Once the patient is walking with the knee fully extended diclofenac gel 20gm without a prescription arthritis in feet arches, repeat the procedure and apply a further cast 20gm diclofenac gel arthritis in back mayo clinic, until the foot will reach the This is the most common deformity in a child 20 gm diclofenac gel visa arthritis diet blog, and is neutral position with the leg extended. If you are Where serial casting is inadequate, with also a minor varus inexperienced, you will find serial casts very useful. The closed operation is simpler, In a child, tenotomy is contraindicated if: and there is less risk of infection, or keloid formation. Use a small tenotomy knife, or the improvised one If you have cut the whole Achilles tendon, do not be (32-17). It will almost always heal satisfactorily in the gown yourself, use gloves, and apply a tourniquet (3. Do this by pushing patient did not wear a calliper, or wore one without a the knife into the tendon from the medial side, in the line backstop (32-13B). If he fails to wear one initially, of its fibres, at the junction of the anterior third and the the deformity is sure to recur. Follow up carefully, posteriorly, until you feel the knife cutting very easily, so that you can decide about this. If you fracture the lower tibia because you have 2nd incision, push the knife into the tendon in the line of its manipulated it too vigorously, fit a cast. Use the lateral position, with the leg to (4),Do not try to divide the tight posterior capsule of the be operated on uppermost. This is not tightened in poliomyelitis, unless there is an associated varus Make a longitudinal incision over the lower of the leg, deformity, which must be corrected at open operation. Do not apply force to the You may see the small tendon of the plantaris (35-22I) distal tibia; you can easily break it. Make 2 incisions half way across the Achilles tendon: the If necessary, manipulate it again 2wks later. If there is any varus If the ankle does not reach the neutral position (90), deformity of the foot leave the lateral side intact. If there is check that the tendon has been divided properly, any valgus deformity, leave the medial side intact. If the ankle is still not fully corrected to 90, tendon to correct the deformity. If necessary, release the ankle on the same incision opposite the first one (32-18A,B). If you fail to put the foot into satisfactory dorsiflexion, make a longitudinal incision down the middle of the If the knee is stable, apply a well-padded below-knee tendon joining the two cuts. If this still does not correct the walking cast, with the foot near the maximum correction, position of the foot, dissect down to the posterior aspect of but not at the extreme limit of extension. Review a young capsule of the ankle joint transversely (32-18D), child in 3wks, and an older child or adult in 6wks. Pad the leg, apply a below-knee cast with the knee flexed to 90 and release the tourniquet. At the same time, the forefoot is adducted at its tarso-metatarsal joints, and the 1st metatarsal is plantarflexed to a greater degree than the 5th metatarsal (cavus). If the deformity is left to progress without correction, the navicular bone may be pulled medially, and sometimes even away from the front of the talus. D, cross-section at Manipulation and casting by the Ponseti method when level of mid-malleoli: (1) saphenous nerve and vein. Provide crutches, These may be helped but are often resistant to conservative and check the cast in 3wks. You need to use the Ponseti technique properly permanently, so that a child will be able to walk normally and carefully, but it has probably the highest cost-benefit in normal shoes, if you start treatment in the first days after ratio of any surgical procedure. Manipulation weekly and applying plaster casts for start before 9months of age, but may still correct 85% of 5 to 6wks is normally successful. A, the arrows show cavus, the high medial arch, due to pronation of the forefoot in relation to the hindfoot. B, correct cavus by supinating the forefoot with pressure against the head of the talus. You should avoid other operations which tend to produce C, cavus (the forefoot adducted at its tarso-metatarsal joints) scarring and a chronically painful foot, until at least 2yrs. E, correct adductus by You should aim to correct the components, cavus and gently abducting the forefoot whilst stabilizing the talus with your thumb and holding the lateral malleolus with your index finger. Distinguish between inversion & eversion at the ankle, and pronation & supination at the forefoot! F, leave the toes exposed removing plaster to the mtp joints dorsally, but leaving the plantar side as a support. I, apply a th 5 cast with the foot abducted 60-70 with respect to the front of the tibia. K, the Steenbeek brace: different sized boots, the materials needed to make the boot, and the final result. The adducted metatarsus has only a midfoot and no hindfoot contracture and is not a club foot Correct cavus by supinating the forefoot and making a normal longitudinal arch (32-20A, 32-24J) and correct adductus by abducting the forefoot in proper alignment with the hindfoot. So, make sure you can locate the head of the talus by first feeling for the lateral malleolus, and moving your thumb forward in front of the ankle mortice. The navicular (32-24J) is displaced medially to a position in front of the head of the talus, almost touching the medial malleolus. Gently abduct the forefoot, whilst stabilizing the head of the talus and holding the lateral malleolus, as far as you can without causing discomfort to the child. Hold this position with gentle pressure for 1min (32-20E) so that the big toe is almost straight, and apply a cast for 1wk. Continue further abduction, holding the position in the 2nd and 3rd casts, each for 1wk. Correct heel varus when you have corrected adductus, keeping the position in the 3rd and 4th casts (32-20F), again for 1wk. The purpose of the casting is to immobilize the contracted ligaments at the maximum stretch obtained after each manipulation. Apply the cast with plaster of Paris in 3-4 turns first around the toes (32-21A), and continue up the leg, adding a little tension above the heel (32-21B). Keep some space around the toes by wrapping the cast around your assistants holding fingers (32-21A)! Do not force the correction with the plaster, and do not press continuously on the head of the talus, but rather, mould the plaster over the head of the talus and under the Table 32-1 Columbian club foot score arch to avoid flatfoot. Trim the plaster dorsally up to the mtp then every 4months till age 3, every 6 months till age 4, joints, leaving the plantar surface intact to support the toes then every year till skeletal maturity. Do not pronate or evert the foot because this increases Start removing it at the thigh. Do not allow a long interval the cavus and does nothing to unlock the calcaneus locked between re-casting because you may lose considerable under the talus, and will result in a bean-shaped foot. Do not abduct the foot at the mid-tarsal joints by pressing on the cuboid with the thumb, because this will Finally, correct equinus by dorsiflexing the foot. Do not externally rotate the foot while the calcaneus tenotomy of the Achilles tendon, unless the Pirani score is remains in varus, because this produces posterior <1 for hindfoot and midfoot deformity and the talar head is displacement of the lateral malleolus. Do not forget to immobilize the foot after each Do not perform a tenotomy if the heel is in varus, because manipulation, with ligaments at maximal stretch.
For exam ple generic diclofenac gel 20gm amex arthritis medication for back pain, intake of polyunsaturated fat in ethanol-fed rats purchase 20gm diclofenac gel rheumatoid arthritis united states, but not in pair-fed controls purchase diclofenac gel amex arthritis relief devices, results in a synergistic priming effect on induction of cytochrome P4502. Whereas a slight increase in hepatic iron content by dietary iron supplementation is harmless in control rats, it exacerbates alcoholic liver injury via accentuation of oxidative stress . In turn, deleterious effects of acetaldehyde-protein adduct formation may be accentuated by oxida tive stress since malondialdehyde, a lipid peroxidation end product, can increase the bind ing affinity of acetaldehyde by 13-fold . The resulting novel hybrid adducts are highly immunogenic and may incite immune response mediated liver injury [105, 106]. It is need experts in various disciplines need to work together to provide cutting-edge science for elucidating the precise nature and mecha nisms that underlie interactions. Some compounds that have been studied as possible protectors against liver cirrhosis are known for their anti-inflammatory and antioxidant properties. Plants contain numerous pol yphenols, which have been shown to reduce inflammation and thereby to increase resist ance to disease . It contains a number of phenolic hydroxyl groups, which have strong antioxidant activity [116, 117]. By increasing the endogenous antioxidant defenses, flavonoids can modulate the redox state of organisms. While a signifi cant body of epidemiological and clinical data suggests that antioxidant-rich diets reduce blood pressure and cardiovascular risk, randomized trials and population studies using nat ural antioxidants have yielded disappointing results. Currently exist incomplete knowledge of the mechanisms of action of these agents, lack of target specificity, and potential interindividual differences in therapeutic effi cacy preclude us from recommending any specific natural antioxidant for antihypertensive therapy at this time. Superoxide is short-lived molecule that can subsequently 2 undergo enzymatic dismutation to hydrogen peroxide. Peroxynitrite and other reactive nitrogen species can subsequently ox idize proteins, lipids, and critical enzymatic cofactors that may further increase oxidative stress . The balance between superoxide production and consumption likely keeps the concen tration of O in the picomolar range and hydrogen peroxide in the nanomolar range . Similar interventions demonstrated to reduce cardiovascular morbidity and mortality continue to maintain inter est in the potential of isolating specific compounds enriched in these diets that may be re sponsible for the overall dietary benefits . The dietary components in these studies are high in compounds known to have antioxidant properties leading many to ascribe the benefits of these diets to their increased content of 370 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants natural antioxidants. However, prior randomized trials and population studies in healthy populations and patients at high risk for cardiovascular events that have employed combi nations of some of these natural antioxidants as dietary supplements have, for the most part, shown disappointing results [138-145]. The reasons behind these disappointing results are not completely clear, but likely include a combination of 1) ineffective dosing and dosing regimens 2) the potential pro-oxidant capacity and other potentially deleterious effects of these some of these compounds under certain conditions [146-148], 3) selection of subjects less likely to benefit from antioxidant therapy (too healthy or too sick). When considering antioxidant therapy for hypertension, lessons from prior disappointing attempts to reduce blood pressure and cardiovascular risk with antioxidant therapy should be considered. Vitamin A precursors and derivatives Vitamin A precursors and derivatives are retinoids that consist of a beta-ionone ring attach ed to an isoprenoid carbon chain. Initial interest in vitamin A-related compounds focused primarily on beta-carotene, given initial promising epidemiological data with respect to its cardioprotective effects and some correlation with higher plasma levels to lower blood pres sure in men. However, concerns about beta-carotenes pro-oxidative potential came to light with a report suggesting adverse mitochondrial effects of beta-carotene cleavage products. Further, adverse mortality data with respect to beta-carotene has limited interest in this compound as an effective antihypertensive agent. Recently, interest in vitamin A derivatives has turned to lycopene, itself a potent antioxidant , found concentrated in tomatoes. One small study has shown a reduction in blood pressure with a tomato-extract based intervention (containing a combination of potential an ti-oxidant compounds including lycopene) in patients with stage I hypertension,  al though second study showed no effect in pre-hypertensive patients . Ascorbic acid (Vitamin C) L-ascorbic acid is a six-carbon lactone and, for humans, is an essential nutrient. Toxicity potential of this compound is low, al though an increased risk of oxalate renal calculi may exist at higher doses (exceeding 2 grams/day). The initial purported mechanisms for the potential benefits of ascorbate supplementation were centered on quenching of single-electron free radicals. Subsequent research has dem onstrated that the plasma concentrations of ascorbate required for this mechanism to be physiologically relevant are not attainable by oral supplementation . However, vitamin C can concentrate in local tissues to levels an order of magnitude higher than that of plasma. At this ascorbate may to effectively compete for superoxide and reduce thiols . Ascorbates anti-hypertensive efficacy has been evaluated in multiple small studies [160-163] but not all, show modest reductions in blood pressure in both normotensive and hypertensive populations. These data also suggest that supplementation has limited effect on systemic antioxidant markers and little additional blood pressure benefits are seen be yond the 500 mg daily dose. Large scale randomized trial data specific to ascorbate supple mentation and its effects on hypertension are currently lacking. In the inflammatory processes follow next scheme in the therapy antioxidant . While there are four isomers in each class of Vitamin E compounds, the over whelming majority of the active form is -tocopherol. However, studies demonstrating vi tamin Es pro-oxidant capacity under certain cellular conditions suggest that local condition may influence the vitamin Es redox activity . However, recent concerns about potential deleterious increases in homocysteine in the set ting of L-arginine supplementation have been raised. The majority of L-arginine is process ed into creatine, which leads increased homocysteine levels. The exact structure and composition of the flavonoid compounds varies between food sources, and flavonoid content can be altered based on the manner of food preparation . Interest in flavonoids as antioxidants therapy for cardiovas cular disease originates from epidemiological data suggesting improved cardiovascular out comes in individuals with high intake of food and beverages with high flavonoid content as well as cellular work suggesting a strong anti-oxidant effect of these compounds . Studies investigating the anti-hypertensive effects of flavonoids are inconclusive. The specific flavonoids and combination of flavonoids that exert the largest beneficial effects remain unknown. Conclusions The antioxidants present in food playing an important role in preventing chronic diseases. A balanced diet can prevent diseases associated with oxidative stress and help keep the body in top condition. Iron overload and its association with cancer risk in humans: evi dence for iron as a carcinogenic metal. Role of free radicals in the neurodegenerative diseases: therapeu tic implications for antioxidant treatment. Reactive oxygen species, cell growth, cell cycle progression and vascular remodeling in hypertension. The potential role of antioxidant vitamins in preventing cardiovascular diseases and cancers. Treatment of Mcf-7 Breast Can cer Cells with a Red Grape Wine Polyphenol Fraction Results in Disruption of Calci um Homeostasis and Cell Cycle Arrest Causing Selective cytotoxicity J.
We used distributed in the environment of infected turkey Ct value of 38 as the cutoff to determine barns but diminished with the distance away from the positive/negative status of the samples buy diclofenac gel 20 gm mastercard arthritis in dogs how to tell. Average Ct value order diclofenac gel 20gm free shipping arthritis lung cancer, the operations generic diclofenac gel 20gm online arthritis pain in thumb, as well as the guidance for the cleaning positive rate, and the standard deviation of Ct values and disinfection practices. Of the th 84 65 Western Poultry Disease Conference 2016 141 samples, those collected inside the barn had the barns. The Pennsylvania/Virginia Ct values between the inside the infected barns group Experience in Eradication of Avian Influenza and other groups are significant (p-value < 0. Environment: a potential source of animal linear regression model, we discovered no linear and human infection with influenza A (H5N1) virus. Location Total number of % of positive Average Ct value of Sample type of samples samples positive samples positive samples Inside the infected barns 44 50 30. The cells were harvested 72 h remained constant until the termination of the post-infection, freeze thawed five times, experiment. The copy number of hexon weeks of age (first time point) and remained gene was calculated by using the formula; plasmid consistent through-out the experiment. Sera samples were heat present for the serotypes of species E, but not for inactivated at 56C for 30 min and 2-fold serial species D. Adult broiler breeders were previous studies showing anti-viral IgA exists in gut randomly divided in two groups of 24 birds each (n = mucous (3) or at other mucosal surfaces (7), it is 24/group). Locally produced mucosal IgG in th 87 65 Western Poultry Disease Conference 2016 chickens immunized with conventional vaccines for adenovirus 9 vector. Induction of fecal excretion patterns of strain 93 chick embryo mucosal immunity in the avian Harderian gland with lethal orphan virus in chicks. Infection and Immunity a replication-deficient Ad5 vector expressing avian 5:60-64. Journal of Adenovirus Associated with Inclusion Body Hepatitis virological methods 183:147-153. Adenoviral gizzard with Inclusion Body Hepatitis in Saskatchewan erosion in commercial broiler chickens. Protective immunity induced by Six chickens were randomly selected on day combined, in ovo vaccination with herpesvirus of four postchallenge and necropsied. The speed, efficiency and success of infection control depends on the ability of these Highly pathogenic Eurasian origin H5 influenza groups to work cooperatively to address a goal. The regulatory community gains in turkeys and from Mar 4April 11, the outbreak information during the outbreak, and hoarding of was restricted to turkeys. On April 11, the first egg information may leave the industries, the scientific layer flock was infected. From April 11June 5, both communities, and the public without needed turkey and egg laying hens were infected. The eradication team may not have time cases from June 518 were in egg laying chicken to access information held by the scientific flocks. The region is covered by Eastern forest and constitutes effective disease control vary within the grasslands biomes and is largely defined by the broiler, layer and turkeys industries. The poultry Mississippi river and its tributaries, the Ohio and industries are structured to reduce the risk of Missouri rivers. The climate of the area varies from common diseases but have little experience in the subtropical at the southern extent of the range to a control of diseases that go beyond the boundaries of a humid continental climate at the northern extent. Regulatory officials region is covered by two migratory bird flyways, the have specific training and expertise in the control of Central and Mississippi flyways, and nine states. In transboundary diseases but are often unfamiliar with this region, there are nearly 47 million turkeys, more standard operating procedures in the poultry than 100 million egg laying hens and approximately industries. The affected farmer may have It was apparent during and after the outbreak little to do, while the industries must figure out how that, in addition to these regional risks, the barriers to to keep operating safely. This may result in cooperative efforts in infection control also inattention to details surrounding virus containment contributed to the outbreak. The barriers to effective on the infected farm while these scores or hundreds cooperative control that may go unrecognized in an of contaminated people leave the farm each day. As the communication channels that exist to make everyday outbreak unfolds, great confusion exists about the activities of business and government go smoothly. In introductions presumably from the wild bird the absence of an outbreak, these groups interact very reservoir. Whether these primary introductions arose differently than how they need to interact during an from dust borne virus carried into barns or from th 92 65 Western Poultry Disease Conference 2016 being tracked in has not been established. Lateral months; and continuity of business efforts transmission from farm to farm appeared to occur via successfully allowed low-risk movement of poultry familiar means: movement of live or dead birds or industry products and day-old poultry. Silos tend to Lessons learned include the continuing need to keep fragmentary phylogenetic analysis, survey break down communication silos involving results, and industry information from coalescing into industries, agencies and academics; to explore an enlightening epidemiology report of what regional biosecurity practices; to change industry happened (1). Dexamethasone, rye-based of inflammation can cause a decrease in nutrient diet, and water withdrawal resulted in the highest absorption efficiency and growth. In process not conducive to high-throughput screening Experiment 2, all chicks were exposed to a mild cold models. Additionally, morphological repairs are slow stress, (30C for six h) at three days of age plus an to develop and may not be fully indicative of enteric inflammation-inducing treatment, followed by function once treatment has begun. Birds were circulation has previously been associated with bone monitored for lameness through day 70. Two and short-term water withdrawal may be sufficient experiments were conducted to evaluate the effect of for inducing meaningful amounts of decreased stress on intestinal permeability induced by enteric integrity. All numerical data were nutritional requirements of poultry recommended by subjected to Analysis of Variance as a completely National Research Council (1994). Incidence Institutional Animal Care and Use Committee at the data were compared using the Chi Square Test of University of Arkansas. Microbiota Composition and Bone Mineralization in Bone circulatory disturbances in the development of Turkey Poults. Work undertaken in both the laboratory and the field has looked at the impact The use of oregano oil in laboratory infections of oregano-based (Orego-Stim) and carrier-based with Eimeria has been well documented with organic acid products on the prevalence of Eimeria promising results, although typically the studies are infections or histomoniasis. Where hatchery Eimeria and Histomonas are responsible for two vaccination with a anticoccidial vaccine significantly of the main protozoal diseases that affect poultry: adversely affected performance relative to a coccidiosis and Blackhead (histomoniasis). In a acid to have a significant role in protozoal (Eimeria laboratory study, four out of 43 plant substance and Histomonas) management programs. More work extracts demonstrated in vitro efficacy against is necessary to explore and understand their potential Histomonas meleagridis but all failed to be protective further. Blackhead disease improvement in turkey performance following (Histomoniasis) in poultry: a critical review. In vitro effect of herbal products against laboratory work is underway to understand the Histomonas meleagridis. Evaluation of dietary Natustat for control of Histomonas meleagridis in male turkeys on infected litter. The yearly number of cases disease of chickens, mostly broilers, of two to eight varied widely between three and 56 showing no clear weeks of age. Monthly numbers were more enlargement, atony and pallor of the proventriculus evenly distributed and varied between 13 and 33 and weakness of the gastric isthmus (9).
Mayos pins keep forceps together in bunches more and more rolls of cotton wool and bandage purchase diclofenac gel 20 gm visa what is arthritis in back. Predictably purchase on line diclofenac gel arthritis pain nz, there was quite a lot of bleeding seen when he Blalock artery clamps (various sizes) released the big aortic clamps cheap 20 gm diclofenac gel fast delivery arthritis gout diet cure. In fact he hadnt seen so much blood in the abdomen outside of the trauma situation, where there was always frantic activity to stem the bleeding. When the professor had sutured in the graft, there was considerable oozing from the suture lines. He simply put in a big pack and asked the assistant to press gently, but firmly, till he returned, and went off to have a cup of tea! When the professor came back 10mins later well refreshed, he re-scrubbed, and removed the pack; the operative field was perfectly dry. Kochers are large haemostats with a tooth at the end of their jaws, for use on a wide vascular pedicle when an ordinary haemostat may slip. When you remove a haemostat 5mins later, you will probably find that bleeding will have stopped. If you can see a bleeding vessel, you can usually grasp it with these by twisting the haemostat before you remove it, or if the locking forceps, which are one of the great inventions of surgery. Haemostats can be large or small, straight, or curved, so that they rest over the edge of the wound. Each time you tie off a bleeding vessel you leave some crushed tissue and some suture material in the wound. The tips of haemostats, especially small ones, must meet accurately, so good quality instruments are important. Order them in sets of 6 (you can hardly have too many) because they will enable you to make up several sets (4. It is best to cut skin boldly, which produces less bleeding, than tentatively and timidly which produces a sawing-type of action on the vessels. Do not use catgut for larger and more important vessels: it slips off too easily and may be reabsorbed too quickly. This is the method for critically important vessels, A, do not leave too long an end; this will leave unnecessary dead tissue such as those of the renal pedicle. B, to free a vessel buried in tissue, insert Mixter tie it proximal to a branch, and then cut it distal to this. D, tie the artery and insert a transfixion ligature; the needle is going through the vessel and its distal end is If it is a critically important vessel, ask yourself about to be cut off. You may be able and tie a major vessel, such as the external carotid or the to use ligaclips (4. Use linen, cotton thread, or silk; do not divide the vessel after you have tied it, as it may recannulate. Control of the vessels will be safer provide sufficient heat on a small area but without causing if you take one or more bites of the pedicle and tie them muscle spasm and cardiac dysrhythmia, diathermy uses separately. First find the artery In monopolar diathermy, there is a high current density by feeling for pulsation. Push the points of a fine ensured at the point of contact with the active electrode at haemostat into the connective tissue around it and separate the diathermy probe tip but the current is then dissipated in them to open up a plane (3-4B). Gradually develop this a large volume of tissue through a large surface area plane until you can see the artery you are looking for. Usually you will pick up a blood vessel with coagulation in the testicular vessels, especially if you lift dissecting forceps, and touch the forceps with the the scrotum up in your hand. As metal is a good conductor of current, little heat is generated in its passage through the forceps. Do not use diathermy in an amputation for an ischaemic Make sure though that your gloves have no holes, leg (35. In bipolar diathermy, the current passes between two If the patient has a cardiac pacemaker, the diathermy point electrodes placed across the vessel to be coagulated. Do not use diathermy in the presence of inflammable Bipolar diathermy only works with low currents, and is anaesthetic agents, e. Do not use of diathermy on obstructed bowel: it may detonate if methane gas has accumulated inside! You can use any of these: A special pneumatic tourniquet which resembles the cuff of a sphygmomanometer. The pressure at which a tourniquet is applied is important; this is more easily Fig. A, monopolar diathermy produces high current density at the active controlled pneumatically, so a pneumatic tourniquet is electrode dissipated through the body tissues through the much the best. Also you can, if necessary, let it down indifferent electrode with resulting low current density. B, bipolar rapidly during an operation to perfuse the tissues, or to diathermy produces high current density across insulated diathermy find arteries that need tying. If you touch the skin or vessels very close to the skin (2) You do not put it on too tight, especially on a thin limb. If small, it is best to excise this, especially if it tyre (3-7): the tube from an ordinary car tyre is too thick) is on the edge of a wound. You may not have a special pneumatic tourniquet, so this is probably what you Do not use diathermy on the penis: you may cause will have to use. A tourniquet will prevent blood entering a thrombosis in the corpora unless you use bipolar limb, but it will not remove blood which was already there diathermy. At this point the femoral artery lies close to Then apply a pneumatic tourniquet (or a sphygmo- the femur and is easily compressed. This will provide an almost totally bloodless field, but is only safe if there is no sepsis, which would then be spread proximally. A tourniquet has disadvantages: (1) If you apply too much pressure for too long over too narrow an area, you may injure the nerves to the limb, and cause a paresis; this is usually only temporary, but it may be permanent. A transient radial nerve palsy is common, even if you apply a tourniquet correctly. So apply a tourniquet carefully; record the time when you applied it, and do not leave it on too long. A tourniquet is painful and a conscious apply a tourniquet, take the time and record it. J, inflate the pneumatic tourniquet, then unwind the bandage, starting proximally in the limb. When you do apply it, apply 2 more winds than are (1);A tourniquet on the forearm or on the lower leg is necessary to obliterate the pulse. When you have finished, dangerous, because you may damage the radial nerve at it should feel moderately firm, but not rock hard.