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Buat para pembisnis online yang sudah putus asa dalam dunia Bisnis Online. Jangan menyarah dan meninggalkan Bisnis Online karena sekarang telah hadir Bisnis Online yang murah dan terjangkau. Isi data anda dan mulailah bisnis ini. Payout minimal 200.000 .
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Isi Survei Dapat Uang

Zaman sekarang sangat susah untuk mencari uang. Perlu kerja keras untuk mendapatkan penghasilan yang lumayan. Banyak orang mencari pekerjaan dengan sulit.
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Transplantasi Jantung

Transplantasi jantung adalah prosedur mengganti jantung yang gagal berfungsi dengan jantung lain dari donor yang memenuhi persyaratan. Prosedur ini dilakukan pada pasien dengan gagal jantung stadium akhir yang diperkirakan mempunyai usia hidup kurang dari satu tahun apabila tidak dilakukan transplantasi dan bukan calon ataupun belum pernah ditangani dengan terapi medis konvensional. Sebagian besar calon pasien yang ditransplantasi tidak dilakukan prosedur bedah lain karena kondisi jantung yang sudah buruk. Komponen penting dalam tahapan proses transplantasi jantung adalah menentukan calon pasien yang akan ditransplantasi, pemeriksaan, tindak lanjut setelah operasi, dan supresi imun. Pelaksanaan yang tepat dari langkah-langkah tersebut dapat berujung pada hasil yang sangat menggembirakan baik bagi dokter maupun pasien. Calon pasien untuk transplantasi jantung secara umum adalah pasien dengan gejala NYHA kelas III (moderat) atau kelas IV (berat). Pada pemeriksaan biasanya didapatkan ejeksi fraksi kurang dari 25%. Pada saat pemeriksaan, beberapa penyesuaian dilakukan untuk menstabilkan kondisi jantung. Terapi tambahan berupa agen oral biasanya diberikan, misalnya obat-obat inotropik. Bantuan mekanik dengan pompa balon intraaortik (IABP) atau perangkat pembantu lain yang diimplan membantu bagi beberapa pasien sebagai terapi tambahan sebelum transplantasi. Transplantasi jantung dilakukan sekitar 1% per tahun. Semakin baiknya penanganan medis pada pasien gagal jantung telah menurunkan populasi calon pasien yang ditransplantasi. Selain itu, ketersediaan organ juga masih menjadi masalah. Penyakit yang Membutuhkan Transplantasi Jantung Penyakit-penyakit yang membutuhkan transplantasi jantung dapat dibagi menjadi beberapa kategori, pembesaran kardiomiopati (54%), iskemik kardiomiopati (45%), serta penyakit jantung kongenital dan penyakit lain yang tidak dapat diterapi dengan bedah. Patofisiologi kardiomiopati yang membutuhkan transplantasi jantung bergantung pada proses primer penyakit. Iskemik kronik mempercepat kerusakan sel miokard, dengan pembesaran yang progresif dari miosit diikuti kematian sel dan pembentukan jaringan parut. Kondisi dapat diterapi dengan angioplasti atau bypass. Namun, penyakit pembuluh darah kecil berkembang cepat dan menyebabkan kerusakan progresif dari jaringan miokard. Hal ini menghasilkan kehilangan fungsi yang signifikan dan pembesaran jantung yang progresif. Patofisiologi Jantung Transplan Patofisiologi jantung transplantasi sangatlah unik. Tidak adanya persyarafan organ membuatnya bergantung pada tingkat intrinsiknya. Sebagai hasil kurangnya input neuronal, beberapa berkembang menjadi hipertrofi ventrikel kiri. Fungsi ventrikel kanan bergantung pada waktu iskemik sebelum reimplantasi dan lama waktu tersedia. Ventrikel kanan mudah rusak dan mulanya akan berfungsinya sebagai penghubung pasif sampai pemulihan terjadi. Proses penolakan yang terjadi pada allograft mempunyai 2 bentuk primer, seluler dan humoral. Penolakan seluler adalah bentuk klasik dari penolakan organ yang ditandai dengan infiltasi perivaskuler dari limfosit, dengan kerusakan miosit bertahap dan nekrosis apabila dibiarkan tidak tertangani. Rejeksi humoral lebih sulit didiagnosis. Hal ini berupa respon antibodi diinisiasi oleh beberapa faktor yang tidak diketahui. Deposisi antibodi ke dalam miokard menghasilkan disfungsi kardiak umum. Diagnosis secara umum dibuat sebagai dasar kecurigaan klinis dan ekslusi. Penyakit arteri koroner adalah proses patologi umum pada semua allograft kardiak ditandai dengan hiperplasia miointimal dari pembuluh darah berukuran sedang dan kecil. Lesi difus dan akan muncul dalam 4 bulan sampai beberapa tahun setelah implantasi. Penyebab masih belum jelas, dipikirkan karena infeksi cytomegalovirus (CMV) dan dampak penolakan kronik. Mekanisme proses ini dipikirkan bergantung pada produksi faktor pertumbuhan pada allograft yang diinisiasi oleh limfosit. Saat ini, tidak ada terapi lain selain reimplantasi ulang. Indikasi Indikasi umum dari transplantasi jantung adalah penurunan fungsi jantung dan prognosis hidup yang kurang dari 1 tahun. Indikasi spesifik meliputi pembesaran kardiomiopati, iskemik kardiomiopati, penyakit jantung kongenital yang belum ada terapi konvensional maupun yang gagal dengan terapi konvensional, ejeksi fraksi kurang dari 20%, aritmia jantung malignan yang gagal dengan terapi konvensional, resistensi pembuluh darah pulmonal yang kurang dari 2 unit Wood, umur kurang dari 65 tahun. Kontraindikasi Kontraindikasi transplantasi jantung meliputi umur lebih dari 65 tahun (kontraindikasi relatif), resistensi pulmonal lebih dari 4 unit Wood, infeksi sistemik aktif, penyakit sistemik aktif, keganasan aktif, riwayat penyalahgunaan zat, dan instabilitas psikososial. Hasil Tingkat harapan hidup setelah transplantasi jantung sekitar 81,8% dengan tingkat harapan hidup dalam 5 tahun sekitar 69,8%. Jumlah pasien yang hidup lebih dari 10 tahun setelah prosedur cukup signifikan. Setelah transplantasi, pasien dewasa dengan penyakit jantung kongenital memiliki tingkat kematian 30 hari yang tinggi tetapi setelah itu tingkat harapan hidupnya yang lebih baik. Status fungsional penerima donor setelah prosedur sangat baik, bergantung pada tingkat motivasi pasien bersangkutan. Pada pasien dengan kegagalan biventrikuler berat yang menerima perangkat bantuan biventrikular pneumatik sebagai jembatan sebelum transplantasi, tingkat harapan hidupnya 89% dibandingkan 92% pada pasien tanpa perangkat pembantu ventrikel. Hipertensi, diabetes mellitus dan obesitas dihubungkan dengan peningkatan angka kematian postoperatif secara eksponensial. Penerima donor jantung dengan faktor risiko metabolik ini didapatkan peningkatan tingkat kematian 63% dibandingkan dengan yang tanpa faktor risiko ini. Arnaoutakis et al menemukan bahwa pasien risiko tinggi memiliki tingkat harapan hidup 1 tahun lebih baik pada senter yang melakukan lebih dari 15 prosedur per tahun dibandingkan dengan senter yang lebih sedikit (79% vs 64%). Oleh karena itu, seluruh prosedur transplantasi risiko tinggi dilakukan pada senter yang sudah banyak melakukan prosedur. Evaluasi Sebelum Prosedur Evaluasi transplantasi jantung meliputi tes laboratorium, pencitraan, dan tes lain. Tanda perburukan klinis harus dipantau ketat selama periode menunggu organ donor. Panel hepatitis dapat dilakukan sebagai skrining, menunjukkan bahwa tidak ada antigen aktif. Pasien yang merupakan karier penyakit atau yang memiliki penyakit aktif tidak dipilih untuk menjadi calon transplantasi jantung. Pasien positif hepatitis C masih kontroversial. Studi kohort multisenter menemukan bahwa pasien positif hepatitis C dihubungkan dengan penurunan harapan hidup rata-rata 5,6 tahun setelah transplantasi. Pasien tidak boleh terinfeksi HIV. Pasien positif HIV adalah kontraindikasi transplantasi. Uji virus lain, meliputi Epstein-Barr Virus (EBV), Cytomegalovirus (CMV) dan Herpes Simplex Virus (HSV) dilakukan untuk mengetahui apakah ada pajanan lampau dan penyakit yang sedang aktif. Pajanan di waktu lampau mengindikasikan risiko reaktivasi, profilaksis harus diberikan setelah transplantasi. Obati penyakit yang aktif sebelum transplantasi dilakukan. Penerima donor yang hasil tes CMV negatif diberikan immunoglobulin CMV. Lakukan imunisasi pada pasien yang hasil tesnya negatif untuk agen virus lain selama periode evaluasi. Lakukan test serologis fungal dan tes kulit TBC untuk memberikan perhatian menyeluruh pada pajanan lingkungan. Penelitian ini digunakan untuk mengetahui pajanan lampau dan memprediksi reaktivasi. Pasien dengan hasil tes kulit TBC positif biasanya diobati sebelum dimasukan ke dalam daftar pasien transplantasi. Jika hasil tes prostat-spesifik antigen (PSA) positif mulai pemeriksaan dan terapi sebelum menyelesaikan pemeriksaan transplantasi. Hasil tes papanicolau sebaiknya negative sebelum dimasukan ke dalam daftar transplantasi. Jika hasilnya positif, rujuk untuk evaluasi dan terapi sebelum melakukan pemeriksaan untuk transplantasi. Lakukan pemeriksaan darah lengkap dengan hitung keping darah, protrombin time (PT), activated partial thromboplastin time (aPTT) dan kimia darah lengkap (termasuk pemeriksaan hati, lipid, dan urinalisis). Hasil tes ini harus normal. Kelainan harus dinilai sebelum dilanjutkan ke tahap selanjutnya. Skrining dan golongan darah, pemeriksaan panel-reaktif antibody (PRA) dan jenis jaringan digunakan untuk menentukan kecocokan imunologik pasien untuk transplantasi dan kecocokan donor. Biopsi endomiocardial pada calon pasien transplantasi tidak rutin dilakukan. Prosedur dipertimbangkan jika proses sistemik melibatkan jantung dipikirkan penyebab kardiomiopati. Lakukan biopsi pada area yang tepat jika pasien memperlihatkan gejala penyakit sistemik. Biopsi dilakukan untuk menentukan luas dan aktivitas proses penyakit. Proses penyakit sistemik adalah kontraindikasi transplantasi jantung. Monitoring dan Tindak Lanjut Setelah transplantasi, biopsi endomiokardial dilakukan untuk menilai rejeksi allograft. Prosedur ini dilakukan setiap minggu dalam bulan pertama, dengan frekuensi menurun terus menerus. Kunjungan follow up dilakukan pada bulan pertama karena pengaturan supresi imun disesuaikan dalam waktu ini. Frekuensi kunjungan perlahan-lahan dikurangi sampai pasien secara umum terlihat seperti keadaan normal. Beberapa senter melakukan prosedur angiografi koroner setiap tahun setelah transplantasi untuk memonitor pasien terhadap pembentukkan penyakit vaskuler dari allograft. Pendekatan Prosedur transplantasi jantung dibatasi oleh ketersediaan organ. Patologi pada jantung donor yang sering ditemui meliputi kontusi jantung, penggunaan kokain, patologi jantung atau riwayat sosial. Karena waktu toleransi yang pendek untuk organ jantung (4-6 jam), sehingga waktu pemesanan terbatas. Donor jantung potensial harus memenuhi syarat mati otak dan bebas dari patologi jantung. Pemeriksaan ekokardiografi masih menjadi mekanisme skrining awal terbaik bagi donor potensial. Ejeksi fraksi normal (lebih dari 50%) dengan struktur katup normal dan fungsi dan ketiadaan hipertrofi ventrikel kiri (yang ditentukan oleh ekokardiografi) adalah indikator jantung yang bagus untuk transplantasi. Kelainan minimal ada ekokardiografi (seperti regurgitasi trikuspid atau mitral, hipertrofi ventrikel kiri marginal, atau pengurangan ejeksi fraksi adalah indikator organ yang diterima, bergantung pada riwayat donor dan kondisi penerima. Secara praktis apabila penerima dalam kondisi ekstrim, jantung donor yang kurang ideal bisa diterima dengan tujuan untuk menyelamatkan kehidupan pasien. Donor yang memiliki riwayat merokok berat harus diskrining CAD dengan kateterisasi jantung. Kriteria donor meliputi umur lebih muda dari 65 tahun, fungsi jantung normal, tidak adanya coronary artery disease (CAD). Jika seluruh kriteria ini terpenuhi, donor dan penerima potensial dicocokkan berdasarkan kompatibilitas golongan darah ABO dan ukuran. Keputusan akhir tergantung pada kecocokan jantung donor dapat dibuat berdasarkan inspeksi ahli bedah berpengalaman. Insisi sternotomi median dilakukan untuk memudahkan inspeksi jantung. Perawatan dilakukan untuk menilai organ kontusi potensial dan fungsi keseluruhan. Jantung dialiri dengan larutan kardioplegia dingin, diambil, dan ditempatkan di larutan elektrolit steril dingin untuk transportasi. Operasi dilakukan dengan melalui bypass kardiopulmoner. Jantung penerima diambil dan jantung donor dimasukan pada tempatnya. Anastomosis atrium kiri dilakukan diikuti atrium kanan dan pembuluh darah besar. Transplantasi jantung Saat mempersiapkan graft untuk transplantasi, melihat patensi foramen ovale. Jika lubang foramen ovale ada maka lubang ditutup. Terkadang dilakukan annuloplasti katup trikuspid pada graft donor sebagai pencegah terbentuknya regurgitasi trikuspid pada periode postoperatif. Insiden regurgitasi trikuspid setelah transplantasi jantung dilaporkan 47-98%. Selama prosedur transplantasi jantung, ventrikel dieksisi, meninggalkan pembuluh darah besar, atrium kanan, dan atrium kiri. Jantung donor kemudian dijahit pada area ini. Ilustrasi dada penerima donor setelah jantung dihilangkan dengan pasien dilakukan bypass kardiopulmoner Jahitan jantung donor, anastomosis atrial kiri dilakukan pertama Operasi selesai, terlihat garis jahitan pada jantung implan Allograft jantung dijahit baik posisi heterotropik atau ortotopik. Transplantasi jantung heterotropik jarang dilakukan karena beberapa masalah (kompresi pulmoner, kesulitan mendapatkan biopsi endomiokardial, antikoagulasi). Namun transplantasi heterotropik adalah teknik yang bagus untuk pasien dengan hipertensi pulmoner berat. Transplantasi heterotropik Transplantasi jantung ortotopik dilakukan baik dengan teknik Shumway-Lower klasik atau sebagai anastomosis bikaval. Saat ini, ada tren melalui anastomosis bikaval daripada anastomosis atrium kanan dalam rangka menurunkan insiden insufisiensi trikuspid postoperatif. Ilustrasi setelah kardiektomi memperlihatkan anastomosis bikaval Teknik transplantasi bikaval lengkap Metode Shumway-Lower lebih sederhana dan menghemat 10-15 menit waktu iskemik. Satu manfaat metode bikaval adalah dengan mencegah atrium kanan besar, pembedah dapat menjaga transpor atrial yang lebih baik. Manfaat lain dari teknik ini adalah laporan yang lebih rendah insiden regurgitasi trikuspid. Setelah prosedur, pasien diberi pada kombinasi agen pressor sambil menunggu jantung donor mendapatkan kembali energinya. Level kalsium pasien dimonitor dan diberikan kalsium klorida karena fungsi jantung sangat bergantung pada ion kalsium. Status asam basa pasien dijaga dan dimonitor hati-hati dan dikoreksi. Imunosupresi dimulai sesegera mungkin setelah bedah. Beberapa regimen dapat digunakan meliputi terapi induksi sebelum transplantasi dan terapi perawatan setelah operasi sederhana. Pilihan regimen bergantung pada latihan dan pengalaman pusat transplantasi. Setelah stabil, pasien secara cepat dilepas dari ventilator dan pressor. Lama perawatan di rumah sakit bisa lebih pendek dari 5 hari bergantung pada kondisi penerima sebelum operasi. Pada proses transplantasi, nodus sinoatrial donor dan penerima tetap dijaga intak kedua-duanya. Untuk kira-kira 3 minggu setelah bedah, EKG memperlihatkan 2 gelombang P, namun denyut jantung dan aktivitas elektrik jantung yang baru bergantung pada sistem kelistrikan jantung, bukan pada input neurologi dari penerima. Komplikasi Komplikasi setelah transplantasi meliputi perdarahan dari jahitan. Hal ini jarang terjadi tetapi membutuhkan eksplorasi ulang pada masa awal postoperasi. Rejeksi hiperakut dapat terjadi tiba-tiba setelah aliran darah tersimpan pada alograft dan sampai 1 minggu setelah prosedur, diluar imunosupresi terapeutik. Infeksi adalah perhatian utama pada pasien posttransplantasi. Ukuran preventif sebaiknya dilakukan. Selama awal posttransplantasi, infeksi bakterial adalah perhatian utama. Infeksi fungal dapat muncul jika pasien menderita diabetes atau imunosupresi kurang. Profilaksis untuk Pneumocystis carinii umum diberikan seperti halnya terapi infeksi CMV. Jaga kerentanan terhadap proses infeksi yang jarang seperti Listeria, Legionella, Chlamydia, dan infeksi Nocardia. Profilaksis Pneumocystis carinii diberikan secara universal, sebagai terapi infeksi CMV. Gangguan psikiatrik dari terapi steroid dapat terjadi pada waktu postransplantasi. Gangguan ini dapat diprediksi dari evaluasi psikiatrik sebelum transplantasi dan sebaliknya. Rejeksi jantung diharapkan dan sebaiknya dideteksi dengan biopsi endomiokardial. Bergantung pada keparahan insiden, proses dapat diterapi dengan terapi steroid sendiri, terapi antibodi poliklonal, atau terapi antibodi monoklonal. Penyakit vaskular allograft adalah penyebab utama kegagalan graft dan kematian. Hiperplasia miointimal konsentrik progresif membangun arteri koroner, kadang pada awal 3 bulan setelah transplantasi. Penyebab proses masih belum jelas. Namun, infeksi CMV dan episode rejeksi rekuren dipikirkan berhubungan dengan penyebab. Penelitian menunjukkan bahwa cedera iskemi-referfusi awal berpasangan dengan episode rejeksi berulang, akan berkontribusi pada proses. Terapi satu-satunya yang ada untuk penyakit vaskuler allograft adalah retransplantasi. Penyakit vaskuler allograft dapat diterapi dengan stent pada pembuluh darah yang rusak. Stent lebih efektif dalam terapi vaskulopati allograft kardiak daripada stent logam. Stent mengurangi lesi target revaskularisasi, seperti halnya kematian jantung dan infark miokardial nonfatal. Pada pasien pediatrik, ada 30% peningkatan risiko kehilangan grat dalam 6 bulan saat waktu iskemik lebih dari 3,5 tahun. Ringkasan Pengobatan Tujuan farmakoterapi adalah mencegah komplikasi untuk mengurangi kesakitan dan untuk mengurangi rejeksi organ. Imunosupresi Imunosupresi dimulai segera setelah bedah. Penerima transplan diberi regimen imunosupresi yang meliputi 1-3 obat. Secara umum obat dibagi 3 kategori: steroid, antimetabolit, dan imunosupresan lain. Beberapa regimen dapat digunakan termasuk terapi induksi pretransplantasi dan terapi maintenance postoperatif sederhana. Pilihan regimen bergantung pada latihan dan pengalaman pusat transplantasi. Siklosporin Siklosporin adalah polipeptida siklik yang menekan beberapa imunitas humoral dan reaksi imun dimediasi sel seperti delayed hypersensitivity, rejeksi allograft, encephalomyelitis alergik eksperimental, dan penyakit graft versus host untuk berbagai organ. Untuk anak-anak dan dewasa, dosis dasar sesuai berat badan. Menjaga level obat dalam pembuluh darah adalah penting untuk menjaga penjagaan allograft. Makanan dapat mengganggu level obat dan waktu pemberian. Pengobatan harus diminum pada waktu yang sama setiap hari. Neoral adalah bentuk kapsul siklosporin, tersedia dalam kapsul 25 mg dan 100 mg. Sandimun adalah bentuk cair. Gengraf adalah bentuk generik bermerk, tersedia dalam kapsul 25 mg dan 100 mg. Prednison Prednison adalah imunosupresan digunakan untuk terapi gangguan autoimun. Obat ini akan mengurangi radang dengan menghambat peningkatan permeabilitas kapiler dan menekan aktivitas leukosit PMN. Obat ini adalah steroid oral dengan kira-kira 5 kali potensi steroid endogen. Minimal sampai prednison diberikan untuk 21 hari setelah transplantasi jika rejeksi terjadi. Metilprednisolon Metilprednisolon adalah imunosupresan yang digunakan untuk mengobati ganggun autoimun. Obat ini akan mengurangi radang dengan menghambat peningkatan permeabilitas kapiler dan menekan aktivitas PMN. Obat ini adalah bentuk IV prednison. Takrolimus Takrolimus menekan imunitas humoral (aktivitas sel T). Obat ini adalah inhibitor calcineurin dengan potensi 2-3 kali siklosporin. Takrolimus dapat digunakan pada dosis rendah daripada siklosporin tetapi memiliki efek samping yang berat seperti disfungsi renal, diabetes, dan pankreatitis. Level disesuaikan menyesuaikan fungsi ginjal, fungsi hepar, dan efek samping. Mycophenolate mofetil Mycophenolate mofetil menghambat inosin monofosfat dehydrogenase (IMPDH) dan menekan sistesis purin de novo dengan limfosit, kemudian menghambat proliferasi. Obat ini menghambat produksi antibodi. Azathioprine Azathioprine merupakan antagonis metabolisme purin dan menghambat sintesis DNA, RNA, dan protein. Obat ini mengurangi proliferasi sel imun, yang menghasilkan aktivitas autoimun yang lebih rendah. Antimetabolit digunakan untuk memblok ambilan zat vital yang dibutuhkan oleh sel. Sebagai dampaknya, obat ini mempengaruhi tidak hanya sel sistem imun tetapi juga sel lain dalam tubuh. Potensi terapi obat ini tergantung dosis. Obat ini tidak efektif untuk rejeksi episode akut tetapi masih menjadi pilihan ekonomis untuk imunosupresi jangka panjang. Sirolimus Sirolimus dikenal juga dengan rapamycin, Obat ini adalah imunosupresan yang menghambat aktivasi sel T dan proliferasi dengan mekanisme yang berbeda dengan seluruh imunsupresi lain. Penghambatan ini menekan prolifeasi sel T sitokin dengan menghambat progresi dari fase G1 ke fase S pada siklus sel. Agen inotropik Setelah prosedur dilakukan, pasien dijaga dengan kombinasi agen pressor sambil jantung donor mengumpulkan energi. Setelah stabil, pasien secara cepat dilepaskan dari ventilator dan pressor. Dopamin Dopamin adalah katekolamin endogen yang menstimulasi reseptor beta-1 dan alfa-1 adrenergik dan dopaminergik pada ginjal dan pembuluh darah splanknik, menyebabkan vasodilatasi pada pembuluh darah splanknik. Dalam dosis menengah (5-15 mikrogram/kg/menit), obat ini bekerja pada reseptor beta adrenergik untuk meningkatkan denyut jantung dan kontraktilitas. Pada dosis tinggi (15-20 mikrogram/kg/menit) obat ini bekerja pada reseptor alfa adrenergik untuk meningkatkan resistensi vaskuler sistemik dan meningkatkan tekanan darah. Dobutamin Dobutamin adalah amin simpatomimetik dengan efek lebih kuat pada beta daripada alfa. Obat ini meningkatkan kondisi inotropik. Penguatan vasopressor koroner dan aliran darah serebral selama keadaan aliran rendah dihubungkan dengan hipotensi berat. Dopamin dan dobutamin adalah obat pilihan untuk meningkatkan kontraktilitas jantung dengan dopamine merupakan agen terpilih pada pasien hipotensi. Dosis yang lebih tinggi dapat menyebabkan peningkatan denyut jantung, eksaserbasi iskemi miokard. Epinefrin Obat ini memiliki efek agonis alfa meliputi peningkatan resistensi vaskuler perifer, vasodialtasi perifer, hipotensi sitemik, dan permeabilitas vaskuler. Efek agonis beta2 meliputi bronkodilatasi, aktivitas kardiak kronotropik, dan efek inotropik positif. Norepinefrin Norepinefrin menstimulasi reseptor beta1 dan alfa adrenergik, meningkatkan kontraktilitas otot jantung dan denyut jantung, seperti halnya vasokontriksi. Hasil ini dalam tekanan darah sistemik dan meningkatkan aliran darah coroner. Setelah mendapatkan respon, tingkat aliran sebaiknya disesuaikan dan dijaga pada tekanan darah rendah-normal, seperti 80-100 mmHg sistolik, cukup untuk perfusi organ vital. Sumber: Medscape. Available from: http://emedicine.medscape.com/article/429816-medication#3 Gambar diambil dari http://heartfoundation2009.com/wp-content/uploads/2010/11/heart-transplantation.jpg

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How to Memorize Heavy Content Quickly

Instructions o 1 For years, I would go through unnecessary stress when it came to learning my lines quickly. I would find one of my friends who would take the time to read the script with me or read along with me as I worked my way through a monologue or speech. The problem with that was, that no matter how much my friends showed their support by rehearsing with me, they would eventually get tired, regardless of how much material I had left to memorize. Then one day an idea hit me like a lightbulb. With a script, how would it work if I read my lines to myself, a little slower than normal, and read everyone else's lines aloud and into a recording device? Back then, it was a tape recorder, but today there are digital recording devices so small they can fit in the palm of your hand and hold several hours of storage. The tape recorder worked even better than a live person because the recording device never gets tired. I can rehearse that scene as many times as I desire just by the push of a button. Suddenly, I was learning lines in half the time. o 2 This technique was put to the test when I was asked to replace a lead actor unexpectedly and told to be ready to perform in three days. On the first day of rehearsal, I went through and wrote down all the blocking so that when I rehearsed with my recording device, I was also rehearsing dialogue and blocking together. During that time, I also noticed that this technique allowed me to learn blocking in half the time as well. To memorize a large amount of content, whether it be a script, monologue or speech, you must memorize it a little bit at a time or your brain will get overwhelmed. First, read through the material you need to memorize, four to five times in its entirety. After about the fifth time, you will notice that you're beginning to remember sections of the content, sometimes almost half of it, without looking at the material. Also, by the fifth time or so, you usually have given yourself enough time to understand what you're reading. Once you really understand the material, no matter what it is, that is half the battle. And your brain will say, "That's no so bad. Let's learn some more." The key to memorizing anything is to avoid overwhelming the brain with trying to remember too much content at one time. Depending on how heavy the exchanges are, I divide scripts into pages unless you have a monologue, which I will cover later. With your recording device, rehearse the first page repeatedly until you have memorized your lines on the first page. Then move on to the next page. Once you have memorized the second page, rehearse the first two pages together until you have those two pages completely memorized. ontinue the same process with the third page until you have completed all of the pages. That's the most time-consuming part of the process. Once you have all the pages memorized individually, you are ready to rehearse them all together over and over again. This can be done while driving, while waiting idly at some location or by making some time at home. The recording device will never get tired. o 3 Now when you work with monologues or speeches, the memorization process is similar. The only difference being that you don't need the recording device to interact with. However, if you have a recording device, it still has a useful job. First, read your entire content into the recording device. Then listen to that content while driving or while napping or retiring for the evening. This may seem ridiculous, but your subconscious mind never sleeps. When it comes time to work on memorizing the material, you will be amazed how familiar the material seems to you because your brain has been exposed to it. o 4 Just as we did with the script earlier, take your content and divide it evenly into sections. You will work on each section individually before moving on to the next section. As you add a new section and memorize it, repeat both memorized sections together. Then, add the next section. Repeat this process until you have the entire content memorized. Once you have memorized all the content and feel confident, go to a mirror and perform the content to your reflection. This step will feel strange at first but will simulate what it feels like to have an audience. Your reflection is your first audience member. Looking yourself in the eyes as you deliver your content will help quell the fear of being in front of an audience for the first time. This is also the time to use any supportive family members or friends who are willing to listen to you deliver your content as well. Repeat the content to yourself at least five times perfectly each day. If you mess up at any part, that doesn't count. Go back and start again. This could mean it may take you 10 times to deliver five perfect run-throughs. Once you have successfully made it through your five perfect run-throughs without error, you are ready to perform it once a day, perfectly, until performance day. o 5 Whether you perform your content in front of a camera or a large audience, the feeling is the same. Once the excitement of the event hits you shortly before your performance, your adrenalin will have your heart racing. If you have rehearsed your material as described, your adrenalin will work to your advantage and lead to a well-performed speech or monologue. If you are not well-rehearsed, that same adrenalin will cause you to be a nervous wreck moments before and end up with a horrible performance. Feeling out of control or nervous because of a lack of preparation or poor rehearsal time doesn't always mean a disaster. If you studied the material to the point that you understand what you are saying, that one element alone can help you make it through to the end and leave with the satisfaction that you avoided a disaster. Read more: How to Memorize Heavy Content Quickly | eHow.com http://www.ehow.com/how_2301463_memorize-heavy-content-quickly.html#ixzz2958ccB5l

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Innovation Is A State Of Mind

You probably know the myth of innovation as a sudden flash of insight that comes from nowhere. We read about that "aha" moment, or that light bulb turning on in the mind of some inventor or innovator, and this is true to an extent. Einstein really did get flashes of insight while shaving in the morning. However, he was of course working on the particular problems he had insight into, and he didn't suddenly have ideas for new kitchen gadgets or movie plots.

Einsteins innovations, in other words, no matter how "sudden" the original ideas were, came from past and present mental work. It is like a singer who works at his craft for ten years and then becomes an "overnight success." Innovative people only have "sudden" new ideas because they have habitually worked and thought in certain ways for some time. If you want to become an innovative thinker, then, why not start cultivating those mental habits?

Mental Habits Lead To Innovation

Problems can be opportunities. "Problem" may have a negative connotations, such as being a hassle or stressful, but any problem can lead to an innovation that improves our lives. Not knowing the time lead to clocks small enough to put on our wrists. Nasty diseases lead to sanitary sewer systems. Start looking for opportunity in every problem. Even a mundane problem like not having enough storage space could lead to a new innovation. You may just build a plywood floor in the attic, but you could invent a new type of outdoor storage unit.
Innovation begins with understanding the key elements. Metal, wood or glass are not key elements of a door to an innovator. A way to get in, a way to keep others out - these are key elements. Begin with these, and soon you're imagining new ways to make a door. You could design a door that is opened by your voice (nice when your hands are full), or one that shuts and locks itself when anyone else approaches. Think of the key elements in things.

Attitude helps innovation. The creative problem-solving technique of concept-combination involves combining two ideas to see what new idea or product results. The crucial point is that you assume there will be a useful new idea. Starting with that assumption, your mind will work overtime to produce something. A shoe and a CD have nothing to do with each other, but it took just a minute to imagine a CD player with headphones that only plays the music correctly if a jogger maintains his ideal pace. When you assume there is something there you'll often find something.

Playfulness helps innovation. A playful mind is a creative mind, and while high IQ doesn't correlate with creativity, put it together with playfulness, and you have an Einstein. Remember, he imagined himself riding on a beam of light in order to arrive at his theory of relativity. Why not start playing with ideas and things, in your mind and in your surroundings. Innovation should be fun.

How To Barbeque Perfect BBQ Ribs

If you are grilling BBQ ribs on a regular charcoal grill, then you're probably frustrated when you find that your ribs are tough instead of "meat falling off the bones" tender. If this is the case, then you can learn how to barbeque perfect ribs easily by preparing your ribs properly in advance, before you ever place them on your grill.

Most master grillers prepare their ribs first, before cooking them on a charcoal grill. This is why some grillers cook perfect ribs every time. Usually at a BBQ event, guests see the cook placing the ribs on the grill, never knowing that work was done beforehand to get the ribs ready. Those new to grilling assume that the cook is just brushing sauce on the ribs, and then cooking them until done directly on the grill and this isn't always so.

To prepare your ribs, first bring a large pot of water to a boil. You should do this the day before your BBQ event or dinner. Add a bit of salt to the water, and then bring it down to a simmer. Add your ribs, cover and simmer them for 1 to 2 hours and then carefully remove them from the pot. Your ribs should be tender and juicy now, but you shouldn't place them on the grill just yet.

Place them in a large bowl, add your BBQ sauce, cover and refrigerate this overnight. This provides ample time for the ribs to marinate in the sauce, to produce that rich BBQ flavor that everyone loves so well.

The next day, light your grill and let the coals die down to warm glowing embers. You should never BBQ your ribs over an open flame; this can burn the sauce and ruin the flavor of your BBQ ribs.
Once the flames have died down, brush some more sauce on your ribs and place them directly on the grill. Cook for 10 minutes, brush some more sauce on the top of the ribs, turn and cook the other side for 10 minutes. Continue cooking the ribs in this fashion until they are fully done, turning your BBQ ribs every 10 minutes while adding fresh sauce at every turn.

Once your ribs are done, place them on a serving platter and serve while they are still hot. Your guests will go crazy over your delicious, juicy and tender ribs. This is the proper way to cook perfect BBQ ribs. If you just throw the ribs on a grill, without preparing them first, then your ribs will be very tough and not very good no matter what type of sauce is used.

BBQ sauce is used to add flavor, not to cover up inferior cooking. Don't you owe it to yourself and to your dinner guests to go that extra mile, ensuring that your ribs are not only tasty, but also mouth watering tender? You'll be known as the best BBQ rib griller in your area. Especially if you combine your juicy and tender ribs with your very own homemade BBQ rubs, sauce or marinades instead of using those pre-bottled sauces provided in local grocery stores.

Important Information Before Going To Brazil

Brazil has a very diverse culture and a wonderful climate. Summer starts in December and ends in February in this South American country. So before going on a trip to Brazil, one has to have enough information on what to bring. Here are a few tips to help in deciding in what to prepare for a trip to this fine country.

* Protect your photo equipment and other equipment sensitive to humidity.

Humidity is high in Brazil. Sealable plastic bags are also useful, so make sure to bring some.

* Bring your medication and prescription.

If you brought some medication, make sure you declare it at the Customs. There are also some drugs that can be bought from the chemist without a prescription.

* Buy mosquito repellent and sun block when you get there.

These are of good quality and are suitable formulated for the conditions of the country.

* Get Hepatitis shots before leaving for Brazil.

Hepatitis A, B and C cases are prevalent in Brazil. Also, always wash your hands before eating. Use appropriate disinfectants and antiseptics.

* Pack light

Most air carriers have a luggage limit of 20 kilos. Having your clothes washable and mix-matched for different look is more advisable than carrying more clothes. When not on a business trip, pack casual clothes as most Brazilians dress casually.
<* Keep copies of all your important documents.

You may leave copies of these with a friend back home, or keep copies in a separate location from the originals. You can also email the copies to yourself.

* Bring a pair of sandals

If the reason for the trip to Brazil is the beaches, then a pair of sandals, together with one's bathing suit and hat is necessary.

* Bring some deodorant and perfume.

One sweats too here and these essentials are very handy.

* Never leave your belongings unattended.

If you can settle for disposable cameras, then, do so.

* Learn some Portuguese.

Knowledge of Portuguese can help when communicating with the locals. English, Spanish, German, French and Italian are also spoken in tourist areas.

* Have valid entry documents.

One's passport should be valid for at least six months from the date of entry. Foreign tourists are given a maximum of 180 days to stay in 1 year. Renewals for 90 days may be obtained from Policia Federal.

* Have some cash handy.

Major credit cards- MasterCard, Visa, Amex and Diners - are accepted, as well as traveler's checks. Cash will be needed if you are going outside the major cities.

With these guidelines, one can look forward to having an enjoyable travel to Brazil.

Blog And Ping Software Review

There are many people who ask as to which are the best blog and ping softwares around. Blog and ping softwares are softwares that can automatically post information and links from your websites to the blog sites so that they can be easily searched by sites like Google and Yahoo. The final result is that your site will become more famous and will reach the top rankings in Google and other search sites.

Wordpress and RSS to Blog are one of the most widely used softwares by people all over the world. They automatically send information about your site and links to all the blog sites at the click of a button. They can save your list of links for future use also. Another very good software to use for blog and ping is BlogSolution. BlogSolution is one of the most advanced blog, ping and SEO softwares around. It brings in results quickly and it is very effective. You can make your site easily searchable by search engines as the software posts your links directly on thousands of blogs in one go. The whole process can be achieved thorough the click of a button.

BlogSolution can at least creates hundred blogs a second using its own highly advanced blogging platform. BlogSolution is a multi manager as all your BS2 domains can be managed from a single place. It easily interlinks your sites and also posts one way links to your sites. There is a very good feature by the name of Smartjobs that automatically creates blogs in your absence

BlogSolution indexes entries very quickly using the Indexing Turbocharger which leads to extremely fast indexing. BlogSolution can get more spiders than any other blog software at present. The interface of BlogSolution is extremely simple to use and is very user friendly. You can learn the full use of BlogSolution within a short period of time with its help tool. There are also video tutorials provided with the package. Using BlogSolution you can post hundreds of one way links on various sites.

If you use BlogSolution then you don't need to use any other blogging solution. BlogSolution takes care of all your blogging needs and brings in positive results for your site very quickly. If you would like to test BlogSolution first before buying it then you can download demo software from the BlogSolution website. Once you are satisfied with its performance you can buy the software online paying through your credit card.

Hence we see that BlogSolution is the best blog solution ever found. The users of BlogSolution have found it to be extremely effective and also they would not like to use any other blog software. It is the next generation software that has taken the world by storm with its simple user interface and bringing in positive results for all its customers. Watch your income grow as more and more people can find your website on the search engines and order for products and services.

Blog Your Way To Traffic!

Using a blog has become one of the most popular methods of promoting an affiliate program today. What is great about a blog is that in many cases you can post it free. Blogs serve a great number of purposes today and promoting your affiliate program is just one of the many uses for a blog. Why should you spend hundreds or thousands of dollars in promotion and advertisement of your affiliate program? All you need is a free blog and some good information to offer your visitors. With these two simple items, you could dramatically increase the amount of traffic you get for your affiliate program. Why all the hype about blogs anyway? What is a blog? Well, if you have not discovered a blog by now, you have been living in the dark. Blogs are everywhere and include information about many different things. Take, for instance, using a blog to promote your affiliate program. All you need to do is generate a few articles or stories about your specific affiliate program. They can be about anything at all. Consider articles such as how to use your specific program, what is special and unique about your program, why people should use it and how they can benefit from your affiliate program. Ok so I create a blog, now what? The key point in posting a blog, is to generate interest in your users and make them click that ever-special link directly to your affiliate program. Now, that being said, an important key that everyone should know about blogging is that you should post to your blog each and every day at least once per day. Doing so will help drive people to your blog and further on to your affiliate program. That means more traffic for you.

How To Interview A Wedding Photographer

The photographer is going to be your employee in many ways, so you will need to be absolutely sure that this is a person that you can trust with your wedding pictures. Treat him or her like a job applicant and see how you interact with each other. Making a list You can find a list of wedding photographers in your local phone book, but it's much easier to get onto a wedding website and see who local people recommend. This list is much shorter and can lead you to higher quality people without having to call everyone from A to Z. Once you have a list of photographers, start to call them to set up appointments. Try not to schedule them too close to each other so that you can spend as much time as you need with each one. If you're rushed, you may forget to ask particular questions and you may also forget which photographer said what. Make a list of questions that you want to ask. You can ask about pricing, hourly fees, added costs, location costs, various developing techniques, and more. Try to think of every question that you and your soon-to-be spouse can, even if you think they sound silly. No question is too silly, and if the photographer has been around long enough, then they will have heard them all. Your interview style One of the things that works best in talking with photographers is to try to make sure that you are leading the conversation. You want to make sure that you are getting your opinion into the talks, rather than being told what other couples are doing and saying about them and how much their fees are. If you feel like you're being sold a product, rather than an opportunity to have some great pictures, then you can cut the appointment off and leave. You have no obligation to choose anyone until you're completely satisfied with your choice. Look at the samples carefully and make sure that you're looking at ones that are recent. Sometimes photographers will try to show you older photos, but if that's not your style, then it's really not applicable. Study the quality of the pictures and look for poses that you like. Your pictures will serve as a reminder of the happiness and joy of your wedding day. You need to find someone who will create masterpieces of your photos. Take your time in finding someone, but do it early-if you live in a smaller town, these professionals can book up early.

Bass Fishing for fun

Bass fishing in the USA is a great combination of sports, adventure and recreation. Bass fishing ,means pursuing black bass, a type of fish. Bass fishing has caught the fancy of Americans. You will find morning shows on TV about bass fishing. You will find thousands of websites exclusively on bass fishing. Bass fish is not about catching and eating. It is about catching and releasing. Bass fishing is a great sports which doesn't need the skills possessed by a football athlete or the resilience of an acrobat. You need to be obsessed with the 'catch'. Hours of practicing can elevate you to the level of being called a pro. Bass fishing is about catching various species of bass - large mouth bass, small mouth bass, Kentucky bass, spotted boss, etc. Experts opine that the beginners should start bass fishing in smaller ponds. They should avoid large lakes for this purpose. Once you have gained enough confidence, then only move to deeper areas in lakes. Bass fish loves to play hide and seek. Their natural habitat is behind rocks or plants or any such structures in the water body. Look for bass in such places. It is not necessary that the fish will be around large structures only. In fact, you have an equal probability of finding fish near a smaller structure Bass fish have a great vision - they can easily see in the night as well. Their see and feel organs work simultaneously. Bass fish are also supposed to have taste buds outside their mouths and inside too. This can help them avoid any unwanted situation. These characteristics make bass fishing such an exciting sports activity and a great pastime for people in leisure time. One needs a set of equipment for bass fishing. This includes a pole, reel, hook and baits. Baits are available in many varieties chiefly, jigs, crank bait, spinner bait and plastic worms. It is recommended to beginners to start with crank baits and then advance themselves through spinner baits to plastic worms. Plastic worms need the most skills and practice. While Crank baits are suitable for beginners, it is the spinner baits which are popular among experienced anglers and seasoned fishermen. There are many tournaments of bass fishing. Premier among these are American Bass Anglers Fishing Tournament, Superbass tournament, etc. Enthusiasts from all over the country take part in the tournaments. Bass fishing brings so much excitement today that it has become the most valuable freshwater sports industry.

Impossible is Just a Word

Everyone, at some point of his or her life, has dreamed of being somebody special, somebody big. Who hasn't fantasized about being the one who hits the game-winning homer? Who hasn't dreamed of being the homecoming queen? And how many times have we dreamed of being rich, or successful, or happy with our relationships? Often, we dream big dreams and have great aspirations. Unfortunately, our dreams remain just that – dreams. And our aspirations easily collect dust in our attic. This is a sad turn of events in our life. Instead of experiencing exciting adventures in self actualization, we get caught up in the humdrum of living from day-to-day just barely existing. But you know what? Life could be so much better, if only we learned to aim higher. The most common problem to setting goals is the word impossible. Most people get hung up thinking I can't do this. It's too hard. It's too impossible. No one can do this. However, if everyone thought that, there would be no inventions, no innovations, and no breakthroughs in human accomplishment. Remember that scientists were baffled when they took a look at the humble bumblebee. Theoretically, they said, it was impossible for the bumblebee to fly. Unfortunately for the bumble, bee no one has told it so. So fly it does. On the other hand, some people suffer from dreaming totally outrageous dreams and not acting on them. The result? Broken dreams, and tattered aspirations. If you limit yourself with self-doubt, and self-limiting assumptions, you will never be able to break past what you deem impossible. If you reach too far out into the sky without working towards your goal, you will find yourself clinging on to the impossible dream. Try this exercise. Take a piece of paper and write down some goals in your life. Under one header, list down things 'you know you can do'. Under another header, write the things 'you might be able to do.' And under one more, list the things that that are 'impossible for you to do.' Now look at all the headers strive every day to accomplish the goals that are under things 'you know you can do'. Check them when you are able to accomplish them. As you slowly are able to check all of your goals under that heading, try accomplishing the goals under the other header-the one that reads 'you might be able to do.' As of the items you wrote under things I could do are accomplished, you can move the goals that are under things that are 'impossible for you to do' to the list of things 'you might be able to do.' As you iterate through this process, you will find out that the goals you thought were impossible become easier to accomplish. And the impossible begin to seem possible after all. You see, the technique here is not to limit your imagination. It is to aim high, and start working towards that goal little by little. However, it also is unwise to set a goal that is truly unrealistic. Those who just dream towards a goal without working hard end up disappointed and disillusioned. On the other hand, if you told someone a hundred years ago that it was possible for man to be on the moon, they would laugh at you. If you had told them that you could send mail from here to the other side of the world in a few seconds, they would say you were out of your mind. But, through sheer desire and perseverance, these impossible dreams are now realities. Thomas Edison once said that genius is 1% inspiration and 99% perspiration. Nothing could be truer. For one to accomplish his or her dreams, there has to be had work and discipline. But take note that that 1% has to be a think-big dream, and not some easily accomplished one. Ask any gym rat and he or she will tell you that there can be no gains unless you are put out of your comfort zone. Remember the saying, "No pain, no gain"? That is as true as it can be. So dream on, friend! Don't get caught up with your perceived limitations. Think big and work hard to attain those dreams. As you step up the ladder of progress, you will just about find out that the impossible has just become a little bit more possible. Find even more self-improvement related information at http://www.selfimprovement.thegreat.info .