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B cells whose V regions have acquired mutations that improve the affinity of the B-cell receptor for antigen are able to compete more effectively for antigen symptoms bipolar disorder generic cabgolin 0.5 mg on line, and receive signals that drive their proliferation and expansion. This process of mutation and selection can continue in the lymph node germinal center through multiple cycles in response to secondary and tertiary immune responses elicited by further immunization with the same antigen (center and bottom panels). In this way, the antigen-binding efficiency of the antibody response is improved over time. Some of the proliferating B cells undergo repeated cycles of entry to the dark zone, mutation, and selection (fourth panel), and other progeny B cells undergo differentiation to either memory B cells or plasma cells (not shown). Radiolabeled antigen localizes to , and persists in, lymphoid follicles of draining lymph nodes (see the light micrograph and the schematic representation (middle panel), showing a germinal center in a lymph node). The intense dark staining shows the localization in the germinal center of radiolabeled antigen that had been injected 3 days previously. These complexes are not internalized, as such antigen can persist in this form for long periods. In panels b and c, the iccosome has been formed with immune complexes containing horseradish peroxidase, which is electrondense and therefore appears dark in the transmission electron micrographs. In this way, the affinity and specificity of B cells are continually refined during the germinal center response, through affinity maturation (see Section 10-6). This condition leads to the production of predominantly IgM antibodies and the absence of affinity maturation, a syndrome known as hyper IgM type 2 immunodeficiency (discussed in Chapter 13). Somatic hypermutation does not occur in loci that are not being actively transcribed. Some actively transcribed genes in B cells besides those for immunoglobulins can also be affected by the somatic mutation process, but at a much lower rate. Repair of the single-strand nick proceeding through double-strand breaks may result in gene conversion. Gene conversion is not used in the diversification of immunoglobulin genes in humans and mice, but is of importance in some other mammals and in birds. Acting together, these can generate point mutations at and around the site of the original C:G pair. In class switch recombination, single-strand breaks made in two of the so-called switch regions upstream of the C-region genes are converted to double-strand breaks. Individuals with a defect in the translesion polymerase Pol have relatively fewer mutations than usual at A:T, but not at C:G, in their hypermutated immunoglobulin V regions. This fact suggests that Pol is the repair polymerase involved in this pathway of somatic hypermutation. The first antigen receptors expressed by B cells are IgM and IgD, and the first antibody produced in an immune response is always IgM. Later in the immune response, the same assembled V region may be expressed in IgG, IgA, or IgE antibodies.

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One single-center study of patients undergoing atriofascicular pathway ablation reported 71% freedom from tachycardia after mean 9 treatment 3 nail fungus generic 0.5 mg cabgolin with visa. Radiofrequency catheter ablation of right atriofascicular (Mahaim) accessory pathways guided by accessory pathway activation potentials. Characteristics of the ventricular insertion sites of accessory pathways with anterograde decremental conduction properties. Effects of right bundle branch block on the antidromic circus movement tachycardia in patients with presumed atriofascicular pathways. Modulation of conduction and refractoriness in atrioventricular junctional reentrant circuit. The atrioventricular interval during pre-excited tachycardia: A simple way to distinguish between decrementally or rapidly conducting accessory pathways. Predictors of longterm success after catheter ablation of atriofascicular accessory pathways. The key maneuver (as discussed earlier) is insertion of an atrial premature beat when the septal A is refractory. If this maneuver resets the tachycardia, then the atrium and atriofascicular pathway are part of the circuit and constitute strong evidence for an atriofascicular tract. Care must be taken to correctly diagnose the arrhythmia circuit and even greater attention must be given during the ablation procedure to avoid inadvertent damage to the pathway. Nouvelles recherches sur les connexions superieures de la branche gauche du faisceau de His-Tawara avec cloison interventriculaire. Catheter ablation in this group of patients tends to be more difficult than in those with structurally normal hearts, and although cases may be straightforward, they can make for a long and difficult day. Hemodynamic instability during tachycardia, low-frequency and fragmented signals, difficulty locating and maintaining stability on the tricuspid annulus, and multiple pathways are just some of the challenges that may arise. Patients may have other coexisting cardiac anomalies, most commonly ventricular septal defects and pulmonary stenosis. Although some infants require early surgical intervention, a majority of individuals do not require any intervention for years. Over time, however, tricuspid regurgitation leads to atrial and ventricular enlargement, widening of the tricuspid valve annulus, and possible right-to-left shunting (a majority of patients will have an atrial-level communication consisting of a patent foramen ovale or a secundum atrial septal defect). The exception is the congenitally corrected transposition with an Ebsteinoid left-sided systemic tricuspid valve. Atriofascicular pathways (so called Mahaim fibers) can also be seen in this population but are less common. With age, atrial dilation can lead to atrial flutter, intra-atrial reentrant tachycardia, and atrial fibrillation.

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The strength in the lower extremities is 3 out o 5 with decreased deep tendon re exes symptoms definition purchase cabgolin us. Sensation to light touch and pinprick also demonstrates a decrease in perception to the level o 8. Sheets o small, round cells with dark nuclei, scant cytoplasm, and salt-and-pepper chromatin with indistinct nucleoli; requent mitotic gures are also seen 34. A 32-year-old A rican American man presents to the emergency department with progressive lower extremity weakness that has been present or the past month. He also has been experiencing loss o sensation and aching pains in his mid-back and a sensation o incomplete voiding with mild urinary incontinence. His past medical history is signi cant or a stab wound to the le chest 9 months prior. Physical examination con rms lower extremity paresis with strength o only 3/5 and decreased deep tendon re exes. Gadolinium administration shows enhancement in a nodular ashion o the sur ace o the cord. A chest radiograph demonstrates enlargement o the hilar lymph nodes without pulmonary in ltrates. On chest C, bilateral hilar, subcarinal, and precarinal lymphadenopathy is observed with 35. A 32-year-old woman presents or neurologic evaluation a er experiencing a severe burn on the palm o her right hand. She did not eel the burn when it occurred, and only when she picked her hand up did she notice the burn. A er that, it was discovered that the patient unknowingly has bilateral loss o pain and temperature sensation in both hands. Mapping o her loss o sensation shows decreased pain sensation in the nape o her neck, shoulders, and upper arms as well in a capelike distribution. Deep tendon re exes are absent at the biceps and triceps, and there is visible muscle wasting o the right biceps and shoulder musculature. She has had intermittent blurring o her vision or the past 2 months, although it has been more persistent or the past 2 weeks. She states that she also notes that colors seem less vivid and that her symptoms are worse in the right eye. T ree months ago, she did notice some sharp pains in the right eye that were worse when she looked around. At the same time, she eels as though she is sti in her legs and also eels that her le leg is weak. Her past medical history is signi cant or type 1 diabetes mellitus or which she uses an insulin pump. On physical examination, there is spasticity in both o her lower extremities with passive motion.

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Increased signal is seen in the border zones bilaterally between the middle cerebral artery and anterior cerebral artery territories medications i can take while pregnant buy discount cabgolin line. T rombus in the heart itsel as well as atheromas in the aortic arch can become dislodged during cardiac surgeries, releasing a shower o particulate matter into the cerebral circulation. Cross-clamping o the aorta, manipulation o the heart, extracorporeal circulation techniques ("bypass"), arrhythmias such as atrial brillation, and introduction o air through suctioning have all been implicated as potential sources o emboli. Histologic studies indicate that literally millions o tiny emboli may be released, even using modern surgical techniques. Occasionally, a single large embolus leads to an isolated large-vessel stroke that presents with obvious clinical ocal de cits. When there is a high burden o these small emboli, an acute encephalopathy can occur postoperatively, presenting as either a hyperactive or hypoactive con usional state, the latter o which is requently and incorrectly ascribed to depression or a sedative-induced delirium. Filters placed in the aortic arch may have some promise in capturing these emboli, although convincing evidence is lacking. Neurologic consultants should view these patients as a special population at risk or both unique neurologic complications as well as or the usual disorders ound in any critically ill inpatient. Immunosuppressive medications are administered in high doses to patients a er solid organ transplant, and many o these compounds have well-described neurologic complications. In patients with headache, seizures, or ocal neurologic de cits taking calcineurin inhibitors, the diagnosis o hyperper usion syndrome should be considered, as discussed above. This neurotoxicity occurs mainly with cyclosporine and tacrolimus and can present even in the setting o normal serum drug levels. Sirolimus has very ew recorded cases o neurotoxicity and may be a reasonable alternative or some patients. In any solid organ transplant patient with neurologic complaints, a care ul examination o the medication list is required to search or these possible drug e ects. Cerebrovascular complications o solid organ transplant are o en rst recognized in the immediate postoperative period. Border zone territory in arctions can occur, especially in the setting o systemic hypotension during cardiac transplant surgery. Embolic in arctions classically complicate cardiac transplantation, but all solid organ transplant procedures place patients at risk or systemic emboli. When cerebral embolization accompanies renal or liver transplantation surgery, a care ul search or right-to-le shunting should include evaluation o the heart with agitated saline echocardiography. Renal and some cardiac transplant patients o en have advanced atherosclerosis, providing yet another mechanism or stroke. Given that patients with solid organ transplants are chronically immunosuppressed, in ections are a common concern. In the rst month posttransplant, common pathogens include the usual bacterial organisms associated with surgical procedures and indwelling catheters.

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An exception is the syndrome o IgM kappa monoclonal gammopathy associated with an indolent medications used to treat bipolar order cabgolin 0.5 mg overnight delivery, longstanding, sometimes static sensory neuropathy, requently with tremor and sensory ataxia. Management o these neuropathies, including the "nonsystemic" vasculitic neuropathy, consists o treatment o the underlying condition as well as the aggressive use o glucocorticoids and cyclophosphamide. Use o these immunosuppressive agents has resulted in dramatic improvements in outcome, with 5-year survival rates now greater than 80%. Recent clinical trials ound that the combination o rituximab and glucocorticoids is not in erior to cyclophosphamide and glucocorticoids. The onset is of en asymmetric with dysesthesias and sensory loss in the limbs that soon progress to a ect all limbs, the torso, and the ace. Marked sensory ataxia, pseudoathetosis, and inability to walk, stand, or even sit unsupported are requent eatures and are secondary to the extensive dea erentation. An encephalomyelitis may accompany the sensory neuronopathy and presumably has the same pathogenesis. The sensory neuronopathy runs its course in a ew weeks or months and stabilizes, leaving the patient disabled. Failure o transmission at many neuromuscular junctions results in weakness o muscle contraction. In the myasthenic patient, the decreased e ciency o neuromuscular transmission combined with the normal rundown results in the activation o ewer and ewer muscle bers by successive nerve impulses and hence increasing weakness, or myasthenic fatigue. This mechanism also accounts or the decremental response to repetitive nerve stimulation seen on electrodiagnostic testing. T us, immunotherapeutic strategies directed against either the antibodyproducing B cells or helper cells are e ective in this antibody-mediated disease. It a ects individuals in all age groups, but peaks o incidence occur in women in their twenties and thirties and in men in their f ies and sixties. The weakness increases during repeated use (atigue) or late in the day and may improve ollowing rest or sleep. Exacerbations and remissions may occur, particularly during the rst ew years af er the onset o the disease. Unrelated in ections or systemic disorders can lead to increased myasthenic weakness and may precipitate "crisis" (see below). Facial weakness produces a "snarling" expression when the patient attempts to smile. Speech may have a nasal timbre caused by weakness o the palate or a dysarthric "mushy" quality due to tongue weakness.

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I a patient experiences any additional episodes o major depression symptoms 7 days after embryo transfer buy cheap cabgolin, he will likely require inde nite maintenance treatment because it is recommended that anyone with more than two episodes o major depression continue treatment inde nitely. Patients should be screened or an alcohol use disorder by asking speci c questions regarding alcohol consumption, although many patients may minimize their alcohol use. The patient in the scenario presented reports daily alcohol consumption and some symptoms o an alcohol use disorder, including blackouts rom drinking and requent hangovers while working. Laboratory tests may be help ul in this situation as they can be elevated in individuals who regularly consume six or more drinks daily. Using both o these tests combined is more likely to be accurate than using either test alone. One actor that increases absorption is rapid gastric emptying, which can be induced by concurrent consumption o carbonated beverages. Another actor that increases absorption rom the gut to the blood is the ingestion o alcohol in the absence o other calorie sources such as proteins, at, or carbohydrates. A nal actor that can increase absorption is drinking o alcohol that is diluted to a modest concentration (~20% or less). At high alcohol concentrations, absorption is decreased, although high blood levels may be achieved because the amount o alcohol ingested is high. The euphoric e ects o alcohol consumption are related to increases in dopamine, which is common to all pleasurable activities. In addition, alcohol alters opioid receptors and can lead to a release o -endorphins during acute ingestion. Glutamate is the primary excitatory neurotransmitter o the brain, and its inhibition urther contributes to the sedative e ects o alcohol. Additional important e ects on neurotransmitters include increased serotonin activity and decreased nicotinic acetylcholine receptors. Light coma and depression o respiratory rate, blood pressure, and pulse occur at levels around 0. However, in individuals who drink heavily, tolerance begins to develop to alcohol. Cellular or pharmacodynamic tolerance also occurs and re ers to the neurochemical changes that allow an individual to maintain more normal physiologic unction despite the presence o alcohol. The individual in this case scenario is likely alcohol dependent given his large amount o alcohol intake on a daily basis. Symptoms o alcohol withdrawal can range rom mild tremulousness to hallucinations, seizures, or development o delirium tremens. Other clinical eatures o alcohol withdrawal include anxiety, insomnia, and autonomic nervous system overactivity mani ested as tachycardia, tachypnea, elevated blood pressure, and ever. This patient exhibits symptoms o the more severe delirium tremens, with mental con usion, agitation, and uctuating levels o consciousness.

Syndromes

• Night sweats
• Excessive bleeding
• Disorientation
• In the face and around the eyes (facial swelling)
• The contract should list the rules and what teens can expect if rules are broken.
• Endoscopic ultrasound (EUS)
• Problems finding words
• Weight loss (you will need to eat extra calories)
• Neuroretinitis

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The hypernatremia caused by excessive retention or intake o sodium can be distinguished by the presence o thirst as well as the physical and laboratory signs o hypervolemia rather than hypovolemia treatment 3 phases malnourished children 0.5 mg cabgolin purchase with amex. This amount plus an allowance or continuing insensible and urinary losses should be given over a 24to 48-h period. I hyperglycemia and/or hypokalemia are present, insulin and/or potassium supplements should be given with the expectation that both can be discontinued soon a er rehydration is complete. Plasma urea/creatinine should be monitored closely or signs o acute renal ailure caused by rhabdomyolysis, hypovolemia, and hypotension. A long-term management plan to prevent or minimize recurrence o the uid and electrolyte imbalance also should be developed. This should include a practical method to regulate uid intake in accordance with variations in water balance as indicated by changes in body weight or serum sodium determined by home monitoring analyzers. Prescribing a constant uid intake is ine ective and potentially dangerous because it does not take into account the large, uncontrolled variations in insensible loss that inevitably result rom changes in ambient temperature and physical activity. The hypovolemic orm typically occurs in disorders such as severe diarrhea, diuretic abuse, or mineralocorticoid de ciency. One is a nonhemodynamic stimulus such as nausea or a cortisol de ciency, which can be corrected quickly by treatment with antiemetics or cortisol. The other is a primary de ect in osmoregulation caused by another disorder such as malignancy, stroke, or pneumonia that cannot be easily or quickly corrected. Clin ica l cha ra cteristics Antidiuresis o any cause decreases the volume and increases the concentration o urine. I not accompanied by a commensurate reduction in uid intake or an increase in insensible loss, the reduction in urine output results in excess water retention which expands and dilutes body uids. I the hyponatremia develops gradually or has been present or more than a ew days, it may be largely asymptomatic. However, i it develops acutely, it is usually accompanied by symptoms and signs o water intoxication that may include mild headache, con usion, anorexia, nausea, vomiting, coma, and convulsions. Other clinical signs and symptoms vary greatly, depending on the type o hyponatremia. The hypervolemic orm is characterized by generalized edema and other signs o marked volume expansion. All three orms are associated with a ailure to ully dilute the urine and mount a water diuresis in the ace o hypotonic hyponatremia. The inappropriate antidiuresis in these patients appears to be permanent, although the hyponatremia is variable owing presumably to individual di erences in uid intake. T us, an increase in body water o 10% (~4 L in a 70-kg adult) reduces plasma osmolarity and sodium by approximately 10% (~28 mosmol/L or 14 meq/L). An increase in body water o this magnitude is rarely detectable on physical examination but will be re ected in a weight gain o about 4 kg. It also increases glomerular ltration and atrial natriuretic hormone and suppresses plasma renin activity, thereby increasing urinary sodium excretion. The resultant reduction in total body sodium decreases the expansion o extracellular volume but aggravates the hyponatremia and urther expands intracellular volume.

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Human atrial fibrillation drivers seen simultaneously by focal impulse and rotor mapping and high-resolution optical mapping [abstract] treatment kitty colds cabgolin 0.5 mg discount. Classifying fractionated electrograms in human atrial fibrillation using monophasic action potentials and activation mapping: Evidence for localized drivers, rate acceleration and non-local signal etiologies. Evaluating fluctuations in human atrial fibrillatory cycle length using monophasic action potentials. Frequency analysis of atrial action potential alternans: A sensitive clinical index of individual propensity to atrial fibrillation. Disparate evolution of right and left atrial rate during ablation of long-lasting persistent atrial fibrillation. Clinical mapping approach to identify rotors and focal beats in human atrial fibrillation. Quantitative analysis of localized sources identified by focal impulse and rotor modulation mapping in atrial fibrillation. Regarding article, "Quantitative analysis of localized sources identified by focal impulse and rotor modulation mapping in atrial fibrillation. Body surface localization of left and right atrial high frequency rotors in atrial fibrillation patients: A clinical-computational study. Organized sources are spatially conserved in recurrent compared to pre-ablation atrial fibrillation: Further evidence for non-random electrical substrates. Human atrial fibrillation may share electrical mechanisms with atrial tachycardia (abstract). Acute and short-term outcomes in persistent and long-standing persistent patients undergoing rotors-only ablation (abstract). Focal impulse and rotor modulation as a stand-alone procedure for the treatment of paroxysmal atrial fibrillation: A withinpatient controlled study with implanted cardiac monitoring. Nine-month outcomes following focal impulse and rotor modulation for the treatment of atrial 46. Focal impulse and rotor modulation: Acute procedural observations and extended clinical followup (abstract). Rotor-mapping/-ablation of redo-cases of persistent atrial fibrillation: Procedural and follow-up data (abstract). However, how to identify the critical arrhythmogenic atrial substrate remained unclear. Preprocedural Planning: Technological Considerations A Fourier transform is based on the concept that the signals can be approximated by the sum of the sinusoidal waveforms with different frequencies. Then, the Hilbert transform is applied to get the time-varying frequency and amplitude of the fractionated waves.

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If the initial light-chain gene rearrangement is productive treatment xyy order 0.5 mg cabgolin visa, a complete immunoglobulin B-cell receptor is formed, gene rearrangement again ceases, and the B cell continues its development. If the first light-chain gene rearrangement is unsuccessful, rearrangement continues until either a productive rearrangement is made or all available J regions are used up. Once a complete immunoglobulin receptor is expressed on the surface of the cell, immature B cells undergo tolerance to self antigens. This process begins in the bone marrow and continues for a short time after immature B cells emigrate to the periphery. The state of the immunoglobulin genes, the expression of some essential intracellular proteins, and the expression of some cell-surface molecules are shown for successive stages of conventional B-2 B-cell development. During antigen-driven B-cell differentiation, the immunoglobulin genes undergo further changes, such as class switching and somatic hypermutation (see Chapter 5), which are evident in the immunoglobulins produced by memory cells and plasma cells. Like B cells, T lymphocytes derive from the multipotent hematopoietic stem cells in the bone marrow. T-cell development parallels that of B cells in many ways, including the orderly and stepwise rearrangement of antigen-receptor genes, the sequential testing for successful gene rearrangement, and the eventual assembly of a heterodimeric antigen receptor. Nevertheless, T-cell development in the thymus has some features not seen for B cells, such as the generation of two distinct lineages of T cells expressing antigen receptors encoded by distinct genes, the: lineage and the: lineage. We begin with a general overview of the stages of thymocyte development and its relationship to thymic anatomy before considering gene rearrangement and the mechanisms of selection. T-cell precursors migrate from the bone marrow to the thymus, where they commit to the T-cell lineage following Notch receptor signaling. Self-reactive receptors transmit a signal that leads to cell death, and cells bearing them are removed from the repertoire in a process of negative selection (top second panel). T cells that survive selection mature and leave the thymus to circulate in the periphery; they repeatedly leave the blood to migrate through the peripheral lymphoid organs, where they may encounter their specific foreign antigen and become activated (top third panel). Some of these are attracted to sites of infection, where they can kill infected cells or activate macrophages (top fourth panel); others are attracted into B-cell areas, where they help to activate an antibody response (not shown). In young individuals, the thymus contains large numbers of developing T-cell precursors embedded in a network of epithelia known as the thymic stroma. This provides a unique microenvironment for T-cell development analogous to that provided for B cells by the stromal cells of the bone marrow. The thymus, which lies in the midline of the body, above the heart, is made up of several lobules, each of which contains discrete cortical (outer) and medullary (central) regions. As shown in the diagram on the left, the cortex consists of immature thymocytes (dark blue); branched cortical epithelial cells (pale blue), with which the immature cortical thymocytes are closely associated; and scattered macrophages (yellow), which are involved in clearing apoptotic thymocytes. The medulla consists of mature thymocytes (dark blue) and medullary epithelial cells (orange), along with macrophages (yellow) and dendritic cells (yellow) of bone marrow origin. The thymocytes in the outer cortical cell layer are proliferating immature cells, whereas the deeper cortical thymocytes are mainly immature T cells undergoing thymic selection. The photograph shows the equivalent section of a human thymus, stained with hematoxylin and eosin. The thymic epithelium arises early in embryonic development from endodermderived structures known as the third pharyngeal pouches.

Dudley, 54 years: In late stages of apoptosis (panel c), the cell nucleus (middle cell) is very condensed, no mitochondria are visible, and the cell has lost much of its cytoplasm and membrane through the shedding of vesicles. In the accessible area with lesser fat pads, catheter ablation may be effective even at the site with far-field electrograms.

Mufassa, 44 years: Some patients are hyponatremic due to inappropriate secretion o antidiuretic hormone. Therefore, obtaining adequate contact with the balloon in order to allow delivery of high-power lesions is of the utmost importance.

Kasim, 27 years: We will now examine the responses of innate immunity induced as an immediate consequence of pathogen recognition by the sensors described in the last section. Not only can the adaptive immune response eliminate a pathogen, but, in the process, it also generates increased numbers of differentiated memory lymphocytes through clonal selection, and this allows a more rapid and effective response upon reinfection.

Inog, 49 years: Animal stu ies o ear con itioning have in icate that processing o the ear stimulus occurs through the lateral nucleus o the amyg ala, exten ing through the central nucleus an projecting to the periaque uctal gray region, lateral hypothalamus, an paraventricular hypothalamus. B cells whose V regions have acquired mutations that improve the affinity of the B-cell receptor for antigen are able to compete more effectively for antigen, and receive signals that drive their proliferation and expansion.

Dennis, 65 years: Thus far, balloon energy sources have included ultrasound,5-8 cryoablation,9,10 and now laser ablation. Echocardiography is an essential component of the preprocedural evaluation of the patient.

Karmok, 24 years: Antibody and memory lymphocytes remaining in an immunized individual can have the effect of reducing the activation of naive B and T cells on a subsequent encounter with the same antigen. The intramuscular bloo vessels show en othelial hyperplasia with tubuloreticular pro les, brin thrombi, an obliteration o capillaries.

Randall, 55 years: Later, if the inflammation continues, eosinophils also migrate into inflamed tissues and contribute to the destruction of the invading microorganisms. Consequently, they develop a hyponatremic syndrome indistinguishable rom inappropriate antidiuresis.

Jerek, 48 years: Our experience is that these perforation events, even with large-bore sheaths or devices, typically close without requirement for cardiothoracic surgery. The thymic stromal cells may simply be in closest proximity to the developing thymocytes, as there are very few macrophages and dendritic cells in the cortex to perform the antigen presentation.

Kafa, 34 years: To resolve this issue, local raw electrograms need to be checked manually to ascertain sequential propagation of regional waves. On a noncontrast head C, blood is demonstrated as a hyperdense white area, and this is an emergent nding.

Sanuyem, 38 years: T cells exit from a lymph node via the cortical sinuses, which lead into the medullary sinus and then the efferent lymphatic vessel. T rombolytic administration should be considered in all patients 18 years old with a clinical diagnosis o stroke presenting with symptom onset o 4.

Brontobb, 22 years: The advantage of using an isochronal display is the ease of visualizing areas of isochronal crowding, which represents a deceleration zone with the slowest conduction velocity. A ow serum potassium eve uring an attack, exc u ing secon ary causes, estab ishes the iagnosis.