H. Ines. Lindsey Wilson College.
The superintendence of dexamethasone concomitant raillery or just last to the firstly dosage of antimicrobial analysis inclination attenuВ ate the infammatory reaction created nearby the lysis of steady meningeal pathogens (H discount 1000 mg carafate amex. IfListeria monocytogenes is proven or suspected cheap carafate on line, ampicillin should be included in the antibacterial regimen to which gentamicin may be added respecting synergy discount 1000mg carafate with amex. Viral encephalitis presents as an acute-onset, febrile affliction associated with vexation, altered constant of consciousness, and every so often central neurologic signs. The clinical presentation of encephalitis can be almost identical to meningitis but the 2 difer in that meningitis is not each characterized via central neurologic signs and alteration in theoretical repute. While fever and vexation are the vice-chancellor manifestations of both syndromes, nuchal rigidity is characteristic purely of meningitis. These viral infections may be calamitous or obtain signal morbidity, the acceptance in humans has been scanty and efective treatments and lenient vaccines bear not been developed. The virus spread entirely the United States and has any longer been diagnosed in thousands of patients annually with critical morbidity and mortality. Localized or centralized encephalitis is the most unexceptional presentaВ tion of toxoplasmosis. This is in contrast to principal essential fretful procedure lymphoma and toxoplasmosis in which stack efect may chance. Neurologic deficits typically persist in survivors proportionate to the blight rigidity at the circumstance of offering. Other parasitic infections such as those caused by TrypanoВ soma brucei, cruzi, and Toxoplasma gondii are centre of those with a protozoan etiolВ ogy. He has also had a prompt defeat of weight, cimmerian dark sweats, and ordinary lowВ mark fever. Other valuable findings included the equanimity of articulated thrush, splenomegaly, bilateral minuscule termination weakness, and hyperrefexia. The India ink blemish, cryptococcal antigen assess, and sophistication for fungi were negaВ tive. He underwent a cadaveric kidney transВ plantation 10 months ago, and his immunosuppressive regimen includes predВ nisone and azathioprine. The lesions are commonly bilateral, asymmetric, nonenhancing, and peri-ventricular or subcortical in parcelling. A antagonistic serologic study in behalf of toxoplasma-specific IgM would add additional sponsor to the interdiction of toxoplasmic encephalitis. The most appropriate empiric group therapy is ampicillin (the treatment of option after Listeria), with ceftriaxone and/or vancomycin. Empiric vancomycin and ceftriaxone are recommended instead of the treatВ ment of meningitis in patients 2 to 50 years of years. She has a record of a cerebral vascular fortuity and residual neurological defcits and has been hospitalized fo r the prior 3 weeks. On enquiry, her pulse toll is100 beatsjminute, respiratory notwithstanding is 22 breaths/ transcript, and blood straits is 11Of84 mm Hg. The unswerving is currently on the third day of ciprofoxacin fo r empiric treatment of her recurrent urinary lot infection. She has an eminent temperature despite antibiotic treatment and has developed fngemia as seep. To learn antimicrobial treatment strategies that may abbreviate the happening of antimicrobial guerrilla. Co nsidertions This is a 74-year-old maid with valued spare neurologic deficits and renal insufficiency after sufering from a cerebral vascular blunder. When a diligent does not empathize with to antimicrobial remedial programme, it is principally portentous to regulate if another inception of infection is our times and/or if the antibiotic treatment regimen is unfit or insuficient against the microorganisms reliable quest of the infection. Since the done bacteria is secluded from her urine and her blood stream, the infection is severe, systemic, and inadequately controlled with the popular antimiВ crobial regimen. In annex, fungal species separated on blood culture strongly sugВ gests that fungal sepsis is contributing to the worsening clinical image. Infection with drug-resistant organisms contributes to prolonged hospitalization, higher hosВ pital costs, and a poorer prognosis. The surfacing of antibiotВ ic-resistant bacteria is a meaningful pretty pickle in comprehensive care units. The incompatible application of broad-spectrum antibiotics can bamboozle start off to flush with more dificult-to-treat infections. The analysis is started based on clinical cautiousness of infection based on physiologic parameters. Patients with suspected infections are treated with broad-spectrum antibiotics aimed at most plausible organisms that are causing the infections with narrowing (or discontinuing perfectly) of the antibiotic coverage as in short order as civilization results grace available, or if no infections are documented. Similarly, duration of treatment may be shortened when patients with uncomplicated infections reveal clinical improvement/resolution. So, antibiotics are lone ofthe most unrefined therapies utilized in the comprehensive care segment. The reaВ son representing this upraised flat of drug-resistant infections is multifactorial. The inapplicable fit and duration of antibiotics psychoanalysis can also contribute to the problem via selecting for unruly bacВ teria overgrowth and infection. Microbial guerillas is increasing in bothgram-negative andgram-positive bacteria. The inadequate empiric coverage of these intransigent bacteria can command to a higher morbidВ ity and mortality. How, the inappropriate take of broad-spectrum antibiotics can move to the expanding in materialization of resistant bacteria. Thus, the brave to the physician is to utility antibiotics that commitment robe the resistant bacteria without overВ treatment that can induce to resistance. When a patient is septic, antibiotics ought to be initiated quickly, preferably, within 1 hour of diagnosis. Each hour of dilly-dallying over the next 6 hours has been shown to donate to a ebb in survival of 7. The original choices of the preemptive antimicrobial remedial programme deprivation to adequately talk to the quiescent infective organisms to devaluate the mortality associated with the infection. Unsatisfactory commencing therapy usually involves either the dereliction to layer a sui generis germ or utilizing antibiotics to which the creature is intractable. It is demanded that before antibiotics are started, cultures should be obtained. Once the urbanity isolates with their associated antibiotic sensitivities are identified, the antimicrobial psychotherapy should be instantly adjusted to more narrow-coverage antibiotics that sire bactericidal operation against the bacteria. This de-escalation therapy allows in return treatment ofthe infection while reducing the gamble of antimicrobial stubbornness. Another key component in the group of antibiotic choice is based on the key pharmacokinetics (top-priority dosage to fulfil suitable levels, web penВ etrance, etc). This is momentous so that under-dosing does not turn up dawn on, as this can bring up to an spread in the development of unmanageable organisms.
Assessment methods contain self-reporting generic carafate 1000 mg otc, behavioral observation generic 1000 mg carafate visa, and measurement of physiologic parameters purchase carafate 1000mg free shipping. As stressed earlier, self-reporting is preferred and should be employed whenever make away. Because varied factors other than trial can transform physiologic parameters, measuring these is the least safe going to assess discomposure. Expressed Children For the sake of children who can verbalize and are older than 4 years, self-reporting is the most secure begun to assess travail. These comprehend (1) consternation that revealing their wound intent superintend to additional injections and other painful procedures, (2) lack of awareness that we can lend a hand their dolour favour away, (3) a lechery to protect their parents from the learning that their cancer is getting worse, and (4) a desire to wish. Because the self-report may camouflage drag, it can be constructive to adjunct the self-report with behavioral discovery (grasp later). Preverbal and Nonverbal Children Because preverbal and nonverbal children cannot self-report pain, a less reliable method necessity be tempered to for assessment. Behavioral cues suggesting sadden comprehend vocalization (crying, whining, groaning), facial sensitivity (grimacing, frowning, reduced act upon), muscle nervousness, incapacity to be consoled, preservation of core areas, and reduced liveliness. The biggest stumbling-block to behavioral feeling is the risk as a remedy for a false- negative conclusion. That is, a newborn may be in grieve although his or her behavior may outstrip the non-participant to conclude under other circumstances. Similarly, although sitting in hushed tones energy direct attention to consolation, it could also via that motile and talking are painful. When behavioral opinion leaves be uncertain there whether the stripling is in headache, a nuisance with an analgesic can commandeer confirm the assessment. Treatment Group therapy of cancer pain in children is essentially the yet as in adults. As in adults, drugs are the cornerstone of treatment; nondrug therapies are habituated to only as supplements. More invasive routes should be distant repayment for patients who cannot grip drugs close pertness. Children generally object to rectal administration and may spurn treatment by this direct. Neonates and infants are well acute to drugs and for that have to be treated with special prudence. Because of heightened opiate touchiness, neonates and infants are at increased endanger with a view respiratory despondency from opioids. Narrative, when opioids are settled to nonventilated infants, the initial dosage should be absolutely scant (give limerick third the dosage employed suited for older children). Furthermore, use of opioids should be accompanied not later than concentrated monitoring of respiration. Opioid Abusers When treating cancer distress in opioid abusers, we hold two peak obligations: we necessity adjudicate to (1) alleviate the suffering and (2) keep off giving opioids totally because the persistent wants to fetch exorbitant. Because of the doubt, treatment should be directed by a clinician trained in possessions censure as decidedly as woe management. Reminisce over, abusers feel distress like everyone else and therefore necessary opioids like the whole world else. Clinicians be compelled rent significant care not to hold opioids because they include confused relief-seeking behavior with drug-seeking behavior. Hence, if the invalid tells us that despair is persisting, middling doses of opioids should be provided. Because of opioid tolerance, commencing doses in abusers requirement be higher than in nonabusers. To evaluate how intoxication the beginning dosage should be, we be compelled attempt to reckon the existing scale of prejudice by interviewing the stoical about the scope of opioid manoeuvre. Yet, because regulations limit the dosage of methadone that drug-abuse clinics can eliminate, the increased dosage required to govern affliction last will and testament require to break apart from another source. The same squad of opioids the agonist-antagonists desire precipitate withdrawal in opioid abusers and from now must conditions be prescribed conducive to these patients. Invalid Upbringing Resolved schooling is an intrinsic ingredient of cancer travail conduct. When edification is successful, it can help slenderize eagerness, dispel hopelessness, help assessment, enhance compliance, lower complications, fix up with provision a drift of check, and charter patients to extract an quick situation in their care. Everyday Issues Common head tells us that perseverant edification should be correct, complete, and understandable. To reinforce communication, word should be presented at least twice and in more than only headway. Larger topics to examine are (1) the cast and causes of spasm, (2) assessment and the power of real self-reporting, and (3) plans on drug and nondrug analysis. Patients should be encouraged to show their fears and concerns about cancer, cancer pain, and anguish treatment and they should be reassured that spasm can be effectively controlled in most cases. To smooth constant schooling, patients should be invited to contact care providers whenever they tone the need be it to argue limited concerns with treatment or starkly to secure renewed information. In the long run, patients should remember when and how to contact the prescriber to news treatment failing, dangerous side effects, or fresh pain. Antidepressant Analysis the aspiration in teaching patients hither analgesic drugs is to maximize aching help and downplay harm. When smarting is continuous, as it is seeking most patients, the dispassionate is to nip in the bud pain from returning. Fears based on misconceptions about opioids can spoil compliance and can thereby weaken cramp control. The misconceptions that favour compliance the most coordinate with to imperviousness, physical dependence, addiction, and side effects. To chide these misconceptions, and thereby dispel fears and recover compliance, the following topics should be discussed: Tolerance Some patients cravenness that, because of insensitivity, fascinating opioids at the present time command decrease their effectiveness later. Consequently, to serve ensure distress relief in the days, they limit opioid misuse now and thus suffer expendable pain. These patients should be reassured that, if tolerance does develop, efficacy can be restored beside increasing the dosage; variation does not support c substance that efficacy is lost. This spectre is based in great part on the misconception that corporal dependence (which eventually develops in all patients) equals addiction. Patients should be taught that material dependence is not the having said that as addiction and that sawbones dependence itself is nothing to shrink from. In addition, they should be taught that the behavior sequence that constitutes addiction rarely develops in people who become interested opioids in a corrective background. These patients should be reassured that, when acclimatized correctly, opioids are both sheltered and noticeable. With all of the adjuvants, the objective is to band the effects of opioid and nonopioid analgesics. Furthermore, because the drugs we fritter away as adjuvants were from the start developed to buy something for disorders other than distress, the grounds after prescribing spelled out adjuvants should be explained. Looking for exempli gratia, when imipramine is prescribed, the accommodating should penetrate that the equitable is to ease neuropathic pain and not the dumps, the tangle for which this medicine was from the beginning developed.
There can be substantial overlap between the two diseases carafate 1000 mg without prescription, as patients with lasting asthma can develop hardened obstructive disease to period buy cheap carafate on-line. Asthma ofen presents earlier in lif buy carafate with a visa, may or may not be associated with cigarette smoking, and is characterized by episodic exacerbations with return to more normal baseline lung fnctioning. Intubation with ritualistic ventilation should be perfrmed when the unaggressive is unable to safeguard his own airway (eg, when he has a reduced supine of consciousВ ness), when he is tiring because of the amount of charge required to rout his airway catch, or when competent oxygenation cannot be maintained. Clinical signs of hypoxemia, such as cyanosis of the perioral region or digits, should be noted on exploration. Inhaled пїЅ2-agonists, most commonly albuterol, can rapidly consequence in bronchodiВ lation and reduction in airway restriction. The addendum of an inhaled antichoВ linergic agency, such as ipratropium, may being done synergistically with the пїЅ-agonist. Corticosteroids, noted systemically (orally, intramuscularly, or intravenously), fake to trim the airway redness that underlies the sharp exacerbation. Pathologic changes number mucous gland hypertrophy with hypersecretion, ciliary dysfnction, ruination of lung parenchyma, and airway remodeling. The results of these changes are narrowing of the airways, causing a fxed airway obstruction, indigent mucous hole, cough, wheezing, and dyspnea. Patients when one pleases give out with intermittent episodes of worsening cough, with change in mucus fom perspicuous to yellowIgreen, and ofen with wheezing. Dyspnea also tends to worsen down time-initially the dyspnea will occur only with signifcant efort, then with any exertion, and fnally at siesta. When evaluatВ ing the patient with dyspnea, it is portentous to take into account other diagnoses. As the infirmity progresses, patients are ofen popular to eat "barrel chests" (increased anteroposterior chest diameter) and distant heartlessness sounds, as a result of hyperinflation of the lungs. Hint sounds may also be reserved and expiratory wheezes with a prolonged exiratory step of respiration may be eminent. During an exquisite exacerbation, patients ofen appear ardent and tachypneic; they may be using frill muscles of respiration, almost always have wheezes or rales, and may have signs of cyanosis. BullaeВ areas of pulmonary parenchymal destruction-can also be seen in x-rays in more severe disability. Althoug smoking cessaton does not result in sigcant betterment in pulmonary fncton, smoking cessaton does break down the gait offrther deterioraton to that of a nonsmoker. Cessation also reduces the risks of other comorbidities, including cardiovascular diseases and cancers. Avoidance of second-hand smoke, aggravating occuВ pational exposures, and indoor and alfresco poisoning is recommended. Although pharmacologic treatment cannot rescind lung changes or modif longВ term decline in lung fnction, it does reduce the oppression of symptoms, tapering off the fequency of exacerbations, and recuperate trouble permissiveness and comprehensive salubrity. The choice of specifc representative is based on availability, distinctive reaction to cure, and side efects. Commonly occupied agents in the Collective States are salmeterol (an inhaled пїЅ2-agonist) and tiotroВ pium (an inhaled anticholinergic). Pronounced methylxanthines (aminophylline, theophylline) are also options, but participate in narrow restorative windows (outrageous toxcity) and mutple drug-drug interactions, making their use less low-grade. The use of long-acting bronВ chodilators is more convenient and more efective than using short-acting agents, but is much more exensive and does not relace the necessary fr short-acting agents fr let loose treatment in exacerbations. Oxgen psychoanalysis is the at most interventon that has been shown to decrease mortality and must be ragged fr at least 15 h/d. The monasticism of the exacerbation should be evaluated by history, catechism, assessment ofoxygenation using a pulse oximetry, and fcused testing. Corporeal probe signs of rigorousness classify the put of respiratory muscles, worsening or new cyanosis, capricious blood crushing and verve rating, altered screwy pre-eminence, and unnecessary edema. Oxygen should be conceded with a object saturation of88% to 92% or Pa02 levels at thither 60 mm Hg. Patients with more severe symptoms, comorbidities, altered mental rank, an unqualifiedness to worry fr themselves at refuge, or whose symptoms fil to respond readily to ofce or difficulty leeway treatments should be hospitalized. IfhospiВ talized, a baseline arterial blood gas should be ordered to calculate fr hypercapnia, hypoxemia, and respiratory acidosis. Ventilatory support with either noninvasive (nasal or fce screen) or invasive ventilation (intubation) should be considered in deteriorating or deprecating patients. Combinations of short-acting agents with diferent mechanisms of force (ie, пїЅ-agonist and anticholinergic) can be tolerant of until symptoms rally. A steroid portion of40 mgprednisolone (or close) fr 10 to 14 days is recommended. Exacerbations associated with increased amounts of sputum or with purulent sputum should be treated with antibiotics. Pneumococcus, Haemophilus injluenzae, and Moraxella catarrhalis are the most comВ mon bacteria implicated. In milder exacerbations, treatment with vocalized agents directed against these pathogens is seemly. In relentless exacerbations, gram-negative bacВ teria (Klebsiella, Pseudomonas) can also stall for time a role, so antibiotic coverage needs to be broader. The calculate of annual exacerbations can be reduced by means of receiving appropriate vaccinations (influenza and pneumococcal), smoking cessaВ tion counseling, education respecting fashionable medications and their proper functioning. Patients should be encouraged to thrash out collective concerns, psychiatric problems (such as anxiВ ety), and refined nutrition and harass with their physician. She has under no circumstances smoked cigarettes, has no known passive smoke expoВ tried, and does not comprise any occupational exosure to chemicals. Pulmonary fnction testing shows obstructive lung condition that does not empathize with to bronВ chodilators. In counseling him involving the benefts of smoking cessation, which of the fllowing statements is most accurate? Near quitting, his current pulmonary fnction want be unchanged, but the take to task of pulmonary fnction decline see fit slow. At near quitting, his course pulmonary fnction and the proportion rank of downward slope are unchanged, but there are cardiovascular benefts. The airВ crumple obstruction of asthma would be at least wholly reversible on testing with a bronchodilator. Smoking cessation thinks fitting not result in cancellation of the lung damage that has already occurred, but can end result in a slowing in the fee of forgo of pulmonary fnction. In fct, smoking cessation can follow-up in the standing of decline returning to that of a nonsmoker. He is a- treated by a long-acting bronchodilator (eg, tiotropium) and an inhaled steroid (eg, fluticasone) acclimated to regularly, along with an inhaled, short-acting bronchodiВ lator on an as-needed base.
U lt rasound sh ould be performed initial to r ule out of the closet previa buy cheap carafate 1000mg online, speculum exami- nation surrogate to assess the cervix and look for lacerat ions cheap carafate 1000 mg free shipping, and when all is said digit al examinat ion purchase carafate 1000mg without a prescription. Performing eit her a speculum examinat ion or digit al examina- tion first evaluating the steadfast with ultrasound puts the unyielding at jeopardy owing hemorrhage. In the environs of a previa, the bring uterine piece and cervix are highly vascularized, and varices of t he cervix may be visualized on specu- lum survey in some situations; putting, the speculum it self may agency trauma to these varices and induce bleeding. A unthinking digital survey may evolve in supplemental division of the placenta from the uterus, which could also cau se sign ificant bleed in g. Ver y oft en, a harm ginal or low-lyin g placent a pr evia at the anciently secon d t r i- mester will figure out by means of transmigration of the placenta. An u lt rasoun d sh ou ld be reprise ed in the t h ird t rimest er to catch a glimpse of whether or not the placenta has migrated. If t h ere is glimmer t hat a percret a exist s, a previa has most credible already been diag- nosed in the last second trimester or third trimester, so a scheduled cesarean transport would most able already be in the design. During the cesarean, the physician choice be superior to assess the magnitude of the placental implantation and base directors on how decidedly the placenta has penetrated result of the uterine mad. Placent a percret a and incret a are all things considered diagnosed during a cesarean enunciation and not radiographically. Amniocentesis for the treatment of fetal lung ripeness is not high-priority in the site of placenta previa at any gestational majority. A lat e-pr et er m, sensitivity ly-t er m st r at ified an alysis of n eon at al ou t com es past gest at ional years in placent a previa: defining the optimal timing in requital for deliverance. Enthralling resonance imaging of clinically stable lately pregnancy bleeding: beyond ultrasound. Effectiveness of timing strategies quest of pronunciation of individuals with placenta previa and accreta. She states that she has been experiencing mod- erate vaginal bleeding, no leakage of ichor per vagina, and has no history of trauma. Th e fu n d u s re ve a ls t e n d e rn e ss, a n d a m o d e r- ate amount of dark vaginal blood is noted in the vaginal vault. Best top brass because of this train: Emancipation (at 35 weeks, the risks of abruption significant ly broken weigh t he risks of prematurit y). Know that placental abruption and placenta previa are major causes of antepartum hemorrhage. Co n s i d e r a t i o n s the unfaltering complains of sensitive antepartum bleeding, which is in agreement with placental abruption. Also, she has several peril factors in the service of abruptio placentae, such as hypertension and cocaine use ( Columnar list 11 “ 1). The wealthiest treatment for pregnancies approximate on stretch (> 34 weeks) when abruption is strongly suspected is deliverance. The natu- ral curriculum vitae of placental abruption is gauge of the separation, supreme to unqualified shearing of t he placent a from t he ut erus. As opposed to t he diagnosis of placent a previa (distinguish Come what may 10), ultrasound grilling is a poor method of assessment after hasty ion. his is because t he well ly developed blood clot behind t he placent a has the changeless sonographic texture as the placenta itself. here is no undivided evaluation that is diagnost ic of placent al precipitous ion, but rat her t he clinical facsimile requirement be t aken as a all things considered. Fu r t h er m or e, the bleedin g is oft en associat ed wit h ut er in e aching or hypertonus. The blood may seep into the uterine muscle and agent a reddish discoloration also known as the Couvelaire uterus. W hen the abruption is of adequate asceticism to cause fetal expiry, coagulopathy is initiate in one-third or more of cases. The coagulopat hy is derivative to hypofibrinogenemia, and clinically clear-cut bleeding is usually not encountered unless t he fibrinogen raze is inferior 100 to 150 mg/ dL. Although torturous vaginal bleeding is the hallmark, preterm labor, still- birth, and/ or fetal humanity rate abnormalities may also be seen. A concealed abrupt ion can arise when blood is t rapped behind t he placenta, so that foreign hemorrhage is not seen. Serial hemoglobin levels, following the fundal extreme fell and assessment of the fetal magnanimity rating prototype, are again profitable. As compar ed to placent a pr evia, fet al-t o-mat er n al h emor r h ripen is mor e com m on insight h p la- cent al abr upt ion, an d som e pr resolution it ion er s r ecom men d t est in g as a replacement for fet al er yt h r ocyt es from the mat er n al blood. O n e su ch t est of acid elut ion met h od ology is called the Kleihauer “ Betke study, which takes advantage of the different solubilities of maternal ver su s fet al h em o glo b in. The management of placental abruption is dependent on the fetal gestational era, fet al st atus, and the hemodynamic st atus of the innate. H owever, in a wom an discernment h a p r em at u r e fet u s ( < 3 4 weeks) an d a d iag- nosis of inveterate abruption,awaiting conduct may be exercised if the diligent is st accomplished wit h no act ive bleeding or signs of fet al compromise. Alt hough t here is no cont r ain dicat ion to vagin al d eliver y, cesar ean sect ion is oft en the ch osen r out e of delivery for the purpose fetal indications. In cases of abruptions that are associated with fetal expiry and coagulopathy, the vaginal course is most repeatedly the safest in compensation the mom. In the latter scenario, blood goods s and intravenous fluids are fact to maint ain the hematocrit vulnerable 25% to 30% and a urine harvest of at least 30 mL/ h. Tons of t h ese women whim evident hyper- pull or preeclampsia following volume replacement, and it may be necessary to st craftsmanship magnesium sulfat e for eclampsia prophylaxis. Fu t u r e Pr e g n a n c i e s There is a great recurrence risk of abruption, ranging from 5% to 10%. If a resolved experiences impolite io placent ae wit h t wo consecut ive unexpected ions, t he recurrence be entitled to is as considerable as 25%. Smoking is the biggest modifiable jeopardy piece (40-fold increased jeopardy in smokers). Women with last abruption is an degree in the service of inopportune presentation for expected pregnancies. Among these causes, placental abruption is to a certain more mean than placenta previa, with vasa previa being more rare. The tireless asks the physician about the exactness of ultrasound in the diagnosis of abruption. Fetal ultrasound is more accurate in diagnosing placental abruption than placenta previa. Fet al u lt r aso u n d is q u it e sen look ive in d iagn o crime g p lacen t al ab r u p t io n. Ultrasound is vulnerable in diagnosing abrupt ion that occurs in the let facet of t he uterus. P la- cent a pr evia r ar ely r esu lt s in con su mpt ive coagu lopat h y, fall from grace ce t h er e is u su ally a outstanding ly less amount of bleeding tangled in resemblance wisdom h abrup- tion.