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Voice over IP over MPLS (VoIPoMPLS) In this case, the typical protocol stack contains voice samples encapsulated in IP layer protocols such as the Real-Time Transfer Protocol (RTP), User Datagram Protocol (UDP), and IP followed by encapsulation in the MPLS protocol. Compressed headers may be utilized in some implementations. The result is then conveyed by an MPLS transport arrangement such as Frame Relay, Asynchronous Transfer Mode (ATM), Point-to-Point Protocol (PPP), or Ethernet. Voice directly over MPLS (VoMPLS) (without the IP encapsulation of the voice packet) In this case, the typical protocol stack consists of voice samples encapsulated in the MPLS protocol on top of an MPLS transport arrangement such as Frame Relay, ATM, PPP, or Ethernet.

When an anxiety state is accompanied by faintness, the pattern of symptoms can often be reproduced by having the subject hyperventilate that is, breathe rapidly and deeply for 2 to 3 min This test may also be of therapeutic value, because the underlying anxiety tends to be lessened when the patient learns that the symptoms can be produced and alleviated at will simply by controlling breathing Most patients with tussive syncope cannot reproduce an attack by the Valsalva maneuver but can sometimes do so by voluntary coughing if severe enough Another useful procedure is to have the patient perform the Valsalva maneuver for more than 10 s (thus trapping blood behind closed valves in the veins) while the pulse and blood pressure are measured (see Tests for Abnormalities of the Autonomic Nervous System, Chap 26).

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In each of the aforementioned instances, the crucial point is not whether symptoms are produced but whether they reproduce the exact pattern of symptoms that occurs in the spontaneous attacks Other conditions in which the diagnosis is clari ed by reproducing the attacks are carotid sinus hypersensitivity (massage of one or the other carotid sinus) and orthostatic hypotension (observations of pulse rate, blood pressure, and symptoms in the recumbent and standing positions or, even better, with the patient on a tilt table) The tilt table test is now a regularly used procedure when the diagnosis of syncope is not evident from physical examination and routine studies such as electrocardiography (ECG), blood count, and bedside sphygmomanometry There is a distinct difference in the cardiovascular challenge imposed by a tilt table and that created by the simple act of standing up from a sitting or recumbent position, as discussed below.

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As stated earlier, in the regulation of sodium excretion, the control of tubular sodium reabsorption is more important than control of GFR. One reason for this is that a change in GFR automatically induces a proportional change in the reabsorption of sodium by the proximal tubules, so that the fraction reabsorbed (but not the total amount) remains relatively constant (Table 7 1). This phenomenon has the rather ungainly name of glomerulotubular balance. In response to a primary change in GFR, the percentage of the filtered sodium reabsorbed proximally remains approximately constant (about 65%). The fraction not reabsorbed also remains approximately constant (about 35%). Therefore, a change in GFR is still reflected as a change in the sodium and water presented to the loop of Henle. Glomerulotubular balance does not mean that proximal reabsorption is always exactly 65% of filtered sodium. It only says that when the fraction reabsorbed is changed, the change is caused by processes other than changes in GFR. Several mechanisms are manifested in the proximal tubule to stimulate sodium reabsorption (raise the percentage reabsorbed above 65%) or inhibit sodium reabsorption (lower the percentage below 65%).

It should be re-emphasized that, from the perspective of detecting an underlying autonomic failure, having the patient stand abruptly from a lying position and then recording the blood pressure every 30 to 60 s for up to 3 min is more informative than interposing a period of sitting between the lying and standing positions Patients with sympathetic failure of central or peripheral type, and those with hypovolemia will show a drop in blood pressure within 30 s; those with a propensity to re ex fainting may take much longer, or show no drop at all The measurement of beat-to-beat variation in heart rate is a simple but sensitive means of detecting vagal dysfunction, as described in Chap 26 Careful, continuous monitoring of the ECG in the hospital or by using a portable recorder may determine whether an arrhythmia is responsible for the syncopal episode.

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