Desyrel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jonathan D. Kirsch, MD

• Assistant Professor, Diagnostic Radiology
• Associate Chief, Section of Ultrasound
• Yale University School of Medicine
• Yale-New Haven Hospital
• New Haven, Connecticut

It is important to know if patients smoke or consume alcohol because both of these are common laryngeal irritants anxiety symptoms electric shock discount 100mg desyrel with visa. A history of smoking and alcohol use should also prompt an investigation for head and neck or other cancers anxiety symptoms 24 hours day order desyrel 100mg line. Nausea anxiety vertigo buy generic desyrel 100 mg online, vomiting anxiety symptoms how to stop it cheap desyrel 100 mg free shipping, and weight loss may suggest a diagnosis of bullemia predisposing to irritant laryngitis anxiety symptoms weakness order 100mg desyrel fast delivery. This should include careful inspection of the ears anxiety symptoms in males best order for desyrel, nose, mouth, and throat with Chapter 8 / Laryngitis and Hoarseness 97 particular attention to the mucosa, looking for signs of inflammation and/or unusual masses. For presentations of hoarseness that are not obvious on routine examination, further work-up should include routine labs, chest X-ray, and referral to an ear, nose, and throat specialist for direct laryngoscopy and further evaluation. Treatment options are directed towards symptomatic complaints and preventing complications. Patients should be taught vocal hygiene to expedite recovery and prevent future episodes of acute laryngitis. Patients should avoid excessive and loud talking, including whispering, which results in excess strain on the inflamed larynx. In cases of infectious laryngitis, hoarseness will resolve as the upper respiratory tract infection improves. Decongestants and antihistamines should be avoided if possible because of the anticholinergic effects of drying the mouth and throat. Instead, voice rest and adequate hydration should be preserved, whereas caffeine, smoking, and other irritants should be avoided. Adequate hydration keeps the vocal folds well-lubricated and free of irritating mucous. A mucolytic agent also may be helpful to minimize mucus from irritating the vocal cords. Aspirin and non-steroidal anti-inflammatory drugs should be avoided because their use in this setting may increase the risk of vocal cord hemorrhage (4). Antibiotics should only be considered if the practitioner is suspicious of the presence of a secondary bacterial infection. For non-infectious acute laryngitis, treatment should be targeted at eliminating or minimizing exposure to the causative irritants to the vocal folds. Allergen avoidance, antihistamines, and intranasal steroids may be appropriate medical therapies to minimize symptoms caused by laryngitis from postnasal drip. Rarely, sinus surgery may be considered when conservative medical therapies have failed. Chronic laryngitis may respond to good vocal hygiene and irritant avoidance, but may require more sophisticated therapy, which should be directed at the underlying cause. Nodules are reversible lesions that improve with vocal hygiene and speech therapy. Polyps and cysts are less commonly reversible and often require surgical excision. Oral steroid therapy and speech therapy may be beneficial before surgical interventions. Vocal therapy after surgery is expected to improve voice quality postoperatively (2). The goals of voice therapy are to correct maladaptive vocal behaviors and produce appropriate speaking mechanics. With the assistance of a therapist and voice analysis, patients learn appropriate behaviors related to pitch, loudness, and voice quality. Whispering and whistling should be avoided because these potentially further damage the vocal folds. Patients with hoarseness lasting for longer than 2 weeks should be referred to a specialist for a work-up of possible malignancy (2). Flexible nasolaryngoscopy allows direct visualization of the larynx and the opportunity to identify pathology. This allows the examiner to evaluate the high-speed vibrations of the vocal cords. Early detection of squamous carcinomas often results in a good prognosis, owing to their tendency to metastasize late in their clinical course. Local T1N0M0 lesions are either endoscopically excised or treated with primary radiation. This modality minimizes resection of healthy tissue and preserves voice production. In the case of bilateral vocal cord paralysis, a temporary tracheostomy may be indicated if return of function is expected. Unilateral arytenoidectomy may allow decanulation from a tracheostomy should the condition become permanent. For unilateral paralysis, re-approximation may be achieved with injection of gelfoam or autologous fat into the affected vocal cord. This may improve voice production and minimize aspiration with improved glottic closure. Although most cases are acute in nature and self-limiting, a careful history and thorough evaluation of the patient is important (2). In the case presented here, the patient is most likely presenting with hoarseness secondary to an acute viral infection. Although her symptoms are expected to be self-limiting, she should be encouraged to avoid other irritants. She could Chapter 8 / Laryngitis and Hoarseness 99 be at risk for functional dysphonia, given her profession. In addition to reassurance, the patient should be referred to a voice therapist for treatment and education about vocal hygiene. Literature search service Consider testing the parents and siblings of affected school-age children. Oral clindamycin is an acceptable alternative, if one is unable to use a first-generation cephalosporin. Levels of evidence reflect the best available literature in support of an intervention or test: A =randomized controlled trials; B = controlled trials, no randomization; C = observational trials; D = opinion of expert panel. An Approach to the Patient with Pharyngitis fi Concurrent diagnosis of rheumatic fever or a past history of rheumatic fever, especially with carditis or valvular disease fi Household contact with someone having a history of rheumatic fever Table 2. It avoids the problem of adherence, but administration is painful for 2-3 days at injection site. At-risk patients include those with a slower-than-normal heartbeat, with potassium or magnesium deficiencies, and those using medications to treat existing heart arrhythmia. Macrolides and cephalosporins are not included because data are insufficient regarding their efficacy for recurrent episodes. Pharyngitis, either as a part of a viral upper pharyngitis depends on the probability of the disease. The benefit of follow-up laboratory testing differs by then supported by performance of a lab test. Using age, resulting in different follow-up recommendations for epidemiological and clinical factors alone to initiate children and adults. Signs and symptoms can only provide guidance to was performed on only 15-36% of children with sore throats, determine which patients should have laboratory testing to even though 53% of them received antibiotics. The endemic incidence of acute rheumatic fever is classic viral exanthem (such as vesicles or maculopapular around 0. Both tonsillar fauces and the diminish the risk of post-streptococcal glomerulonephritis. For patients less than 16 fever (see Table 1); specifically, those who have had years old, negative results are confirmed in the laboratory rheumatic carditis or valvular disease. A high-risk patient the properties of these tests, their costs, and strategy in presenting with a sore throat should be prescribed immediate selecting them. Because of this very high specificity, a positive test cases that require a confirmatory testing in the laboratory. In patients with a concurrent infection is low and the risk of developing acute rheumatic diagnosis of rheumatic fever or a past history of rheumatic fever is extremely low. Results were available in acute rheumatic fever, antibiotics may be initiated within 9 1-3 days. The sensitivity is slightly higher than culture, and results are usually available in one day, compared to two Penicillin V administered orally two or three times daily is days for culture. Laboratory charges can contribute significantly to the total cost of treatment for a patient with First-generation cephalosporins (such as cephalexin) are now pharyngitis. When prescribing azithromycin, note that the dose is the patient to return to normal activity sooner. A single intramuscular injection of penicillin G benzathine has been shown to be slightly more efficacious than oral Treatments for recurrence. For frequent recurrences, expert opinions differ about the Alternative primary treatments. Table 6 presents examples of treatments for frequent Failure to improve with treatment. An exam should be performed to rule out occurrence of a local complication, such as peritonsillar Special Circumstances or retropharyngeal abscess. These complications require immediate consultation with otolaryngology as they may Reevaluate high-risk patients. Throat culture surveys in patients who remain symptomatic, whose symptoms recur, of asymptomatic children during school outbreaks of or who are high-risk patients as outlined above. The decision Therefore, a single course of antibiotic therapy should be may be made to opt for intramuscular penicillin G administered to a patient who has acute pharyngitis and any benzathine in order to ensure adequate treatment. Acute rheumatic fever current episode and appropriate use of health care services in has not been described as a complication of either group C the future. Some points that may be relevant to communicate and group G streptococcal pharyngitis. If the rapid test is negative, the nurse counsels the patient Antibiotic side effects. These can include rash, nausea, on symptomatic therapy and when to return to the office. Patients are considered to work the patient into the physician schedule to confirm noncontagious 24 hours after starting therapy. This would help with patient as 9 days after the onset of symptoms and still be effective access, cost, and patient satisfaction. Within these major keywords, specific mentioned below, some physicians have recommended oral searches were performed for the following topics: history; corticosteroids for pain relief. However, the benefits (mean physical exam, signs, symptoms throat culture (strep reported onset of pain relief was 6. Another set of searches used the major keywords of viral pharyngitis/ viral sore throat with Avoidance of antibiotic treatment for acute specific searches performed for: alternative and bronchitis/bronchiolitis. The percentage of episodes for complimentary therapies (eg, zinc, Vitamin C, Echinacea); members ages 3 months and older with a diagnosis of acute other treatment. The search was supplemented with recent immunizations, tobacco use assessment in adults) can apply clinical trials known to expert members of the panel. Conclusions were based on prospective randomized controlled trials if available, to the exclusion of Disclosures other data; if randomized controlled trials were not available, observational studies were admitted to consideration. If no Neither the members of the Pharyngitis guideline team nor such data were available for a given link in the problem the consultant have a relationship with commercial formulation, expert opinion was used to estimate effect size. The Executive Committee for for the Diagnosis and Management of Group A Clinical Affairs of the University of Michigan Hospitals and Streptococcal Pharyngitis, 2002 Health Centers endorsed the final version. Measures of Clinical Performance Acknowledgments National programs that have clinical performance measures Listed on the first page are members of the team that for pharyngitis include the following. These programs have clinical performance measures for pharyngitis addressed in this guideline. While specific measurement details vary (eg, method of data collection, Annotated References population inclusions and exclusions), the general measures are summarized below. Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis. Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background. The Red Book, Baltimore, Bisno and Gerber articles do not include selective empirical treatment as an option.

For T2a lesions anxiety treatment without medication discount desyrel 100mg without prescription, the 5-year local control rate was 76% anxiety symptoms in 9 year old order desyrel 100mg line, irrespective of anterior commissure involvement anxiety symptoms 97 purchase desyrel now. Conclusion: In early glottic cancer treated by transoral laser microsurgery anxiety symptoms during exercise desyrel 100mg with amex, a decrease in local control is evident in case of anterior commissure involvement for T1a and T1b but not for T2a tumors anxiety symptoms - urgency and frequent urination desyrel 100 mg without a prescription. Supraglottis & Hypopharynx Supraglottic and hypopharyngeal cancers tend to spread to the lymph nodes early on in their growth due to the rich lymphatics and vascularity in this region anxiety 34 weeks pregnant generic 100mg desyrel with visa. Endoscopic procedures should be limited to tumors that can be completely visualized during diagnostic microlaryngoscopy. If complete resection can be achieved, the oncologic results of transoral laser surgery appear to be comparable to those of classic supraglottic laryngectomy. In addition, functional results of transoral laser resection are superior to those of the conventional open approach, in terms of the time required to restore swallowing, tracheotomy rate, incidence of pharyngocutaneous fistulae, and shorter hospital stay. The management of the neck remains of paramount importance, as survival of patients with supraglottic cancer depends more on cervical metastasis than on the primary tumor. However, in selected cases (T1,T2 clinically negative [N0] lateral supraglottic cancers), ipsilateral selective neck dissection could be performed without compromising survival. The authors conclude that with careful selection of patients, laser supraglottic laryngectomy is a suitable, and often the preferred, treatment option for supraglottic cancer. Hypopharynx: Organ preserving transoral laser microsurgery for cancer of the hypopharynx. Department of Otorhinolaryngology-Head and Neck Surgery, University of Gottingen, Gottingen, Germany. Study Design: Prospective case-series study at a single institute, an academic tertiary referral center. Overall survival, recurrence-free survival, organ preservation, and local control were analyzed as end points. Rate of tracheotomies, postoperative complications, and swallowing function (feeding tube dependency) were also analyzed. The clinical tumor response was assessed after two cycles of chemotherapy, and patients with a response received a third cycle followed by definitive radiation therapy (6600 to 7600 cGy). Results: After two cycles of chemotherapy, the clinical tumor response was complete in 31 percent of the patients and partial in 54 percent. After a median follow-up of 33 months, the estimated 2-year survival was 68 percent (95 percent confidence interval, 60 to 76 percent) for both treatment groups (P = 0. Patterns of recurrence differed significantly between the two groups, with more local recurrences (P = 0. Conclusions: these preliminary results suggest a new role for chemotherapy in patients with advanced laryngeal cancer and indicate that a treatment strategy involving induction chemotherapy and definitive radiation therapy can be effective in preserving the larynx in a high 91 percentage of patients, without compromising overall survival. Patients with a complete response after two or three cycles of chemotherapy were treated thereafter by irradiation (70 Gy); nonresponding patients underwent conventional surgery with postoperative radiation (50-70 Gy). Results: Two hundred two patients entered the trial and were randomly assigned; only 194 were eligible for treatment (94 in the immediate-surgery arm and 100 in the induction-chemotherapy arm). Treatment failures at local, regional, and second primary sites occurred at approximately the same frequencies in the immediatesurgery arm (12%, 19%, and 16%, respectively) and in the induction-chemotherapy arm (17%, 23%, and 13%, respectively). In contrast, there were fewer failures at distant sites in the induction-chemotherapy arm than in the immediate-surgery arm (25% versus 36%, respectively; 93 P =. The median duration of survival was 25 months in the immediate-surgery arm and 44 months in the induction-chemotherapy arm and, since the observed hazard ratio was 0. The 3and 5-year estimates of retaining a functional larynx in patients treated in the induction-chemotherapy arm were 42% (95% confidence interval = 31%-53%) and 35% (95% confidence interval = 22%-48%), respectively. Conclusions and Implications: Larynx preservation without jeopardizing survival appears feasible in patients with cancer of the hypopharynx. The rate of locoregional control was also significantly better with radiotherapy and concurrent cisplatin (78 percent, vs. Both of the chemotherapy-based regimens suppressed distant metastases and resulted in better disease-free survival than radiotherapy alone. We now present the 5-year results (after median follow-up for surviving patients of 6. Pharyngocutaneous fistula was lowest in arm 3 (15%) and highest in arm 2 (30%) (P>. At 24 months, the overall survival was 69% (arm 1), 71% (arm 2), and 76% (arm 3) (P>. Postop courses and quality of surgical resections did not differ between both arms (ie. The American (n = 332) and French (n = 68) trials included laryngeal tumors and the European (n = 202), pharyngeal & epilaryngeal tumors. Background: Both induction chemotherapy followed by irradiation and concurrent chemotherapy and radiotherapy have been reported as valuable alternatives to total laryngectomy in patients with advanced larynx or hypopharynx cancer. We report results of the randomized phase 3 trial 24954 from the European Organization for Research and Treatment of Cancer. Survival with a functional larynx was similar in sequential and alternating arms (hazard ratio of death and/or event = 0. Grade 3 or 4 mucositis occurred in 64 (32%) of the 200 patients in the sequential arm who received radiotherapy and in 47 (21%) of the 220 patients in the alternating arm. Late severe edema and/or fibrosis was observed in 32 (16%) patients in the sequential arm and in 25 (11%) in the alternating arm. Induction Chemotherapy in organ preservation setting remains investigational to be conducted only in a trial setting Laryngeal Cancer Survival Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Background: Survival has decreased among patients with laryngeal cancer during the past 2 decades in the United States. Study Design: the authors conducted a retrospective, longitudinal study of laryngeal cancer cases. Conclusions: the decreased survival recorded for patients with laryngeal cancerin the mid-1990s may be related to changes in patterns of management. Events are death, local relapse, total or partial laryngectomy, tracheotomy at 2 years or later, or feeding tube at 2 years or later. Recommended secondary endpoints are overall survival, progression-free survival, locoregional control, time to tracheotomy, time to laryngectomy, time to discontinuation of feeding tube, and quality of life/patient reported outcomes. N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension. N2b Metastasis in multiple ipsilateral lymph nodes, none more that 6 cm in greatest dimension. Residual microscopic disease in resected specimens with complete clinical response has been reported upto 30%. A meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically nodenegative neck. May 2007; 47 (5): 320-24 There is still no consensus on the optimal treatment of the neck in oral cavity cancer patients with clinical N0 neck. A comprehensive search and systematic review of electronic databases was carried out for randomized trials comparing elective neck dissection to therapeutic neck dissection (observation) in oral cancer patients with clinical N0 neck. This reduction in disease-specific death rate supports the need to perform elective neck dissection in oral cancers with clinical N0 neck. Meta-analysis of pairs of sensitivity and specificity was performed using bivariate analysis. Results: In this analysis, 729 abstracts and 177 full text papers were screened (Kappa statistic 0. Management of the neck after chemoradiotherapy for head and neck cancers in Asia: consensus statement from the Asian Oncology Summit 2009 Review Article. Background: the management of patients with a small pharyngolaryngeal cancer (T1 and T2) with large nodal metastases is a subject of debate. We present data on the feasibility and outcome of treating these patients with surgery for the nodal metastases followed by definitive radiotherapy. Methods: Prospective study of 59 patients of small pharyngolaryngeal primary squamous carcinomas with operable (N2/N3) nodal metastasis treated with neck dissection followed by radiotherapy. They are a heterogenous group of lesions with different sites and originating from different histopathologic components including Schneiderian mucosa, minor salivary glands, neural tissue, and lymphatics. This heterogeneity and the small numbers in each group make it difficult to obtain a high level of evidence in their management. Prosthetic / Dental Workup Pre-operative dental impression for post-op prosthesis 4. Ophthalmologic examination 125 Documentation of visual acuity, fundoscopy and visual field (perimetry) is important both in the management of the disease as well for comparison post-treatment, especially when combined with radiation therapy. Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses 126 T4b Very advanced local disease. Treatment of Neck: N0 Observe N+ Appropriate neck dissection and post-operative radiotherapy to both necks. Treatment of Neck: N0 Observe N+ Appropriate neck dissection and post-operative radiotherapy. Final maxillary prosthesis after 2-3 months Follow up Policy: Regular follow up as usual for all head neck malignancies. Craniofacial resection for malignant paranasal sinus tumors: Report of an International Collaborative Study. Patients with esthesioneuroblastoma were excluded and are being reported separately. The most common histologic findings were adenocarcinoma in 107 (32%) and squamous cell carcinoma in 101 (30. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent were independent predictors of overall, diseasespecific, and recurrence-free survival on multivariate analysis. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent are independent predictors of outcome. Cancer 2001 Dec 15;92(12):3012-29 Background: the authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review. Factors that were associated statistically with a worse prognosis, with results expressed as 5-year actuarial specific survival rates, included the following: 1) histology, with rates of 79% for patients with glandular carcinoma, 78% for patients with adenocarcinoma, 60% for patients with squamous cell carcinoma, and 40% for patients with undifferentiated carcinoma; 2) T classification, with rates of 91%, 64%, 72%, 134 and 49% for patients with T1, T2, T3, and T4 tumors, respectively; 3) localization, with rates of 77% for patients with tumors of the nasal cavity, 62% for patients with tumors of the maxillary sinus, and 48% for patients with tumors of the ethmoid sinus; 4) treatment, with rates of 79% for patients who underwent surgery alone, 66% for patients who were treated with a combination of surgery and radiation, and 57% for patients who were treated exclusively with radiotherapy. In the presence of an intraorbital invasion, enucleation was associated with better survival. Conclusions: Progress in outcome for patients with nasal and paranasal carcinoma has been made during the last 40 years. Endoscopic surgery for malignant tumors of the sinonasal tract and adjacent skull base: A 10-year experience Piero Nicolai, M. We report our experience with the endoscopic management of nasoethmoidal malignancies possibly involving the adjacent skull base. The tumor histologic type was adenocarcinoma in 54, squamous cell carcinoma in 17, esthesioneuroblastoma in 9, and adenoid cystic carcinoma in 4. The 5-year local control, overall survival, disease-specific survival, disease-free survival, and freedom from distant metastasis rate was 70. No difference was found in local control and survival between patients with primary or recurrent tumors. On multivariate analysis, invasion of the cribriform plate was significantly associated with lower local control (p = 0. Nonocular late radiation-induced toxicity comprised complete lacrimal duct stenosis in 1 patient and brain necrosis in 3 patients. It is shown that chemotherapy plus radiotherapy improves disease free and progression free survival compared to radiotherapy alone in advanced nasopharyngeal carcinomas. All patients being contemplated for Chemoradiotherapy/ radiotherapy should undergo a. Gross disease and High risk volumes should receive doses biologically equivalent to 70 Gy/35#/ 7weeks, conventional. Hypofractionated schedules using simultaneous integrated boost technique maybe employed. However chemoradiotherapy is the minimum basic treatment recommended for locally advanced nasopharyngeal carcinomas. Neck dissection is reserved for palpable nodes persisting 8 weeks after radiotherapy and when the primary is controlled. Follow-up should include examination of the nasopharynx and neck, cranial nerve function and evaluation of systemic complaints to identify distant metastasis. Evaluation of thyroid function in patients with irradiation to the neck is recommended at 1, 2 and 5 years. Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients. Concomitant radiotherapy and chemotherapy for early-stage nasopharyngeal carcinoma. Plasma Epstein-Barr viral deoxyribonucleic acid quantitation complements tumor-node-metastasis staging prognostication in nasopharyngeal carcinoma. Tumor invades skin, mandible, ear canal, and/or facial nerve T4b:Very advanced disease. Adequate parotidectomy: Implies removing the tumor completely, taking care to avoid capsular rupture or nerve damage, with approximately 0. Total Conservative parotidectomy: Implies excision of entire parotid gland (superficial and deep lobes), while preserving the facial nerve. Done for: o tumors involving the deep lobe, with intact facial nerve functions o high-grade malignant tumors with a high risk for metastasis o any parotid malignancy with an indication of metastasis to intraglandular or cervical lymph nodes o any primary malignancy originating within the deep lobe itself o Positive margin (base) after superficial parotidectomy 155 Total Parotidectomy with the excision of facial nerve: indications as above, when the nerve is involved by the tumor. Radical parotidectomy:Implies excision of other structures than the parotid gland and facial nerve. A comprehensive modified neck dissection (Levels I-V) should be performed in N+ necks. In case of adenoid cystic carcinoma, if the sectioned nerve is involved, drilling of the temporal bone must be done till a free proximal stump is confirmed on frozen section E.

Plant Communities: Grows in mixed evergreen forest anxiety levels order desyrel 100 mg otc, valley foothill and woodland anxiety symptoms ear ringing cheap desyrel 100mg line, yellow pine forest and montane chaparral anxiety symptoms 8 weeks cheap desyrel 100 mg free shipping. Habitat: Occurs in woodlands where thickets can exclude other understory plants anxiety quick fix discount desyrel 100 mg without a prescription, in chaparral anxiety symptoms stuttering order 100mg desyrel overnight delivery, and on steep anxiety 5 things you can see purchase desyrel on line, dry slopes and shallow soils; plant communities: Chaparral and Central Oak Woodland Size: this shrub grows 5 10 feet (1. Bark/Trunk/Twigs: Bark is gray and scaly, twigs are yellowish-gray and generally tomentose (covered with fine hairs). The flowers are monoecious (individual flowers are either male or female, but both sexes can be found on the same plant) and are pollinated by Wind. The acorn cap is turban shaped and covers approximately one third to one half of the acorn. Site Ecology: Leather oak is largely confined to growing on soils formed from serpentine rock. Natural Significance: Like most shrub oaks, leather oak serves as habit for numerous wild life species. Any galls produced on the tree are strongly astringent and can be used in the treatment of hemorrhages, chronic diarrhea, or dysentery. The leaf mulch from the Leather Oak is applied to gardens for its efficacy in repelling slugs and grubs; however, it may impact the growth of other plants. Found on the Central and North Coast, and in the foothills of the Klamath and Sierra Nevada Mountain Ranges. Plant Communities: Oregon oak grows in northern mixed evergreen forests, at the edges of redwood and Douglas fir forests, northern and southern oak woodlands, and foothill woodlands. Habitat: Oregon oak exists in a variety of sites including, upland slopes, exposed ridges, and valley bottomsoften found in pure stands or with other oaks. Bark/TrunkTwigs: the unbranched, straight trunks have thin, gray-white bark and are finely fissured. The main branches tend to grow upright and the lesser are horizontal and spreading. Flowers: Slender, yellow to greenish catkins hang downward and hold small pollen bearing flowers. Site Ecology: Unlike many oaks, tolerates part shade and a variety of soil types including, rocky or gravelly sites and heavy clay. Oregon Oak acorns were a food staple for Native Americans that lived in areas where trees were plentiful. Other uses included: a decoction of bark taken for tuberculosis, infusion of plant taken by mother before her first baby, and wood used for a variety of applications. Propagation: Not researched Remarks: the largest specimen ever recorded in California measured 120 feet in height (36 meters) with a trunk diameter of 8 feet (2. Plant Communities: Black oak grows in yellow pine forests, montane coniferous forests, and mixed evergreen forests. Habitat: Found in woodlands and coniferous forests in foothills and mountains away from the coast. Bark/Trunk/Twigs: Dark brown to black bark is divided into broad, irregular ridges. The fall autumn foliage is striking display of russet and yellow against the backdrop of it evergreen neighbors. Tolerates many soil types and will grow in dry to moist sites, but typically requires about 25 inches (62 cm) of annual precipitation. Natural Significance: Like other oaks, may animal species utilized black oak acorns for food. Because the black oaks tends to be and understory tree to the associated conifers, it is less valuable as an animal habitat. Ethnobotanical Use: Historically, the acorns have been a valuable food source; in fact, black oak acorns were preferred over others by Native Americans. Native Americans also favored black oak wood to make cooking paddles and stirrers. Commercial Use: Black Oak wood is used in the manufacture of furniture, paneling and cabinets. Remarks: the largest specimen grows in Siskiyou National Forest and measures 124 feet (37. Hybridizes with Coast Live Oak and Interior live oak, the interior live oak hybrid is called oracle oak. Albert Kellogg who observed the leafless winter branches and trunk as black from the snowmelt that trickles over the tree in the spring. Alves Quercus lobata Valley Oak (California White Oak) (Quercus is Latin for oak, quer is Celtic for fine and cuez is Celtic for tree; lobata is Latin for deeply lobed) Plant Family: Fagaceae the Oak Family Geographical Distribution: Widely distributed in great central valley from Shasta Lake to southern San Joaquin Valley; also found in inner coast and transverse ranges. Grows from sea level to 2,000 feet (600 meters) to the north and 4,000 feet (1,200 meters) to the south Plant Communities: this tree was once common in the valley grass land, oak woodlands, and chaparral. Habitat: Central valley, oak savanna, and low elevation riparian forests; but now found in inner coast range and surrounding foothills Size: Valley oak grows to 100 feet tall (30. Bark/Trunk/Twigs Young trees have a grayish bark in a checkered of vertically fissured pattern, as trees age the bark becomes very thick with deep fissures. Small branches and leaves usually bear woody spherical galls that are occupied by the larvae of small natives wasps. Seed bearing flowers can be either solitary or in small clusters found at leaf bases. Oak galls (these galls are called oak apples) were collected and stored by Yokut Indians for tinder. Commercial Use: the pale yellow to dull brown wood of the valley oak is of little commercial value except as fuel. Valley oaks have an obligate relationship with mycorrhizal fungi, which provide critical moisture and nutrients. Valley oaks suffer from oak root fungus which can result in sudden breakage of large scaffolds. Recommend that it be watered for the first 5 to 10 years and then weaned to one or two deep summer watering per year. Keystone species help to support the ecosystem (entire community of life) of which they are a part. This not a high elevation plant and seems to do best when planted under 600 feet (200 meters) elevation. Plant Communities: Cork oaks are found in forest mosaics alongside other tree species, including a variety of other oaks, stone and maritime pines, and even wild olive trees. Bark/Trunk/Twigs: Very unique, light gray with deep reddish brown furrows, developing very thick (inches) layers of cork, ruggedly ridged and furrowed; reddish brown when recently harvested for cork. Twigs are moderately, light gray-brown, with abundant gray fuzz; buds are clustered, reddish brown, with some gray fuzz, broadly triangular and pointed. Fruit: the acorns are fi 1 fi inches (2 3 cm) long, in a deep cup fringed with elongated scales. Site Ecology: Cork oak grows in loamy to clay soil, part shade to full sun and is drought tolerant. Natural Significance: Natural stands of cork oak support numerous endangered species. For example, in parts of northwestern North Africa, some cork oak forests are habitat to the endangered Barbary Macaque, Macaca sylvanus, a species whose habitat is fragmented and whose range was prehistorically much wider. In Western Europe, namely in Portugal and Spain, the cork oak forests are home to endangered species such as the Iberian Lynx, the most critically threatened feline in the world. Ethnobotanical Use: Seed can be dried, ground into a powder and used as a thickening in stews etc. Commercial Use: It is the primary source of cork for wine bottle stoppers and other uses, such as cork flooring. The harvesting does not harm the tree, in fact, no trees are cut down during the harvesting process. Only the bark is extracted, and a new layer of cork regrows, making it a renewable resource. Propagation: Planting seeds directly in the spot they are to be located seems the best propagation option. Remarks: the Rainforest Alliance is working with cork producers throughout Spain and Portugal to help them achieve Forest Stewardship Council certification. Plant Communities: Huckleberry oaks grow in yellow pine forests, montane chaparral, red fir forests, lodgepole forests, and subalpine forests. Site Ecology: It grows on shallow soils and even Serpentine rock and is shade intolerant. Natural Significance: Leaves provide browse for deer, acorns are a food source for a variety of wildlife species. Ethnobotanical Use: Not researched Commercial Use: Not researched Propagation: Not researched Remarks: Occurs at higher elevations than all other California Oaks. Wislizenius) Plant Family: Fagaceae the Oak Family Geographical Distribution: Southern Cascade and Klamath Ranges; West slope of Sierras from Siskiyou to Kern Counties; scattered in Coast Range into the inner Transverse and Peninsular ranges. Plant Communities: Interior live oak is found in northern and southern oak woodland, foothill woodlands and chaparral. Habitat: Wide spread below 5,000 feet (1,525 meters) in foothills, riparian flood plains, and valleys away from the coast. Foliage: Thick, leathery evergreen leaves oblong to elliptic or lanceolate 1-3 inches long (2. Both leaf surfaces are shiny green but upper surface is darker and the lower may exhibit a yellow green color. Natural Significance: Wildlife habitat and food provided for black-tailed jackrabbit, Audubon cottontail, brush rabbit (endangered), Beechy ground squirrel, Sonoma chipmunk, beaver, porcupine, Columbian Black-tail deer, and elk. Ethnobotanical Use: Native Americans leached bitter tannins from acorns and then used the acorns for cooking oils, soup, stews, and breads. Its leaves are very much like the tree form and is mostly found in southern California. Plant Family: Fagaceae the Oak Family Geographical Distribution: Southern Cascade and Klamath Ranges; West slope of Sierras from Siskiyou to Kern Counties; scattered in Coast Range into the inner Transverse and Peninsular ranges. Plant Communities: the shrub form of interior live oak is found in northern and southern oak woodland, foothill woodlands and chaparral. Bark/Trunk/Twigs: Smooth and grey on young trees but becomes darker and fissured with age. Mature trees are a wide as tall with numerous horizontal scaffolds that touch the ground. Ethnobotanical Use: Native Americans leached bitter tannins for cooking oils, soup, stews, and breads. Alves Rhamnus californica California or Coast Coffeeberry Plant Family Rhamnaceaethe Buckthorn Family Geographical Distribution: Occurs is Western California, ranging from south to north and extending into South-western Oregon, and in the foothills of the Sierra Nevada and the Desert Mountains at elevations below 7,500 feet (2,270 meters). Plant Communities: Commonly found in yellow forests, foothill woodlands, chaparral, and coastal sage scrub. Habitat: Grow in a variety of habitats; from cooler moister sites, to dry exposed sites, or as an understory shrub. Flowers Clusters of 1 60 small, inconspicuous 5-petaled, fragrant flowers appear in leaf axils and produce large quantities of nectar.

Standing with your side to the wall anxiety 12 year old boy discount 100mg desyrel with mastercard, hold the loop as shown in the Start position anxiety symptoms worksheet buy discount desyrel 100mg line. Keeping your elbow close to your side anxiety symptoms lingering 100mg desyrel otc, rotate the arm outward slowly and then slowly return to the Start position anxiety upset stomach 100 mg desyrel overnight delivery. Keeping your arm close to your side anxiety hives cheapest desyrel, slowly pull the arm straight back and then slowly return to the Start position anxiety 2 days before menses purchase desyrel pills in toronto. Keeping your elbow close to your side, rotate the arm across your body slowly and then slowly return to the Start position. Bend at the waist with your side supported on the table and the other arm hanging straight down and holding a light weight (up to 5 pounds). Keeping the arm straight, slowly raise the hand up to eye level and then slowly lower it back to the starting position. Holding a light weight (up to 5 pounds) and keeping the arm close to the side, slowly bend the elbow up toward the shoulder as shown; hold for 5 seconds, slowly return to the starting position, and then relax. Holding a light weight (up to 5 pounds), raise your arm with the elbow bent and with your opposite hand supporting your elbow. Slowly straighten the elbow overhead, hold for 5 seconds, and then slowly lower the arm to the starting position. To prevent infiammation, apply ice, such as a bag of crushed ice or frozen peas, to the painful area of the elbow for 20 minutes after performing both exercises. If you are unable to add weight or perform the indicated number of repetitions because of pain, call your doctor. To exercise the wrist extensors, rest the forearm on a hard surface with the hand extending over the side. For the forearm supination exercise, supinate the forearm and then return to vertical as shown. Use no weight initially; add weight in 1-pound increments to a maximum of 5 pounds. If numbness steadily worsens, if the exercises increase the pain, or if the pain does not improve after you have performed the exercises for 3 to 4 weeks, call your doctor. Apply dry or moist heat to the hip for 5 to 10 minutes before the exercises to prepare the tissues. Alternatively, riding a stationary bicycle for 10 minutes will also prepare the tissues for stretching. Apply a bag of crushed ice or frozen peas to the hip for 20 minutes after the exercises to help reduce infiammation. If you experience pain in the hip during or after the exercises, discontinue the exercises and call your doctor. Place the ankle of the affected leg on the opposite knee and clasp your hands behind the thigh as shown. Perform 2 to 3 sets of 4 repetitions 5 to 7 days a week, continuing for 2 to 3 weeks. Ankle weights should be used, starting with light enough weight to allow 2 sets of 8 repetitions. After each set of exercises, apply ice, such as a bag of ice cubes or crushed ice or a bag of frozen peas, to the hip for 20 minutes. If the pain in the hip is aggravated by the exercises or does not go away within 3 to 4 weeks, call your doctor. Ankle weights should be used, starting with light enough weight to allow 2 sets of 8 repetitions, progressing to 3 sets of 12 repetitions. Rotating from the hip, move the ankle slowly from side to side, attempting to touch the fioor. Apply dry or moist heat to the thigh for 5 to 10 minutes before exercising to prepare the tissues, and apply a bag of crushed ice or frozen peas for 20 minutes after exercising to prevent infiammation. If the exercises increase pain or the pain does not go away after adhering to the program for 3 to 4 weeks, call your doctor. Your partner raises one leg just to the point of tightness and applies resistance for 30 seconds while you try to lower the leg. Grasp the calf of one leg and slowly pull the leg toward your ear, keeping your back straight. Ankle weights should be used, starting with a weight that allows 2 sets of 8 repetitions and progressing to 3 sets of 12 repetitions. Then return to 2 sets of 8 repetitions and add weight in 2to 3-pound increments, progressing each time to 3 sets of 12 repetitions. When performing the exercises, you should stretch slowly to the limit of motion, taking care to avoid pain. Slowly lift and pull the leg toward your ear, keeping your back straight and the other leg fiat on the fioor or bent slightly if necessary for comfort. Cross one leg over the other, place the elbow of the opposite arm on the outside of the thigh, and support yourself with your other arm behind you. Try to keep the other leg fiat on the fioor, but you may bend it slightly if needed for comfort. Begin with your weight distributed evenly over both feet, and then cross one leg behind the other. Lean the hip of the crossed-over leg toward the wall until you feel a stretch on the outside of the leg. Bend one knee up toward your buttocks and grasp the ankle with the hand on the same side. Pull on the ankle and hold at the point of maximum stretch for 30 seconds, then relax for 30 seconds. Ankle weights should be used, starting with light enough weight to allow 6 to 8 repetitions, working up to 12 repetitions. Ankle weights should be used, starting with light enough weight to allow 6 to 8 repetitions, progressing to 12 repetitions. Start with the foot of the top leg below the level of the top of the table; lift to the Finish position, which is rotated as high as possible. Start with the foot below the level of the top of the table; lift to the Finish position, which is rotated as high as possible. Begin with an ankle weight that allows 6 to 8 repetitions, progressing to 12 repetitions. After each exercise session, apply ice (such as a bag of crushed ice or a bag of frozen peas) to the knee for 20 minutes, keep the leg elevated, and apply a compression bandage to the knee. If pain or swelling increases at any time or if it does not improve after you have adhered to the program for 3 to 4 weeks, call your doctor. Bend the injured knee, raising the heel of the affected leg toward the ceiling as far as you can without pain. Tighten the thigh muscle of the injured leg and slowly raise it 6 to 10 inches off the fioor. Perform 3 sets of 20 repetitions, 4 to 5 days a week, continuing for 3 to 4 weeks. Hold the position of maximum fiexion for 5 seconds and then slowly straighten the leg. Dry or moist heat may be applied to the back of the knee during the passive knee extension. Apply a bag of crushed ice or frozen peas to the injured side of the knee for 20 minutes after completing the exercises to prevent additional infiammation. If pain increases at any time or does not improve after performing these exercises for 3 to 4 weeks, call your doctor. Bend the injured knee, lifting the heel toward the ceiling as far as possible without pain. Perform 3 sets of 25 to 45 repetitions, 5 to 6 days a week, continuing for 3 to 4 weeks. Repeat this 2 to 3 times per day, 5 to 6 days a week, continuing for 3 to 4 weeks. Perform 3 sets of 25 to 50 repetitions, 5 to 6 days a week, continuing for 3 to 4 weeks. After performing the calf raises, apply a bag of crushed ice or frozen peas to the injured area for 20 minutes to prevent further infiammation. Apply moist or dry heat to the injured area before and during the heel cord stretch. If the exercises increase the pain or if the pain does not improve after you have performed the exercises for 3 to 4 weeks, call your doctor. Hold onto the back of a chair or the wall for balance and lift the foot on the uninjured side. Keeping the knee of the injured leg straight, raise the heel off the fioor as high as you can, using your body weight as resistance. Work up to 3 sets of 10 repetitions, 3 to 4 days a week, continuing for 3 to 4 weeks. The toe of the affected leg should be pointed in, and the heel should not come off the ground. Hold the stretch for 30 seconds with the knee straight and then relax for 30 seconds. If the exercises increase the pain in your knee or if the pain does not improve after performing the exercises for 3 to 4 weeks, call your doctor. Bend the injured knee, raising the heel toward the ceiling as far as possible without pain. To prevent infiammation, apply a bag of crushed ice or frozen peas just below the kneecap after completing all the exercises. Slowly fiex the affected knee (bend it up toward your buttocks) as far as possible without pain and then lower it. Bend the affected knee and grasp the ankle with your hand (or use a towel or rubber tubing). Keeping your thigh fiat on the surface, pull gently and hold for 30 seconds; then relax for 30 seconds. Perform 2 to 3 sets of 4 repetitions 5 to 6 days a week, continuing for 3 to 4 weeks. To prevent infiammation, apply a bag of crushed ice or frozen peas along the sides of the kneecap for 20 minutes after completing the exercises. Keep the affected leg straight and bend the other leg at the knee so that the foot is fiat on the fioor. Tighten the thigh muscle of the affected leg and slowly raise it 6 to 10 inches off the fioor. Tighten the hamstrings of the affected leg and raise the leg toward the ceiling as far as you can. To prevent infiammation, apply a bag of crushed ice or frozen peas to the injured side of the knee for 20 minutes after completing the exercises. Bend the affected knee, raising the heel toward the ceiling as far as possible without pain. Perform 3 sets of 25 repetitions, progressing gradually to 3 sets of 45 repetitions. Apply a bag of crushed ice or frozen peas to the back of the knee for 20 minutes after completing all the exercises to prevent infiammation. If pain does not improve or worsens or if the knee joint becomes infiamed, call your doctor. Keep the injured leg straight and bend the other leg at the knee so that the foot is fiat on the fioor. Tighten the hamstrings of the injured leg and raise the leg toward the ceiling as far as you can. Keeping your feet close together and your legs straight, slowly bend forward toward your toes. Tighten the thigh muscle of the straight leg and slowly raise it 6 to 10 inches off the fioor. Keeping the leg straight, tighten the hamstrings of one leg and raise the leg as high as you can. Lunge forward, bending the forward knee and keeping the back and the back leg straight. Elevate the leg off the fioor to a count of 5, lifting the leg straight up with the knee bent. Before stretching, warm up the tissues by applying moist heat or riding a stationary bicycle for 10 minutes. To prevent infiammation, apply a bag of crushed ice or frozen peas to the heel for 20 minutes after exercising. If you are unable to perform the exercise because of pain or stiffness or if your symptoms do not improve in 3 to 4 weeks, call your doctor. If you continue to experience pain or limited mobility of the ankle after performing the exercises for 2 to 3 weeks, call your doctor. Begin with 3 sets of 25 repetitions and increase gradually to 3 sets of 45 repetitions. To prevent infiammation, apply a bag of crushed ice or frozen peas to the heel for 20 minutes after performing the exercise. If you are unable to perform the exercise because of pain or stiffness or if your symptoms do not improve after performing the exercise for 3 to 4 weeks, call your doctor. If your symptoms do not improve after performing the exercise for 3 to 4 weeks, call your doctor. Stretch with knee straight: Keeping the heel in contact with the ground and the knee straight, place the foot as far back as possible until a stretch is felt in the calf. Stretch with knee extended: Same position but bend the knee of the leg being stretched. Slowly move your foot from side to side, keeping the lower leg motionless and moving only at the ankle. Begin by gently bowing your head toward your chest, then stretching your right ear toward your right shoulder (1), then your left ear toward your left shoulder (2). If the pain worsens or if it does not improve after performing the exercises for 3 to 4 weeks, call your doctor.

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