![]() The combination of headache, papilloedema and vomiting is considered indicative of raised ICP the headache is oftentimes worse on waking, straining and bending. However, management of headache in the acute setting should focus on excluding serious secondary causes, of which raised ICP is one. The majority of patients presenting with headache have primary headaches, with migraine being the most frequent diagnosis. Secondary headaches are a symptom of another disorder. Primary headaches, such as migraine, are usually benign. Headaches are classified as either primary or secondary. Headache is a common symptom associated with many conditions and accounts for up to 5% of attendances to emergency departments and acute medical units. ![]() Suggestions to encourage carrying out fundoscopy included making it a part of the clerking proforma and the delivery of teaching sessions. Respondents ranked readily available ophthalmoscopes as the most likely intervention to encourage them to perform fundoscopy, followed by further knowledge on fundoscopy technique and interpretation of findings. The most frequent reasons given for not performing fundoscopy were: lack of ophthalmoscopes and dilating eyedrops (and / or lack of awareness of their location), insufficient knowledge on fundoscopy technique, and low confidence when interpreting findings. Seventy percent of respondents were not aware of the BASH guidelines. ![]() Nine percent of respondents declared they always perform fundoscopy, 42% sometimes and 49% never. Thirty-three responses to the survey were received. Of the remaining 52/59 (88%) patients who did not have fundoscopy performed, none had it done on the subsequent post take ward round.Furthermore, a survey was emailed to all doctors within the Trust to gather information on their level of awareness of BASH guidelines, whether they perform fundoscopy in patients presenting with headache, what they believed were obstacles and what interventions they felt would help to increase the likelihood of them doing so. Papilloedema is the clue”įundoscopy was performed in the initial acute medical clerking of 7/59 (12%) patients, only one of whom had documentation that their pupils were dilated beforehand. “Fundoscopy plays a crucial role in uncovering a diagnosis of raised ICP. The majority (71%) of clerkings were carried out by junior and senior house officers. Patients’ age ranged from 18 to over 70 years the most numerous age group consisted of patients 70+ years old (27%). ![]() ResultsĪ total of 59 acute medical clerkings with a presentation of headache to our district general hospital between August and October 2017 were reviewed, 38/59 (64%) of whom were female and 21/59 (36%) male. We have therefore sought to assess the compliance of our acute medical department with BASH guidelines, and to bring to light the impediments to delivering appropriate management in patients presenting with headache and suggest improvements. However, studies have revealed that a minority of doctors would perform fundoscopy in such cases. ![]() Papilloedema is optic disc swelling specifically secondary to raised ICP and is a vital clue for accurate diagnosis performing fundoscopy is essential in detecting this sign. įigure 1: Numbers of respondents who perform fundoscopy on a patient presenting with headache.įigure 2: Pie chart showing whether respondents were aware of the BASH guidelines.Ī worrying cause of headache is raised intracranial pressure (ICP). Additionally, The National Institute for Health and Care Excellence (NICE) also advises carrying out fundoscopy as part of a neurological examination for headache, as well as cranial and peripheral nerve examination. The British Association for the Study of Headache (BASH) National Headache Management System for Adults 2019 guidelines recommend a thorough neurological investigation including fundoscopy when assessing a patient with headache. The likelihood of headache sufferers seeking help is low, and when they do, the condition is less than optimally managed. Neurological emergencies, of which headaches account for a significant proportion, are the third leading trigger of acute medical presentations and represent up to 25% of the medical take this is second only to cardiac and respiratory cases. The authors review the use of fundoscopy in their own district general hospital. Papilloedema is a vital clue for accurate diagnosis and performing fundoscopy is essential in detecting this sign. A worrying cause of headache is raised intracranial pressure (ICP). ![]()
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![]() ![]() 6 There is a high incidence of atrial fibrillation in patients with SSS requiring pacemaker, so thrombotic risk must be considered and anticoagulation initiated as indicated. 1Ī prospective multicenter study that examined the 12 months before and after pacemaker placement in 87 patients found a significant decrease in symptoms including syncope and dizziness after pacemaker placement as well a significant decrease in number of falls. 3 Pacemakers have not been shown to reduce mortality in SSS but are associated with decreased symptoms and improved quality of life. 5Īpproximately 30-50% of the pacemakers placed in the United States are for the treatment of SSS. Those who are stable should be monitored with transcutaneous pads in place while arranging definitive care. Transcutaneous pacing is a temporizing measure while arranging to place a transvenous pacemaker. 3 In the acute setting, any unstable patient presenting with findings consistent with SSS should be treated by standard ACLS, considering atropine but not delaying initiation of pacing. 1Īfter ruling out secondary causes including cessation of nonessential medications and monitoring for clearance through 3-5 half lives, 5 SSS in patients with clinical symptoms should be treated by placement of a permanent pacemaker. 3 Medications that affect the atrioventricular node such as beta blockers, calcium channel blockers, digoxin, antiarrhythmics, and acetylcholine esterase inhibitors should be considered as reversible causes of sick sinus syndrome, 2 as should electrolyte abnormalities, hypothyroidism, hyperthyroidism, hypoxia, hypothermia, and toxins. Infiltrative processes or ischemia stemming from coronary artery disease can also affect the function of the sinus node. Sinus node dysfunction may be related to atrial remodeling secondary to aging, heart failure, or atrial fibrillation, or it may be genetic and secondary to ion channel dysfunction. ![]() With an increase in our geriatric population, the prevalence of SSS in the United States is expected to double in the next 50 years. 3 The incidence of SSS increases with age and affects males and females similarly. 2 It is a fairly common condition, particularly in elderly patients with concomitant cardiac disease, and prevalence is high in patients who have an increased BMI or a history of hypertension, diabetes, coronary artery disease, or heart failure.Ībout half of patients with SSS will have a tachycardia- bradycardia syndrome in which they have a rapid heart rate, often atrial fibrillation or atrial flutter, followed by bradyarrhythmia. It is often associated with clinical signs and symptoms including fatigue, lightheadedness, presyncope, syncope, dyspnea on exertion, chest discomfort, or palpitations. 1 This syndrome is diagnosed based on electrocardiographic findings of arrhythmia, such as bradyarrhythmia or sinus pause. Sick sinus syndrome (SSS) is a collection of disorders in which the heart does not successfully perform its pacemaking function. ![]() The decision is made to place an emergent transvenous pacemaker. Seconds later she is again awake and alert, now sinus rhythm in 80s. ![]() Moments later her heart rate decreases significantly, rhythm noted to be a complete heart block followed by asystole (Figure 1) she is unresponsive at this time. Upon arrival to the ED she is noted to be in atrial fibrillation at a rate of 110-120 with a blood pressure of 101/60, complaining of pain of chest and abdomen and dry heaving. EMS reports that upon their arrival she was found to be in atrial fibrillation and subsequently passed out, at which time she was noted to have an asystolic episode of about 4.5 seconds, which self-resolved. Sick sinus syndrome, rather than being a single specific disease, is a collection of disorders that add up to trouble for the sinus node.Ī 78-year-old female with history only of leg edema presents to the ED complaining of nauseaĪnd dizziness for the past few hours. ![]() ![]() ![]() The league rejected the request and instead agreed to award an expansion franchise, the San Jose Sharks, to the Gund brothers. However, by the early 1990s, declining attendance and the inability to secure a new downtown revenue-generating arena led ownership to request permission to move the team to the San Francisco Bay Area in 1990. The merger brought with it a number of talented players, and the North Stars were revived-they reached the Stanley Cup Finals in 1981, where they lost in five games to the New York Islanders. However, the Gunds were the merged team's principal owners, and the North Stars assumed the Barons' place in the Adams Division in order to balance out the divisions. The merged team continued as the Minnesota North Stars, while the Seals/Barons franchise records were retired. With both teams on the verge of folding, the league permitted the two failing franchises to merge. ![]() In 1978, the North Stars merged with the Cleveland Barons (formerly the California Golden Seals), owned by George III and Gordon Gund. When the team moved to Dallas in 1993, it used a similar logo, usually with the word "DALLAS" above "STARS," until 2013. The logo of the Minnesota North Stars from 1991 to 1993. Initially successful both on the ice and at the gate, the North Stars fell victim to financial problems after several poor seasons in the mid-1970s. Home games were played at the newly constructed Metropolitan Sports Center (" Met Center") in Bloomington, Minnesota. The Minnesota North Stars began play in 1967 as part of the league's six-team expansion. In 2010, brothers Derian and Kevin Hatcher were also inducted to the United States Hockey Hall of Fame.įranchise history Minnesota North Stars (1967–1993) In 2009, Brett Hull became the first Dallas Stars player inducted into the Hockey Hall of Fame, followed by Ed Belfour and Joe Nieuwendyk in 2011 and Mike Modano in 2014 Modano is the highest-scoring player in franchise history. In 2000, Neal Broten was inducted into the United States Hockey Hall of Fame. ![]() ![]() Over the course of the franchise's history in both Minnesota and Dallas, the franchise has appeared in the Stanley Cup Finals five times ( 1981, 1991, 1999, 2000, and 2020). The Stars have won eight division titles in Dallas, two Presidents' Trophies as the top regular season team in the league, the Western Conference championship three times, and the Stanley Cup in 1999, where center Joe Nieuwendyk won the Conn Smythe Trophy as the most valuable player of the playoffs that year. The Stars played out of Reunion Arena located in downtown Dallas from their relocation in 1993 until 2001, when the team moved less than 1.5 miles (2.4 km) into the American Airlines Center located in the nearby Victory Park neighborhood of Dallas, an arena they share with the Dallas Mavericks of the National Basketball Association (NBA). Eventually, the franchise relocated to Dallas for the 1993–94 NHL season where the team was rebranded as the Dallas Stars. Before the 1978–79 NHL season, the team merged with the Cleveland Barons after the league granted them permission due to each team's respective financial struggles. They compete in the National Hockey League (NHL) as a member of the Central Division in the Western Conference, and were founded during the 1967 NHL expansion as the Minnesota North Stars, based in Bloomington, Minnesota. The Dallas Stars are a professional ice hockey team based in Dallas. ![]() ![]() ![]() Starfire is an optimistic, eager, fearless girl who loves to see the joy around her (much to the opposite of Raven) and enjoys spreading love and happiness around the Tower. Starfire wears a simple white sheet over her body with holes for eyes made at the top. It is unknown how she learned language until now.Īfter being changed into a child by the Halloween Spirit, Starfire and her friends dress up for trick-or-treating. She couldn't understand English at all for she and Robin haven't kissed each other yet to recognize the language. Her hair was also poofed out and curled, reaching longer than her feet. At that time, she wore a single-piece swimsuit-like clothing, and her armor has more corners than curves. In the flashback when the Titans first formed, Starfire looked exactly the same as her first appearance from the New Teen Titans comic series. Starfire shaved off most of her hair off (which was now black), wore a orange jumpsuit with the sleeves torn off, and had numerous tattoos with buff arms. ![]() When Raven embraces her demon side and starts tormenting her teammates, she gives Starfire huge poofy big blonde hair, much to Starfire's horror.īecause of Starfire's mean older sister, Blackfire, Starfire is sent to space prison and during the course of a few weeks (or days) she changed how she looks. Due to the mask, her hair is fixed into a single ponytail. She wears a black suit with bat ears and a cape with a yellow belt, boots, gloves with a yellow Batman emblem on it. When she and the other Titans visit the Batcave with Robin, she tries on a Batgirl costume, which causes Robin to drool and stare in awe. Her hair is fixed into a single ponytail due to the mask. Unlike her normal attire, this costume is nearly all black with some purple spikes on her neck-plate and gauntlets, and covering most of her body except her arms and face. Starfire once again took up sewing and this time created a legitimate villain costume. Starfire can briefly been seen with two large ponytails, tied with green bows as Pink Raven brushes her hair. Her wristbands and necklace are the same. The outfit consists of a blue headband that covers her eyebrows, a blue top, long white socks with small stripes near the top, and blue shoes. She wears a sports outfit in Artful Dodgers, which is quite similar to her usual outfit. In an attempt to replace her clothes while Raven washed them, Starfire took up sewing and created a beautiful ball gown which she says is hideous. However, when the spell breaks at daybreak, she was eventually turned back to normal. ![]() In Alvin and the Chipmunks: The Left Leg, when Alvin Seville (Justin Long) turned her into a horse, she wears a reddish-pink feather headdress that replacing her long reddish-pink hair and hot pink saddle on her back that replacing her purple midriff shirt. As seen in Dude Relax and Laundry Day, she is seen wearing a pink bathrobe and towel on her head, which indicates that she enjoys wearing pink when relaxing. She has pale orange skin, long reddish-pink hair and green eyes with the sclera of her eyes being light green along with large feminine eyelashes. Starfire wears a light purple two-piece suit, grey gauntlets, and tall purple go-go boots with stars on the soles. Her usual mood is extremely friendly, but she will flip into a rampage if a friend/loved one is in danger or betrayed her. Even though she is often the one to ask the meaning of a word, she is extremely loyal and kindhearted, putting her friends before herself. Starfire reprises her role from the original Teen Titans (Series) as the quirky, compassionate, yet powerful alien of the team. Once she was officially free of the Gordanians, Koriand'r decided to stay on Earth, took the name Starfire (which is what Koriand'r translates to in English), and joined the other heroes in forming the Teen Titans. The Gordanians followed in hot pursuit, but were defeated when Koriand'r was defended by four superpowered teenagers. Koriand'r then managed to escape during space flight and fled to the nearest planet, Earth. ![]() Koriand'r went with them convinced it was for the good of her planet, only to discover Komand'r's treachery and the Gordanians' plan to bring her to their Citadel to live out the rest of her days as a tortured slave. When the powerful Gordanians invaded the planet, her devious sister Komand'r (aka Blackfire), wanting the throne for herself, took the opportunity to convince the Gordanians to capture Koriand'r as Tamaran's soon-to-be-queen, in exchange for peace and her place in the throne. "Starfire is a alien struggling to fit in and learn the ways of Earth while driving Robin insane with unrequited puppy love."Īs revealed in the original series, Starfire was Koriand'r, an alien princess from the planet Tamaran who was in line for the throne. ![]() ![]() ![]() In the second row, a giant check mark and a small arrow tab in the center both reveal a pull-down menu with added filtering options, as well as some stats on the number of blocked items. The upper-right area sports the standard closing and minimizing buttons, as well as a drop-down menu that lives alongside them. 360 is no exception: the interface, menus, and buttons are all bright, clean, and simulates Windows 8's switch-toggle option items. Modern AV programs have been following suit after Windows 8's design makeover by incorporating bright, flat UI elements into their programs. ![]() For the purpose of this review, we chose to opt out of the toolbar and focus on the core 360 IS experience. Again, layering multiple AV programs is generally bad practice, but if used in a corporate environment with preinstalled security software, you might have to take into consideration that 360 IS may not function properly with any neighboring security suites.ģ60 also gives you the option of installing a Chrome extension, but in an unconventional accepting or cancelling call to action. The setup process will then notify you of any potentially conflicting AV programs you have already installed and give you the option of uninstalling them. Still, the opt-out option might appear a bit suspicious, especially for users who are simply trying out the software. And though it's more or less required to move on, those who are more keen on privacy details or interested in the terms of agreement should keep this in mind before they install the software. Prior to installation, 360 will automatically prompt you to agree to their license and usage terms, something that's normally an opt-out process. The installer is a light 17MB, and though the overall installation time and duration was relatively fast, it's update process took longer than we had expected. 360 Internet Security 2013 is anti-virus and anti-malware protection software for Windows PCs. ![]() ![]() ![]() ![]() Adam Smith's own appearance in the game, however, averts this he enables you to build very useful factories in the original or increase your production rates in the remake.Furthermore, the price you get for selling goods is always lower than the price you pay for buying them. Key manufactured goods do get more expensive over time, but this is probably the game's not-so-subtle way to force you to develop your own economy.This game presents examples of the following tropes: In 2008 a remake named Sid Meier's Civilization IV: Colonization came out.There's also an open-source Fan Remake of the game, called FreeCol (you can switch between "Classic" and "FreeCol" rules). Another important feature is that the player can get "founding fathers" like Washington, Cortez or Simon Bolivar, who give unique benefits to your country. To get a productive empire, you need to have a combination of all these specialists. You have lumberjacks, elder statesmen, fishermen, blacksmiths, indentured servants, gunsmiths and tons and tons of other types. However, the main difference with the Civilization games is that your population consists of different specialists. In many regards it resembles its spiritual predecessor, Civilization, as you build cities, grow your population, wage war with other factions and in general guide your faction towards an end goal, in this case independence from the mother land. In Colonization you colonize the New World as either England, Spain, France or the Netherlands. Sid Meier's Colonization is a Turn-Based Strategy game from 1994. ![]() |
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