;
Order cheap Viagra capsules no RX - Safe Viagra capsules OTC

Loading

Viagra capsules

Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults discount viagra capsules uk. Use of propranolol for severe dynamic infundibular obstruction prior to balloon pulmonary valvuloplasty (a brief communication) discount viagra capsules 100 mg. Long-term results (up to 17 years) of pulmonary balloon valvuloplasty in adults and its effects on concomitant severe infundibular stenosis and tricuspid regurgitation buy 100mg viagra capsules otc. The Recent Improvements in the Art of Distinguishing the Various Diseases of the Heart. Repair of double-chambered right ventricle: surgical results and long-term follow-up. Initial clinical manifestations and mid- and long-term results after surgical repair of double-chambered right ventricle in children and adults. Treatment of dynamic subvalvar muscular obstruction in the native right ventricular outflow tract by percutaneous stenting in adults. Long-term prognosis after repair of double- chamber right ventricle with ventricular septal defect. The roentgenologic features of single and multiple coarctations of the pulmonary artery and branches. The syndrome of supravalvular aortic stenosis, peripheral pulmonary stenosis, mental retardation and similar facial appearance. The use of three-dimensional rotational angiography to assess the pulmonary circulation following cavo-pulmonary connection in patients with single ventricle. Gadolinium-enhanced 3-dimensional magnetic resonance angiography of pulmonary blood supply in patients with complex pulmonary stenosis or atresia: comparison with x-ray angiography. Transvenous angioplasty of experimental branch pulmonary artery stenosis in newborn lambs. Early results and follow-up of balloon angioplasty for branch pulmonary artery stenoses. Midterm clinical impact versus procedural success of balloon angioplasty for pulmonary artery stenosis. High pressure balloon angioplasty for branch pulmonary artery stenosis: early experience. Balloon dilation angioplasty of peripheral pulmonary stenosis associated with Williams syndrome. Experimental branch pulmonary artery stenosis angioplasty using a novel cutting balloon. Cutting balloon angioplasty for children with small-vessel pulmonary artery stenoses. Follow-up results of Cutting Balloon angioplasty used to relieve stenoses in small pulmonary arteries. Comparison of efficacy of medium-sized cutting balloons versus standard balloons for dilation of peripheral pulmonary stenosis. Intravascular stents in congenital heart disease: short- and long-term results from a large single-center experience. Refinements in the implantation of pulmonary arterial stents: impact on morbidity and mortality of the procedure over the last two decades. Impact of Percutaneous Interventions for Pulmonary Artery Stenosis in Alagille Syndrome. Interventional strategies in the management of peripheral pulmonary artery stenosis. First successful implantation of a biodegradable metal stent into the left pulmonary artery of a preterm baby. Effect of abnormal pulmonary flow distribution on ventilatory efficiency and exercise capacity after arterial sw itch operation for transposition of great arteries. Nykanen Robert Mark Freedom 1941–2005 A discussion of pulmonary atresia and intact ventricular septum would be incomplete without acknowledging the legacy of Robert M. As a clinical cardiac morphologist his monogram described the diversity of this malformation, emphasizing the complexity of a disorder that appears so simple on the surface (1). His understanding of the nature of this condition has endured the test of time and continues to influence our treatment strategies today. To those who were fortunate to know him, he was a passionate, tireless teacher dedicated to the concept that the practice of knowledge-based medicine incorporates observations gained from both an understanding of the literature and the recognition of the value of cumulative experience. It is appropriate that many of his insights continue to be reflected in the pages that follow. Pulmonary atresia and intact ventricular septum was first described in 1783 by Hunter (2) and then revisited 86 years later in 1869 by Peacock (3). While its name focuses primarily on membranous or muscular atresia of the right ventricular outflow tract, this disorder is characterized by striking heterogeneity of the right ventricle, its inlet, and its functional size. Furthermore, many of these patients have connections between the right ventricle and subepicardial coronary arteries and a predisposition for an unusual coronary circulation. These connections were originally a pathologic curiosity; however, management can be dictated by their nature. Prognosis appears to relate to the nature of the coronary circulation in the patient with a right ventricle at high pressure, or alternatively to the presence of severe tricuspid regurgitation in the setting of a low-pressure right ventricle (4,5,6). It is truly a complex, diverse disorder that challenges surgical and catheter-based interventional strategies. Current interventional algorithms range from achieving a biventricular circulation through variations of the cavopulmonary circulation to cardiac transplantation. Epidemiology Data obtained from the New England Regional Infant Cardiac Program identified 75 patients with this disorder, accounting for 3. The Baltimore–Washington Infant Study defined the prevalence for this disorder as 0. Despite being uncommon, when integrated into the overall statistics of congenital heart disease, pulmonary atresia and intact ventricular septum is one of the more common types of cyanotic congenital heart disease in the neonate, along with transposition of the great arteries and pulmonary atresia with ventricular septal defect. A published study from the United Kingdom and Eire defined the incidence of pulmonary atresia and intact ventricular septum to be 4. Overall, by the best estimates pulmonary atresia and intact ventricular septum occurs at a rate of 0. However, if one includes pregnancies that are spontaneously or electively aborted after 20 weeks gestational age with live births the rate has been reported as much as 10 times higher at 0. Fetal echocardiography provides a unique window to study the later phases of the fetal cardiac development recognizing that cardiac organogenesis is complete by about 8 weeks of gestation. There is increasing evidence that fetuses with severe tricuspid regurgitation may not fare well. Such fetuses are known to develop right-sided heart failure with pleural and pericardial effusions, ascites, pulmonary hypoplasia, and fetal death. Thus, fetal loss might be anticipated in a specific subset of patients with pulmonary atresia, intact ventricular septum, extremely severe tricuspid regurgitation, and a low-pressure right ventricle. The data collected from the United Kingdom and Eire also showed that termination of pregnancy once this diagnosis was established led to an important reduction in live-born incidence in mainland Britain (8).

purchase viagra capsules online pills

The retroaortic (anterior–superior) rim buy viagra capsules uk, the tissue between the aorta and defect discount 100mg viagra capsules with visa, can be assessed in the parasternal short-axis view purchase viagra capsules cheap online. Superior and inferior vena caval sinus venosus defects are best seen in the subcostal sagittal view. The transducer should be swept posterior and rightward to investigate possible associated partial anomalous pulmonary venous return. The ostium primum defect is related to the crux of the heart and is best seen in the apical four-chamber view. A coronary sinus defect is visualized by sweeping the transducer posterior from the standard apical four-chamber view. Pulmonary Veins and Left Atrium The pulmonary veins can be identified in multiple imaging planes, including the suprasternal short-axis (Fig. Color Doppler with a low-velocity aliasing limit can aid in visualizing the individual pulmonary veins (29). Unlike systemic venous anomalies, in which color Doppler demonstrates flow coursing toward the heart, these anomalous pulmonary venous pathways will have low-velocity color Doppler flow coursing away from the heart, often the first sign alerting the echocardiographer to one of these conditions. Membranes, such as a supravalvar mitral ring and cor triatriatum, can be identified in the apical four-chamber view. The relationship of these membranes relative to the left atrial appendage is diagnostic. This type of membrane may be associated with hypoplasia of the mitral valve annulus. The pulmonary veins drained to a pulmonary vein confluence immediately superior to the roof of the left atrium. Atrioventricular Connection Type The next order of business for the echocardiographer is to delineate and describe the type and morphologic characteristics of the atrioventricular connection (Fig. The septal structures of the atrioventricular valves serve as the only consistent feature allowing morphologic diagnosis. The tricuspid valve has multiple chordal attachments to the ventricular septum (septophilic), seen best in the apical four-chamber view. On the other hand, the normal mitral valve has no chordal insertions to the ventricular septum (septophobic). In addition, the hinge point of the septal leaflet of the tricuspid valve is inferior to the hinge point of the anterior leaflet of the mitral valve. Because each atrioventricular valve is associated with its respective ventricle (i. Instead, there is a venous structure that is adjacent and slightly posterior to the aorta. The structure is also rightward of the aorta indicating that it is an azygos continuation of interrupted inferior vena cava. Atretic atrioventricular connections are easily identified in the apical and subcostal views. The relationships of the atrioventricular valves to each other in double-inlet connections are explored in the parasternal views. The five leaflets of the common atrioventricular valve (superior/anterior bridging, right superior, right mural, inferior/posterior bridging, and left mural) are best seen in a right anterior oblique subcostal view (midway between the coronal and sagittal planes). The degree of bridging of the superior leaflet and its attachments are identified, allowing for Rastelli classification (Fig. Straddling and criss-cross connections are seen in the apical four-chamber and subcostal views. A straddling atrioventricular valve has attachments to the contralateral ventricle, whereas overriding refers to the valve annulus being partially displaced over the contralateral ventricle in these views. Tricuspid Valve The tricuspid valve is examined in the parasternal long-axis plane (sweeping right from the standard plane), the apical four-chamber view, and the subcostal coronal and sagittal views. The septal leaflet and its attachments to the interventricular septum are best seen in the apical four-chamber view. Also, in this view, the inferior (posterior) leaflet (with a slight posterior sweep) or the anterior leaflet (with a slight anterior sweep) is seen on the lateral portion of the right ventricular free wall. The anterior leaflet and its attachments to the conal papillary muscle (Lancisi) are best visualized in the subcostal coronal view sweeping anteriorly. In the evaluation of Ebstein anomaly of the tricuspid valve, the degree of atrialization of the right ventricle is assessed from the apical four-chamber view. The inferior (posterior) mural leaflet is seen with a slight posterior sweep from the apical four- chamber view. A portion of the anterior mural leaflet can be seen with an anterior sweep from the apical four- chamber view but the subcostal coronal view is required to visualize the displacement of the anterior leaflet into the right ventricular outflow tract and the degree to which it may cause obstruction. The tricuspid valve annular dimension, which is important to evaluate in conditions with right ventricular hypoplasia (e. Mitral Valve The mitral valve is visualized in the parasternal, apical four-chamber, and subcostal coronal and sagittal views. The size of the mitral valve annulus, which is important in determining suitability for biventricular repair in cases of relative left-sided hypoplasia, should be measured in orthogonal planes of the parasternal long-axis and apical four-chamber views. The papillary muscles, important to assess for repair of complete atrioventricular septal defect and for diagnosing parachute mitral valve, are best visualized in the parasternal short-axis and subcostal sagittal sweeps. Mitral stenosis is assessed in the parasternal long axis and the apical four-chamber views, where the degree of leaflet excursion can be seen clearly. Mitral valve prolapse is best identified in the parasternal long-axis and apical four-chamber views. Assessment of a cleft in the anterior mitral valve leaflet or double-orifice mitral valve is best visualized in the parasternal short-axis sweep. Ventricles Ventricular Morphology During embryologic development, the heart begins as a straight tube anchored cephalad by the truncus arteriosus and caudad by the sinus venosus. The tube undergoes differential and rapid growth in its midsection that, because of the anchoring, forces it to bend to the right or the left. Bending to the right (D-looping) results in the right ventricle developing to the right and the left ventricle to the left. Definition of the embryologic type of ventricular looping first requires clear identification of ventricular morphology. As mentioned in the previous section, a reliable determinant of ventricular morphology is identification of the atrioventricular valve type committed to it. The right ventricle can also be identified by its coarse trabeculations along the septum and free wall. One of these trabeculations, the moderator band, is particularly prominent, running transversely from free wall to septum in the inferior third of the right ventricular cavity in the apical view (Fig. Once ventricular morphology has been established, ventricular looping is determined. This is performed by imagining one is standing in the right ventricle facing the right ventricular side of the interventricular septum and placing an imaginary hand on the ventricular septum (Fig. The looping is determined by which of the two hands allows the palm to lie on the septum, the thumb to point into the atrioventricular valve and the fingers to point into the outflow tract. In ventricular D-loop, the palm of the right hand is placed over the septum with the thumb in the tricuspid valve and the fingers in the right ventricular outflow tract. In ventricular L-loop, the palm of the left hand is placed over the septum with the thumb in the inflow and the fingers in the right ventricular outflow tract.

purchase genuine viagra capsules line

They do not have the neuronal tissue elements that can be found in intrapericardial teratomas (195 viagra capsules 100mg with amex,200 order viagra capsules overnight delivery,202) discount 100 mg viagra capsules overnight delivery. The true incidence of intrapericardial teratomas remains somewhat unclear because earlier reports may have included intrapericardial bronchogenic cysts (195,200). Half of all intrapericardial teratomas are diagnosed in newborns and infants younger than 1 month of age and two-thirds in infants younger than 1 year of age (200,206). Critically ill newborns and infants have a distinct clinical presentation consisting of respiratory distress, pericardial effusion, and direct cardiac compression by the tumor mass as well as cardiac tamponade (193,194,195,196,197,198,199,200,201,202,203,204,205,206,207). Direct compression of pulmonary parenchyma may contribute to the extreme respiratory distress in the newborn or infant (195,199,206,207). Sudden deaths occurred in two-thirds of pediatric patients who had intrapericardial teratomas (196). These events were attributed to acute rupture of cysts into the pericardial space with sudden tamponade (210), severe encroachment by the tumor on the heart and great vessels (196,199), and infectious pericarditis (199). Signs and symptoms of severe disease may not be apparent in the rare situation in which an infant does not have an associated significant pericardial effusion (197,200,206). Patients older than 3 months of age are usually asymptomatic or have findings of a chronic pericardial effusion (197,200,206). Intrapericardial teratomas can be diagnosed in the asymptomatic older child during evaluation of an abnormal chest radiograph or as an incidental finding at autopsy (197,200,206). Heart sounds are distant or muffled, murmurs are inaudible, and the precordial impulse conspicuous for its absence in the newborn or infant who has impending tamponade (193,197,200,204,207). The patient may have marked hepatomegaly and diminished peripheral pulses (193,200,206). Stenotic murmurs may be heard when the tumor mass compresses cardiac chambers or great vessels (203,206). The newborn may present with cyanosis from compression of the pulmonary parenchyma (193,207) or from right-to-left atrial shunting (203). In critically ill patients, a markedly enlarged cardiac silhouette is seen on chest radiographs (193,194,195,196,197,198,199,200,201,202,203,204,205,206,207). Irregularity of the cardiac silhouette may be the only abnormal finding in older asymptomatic patients (200). Pericardiocentesis is nondiagnostic except for the absence of a bloody effusion (197). A hemorrhagic effusion almost always is associated with a malignant cardiac or pericardial tumor (197). Recurrence of the pericardial effusion invariably occurs if the tumor is not removed (197,199). Intrapericardial teratomas have been visualized by 2-D echocardiography in the fetus, neonate, and infant (Figs. The tumor appears as a single, nonhomogeneous, lobular, intrapericardial mass (Fig. Cystic formations appear as echolucent areas, calcifications as echogenic foci (193,195,204). Attachment of the pedicle to the aorta can be visualized, and compression of the great vessels and intracardiac chambers may occur (195,201,204,205,206,207,208). Neonates and infants have been operated on the basis of echocardiography alone (86,193,195,204). A: Four-chamber view showing the heterogeneous mass with multiple vacuoles at the region of the right atrium, within the pericardial space. Early noninvasive diagnosis, surgical removal of the intrapericardial teratoma, and decompression of the pericardial effusion result in high survival rates, even in critically ill neonates and infants. In utero recognition allows prompt postnatal surgical intervention before significant cardiopulmonary distress develops (205). Surgery in older asymptomatic patients is indicated because of the propensity of these tumors to cause sudden death (193,195,196,197,199,203) or to undergo rare but known malignant degeneration (193,206). Careful dissection is necessary to remove a tumor that is adherent to the external surface of the heart or coronary arteries (195,197,199) and to remove the tumor pedicle from the aorta or pulmonary artery (195,199,200,206,207). Successful long-term results have been reported following surgery (136,193,194,195,200,206,207). Other Primary Benign Myocardial Tumors Cardiac hemangiomas are another more common benign tumor in this age group (Videos 72. These tumors are almost always single and can occupy the epicardial, intramural, or intracavitary space (214). Hemangiomas are polypoid or sessile, often with central areas of necrosis and calcification (18,63,213). These tumors consist of large blood vessels and small vascular channels interdigitating within the myocardium (18,213). On echocardiography, these vascular channels appear as large echolucent areas (18,212,213). Angiography has been used to demonstrate the highly vascular nature of these tumors (18,63,212). The importance of tissue differentiation has been emphasized in that congenital hemangiomas may regress in size with interferon or steroid administration (72). The variability in clinical course may be related to the variability in histology (72). Surgical intervention has been successful in removal of singular intracavitary tumors (18,212,213). Cardiac transplantation has been considered in some patients who had severe invasion of the myocardium (18). Other examples of rare primary benign cardiac tumors include papillary tumors (215), accessory endocardial cushion tissue (216), cardiac lipomas (73,217,218,219), and fibroelastomas (220). These tumors have been associated with a myriad of cardiac signs and symptoms ranging from minimal disease to systemic embolization to near-death episodes. Primary Malignant Myocardial Tumors Malignant myocardial tumors constitute <10% of primary cardiac tumors in pediatric patients (7,9,64). The most common histology was soft tissue sarcoma (40%), followed by non-Hodgkin lymphoma and teratoma (both 12%) (221). These malignant tumors include fibrosarcoma, angiosarcoma, lymphosarcoma, giant cell sarcoma, fibromyxosarcoma, leiomyosarcoma, neurogenic sarcoma, rhabdomyosarcoma, and undifferentiated sarcoma (44). Pathologically they are classified by histologic type into three categories: primary cardiac sarcomas (angiosarcoma), endomyocardial based (smooth muscle or fibroblast differentiation), and striated muscle forms (rhabdomyosarcoma) (222). Some pathologists argue that the imprecise terminology applied to these tumors has been a general source of confusion (155). Moreover, the histologic differentiation of benign from malignant tumors may be subtle (153). Patients present with cardiac tamponade, right-sided heart failure, and superior vena caval obstruction. Pericardial effusions are hemorrhagic; metastatic involvement of the liver, lungs, and central nervous system is common. Despite early noninvasive diagnosis and surgical and chemotherapeutic interventions, the outlook remains poor. Although rare in pediatrics, primary cardiac sarcomas have been diagnosed in infants as young as 3 months of age (44).

purchase viagra capsules in united states online

On examination generic viagra capsules 100 mg otc, significant chronic aortic regurgitation results in a wide pulse pressure (elevated systolic and low diastolic pressures) and bounding pulses buy discount viagra capsules 100mg on-line. Precordial activity is increased 100mg viagra capsules with visa, and the apical impulse is displaced laterally due to the dilated left ventricle. The typical diastolic murmur of aortic regurgitation is relatively high pitched, decrescendo, and heard best along the left sternal border with the patient leaning forward at end-expiration. The duration of the murmur rather than the intensity correlates with the severity of regurgitation. A short systolic ejection murmur may be heard at the mid-left or upper right sternal border from increased flow across the left ventricular outflow tract or associated aortic valve stenosis. In patients with moderate-to-severe aortic regurgitation, a low-pitched mid-to-late diastolic rumbling murmur may be audible at the apex in the absence of organic mitral stenosis (“Austin Flint” murmur). The chest radiograph is usually normal in mild aortic regurgitation and shows progressive cardiomegaly with increasing severity of aortic valve incompetence. On echocardiography, the aortic valve leaflets may show thickening, retraction, and variable commissural fusion. Three- dimensional (3-D) echocardiography may provide images allowing better understanding of the mechanism(s) of aortic regurgitation (266). The severity of the aortic regurgitation should be assessed (240) along with documentation of associated lesions, in particular mitral valve stenosis or regurgitation. Left ventricular size and function should be assessed in all patients with aortic regurgitation. In contrast, symptomatic rheumatic mitral stenosis may occur as early as the second decade of life in children from developing countries of the world (27,29,32,38,267). Mitral stenosis may occur as the dominant lesion, with insignificant amounts of associated regurgitation (“pure” mitral stenosis), or in combination with significant mitral regurgitation (268). A combination of leaflet thickening, fusion of commissures, cusps and chordae, and chordal shortening result in a funnel- shaped, stenotic mitral valve orifice. The process is usually continuous and slowly progressive (at least in industrialized countries), eventually resulting in left ventricular inflow obstruction and a diastolic gradient between the left atrium P. With increasing stenosis, however, left atrial and pulmonary venous pressures rise, leading to pulmonary venous congestion and, eventually, pulmonary hypertension (27). Many patients accommodate their lifestyle to the gradual development of symptoms and are unaware of their significant functional limitations. The most common early symptoms are due to decreased cardiac output, and include fatigue and decreased exercise tolerance. Although uncommon in children, atrial fibrillation may result in atrial thrombi and systemic embolization. With severe mitral inflow obstruction and pulmonary hypertension, hemoptysis and signs of right heart failure, including edema and abdominal distension may be evident. On examination, findings depend on the severity of the stenosis and associated lesions. Precordial activity may be abnormal with a tapping, palpable first heart sound, but the apical impulse is not usually displaced unless there is associated mitral and/or aortic regurgitation. On auscultation, the characteristic findings of mitral stenosis are an increased S1, an early diastolic opening snap, and a low-pitched, rumbling diastolic murmur best heard at the apex with the patient in a left lateral decubitus position. The duration rather than the intensity of the murmur correlates with the severity of obstruction. In addition, the interval between S1 and the opening snap decreases with increased stenosis (elevated left atrial pressure results in earlier opening snap). For patients in sinus rhythm, late diastolic or presystolic accentuation of the murmur may be audible due to the increased gradient associated with atrial contraction. With severe stenosis and a rigid, calcified mitral valve, the opening snap and S1 may be inaudible. When secondary pulmonary hyper tension occurs, P2 increases, and a right ventricular impulse or lift may be noted. Tricuspid regurgitation due to a combination of rheumatic tricuspid valve involvement and pulmonary hypertension may become clinically evident with a regurgitant systolic murmur at the lower left sternal border, a pulsatile liver, and abnormal jugular venous pulsations. A: Two-dimensional echocardiographic parasternal long-axis image demonstrating bent-knee or hockey-stick configuration to thickened anterior mitral valve leaflet (arrow). Typically normal in patients with mild mitral stenosis, the chest radiograph may show left atrial enlargement in patients with more significant mitral valve obstruction. The heart is not enlarged unless there is associated mitral or aortic regurgitation. The pulmonary artery and right ventricle may enlarge when there is associated pulmonary hypertension. Right axis deviation, right atrial enlargement, or right ventricular hypertrophy may be evident if there is secondary pulmonary hypertension. On echocardiography, patients with rheumatic mitral stenosis have valvar and subvalvar changes including: thickened echo- dense leaflets, commissural fusion, abnormal diastolic leaflet excursion (doming), and calcification; fusion, shortening, fibrosis, and calcification of the mitral valve chordae. The leaflets begin to open in diastole, and although the body of the leaflets may continue to move, commissural fusion limits the excursion of the leaflet tips resulting in the characteristic “bent-knee” or “hockey-stick” appearance of the anterior leaflet typical of rheumatic mitral stenosis (Fig. With increased thickness and calcification, the leaflets become less pliable and motion is further restricted. Although the left atrium is dilated with significant stenosis, the left ventricle is normal in size unless there is concomitant mitral and/or aortic regurgitation. The severity of the mitral stenosis may be assessed from Doppler peak and mean gradients, planimetry of the valve opening, pressure half time, or proximal Doppler flow convergence (269,270). Leaflet mobility, thickening, calcification, and subvalvular thickening have been shown to be useful echocardiographic features for identifying patients who are good candidates for balloon valvotomy of mitral stenosis (271,272,273). When possible, pulmonary artery pressures should be estimated from the tricuspid and pulmonary regurgitation velocities since pulmonary hypertension may occur with more severe degrees of mitral stenosis. Both right and left ventricular function should be assessed in all patients with mitral stenosis. When available, 3-D echocardiography allows better assessment of both valve area and commissural fusion than 2-D imaging; as such it may also be valuable in evaluating candidacy for balloon valvotomy as well as preoperative planning for possible valve repair (274,275,276,277). Exercise or other forms of stress testing may be of value in evaluating patients with equivocal symptoms or in whom the symptoms are greater than would be expected based on the resting echocardiogram. In some patients, the transmitral gradient and pulmonary artery pressure rise significantly with exercise. Asymptomatic patients with significant mitral stenosis who show poor exercise capacity or a significant rise in estimated pulmonary artery systolic pressure (>60 mm Hg) with stress testing may be considered for transcatheter or surgical intervention (241,278). These changes lead to decreased leaflet mobility, decreased aortic orifice size, and obstruction to flow. Rheumatic aortic stenosis and regurgitation often occur concurrently, usually along with rheumatic mitral valve disease. The increase in stenosis is gradual, allowing ventricular compensation and the absence of symptoms. With time, compensation fails and symptoms develop (including angina, syncope, dyspnea on exertion, and heart failure), most often in the fifth to sixth decades of life (279).