional seasoning and maintenance of raw cast iron. Specially formulated for higher surface temperature cooking, the enamel develops a natural patina over time that is ideal for searing. The high ridges create perfect sear marks and allow excess fat and grease to drain away from the food. Loop handles make it easy to maneuver a full pan, and the spouts on two sides allow for drip-free pours. Le Creuset Enameled Cast Iron Cookware has been the world's color and quality benchmark for almost a century. Each piece is cast individually in sand molds, then hand-inspected by 15 artisans to ensure perfection. Each cast iron piece features a rich heritage design, unrivaled cast iron performance as well as ergonomic handles and knobs. Ideal in the oven, on the stove, or at your table, the iconic Le Creuset Enameled Cast Iron cookware line is beloved for both its chip-resistant enamel exterior and superior heat retention properties that lock in flavor and keep food moist and tender. Depending on the piece you select, Le Creuset has custom-tailored the interior finish to suit the style of cooking intended for that piece. Each oven, braiser, saucepan, and soup pot in the Enameled Cast Iron line features world-class cast iron valued for its intrinsic thermal properties and a durable yet nonreactive sand-colored interior that is ideal for slow cooking with moisture and has a smooth, glass-like finish that helps to resist sticking and burning. Each skillet, grill, griddle, and wok features the same high-quality cast iron construction but has a textured black enamel interior that has been perfected for searing, browning, grilling, and blackening. This textured surface allows the build-up of a "patina" which helps to enhance flavor. This hard-wearing enamel surface also allows for higher temperature cooking and requires little to no maintenance or seasoning. Wildly popular the world around, Le Creuset has been producing some of the finest stoneware and porcelain enameled cast iron cookware available anywhere since 1925, and their latest cookware lines reaffirm Le Creuset's dedication to excellence and quality. Professional chefs worldwide place a high value on not only the elegance in design but the high performance of Le Creuset, especially the thermal properties of the enameled cast-iron cookware line. Now you can make cooking fun again by bringing the excellence of Le Creuset into your home! Modern colors and timeless design principles allow you to fill your kitchen with a contemporary flair and cookware pieces that will be treasured for generations to come! Designed to enhance the culinary skills of even the most novice chef, Le Creuset offers a wide variety of products made to make kitchen work much easier. The Enameled Cast Iron line features unparalleled performance and a design to fall in love with. Heavy cast iron provides even heat distribution and the porcelain enamel makes for easy cleanup. A wide variety of shapes and sizes allow for versatility not seen in other cookware lines. The stainless steel and forged hard-anodized nonstick cookware lines are a must-have for anyone seeking to reduce the toil involved with everyday cooking. These lines feature only the highest quality steel, and the forged hard-anodized line comes with a nonstick cooking surface that resists scratching and allows you to cook with less oil for a healthier meal. If durability and toughness are required, look no further than the Le Creuset Stoneware line! This line is extremely scratch-resistant and can be used with temperatures from below freezing to 500°F and everywhere in between! With handcrafted designs that are made to last for many generations, it's easy to see why Le Creuset has been adored around the world for over 80 years. Get yours today and enjoy all that Le Creuset has to offer! |Name:||Le Creuset Square Grill Pan - 9.5″|

Dental Implants FAQs How much do dental implants cost? The price of dental implants varies significantly, based on a number of factors. The patient's health, and whether prerequisite procedures are necessary, certainly affect price. The number of implants required, as well as the type and quality of the prosthetic, also influence cost. Location, and local economy, are often factors in implant pricing, as is the doctor's training and expertise. The most important consideration for the potential implant patient should be peace of mind. You need to feel confident in your implant dentist and comfortable in his or her office. Ultimately, because dental implants greatly enhance quality of life and confidence, and because they can last a lifetime with proper care and good oral health, dental implants are a cost-effective, logical solution to replace missing teeth. What is an implant dentist or implantologist? Implant dentist and implantologist are synonymous. Any general dentist can be an implant dentist and perform both surgery and placement of dental implant restorations. However, most general practitioners place implant restorations, meaning the crown, bridge, partial, or denture that fits on implant posts. A good number of general dentists prefer to refer the surgical phase of an implant case to an oral surgeon or periodontist. Do I need an implant to replace each of my missing teeth? No. One implant post can hold one implant restoration, or crown. Two implants may secure a bridge or partial. Four to six implants are often sufficient to stabilize an upper or lower denture. Does implant surgery hurt? Like all oral surgeries, implant placement is performed with anesthesia. Some dentists use nitrous oxide and local anesthetic, while others prefer to deliver oral sedation, conscious sedation (oral and nitrous oxide), or IV sedation when placing implants. Most patients report post-procedure pain, and dentists commonly prescribe over-the-counter or prescription pain relievers and a special diet during the first few days after surgery. The diet should include a good amount of water, no use of a straw, and soft, cool foods that don't need to be chewed. Soups, yogurt, hummus, and guacamole are good examples of tolerable foods after implant surgery. Do not chew on the implant or implant restoration until the dentist tells you to do so. If your implant abutment or restoration dislodges, contact your implant dentist immediately so that it can be reattached. A bit of bleeding or oozing is normal, and the patient can bite on gauze or a moist teabag for about a half hour to reduce bleeding or oozing. After implant surgery, smoking is strictly prohibited during healing. Stitches will naturally dissolve in about a week, but if they come loose before this time, the patient should not worry unless excessive bleeding occurs. Swelling will subside in approximately 24 to 48 hours following surgery and can be minimized by applying an ice pack to the outside of the cheek, over the area where the implant was placed. To aid healing, elevate the head at a 45-degree angle when lying down. An implant patient should rinse the mouth with room-temperature salt water three times per day for about a week, and brushing can resume the day following surgery. Be cautious not to scratch or irritate the implant surgery site while the mouth heals. Dentures and partials should not be replaced without the consent of your dentist. Implant patients should attend all follow-up appointments on time, as directed by the dentist, to ensure optimal results from implant placement surgery. Will implants make dentures more comfortable? With traditional dentures, the underlining rests on the gums, on natural ridges. For upper dentures, natural suction or adhesive creates stability; for lower dentures, adhesive is required. Over time, friction between the denture underlining and gums causes natural bony ridges to flatten. When this occurs, dentures must be relined for a more accurate fit. Ultimately, the gum ridges completely wear down, and the gums become smooth and flat, and dentures, even with adhesive, become chronically loose or wobbly. The potential for slippage increases. In other cases, patients never find a comfortable fit with a denture. Because implant-retained dentures snap or are affixed to posts anchored in the jaw, they will not loosen, wobble, or come loose. They usually fit comfortably, from day one. Furthermore, because of their stability, implant dentures make the patient feel more confident and comfortable in public, particularly when dining out. Are implant dentures removable or fixed? Either. Your implantologist will discuss your preference and explain the pros and cons of fixed and removable dentures. You can then decide which option will work best with your lifestyle. When are mini dental implants a good choice? Miniature dental implants are best reserved for older patients who have poor jawbone density, but cannot endure bone grafting surgery. Will insurance pay for dental implants? Dental and medical insurance policies can be extremely diverse in their coverage. In some cases, dental insurance will cover all or part of the cost of prosthetics, and medical insurance will cover all or part of implant placement surgery. However, not all insurances cover dental implants. Most dentist offices accept credit cards and offer payment options through third-party banks or in-house financing.

Termite Infestation in Subtropical Region and Solution Termites though neglected because of their minute dimensions can cause irresistible damage to any random household. The more alarming fact is that once there is a termite infestation. Goodbye Pest with their specialization in termite control in Kolkata has solved the problem of many. In a tropical country like ours, the hot and humid climate favors the growth of termites. It allows them to build up a colony within no time. Termites mainly thrive on cellulose found in dead plants and animals. They also cause diseases. A single termite may bring upon multiple problems, so pest control expertise for the prevention of termite becomes necessary whenever there is a termite attack in your home. Termites Infestation in Sub Tropical Region Termites are detritus feeders and thrive mainly on dead matters. They mainly take up nutrients like cellulose from dead wood or animals body (cow’s gut). The termites mainly target the interiors of the houses for the infestation in wooden doors. They also target windows, frames and destroy them from within. The furniture looks well but is destroyed from the inside. Multiple pest control sessions from professionals are required to make an infested house completely termite-free. Termites found in the Indian Subcontinent Approximately there are 220 species of termites in the Indian subcontinent. The humid and moist weather makes India home to a large variety of termites. These termites pose different levels of damage. Major types of termites include Coptotermes heimi, Heterotermes indicolite, Schedorhinotermes sp, Ondototermes sp, Psammotermes rajathanicus, Macrotermes gilvus, and many more. Effects of Termites Infestation The immediate effect lies in the widespread destruction of furniture, wooden frames and leads to potential property damage. Also, the constant fluttering of the termites around the house is a source of acute irritation. Apart from all these the damage and repair cycles continues until a professional pest control service is called to inspect the matter and understand the damages caused by termites. Problems of termites on humans Termites although incapable of transmitting deadly disease. In most cases, wood that releases wood dust into the air. This causes allergic reactions in many individuals who are prone to dust allergy. Dust allergy may prove fatal if you are already suffering from asthma. So, although termites do not possess direct harm, their co-existence with the human is impossible. It is cost bearing along with terrific where long-term effects are best to be avoided. Importance of pest control in the removal of termites The pest control eliminates termites from your house once and for all gifting you lots of positive aspects: - End to your day-to-day suffering from dust allergy from wood dust. - Ends the endless damage-repair cycle of furniture and increases their longevity. - Proper eradication by understanding the degree of infestation. - Using chemicals knowledgeably so that termites are harmed but not your health. If you love your home, then don’t let the termites feast on your furniture. Rather than using up some weird unfruitful home remedies. Let the experts show their expertise, consult professional pest control services in Kolkata. Goodbye has pioneered in Termite Control with a large number of satisfied clients benefitting from these services. It helped them in maintenance and cost reduction of wooden goods. At the same time helped their environment to be termite-free. Especially for humid conditions in places like Kolkata professional pest control and termite control services are always required. Author Bio: Avijit Ghosh Avijit Ghosh completed his M. Sc. in Chemistry from the University of Calcutta & higher studies of entomology from Indian Grain Storage Management and Research Institute (I.G.M.R.I.), Hapur, UP. The author has more than twelve years of field experience since 2009. He worked as a certified entomologist in various reputed organizations. Now he is a start-up entrepreneur of Mom’s Smile and Goodbye Pest, A unit of Aknamos Home Care Pvt. Ltd.

If you’ve never been to Stehekin, it takes some time to get to. Lying at the head of Lake Chelan, Stehekin is only accessible on foot, by boat, or plane. I’ve traveled in and out many times over Lake Chelan in the past year and each time, it gave me time to witness the climatic, topographic, and glacial changes that make this area biologically diverse. Lake Chelan is cleaved into the heart of the North Cascades and is one of the more spectacular places in the area, biologically and geologically. Most people who arrive in Stehekin in Lake Chelan National Recreation Area do so via ferry. When the ferry motors away from Fields Point Landing, about one third the distance from Chelan to Stehekin, it leaves a relatively dry habitat with sparse tree cover, but this can look lush compared to areas farther down lake. At the lake’s outlet, the town of Chelan receives only 11.4 inches (29 cm) of precipitation per year. It is a downright arid place. As the boat continues up lake, stands of ponderosa pine and Douglas-fir slowly thicken. At the elevation of the lake (1,100 feet, 335 meters) however, several factors continue to limit tree growth even along the lake’s upper reaches. Fires frequently burn the slopes while bare rock and sheer walls inhibit soil formation. Summer drought is common with scant rain and hot, dry temperatures that bake the lake’s western and south facing slopes. During spring, the mountainsides are flush with water from snow melt, but in late July and August the soil will become so desiccated it rises like powder under your footsteps. The North Cascades are famous for prodigious snowfall and plenty still clings to the mountains at this time of year. During the last glacial maximum, nearly the whole lake basin was filled with a glacier that carved it into a land-locked, steep-walled fjord. In its middle reaches, Lake Chelan plunges to great depths. The mountain topography on either side of the valley restricted the glaciers outward flow, but not its forward movement. The tight topographic pinch created by the mountains enhanced downward erosion by the glacier. The lake basin, averaging only a mile wide over 50 miles, was greatly over-deepened, even reaching below sea level. At its deepest point the lake is almost 1500 feet (456 meters) deep. (More info about Lake Chelan’s underwater topography.) The volume of the former glaciers is apparent by looking at the shape of the mountains. Where glaciers overran the mountains, the ridges and peaks are smoothed over and somewhat rounded. Mountains that were tall enough to escape complete glaciation remain craggy and jagged. Measured perpendicularly from the deepest area on the lake to the crest of nearby mountains, vertical relief can reach 9,000 feet (2,744 m) and glaciers filled most of the space in between. Looking at a map of Washington before I arrived here, I didn’t fully understand or appreciate the area’s diversity or its glacial story. Here, arid adapted species like sagebrush can live on hot, dry rocky outcrops just a short distance away from a cool, moist ravine with western red cedar and thimbleberry. Glaciers left their mark up and down the lake, accentuating topography even further. Lake Chelan is Washington’s inland fjord surrounded by, perhaps, the most diverse habitats in the whole North Cascades ecosystem.

Hundreds of miles apart, but still connected by the same stubborn weather system, urban St. Louis and rural Appalachia are showing how devastating flash flooding can be when souped-up storms dump massive amounts of rain with no place to go. In St. Louis, the paved city environment couldn’t soak up the intense rainfall. In Kentucky, Virginia and West Virginia, steep hills and terrain of narrow river channels funneled water into the same place. Although a single storm system triggered the downpours, different geographic features played a role in the middle, ending with the same result: Flooding, the second deadliest weather phenomenon in the United States. Floods kill about 98 Americans a year and last year claimed 146 lives. “Places like St. Louis and Kentucky, even though they’re different, they’re overwhelmed,” said private meteorologist Ryan Maue, a former chief scientist for the National Oceanic and Atmospheric Administration. “There’s just no way to move that much water coming out of the sky fast enough. It needs to go somewhere.” A LOT OF RAIN In Missouri and Illinois, the first batch of downpours Tuesday and Wednesday dropped a foot (30 centimeters) of rain in some places, up to 10 inches (25 centimeters) in others with another 2 to 4 inches falling Thursday. In eastern Kentucky, 8 to 10.5 inches (20 to 27 centimeters) fell. “It’s not just how much rain fell, but where it fell, how exposed people were, how close the infrastructure is to where the heavy rainfall falls or where the channels rise,” said Kate Abshire, flash flood services lead at the National Weather Services’ Water Resources Branch. In urbanized St. Louis, rainfall that would normally seep into the ground like a sponge ponded and flooded, Abshire said. In Appalachia, the people who live in the region, the roads, the buildings and the rainfall all were concentrated by river channels that flooded, she said. HOW IT STARTED It all started with the same weather condition — a stationary boundary between different pressure systems “that’s been hanging out between the central Plains and central Appalachians, east to west,” said Bob Henson, a Colorado-based meteorologist and writer. “The same frontal zone that triggered the St. Louis flooding also triggered the mid-Appalachia flooding.” What happens is that unstable moist hot air, pumped from a warm Gulf of Mexico over a dry and super hot Texas, travels along the boundary and forms storms, one after another. And they keep smacking the same place with storms, similar to a line of trains chugging down the track, meteorologists said. This means “extreme rainfall rates” of one, two and even three inches per hour, said Zack Taylor, a senior meteorologist at NOAA’s Weather Prediction Center. “These little episodes of storm systems have been riding along the boundary.” And the storm track isn’t moving much to take them elsewhere, instead it “just kind of hangs out there,” Taylor said. WARMING AND DOWNPOURS As the world warms, scientists expect more frequent and intense downpours — and this event fits that, meteorologists said. No one has done the specific studies needed to attribute these storms to climate change yet. But these aren’t the first big floods of the year or even the season. Some experts fear that weather forecasting models aren’t keeping up with extreme rainfall and are under-predicting how much rain will fall. That was the case last month, when the Yellowstone region had massive evacuations because of flooding, and last year when the New York-New Jersey area was hit by the remnants of Hurricane Ida. Warmer air holds greater amounts of water that it can then dump. In the case of the St. Louis and Appalachia flooding, the air coming north from the Gulf of Mexico is one or two degrees warmer than normal for this time of year — and on the way north it passes over a Texas that is breaking records for heat with Galveston going 10 straight nights of the warmest on record, Henson said. In both places, downpours persist with forecasters seeing more rain, at times heavy, through the weekend and into early next week. “The ingredients are certainly there for some intense rainfall,” Taylor said. Follow AP’s climate and environment coverage at https://apnews.com/hub/climate-and-environment Follow Seth Borenstein on Twitter at @borenbears

A cleft lip is a birth defect: Most times, cleft lip repair is done when the child is 6 to 12 weeks old. A cleft, or separation of the upper lip and/or the roof of the mouth, occurs very early in the development of the unborn child. During fetal development, certain components of the upper lip and roof of the mouth fail to form normally. Cleft lip and cleft palate repair is a type of plastic surgery to correct this abnormal development both to restore function and to restore a more normal appearance. Most clefts can be repaired through specialized plastic surgery techniques, improving childs ability to eat, speak, hear and breathe, and to restore a more normal appearance and function. Risks of repair Problems these surgeries may cause are: Before the Procedure You will meet with a speech therapist or feeding therapist soon after your child is born. The therapist will help you find the best way to feed your child before the surgery. Your child must gain weight and be healthy before surgery. The child’s surgeon may ask for: Always tell child’s doctor or nurse: During the days before the surgery: On the day of the surgery: Most times, your child will not be able to drink or eat anything for several hours before the surgery. After the Procedure Your child will probably be in the hospital for 5 to 7 days right after surgery. Complete recovery can take up to 4 weeks. The surgery wound must be kept very clean as it heals. It must not be stretched or have any pressure put on it for 3 to 4 weeks. You will be taught how to take care of the wound. You will need to clean it with soap and water or a special cleaning liquid, and keep it moist with ointment. Until the wound heals, your child will be on a liquid diet. Your child will probably have to wear arm cuffs or splints to prevent picking at the wound. It is important for your child not to put hands or toys in the mouth. Most babies heal without problems. How your child will look after healing often depends on how serious the defect was. Your child might need another surgery to fix the scar from the surgery wound. A child who had a cleft palate repair may need to see a dentist or orthodontist. The teeth may need correcting as they come in. Hearing problems are common in children with cleft lip or cleft palate. Your child should have a hearing test early on, and it should be repeated over time. Your child may still have problems with speech after the surgery. This is caused by muscle problems in the palate. Speech therapy will help your child. A cleft lip is an opening extending through the upper lip. It may be in the center or left and/or right side of the lip. A cleft palate is an opening of the hard palate, the bony front portion of the roof of the mouth or the soft palate, the muscular non-bony region in the rear of the roof of the mouth. Similar to a cleft lip, a cleft palate may be midline and/or to either right of left side of the palate. A cleft palate may extend from the upper jawbone to the rear of the throat. Since development of the lip and palate occur at different times during gestation, an infant may have either a cleft lip or cleft palate or clefting of both regions. There are a number of complications that may affect infants and children with cleft lip and palate. These include the following: While the effective treatment for cleft lip and cleft palate requires many surgical procedures, speech therapy, and consultation with many medical specialists, it should be anticipated that an excellent outcome regarding appearance and function can be achieved. I came from Baghdad to India with the help of the HTW office over there. I got a good driver and the accommodation in the hospital was also good. Doctors are excellent and experienced. Ms. Tahmina (of HTW) was very helpful. The translator (Ahmed) was good. I will call the HTW office for my friends or family if they have to go to India for their operation.Mr. Hussein Ali Al-Egabi I came to India with a diagnosis of HSIL (High-grade Squamous Intraepithelial Lesion), doctor suggested surgery after my first biopsy results showed negative. Initially, I was afraid to undergo surgery but the doctors and nurses were extremely good and their approach made me feel like home. I would like to thank Health Travellers Worldwide (HTW) for their guidance and support throughout our stay in India.Ms. Ciyizire R Clementine, Rwanda Knee Arthritis had bedridden me and had deprived me of all the wonderful time for past 4 years. I sought advice from Health Travellers Worldwide. Big thanks to Dr.Shailaja, HTW and Muthira who took care of both me and my family in a professional way.Mr. Unaya Mohammed Salim Alrashdi, Oman I want to thank you from the bottom of my heart for everything you have done for me. I am delighted with your work. I would, without a shadow of a doubt, not hesitate to recommend Health Travellers Worldwide. I am happy that in this short time I am back with my family and friends.Mr. Salman Abdullah Dawood Salman, Iraq After years of suffering from knee pain, I decided to undergo surgery. I heard a lot about medical facilities in India. I sought advice from Health Travellers Worldwide. They suggested me the right hospital for Knee surgery. I chose North India and I am really happy with the hospital’s services and care by the entire teamMr. Hind Abdul Amir Hassan, Iraq [dflip id="37081" ][/dflip]

A brief summary of climate and hydrological conditions in the region. This service is only updated during periods in which closer monitoring is required (regardless of time of the year), in recognition that there is potential for dry spells, or irregular hydrological recharging. It does not define an official council position on drought or drought declaration. Updated 9 September 2022. Next update due when there is a significant change of conditions, as the situation evolves. Very significant, widespread rain fell in the region during winter. The western side of the ranges had the wettest winter on record by a far margin, even for long-term recording sites going back to almost 150 years of observations. This is a very significant wet phase of a climate signal, amplified by the fact that summer was also the wettest on record for both Wellington and the Wairarapa. In the Wellington case, various slips developed as a result of the extreme saturation levels of the soil which had already carried on the abnormal moisture from summer. For the Wairarapa, the winter rainfall was less impressive but still above average. As a result, soils and underground water for the Wairarapa remained reasonably replenished and within normal levels for the beginning of spring. Some farms experienced damage and losses due to excessive winter rain, after a lack of summer drying. The global climate remains ‘phase-locked’ into a semi-permanent La Niña mode. This cooling of the Equatorial Pacific contributes to more marine heatwaves around New Zealand (via the oceanic circulation). This helps explain the excessive rainfall and remarkable incursion of atmospheric river events during both summer and winter. Thanks to the background global warming and the semi-permanent La Niña, 2022 was the second consecutive year with the warmest winter on record for both our region and New Zealand as a whole. Most dynamical climate models are predicting the persistence of high pressure south-east of New Zealand into spring, continuing with significantly warmer than average seasonal temperatures. A prevailing La Niña easterly flow is expected to alternate with strong westerlies at times. Humidity corridors (atmospheric rivers) under the influence of moist tropical air masses are expected to continue to occur, albeit less frequently in spring. A continuing negative phase of the Indian Ocean Dipole can also contribute towards above normal rainfall on the western coast and about normal in the Wairarapa, with a large month-to-month variability expected. The ‘normal’ longer-term water balance is becoming increasingly hard to maintain quite possibly due to climate change influences, and increased high frequency climate variability, with more unreliable weather patterns. Droughts are expected to become more severe and frequent in the Wellington region, particularly in the Wairarapa. Even if international climate policy efforts successfully contain global warming under 1.5-2 degrees (the Paris Agreement’s ambition), it is important that we enhance our water resilience and be prepared for a “new normal” climate pattern, significantly drier than in the past. We note that the warming temperatures also mean that evapotranspiration will greatly increase. There is some evidence that our soils are getting drier, and groundwater storage may be decreasing, in the long-term. Browse the data How different has recent rainfall/soil moisture been compared with the same time in previous years? |Kapiti Coast (lowland)||Otaki at Depot| |Kapiti Coast (high altitude)||Penn Creek at McIntosh| |Porirua||Horokiri Stream at Battle Hill| |Wellington City||Kaiwharawhara Stream at Karori Reservoir| |Hutt Valley (upper catchment)||Hutt River at Kaitoke Headworks| |Upper Hutt||Upper Hutt at Savage Park||Upper Hutt at Savage Park AQ| |Wainuiomata||Wanuiomata River at Wainui Reservoir| |Wairarapa (high altitude)||Waingawa River at Angle Knob| |Wairarapa Valley (north)||Kopuaranga River at Mauriceville| |Wairarapa Valley (Masterton)||Ruamahanga River at Wairarapa College||Wairarapa College AQ| |Wairarapa Valley (south)||Tauherenikau River at Racecourse||Tauherenikau River at Racecourse| |Wairarapa (north-eastern hills)||Whareama River at Tanawa Hut||Whareama River at Tanawa Hut| |Wairarapa (south-eastern hills)||Waikoukou at Longbush||Waikoukou at Longbush| Get in touch

BERGENIA VINTAGE TM PINK Pink Dragonfly™ Bergenia features unusual spikes of pink flowers rising above the foliage from late spring to early summer. Its attractive large succulent round leaves are dark green in color with curious red undersides. As an added bonus, the foliage turns a gorgeous burgundy in the fall. The fruit is not ornamentally significant. Pink Dragonfly™ Bergenia is an herbaceous evergreen perennial with a ground-hugging habit of growth. Its wonderfully bold, coarse texture can be very effective in a balanced garden composition. This is a relatively low maintenance plant, and is best cleaned up in early spring before it resumes active growth for the season. Deer don’t particularly care for this plant and will usually leave it alone in favor of tastier treats. It has no significant negative characteristics. Pink Dragonfly™ Bergenia is recommended for the following landscape applications; - Mass Planting - Border Edging - General Garden Use Planting & Growing Pink Dragonfly™ Bergenia will grow to be about 15 inches tall at maturity, with a spread of 18 inches. Its foliage tends to remain dense right to the ground, not requiring facer plants in front. It grows at a medium rate, and under ideal conditions can be expected to live for approximately 10 years. This plant performs well in both full sun and full shade. It is very adaptable to both dry and moist locations, and should do just fine under typical garden conditions. It is considered to be drought-tolerant, and thus makes an ideal choice for a low-water garden or xeriscape application. It is not particular as to soil type or pH. It is highly tolerant of urban pollution and will even thrive in inner city environments. This particular variety is an interspecific hybrid. It can be propagated by division; however, as a cultivated variety, be aware that it may be subject to certain restrictions or prohibitions on propagation.

Strawberry bread! It’s like banana bread — in fact, it’s even made with bananas — but instead of being cloyingly sweet like banana bread, it’s moist, moderately sweet, and chewy because of the delicious dried strawberries. And, if you WANT it to be super sweet, simply use very very brown and ripe bananas, and voila! But that version I would call “strawberry banana bread” versus what this is, strawberry bread that is made with bananas. If you WANT it to be super sweet, simply make sure the bananas are very very brown and ripe, and voila! Here is the recipe I originally made, my thoughts, and the feedback I got from my INTJ boss lady (who is of course, a masterful cook herself) and three coworkers. (I’m INFJ — what? You’re 0.0% shocked???) 3 yellow (not rotting, zombie, fly-infested, bruised) bananas 3 small or 2 large eggs 1 box of white cake mix 1 4oz package of dried strawberries Preheat the oven to 350 F. Mash the bananas till they’re totally disgusting and gooey and look like elephant mucus and then mix the eggs in, until the bowl is filled with an even grosser looking concoction of what definitely resembles bodily fluids. Then pour in the cake mix — just dump it all in otherwise you’ll over mix it and the bread will be tough. Mix thoroughly and add the small bag of dried strawberries and give it a good stir to evenly incorporate the strawberries (if you are not a total brat like some people who get a craving for a certain food and then don’t want to spend extra time on making it, chop the strawberries until they’re minced before stirring them in). Then pour the batter into an ungreased (or, fine, grease it if you want to) loaf pan. Here’s exactly how I baked it and it came out perfectly: 42 minutes — checked it, not set on top Another 10 minutes — looked good but still too soft when I pushed gently on the top 5 minutes later, knife inserted in the center came out perfectly clean. My oven is exactly the right temperature so when I make this again, I’ll probably check at 52 minutes and again at 55 with the knife. Now I LOVE pinterest and I love banana bread … but I love strawberries more, and if you know anything about pinterest, you know that it’s very easy to fall down a rabbit hole quickly. One thing leads to another — you’ve gone from banana bread to strawberry banana bread to strawberry pudding to butterscotch pudding to jello to hello dolly in ten seconds and you wonder if you accidentally fell through a Narnia portal into an abyss of non sequiter pins. BUT FEAR NOT — the search bar remembers what you were actually looking for and it’s easy to get back!! So during one of these click-bait adventures, I saw a recipe for “cake mix banana bread” which only required one box of yellow cake mix, 2 large eggs, 3 bananas, stir, pour, bake, etc. I thought, Wow, I hate yellow cake. It’s so gross. I bet that tastes like banana yellow cake. Ick. So I simply moved on, and that’s when I saw a strawberry cake mix recipe – exactly the same additional ingredients, but instead of yellow cake mix, strawberry. Now, again, I’ve had “strawberry” cake mix before and it doesn’t taste like strawberry at all. It tastes … pink. Or like strawberry gum. It’s okay but I wanted the taste of real strawberries. Now, I did see a recipe that called for adding a few tablespoons of strawberry jam to the recipe I modified (so made with yellow cake mix instead of white) and I’m glad I did not add that, because I really liked the taste of the bread I ended up with and so did most everyone who tried it (4 out of 5, including me). Me: UMMM, I like this, yum. OMG the butter is melting and drizzling off the bread onto my fingers, oh God, this is so good. I think I’ll add half a cup of brown sugar next time. Me after it cooled completely the next day — without butter: Ummm, this would be really good with lemon curd on it. I love the bites with the dried strawberries — next time I’ll try it with TWO packages of dried strawberries and mince them. (Notice I did not have the same thought about adding brown sugar the next day. Why? Does anyone know why?) Once I got to work … Boss: This is good but how ripe were the bananas? Me: They were yellow – I don’t like them mushy, so it’s more like strawberry bread than strawberry banana bread. (Contemplative pause.) You don’t like it. Her: I do. I like the dried strawberries. Me: I don’t like how frozen strawberries turn everything red and I didn’t want pink bread. Her: Yes, the dried strawberries are a really nice touch. Me: I couldn’t get the loaf to come out of the pan so I had to bring it with. Her: Next time let it cool just fifteen minutes before you cut around the sides and it will slide right out. Enter our resident hipster foodie musical-lover (INTJ escapes my further analysis of her microexpressions): Him: Sarah. (pause) I tried the bread. (pause pause) It’s great. GREAT. Moist. Really suave. Loved it. Me: you did?? you didn’t think it wasn’t banana-y enough? Him: No. Perfect. Light. I LOVE the strawberries. They’re dried? Me: Yes, I just mixed in a small pouch of dried strawberries because I didn’t want pink bread. Him (before vanishing back into a windowless room he lights up with his soul): Good. Job. Enter my Boomer friend who is a great baker and who was skeptical about making a bread with a cake mix when I told her about the pinterest recipe I’d seen the day before. Her: Sarah, I love it! It’s great! I had a substantial chunk. Me: Wouldn’t it taste so good with lemon curd? (admittedly, yes, that was random – I basically like my sweet bread the way I like my ice cream — Ben and Jerry-rigged) Her: Ahhh, I wouldn’t say lemon curd but maybe toasted with a little butter or almond butter. Me: … or maybe strawberry jam? Her: Actually, it’s exactly right the way it is, plain. It needs nothing. So did you use a cake mix?? Me: Yes! I used a white cake mix instead of yellow, and used dried strawberries instead of frozen. Her: great idea! I’m amazed that the cake mix tastes so good. I would have thought the old fashioned way would have tasted better — I can’t tell the difference. Wow! Good job! (Me: speechless I was so glad she liked it — her chocolate cake tastes like it comes fedexed from an enchanted Mayan realm of cocoa bliss through a space-time interruption pipe) Enter my fellow Millennial who is a self described picky eater: Her: I really liked the parts where I couldn’t taste the banana. Me: You couldn’t taste the banana in some parts? Her: I bit into a chunk of banana and I didn’t like that part but the rest – Sarah – it was good. Me: You didn’t think you would like it? Me: You liked the dried strawberries? (note to self: next time I make it, I will completely blend the batter in the blender or mixer so there are no banana chunks if I’m bringing it to work) VERDICT: Suave as charged. Everyone loved the dried strawberries. No one could tell it was made with cake mix instead of the old fashioned way. Suave. Hipster coworker captured the essence of this recipe. This bread would be a great gift to someone you want to give a unique food present to, such as a teacher or good friend or sister or aunt … it’s the Anthropologie of bread: it seems unusual when taken altogether but each individual part is familiar if you look closely. If you want it to be a comfort food bread, make sure the bananas are all very very ripe and sweet, and you have strawberry banana bread! (And maybe add that fourth a cup of strawberry preserves or jam.) Final thoughts: This bread would be really nice as a light dessert with butter spread on top along with a glass of rose while enjoying the cool breeze on a summer picnic … in an enchanted strawberry forest. If you make it, I would love to know your thoughts!

Including a toner in your skincare routine can do wonder for your facial skin! Check out these best Japanese toners to up your skincare game and get beautiful skin! One thing that sets the Japanese apart from the rest is their flawless skin. Japanese women take skincare very seriously, and when we talk of a skincare routine, it is always important to include a toner. Japanese toners are also known as Japanese lotions, so if you were wondering about that Japanese lotion you saw, it probably was a toner. Japanese toners are lightweight and clear; the product has an almost watery consistency. If you follow a moisturizing regimen, the best Japanese toner is a must. It is basically a moisturizer in liquid form. Which is the best Japanese toner? I tried and tested several Japanese toners and rated them based on formula, hydration and moisturization. I found that Obagi Nu-Derm Toner is the best Japanese toner. Obagi Nu-Derm Toner is an all-round toner. Obagi Nu-Derm Toner moisturizes and repairs the skin if used everyday. Obagi Nu-Derm Toner works to brightens the skin tone and clean out the pores. Obagi Nu-Derm Toner works well for dull skin as it works well to hydrate and and promote a clear complexion. Obagi Nu-Derm Toner is alcohol-free and works to heal scars and wounds, promoting clear and spot-free skin. It is available on Amazon for $43.00 Why Do We Need Japanese Toners Japanese toners are not only formulated to rejuvenate the skin but also replenish it. Most Japanese toners are easy to apply as they have a watery formula. Japanese toners are also moisturizing in nature and help balance the pH levels of your skin. Japanese toners are formulated to lock-in moisture throughout the day. You’ll find Japanese toners specially formulated for your particular skin type and skin concerns like open pores, acne, dark spots, etc. Our Top Picks For Best Japanese Toner - DHC Mild Lotion Toner – Best for sensitive skin – Get it here! - Shiseido Aqualabel Hyaluronic Acid Lotion Toner – Reduces signs of aging – Get it here! - HADA LABO Gokujun Hyaluronic Lotion Mist Toner – Best for dry skin – Get it here! Best Japanese Toner : Quick Summary |Best Japanese Toner||Key Ingredients| |Obagi Nu Derm Toner||Hyaluronic acid, aloe vera, panthenol| |Onsen Face Toner||Witch hazel, vitamin A, C and E| |DHC Mild Lotion Toner||Cucumber juice extracts, emollients| |Minon Amino Moist Charge Lotion Toner||Amino acids, HCI and carnosine| |Shiseido Aqualabel Hyaluronic Acid Lotion Toner||Double hyaluronic acid, double collagen GL, double royal jelly, D-amino acids| |Muji Sensitive Skin Lotion Toner||Natural water from Kamaish, purslane extract| |HADA LABO Gokujun Hyaluronic Lotion Mist Toner||Types of hyaluronic acid| |Labo Labo Super Pores Lotion Toner||Lactic acid, malic acid, artichoke leaf extract, and pepperwort leaf extract| |Nameraka Sana Isoflavone Lotion Toner||Carrot extracts, collagen| |IPSA The Time R Aqua Toner||Antioxidant EPC-K, pyrola calliantha| - Best Toners From Japan - #1 — Obagi Nu-Derm Toner – Best Japanese Toner For Dry Skin - #2 — Onsen Face Toner – Best Alcohol Free Toner From Japan - #3 — DHC Mild Lotion Toner – Best Japanese Toner Brand 2020 - #4 — Minon Amino Moist Charge Lotion Toner – Top Japanese Toner For Skincare Routine - #5 — Shiseido Aqualabel Hyaluronic Acid Lotion Toner – Top Japanese Toner Brands 2020 - #6 — Muji Sensitive Skin Lotion Toner - #7 — HADA LABO Gokujun Hyaluronic Lotion Mist Toner - #8 — Labo Labo Super Pores Lotion Toner - #9 — Nameraka Sana Isoflavone Lotion Toner - #10 — IPSA The Time R Aqua Toner - Best Toners To Buy From Japan: FAQs Best Toners From Japan #1 — Obagi Nu-Derm Toner – Best Japanese Toner For Dry Skin Obagi is a very popular cosmetic brand in Japan and offers one of the best Japanese toners in the market! It is an alcohol-free and non-drying toner that balances the pH level of your skin. If you are somebody with rough and dry skin, this toner is the answer to your woes. Three of the key ingredients in this toner are the magical hyaluronic acid, aloe vera, and panthenol. These ingredients love your skin and will ensure that it always remains in the best condition. They also help lock in moisture and prevent dehydration of the skin. Also, these products are so gentle that they suit every skin type. If you use this Japanese toner, you will soon start noticing that it is clarifying and brightening your skin. So, if you wish to correct your skin’s complexion, this is the product to go for. The toner is also excellent for large pores; it also helps prevent signs of aging, such as wrinkles and fine lines. The toner is an effective base for the absorption of all other products. Definitely one of the best Japanese toners! #2 — Onsen Face Toner – Best Alcohol Free Toner From Japan This is another best Japanese toner that is naturally enriched with botanical components that make sure you get skin that is youthful and radiant. One of the ingredients of this toner is witch hazel, which is known to have excellent properties that are good for the skin. In fact, it makes its appearance in several DIY skin care regimen followed by women across the globe. Witch Hazel in the toner helps fight acne and prevent breakouts. Other ingredients include aloe vera, hyaluronic acid, as well as green tea. All of these ingredients love taking care of our skin. You will also find Vitamins A, C, and E as a part of the ingredients list. It is free of mineral oils, parabens, as well as other ingredients that can be harsh on the skin. Also, the toner has not been subjected to animal testing which is why it deserves to be in this list of best Japanese toners. #3 — DHC Mild Lotion Toner – Best Japanese Toner Brand 2020 DHC is one of the most well-known Japanese brands. The toner is another of its great products. It is free of alcohol and is effective for refreshing, toning, and soothing the skin. You can choose this toner even if you have very sensitive skin; the toner is extremely gentle on the skin. One of the ingredients of this toner is cucumber juice extract. Cucumber, as we all know, has cooling properties. You must have noticed how cucumber slices are an important part of a skincare regime. It is highly effective in removing puffiness and dark circles. The cucumber juice extract in the toner helps in cooling and refreshing your skin instantly. The toner also has other emollients that work towards making your skin softer and smoother. Hands down, one of the best Japanese toners in the market! You have to check it out! #4 — Minon Amino Moist Charge Lotion Toner – Top Japanese Toner For Skincare Routine Minon Amino toner is special as it contains nine types of amino acids. These amino acids pack the toner with power that penetrates deep into your skin to replenish its moisture. It also strengthens your skin. The toner also acts as a barrier, preventing any damage to the skin from external elements. Two of the nine amino acids included in this toner are HCI and carnosine. These two ingredients are known to have clarifying benefits for your skin. The toner sinks right into your skin without drying it out. It also helps improve skin elasticity. The acids in the toner help make your skin smoother and softer. It’s one of my personal favorites and one of the best Japanese toners out there! #5 — Shiseido Aqualabel Hyaluronic Acid Lotion Toner – Top Japanese Toner Brands 2020 The name Shiseido is quite a compelling reason to get this toner. The brand has made its name all around the world and offers one of the best Japanese toners. The toner comes with a light rose fragrance that does not overpower you, but lingers on to give you that floral shield. It does not have a strong chemical odor like others. The toner has a watery consistency, which absorbs easily into the skin. The major ingredients of this toner are double hyaluronic acid, double collagen GL, double royal jelly, and D-amino acids. These ingredients replenish moisture in the skin and prevent dryness. And not just that, the toner also improves skin elasticity and is a great option to choose as you age. The toner has Aqua Synergy and Lift Synergy formula. Both of these exclusive ingredients keep the skin feeling moist and supple, giving you that fresh and dewy look. It is also an effective base for all other products that you use on your face. It increases absorption. #6 — Muji Sensitive Skin Lotion Toner Here’s another one of the best Japanese toner for you. MUJI is a cult-favorite in Japan and one of the most reliable brands. This best Japanese toner uses natural water from Kamaishi and contains grapefruit seed extract, Lipidure, and purslane extract. The formula of this Japanese toner is safe to use on sensitive skin as it is fragrant free, is a low-irritation formula, and allergy-tested. It is also free of alcohol, parabens, and mineral oils. #7 — HADA LABO Gokujun Hyaluronic Lotion Mist Toner Even though the name of the products says it’s a lotion, this product is more like a lightweight thin liquid that is quickly absorbed into the skin when applied. It makes your skin dewy and soft. This Japanese toner is perfect for dry skin! If you suffer from dehydrated skin, you’re sure going to love this best Japanese toner! This toner is formulated with three types of hyaluronic acid that’s known to nourish your skin. The Japanese toner comes in the form of a mist – all you have to do is spray it on your face directly and massage! #8 — Labo Labo Super Pores Lotion Toner This Japanese toner is manufactured by one of the famous Japanese skin care brands called Dr. Ci:Labo. This Japanese skincare brand is a popular Japanese cosmetic brand that offers medicated beauty products. This Japanese brand specialises in formulating products that are safe on the skin. So even if you have sensitive skin, you can use this Japanese toner with no doubt! It’s a wipe-off lotion type toner that removes the top keratinized layer of the skin to reveal a softer and firmer layer. Using the toner also improves the permeability of the skin so the following skincare products you use penetrate deep into the skin! This Japanese toner is formulated with water-soluble collagen, sodium hyaluronate, royal jelly acid, hamamelis leaf extract, lactic acid, malic acid, artichoke leaf extract, and pepperwort leaf extract. Check out this best Japanese toner here! #9 — Nameraka Sana Isoflavone Lotion Toner The next best Japanese toner on the list is the Nameraka Sana Isoflavone Toner. This toner penetrates deep into the skin allowing your skin to absorb all the ingredients in the toner. It doesn’t have a greasy after effect even if you sweat. However, this toner does contain alcohol so folks with extremely dry skin steer away from this one. The ethanol in this toner actually helps with the penetration. So I guess it’s a boon and a curse this toner has to carry. Anyway, if this toner does suit your skin, after application your skin will soften. It’s also super effective to remove makeup! Check out this best Japanese toner below! #10 — IPSA The Time R Aqua Toner This best Japanese toner has three times the moisturizing effects than your regular toner. This toner is formulated with 1,000 trillion fine moisturizing molecules that penetrate deep into the skin to stimulate skin’s hydration production. It also locks in moisturizer by creating a skin barrier. This is one of the best Japanese toners for acne prone skin as it helps control excess oil production and also prevents acne. This Japanese toner is formulated with Aqua Presenter III that locks in moisture. It also contains peony and marjoram extracts that helps soothe any inflammation. It also contains antioxidant EPC-K that protects your skin from free radicals. The tone also makes your skin smooth as it contains pyrola calliantha and other herbal extracts. Check out this best Japanese toner below! How to choose the best Japanese toner? Consider the following factors when you are choosing the best Japanese toner: - Skin type #1 — Texture The first thing you would want to check is the texture of the best Japanese toner that suits you. Toners that are lightweight get absorbed quickly. However, toners that have a thicker consistency usually take longer to get absorbed by the skin. You need to know which toner you prefer. #2 — Fragrance The fragrance of the toner is extremely important to me. It plays on the mind, which makes it one of the most important things to consider when choosing a toner. There are Japanese toners that smell like chemicals. Look for one that has a lovely and refreshing fragrance. You would love using the toner if it smells good. #3 — Ingredient What makes these best Japanese toners so effective are the ingredients used to make them. The most popular and common ingredients that you will find in toners include butylene glycol, sodium hyaluronate, trehalose, and collagen. #4 — Skin Type You need to know your skin type before choosing the best Japanese toner for yourself. If you have sensitive skin, it is a good idea to steer clear of toners that have alcohol. Alcohol may irritate your skin and trigger harsh reactions. However, not many Japanese toners use alcohol. However, if your skin is not sensitive, alcohol is not really a bad thing. It helps to penetrate the toner deeper. Best Toners To Buy From Japan: FAQs What is the Difference Between Japanese and American Toners? The main difference between Japanese and American toners is that Japanese toners are formulated to moisturize the skin and it can be compared to a liquid moisturizer. Japanese toners also work to make your skin softer. American toners, on the other hand, are astringent-based and are formulated to cleanse your skin which results in dryness. How do you use Japanese toners? To use a Japanese toner, wash your face with water first. Then wash your face with your favorite cleanser. Take a round cotton ball, put your favorite Japanese toner on the cotton ball, completely soaking it. Then apply it to your face. You can also splash some of the Japanese toner directly onto your face and spread it using your fingers. What are the Ingredients in a Japanese Toner? Common ingredients found in Japanese toners are cucumber juice extracts, will bark extract, oat kernel extract, and aloe leaf extract. Another common ingredient in Japanese toners is purified water. However, you won’t find harsh ingredients like alcohol in most Japanese toners. What is the best toner from Japan? Shiseido Aqualabel Hyaluronic Acid Lotion Toner is one of the best toners in the market from Japan. It has a watery consistency and has ingredients like double hyaluronic acid, double collagen GL, double royal jelly, and D-amino acids. The toner prevent your skin from drying and improves skin elasticity as well! Are Japanese toners good? Japanese toners are some of the best in the world. In fact, Japanese beauty products are some of the best! Japanese toners use the best ingredients for your skin for effective results! Here’s why using Japanese toners is extremely beneficial for your skin: A Japanese toner is essential to restore the pH balance of your skin. It is a coating that prepares your face for all the other products that you are going to apply. By getting your face ready for other products such as moisturizer and serum, the Japanese toners make sure of optimal absorption. It helps lock in moisture so your skin does not feel dehydrated. Japanese toners are loaded with skin-loving ingredients. Japanese toners use a lot of soothing and emollient ingredients right from natural sources. Depending on the toner you use, it may help in fighting off acne, preventing the visible signs of aging, brightening your complexion, and firming the skin. With the best Japanese toners, take your skincare regime to the next level. The Japanese toners mentioned above will help you take care of your skin in the most loving way possible. These toners will make your skin smooth and glowing. So, with all these wonderful Japanese toners, walk on the path to excellent skin. - Here are 18 drugstore products in Japan you CANNOT miss out on! - Check out these Japanese lip balms for soft, supple lips! - Taking care of your hair is equally important! Check out some of the hair nourishing Japanese shampoos for hair loss Erika is the main author of the website. She is obsessed with Japanese products and always looks for an opportunity to share her love for Japanese products with everybody around her! She combined her love for writing, research and testing products to create Best Japanese Products. When she’s not reviewing latest Japanese products, you’ll find her pampering her cats. Erika is the definition of ‘The Crazy Cat Lady’.

Tuatara: Volume 9, Issue 3, January 1962 New Zealand Land Slugs — Part I New Zealand Land Slugs — Part I To most people, the word slug conjures up a picture of a rather repulsive, brownish-grey slimy animal, passionately addicted to eating cabbages. There are in New Zealand, however, representatives of two widely differing families of slugs, the introduced European Limacidae, and the native Athoracophoridae which are found only in the Western Pacific area. External differences between the two are easily observed: the Limacidae have two pairs of tentacles, a mantle area covering the anterior aspect of the back, a brown or grey coloration, and carnivorous or herbivorous habits, whereas the Athoracophoridae have only one pair of tentacles, a smaller, much less obvious mantle area, a distinct pattern of dorsal grooves, and a highly developed dorsal tracheate lung of a nature found in no other mollusc. The native slugs may grow up to six inches in length, are often more attractively coloured than their introduced counterparts, and frequently have numerous dorsal papillae. New Zealand slugs are fairly common in bush and grassland, and are frequently found under logs, in leaf mould, and in the leaf bases page 88 of flax bushes and nikau palms. The mainland native slugs, and those found in the subantarctic islands, are closely allied to those found on New Caledonia, New Hebrides, New Britain, the Admiralty Islands, and the eastern coast of Australia. In a recent paper (Solem, 1959) the New Zealand slugs are regarded as primitive members of the group isolated by the submergence of a land bridge which, it is claimed, previously connected the North Island with the islands of Melanesia. During recent work on the native slugs of New Zealand the writer has found no evidence to suggest that the structure of our slugs is ‘primitive’, and the origin of the group and its dispersal cannot be determined from our present knowledge. There are in New Zealand four genera of native slugs (one genus newly described — Burton, Trans. Roy. Soc. N.Z. in press) containing twenty-two known species (eleven newly described — Burton, Trans. Roy. Soc. N.Z. in press). There are some wide ranging common species such as Pseudaneitea papillata in the South Island and southern North Island, and Athoracophorus bitentaculatus which is widespread in both islands, but in general the species tend to be restricted in range, for example Pseudaneitea dendyi found as yet only in Mid-Canterbury, and Pseudaneitea schauinslandi, only in the Marlborough Sounds area. Slugs are rare or absent in very dry areas such as Central Otago and in the volcanic central plateau of the North Island, but are otherwise fairly common. The distribution of the subantarctic Athoracophoridae poses interesting problems. Five species are known from four islands, but none as yet have been found on the mainland. Only one species occurs on more than one island. This species is found on both Campbell and Macquarie Islands, and its mode of dispersal is as yet unknown. Dispersal over a land bridge seems unlikely for two reasons. First, the slugs would have to survive the Pleistocene glaciation subsequent to the loss of the bridge, and secondly, the broad expanse of deep water between Macquarie and Campbell Islands makes a land bridge between the two improbable. Furthermore, oceanic wind drift dispersal of eggs or adults among rafting masses of vegetation does not seem probable, as this envisages the raft either moving against the West Wind Drift or completing a circumpolar journey. However, it is possible that Macquarie Island has been colonised by animals drifting from the coast of Australia, and if this is so the colonisation of Campbell Island would easily follow. The four species found are contained in two genera, one of which, Pseudaneitea, is common on the mainland. The other genus, however, is only found in the subantarctic islands. If the slugs have been on the islands only since the Pleistocene, this points to a high rate of speciation. Generic differentiation appears to be considerably slower. The slugs eat only fungi, and usually select encrusting fungi. For example Athoracophorus bitentaculatus is often found at night feeding on Capnocdium moniliforme on the leaves of Pseudowintera axillaris. The jaw is elasmognathic, having a horny plate held vertically in the anterior portion of the buccal mass and protruded through the mouth to scrape up fungus as the slug moves. As the animal moves successive waves of contraction and relaxation traverse the sole from posterior to anterior. The expanded, relaxed parts of the sole stay fixed with mucous while the contracted zone is in forward motion. The slug breathes mainly through the skin of the back, which is kept moist by a renal secretion passing along the grooves. The role of the lung in respiration is not yet known, but it is probably not very effective. The eggs (Pl. 3, fig. 3) are round, gelatinous, papillated, and a light translucent yellow. They vary in diameter according to the species, ranging from 3-4 mm. in Athoracophorus bitentaculatus to 7 mm. in Pseudaneitea papillata. They are laid in batches of up to fifty in damp, cool surroundings from the beginning of spring through to late summer, and take up to three months to hatch. The young slug develops in a curled position, with the mouth opposite the posterior tip of the sole. When the slug is due to hatch, it attempts to straighten out, as though exerting pressure opposite the head, which soon breaks through the egg wall. The slug then crawls away. Specimens deprived of water shrink and soon die. One specimen which escaped at night was found as a small heap of dried-up tissue at the end of a forty-yard slime trail. It is usually necessary to narcotise the slugs carefully before preserving them, otherwise the buccal mass will be protruded through the mouth and the animal may contract and distort so much that many features will be obscured. The most readily available narcotic is an infusion of tobacco in water. One large pinch of tobacco to a pint of water is sufficient, and after the container is thoroughly shaken the narcotic is ready for use. Specimens should be immersed for at least eight hours, preferably longer if they are large. Other narcotics may be better for large specimens; a dilute solution of Blackleaf 40, which also contains nicotine, is suitable. When properly narcotised the slugs will be relaxed and extended, sometimes with their tentacles protruding. They may be preserved in either 70% alcohol or 4-6% formalin solution. In general formalin is preferable, as the tissues remain softer and colour retention is slightly better.page 90 For injection of the circulatory system, freshly narcotised specimens only can be used, otherwise the arteries become constricted and burst under pressure. A fine capillary tube drawn from glass tubing and fitted with a rubber pipette bulb is best for this purpose. Slugs may be injected with a gelatin solution stained with indian ink, or with coloured latex; injections are usually made into the ventricle or common aorta (Pl. 2, fig. l). To prepare a whole mount of the radula, remove the entire buccal mass and macerate it in strong caustic soda. The radula should not be left too long after the flesh around it has dissolved, otherwise the basement membrane disintegrates. Wash the radula in water, then transfer to concentrated aniline blue for two minutes. Wash in lactic acid. Unroll and flatten the radula before mounting in polyvinyl alcohol. A detailed account of one species only (Pseudaneitea papillata) is given. This species is common and anatomically typical. External Features (Plate 1, fig. 1) PLATE I : Pseudaneitea papillata (Hutton). Fig. 1: Externals — dorsal aspect. Fig. 2: Buccal mass and associated structures. Fig. 3: Sub-buccal arteries and nerves. Fig. 4: Sub-buccal arte:ies, ganglia removed. Fig. 5 : Radula — central and lateral teeth. an., anus; ao, anterior branch of aorta; b.a., buccal artery; b.g., buccal ganglion; b.m., buccal mass; c.a.v., cerebral arterial vesicle; c.g., cerebral ganglion; ga.a., ganglionic artery; g.o., genital orifice; h.s., head shield; l.gr., lateral groove; b.a., mantle area; m.gr., median groove; mo., mouth; o.a., oral artery; od., odcntophore; oes., oesophagus; o.n., oral nerve; ov., oviduct; p.a., pulmonary aperture; ped.g., pedal ganglion; ped.gl., pedal mucous gland; ped.n., pedal nerve; pen., penis; ph.a., pharyngeal artery; r.o., renal orifice; sal.d., salivary duct; ten., tentacle; ten.a., tentacular artery; ten.n., tentacular nerve; vag., vagina; v.d., vas deferens; v.g., visceral ganglion; I, II, III, IV, visceral nerves. With scissors make a lateral incision along the left side just dorsal to the perinotum, and continue it over the dorsal aspect of the head. Carefully reflect the skin, except for the region around the mantle area to which the circular lung, bilobed renal organ, shell rudiments, and thin-walled atrium are attached. The lung and renal organ may be reflected with the skin, but the atrium must be carefully detached from the ventral wall of the dorsal blood sinus before the skin can be completely reflected and pinned down. Remove the thin, membranous wall to expose the viscera in the haemocoele.page 93 PLATE II: Pseudaneitea papillata (Hutton). Fig. 1 : Anatomy — in situ. Fig. 2: Alimentary system and associated blood vessels. alb., albumen gland; at., atrium; b.m., buccal mass; g., ganglionic mass; her., hermaphrodite gland; int., intestine; liv., liver; od., odontophore; oes., oesophagus; p.ao., posterior branch of aorta; ped.gl., pedal mucous gland; ped.n., pedal nerve; pen., penis; ren., renal organ; r.m., retractor muscle; sal.a., salivary artery; sal.d., salivary duct; sal.gl., salivary gland; st., stomach; vag., vagina; vas def., vas deferens; ven., ventricle. The mouth opens into a buccal chamber in the highly muscular buccal mass (Pl. 2, fig. 1; Pl. 3, fig. 2). A thin-walled oesophagus traverses the dorsal aspect of the buccal mass, passes ventral to the connective between the cerebral ganglia, and expands into an elongate, thin-walled stomach, which extends posteriorly to the liver. Here it recurves to merge into a thicker-walled, narrower intestine, which extends forwards to loop around the common aorta, passes back to the liver, then recurves to extend anteriorly to the rectum. The stomach and the loops of the intestine spiral around each other. The lobulate liver, orange in fresh material, occupies the posterior third of the body cavity. A pair of off-white, lobulate salivary glands flank the anterior wall of the stomach, and give off from their anterior ends each a tubular, convolute salivary duct, passing ventral to the supraoesophageal connective to merge into the anterior aspect of the buccal mass. Reproductive System (Pl. 3, fig. 1) The genital orifice, a short, narrow, slightly curved slit in the margin of the head shield lateral to the right tentacle, opens from a broad, short, often thin-walled vagina, to the end of which are attached the broad, long, muscular, slightly sinuous oviduct and the muscular, twisted penis. A thin-walled, rounded receptaculum seminis is attached to the oviduct near its anterior end by a narrow stalk. The convolute glomerate gland, of unknown function, is attached to the oviduct near its posterior end. Attached at the posterior end of the oviduct are four structures: a rounded bulbose gland of unknown function, a yellow, U-shaped albumen gland, the end of the vas deferens, and the end of the highly convoluted hermaphrodite duct. The other end of the hermaphrodite duct arises from a large, oval, lobed ovotestis, which lies dorsally, posterior to the rectum. From the oviduct the vas deferens runs to the bulbose gland, and then along the course of the oviduct, under the right tentacular nerve, and out to the distal tip of the penis, which is marked by the insertion of a long retractor muscle with its origin in the dorsal midline.page 95 PLATE III : Pseudaneitea papillata (Hutton). Fig. 1 : Reproductiva system. Fig. 2 : Buccal mass — sagittal section. Fig. 3 : Eggs. Fig. 4 : Elasmognathic jaw. Fig. 5 : Head-ventral aspect. Ib.gl., albumen gland; ant.ao., anterior aortic branch; ant.gen.a., anterior genital artery; a.p., accessory plate; b.c., buccal cavity; bulb.gl., bulbose gland; gen.a., genital artery; glom.gl., glomerate gland; her.d., hermaphrodite duct; her.gl., hermaphrodite gland; j., elasmognathic jaw; m.c., median cusp; mo., mouth; od., odontophore; oes., oesophagus; ov., oviduct; ov.a., oviducal artery; pen., penis; rec.sem., receptaculum seminis; r.m., retractor muscle; vag., vagina; vas def., vas deferens; w., wing. The accessory glands, that is, the glomerate and bulbose glands, and the albumen gland are subject to an annual cycle, during which they grow to a very large size in May and June, and then diminish in size during the summer. Only when these glands reach their maximum development do the viscera fill the entire body cavity. During summer and autumn, the posterior tip of the liver lies at about two-thirds body length, and the body cavity posterior to this is unoccupied. Circulatory System (Pl. 1, 2 and 3) The heart, situated dorsally, consists of a thin-walled, transparent atrium which communicates with the smaller, thick-walled, white, muscular ventricle, from the left side of which the common aorta arises. This short vessel divides almost immediately into anterior and posterior aortic branches. The anterior branch gives off a genital artery which supplies the hermaphrodite gland, oviduct, and accessory glands, and then gives off a salivary artery to the salivary glands, before expanding to form a small vesicle between the visceral and pedal ganglia. From the vesicle arise paired tentacular and oral arteries, median buccal and pharyngeal arteries, and the anterior genital artery on the right side. The posterior aorta, before terminating in the liver, gives off numerous branches which ramify to supply the stomach and intestine. Blood collects in the large ventral sinus, which encloses the alimentary and reproductive systems, and in two small dorsal sinuses enclosing the renal organ and the pulmonary diverticula. Blood passes into the pulmonary sinus, and thence to the atrium for recirculation. Nervous System (Pl. 1, fig. 2; Pl. 2, fig. 1) The cerebral ganglionic mass is composed of paired cerebral, visceral, and pedal ganglia, just posterior to the buccal mass. The cerebral ganglia are smooth, white, rounded structures, superimposed on the lateral aspects of the paired visceral ganglia. The paired pedal ganglia are posterior and ventral to the visceral ganglia. The cerebral ganglia give off paired tentacular nerves, paired nerves to the buccal ganglia situated on either side of the dorsal aspect of the buccal mass, and three pairs of nerves, arising in a common root on either side, to the oral region. The visceral ganglia, composed of numerous small ganglia just visible to the naked eye, give off four nerves from the posterior side, numbered I-IV from left to right. N. I runs on the left side of the stomach to enter the muscles of the back close to the renal organ. N. II runs along the anterior branch of the aorta to enter the back posterior to the renal organ. N. III at first follows N. II, but then runs posteriorly, following the coiling of the intestine; it gives branches to the hermaphrodite gland and the intestinal loop. N. IV runs over the dorsal aspect of the rectum into the skin. A major pedal nerve arises from the lateral page 97 aspect of each pedal ganglion to run down the side of the body cavity to the tail. Short nerves arise from the lateral aspects of the pedal ganglia to supply the anterior muscles of the sole. Surprisingly, no nerve supplying the penis, vagina, and oviduct has been found. The pulmonary aperture lies in the centre of the mantle area, and is bordered by a sphincter muscle. Lying immediately below it is an expanded pulmonary chamber, its floor and walls lined with muscle tissue. Several passages through this muscle branch to form numerous thin-walled, fingerlike diverticula which radiate out to form the roof of the pulmonary sinus. The effectiveness of the lung as a respiratory structure is not yet known. Some workers believe that it is primarily secretory in function. Probably the major part of air exchange takes place through the skin, which is kept moist by a secretion from the renal organ. The secretion is pumped from the renal orifice at intervals ranging from 2-20 seconds, and runs over the entire back, aided by contractions of the muscles bordering the grooves. The Radula (Pl. 1 and 3) The radula is saddle-shaped, inrolled dorsally at the sides, and expanded anteriorly to form a broad rasping surface in the buccal chamber. When flattened out on a slide, it forms a broad chevron with 130-150 rows of teeth, each row with up to 150 teeth on either side; these figures are variable. In each row there is only one central tooth; all others are laterals. Each tooth consists of a broad, flat stem rooted proximally in the transparent basement membrane, and a distal recurved head bearing a number of denticulate reflections. The denticle number in any given specimen is subject to wide variation, and is unsuitable for diagnosing species. Tooth formation takes place at the root of the odontophores, located at the posterior end of the radula; teeth here are rudimentary, with very long denticles in proportion to stem length. They remain clear when the radula is stained in aniline blue, presumably because they are still surrounded by non-staining basement membrane.

Beware of Ticks This Fall Does your dog or cat enjoy exploring the fields and forests near your home? These areas are prime habitats for ticks, small parasites that survive by drinking a host's blood. Ticks spread a variety of diseases, including Lyme disease and Rocky Mountain spotted fever. During the fall, ticks become more active, which increases your pet's risk of illness. How Ticks Make Pets Sick Ticks may look like bugs, but they're actually arachnids, an animal class that includes spiders, daddy longlegs, and mites. You'll find ticks in shady, moist places, like tall grass, brush, shrubs, logs, wood piles, and stone fences. Your pet could pick up a tick simply by walking through a pile of wet leaves or taking an autumn walk with you through the woods. Ticks attach themselves to a host's body with their mouths and begin to feed on that animal's blood. As the tick feeds, it may inject a virus, bacteria, or protozoa into its host's blood. A series of small hook-like structures in the tick's mouth can dig into your dog or cat's skin, making it possible for the tick to remain attached to your furry friend for hours. Your pet doesn't automatically become sick the instant that a tick begins to feed. Disease transmission can take two to 90 hours, depending on the type of tick. Ticks aren't easy to see when they're not full of blood. In fact, they're no bigger than the head of a nail, according to the ASPCA. Once they're engorged with blood, they can grow to 1/4" or more in diameter. Diseases Caused by Ticks in the U.S. Your pet could develop one of these diseases if bitten by a tick: - Lyme Disease. Black-legged (deer) ticks transmit the bacteria that causes Lyme disease. Symptoms of Lyme disease include joint pain, swollen joints, fever, limping, lameness, enlarged lymph nodes, and loss of appetite. Pets that have Lyme disease may get tired easily or have less stamina than usual. If the disease isn't treated promptly, kidney failure, heart problems, or joint damage can occur. - Anaplasmosis. Black-legged and brown dog ticks can also spread anaplasmosis, a disease that has many of the same symptoms as Lyme disease. According to the American Kennel Club, some unlucky pets can have both anaplasmosis and Lyme disease at the same time. - Rocky Mountain Spotted Fever. Rocky Mountain spotted fever has been reported in nearly every state, although the Centers for Disease Control and Prevention note that the disease is most often found in Central, Eastern and Western states. If your pet has Rocky Mountain spotted fever, it may experience joint pain, fever, swollen lymph nodes, poor appetite, coughing, vomiting, diarrhea, abdominal pain, balance problems, and purple spots on the mouth or eyelids due to damaged blood vessels. In severe cases, organ failure can occur due to blood clots. The American Dog Tick, Brown Deer Tick and Rocky Mountain Wood Tick can transmit Rocky Mountain spotted fever. - Cytauxzoonosis. This tick-borne disease spread by the American dog tick and lone star tick affects cats, many of whom die from the illness. Symptoms include high fever, weakness, fatigue, dehydration, vomiting, diarrhea, jaundice, enlarged lymph nodes, abdominal pain, seizures, and coma. - Ehrlichiosis. Spread by the lone star, American dog, and brown dog ticks, ehrlichiosis can cause fever, trouble breathing, swollen lymph nodes, weight loss, swollen limbs, and bleeding disorders. - Babesiosis. Babesiosis attacks your pet's red blood cells, causing fever, anemia, swollen lymph nodes, weakness, jaundice, pale gums, fatigue, and dark brown, orange, or red urine. Your pet can develop babesiosis after being bitten by a black-legged tick. - Hepatozoonosis. A bite from either the lone star or gulf coast tick could cause hepatazoonosis. Loss of appetite, weight loss, fever, eye and nose discharge, muscle pain and weakness, and difficulty moving are common symptoms. Like other tick-borne illnesses, pets can die from hepatozoonosis without quick treatment. How to Protect Your Pet from Ticks Reduce your pet's risk of tick-borne diseases by: - Performing Tick Checks After a Trip Outdoors. If you find a tick, remove it by grasping the head and slowly pulling it out of your pet's skin with tweezers. Kill the tick by putting it in a container filled with rubbing alcohol. If you can't remove the tick or only removed part of it, call your veterinarian. - Watching Your Pet. Look for symptoms of tick-borne illness, which include redness around the tick bite, fever, and painful joints, for several weeks after the bite. (In some cases, symptoms may not appear for several months). - Calling Your Veterinarian. Your veterinarian can provide products that kill ticks before they can harm your pet.

My family absolutely loves this Cinnamon Roll Pancakes with Cream Cheese Icing. I am completely gluten and dairy free, however some of my family is not. Sometimes I make these for them, and they can’t stop raving! Babes! You guys are going to love these!! Your whole house will smell like a cinnamon roll! Let’s get started! Ingredients for Pancake Batter: 2 cups flour measured with a spoon, do not sift 2 tsp baking soda 1 tsp salt 3 tbsp white granulated sugar 2 1/3 cups low fat buttermilk or 1 tbsp of vinegar for every cup of milk used unsalted butter for cooking Ingredients for Cinnamon Filling: 1/3 cup unsalted butter, creamed (do not melt it completely or your filling will be runny) 3/4 cup packed brown sugar 1 tbsp ground cinnamon Ingredients for Cream Cheese Glaze: 4 tbsp butter 2 ounces cream cheese 1 1/4 cups powdered sugar 1 tsp vanilla extract Instructions for Cinnamon Filling (prepare this first): - In a medium bowl, mix the butter, brown sugar and cinnamon. - Scoop the filling into a small zip baggie, tie the baggie so that the filling is densely packed into the corner, and set aside. *If you melted your butter too much and your filling is runny, let it sit for at least 30 minutes or longer so that it gets thick. You do not want it runny. You can also try setting the baggie with the filling into the refrigerator for some time to help it harden should it be too runny. Instructions for Pancake Batter: - Whisk eggs and buttermilk together in a medium bowl. - Add flour, baking soda, salt, and sugar. Whisk just until combined. Instructions for Cream Cheese Glaze: - In a medium glass or microwave-safe bowl, heat the butter and cream cheese until creamy, but not completely melted. - Whisk together until smooth. This process can take a bit. At first, the cream cheese and butter mixed together will look lumpy and weird. - Continue whisking together and I promise you it will start looking creamy and smooth after a bit. Once you have whisked the butter and cream cheese together until it is completely smooth, then you are ready to whisk in the powdered sugar and vanilla. Once complete, scoop this glaze into a zip baggie. Tie the baggie so that the filling is densely packed into the corner and set aside. Time to cook the pancakes!!!! - Heat a large skillet or griddle over low heat. *Please make sure the heat is low so that the cinnamon filling does not burn. If your filling starts burning, one of two things is happening or a combination of both: 1) your heat is too high and/or 2) your cinnamon filling is too runny due to your butter being too melted instead of creamy. - Spray with non-stick cooking spray. I use Pam. - Scoop the pancake batter onto the griddle until desired pancake size is reached. - Snip the corner of your cinnamon filling baggie and squeeze a spiral of the filling onto the top of the pancake. - When bubbles begin to appear on the surface, flip carefully with a spatula and cook until lightly browned on the underside. This usually takes about 1-2 minutes more. - Transfer the pancake to a baking sheet and keep warm in the oven while you make the rest of the pancakes. - When ready to serve, snip the corner of your cream cheese filling baggie. Make sure you snip the corner a decent size so that your cream cheese swirl is nice and chunky. This gives it a nice, cinnamon roll look. - Swirl the cream cheese in circles onto a stack of pancakes. - Pour your favorite syrup on top and enjoy these cinnamon roll pancakes! Let me know what you babes think of this Cinnamon Roll Pancakes with Cream Cheese Icing Recipe! Make sure to tag me on all your pics on Instagram, @realdenisewilliams. I can’t wait to see! Enjoy! If you’re looking for a gluten free and dairy free alternative to something sweet, you would love the recipe for my banana bread. Let me know what you think! Super Moist Gluten and Dairy Free Banana Bread Recipe (lifewithdenise.com)

This vegan cornbread is fluffy, moist and has just the right amount of sweetness. It comes together quickly and is the perfect comforting side to a big bowl of soup or chili. I love cornbread! It’s the perfect recipe to bake in the fall and winter months and pairs well with so many recipes! I have shared a recipe for pumpkin cornbread muffins but never a classic cornbread recipe… until now! Why You’ll Love This Cornbread It’s dairy-free and vegan with an option for gluten-free as well. It comes together in just 40 minutes… with only 10 minutes of prep! Such an easy vegan cornbread recipe. It’s the perfect blend of savory and sweet. It pairs well with so many main dishes. Chili, stews, soups – the options are endless! Here’s What You Need flax egg – instead of using a traditional egg, keep this cornbread vegan by mixing 1 Tablespoon ground flaxseed with 3 Tablespoons of water. Set aside to let the mixture gel up. unsweetened plain almond milk – make your own vegan “buttermilk” by mixing apple cider vinegar with almond milk (store-bought or homemade almond milk works)! Whisk the ACV and almond milk and set aside at room temperature. The mixture should bubble, thicken and potentially even curdle after a few minutes. Not all non-dairy milk will work for vegan buttermilk but soy milk does if you don’t have almond milk on hand. apple cider vinegar – when shopping for ACV, look for a brand that’s unpasteurized with “the mother” included. This is where all the nutrients are. I personally recommend Bragg’s apple cider vinegar. It’s organic, raw and the best of the best. all-purpose flour or 1:1 gluten-free all-purpose flour – either flour works great so use what you have or make sure you use gluten-free flour if needed. fine yellow cornmeal – there are different ground levels of cornmeal – make sure you get fine ground for light and fluffy texture. If you like a grittier cornbread, you can also use medium ground cornmeal. baking soda and baking powder – to help the cornbread rise. sea salt – to bring all of the flavors together! cane sugar or coconut sugar – your cornbread will turn out darker in color if you use coconut sugar but either sweetener works! vegan butter – oil works as well. I recommend avocado oil, coconut oil or olive oil. maple syrup – optional for topping. How to Make Vegan Cornbread Start by prepping a few things before you dive in! Grease an 8×8 inch baking dish with nonstick cooking spray or vegan butter. Make your flaxseed egg by mixing the ground flaxseed with water in a small bowl and let sit at room temperature to gel up. Lastly, mix the almond milk and apple cider vinegar in a medium bowl and let curdle for about 5-10 minutes at room temperature. In a large bowl, mix the flour, cornmeal, baking soda, baking powder and salt. Add the flax egg, coconut sugar and vegan butter to the milk mixture and stir to combine. Add the wet ingredients to the dry ingredients and mix until fully combined and the batter is smooth. Pour the batter into the pan and use a spatula to make sure the top is smooth and in an even layer. Bake in the oven at 375ºF for 28-30 minutes. The bread is done when a toothpick inserted into the center comes out clean. Let the cornbread cool for at least 10-15 minutes before cutting into slices and serving! I like to wait until the cornbread is completely cool otherwise the bread might be a bit crumbly. If you just want a dairy-free cornbread and not vegan, you can use 1 egg in place of the flaxseed egg. To make dairy-free, vegan buttermilk mix apple cider vinegar with almond or soy milk. If you use coconut sugar as a sweetener, your cornbread will be a little darker in color but still delicious! Make sure to let the cornbread cool before serving, otherwise it could turn out a little crumbly! How to Serve Cornbread I like to top my cornbread with vegan butter and a drizzle of maple syrup! If you don’t need this recipe to be vegan it’s also delicious served with honey! Serve alongside any of these dishes for the ultimate meal: After allowing the cornbread to cool completely, store it in an airtight container at room temperature for 1-2 days. Store in the refrigerator for up to 1 week or in the freezer in a freezer-safe container for up to 3 months.

Walking through the farmers market, I can’t help but ogle the tiny baskets of cucamelons on display. I know, that’s the point, a unique and truly adorable vegetable right out front that draws you into the stand. Cucamelons (also known as mouse melons and Mexican sour jerkins) are more than just a cute farmers market novelty. These tiny mouse melons are truly delicious, with a flavor like fresh cucumber mixed with a hint of lime. Since they can be popped into your mouth on a walk through the garden, growing cucamelons is a really rewarding use of garden space. What are Cucuamelons? At first glance, cucamelons look like miniature 1” watermelons. The name suggests that they’re a cross between a cucumber and a melon, only in miniature. While cucumbers and melons can cross-pollinate, cucmelons are a different crop altogether. Botanically, cucamelons are neither cucumber nor a melon, and the plants will not cross-pollinate with either. They’re in the cucumber family, but they’re a different species altogether (Melothria scabra). Cucuamelons are nothing new, they’ve been grown in Mexico and Central America since before European colonization. In their native land, they’re known as pepquinos (little cucumbers) or sandiita (little watermelons). These days, they also go by the names mouse melon, Mexican sour gherkin, Mexican miniature watermelon or Mexican sour cucumber. How do Cucamelons Taste? Though one of their names is “Mexican sour cucumber” I wouldn’t call them sour. Cucamelons taste like a fresh, crisp cucumber that has been kissed with a hint of lime. That mild citrus acidity helps make these miniature mouse melons extra refreshing in the summertime. While you might imagine that these little watermelon looking fruits might have red flesh inside, they actually just cucumbers inside, with tiny seeds and cucumber like flesh. How to Grow Cucamelons Though they start out as slow growing, delicate seedlings, cucamelon plants will eventually grow to be huge sprawling vines. They thrive on full sun and hot soils, and in the heat of summer the vines will take over a huge vertical trellis. Starting Cucamelon Seeds Indoors Start cucamelon seeds indoors about 4 weeks before the last frost date. This is the same time you start cucumbers from seed, and it’s well after other crops like tomatoes and peppers. Members of the cucumber family don’t transplant well once they’re older, so while it’s important to help cucamelons get a good early start, don’t get carried away. Cucamelon seeds should be planted about 1/4 to 1/2 inch deep and take about 7 to 14 days to germinate, depending on temperature. Ideally, they’d be germinated with warm soil, somewhere between 70 and 75 degrees F. A seedling heat mat can ensure success if your seed starting area is cool or drafty. In the warmest areas, you can direct seed cucamelons outdoors, but soil temperatures need to be above 70 degrees before planting. Outdoor seed starting is only really viable in areas where cucamelons can be grown as perennials, zones 7 through 10. Transplanting Cucamelon Plants Cucamelon plants can be hardened off outdoors after the risk of last frost has passed. After a few days getting used to the sun and air outdoors, transplant the young seedlings to well-drained garden soil. The seedlings may be small, and the vines spindly, but they’ll really take off when things heat up mid-summer. Be sure to plant the young cucamelon seedlings 12 inches apart, and give them a tall trellis to climb. The trellis ensures that the plants get good sunlight all around, helps keep soil temperatures warm and makes the cucamelons much easier to pick. In areas with long summers, cucamelon vines can grow 10+ feet tall, so give them plenty of vertical space. Growing Cucamelon Plants Once the plants are in the garden, they’re pretty low maintenance. Cucamelons are classed as light to medium feeders, and they don’t require supplemental fertilizer (except in the worst soils). Cucamelons store energy in tubers under the soil (more on that later) and those tubers require good drainage or they’ll rot in the ground. Avoid planting cucamelons in overly wet soils. Some guides even suggest adding perlite or sand to the garden soil around cucamelons, to ensure good drainage. Generally, cucamelons don’t require much supplemental water, but they do appreciate roughly 1” of water per week during the growing season. In extremely hot dry areas, mulch them to help maintain adequate soil moisture and water as necessary. Cucamelon Days to Maturity Since cucamelons are open pollinated, there’s a bit of variation in days to maturity. In general, cucamelon plants are 65 to 75 days to maturity, provided they’re grown in warm soil with strong, full sun. While cucamelons grow best in areas with hot, relatively dry summers, they’re adaptable. The plants are commonly grown as a farmer’s market crop in the northeast, which often has cool, rainy summers. Yields may be a bit lower and plants may take a bit longer to mature, but you’ll still bring in a respectable harvest. In the coldest areas, it’s best to grow cucamelons as tender perennial tubers, by harvesting the underground tubers at the end of the growing season and replanting them in spring. Growing Cucamelons as Perennials Believe it or not, cucuamelon plants are actually perennials. Below the soil, each cucamelon plant produces a tuber. While the plants are slow to start from seed, cucamelon plants grown from tubers have a head start on the growing season. The trick is, cucamelon plants cannot tolerate cold winter temperatures, and the tubers are only hardy outdoors year-round to zone 7. In zones 7 to 10, mulch the plants during winter, and they’ll go dormant and come back in the same spot the following year. Even in colder climates, cucamelons can be grown as a perennial with a few modifications. Cut off the vining tops after the first few fall frosts, when the plants begin to die back on their own. Carefully dig up the cucamelon tubers, taking care not to bruise or damage them. Each plant should have produced several 4 to 6 inch warty tubers. Don’t dust the dirt off because the tubers need to be stored in soil during the winter months anyway. Place the tubers in a bucket or pot, filled with moist (but not soaking) potting soil. You can bury them in layers to save space, but make sure there is at least 2 inches of soil above and below each tuber, and ensure they don’t touch. Store the cucamelon tubers in soil in a cool but frost-free location for the winter. A root cellar, basement or unheated garage should be just right in most locations. In the spring, pot up the cucamelon tubers about 6 to 8 weeks before the last frost. This should be right about when you start tomato seedlings. Allow the plants to begin growing, then once the last frost has passed, harden off the seedlings outdoors before planting them in the garden. Here’s a great article on overwintering cucamelon tubers (with pictures) if you need more information. Growing Cucamelons in Containers Containers are another good option for cold climates or small space gardeners. Cucamelons take well to container growing, and in cold areas, the whole container can be brought indoors after the first few frosts. The pot should be stored in a cool, unheated space until the next growing season. Cucamelons are also a great option for patio or patio gardeners. Just be sure to give each plant about 1 foot apart in a container. That means you’ll need relatively large containers to grow multiple plants, and most small pots can only support a single plant. Give them a good trellis and watch them grow! Cucamelon Plant Pollination A quick note on cucamelon pollination… Like other members of the cucumber family, cucamelons produce separate male and female flowers. They’re insect pollinated, most commonly by bees. Cucumbers, melons, and cucamelons are all at risk as pollinator populations decline. To ensure good pollination, plant other bee food sources in the area, and consider hand pollination if your area is particularly short on natural pollinators. Male blossoms grow on long stems, while female blossoms have a small immature fruit attached to their base. Take a small paint brush or Q tip, tip it into a male flower and then hand pollinate individual female flowers. This can be tedious and time-consuming, especially for fruit as small as little mouse melons. It’s easier to just take steps to ensure healthy pollinator populations in your area. Where to Buy Cucamelon Seeds While cucumber and melon seeds are commonly available from garden centers as small seedlings, cucamelons are a bit harder to find. For the most part, if you want to grow cucamelons you’re going to have to start them from seed. Once someone in your area is growing them, you can ask them for a spare tuber, but lacking that, seeds are the way to go. Since cucamelons are a still a relatively rare crop, you’re unlikely to find seeds even in a well-stocked garden center. There are many seed catalogs that carry the seeds, and often you can order them alongside your other garden seeds from your preferred supplier. How to Harvest & Store Cucamelons Harvesting cucamelons is just like picking a cucumber from the vine. They pop off easily, and you can easily harvest a bucket full in a short time. Once cucamelons are harvested, they actually store pretty well. The fruits are remarkably robust for their size, and they don’t bruise easily. Cucamelons will keep for a long time at room temperature, but eventually, they’ll dry out and begin to shrivel. At that point, they’re still tasty, but they’ve lost their crunch. Once they’re past prime and a bit soft, cucamelons are still wonderfully infused in a bit of liqueur, where they impart their distinctive cucumber/lime taste. I love making cucamelon gin because cucumber and lime are the perfect compliments to gin already. How to Use Cucamelons Beyond cucamelon gin, which is delicious, there are plenty of healthy ways to use cucamelons. They hold up remarkably well to quick cooking, and they add a lovely crunch to stir-fries if added in the last minute of cooking. That said, they’re usually eaten fresh. Since they’re a close cucumber relative, it makes sense to turn them into homemade pickles. You can use a regular dill pickle recipe for canning, or a quick refrigerator pickle recipe and substitute cucamelons in place of pickling cukes. Beyond pickles and popping them in your mouth right in the garden, here’s a few cucamelon recipes to get you started: - Cucamelon Salsa - Marinated Cucamelon Salad - Cucamelon Sunomono (Japanese noodles w/ cucamelon) - Cucamelon Bruschetta - Cucamelon & Radish Salad Feeling inspired? How do you plan to use your cucamelon harvest? Leave me a note in the comments.

Avocados are a popular fruit that are often grown in home gardens. When potting an avocado tree, it is important to use a potting soil that is well-draining and high in organic matter. Some good potting soils for avocado trees include those made with perlite, vermiculite, or coco coir. Best potting soil for avocado tree: For an avocado tree, the best potting soil would be one that is well-draining yet moisture-retentive. A good mix would be two parts peat moss to one part perlite or coarse sand. The addition of some organic matter such as compost or aged manure will also help to provide nutrients and improve drainage. The soil should be kept evenly moist but not soggy, and fertilized monthly with a balanced fertilizer. What kind of soil is best for an avocado tree? The best potting soil for an avocado tree is one that is light and well-draining. Avocado trees do not like to sit in wet, soggy soil, so a potting mix that contains perlite or vermiculite is ideal. The tree also needs plenty of nutrients to thrive, so a good potting mix will also contain compost or manure. What kind of pot should I use for my avocado tree? For an avocado tree, it is best to use a pot that is at least 18 inches wide and 18 inches deep. The pot should have drainage holes to allow for proper drainage. The potting soil should be a high-quality, well-draining potting mix. How do I care for my avocado tree? When it comes to potting soil, avocado trees prefer a mix that is light and well-draining. A good quality potting mix will provide the tree with the necessary nutrients and aeration. The tree also needs to be able to access water easily, so make sure the soil is moist but not soggy. If you are unsure about the quality of your potting mix, you can add some organic matter such as compost or peat moss to improve drainage and aeration. To keep your avocado tree healthy, it is important to fertilize regularly. A balanced fertilizer such as 10-10-10 or 8-8-8 can be applied every two months during the growing season. Be sure to follow the instructions on the fertilizer package and apply the fertilizer at the base of the tree, avoiding the leaves and branches. In addition to regular watering and fertilizing, avocado trees need to be pruned to promote growth and keep the tree manageable. Pruning should be done in the late winter or early spring, before the tree begins to produce new leaves. branches that are crossing or rubbing against each other should be trimmed, as well as any dead or damaged branches. What kind of fertilizer should I use for my avocado tree? The best potting soil for an avocado tree is a mix of two parts peat moss to one part perlite. The tree will also need a location that receives full sun for at least six hours a day. If you are using a fertilizer, use one that is low in nitrogen. When should I prune my avocado tree? It is best to prune your avocado tree in early spring before new growth begins. You should remove any dead or diseased branches, as well as any branches that are crossing or rubbing against each other. You should also thin out the canopy to allow light and air to reach the inner branches. How do I harvest my avocado tree? The best potting soil for an avocado tree is a mix of organic matter and sand. The organic matter can be compost, manure, or peat moss. The sand should be coarse and help to drainage. The soil should be moist but not wet. To harvest an avocado tree, wait until the avocados are ripe. The skin of the fruit should be dark green or black. Gently twist the fruit to detach it from the tree. Be careful not to damage the tree. Place the avocados in a cool, dark place until you are ready to use them. It is always my pleasure to provide insightful information on important topics and if you have learned something from my article then I thank you for taking the time to share it with your friends or family. We put a lot of heart and invest a lot of time trying to bring you the most interesting articles. You would encourage us to do it even better in the future. Thank you!

Your oven, like every other kitchen appliance, needs to be in a flawless condition in order to work properly and ensure the good taste of the prepared meals. If you want to be certain that your oven will be used for a long time and function well, you can book our reliable oven cleaning service. We provide thorough and fast cleaning of the interior, exterior and all removable parts of your oven. The kitchen is an area of the house that must be maintained clean and sanitised at all times. Storing and preparing our food there, as well as the moist, warm conditions in it, create the perfect environment for bacteria and microbes. What is more, baked on food spills and other carbonised particles can cause smoke or burning smell occurring in your kitchen. The oven is usually out of sight, which usually means we overlook it when performing the regular cleaning of our homes. The oven however, is the place where most of the carbonised grease and grime gather. When not regularly maintained, the oven may cause fire, off-tasting meals and generally unhygienic conditions at home. We strongly suggest that you clean your oven regularly ( once every 3-4 months), depending on how often it is being used, of course. We know how annoying and time-consuming scrubbing the inside of the oven can be, especially if you do not have the right skills and products. This is exactly why we want to offer you the perfect solution to this problem of yours. We provide exceptional oven cleaning and all cleaning technicians that perform the service are highly experienced and capable. You will not be disappointed. |Single Oven (60cm)||£45| |Combination Microwave Ovens||£25| |Shelves & Racks (each)||£2| |BBQ racks (each)||£3| “My oven used to be very greasy and filled with burnt food so, I decided to use the oven cleaning which this company provides. The staff dismantled all removable parts and soaked them in cleaning solution. They made my oven flawlessly clean.” – Chloe Oven Cleaners Cricklewood We offer excellent oven cleaning services to all residents of Cricklewood, London. You can order them by phone, e-mail or by filling in the online booking form on our website. Cleaners Cricklewood is at your disposal seven days a week. Our professional oven cleaning will ensure the proper and fast functioning of your oven. 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We place them in our vans, where the cleaning solution is heated in special tanks. It will loosen and remove all obstinate stains from food, grease and carbon residue. - The door of some ovens will be dismantled, so that the glass panels can be cleaned and polished till they become flawlessly clean. Use our services if you need professional domestic or commercial oven cleaning, and your property is located in Cricklewood. - The inside of the oven will be cleaned next. A special cleaning paste will be applied to the whole inside of it. The oven will be turned on so the heat activates the paste. The chemical composition of this product reacts with all grease and dirt and dissolves the basic components of it. When the process is finished, our technicians will scrape the product along with the dirt from the inside of your oven, wipe and disinfect it. - The stove top of your oven will be thoroughly cleaned as well. The technicians use a special blade to scrape off all burned food and spills. They are trained to do that efficiently, without scratching the surface of it. - When all areas and parts of the oven are cleaned, we wipe and disinfect them and put them back together. Thanks to the no-toxic safe nature of the products, you will be able to use your oven right after the cleaning technicians are done with the job. It is important to mention that all products and solutions used in this process are 100% biodegradable, non-toxic, safe and eco-friendly. They contain no harsh chemicals and will not harm you or your family members. We also clean: - Professional cookers - Single or Double ovens If your oven is dirty and needs professional cleaning, you can use our reliable oven cleaning services. They can guarantee you the better performance of your oven and its gleaming condition. Use our website or call centre to schedule your oven cleaning for any date and time which is convenient to you. 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We avoid using harsh chemicals so you can rest assured your children and pets will be safe. - Flexible working hours. All our teams are available 7 days a week, including all holidays. We know that most people nowadays are busy and we aim to fit everyone’s schedule in the best way possible. Do not hesitate and call us. - Affordable rates. It has been our mission to create cleaning services that are available and affordable to anyone who might need them. We worked hard and now we are proud to offer you great quality services for reasonable prices. Check our other services: Deep Cleaning Cricklewood Upholstery Cleaning Cricklewood End Of Tenancy Cleaning Cricklewood Carpet Cleaning Cricklewood After Builders Cleaning Cricklewood Gardening Services Cricklewood To receive more information feel to call 020 3745 5245. Our call centers work every day of the week, including all holidays. The office agents there will be able to assist you in every way and give you a free quote over the phone.

BB cushions are fast becoming my go-to bb cream on a daily basis. I have been using it almost every day and haven’t gone back to using the regular liquid bb cream since. Last week, i reviewed the Missha M Magic Cushion SPF50+ PA+++ on my blog (here). Today, i will be reviewing the All Proof Oil Control Water Cushion SPF50+ PA+++ from TheFaceShop. Read on to find out what I think about it! First, a little something from the brand: According to the brand, TheFaceShop All Proof Oil Control Water Cushion is/has: - Moist-cover: Provides a good coverage concealing imperfections and pigmentation - Cotton skin (Fresh fit): Sebum control formula offers shine-free makeup - Sweat proof (Long lasting): Keeps makeup as fresh as it was first applied - NEW Microfoam technology: Cushion with cells that are 4 times denser than conventional cushion sponge. This in turn helps to protect the formula and active ingredients fresh. It also helps the makeup to go on evenly for more meticulous application and coverage And below is my experience with the cushion: Roaring view for [TheFaceShop All Proof Oil Control Water Cushion SPF50+ PA+++]: |Product’s packaging||:||Round compact container with a smooth-surface cover| |Product’s texture||:||Smooth, lightweight BB liquid| |Product’s scent||:||Subtle, sweet-floral scent| |Can be purchased from TheFaceShop Singapore outlets islandwide| |Try-out period||:||On and off for about 2 months| |Personal take||:||I purchased this All Proof Oil Control Water Cushion mainly because it claims that it provides a “moist-cover” while controlling sebum/shine and lasts a while with its sweat-proof formula. Although the coverage for me wasn’t that impressive, the scent and oil-controlling effect of it was! Overall, i noted that the coverage was light to medium and can be build upon if required. Although the coverage was light, the natural soft-focus effect means that flaws are slightly blurred, making it look a lot less offensive. The oil-controlling effect for me was above average since the shine came about 4~6 hours later. I had an issue with its durability because it became patchy towards 6~8 hours later. The timing coincide with the appearance of the shine, so i deduced that it could be the sebum and perspiration affecting the long-lastingness of the cushion. For this cushion, i am using shade no. V201 Apricot Beige |Will i recommend it?||:||If you do not have much imperfections, this is a good cushion for you. Unfortunately, i have plenty of redness and post-acne marks to be just relying on this cushion alone. Therefore, i am on the fence with this one.|

Untrustworthy and sensational news about insects and arthropods are constantly shared through social networks, spreading tergiversated data and confusing amateur users. As a result, this usually leads to misidentifications and unnecessary alarmism toward harmless organisms. Here we bring you a brief list of some insects and other arthropods that are usually confused and how to tell them apart. Don’t get tricked! Spiders VS ‘Anything resembling them’ Spiders (Order Araneae) probably are some of the most feared arthropods among users for two main reasons: they are venomous and there are a lot of other arachnids that resemble them. So, it is quite understandable some people have serious doubts when finding an organism with eight long legs and a grim face. However, most of these spider-like organisms are harmless and unable to weave webs: Harvestmen: unlike other arachnids, harvestmen or daddy longlegs (Order Opiliones) don’t have their body divided into two parts (prosoma and opisthosoma) by a thin waist, so they remind off a ‘ball with legs’. Also, they only have a pair of central eyes very close to each other. They neither have venom glands nor silk glands, so they can’t bite nor weave webs. They live in moist places, caves and near to streams and harvests. They are usually confused with spiders of the Pholcidae family because of their long legs. Solifugae: also known as camel spiders, Solifugae is an order of tropical arachnids characterized for having a segmented body and a pair of conspicuously large chelicerae forwardly projected. However, and despite their menacing appearance, they aren’t venomous (even though they bite can be very painful) nor weave webs. They inhabit desert and arid places, some of them are nocturnal and the diurnal ones move quickly looking for shadows to escape from sunlight. Amblypygi: also known as whip spiders or tailless whip scorpions, Amblypygi is an order of tropical arachnids that are neither spiders nor scorpions. Despite their menacing appearance, as it happens with camel spiders, whip scorpions don’t have venom glands. They have a pair of big thorny pedipalps ended in a pincer for grabbing preys, while the first pair of legs, which are filiform and segmented, act as sensory organs (not for walk). They don’t weave webs and have nocturnal habits. Pill bugs VS Pill millipedes When playing in a park or in some natural place as a kid, you some time probably found a small animal, full of legs that rolled up when being touched. These organisms are commonly known as woodlice. Woodlice belong to the suborder Oniscidea, a group of terrestrial crustaceans within the order Isopoda. They have a tough, calcarean and segmented exoskeleton, and inhabit moist places. Woodlice of the family Armadillidae, also known as pill bugs, are usually confused with pill millipedes (Subphylum Myriapoda, Class Diplopoda, Superorder Oniscomorpha), both groups with a similar external appearance and able to roll up into an almost perfect sphere as a defensive mechanism (convergent evolution). To tell them apart, you have to count the total number of legs per segment: if it has only a pair of legs per segment (one at each side of the segment), it is a pill bug; if it has two pairs, it is a pill millipede. Bees and wasps VS Hoverflies We talked widely about the main differences between bees and wasps (Order Hymenoptera) in this post. This time, we introduce you the hoverflies or syrphid flies (Order Diptera, Suborder Brachycera, Family Syrphidae), which resemble a lot to bees and wasps. Resemblance of hoverflies to bees, wasps and bumblebees is a clear example of Batesian mimicry, which we explained widely in this post about animal mimicry. Moreover, hoverflies mimicry goes even further, since some of them also imitate the flight and the hum of these hymenopterans. To tell them apart, you have to pay attention to their eyes, antennae and wings: since they are flies, hoverflies have a pair of big compound eyes that occupy almost all their head, very short antennae with eight or less segments and a single pair of wings (the second pair has evolved into small equilibrium organs, the halteres), while wasps, bees and bumblebees have smaller compound eyes that occupy only the sides of the head, longer antennae with ten or more segments and two pairs of functional wings. Moreover, female hoverflies don’t have the abdomen ended in a stinger, so they are completely harmless. Ladybugs VS Pyrrhocoris apterus If you look for ladybugs pictures on Internet, you’d probably find a picture of this insect: This is Pyrrhocoris apterus, a very common insect in the Palearctic area (from Europe to China) and recorded to the USA, Central America and India. You can find it on common mallows (Malva sylvestris), from which they eat seeds and sap, and they usually congregate in big groups because of their gregarious behavior. Ladybugs are coleopterans (Order Coleoptera) with a more or less globular shape; they are carnivorous (with a diet based mainly on the intake of aphids) and can fly. Their first pair of wings are hard (elytra) and form a kind of shield that encloses the second pair of membranous wings. On the other hand, Pyrrhocoris apterus is a bug (Order Heteroptera) with a depressed body, phytophagous habits and, unlike ladybugs and other bugs, it is unable to fly. Moreover, it doesn’t have a hardened shield. Mantises VS Mantidflies Mantises (Order Dyctioptera), which were widely addressed in this post, are very alike to this insect: This insect belongs to the family Mantispidae (Order Neuroptera), also known as mantidflies or mantispids. This group is very well represented in tropical and subtropical countries, and just a few species are known from Europe. They have a pair of raptorial legs like those of Mantodea which they use for grabbing their preys. Neuropterans, like mantidflies, green lacewings and antlions, have two pairs of similar sized wings with a very complex and branched venation. In Mantodea, the first pair of wings are smaller and harder than the second one, which are membranous and functional for flying; also, this second pair doesn’t have such a complex venation like that of neuropterans. Mantidflies of the genera Climaciella and Entanoneura have a body coloration like that of some wasps, but they are totally harmless. Mosquitoes VS Crane flies Have you ever seen a giant mosquito and dreaded its bite? Well, you can stop being afraid of it. These giant ‘mosquitoes’ (Order Diptera), which are commonly known as crane flies or daddy longlegs (Family Tipulidae), are totally inoffensive (and somewhat clumsy). They are distributed all over the world and inhabit moist places, like meadows and streams. Adults feed on nectar or don’t feed; in any case, they don’t suck blood! Females have the abdomen ended in a kind of stinger; however, it is only their sharp ovipositor (not a stinger like those of bees or wasps). Dragonflies VS Damselflies Both groups belong to the Order Odonata and have very similar appearance and behavior, being very common near sitting waters and lakes. Two thirds of the Odonata are dragonflies (suborder Anisoptera), while the other third are damselflies (suborder Zygoptera). An easy way to tell them apart is by paying attention to their wings at rest: in dragonflies, wings are held flat and away from the body, while in damselflies they are held folded, along or above the abdomen. On the other hand, eyes of dragonflies are large and touch in the vertex of the head, of which they occupy most of its surface, while those of dragonflies are smaller and are usually located on the sides of the head. . . . If you know about any other insect or arthropod that can be confused, let us know it by leaving a comment! - Capinera, J. L. (Ed.). 2008. Encyclopedia of entomology. Springer Science & Business Media. - Resh, V. H. & Cardé, R. T. (Eds.). 2009. Encyclopedia of insects. Academic Press. - Cooke, F. 2004. The encyclopedia of animals: a complete visual guide. University of California Press.