Myasthenia gravis is a long-term neuromuscular disease that leads to varying degrees of skeletal muscle weakness. The most affected muscles are those of the eyes and swallowing, it can result in double vision, drooping eyelids, trouble talking, trouble walking. Onset can be sudden; those affected have a large thymus or develop a thymoma. Myasthenia gravis is an autoimmune disease which results from antibodies that block or destroy nicotinic acetylcholine receptors at the junction between the nerve and muscle; this prevents nerve impulses from triggering muscle contractions. An inherited genetic defect in the neuromuscular junction results in a similar condition known as congenital myasthenia. Babies of mothers with myasthenia may have symptoms during their first few months of life, known as neonatal myasthenia. Diagnosis can be supported by blood tests for specific antibodies, the edrophonium test, or a nerve conduction study. Myasthenia gravis is treated with medications known as acetylcholinesterase inhibitors such as neostigmine and pyridostigmine.
Immunosuppressants, such as prednisone or azathioprine, may be used. The surgical removal of the thymus may improve symptoms in certain cases. Plasmapheresis and high dose intravenous immunoglobulin may be used during sudden flares of the condition. If the breathing muscles become weak, mechanical ventilation may be required. MG affects 50 to 200 per million people, it is newly diagnosed in three to 30 per million people each year. Diagnosis is becoming more common due to increased awareness, it most occurs in women under the age of 40 and in men over the age of 60. It is uncommon in children. With treatment, most of those affected lead normal lives and have a normal life expectancy; the word is from the Greek "mys" "muscle" and "astheneia" "weakness", the Latin "gravis" "serious". The initial, main symptom in MG is painless weakness of specific muscles, not fatigue; the muscle weakness becomes progressively worse during periods of physical activity and improves after periods of rest. The weakness and fatigue are worse toward the end of the day.
MG starts with ocular weakness. In about two-thirds of individuals, the initial symptom of MG is related to the muscles around the eye. There may be eyelid double vision. Eye symptoms tend to get worse when watching television, reading, or driving in bright conditions; some affected individuals choose to wear sunglasses. The term "ocular myasthenia gravis" describes a subtype of MG where muscle weakness is confined to the eyes, i.e. extraocular muscles, levator palpebrae superioris, orbicularis oculi. This subtype evolves into generalized MG after a few years; the weakness of the muscles involved in swallowing may lead to swallowing difficulty. This means that some food may be left in the mouth after an attempt to swallow, or food and liquids may regurgitate into the nose rather than go down the throat. Weakness of the muscles that move the jaw may cause difficulty chewing. In individuals with MG, chewing tends to become more tiring when chewing fibrous foods. Difficulty in swallowing and speaking is the first symptom in about one-sixth of individuals.
Weakness of the muscles involved in speaking may lead to hypophonia. Speech may have a nasal quality. In some cases, a singing hobby or profession must be abandoned. Due to weakness of the muscles of facial expression and muscles of mastication, facial weakness may manifest as the inability to hold the mouth closed and as a snarling expression when attempting to smile. With drooping eyelids, facial weakness may make the individual appear sad. Difficulty in holding the head upright may occur; the muscles that control breathing and limb movements can be affected. In a myasthenic crisis, a paralysis of the respiratory muscles occurs, necessitating assisted ventilation to sustain life. Crises may be triggered by various biological stressors such as infection, fever, an adverse reaction to medication, or emotional stress. MG is an autoimmune synaptopathy; the disorder occurs when the immune system malfunctions and generates antibodies that attack the body's tissues. The antibodies in MG attack a normal human protein, the nicotinic acetylcholine receptor, or a related protein called MuSK a muscle-specific kinase.
Other less frequent antibodies are found against Agrin and titin proteins. Human leukocyte antigen haplotypes are associated with increased susceptibility to myasthenia gravis and other autoimmune disorders. Relatives of people with MG have a higher percentage of other immune disorders; the thymus gland cells form part of the body's immune system. In those with myasthenia gravis, the thymus gland is abnormal, it sometimes contains clusters of immune cells which indicate lymphoid hyperplasia, the thymus gland may give wrong instructions to immune cells. For women who are pregnant and have MG, in a third of cases, they have been known to experience an exacerbation of their symptoms, in those cases it occurs in the first trimester of pregnancy. Signs and symptoms in pregnant mothers tend to improve during the third trimesters. Complete remission can occur in some mothers. Immunosuppressive thera
Gia Bình is a rural district of Bắc Ninh Province in the Red River Delta region of Vietnam. The district was called Gia Định district, but since this caused it to be confused with Thành Gia Định, the name of Saigon at the time, Nguyễn dynasty officials changed the name to Gia Bình district in 1820. In August 5, 1472, the second king of the Post-Lê dynasty, Lê Thái Tông died at the age of 20, at Lệ Chi Viên. Nguyễn Trãi and his wife, Nguyễn Thị Lộ, were accused of murdering the King, which resulted in the death of Nguyễn Trãi's relatives Lệ Chi Viên In 1950, Gia Bình was united with Lương Tài to form Gia Lương district, separated again in August 9, 1999; as of 2003 the district had a population of 102,753. The district covers an area of 108 km²; the district capital lies at Gia Bình. The district has an area of 107.9 km2. Gia Bình is administratively divided into 14 subdivisions: one township, Gia Bình, 13 communes: Bình Dương, Cao Đức, Đại Bái, Đại Lai, Đông Cứu, Giang Sơn, Lãng Ngâm, Nhân Thắng, Quỳnh Phú, Song Giang, Thái Bảo, Vạn Ninh and Xuân Lai.
Gia Bình is well known for some products such as Xuân Lai Bamboo. Gia Bình district features a warm humid subtropical climate with plentiful precipitation; the annual average temperature is 24 °C. The highest is 30 °C in July; the average annual sunshine is 1,530-1,776 hours, while the relative humidity is 79%. The district experiences the typical climate of northern Vietnam, where summers are hot and humid, winters are, by national standards cold and dry. Summers, lasting from May to September, are hot and humid, receiving the majority of the annual 1,680 millimetres of rainfall; the winters, lasting from November to March, are mild, while spring in April can bring light rains. Autumn in October is the best time of the year in terms of weather
Pullman–Moscow Regional Airport is a public airport in the northwest United States, located in Whitman County, two miles east of Pullman and four miles west of Moscow, Idaho. The airport is accessed via spurs from State Route 270, has a single 7,101-foot runway, headed northeast/southwest, which entered service in October 2019; the former runway was 6,730 feet and aligned with Moscow Mountain twelve miles to the northeast, the highest summit in the area. The rural airport in the Palouse region is the primary air link for its two land-grant universities, Washington State University in Pullman and the University of Idaho in Moscow. Both universities use the airport for jet charters from Alaska Airlines, Frontier Airlines, Allegiant Air for their intercollegiate athletic teams. Horizon Air is the sole commercial airline serving the airport, flying Bombardier Q400 turboprop aircraft, it began limited service to Pullman–Moscow 38 years ago in December 1981 with Fairchild F-27 aircraft, daily service in March 1983, on F-27 and Metroliner aircraft.
Horizon Air offers 4-5 daily scheduled flights to Seattle/Tacoma. Flight schedules have sometimes included a stop in Lewiston, but all scheduled flights at PUW are nonstop to/from Seattle. Prior to Horizon, Cascade Airways was the main carrier at the airport. Seattle air traffic control, 250 miles west, manages commercial traffic for the airport; the nearest major airport is Spokane International, ninety miles north. The Federal Aviation Administration National Plan of Integrated Airport Systems for 2017–2021 categorized the airport as a non-hub primary commercial service facility. Pullman–Moscow Regional Airport covers an area of 467 acres at an elevation of 2,567 feet above sea level, it has one asphalt paved runway designated 5/23. The airport was annexed by the City of Pullman in August 1988, the present terminal opened in February 1990 at a cost of $2.7 million. A new and larger terminal is expected in the early 2020s; the modest commercial terminal is a single large room, divided between pre- and post-security areas by a single security checkpoint and glass walls.
The waiting area occupies all space beyond the checkpoint but is not used for waiting, as most passengers pass through the security checkpoint before boarding. Both passenger gates are ground-level doors to the tarmac. Gate 1 on the east side of the terminal is used by Horizon Air; the public airport shares the runway with a fixed-base operator, Interstate Aviation, which conducts chartered air service and flight school. Local engineering firm Schweitzer Engineering Laboratories, Inc. owns and operates private hangars at the airport. For the 12-month period ending January 1, 2014, the airport had 29,350 aircraft operations, an average of 80 per day: 85% general aviation, 14% scheduled commercial, 1% air taxi, <1% military. The airport has accepted Boeing 737 aircraft on Alaska Airlines charter flights. In January 2018, there were 71 aircraft based at this airport: 60 single-engine, 7 multi-engine, 3 jet, 1 glider. Official website Pullman–Moscow Regional Airport - WSDOT Aviation FAA Terminal Procedures for Pullman–Moscow Regional, effective February 27, 2020 Resources for this airport: FAA airport information for PUW AirNav airport information for KPUW ASN accident history for PUW FlightAware airport information and live flight tracker NOAA/NWS weather observations: current, past three days SkyVector aeronautical chart, Terminal Procedures