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The most documented electrocardiographic changes were T wave inversion in DII, III, aVF and V5-V6, and ST elevation 18 , 23 , 28 , 29 . These are relatively nonspecific findings, which are encouraged to be interpreted within the whole clinical context so that other compatible differential diagnoses such as acute coronary syndrome, electrolyte disorder, or even digitalis intoxication, can be dismissed 20 . In addition, echocardiograms mostly reveal biventricular hypertrophy and dyskinesia of wall movements; and these results are compatible with myocarditis. Ejection fraction may be mildly diminished and pericardial effusion is rare. Creatine Phospho-Kinase (CPK) levels may be increased after the first phase 28 .

The second phase is known as the “arrhythmic phase”. It starts when the recent myocardial injury can no longer permit an adequate functioning of the cardiac conduction system. Again, according to the severity, findings may range from premature auricular and ventricular extrasystoles to atrial fibrillation with high risk of thromboembolism; and in the worst-case scenario, ventricular fibrillation and sudden death 19 . This wide spectrum directly correlates with the symptoms and hemodynamic state of the patient 31 .

The patients after the acute and subacute phase that are most affected will invariably develop heart failure, displaying some a right side insufficiency with pulmonary and peripheral edema and hepatomegaly; but more frequently a left side insufficiency with low perfusion and shock clinic 19 . Reduced peripheral blood flow can be responsible for many pathological events too, blurring the line between expected consequences of shock and the real direct organ damage of CHIKV. Kidneys are an example, as in Economopolou et al’s retrospective study, 20% of the patients with heart failure also presented with pre-renal failure 23 , which suggests it is more of a consequence of shock in this instance. In contrast, lesions such as nephritis are more likely to be caused by the virus. Additionally, in this third stage, a constrictive syndrome has also been described, with extensive compromise and pericarditis, but it is indeed less common 24 .

A summary of most the common clinical manifestations during CHIKV infection that suggest cardiac viral compromise is given in Table 3 . Isolated signs and symptoms reported in single case reports that seemed to relate more to the pre-morbidities of the patient were excluded. Regarding blood pressure, there are significant variations in the reports, but recently hypotension was reported during acute CHIKV infection in patients with high blood pressure undergoing antihypertensive treatment. A pattern through the revised articles could not be identified, so having hypo or hypertension may be a poor predictor of cardiac compromise during CHIKV infection and seems more a product of the severity of the case and the numbers previously managed by the patient 20 .

Derrida, in his response to Searle ( "a b c ..." in Limited Inc ), ridiculed Searle's positions. Claiming that a clear sender of Searle's message could not be established, Derrida suggested that Searle had formed with Austin a société à responsabilité limitée (a " limited liability company ") due to the ways in which the ambiguities of authorship within Searle's reply circumvented the very speech act of his reply. Searle did not reply. Later in 1988, Derrida tried to review his position and his critiques of Austin and Searle, reiterating that he found the constant appeal to "normality" in the analytical tradition to be problematic. [25] : 133 [46] [51] footlocker finishline Office Saffy Rose Gold Leather Gladiator Lace Up Sandals discount original low shipping get authentic sale online find great for sale 9tQxUC
[53] [54] [55] [56]

In the debate, Derrida praised Austin's work, but argued that Austin is wrong to banish what Austin calls "infelicities" from the "normal" operation of language. One "infelicity", for instance, occurs when it cannot be known whether a given speech act is "sincere" or "merely citational" (and therefore possibly ironic). Derrida argues that every iteration is necessarily "citational", due to the graphematic nature of speech and writing, and that language could not work at all without the ever-present and ineradicable possibility of such alternate readings. Derrida takes Searle to task for attempting to get around this issue by grounding final authority in the speaker's inaccessible "intention". Derrida argues that intention cannot possibly govern how an iteration signifies, once it becomes hearable or readable. All speech acts borrow from a language whose significance is determined by historical-linguistic context, and by the alternate possibilities that this context makes possible. This significance, Derrida argues, cannot be altered or governed by the whims of intention.

Derrida argued against the constant appeal to "normality" in the analytical tradition of which Austin and Searle were paradigmatic examples. [25] : 133

In the description of the structure called "normal," "normative," "central," "ideal,"this possibility must be integrated as an essential possibility. The possibility cannot be treated as though it were a simple accident-marginal or parasitic. It cannot be, and hence ought not to be, and this passage from can to ought reflects the entire difficulty. In the analysis of so-called normal cases, one neither can nor ought, in all theoretical rigor, to exclude the possibility of transgression. Not even provisionally, or out of allegedly methodological considerations. It would be a poor method, since this possibility of transgression tells us immediately and indispensably about the structure of the act said to be normal as well as about the structure of law in general.

It feels like Brooks’s best hope is that the Democratic Party, in some kind of “Save America from Trump” move, embraces a style of politics that Jeff Flake, John McCain, etc., agree with but does not piss off young voters, minorities, women, socialists, Sanders types.

In other words, the parties really sort along immigration lines — the people with Trumpish views on race/immigration in one party, the others in a second party.

natesilver : Obama, in some ways, united all these different groups together in 2008 because George W. Bush was so unpopular. So if Trump is really, really unpopular by 2020, a Biden type could do great.

In the long run, I don’t think you can avoid these tensions, though.

perry : That’s a great point. The 2008 Obama campaign was a kind of unity ticket. He couldn’t recreate that in 2012.

micah : OK, and to wrap up: Is there any chance that the Republican Party becomes the party Brooks wants it to be?

clare.malone : That’s a negatory. At least in any sort of near-term future. I don’t think you can just forget about the forces in the party that manifested Trump.

perry : If Trump and Putin had a July 2016 phone call during which Trump told him to hack Podesta’s email, that call becomes public and Trump is impeached and removed from office … then maybe.

micah : See, I disagree with that, Perry.

perry : You think Putin made the hacking suggestion first?

micah : LOL.

The Trumpism in Republicanism predates Trump and — to a first approximation — would postdate him too, wouldn’t it?

natesilver : I’m on Perry’s side. If Trump is perceived to be a failure, there could be a reasonably sharp counterreaction to Trump. (Although, I’m thinking “failure” more in the sense of “he loses re-election,” not “he gets impeached,” which raises a different set of issues.)

micah : So, if Trump loses re-election, Republican primary voters suddenly move to the middle on immigration?

natesilver : STRAW MAN MICAH IS BACK

micah : Whose team are you on, Clare?

clare.malone : I’m not sure about my team. I guess I could see, in the case of a Trump flameout, Trumpians getting completely steamrollered by national establishment figures.

But then you’ve got a part of your base that is wildly unhappy with you. I guess they either leave or just become pains in your asses for the rest of time.

I’m not sure I’m on a team. I’m agnostic.

natesilver : Voters (maybe not voters in the GOP, but voters overall) are already moving left on immigration . The reaction to Trump has been fairly thermostatic , as the political scientists like to say.

micah : What does thermostatic mean?

natesilver : Public opinion tends to move in the opposite direction of the president’s policy preferences.

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