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For this reason impotence young adults discount 400mg viagra plus amex, it is initiated as soon as possible after the patient is admitted tobacco causes erectile dysfunction buy viagra plus 400mg low price, or ideally erectile dysfunction drug types purchase viagra plus master card, at the time of precertification erectile dysfunction neurological causes order viagra plus 400 mg with amex. Discharge planning requires anticipating and/or coordinating resources for ongoing care. The role of the Medical Management Nurse as it pertains to the discharge planning is to: • Identify opportunities to improve healthcare efficiency (from quality and/or cost standpoint) • Discuss the plan of care with the patient’s physician • Refer the treatment plan to our Medical Director for additional review whenever indicated • Identify strategies for more cost-effective use of patient healthcare resources, consistent with quality care in the most appropriate setting • Identify patients for additional case management opportunities by reviewing benefit options and discharge plans with the potential for alternative levels of care Please contact the Medical Management Nurse as soon as discharge needs are known. Individualized Care Management Program Care management is a collaborative process used to develop individualized care plans to help optimize an individual members’ health care coordination and outcome across the care continuum. Working directly with you, the healthcare provider treating physician, our member and his or her family, our registered nurses can assist you by educating the member regarding their options and help them access 122 | Page the covered services you have recommended as appropriate to meet their individual health needs. In partnership with you, we intend to promote quality outcomes and optimize use of health care benefits. Our goal is to reach as many members as possible with complex medical conditions that are experiencing challenges with access to care or difficulty managing their disease process. We need your assistance in identifying members who are appropriate for this program and your cooperation with the Empire clinicians who will work directly with you to assist in successfully implementing your plan of care to manage the member’s medical condition and help to minimize re-admissions or other acute /urgent situations. Examples of Care Management at work: • A member that lives alone is unable to get to your office due to lack of transportation and lack of family support. The benefit plan does not cover an ambulette, but we can connect this member to local community groups or city services such as, Access-A-Ride, who will provide safe and low cost (either free or minimal payment) options. This is an example of how we can assist you in providing the high quality care we all desire and avoid the unnecessary use of the emergency room. With your assistance and encouragement, we refer the member to support groups hosted by the American Cancer Society. The member attends the meeting and vents expresses their fears, sees that they are not alone and learns how others are struggling, but succeeding in maintaining a good nutritional status. After this interaction, the member agrees to receive Meals on Wheels and other support to maintain their nutritional status. Members of certain groups, such as our hospital only contracts, (this includes New York City and New York State enrollees), State and Federal Health Benefit program beneficiaries, are not eligible. Due to the condition/disease as above, the enrollee requires specialized medical care over a prolonged period of time. Standard Appeals If Empire Medical Management determines that an admission, extension of a continued stay, or some other health care service is not medically necessary, the health care provider, the member or his/her authorized representative may request reconsideration or appeal an adverse determination in the following manner. The following can be appealed internally with Empire: • Our initial adverse determination (Level 1 appeal) • Our final adverse determination following a standard Level 1 appeal if available under the health benefit plan (Level 2 appeal) the following can be reconsidered: • An initial pre-service or concurrent denial. Depending on the health benefit plan, Empire offers either one or two levels of standard appeal. Appeals should be accompanied by a letter stating why the decision is being appealed and why you feel the decision should be overturned. If additional information is necessary to conduct a standard internal appeal, Empire will notify you, the provider, within fifteen (15) days of receipt of appeal to identify and request the necessary information. In the event that only a portion of the requested necessary information is received, Empire shall request the missing information, in writing, within five (5) business days of the partial information receipt. Empire will notify the member, the member’s designee and the provider in writing of the appeal determination within two (2) business days of the decision. An appeal is initiated by calling or writing to the Empire Medical Management Appeals Department at 1 800-634-5605, 8:30 a. Appeals filed after that date will not be considered, and you will receive a letter stating that the opportunity to file an appeal has been exhausted. The appeal should be accompanied by a letter stating why the determination is being appealed and why it should be overturned, as well as the information necessary to review it, such as the medical record. If we make a decision favorable to the person filing the appeal, written notification is sent stating that the initial denial decision has been reversed. If we make a final adverse determination upholding our prior decision, we will provide written notification that will include: • the basis and clinical rationale upon which the appeal determination is based • the words “final adverse determination” • the health service that was denied, including the facility/provider and/or the developer/manufacturer of service as available. Notwithstanding the foregoing, the aforementioned requirement as far as the reversal of an adverse determination shall only apply to insured benefit plans that are regulated by New York law. Expedited Appeals the health care provider, member or his/her authorized representative may request an urgent/expedited appeal to be implemented when the denial of coverage involves any of the following: • Cases involving continued or extended healthcare services, procedures or treatments (including home health care services following an inpatient hospital admission); • Requests for additional services for a patient undergoing a continuing course of treatment • Any case in which the member’s physician or healthcare provider believes an immediate appeal is warranted. Expedited appeals that are not resolved to the satisfaction of the appealing party may be further appealed via the standard appeal process as a Level 2 appeal or through the external appeal process. If sufficient documentation to conduct the expedited appeal is not provided, the Empire Appeals Department will immediately notify the member and the member’s health care provider by telephone or facsimile to identify and request the necessary information followed by written notification. Expedited appeals will be decided within 2 business days of receipt of necessary information. Written notice of final adverse determination concerning an expedited appeal shall be transmitted to the member within 24 hours of rendering the determination. Expedited appeal outcomes are also telephonically relayed to the person filing the appeal. We will provide reasonable access to a Medical Director within one (1) business day of receiving notice of the request for an expedited appeal. An Expedited Appeal is initiated by calling or writing to the Empire Medical Management Appeals Department at 1-800 634-5605, 8:30 a. You can initiate an external review using the form Empire will send you when our final adverse determination is made. Providers may request an External Review only when representing a member on pre-service (prospective) appeal or themselves in connection with concurrent adverse determinations or on a post service (retrospective) appeal. An external appeal may be filed: • When the enrollee has had coverage of a health care service which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, on the grounds that such health care services is not medically necessary and Empire has rendered a final adverse determination with respect to such health care services or both Empire and the enrollee have jointly agreed to waive any internal appeal. Any physician certification provided shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation, and the specific health service or procedure recommended by the attending physician would otherwise be covered under the policy except for the health care plan’s determination that the health service or procedure is experimental or investigational. Note: the enrollee and Empire may jointly agree to waive the internal appeal process; if this occurs Empire will provide a written letter with information regarding filing an external appeal to member within twenty four (24) hours of the agreement to waive Empire’s internal appeal process. An external appeal must be submitted within one hundred and twenty (120) days upon receipt of the final adverse determination of the first level appeal, regardless of whether or not a second level appeal is requested. If a member chooses to request a second level internal appeal, the time may expire for the member to request an external appeal. Predetermination Overview Empire has established a predetermination process for services where precertification is not required and you can confirm in advance of providing the service whether the service meets medical policy criteria. Services available for predetermination include bariatric surgeries, spinal surgeries and specialty pharmacy drugs. The predetermination enables the member and physician or other healthcare provider to verify the service meets our medical necessity criteria before delivering the care. Although a predetermination is not required, we encourage physicians or other healthcare providers to obtain one prior to performing any of these procedures. When a predetermination is not obtained prior to the procedure, the claim for the service will be reviewed for medical necessity on a retrospective basis. In cases when an adverse determination is issued, you and the member may access available appeal levels before delivery of the service. The medical necessity criterion is available online for your review at empireblue. Empire as Secondary Payor If Empire is the secondary payor, it will not require the hospital or the member to obtain precertification from Empire, and will not deny or reduce amounts that would otherwise be owed because a provider or subscriber did not comply with its administrative or utilization review requirements, including notification, precertification, or concurrent review. However, Empire will not be bound by the primary 128 | Page Payor’s decisions concerning the medical necessity of a service. All Empire associates who may encounter clinical care/service concerns or sentinel events are informed of these policies. If the clinical associate determines the case is a non issue with no identifiable quality issue, the clinical associate may assign a severity level C-0. A clinical associate may also assign a severity level rating of C-1 if the case meets the criteria for a known complication. A clinical associate may issue a C-3 rating for a Provider’s or Facility’s failure to submit requested information. Otherwise, the clinical associate will send a case summary to the Medical Director for review. The case summary will include a list of previous severity levels assigned to the involved Provider and/or Facility on a rolling 12-month basis. The Medical Director will select a specialty matched reviewer to evaluate the case, as appropriate. Upon completion of the review, the Medical Director makes a final determination and assigns a severity level for tracking and trending purposes. Upon completion of First Level Peer Review, if the case is a Member grievance, the Member is sent a resolution letter within thirty (30) calendar days of Empire’s receipt of the grievance.

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The aim and proposed benefits of delayed primary realignment are the same as mentioned for immediate realignment erectile dysfunction statistics uk purchase viagra plus 400 mg with amex. It is restricted to erectile dysfunction drugs sales purchase viagra plus paypal stable patients with a short distraction defect erectile dysfunction doctors san francisco viagra plus 400 mg mastercard, who are able to erectile dysfunction prostate order viagra plus 400mg without a prescription lie down in the lithotomy position [296]. Considering the limited accumulated experience with this approach, it cannot be generally recommended [296, 298, 299]. However, some authors have reported worse outcomes of subsequent urethroplasty after failed initial urethral manipulation (realignment or urethroplasty) [295, 296, 301]. Due to this concern and the excellent results obtained with deferred urethroplasty, early realignment or urethroplasty should only be selectively performed in highly experienced centres [294, 295]. Treatment options for these posterior urethral strictures are deferred urethroplasty (4. After 3 months of suprapubic diversion, the pelvic haematoma is nearly always already resolved, the prostate has descended into a more normal position and the scar tissue has stabilised [296] and the patient is clinically stable and able to lie down in the lithotomy position [256, 257]. Most posterior urethral distraction defects are short and can be treated using a perineal anastomotic repair [256, 296]. The key objective of the operation is to achieve a tension-free anastomosis between two healthy urethral ends. After resection of fibrosis and spatulation of both healthy urethral ends, the gap between both ends is bridged by the so-called ‘elaborated perineal approach’, which is a series of consecutive manoeuvres, first described by Webster and Ramon [302] with reported success rates of 80-98% [303-305]. Most urethral stenoses are short and can be treated by mobilisation of the bulbar urethra, with or without separation of the corpora cavernosa [296]. This is in contrast to the situation in developing countries, where stenoses are more complex, and where additional manoeuvres, such as inferior pubectomy and supracrural rerouting or a combined abdominoperineal approach are needed more often [292, 304]. A number of situations may prevent the use of perineal anastomotic repair, either as an initial or as a salvage therapy. This is seldom required and most patients that require flap urethroplasties have previous failed repairs of posterior urethral rupture [277]. Fistulae these might require a combined abdominoperineal approach to secure adequate closure [304]. Synchronous anterior the presence of anterior urethral stricture may compromise the blood supply to urethral stricture the bulbar urethra following division of the bulbar arteries. Urinary incontinence the distal urethral sphincter mechanism can be defunctionalised by urethral distraction, so that urinary continence is maintained primarily by the proximal bladder neck sphincter. Concomitant bladder neck injury might increase incontinence and should require an abdominoperineal procedure to allow simultaneous bladder neck and urethral reconstruction [256, 277, 304]. Outcome after deferred urethroplasty is excellent with a stricture rate of around 10% [302, 309]. Decompression of the erectile nerves after excision of the scar tissue might explain the amelioration of erectile function after urethroplasty [310]. Incontinence is rare with deferred urethroplasty (< 4%) [296] and is usually due to incompetence of the bladder neck [277, 304]. Standard therapy is a deferred urethroplasty at a minimum of three months after trauma, using a one-stage perineal approach, whenever possible. The results of this technique are poor [311, 312] and the procedure is therefore not recommended. For short, non-obliterative strictures following realignment or urethroplasty, direct vision urethrotomy can be performed [305] while in other cases, urethroplasty is warranted. If possible, immediate exploration by the retropubic route and primary repair or realignment can be performed [194, 272, 277]. In those cases, suprapubic diversion with delayed abdominoperineal urethroplasty is advised [194, 265, 272]. Concomitant vaginal lacerations are repaired transvaginally at the same time [257, 260, 278, 279]. Distal urethral injuries can be managed vaginally by primary suturing and closure of the vaginal laceration [257, 279]. Nonetheless, distal urethral injuries can be left unrepaired and hypospadiac since they do not disrupt the sphincteric mechanism [257, 260, 278, 279]. In difficult cases, catheter insertion may be assisted by cystoscopy and guidewire placement [315], and suprapubic catheterisation is an alternative. Endoscopic management, either with incision or resection, can successfully treat iatrogenic prostatic urethral strictures. Indwelling catheter placement or an open procedure (which is associated with increased morbidity) are alternatives [316]. Urethral lesions following radiotherapy are often more difficult to treat and may require complex reconstructive surgery [249, 250]. Assess for acute surgical If patient unstable or If patient unstable or indications: significant associated Suprapubic significant associated bladder neck injury, non-urological cystostomy non-urological rectal tear, injuries, suprapubic injuries, suprapubic pie-in-the-sky bladder cystostomy cystostomy No Yes Suprapubic Suprapubic tube Stricture No stricture cystostomy + endoscopic re-alignment. In industrialised societies pelvic 3 fracture-related injuries of the posterior urethra are the most common non-iatrogenic injuries. Erectile dysfunction occurs in 20-60% of patients after traumatic urethral rupture. B Treat partial posterior urethral ruptures by urethral or suprapubic catheterisation. Implementing training programmes on urinary catheter insertion significantly improves the rate of 2b catheter-related complications. A Only carry out urethral instrumentation when there are valid clinical indications. A Ensure that when catheterisation is necessary, its duration is kept to a minimum. Genital trauma is much more common in males than in females, especially between the ages of 15 and 40 years. This is due to anatomical differences, increased frequency of road traffic accidents and increased participation in physical sports, war and violent crime. The risk of associated injuries to neighbouring organs (bladder, urethra, vagina, rectum and bowel) after blunt trauma is higher in females than in males. In males, blunt genital trauma frequently occurs unilaterally and only approximately 1% present as bilateral scrotal or testicular injuries [317]. Any kind of contact sport, without the use of necessary protective aids, may be associated with genital trauma. Off-road bicycling and motorbike riding (especially on motorbikes with a dominant petrol tank), rugby, football and hockey are all activities which are associated with blunt testicular trauma [318-321]. Penetrating injuries account for 20% of genito-urinary trauma, with 40-60% of all penetrating genito-urinary lesions involving the external genitalia [262, 322]. Thirty-five per cent of all genito-urinary gunshot wounds involve the genitalia [317]. In both males and females, penetrating genital injuries occur with other associated injuries in 70% of patients. In males, penetrating scrotal injuries affect both testes in 30% of cases compared with 1% in blunt scrotal injuries [317, 324]. Self-mutilation of the external genitalia has also been reported in psychotic patients and transsexuals [325]. Genital burns are rare in isolation, usually due to industrial flame or chemicals in adults, and all but the full thickness type are treated conservatively [326]. Both male and female genital piercings increase the risk for unexpected genital trauma [327]. The presence of visible and/or non-visible haematuria requires a retrograde urethrogram in males. In females, flexible or rigid cystoscopy has been recommended to exclude urethral and bladder injury [328, 329]. In women with genital injuries and blood at the vaginal introitus, further gynaecological investigation is needed to exclude vaginal injuries [329]. The potential for significant injury should never be discounted in those patients who may also have blood in the vaginal vault from menstruation. High-velocity missiles transmit large amounts of energy to the tissues and can produce trauma to structures outside the wound track.

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Integrates a comprehensive knowledge of the causes and pathophysiology into the management of shock erectile dysfunction in diabetes type 1 purchase viagra plus 400mg overnight delivery, respiratory failure or arrest with an emphasis on early intervention to impotence natural remedies order viagra plus 400 mg free shipping prevent arrest impotence statistics discount 400 mg viagra plus otc. With every breath erectile dysfunction wikihow order discount viagra plus on-line, muscle contractions in the chest and diaphragm reduce the pressure within the lungs and chest cavity. That same low pressure created within the chest during inspiration sucks blood into the cavity and right atrium. Basic Cardiac Life Support (Refer to current American Heart Association guidelines) 1. Special arrest and peri-arrest situations Refer to the current American Heart Association guidelines A. Transport Page 242 of 385 Trauma Trauma Overview Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Transfer of patients to the most appropriate hospital Page 246 of 385 Trauma Bleeding Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Unable to maintain +90% investigate cause (tension pneumothorax) Page 251 of 385 4. Fluid choice a) Types of fluid (Refer to American College of Surgeons guidelines) i) Advantages ii) Disadvantages iii) Role of hydrostatic pressure iv) Role of colloid oncotic pressure b) Blood substitute products c) Blood administration in the field c. Review knowledge from previous levels Page 253 of 385 Trauma Chest Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Loss of lung adhesion to chest wall due to loss of surface tension collapse of lung Page 256 of 385 2. If chest wall hole is 2/3 size of trachea, more air will enter from the atmosphere – sucking sound will be present f. Delayed or improper treatment will lead to tension pneumothorax with large open wounds 2. Fluid replacement (see Trauma: Bleeding: Pediatric considerations Respiratory distress symptoms 3. Geriatric considerations in chest trauma Page 260 of 385 Trauma Abdominal and Genitourinary Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Internal venous bleeding may be more severe because arterial bleeds can occlude the lumen of the artery. Most patients with penetrating abdominal injury have underlying solid and hallow organ injures (cover elsewhere) 3. Torsion injuries – feet fixed in one direction while body is moving in different direction i. Rotator cuff tendon injuries – acute or chronic – deltoid muscle involvement – violent pull on arm, an abnormal rotation, or fall on outstretched arm which tears or ruptures tendons B. Traction control hemorrhage by apply pressure on internal bleeding within muscles wrapped by muscle sheaths. Humerous head – forced out of articular capsule, fall with inward rotation and abduction of an arm. Shoulder joint – maintained in place by ligaments, impact drives acromion downward away from clavicle which sustains its position g. Description – shearing force causes tissue to completely separated from base, and either lost or left with a flap. Burn extends into subcutaneous tissue possibly including bone and muscle tissue h. Trauma damages a nerve, or nerve group between the ganglion and its intervention point. Pharmacological assistance Page 286 of 385 Trauma Special Considerations in Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Attempt to listen to fetal heart tones – 4 o’clock position, about 2” from mother umbilicus Page 287 of 385 D. Airway, Breathing, and Circulation (improper management is the most common cause of preventable pediatric death) a. Continued drops in temperature causes hypothalamic center to stimulate shriving Page 294 of 385. At 85 degrees the individual become stuporous, cardiac output drops, cerebral blood flow is decreased g. Many toxins cause the patients cells to release bradykinins, histamines, and serotonin c. May cause head trauma, cardiac damage, burns, extremity vasospasm, paresis or parethesias. Prevention is best, many patients take acteazolamide Page 297 of 385 Trauma Multi-System Trauma Paramedic Education Standard Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. Looking a trauma scene and attempting to determine what injuries might have resulted 2. Typically a patient considered to have “multi-trauma” has more than one major system or organ involved a. Multi-trauma treatment will involve a team of physicians to treat the patient such as neurosurgeons, thoracic surgeons, and orthopedic surgeons 4. Consider use of tourniquets in emergent, hostile or multiple patient situations where bleeding is considerable 3. The definitive care for multi-system trauma is surgery which can not be done in the field b. Early notification of hospital resources is essential once rapidly leaving the scene f. Changes in vital signs or assessment findings while en route are critical to report and document 7. Newly licensed paramedics who have not seen many multi-system trauma patients need to stick with the basics of life saving techniques b. Be suspicious at trauma scenes, sometimes an obvious injury is not the critical cause one the potential for harm. Blast waves when the victim is close to the blast cause disruption of major blood vessels, rupture of major organs, and lethal cardiac disturbances b. Bleeding Related to Pregnancy: pathophysiology, assessment, complications, management 1. Complications of Delivery: pathophysiology, assessment, complications, management A. Post partum depression Page 306 of 385 Special Patient Population Neonatal Care Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Complete airway obstruction a) Atelectasis b) right-to-left shunt across the foramen ovale ii. Transport consideration transport to a facility with special services for low birth weight newborns g. Morbidity/ mortality represent relative medical emergencies as they are usually a sign of an underlying abnormality c. Risk factors prolonged and frequent multiple seizures may result in metabolic changes and cardiopulmonary difficulties 2. Term newborns will produce beads of sweat on their brow but not over the rest of their body g. Pharmacological administration of antipyretic agent is questionable in the prehospital setting d. Pathophysiology Increased surface-to-volume relation makes newborns extremely sensitive to environmental conditions, especially when wet after delivery a. Increased metabolic demand can cause metabolic acidosis, pulmonary hypertension and hypoxemia 4. Erythema, abrasions, ecchymosis and subcutaneous fat necrosis can occur with forceps delivery iii. Psychological support/ communication strategies Page 325 of 385 Special Patient Population Pediatrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. The head contributes a larger portion of the body’s surface area than in adults 3. In children younger than 10 years, narrowest part of the airway is below the vocal cords at the non-distensible cricoid cartilage 7.

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One such projection is a large shift in the distribution of commercially important sh species to erectile dysfunction protocol scam discount 400mg viagra plus otc higher latitudes and reduced harvesting potential in their original areas erectile dysfunction cures generic viagra plus 400mg without prescription. But producing detailed projections erectile dysfunction treatment with viagra 400mg viagra plus with mastercard, for example erectile dysfunction viagra does not work generic 400 mg viagra plus amex, what species and how far they will shift, is challenging because of the number and complexity of interactive feedbacks that are involved. At the moment, the uncertainties in modeling and complexities of the ocean system even prevent any quanti cation of how much of the present changes in the oceans are being caused by anthropogenic climate change or natural climate variability, and how much by other human activities such as shing, pollution, etc. It is known, however, that the resilience of marine ecosystems to adjust to climate change impacts is likely to be reduced by both the range of factors and their rate of change. The current rate of environmental change is much faster than most climate changes in the Earth’s history, so predictions from longer term geological records may not be applicable if the changes occur within a few generations of a species. A species that had more time to adapt in the past may simply not have time to adapt under future climate change. Such knowledge aids the interpretation and from which the environment selects the fittest genotypes (Rando and attribution to climate change of observed effects and is a major asset Verstrepen, 2007; Reusch and Wood, 2007). As anthropogenic climate change accelerates, evolutionary adaptation is constrained by long generation times, but a key issue is whether and how quickly organisms can compensate for enhanced by high phenotypic variability and high mortality rates among effects of individual or multiple drivers, by short-term acclimatization early life stages as a selection pool. Ambient temperature interacts with other drivers such as ocean acidification and hypoxia (Section 6. Ambient temperature plays a Comprehensive understanding of climate change effects on ecosystems more limited role for marine mammals and seabirds (Section 6. All organisms including marine ones have limited temperature ranges within which they live and function. Organismal performance is related to temperature by curves called thermal reaction norms (Figure 6-5), 6. This requires that information on organisms’ thermal and Luning, 1982; Muller et al. Heat tolerance thresholds temperature changes have affected and will continue to affect species differ greatly between organisms and are hypothesized to be lowered distributions, abundances, diversity, trophic interactions, community by rising organizational complexity and body size (Portner, 2002a,b). Surpassing the rst low and high-temperature thresholds (Tp; p, pejus: getting worse) means going into time-limited tolerance. Once further cooling or warming surpasses the next low or high thresholds (T; c, critical), oxygen availability becomes insuf cient and an anaerobicc metabolism begins. Denaturation temperatures (Td) are even more extreme and characterized by the onset of damage to cells and proteins. Horizontal arrows indicate that Tp, T,c and Tdthresholds of an individual can shift, within limits, between summer and winter (seasonal acclimatization) or when the species adapts to a cooler or warmer climate over generations (evolutionary adaptation). Blue to red color gradients illustrate the range between cold and warm temperatures (after Portner, 2002a, 2012; Portner and Farrell, 2008). High organizational complexity is hypothesized to be associated with decreasing tolerance to heat and to enable an increase in body size which in turn, decreases heat tolerance further (Sorokin and Kraus, 1962; Chevaldonne et al. In the domain Bacteria, the Thermotogales are less complex and most tolerant to high temperatures (Huber et al. The highest temperature at which growth can occur is 122°C for hydrothermal vent archaea, seen under elevated hydrostatic pressure in laboratory experiments (Kashe and Lovley, 2003; Takai et al. A warming ocean reaction norms, thermal limits, and underlying mechanisms is most may initially enhance the metabolic rates of microbes (Banse, 1991) and advanced in animals (Portner et al. Data from the role in underpinning biogeography has not been explored systematically Continuous Plankton Recorder (Section 6. Eventually, with warming, the thermal performances influence growth, body size, behavior, immune defense, tolerance of some groups will be challenged (Chevin et al. Shape and width of the curves smaller phytoplankton in warmer relative to colder waters (Moran et can shift through acclimatization and evolutionary adaptation (Figure al. In response to transient warming, phytoplankton distribution in the North Atlantic shifted poleward by hundreds of kilometers per decade For any species, tracking the climate-induced displacement of tolerated since the 1950s. Phenology of plankton in the North Atlantic was also ambient temperatures by undergoing shifts in biogeographical ranges affected, with differences in sensitivity between groups (high to. Coccolithophore blooms (Emiliania be understood as a simple mode of adaptation, implemented through huxleyi) in the Bering Sea were reported for the first time during the dispersal. Loss of multi-year Arctic sea 6 or evolutionary adaptation (Figure 6-5) would involve shifting thermal ice has had a profound effect on the diversity, structure, and function tolerance ranges and allow species to resist the temperature trend. Microbes Warming may also have caused the southward range extension of coccolithophores in the Southern Ocean in the 2000s (Cubillos et al. However, further experimental and field observations (Giovannoni community structure of highly diverse microbes have large implications and Vergin, 2012) are required to validate model projections (Taucher 428 Ocean Systems Chapter 6 and Oschlies, 2011) of differential responses to warming by different 1998; Schluter et al. During early life, owing to incomplete development, or as adult spawners, owing to large body size, animals may become more sensitive to warming because of 6. This may cause high vulnerability of winter-spawning Atlantic cod to warming winter to Macrophytes in coastal waters (Chapter 5) cover 0. In contrast, adult bigeye, bluefin, marine areas and supply about 2 to 5% of total oceanic production and skipjack tuna spawn at high temperatures. They have limited temperature ranges and are sensitive to temperature extremes (high confidence), resulting in changes of photosynthesis, Although temperature means are still most commonly used when growth, reproduction, and survival (following the principles of Figures attributing responses of marine organisms to climate effects, temperature 6-5, 6-6; and Harley et al. Temperate macroalgae with wide windows of thermal Local extinction events follow as a result of mortality or behavioral tolerance acclimatize by shifting these windows following seasonal avoidance of unfavorable thermal environments (Breau et al. Antarctic and tropical Shifted species distribution ranges follow temperature clines from high macroalgae are exposed to permanently low or high temperatures, to low, usually along latitudes, a lateral gradient at basin scale (Perry et respectively, and have consequently specialized in a limited temperature al. For example, long-term observations show mortality in the Mediterranean Sea (Marba and Duarte, 2010). The temperature range at which animals can function best results from optimal oxygen supply at minimal oxygen usage. At temperature Thermal windows of fishes and invertebrates roughly match ambient extremes, oxygen supply capacity becomes constrained in relation to temperature variability (Figure 6-1) according to climate regime and demand, and metabolism becomes thermally limited. Sub-Arctic, lower temperature thresholds (Tp, Figure 6-5a), growth, reproduction, small, or highly mobile species are eurytherms. These thresholds change during the wide temperature range, that is, they have wide thermal windows and individual life cycle, and with body size. At large body size, limitations distribution ranges, at the expense of higher energetic costs and in oxygen supply are exacerbated and heat tolerance limits shift to associated lifestyles (Portner, 2002a, 2006). In a warming world, polar stenotherms will be marginalized, warming causes a reduction of abundance (Portner and Knust, 2007; with no possibility to escape to colder regions (high confidence). Phenomenon Key drivers Mechanism/Sensitivity Biogeography Northward shift in the distribution of North Sea cod Temperature Bottlenecks of high sensitivity during early life stages as well as (Gadus morhua) stocks between 1977 and 2001. Shift from sardines (Sardinops melanostictus) to Temperature Thermal windows of growth and reproductive output are anchovies (Engraulis japonicus) in the western North found at higher temperatures for anchovies than sardines, food Paci c observed between 1993 and 2003. Variable sensitivity of Paci c tuna species to the Oxygen Oxygen transport via hemoglobin is adapted to be highly availability of dissolved O2. Bigeye tuna routinely ef cient supporting high metabolic rates as needed during reach depths where ambient O2 content is below 1. Calanus glacialis and the dino agellate Ceratium arcticum between 1960 and 2000 in the Newfoundland Shelf, Northwest Atlantic. Phenology Migration time of pink salmon (Oncorhynchus Warming Rapid microevolution for earlier migration timing. Tropical species boundaries is limited and depends on the species and the prevailing (with thermal windows of intermediate width) live close to the highest climate regime (Portner et al. Ocean acidification, hypoxia, 6 temperatures tolerated by marine animals (Figure 6-6). Local adaptation may reduce climate vulnerability at the species level, Short-term shifts in thermal thresholds of an individual organism may by causing functional and genetic differentiation between populations, happen over days and weeks, such as during seasonal acclimatization. Local adaptation on small spatial adaptation of a population to cooler or warmer climates (Figure 6-5a; scales is particularly strong in intertidal organisms (Kelly et al. Both On larger scales, the widening biogeographic and roaming ranges of 430 Ocean Systems Chapter 6 Northern Hemisphere eurytherms into Arctic waters (Portner et al. Tropical reef fishes undergo rapid warm acclimation across participating animal species (Figure 6-7;. The rates, mechanisms, and limits of thermal acclimatization and species from different domains, impeding a deeper understanding of evolutionary adaptation are poorly understood (low confidence). Warm and cold-water coral communities For example, in a coastal microcosm (small-scale, simplified experimental Tropical corals live in shallow water and differ from most other animals ecosystem) resident heterotrophic bacteria were stimulated by warming by hosting dinoflagellates (Symbiodinium sp. High light, rapid salinity changes, and small increases in autotrophs (gaining energy from photosynthesis) to chemo-heterotrophs temperature can trigger ”coral bleaching”, the loss of symbionts and tissue (Hoppe et al. The damage the symbionts (Hoegh-Guldberg and Smith, 1989; Glynn and principles and wider applicability of these findings require further D’Croz, 1990; Jones et al. The degree of impact will depend on the coral reefs’ adaptability to In the North Atlantic as a key example, many biological events have thermal stress and the interaction of multiple drivers (Meissner et al.

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