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External ear patients were grouped using terms such as otoplasty menstruation cup cheap danazol 100 mg with visa, pinna menstruation unclean bible buy danazol 200 mg amex, postauricular menstruation uterine lining purchase danazol once a day, and otitis externa womens health jan 2014 buy danazol 100mg with visa. Restoring the charts was an impossible task, and the records were determined to be either incomplete or a total loss. Pure tone test results revealed normal hearing sensitivity for the right ear and a moderate sensorineural hearing loss in the left ear. Tympanograms were characterized by normal shape, amplitude, and peak pressure points bilaterally. The contralateral acoustic refiex was normal for the right ear but absent for the left ear at the frequencies tested (500 to 4000 Hz). The ipsilateral acoustic refiex was present with the probe in the right ear and absent with the probe in the left ear. She reported to the ambulatory surgery center an hour before her scheduled procedure. Before transfer to the operating room, she spoke with her ophthalmologist and reviewed the surgical plan. After anesthesia and akinesia were achieved, the eye area was prepped and draped in sterile sheets. Miochol was injected to achieve papillary miosis, and the wound was closed with one 10-0 suture. It is divided for study into the axial skeleton and the appendicular skeleton (Fig. Between the vertebrae are disks of cartilage that add strength and fiexibility to the spine. Although bone appears to be inert, it is actually living tissue that is constantly being replaced and remodeled throughout life. The process of destroying bone so that its components can be taken into the circulation is called resorption. This process occurs normally throughout life; in disease states, resorption may occur more rapidly or more slowly than bone production. Within the shaft is a medullary cavity containing the yellow form of bone marrow, which is high in fat. Between the diaphysis and the epiphysis at each end of the bone, in a region called the metaphysis, is the growth region or epiphyseal plate. When the bone stops growing in length, this area becomes fully calcified but remains visible as the epiphyseal line. The thin layer of fibrous tissue that covers the outside of the bone, the periosteum, nourishes and protects the bone and also generates new bone cells for growth and repair. Synovial joints are stabilized and strengthened by ligaments, which connect the articulating bones. Yellow marrow fills the central cavity of the long bones; blood cells are formed in red bone marrow, which is located in spongy bone tissue (root myel/o). The appendicular skeleton (126 bones) contains the bones of the arms and legs, shoulder girdle, and pelvis. Physical therapists and occupational therapists must also understand these systems. The effects of a fracture depend on the location and severity of the break; the amount of associated injury; possible complications, such as infections; and success of healing, which may take months. Traction refers to using pulleys and weights to maintain alignment of a fractured bone during healing. A traction device may be attached to the skin or attached to the bone itself by means of a pin or wire. Efforts to prevent osteoporosis include adequate intake of calcium and engaging in weight-bearing exercise. Other conditions that can lead to osteoporosis include nutritional deficiencies; disuse, as in paralysis or immobilization in a cast; and excess steroids from the adrenal cortex. Certain drugs, smoking, lack of exercise, and high intake of alcohol, caffeine, and proteins may also contribute to the development of osteoporosis. A section of the vertebral column showing a loss of bone tissue and a compression fracture of a vertebra (top). Possible causes include deficiency of vitamin D, needed to absorb calcium and phosphorus from the intestine; renal disorders; liver disease; and certain intestinal disorders. Paget disease (osteitis deformans) is a disorder of aging in which bones become overgrown and thicker, but deformed. The disease results in bowing of the long bones and distortion of the fiat bones, such as those of the skull. Paget disease usually involves the bones of the axial skeleton, causing pain, fractures, and hearing loss. With time, there may be neurologic signs, heart failure, and predisposition to cancer of the bones. Signs of bone tumors are pain, easy fracture, and increases in serum calcium and alkaline phosphatase levels. It usually appears at midlife and beyond and involves the weight-bearing joints and joints of the fingers. Predisposing factors are age, heredity, injury, congenital skeletal abnormalities, and endocrine disorders. Rheumatoid arthritis is a systemic infiammatory disease of the joints that commonly appears in young adult women. A group of antibodies called rheumatoid factor often appears in the blood, but is not always specific for rheumatoid arthritis because it may occur in other systemic diseases as well. As this membrane covers and destroys the joint cartilage, synovial fluid accumulates, causing swelling of the joint (Fig. There is degeneration of the underlying bone eventually causing fusion of the bones, or ankylosis. It mostly occurs in middle-aged men and almost always involves pain at the base of the great toe. Gout is treated with drugs to suppress formation of uric acid or to increase elimination of uric acid (uricosuric agent). Disorders of the Spine Ankylosing spondylitis is a disease of the spine that appears mainly in males. Joint cartilage is destroyed; eventually the disks between the vertebrae calcify and there is fusion of the bones (ankylosis) (Fig. The herniated or “slipped” disk puts pressure on the spinal cord or spinal nerves, often causing pain along the sciatic nerve (sciatica). Treatment is bed rest; drugs to reduce pain, muscle spasms, and infiammation; followed by an exercise program to strengthen muscles. In orthopedics, several names is genu varum, in which the knees are far apart for types of bursitis are based on the repetitive and the bottom of the legs are close together, stress that leads to the irritation. The affected arm, when abthe term knock-knee describes genu valgum, ducted with the elbow fiexed, reveals a bulge on in which the knees are abnormally close and the the upper arm—just like Popeye’s! In a closed or simple fracture, the broken bone does not penetrate the skin; in an open fracture, there is an accompanying wound in the skin. The ends of the bones are destroyed, commonly at the knee, by a large mass that does not metastasize. Endoscope is inserted between projections at the end of the femur to view the posterior of the knee. The type of tissue that covers the ends of the bones at the joints is. The part of the vertebral column that articulates with the ilium is the. She was given general endotracheal anesthesia, and a vertical incision was made from the superior aspect of the right ear down to the base of the attachment of the right earlobe. After appropriate dissection and retraction, the posterior-superior aspect of the right zygomatic arch was bluntly dissected anteroposteriorly. An inferior dissection was then made along the capsular ligament and retracted posteriorly. With a Freer elevator, the meniscus was freed, and a horizontal incision was made to the condyle. With a Hall drill and saline coolant, a high condylectomy of approximately 3 mm of bone was removed while conserving function of the external pterygoid muscle. The lateral capsule, periosteum, subcutaneous tissue, and skin were then closed with sutures. He has been in a research study and receives a bisphosphonates infusion every 2 months.
This effectiveness was achieved through a combination of organism wash-off 722 and peracetic acid sterilant killing the test organisms women's health recipe finder safe 50mg danazol. In these experiments pregnancy 3d week by week cheap danazol 50 mg visa, the lumen test unit was not connected to pregnancy at 6 weeks buy danazol in united states online channel irrigators breast cancer 2nd stage survival rate purchase generic danazol on line. The authors attributed the failure of the peracetic acid immersion system to eliminate the high levels of spores from the center of the test unit to the inability of the peracetic acid to diffuse into the center of 40-cm long, 3-mm diameter tubes. This may be caused by an air lock or air bubbles formed in the lumen, impeding the flow of the sterilant through the long and narrow lumen and limiting complete 137, 856 access to the Bacillus spores. Experiments using a channel connector specifically designed for 1-, 2-, and 3-mm lumen test units with the peracetic acid immersion system were completely effective in 6 7 eliminating an inoculum of 10 Geobacillus stearothermophilus spores. The restricted diffusion environment that exists in the test conditions would not exist with flexible scopes processed in the peracetic acid immersion system, because the scopes are connected to channel irrigators to ensure that the sterilant has direct contact with contaminated surfaces. Alfa and associates attributed the efficacy of the peracetic acid immersion system to the ability of the liquid chemical process to dissolve salts and 722 remove protein and bacteria due to the flushing action of the fluid. Bioburden of Surgical Devices In general, used medical devices are contaminated with a relatively low bioburden of 179, 911, 912 organisms. Nystrom evaluated medical instruments used in general surgical, gynecological, orthopedic, and ear-nose-throat operations and found that 62% of the instruments were contaminated 1 2 3 with <10 organisms after use, 82% with <10, and 91% with <10. After being washed in an instrument 1 2 911 washer, more than 98% of the instruments had <10 organisms, and none >10 organisms. For example, after a standard cleaning procedure, 1 2 2912 72% of 50 surgical instruments contained <10 organisms, 86% <10, and only 6% had >3 X 10. In another study of rigid-lumen medical devices, the bioburden on both the inner and outer surface of the 1 4 lumen ranged from 10 to 10 organisms per device. In all of these studies, the contaminating microflora consisted mainly of vegetative 179, 911, 912 bacteria, usually of low pathogenicity. An evaluation of the microbial load on used critical medical devices such as spinal anesthesia needles and angiographic catheters and sheaths demonstrated that mesophilic microorganisms were 1 2 detected at levels of 10 to 10 in only two of five needles. Effect of Cleaning on Sterilization Efficacy the effect of salt and serum on the efficacy of low-temperature sterilization technologies has raised concern regarding the margin of safety of these technologies. Experiments have shown that salts 426, 469 have the greatest impact on protecting microorganisms from killing. However, other studies have suggested that these concerns may not be clinically relevant. One study evaluated the relative rate of removal of inorganic salts, organic soil, and microorganisms from medical devices to better understand 426 the dynamics of the cleaning process. These tests were conducted by inoculating Alfa soil (tissue469 6 culture media and 10% fetal bovine serum) containing 10 G. After drying for 30 minutes at 35 C followed by 30 minutes at room temperature, the samples were placed in water at room temperature. The blades were removed at specified times, and the concentration of total protein and chloride ion was measured. The results showed that soaking in deionized water for 60 seconds resulted in a >95% release rate of chloride ion from NaCl solution in 20 seconds, Alfa soil in 30 seconds, and fetal bovine serum in 120 seconds. Thus, contact with water for short periods, even in the presence of protein, rapidly leads to dissolution of salt crystals and complete inactivation of spores by a low-temperature sterilization process (Table 10). Based on these experimental data, cleaning procedures would eliminate the detrimental effect of high salt content on a low-temperature sterilization process. These data support the critical need for healthcare 472 facilities to develop rigid protocols for cleaning contaminated objects before sterilization. Sterilization of instruments and medical devices is compromised if the process is not preceded by meticulous cleaning. The cleaning of any narrow-lumen medical device used in patient care presents a major challenge to reprocessing areas. While attention has been focused on flexible endoscopes, cleaning 913 issues related to other narrow-lumen medical devices such as sphinctertomes have been investigated. This study compared manual cleaning with that of automated cleaning with a narrow-lumen cleaner and found that only retro-flushing with the narrow lumen cleaner provided adequate cleaning of the three channels. In another study involving simulated-use cleaning of laparoscopic devices, Alfa found that minimally the use of retro914 flushing should be used during cleaning of non-ported laparoscopic devices. Sterilization by ionizing radiation, primarily by cobalt 60 gamma rays or electron accelerators, is a low-temperature sterilization method that has been used for a number of medical products. Some deleterious effects on patient-care equipment 915 associated with gamma radiation include induced oxidation in polyethylene and delamination and 916 917, 918 cracking in polyethylene knee bearings. Several reviews dealing with the sources, effects, and application of ionizing radiation may be referred to for more detail. This method should be used only for materials that might be damaged by moist heat or that are impenetrable to moist heat. The advantages for dry heat include the following: it is nontoxic and does not harm the environment; a dry heat cabinet is easy to install and has relatively low operating costs; it penetrates materials; and it is noncorrosive for metal and sharp instruments. The disadvantages for dry heat are the slow rate of heat penetration and microbial killing makes this a time-consuming method. In addition, the high temperatures 68 Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 919 are not suitable for most materials. The most common time-temperature relationships for sterilization o o o o o with hot air sterilizers are 170 C (340 F) for 60 minutes, 160 C (320 F) for 120 minutes, and 150 C o (300 F) for 150 minutes. There are two types of dry-heat sterilizers: the static-air type and the forced-air type. The staticair type is referred to as the oven-type sterilizer as heating coils in the bottom of the unit cause the hot air to rise inside the chamber via gravity convection. This type of dry-heat sterilizer is much slower in heating, requires longer time to reach sterilizing temperature, and is less uniform in temperature control throughout the chamber than is the forced-air type. The forced-air or mechanical convection sterilizer is equipped with a motor-driven blower that circulates heated air throughout the chamber at a high velocity, 920 permitting a more rapid transfer of energy from the air to the instruments. These solutions are commonly used as high-level disinfectants when a shorter processing time is required. The survival kinetics for thermal sterilization methods, such as steam and dry heat, have been studied and characterized extensively, whereas the kinetics for sterilization with liquid sterilants are less 921 well understood. The information that is available in the literature suggests that sterilization processes based on liquid chemical sterilants, in general, may not convey the same sterility assurance level as 823 sterilization achieved using thermal or physical methods. The data indicate that the survival curves for liquid chemical sterilants may not exhibit log-linear kinetics and the shape of the survivor curve may vary depending of the formulation, chemical nature and stability of the liquid chemical sterilant. Therefore, sterilization with a liquid chemical sterilant may not convey the same sterility assurance as other sterilization methods. One of the differences between thermal and liquid chemical processes for sterilization of devices is the accessibility of microorganisms to the sterilant. Heat can penetrate barriers, such as biofilm, tissue, and blood, to attain organism kill, whereas liquids cannot adequately penetrate these barriers. In addition, the viscosity of some liquid chemical sterilants impedes their access to organisms in the narrow 922 lumens and mated surfaces of devices. Another limitation to sterilization of devices with liquid chemical germicides is the post-processing environment of the device. Devices cannot be wrapped or adequately contained during processing in a liquid chemical sterilant to maintain sterility following processing and during storage. Furthermore, devices may require rinsing following exposure to the liquid chemical sterilant with water that typically is not sterile. Therefore, due to the inherent limitations of using liquid chemical sterilants, their use should be restricted to reprocessing critical devices that are heatsensitive and incompatible with other sterilization methods. Several published studies compare the sporicidal effect of liquid chemical germicides against 78, 659, 660, 715 spores of Bacillus and Clostridium. Performic acid is a fast-acting sporicide that was incorporated into an 400 automated endoscope reprocessing system. Some investigators have appropriately questioned whether the removal of microorganisms by filtration really is a sterilization method because of slight bacterial passage through filters, viral passage through filters, and transference 924 of the sterile filtrate into the final container under aseptic conditions entail a risk of contamination. Microwaves are used in medicine for disinfection of soft contact lenses, dental 925-931 instruments, dentures, milk, and urinary catheters for intermittent self-catheterization. The microwaves produce friction of water molecules in an alternating electrical field.
In a maneuver called the difference between depolarization carotid sinus massage pregnancy after vasectomy purchase danazol 200 mg without a prescription, baroreceptors in the carotid arteries are and repolarization menopause yeast infection purchase 100 mg danazol mastercard, purposely activated in an effort to womens health australia purchase discount danazol line slow a rapid heart rate women health order 200 mg danazol free shipping. Transmission of electrical impulses Remember that repolarization is the the heart can’t pump unless an electrical stimulus occurs first. Cell memThose impulses branes separate different concentrations of ions, such as sodium really get around! After a stimulus occurs, ions cross the cell membrane and cause an action potential, or cell depolarization. When a cell is fully depolarized, it attempts to return to its resting state in a process called repolarization. The action potential is represented by a curve that shows voltage changes during the five phases. During phases 1 and 2 and at the beginning of phase 3, the cardiac cell is said to be in its absolute refractory period. K+ • Active transport via the sodiumSodiumpotassium pump begins restoring potaspotassium K+ pump sium to the inside of the cell and sodium to Na+ the outside of the cell. Phase 3, the rapid repolarization phase, occurs as the cell returns to its original state. During the last half of this phase, when the cell is in its relative refractory period, a very strong stimulus can depolarize it. From there, they travel through the bundle of His, the bundle branches, and lastly to the Purkinje fibers. They usually can’t flow backward because the cells can’t respond to a stimulus immediately after depolarization. Impulses are thought to be transmitted throughout the right atrium through the anterior, middle, and posterior internodal tracts. Impulse transmission through the right and left atria occurs so rapidly that the atria contract almost simultaneously. Although the nodal tissue itself has no pacemaker cells, the tissue surrounding it (called junctional tissue) contains pacemaker cells that can fire at a rate of 40 to 60 times per minute. This delay the bundle of His eventually divides allows the ventricles to complete their filling phase as the atria into the right and left contract. Branch splitting the bundle of His, a tract of tissue extending into the ventricles next to the interventricular septum, resumes the rapid conduction of the impulse through the ventricles. The right bundle branch extends down the right side of the interventricular septum and through the right ventricle. The left bundle branch extends down the left side of the interventricular septum and through the left ventricle. The left bundle branch then splits into two branches, or fasciculi: the left anterior fasciculus, which extends through the anterior portion of the left ventricle, and the left posterior fasciculus, which runs through the lateral and posterior portions of the left ventricle. Impulses travel much faster down the left bundle branch (which feeds the larger, thicker-walled left ventricle) than the right bundle branch (which feeds the smaller, thinner-walled right ventricle). The difference in the conduction speed allows both ventricles to contract simultaneously. The entire network of specialized nervous tissue that extends through the ventricles is known as the His-Purkinje system. Those perky Purkinje fibers Purkinje fibers extend from the bundle branches into the endocardium, deep into the myocardial tissue. These fibers conduct impulses rapidly through the muscle to assist in its depolarization and contraction. Purkinje fibers can also serve as a pacemaker and are able to discharge impulses at a rate of 20 to 40 times per minute, sometimes even more slowly. Abnormal impulses Now that you understand how the heart generates a normal impulse, let’s look at some causes of abnormal impulse conduction, including automaticity, backward conduction of impulses, reentry abnormalities, and ectopy. When the heart goes on “manual” Automaticity is a special characteristic of pacemaker cells that generates impulses automatically, without being stimulated to do so. This backward, or retrograde, conduction usually takes longer than normal conduction and can cause the atria and ventricles to beat out of synch. Coming back for more Sometimes impulses cause depolarization twice in a row at a faster-than-normal rate. In these cases, the active impulse reenters the same area and produces another impulse. Repeating itself An injured pacemaker (or nonpacemaker) cell may partially depolarize, rather than fully depolarizing. Partial depolarization can lead to spontaneous or secondary depolarization, which involves repetitive ectopic firings called triggered activity. Early afterdepolarization occurs before the cell is fully repolarized and can be caused by hypokalemia, slow pacing rates, or drug toxicity. If it occurs after the cell has been fully repolarized, it’s called delayed afterdepolarization. These problems can be caused by digoxin toxicity, hypercalcemia, or increased catecholamine release. Then the • Cardiac veins — collect blood from the blood returns to the left atrium and flows capillaries of the myocardium to the left ventricle. Automaticity, the ability of a cell to initiate an impulse on its own, is a unique characteristic of cardiac cells. The coronary arteries fill with blood when the ventricles are in diastole and filling with blood. The aortic valve is closed at that time, so it no longer blocks blood flow through the coronary ostium into the coronary arteries. Passive stretching exerted by blood on the ventricular muscle at the end of diastole is referred to as: A. Preload is the passive stretching exerted by blood on the ventricular muscle at the end of diastole. Based on this finding, which area of the heart is most likely serving as the pacemakerfi You might remember that myocardial depolarization occurs when a wave of stimulation passes through the heart and stimulates the heart muscle to contract. It allows the nurse to monitor phases of myocardial contraction and to identify rhythm and conduction disturbances. Take the lead A lead provides a view of the heart’s electrical activity between one positive pole and one negative pole. Between the two poles lies an imaginary line representing the lead’s axis, a term that refers to the direction of the current moving through the heart. Current direction and wave deflection this illustration shows possible directions of electrical current, or depolarization, on a lead. The direction of the electrical current determines the upward or downward deflection of an electrocardiogram waveform. When current flows perpendicular to the lead, the waveform As current travels may be small or go in toward the negative pole, both directions the waveform deflects (biphasic). The frontal plane, a vertical cut through the middle of the heart, provides an anterior-to-posterior view of electrical activity. The horizontal plane, a transverse cut through the middle of the heart, provides either a superior or an inferior view. These 12 views are obtained by placing electrodes on the patient’s limbs and chest. The limb leads and the chest, or precordial, leads reflect information from the different planes of the heart. The six precordial or V leads—V1, V2, V3, V4, V5, and V6—provide information about the heart’s horizontal plane. Like the augmented leads, the precordial leads are also unipolar, requiring only a single electrode. Just one view A rhythm strip, which can be used to monitor cardiac status, provides information about the heart’s electrical activity from one or more leads simultaneously. Chest electrodes pick up the heart’s electrical activity for display on the monitor.
Botox women's health center tampa florida purchase discount danazol line, currently injected into the skin sulin made by genetic engineering women's health clinic lansing mi buy cheap danazol line, points up the for cosmetic removal of wrinkles pregnancy yoga cheap 200 mg danazol overnight delivery, is the toxin fact that this is human insulin and not a horfrom the organism that causes botulism women's health center alamogordo nm generic danazol 50 mg without a prescription, a type of mone from animal sources. Herbal Medicines For hundreds of years, people have used plants to treat diseases, a practice described as herbal medicine or phytomedicine. Many people in industrialized countries are now turning to herbal products as alternatives or complements to conventional medicines. Some issues have arisen with the increased use of herbals, including questions about their purity, safety, concentration, and efficacy. Health care providers should ask about the use of herbal remedies when taking a patient’s drug history, and patients should report any herbal medicines they take when under treatment. There are, however, restrictions on the health claims that can be made by the manufacturers of herbal medicines. Displays 8-1 through 8-5 (after the word exercises) summarize information on drugs. Display 8-1 outlines the major categories of drugs, with examples cited by both generic and trade names. Comparison of the angles of insertion for intramuscular, subcutaneous, and inSubcutaneous injection tradermal injections. When a drug has lost its effect at a constant dose, the patient has developed. Phytomedicine is the practice of treating with. During a 9-month period of disease exacerbation, he took oral corticosteroids (prednisone) to reduce the infiammatory response. He experienced many of the drug’s side effects, but has been in remission for 4 years. Her current meds included several bronchodilators, which she takes by mouth and by inhalation, and a tranquilizer that she takes when needed for nervousness. She also admitted to occasional use of marijuana and ecstasy, a hallucinogen and mood-altering illegal recreational drug. Arnica Montana was prescribed to decrease discomfort, swelling, and bruising; 3 tabs sublingual tid the evening after surgery and for the following 10 days. Bromelain and Arnica Montana are herbal products that can be described as all of the following except: a. Each chapter begins with a description of normal structure and function because these form the basis for all medical studies. This system forms a continuous circuit that delivers oxygen and nutrients to Ball cells and carries away waste products. Also functioning in circulation is the lymphatic system, which drains fiuid and proteins from the tissues and returns them to the bloodstream. The right side pumps blood to the lungs to be oxygenated through the pulmonary circuit. Blood Flow Through the Heart the pathway of blood through the heart is shown by the arrows in Figure 9-2. The valve in the septum between the right atrium and ventricle is the tricuspid valve (meaning three cusps or fiaps); the valve in the septum between the left atrium and ventricle is the bicuspid valve (having two cusps), usually called the mitral valve (so named because it resembles a bishop’s miter). The valve at the entrance to the pulmonary artery is specifically named the pulmonic valve; the valve at the entrance to the aorta is the aortic valve. The loudest of these, the familiar lubb and dupp that can be heard through the chest wall, are produced by alternate closing of the valves. The second heart sound (S2) is produced when the valves leading into the aorta and pulmonary artery close. Each time the heart beats, both atria contract and immediately thereafter both ventricles contract. The wave of increased pressure produced in the vessels each time the ventricles contract is the pulse. Contractions are stimulated by a built-in system that regularly transmits electrical impulses through the heart. Although the heart itself generates the heartbeat, factors such as nervous system stimulation, hormones, and drugs can infiuence the rate and the force of heart contractions. Both systolic and diastolic pressures are measured and reported as systolic then diastolic separated by a slash, such as 120/80. Capillaries, the smallest vessels, through which exchanges take place between the blood and the tissues. The small veins that receive blood from the capillaries and drain into the veins are venules. All veins, except the pulmonary vein (and the umbilical vein in the fetus), carry blood low in oxygen. Nervous system stimulation can cause the diameter of a vessel to increase (vasodilation) or decrease (vasoconstriction). The Lymphatic System the lymphatic system is a widely distributed system with multiple functions (Fig. Everyday examples are graham cracker, genus and species names of microorganisms Ferris wheel, and boycott. In the heart, the bunoften are based on the names of their discoverdle of His and Purkinje fibers are part of that ers, Escherichia, Salmonella, Pasteurella, and organ’s conduction system. In A curie is a measure of radiation, derived from treatment, Doppler echocardiography is named the name of Marie Curie, a co-discoverer of for a physicist of the 19th century. Another function of the lymphatic system is to absorb digested fats from the small intestine (see Chapter 12). Other organs and tissues of the lymphatic system include the tonsils, located in the throat (described in Chapter 11), the thymus gland in the chest, and the spleen in the upper left region of the abdomen (see Fig. All except the pulmonary and umbilical arteries carry oxygenated blood (root arter, arteri/o). The two loudest sounds are produced by alternate closing of the valves and are designated S1 and S2. All except the pulmonary van and umbilical veins carry blood low in oxygen (root ven, phleb/o). Plastic repair of a vessel Use the appropriate root to write a word with each of the following meanings: 19. Infiammation of a tonsil Clinical Aspects of the Circulatory System Atherosclerosis the accumulation of fatty deposits within the lining of an artery is termed atherosclerosis (Fig. Plaques gradually thicken and harden with fibrous material, cells, and other deposits, restricting the lumen (opening) of the vessel and reducing blood fiow to the tissues, a condition known as ischemia. Other risk factors for atherosclerosis include smoking, high blood pressure, poor diet, inactivity, stress, and family history of the disorder. Philadelphia: Lippincott Williams & A Fat deposits B Occlusion C Blood clot Wilkins, 2000. Thrombosis and Embolism Atherosclerosis predisposes a person to thrombosis, the formation of a blood clot within a vessel. Blockage of a vessel by a thrombus or other mass carried in the bloodstream is an embolism, and the mass itself is called an embolus. Often a venous thrombus will travel through the heart and then lodge in an artery of the lungs, resulting in a life-threatening pulmonary embolism. Aneurysm An arterial wall weakened by atherosclerosis, malformation, injury, or other causes may balloon out, forming an aneurysm. In simple terms, hypertension is defined as a systolic pressure greater than 140 mm Hg or a diastolic pressure greater than 90 mm Hg. Drugs that are used include diuretics to eliminate fiuids, vasodilators to relax the blood vessels, and drugs that prevent the formation or action of angiotensin, a substance in the blood that normally acts to increase blood pressure. Often there is anxiety, diaphoresis (profuse sweating), and dyspnea (difficulty in breathing). If further intervention is required, the blocked vessel may be surgically bypassed with a vascular graft (Fig. Bradycardia is a slower-than-average rate, and tachycardia is a higher-than-average rate. Cardioversion is the general term for restoration of a normal heart rhythm, either by drugs or application of electric current. The result of a septal defect is that blood is shunted from the left to the right side of the heart and goes back to the lungs instead of out to the body. Symptoms of septal defect include cyanosis (leading to the description “blue baby”), syncope, and clubbing of the fingers.
In addition menstruation 3 weeks apart purchase danazol no prescription, resetting and entrainment are more likely 1 to women's health center amarillo tx cheap danazol 200mg overnight delivery occur when the excitable gap is longer pregnancy quant levels buy danazol 100 mg visa. The excitable X1X1 X1S2 S2X3 gap can be exploited to womens health nurse practitioner programs buy danazol 200mg with visa terminate a reentrant tachycardia. Termination of arrhythmias by stimulation would be expected to be much more diffcult when the reentrant circuit has only a small partially excitable gap. The coupling interval of the extrastimulus is a large excitable gap will respond to drugs that decrease [X1S2]. In the top portion of the fgure, the extrastimulus does not affect the conduction velocity, preferentially at pivot points. On the other hand, the reentrant wavefront in anatomical and nonuniform To reset a reentrant tachycardia, the stimulated wavefront anisotropic reentrant circuits, in general, is not propagating must reach the reentrant circuit, encounter excitable tissue in myocardium that has just recovered excitability and the within the circuit. This property can contribute to trant circuit), collide in the antidromic (retrograde) directhe stability of these reentrant circuits. Therefore, earlier than expected time and perpetuate the tachycardia instability of anatomical reentry is confned to variations of (Fig. This able tissue, which commonly occurs in reentrant tachycarinstability is characterized by the wavefront invading the dias with large excitable gaps, the tachycardia is advanced repolarizing phase of the preceding wave, resulting in oscilby the extent that the stimulated wavefront arrives at the lations of the rotation period. If the tissue is partially excitable, which can occur in reentrant tachycardias with small or partially excitable gaps or even in circuits with large excitR e s e t t in e e n t r n t h r d ia s able gaps when the extrastimulus is very premature, the stimulated wavefront will encounter some conduction delay Defnition in the orthodromic direction within the circuit (see Fig. Therefore, the degree of advancement of the next tachytachycardia impulse by timed premature electrical stimuli. The tachycardia complexes that return frst should quently can be early, on time, or delayed. This occurs when the premature tachycardia yields a return cycle (S2X3) if the tachycardia is impulse enters the reentrant circuit early in the relative not terminated (Fig. If S2 does not affect the arrhythrefractory period; it fails to propagate in the anterograde mogenic focus, the coupling interval (X1S2) plus the return direction because it encounters absolutely refractory tissue. In this situation, X1S2 + S2X3 Resetting does not require that the pacing site be located will be less than 2 fi (X1X1), as measured from the surface in the reentrant circuit. This correEntrance Exit sponds to the time required for the stimulated impulse to reach the reentrant circuit, conduct through the circuit, exit the circuit, and travel back to the pacing site. Conduction time between the pacing site and the tachycardia circuit may or may not be equal to that from the B circuit to the pacing site. Differences in location of the site of stimulation, as well as the tachycardia circuit entrance Stim and exit, can result in differences in conduction time to and from the pacing site. Antidromic resetting occurs when intracardiac sites are directly capTermination tured by the premature stimulus without traversing the reentrant circuit and the zone of slow conduction. The dark portion of with differing morphology of the captured as compared the arrow represents fully refractory tissue and the fading portion represents with the spontaneous electrogram. B, A premature stimulus (Stim) introduced during the of an antidromic resetting response can indicate a tachycartachycardia results in a wavefront of depolarization (red arrow), which enters the dia mechanism other than reentry, an antidromic resetting reentrant circuit and conducts antegradely over fully excitable tissue while it pattern can also be observed during reentry with an excitcollides retrogradely with the already propagating wavefront (blue arrow). The able gap if the pacing site is located distal to a region of slow premature wavefront (red arrow) then propagates around the circuit to the exit conduction in the reentry circuit. Conversely, if the recordsite, leading to the less than compensatory pause and resetting of the tachycardia. As a result, circus movement in the Orthodromic resetting occurs when the premature stimcircuit is extinguished and tachycardia terminates. Am J cardiac areas that are orthodromically reset are advanced Cardiol 1988;61:770. For an extrastimduction interval from the pacing stimulus to the orthoulus to be able to reset the reentrant circuit, it has to penedromically captured electrogram exceeds the tachycardia trate the circuit during its excitable gap. Thus, an orthoresulting in resetting is defned as the resetting interval or dromic resetting response implies that the pacing site is resetting zone. Therefore, the entire extent of ting is critically dependent on the location of pacing and the fully excitable gap would be the zone of coupling interrecording electrodes relative to the region of slow conducvals from the onset of tachycardia resetting until tachycartion in the circuit. The excitable gap, however, can be an orthodromic resetting response does not exclude underestimated by using only a single extrastimulus or by reentry with an excitable gap as a possible tachycardia using single or double extrastimuli in the absence of tachymechanism. Resetting Response Curves All tachycardias reset by a single extrastimulus can be reset by double extrastimuli, unless tachycardia terminaResponse patterns during resetting are characterized by tion occurs. Double extrastimuli produce resetting over a plotting the coupling interval of the extrastimulus produclonger range of coupling intervals and should therefore be ing resetting versus the return cycle measured at the pacing used to characterize the excitable gap of the reentrant circuit site. The return cycle is the time interval lus should be 20 or more milliseconds earlier than the M from the resetting stimulus to the next excitation of the expected compensatory pause following a single extrastimIn all cases in which a single extrastimulus resets the Flat Increasing Mixed tachycardia, double extrastimuli from the same pacing site produce an identical or expected resetting curve. Thus, if a single extrastimulus produces a fat curve, double extrastimuli produce a fat or mixed curve. If a single extrastimulus produces an increasing or mixed curve, double 1 extrastimuli will produce the same curve. X-50 X X-50 X X-50 X the type of resetting curves can vary depending on the Coupling interval (ms) Coupling interval (ms) Coupling interval (ms) site of stimulation. Extrastimuli from different pacing sites likely engage different sites in the reentrant circuit that are S in different states of excitability or refractoriness and, thereEntrance Exit fore, result in different conduction velocities and resetting patterns. A fat interval X ms resetting curve implies the presence of a fully excitable gap within the reentrant circuit over a range of coupling intervals. The total duration of the excitable gap should exceed the range of coupling intervals that produce resetting with a fat response. Large excitable gaps are more likely to result Coupling in fat response curves, because the increasingly premature interval extrastimuli are less likely to encroach on the trailing edge X-50 ms of refractoriness and encounter decremental conduction (see Fig. The reentrant circuit is depicted as having a separate response, the response to double extrastimuli would also be entrance and exit in each pattern. However, because the use of double extrastimuli allows period of absolute refractroriness (blue arrow), which is then followed by a period of relative refractoriness (fading tail of the arrow) of variable duration. On the left engagement of the reentrant circuit at relatively long couside, a fat curve results when the stimulated wavefront reaches the tachycardia pling intervals with greater prematurity, resetting will begin circuit and fnds a fully excitable gap between the head and tail of the tachycardia at longer coupling intervals and will continue over a greater wavefront. Therefore, range of coupling intervals than that observed with a single the conduction time from the entrance to exit is the same. Therefore, double extrastimuli can produce shown in the middle; this results when the initial stimulated wavefront enters the a fat and then increasing response curve. A mixed curve (right side) results when the less premature return cycles in response to increasingly premature extraextrastimuli fnd the reentrant circuit fully excitable, whereas the more premature one (at coupling intervals of X-50) fnds it in the relative refractory stimuli and indicate a zone of decremental slow conduction, period. In before assessing any perturbation in tachycardia presumed a mixed response curve, the initial coupling intervals demto be caused by resetting. During the fat response pattern, the return cycle is concurve is seen with a single extrastimulus; it is only by using stant (less than 10 milliseconds difference) over a 30double extrastimuli that an increasing response can be millisecond range of coupling intervals. With the increasing response pattern, the return cycle Decreasing Response Curves in Reentrant increases as the coupling interval increases. With a decreasing response pattern, the return cycle reentry but can be seen in triggered rhythms, although fat decreases as the coupling interval increases. A fat fusion requires a signifcant mass of myocardium to be response can be observed in automatic, triggered, or reendepolarized by both the extrastimulus and the tachycarM 68,70-72 trant rhythms. Site specifcity for resetting is the orthodromic wavefront of the tachycardia impulse decreased with the use of multiple extrastimuli. A fat resetting curve can be seen in automatic, trigreentrant circuit, capturing a certain portion of myocargered, or reentrant rhythms. Reentrant rhythms never demdium before colliding with the paced antidromic wavefront. The ability to reset a tachycarthe reentrant circuit, with the stimulus wavefront preferendia after it has begun activating the myocardium. Because the onset of the tachycardia complex and enters and resets the entrance and exit sites of focal rhythms (automatic or circuit will always demonstrate local fusion. Resetting with triggered) are not separate, a tachycardia wavefront cannot local fusion and a totally paced complex morphology proexit the focus once the exit or entrance site has already vides evidence that the reentrant circuit is electrocardiobeen depolarized and rendered refractory by the paced graphically small. This would produce dence of fat resetting curves, longer resetting zones, and a fully compensatory pause. Resetting with fusion is a potential indication that the pacing site is located E n t r a in m e n t o f R e e n t r a n t T a c h c a r d ia s proximal to the zone of slow conduction. The ability to entrain different mechanisms, including reentry, normal or abnora tachycardia also establishes that the reentrant circuit conmal automaticity, and triggered activity. Triggered activity and front—and the ability to demonstrate resetting is a strong M automaticity do not demonstrate site specifcity for resetindication that entrainment can occur from that specifc 2 pacing site.
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