Congestive Cardiac Failure With Digoxin Toxicity

Congestive Cardiac Failure With Digoxin Toxicity Contents (Jump to) Criterion-1 Causes, Incidences and Risk Factors of Congestive Cardiac Failure with Digoxin Toxicity: Comprehensive Understanding of the Disease on Patient and Family: Criterion-2 Signs Symptoms Pathophysiology Criterion-3 Drug Class Physiological Effect Criterion-4 Interventions-Rationales: Comprehensive Treatment of the Identified Condition: Supportive care Electrolyte abnormality management Bradycardia management Hemodynamic compromise management Ongoing monitoring and change of medicine CASE STUDY ON CONGESTIVE CARDIAC FAILURE WITH DIGOXIN TOXICITY Criterion-1 Causes, Incidences and Risk Factors of Congestive Cardiac Failure with Digoxin Toxicity: Digoxin toxicity caused by high levels of digitalis in the body. As in our case study Mrs. Sharon McKenzie, a 77 year old woman, used to take daily 250 mcg of digoxin, which is a very high dose for adult patients. Especially those, who are suffering from congestive cardiac failure, like our patient Mrs. Sharon McKenzie (Neo, et al, 2010). Body receives the therapeutic effect when it stores of 8 to 12 mcg/kg generally with minimum risk of toxicity in most patients with failure of heart and normal sinus or breathing rhythm (Mangoni, 2010). People withheart failurewho have this digoxin are commonly prescribed medications called diuretics that remove excess fluid from the part of body. This is also happens that many diuretics can cause potassium loss from the body (Johnson, Inder, Nagle Wiggers, 2010). Though ultimately it increases the risk of digitalis toxicity. Again, our patient, Mrs. Sharon McKenzie’s potassium level is low; 2.5 mmol/l. whereas a normal potassium level ranges from 3.5-5.0 mmol/l. You are more likely to fall into that condition if you take digoxin, digitoxin, or other digitalismedicinesalong with the higher effective drugs that interact withit such as flecainide, quinidine, amiodarone, verapamil, and others. Similarly, Mrs. Sharon McKenzie’s was also taking medication with digoxin like furosemide, warfarin, and enalapril (Siabani, Leeder Davidson, 2013). In recent years the incidence of digoxin toxicity has dropped among patients in hospitals. A study has been done on 183 outpatients, who are receiving on going treatment of digoxin toxicity at 10 urban and rural Department of Veterans Affairs Medical Centers in the Rocky Mountain region, to evaluate whether a similar decline of digoxin toxicity has occurred or not. The statistics over 1-year period, of that study is like that: Out of the 183 patients: 50 (27.3%) had one or more risk factors for digoxin toxicity. Serum digoxin levels were elevated in 13.6% of patients. Hypokalemia in 14.3%. Elevated creatinine levels in 17.9%. And possible drug interactions in 5.5% of patients. The most common risk factor of digoxin toxicity is the patient’s elderly age. Like in our case study, Mrs. Sharon McKenzie is also 77-year old woman. However there are other risk factors too, which render the elderly more vulnerable to digoxin toxicity. These contain an age-related decline in renal function and a decrease in volume of digoxin distribution. There is also an increase in the number of comorbid conditions, including cardiovascular and chronic obstructive pulmonary disease, which heightens vulnerability to digoxin toxicity. Comprehensive Understanding of the Disease on Patient and Family: Digoxin toxicity is a life-threatening condition, and when a serious disease like congestive cardiac failure caused by digoxin toxicity then it can impact severely in a bad way on a patient as well as his/her family (Betihavas, 2011). Due to which his/her family also suffer by seeing their loved one mentally disturbed. Often the patients with CHF who are depressed or who lack social support, the higher the support from the social side the higher the rate of healing as the family and the patient both in complex and double trouble. Criterion-2 Signs Symptoms Pathophysiology Severe ventricular arrhythmias: Sudden cardiac death and loss of consciousness are the basic signs and symptoms of the cardiac arrhythmias. Complaints such as dizziness, lightheadedness, fluttering, dizziness, and pounding, chest discomfort, quivering, shortness of breath, and forceful or painful fast beats are commonly reported with arrhythmias patients. Often, patients notice arrhythmias only after checking their peripheral pulses (Mudge, et al, 2010). The pathogenesis of the arrhythmias falls into one of two basic mechanisms: increased or covered up automaticity, triggered activity, or re-entry. Triggered activity occurs when early after depolarization and delayed after depolarization initiate spontaneous multiple depolarization, precipitating ventricular arrhythmias (Johnson, Inder, Nagle Wiggers, 2010). Arrhythmogenesis is probably the most common procedure and results from re-entry. It causes the change of state of mind and mood too. 2) Hyperkalemia: Higher potassium rate in your blood can affect how your heart works. Symptoms of hyperkalemia can include: Abnormal heart rhythm arrhythmia that can be life-threatening Slowheart rate Weakness (Neo, et al, 2010) Hyperkalemia may result from an increase in total body potassium secondary to imbalance of intake vs. excretion or from misdistribution between intra- and extracellular space (Nanda, 2009). 3) Hypokalemia: Usually symptoms of low potassium are mild Weakness, tiredness, or pain in arms or legs muscles, sometimes this might be so severe to cause inability and disability to move arms or legs due to weakness of muscles (much like a paralysis) (Hughes Crowe, 2010) Tingling or numbness Nausea or vomiting Abdominal cramping, bloating Constipation Palpitations (feeling your heart beat irregularly) Urine passing rate is too high simultaneously feeling thirsty mostly (Neo, et al, 2010). In the heart, low potassium levels make the myositis hypo-polarized or hyper excitable. Thus, arrhythmia occurs as a result of the atrium’s lowered membrane potential due to recovery from inactivation of the Na channel, which may trigger an action potential. In addition to this, reduced potassium in the extracellular space inhibits the IKr potassium current activity, and ventricular depolarization is delayed, which thereby promotes reentrant arrhythmias (Jeon, Kraus, Jowsey Glasgow, 2010). 4) Neurologic Symptoms: In the identified condition, the patient may also go through with neurologic symptoms which are: Visual disturbances, disorientation, and confusion.You might experience confusion. Although rare, you might also see bright spots, have blurry vision, or experience blind spots. In addition, you might urinate much more or less than usual (Betihavas, 2011). Your body could also become swollen. The physiologies of neurological symptoms are not easy to judge and too complex and our getting of them are incomplete mostly. From an evolutionary perspective it is easy to judge the neurological symptoms. Though it makes sense that the genuine physiologies of neurological symptoms are intricate and interrelated (Courtney, et al, 2009). 5) Sinus Node Dysfunction: Sinus node dysfunction refers to a number of conditions causing physiologically inappropriate atrial rates. Symptoms may be minimal or include weakness, effort intolerance, palpitations, and syncope. Diagnosis is by ECG. Symptomatic patients require a pacemaker. Sinus node dysfunction includes inappropriate and misbalancing the sinus bradycardia, alternating bradycardia and atrial tachyarrhythmia, sinus pause or arrest, and sinoatrial exit block (Jeon, Kraus, Jowsey Glasgow, 2010). SND also causes the abnormalities in SN impulse formation and propagation that also causes abnormalities in the atrium and in the conduction system of the heart (Higgins, et al, 2013). Slow ventricular rates and pauses at the time of stress is the general causes, furthermore, it includes following: Fatigue Angina Syncope Dizziness Fall Confusion Heart failure symptoms and palpitations Criterion-3 Drug Class Physiological Effect Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitors cause blood vessels broadness, further descent the amount of work the heart has to do they may also have direct beneficial effects on the heart. These drugs are reducing the symptoms and the need for hospitalization moreover they are helpful to prolong life (Mudge, et al, 2010). Beta-blockers: Beta-blockers drugs lower down the heart rate and block excessive blockage in the heart. They also helpful in the heart disease. These drugs are usually used with ACE inhibitors and provide an added benefit. They may temporarily worsen symptoms but result in long-term improvement in heart function (Betihavas, 2011). Although ACE inhibitors improve outcome in patients with systolic dysfunction, many patients with hypertension experience congestive heart failure due to diastolic dysfunction related to left ventricular hypertrophy. ACE inhibitors have been shown to reverse left ventricular hypertrophy in patients with hypertension.A meta-analysis of the effects of several antihypertensive agents suggested that ACE inhibitors were the most effective agent in reducing left ventricular hypertrophy (Katz Konstam, 2012). Beta blocker is helpful in improving the function of the failing LV and need to prevent or reverse progressive LV dilation, sphericity, chamber and hypertrophy. Beta blockers also lower down the heart beating rate and LV wall stress. According to recent studies from laboratories have also proven that beta blockers can satisfy cardiomyocyte apoptosis in HF. These are the basic advantages and benefit of beta-blocker for the patient of heart at any higher stage (Katz Konstam, 2012). Criterion-4 As a registered nurse, my care plan for a patient suffering from Congestive Cardiac Failure with digoxin toxicity would be like, (Driscoll, et al, 2009) Interventions-Rationales: I realize that I would hold the medication Due to possibility of toxicity Wait for Electrolytes and digoxin test, as these tests were already ordered for our patient electrolytes can affect the action of dig and cause dysthymias and to find out the level of dig Monitor I O monitoring for renal function Monitor for edema and auscultator the lungs Monitor symptoms, VS S/E of dig toxicity Call the doctor. To get orders to carry out interventions and inform doctor Start an IV. For administration of medications (Mudge, et al, 2010). Comprehensive Treatment of the Identified Condition: The main goal of treatment is to correct cardiac toxicity.If the person has stopped breathing, as our patient Mrs.Sharon McKenzie confronting with shortness of breath, startCPRand get emergency medical help (Betihavas, 2011). Initial treatment includes: General supportive care Discontinuation of digoxin therapy and prevention of further exposure Administration of digoxin-specific antibody fragments (digoxin immune Fab) Treatment of specific complications: for example, dysrhythmias and electrolyte abnormalities (Jeon, Kraus, Jowsey Glasgow, 2010). Supportive care General supportive care includes attaching patients to a cardiac monitor, providing IV fluids in patients with hypotension or volume depletion (with caution for patients with CHF), supplemental oxygen, and/or repletion of electrolytes in patients with electrolyte abnormalities (Mudge, et al, 2010). Electrolyte abnormality management In case of Mrs. Sharon McKenzie, hyperkalemia is only corrected (e.g., with insulin/glucose) if it is considered life-threatening, because of the risk of producing hypokalemia, because her potassium level is low i.e. 2.5 mmol/l. One study showed that insulin interacts directly with Na(+)/K(+) ATPase pump and alters the effect of digoxin (Betihavas, 2011). This supports the finding that for patients with diabetes, insulin has been shown to have cardio protective effects after digoxin intoxication. Calcium is not used to treat hyperkalemia in patients with suspected digoxin toxicity as it may induce arrhythmia or cardiac arrest. Bradycardia management As Mrs. Sharon McKenzie’s ECG report showed sinus bradycardia, this will be treated with atropine. Atropine can be given every 3 to 5 minutes until there is a response or the 3 mg maximum dose is reached (San Miguel, et al, 2013). Hemodynamic compromise management As Mrs. Sharon McKenzie has signs of hemodynamic insufficiency and/or compromise (e.g., hypotension, altered consciousness or dizziness), digoxin immune Fab is given as primary management (Mudge, et al, 2010). Ongoing monitoring and change of medicine Ideally, digoxin is discontinued and a different medicine for rate control or a different inotrope prescribed (for AF, atrial flutter or CHF, respectively). If the patient has to remain on digoxin for some reason, then the dose of digoxin is adjusted for the patients medication profile (Edgley, Krum Kelly, 2012). Referencing: Jeon, Y. H., Kraus, S. G., Jowsey, T., Glasgow, N. J. (2010). The experience of living with chronic heart failure: a narrative review of qualitative studies. BMC health services research, 10(1), 77. Hughes, J., Crowe, A. (2010). Inhibition of P-glycoprotein-mediated efflux of digoxin and its metabolites by macrolide antibiotics. Journal of pharmacological sciences, 113(4), 315-324. Mangoni, A. A., Woodman, R. J., Gaganis, P., Gilbert, A. L., Knights, K. M. (2010). Use of nonà ¢Ã¢â€š ¬Ã‚ steroidal antià ¢Ã¢â€š ¬Ã‚ inflammatory drugs and risk of incident myocardial infarction and heart failure, and allà ¢Ã¢â€š ¬Ã‚ cause mortality in the Australian veteran community. British journal of clinical pharmacology, 69(6), 689-700. Siabani, S., Leeder, S. R., Davidson, P. M. (2013). Barriers and facilitators to self-care in chronic heart failure: a meta-synthesis of qualitative studies. SpringerPlus, 2(1), 320. Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., Hamilton, K. (2009). Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24à ¢Ã¢â€š ¬Ã‚ Week Exercise and Telephone Followà ¢Ã¢â€š ¬Ã‚ Up Program. Journal of the American Geriatrics Society, 57(3), 395-402. Nanda, A., Chen, M. H., Braccioforte, M. H., Moran, B. J., D’Amico, A. V. (2009). Hormonal therapy use for prostate cancer and mortality in men with coronary artery disease–induced congestive heart failure or myocardial infarction. Jama, 302(8), 866-873. Edgley, A. J., Krum, H., Kelly, D. J. (2012). Targeting Fibrosis for the Treatment of Heart Failure: A Role for Transforming Growth Factorà ¢Ã¢â€š ¬Ã‚ ÃŽ ². Cardiovascular therapeutics, 30(1), e30-e40. Betihavas, V., Newton, P. J., Du, H. Y., Macdonald, P. S., Frost, S. A., Stewart, S., Davidson, P. M. (2011). Australias health care reform agenda: Implications for the nurses’ role in chronic heart failure management. Australian Critical Care, 24(3), 189-197. Mudge, A., Denaro, C., Scott, I., Bennett, C., Hickey, A., A Jones, M. (2010). The paradox of readmission: effect of a quality improvement program in hospitalized patients with heart failure. Journal of Hospital Medicine, 5(3), 148-153. Johnson, N. A., Inder, K. J., Nagle, A. L., Wiggers, J. H. (2010). Attendance at outpatient cardiac rehabilitation: is it enhanced by specialist nurse referral. Australian Journal of Advanced Nursing, 27(4), 31-37. Higgins, R., Navaratnam, H. S., Murphy, B. M., Walker, S., Worcester, M. U. M. U. (2013). Outcomes of a chronic heart failure training program for health professionals. Journal of Nursing Education and Practice, 3(7), p68. Driscoll, A., Davidson, P., Clark, R., Huang, N., Aho, Z. (2009). Tailoring consumer resources to enhance self-care in chronic heart failure. Australian Critical Care, 22(3), 133-140. Neo, J. H., Ager, E. I., Angus, P. W., Zhu, J., Herath, C. B., Christophi, C. (2010). Changes in the renin angiotensin system during the development of colorectal cancer liver metastases. BMC cancer, 10(1), 134. Katz, A. M., Konstam, M. A. (2012).Heart failure: pathophysiology, molecular biology, and clinical management. Lippincott Williams Wilkins. San Miguel, J. F., Sonneveld, P., Orlowski, R. Z., Moreau, P., Rosià ±ol, L., Moslehi, J. J., Richardson, P. G. (2013). Quantifying the risk of heart failure associated with proteasome inhibition: a retrospective analysis of heart failure reported in phase 2 and phase 3 studies of bortezomib (Btz) in multiple myeloma (MM).Blood,122(21), 3187-3187

Machiavelli: Realism over Idealism

Luke Pelagio Due 5/27/2011 Period 4 Machiavelli: Realism Over Idealism Nicolo Machiavelli is known as being an archetypical realist; in other words, he was someone who originated the idea that we should not try to figure out how people should be, but rather accept and deal with the world as it literally is. Unlike Machiavelli, Plato posited an idealist view of a philosopher king reigning through virtue. To Machiavelli, this is an extremely dangerous delusion for it ignores what he considers the reality of the human condition: humans are brutal, selfish, and fickle (Machiavelli and Power Politics).You don’t need a philosopher king to secure off enemies and reinforce order/stability; on the other hand, you need a prince or a leader who understands what it takes to lead. It is better to be feared than loved if you can’t be both. â€Å"Nevertheless a prince ought to inspire fear in such a way that, if he does not win love, he avoids hated; because he can endure very well b eing feared whilst he not hated, which will always be as long as he abstains from the property of his citizens and subjects and from their women,† (Machiavelli, The Prince).Machiavelli applied force to get what he wanted, but he always kept his hands off the property of others. This is because men more quickly forget the death of their father than the loss of their patrimony (Machiavelli, The prince). In The Prince, Machiavelli demonstrates how to obtain and keep political power. This is what he did using witty tactics. 1 A prince must always pay diligent attention to military circumstances if he wants to reside in power, so the most desirable and beneficial type of army are native troops, composed of one’s own citizens or subjects.The prince has many characteristics that are crucial to his standing in a society such as: it is better to be stingy than generous, it is better to be cruel than merciful, it is better to break promises if keeping them would be against oneâ⠂¬â„¢s interests, and princes should choose wise advisors rather than flatterers. All these attributes are key to how well a Prince thrives (Public Bookshelf, The Prince). A prince must learn not to be limited to morality when unavoidable; a leader has to be able to use lies, force and deception if required in the world. Whether it is better to be feared or loved clearly addresses the reason for this.You can’t trust people, for they will turn on you. It is inevitable. Human nature means that doing what you must do at all costs according to any moral code simply puts you at a disadvantage. In addition, humans are generally under agreement to throw out such moral concerns if it is to their advantage. â€Å"Men have less scruple in offending one who is beloved than one who is feared, for love is preserved by the link of obligation which, owing to the baseness of men, is broken at every opportunity for their advantage; but fear preserves you by a dread of punishment which never fails,† (Machiavelli, The Prince).This quote perfectly demonstrates Machiavellian realism. First, it is a very opposing and adverse view on human nature. Second, it is realistic and logical. If, by any chance, you are a prince or a leader, and you do not understand the atrocious inherent in 2 men, you will fail. Those who are most ruthless will have power; this is just reality. â€Å"For my part I consider that it is better to be adventurous than cautious, because fortune is a woman, and if you wish to keep her under it is necessary to beat and ill-use her; and it is seen that she allows herself to be mastered by the adventurous rather than by those who go to work more coldly.She is, therefore, always, woman-like, a lover of young men, because they are less cautious, more violent, and with more audacity command her,† (Machiavelli, The Prince). Machiavelli politics is definitely aimed toward the masculine side. It is power and control, so fortune is feminine and more ana rchy. If not under control, it will be unstable and chaotic. His influence stretches far beyond Italy in the sixteenth century and lies with us today in how we think/understand the world of international relations.Everything I have read such as: ideas about Plato, Aristotle, Thomas Hobbes, and Nicolo Machiavelli are all extremely important to my knowledge and insight about political concepts/background. I believe that to be educated one must have familiar knowledge with those who have shaped today’s political society and government. Machiavelli’s ideas, in particular, are used everywhere today. One who has not been informed of Nicolo Machiavelli would be living in ignorance, for that individual would be clueless of how ideas today became what they are/how they are.When President Nixon organized the Watergate Scandal in 1973, the public had 3 no inclination that their leader was capable of such corrupt and unscrupulous means. Nixon, under the impression that his campaig n was vulnerable, manipulated for power in the only way he saw fitting, hoodwinking. Take a look at President Truman; he dropped a bomb on Hiroshima and Nagasaki reaching casualties of 120,000. According to him, survival of the United States was so admonished that the use of such insignificant means was necessary.Even President Obama has his faults. The ideas of hope were what we, the people, needed to hear. It would allow us to be optimistic, and contain a false sense of protection thinking that everything would work out. Barak Obama made many promises; he said everything that we would ever want to hear. However, none of his promises have come true. Maybe in extremely insufficient ways we are approaching the goals of what he promised. This is barely noticeable though. In conclusion, the tactics and ideas formed and created by Nicolo Machiavelli are ingenious.President Obama noticed that Machiavelli’s ideas â€Å"work,† and he used them to his advantage to help him bec ome the President of the United States of America. Lastly, I don’t think that I could live in a Machiavellian-ruled/based society. While the Prince or ruler thrives, the people are lied to and don’t have very much value. One thing is absolute, though: Machiavelli’s ideas can’t be ignored or discarded simply because we do not wish them to be true. We must accept the reality of everything, and do something positive for our country. 4

Chemistry Exam Review

Melting solid silver to form liquid silver 006 10. 0 points Which of the processes I) chopping broccoli l) baking bread Ill) burning a match involves a chemical change? 2. Pulling silver into silver wire . Ill only 3. Passing electric current Again (as) to plate out silver through 4. Dissolving silver nitrate in water to form a solution 2. II and Ill only 3. Only 4.All of these 004 10. 0 points Which of the following is a chemical property of sulfur? And Ill only 5. 6. II only . Burns in air 7. And II only 2. Melts at 119 C Dowses (vivid) – Exam review – Dowses 8. None of these – (241 27) 007 10. 0 points Which Of the properties I) conductivity II) combustibility Ill) hardness are chemical properties? 2 to identify a type of matter? 1. Density 2. Heat 3. Mass 4. Volume 2. And Ill only 011 10. 0 points Write 0. 0000072 using scientific notation. 1. 7. 2 x 10-6 4. Only 2. 72 x 10-7 5. All of these 3. 7. 2 x 10-7 6. Ill only 4. 0. Xx 10-5 7.II only 8. And II only 00 8 10. 0 points Which process does NOT involve a chemical change? 012 10. 0 points What is in between the electrons and nucleus of an atom? 1. Nothing 2. No one knows. 1. Melting of a solid 3. Water vapor 2. Oxidation of a metal 4. Air 3. Combustion 5. Smaller atoms go 10. 0 points Which of the following is an intensive property? 1. 16 cubic feet 013 10. 0 points Which scientist discovered that the atomic number, rather than the atomic weight, is more responsible for the properties of an element? (Tragically this scientist died soon after as a soldier in WWW. 00 Kelvin 2. 1. SST. Augustine 3. 3 miles 2. Chadwick 4. 4 days 3. Mosey 010 10. 0 points Which of the following properties can be used 4. Milliken 5. Rutherford 014 10. 0 points Which of the following is F-ELSE? 3 2. 45 protons; 35 electrons; 45 neutrons 3. 35 protons; 45 electrons; 45 neutrons 4. 35 protons; 35 electrons; 45 neutrons 1 The mass of neutrons and electrons are about the same. 2. The mass of a hydrogen atom is abo ut the same as a proton. 5. 45 protons; 35 electrons; 35 neutrons 6. 45 protons; 45 electrons; 35 neutrons 7. 35 protons; 45 electrons; 35 neutrons 3.The mass of protons and neutrons are 4. The mass of a proton is much greater than the mass of an electron. 015 10. 0 points How many protons are present in one V+ ion? 8. 35 protons; 35 electrons; 35 neutrons 018 10. 0 points Determine the number of protons, electrons, and neutrons in the the isotope sodium-23. 1. 11 protons; 12 electrons; 12 neutrons 12 protons.

Political Islam And The Islamic Islam - 2058 Words

Political Islam is a term that was coined inside the scholarly realm to allude to the more extensive group of political frameworks that are Islam oriented. The greater part of the states that draw on the Islamic instructions to influence political and social elements of the general public are said to be practicing political Islam. The vast majority of the practices will look for direction from the Islamic conventions and the Muslim scriptural foundation to settle on choices that influence the whole state and how it identifies with whatever is left of the world. While the term may not be as old, political Islam or Islamism are old ideas going back to the 1920s. Gatherings, for example, the Egypt s Muslim Brotherhood in 1927, are a portion†¦show more content†¦The thought borne of philosophies that were presented by any semblance of Maulana Maudoodi and Jamaat, were ready to make Islam a formula that would guide the contemporary life, policies and law in a thorough and pure s tructure, a portion of the fundamental components still remain while there are some subtle contortions particularly with terrorism. Political Islam has quite a bit of consequences for policies in Middle East where Islam is a center religion. In the meantime the essential elements of political Islam control how the laws of the states are produced close by the way the states in the Middle East cooperate with the rest of the world. Political Islam is powerful in the Middle East nations, controlling how laws, policies and global connections are managed. Political Islam Political Islam or Islamism is to a greater degree of a political outfit as the name proposes as opposed to a religious develop. As indicated by Ayoob, a large portion of the general population that adherents of the ideology trust that it is really a collection of faith, which has something critical to say in regards to the order of the public and legislative issues in a contemporary Muslim society and the style to be utilized to execute the same. For the vast majority, it is the manual for living a definitive Islamic life. In any case this is entirely broad when attempting to reveal the