Right Paratracheal Stripe
Posterior wall of the bronchus intermedius
Left Paratracheal Stripe
Left subclavian artery border
Posterior-superior junction line
Right Paratracheal Stripe
Posterior wall of the bronchus intermedius
Left Paratracheal Stripe
Left subclavian artery border
Posterior-superior junction line
USMLE CVS 001 Mediastinum anatomy medical chest .pdfAHMED ASHOUR
The mediastinum is the central compartment of the thoracic cavity, located between the lungs.
It is a three-dimensional space that houses various structures within the chest.
The mediastinum extends from the sternum (front of the chest) to the vertebral column (back of the chest) and from the superior thoracic aperture (top of the chest) to the diaphragm (bottom of the chest).
Understanding the anatomy of the mediastinum is crucial for healthcare professionals to interpret diagnostic findings and manage conditions affecting this central compartment of the thoracic cavity.
Here is a detailed presentation on anatomy of heart
I sincerely agree that few of my slides are copied and most of them are prepared by myself
But that is how we help each other!!
Hope the presentation helps the one in need
And it's free to download for anyone
The whole purpose of uploading is.. So that anyone can use it ..
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. • Superior - imaginary line traversing the
manubriosternal joint and the lower surface of the
fourth thoracic vertebra.
• Inferior – Anterior
Middle
Posterior
• Felson’ method - line extending from the diaphragm
to the thoracic inlet along the back of the heart and
anterior to the trachea separates the anterior and
middle mediastium.
• A line that connects points 1 cm behind the anterior
margins of the vertebral bodies separates the middle
and posterior mediastinal compartments.
3. Anterior Mediastinum
• Boundaries - anteriorly by the sternum;
posteriorly by the pericardium, aorta, and
brachiocephalic vessels; superiorly by the
thoracic inlet; and inferiorly by the diaphragm.
• Contains - thymus, lymph nodes, adipose
tissue, and internal mammary vessels
5. Anterior Junction Line
• The line is formed by the anterior apposition of the
lungs and consists of the four layers of pleura
separating the lungs behind the upper two-thirds of
the sternum.
• The line runs obliquely from upper right to lower left
and does not extend above the manubriosternal
junction.
• Contains variable amount of fat.
7. CT scan shows the four layers of pleura that
constitute the anterior junction line
8. • Anterior mediastinal masses
prevascular - Thymic masses
- Retrosternal thyroid
- Teratoma
- Lymph nodal mass
precardiac - Epicardial fat pad
- Morgagni ‘ s hernia
- pleuropericardial cyst
- Anterior mediastinal masses in the prevascular
region can obliterate the anterior junction line.
9. • The hilum overlay sign is present when the
normal hilar structures project through a
mass, such that the mass can be understood as
being either anterior or posterior to the hilum.
• The craniocaudal location and tissue density of
a mass may also help in developing a
differential diagnosis.
10. Posteroanterior
chest radiograph
clearly depicts the
hila (white
arrow), which
indicates that the
mass is either
anterior or posterior
to the hila. In
addition, the
descending aorta is
clearly seen (black
arrow), indicating
that the mass is not
within the posterior
mediastinum.
11. Chest CT scan
demonstrates an
anterior
mediastinal mass.
The anterior
junction line is
obliterated, where
as the lung
interfaces with the
hilar vessels
(arrow) and aorta
(arrowhead) are
preserved.
13. CT scan shows
the fat pad
(arrow) as an
area of
homogeneous
fat attenuation
adjacent to the
right border of
the heart.
14. • Posterior masses above the level of the
clavicles have an interface with lung and
therefore typically have sharp, well-defined
margins; in contrast, anterior masses above the
level of the clavicles do not have an interface
with lung, so that their margins are not usually
sharp.
16. CT scan shows the mass (arrow) between the trachea and right lung, a
location that explains the obliteration of the right paratracheal stripe.
17. Middle Mediastinum
• Boundaries - anteriorly by the
pericardium, posteriorly by the pericardium and
posterior tracheal wall, superiorly by the thoracic
inlet, and inferiorly by the diaphragm.
• Contains - heart and pericardium; the ascending
and transverse aorta; SVC and IVC; the
brachiocephalic vessels; the pulmonary vessels;
the trachea and main bronchi; lymph nodes; and
the phrenic, vagus, and left recurrent laryngeal
nerves.
18.
19. Right Paratracheal Stripe
• The right paratracheal stripe is seen projecting
through the SVC. It is formed by the
trachea, mediastinal connective tissue, and
paratracheal pleura and is visible due to the air–
soft tissue interfaces on either side.
• paratracheal stripe should be uniform in width
with a normal width ranging from 1 to 4 mm.
• The azygos vein lies at the inferior margin of the
right paratracheal stripe at the tracheobronchial
angle.
20. Posteroanterior chest radiograph shows the right paratracheal stripe (arrow).
The azygos vein is seen at the inferior margin of the stripe at the
tracheobronchial angle.
21. CT scan shows the
right wall of the
trachea with medial
and lateral air–soft
tissue interfaces
caused by air within
the tracheal lumen
and right lung.
22. • The right paratracheal stripe can be widened
due to abnormality of any of its
components, from the tracheal mucosa to the
pleural space.
26. • The AP window is bounded by the aortic arch
superiorly and the pulmonary artery
inferiorly, with its lateral aspect seen as the
aortic-pulmonary window reflection due to the
interface between the left lung and the
mediastinum.
• A convex border between the AP window and
the lung is considered abnormal. Most
commonly - lymphadenopathy
27. On a posteroanterior
chest radiograph, the AP
window reflection
(arrowhead) extends
from the aortic knob to
the left pulmonary
artery and has a normal
concave appearance.
The aortic-pulmonary
reflection (arrow) is a
more anterior line and
extends from the aortic
arch to the level of the
left main bronchus.
31. CT scan reveals an aneurysm (arrow) arising laterally from the
aortic arch, a finding that accounts for the abnormality.
32. pitfalls
• A right-sided aortic arch, seen in 0.5% of the
general population, may mimic paratracheal
lymphadenopathy because it obliterates the
right paratracheal stripe.
• Absence of the aortic knuckle on the left
should help correctly identify this variant.
• Left sided SVC.
33. Posteroanterior chest radiograph demonstrates an abnormality in the
right paratracheal region (arrow) with loss of the paratracheal stripe.
Note, however, the absence of the aortic knuckle on the left.
37. Posterior Mediastinum
• The posterior mediastinum is bounded
anteriorly by the posterior trachea and
pericardium, anteroinferiorly by the
diaphragm, posteriorly by the vertebral
column, and superiorly by the thoracic inlet.
• Contents -Esophagus, descending
aorta, azygos and hemiazygos veins, thoracic
duct, vagus and splanchnic nerves, lymph
nodes, and fat
40. Azygoesophageal Recess
• The azygoesophageal recess is the interface between
the right lung and the mediastinal reflection, with
the esophagus lying anteriorly and the azygos vein
posteriorly within the mediastinum.
• On X-ray,it appears as a line –
- in its upper 1/3rd , it deviates to the right at the
level of the carina to accommodate the azygos vein
arching forward.
- middle 1/3rd , the line has a variable appearance: It
is usually straight.
- lower 1/3rd , usually straight. ( air in esophagus)
42. CT scan shows the
azygoesophageal recess
(white arrow) formed
by the esophagus
anteriorly (black arrow)
and the azygos vein
posteriorly
(arrowhead).
43. • The azygoesophageal recess reflection is a pre-
vertebral structure and is, therefore, disrupted
by prevertebral disease.
• It has an interface with the middle
mediastinum; thus, the resulting line seen at
radiography can be interrupted by
abnormalities in both the middle and posterior
compartments.
44. Posteroanterior chest radiograph demonstrates a subcarinal abnormality with
increased opacity (*), splaying of the carina, and abnormal convexity of the
upper and middle thirds of the azygoesophageal line (arrowheads)
45. Corresponding CT scan helps confirm a subcarinal mass
(arrow), which proved to be a bronchogenic cyst.
46. Posterior Junction Line
• Seen above the level of the azygos vein and aorta
and that is formed by the apposition of the lungs
posterior to the esophagus.
• usually extend from third to fifth thoracic vertebrae.
• posterior junction line can be seen above the
suprasternal notch and lies almost vertical, whereas
the anterior junction line deviates to the left.
47. Collimated posteroanterior chest radiograph shows the posterior
junction line (arrow) projecting through the tracheal air column.
48. CT scan shows the posterior junction line (arrow), which is formed by
the interface between the lungs posterior to the mediastinum and
consists of four pleural layers.
49. Posteroanterior chest radiograph shows a mass (arrow) obliterating
the posterior junction line. Note that the mass extends above the
level of the clavicle and has a well-demarcated outline due to the
interface with adjacent lung (arrowhead).
50. CT scan helps confirm the posterior location of the mass
(arrow), which proved to be a bronchogenic cyst.
51. Paraspinal Lines
• The paraspinal lines are created by the interface
between lung and the pleural reflections over the
vertebral bodies.
• The left paraspinal line is much more commonly
seen than the right. The descending aorta holds
the pleural reflection off the vertebral
body, allowing the lung–soft tissue interface to be
more tangential to the x-ray beam.
• The left paraspinal line runs parallel to the lateral
margin of the vertebral bodies and can lie
anywhere medial to the lateral wall of the
descending aorta
53. CT scan shows the left paraspinal line. The descending aorta holds the pleural
reflection (arrow) away from the vertebral body, which allows the lung–soft
tissue interface to be more tangential to the x-ray beam and therefore
visualized as a line
54. • The paraspinal lines are disrupted by
paravertebral disease—which commonly
includes diseases originating in the
intervertebral disks and vertebrae—and by
neurogenic tumors.
55. Posteroanterior chest radiograph shows a mass (arrow) effacing the left
paraspinal line. The lateral wall of the descending aorta is seen as a separate
entity (arrowhead).
56. CT scan shows a paraspinal abscess (arrow) effacing the paraspinal lines.
The air–soft tissue interface between the lung and aorta remains intact
(arrowhead), thereby preserving the normal radiographic appearance of
the lateral aortic wal
57. Posteroanterior chest radiograph shows lateral displacement of the lateral
margin of the descending thoracic aorta due to an aortic aneurysm
(arrowheads).