However treatment bipolar disorder buy paroxetine in india, disorders related to female reproductive health may develop during sensitive windows throughout fetal development treatment 11mm kidney stone purchase 10 mg paroxetine with mastercard, childhood ombrello glass treatment order 20mg paroxetine with amex, adolescence treatment 4 autism purchase paroxetine 20 mg line, or adulthood medicine valley high school paroxetine 20 mg. All the physical medications 5 songs order paroxetine 10 mg free shipping, chemical treatment questionnaire discount paroxetine 20 mg with amex, biological and social factors that may affect the origin symptoms xanax addiction order paroxetine australia, growth, development and survival of a person in a given setting. These periods are directly related to reproductive health throughout the life course, including the period before conception, at conception, fertility, pregnancy, child and adolescent development, and adult health. Exposures to different environmental contaminants may influence reproductive health status of the individual and its offspring, through the process of epigenetics. Environmental toxins may potentially induce effects in human reproductive processes. However, the extent of this hypothesis must be supported through greater levels of research. Proceedings of the Summit on Environmental Challenges to Reproductive Health and Fertility: executive summary. In addition to highly sensitive windows for morphological abnormalities (birth defects), there are also time windows important for the development of physiological defects and morphological changes at the tissue, cellular and subcellular levels. Data on prenatal exposures are based mainly on studies of maternal exposure to pharmaceuticals. Information on critical windows for exposure during the postnatal period is scarce. Postnatal exposures have been examined in detail for only a few environmental agents, including lead, mercury, some pesticides, and radiation. Age at menarche and tanner stage in girls exposed in utero and postnatally to polybrominated biphenyl. Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy. Sexual precocity after immigration from developing countries to Belgium: evidence of previous exposure to organochlorine pesticides. Science linking environmental contaminant exposures with fertility and reproductive health impacts in the adult female. Principles for evaluating health risks in children associated with chemical exposure. Significant scientific concerns over the potential impact of these environmental hazards on reproductive health have increased research and public debate on this issue. In life, we are all exposed to a combination of environmental risk factors and mixtures of chemicals. We must learn more about low level exposures, effects of combined exposures and mixtures and importance of the timing of exposures. Decrease in anogenital distance among male infants with prenatal phthalate exposure. After adjusting for age at examination, p-values for regression coefficients ranged from 0. We defined a summary phthalate score to quantify joint exposure to these four phthalate metabolites. The associations between male genital development and phthalate exposure seen here are consistent with the phthalate-related syndrome of incomplete virilization that has been reported in prenatally exposed rodents. These data support the hypothesis that prenatal phthalate exposure at environmental levels can adversely affect male reproductive development in humans. The endocrine glands include the pituitary, thyroid, adrenal, thymus, pancreas, ovaries, and testes. These glands or organs release carefully-measured levels of hormones into the bloodstream that act as natural chemical messengers to control important processes of the body. Endocrine disruptors are exogenous agents that interfere with the synthesis, secretion, transport, binding, action, or elimination of natural hormones in the body that are responsible for the maintenance of homeostasis, reproduction, development, and/or behavior. Endocrine disruptors can change normal hormone levels, stimulate or halt the production of certain hormones, or change the way hormones move through the body. Adverse effects of environmental antiandrogens and androgens on reproductive development in mammals. In addition, smoking, alcohol consumption, and other lifestyle factors play an increasingly important role in determining the health status of women. There is now abundant evidence that environmental factors may contribute to many of the disease processes discussed above. Imbalanced or unopposed estrogen exposure is a leading risk factor for many gynecologic malignancies, as well as benign proliferative disorders such as endometriosis and leiomyoma. The potential impact of these compounds on hormone-dependent physiological processes such as conception and fetal development, as well as on disease processes such as osteoporosis and cardiovascular disease, demands further exploration. Systemic toxicity 14 There are several mechanisms of action that environmental contaminants may have within the human body. An environmental contaminant acting directly on gene expression would alter hormone function and influence changes in reproductive processes and systems. This could either increase or decrease levels of endogenous hormones within the body. Neuroendocrine effects could occur by nervous system monitoring of the environment and neuronal signaling to the endocrine system. It is important to note that epigenetic changes may sometimes confer developmental advantages, enabling the growing organism to modify development of organs and systems in response to downstream requirements. Finally, systemic toxicity indicates that an environmental exposure may result in widespread effects on many systems. Direct gene expression means that an environmental contaminant, once it enters the human body, will directly change the normal function of naturally occurring human hormones. This environmental contaminant will change normal hormonal functioning by acting directly on the gene responsible for this process. This binding process may directly change the normal hormonal functioning of a specific system and lead to augmentation in gene expression. In addition, an environmental contaminant may directly alter gene expression that regulates hormone production or secretion. This action may result in an increase or decrease in the levels of naturally occurring hormones in the body, leading to an imbalance of the endocrine system. Such an imbalance may have significant effects on the proper functioning of the reproductive system. Headliners: Neurodevelopment: genome-wide screen reveals candidate genes for neural tube defects. For this reason, this field of study is known as "epi," the greek root for "above," indicating that a change has occurred that is not directly related to the genetic code, but above it somehow. In epigenetics, non-genetic causes are considered responsible for different expressions of phenotypes. Exogenous, or environmental components may affect gene regulation and thus, potentially, subsequent expression in the phenotype. Changes to gene expression induced by environmental contaminants can be permanent or transient. Despite the devastating clinical consequences of aneuploidy, relatively little is known of how it originates in humans. The female mice were found to have significant defects in the number and quality of their eggs, or oocytes. However, the evidence from this study is inadequate to determine a true causal pathway. It is important to note there is a lack of human studies that validate this genetic route of action. Aneuploidy (trisomy or monosomy) is the most commonly identified chromosome abnormality in humans, occurring in at least 5% of all clinically recognized pregnancies. Most aneuploid conceptuses perish in utero, which makes this the leading genetic cause of pregnancy loss. However, some aneuploid fetuses survive to term and, as a class, aneuploidy is the most common known cause of mental retardation. Despite the devastating clinical consequences of aneuploidy, relatively little is known of how trisomy and monosomy originate in humans. However, recent molecular and cytogenetic approaches are now beginning to shed light on the non-disjunctional processes that lead to aneuploidy. There is increasing concern that exposure to man-made substances that mimic endogenous hormones may adversely affect mammalian reproduction. Although a variety of reproductive complications have been ascribed to compounds with androgenic or estrogenic properties, little attention has been directed at the potential consequences of such exposures to the genetic quality of the gamete. We identified damaged caging material as the source of the exposure, as we were able to recapitulate the meiotic abnormalities by intentionally damaging cages and water bottles. Specifically, in the female mouse, short-term, low-dose exposure during the final stages of oocyte growth is sufficient to elicit detectable meiotic effects. These results provide the first unequivocal link between mammalian meiotic aneuploidy and an accidental environmental exposure and suggest that the oocyte and its meiotic spindle will provide a sensitive assay system for the study of reproductive toxins. It is believed that endocrine disruptors act by interfering with synthesis, secretion, transport, metabolism, binding action, or elimination of natural hormones that are present in the body and are responsible for homeostasis, reproduction, and developmental process. Estrogenic environmental endocrine-disrupting chemical effects on reproductive neuroendocrine function and dysfunction across the life cycle. They can alter hormone synthesis, disrupt neural and immune signaling pathways, and alter the regulation of gene expression. Xenohormones interact with steroid hormones receptors, in particular those for estrogens and androgens. Xenohormones act through several mechanisms that can affect the reproductive system. Many documented incidents of decreased reproductive capacity in wildlife population are strongly associated with exposure to chemicals in the environment. Reproductive disorders in wildlife have included egg shell thinning of birds, widespread population declines, morphologic abnormalities, sex reversal, impaired viability of offspring, altered hormone concentration and changes in socio-sexual behavior. This includes some metals, organic solvent agrochemicals, poly-halogenated aromatic hydrocarbons, and pharmaceuticals. The neuro-endocrine system describes the collaborative functioning between the nervous and the endocrine system. These two systems are closely related because the secretion of certain important hormones in the body is regulated directly through the hypothalamus in the brain. When environmental contaminants affect the neuro-endocrine system, serious impacts can result on reproductive function. The neuro-endocrine mechanism of action describes how the nervous system senses changes in the environment and alerts the endocrine system of necessary changes that must be made in the body to maintain adequate health status. For example, if the nervous system notices the presence of a certain environmental contaminant, it may send signals to the endocrine system to augment production and secretion of a specific hormone. The induction of specific changes related to environmental exposures may result in adverse affects in reproductive function through the over-secretion or under-secretion of specific reproductive hormones. Certain environmental contaminants may activate specific properties in adults and produce transient changes in the nervous system, or, exposure to environmental contaminants during neural development may induce changes in neurobehavioral function, specifically sex-related behaviours. Disruption of neuroendocrine control of luteinizing hormone secretion by Aroclor 1254 involves inhibition of hypothalamic tryptophan hydroxylase activity. Neurosteroids: Expression of steroidogenic enzymes and regulation of steroid biosynthesis in the central nervous system. There are several known pathologies that may result in adverse effects in reproductive function. Infections are very important and preventable causes of infertility in the developed as well as developing world. Chlamydia has been shown to cause fallopian tube infection which often does not present any symptoms, but can lead to significant reproductive dysfunction and subsequent infertility. Environmental risk factors, such as alcohol and mercury can also affect reproductive status. For instance, alcohol has been linked to irregular menstrual cycles and premature birth and alcohol consumption during pregnancy causes fetal alcohol spectrum disorders. Reproductive Health Strategy to accelerate progress towards the attainment of international development goals and targets. Exogenous substances, such as environmental endocrine disruptors, may disturb the hormonal balance and thereby cause reproductive disorders. Three specific classes of female reproductive disorders are of particular concern. Ovarian disorders relate to the ovary, which is responsible for the production, storage, and release of the female reproductive cell, the egg, or the oocyte. Ovarian disorders also include pathologies that relate to the natural cyclicity of the female reproductive cycle. Uterine disorders relate to the internal female reproductive structure that will act as the future womb of the developing fetus. Pubertal disorders relate to the maturation phase of the female as she enters the fertile phase of her adolescent and adult life. Environmental factors may or may not be related to the development of these classes of disorders. Altered menstrual cycles and fecundability 23 Women are born with a specific number of oocytes. Oocytes are stored in the ovary until they are ready to be released during the menstrual cycle. Due to the physiology of the female reproductive system, it is difficult to measure the quantity and quality of female oocytes as well as the proper functioning of the ovary. However, understanding the developmental process of the ovary provides some insight into potential causes of disorders. Three specific disorders and occurrences will be explored to see potential environmental effects on the ovary: polycystic ovarian syndrome, premature ovarian failure, and altered menstrual cycles and fecundability. The prevalence and features of the polycystic ovary syndrome in an un selected population. Following this initial formation, the ovarian cells, called follicles, will remain dormant for 15 to 50 years. This extended period of dormancy indicates that these follicles may be exposed to a variety of environmental factors. Furthermore, this indicates that the ovarian tissue may be affected by the environment either during the development of the organ in utero, or during the dormancy period. This demonstrates an increased sensitivity for this specific female reproductive organ. However, it is still not known which environmental agents may influence the health of the ovarian follicle. Female reproductive disorders: the roles of endocrine-disrupting compounds and developmental timing. Neonatal exposure to estrogens suppresses activin expression and signaling in the mouse ovary. Research has shown that proper ovarian development is dependent on the proper balance of estrogen in the fetal environment. Furthermore, estrogenic activity at the time of ovarian follicle development is also crucial to achieve adequate oocyte quality. Thus, the maintenance of a proper balance of estrogen is crucial for healthy ovarian tissue and follicular development. Changes in the hormonal environment of the developing ovary may disrupt this fragile and sensitive process. Some environmental contaminants that mimic natural estrogen may disrupt or affect the ovarian development process. First, an animal model using laboratory mice has demonstrated that exposure to estrogenic compounds resulted in a failure of normal ovarian follicle formation. Likewise, a wildlife study of the American alligator showed that female alligators that had high levels of estrogenic environmental contaminants in their bodies, specifically, the pesticide difocol, also failed to produce healthy ovarian follicles. However, the most recent research has hypothesized that the development of polycystic ovary syndrome may be a combined effect from an environmental exposure and a genetic effect while a fetus is developing in utero. It is believed that excess exposure to the reproductive hormone testosterone in utero may potentially promote development of this syndrome. However, exposure to this excess testosterone may occur due to a genetic predisposition of hyper secretion of testosterone and environmental toxin exposure may lead to elevation of prenatal testosterone. Thus, polycystic ovary syndrome may be a good example of a female reproductive disorder that relies on both environmental and genetic factors for development. The prevalence and features of the polycystic ovary syndrome in an un-selected population. Between July 1998 and October 1999, 400 unselected consecutive premenopausal women (18-45 yr of age) seeking a preemploymentphysical at the University of Alabama at Birmingham were studied (223 Black, 166 White, and 11 of other races). Evaluation included a history andphysical examination, a modified Ferriman-Gallweyhirsutismscore, and serum screening for hyperandrogenemia, hyperprolactinemia, and 21-hydroxylase-deficient nonclassicaladrenal hyperplasia. Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. The vast majority of these reports have studied White populations in Europe, used limited definitions of the disorder, and/or used bias populations, such as those seeking medical care. Body measures were obtained, and body hair was quantified by a modified Ferriman-Gallwey(F-G) method. All exams were initially performed by 2 trained nurses, and any subject with an F-G score above 3 was reexamined by a physician, the same for all patients. Hirsutismwas defined by a F-G score of 6 or more, and hyperandrogenemiawas defined as a total or free testosterone, androstenedione, and/or dehydroepiandrosteronesulfate level above the 95th percentile of control values [i.
Epidemiology P r i m a r y h y p e r p a r a t h y r o i d i s m c a n o c c u r a t a n y a g e medicine 524 order paroxetine on line amex, b u t t h e g r e a t m a j o r ity of cases occur over the age of 45 years medications in pregnancy paroxetine 10 mg mastercard. Clinical Primary hyperparathyroidism is most often detected incidentally by routine biochemical screening treatment restless leg syndrome purchase discount paroxetine on line. Most patients are either asymptomatic or experi ence subtle and vague symptoms such as fatigue medicine cat herbs paroxetine 20 mg lowest price, depression medicine zolpidem purchase genuine paroxetine line, difficulty in concentration medicine xanax order cheapest paroxetine and paroxetine, and generalized weakness medicine 750 dollars purchase paroxetine 20 mg fast delivery. G Gastrointestinal: Hypercalcemia associated symptoms include anorexia medicine 035 buy paroxetine with a mastercard, nausea, vomiting, constipation, and peptic ulcer disease. G Psychiatric and neurocognitive: Patients may have depressed mode, lethargy, emotional lability, and decreased cognitive function. Imaging G Sestamibi scan: 99mTc sestamibi localizes to the mitochondria of para thyroid cells, which are rich in mitochondria. Disadvantages include difficulty of localization of nonstandard locations and the potential of confusion with thyroid abnormalities, and interoperator variability. G Selective venous sampling: the veins draining the parathyroid region can be sampled. Low serum phosphorus, increased 24-hour urinary calcium excretion, elevated serum 1,25-dihydroxyvitamin D may be seen. It is important to rule out familial hypocalciuric hypercalcemia because usually the course of this disease is benign and parathyroidectomy is not indicated. Past medical history should be carefully obtained as these patients are asymptomatic and have a history of elevated calcium levels since childhood. Secondary hyperparathyroidism should also be ruled out (either from a renal source or from decreased calcium absorption/intake or vitamin D deficiency). Treatment Options Medical Medical treatment is indicated in patients who do not meet the criteria for surgery, refuse surgery, or are poor surgical candidates. Medications used in the treatment of osteoporosis, such as bisphosphonates, may be useful. Surgical Surgery is curative and is indicated in all cases with symptomatic dis ease. Following are the indications of surgery in asymptomatic patients: (1) serum calcium "1. Preoperative imaging localization allows for guided and minimally invasive parathyroi dectomy in most cases. Common ectopic sites include the thymus/mediastinum, transesophageal groove, retroesophageal, intrathyroidal, and the carotid sheath. Head and Neck 499 this disease is more likely to be associated with profound hypercalcemia or hypercalcemic crisis. In a bilateral neck exploration, identify all four glands; perform a subtotal or total parathyroidectomy with thymectomy and autotransplantation of gland as needed. It is controversial if a subtotal or total parathyroi dectomy should be performed. After a bilateral exploration, a subtotal or total parathyroidectomy with auto transplantation can be done. Treatment consists of treating the initial cause of the secondary hyperparathyroidism. N Tertiary Hyperparathyroidism Tertiary hyperparathyroidism is due to prolonged hypercalcemia that causes parathyroid gland hyperplasia. Most commonly seen after renal transplant for end-stage renal disease that is associated with severe secondary hyperparathyroidism. Stuttgart/ New York: Thieme; 2009:197225 500 Handbook of OtolaryngologyHead and Neck Surgery 5. N Etiology G Iatrogenic (surgical): this is the most common cause of hypoparathyroid ism. This may occur after surgery on the neck (thyroidectomy, parathy roidectomy, or neck dissection). It usually occurs as a result of manipulation of blood supply to the parathyroid glands during surgery or injury to or removal of one or more parathyroid glands. G Hypoparathyroidism may also occur in the setting of hungry bone syndrome,following surgery. This is usually associated with severe preoperative hy perparathyroid bone disease. G Autoimmunity: this occurs secondary to immune-mediated destruction of parathyroid glands. G Hypoparathyroidism may occur due to abnormal development of the parathyroid glands. This is usually associated with DiGeorge syndrome, which is a congenital abnormality of the third and fourth branchial pouches and results in the absence of parathyroid glands and thymus. N Clinical Signs and Symptoms Patients present with symptoms and signs of hypocalcemia (see Chapter 5. Differential Diagnosis Hypoparathyroidism is usually associated with hypocalcemia (low serum calcium levels), hyperphosphatemia (high phosphate levels), and low or 5. Note that, in contrast, hungry bone syndromeis associated with hypocalcemia, and hypophosphatemia (low phosphate levels). Patients with hypoparathyroidism may require lifelong supplementation with calcium and vitamin D, except for those with transient hypoparathyroidism. The goal of treatment is to maintain serum calcium levels in the low normal range. G Hypocalcemia occurs in patients with renal failure, vitamin D deficiency, magnesium deficiency, acute pancreatitis, and with hypoparathyroidism and pseudohypoparathyroidism. A basic 502 Handbook of OtolaryngologyHead and Neck Surgery metabolic panel and a comprehensive metabolic panel measure the total calcium levels (bound plus unbound), although it is the free (unbound) form that is most important. N Control of Calcium Metabolism Calcium is absorbed from the gut, stored in the bone, and excreted by the kidneys. G Calcitonin: Calcitonin is synthesized in the C cells of the thyroid and causes a decrease in plasma calcium and phosphate levels. N Hypocalcemia Etiology G Hypoparathyroidism: the most common cause is iatrogenic (surgery); see Chapter 5. G Renal failure G Vitamin D deficiency G Hypomagnesemia G Acute pancreatitis G Hyperphosphatemia Clinical G Neuromuscular irritability: Patients may present with tingling, par esthesias in fingers and periorally, tetany, carpopedal spasm, seizures, irritability, and confusion. G Other manifestations include subcapsular cataracts, dry flaky skin, and brittle nails. Head and Neck 503 Evaluation Serum albumin concentration should be measured in patients with hypocalcemia. When albumin is low, the calcium level should be corrected (adjusted) for the level of albumin. G Acute hypocalcemia: Patients with symptomatic tetany, seizures, or stridor need immediate correction of hypocalcemia. G Chronic hypocalcemia: Calcium and vitamin D supplementation are the mainstays of treatment. Vitamin D supplementation is given as ergocalciferol (vitamin D2), which has a long duration of action, or calcitriol (Rocaltrol), which has a short duration of action. N Hypercalcemia Etiology G Hyperparathyroidism is the most common cause of hypercalcemia; see Chapter 5. Other lab values should be obtained to diagnose the suspected underlying etiology. Treatment Options Treatment should focus on the underlying etiology of hypercalcemia. Use with caution in patients with heart failure or renal failure to avoid fluid overload. The serum electrolytes, calcium, and magnesium levels should be monitored closely. Once the fluid deficit has been corrected, consider adding furosemide (loop diuretic). Bisphosphonates can be given as these inhibit bone resorption by osteoclasts and are effective in lowering calcium levels to the normal range within 2 to 5 days. Calcitonin rapidly lowers serum calcium and can be administered subcutaneously as an adjunct. G Chronic severe hypercalcemia: the cause should be identified and treated accordingly (see Chapter 5. Bisphosphonates, gallium nitrate, or glucocorticoids can be used in the treatment of malignancy associated hypercalcemia. Hypercalcemia associated with granulomatous diseases is also treated with glucocorticoids. If hypercalcemia is caused by medi cation overdose, then that medication should be stopped. Stuttgart/New York: Thieme; 2009 6 Pediatric Otolaryngology Section Editor Michele M. G Many conditions causing respiratory distress in infants resolve spontaneously with growth. The pediatric airway is proportionally smaller than the adult: the tongue is relatively larger and more anterior, the soft palate descends lower, the adenoid is larger, the epiglottis is omega shaped, larger, and more acutely angled toward the glottis; the cricoid ring is narrower, the trachea is shorter and narrower, the surrounding soft tissue is looser, and cartilaginous struc tures are less rigid. Thus the pediatric airway is more prone to compromise by infection, inflammation, neoplasia, and normal breathing. If the object is large enough to cause nearly complete obstruction of the airway, asphyxia may rapidly cause death. Infants are at risk for foreign body aspiration because of their tendency to put everything in their mouths and because of immature chewing. If present, physical findings may include stridor, fixed wheeze, or diminished breath sounds. N Clinical Signs and Symptoms G Stridor: Harsh high-pitched sound of turbulent airflow past partial ob struction in upper airway Inspiratory stridor signifies supraglottic obstruction. G Stertor: Low-pitched, snorting sound resulting from partial nasal/nasopha ryngeal/hypopharyngeal obstruction G Wheezing: A continuous whistling or musical sound on expiration from a small bronchiole constriction F o r s u b j e c t i v e a s s e s s m e n t o f r e s p i r a t o r y d i s t r e s s, s e e Table 6. Difficult delivery, history of prematurity, and postpartum complications (asphyxia, duration of intubation) should be noted. Physical Exam On the physical exam, note respiratory rate, nasal flaring, intercostal and su praclavicular retraction, gasping, or respiratory fatigue. Note change in breathing when positioning child upright, supine, prone, and on each side. Bronchoscopy (rigid or flexible) may be both diagnostic and therapeutic (see A1 in Appendix A). Obtain gastric emptying scans and esophageal pH monitoring if reflux is suspected. Other Tests Although pulmonary function testing with a flow-volume loop can help distinguish inspiratory versus expiratory as well as intrathoracic versus extrathoracic obstruction, the test requires a cooperative subject and is not 510 Handbook of OtolaryngologyHead and Neck Surgery often feasible in children! Polysomnography is very helpful in the evaluation of possible pediatric sleep-related respiratory disorders; a dif ferentiation between obstructive versus central apnea can be obtained. N Treatment Options Acute choking, with respiratory failure associated with airway foreign body obstruction, may be successfully treated at the scene using standard first aid techniques such as the Heimlich maneuver, back blows, and abdominal thrusts. Even in less urgent settings, expeditious removal of airway foreign bodies is recommended and a workup may be performed. Medical D e f i n i t i v e m a n a g e m e n t w i l l, o f c o u r s e, d e p e n d u p o n t h e s p e c i f i c d i a g n o s i s. But in general terms, for the child with airway compromise continuous mon itoring with pulse oximetry is necessary. Supplemental humidified oxygen, racemic epinephrine, or heliox may be implemented. Surgical Again, definitive management will, of course, depend upon the specific diagnosis. However, many cases of laryngomalacia may be managed with observation (see Chapter 6. Subglottic stenosis can be dilated, or a cricoid split or car tilage graft reconstruction performed (see Chapter 6. N Outcome and Follow-Up the child should be monitored closely overnight in case of bleeding or edema compromising airway. Child can be fol lowed with the usual well-child checks, and immunizations should be kept up to date. L a r y n g o m a l a c i a i s a t e m p o r a r y p h y s i o l o g i c d y s f u n c t i o n d u e t o a b n o r m a l f l a c cidity of laryngeal tissues or incoordination of supralaryngeal structures. Comorbidities, including prematurity, cardiovascular malformation, and neurologic and congenital or chromosomal abnormalities, are present in! N Clinical Signs and Symptoms Most commonly, patients present with intermittent inspiratory stridor that is relieved by neck extension and a prone position. In extreme cases, patients become cyanotic, have a poor oral intake, have chest retractions, and develop pectus excavatum. N Evaluation Physical Exam An examination of any child with a possible breathing problem should discern if there is an oxygenation problem, and if so, an oxygen require ment. In the physical examination, one should assess for the location of a possible obstruction and include auscultation, inspection for chest retrac tion, assessment for cyanosis and other anomalies such as micrognathia. To diagnose laryngomalacia and assess for other upper airway abnor malities, direct flexible endoscopic examination during respiration must be performed. Direct laryngoscopy and bronchoscopy in the operating room is the definitive evaluation. Pathology H i s t o l o g i c a l l y, s u b m u c o s a l e d e m a a n d l y m p h a t i c d i l a t a t i o n a r e s e e n. Pediatric Otolaryngology 513 Hollinger considered the occurrence of two or more synchronously as causal in airway obstruction. These factors include an inward collapse of aryepiglot tic folds, an elongated epiglottis (flaccid) curled on itself, anterior and medial collapsing movements of the arytenoid cartilages, posterior and inferior displacement of the epiglottis, short aryepiglottic folds, and an overly acute angle of epiglottis. N Treatment Options Medical If an infant has good progress, which is indicated by adequate weight gain and normal development, then surgical therapy is not necessary. Surgical In one series of 985 patients with laryngomalacia, 12% required surgical intervention. Patients who should be considered for surgical management are those with severe stridor and failure to thrive, obstructive apnea, weight loss, severe chest deformity, cyanotic attacks, pulmonary hypertension, or cor pulmonale. Supraglottoplasty is performed using carbon dioxide laser or laryngeal microscissors, or other cold instruments such as pediatric eth moid thru-cutting forceps. Most commonly, surgery involves removal of the prolapsing aryepiglottic fold with cuneiform cartilage or division of tight, short aryepiglottic fold. Unilateral supraglottoplasty has been advocated by some to reduce the risk of supraglottic stenosis. Potential complications include continued airway obstruction and poste rior stenosis. In the event of continued airway obstruction, a tracheotomy may be necessary until the child outgrowslaryngomalacia. The use of postoperative antibiotics has not been well evaluated in the literature and is controversial. N Outcome and Follow-Up Supraglottoplasty relieves symptoms of airway obstruction in 90% of patients. Congenital laryngeal stridor (laryngomalacia): etiologic fac tors and associated disorders. G It typically requires a tracheotomy for maintenance of airway until vocal fold mobility returns, or definitive airway surgery is performed. Usually, however, the voice quality is de graded when there is an intervention to enlarge/improve the laryngeal airway. Acquired cases are most likely to occur as a result of surgery in the chest or from forceps delivery or infections. N Clinical Signs Vocal fold immobility can be seen using flexible laryngoscopy in the clinic. Pediatric Otolaryngology 515 Differential Diagnosis G Vocal fold fixation G Laryngeal mass G Laryngeal web N Evaluation Physical Exam Assess for stridor, respiratory effort and rate, color, and weight (plot on a growth chart). Flexible laryngoscopy is mandatory (it may show twitching of cords with respiration; it typically shows paramedian vocal folds). Other complications related to laryngeal airway surgeries include dysphonia, aspiration in 4 to 6%, and dyspnea in 3 to 8% of patients undergoing arytenoid procedures. Other procedures have not been studied enough to ascertain their complication rates. Assessment for aspiration should be done preoperatively, as posterior glottic expansion surgery can increase risk of aspiration. These two Prolene sutures, placed through car tilage adjacent to the tracheal opening at the time of surgery and secured to the neck skin with Steri-Strips, greatly facilitate the replacement of a tracheotomy tube into the airway if there is accidental displacement. To help prevent displacement, the tracheotomy appliance should be secured to the skin with four sutures as well as the umbilical neck tie. Overall, arytenoidopexy and arytenoidectomy yield high rates of success ful decannulation. G Most clefts are short, but complete laryngotracheoesophageal clefts have a mortality rate greater than 90%. Failed fusion of the poste rior cricoid lamina and incomplete development of the tracheoesophageal septum results in a laryngeal cleft, an abnormal communication of the larynx and esophagus. N Clinical Signs and Symptoms the r e a r e n o p a t h o g n o m o n i c f i n d i n g s. Small clefts, whose anatomic involvement is limited to the interarytenoid musculature, present with stridor and feeding problems. There may be coughing, choking, stridor, aspiration pneumonias, or cyanotic episodes. However, the most severe clefts are accompanied by aphonia, severe upper airway obstruction, and respiratory distress.
Limited or guarded range of motion with pain treatment zoster order paroxetine 20 mg online, local tenderness treatment 4 stomach virus generic 20 mg paroxetine amex, swelling treatment qt prolongation order paroxetine 10 mg without prescription, deformity and possibly ecchymosis over the affected area are common symptoms 8 dpo generic paroxetine 20 mg on-line. Distal Forearm Fractures Wrist injuries associated with significant pain medicine bg purchase paroxetine overnight, swelling medicine logo cheap paroxetine uk, ecchymosis treatment of gout buy paroxetine 20mg with amex, crepitance treatment yellow fever purchase paroxetine now, or deformity should be considered to be fractured until proven otherwise. Forearm fractures may also result in concomitant vascular, neurological, ligament and tendon injuries. Further, as distal forearm fractures are the result of trauma, careful inspection for other traumatic injuries should be included, such as elbow, shoulder, neck, head, and hip. In general, most distal forearm fractures should be managed by an orthopedic or hand surgeon and consultation is recommended. Occasionally patients with noticeable ganglia will complain of mild nuisance pain, and less often of severe pain. In the assessment of wrist pain in the absence of palpable ganglia, the unexplained wrist pain may be a result of occult ganglia and should be included in the differential diagnosis. The pain from an occult dorsal lesion has been linked to the compression of the posterior interosseous nerve. The clinical symptoms may include episodic tingling, numbness, blanching white fingers, pain and paresthesia, burning sensation, clumsiness, poor coordination, sleep disturbance, hand weakness measured in grip strength, and diffuse muscle, bone and joint pain from the fingers to the elbow. Laceration Management A thorough history of the injury, with particular attention to mechanism, potential degree of wound contamination, potential for foreign bodies, and presence of other trauma should be obtained. Additionally, inquiry of personal factors that may contribute to delayed healing or increased risk for infection, such as diabetes mellitus, chronic renal failure, or the use of immunosuppressive medications should be included. For persons >10 years, Tdap is preferred to Td if the patient has never received Tdap and has no contraindication to pertussis vaccine. Human Bites, Animal Bites and Associated Lacerations A careful history for time and location of the bite should be obtained as it will help guide clinical decisions regarding prophylaxis. If possible, information about the type of animal and its health status as well as the circumstances related to why the bite occurred should be obtained. Hand/Finger Osteoarthrosis Most cases of osteoarthrosis are believed to result from genetic factors, although discrete trauma is a potential cause. The initial assessment is usually relatively concise and generally involves securing a diagnosis and initiating treatment. Medical History Asking the patient open-ended questions allows gauging of the need for further discussion or make specific inquiries to obtain more detailed information. Consider initiating the clinical visit with an open-ended question such as What can I do for you More specific questions for hand, wrist, and forearm conditions include: Symptoms: What symptoms are you having Prior Injuries and Prior Treatments: Have you had this problem or similar symptoms previously with this hand Evidence appears most consistent in the retrospective studies for age, obesity, female gender, diabetes mellitus, and combinations of forceful and repetitive grasping. Table 2: Possible Risk Factors for Carpal Tunnel Syndrome this list is based on prospective, cross-sectional, and case-control studies, case series, and case reports. A click or clunk in the ulnar wrist joint may be reproduced with forearm rotation (supination/pronation). Commonly reported mechanisms of injury include a fall on an outstretched hand(222-224) as well as sports. Those with occupational cases will tend toward symptomatic onset after a discrete traumatic event such as a slip and fall. Crush Injuries and Compartment Syndrome Patients have pain, and may have paresthesias. Those with vascular compromise may have a cool extremity compared with the unaffected limb. However, there are many causes of compartment syndrome including trauma, excessive traction from fractures, tight casts, bleeding disorders, burns, snakebites, intraarterial injections, infusions, and high pressure injection injuries. Wrist Sprains Patients invariably have incurred an acute traumatic event, usually a slip, trip, or fall with forceful loading of the wrist joint usually in a fully deviated position. Mallet Finger the mechanism of injury most typically involves forcefully striking the tip of the extended digit on an object. Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) Epidemiological evidence is weak, thus lines of query are unclear and causal conclusions tenuous. Symptoms are variable and may include pain, stiffness, clicking, snapping, and locking. It is reportedly usually not associated with pain, in contrast with carpal tunnel syndrome that appears to more frequently involve pain. Patients with traumatic causes of ulnar neuropathy tend to have motor symptoms, whereas those with idiopathic or non-trauma related causes usually manifest sensory symptoms. The medical history should search for sensory symptoms including paresthesias with precision of the location of the paresthesias to a typical radial nerve distribution on the dorsal hand, particularly in the first dorsal web space. Distinguishing from other sources of sensory symptoms is usually possible, particularly including radiculopathies and other entrapment syndromes. An assessment of motor symptoms, including wrist extensor weakness as well as wrist drop, are also helpful, particularly in conjunction with absence of weakness in other distributions. Non-Specific Hand/Wrist/Forearm Pain Patients most commonly give a history of gradual onset of pain or other symptoms in the absence of discrete trauma. Scaphoid Fracture Historical features most commonly involve a high-energy injury such as a fall on an outstretched, extended hand with immediate, non-radiating pain in the radial carpus. Other common mechanisms include grasping a steering wheel in a frontal motor vehicle crash, or direct blow to the scaphoid such as when using the heel of the wrist as a hammer. Distal Phalanx Fractures and Subungual Hematoma Tuft fracture should be suspected when a patient presents with a crush injury or perpendicular shearing force injury to the fingertip, particularly if there is a subungual hematoma. Injuries resulting in avulsion of the nail plate can also be associated with tuft fractures. Middle and Proximal Phalangeal and Metacarpal Fractures Careful history regarding the mechanism of injury including and direct axial blow or angular or rotational trauma will reflect substantially on the nature of the fracture and its inherent stability. Human Bites, Animal Bites and Associated Lacerations A detailed medical history pertaining to tetanus and in the case of animal bites, rabies immunization status, and underlying medical conditions such as diabetes mellitus or other immune-compromising conditions is important. Hand/Finger Osteoarthrosis Patients usually have no recalled acute traumatic event. A minority have a history of significant trauma, such as a fracture or dislocation. Regardless of cause, symptoms usually consist of gradual onset of stiffness and non-radiating pain. Gradual joint enlargement is often present, although frequently unnoticed by the patient. Swelling, erythema, warmth and other signs of infection or inflammation are not present, and if present signal an inflammatory, crystalline arthropathy, septic arthritis or other cause. The history should include symptoms affecting any other joints in the body, presence of other potential causes. Physical Examination Guided by the medical history, the physical examination includes: General observation of the patient; and Appropriate regional examination of upper limbs (hands, wrists, forearms, elbows, arms, shoulders, and neck). Are there differences in use depending on whether there is active rather than casual observation and examination These aspects of the physical examination are under-rated, yet perhaps the most important aspects for ascertainment of degrees of impairment and severity of the condition. Most components of the examination are at least in part, subjective since the patient must exert voluntary effort or state a response to a stimulus such as the sensory examination or tenderness. In many cases of hand, wrist, or forearm problems, there are no strictly objective findings. Exceptions include palpable trigger finger, ganglia, thenar atrophy, and fracture-related deformities. In some cases, careful examination will reveal one or more truly objective findings, such as swelling, deformity, atrophy, reflex changes or spasm, fasciculations, trophic changes, or ischemia. Regardless of whether completely objective findings are present, all findings should be documented in the medical record. Regional Examination of Hand, Wrist, and Forearm the inter-related hand, wrist, forearm, arm, shoulder, and neck should be examined individually and functionally together for observation of use, function, swelling, masses, redness, deformity, asymmetry, or other abnormality. Specific areas of decreased pinprick sensation may indicate median or ulnar nerve compression. Physicians should primarily rely on the clinical history as well as the physical examination. The most sensitive screening methods appear to combine night discomfort, abnormal Katz hand diagram, and abnormal sensibility by monofilament Semmes-Weinstein testing comparing affected with unaffected nerve distributions. It reportedly has high sensitivity and specificity; however, it is a historical finding rather than a true physical examination sign. The historical feature is positive when a patient reports shaking his or her hand in an effort to relieve paresthesias. However, some patients only have tenderness over the flexor surface of the metacarpal phalangeal joints, which may make this examination more difficult. A ganglion may be present on either inspection, or for smaller ganglia, only on palpation. The severity of symptoms on physical examination is usually the basis for aspiration or surgical excisions. Fractures are most commonly discovered by deformity in the context of focal pain and an inciting trauma history. Some occur without deformity and are only found on x-rays, although most have focal tenderness on a careful palpatory examination. Neurovascular Screening the neurologic and vascular status of the hand, wrist, forearm, and upper limb should include peripheral pulses, motor function, reflexes, and sensory status. Examining the neck and cervical nerve root function is also recommended for most patients. For example, a C6 radiculopathy may cause tingling in the thumb and index finger and may affect the wrist extensors while T1 radiculopathy can present as dysfunction of the intrinsic muscles of the hand. Assessing Red Flags Potentially serious conditions for the hand, wrist, and forearm are listed in Table 3. Some believe the physical examination is highly useful(255) while others suggest the physical examination findings are of limited use in securing a diagnosis as compared with a careful history, and add little to a careful history combined with electrodiagnostic evidence. These include Semmes-Weinstein monofilament test, Ten Test, 2-point discrimination, paper clips and various devices. However, sensibility (ability to sense or detect cutaneous stimuli) decreases with age resulting in challenges in interpreting results. A positive test results when a filament of greater than normal size is required in order for its application to be perceived by the patient. A positive test occurs when the taps cause paresthesias or shooting pain in the median nerve distribution. It is unclear if these two means of performing this sign result in different sensitivities and specificities. A positive test produces paresthesias in the distribution of the affected median nerve. A positive test is indicated by tingling or paresthesia into the thumb, index finger, and middle and lateral half of ring finger within 30 seconds. Swelling is generally not present, although it may be present with an acute, large tear. The examiner should generally attempt to reproduce catching or snapping in the ulnar wrist joint, either by having the patient place the wrist into a position that elicits the symptoms and/or moving the wrist and forearm through a combined supination movement with simultaneous movement of the wrist from flexion to extension. Crush Injuries and Compartment Syndrome the physical examination ranges from mild abnormalities with mild injuries. Kienbock Disease the physical examination may be normal early, but generally the patient has mild to moderate dorsal wrist tenderness while also having asymmetric, limited range of motion. Swelling often signifies a fracture fragment, while most are extensor tendon ruptures(264) and have no significant swelling. Flexor Tendon Entrapment (Tenosynovitis and Trigger Digit) Patients without triggering will typically have tenderness localized over the A1 pulley. Active movement is often required to demonstrate triggering as passive motion is often normal. Some believe swelling and crepitus are also only present among those with peritendinitis if there is no inflammatory or infectious disease. Pain in the affected compartment is generally present with use or any provocative maneuver. Sensory loss is typically most prominent at the palmar tip of the 5th finger, in contrast with ulnar neuropathies at the elbow which present with sensory loss on the palmar and dorsal surfaces of the 5th digit. Motor weakness may be demonstrated by resisting spreading of the fingers to assess intrinsic muscle strength. A vascular exam and auscultation for bruits should be performed,(283) particularly for those cases thought to involve vascular symptoms and hypothenar hammer-like symptoms. Radial Nerve Entrapment the physical examination attempts to localize the site of nerve entrapment and should include sensory (especially sensation) and motor components (movement, range of motion, strength, reflexes) to localize the entrapment. Non-Specific Hand/Wrist/Forearm Pain the examination is generally without any unequivocally objective evidence. Qualitative muscle strength testing may be weak compared with the unaffected side. Precise documentation of the location of the pain should be made with consideration for photographing the location for future reference. In cases where the pain does not migrate, the probability of specifically defined pathology is believed to increase. Scaphoid Fracture Physical examination findings include antalgic behavior with avoidance of use of the hand, and tenderness over the scaphoid tubercle. The scaphoid tubercle is located at the volar wrist at the junction of the distal wrist crease under the flexor carpi radialis. The tubercle becomes prominent and readily palpable with radial deviation of the wrist. Patients may also have tenderness over the snuffbox, absence of tenderness in the distal radius, wrist joint effusion,(287-289) and scaphoid pain on axial loading of the thumb (scaphoid compression test). An isolated finding of snuffbox tenderness appears to be sensitive, but has poor positive predictive value for scaphoid fracture. Passive range of motion and joint stability should be assessed through dorsal, volar, and lateral stressing. An estimate of subungual hematoma size relative to the nail bed surface should be noted. Middle and Proximal Phalangeal and Metacarpal Fractures Prior to fracture manipulation, physical examination includes evaluation of digital nerves using two point discrimination or pin prick, tendon and ligament integrity with active and passive range of motion at each joint, vascular status with capillary refill, and surrounding soft tissue structures of affected areas. Bone alignment should be checked for rotational deformity by finger flexion of hand, with the nails pointing toward the scaphoid tubercle. The natural alignment will be disrupted if a rotational fracture is present, such that one finger will overlap another. Distal Forearm Fractures Comprehensive physical examination for traumatic injuries at the wrist as well as elbow, shoulder, neck, head, and hip should be included.
Another function related to movement is the movement of substances inside the body treatment diffusion order paroxetine cheap online. The cardiac and visceral muscles are primarily responsible for transporting substances like blood or food from one part of the body to another medicine 751 purchase paroxetine now. When we exert ourselves more than normal medicine journal buy cheap paroxetine 10 mg on-line, the extra muscle contractions lead to a rise in body temperature and eventually to sweating treatment of ringworm paroxetine 20 mg lowest price. Skeletal Muscles as Levers Skeletal muscles work together with bones and joints to form lever systems medicine 20 purchase genuine paroxetine online. The muscle acts as the effort force; the joint acts as the fulcrum; the bone that the muscle moves acts as the lever; and the object being moved acts as the load symptoms e coli cheap paroxetine online. There are three classes of levers medications hyponatremia buy 20 mg paroxetine with mastercard, but the majority of the levers in the body are third class levers treatment zone lasik 10mg paroxetine visa. A third-class lever is a system in which the fulcrum is at the end of the lever and the effort is between the fulcrum and the load at the other end of the lever. The third-class levers in the body serve to increase the distance moved by the load compared to the distance that the muscle contracts. The trade-off for this increase in distance is that the force required to move the load must be greater than the mass of the load. For example, the biceps brachia of the arm pulls on the radius of the forearm, causing flexion at the elbow joint in a third class lever system. A very slight change in the length of the biceps causes a much larger movement of the forearm and hand, but the force applied by the biceps must be higher than the load moved by the muscle. For example, in order to flex your elbow, you need to contract (shorten) the biceps brachii and other elbow flexor muscles in the anterior arm. Notice that in order to extend your elbow, the posterior arm extensor muscles need to contract. For example, in order to be able to flex the elbow, the elbow extensor muscles must extend in order to allow flexion to occur. The size of motor units varies throughout the body, depending on the function of a muscle. One of the ways that the body can control the strength of each muscle is by determining how many motor units to activate for a given function. This explains why the same muscles that are used to pick up a pencil are also used to pick up a bowling ball. Contraction Cycle Muscles contract when stimulated by signals from their motor neurons. The motor end plate contains many ion channels that open in response to neurotransmitters and allow positive ions to enter the muscle fibre. The positive ions form an electrochemical gradient to form inside of the cell, which spreads throughout the sarcolemma and the T-tubules by opening even more ion channels. Muscles continue contraction as long as they are stimulated by a neurotransmitter. When a motor neuron stops the release of the neurotransmitter, the process of contraction reverses itself. Calcium returns to the sarcoplasmic reticulum; troponin and tropomyosin return to their resting positions; and actin and myosin are prevented from binding. Sarcomeres return to their elongated resting state once the force of myosin pulling on actin has stopped. A single nerve impulse of a motor neuron will cause a motor unit to contract briefly before relaxing. If the motor neuron provides several signals within a short period, the strength and duration of the muscle contraction increases. If the motor neuron provides many nerve impulses in rapid succession, the muscle may enter the state of tetanus, or complete and lasting contraction. A muscle will remain in tetanus until the nerve signal rate slows or until the muscle becomes too fatigued to maintain the tetanus. Isometric contractions are light contractions that increase the tension in the muscle without exerting enough force to move a body part. When people tense their bodies due to stress, they are performing an isometric contraction. Holding an object still and maintaining posture are also the result of isometric contractions. Muscle tone is a natural condition in which a skeletal muscle stays partially contracted at all times. All muscles maintain some amount of muscle tone at all times, unless the muscle has been disconnected from the central nervous system due to nerve damage. They are very resistant to fatigue because they use aerobic respiration to produce energy from sugar. Near the spine and neck regions, very high concentrations of Type I fibres hold the body up throughout the day. Muscles quickly tire as they burn through their energy reserves under anaerobic respiration. The Cardiovascular/Circulatory System Cardiovascular or Circulatory system means the system of heart and blood vessels of human body. The term cardio is derived from cardiac meaning heart and the term vascular means blood vessels. So the name itself indicates that cardiovascular systems is the system of heart and blood vessels. The cardiovascular or circulatory system consists of the heart, blood vessels, and approximately 5 litres of blood that the blood vessels transport. Even at rest, the average heart easily pumps over 5 litres of blood throughout the body every minute. The Cardiovascular or Circulatory System the Heart the heart is a hollow muscular organ made of strong cardiac muscles. In fact, push of the heart is the major force that causes circulation of blood throughout human body. Human beings have a closed type of circulatory system in which blood does not come in direct contact with body tissues. Materials are exchanged between blood and body tissues through the walls of blood vessels. Its temperature 38 degrees Celsius, is always slightly higher than body temperature. Main Blood Vessels There are three main types of blood vessels; Arteries, Capillaries and Veins. The first part of the systemic circulation is the aorta, a massive and thick-walled artery. When the aorta receives almost 5 litres of blood from the heart, it recoils and is responsible for pulsating B. As the aorta branches into smaller arteries, their elasticity goes on decreasing and their compliance goes on increasing. The venous system finally coalesces into two major veins: the superior vena cava (roughly speaking draining the areas above the heart) and the inferior vena cava (roughly speaking from areas below the heart). Plasma is an important component of the blood and transports nutrients throughout the body. Additionally, plasma has the following functions: Transport Waste: Plasma transports waste products, such as uric acid, creatinine and ammonium salts, from the cells of the body to the kidneys. Maintain Blood Volume: Approximately 7 percent of the plasma is protein, the protein that has the highest concentration in plasma is albumin, a protein important for tissue repair and growth. This high concentration of albumin is important for maintaining the osmotic pressure of the blood. Albumin is also present in the fluids that surround the cells, known as the interstitial fluid. Because of this, water is not able to move from the interstitial fluid into the blood. Balances Electrolytes Plasma carries salts, also called electrolytes, throughout the body. These salts, including sodium, calcium, potassium, magnesium, chloride and bicarbonate are important for many bodily functions. Without these salts, muscles would not contract, and nerves would not be able to send signals to and from the brain. It is the Great Defender Plasma carries other proteins besides albumin throughout the body. Immunoglobulins, also known as antibodies, are proteins that fight off foreign substances, such as bacteria, that invade the body. Fibrinogen is a protein necessary to help the platelets (cells in the blood) to form blood clots. By carrying these proteins, the plasma is playing a critical role in defending the body against infection and blood loss. Carbon dioxide, produced by cells, is transported in the blood to the lungs, from which it is expelled. Ingested nutrients, ions, and water are carried by the blood from the digestive tract to cells, and the waste products of the cells are moved to the kidneys for elimination. Most substances are produced in one part of the body and transported in the blood to another part. Various hormones and enzymes that regulate body processes are carried from one part of the body to another within the blood. Warm blood is transported from the inside to the surface of the body, where heat is released from the blood. Albumin is also an important blood buffer and contributes to the osmotic pressure of blood, which acts to keep water in the blood stream Shock There are 4 different types of shock however regardless of the cause, shock is a life-threatening condition that occurs when the body is not getting enough blood flow. From there it is pumped through the pulmonary semilunar valve into the pulmonary artery on its way to the lungs. When it gets to the lungs, carbon dioxide is released from the blood and oxygen is absorbed. These vessels can develop throughout the body and specifically in the heart as an adaptation to ischemia. When there is severe stenosis or narrowing in blood vessels these vessels serve as bridges connecting territory supplied by one vessel to that of another. A decrease in oxygen is known as hypoxia and a complete lack of oxygen is known as anoxia. These conditions can be fatal; after approximately four minutes without oxygen, brain cells begin dying, which can lead to brain damage and ultimately death. In the average human, around 7,572 litres of blood travel daily through about 96,560 kilometres of blood vessels approximately. One of the most common diseases of the circulatory system is arteriosclerosis, in which the fatty deposits in the arteries causes the walls to stiffen and thicken the wall. The causes are a build-up of fat, cholesterol and other material in the artery walls. This can restrict blood flow or in severe cases stop it all together, resulting in a heart attack or stroke. A stroke involves blockage of the blood vessels to the brain and is another major condition of the circulatory system. An aortic aneurysm occurs when the aorta is damaged and starts to bulge or eventually tear, which presents as severe internal bleeding. Circulation and Body Systems the Lungs the circulatory system of the lungs is the portion of the cardiovascular system in which oxygen depleted blood is pumped away from the heart, via the pulmonary artery, to the lungs and returned, oxygenated, to the heart via the pulmonary vein. Oxygen deprived blood from the superior and inferior vena cava enters the right atrium of the heart and flows through the tricuspid valve (right atrioventricular valve) into the right ventricle, from which it is then pumped through the pulmonary semilunar valve into the pulmonary artery to the lungs. Systemic Circulation Systemic circulation is the portion of the cardiovascular system which transports oxygenated blood away from the heart through the aorta from the left ventricle where the blood has been previously deposited from pulmonary circulation, to the rest of the body, and returns oxygen depleted blood back to the heart. It branches from the abdominal aorta and returns blood to the ascending vena cava. It is the blood supply to the kidneys, and contains many specialised blood vessels. It is a network of lymphatic vessels and lymph capillaries, lymph nodes and organs, and lymphatic tissues and circulating lymph. Blood moves from the heart, through a network of arteries, arterioles and capillaries. As the blood flows through the capillaries, it brings vital nutrients to body cells and removes waste. Any interruption in this circulatory system can have a ripple effect on vessels and capillaries downstream. A common way to test blood flow is simply to apply pressure to the skin, and then to wait to see how long it takes for blood to flow back into the site. The muscle cells of the heart are unique and responsible for the electrical stimulation that leads to proper mechanical function. Myocardial cells have several different electrophysiologic properties: automaticity, excitability, conductivity, contractility. Conduction of the Heart the cardiac conduction system is a group of specialized cardiac muscle cells in the walls of the heart that send signals to the heart muscle causing it to contract. As the heart beats, it circulates blood through pulmonary and systemic circuits of the body. In the diastole phase, the heart ventricles are relaxed and the heart fills with blood. Functional syncytium is the ability of the heart to function independently and because all myocardial cells are interconnected which allows easy flow of electrical charges the heart contracts as a single unit known as a functional syncytium. Preload Is the tension in the chamber of the heart at the end of diastole of that chamber. In paramedic practice we are primarily concerned with ventricular preload and this can be defined as the tension in the ventricle at the end of ventricular diastole. The degree of tension correlates to the stretch of the myocardial wall and hence causes a greater force of contraction due to the starling mechanism. So, the more preload, the greater the percentage of blood ejected from the ventricle, to a point and all other things being equal. Afterload Is the pressure or resistance in which the heart must pump against to exert blood from the left ventricle, which it pumps against the pressure in the aorta (atrial diastolic pressure). If we refer to the left and right ventricular afterload, we are talking about diastolic pressures in the aorta and pulmonary artery respectively. The left ventricular afterload is essentially the arterial diastolic pressure, whereas the right ventricular afterload is the diastolic pressure in the pulmonary artery, which is usually about 15-20mmHg. The greater the afterload, the more impeded the ventricle is in pumping out blood. So, a high diastolic pressure (high afterload), will impede the ability of the left ventricle to pump out blood. The period of contraction that the heart undergoes while it pumps blood into circulation is called systole. The period of relaxation that occurs as the chambers fill with blood is called diastole. Tachycardia decreases ventricular filling which decreases the starling mechanism of myocardium stretch, which decreases cardiac output. Perfusion (again) the ability of the cardiovascular system to provide the tissues with an adequate blood supply to meet their metabolic demands and to effectively removes metabolic waste. A simple equation is needed to work out the mean arterial pressure and is simply the diastolic blood pressure plus 1/3 of the difference between the systolic and diastolic blood pressure (pulse pressure). The capillaries of the body (the smallest vessels) actually have a moderate blood pressure of around 40mmHg. Up to a point the wider pulse pressure the better the state of the circulatory system.
However medicine go down 10mg paroxetine with mastercard, immunocompromised individuals are highly susceptible and infections are likely to have serious consequences treatment 4 toilet infection purchase paroxetine overnight. The Guideline Development Group agreed on the following recommendations based the above studies medications that cause hyponatremia cheap paroxetine 10mg with amex, on their medical and scientifc knowledge and experience from best practice medicine omeprazole cheap paroxetine 20 mg on line. The development of West Nile virus safety policies by Canadian blood services: guiding principles and a comparison between Canada and the United States treatment zona order paroxetine 10 mg on line. Infection is acute and rapid medicine zebra buy paroxetine 10mg without a prescription, but infected individuals would normally be asymptomatic whilst infectious medications 44 175 discount 10mg paroxetine with visa. Infection is generally seasonal with cases occurring during the season when mosquitoes are most active 7r medications generic paroxetine 10 mg fast delivery. In endemic areas, all donors may require specifc screening if cases of transfusion transmission are to be avoided. Decision-making process Dengue and chikungunya are infectious agents which have been present for some time, but more recently have increased in signifcance in relation to transfusion transmission. Transfusion-transmissions of dengue and chikungunya have been reported, but are relatively low in number considering the number of infected individuals. In non-endemic countries, risk may often be mediated through existing malarial deferral policies; where this is not the case, individuals who have visited endemic areas should be deferred for a minimum of 28 days following their return. The Guideline Development Group agreed on the following recommendations based on the above studies, their medical and scientifc knowledge and experience from best practice. Documented cases of post-transfusion malaria occurring in England: a review in relation to current and proposed donor-selection guidelines. Decision-making process the Guideline Development Group agreed on the following recommendations based on data from the above studies, their expert knowledge and experience from best practice. Assessment of a travel Question to identify donors with risk of Trypanosoma cruzi: operational validity and field testing. Decision-making process In non-endemic countries, individuals with potential exposure to T. In endemic countries infected individuals can be identifed through antibody screening, but the possibility of recent infection where antibody has not yet become detectable must be considered. The Guideline Development Group agreed on the following recommendations based on data from the above studies, their expert knowledge and experience from best practice. Individuals presenting as potential donors are likely to be asymptomatic and only those who have previously been diagnosed with babesiosis can be identifed and deferred. Recommendation Defer permanently Individuals who have ever had a diagnosis of babesiosis 7. Decision-making process the identifcation of individuals at risk of leishmaniasis is not straightforward. Although travel to an endemic area is a clear risk, sand fies are not present all year round in many endemic areas. Those spending signifcant amounts of time in such areas may have been exposed, but are likely to remain asymptomatic for long periods of time, in some cases for longer than a year. The Guideline Development Group agreed on the following recommendations based on their expert knowledge and experience from best practice. Recommendations Defer Individuals who have spent extended periods in endemic areas: defer for at least 12 months since their last return 209 Defer permanently Individuals who have ever had a diagnosis of leishmaniasis 7. Decision-making process No publications were identifed that directly address the specifc questions. Recommendations Accept Household contacts of individuals with syphilis Defer Current sexual contacts of individuals with syphilis Former sexual contacts of individuals with syphilis: defer for 12 months since last sexual contact Individuals with gonorrhoea: defer for 12 months following completion of treatment and assess for high-risk behaviour Current sexual contacts of individuals with gonorrhoea Former sexual contacts of individuals with gonorrhoea: defer for 12 months since last sexual contact Defer permanently Individuals who have ever had a diagnosis of syphilis 7. Fatal Yersinia enterocolitica biotype 4 serovar O:3 sepsis after red blood cell transfusion. Decision-making process the Guideline Development Group agreed on the following recommendations based on the above study, their medical and scientifc knowledge and experience from best practice. Recommendation Defer Individuals with recent abdominal symptoms, particularly diarrhoea, suggestive of Y. Decision-making process the Guideline Development Group agreed on the following recommendations based on this published article, their medical and scientifc knowledge and experience from best practice. Risk of acquiring Creutzfeldt-Jakob disease from blood transfusions: systematic review of case-control studies. Managing the risk of transmission of variant Creutzfeldt-Jakob disease by blood products. Decision-making process the Guideline Development Group agreed on the following recommendations based on published literature, their medical and scientifc knowledge and experience from best practice. Three are risk/ beneft studies using mathematical modelling; seven are discussions of available evidence, two of which are by the same author. Evaluation of the de-selection of men who have had sex with men from blood donation in England. Quantitative estimate of the risks and benefts of possible alternative donor deferral strategies for men who have had sex with men. Moreover, the studies use epidemiological data from the developed world and the risk estimates are applicable only to the blood transfusion services in which they were carried out. Scientifc background on the risk engendered by reducing the lifetime blood donation deferral period for men who have sex with men. Why are all men who have had sex with men even once since 1977 indefnitely deferred from donating blood Reconsidering the lifetime deferral of blood donation by men who have sex with men. However, he considered that a continued policy of permanent deferral was diffcult to justify on scientifc grounds, in the absence of evidence of increased risk resulting from a deferral period of fve years since last sexual activity. They conclude that, in Canada, any potential negative consequences of a change in deferral policy would be offset by benefts. No evidence of a signifcantly increased risk of transfusion-transmitted human immunodefciency virus infection in Australia subsequent to implementing a 12-month deferral for men who have had sex with men. Recommendations Defer Current sexual contacts of individuals whose sexual behaviours put them at high risk of transfusion-transmissible infections Former sexual contacts of individuals whose sexual behaviour put them at high risk of transfusion-transmissible infections: defer until 12 months since last sexual contact Defer permanently Individuals whose sexual behaviour put them at high risk of transfusion transmissible infections 7. Two papers (Cramplin et al, Aitken et al) considered the risks of blood-borne virus infection in users of injected anabolic steroids, with somewhat differing conclusions. The quality of evidence of the observational studies of Crampin and Aitken is limited by the extremely small size of the study populations. There are no criteria for the assessment of mathematical models; the authors acknowledge the limitations of accuracy because of the need to estimate some inputs. Prevalence of infection was signifcantly lower than in heroin injectors (18%) or amphetamine injectors (12%). Steroid injectors should not be neglected in blood-borne virus prevention efforts. Body piercing as a risk factor for viral hepatitis: an integrative research review. Relationship of cosmetic procedures and drug use to hepatitis C and hepatitis B virus infections in a low-risk population. Epidemiology of hepatitis C infection and its public health implications in Puerto Rico. Decision-making process the papers selected confrmed that the procedures in question carry a risk of transfusion-transmissible infection but provided no recommendations regarding deferral. Recommendation Defer Individuals who have had acupuncture, piercing, tattoos, scarifcation or any other invasive cosmetic procedures: defer for 12 months following the last procedure 230 978 92 4 154851 9. All copies must retain all author credits and copyright notices included in the original document. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Hence, the authors hope that this lecture note would be immensely useful in solving this existing problem at significant level. The lecture note is intended for use by laboratory technologist both during their training and in their work places. There are twenty two chapters each beginning with specific learning objectives in which succeeding by a background of the topic in discussion. There are study questions at the end of each chapter for the reader to evaluate his understanding of the contents. In addition, important terms are defined in the glossary section at the end of the text. Special thanks are due to Mohammed Awole, Serkadis Debalke, Ibrahim Ali, Misganaw B/sellasie, Abiye Shume, Shewalem Shifa and Simon G/tsadik for their assistance in reviewing and critiquing this material. For her sustained devotion and extra effort, I express my deep gratitude and sincere appreciation to Zenaye Hailemariam, who has been most supportive with scrupulous attention and dedication in helping me throughout the preparation of this lecture note (Y. Included in its concerns are analyses of the concentration, structure, and function of cells in blood; their precursors in the bone marrow; chemical constituents of plasma or serum intimately linked with blood cell structure and function; and function of platelets and proteins involved in blood coagulation. Mankind probably has always been interested in the blood, since primitive man realized that loss of blood, if sufficiently great, was associated with death. And in Biblical references, to shed blood was a term used in the sense of to kill. Before the days of microscopy only the gross appearance of the blood could be studied. Clotted blood, when viewed in a glass vessel, was seen to form distinct layers and these layers were perceived to constitute the substance of the human body. Health and disease were thought to be the result of proper mixture or imbalance respectively of these layers. Microscopic examination of the blood by Leeuwenhoek and others in the seventeenth century and subsequent improvements in their rudimentary apparatus provided the means whereby theory and dogma would gradually be replaced by scientific understanding. Currently, with the advancement of technology in the field, there are automated and molecular biological techniques enable electronic manipulation of cells and detection of genetic mutations underlying the altered structure and function of cells and proteins that result in hematologic disease. It is composed of different kinds of cells (occasionally called corpuscles); these formed elements of the blood constitute about 45% of whole blood. Blood is about 7% of the human body weight, so the average adult has a blood volume of about 5 liters, of which 2. Blood plasma When the formed elements are removed from blood, a straw-colored liquid called plasma is left. Some of the proteins in plasma are also found elsewhere in the body, but those confined to blood are called plasma proteins. These proteins play a role in maintaining proper blood osmotic pressure, which is important in total body fluid balance. Most plasma proteins are synthesized by the liver, 2 Hematology including the albumins (54% of plasma proteins), globulins (38%), and fibrinogen (7%). Other solutes in plasma include waste products, such as urea, uric acid, creatinine, ammonia, and bilirubin; nutrients; vitamins; regulatory substances such as enzymes and hormones; gasses; and electrolytes. Formed elements the formed elements of the blood are broadly classified as red blood cells (erythrocytes), white blood cells (leucocytes) and platelets (thrombocytes) and their numbers remain remarkably constant for each individual in health. In adults, they are formed in the in the marrow of the bones that form the axial skeleton. Mature red cells are non nucleated and are shaped like flattened, bilaterally indented spheres, a shape often referred to as biconcave disc with a diameter 7. In stained smears, only the flattened surfaces are observed; hence the appearance is circular with an area of central pallor corresponding to 3 Hematology the indented regions. The red cells contain the pigment hemoglobin which has the ability to combine reversibly with 02. In the lungs, the hemoglobin in the red cell combines with 02 and releases it to the tissues of the body (where oxygen tension is low) during its circulation. Carbondioxide, a waste product of metabolism, is then absorbed from the tissues by the red cells and is transported to the lungs to be exhaled. The red cell normally survives in the blood stream for approximately 120 days after which time it is removed by the phagocytic cells of the reticuloendothelial system, broken down and some of its constituents re utilized for the formation of new cells. Their production is in the bone marrow and lymphoid tissues (lymph nodes, lymph nodules and spleen). Increase in their number (eosinophilia) is associated with allergic reactions and helminthiasis. Basophiles have a kidney shaped nucleus frequently obscured by a mass of large deep purple/blue staining granules. Their cytoplasmic granules contain heparin and histamine that are released at the site of inflammation. Small lymphocytes have round, deep-purple staining nucleus which occupies most of the cell. They have more plentiful cytoplasm that stains pale blue and may contain a few reddish granules. Their cytoplasm stains pale grayish blue and contains reddish blue dust-like granules and a few clear vacuoles. They are capable of ingesting bacteria and particulate matter and act as "scavenger cells" at the site of infection. Platelets these are small, non nucleated, round/oval cells/cell fragments that stain pale blue and contain many pink granules. They 8 Hematology are produced in the bone marrow by fragmentation of cells called megakaryocytes which are large and multinucleated cells. When blood vessels are injured, platelets rapidly adhere to the damaged vessel and with one another to form a platelet plug. During this process, the soluble blood coagulation factors are activated to produce a mesh of insoluble fibrin around the clumped platelets. This assists and strengthens the platelet plug and produces a blood clot which prevents further blood loss. It also carries nutrients from the gastrointestinal tract to the cells, heat and waste products away from cells and hormones form endocrine glands to other body cells. It also adjusts body temperature through the heat-absorbing and coolant properties of its water content and its variable rate of flow through the skin, where excess heat can be lost to the environment. Blood osmotic pressure also influences the water content of cells, principally through dissolved ions and proteins. In postnatal life in humans, erythrocytes, granulocytes, monocytes, and platelets are normally produced only in the bone marrow. Lymphocytes are produced in the secondary lymphoid organs, as well as in the bone marrow and thymus gland. Although many questions 10 Hematology remain unanswered, a hypothetical scheme of hemopoiesis based on a monophyletic theory is accepted by many hematologists. According to this theory, the main blood cell groups including the red blood cells, white blood cells and platelets are derived from a pluripotent stem cell. This stem cell is the first in a sequence of regular and orderly steps of cell growth and maturation. The pluripotent stem cells may mature along morphologically and functionally diverse lines depending on the conditioning stimuli and mediators (colony-stimulating factors, erythropoietin, interleukin, etc. During fetal life, hemopoiesis is first established in the yolk sac mesenchyme and later transfers to the liver and spleen. The splenic and hepatic contribution is gradually 11 Hematology taken over by the bone marrow which begins at four months and replaces the liver at term. From infancy to adulthood there is progressive change of productive marrow to occupy the central skeleton, especially the sternum, the ribs, vertebrae, sacrum, pelvic bones and the proximal portions of the long bones (humeri and femurs). Hemopoiesis occurs in a microenvironment in the bone marrow in the presence of fat cells, fibroblasts and macrophages on a bed of endothelial cells. An extracellular matrix of fibronectin, collagen and laminin combine with these cells to provide a setting in which stem cells can grow and divide. In the bone marrow, hemopoiesis occurs in the extravascular part of the red marrow which consists of a fine supporting reticulin framework interspersed with vascular channels and developing marrow cells. A single layer of endothelial cells separates the extravascular marrow compartment from the intravascular compartment. When the hemopoietic marrow cells are mature and ready to circulate in the peripheral blood, the cells leave the marrow parenchyma by passing through fine "windows" in the endothelial cells and emerge into the venous sinuses joining the peripheral circulation. Increased demands for cells as a consequence of disease or physiologic 14 Hematology change are met by increased cell production. Several hematopoietic growth factors stimulate differentiation along particular paths and proliferation of certain progenitor cells. In addition, there are several different cytokines that regulate hematopoiesis of different blood cell types. Cytokines are small glycoproteins produce by red bone marrow cells, leucocytes, macrophages, and fibroblasts. They act locally as autocrines or paracrines that maintain normal cell functions and stimulate proliferation. The classes of hematopoietic growth factors and their functions are described in Table 1. Also fatty marrow that starts to replace red marrow during childhood and which consists of 50% of fatty space of marrow of the central skeleton and proximal ends of the long bones in adults can revert to hemopoiesis as the need arises. Formation of apparently normal blood cells outside the confines of the bone marrow mainly in the liver and spleen in post fetal life is known as Extramedullary Hemopoiesis. Formation of Red blood cells (Erythropoiesis) 17 Hematology Erythropoiesis is the formation of erythrocytes from committed progenitor cells through a process of mitotic growth and maturation.
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