© 2000 james walker whether one plays mallet instruments with two mallets or four, it is an important but often overlooked issue : what sticking is best for a particular passage? while there usually is more than one solution for a given melodic line, there are factors which one should consider when creating stickings. 1. alternating hands as a starting point a good starting point for creating stickings is alternating hands. the consistent " left - right - left... " pattern lends itself to even articulation and rhythm, whether leading with the left hand or the right. when doubling in either hand, the tendency is for the second note of the doubling to be " ghosted " slightly, played at a lower volume than the first note. 2. adjusting stickings to suit the rhythmic / metric phrasing players of brass instruments will utilize consistent tonguing when articulating similar passages, and this is a concept which may be applied to percussion instruments. consistency of sticking contributes greatly to consistency of sound and phrasing in these two examples : 3. accented patterns or polyphonic textures if a melodic line utilizes accents, or suggests some sort of polyphony ( such as the pedal point shown in the second example here ), one ' s sticking may be altered to suit the line ; assigning all of the accented notes to one hand or the other makes it easier to maintain two separate dynamics levels within a phrase. ( this sort of approach is recommended only if the physical execution of the phrase allows it, as in the examples shown here ; the difficulty of applying this concept to lines which cross above and below each other may negate the benefits. ) 4. optimizing movement around the instrument certain scales and arpeggios lend themselves to playing all notes on the lower manual of the mallet instrument ( same as the white keys of a piano ) with one hand, and all notes on the upper manual ( the black keys of a piano ) with the other. while this approach incorporates the challenge of executing double stickings evenly, that challenge is balanced against the minimized arm movement required to execute a line. in the diagrams here, note how much less motion away from and towards the player ' s body, is involved when one utilizes this upper manual vs. lower manual approach. while there often is more than one acceptable sticking for a given passage, there are certain factors one should address when making these decisions. eventually, these concepts become internalized, and one instinctively selects an appropriate sticking for a given phrase. ( this page and all


» ( v, 2 ) claudius : « … then, venom, to thy work, » ( v, 2 ) laertes : « they bleed on both sides … » ( v, 2 ) polonius : « … dead for a ducat, dead, » ( iii, 4 ) ophelia : « what the fair ophelia! » ( v, 2 ) at one point hamlet was so mad and depressed he wanted to kill himself. « to be, or not to be, that is the question … » ( iii, 1 ) the worst possible thoughts that hamlet could have ever thought, he thought incestuously about his mother and himself. he never said that he wanted to be with his mother, but he was just mad that claudius took the throne from him at the beginning of the play, not that his father was dead. hamlet complained about gertrude and claudius incestuous acts, but rarely mentioned his father until towards the end of the play. hamlet was a very selfish man. he talked to his mother like a son shouldn ' t talk to his mother ; « come, come, and sit you down … » ( iii, 4 ) « … here ' s metal more attractive. » ( iii, 2 ) hamlet cared about himself more than anyone else. when his childhood friends rosencrantz and guildenstern were executed he felt no remorse even though it was his fault ; « he should the bearers put to sudden death, not shriving - time allow ' d. » ( v, 2 ) hamlet thinks that everyone should grieve for his father as long as he does. it had been at least a month and there was a party going on and he thought it was wrong ; « the king doth wake tonight and takes his rouse … » ( i, 4 ) hamlet is intelligent, mad, and selfish. hamlet was the cause of ophelia ' s death because she just gave up on life. hamlet was intelligent enough to hide his pain and grieving about his father at the beginning well. hamlet was mad because he had only one person he could trust and that was horatio. please do not pass this sample essay as your own, otherwise you will be accused of plagiarism. our writers can write any custom essay for you! english – hamlet ' s maddness hamlet appears to be insane, after polonius ’ s death, in act iv scene ii. there are indications, though, that persuade me to think other wise. certainly, hamlet has plenty of reasons to


! english – hamlet ' s maddness hamlet appears to be insane, after polonius ’ s death, in act iv scene ii. there are indications, though, that persuade me to think other wise. certainly, hamlet has plenty of reasons to be insane at this point. his day has been hectic — he finally determined claudius had killed his father, the chance to kill claudius confronted him, tragedy in hamlet the tragedy in hamlet lies in the fact that hamlet, the hero was human and was violently wronged and was justified in seeking revenge. hamlet the play is a tragedy, and hamlet the character is the tragic hero of the play. hamlet, like all tragic heroes, brings out feelings of pity and fear from the hamley was not looney toones hamlet was indeed a very sane man. he was only feigning madness to further his own plans for revenge. his words were so cleverly constructed that others will perceive him as mad. it is this consistent cleverness that is the ultimate evidence of his complete sanity. can a mad person be so clever? no, a hamlet : in his right mind ’ s eye crazy, or not crazy - that is the question. the matter of hamlet ' s so called madness, has been an item of debate since the first performance, and will probably be a continuing argument well into the future. i believe hamlet was not crazy, because he proves to be in complete control of his psyche in a critical analysis of shakespeare ' s hamlet dave beaston. hamlet. is he an insane madman or a revengeful, scheming, genius? there are many conflicting ideas and theories on this subject, and hopefully this paper may be of some assistance in clearing up the confusion. the paper is divided into three separate analytic sections beginning with the beginning of hamlet ' s so called madness, need book reports, essays, lectures? save to bookmarks - » the mad hamlet. collections of essays on literature!


tools and materials - paper clay - black permanent marker ( optional ) - bowl with round bottom - toilet paper roll note : if you don ' t have a bowl with a perfectly round bottom, place cotton on the bottom of a flat - bottomed bowl, then cover with plastic wrap to create a perfectly round work surface for the igloo. polar bear how - to - starting with a golf ball - size ball of clay, use palms to roll clay into a teardrop shape. hold in palm and press side of pointer finger into teardrop vertically, leaving a little bit of clay untouched at the tapered top ( this will be the head ). - press side of pointer finger into clay horizontally, one third of the way down from the tapered top, to create a cross. - pinch each quadrant divided by the cross to create four legs. to make a tail, push the clay up on bear ’ s backside. - if you want your bear to sit, place the bear ' s backside down on table and push head downward. if you want it to stand on all fours, place legs on table and push head upward. use a finger dipped in water to smooth out any imperfections. - to create ears, place two tiny balls of clay on head ; smear back of ear with finger to attach. - place a pencil under the arms to hold the shape ; let dry. add eyes with a black permanent marker, if desired. - tuck in an edge of a toilet paper roll so it sits flush against the bowl ; attach to bowl with tape. - roll out a thin layer of clay. drape clay over bowl and press around form. - create " blocks " using the handle of a paintbrush, starting from the top and working your way down. let dry. paper clay by creative paperclay co.


| | this article needs additional citations for verification. ( march 2010 ) | the rugby football league championship was the major professional competition organized by the rugby football league in great britain. in 1996 it was superseded by the super league and the rugby league national leagues. winning super league is still regarded as winning the championship, hence for completeness this article includes championships from the super league era. the first season of rugby league ( 1895 – 96 ) saw all the breakaway clubs play in a single league competition. the addition of new teams and the problems of travelling led to the league being split in two for the following season ; into the yorkshire league and the lancashire league. this arrangement lasted until the 1901 - 02 season, when the top clubs from each league resigned and formed a single new competition. the following season the remaining clubs in the yorkshire and lancashire leagues were re - organized to form a second division. in 1905 - 06 the two divisions were re - combined into a single competition. clubs played all the teams in their own county on a home - and - away basis, results counting towards the re - formed yorkshire and lancashire leagues. they also organized inter - county fixtures on an individual basis ; all results were collated into a single table for the championship. in order to even up the competition a top - four play - off series was used to determine the championship. apart from the interventions of the world wars, this system was retained until the 1962 - 63 season, when the league briefly returned to a two divisional system. this lasted only two years, and in the 1964 - 65 season they returned to one large division subdivided into county leagues. the play - off were expanded to the top 16 teams. in the 1973 - 74 season they once again went back to two divisions. the play - off and the yorkshire and lancashire league were abandoned, and a new play - off type competition, the premiership, was introduced. | season | | champions | | titles | | decided by | | source | | 1896 – 01 | | separate county leagues | | n / a | | n / a | | 1903 – 04 | | bradford fc | | 1 | | league ( play - off ) | | 1915 – 19 | | no competition due to world war i | | n / a | | n / a | | 1922 – 23 | | hull kingston rovers | | 1 | | play - off | | 1924 – 25 | | hull kingston rovers | | 2 | | play - off | | 1939 – 45 | | war emergency league during world war ii | |


1922 – 23 | | hull kingston rovers | | 1 | | play - off | | 1924 – 25 | | hull kingston rovers | | 2 | | play - off | | 1939 – 45 | | war emergency league during world war ii | | n / a | | n / a | | 1978 – 79 | | hull kingston rovers | | 3 | | league | | 1983 – 84 | | hull kingston rovers | | 4 | | league | | 1984 – 85 | | hull kingston rovers | | 5 | | league | note bold donates club winning challenge cup in the same season ; thus completing the championship and challenge cup ' double '. as of the 2012 season, three of the fourteen clubs participating in the super league have never won the rugby football league championship or super league, they are ; castleford tigers, catalans dragons, london broncos. as of the 2012 season, twelve clubs not currently participating in the super league have won the rugby football league championship. the five, of the twelve, clubs with pre - world war ii ( wwii ) rugby football league championship wins are ; batley ( 1 ), bradford fc ( now the association football club bradford park avenue a. f. c. ) ( 1 ), broughton rangers ( now defunct ) ( 1 ), hunslet ( 2 ), manningham ( now the association football club bradford city ) ( 1 ). the four, of the twelve, clubs with both pre - and post - wwii rugby football league championship wins are ; halifax ( 4, i. e. 2 pre - & 2 post - wwii ), leigh ( 2, i. e. 1 pre - & 1 post - wwii ), oldham ( 4, i. e. 3 pre - & 1 post - wwii ), swinton ( 6, i. e. 4 pre - & 2 post - wwii ). of these twelve former rugby football league championship winning clubs, only four have ever participated in the super league, they are ; halifax, leigh, oldham, workington town, all of whom have had post - wwii wins. of these twelve former rugby football league championship winning clubs, none have been granted super league 2012 licences, and are therefore precluded from the super league for the foreseeable future. | 1 | | wigan | | 19 | | 1908 / 09, 1921 / 22, 1925 / 26, 1933 / 34, 1945 / 46, 1946 / 47, 1949 / 50, 1951 / 52, 1959 / 60, 1986 / 87, 1989 / 90,


wigan | | 19 | | 1908 / 09, 1921 / 22, 1925 / 26, 1933 / 34, 1945 / 46, 1946 / 47, 1949 / 50, 1951 / 52, 1959 / 60, 1986 / 87, 1989 / 90, 1990 / 91, 1991 / 92, 1992 / 93, 1993 / 94, 1994 / 95, 1995 / 96, 1998, 2010 | | 2 | | st. helens | | 12 | | 1931 / 32, 1952 / 53, 1958 / 59, 1965 / 66, 1969 / 70, 1970 / 71, 1974 / 75, 1996, 1999, 2000, 2002, 2006 | | 3 | | leeds | | 9 | | 1960 / 61, 1968 / 69, 1971 / 72, 2004, 2007, 2008, 2009, 2011, 2012 | | 4 | | huddersfield | | 7 | | 1911 / 12, 1912 / 13, 1914 / 15, 1928 / 29, 1929 / 30, 1948 / 49, 1961 / 62 | | 5 | | swinton | | 6 | | 1926 / 27, 1927 / 28, 1930 / 31, 1934 / 35, 1962 / 63, 1963 / 64 | | 6 | | salford | | 6 | | 1913 / 14, 1932 / 33, 1936 / 37, 1938 / 39, 1973 / 74, 1975 / 76 | | 7 | | hull | | 6 | | 1919 / 20, 1920 / 21, 1935 / 36, 1955 / 56, 1957 / 58, 1982 / 83 | | 8 | | bradford northern / bulls | | 6 | | 1979 / 80, 1980 / 81, 1997, 2001, 2003, 2005 | | 9 | | hull kr | | 5 | | 1922 / 23, 1924 / 25, 1978 / 79, 1983 / 84, 1984 / 85 | | 10 | | oldham | | 4 | | 1904 / 05, 1909 / 10, 1910 / 11, 1956 / 57 | | 11 | | halifax | | 4 | | 1902 / 03, 1906 / 07, 1964 / 65, 1985 / 86 | | 12 | | warrington | | 3 | | 1947 / 48, 1953 / 54, 1954 / 55 | | 13 | | widnes | | 3 | | 1977 / 78, 1987 / 88, 1988 / 89 | | 15 | | wakefield trinity | | 2 | | 1966 / 67, 1967 / 68 | note. in the event of a tie, the team that won x amount of titles first is given preference. in rugby league, the term ' the double


history of the mapping of new england in new england begins with a controversy. in 1677, two editions of william hubbard ' s narrative of the troubles with the indians appeared in printthe first issued in boston and another, within a few months, released in london. each book included a map, both entitled a map of new - england, but varying in some particulars. most prominently, in the american printing the white hills of new hampshire are labeled as such ; in the english version, they carry the name " wine hills. " boston release was, apparently, the first map published in the english colonies of north america and probably the first map published in the western hemisphere. historians attribute the piece to john foster, the printer responsible for the american edition of hubbard ' s narrative and also, most likely, the only engraver working in boston at that time. the two versions of the map have perplexed bibliographers for more than a century. map collectors and historians of printing continue to puzzle over the exact chronology of the printing and the question of authorshipspecifically, whether john foster engraved both versions. massachusetts historical society owns copies of the american and english printings of a map of new - england. its copy of the " white hills " map is unique in that it contains a symbol for an unnamed town ( at the lower left corner of the map between " seaconk " and " plimouth " ) that appears on no other surviving copy of this version. mhs collections include more than 5, 000 historical maps and charts, 200 early atlases that contain separately printed maps, and many early printed books illustrated with maps.


jc virus ( jcv ) detection by in situ hybridization clinical information discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test jcv was isolated from brain tissue of a patient with progressive multifocal leukoencephalopathy ( pml ), a rare, demyelinating, fatal disorder of the central nervous system which occurs on a background of immune deficiency. pml occurs as an infrequent complication of a wide variety of conditions, including : lymphoproliferative disorders such as hodgkin ' s disease, chronic lymphocytic leukemia, and lymphosarcoma ; chronic diseases such as sarcoidosis and tuberculosis, and primary immunodeficiency diseases. pml has also been recognized as a frequent complication of the aids. most cases of pml, not associated with aids, occur in middle age or later life, but the disease may occur in an immunocompromised individual of any age and has been recognized in young children with immunodeficiency diseases. jcv also infects humans in childhood and is present in most of the world ' s population. it is the etiologic agent of pml. clinically, signs and symptoms of asymmetric multifocal brain disease without signs of increased intracranial pressure in a person who is immunocompromised would suggest the diagnosis of pml. computed tomographic scan or magnetic resonance imaging of the brain is effective in establishing the diagnosis of pml in a noninvasive manner. the unique histopathologic features of pml can be identified by light microscopy of a brain biopsy specimen. jcv can be cultivated in cell cultures, and serologic assays have have been developed, but nucleic acid detection methods are much more sensitive and rapid for making the laboratory diagnosis of pml using brain tissue. confirming a clinical and histopathologic diagnosis of progressive multifocal leukoencephalopathy ( pml ) ; especially helpful when only a small piece of biopsy material is available " positive for polyomavirus ( jc virus ) " indicates the presence of infection with jcv. " negative for polyomavirus ( jc virus ) " indicates the absence of cells infected with jcv. a negative result is normal. cautions discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances prolonged formalin fix


##virus ( jc virus ) " indicates the absence of cells infected with jcv. a negative result is normal. cautions discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances prolonged formalin fixation may cause false - negative results. a few weeks appears to be the maximum time of fixation. submitted specimens will be screened by a pathologist to determine the acceptability of the specimen for the test. slides must be specially prepared, therefore, a paraffin - embedded, formalin - fixed tissue must also be submitted. reference values describes reference intervals and additional information for interpretation of test results. may include intervals based on age and sex when appropriate. intervals are mayo - derived, unless otherwise designated. if an interpretive report is provided, the reference value field will state this. this test, when not accompanied by a pathology consultation request, will be answered as either positive or negative. if additional interpretation / analysis is needed, please request 5439 surgical pathology consultation along with this test. clinical references provides recommendations for further in - depth reading of a clinical nature 1. aksamit aj, mourrain p, sever jl, major eo : progressive multifocal leukoencephalopathy : investigation of three cases using in situ hybridization with jc virus biotinylated dna probe. ann neurol 1985 ; 18 : 490 - 496 2. telenti a, aksamit aj jr, proper j, smith tf : detection of jc virus dna by polymerase chain reaction in patients with progressive multifocal leukoencephalopathy. j infect dis 1990 ; 162 : 858 - 861 3. aksamit aj jr : nonradioactive in situ hybridization in progressive multifocal leukoencephalopathy. mayo clin proc 1993 ; 68 : 899 - 910


mammograms : what every woman needs to know this year, more than 192, 000 women will be diagnosed with invasive breast cancer. more than 40, 000 women will die of the disease, according to the american cancer society ( acs ). except for skin cancer, breast cancer is the most common cancer among women. mammograms can detect many breast cancers before anyone can feel them. when breast cancer is found in its earliest stages, the majority of patients survive for at least five years. the benefits and limitations of mammography vary based on factors like age and personal risk. experts have different recommendations for mammography. currently, the u. s. preventive services task force ( upstf ) recommends screening every two years for women ages 50 to 74. the acs recommends yearly screening for all women ages 40 and older. women should talk with their doctors about their personal risk factors before making a decision about when to start getting mammograms or how often they should get them. the acs recommends clinical breast exams ( cbes ) at least every three years for all women in their 20s and 30s and annual cbes for women ages 40 and older. the uspstf, however, believes there is not enough evidence to assess the value of cbes for women ages 40 and older. women should talk with their doctors about their personal risk factors and make a decision about whether they should have a cbe. what is a mammogram? this low - dose x - ray produces an image of the inner structures of the breast. it can detect tiny calcium deposits or microcalcifications that are too small to feel. most of these deposits are benign, but sometimes - - especially when in clusters - - they may be an early sign of breast cancer. preparing for the exam if you ' ve never had a mammogram, you may be nervous about it. knowing what to expect and how to prepare for the exam may help ease your concerns. try these tips : if your breasts are sensitive before and during menstruation, schedule your mammogram the week after your period. on the day of your appointment, wear a shirt and bra that you can remove easily because you ' ll need to undress from the waist up. don ' t wear deodorant, powder, or lotion, which can affect your x - rays. if you ' ve had a mammogram before but at a different facility, arrange in advance to have the most recent x


. don ' t wear deodorant, powder, or lotion, which can affect your x - rays. if you ' ve had a mammogram before but at a different facility, arrange in advance to have the most recent x - ray sent to your current facility. your health care provider will want to check for changes since your last screening. during the mammogram a technician will help position your breast on a platform. the technician will take two x - rays for each breast, each from a different angle. the machine will compress your breast to get a clear picture of as much tissue as possible, including the armpit. this process lasts just a few seconds. having your breast flattened may be uncomfortable, but it shouldn ' t hurt. the machine can be adjusted, so tell the technician if you experience any pain. after the exam you may receive your mammogram results that day, or the results may come in the mail within 15 to 20 days ; all mammogram facilities are now required to send your results to you within 30 days. a copy of the report also will go to your doctor. follow up with him or her if you haven ' t been contacted in more than a month. do not presume that no news is good news. call your physician ' s office and ask for the result of the report. if your results show an area of concern, don ' t panic : approximately 80 percent of breast lumps are not cancerous. other tests, such as a diagnostic mammogram that takes more x - rays, or a biopsy, can help your doctor determine the cause.


phosphatase is an enzyme that is primarily made in the liver and bone while other organs such as the kidneys and intestines also contribute to its production to a smaller degree. the enzyme is also created by the placenta of pregnant women usually in their third trimester. while normal values of alkaline phosphatase may vary from lab to lab, the generally accepted levels read at between 30 and 126 nits per liter of blood in adults and between 30 to 300 units per liter in children. children would usually have higher levels of alkaline phosphatase than adults because of continuing bone growth. alkaline phosphatase comes in many different forms, depending largely on the area of the body and organ in which they are produced. alkaline phosphatase isoenzyme tests will help measure the amounts of different types of alkaline phosphatase present in the blood. this test is also regularly ordered if the doctor is unaware of the exact reason for an increase in the alp levels of the body. any evidence of liver disease along with high alp levels will be the sign of blocked bile ducts. very often, one will also see that individuals affected by cancer that has spread to the liver or bones will have higher levels of alp and these tests can help doctors identify if this has happened. isoenzymes of alkaline phosphatase tests are performed to help diagnose conditions such as liver disease, parathyroid disease, vitamin d deficiency, bone disease and upper abdominal pain. it is also usually administered to identify the amount of damage being caused to your liver by consuming certain medications. a high reading of alp levels could be an indicator for a number of conditions such as rickets, leukemia, bone disease, hepatitis, anemia, thyroid gland inflammation and hepatitis amongst a host of others. low levels may be an indicator of protein deficiency, poor nutrition, too much vitamin d or too little vitamin c. since the test is usually performed with a routine blood test, there is usually no special preparation required. however, you may be instructed to avoid eating anything for about 10 to 12 hours prior to the isoenzyme of alkaline phosphatase test as the alp levels tend to be higher after eating. also inform your doctor about any medication you are taking, prescription or non prescription as they do tend to affect the readings of your test. like most blood test, isoenzymes of alkaline phosphatase tests


- organize and conduct two impressive opening and closing ceremonies for your ship. - submit an essay of 500 to 1, 000 words on how our nation ' s maritime history has contributed to our way of life. - active membership - attend at least 75 percent of your ship ' s meetings and special activities for one year. note : check with your ship ' s yeoman. - prepare and present a program on sea scouts for a boy scout troop, venturing crew, venturing officers ' association meeting, school class, or other youth group. your presentation should last a minimum of 15 minutes and describe the activities of your ship and sea scouts. either serve and fulfill the responsibilities of a crew leader or an elected officer of your ship, or serve as an activity chair for two major ship events. responsibilities should include planning, directing, and evaluating the event. ( these events are in addition to the ordinary requirement. ) pass all requirements for the bsa ' s lifesaving merit badge. - develop and use a customized vessel safety checklist for a boat used by your ship. - demonstrate your understanding of fire prevention on vessels. - know the classes of fires and the substances that will extinguish each type of fire. - in a safe place, under adult supervision, demonstrate your ability to successfully extinguish a class a and a class b fire with an approved fire extinguisher. see that the fire extinguisher used is properly recharged or replaced. - conduct a fire safety inspection of the vessel normally used by your ship or of your ship ' s meeting place. note any fire hazards and report them to your ship ' s adult leaders. - complete the american red cross standard first aid course. - obtain cpr certification from a certified agency. - demonstrate the heimlich maneuver and tell when it is used. - marlinspike seamanship - complete a back splice, eye splice, short splice, long splice, and a palm - and - needle whipping. - sew a flat seam, round seam, and grommet eye in canvas or sail material. describe how each is used in construction of and the care of sails. - describe the parts of a block and explain how blocks are sized. describe the following types of tackle : luff, gun, double purchase, single whip, and runner. with the help of another shipmate, reeve a double purchase tackle. - boat handling - demonstrate your ability to properly operate a small boat equipped with a motor. included should be fueling


a known object using " double the angle on the bow " and explain how to set a danger angle. - discuss how gps ( global positioning system ) operates and the purpose of waypoints. while underway, demonstrate your ability to use a gps using three different waypoints. - discuss the method of establishing a radar fix. - practical deck seamanship - demonstrate your knowledge of personal safety equipment needed while cleaning, maintaining, or repairing your vessel. - know the names, uses, sizes, and proper care of the common hand tools used by your ship. - identify and explain the use of the following : thimble, shackle, turnbuckle, pelican hook, and other ship ' s hardware and fittings commonly used aboard your ship ' s vessels. describe how each is sized. - demonstrate proper surface and coating preparation, coating techniques, care of stored coatings, and cleaning of brushes and tools used to maintain surfaces on your ship ' s vessel. - explain techniques used for the maintenance, protection, and repair of hulls and decks on your ship ' s vessel. - demonstrate your knowledge of local environmental laws related to the proper storage, disposal, and cleanup of maritime coating materials, fuels, and other environmentally sensitive materials. - discuss with an adult leader the dumping of garbage in the marine environment. review the contents of the marpol placard and locate it aboard your ship ' s vessels. - write a 500 - word report on a marine endangered species ( mammal, bird, fish, or reptile ). the report should include a description of the species, its habitat, history, current population numbers, and current steps being employed to help earn the long cruise badge. - electives - do any three of the following. - sailing : while leading a crew of not less than two other persons, demonstrate your ability to sail a sloop or another suitable vessel correctly and safely over a triangular course ( leeward, windward, reaching marks ), demonstrating beating, reaching, running, and the proper commands. - vessels : teach and lead a crew under oar using a boat pulling at least four oars single - or double - banked. perform the following maneuvers : get underway, maneuver ahead and back, turn the boat in its own length, dock, and secure. - drill : demonstrate your ability to give and execute commands in close - order drill. - understand the safe and proper procedures for the use of gasoline and diesel inboard engines, including fueling, pre - start checks, ventilation, starting, running, periodic


drill : demonstrate your ability to give and execute commands in close - order drill. - understand the safe and proper procedures for the use of gasoline and diesel inboard engines, including fueling, pre - start checks, ventilation, starting, running, periodic checks while running, securing, postoperative checks, and keeping an engine log. - using the type of engine aboard the vessel you most frequently use, demonstrate your understanding of basic troubleshooting and the preventive maintenance schedule recommended by the manufacturer. - yacht racing : - demonstrate your understanding of the shapes, flag hoists, gun, and horn signals used in yacht racing as well as a working knowledge of the racing rules of the international sailing federation. - serve as helmsman, with one or more additional crew members, of a sloop - rigged or other suitable boat with a spinnaker in a race sailed under isaf racing rules. - maritime history : know the highlights of maritime history from the earliest times to the present. include the evolution of vessel construction and propulsion, important voyages of exploration and development, the origin of maritime traditions, and the achievements of notable maritime leaders in u. s. sea history. - ornamental ropework : demonstrate your ability to fashion the following items of ornamental ropework : four - strand turk ' s head, coach whipping, cockscombing, round braid, flat sennit braid, wall knot, and crown knot. make a useful item such as a boatswain ' s lanyard, rigging knife lanyard, bell rope, etc., or decorate a portion of your ship ' s equipment such as a stanchion, rail, lifeline, tiller, etc. - fiberglass repair and maintenance : demonstrate your proficiency and knowledge of fiberglass repair and gel coating while working on your ship ' s vessel or other similar vessel. - specialty proficiency : become a certified scuba diver or become proficient in boardsailing, surfing, kayaking, or whitewater rafting / canoeing. - usps : as an apprentice member of the united states power squadrons complete the seamanship and piloting courses. the text of these requirements is locked and can only be edited by an administrator. please note any errors found in the above requirements on this article ' s talk page.


| basic informationmore informationlatest news | 1 in 5 u. s. kids has a mental health disorder : cdcschool - based smoking prevention programs workbrain anatomy in dyslexics varies by gender, study findseven mild iodine deficiency can affect child ' s cognitionmany u. s. kids victims of violence, abuse : surveymore time in gym class equals stronger kidsmagnesium - rich food may help keep kids ' bones stronggasoline poisonings in kids spike during summer : studypas : children with strep don ' t need to toss toothbrushesmany parents texting, phoning while driving their kids : surveymany suicidal kids have access to guns at home : studymore kids diagnosed with mental health disabilities, study finds1997 to 2011 saw increase in allergies among u. s. childrenpreordered school lunches may be healthier, study findsat - home drug errors common for kids with cancer, research showsfood, skin allergies on the rise among children : cdcmore than 4, 000 u. s. kids hurt each year on amusement ridesfda concerned caffeinated foods could harm childrensecondhand smoke tied to lower ' good ' cholesterol in teen girlschild fruit consumption up with pre - slicing in schoolsallergies : as american as apple pie? why johnny can ' t add, even after tutoringpoor parenting styles linked to bullying behavior in kidsimpact of childhood bacterial meningitis lasts into adulthood ' clean your plate ' orders from parents may backfire for kidspopular cinnamon stunt can have serious lung effectsamssm : cognitive effect of concussion lasts in childrenmany parents text, phone with kids in car : surveymigraines in children linked to infantile colichelping children make sense of the senselesssocial networks affect parents ' vaccination decision - makinghealth tip : what ' s keeping your child awake? parenting magazines give little attention to sun protectionsleep apnea tied to behavioral, attention problems in youthsparents ' military deployment takes toll on kids, study findsmental health care lacking for kids, advocates saydespite big progress, many kids have high lead levels in bloodmelanoma rates rising in u. s. childrenhigher activity levels may protect children from stressmanagement of short stature in childhood discussedcertain parents less likely to follow doctors ' advice : pollu. s. agency puts poison prevention in spotlightantipsychotic drug use


s. childrenhigher activity levels may protect children from stressmanagement of short stature in childhood discussedcertain parents less likely to follow doctors ' advice : pollu. s. agency puts poison prevention in spotlightantipsychotic drug use rising for kids on medicaid, study findspicky eating in youngsters might be largely caused by genesgene mutations appear key to childhood leukemia risk, study saysblack children less likely to get antibiotics : studyparents ' worries about hpv vaccine on the rise : studyknow what ' s in your child ' s medications, fda warnsavoiding scary situations may leave kids more anxious : studyhealth tip : protect kids from stresslinks health tip : giving your child medicine by - - diana kohnle updated : jul 5th 2012 ( healthday news ) - - even over - the - counter medicine can hurt your child if given incorrectly. the american academy of family physicians offers this advice when giving your child an over - the - counter medication : - always read the drug ' s label and make sure you understand it. - use a medication that treats only the symptoms your child has. - carefully read the label, looking for any special instructions or the names of other medications that might negatively interact with the one you ' re giving. - make sure all caregivers know how much medication your child needs, and how and when to give it. - keep a medication in its original packaging, so that you have easy access to the label and expiration date. - store any medication safely out of a young child ' s reach. this article : copyright © 2012 healthday. all rights reserved.


i started a new unit in geometry - parallel and perpendicular lines. i started with a card sort. i numbered the back of the page going across 1 - 12. then i copied each page on a different color of card stock and cut those in half. i passed it out to the students and had them cut out the individual squares. ( yay for student labor! ) unfortunately, when they cut, the numbers were cut in half which posed some problems. maybe you should have students number them after they cut? not sure what happened on my end. i asked students to sort into groups. some students sorted the ones with fractions, parentheses, and neither. i ' m sure you will see a wide variation. the first hint i gave was that students should have three groups. they resorted and i went back around the room to observe. next, i told them they would have one group of six and two groups of three. from here, almost everyone had their cards in the correct group. i displayed this slide to make sure everyone had the correct groups. a few students recognized that the one group of six were in slope - intercept form. yay for algebra i. i asked them to put those six cards back into their envelope. then i passed out this worksheet and asked students to write in the equations on the cards onto the worksheet and solve for y. they did okay at this. after they were done i told them to get the six back out of the envelope because these were the answers to the top of their worksheet. see what i did there? from there we went to the bottom half of the worksheet which was graphing lines on the calculator. then on the back we worked down each column individually. we solved a pair of equations for y. we graphed. we noticed both lines were parallel. we compared the equations. oh my, they have the same slope! we did this three times and summarized that all parallel lines must have the same slope.


from the colorful, often dickensian image of unaccompanied, soot - smudged children ( aka urchins, ragamuffins, gamins, guttersnipes, street rats, or lil ’ imps ) roaming the streets of 19th - century industrial cities to contemporary reports of meninos de rua ( street children ) in rio de janeiro, throwaway kids in american urban centers, and youth displaced by civil war in sierra leone, prematurely emancipated children remain a distressing sociological phenomenon — and a compelling cinematic subject. the moving picture also developed as a product of industrial innovation in the late 19th century, and the medium used daily life as inspiration for the earliest actualites and narrative films. not only did the motion picture capture the derelict sociological status of youth emancipated by choice or fate, the camera also recorded children at play, at school, pursuing physical education, and creating youth - centric cultures. in the cinema, children are often positioned as taciturn witnesses to trauma and domestic events ; sometimes they emerge with their psyches intact and sometimes they don ’ t. the works selected for this exhibition — drawn primarily from moma ’ s collection — trace the image of the emancipated child, as central subject, as witness, and sometimes as catalyst for change. organized by anne morra, associate curator, department of film. image : hollow city. 2004. angola. directed by maria joao ganga


it is assumed that the romans quarried stone here as they did for lead on the mendips. the pennant sandstone in nailsea, portbury and many areas of bristol gave rise to coal mining which flourished locally for some four hundred years. the earliest date for coal mining in nailsea is 1507 when coal was being transported to fire the limekiln at yatton. at this period the coal would only have been mined where it outcropped near the surface, but by the mid nineteenth century the golden valley pit operated at a depth of six hundred and twenty feet. whilst some seams were up to three feet six inches thick, others were only eighteen inches and barely viable. the last pit closed in 1882 in the face of competition from larger mines in south wales and the north of england where the coal was easier and cheaper to extract. several examples of winding and pumping houses remain, three as ruins, two as conversions into dwellings. the most obvious is the small winding tower and horse whim in the millennium park, but of national importance is the middle engine pit complex in golden valley, now a scheduled monument. the abundance of good quality coal attracted a glassworks to nailsea in 1788. in the 18th and 19th century nailsea was a substantial producer of glass and gave its name to a particular type of coloured glass which has become highly sought after by collectors around the world. ( there is a fine collection of nailsea glass on display at clevedon court – a national trust property about 3 miles from nailsea ). established on the open heath against the nailsea / wraxall border, john robert lucas initially built two cones – one for bottle making, the other for the production of window glass for the so - called industrial revolution. his works became the fourth largest glassworks in britain covering some six acres between the royal oak public house and nailsea park. crown, cylinder and plate glass were produced, along with a limited amount of coloured. however, it was the ' end of shift ' domestic ware and novelty pieces made by the skilled and apprentice blowers that have accorded nailsea glass its international recognition. when the glassworks closed in 1873, and the last mine within the following ten years, most of the skilled workers moved away and nailsea reverted to a largely agricultural community as well as having a vibrant cider making industry. after the initial decline in the population, it remained fairly static until the middle of the last century. in the late 1950 ', nailsea, a village which had inherited an unusually large population


january 4, 2007 there has been a lot of misinformation shared around the country about mental health screening and the teenscreen program since the release of president bush ’ s new freedom commission report in 2003 that recognized the columbia university teenscreen program as a model program. recently the new england journal of medicine published an article on mental health screening that discusses the merits of mental health screening. the columbia university teenscreen program is a national mental health and suicide risk screening program for youth. the goal of the national teenscreen program is to make voluntary mental health check - ups available for all american teens. teenscreen works by assisting communities throughout the nation with developing locally operated and sustained screening programs for youth. screening can take place in schools, doctors ’ offices, clinics, youth groups, shelters, and other youth - serving organizations and settings. the study in the new england journal of medicine is an examination of issues regarding teen mental health and suicide, written by dr. friedman. the article outlines a rationale for screening programs, gives a historical perspective, examines statistics, and offers the personal experiences of actual teens and their parents. read the full story from the new england journal of medicine. ( opens in a new window ) learn more about the teenscreen program at columbia university. ( opens in a new window )


the following html text is provided to enhance online readability. many aspects of typography translate only awkwardly to html. please use the page image as the authoritative form to ensure accuracy. climate stabilization targets : emissions, concentrations, and impacts over decades to millennia 4. 9 ocean acidification the oceanic uptake of excess atmospheric carbon dioxide alters the chemistry of seawater, which may impact a wide range of marine organisms from plankton to coral reefs ( doney et al., 2009a, b ; nrc, 2010 ) ( see also section 6. 3 ). ocean acidification is in fact a series of interlinked and wellknown changes in acid - base chemistry and carbonate chemistry due to the net flux of co2 into surface waters ( figure 4. 26 ). the chemical shifts include increases in the partial pressure of carbon dioxide ( pco2 ), the concentration of aqueous co2, and the hydrogen ion ( h + ) concentration and decreases in ph ( ph = – log10 [ h + ] ). the increase in hydrogen ion concentration acts to lower the concentration of carbonate ions ( co32 – ) through the reaction h + + co32 – = > hco3 –, even though the total amount of dissolved inorganic carbon ( dic ) goes up ( dic = [ co2 ] + [ hco3 – ] + [ co32 – ] ). declining co32 – in turn lowers calcium carbonate ( caco3 ) mineral saturation state, ω = [ ca2 + ] [ co32 – ] / ksp, where ksp is the thermodynamic solubility product that varies with temperature, pressure, and mineral form. ocean surface waters figure 4. 26 schematic indicating the effects on seawater carbonate chemistry due to the uptake of excess carbon dioxide ( co2 ) from the atmosphere. ocean acidification causes increases in some chemical species ( red ) and decreases in other species ( blue ). ocean acidification also causes a reduction in ph ( ph = – log10 [ h + ] ) and the saturation states, ω, of calcium carbonate minerals in shells and skeletons of planktonic and benthic organisms and in carbonate sediments. on millennial and longer time scales, ocean ph perturbations are buffered by external inputs of alkalinity, denoted by calcium ions ( ca2 + ) and changes in the net burial rate of carbonate sediments.


nasa ' s nuclear spectroscopic telescope array, or nustar, is now perched atop its pegasus xl rocket, strapped to the plane that will carry the mission to an airborne launch. launch is scheduled for june 13, no earlier than 8 : 30 a. m. pdt ( 11 : 30 a. m. edt ). the plane - - the l - 1011 " stargazer " aircraft - - is now at vandenberg air force base in central california. it is scheduled to fly to kwajalein atoll in the central pacific ocean from june 5 to 6. about an hour before launch, the plane will lift off from the island, and drop nustar and its rocket over the ocean. the rocket will then ignite, carrying nustar to its final orbit around earth ' s equator. nustar will be the first space telescope to create sharp images of x - rays with high energies, similar to those used by doctors and dentists. it will conduct a census for black holes, map radioactive material in young supernovae remnants, and study the origins of cosmic rays and extreme physics around collapsed stars. nustar is a small explorer mission led by the california institute of technology in pasadena and managed by nasa ' s jet propulsion laboratory, also in pasadena, for nasa ' s science mission directorate in washington. the spacecraft was built by orbital sciences corporation, dulles, va. its instrument was built by a consortium including caltech ; jpl ; the university of california, berkeley ; columbia university, new york ; nasa ' s goddard space flight center, greenbelt, md. ; the danish technical university in denmark ; lawrence livermore national laboratory, livermore, calif. ; and atk aerospace systems, goleta, calif. nustar will be operated by uc berkeley, with the italian space agency providing its equatorial ground station located at malindi, kenya. the mission ' s outreach program is based at sonoma state university, rohnert park, calif. nasa ' s explorer program is managed by goddard. jpl is managed by caltech for nasa. launch management and government oversight for the mission is the responsibility of nasa ' s launch services program at the kennedy space center in florida.


congestive heart failure ( chf ) | integrative therapy quick links : | - amyloidosis, anemia, angioplasty, aortic valve, aquapheresis, arrhythmias, arteriosclerosis, atherosclerosis, bnp, b - type natriuretic peptide, cabg, cad, calcium, cardiac catheterization, cardiomyopathy, cholesterol, coronary artery bypass graft, coronary artery disease, c - reactive protein, crp, ecg, echocardiogram, edema, ekg, electrocardiogram, electrolyte, emphysema, fatigue, heart attack, heart failure, hemochromatosis, homocysteine, hypertension, hyperthyroidism, hypothyroidism, iabp, icd, idiopathic, implantable cardiac defibrillator, intra - aortic balloon pump, keshan disease, left atrium, left ventricle, left ventricular assist device, left ventricular hypertrophy, lvad, murmer, myocardial infarction, myocarditis, nuclear stress test, pacemaker, pneumonia, post - pericardiotomy syndrome, potassium, pulmonary edema, pulmonary valve, radionuclide ventriculography, right atrium, right ventricle, sleep apnea, sodium, stethoscope, tress test, tricuspid valve, valve, x - ray. - congestive heart failure ( chf ), or heart failure, is a condition in which the heart is unable to adequately pump blood throughout the body and / or unable to prevent blood from accumulating, or " backing up, " into the lungs. - in most cases, chf is a process that occurs over time, when an underlying condition damages the heart or makes it work too hard, weakening the organ. health conditions that may lead to chf include : coronary artery disease, hypertension ( high blood pressure ), or arrhythmias. - symptoms of heart failure include shortness of breath and abnormal fluid retention, which usually results in swelling in the feet and legs. - according to the american heart association ( aha ), nearly five million individuals experience heart failure and about 550, 000 new cases are diagnosed each year in the united states. heart failure becomes more prevalent with age and the number of cases is expected to grow


according to the american heart association ( aha ), nearly five million individuals experience heart failure and about 550, 000 new cases are diagnosed each year in the united states. heart failure becomes more prevalent with age and the number of cases is expected to grow as the overall age of the population increases. signs and symptoms - congestive heart failure ( chf ) is chronic ( long - term ) and generally occurs slowly. congestion, or the backing up of blood, occurs in the liver, abdomen, lower extremities, and lungs. the backing up of blood causes symptoms such as shortness of breath, fatigue, and swelling ( particularly in the legs and feet ). other symptoms develop as the body tries to compensate for the heart ' s reduced pumping ability. the heart beats faster, its muscle thickens, and the ventricles may stretch to accommodate more blood. damage to the ventricles may cause them to pump out of sync, further reducing the efficient delivery of blood to the body. symptoms of chf include : a dry, hacking cough, especially when lying down ; confusion, sleepiness, and disorientation may occur in older individuals ; dizziness, fainting, fatigue, or weakness ; fluid buildup, especially in the legs, ankles, and feet ; increased urination at night ; nausea ; abdominal swelling, tenderness, or pain ; weight gain due to fluid buildup ; weight loss as nausea causes a loss of appetite and as the body fails to absorb food well ; rapid breathing, bluish skin, and feelings of restlessness, anxiety, and suffocation ; shortness of breath and lung congestion as the blood backs up in the lungs ; and wheezing and spasms of the airways similar to asthma. - physical examination and medical history : during a physical examination, a doctor will look for underlying causes of the problem and assess heart function. a stethoscope is used to detect murmurs ( abnormal heart sounds ) that may indicate a leaky or narrowed valve, and to detect fluid accumulation in the lungs. the doctor also looks for enlarged veins in the neck and for edema ( swelling ) in the legs, particularly the ankles, feet, and / or the abdomen. - a patient history may include information about risk factors, such as family medical history, past surgeries and medications, history of chest pain, high blood pressure ( including treatments ), heart attack, recent viral illness, or recent pregnancy. - blood tests : blood tests may include : blood cell counts to test for conditions such as


history, past surgeries and medications, history of chest pain, high blood pressure ( including treatments ), heart attack, recent viral illness, or recent pregnancy. - blood tests : blood tests may include : blood cell counts to test for conditions such as anemia ( low red blood cells ) ; electrolyte levels, including sodium, potassium, and calcium ; nutrient levels, such as vitamins and trace minerals ; tests for kidney function, including blood urea nitrogen ( bun ) and creatinine levels ; and testing for homocysteine and / or c - reactive protein ( crp ), both markers of inflammation and heart disease. the diagnostic test marker for chf is n - terminal prohormone brain natriuretic peptide or nt - probnp. brain natriuretic peptide ( bnp ) is a hormone produced at higher levels by the failing heart muscle. - electrocardiogram : an electrocardiogram ( ecg or ekg ) is a noninvasive test used to measure electrical activity in the heart. electrical sensors called leads are attached to predetermined positions on the arms, legs, and chest to record electrical activity and help assess heart function. the heart ' s rhythm of contraction is controlled by the sinoatrial node ( sa node ), often called the pacemaker. electrical impulses generated from the sa node spread through the heart via a nodal tissue pathway that coordinates the events leading to heart beat. the conduction system initiates and coordinates the muscular activity of the heart. - echocardiogram : echocardiogram, or echo, is an ultrasound examination of the heart that produces detailed images of the organ. it can be used to detect abnormalities in the structure of the heart and to measure the amount of blood ejected from the heart. during an echocardiogram, a microphone - like device ( transducer ) is used to transmit and receive ultrasonic waves that travel through the chest wall to the heart and are reflected back to the transducer. the reflected sound waves are translated into images of the heart, including the valves, chambers, and walls. - echocardiogram also is used to measure the pressure change ( gradient ) between the left ventricle and the aorta, to assess thickening of the walls of the heart, to evaluate pumping function, and to measure the amount of dilation ( increased diameter ) of the left ventricle. - chest x - ray : a chest x - ray is used in identifying the build


thickening of the walls of the heart, to evaluate pumping function, and to measure the amount of dilation ( increased diameter ) of the left ventricle. - chest x - ray : a chest x - ray is used in identifying the buildup of fluid in the lungs. also, the heart usually enlarges in chf, which may be visible on the x - ray film. - cardiac catheterization : cardiac catheterization may be performed in individuals with angina and in those with a history of heart attack to determine if coronary heart disease ( chd ) is causing heart failure. cardiac catheterization produces angiograms ( such as x - ray images ) of the coronary arteries and the left ventricle, and can be used to monitor heart function. - cardiac catheterization involves injecting a small amount of radioactive dye, called a contrast agent, into the left ventricle through a catheter ( a thin flexible tube ). a special camera is then used to determine how much of the dye is ejected from the heart with each beat. the infusion of dye typically produces a characteristic " hot flash " sensation throughout the body that lasts 10 - 15 seconds. - stress test : in some individuals, a less invasive procedure called a stress test is used to assess the possibility of coronary heart disease. if the results of this procedure suggest the presence of coronary artery disease, a subsequent referral for cardiac catheterization is likely. - several types of stress tests may be used by doctors to access heart function. in some cases, the individual simply walks on a treadmill while connected to an electrocardiogram ( ecg ). another type uses intravenous ( iv, or in the veins ) medication, usually dipyridamole ( persantine® ), which reproduces the stress of exercise on the heart. - nuclear stress test : nuclear stress tests involve injecting a radioactive substance, most commonly technetium or tc - 99m sestamibi ( cardiolite® ), into a vein. a special camera is then used to obtain images of the heart during rest and immediately following exercise on a treadmill as the radioactivity flows through the heart. the radioactivity levels used are not harmful. - a nuclear test called a radionuclide ventriculography or multiple gated acquisition ( muga ) scanning allows doctors to see how much blood the heart pumps with each beat, called the eject


maximal therapy ). doctors can use these classifications to identify the risk factors and begin early, more aggressive treatment to help prevent or delay heart failure. - congestive heart failure can affect many organs of the body. for example, the weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt ( sodium ) and water. this diminished kidney function can cause the body to retain more fluid. the lungs may become congested with fluid ( pulmonary edema ) and the person ' s ability to exercise is decreased. fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins. the intestines may become less efficient in absorbing nutrients and medicines. over time, untreated congestive heart failure will affect virtually every organ in the body. the lack of blood flow to the heart can lead to irreversible damage to the heart muscle. - chest pain ( angina ) is an indicator of a heart attack ( myocardial infarction ). a heart attack can cause sudden death. - treatment for congestive heart failure ( chf ) varies and involves reducing symptoms, treating the underlying cause of the condition when possible, and using medications to prevent further deterioration of heart function. - lifestyle changes : - lifestyle changes can help reduce symptoms such as fatigue, shortness of breath, and edema ( swelling ). these modifications may include dietary changes ( such as a restricted salt intake of less than 2, 000 mg daily ), abstaining from alcohol, stopping smoking, and exercising regularly ( under the supervision of a doctor ). - a combination of medications is used to treat chf. depending on the symptoms, individuals with chf may take one, two, or more of these drugs. several types of medications have proved useful in the treatment of heart failure including : angiotensin - converting enzyme ( ace ) inhibitors, angiotensin receptor blockers ( arbs ), beta - blockers, digoxin, diuretics, and aldosterone antagonists. - angiotensin - converting enzyme ( ace ) inhibitors : angiotensin - converting enzyme ( ace ) inhibitors are a medication that dilates or widens blood vessels to lower blood pressure, improve blood flow, and decrease the workload on the heart. ace inhibitors include enalapril ( vasotec® ), lisinopril ( prinivil®, zest


the body. other side effects include low blood pressure, difficulty breathing, sexual dysfunction, nausea, and weakness with exertion. - diuretics : diuretics, or water pills, make individuals urinate more frequently and keep fluid from collecting in the body. commonly prescribed diuretics for heart failure include hydrochlorothiazide ( diuril® ) and furosemide ( lasix® ). diuretics also decrease fluid in the lungs, helping individuals breathe more easily. side effects include frequent urination and low potassium blood levels. because of this, blood tests are performed periodically and a potassium supplement is prescribed if blood levels are low. individuals may be asked to eat more fruits high in potassium, such as bananas and oranges, while on diuretic therapy. - aldosterone antagonists : aldosterone antagonists are primarily potassium - sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart, and may help individuals with severe heart failure live longer. aldosterone antagonists include spironolactone ( aldactone® ) and eplerenone ( inspra® ). unlike other diuretics, spironolactone can raise the level of potassium in the blood to dangerous levels. healthcare professionals recommend eliminating high - potassium foods, such as bananas, lentils, nuts, peaches, potatoes, salmon, tomatoes, and watermelon while taking aldosterone antagonists. - others : a medication called bidil® is a single pill that combines hydralazine and isosorbide dinitrate, both of which dilate and relax the blood vessels. bidil® increases survival when added to standard therapy in african american individuals with advanced heart failure. this is the first drug studied and approved for a specific racial group. further studies will be necessary to determine if this combination medicine will be helpful for others with heart failure. side effects may include blurred vision, dry mouth, irregular heartbeat, blood in the urine or stools, numbness or tingling in the arms or legs, and fainting. - doctors often prescribe other heart medications, such as hmg - coa reductase inhibitors ( statin ) drugs, for cholesterol reduction. statin drugs include atorvastatin ( lipitor® ) or lovastatin ( mevacor® ). they may cause liver problems or muscle pain. anti - arrhythmic drugs may also be


of each treatment depends on the rate at which fluid can be removed from the body and the amount that must be removed. - angioplasty : chf caused by reduced blood flow in the heart as a result of blockages ( plaques ) in one or more coronary arteries may be treated using coronary angioplasty. in this procedure, a hollow tube ( catheter ) is inserted through an artery ( usually the femoral artery in the groin ), into the coronary artery, and to the blockage. a small balloon is then inserted through the catheter and is inflated to open the blocked artery. there is a slight risk for damage to the artery during angioplasty, but heart failure symptoms usually improve following the procedure. stenting is used along with balloon angioplasty. stenting involves placing a mesh - like metal device into an artery at a site narrowed by plaque. the stent is mounted on a balloon - tipped catheter, threaded through an artery, and positioned at the blockage. the balloon is then inflated, opening the stent. then, the catheter and deflated balloon are removed, leaving the stent in place. the opened stent keeps the vessel open and stops the artery from collapsing. re - closure may occur with both balloon angioplasty and stenting. doctors will prescribe blood thinning medications to help keep the arteries open, including aspirin, warfarin ( coumadin® ), and clopidogrel ( plavix® ). - coronary artery bypass graft surgery ( cabg ) : a coronary artery bypass surgery ( cabg ) may be recommended if the individual has severe coronary artery disease in addition to chf. this may improve the blood supply to the heart. coronary artery bypass graft ( cabg ) surgery uses blood vessel grafts, which usually come from the patient ' s own arteries and veins located in the chest, leg, or arm. the graft goes around the clogged artery to create new pathways for oxygen - rich blood to flow to the heart. some problems associated with cabg include a heart attack ( occurs in 5 % of patients ), stroke ( occurs in 5 %, with the risk greatest in those over 70 years old ), blood clots, death ( occurs in 1 - 2 % of individuals ), and wound infection ( occurs in 1 - 4 % ). infection is most often associated with obesity, diabetes,


with the risk greatest in those over 70 years old ), blood clots, death ( occurs in 1 - 2 % of individuals ), and wound infection ( occurs in 1 - 4 % ). infection is most often associated with obesity, diabetes, or having had a previous cabg. in about 30 % of patients, post - pericardiotomy syndrome can occur anywhere from a few days to six months after surgery. the symptoms of this syndrome are fever and chest pain. symptoms can be treated with medications, including antibiotics ( for infection ), nitroglycerin, and anti - inflammatory drugs. the incision in the chest or the graft site ( if the graft was from the leg or arm ) can be itchy, sore, numb, or bruised. some individuals report memory loss, loss of mental clarity, or " fuzzy thinking " following a cabg. - implantable cardiac defibrillator : an implantable cardiac defibrillator ( icd ) may be used to treat severe heart failure. an icd is a small electronic device that is surgically implanted under the skin in the chest to monitor heart rhythm. when an abnormal rhythm is detected, the defibrillator delivers an electrical " shock " to the heart to restore normal heart rhythm. - intra - aortic balloon pump : an intra - aortic balloon pump ( iabp ) is a device that is inserted through an artery in the groin ( femoral artery ) and then placed within the main artery ( aorta ). an iabp is an inflatable balloon that expands and deflates in coordination with each heartbeat. it can be left in place for days to weeks, and decreases the strain on the heart and increases blood flow throughout the body. - valve replacement surgery : individuals with heart failure caused by an abnormal heart valve may require valve repair or valve replacement surgery. these are open - heart procedures in which an abnormal valve is repaired or replaced with a porcine valve ( from pig tissue ), a mechanical valve ( made of synthetic material ), or a homograft valve ( from a human donor ). complications include bleeding, blood clots, infection, kidney failure, stroke, heart attack, and death. a homograft valve is preferred, as these valves are not associated with a significant risk for blood clot formation and, thus, do not require blood thinner therapy. most individuals remain in the hospital for a week after surgery and recovery takes approximately three to four weeks, after which most patients can


these valves are not associated with a significant risk for blood clot formation and, thus, do not require blood thinner therapy. most individuals remain in the hospital for a week after surgery and recovery takes approximately three to four weeks, after which most patients can resume leisure activities and many return to work. approximately 60 % of individuals who have valve replacement have a ten - year post - surgery survival rate. - left ventricular assist device : a left ventricular assist device ( lvad ) is a mechanical pump that is surgically implanted in the upper abdomen to bypass the left ventricle and pump blood throughout the body. this device may be used in patients with end - stage heart failure who are awaiting heart transplantation. long - term use of the device in patients with severe heart failure is being explored and defined. - pacemaker : if individuals with chf experience arrhythmias that will not respond to medication therapy, the arrhythmias may be corrected with a pacemaker. a pacemaker is a small, battery - powered device that is usually implanted near the collarbone. pacemakers can be surgically placed into the chest ( a permanent pacemaker ) through a small incision, or they can be worn outside the body ( a temporary pacemaker ) and attached to the heart through a wire that is threaded through a neck vein. temporary pacemakers are used only while an individual is in the hospital. - the surgery needed to implant a permanent pacemaker is considered a minor surgical procedure. the procedure may take one to two hours to complete. the area where the pacemaker will be inserted will be numbed with an injection of an anesthetic such as lidocaine ( xylocaine® ). the individual should not feel any pain during the procedure, and should inform the doctor or staff if they are having pain so that more anesthetic medication may be given. one or more electrode - tipped wires run from the pacemaker through the blood vessels to the inner heart. if the heart rate is too slow or if it stops, the pacemaker sends out electrical impulses that stimulate the heart to beat at a steady, proper rate. the more advanced pacemakers can monitor and pace either the atria or ventricles ( or both ) in proper sequence to maximize the amount of blood being pumped from the heart. the pacemaker ' s batteries may need to be changed every five to ten years. it is recommended by the american heart association to limit exposure to devices that may interfere with pulse generators such


sequence to maximize the amount of blood being pumped from the heart. the pacemaker ' s batteries may need to be changed every five to ten years. it is recommended by the american heart association to limit exposure to devices that may interfere with pulse generators such as cellular phones, cb radios, electric blankets, and microwaves. - it is normal for the surgical wound to be somewhat painful and swollen for a few days after the procedure. this can usually be controlled with medications, such as ultram ( tramadol® ) or ibuprofen ( motrin® ). the wound may also appear mildly red for a few days ; however, if the area of redness enlarges, a doctor should be notified due to the potential for a serious infection. if there are no other problems, most individuals who have a permanent pacemaker surgically implanted can go home the next day. they can usually return to normal activities within six weeks. for several weeks after having a pacemaker implanted, the individual may be asked not to lift more than five pounds or raise the affected arm over their shoulder. - heart transplant : in some cases, despite the use of optimal therapies as described above, the individual ' s condition continues to deteriorate due to progressive chf. in selected individuals, heart transplantation is a viable treatment option. candidates for a heart transplant are generally under age 70, do not smoke, and do not have severe or irreversible diseases affecting the other organs. additionally, a transplant is done only when it is clear that the individual ' s prognosis on continued medical treatment is poor. transplant patients require close medical follow - up while taking necessary drugs that suppress the immune system and because of the risk of rejection of the transplanted heart. they must even be monitored for possible development of coronary artery disease in the transplanted heart. - although there are thousands of patients on waiting lists for a heart transplant at any given time, the number of operations performed each year is limited by the number of available donor organs. for these reasons, heart transplantation is a realistic option in only a small subset of the large numbers of patients with congestive heart failure. - strong scientific evidence : - hawthorn : hawthorn ( crataegus sp. ), a flowering shrub of the rose family has an extensive history of use in cardiovascular disease dating back to the 1st century. increased blood flow to the heart and heart performance has been observed in animals when given hawthorn supplements. extracts of the leaves and flowers of hawthorn have


flowering shrub of the rose family has an extensive history of use in cardiovascular disease dating back to the 1st century. increased blood flow to the heart and heart performance has been observed in animals when given hawthorn supplements. extracts of the leaves and flowers of hawthorn have been reported as effective in the treatment of mild - to - moderate congestive heart failure ( chf ), improving exercise capacity and reducing symptoms of cardiac insufficiency. however, whether hawthorn is as effective as drugs considered standard - of - care for heart failure ( such as angiotensin converting enzyme inhibitors, diuretics, or beta - adrenergic receptor blockers ) is unclear, as is the effect of the combined use of hawthorn with these drugs. nonetheless, hawthorn is a potentially beneficial treatment for patients who cannot or will not take prescription drugs and may offer additive benefits to established therapies. further study is warranted. - avoid if allergic to hawthorn or to members of the crataegus species. avoid with a history of low blood pressure, irregular heartbeat, asthma, low blood pressure when standing or insomnia. use cautiously in elderly patients. avoid if pregnant or breastfeeding. - good scientific evidence : - arginine : studies of arginine in patients with chronic heart failure have shown mixed results. some studies report improved exercise tolerance. additional studies are needed to confirm these findings. - avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. avoid if pregnant or breastfeeding. use caution if taking blood - thinning drugs ( like warfarin or coumadin® ) and blood pressure drugs or herbs or supplements with similar effects. blood potassium levels should be monitored. l - arginine may worsen symptoms of sickle cell disease. caution is advised in patients taking prescription drugs to control blood sugar levels. - berberine : berberine is a bitter - tasting, yellow, plant alkaloid with a long history of medicinal use in chinese and ayurvedic medicine. berberine is present in the roots, rhizomes, and stem bark of various plants including hydrastis canadensis ( goldenseal ), coptis chinensis ( coptis or goldenthread ), berberis aquifolium ( oregon grape ), berberis vulgaris ( barberry ), and berberis aristata ( tree turmeric ). preliminary clinical research suggests that berberine, in addition to a standard prescription drug regimen for chronic congestive


are needed. - coleus is generally regarded as safe, although long - term safety data are lacking. avoid with a known allergy or hypersensitivity to coleus forskohlii and related species. rash may occur in sensitive individuals. inhalation of forskolin may cause sore throat, upper respiratory tract irritation, mild to moderate cough, tremor, or restlessness. coleus eye drops may produce a milky covering over the eyes. use cautiously in patients with heart disease, asthma, thyroid disorders, diabetes, a history of bleeding, hemostatic disorders or drug - related hemostatic problems, low blood pressure, or in patients at risk for hypotension. discontinue use in patients at least two weeks prior to surgical or dental procedures, due to risk of bleeding. avoid in patients with active bleeding. avoid during pregnancy. - creatine : creatine is naturally synthesized in the human body from amino acids primarily in the kidney and liver, and transported in the blood for use by muscles. cardiac creatine levels have been reported as depressed in patients with chronic congestive heart failure. several studies report that creatine supplementation is associated with improved heart muscle strength, body weight, and endurance in patients with heart failure. however, it is not clear what dose may be safe or effective. supplementation is also reported to increase creatine in skeletal muscle in these patients, helping to increase strength and endurance. well - designed studies comparing creatine with drugs used to treat heart failure are needed. - avoid if allergic to creatine or with diuretics ( like hydrochlorothiazide, furosemide ( lasix® ) ). use caution in asthma, diabetes, gout, kidney, liver, or muscle problems, stroke or a history of these conditions. avoid dehydration. avoid if pregnant or breastfeeding. - selenium : selenium is a trace metal that has been reported to have antioxidant properties. prophylactic administration of sodium selenite has been shown to significantly decrease the incidence of keshan disease, which is cardiomyopathy ( heart disease ) restricted to areas of china in people having an extremely low selenium status. - avoid if allergic or sensitive to products containing selenium. avoid with a history of nonmelanoma skin cancer. selenium is generally regarded as safe for pregnant or breastfeeding women. however, animal research reports that large doses of selenium


allergic or sensitive to products containing selenium. avoid with a history of nonmelanoma skin cancer. selenium is generally regarded as safe for pregnant or breastfeeding women. however, animal research reports that large doses of selenium may lead to birth defects. - unclear or conflicting scientific evidence : - aconite : the toxic effects associated with aconite limit its ability to be used to treat heart failure, including reno - cardiovascular disease and left ventricular function. further study is needed. - aconite is highly toxic and is not safe for human consumption. avoid with heart disease, heart dysfunction, irregular heartbeat, hemodynamic instability ( abnormal blood flow ), gastrointestinal disorders, ulcers, reflux esophagitis, ulcerative colitis, spastic colitis, and diverticulosis. use caution with diabetes and suicidal tendencies. avoid if younger than 18 years old. avoid if pregnant or breastfeeding. - astragalus : astragalus ( astragalus membranaceus ) is used in combination with other herbs in chinese medicine to treat various heart diseases. there is some evidence that astragalus may offer symptomatic improvement for chronic heart failure. recommendations cannot be made until well - designed clinical trials have been conducted. - avoid if allergic to astragalus, peas, or any related plants or with a history of quillaja bark - induced asthma. avoid with aspirin or aspirin products or herbs or supplements with similar effects. avoid with inflammation ( swelling ) or fever, stroke, transplant or autoimmune diseases ( like hiv / aids ). stop use two weeks before surgery / dental / diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders or kidney disorders. use cautiously with blood - thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. avoid if pregnant or breastfeeding. - ayurveda : ayurveda, which originated in ancient india over 5, 000 years ago, is probably the world ' s oldest system of natural medicine. preliminary evidence suggests that sodium nimbidinate, made from the traditional ayurvedic herb nimba / neem / arishta ( azadirachta indica ), may be an effective diuretic in patients with congestive heart failure. more studies are needed


research is needed. - ginseng may also lower blood pressure. caution is used when taking ginseng supplements, as adverse effects including drug interactions are possible. ginseng supplements are not used if pregnant or breastfeeding unless otherwise directed by a doctor. - goldenseal : limited available study suggests that berberine in addition to a standard prescription drug regimen for chronic congestive heart failure ( chf ) may improve quality of life and decrease ventricular premature complexes ( vpcs ) and mortality. further research is needed to confirm these results. - use cautiously in patients with gastrointestinal disorders, cardiovascular disease, bleeding disorders or in those taking anticoagulants, diabetes or in those taking antidiabetic agents. use cautiously in infants with increased bilirubin levels or individuals with glucose - 6 - phosphate deficiency. use cautiously in pregnancy. - hawthorn : herbal combinations containing hawthorn have been found effective in the treatment of functional cardiovascular disorders. however, due to a lack of information on the use of hawthorn alone, there is not enough evidence to recommend for or against this use of hawthorn. - avoid if allergic to hawthorn or to members of the crataegus species. avoid with a history of low blood pressure, irregular heartbeat, asthma, low blood pressure when standing or insomnia. use cautiously in elderly patients. avoid if pregnant or breastfeeding. - l - carnitine : l - carnitine, carnitine, or acetyl - l - carnitine, is an amino acid found in the body. although preliminary results are promising, there is insufficient available clinical evidence for the use of l - carnitine in congestive heart failure. - avoid with a known allergy or hypersensitivity to carnitine. use cautiously with peripheral vascular disease, hypertension ( high blood pressure ), alcohol - induced liver cirrhosis, and diabetes. use cautiously in low birth weight infants and individuals on hemodialysis. use cautiously if taking anticoagulants ( blood thinners ), beta - blockers, or calcium channel blockers. avoid if pregnant or breastfeeding. - meditation : meditation may improve quality of life in elderly patients, and may potentially reduce the risk for congestive heart failure. however, there is not enough evidence to make a conclusion. - use cautiously with underlying mental illnesses. people with psychiatric disorders should consult with their primary mental healthcare professional ( s ) before starting a program of meditation, and should explore how meditation may


failure. however, there is not enough evidence to make a conclusion. - use cautiously with underlying mental illnesses. people with psychiatric disorders should consult with their primary mental healthcare professional ( s ) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. avoid with risk of seizures. the practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. - oleander : the term " oleander " refers to two plants : nerium oleander ( common oleander ) and thevetia peruviana ( yellow oleander ). both plants contain heart - active " cardiac glycoside " chemicals ( similar to the prescription drug digoxin ) and have been associated with serious side effects in humans, including death. the plants have been used to treat congestive heart failure in china and russia for decades, but scientific evidence supporting this use is limited to small, poorly designed studies. human research began in the 1930s, but was largely abandoned due to serious gastrointestinal and heart toxicity. - all parts of the oleander plant, including flowers, leaves, and nectar are considered toxic and may cause death. avoid if allergic to oleander or other cardiac glycosides such as digoxin. avoid with a history of irregular heartbeat ( arrhythmia ), seizures, liver or kidney disease, depression, or asthma. avoid if pregnant or breastfeeding. - passionflower : an extract containing passionflower and hawthorn has been studied for potential enhancement of exercise capacity in congestive heart failure patients. individuals using this combination of herbs have experienced improvements in symptoms ; however, any positive effects may have resulted from hawthorn, which is more commonly used for congestive heart failure. high quality human research of passion flower alone and compared to prescription drugs used for this condition is needed. - avoid if allergic to passion flower or any of its constituents. avoid consuming raw passiflora fruit ( passiflora adenopoda ), due to possible cyanide constituents. passionflower extracts may cause drowsiness in sensitive individuals. avoid driving or operating heavy machinery while taking passion flower. use cautiously with low blood pressure. avoid if pregnant or breastfeeding. - physical therapy : both supervised and home - based exercise training may enhance exercise capacity in patients with chronic heart failure. however, consensus has not been obtained regarding a standard rehabilitation program for these patients and the literature often suggests


if pregnant or breastfeeding. - physical therapy : both supervised and home - based exercise training may enhance exercise capacity in patients with chronic heart failure. however, consensus has not been obtained regarding a standard rehabilitation program for these patients and the literature often suggests individually - tailored programs. due to the lack of standardization, duration of treatment, and various outcomes measures, more study is needed before a conclusion can be made. - not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. physical therapy may aggravate pre - existing conditions. persistent pain and fractures of unknown origin have been reported. physical therapy may increase the duration of pain or cause limitation of motion. pain and anxiety may occur during the rehabilitation of patients with burns. both morning stiffness and bone erosion have been reported in the literature although causality is unclear. erectile dysfunction has also been reported. physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. all therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician / gynecologist before initiation. - relaxation therapy : early studies suggest that progressive muscle relaxation training may benefit patients with heart failure when used as an adjunct to standard care. - avoid with psychiatric disorders like schizophrenia / psychosis. jacobson relaxation ( flexing specific muscles, holding that position, then relaxing the muscles ) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques. - selenium : low selenium levels have been associated with the development of cardiomyopathy, and selenium supplementation is likely of benefit in such cases ( for example in keshan disease and chagas ' disease ). however, most cases of cardiomyopathy are not due to low selenium levels and therefore selenium may not be helpful. it has been suggested that low selenium levels may be a risk factor for coronary heart disease, although this remains unclear. - avoid if allergic or sensitive to products containing selenium. avoid with a history of nonmelanoma skin cancer. selenium is generally regarded as safe for pregnant or breastfeeding women. however, animal research reports that large doses of selenium may lead to birth defects. -


conclusion can be reached. - avoid if allergic or hypersensitive to thiamin. rare hypersensitivity / allergic reactions have occurred with thiamin supplementation. skin irritation, burning, or itching may rarely occur at injection sites. large doses may cause drowsiness or muscle relaxation. use cautiously if pregnant or breastfeeding with doses higher than the u. s. recommended daily allowance ( rda ). - thymus extract : the thymus is a lobular gland located under the breastbone near the thyroid gland. it reaches its maximum size during early childhood and plays a large role in immune function. preliminary evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival in patients with cardiomyopathy. additional research is needed to confirm these results. - it is important to use high quality thymus gland supplements. avoid if allergic or hypersensitive to thymus extracts. use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes " mad cow disease. " avoid use with an organ transplant or other forms of allografts or xenografts. avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis ( neuromuscular disorder ), untreated hypothyroidism, or if taking hormonal therapy. avoid if pregnant or breastfeeding ; thymic extract increases human sperm motility and progression. - traditional chinese medicine ( tcm ) : many studies of tcm herbs have focused on treatment of congestive heart failure. further research of better design is needed before recommendations can be made. - chinese herbs can be potent and may interact with other herbs, foods or drugs. consult a qualified healthcare professional before taking. there have been reports of manufactured or processed chinese herbal products being tainted with toxins or heavy metals or not containing the listed ingredients. herbal products should be purchased from reliable sources. avoid ma huang, which is the active ingredient in ephedra. avoid ginseng if pregnant or breastfeeding. - fair negative scientific evidence : - guided imagery : therapeutic guided imagery may be used to help individuals relax and focus on images associated with personal issues they are confronting. preliminary human research does not report benefits of guided imagery in congestive heart failure. - guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. contact a qualified health


not report benefits of guided imagery in congestive heart failure. - guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. contact a qualified health care provider if mental or physical health is unstable or fragile. never use guided imagery techniques while driving or doing any other activity that requires strict attention. use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. if feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery. - smoking cessation : smoking damages blood vessels, reduces the amount of oxygen in the blood, and makes the heart beat faster. if an individual smokes, a doctor can help recommend a program to help them quit. individuals are not considered for a heart transplant if smoking is continued. - weight control : it is recommended that individuals weigh themselves each morning after urination, but before breakfast. notify a doctor if there is a weight gain of three or more pounds in a day. weight gain may indicate fluid build - up. - being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease, and diabetes. weight loss of as little as ten pounds may lower blood pressure and improve cholesterol levels. - exercise can lower blood pressure, increase the level of high density lipoprotein ( hdl cholesterol or good cholesterol ), and improve the overall health of blood vessels and heart. it also helps control weight, control diabetes, and reduce stress. cardiac rehabilitation programs exist for individuals recovering from heart surgery. cardiac rehabilitation is a medically supervised program to help heart patients recover quickly and improve their overall physical, mental, and social functioning. the goal is to stabilize, slow, or even reverse the progression of cardiovascular disease, thereby reducing the risk of heart disease, another cardiac event, or death. cardiac rehabilitation programs include : counseling so the individual can understand and manage the disease process ; an exercise program ; counseling on nutrition ; helping the patient modify risk factors such as high blood pressure, smoking, high blood cholesterol, physical inactivity, obesity, and diabetes ; providing vocational guidance to enable the patient to return to work ; information on physical limitations ; lending emotional support ; and counseling on appropriate use of prescribed medications. a doctor can help initiate an exercise program and cardiac rehabilitation tailored to the individual with congestive heart failure


vocational guidance to enable the patient to return to work ; information on physical limitations ; lending emotional support ; and counseling on appropriate use of prescribed medications. a doctor can help initiate an exercise program and cardiac rehabilitation tailored to the individual with congestive heart failure ( chf ). - salt restriction : too much sodium ( from salt ) contributes to water retention, which makes the heart work harder. excess sodium may causes shortness of breath and swollen legs, ankles, and feet. for individuals with heart failure the recommended sodium intake is no more than 2, 000 mg daily. some substitutes or " lite " salts contain a mixture of salt and other compounds. to get that familiar salty taste, individuals may use too much of the substitute and actually not reduce sodium intake. in addition, many salt substitutes contain potassium chloride. too much potassium can be harmful. a dietitian can help outline a healthy, low - salt diet. - stress management : stress can cause an increase in blood pressure along with increasing the blood ' s tendency to clot. managing stress can be vital to keeping a heart healthy. - diet modification : eating healthy foods is important. a heart - healthy diet should include five or more daily servings of fruits and vegetables, foods rich in soluble fiber ( such as oatmeal and beans ), foods rich in calcium ( dairy products, spinach ), soy products ( such as tempeh, miso, tofu, and soy milk ), and foods rich in omega - 3 fatty acids, including cold - water fish, such as salmon, mackerel, and tuna. pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold - water fish because of the potential for mercury contamination. limiting red meats and high fat foods ( such as doughnuts, cookies, and chips ) is recommended by healthcare professionals. - alcohol : excessive use of alcohol may weaken the heart muscle or increase the risk of abnormal heart rhythms, further worsening existing heart failure. alcohol may also interact with some medications used to treat heart conditions. one glass of red wine daily may be beneficial for heart health. - swelling : leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. leg elevation alone may be sufficient therapy for patients with mild venous insufficiency, but is usually not adequate for more severe cases. in addition, it may not be practical for those who work to elevate


or four times per day. leg elevation alone may be sufficient therapy for patients with mild venous insufficiency, but is usually not adequate for more severe cases. in addition, it may not be practical for those who work to elevate their legs several times per day. - leg edema ( swelling ) can also be prevented and treated with the use of compression stockings. many types are available, including knee - high, thigh - high, and pantyhose. knee - high stockings are sufficient for most individuals ; thigh - high stockings are less desirable because they tend to provide too much pressure behind the knees, reducing blood flow in the veins, and causing discomfort. the stockings should be put on as early as possible in the morning when edema is minimal. healthcare professionals can help with choosing the right compression stocking for each individual. - sleep : it is recommended that individuals with chf who have shortness of breath sleep with their head propped up at a 45 degree angle using a pillow or a wedge. - this information has been edited and peer - reviewed by contributors to the natural standard research collaboration ( www. naturalstandard. com ). - allard ml, jeejeebhoy kn, sole mj. the management of conditioned nutritional requirements in heart failure. heart fail rev. 2006 ; 11 ( 1 ) : 75 - 82.. - american heart association.. accessed march 11, 2009. - boekholdt sm, sandhu ms, day ne, et al. physical activity, c - reactive protein levels and the risk of future coronary artery disease in apparently healthy men and women : the epic - norfolk prospective population study. eur j cardiovasc prev rehabil. 2006 ; 13 ( 6 ) : 970 - 6.. - dauchet l, amouyel p, hercberg s, et al. fruit and vegetable consumption and risk of coronary heart disease : a meta - analysis of cohort studies. j nutr. 2006 ; 136 ( 10 ) : 2588 - 93.. - jiang w, kuchibhatla m, clary gl, et al. relationship between depressive symptoms and long - term mortality in patients with heart failure. am heart j. 2007 ; 154 ( 1 ) : 102 - 8.. - national institutes of health.. accessed march 11, 2009. - natural standard : the authority on integrative medicine. copyright © 2009.. accessed march 11, 2009. - riegel b