Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
There is a wide spectrum in phenotypic expression and some cases may not be diagnosable in utero order online combipres arrhythmia nclex. In about 50% of cases buy combipres mg without prescription blood pressure ranges for infants, there are simple transverse reduction deficiencies of one forearm or hand without associated anomalies buy combipres with american express arteriosclerosis vs atherosclerosis. In the other 50% of cases, there are multiple reduction deficiencies and, in 25% of these, there are additional anomalies of the internal organs or craniofacial structures. In general, limb deficiency of the upper extremity is an isolated anomaly, whereas congenital amputation of the leg or bilateral amputations or reductions of all limbs are usually part of a genetic syndrome. Isolated amputation of an extremity can be due to amniotic band syndrome, exposure to a teratogen or a vascular accident. There is an association between chorion villous sampling before 10 weeks of gestation and transverse limb defects. Syndromes associated with limb deficiencies include the aglossia–adactylia syndrome (transverse amputations of the limbs ranging from absent digits to severe deficiencies of all four extremities, micrognathia, and vestigial tongue or ankylosis of the tongue to the hard palate, the floor of the mouth or the lips), and the Moebius sequence (facial anomalies attributed to paralysis of the 6th and 7th cranial nerves, leading to micrognathia and ptosis with upper limb defects, ranging from transverse amputations to absent digits). This is characterized by strict demarcation of the skin lesions to one side of the mid-line and limb deficiencies, which are unilateral, varying from hypoplasia of phalanges to complete absence of an extremity. The condition is also associated with heart defects and unilateral hydronephrosis or renal agenesis. Typically, the hands and feet are present (these may be normal or abnormal), but the intervening arms and legs are absent. Phocomelia can also be caused by exposure to thalidomide, but this is only of historical interest. One or both femurs can be affected but the right femur is more frequently involved. Femoral hypoplasia–unusual facies syndrome, which is sporadic, consists of bilateral femoral hypoplasia and facial defects, including short nose with broad tip, long philtrum, micrognathia and cleft palate. If the defect is unilateral, it may correspond to the femur–fibula–ulna or femur–tibia–radius complex. These two syndromes have different implications for genetic counselling; the former is non-familial, while the second has a strong genetic component. The typical variety (found in 1 per 90 000 births and usually inherited with an autosomal dominant pattern) consists of absence of both the finger and the metacarpal bone, resulting in a deep V-shaped central defect that clearly divides the hand into an ulnar and a radial part. The atypical variety (found in 1 per 150 000 births) is characterized by a much wider cleft formed by a defect of the metacarpals and the middle fingers; the cleft is U-shaped and wide, with only the thumb and small finger remaining. Split hand and foot deformities can occur as isolated anomalies, but more commonly they are part of a more complex syndrome. Other syndromes include split foot and triphalangeal thumb, split foot and hand and central polydactyly, Karsch–Neugebauer syndrome (split hand/foot with congenital nystagmus), acrorenal syndrome and mandibulofacial dysostosis (Fontaine syndrome). Radial clubhand includes a wide spectrum of disorders that encompass absent thumb, thumb hypoplasia, thin first metacarpal and absent radius. Ulnar clubhand, which is less common, ranges from mild deviations of the hand on the ulnar side of the forearm to complete absence of the ulna. While radial clubhand is frequently syndromatic, ulnar clubhand is usually an isolated anomaly. Postaxial polydactyly (the most common form) occurs on the ulnar side of the hand and fibular side of the foot. Preaxial polydactyly is present on the radial side of the hand and the tibial side of the foot. The majority of conditions are isolated with an autosomal dominant mode of inheritance. Preaxial polydactyly, especially triphalangeal thumb, is most likely to be part of a multisystem syndrome. Central polydactyly, which consists of an extra digit (usually hidden between the long and the ring finger), is often bilateral and is associated with other hand and foot malformations; it is inherited with an autosomal mode of inheritance. Neurological, muscular, connective tissue, and skeletal abnormalities result in multiple joint contractures, including bilateral talipes and fixed flexion or extension deformities of the hips, knees, elbows and wrists. This sequence includes congenital lethal arthrogryposis, multiple pterygium and Pena–Shokeir syndromes. The deformities are usually symmetric and, in most cases, all four limbs are involved. The severity of the deformities increases distally in the involved limb, with the hands and feet typically being the most severely affected. The condition is commonly associated with polyhydramnios (usually after 25 weeks), narrow chest, micrognathia and nuchal edema (or increased nuchal translucency at 10–13+6 weeks). In the first trimester, a common feature of many chromosomal defects is increased nuchal translucency thickness. In later pregnancy, each chromosomal defect has its own syndromal pattern of abnormalities. Trisomy 21 Trisomy 21 is associated with a tendency towards brachycephaly, mild ventriculomegaly, flattening of the face, nuchal edema, atrioventricular septal defects, duodenal atresia and echogenic bowel, mild hydronephrosis, shortening of the limbs, sandal gap and clinodactyly or mid-phalanx hypoplasia of the fifth finger. Trisomy 18 Trisomy 18 is associated with strawberry-shaped head, choroid plexus cysts, absent corpus callosum, Dandy–Walker complex, facial cleft, micrognathia, nuchal edema, heart defects, diaphragmatic hernia, esophageal atresia, exomphalos, renal defects, myelomeningocele, growth retardation and shortening of the limbs, radial aplasia, overlapping fingers and talipes or rocker bottom feet. Trisomy 13 In trisomy 13, common defects include holoprosencephaly and associated facial abnormalities, microcephaly, cardiac and renal abnormalities (often enlarged and echogenic kidneys), exomphalos and postaxial polydactyly. Triploidy Triploidy, where the extra set of chromosomes is paternally derived, is associated with a molar placenta and the pregnancy rarely persists beyond 20 weeks. When there is a double maternal chromosome contribution, the pregnancy may persist into the third trimester.
Effect of short-term acclimatization to order mg combipres amex blood pressure 50 30 high altitude on sleep and nocturnal breathing buy discount combipres on-line blood pressure high diastolic. Theophylline and acetazolamide reduce sleep-disordered breathing at high altitude buy combipres mg cheap pre hypertension pathophysiology. Sleep and breathing in high altitude pulmonary edema susceptible subjects at 4,559 meters. Exacerbation of sleep apnoea by frequent central events in patients with the obstructive sleep apnoea syndrome at altitude: a randomised trial. Patients with obstructive sleep apnea syndrome benefit from acetazolamide during an altitude sojourn: a randomized, placebo-controlled, double-blind trial. Sleep-disordered breathing in heart failure with normal left ventricular ejection fraction. The effect of successful heart transplant treatment of heart failure on central sleep apnea. Sleep disorders in systolic heart failure: a prospective study of 100 male patients. Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Influence of pulmonary capillary wedge pressure on central apnea in heart failure. Prevalence and physiological predictors of sleep apnea in patients with heart failure and systolic dysfunction. Sleep disordered breathing in heart failure patients with reduced versus preserved ejection fraction. Obesity and sleep apnea are independently associated with adverse left ventricular remodeling and clinical outcome in patients with atrial fibrillation and preserved ventricular function. Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne–Stokes respiration. Increased long-term mortality in heart failure due to sleep apnoea is not yet proven. Increased mortality associated with Cheyne–Stokes respiration in patients with congestive heart failure. Sleep and exertional periodic breathing in chronic heart failure: prognostic importance and interdependence. Prognostic impact of sleep disordered breathing and its treatment in heart failure: an observational study. Prognostic impact of sleep-disordered breathing and its treatment with nocturnal ventilation for chronic heart failure. Central sleep apnea, right ventricular dysfunction, and low diastolic blood pressure are predictors of mortality in systolic heart failure. Sleep disordered breathing and post-discharge mortality in patients with acute heart failure. Cheyne–Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Usefulness of sleep-disordered breathing to predict occurrence of appropriate and inappropriate implantable-cardioverter defibrillator therapy in patients with implantable cardioverter-defibrillator for primary prevention of sudden cardiac death. Cardiac resynchronization therapy improves central sleep apnea and Cheyne–Stokes respiration in patients with chronic heart failure. Elimination of central sleep apnoea by mitral valvuloplasty: the role of feedback delay in periodic breathing. Resolution of central sleep apnoea following implantation of a left ventricular assist device. Effects of inhaled carbon dioxide and oxygen on Cheyne–Stokes respiration in patients with heart failure. Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study. Differential effects of theophylline on sympathetic excitation, hemodynamics, and breathing in congestive heart failure. Low-concentration carbon dioxide is an effective adjunct to positive airway pressure in the treatment of refractory mixed central and obstructive sleep-disordered breathing. Acetazolamide attenuates hunter-Cheyne–Stokes breathing but augments the hypercapnic ventilatory response in patients with heart failure. The effect of oxygen on respiration and sleep in patients with congestive heart failure. Comparison of oxygen therapy with nasal continuous positive airway pressure on Cheyne–Stokes respiration during sleep in congestive heart failure. Effects of nasal O2 on sleep-related disordered breathing in ambulatory patients with stable heart failure. Improvement of exercise capacity with treatment of Cheyne–Stokes respiration in patients with congestive heart failure. Effect of oxygen on sleep quality, cognitive function and sympathetic activity in patients with chronic heart failure and Cheyne–Stokes respiration. Adaptive pressure support servo-ventilation: a novel treatment for Cheyne–Stokes respiration in heart failure. Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure. Efficacy of adaptive servoventilation in patients with congestive heart failure and Cheyne–Stokes respiration. Treatment of congestive heart failure and Cheyne–Stokes respiration during sleep by continuous positive airway pressure. Effect of continuous positive airway pressure on mitral regurgitant fraction and atrial natriuretic peptide in patients with heart failure. Beneficial effect of bilevel positive airway pressure on left ventricular function in ambulatory patients with idiopathic dilated cardiomyopathy and central sleep apnea-hypopnea: a preliminary study.
In addition mg combipres amex hypertension medications list, gemcitabine plus sorafenib is not with advanced pancreatic cancer cheap combipres mg without prescription hypertension natural treatment, median survival was increased in the recommended buy generic combipres on line hypertension xanax. Gemcitabine combinations are currently being used and to the standard infusion of gemcitabine over 30 minutes (category 2B). Adverse events, such as rash of patients from that arm were alive at 42 months, whereas no patients and diarrhea, were increased in the group receiving erlotinib, but most were alive from the control arm at that time. A retrospective study from Johns Hopkins University School of capecitabine had a greater overall response rate, compared to patients Medicine of patients with metastatic pancreatic cancer and a family history who received gemcitabine only (43. Although there are concerns large survival advantage when treated with platinum-based chemotherapy about dosing and toxicity of capecitabine in a U. Angiogenesis inhibitors may be more useful after more effective first-line treatments. Clearly, additional trials are Fluoropyrimidine Plus Oxaliplatin needed in this important area. With the success of more effective regimens in patients with advanced Second-line systemic therapy should be administered to patients with disease, questions have been raised about how best to manage the good performance status only. Final results of the trial were without evidence of progression after 6 months of initial therapy (n = 55; 317 published in 2014. Options for patients with good antibodies that inhibit the interactions between immune cells and antigen performance status and previously treated with fluoropyrimidine-based presenting cells, including tumor cells. Adverse events were experienced by 74% of all patients receiving pembrolizumab; most were Radiation and Chemoradiation Approaches low grade (20% experienced grade 3 or 4 adverse events, such as In patients with pancreatic cancer, radiation is usually given concurrently diarrhea/colitis, pancreatitis/hyperamylasemia, fatigue, arthritis/arthralgias, with gemcitabine or fluoropyrimidine-based chemotherapy. Although the mechanism of radiosensitization is Immunotherapy-Related Toxicities, available at It also treatment-related toxicity, particularly in patients with unresectable may be used to enhance local control and prevent disease progression, disease. Studies are presently investigating the from adjuvant chemoradiation than those with negative nodes. Chemoradiation is a conventional option for the management of locoregional pancreatic cancer, although the utility of chemoradiation in Studies that have looked at R0 or R1 subsets of patients have found this population of patients is controversial. One retrospective review compared 370-374 radiation sensitizer in the locally advanced setting. A retrospective of upfront chemotherapy followed by chemoradiation in locally advanced analysis of 77 patients with unresectable disease demonstrated that while disease have been discussed. Hypofractionated dosing patients with locally advanced pancreatic cancer, was closed early due to 387 may also be used in these patients, with acceptable toxicity. Employing an initial course of chemotherapy may improve local disease progression. In addition, the natural history of chemotherapy regimens than gemcitabine monotherapy, additional studies the disease can become apparent during the initial chemotherapy, thus are planned to assess the role of radiation after more active allowing the selection of patients most likely to benefit from subsequent chemotherapy. Moreover, clinically meaningful tumor should only be performed at specialized centers. For instance, patients who complain of intractable nausea and vomiting may have the primary goals of treatment for metastatic pancreatic cancer are gastric outlet obstruction rather than chemotherapy-induced emesis. However, have noted that the opportunity for curative intent resection occasionally patients may demonstrate progressive disease clinically without objective arises. Following resection, these patients Management of Locally Advanced Disease have similar survival rates as those initially determined to be resectable. This technique has been used in patients with locally advanced the role of modern, more active regimens in locoregionally advanced pancreatic cancer. Five patients (23%) were able to undergo R0 resections, although Management of Resectable and Borderline Resectable 3 of these patients experienced distant recurrence by 5 months. The goals of surgery for adenocarcinoma of the pancreas include an oncologic resection of the primary tumor and regional lymph nodes. However, more than 80% of patients present with Based on their clinical experience with the primary management of disease that cannot be cured with surgical resection. Early concerns about tumor resectability so as to improve patient selection for surgery and high mortality associated with various pancreatic resection procedures428 increase the likelihood of an R0 resection. Using a combination of these sets of converse statement—the survival benefits of an R1 resection may be criteria, tumors are classified as resectable, borderline resectable, locally comparable to definitive chemoradiation without surgery. A review of 4 studies with 2580 patients management and resectability always involve multidisciplinary consultation showed that additional resection to achieve a negative surgical margin at high-volume centers with use of appropriate high-quality imaging was not associated with improved survival. Although it is clear that patients taken approximately 5 mm from the transection margin, with the clean-cut with visceral, peritoneal, or pleural metastases or with metastases to side facing down, to avoid cautery artifact that may confound analysis and nodes beyond the field of resection derive no benefit from resection, result in false negatives. If tumor is located within 5 mm of margins, further institutions differ in their approaches to patients with locoregional disease excision of the pancreas should be considered to ensure at least 5 mm of involvement (pancreas and peripancreatic lymph nodes). Careful intraoperative staging should rule out peritoneal, liver, and distant For cancers of the pancreas head and uncinate, a lymph node metastases, and resection of the primary tumor should only pancreatoduodenectomy (Whipple procedure) is done. The surgical procedure pancreas body and tail, a distal pancreatectomy with en-bloc splenectomy required is based on the location of the primary tumor and relationship to is done. The panel has adapted the criteria put forth by other groups and lists its recommended criteria for defining resectability status in the guidelines. Overall, the likelihood of attaining recommends biopsy confirmation of adenocarcinoma at this time, if a negative margins is the key criterion for consideration when determining biopsy was not previously performed. If a patient with jaundice is found to whether a patient is a potential candidate for resection. If a stent has been previously placed, then surgical there is a higher likelihood of an incomplete resection. In addition, gastrojejunostomy can be for positive surgical margins are not considered to be good candidates for considered if appropriate regardless of jaundice (category 2B for an upfront resection but may be potentially downstaged and safely prophylactic gastrojejunostomy). Celiac plexus neurolysis can also be resected following neoadjuvant therapy [see Preoperative (Neoadjuvant) performed, especially when indicated by pain in a patient with jaundice Therapy below].
Buy combipres with american express. Does alcohol cause high blood pressure?.
Benignity of fetal and infantile neoplasms Some neonatal and infantile tumors have a benign clinical behavior despite histological evidence of malignancy combipres mg low cost hypertension recipes. Examples include congenital neuroblastomas and hepatoblastomas in the first year of life order combipres canada arteria definicion, and congenital and infantile fibromatosis purchase mg combipres with visa heart attack quizlet, and sacrococcygeal teratomas in the first few months of life. The factors responsible for this ‘oncogenic period of grace’, which starts in utero and extends through the first few months of extrauterine life, are uncertain. Association of neoplasia and congenital malformations the concept that teratogenesis and oncogenesis have shared mechanisms is well documented by numerous examples. Probably, there is simultaneous or sequential cellular and tissue reaction to specific injurious agents. The degree of cytodifferentiation, the metabolic or immunological state of the embryo or fetus, and the length of time of exposure to the agent will determine whether the effect is teratogenic, oncogenic, both, or neither. Many biological, chemical and physical agents known to be teratogenic to the fetus or embryo are carcinogenic postnatally. Alternatively, a teratogenic event during intrauterine life may predispose the fetus to an oncogenic event later in life. This would explain neoplastic transformation occurring in hamartomas, developmental vestiges, heterotopias and dysgenetic tissues. It is postulated that the anomalous tissues harbor latent oncogenes which, under certain environmental conditions, are activated, resulting in malignant transformation of a tumor. Apart from distinguishing solid from cystic lesions, probably the best classification should be by location. The main compartments of fetal tumors are the head and brain, face and neck, thorax (including the heart), abdomen and retroperitoneum, extremities, genitalia, sacrococcygeal region, and skin. Prenatal diagnosis the approach for prenatal diagnosis of fetal tumors should be based on three sets of ultrasound signs: general signs, organ-specific signs and tumor-specific signs. The general sonographic features, that should raise the suspicion of an underlying fetal tumor, include: (1) Absence or disruption of contour, shape, location, sonographic texture or size, of a normal anatomic structure; (2) Presence of an abnormal structure or abnormal biometry; (3) Abnormality in fetal movement; (4) Polyhydramnios; and (5) Hydrops fetalis. Polyhydramnios is particularly important, because almost 50% of fetal tumors are accompanied by this finding. The underlying mechanisms include interference with swallowing (such as thyroid goiter or myoblastoma), mechanical obstruction (such as gastrointestinal tumors), excessive production of amniotic fluid (such as sacrococcygeal teratoma), and decreased resorption by lung tissue in lung pathology. Intracranial tumors are also commonly associated with polyhydramnios and the mechanism may be neurogenic lack of swallowing or inappropriate polyuria. Tumor-specific signs include pathological changes within the tumor mass (calcifications, liquefaction, organ edema, internal bleeding, neovascularization and rapid changes in size and texture). Organ-specific signs are rare, but in some cases they are highly suggestive of the condition (such as cardiomegaly with a huge solid or cystic mass occupying the entire heart, suggesting intrapericardial teratoma). Examples may vary from severe cases of bladder exstrophy (where the protruding bladder mass appears as a solid tumor-like structure), to rare cases of fetal scrotal inguinal hernia (where bowel loops occupy the scrotum, appearing as huge masses). Prognosis Apart from intracranial tumors (where the prognosis is generally poor), the prognosis for tumors in other locations is variable and depends on the size of the tumor (with resultant compression of adjacent organs), degree of vascularization (with the risk of causing heart failure and hydrops), and associated polyhydramnios (with the risk of preterm delivery). Prevalence Brain tumors are exceedingly rare in children, and only about 5% arise during fetal life; teratoma is the most frequently reported. Etiology Embryonic tumors are thought to derive from embryologically displaced cells. Brain tumors have been produced in animals by the use of chemical and viral teratogens. Diagnosis A brain tumor should be suspected in the presence of mass-occupying lesions (cystic or solid areas), and a change in shape or size of the normal anatomic structures (such as shift in the mid-line). Cystic tumors and teratomas are usually characterized by complete loss of the normal intracranial architecture. In some cases, the lesion appears as a low echogenic structure, and it may be difficult to recognize. Hydrocephalus is frequently associated with brain tumors and may be the presenting sign. The ultrasound appearances of all intracranial tumors are similar and, therefore, precise histological diagnosis from a scan is almost impossible. Possible exceptions are lipomas (that have a typical hyperechogenic homogeneous appearance) and choroid plexus papillomas (that appear as an overgrowth of the choroid plexus). Identification of brain neoplasm associated with tuberous sclerosis, neurofibromatosis, and systemic angiomatosis of the central nervous system and eye can be attempted in patients at high risk; in most cases, however, antenatal sonography is negative, at least in the second trimester. Prognosis Prognosis depends on a number of factors, including the histological type and the size and location of the lesion. The limited experience with the other neoplasms in prenatal diagnosis precludes the formulation of prognostic considerations. From their sites of origin, the tumors grow into the oral or nasal cavity or intracranially. The tumors, which are usually benign, consist of tissues derived from any of the three germinal layers; most of them contain adipose tissue, cartilage, bone, and nervous tissue. Prenatal diagnosis is suggested by the demonstration of a solid tumor arising from the oral cavity; calcifications and cystic components may also be present. Differential diagnosis includes neck teratomas, encephaloceles, and other tumors of the facial structures. A careful examination of the brain is important because the tumor may grow intracranially. The outlook depends on the size of the lesion and the involvement of vital structures. Myoblastoma this is a very rare benign tumor, which usually arises from the oral cavity. The tumor occurs in females exclusively and it may be the consequence of excessive production of estrogens by the fetal ovaries under human chorionic gonadotropin stimulation. The ultrasound features are those of a large solid mass protruding from the fetal mouth.
Through this evolu tion buy generic combipres pills arteria tibialis anterior, the horse has kept his noble and loyal character purchase cheap combipres line pulse pressure waveform, his heart buy generic combipres line phase 4 arrhythmia, and his ever readiness for flight. A more holistic approach using alternative medicine is now pre ferred by many trainers and riders. We must take into consideration all the various factors affecting both the internal and external environment of the horse. Any dysfunction of the musculoskeletal system requires that an overall assessment be made as to the causative factors. We know that the body will strive to heal, repair, and maintain itself—if the right conditions are present. In order to help with the healing capacity of the body, the horse’s emotional stability, lifestyle, nutri tional balance, exercise, and hygiene programs, as well as structural soundness, are our responsibility. Massage therapy helps us to trig ger the body into getting itself back to optimal health. Massage therapy is the manipulation of the soft tissues of the body in order to achieve specific goals of drainage, relaxation, or stimulation, and of resolving muscle-related problems such as trig ger points and stress points. It contributes to the overall economy of the body and to its ability to function efficiently. It greatly improves circulation, thereby promoting a good supply of nutri ents to the muscle groups. Massage therapy also reduces stress on the nervous system, helping the psychophysiologic self-regulation factors between body and mind. Massage therapy’s healing func tion has been known to speed up recovery from injury. Furthermore, massage increases our emotional bonding with the animal—and especially the young horse—which learns to relax and accepts being handled better. You will be able to feel and detect any abnormalities and problems much sooner than by sight. Massage will help you avoid possible complications that could be very costly to treat. It is one of the oldest forms of therapy; it has been used by people from ancient times to the present. Forms of equine massage therapy were practiced by the ancient Chinese and Romans and more recently by the Hopi Indians of the western United States. Beginning Your Journey In this book, you will find everything you need and want to know about massage movements, pressures, rhythms, techniques, and sequences. You will learn about the various areas of stress in a working animal and how these areas of stress can be present in horses of various disciplines. You will learn how to apply myofas cial massage, how to treat equine temporomandibular dysfunction syndrome and equine compensation syndrome, and you will also learn how improper saddle fitting can be corrected through mas sage and what you can do to ensure a proper fit. After you have satisfied your curiosity and familiarized yourself with the content by scanning the book, proceed with the study of Introduction 3 the material. These basic terms will help you remain oriented throughout your study of this book. Finally, go through it again, this time taking notes, and duplicating the drawings. Maximizing Your Study Having a life doesn’t leave much free time for hobbies or studies. It is eas ier and faster to study little sections at a time than large ones at once. To get a good start, spend at least 1 hour a day minimum, up to 5–6 hours of study per week in the beginning. The few moments spent each day on studying are a small price to pay for the knowl edge, happiness, and success that will be yours when finished with this home study course. In order to get the most out of your study of massage, it’s impor tant that you make sure you’ve absorbed all of the material you’ve read. If, at any point in the text, you become confused, go back and review the previous sections. You can’t afford to progress in your education with parts of your knowledge remaining unclear. It would make your overall study much harder, and would ultimately affect your performance. At first, absorbing all the information in this guide may seem to be a rather large task to undertake. But remember, the equine massage knowledge you are developing will stay with you for a lifetime. Take it one step at a time, and before you know it, you will have absorbed a lot and feel pretty confident. Making It a Fun Experience Quiz yourself regularly over each chapter and each chart. To help my students, I offer various musculoskeletal charts, a stress point location poster, and work books containing hundreds of ques tions. A part of making the learning process a fun experience is to give yourself rewards as you complete each section of the course. Do not forget to appreciate the learning experience you are going through, as well as the deep bond you are developing with your horse during the hands-on periods. On Going Learning Be patient in your learning process as everything takes time to mature.