Dental Institute, King? College London, London, UK
In the upper third of the esophagus between the tissues of the body and the external the muscularis is skeletal muscle erectile dysfunction 20s buy apcalis sx us. The membranes are constantly wet third both smooth and skeletal muscle is present and lubricated by mucus erectile dysfunction 24 discount apcalis sx 20 mg free shipping. The mucosa has three and in the lower third only smooth muscle is pres parts: an epithelium erectile dysfunction treatment dallas texas generic apcalis sx 20 mg visa, lamina propria and muscu ent male erectile dysfunction age order generic apcalis sx online. When glands are An abrupt transition occurs at the cardio-esoph found in this layer they are referred to as mucosal ageal junction erectile dysfunction treatment atlanta ga 20mg apcalis sx with visa, where stratifed squamous epi glands erectile dysfunction at age of 30 buy online apcalis sx. The muscularis mucosa erectile dysfunction review 20 mg apcalis sx free shipping, when present psychological reasons for erectile dysfunction causes apcalis sx 20 mg amex, thelium gives way to simple columnar epithelium. It the simple columnar epithelium (surface mucous facilitates localized movement of the mucous mem cells) dips into the lamina propria to form gastric brane, aiding expression of secretions and move pits (150-300 um deep). The base of gastric glands rests on Submucosa: the submucosa is a layer of f a muscularis mucosa. The submucosa is quite broelastic connective tissue that supports the mu prominent and contains numerous arteries, veins, cosa. When the stomach gion (esophagus and duodenum) they are referred is empty the surface is thrown into folds (rugae). The stomach is divided into three histological re Muscularis externa: this is a separate layer not gions (cardiac, body/fundus, pyloric) based on their to be confused with muscularis mucosa. Between the layers is a cardiac glands are short tubular glands that are Chapter 14 Gastrointestinal tract 224 coiled at the base. The glands consist mostly of um in length) on the surface of the simple mucus secreting cells. The fundus and body make up projections make up the striate border of more than 90% of the stomach and have the same intestinal epithelium. The glands of the body and fundus are straight tubular and have three re the second main function of the small intestine gions: the upper third is the isthmus and empties is digestion and is dependent on secretions from into the gastric pits, the middle third is the neck three types of glands: and the bottom third is the base. Exocrine glands (liver and pancreas) de liver their secretions (bile and digestive en erative cells are found at the boundary between zymes) into the duodenum by way of the the isthmus and the gastric pit. Parietal cells are distinctive eo tions of the surface epithelium down into sinophillic cells with a centrally located nucleus and the underlying lamina propria. Cell types found in the intestinal epithelium in Some parietal cells are also be found in the base of clude: the gland. The primary cell type in the base is the chief cell which has a basophilic cytoplasm in its 1. Chief cells secrete pepsinogen and cells have a microvillus (striate) border and gastric lipase. These One of the main functions of the small intestine is cells have very eosinophillic secretion nutrient absorption. Circular transverse folds (plicae circu the columnar cells are replaced by the lares or valves of Kerckring) of the en cuboidal to squamous M cells. M cells be tire mucosa (with a core of submucosa) long to the mononuclear phagocytic sys project permanently into the lumen. The tem of macrophages and antigen present plicae are prominent in the duodenum and ing cells. The shape of villi hormones and are not readily distinguished varies in the different regions of the small in routine preparations. Microvilli are cytoplasmic projections (1-2 and sends fbers into the core of the villi. The sub Chapter 14 Gastrointestinal tract 225 mucosa is irregular fbroelastic tissue with a rich seen. The muscularis crypts are short (150-250 um) in comparison to the externa, is responsible for peristalsis, and has an colon. Enteroendocrine cells are found in the base inner circular and outer longitudinal layer. The muscularis the small intestine is divided into three regions: mucosa is very thin. The pyloric stom ner circular and outer longitudinal layers of smooth ach transitions to the duodenum at the pyloric muscle. The duodenum is the shortest seg ment (25 cm) and receives secretions from the liver (bile) and pancreas (digestive enzymes). Lymphoid tissue in the lamina propria progressively increases from the jejunum to the il eum. Villi become shorter, broader and have increasingly larger lacteals (blind ending lymphoid vessels in the core of villi) in the ileum. Frequency of goblet cells and Paneth cells increases as one progresses from the duodenum to the ileum. The parts of the large intestine are the cecum, appendix, colon, rectum and anal ca nal. The intestinal glands (crypts of Lieberkuhn) are frequent and closely packed together. The two ma jor cell types are simple columnar absorptive cells with striated border and numerous goblet cells. The muscularis externa con sists of an inner circular layer and an unusual outer longitudinal layer. The outer layer is gathered into three distinct bundles (taenia coli) that are equally spaced around the gut. Epithelium: stratifed squamous non non-keratinizing epithelium to a simple keratinizing columnar epithelium. Mucosa sue support for epithelium in mucous Chapter 14 Gastrointestinal tract 227 a. The Committee on Ambulance Design Criteria published Medical Requirements for Ambulance Design and Equipment. Incidence-IoM report To Err is Human up to 98,000 patients die due to medical errors C. Research Principles to Interpret Literature and Advocate Evidence-Based Practice A. High-quality patient care should focus on procedures proven useful in improving patient outcomes 3. If evidence supports a change in practice, adopt the new therapy allowing for unique patient needs. Short a) Traditional wooden device b) Vest type device i) Scoop or orthopedic stretcher ii) Flexible stretcher b. Mobile transmitters usually transmit at lower power than base stations (typically 20-50 watts) c. Arrival at the receiving facility or rendezvous point - dispatcher must be notified 6. Paramedics may need to contact medical control for consultation and to get orders for administration of medications 3. Orders that are unclear or appear to be inappropriate should be questioned or clarified for the paramedic B. Principles of communicating with patients in a manner that achieves a positive relationship A. When practical, position yourself at a level lower than the patient or on the same level 4. Diversity (a term once used primarily to describe "racial awareness") now refers to differences of any kind: race, class, religion, gender, sexual preference, personal habitat, and physical ability c. By revealing awareness of cultural issues, the paramedic will convey interest, concern, and respect f. When dealing with patients from different cultures, remember the following key points: i. Different generations and individuals within the same family may have different sets of beliefs iii. Realize that people may not share your explanations of the causes of their ill health, but may accept conventional treatments vii. Recognize your personal cultural assumptions, prejudices, and belief systems and do not let them interfere with patient care ix. Both the paramedic and the patient will bring cultural stereotypes to a professional relationship. Space a) Intimate zone b) Personal distance c) Social distance d) Public distance xiv. Cultural issues a) Variety of space b) Accept the sick role in different ways c) Nonverbal communication may be perceived differently d) Asian, Native Americans, Indochinese, and Arabs may consider direct eye contact impolite or aggressive e) Touch f) Language barrier xv. Ryan White Act Page 30 of 385 Anatomy and Physiology Paramedic Education Standard Integrates a complex depth and comprehensive breadth of knowledge of the anatomy and physiology of all human systems. Changes in air pressure that occur within the thoracic cavity during respiration i. Medulla and autonomic nervous system regulation of the diameter of the blood vessels 16. Location, Structure, and Function of the Stomach, Small intestine, Liver, Gallbladder, and Pancreas Page 48 of 385 J. Menstrual Cycle in Terms of Changes in Hormone Levels and the Condition of the Endometrium I. Metabolism, Catabolism, Anabolism, Basal Metabolic Rate, Kilo-Calories Page 52 of 385 D. Significance of caloric value of foods Page 53 of 385 Medical Terminology Medical Terminology Paramedic Education Standard Integrates comprehensive anatomical and medical terminology and abbreviations into the written and oral communication with colleagues and other health care professionals. Body Systems Page 54 of 385 Pathophysiology Pathophysiology Paramedic Education Standard Integrates comprehensive knowledge of pathophysiology of major human systems. Perform one function or act in concert with other cells to perform a more complex task C. Bacteria produce enzymes or toxins a) Toxins i) Exotoxins ii) Endotoxins b) Fever is caused pyrogens c) Inflammation d) Hypersensitivity e) Bacteremia or Septicemia c. Vascular endothelial damage, neuroendocrine response, and release of inflammatory mediators c. Pituitary gland and adrenal cortex sensitivity to emotional, psychologic and social influences 4. Financial burdens Page 75 of 385 Public Health Public Health Paramedic Education Standard Applies fundamental knowledge of principles of public health and epidemiology including public health emergencies, health promotion, and illness and injury prevention. Techniques of Medication Administration (Advantages, Disadvantages, Techniques) 1. Fever Reaction Page 86 of 385 Pharmacology Emergency Medications Paramedic Education Standard Integrates comprehensive knowledge of pharmacology to formulate a treatment plan intended to mitigate emergencies and improve the overall health of the patient. Individual training programs have the authority to add any medication used locally by paramedic. Thiamine Page 88 of 385 Airway Management, Respiration, and Artificial Ventilation Airway Management Paramedic Education Standard Integrates complex knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of assuring a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. See Special Patient Populations section Page 92 of 385 Airway Management, Respiration, and Artificial Ventilation Respiration Paramedic Education Standard Integrates complex knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of assuring a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. Blood volume circulation disturbances due to Cardiac, Trauma, Systemic Vascular Resistance 1. Precapillary arterioles and smooth muscle effects of alpha and beta cholinergic receptors, effects of hypoxia, acidosis, temperature changes, neural factors and catecholamines. Cell and tissue beds and disruptions of membrane integrity, enzyme systems and acid-base balance. Disruptions in oxygen transport associated with diminished oxygen carrying capacity 1. Age-Related Variations in Pediatric and Geriatric Patients Page 98 of 385 Airway Management, Respiration, and Artificial Ventilation Artificial Ventilation Paramedic Education Standard Integrates complex knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of assuring a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. Review of the physiologic differences between normal and positive pressure ventilation C. AgeRelated Variations in Pediatric and Geriatric Patients Page 100 of 385 Patient Assessment Scene Size-Up Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. After making the scene safe for the paramedic, the safety of the patient becomes the next priority b. If the paramedic cannot alleviate the conditions that represent a health or safety threat to the patient, move the patient to a safer environment 2. If the paramedic cannot minimize the hazards, remove the bystanders from the scene. Paramedics should not enter a scene or approach a patient if the threat of violence exits. Park away from the scene and wait for the appropriate law enforcement officials to minimize the danger D. A variety of specialized protective equipment and gear is available for specialized situations. Chemical and biological suits can provide protection against hazardous materials and biological threats of varying degrees. Specialized rescue equipment may be necessary for difficult or complicated extrications. Based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any healthcare delivery setting c. The extent of standard precautions used is determined by the anticipated blood, body fluid, or pathogen exposure. Personal protective equipment includes clothing or specialized equipment that provides some protection to the wearer from substances that may pose a health or safety risk. Consider if this level of commitment is required Page 103 of 385 Patient Assessment Primary Assessment Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. Primary assessment: unstable Page 105 of 385 Patient Assessment History Taking Paramedic Education Standard Integrates scene and patient assessment findings with knowledge of epidemiology and pathophysiology to form a field impression. Special emphasis on conditions contributing to morbidity and mortality in trauma b. Chest pain a) Onset b) Duration c) Quality d) Provocation e) Palliation f) Palpitations g) Orthopnea h) Edema i) past cardiac evaluation and tests i. Requires use of knowledge of anatomy, physiology and pathophysiology to direct the questioning a. Results of questioning may allow you to think about associated problems and body systems c. Clinical reasoning requires integrating the history with the physical assessment findings 2. Develop a working hypothesis of the nature of the problem (differential diagnosis) b. Test differential diagnosis list with questions and assessments relating to systems with similar types of signs and symptoms c. Pay careful attention to the signs and symptoms that do not fit with the working differential diagnosis H. Patients may use this to collect their thoughts, remember details or decide whether or not they trust you b. Do not attempt to have the patient lower their voice or stop cursing; this may aggravate them H. Be prepared for the confusion and frustration of varying behaviors and histories 2. Do not overlook the ability of these patients to provide you with adequate information 2.
The osmotic gradient induced causes excretion of water into the canaliculi erectile dysfunction lyrics discount generic apcalis sx canada, which is a major driving force of the bile flow erectile dysfunction endovascular treatment generic apcalis sx 20 mg line. When bile reaches the intestinal tract impotence propecia best apcalis sx 20 mg, conjugated bile acids are partly transformed by enteral bacteria in 2 ways erectile dysfunction oral treatment purchase apcalis sx 20 mg overnight delivery. The secondary bile acids how to avoid erectile dysfunction causes buy apcalis sx online from canada, deoxycholate and lithocho late erectile dysfunction drugs india cheap 20 mg apcalis sx, are produced by hydroxylation from cholic acid and chenodeoxycholic acid best erectile dysfunction pump discount apcalis sx 20 mg mastercard, respectively causes of erectile dysfunction in 60s buy generic apcalis sx 20mg on-line. Lithocholic acid is poorly absorbed, but it is hepatotoxic and may induce severe cholestasis. The small reabsorbed fraction is sulfated (tertiary sulfolithocholic acid) in the liver; in this form it is not reabsorbable in the next enteric cycle. Unconjugated bile acids are absorbed in the entire intes tinal tract by passive diffusion. All reabsorbed bile acids are transported to the liver by the portal blood flow, efficiently (90% in each passage) cleared by the liver, and if necessary reconjugated and then re-excreted into the canaliculi. Only a small fraction of the bile acid pool is lost in this enterohepatic circulation which cycles 10 to 15 times per day. Some bile production occurs by secretion by hepatocytes of Na1into the canaliculi, passively followed by water. The remaining 30% of the bile is produced by the epithe lium of the intrahepatic bile ducts by excretion of water in combination with bicar bonate and chloride. The cause of cholestasis may be inside (intrahepatic) or outside the liver in the common bile duct (extrahepatic). Obstruction of the bile flow by focal lesions is easily compensated for by the remaining liver. Intrahepatic cholestasis occurs predominantly at the level of hepatocytes and canaliculi or in bile ductuli in zone 1 of the liver lobules (the periportal zone). Again, due to the reserve of the liver, clinical signs occur only when there is nearly complete blockage of the passage. Intrahepatic cholestasis Intrahepatic cholestasis may occur due to leakage of the tight junctions that separate bile canaliculi from blood sinusoids. This situation occurs in endotoxemia and sepsis, and in cases of adverse reaction to drugs. Leptospira produce enzymes that destroy the tight junctions, leading to severe intrahepatic cholestasis in leptospirosis without severe reduction of other liver functions. Another reason for intrahepatic cholestasis is swelling of hepatocytes, which occlude the canaliculi and bile ductules (feline liver lipidosis). Necrosis of liver cells may occur in almost all liver diseases and gives a direct connection between canaliculi and the sinusoidal/perisinusoidal lymph and blood flow. Because active excretion of bile components with water causes pressure in the biliary system, bile leaks easily back into the low pressure blood and lymphatic system. In many liver diseases there are portal or periportal processes that block the bile flow out of the liver lobules. Examples are infiltration of inflammatory cells (hepatitis), tumor cells (malignant lymphoma and other forms), and deposition of collagen (chronic hepatitis, other fibrotic diseases, cirrhosis). Diffuse swelling of hepa tocytes (lipidosis), diffusely spread space-occupying lesions (tumor metastases), and Clinical Syndromes Associated with Liver Disease 421 disruption of the normal acinar architecture (cirrhosis) affect the bile flow at different levels in the liver lobules. The most severe form of intrahepatic cholestasis is seen in dogs with destructive cholangitis, whereby many or all peripheral intrahepatic branches of the biliary tree become necrotic (eg, due to idiosyncratic reaction to sulfonamides/trimethoprim-sulfamethoxazole). In all cases of cholestasis (also extrahepatic) the hepato cytes may become overloaded with substances that cannot be adequately excreted. Due to diffusion through the sinusoidal membrane, they may enter the peri sinusoidal space of Disse. With the hepatic lymph flow, all such compounds will then enter the blood circulation. Extrahepatic cholestasis, extrahepatic bile duct obstruction Extrahepatic causes of cholestasis are rare. In dogs and cats, clinical cases of extra hepatic cholestasis have common bile duct obstruction. Hyperplasia of the biliary epithelium due to long-term high doses of progestins may also occlude the extrahepatic bile ducts. Cholangiocarcinomas may spread through the biliary tree and cause severe extrahepatic (and intrahepatic) cholestasis. Nematodes ascending into the biliary system have been reported to cause common bile duct obstruction, but this is a rare event, if it occurs at all in vivo. The common bile duct or lobular ducts may become obstructed if (part of) the liver is dislocated in a diaphragmatic herniation. Cholangitis may cause diffuse intra and extrahepatic cholestasis, which is rare in dogs, but the most common cause in cats. The gallbladder is not always distended, and in chronic cases it may even be abnormally small, containing highly concentrated mucinous bile from which the pigment has been resorbed (white bile). Morphine derivatives induce complete closure of the sphincter of Oddi,15 so that a full gallbladder during surgery may be normal. Bile acid-driven fat resorption is then also disturbed, resulting in soft grey feces with a high fat content (acholic feces). In the canaliculi, cellular debris and bile may produce bile thrombi, visible as brown casts in the canaliculi. However, these casts are easily washed out of the liver tissue on the slide during staining procedures. Cellular debris and bile plugs containing bile pigment (bilirubin) are phagocytosed by Kupffer cells and are seen as intracellular brown-yellow material. Accumulation of bile pigment in hepatocytes may also be visible as brown-yellow pigmentation. In chronic cases bile ducts proliferate and become tortuous, which is visible as multiple bile ducts instead of just one in the portal areas. In severe chronic cholestasis of any origin the biliary excretion of copper may be decreased, leading to increased concentration in the liver. With histochemical staining slight accumulation of copper may be detectable in the periportal zone (primary copper storage diseases give more severe accumulation in the centrilobular area). Biochemistry of cholestasis Biochemically, cholestasis leads to increased concentration of all bile constituents, such as cholesterol, bile acids, and bilirubin, and also of enzymes that are highly active in biliary epithelial cells or the specialized biliary part of the membrane of hepatocytes: It is not possible to differentiate between extra and intrahepatic cholestasis with biochemistry. Bilirubin Metabolism and Icterus Bilirubin is the pigment that gives bile its yellow-brown color. Heme resides in red cell hemoglobin and in many enzyme systems, which are preferentially localized in the liver (cytochromes, catalase, and peroxidase). Although the pool size of hemoproteins in the liver is small compared with the hemoglobin pool, the production of bilirubin from hepatic heme accounts for 30% of the total production, because the hepatic heme turnover rate is much higher (2 hours to 4 days versus 98 days for hemoglobin). Bilirubin is cleared from the plasma by the liver, and has to be conjugated by the hepatocytes preceding biliary excretion. The unconjugated form is stringently hydrophobic and bound to albumin in the circulation. On conjugation, bilirubin is excreted into bile and the conju gate is not reabsorbed from the intestines. Rarely, in cases of bacterial overgrowth, bilirubin is deconjugated by bacterial enzymes and the unconjugated pigment is reab sorbed in the small intestines into an enterohepatic cycle. Bacterial degradation of bili rubin in the colon produces stercobilins, black and brown pigments that give feces its normal color. Cholestasis causes accumulation of conjugated bilirubin in plasma, which is not only re-excreted by the liver but may also be excreted by the kidneys in the urine. However, the kidney in dogs, particularly males, has all the enzymes to produce bilirubin out of heme and to conjugate it, so that it can be excreted into urine. Therefore, the urine of healthy male dogs may contain detectable concentrations of bilirubin. Urobilinogen is a colorless product, a small fraction of which is absorbed into the portal blood. Most of it is cleared by the liver, but a minor part reaches the systemic circulation and can be excreted by the kidneys. Measurement of urobilinogen in urine has been used to differentiate between different forms of icterus and cholestasis. However, due to many physiologic variations and technical errors, this parameter has no clinical value. Bilirubin is cleared from the blood, conjugated, and excreted into bile by the liver. The clearance is not an efficient process18,19 in contrast to the hepatic clearance of bile acids. Whereas bile acids are nearly completely cleared during the first passage, bilirubin requires many passages to become cleared completely. As a conse quence, bilirubin is equally distributed over the entire circulation, but bile acids are highly concentrated in the portal blood and have a low concentration in the systemic circulation. This explains the differences in the reaction pattern of bilirubin and bile Clinical Syndromes Associated with Liver Disease 423 Ineffective clearance and recirculation Complete clearance bilirubin in 1 circulation Bile acids gut. Bile acids are reabsorbed and undergo an enterohepatic circulation, which is maintained by an efficient clearance of bile acids from the portal vein. Bilirubin is not absorbed from the small intestines and its hepatic clearance from the blood has low efficiency. Consequently, there is a high gradient between the portal and systemic concentrations of bile acids, but not of bilirubin. Furthermore, systemic bile acids are increased due to portosystemic shunting and cholestasis; bilirubin is only increased due to cholestasis (or increased production in case of severe hemolysis). In diseases with cholestasis, all bile components including bilirubin and bile acids gain entry to the systemic circulation with the hepatic lymph. This process is not related to hepatic clearance or portal perfusion of the liver. Conversely, in diseases characterized by portosystemic shunting (congenital porto systemic shunts, portal hypertension, acquired collateral circulation, and so forth), the high portal bile acid concentration reaches the systemic circulation giving a high plasma bile acid concentration. However, the bilirubin concentration is not influenced by abnormal liver perfusion. The main processes by which plasma bilirubin may increase are increased produc tion and cholestasis. An increased level becomes clinically visible only as icterus (yellow discoloration of sclerae, mucous membranes and skin) when the concentration exceeds 15 mmol/L. Due to the huge liver reserve capacity, most patients remain in the subclinical region and do not become icteric, despite the fact that nearly all nonvascular liver diseases leadto somedegreeofcholestasis. Given the 2 main reasons for hyperbilirubinemia, increased production and chole stasis, measurement of unconjugated and conjugated bilirubin has been used as an expression of these 2 processes. However, with sensitive techniques, it has been shown that hemolytic (increased production) and hepatobiliary diseases (cholestasis) are not different with respect to the fraction of unconjugated bilirubin, which always 424 Rothuizen varies between 15% and 40%. In liver diseases, there is considerable hemolysis (eg, due to portal hypertension causing reduced splanchnic blood flow with prolonged trapping and degradation of red blood cells in the spleen, and altered erythrocyte membrane fluidity caused by high plasma bile acid concentrations). Furthermore, animals with liver disease may have increased bilirubin production from hepatocyte hemoproteins. Hepatic and hemolytic diseases also have comparable reductions of the bile flow as an expression of cholestasis. With mild anemia, the liver is not damaged and the reserve capacity of the liver prevents such patients from becoming icteric. As hepatic and hemolytic jaundice always consist of a mixed type of hyperbilirubinemia, the measurement of unconjugated and conjugated bilirubin is clinically useless. Furthermore, if only severe hemolysis leads to jaundice, such animals should have pale mucous membranes (and hematocrit <20%). Moderately pale or normally colored mucous membranes in the presence of icterus immediately indicate the presence of a primary disease of the liver or biliary tract. Conjugated bilirubin in plasma binds covalently (irreversibly) to protein albumin. This bilirubin can only escape the circulation when albumin becomes catabolized; its half-life is about 2 weeks. Therefore, after complete recovery from the underlying cholestatic disease, icterus may remain for several weeks and does not necessarily reflect the actual situ ation, which may be important when evaluating the effect of therapy. Portal hypertension can be caused by an increased delivery of blood to the portal system, or by an increased resistance to the passage of portal blood. An increased delivery of blood occurs animals with arteriovenous shunts in the splanchnic circulation, usually in the liver, causing the direct connection of the arterial blood pressure with the portal system. Usually, however, portal hypertension is caused by an increased resistance to the portal blood stream. The cause can be prehepatic (in the portal vein itself), intrahepatic, or posthepatic (hepatic veins, caudal vena cava, heart). Posthepatic causes have little influence on the liver functions, but increased hydrostatic portal blood pressure may cause ascites. Most cases of clinically relevant portal hypertension have a cause inside the liver. Liver diseases causing portal hypertension give rise to different liver Clinical Syndromes Associated with Liver Disease 425 dysfunctions, such as reduced protein and albumin production. However, even in severe liver dysfunction, the capacity of the liver to produce proteins is only moder ately affected due to the large plasticity of the liver. Therefore, albumin levels usually do not fall below 18 to 20 g/L, which is more than the concentration that, by itself, may cause edema and ascites (<15 g/L). However, the combination of portal hypertension and moderate hypoalbuminemia often produces ascites in such animals. The hindrance to the portal circulation develops by way of compression of the portal veins in the portal and periportal area of the liver lobules. Because the cause lies at the site of entry of blood into the liver lobules, the liver itself is not congested. Due to loss of functional tissue, most of these diseases are associated with an abnormally small liver. The most frequent cause of portal vein compression is deposition of collagen (fibrosis)23,24 and infiltration of inflammatory cells (chronic hepatitis). In advanced cases, cirrhosis, defined as disruption of the normal lobular architecture of the liver by fibrous tissue, occurs. Then, resistance to the portal blood flow occurs at different levels of the lobule and is most severe. Portal vein hypoplasia (formerly called microvascular dysplasia) is associated with variable degrees of liver fibrosis, which may increase the resistance to normal liver perfusion. Posthepatic causes of portal hypertension may be localized in the inferior vena cava and the heart. Obstruction of the hepatic veins either intra or extrahepatic (Budd Chiari syndrome and veno-occlusive disease, respectively) occur in other species, but not in cats or dogs. Thrombosis of the inferior vena cava is rare, and is often caused by an adrenal tumor giving local thrombophlebitis. Such a thrombus grows out in the direc tion of the blood stream and may occlude the lumen over a long distance. In posthe patic causes of portal hypertension the liver is congested and enlarged. Liver functions, however, remain adequate and biochemical examination usually reveals no or only slight liver cell damage and dysfunction. If disorders affecting the afferent portal system cause reduced perfusion of the liver, there is secondary hypoplasia of the portal veins and increased growth of tortuous hepatic arteries (arterialization) in the portal areas. With the exception of congenital shunts, all of these diseases cause increased resistance for the portal blood flow through the liver, and therefore portal hypertension. In posthepatic causes of portal hypertension, the central vein branches may be dis tended and the liver cells in zone 3 degenerated. In chronic cases, fibrous tissue develops around the terminal veins and hepatocyte hyperplasia may occur in zone 1 (periportally). The stasis or reversion of the portal 426 Rothuizen flow may be visualized with Doppler ultrasonography. Reversed portal flow is only possible if there are acquired portosystemic collateral vessels, and thus is there is chronic severe portal hypertension (see later discussion). Such abnormal flow patterns may occur in the case of portal vein hypoplasia (microvascular dysplasia), arteriove nous fistula, and advanced cirrhosis. Ascites Accumulation of free abdominal fluid may result from severe portal hypertension, or from the combination of moderately increased portal blood pressure and hypoalbumi nemia. Because of the high reserve capacity of the liver, hypoalbuminemia occurs only when liver function is chronically and severely impaired. Examples are chronic hepa titis/cirrhosis, congenital portosystemic shunts, and severe forms of portal vein hypo plasia. Reduced oncotic pressure may be the only cause of edema/ascites when albumin concentrations are %15 g/L. Therefore portal hypertension must be present in liver diseases in order to cause ascites. In posthepatic causes of portal hypertension (eg, heart failure), the liver functions are not or only slightly impaired; protein production remains adequate. In such cases, the hydrostatic blood pressure is the only factor causing ascites, which occurs only if the blood pressure is high. This situation occurs only in cases of near-complete obstruction of the inferior vena cava or severe cardiac failure. Prehepatic portal hypertension (portal vein thrombosis), if located in the stem of the portal vein, may cause near-complete obstruction. In dogs with severe cholestasis, associated with high systemic plasma levels of bile acids, a specific mechanism of ascites formation may occur. Cortisol is present in about tenfold excess to aldosterone, and has the same affinity for the aldosterone receptor.
Rotator cuff tears are indicative of joint instability and respond great to Prolotherapy erectile dysfunction diabetes uk order apcalis sx 20mg mastercard. Injuries to the glenoid labrum can be associated with and can cause instability injections for erectile dysfunction treatment purchase apcalis sx with a mastercard, dislocation impotence natural home remedies buy apcalis sx 20mg cheap, and pain impotence nhs purchase apcalis sx overnight. When the labrum is torn or damaged erectile dysfunction treatment in pune purchase apcalis sx with american express, the shoulder is susceptible to recurrent dislocations zinc causes erectile dysfunction discount apcalis sx 20 mg on-line, subluxation erectile dysfunction doctors in ny cheap 20 mg apcalis sx fast delivery, as well as erectile dysfunction acupuncture purchase 20 mg apcalis sx free shipping, clicking, catching, and locking secondary to partially attached fragments becoming entrapped between the articular surfaces. There are several different types of tears the labrum can sustain and these types are typically categorized based on the lesion location and/or arthroscopic appearance. Mechanisms of injury can include, but are not limited to compression, avulsion, traction, shear, and chronic degenerative changes. The head of the humerus comes into contact with a shallow socket in Figure 6-4: Shoulder instability paradigm. Ligament injury is what the scapula called causes the mechanical instability and proprioceptive deficits that leads to joint mechanical and functional instability (in the shoulder and the glenoid. Prolotherapy should be started first before rehabilitation glenoid labrum is because muscles cannot be adequately strengthened and rehabilitated when the joint they move is unstable. The labrum is distinct from both the fibrous shoulder capsule and the hyaline cartilage of the glenoid. Because the head, or ball, of the humerus is much larger than the glenoid socket, the labrum helps to stabilize the shoulder by increasing the socket depth of the glenoid and providing a point of attachment for the glenohumeral ligaments and the tendon of the long head of the biceps. The labrum has a triangular configuration when viewed in cross section and serves to effectively deepen the glenoid, increasing the stability of the glenohumeral joint. Patients usually report pain with overhead activity and popping, locking, catching, or grinding with movement. Patients will also commonly report a feeling of instability and/or weakness with decreased range of motion. Glenoid labrum tears are especially significant because they are the most common lesion observed in recurrent shoulder dislocations. Similar to the meniscal structure of the knee, the vascular supply to the labrum is greater peripherally than centrally. In short, the blood supply to the glenoid labrum is poor and this is often responsible for glenoid labrum tears not healing. Our glenoid labrum lesion study did show that Comprehensive Prolotherapy eliminated 69% of the symptoms in patients with lesions, primarily tears of the glenoid labrum. The patient-reported assessments were taken 16 months after their5 last Prolotherapy session. Pre-treatment Prolotherapy 10 Post-treatment 22 21 should be the 8 17 treatment of choice 15 for labral tears. For consumption of medications, the ordinate represents the number of medications used or the number of daily scenario in our office pills taken. A better option than corticosteroid injections or anti-inflammatory medications is Prolotherapy because it gets at the root cause of the shoulder pain from labral tears which is instability. When joint instability occurs, the body has three protective mechanisms: engage the muscles, swell the joint, and grow more bone. Notice the cartilage is fairly well preserved Corticosteroid shots and but the large osteophyte on the humeral neck is present. The joint instability without the protection of the joint swelling, which helps brace the joint, puts further pressure on such vital structures in the joint like the articular cartilage. Without resolution of the labral tear, ligament injury, or tendinopathy causing the shoulder instability, the body will eventually overgrow bone to stabilize the joint. This is why long-term labral tears that are not treated lead to shoulder immobility and impingement. So when a patient has waited too long before getting Prolotherapy there are times when even Prolotherapy can only partially resolve the symptoms, and more treatments are typically needed. The supraspinatus tendon is the main abductor and external rotator of the shoulder. The primary role of the rotator cuff is to function as the dynamic and functional stabilizer of the glenohumeral joint. Specifically, the supraspinatus muscle helps seat the humeral head (ball) into the glenoid cavity (socket) when the arm is raised from the side. For the serious athlete or those performing a lot of overhead work, this happens thousands of times, so it is no wonder the supraspinatus tendon becomes injured. Sleeping on the shoulder causes a pinching of the rotator cuff muscles and can lead to rotator cuff weakness. There are cases where the cause of the rotator cuff tendon laxity was due to years of sleeping on the shoulder. In most cases, traditional therapies such as exercise and physical therapy will resolve rotator cuff tendonitis. It is not uncommon, however, for rotator cuff injuries to linger because blood supply to the rotator cuff tendons is poor. In chronic cases of shoulder pain due to rotator cuff weakness, Prolotherapy is the treatment of choice. Prolotherapy will cause the rotator cuff to strengthen and eliminate shoulder pain. As previously stated, the supraspinatus muscle causes shoulder abduction and external rotation. Those who have supraspinatus tendon laxity causing pain will stop moving their arms into the painful position. Although they may not realize it, they are slowly but surely losing shoulder movement. What begins as a simple rotator cuff muscle weakness, easily treated with Prolotherapy, has the potential to become a frozen shoulder because of scar tissue formation inside the shoulder that was left untreated. The scar tissue formation, which causes a decrease in the ability to move the shoulder, is called adhesive capsulitis. The term adhesive capsulitis refers to scar tissue that forms inside the joint due to lack of movement. If a joint is not moved through its full range of motion every day, scar tissue will form inside the joint. Adhesive capsulitis is especially common in stroke victims who are paralyzed on one side, because they 6 are unable to move their shoulders through a full range of motion. Physical therapy modalities, such as myofascial release, massage, range-of-motion exercises, and ultrasound, can often release scar tissue. If these do not relieve the problem, then the scar tissue can be broken up within the joint by the physician injecting the shoulder full of a solution made up of sterile water mixed with an anesthetic. Since the initial cause of the adhesive capsulitis was supraspinatus (rotator cuff) weakness, Prolotherapy injections to strengthen the rotator cuff are done in conjunction with the above technique. Complete to near-complete resolution can be accomplished using this combined approach. This tendon refers pain to the back and side of the shoulder, leading clinicians to believe their patients have a muscle problem, when in fact they have a tendon problem. After the bruising and scrapes healed, she experienced unrelenting pain in her shoulder. She did her best to shower and wash her hair with the other arm, but knew she could not continue to live like this. Kathy tried physical therapy, but it was too painful for her to make it through a whole session. Kathy had known about Prolotherapy for years, and decided to fly to our Chicagoland office. Hauser emphasized that healing her shoulder would be part Prolotherapy and part her dedication to perform the rehabilitation exercises. After only one treatment, she soon started feeling pain relief, enough that she could finally do the recommended exercises that took her the rest of the way to a full recovery. Nearly a year later, Kathy ran smack into a door, with her left shoulder taking the brunt this time. She was aware of the pain all the time and getting through work was becoming more difficult. Her shoulder was becoming more painful and less mobile until she could barely lift her arm. Again, she decided it was overdue for her to just get Prolotherapy and stop living that way. With one treatment to her left shoulder, she was able to return to work without pain and her motion was fully restored. She did just that a few years later when she came in for hip pain, which resolved with only one visit. While the average number of treatments is three to six, some people only need one or two to achieve pain relief! This joint is called the acromioclavicular joint and is noted on the surface of the skin at the apex (top) of the shoulder. When this occurs, the weight of the body is transmitted to the acromioclavicular joint. When these ligaments are injured and become lax, the joint grinds and grates and causes pain. Acromioclavicular ligament laxity causes pain upon lifting or activity involving the hands in front of or across the body. Prolotherapy is extremely effective at strengthening the acromioclavicular ligaments, eliminating the shoulder grinding and chronic shoulder pain from this area. From this little nub of bone, stem some very important structures, Figure 6-8: Prolotherapy of the top of the shoulder. Common including the pectoralis sites of tenderness are marked along the scapular spine, clavicle, minor muscle, and deltoid insertion. This area of the shoulder is palpated during a routine Prolotherapy shoulder examination. Chronic shoulder pain patients are typically very tender in this area and a positive jump sign can be elicited upon palpation. Prolotherapy injections are given to strengthen the fibro-osseous junctions of all the above structures at the coracoid process. Frequent sites of treated to relieve chronic injection are demonstrated, including the coracoid process, shoulder pain. People often develop a bone spur on the clavicle that decreases the space through which the supraspinatus 8 tendon must travel. Occasionally, surgery is needed to give the supraspinatus tendon more room to move. The diagnosis can be easily confirmed in the office by observing a grimaced and painful face upon abducting and internally rotating the shoulder, producing a positive impingement sign. For the few patients who have needed surgery for impingement syndrome after Prolotherapy, the response rate of the combined approach has been excellent. The Prolotherapy has strengthened the rotator cuff tendons and surgery has eliminated the impingement of those tendons, leading to complete relief of the chronic shoulder pain. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves are impinged. We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation), after Prolotherapy. This also included 39% of patients in a sub-group who were told by their medical doctors that there were no other treatment options for their pain and 21% who were told that surgery was their only option. Over 82% of all patients experienced improvements Prolotherapy Shoulder Study Results in sleep, exercise ability, All No Other Surgery anxiety, depression, and Demographics Shoulder Treatment Only overall disability with Patients Option Option Prolotherapy. Remember, these studies were conducted on people who did not have any symptoms of shoulder pain. It is imperative that an evaluation be done by a Prolotherapist because diagnostic tests can often lead a clinician astray. Upon physical exam, we have found that the tear truly is not a complete tear, making Prolotherapy an ideal option in place of surgery. If left untreated, this supraspinatus tendon laxity leads to adhesive capsulitis, or frozen shoulder. The best diagnostic procedure for chronic shoulder pain is palpation of the structure, causing a positive jump sign, and relief of the pain immediately after the structure is treated with Prolotherapy. Prolotherapy is the treatment of choice for chronic shoulder pain because it corrects the underlying weakness causing the pain. Remember, removing any tissue that God has put in the body will have a consequence. That consequence is often joint instability, the primary cause of chronic pain and degenerative arthritis of the knee. The tissues most commonly removed during arthroscopic surgery in the knee are parts of the meniscus and the articular cartilage. Both of these structures are needed by the body to help the femur bone glide smoothly over the tibia. Eventually, whatever meniscus or articular cartilage is left after the arthroscopic surgery is worn away. Once this occurs, bone begins rubbing against bone and proliferative arthritis begins. After a course of cortisone shots, nonsteroidal anti-inflammatory drugs, and several trials of physical therapy, the patient is again under the knife, this time for a knee replacement. Once an arthroscope touches the knee, the chance of developing arthritis in the knee tremendously increases. This is because surgery, especially when any tissue is removed, increases joint instability. Before letting an arthroscope touch you, it is imperative to have an evaluation by a physician familiar with Prolotherapy. Prolotherapy will begin collagen formation both outside and inside the knee joint depending on the structure(s) that are 1 injected. Surgery in the knee is appropriate when a ligament is Lateral & medial Articular femoral condyles cartilage completely torn, such Posterior as would occur from cruciate a high-velocity injury. Synovial fuid ligament Prolotherapy is only Anterior cruciate Medial ligament meniscus helpful to regrow ligaments if both ends Lateral Medial aspect aspect of the ligament remain attached to bone. Lateral Medial Remember, 98% of meniscus collateral ligament ligament injuries are Lateral collateral partial tears for which Tibia ligament Prolotherapy would be helpful. Numerous studies have shown Inferior aspect Prolotherapy is an effective treatment Figure 7-1: Anterior aspect of the right knee. It is no longer acceptable for a physician who treats chronic pain to say that he or she has not heard of Prolotherapy or that there is not evidence for its effectiveness! More than 82% of patients also showed improvement in walking ability, medication usage, athletic ability, depression, and overall disability due to Prolotherapy treatment. The average patient reported pain for an average of 5 years prior to Prolotherapy. Additionally, 2 out of 5 patients were taking at least one pharmaceutical pain medication. The population represented chronic, and often hopeless, cases who had exhausted the traditional medicine system. This reinforced what we see everyday in our clinic: quality of life can be drastically improved with Prolotherapy! This can be due to a number of ligaments and tendons attachments becoming torn or degenerated, as well as damaged or removed cartilage and meniscal tissue. It is also important to understand the Pain Levels Before and After Prolotherapy referral patterns of knee ligaments that can trigger pain sensations further down the leg and into the foot. The medial collateral ligament refers pain down the leg to the big toe and the lateral collateral ligament refers pain to the lateral foot. Figure 7-2: Starting and ending pain levels before and after receiving Hackett-Hemwall dextrose Prolotherapy in 80 the ligaments patients (119 knees) with unresolved knee pain. These ligaments help stabilize the knee, preventing excessive forward and backward movement. If these ligaments are loose, even in a young person, degenerative arthritis begins to form. The feeling of a loose knee is reason enough to suspect a cruciate ligament injury.
Osteoblastoma is a benign bone-forming neoplasm male impotence 30s purchase 20mg apcalis sx visa, which is closely related to osteoid osteoma elite custom erectile dysfunction pump proven 20 mg apcalis sx. However erectile dysfunction band order apcalis sx 20mg line, remember that osteoblastoma is characterized by a larger size (more than 1 erectile dysfunction causes in young men purchase apcalis sx 20mg overnight delivery. Other important entity in the differential diagnosis is intracortical osteosarcoma erectile dysfunction zinc deficiency trusted 20 mg apcalis sx. Look for the presence of significant nuclear atypia and invasive growth pattern indicative of malignancy erectile dysfunction 19 years old apcalis sx 20 mg with amex. Characteristic Radiological Findings: q Plain radiograph shows a well circumscribed impotence specialists 20 mg apcalis sx overnight delivery, low metaphyseal erectile dysfunction due to drug use buy apcalis sx pills in toronto, radiolucent lesion containing matrix type radiodensities. Osteoblasts and osteoclast-like giant cells rim interconnected spicules of osteoid and woven bone. Diagnosis: Osteoblastoma Salient Points (Benign Osteoblastoma and Aggressive Osteoblastoma):: q Osteoblastoma is a rare bone-producing neoplasm that closely resembles osteoid osteoma on microscopic examination. Although any bone may be involved, osteoblastomas tend to arise in the axial skeleton, involving the spine and the sacrum in about 40% of cases. Unlike osteoid osteomas, osteoblastomas do not produce prostaglandin/prostocyclin mediated tissue reaction. But in contrast to osteosarcoma, the tumor shows no atypical mitoses and no evidence of infiltrative growth, or sarcomatous stromal changes. Osteoblastomas may grow to a considerable size and produce bone expansion and cortical destruction. Mosby, Inc, 1998 Available publications for the topic: Osteoblastoma Selected References:: 1. Characteristic Radiological Findings q Plain radiograph shows an ill-defined destructive tumor in the distal femur. Diagnosis: Osteosarcoma, high grade Salient Points: q Osteosarcoma is the most common primary sarcoma of bone. The peak incidence is in the second decade of life during the period of the most active skeletal growth. In adolescents and young adults, osteosarcoma preferentially affects the most rapidly growing parts of the skeleton: the distal femur and proximal tibia (50% of cases), and the proximal humerus. Based on the location within the bone, osteosarcomas are subdivided into intarmedullary, intracortical and surface osteosarcomas. Intramedullary, or central, tumors comprise the largest group and include conventional high-grade osteosarcoma, which accounts for about 90% of all osteosarcomas, and less common types such as well-differentiated (or low-grade) osteosarcoma, chondroblastic, small cell, and teleangiectatic osteosarcoma. Based on the degree of differentiation, osteosarcomas are subclassified into high-grade and low-grade. Osteosarcoma is defined as a malignant tumor composed of neoplastic mesenchymal cells synthesizing osteoid or immature bone. Remember that the presence of malignant osteoid distinguishes an osteosarcoma from other sarcomas. Characteristically, the neoplastic cells fill the spaces between the osteoid deposits and often become entrapped in osteoid. This is very different from the reactive bone pattern, where the bone trabeculae are separated by a fibrovascular stroma. In general, low-grade osteosarcoma should be differentiated from benign bone-producing tumors (osteoblastoma), whereas a high-grade osteosarcoma must be differentiated from other sarcomas. When you choose between benign and malignant, look for the permeative growth pattern, cellular atypia, and mitotic activity. In osteosarcoma, they are filled with the aggregates of malignant mesenchymal cells. The pattern of osteoid deposition is orderly in benign tumors and haphazard or lace-like in osteosarcoma. When you choose between an osteosarcoma and other types of sarcoma, look for malignant osteoid produced directly by mesenchymal cells. The most powerful predictor of outcome is the histologic response of the tumor to pre-operative chemotherapy. Grade 1 0% to 50% necrosis; Grade 2 51% to 90%, Grade 3 91% to 99%, and Grade 4 100% necrosis. Recent studies have shown frequent over-expression of Her2/neu by osteosarcoma and its correlation with a significantly worse histologic response to pre-operative chemotherapy and shorter event-free survival. Its role in the pathogenesis of osteosarcoma remains unclear Available publications for the topic: Osteosarcoma, high grade Selected References. Onda M, Matsuda S, Higaki S, et al: ErbB-2 expression is correlated with poor prognosis for patients with osteosarcoma. Further study of medical terminology, however, is crucial to understanding medicine, and represents a large part of surgical assistant training curriculum. Successful completion of surgical procedures requires the surgeon and the assistant to accurately and efficiently navigate the steps in the proper sequence, and often in unison. Anatomic orientation terminology provides a key language for this communication. Which of the following most accurately describes the movement of the operative thumb (which direction it points) as you carry out the instructions The Lymphatic System: the arrangement of anatomic structures in the body support the physiologic function of the organ systems. These organ systems include the: musculoskeletal; cardio-pulmonary; circulatory; nervous; digestive; endocrine; excretory; reproductive; sensory; integumentary; and immune systems. Surgical procedures in one region impact all the body systems to a greater or lesser degree. For this reason, the surgical assistant is well-served to carry a fundamental understanding of the physiology within each organ system, its anatomic locations/s in the body, and be ever vigilant to correctly identify organ system structures. Avoiding or minimizing traumatic impact to structures peripheral to the procedure at hand, minimizes unnecessary mortality and morbidity of the case. The Musculoskeletal system: Skeletal anatomy must be committed to memory, including the skull, spine, and distal extremities. Tubercles, tuberosities, fossae, canals, and fissures represent important features relative to connective tissue attachment, vascular supply, bone growth, and bone marrow function. Joint alignment, articular cartilage, and soft tissue support; as well as muscular insertions, origins, and innervations; and principle including agonist/antagonist pairing should be studied. Such understanding underpins the importance for the identification and preservation of normal anatomy during surgery. Muscle Physiology: Muscle tissues throughout the body, including striated, smooth, and cardiac muscle types operate via myofibril motor units activated by nerve impulse and neurotransmitter action. Acetylcholine release and reuptake represents one key biochemical step in muscle metabolism and may be acted on by anesthetic agents used in the operating room. Another point of pharmaceutical intervention comes from the calcium ion and potassium ion exchange following contraction. Lactic acid build up in muscles becomes a potential issue for patients who have not been moved during very long procedures. A working knowledge of the blood supply to all organs, extremities, and tissues remains paramount to surgical success. Arteries, arterioles, capillaries, venules, and veins all have distinct properties and require specific handling. A working knowledge of this anatomy, as well as vascular tissue handling techniques, optimizes surgical success. Deliberate and permanent hemostasis for resection procedures also require precise planning and excellent technique. One measure of this phenomenon is shear rate, defined as the local velocity gradient between adjacent blood flow. Shear rate, incidentally, has also been shown to be one of the main regulators of platelet activation and thrombosis. This basic understanding underpins the necessity for resecting aneurismal tissue with meticulous care. The Cardio-Pulmonary System: Cellular function throughout the tissues and organs of the body rely on the delivery of oxygen and nutrients, and facilitation of cellular waste removal. Osmotic forces maintained at the cellular level, and physiologic safeguards such as vasodilation and vasoconstriction, preserve the integrity of the closed circulatory loop. Patient blood volume, blood pressure, oxygen saturation, and cardiac function must be protected. Which of the following cardio-pulmonary conditions may responsible and require urgent surgery For the surgical assistant, however, an in-depth knowledge of neuroanatomy from a procedure specific regional approach is also paramount. Careful study of the cranial nerves and their function provides a surgical assistant the ability for high-level communication with the surgeon on the potential complications of misidentification of structures especially in head and neck procedures. The spinal nerves, their dorsal and ventral roots, and their exit points along the spinal canal must be protected. On the front end of many surgical procedures, identification of these nerve structures must be accomplished with certainty. From the esophagus, through the diaphragm, and at numerous points along the alimentary canal, commonly performed surgical procedures address acute and chronic G. Access to each area of the abdomen, therefore, must be carefully planned and executed. Constant proactive prevention of intra-operative injury and post-operative surgical adhesions represent a skillset retained by the competent surgical professional. An in-depth study of microscopic anatomy and physiology of the digestive system should also be undertaken. This fundamental understanding underpins the necessity for adherence to proper technique. Furthermore, crucial production of digestive enzymes, hormones and chemical messengers are carried out in the pancreas, liver, and cells within the epithelial layers of the G. I tract itself and must be maintained to facilitate normal digestion of nutrients. Hormones are distributed by glands through the bloodstream and carry widespread, long-lasting, and powerful effects on cells of organs and tissues throughout the body. Careful study of the anatomy, function, control, and hormones produced by these glands must be undertaken. Surgery on these areas, furthermore, carry significant risk to vital structures adjacent to the glands themselves, thus intraoperative identification of structures is key. Minimally 21 invasive approaches often improve outcomes, but also add complexity to these procedures. By default, gross anatomy of the pelvis becomes critical, including skeletal structures and landmarks, innervation and vascular supply, and the extremely relevant pelvic floor. Pelvic systems and structures must be studied by the competent surgical assistant, especially with regard to female reproductive procedures. There are organ systems of the body that are involved in this process such as sweat glands, lungs, and the kidneys. The liver plays an important role as well, in detoxifying metabolites for excretion elsewhere. Sweat glands actively excrete lactic acid, urea, as well as various salts, pulling water from the tissues. Alveolar structure within 24 the lungs facilitate carbon dioxide and other toxic gases release from hemoglobin, as well as the uptake of oxygen. One of the most important functions of the kidney is the filtration and excretion of nitrogenous waste products from the blood. Through a complex physiologic process, the kidney nephron also maintains blood pH, regulates water content in blood, and therefore further affects systemic blood volume and blood pressure. Thorough knowledge of kidney anatomy, the urinary system, and normal blood chemistry and osmotic forces involved in excretion are necessary for complete understanding of this complex process. An adult body contains around 10 liters of lymph, consisting of salts, sugars, amino acids, hormones, coenzymes, neurotransmitters, fatty acids and the metabolic waste products. Movement of lymph occur through peristalsis, and muscular action of surrounding tissues. Blood components do not come in direct contact with the tissue cells, but must exit the blood vessels and pass into the interstitial lymphatic fluid. The lymph then carries out cellular exchanges, and subsequently carry materials which do not re-enter the blood stream through the lymphatic vessels, through plexi and lymph nodes before entering the large lymphatics trunks for ultimate collection and drainage to the subclavian vein. Removal of the entire downstream chain of lymph nodes may be performed to eliminate further lymphatic spread. Which of the following statement most accurately describes a Sentinel lymph node biopsy Mastery of surgical anatomy requires being fully cognizant of the anatomical structures next to , adjacent to , and especially deep to , the immediate operative site. Understanding anatomic relations is key to individuals providing exposure for their surgeons. The Skin: the simplest rule for making incisions in the most favorable direction is to follow natural folding lines: Proper incisions come together naturally, and improper ones tend to gape. Palpation of underlying structures enable surgeons to effectively plan incision sites. Surgical assistants must become familiar with these landmarks, especially as they relate to incision sites, patient positioning and padding, graft harvest, and grounding pad placement in conjunction with the use of electrocautery. Skin must be properly protected during procedures, and anatomically re-approximated at closure. Head and Neck: Head and neck surgical anatomy presents a significant challenge to prospective students. Knowledge of the cranial nerves, their locations, and the structures they innervate are extremely important. The more common surgical sites to know surgical anatomy for include the eyes, the face, the neck, and the anterior and posterior spine. The surface anatomy of the neck should be known, and the anatomical triangles of the neck offer excellent focal points for detailed study. The carotid arteries, the thyroid and parathyroid glands, parotid glands, anterior trachea, lymphatic pathways, and myriad other neurovascular structures in this region should be studied in detail. Access to the chest cavity, pleural cavity, pericardium, mediastinum, and to the thoracic spine require precise structure identification. All structures within are vital to life, and crucial for the assistant to commit to memory. Endoscopic approaches and especially robotic procedures have raised the anatomical bar, and require in depth anatomical knowledge for identification of structures on a minute scale. The Heart: Open heart surgical procedures have steadily increased in numbers, and have become important professional avenues for the surgical assistant. Assisting in bypass procedures requires a more extensive familiarity with structures in the thoracic cavity. The Mediastinum: the mediastinum lies within the thorax and is enclosed laterally by pleurae. It is bordered by the chest wall anteriorly, the lungs laterally, the spine posteriorly, and contains all the organs of the thorax except the lungs. It is continuous superiorly with the loose connective tissue of the neck, and extends inferiorly to the thoracic surface of the diaphragm. An assistant should recognize the varied abdominal surgical incisions used in different surgical scenarios. Ideally an incision should provide easy access to the desired structures, heal quickly, and minimize scarring. Abdominal musculature should not be transected, but split, if possible and the incision should be amenable to extension if required. A complete understanding of the abdominal wall facilitates the required planning to achieve optimal results. Much of the digestive tract, and reproductive tract (in women) occupy the peritoneal space, and therefore warrant careful consideration here. In the retroperitoneal space, dwells the great vessels and lymphatic chain, and urinary system. Most every structure within the abdominal cavity is important with respect to surgical anatomy. A surgical assistant must understand the visceral arterial supply, the portal circulation, the biliary tree, the contents of the greater and lesser sac, as well as the genitourinary system in the pelvis. Many of the structures are covered by peritoneum, but are accessible through open abdominal procedures, transvaginal access, laparoscopy, and robotic assisted procedures. Patient positioning and incision site placement dictate visualization and identification of vital structures. Preperitoneal and retroperitoneal spaces may be also accessed through the abdominal wall. Robotic-assisted pelvic dissections bring new levels of detail into view, enabling much better resolution of crucial pelvic innervation identification and preservation.
Order apcalis sx 20mg free shipping. Dr. David Samadi - Erectile Dysfunction (ED) Pills – Identify Fake vs. Real Medication.
