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Similarly buy albendazole with mastercard hiv infection during window period, Rabinowitz & Glaser (1985) pro- titative form of literature review cheap albendazole 400 mg visa antiviral movie, rather than the tra- posed that an adequate understanding of the ditional narrative review that embodies the expert’s knowledge structure would lead to more subjective judgement of the experts who wrote the effective instruction to assist novices in acquiring review buy on line albendazole human immunodeficiency virus hiv infection symptoms. Whether meta-analyses will ultimately If expert clinicians are not consistent in their replace traditional reviews remains to be seen. In this section, we review some recent efforts it is, in our opinion, currently the most popular to teach the logic of clinical decision making that vehicle explicitly advocating a Bayesian approach have been strongly influenced by decision theo- to clinical evidence. Debiasing meth- of a positive or negative test), and at least one ods include educating judges about common recent study suggests that prevalence data may biases, encouraging judges to consider alternative be readily available in the medical literature for hypotheses carefully and making judges more inpatient adult medicine problems (Richardson accountable for errors. Formal statistical reasoning and deci- ness of these methods is mixed (Graber 2003). Decision theory, decision analysis a broad range, including but not limited to: differ- and evidence-based medicine seem to be on their ences between expert and novice clinicians; psy- way to becoming standard components of clinical chological processes in judgement and decision education and training. The role of these programs in medical educa- have sought to understand the process of clinical tion and in future clinical practice is still to be reasoning, improve instructional programmes determined, but they hold out hope for addressing designed for medical students and clinical training, both cognitive and systemic sources of diagnostic assess competence at the level of medical licensure error (Elstein et al 2004, Graber et al 2002). A typical example is at the intersection of the interests of psycholo- the graphical Bayesian nomogram which permits gists, medical sociologists, health policy planners, quick calculation of posterior probabilities from economists, patients and clinicians. Cambridge Lake City University Press, New York Arkes H 1991 Costs and benefits of judgment errors: Barrows H S, Pickell G C 1991 Developing clinical problem- implications for debiasing. Psychological Bulletin solving skills: a guide to more effective diagnosis and 110(37):486–498 treatment. Medical Decision Making 13(1):21–29 Medicine 5(1):49–56 Elstein A S, Schwartz A, McNutt R 2004 Can metacognition Bergus G R, Chapman G B, Gjerde C et al 1995 Clinical minimize cognitive biases? Online reasoning about new symptoms despite pre-existing (eLetters, now available from the authors) disease: sources of error and order effects. Family Eschach H, Bitterman H 2003 From case-based reasoning to Medicine 27(5):314–320 problem-based learning. Academic Medicine 78(5): Bordage G 1987 the curriculum: overloaded and too 491–496 general? Medical Education 21(3):183–188 Eva K W 2005 What every teacher needs to know about Bordage G, Lemieux M 1991 Semantic structures and clinical reasoning. Academic Eva K W, Neville A J, Norman G R 1998 Exploring the Medicine 66(9):S70–S72 etiology of content specificity: factors influencing Bordage G, Zacks R 1984 the structure of medical analogic transfer and problem solving. Academic knowledge in the memories of medical students and Medicine 73(10 Suppl):S1–S5 general practitioners: categories and prototypes. Medical Evidence-based Medicine Working Group 1992 Evidence- Education 18(6):406–416 based medicine: a new approach to teaching the practice Brooks L R, Norman G R, Allen S W 1991 Role of specific of medicine. Journal of the American Medical Association similarity in a medical diagnostic task. Journal of 268(17):2420–2425 Experimental Psychology: General 120(3):278–287 Fagan T J 1975 Nomogram for Bayes’ theorem. New England Bryant G D, Norman G R 1980 Expressions of probability: Journal of Medicine 293(5):257 words and numbers. In: 302(7):411 Neufeld V R, Norman G R (eds) Assessing clinical Chapman G B, Bergus G R, Elstein A S 1996 Order of competence. Journal of Feltovich P J, Johnson P E, Moller J H et al 1984 the role and Behavioral Decision Making 9(3):201–211 development of medical knowledge in diagnostic Croskerry P 2003 the importance of cognitive errors in expertise. In: Clancey W J, Shortliffe E H (eds) Readings diagnosis and strategies to minimize them. In: Davidoff F Friedman M H, Connell K J, Olthoff A J et al 1998 Medical (ed) Who has seen a blood sugar? Academic Medicine 78 University of Pittsburgh, Pittsburgh (8):781 Eddy D M 1982 Probabilistic reasoning in clinical medicine: Graber M, Gordon R, Franklin N 2002 Reducing diagnostic problems and opportunities. Academic Medicine Tversky A (eds) Judgment under uncertainty: heuristics 77(10):981–992 and biases. Cambridge University Press, New York, Groen G J, Patel V L 1985 Medical problem-solving: some p 249–267 questionable assumptions. Medical Education 19(2): Edwards W 1968 Conservatism in human information 95–100 processing. In: Kleinmuntz B (ed) Formal representation Groves M, O’Rourke P, Alexander H 2003 the clinical of human judgment. Medical Einhorn H J, Hogarth R M 1986 Decision making under Teacher 25(3):308–313 ambiguity. Journal of Business 59(4):S225–S250 Gruppen L D, Wolf F M, Billi J E 1991 Information gathering Elstein A S 1988 Cognitive processes in clinical inference and and integration as sources of error in diagnostic decision decision making. Medical Decision Making 11(4):233–239 Reasoning, inference and judgment in clinical Hogarth R M 2005 Deciding analytically or trusting your psychology. The advantages and disadvantages of analytic Elstein A S 1994 What goes around comes around: the return and intuitive thought. Medical Decision Making 12(4):265–273 New York Clinical reasoning in medicine 233 Joseph G M, Patel V L 1990 Domain knowledge and experienced clinician-teachers in internal medicine. Medical Medical Teacher 27(5):415–421 Decision Making 10(1):31–46 Neufeld V R, Norman G R, Feightner J W et al 1981 Clinical Kahneman D 2003 Maps of bounded rationality: a problem-solving by medical students: a cross-sectional perspective on intuitive judgment and choice. Cambridge Nisbett R E, Borgida E, Crandall R, Reed H 1982 Popular University Press, New York induction: information is not always informative. In: Kassirer J P, Gorry G A 1978 Clinical problem solving: a Kahneman D, Slovic P, Tversky A (eds) Judgment under behavioral analysis. Cambridge University 89:245–255 Press, New York, p 101–116 Kassirer J P, Kopelman R I 1991 Learning clinical reasoning. Norman G R 1988 Problem-solving skills, solving problems Williams and Wilkins, Baltimore and problem-based learning. Medical Education 22(4): Kempainen R R, Migeon M B, Wolf F M 2003 Understanding 279–286 our mistakes: a primer on errors in clinical reasoning. Norman G 2005 Research in clinical reasoning: past history Medical Teacher 25(2):177–181 and current trends. Medical Education 39:418–427 Keren G 1990 Cognitive aids and debiasing methods: can Norman G R, Coblentz C L, Brooks L R et al 1992 Expertise cognitive pills cure cognitive ills? Medicine 67(10):S78–S83 North-Holland, Amsterdam, p 523–552 Norman G R, Trott A L, Brooks L R et al 1994 Cognitive Kern L, Doherty M E 1982 ‘Pseudodiagnosticity’ in an differences in clinical reasoning related to postgraduate idealized medical problem-solving environment. Teaching and Learning in Medicine 6:114–120 of Medical Education 57(2):100–104 Oxman A D, Cook D J, Guyatt G H 1994 Users’ guides to the Kuipers B J, Kassirer J P 1984 Causal reasoning in medicine: medical literature, no 6. Cognitive Science 8(4):363–385 of the American Medical Association 272(17):1367–1371 Kuipers B, Moskowitz A J, Kassirer J P 1988 Critical Page G, Bordage G, Harasym P et al 1990 A revision of the decisions under uncertainty: representation and medical council of Canada’s qualifying examination: pilot structure. In: Bender W, Hiemstra R, Scherpbier L’Abbe K A, Detsky A S, O’Rourke K 1987 Meta-analysis A et al (eds) Teaching and assessing clinical competence. Annals of Internal Medicine BoekWerk Publication, Groningen, p 403–407 107(2):224–233 Panzer R J, Black E R, Griner P F 1991 Diagnostic strategies Lee T H 2004 Interpretation of data for clinical decisions. Saunders, Philadelphia, p 23–28 Patel V L, Groen G J 1986 Knowledge-based solution Lemieux M, Bordage G 1992 Propositional versus structural strategies in medical reasoning. In: ill-structured problems: the structuring of medical Kasper D L, Braunwald E, Fauci A S et al (eds) diagnostics.

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A descriptive study of blood in the mouth following routine oral endotracheal intubation discount albendazole 400mg online hiv infection causes statistics. The efect of steam sterilisation at 134 on light intensity provided by fbrelight Macintosh laryngoscopes 400mg albendazole sale hiv infection rates berlin. T e literature states that the incidence of vomiting is about 30% generic albendazole 400 mg stages of hiv infection and treatment, while nausea occurs in about 50% of patients. Inputs also arrive from other areas such as the lateral reticular formation, the higher cortical centers, cerebellum, vestibular apparatus, as well as vagal and glossopharyngeal nerve aferents to trigger the complex motor response of emesis. T e signals between these anatomic areas are mediated through several neurotransmitter receptor systems like serotonergic, dopaminergic, histaminergic, cholinergic, and neurokininergic systems. T e others are duration of anesthesia, postoperative opioid use and use of nitrous oxide. However, it should be noted that nausea is often not recorded, as it is often difcult to assess in this younger patient population. T erefore, minimization of neostigmine dosage has been removed from the list of strategies to reduce the baseline risk. However, aprepitant was signifcantly more efective than ondansetron for preventing vomiting at 24 and 48 hours after surgery. It also reduces the severity of nausea in the frst 48 hours after surgery1 (with a greater antiemetic efect vis-a-vis ondansetron). Henzi et al found that a single dose of perioperative dexamethasone does not appear to increase the risk of wound infection. In most studies, a single dose of perioperative dexamethasone does not appear to increase the risk of wound infection. However, a recent study reported that intraoperative dexamethasone 4–8 mg may confer an increased risk of postoperative infection. In low doses, haloperidol appears to have antiemetic properties which indicate that it can be used as an alternative to droperidol. Dry mouth usually occurs on the frst day of usage while higher occurence of visual disturbances is observed at 24–48 hours. A meta-analysis on perioperative systemic alpha-2-adrenoceptor agonists (clonidine and dexmedetomidine) showed a signifcant albeit weak and short-lived antinausea efect. Midazolam 1 mg/h when compared with a subhypnotic dose of propofol 1 mg/kg/h was found to be equally efective when given at the end of surgery. Among the interventions discussed, reducing baseline risk factors and use of nonpharmacologic therapy are least likely to cause side efects. Use of interventions from diferent drug classes has an additive efect in risk reduction. For rescue antiemetic therapy, the drug should be from a diferent therapeutic class than the drugs already used for prophylaxis. T e relationship between patient risk factors and early versus late postoperative emetic symptoms. Update on the management of postoperative nausea and vomiting and postdischarge nausea and vomiting in ambulatory surgery. A simplifed risk score for predicting postoperative nausea and vomiting conclusions from cross-validations between two centers. T e development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Subhypnotic propofol infusion plus dexamethasone is more efective than dexamethasone alone for the prevention of vomiting in children after tonsillectomy. Efect of ramosetron on patient-controlled analgesia related nausea and vomiting after spine surgery in highly susceptible patients: Comparison with ondansetron. A randomized, double-blind study to evaluate the efcacy and safety of three diferent doses of palonosetron versus placebo for preventing postoperative nausea and vomiting. A comparison of the combination of aprepitant and dexamethasone versus the combination of ondansetron and dexamethasone for the prevention of postoperative nausea and vomiting in patients undergoing craniotomy. Novel therapies for postoperative nausea and vomiting: Statistically signifcant versus clinically meaningful outcomes. Rolapitant for the prevention of postoperative nausea and vomiting: a prospective, double-blinded, placebo-controlled randomized trial. Dexamethasone for the prevention of postoperative nausea and vomiting: A quantitative systematic review. Single dose dexamethasone for postoperative nausea and vomiting—a matched case-control study of postoperative infection risk. Wound complications with dexamethasone for postoperative nausea and vomiting prophylaxis: A moot point? Haloperidol plus ondansetron prevents postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Haloperidol is as efective as ondansetron for preventing postoperative nausea and vomiting. Meclizine in combination with ondansetron for prevention of postoperative nausea and vomiting in a high-risk population. Transdermal scopolamine for the prevention of postoperative nausea and vomiting: a systematic review and meta-analysis. Transdermal scopolamine: An alternative to ondansetron and droperidol for the prevention of postoperative and postdischarge emetic symptoms. Efect of perioperative systemic a2 agonists on postoperative morphine consumption and pain intensity: Systematic review and meta-analysis of randomized controlled trials. T e preoperative use of gabapentin, dexamethasone, and their combination in varicocele surgery: A randomized controlled trial. Midazolam vs ondansetron for preventing postoperative nausea and vomiting: A randomised controlled trial. Prevention of nausea and vomiting in caesarean section under spinal anaesthesia with midazolam or metoclopramide? Transcutaneous nicotine does not prevent postoperative nausea and vomiting: A randomized controlled trial. Efcacy of ondansetron and prochlorperazine for the prevention of postoperative nausea and vomiting after total hip replacement or total knee replacement procedures: A randomized, double-blind, comparative trial. Acupressure wristbands do not prevent postoperative nausea and vomiting after urological endoscopic surgery. Monitoring of neuromuscular blockade at the P6 acupuncture point reduces the incidence of postoperative nausea and vomiting. It was used as a monitoring device to diagnose air embolism by Edmonds-Seal et al. Currently, it is used for several procedures and also as a tool for intraoperative diagnosis. T ey used Doppler to identify the subclavian artery to increase the safety of the supraclavicular brachial plexus block. A sound anatomical knowledge is also essential for performing successful ultrasound-guided procedures.

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Structures passing from the thorax to the abdomen have to pass through apertures in the diaphragm buy albendazole once a day stages of hiv infection diagram. The inferior vena cava is the largest structure entering the thorax from the abdomen generic albendazole 400 mg with mastercard hiv infection latent stage. The trachea is a wide tube lying more or less in the midline purchase 400 mg albendazole overnight delivery hiv infection rates texas, in the lower part of the neck and in the superior mediastinum of the thorax (19. The junction lies opposite the lower part of the body of the sixth cervical vertebra. At its lower end the trachea ends by dividing into the right and left principal bronchi. The level of bifurcation corresponds to the lower border of the manubrium sterni, or to the lower border of the fourth thoracic vertebra. The lumen of the trachea is kept patent because of the presence of a series of cartilaginous rings in its wall. Hence, the posterior part of the wall of the trachea is fat while the rest of it is rounded. Posteriorly, the trachea is related to the oesophagus that runs vertically behind it, and separates it from the bod- ies of the upper four thoracic vertebrae (19. Anteriorly, the trachea is covered by skin, superfcial and deep fascia, and by the manubrium sterni (19. The right and left sternohyoid and sternothyroid muscles (which arise from the posterior aspect of the manubrium sterni) overlap the part of the trachea near the inlet of the thorax. The brachiocephalic trunk is at frst in front of the trachea, but as it passes upwards it reaches the right side of the trachea. The right common carotid artery ascends along the right side of the cervical part of the trachea (19. The left subclavian artery arises from the part of the arch of the aorta that lies to the left of the trachea. It as- cends (for some distance) along the left side of the trachea lying behind the left common carotid artery (19. The left brachiocephalic vein crosses in front of the trachea just above the arch of the aorta. The superior vena cava lie to the right side of the thoracic part of the trachea (19. The terminal part of the azygous vein arches forwards across the right side of the trachea (near its lower end) to join the superior vena cava (19. The left recurrent laryngeal nerve lies in the groove between the trachea and the oesophagus (19. The right vagus nerve is closely applied to the right side of the thoracic part of the trachea (19. On either side (right or left) the trachea is overlapped by the corresponding pleura and lung (19. It arises from the brachiocephalic trunk or from the arch of the aorta and runs upwards in front of the trachea (19. CliniCal Correlation the Trachea the trachea can be palpated in the suprasternal notch. To elicit the sign the examiner stands behind the patient and places his fngers just below the cricoid cartilage. This raises the cricoid cartilage that is retained in this position by the fngers. Pulsations of an aneurysm may then be transmitted through the trachea to the fngers of the examiner. It is used to provide an alternative route for supply of air to the lungs when there is obstruction in the larynx or upper end of the trachea. The 2nd and 3rd (and sometimes the 4th) tracheal rings are cut and a tube inserted into the trachea through the opening. It may be pressed upon by an aortic aneurysm, or by an abnormally located aortic arch. Stenosis can also be produced by fbrosis of the wall of the trachea, and this may occur as an after effect of tracheostomy. The accessory bronchi may be blind, may supply an accessory lobe, or may replace a normal segmental bronchus. Each principal bronchus begins opposite the (lower border of the body of the) fourth thoracic vertebra. There are some important differences between the right and left principal bronchi. The right bronchus is wider, shorter, and more vertical than the left bronchus (19. The right principal bronchus enters the lung opposite the ffth thoracic vertebra, while the left principal bronchus enters the lung opposite the sixth thoracic vertebra. On reaching the hilum of the right lung, the right principal bronchus gives off a superior lobar bronchus (to the superior lobe of the lung). It then descends for a short distance before dividing into the middle and inferior lobar bronchi (which supply the middle and inferior lobes, respectively, of the right lung). In other words, the right principal bronchus ends by dividing into three lobar bronchi. In contrast the left principal bronchus ends by dividing into two lobar bronchi, superior and inferior, cor- responding to the lobes of the left lung. The length of the right principal bronchus, given above, is up to the origin of the superior lobar bron- chus. However, the part of the bronchus between the origin of the superior lobar bronchus and the origin of the middle and inferior lobar bronchi is usually described as a continuation of the principal bronchus. The azygous vein lies just above the bronchus (near its origin) as the former arches forwards to join the inferior vena cava (19. It crosses in front of the bronchus, below the origin of the superior lobar bronchus. Therefore, on reaching the hilum of the lung the artery has the superior lobar bronchus above it, and the continuation of the principal bronchus below it (19. The lower part of the right principal bronchus is also covered by the upper right pulmonary vein. The position of the bronchus, the artery and the veins, at the hilum of the right lung is shown in 19. The left pulmonary artery is frst anterior to the bronchus and then superior to it. The position of the bronchus the artery and the veins, at the hilum of the left lung is shown in 19. The trachea receives its blood supply mainly through the inferior thyroid arteries (lying in the neck). The bronchi are supplied by bronchial arteries that also supply the lower end of the trachea.

Increased insertional activity buy cheap albendazole on-line infection cycle of hiv, positive waves generic 400 mg albendazole visa hiv infection prevalence united states, fibrillations buy generic albendazole 400 mg online hiv infection rates south africa, and complex repet- itive discharges may occur as a result of segmental necrosis of muscle fiber or regeneration of fibers. Upper extremity H-reflex: flexor carpi radialis muscle via median nerve stimu- lated at cubital fossa 2. Upper limit of normal latency: soleus—35 milliseconds; flexor carpi radialis— 21 milliseconds iii. Side-to-side difference of latency: 2 milliseconds between lower extremi- ties; 1. Side-to-side difference of amplitude: less than or equal to 3 milliseconds for both upper and lower extremities v. Physiology: F-waves are produced by antidromic activation (reflected impulse) of motor neuron; useful to estimate conduction in proximal motor nerves by testing length of entire motor nerve; no synapse is tested. Maximal side-to-side difference (A) Hand: 2 milliseconds (B) Calf: 3 milliseconds (C) Foot: 4 milliseconds iii. Less than 70% of normal patients do not have peroneal nerve F-wave, but most should have normal tibial nerve F-waves. Fibrillation and positive sharp waves are from the spontaneous depolarization of a muscle fiber. Fasciculation, doublets, multiplets, cramps, and myokymic discharges are from the motor neuron and its axon. Short duration: seen in all myopathies; occasionally in neuro- muscular junction disorders and early phases of reinnervation c. Amplitude; firing rate, 2 to 20 Hz; high pitched, bi- or tripha- sic; first phase is positive except when recorded in end plate. Most of the charge movement in biologic tissue is attributed to passive properties of the membrane or changes in ion conductance + + 2+ 2. Resting membrane potential: –70 mV (due to difference in permeability of ions + + and sodium–potassium pump forcing K in and Na out) B. Resting membrane potential is based on outward K current through passive leak- age channels. Depending on the ionic currents flowing through the transmitter (ligand)-operated channels, two types of positive-synaptic potentials are generated. Causes hyperpolarization of the positive-synaptic membrane, making it more difficult to reach the threshold potential 8. Resting membrane potential is based only on potassium outward current through leakage channels. With an increase and a subsequent decrease in extracellular potassium concentra- tion, glial cells depolarize and repolarize, respectively. An intracellular electrode notes the interior becoming more positive than it was at rest, whereas an extracellular electrode sees this as a negative potential. Inhibitory synapse: there is an outflow of cations or an inflow of anions at the syn- aptic site. The electrode near the synapse “sees” a positivity and the electrode distant from the synapse a negativity. The movement of charge from excitable tissue to surrounding tissue is called vol- ume conduction. Electrical activity in the deep cortical nuclei produces surface potentials of low amplitude. The largest neurons are involved in efferent outflow and are oriented perpendicu- lar to the cortical surface, producing a vertical columnar orientation of the cortex. Influx of positive ions into the efferent neurons results in a negative extracel- lular field potential; electrotonic depolarization of the soma and axon hillock results in a positive field potential; because of the vertical orientation of the large efferent neurons, the negative field potential is usually superficial to the positive field potential, forming a dipole. It is estimated that 6 to 10 cm of cortex must be synchronously activated for a potential to be recorded at the scalp (note: potentials must be volume con- ducted through the meninges, skull, and skin before being detected by scalp electrodes). Scalp potentials are deter- mined by the vectors of cortical activity; if the superficial layer four of the cortex is a positive field potential and deeper layers are negative, then there is a vertical vector produced, with the positive end pointing toward the scalp electrode; the amplitude of the vector depends on the total area of activated cortex and the degree of synchrony among the neurons. At least one recording electrode is essentially over the source and the reference is not contained in the active region. Generated when depolarization results in synchronous activation of many neurons 2. The negative end of the epileptiform dipole points toward the cortical surface, resulting in a negative deflection at the scalp electrode. The distribution of the epileptiform potential across the cortical surface is called the field. Occasionally, the surface is positive (and in normal patterns of positives and 14- and 6-Hz–positive spikes). Extracellular field potentials characterized by waves of depolarization followed by repolarization b. Ultimately, termination of epileptiform discharges is due to inhibitory feedback to neurons. Note: the previous points are for partial seizures ± secondary generalization; for primary generalized seizures, the generator is likely a loop between the cor- tex and thalamus (possibly also responsible for sleep spindles). Input board: channel—formed by the two selected electrodes, amplifier, and record- ing unit to form a system to display the potential differences between two electrodes B. Filters selectively reduce the amplitude of voltage changes or signals of selected frequencies 2. Square-wave calibration: square-wave pulse of 50-µV amplitude is delivered to the inputs of each amplifier at rate of 1-second intervals from square-wave pulse. Biocalibration: assesses the response of the amplifiers, filters, and so forth, to com- plex biologic signals E. Usually made of gold, silver chloride, or other material that does not interact chemically with the scalp; skin is prepared by abrasion to remove excess oils and dead skin containing low levels of electrolytes that may alter impedance; electrode gel (usually NaCl) is used to reduce resistance and improve contact of the electrode to the skin. Localizes epileptiform potentials by amplitude and complexity (sharpness) of the waveform. Rhythm and frequency differ in that rhythm is a subcortical generation (likely thalamus) of continuous activity, whereas frequency describes that rate at a given time for recorded activity. Physiologic artifacts: usually due to movement, bioelectric potentials, or skin resis- tance changes 1. Galvanic skin response: slow waves of 1 to 2 Hz that last for 1 to 2 seconds with two to three prominent phases; represents an autonomic response of sweat glands and changes in skin conductance in response to sensory stimulus or psy- chic event B. External electrical signal: 60-Hz electrical input; factors that reduce 60-Hz artifact: i. Spike-like potentials that occur in random fashion and are caused by sud- den changes in junction potentials ii. Small movements or alterations of the electrode–gel interface may tempo- rarily short out the junction potential, and the sudden change in junction potential is seen in all channels with that electrode in common. Dissimilar metals build up large junction potentials that are discharged into the amplifier. Duration: at least 3 minutes of adequate effort (5 minutes if absence seizure is suspected) b.

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