By L. Sugut. Grantham University.

At birth buy albenza 400 mg low cost medicine you can give dogs, the lungs undergo the transition from a fluid-filled organ to an air-filled organ for gaseous exchange purchase albenza 400 mg with amex treatment 3rd metatarsal stress fracture. In order to overcome surface active forces and fully expand the lungs, the neonate must generate negative intrathoracic pressures of up to 70 cm H2O. Because neonatal oxygen consumption is two to three times that of the adult, respiratory rate must be increased proportionally. In infants less than 3 weeks of age, hypoxia initially stimulates ventilation, followed by a decrease in ventilation. Large surface area, poor insulation, a small mass from which heat is generated, and inability to shiver place newborn at a disadvantage for maintaining temperature. Catecholamine-stimulated nonshivering thermogenesis (brown fat metabolism) may cause such complications as elevated pulmonary and systemic vascular resistance and higher O2 consumption with resultant stress on the newborn heart. Securing the airway may also involve a cooperative effort between the surgeon and the anesthesiologist. To avoid fires, delivered oxygen concentration should be kept as low as possible when electrocautery is being used. Procedures involving the larynx, trachea and bronchi necessitate the greatest anesthetic depth to prevent airway hyperreactivity. In children with airway edema or foreign body, inhalation agents may improve bronchodilation and decrease airway reactivity. In children with airway emergencies an inhalation induction allows for continuous maintenance of spontaneous ventilation and delivery of high concentration of oxygen. An intravenous induction is appropriate for removal of esophageal foreign body or airway lesions without airway compromise but with high risk of aspiration. Intravenous induction may also be used for upper airway obstruction when mask ventilation may be very difficult but uneventful intubation is anticipated. Intravenous agents such as propofol may also be beneficial adjuncts to primarily inhalational anesthetics. Commonly anticipated complications include airway edema or obstruction, bleeding, and nausea and vomiting. Otherwise, muscle relaxation during rigid bronchoscopy is an excellent method of preventing coughing or bucking on the bronchoscope which could cause the life-threatening complication 13 of bronchial rupture. Use of 100% oxygen while the bronchoscope is in the trachea offers a margin of reserve against possible hypoxia. Hypercapnia frequently occurs because passive ventilation is difficult with the high airway resistance caused by the narrow bronchoscope. High flows may be necessary if there is much discrepancy between the size of the bronchoscope and the size of the trachea. On the other hand, if there is a tight fit, air trapping and “stacking” of ventilation (lungs unable to completely deflate prior to the next inflation) can lead to pneumothorax or impede venous return. For children spontaneous or assisted ventilation through a ventilating bronchoscope is preferred to jet ventilation because of the risk of barotraumas and air trapping. If jet ventilation is used, limit delivered pressure and place a hand on the chest to detect “stacking”. At the end of procedure an anesthesia mask can be used for emergence but intubation is preferred in the presence of airway compromise, edema, blood or secretions. Laser excision of lesions in the lower airway is accomplished under direct vision using the carbon dioxide laser. If it is a cuffed tube, the cuff is filled with methylene blue so that if the balloon is lasered it will be immediately obvious. In older children an inhalation induction with maintenance of spontaneous ventilation is usually advocated. Cricothyrotomy may become necessary in emergent situations (such as a foreign body inextricably stuck partly through the cords). Percutaneous transtracheal jet ventilation is frequently advocated as the system of choice for emergency ventilation. The rapid delivery of high-pressure oxygen to the lungs of an infant could result in barotrauma and pneumothoraces. It may be safer to ventilate more gradually using anesthesia circuit despite the risk of hypercapnea, until tracheostomy can be performed. Indications for tracheostomy in children include chronic airway obstruction/laryngomalacia, bilateral vocal cord palsy, pulmonary toilet when chronic ventilator support is required, as part of major head and neck surgery, to urgently secure airway after cricothyrotomy, rarely for prolonged ventilation. When caring for children with tracheostomies, there should always be an extra tracheostomy tube available since tubes with such small lumens can easily become obstructed by tenacious secretions. Tracheostomy in infants is performed as a last resort since it is associated with such a high mortality.

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The femoral vein lies medial buy 400mg albenza free shipping medicine 751, and the femoral nerve lat- hallucis longus and extensor digitorum are visible on the anterior eral albenza 400mg online symptoms enlarged prostate, to the artery at this point. The hernial sac always lies below and • Passing behind the medial malleolus lie: the tendons of tibialis pos- lateral to the pubic tubercle (cf. The tendon of peroneus brevis inserts onto the tuberosity on • The sciatic nerve has a curved course throughout the gluteal region. Consider two linesaone connects the posterior superior iliac spine and • The heel is formed by the calcaneus. The tendocalcaneus (Achilles) the ischial tuberosity and the other connects the greater trochanter and is palpable above the heel. The division of the sciatic nerve into tibial and • The tuberosity of the navicular can be palpated 2. The tendon of tibialis posterior lies above the sustentaculum tali • The common peroneal nerve winds superficially around the neck of and the tendon of flexor hallucis longus winds beneath it. Footdrop can • The dorsalis pedis pulse is located on the dorsum of the foot be- result from fibular neck fractures where damage to this nerve has tween the tendons of extensor hallucis longus and extensor digitorum. The • The patella and ligamentum patellae are easily palpable with the small saphenous vein drains the lateral end of the arch and passes pos- limb extended and relaxed. The ligamentum patellae can be traced to its terior to the lateral malleolus to ascend the calf and drain into the attachment at the tibial tuberosity. The great saphenous vein passes anterior to the medial • The adductor tubercle can be felt on the medial aspect of the femur malleolus to ascend the length of the lower limb and drain into the above the medial condyle. This vein can be accessed consistently by ‘cutting down’ • The femoral and tibial condyles are prominent landmarks. With the anterior to, and above, the medial malleolus following local anaesthe- knee in flexion the joint line, and outer edges of the menisci within, are sia. Surface anatomy of the lower limb 119 53 The autonomic nervous system Visible Sympathetic Parasympathetic Sympathetic ganglion Cranial outflow 3, 7, 9, 10/11 Parasympathetic T1 Spinal cord Microscopic ganglion Fig. The former initiates the ‘fight or flight’ reac- ramus and are then distributed with the branches of that nerve. B They may pass to adjacent arteries to form a plexus around them Both systems have synapses in peripheral ganglia but those of the sym- and are then distributed with the branches of the arteries. Other pathetic system are, for the most part, close to the spinal cord in the gan- fibres leave branches of the spinal nerves later to pass to the arter- glia of the sympathetic trunk whereas those of the parasympathetic ies more distally. The fibres leave these spinal nerves as the white rami Loss of the supply to the head and neck will produce Horner’s syn- communicantes and synapse in the ganglia of the sympathetic trunk. There will be loss of sweating (anhidrosis), drooping of the • Parasympathetic outflow: this comprises: upper eyelid (ptosis) and constriction of the pupil (myosis) on that side. The trunk constrictor pupillae and the ciliary muscle, synapsing in the ciliary continues upwards into the carotid canal as the internal carotid nerve. Synapses occur in minute ganglia in the cardiac and pulmonary 2 They may pass straight through the corresponding ganglion and travel plexuses and in the walls of the viscera. One exceptional group of supply the pelvic viscera, synapsing in minute ganglia in the walls of fibres even pass through the coeliac ganglion and do not synapse the viscera themselves. Region Origin of connector fibres Site of synapse Sympathetic Head and neck T1–T5 Cervical ganglia Upper limb T2–T6 Inferior cervical and 1st thoracic ganglia Lower limb T10–L2 Lumbar and sacral ganglia Heart T1–T5 Cervical and upper thoracic ganglia Lungs T2–T4 Upper thoracic ganglia Abdominal and pelvic T6–L2 Coeliac and subsidiary ganglia viscera Parasympathetic Head and neck Cranial nerves 3, 7, 9, 10 Various parasympathetic macroscopic ganglia Heart Cranial nerve 10 Ganglia in vicinity of heart Lungs Cranial nerve 10 Ganglia in hila of lungs Abdominal and pelvic Cranial nerve 10 Microscopic ganglia in walls of viscera viscera (down to transverse colon) S2, 3, 4 Microscopic ganglia in walls of viscera The autonomic nervous system 121 54 The skull I Coronal suture Parietal Squamous Frontal temporal Sphenoid, greater wing Ethmoid Lambda Lacrimal Metopic suture (uncommon) Occipital Supraorbital foramen Nasal Position of frontal air sinus Zygomatic Maxilla Frontal External Ethmoid auditory meatus Lacrimal Orbital plate External occipital of frontal Styloid Optic canal Sphenoid, protuberance process Superior lesser wing Fig. The bones are the frontal, parietal, occipital, squamous temporal and the greater wing of the sphenoid. The bones are The vault of the skull separated by sutures which hold the bones firmly together in the mature • The vault of the skull comprises a number of flat bones, each of skull (Figs 54. Occasionally the frontal bone may be separated which consists of two layers of compact bone separated by a layer of into two halves by a midline metopic suture. The anterior, middle and posterior cranial fossae are coloured green, red and blue respectively • There are a number of emissary foramina which transmit emissary • Foramen rotundum (Maxillary branch of trigeminal nerve) veins. These establish a communication between the intra- and extra- • Foramen ovale (Mandibular branch of trigeminal nerve) cranial veins. The interior of the base of the skull comprises the anterior, middle and • In the midline is the body of the sphenoid with the sella turcica on posterior cranial fossae (Fig. The remainder consists of the bones that were seen in the • Foramen ovale (already described) middle and posterior cranial fossae but many of the foramina seen on • Other features: the exterior are not visible inside the cranium. It then opens into the posterior wall • Jugular foramen (already described) of the foramen lacerum before turning upwards again to enter the • Foramen lacerum (the internal carotid through its internal opening) cranial cavity through the internal opening of the foramen. Each • Mental (Mental nerve) ramus divides into a coronoid process and the head, for articulation • Greater and lesser palatine foramina (Greater and lesser palatine with the mandibular fossa. Parasympathetic fibres are shown in orange Superior orbital Superior fissure Cavernous Trochlear oblique sinus nerve Abducent nerve Lateral Internal rectus carotid Petrous artery temporal Fig.

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The pediatric bedpan • Are small sized • Usually made of a plastic Offering and Removing Bed Pan • If the individual is weak or helpless order albenza 400 mg without a prescription treatment quad strain, two peoples are needed to place and remove bed pans • If a person needs the bed pan for a longer time periodically remove and replace the pan to ease pressure and prevent tissue damage • Metal bed pans should be warmed before use by: o Running warm water inside the rim of the pan or over the pan o Covering with cloth • Semi-Fowler’s position relieves strain on the client’s back and permits a more normal position for elimination Improper placement of the bedpan can cause skin abrasion to the sacral area and spillage o Place a regular bed pan under the buttocks with the narrow end towards the foot of the bed and the buttocks resting on the smooth buy albenza 400 mg without prescription symptoms 20 weeks pregnant, rounded rim o Place a slipper (fracture) pan with the flat, low end under the client’s buttocks o Covering the bed pan after use reduces offensive odors and the clients embarrassment Basic Nursing Art 41 If the client is unable to achieve regular defecation help by attending to: 1. Timing – do not ignore the urge to defecate • A patient should be encouraged to defecate when the urge to defecate is recognized • The patient and the nurse can discuss when mass peristalsis normally occurs and provide time for defecation (the same time each day) 3. Nutrition and fluids For a constipated client: increase daily fluid intake, drink hot liquids and fruit juices etc For the client with diarrhea – encourage oral intake of foods and fluids For the client who has flatulence: limit carbonated beverages; avoid gas- forming foods 4. Exercise • Regular exercise helps clients develop a regular defecation pattern and normal feces 5. Positioning • Sitting position is preferred 3 Measures to assist the person to void include: • Running water in the sink so that the client can hear it • Warming the bed pan before use • Pouring water over the perineum slowly • Having the person assume a comfortable position by raising the head of the bed (men often prefer to stand) • Providing sufficient analgesia for pain Basic Nursing Art 42 • Having the person blow through a straw into a glass of water – relaxes the urinary sphincter Perineal Care (Perineal – Genital Care) Perineal Area: • Is located between the thighs and extends from the top of the pelvic bone (anterior) to the anus (posterior) • Contains sensitive anatomic structures related to sexuality, elimination and reproduction Perineal Care (Hygiene) • Is cleaning of the external genitalia and surrounding area • Always done in conjunction with general bathing Patients in special needs of perineal care • Post partum and surgical patients (surgery of the perineal area) • Non surgical patients who unable to care for themselves • Patients with catheter (particularly indwelling catheter) Other indications for perineal care are: 1. Excessive secretions or concentrated urine, causing skin irritation or excoriation 4. Care before and after some types of perineal surgery Purpose • To remove normal perineal secretions and odors • To prevent infection (e. Patient preparation • Give adequate explanation • Provide privacy • Fold the top bedding and pajamas (given to expose perineal area and drape using the top linen. Cleaning the genital area • Put on gloves For Female • Remove dressing or pad used • Inspect the perineal area for inflammation excoriation, swelling or any discharge. In case of post partum or surgical pt • Clean by cotton swabs, first the labia majora then the skin folds between the majora and minora by retracting the majora using gauze squares, clean from anterior to posterior direction using separate swab for Basic Nursing Art 44 each strokes. In case of non-surgical pts • Wash or clean the genital area with soapy water using the different quarters of the washcloth in the same manner. Female Perineum • Is made up of the vulva (external genitalia), including the mons pubis, prepuce, clitoris, urethral and vaginal orifices, and labia majora and minora • The skin of the vaginal orifice is normally moist • The secretion has a slight odor due to the cells and normal vaginal florae • The clitoris consists of erectile tissues and many nerves fibers. Is very sensitive to touch Care • Convenient for a woman to be on a bed pan to clean and rinse the vulva and perineum • Secretion collects on the inner surface of the labia • Use on hand to gently retract the labia • Use a separate section of wash cloth for each wipe in a downward motion (from urethra to back perineum) • Then clean the rectal area Note • Following genital or rectal surgery, sterile supplies may be required for cleaning the operative site, E. Hair care includes combing (brushing of hair), washing/shampooing of hair and pediculosis treatment. Equipments • Comb (which is large with open and long toothed) • Hand mirror • Towel • Lubricant/oils (if required) Procedure 1. Comb the hair by dividing the hair • Hold a section of hair 2-3 inches from the end and comb the end until it is free from tangles. Documentation Shampooing/Washing the Hair of Patient Confined to Bed Purpose • Stimulate blood circulation to the scalp through massaging • Clean the patients hair so it increase a sense of well-being to the pt Equipments • Comb and brush • Shampoo/soap in a dish • Shampoo basin • Plastic sheet • Two wash towels • Cotton balls • Water in basin and pitcher • Receptacle (bucket) to receive the used water • Lubricants/oil as required Procedure 1. Prepare the patient • Assist patient to move to the working side of the bed • Remove any hair accessories (e. Shampooing/washing the hair • Wet the hair thoroughly with water • Apply shampoo (soap) to the scalp. Documentation and reporting Pediculosis Treatment Purpose • To prevent transmission of some arthropod born diseases • To make patient comfortable Definition Pediculosis: infestation with lice Lice: • Are small, grayish white, parasitic insects that infest mammals • Are of three common kinds: ¾ Pediculose capitis: is found on the scalp and tends to stay hidden in the hairs ¾ Pediculose pubis: stay in pubic hair ¾ Pediculose corporis: tends to cling to clothing, suck blood from the person and lay their eggs the clothing suspect their presence in the clothing if: a. There are hemorrhagic spots in the skin where the lice have sucked blood Head and body lice lay their eggs on the hairs then eggs look like oval particles, similar to dandruff, clinging to the hair. Kerosene Oil mixed with equal parts of sweet oil • Destroys both adult lice and eggs of nits • From aesthetic point of view, kerosene causes foul smell and create discomfort to patient and the attendant Guidelines for Applying Pediculicides Hair: • Apply pediculicide shampoo to dry hair until hair is thoroughly saturated and work shampoo in to a lather • Allow product to remain on hair for stated period (varies with products) • Pin hair and allow to dry • Use a fine toothed comb to remove death lice and nits (comb should not be shared by other family members) • Repeat it in 8-10 days to remove any hatched nits • Apply pediculious lotion (or cream) to affected areas • Bath after 12 hrs and put on clean clothes 3. Oil of Sassafras • Is a kind of scented bark oil • Only destroy lice not nits • For complete elimination, the oil should be massaged again after 10 days when the nits hatch • Is used daily for a week with equal parts of Luke warm H2O then it should be repeated after a week 4. Gcmmaxine (Gamma Bengenhexa Chloride) Basic Nursing Art 51 • Emphasize the need for treatment of sexual partner • After complete bathing wash linen available as a cream, lotion, and a shampoo • 1. However, many peoples, because of weakness, immobility and/or one or both upper extremities are unable to feed themselves all or parts of the meal. Therefore, the nurse must be knowledgeable, sensitive and skillful in carrying out feeding procedures. Purpose • To be sure the pt receives adequate nutrition • To promote the pt well-beings Procedure 1. Prepare pt units • Remove all unsightly equipments; remove solid linens and arranging bedside tables. Basic Nursing Art 52 • Control unpleasant odors in the room by refreshing the room. Lab, radiologic examination or surgery) • Assess any cultural or religious limitations, specific likes or dislikes. Feed the patient • Place the food tray in such a way that the patient can see the food. Comfort patient • Assist hand washing and oral care Basic Nursing Art 53 • Offer bedpan and commodes, of indicated • Comfort patient, provide quite environment so that the pt may relax after meal, which also promote good digestion. Objective Symptoms (signs): Are symptoms, which could be seen by the health personnel? Charting Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy Basic Nursing Art 56 Purpose of Patients Chart a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time b. For serving an information in the education of health personnel (medical students, interns , nurses, dietitians, etc) e.

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Endarterectomy The surgical removal of plaque from a blocked artery to restore blood flow buy albenza 400 mg on-line treatment of diabetes. A flexible nasendoscope is inserted through the nose to the throat to observe swallowing buy albenza 400 mg on line medicine 1900s spruce cough balsam fir. A screen designed to identify patients with dysphagia and reduce the risk of aspiration. A measure of the clotting ability of blood, usually following use of anticoagulant drugs. It is calculated as the ratio of the length of time it takes blood to clot over the time it would take the blood of a normal subject to clot. Intracranial A bleed in the brain as a result of a ruptured or bleeding blood vessel. Meta-analysis A statistical technique for combining (pooling) the results of a number of studies that address the same question and report on the same outcomes to produce a summary result. Methodological Features of the design or reporting of a clinical study which are known to limitations be associated with risk of bias or lack of validity. Where a study is reported in this guideline as having significant methodological limitations, a recommendation has not been directly derived from it. A screening tool comprising 5 steps which help identify which adults are malnourished or at risk of malnourishment. Null hypothesis The ‘no difference’ or ‘no association’ hypothesis that can be tested against an alternative hypothesis that postulates a difference or association that is non-zero. Observational study Retrospective or prospective study in which the investigator observes the natural course of events with or without control groups, for example cohort studies and case-control studies. The odds of an event happening in the treatment group, expressed as a proportion of the odds of it happening in the control group. Open-label study In the context of study design, a study in which the physicians or investigators are not blinded to which patients are allocated to which treatment arm. A gastroscope is used to insert a tube through the wall of the abdomen into the stomach. Quality of life Refers to the level of comfort, enjoyment and ability to pursue daily activities. A trial in which people are randomly assigned to two (or more) groups: one (the experimental group) receiving the treatment that is being tested, and the other (the comparison or control group) receiving an alternative treatment, a placebo (dummy treatment) or no treatment. The two groups are followed up to compare differences in outcomes to see how effective the experimental treatment was. Sensitivity The proportion of individuals classified as positive by the gold or reference standard, who are correctly identified by the study test. Sensitivity analysis A measure of the extent to which small changes in parameters and variables affect a result calculated from them. Specialist A clinician whose practice is limited to a particular branch of medicine or surgery, especially one who is certified by a higher medical educational organisation. Specificity The proportion of individuals classified as negative by the gold (or reference) standard, who are correctly identified by the study test. Stakeholder Any national organisation, including patient and carers’ groups, healthcare professionals and commercial companies with an interest in the guideline under development. Statistical A result is deemed statistically significant if the probability of the result significance occurring by chance is less than 1 in 20 (p<0. Stenting A metal mesh tube is placed in an artery or blood vessel to increase blood flow to an area blocked by stenosis. Stroke The damaging or killing of brain cells starved of oxygen as a result of the blood supply to part of the brain being cut off. Types of stroke include Ischaemic stroke caused by blood clots to the brain or haemorrhagic stroke caused by bleeding into/of the brain. Neurologic abnormalities similar to a stroke can also be the result of imbalances of glucose, sodium and calcium. Systematic review Research that summarises the evidence on a clearly formulated question according to a pre-defined protocol using systematic and explicit methods to identify, select and appraise relevant studies, and to extract, collate and report their findings. Venous stroke The formation of a blood clot in the intracerebral veins and venous sinuses. Videofluoroscopy Videofluoroscopy is a test for assessing the integrity of the oral and pharyngeal stages of the swallowing process. It involves videotaping fluoroscopic images as the patient swallows a bolus of barium. Other tools have been developed to improve the speed of diagnosis on arrival in the A&E department to avoid delay in the delivery of specialist assessment and management.

Leukemia The leukemias are a group of disorders characterized by the accumulation of abnormal white cells in the bone marrow purchase 400mg albenza visa treatment lyme disease. These abnormal cells may cause bone marrow failure purchase albenza 400 mg online medicine on airplanes, a raised circulating white cell count and infiltrate organs. Thus common but not essential features include abnormal white cells in the peripheral blood, a raise total white cell count, evidence of bone marrow failure (i. Other chronic types include hairy cell leukemia, prolymphocytic leukemia and various leukemia/lymphoma syndromes. In acute leukemia, in which there are over 50% myeloblasts or lymphoblasts in the bone marrow at clinical presentation, the blast cells fail to differentiate normally but are capable of further divisions. Their accumulation results in replacement of the normal hemopoietic precursor cells of the bone marrow by myeloblasts or lymphoblasts and, ultimately in bone marrow failure. The clinical condition of the patient can be correlated with the total number of leukemic cells in the body. When the abnormal cell number approaches 1012 the patient is usually gravely ill with severe bone marrow failure. Peripheral blood involvement by the leukemic cells and infiltration of organs such as the spleen, liver and lymph nodes may not occur until the leukemic cell population comprised 60% or more of the marrow cell total. The clinical presentation and mortality in acute leukemia arises mainly from neutropenia, thrombocytopenia and anemia because of bone marrow failure and, less commonly, from organ infiltration, e. In over 95% of patients there is a replacement of normal bone marrow by cells with an abnormal chromosome- the Philadelphia or Ph chromosome. This is an abnormal chromosome 22 due to the translocation of part of a long (q) arm of chromosome 22 to another chromosome, usually 9, with translocation of part of chromosome 9 to chromosome 22. It is an acquired abnormality of hemopoietic stem cells that is present in all dividing granulocytic, erythyroid and megakaryocytic cells in the marrow and also in some B and probably a minority of T lymphocytes. In at least 70% of patients there is a terminal metamorphosis to 308 Hematology acute leukemia (myeloblastic or lymphoblastic) with an increase of blast cells n the marrow to 50% or more. It most cases there are no predisposing factors but the incidence was increased n survivors of the atom bomb exposures in Japan. The accumulation of large numbers of lymphocytes to 50-100 times the normal lymphoid mass in the blood, bone marrow, spleen, lymph nodes and liver may be related to immunological non-reactivity and excessive lifespan. It is an unusual disease of peak age 40-60 years and men are affected nearly four times as frequently as women. The is a monoclonal proliferation of cells with an irregular cytoplasmic outline (‘hairy’ cells, a type of B lymphocyte) in the peripheral blood, bone marrow, liver and other organs. The bone marrow trephine shows a characteristic appearance of mild fibrosis and a diffuse cellular infiltrate. There is a tendency to progress to acute myeloid leukemia, although death often occurs before this develops. Malignant Lymphomas 314 Hematology This group of diseases is divided into Hodgkin’s disease and non-Hodgkin’s lymphomas. In many patients, the disease is localized initially to a single peripheral lymph node region and its subsequent progression is by contiguity within the lymphatic system. After a variable period of containment within the lymph nodes, 315 Hematology the natural progression of the disease is to disseminate to involve non-lymphatic tissue. It has bimodal age incidence, one peak in young adults (age 20-30 years) and a second after the age of 50. In developed counties the ratio of young adults to child cases and of nodular sclerosing disease to other types is increased. Tuberculosis may occur • Patients with bone disease may show hypercalcaemia, hypophosphataemia and increased levels of serum alkaline phosphatase. Laboratory findings • A Normochromic, normocytic anemia is usual but auto-immune hemolytic anemia may also occur. Multiple Myeloma Multiple myeloma (myelomatosis) is a neoplastic monoclonal proliferation of bone marrow plasma cells, characterized by lytic bone lesions, plasma cell accumulation in the bone marrow, and the presence of monoclonal protein in the serum and urine. Immunological testing shows these cells to be monoclonal B cells and to express the same 319 Hematology immunoglobulin heavy and light chains as the serum monoclonal protein. These disorders are closely related to each other; transitional forms occur and, in many patients, an evolution from one entity into another occurs during the course of the disease. Polycythemia vera Polycythemia (erythrocytosis) refers to a pattern of blood cell changes that includes an increase in hemoglobin above 17. In polycythemia vera (polycythemia rubra vera), the increase in red cell volume is caused by endogenous myeloproliferation. The stem cell origin of the defect is suggested in many patients by an over production of granulocytes and platelets as well as of red cells. Clonal cytogenetic abnormalities may occur, but there is no single characteristic change • Blood viscosity is increased • Plasma urate is often increased • Circulating erythroid progenitors are increased and grow in vitro independently of added erythropoietin. Essential thrombocythemia Megakaryocyte proliferation and overproduction of platelets is the dominant feature of this condition; there is sustained increase in platelet count above normal (400x109/l). Splenic enlargement is frequent in the early phase but splenic atrophy due to platelets blocking the splenic mirocirculation is seen in some patients.

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Although this bond plays a very important role in protein structure and function order albenza 400 mg fast delivery medicine 75, inappropriately introduced disulfides can be detrimental generic albenza 400mg medications used for bipolar disorder. Oxidative stress also generates peroxides that in turn can be reduced by glutathione to generate water and an alcohol. Several deficiencies in the level of activity (not function) of glucose-6-phosphate dehydrogenase have been observed to be associated with resistance to the malarial parasite, Plasmodium falciparum, among individuals of Mediterranean and African descent. The basis for this resistance is the weakening of the red cell membrane (the erythrocyte is the host cell for the parasite) such that it cannot sustain the parasitic life cycle long enough for productive growth. Coris Cycle or Lactic Acid Cycle In an actively contracting muscle, only about 8% of the pyruvate is utilized by the citric acid cycle and the remaining is, therefore, reduced to lactate. The muscle cramps, often associated with strenuous muscular exercise are thought to be due to lactate accumulation. It is then taken up through gluconeogenesis pathway and becomes glucose, which can enter into blood and then taken to muscle. Significance of the cycle: Muscle cannot form glucose by gluconeogenesis process because glucose 6 phosphatase is absent. In the absence of dietary intake of carbohydrate liver glycogen can meet these needs for only 10 to 18 hours During prolonged fast hepatic glycogen stores are depleted and glucose is formed from precursors such as lactate, pyruvate, glycerol and keto acids. Approximately 90% of gluconeogenesis occurs in the liver whereas kidneys provide 10 % of newly synthesized glucose molecules, The kidneys thus play a minor role except during prolonged starvation when they become major glucose producing organs. Reactions Unique to Gluconeogenesis Seven of the reactions of glycolysis are reversible and are used in the synthesis of glucose from lactate or pyruvate. However three of the reactions are irreversible and must be bypassed by four alternate reactions that energetically favor the synthesis of glucose. Biotin is a coenzyme of pyruvate carboxylase derived from vitamin B6 covalently bound to the apoenyme through an ε-amino group of lysine forming the active enzyme. Elevated levels of acetyl CoA may signal one of several metabolic states in which the increased synthesis of oxaloacetate is required. It must first be reduced to malate which can then be transported from the mitochondria to the cytosol. Regulation by fructose 2,6- bisphoshate Fructose1, 6-bisphosphatase is inhibited by fructose 2, 6-bisphosphate, an allosteric modifier whose concentration is influenced by the level of circulating glucagons. Substrates for Gluconeogenesis Gluconeogenic precursors are molecules that can give rise to a net synthesis of glucose. Glycerol, lactate, and the α-keto acids obtained from the deamination of glucogenic amino acids are the most important gluconeogenic precursors. Glycerol is released during hydrolysis of triacylgycerol in adipose tissue and is delivered to the liver. Lactate is released in the blood by cells, lacking mitochondria such as red blood cells, and exercising skeletal muscle. Ketogenic compounds AcetylCoA and compounds that give rise to acetyl CoA (for example acetocetate and ketogenic amino acids) cannot give rise to a net synthesis of glucose, this is due to the irreversible nature of the pyruvate dehydrogenase reaction, (pyruvate to acetyl CoA. Understand the mechanism and effect of poisons on cellular energy generation Energy Generation and Utilization in the Living System I-Introduction Energy is vital to life. Most organisms obtain energy by oxidation of these fuel molecules Carbohydrates, fats and amino acids. Cellular oxidation of these molecules release energy, part of which is conserved through the synthesis of high-energy phosphate bonds and the rest is lost as heat. It is the universal transfer agent of chemical energy between energy-yielding and energy- requiring cellular processes. The hydrolysis of these high - energy phosphate bonds release energy which powers cellular energy requiring processes. Free energy change of a biological reactions is reported as the standard free energy change 0’ (ΔG ) 0’- ΔG is the value of ΔG for a reaction at standard conditions for biological reactions (pH 7, o 1M, 25 C, 1 atmosphere pressure) Free energy change is used to predict the direction and equilibrium of chemical reactions If ΔG is negative – net loss of energy (exergonic) - reaction goes spontaneously If ΔG is positive - net gain of energy (endergonic) reaction does not go spontaneously If ΔG is zero- reactants are in equilibrium C - Oxidation-Reduction Reactions The utilization of chemical energy in living system involves oxidation – reduction reactions. For example, the energy of chemical bonds of carbohydrates, lipids and proteins is released and captured in utilization form by processes involving oxidation- reductions. Determined by measuring the electromotive force generated by a sample half-cell with respect to standard reference half- cell Anegative E’o = lower affinity for electrons A positive E’o = higher affinity for electrons - H + 2e H2 E’o = - 0. In biological systems the primary electron donors are fuel molecules such as carbohydrates, fats and proteins. The free-energy change of an oxidation – reduction reaction can be calculated from the difference in reduction potentials of the reactants using the formula: O ΔG ’= - nFΔE’o Where n= 2 (No of electrons transferred) F= 23. This occurs by the help of energy conserving system in the inner mitochondrial membrane of eukaryotes or plasma membrane of prokaryotes. The fuel molecules are metabolized to a common intermediate called aceyl CoA which is further degraded by a common pathway called Kreb’s cycle. This metabolic pathway in addition to providing energy provides building blocks required for growth, reproduction, repair and maintenance of cellular viability. Structurally it is bounded by two separate membranes (outer mitochondrial membrane and inner mitochondrial membrane) Out membrane - smooth and unfolded - Freely permeable to most ions and polar molecules (Contain porous channels) Inner membrane - folded into cristae-increased surface area - Highly impermeable to most ions and polar molecules Contain transporters which access polar and ionic molecules in and out Cristae are characteristic of muscle and other metabolically active cell types - Protein-rich membrane (about 75%) Inter membrane space – space between outer and inner membranes Matrix-the internal compartment containing soluble enzymes and mitochondrial genetic material Fig 3. Inside matrix pyruvate is oxidized into acetylCoA by pyruvate dehydrogenase complex which is complex of E1, E2 and E3 enzymes. Considerable free energy is lost as heat due to hydrolysis of thisester bond (drive the reaction forward).

Normal structure and function a) Pharyngeal phase of swallowing i) Tongue is piston - propels food bolus as soft palate is closed ii) Swallowing is reflex generic albenza 400 mg without prescription treatment e coli, once initiated iii) Larynx is elevated and epiglottis covers opening of larynx iv) Pharyngeal pressure increases to 45mm Hg v) Food propelled by pressure gradient into thoracic esophagus vi) Upper purchase 400 mg albenza with amex medicine x pop up, striated portion of esophagus relaxes, then contracts within 0. The presence of a paraesophageal hernia, regardless of the size or symptoms, is an indication for repair S Types: #1—true sliding hernia; the phrenoesophageal ligament fails to keep the esophagogastric junction below the diaphragm and within the abdomen. The fundus/body of the stomach is rotated into the chest with the greater curve as the leading point; usually no esophagitis present. Anatomy: -Intact posterior fixation of the esophagus to the preaortic fascia and the median arcuate ligament -The reason why the greater curve of the stomach herniates is because it is the most mobile portion—gastric cardia is fixed by the left gastric vessels, the gastrosplenic and gastrohepatic ligaments; the pylorus is fixed by the duodenum. This is the path of least resistance because the aorta lies to the left and the heart lies left and anterior. The stomach becomes twisted and angulated in its midportion just proximal to the antrum. Surgical therapy a) Failure of medical tx or complications (stricture, bleeding, severe ulceration) b) Significant symptoms and esophagitis in a young pt. Anatomy and physiology a) Definition=esophagus is lined w/columnar mucosa more than 3cm proximal to the distal end of the muscular esophageal tube b) 3 types of mucosa - gastric fundic, junctional, specialized columnar (80%) c) Acid (and pepsin and gastrin) is produced, but amount is insufficient to explain peptic ulceration of Barrett’s 2. Pathogenesis a) Nearly every patient has pathologic reflux b) Metaplasia of pleuropotential cells in submucosa c) Migration of gastric mucosa not felt to be mechanism 3. Medical management a) Lifestyle changes - behavior, food and drugs b) Medications c) Resolution of symptoms does not correlate with regression of Barrett’s 8. Surveillance a) Surveillance allows detection at an early stage and improves long-term survival b) Endoscopy at least every year 9. Kirschner - Roux-en-Y drainage of esophageal remnant - others say it is unnecessary B. Esophagorespiratory fistula in young, fit pts a) Avoids constant aspiration b) Other option is esophageal intubation 2. Pilot bougie is passed through gastrotomy and tube is sutured to lesser curve over a teflon pledget C. Patients with dysphagia due to extrinsic malignant compression more likely to fail E. All tumor types, any location - exophytic more successful, extrinsic compression less successful E. Dye lasers tuned to appropraite wavelength 2-3 days later - photochemical prrocess C. Barrett’s esophagus increases the risk of developing esophageal cancer 40-fold Cell Cycle 1. H,K, and N-ras genes are members of a super gene family encoding for plasma membrane proteins that are important in signal transduction from cell surface receptors invovled in mitogen-induced proliferation 2. Compartments · Mediastinal borders: thoracic inlet (superior), diaphragm (inferior), sternum (anterior), spine (posterior), pleura (lateral) · Anterosuperior compartment is anterior to pericardium · Contents include thymus and great vessels · Middle, or visceral, compartment is between anterior and posterior pericardial reflections · Contents include heart, phrenic nerves, tracheal bifurcation, major bronchi, lymph nodes · Posterior, or paravertebral, compartment is posterior to posterior pericardial reflection · Contents include esophagus, vagus nerves, sympathetic chains, thoracic duct, descending aorta, and azygos/hemiazygos 2. Mediastinal Emphysema · Introduction of air from esophagus, tracheobronchial tree, neck, or abdomen · Causes include penetrating or blunt trauma, or spontaneous mediastinal emphysema · Presents as substernal chest pain, crepitation, and pericardial crunching sound · May result in tamponade · Treat underlying cause; may require chest tube placement for pneumothorax B. Mediastinal Hemorrhage · Caused by trauma, aortic dissection, aneurysm rupture, or surgical procedures · May result in mediastinal tamponade, which is more insidious than pericardial tamponade · Meticulous hemostasis and adequate chest tube drainage will prevent this syndrome · Spontaneous mediastinal hemorrhage can result from mediastinal masses, altered coagulation status, and severe hypertension D. Features · Represents 20% of all mediastinal masses in adults · Peak incidence is in 3rd to 5th decades of life; rare in children · About half are of mixed cell type, followed by epithelial (28%) and lymphocytic (20%) types · Between 15 and 65% of thymomas are benign · Frequently associated with paraneoplastic syndrome, most commonly myasthenia gravis · Myasthenia gravis is diagnosed in 30-50% of patients with a thymoma, and 15% of myasthenia patients will have a thymoma · Autoimmune reaction directed against the postsynaptic nicotinic receptors results in skeletal muscle fatigability and weakness, especially in axial muscles B. Germ Cell Tumors · Comprise 15-25% of anterior mediastinal masses · Most common in children and young adults · Includes teratomas, teratocarcinomas, seminomas, embryonal cell carcinomas, choriocarcinomas, and endodermal cell or yolk-sac tumors · Identical to germ cell tumors originating in the gonads, but are not metastatic lesions from primary gonadal tumors · About 60% are benign and 40% are malignant A. Predominantly Benign Tumors · Teratomas are complex, multiple tissue element tumors · Symptoms are related to mechanical effects · Simplest form is the dermoid cyst, which consists of mostly dermal and epidermal tissue · More complex teratomas may have well-differentiated bone, cartilage, nerve, or glandular tissue · Malignant tumors are differentiated upon histologic identification of embryonic tissue B. Intrathoracic Thryoid · 80% are substernal extensions of a cervical goiter · True intrathoracic thyroid (derives blood supply from thoracic vessels) comprises only 1% of all mediastinal tumors · More common in women and in the 6th to 7th decades, most are adenomas · Usually presents with tracheal or esophageal compression; thyrotoxicosis is uncommon · I-131 scanning should be done to identify presence of functioning cervical thyroid tissue before resecting these tumors · Resect substernal extensions through a cervical incision and true intrathoracic lesions through the chest B. Parathyroid · Most are adenomas and are found by the superior pole of the thymus due to common embryogenesis from the third branchial cleft · Symptoms are usually due to hyperparathyroid syndrome · Parathyroid cysts are not usually hormonally active 9. Bronchogenic Cysts · Most common primary cysts in the mediastinum (5%) · Arise from ventral foregut and are usually located in the subcarinal or right paratracheal region/a> · Two-thirds are asymptomatic; symptoms include tracheobronchial or esophageal compression and infection from tracheobronchial communication · Complete excision is recommended, even if asymptomatic, to prevent late complications B. A rational approach to wound difficulties after sternotomy: reconstruction and long-term results. High-pressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis. Comparison between closed drainage techniques for the treatment of postoperative mediastinitis. Mediastinitis after cardiovascular operations: a case-control study of risk factors. Coagulase- negative staphylococcal sternal wound infections after open heart operations. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Prognostic factors and long-term results after thymoma resection: a series of 307 patients.

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