By U. Faesul. University of North Carolina at Chapel Hill.

Balance Rehabilitation: Gait training and lower limb resistance training help significantly improve balance in diabetic patients compared with a control exercise regimen (Richardson et al purchase prozac 20mg with mastercard, 2001) buy generic prozac 20 mg on line. Assistive Devices: Assistive devices including canes generic 10 mg prozac otc, walkers, wheelchairs, and ankle-foot orthoses may also be provided if required. Compression caused by:  Obstruction  Invasion  Thrombosis  Or fibrosis of the vessel Lung cancer accounts for 85% of all incidences, malignant lymphomas of non-Hodgkin’s origin are the second main cause, other primary mediastinal tumours like thymoma or germ cell tumours make up <2% of occurrences. Signs & Symptoms  Neck and Facial Swelling  Hoarseness (especially around the eyes)  Headaches  Dyspnoea  Nasal congestion  Cough  Epistaxis  Head Fullness and Pressure  Hemoptysis Sensation  Dizziness  Proptosis  Dysphagia  Stridor  Arm Oedema  Venous Distension in neck and  Syncope thorax *Symptoms often get worse leaning forward or lying down. Also can be used to show location of obstruction and help as a guide for fine needle aspiration biopsy. Causes  Obstruction of lymphatic drainage  Excess fluid secretion from tumour nodules on pericardial surfaces Differential Diagnosis of Pericardial Effusion  Non-malignant e. Treatment Options  Pericardiocentesis plus sclerosing agents like bleomycin or tetracycline  The creation of a pericardial window  Complete pericardial stripping  Systematic chemotherapy 3) Malignant Spinal Cord Compression Compression is caused by extradural metastases from tumours involving the spine. Bone metastases of thoracic (70%), lumbar (20%) or cervical (10%) regions may cause a cord injury. It presents in 5-10% of all cancer patients throughout the course of their disease. Only 10% unable to walk pre diagnosis will recover the ability to mobilise post treatment Signs & Symptoms  Localised back pain o May increase overnight o Does not improve with common analgesics o Worsens with recumberance or with manoeuvres o Worsens with increased pressure e. Severe hypercalcaemia (>13 mg/dl) is linked to a short survival time of several weeks to a few months. Causes  Bone metastases due to increased release of calcium from bone as a result of osteoclastic activity  Increased parathyroid hormone-related protein production  Calcitrol secretion Signs & Symptoms (Serum calcium levels >2. The tumour mass plus surrounding oedema may produce hydrocephalus and as the mass increases, various herniation syndromes may start. However, less than 22% of cancer survivors are physically active and breast cancer survivors have the lowest rate of physical activity of all cancer survivors (Courneya et al 2008). Precautions and contraindications for exercise in breast cancer patients Precautions Contraindications Pts with severe anaemia- delay exercise until improved. Swimming pools – avoid during radiotherapy Pulse at rest >100 beats per minute Severe fatigue – do 10 mins stretching daily Temperature >38°C; respiration frequency >20 per minute Peripheral neuropathy/ataxia – may benefit more from Infections requiring treatment with antibiotics stationary bike than treadmill 9 Fracture risk following hormonal therapy or patients with B thrombocytes <50×10 /l (platelets levels) osteoporosis or bony metastases- avoid high impact activity 81 9 Individuals with cardiac conditions will require B leucocytes <1. This will direct assessment, treatment plan, education needs and goal setting, as well as giving you an idea of the patient’s motivation level. Studies Jones et al, 2004 n=450 Physical Mutrie et al, 2007 n=177 Mutrie et al, 2012 Activity Schneider et al, 2007 n=113 Outcome Exercise, especially a combination of resistance and aerobic can improve physical activity in breast cancer patients during treatment and this can be maintained at a 5 year follow up. Description Breast cancer patients have to deal with the physical and psychologicalside effects of treatment resulting in a substantial impact on QoL. These patients often experience increased physical side effects and more difficulty managing these side effects, and often experience overall reduced QoL. Studies Mental Badger et al, 2007 n=98; Cadmus et al, 2009 n=50; Courneya et al, 2007 n=223; Jones et al, 2004 n=450; Health Mutrie et al, 2007 n=177; Courneya and Friedenreich 1999 n=24 ; Doyle et al 2006 Guidelines; Saxton and Daley et al, 2010 Outcome Exercise can potentially yield a reduction in cancer related depression and anxiety however the higher quality studies found no change. Description Cancer treatment can cause cardiovascular toxicity, pulmonary toxicity resulting in shortness of breath, decreased total lung capacity and decreased diffusion capacity. Studies Kim et al, 2006 n=41; Mutrie et al, 2007 n=177; Physical Adamsen et al, 2009 n=235; Schneider et al, 2007 n=113; Schmitz et al, 2010; Saxton and Daly Capacity 2010; Courneya and Friedenreich 1999 n=24; McNeely et al 2006 n=14. Outcome Category A evidence exercise maintains and improves cardiovascular fitness and pulmornay fitness. Combined aaerobic and resistance exercise, 3 sessions per week for 60 minutes provided the best outcomes. Half of the studies training) does not contribute to the onset or showing statistically significant positive effects worsening of lymphoedema. Type: Supervised program of weights Time: 6 weeks (If a break is taken, back off the level of resistance by 2 wk worth for every week of no exercise (e. Specificity: Tailor type of exercise, as well as intensity, based on the patient’s functional limitations and objective findings Overload, Progression: In order to elicit training adaptations, the intervention must continually challenge the pt to do more than they normally do. Reversibility: it is important to encourage life-long changes in exercise habits, rather than merely performing a set 8 week intervention. Yes cancer stretching) minute Small to medium Low Risk of Bias 7/10 Pedro diagnosis, mean session effect on general age 34. Scottish maintained at 6 Between-group comparisons: breast cancer, circuits) Physical month follow up Yes mean age 51 Control group: Activity with the Low Risk of Bias 8/10 Pedro yrs. QoL was undergoing Mobility Test unchanged at 12 adjuvant weeks but therapy showed a statistically significant improvement at 6 months. Schwartz Group 1 Group 1- Usual Group 2: Group 2: 4 times per Measured at Osteopenia was Random allocation: Yes; et al 2007 Control: 23 medical Moderate 15-30 week for 6 baseline and 6 observed in 39% Concealed allocation: No; patients with management. Weight Between-group comparisons: Exercise: 22 Based weight acceleromet bearing aerobic Yes patients with bearing theraband er. Yes Breast cancer treadmill or elliptical 60-70% of time Esteem Scale Resistance Low Level of Bias mean age 49. Epidemiological statistically Aerobic interventions were progressed Group 3- 2 Studies improved lean Exercise- 78 supervised in a by 10% sets of 8-12 Depression mass and muscle patients with hospital setting. Given improved screening, improved prognosis following diagnosis and the aging population, the number of people living with lung cancer in the community is growing (Granger et al 2011). Pre-Operative Programme Frequency Intensity Type Time 5 Times per week for 60% of baseline peak Aerobic Exercise 20 minutes until surgical aerobic capacity (Supervised Cycle progressing to 30 intervention progressing to 65% Ergometry) minutes after 4 and finally involving weeks of exercising. Implants do not cause ptosis (droop) but are more suited for women with small to moderate sized breasts and those who undergo skin sparring mastectomy’s to reduce ptosis associated with larger breasts. Other reports suggest that silicone implants can rupture and the saline contents seep out resulting in immune system diseases. Despite these reports there is a lack of strong evidence confirming these links and these implants continue to be used routinely. Types of Surgeries 1) One Stage Immediate Breast Reconstruction Surgery Performed with mastectomy. Reservations that immediate reconstruction can delay post-op therapy or subsequent surveillance for recurrence have been refuted by several studies. Benefits:  Immediate reconstruction can offer technical, aesthetic and economical advantages. The skin post mastectomy is allowed to heal, an expander is placed under the chest wall skin and muscles and slowly expanded over a 6 month period.

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With myocardial concussion there is no anatomical cellular injury 20mg prozac with visa, but some functional damage can be seen on two-dimensional echocardiography or other wall-motion studies (41) discount prozac 10mg online. In initial survivors buy prozac 10mg mastercard, if the injury is not surgically addressed, 40% die within 24 hours and 90% are dead by 10 weeks. However, the nature of thoracic aortic injuries in the Scandinavian countries is not well characterized. Furthermore, another study (paper V) was undertaken to review the management of thoracic aortic injuries in Denmark’s busiest medical center, Rigshospitalet in Copenhagen. To clarify the difference, and significance between retrosternal hematoma, and widened mediastinum in thoracic trauma patients. This examination was never done just to make such a diagnosis, since at the time of care of these patients, there was no special attention regarding this diagnosis. For the purpose of analysis, the remaining 74 patients with blunt trauma were separated into two groups: patients with pulmonary contusion and thoracic lesions (n=32), and patients with pulmonary contusion and extrathoracic lesions (n=42). Etiology References Spontaneous - Ruptured aneurysm of the descending thoracic aorta 61, 81, 115 - Avulsion of the 10th intercostal artery from the aorta 21 - Right apical tuberculosis with pleural thickening 69 - Penetrating atherosclerotic aortic ulcer 145 - Ruptured thymic branch aneurysm 60 Iatrogenic - Following sympathectomy 90, 116, 118 - Inadvertent cervical arteriotomy and heparinization 72 - Cannulation of the right internal jugular vein 17, 57 - Subclavian vein catheterization 85 - Extrapleural malposition of chest tube 4 - Following double lung transplantation 52 Traumatic - Motor vehicle crash 7, 13, 65, 68 79,114, 137 - Fall trauma 32, 107 - Industrial crash injuries 114 - Unidentified trauma 76, 127 21 21 Fig. The pleural reflection at the lower margin of the lesion is seen and the costophrenic angle is not obliterated. The most common complication was pain in six patients, chest tube complications and sternal hematoma in two patients each. No patients were found to have a myocardial contusion or aortic injury in the group with sternal fracture. A retrosternal hematoma was found adjacent to many of the fractures and ranged from a few millimeters to 2 centimeters and was more common in fractures to the body of the sternum (Fig. An atherosclerotic (not traumatic) aneurysm was discovered by aortography in one patient who was successfully operated on with a prosthetic graft. One patient had a posttraumatic throacoabdominal aortic aneurysm in the group with widened mediastinum without sternal fractures. Four patients (4/6) in the penetrating group presented with shock and all underwent urgent surgery (emergency room thoracotomy 1, urgent thoracotomy 2, and urgent thoracoabdominal exploration 1) successfully. The treatment and complications in patients with penetrating lung injuries as well as mortality are presented in Tables 8 and 9 respectively. Mechanism of injury (N) (%) - Motor vehicle crash 30 (40) - Fall 24 (32) - Pedestrian-car/tram accident 9 (12) - Crushing 3 (4) - Miscellaneous (abuse 6, football trauma 1) 7 (9. Treatment Complications - Emergency room thoracotomy (right) - None ° Pulmonary hilar cross-clamping ° Ligation of middle lobe pulmonary vessels ° Pneumonorrhaphy of 2 big parenchymal lacerations - Urgent thoracotomy (right) - None ° Ligation of pericardial artery ° Evacuation of pericardial tamponade ° Pneumonorrhaphy of 2 parenchymal wounds; °° One in the right upper lobe °° One in the middle lobe - Urgent thoracotomy (left) - Pain ° Ligation of left internal mammary artery ° Pneumonorrhaphy of 2. In this paper, cardiac wounds involved the left ventricle in three, right ventricle in two, and the pericardium in two patients. The details of surgery in the Copenhagen experience is shown in Table 11, and its mortality in Table 12. Case Operations Lesions 1 Urgent left thoracotomy - 5 mm Apical, and - defibrillation (ventricular fibrillation) pericardial wound - cardiorrhaphy 2 Urgent right thoracotomy - Pericardial lesion - ligation of pericardial artery 3 Urgent left thoracotomy - 1. Case Surgical Procedures Outcome 1 Emergency room thoracotomy - Died during surgery from - cardiorrhaphy exanguination - Rt. Mortality among patients with cardiac injuries (the second patient had a combined cardiac and aortic lesions). Lesion Number Total cardiopulmonary bypass 1 Partial left cardiac bypass * Atrio-aortic 6 * Atrio-arterial 1 * Aortic-arterial 1 30 30 Fig. A 12-mm long rupture in the aortic wall (A), and 11x19 mm pseudoaneurysm located against the defect (B) are clearly illustrated. It highlights the fact that certain entities with significant clinical implications are rare, and that the personal experience in managing these injuries are low among most Scandinavian surgeons. However, when a seriously injured patient is admitted to the emergency department, it is critical to quickly resuscitate the patient (141) and diagnose the full extent of all severe injuries (142, 143). The selection of priorities for the definite treatment of such injuries may tax the wisdom of even the most experienced surgeon, and may present a serious challenge to the less experienced ones. Pain is produced by the friction of one rib fragment against another at the site of fracture, stretching the periosteum with pain release. Reduction of the movement of a fractured rib reduces motion of the underlying lung parenchyma resulting in atelectasis that can lead to pneumonia and death. Chest wall defect which can produce an open pneumothorax, with collapse of the affected lung and impaired ventilation. Paradoxical motion described as flail chest is classically defined as two adjacent ribs fractured in two or more places. The external compression produced by the trauma forces the ribs inward enough to compress the lung and cause contusion. This underlying lung contusion plays a more important role in the pathophysiology of flail chest than does paradoxical movement (25). A simple etiological classification of extrapleural hematoma; spontaneous, iatrogenic and traumatic was presented (Table 2). Insertion of chest tubes is often ineffective and may be dangerous, especially if the pleural space is obliterated. This could be explained by the fact that clinical and laboratory findings of cardiac contusion are sometimes indistinguishable from those found in multiple injuries which were found in the majority of patients in this report (89. Cardiac contusion in this study probably was overshadowed by the overt manifestation of associated skeletal, abdominal, thoracic or cerebral injuries. The incidence of associated aortic rupture was nil in the cases with sternal fractures compared to one in the group of patients with chest trauma without sternal fractures. Postoperative pain was the salient complaint during follow-up visits, causing significant absence from work and even long-term disability (2/29). The retrosternal hematoma in patients with sternal fractures can be differentiated from real mediastinal widening using the features in Tables 3 and 35 35 4, which may aid in the management of sternal fractures and associated injuries. Sternal fractures with or without retrosternal hematomas in this study were not associated with cardiac or aortic injuries, while mediastinal widening is still a fairly reliable clue which should initiate further work-up. The majority of patients with penetrating lung trauma may be treated with chest tubes only (50, 112), while thoracotomy, if indicated, should be performed very soon after admission if it is to be an effective procedure (2, 50). Furthermore, acute thoracotomy is recommended for patients with penetrating chest trauma and in hemorrhagic shock, without evidence of cardiac, aortic, or major vessel injury (103). Chest physiotherapy and pain relief using intravenous analgesia, intercostal nerve blocks, intrapleural and epidural analgesia should be used as needed.

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The mately anastomose with the genicular branches of the popliteal latter branches gain access to the sole deep to abductor hallucis cheap prozac 10mg amex. Posterior to the medial malleolus the structures which can be identifiedafrom front to backaare: tibialis posterior generic prozac 20mg visa, flexor digitorum The trochanteric anastomosis longus 10 mg prozac, posterior tibial artery and venae comitantes, the tibial nerve and This arterial anastomosis is formed by branches from the medial and flexor hallucis longus. It lies close to the trochanteric fossa and pro- • Peroneal arteryathis artery usually arises from the posterior tibial vides branches that ascend the femoral neck beneath the retinacular artery approximately 2. It ends by dividing into a The cruciate anastomosis perforating branch that pierces the interosseous membrane and a This anastomosis constitutes a collateral supply. The deep branch runs • Course: the femoral artery continues as the popliteal artery as it between the 3rd and 4th muscle layers of the sole to continue as the passes through the hiatus in adductor magnus to enter the popliteal deep plantar arch which is completed by the termination of the space. The arch gives rise to plantar metatarsal the capsule of the knee joint and then on the fascia overlying popliteus branches which supply the toes (Fig. In the fossa it is the deepest structure, ren- sends branches which join with the plantar metatarsal branches of dering it difficult to feel its pulsations. Atheroma causes narrowing of the peripheral arteries with a con- • Branches: muscular, sural and five genicular arteries are given off. When symptoms are intolerable, pain is present at The anterior tibial artery rest or ischaemic ulceration has occurred, arterial reconstruction is • Course: the anterior tibial artery passes anteriorly from its origin, required. Disease which is limited in extent may be suitable for inter- membrane giving off muscular branches to the extensor compartment ventional procedures such as percutaneous transluminal angioplasty of the leg. The arteries of the lower limb 95 43 The veins and lymphatics of the lower limb From lower abdomen Inguinal lymph nodes From perineum and gluteal region Vein linking great and small saphenous veins Great saphenous vein Popliteal lymph nodes Short saphenous vein Fig. The arrows indicate the direction of lymph flow Superficial epigastric Inguinal ligament Femoral Pubic tubercle artery Edge of saphenous opening Superficial Femoral vein circumflex Deep fascia of thigh iliac Superficial external pudendal Great saphenous vein Fig. Failure of this ‘muscle pump’ to work efficiently, towards becoming varicose and consequently often require surgery. It passes anterior to the medial malleolus, Varicose veins along the anteromedial aspect of the calf (with the saphenous nerve), These are classified as: migrates posteriorly to a handbreadth behind patella at the knee and • Primary: due to inherent valve dysfunction. It pierces the • Secondary: due to impedance of flow within the deep venous circula- cribriform fascia to drain into the femoral vein at the saphenous open- tion. The terminal part of the great saphenous vein usually receives pelvic tumours or previous deep venous thrombosis. They receive lymph from the majority of the superficial tis- below the medial malleolus, in the gaiter area, in the mid-calf region, sues of the lower limb. They in the perforators are directed inwards so that blood flows from receive lymph from the superficial tissues of the: lower trunk below the superficial to deep systems from where it can be pumped upwards level of the umbilicus, the buttock, the external genitalia and the lower assisted by the muscular contractions of the calf muscles. The superficial nodes drain into the deep nodes tem is consequently at higher pressure than the superficial and thus, through the saphenous opening in the deep fascia. In addition they • The small saphenous vein arises from the lateral end of the dorsal also receive lymph from the skin and superficial tissues of the heel and venous network on the foot. The deep nodes over the back of the calf to pierce the deep fascia in an inconstant posi- convey lymph to external iliac and thence to the para-aortic nodes. This can be congenital, due to aberrant lymphatic formation, or acquired The deep veins of the lower limb such as post radiotherapy or following certain infections. In develop- The deep veins of the calf are the venae comitantes of the anterior and ing countries infection with Filaria bancrofti is a significant cause of posterior tibial arteries which go on to become the popliteal and lymphoedema that can progress to massive proportions requiring limb femoral veins. The veins and lymphatics of the lower limb 97 44 The nerves of the lower limb I Anterior superior iliac spine Inguinal ligament Lateral cutaneous External oblique aponeurosis nerve of thigh Femoral nerve Femoral artery Iliacus Femoral vein Femoral canal Psoas tendon Lacunar ligament Pubic tubercle Lateral cutaneous nerve of thigh Pectineus Iliacus Inguinal ligament Femoral nerve Pubic tubercle Nerve to sartorius To pectineus Tensor fasciae latae Pectineus To vastus lateralis Adductor longus Psoas Femoral vein To vastus intermedius Great saphenous vein and rectus femoris Femoral artery Sartorius Saphenous nerve Intermediate To vastus medialis cutaneous nerve Medial cutaneous of thigh nerve of thigh (Skin of front of thigh) (Skin of medial thigh) Rectus femoris Gracilis Obturator externus Pectineus Posterior division Adductor Adductor brevis longus Anterior division Gracilis Deep fascia (Skin of medial leg Branch to and foot) Fig. The latter supply • Course: the majority of the branches of the plexus pass through the sartorius and pectineus. The latter nerve is the only branch to extend • Intra-abdominal branchesathese are described in Chapter 21. Obese patients sometimes describe paraesthesiae over the • Origins: the anterior divisions of the anterior primary rami of lateral thigh. At this point it lies on iliacus, which it supplies, and is situ- • Anterior divisionagives rise to an articular branch to the hip joint ated immediately lateral to the femoral sheath. It branches within the as well as muscular branches to adductor longus, brevis and gra- femoral triangle only a short distance (5 cm) beyond the inguinal liga- cilis. The nerves unite, and are joined by the lumbosacral trunk (L4,5), artery from the lateral to medial side. The nerve • The superior gluteal nerve (L4,5,S1)aarises from the roots of the crosses the posterior tibial artery from medial to lateral in the mid-calf sciatic nerve and passes through the greater sciatic foramen above and, together with the artery, passes behind the medial malleolus and the upper border of piriformis. In the gluteal region it runs below then under the flexor retinaculum where it divides into its terminal the middle gluteal line between gluteus medius and minimis (both branches, the medial and lateral plantar nerves. In the gluteal region it penetrates and supplies gluteus • Sural nerveaarises in the popliteal fossa and is joined by the sural maximus. It pierces the • The posterior cutaneous nerve of the thigh (S1, 2, 3)apasses deep fascia in the calf and descends subcutaneously with the small through the greater sciatic foramen below piriformis. It passes behind the lateral malleolus and under the supply the skin of the scrotum, buttock and back of the thigh up to flexor retinaculum to divide into its cutaneous terminal branches the knee. It sends four motor branches and a cutaneous supply to the region by passing out of the greater sciatic foramen below pirifor- medial 3 /12 digits. It runs forwards in the pudendal plantar artery to the base of the 5th metatarsal where it divides into (Alcock’s) canal and gives off its inferior rectal branch in the superficial and deep branches. It continues its course to the perineum and the lateral 1 /12 digits and the remaining muscles of the sole. In the gluteal • Branches: region it passes over the superior gemellus, obturator internus and in- • Genicular branches to the knee joint. In addition it supplies the skin over the lateral lower two-thirds • Muscular branchesato the hamstrings and the ischial part of of the leg and the whole of the dorsum of the foot except for the adductor magnus. The central and inferior parts of the acetabulum (a) Iliofemoral ligament (Bigelow’s ligament)ais inverted, Yshaped are devoid of articulating surface. It arises from the anterior inferior iliac spine and notch from which the ligamentum teres passes to the fovea on the inserts at either end of the trochanteric line. The capsule (c) Ischiofemoral ligamentafibres arise from the ischium and some attaches to the femur anteriorly at the trochanteric line and to the bases encircle laterally to attach to the base of the greater trochanter. Posteriorly the capsule attaches to the femur at a The majority of the fibres, however, spiral and blend with the higher levelaapproximately 1 cm above the trochanteric crest. This is an outpouching of synovial 2 Vessels in the ligamentum teres which enter the head through membrane through a defect in the anterior capsular wall under the small foramina in the fovea. The hip joint and gluteal region 103 Gluteus medius Gluteus medius Gluteus minimus Gluteus maximus Superior gluteal artery and nerve Inferior gluteal nerve Piriformis Obturator internus and gemelli Femoral insertion Inferior gluteal artery of gluteus maximus Quadratus femoris Posterior cutaneous nerve of thigh Internal pudendal nerve and artery Sciatic nerve Vastus lateralis Biceps femoris Adductor magnus Semimembranosus Opening in adductor magnus Semitendinosus Biceps (short head) Biceps (long head) Sciatic nerve Semimembranosus tendon Gastrocnemius Fig.

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Everted edges – squamous cell carcinoma Cellulitis – inflammatory reaction spreading through connective tissue planes • Inflammation – Vascular Response Transient vasoconstriction Æ vasodilatation of arterioles Æ hyperaemia (Æ rubor cheap prozac 20mg with visa, calor) Arteriolar dilatation occurs after vasoconstriction and results in an opening of the microvascular bed buy prozac 10 mg on line. Increased blood flow to the injured area is called hyperaemia and causes redness and heat – note also that there is an increase in the net pressure in capillaries and post capillary venules cheap prozac 20 mg mastercard, leading to an outflow of fluid. Direct injury to vessels (or venule endothelial cell contraction) causes alteration of vessel permeability, leading to leakage of fluid and plasma proteins: 1. Endothelial cell contraction and separation of the endothelial junctions (in post- capillary venules) in response to mediators 2. Increased hydrostatic filtration pressure enhances outward movement of fluid and facilitates the passage of larger protein molecules 3. More sustained/serious injury leads to large gaps in endothelial junctions and these changes also affect capillaries (increasing the rate of extravascular fluid flux) 4. Intravascular and extravascular osmotic pressure equalise, the hydrostatic pressure in the tissue increases (so fluid loss is dependent on net hydrostatic pressure) 530. Due to tissue swelling, collagen fibres anchored in the tissue pull open terminal lymphatic channels – leading to increased lymph flow 7. Lymphatic channels assist in draining the fluid and cellular exudate Swelling – accumulation of excess fluid in the interstitial space Æ oedema formation 1. Fibrinous – higher protein content (fibrinogen Æ fibrin) – serosa-lined cavities c. Purulent – production of pus, neutrophils dominant and release lysosomal enzymes e. Catarrhal – mucous membranes The local structure of connective tissue determines the volume of exudate that can collect, extent of swelling, direction of spread, local tension, and associated pain. Accumulation of excess fluid low in protein also leads to oedema, but the fluid is known as a transudate. During inflammation, capillaries open (endothelium, basement membrane, anchoring filaments, intercellular clefts) – while this helps to limit swelling, it raises the possibility of systemic spread of infection agents. Mast cells degranulate in response to injury and discharge their granule contents locally. An immunological mechanism related to IgE which is cytophilic for mast cells Histamine acts on H1 receptors to mediate vasodilatation, and the increase in permeability during the induction phase of the acute inflammatory response. Bradykinin is 100,000 times more active than histamine in increasing vascular permeability, and 10 times more potent in respect to vasodilatory activity. It is involved as a mediator of pain production by direct nerve stimulation, and activation of arachidonic acid metabolism. The eicosanoids (acidic lipids) have a profound effect on many tissues – arteriolar dilation, venous constriction, increased permeability, and stimulate neutrophil adhesion, fever, and pain. The importance of these arachidonic acid derivatives is demonstrated by the effects from inhibiting their generation. Activation of phospholipase A2 stimulates hydrolysis of arachidonic acid from membrane phospholipids. Platelet activating factor is produced by mast cells and leukocytes, inducing platelet aggregation and degranulation (Æ histamine). Its production is initiated by phospholipase A2, and also enhances arachidonic acid metabolism in activated neutrophils. Platelet activating factor also directly causes vasodilatation, promotes increased vascular permeability and is involved in leukocyte aggregation and migration. Cytokines are polypeptide messenger molecules secreted by cells (lymphocytes Æ lymphokines, monocytes Æ monokines). Features: Some are glycoproteins Small, not antigen specific Transient production Pleiotropic – multiple actions, source cells, target cells, redundancy Many have names that reflect the actions that were first discovered – not necessarily the most important factors May be mutually synergistic or antagonistic with other cytokines Notable cytokines include: 1. Tumour necrosis factor – pyrogenic, induces adhesion molecules • Inflammation – Cellular Responses Polymorphonuclear leukocytes are actively attracted (chemotaxis) to the site of acute inflammation where they ingest foreign and degenerate material: 530. Neutrophils – produced in large numbers in bone marrow, first cells to arrive and can function in poor oxygenated conditions. Eosinophils and basophils – limited phagocytic activity, recruited in inflammatory reactions derived from some specific immune responses. Macrophages are derived from monocytes (bone marrow) – the majority of macrophages in inflammatory processes migrate directly from blood vessels. Many lymph node/spleen cells, Kupffer cells, and alveolar/peritoneal macrophages are monocyte-derived. Other similar cells develop specialisation as antigen presenting cells for the immune system. Leukocyte migration (margination, adhesion, emigration, chemotaxis) occurs as follows: 1. Slowing of blood flow and clumping of erythrocytes (rouleaux formation) forces leukocytes to the periphery (margination). Loss of central flow also allows contact between neutrophils, platelets and the endothelium. Expression of adhesion molecules between leukocytes and the endothelium occurs (pavementing). Cell adhesion molecules facilitate leukocyte adhesion by binding to a single cell surface glycoprotein found on activated monocytes, fibroblasts and vascular endothelial cells. Chemotaxis – directional movement of phagocytic cells, mediated by a series of chemical messengers a. Diapedesis – passive escape of erythrocytes – may be facilitated by chemotactic leukocyte migration. Monocytes and macrophages appear after 4 hours and peak 16-24 hours after injury occurs. They have greater killing potential and have a role in preparing the tissue for healing and repair. Adherence between the phagocyte and unwanted material is the first step in the process of phagocytosis. Opsonins, which facilitate adherence of opsonin coated substances to receptors on phagocytes. Specific surface receptors are present on phagocytes for immunoglobulin molecules, C3b and fibronectins – note that not all bacteria bind fibronectins and adhere to phagocytes through non-specific mechanisms. Antibody-mediated opsonization can be enhanced by activation of complement, and is critical if non-specific opsonization is not effective.

If it is necessary to lyse red blood cells discount prozac 20mg free shipping, either hypotonic saline or saponinized saline can be used as a diluent order 20 mg prozac with mastercard. Since acetic acid cannot be used as a diluent purchase prozac 10mg visa, both red and white cells are enumerated at the same time. Cell counts below 200/µl with less than 25% polymorphonuclear cells and no red cells are normally observed in synovial fluid. A low white cell count (200 to 2000/µl) with predominantly mononuclear cells suggests a noninflammatory joint fluid, while a high white cell count suggests inflammation and a very high white cell count with a high proportion of polymorphonuclear cells strongly suggests infection. Eosinophilia may be seen in metastatic carcinoma to the synovium, acute rheumatic fever, and rheumatoid arthritis. It is also associated with parasitic infections and Lyme disease and has occurred after arthrography and radiation therapy. Each product or fraction varies in its individual composition, each contributing to the whole specimen. During ejaculation, 439 Hematology the products are mixed in order to produce the normal viscous semen specimen or ejaculate. These include assessment of fertility or infertility, forensic purposes, determination of the effectiveness of vasectomy, and determination of the suitability of semen for artificial insemination procedures. Collection of semen specimen Give the person a clean, dry, leak-proof container, and request him to collect a specimen of semen at home following 3-7 days of sexual abstinence. When a condom is sued to collect the fluid, this must be well- washed to remove the powder which coats the rubber. Coitus interruptus method of collection should not be used because the first portion of the ejaculate (often containing the highest concentration of spermatozoa) may be lost. Also the acid pH of vaginal fluid can affect sperm motility and the semen may become contaminated with cells and bacteria. This is best achieved by placing the container inside a plastic bag and 440 Hematology transporting it in a pocket in the person’s clothing. Laboratory assays The sample should be handled with car because it may contain infectious pathogens, e. When investigating infertility, the basic analysis of semen (seminal fluid) usually includes: • Measurement of volume • Measurement of pH • Examination of a wet preparation to estimate the percentage of motile spermatozoa and viable forms and to look for cells and bacteria • Sperm count • Examination of a stained preparation to estimate the percentage of spermatozoa with normal morphology Measurement of volume Normal semen is thick and viscous when ejaculated. Estimate the percentage of motile and viable spermatozoa Motility: Place 1 drop (one drop falling from a 21g needle is equivalent to a volume of 10-15µl) of well- mixed liquefied semen on a slide and cover with a 20x20mm or 22x22mm cover glass. Ensure the spermatozoa are evenly distributed (if not, re-mix the semen and examine a new preparation). When more than 60% of spermatozoa are non-motile, examine an eosin preparation to assess whether the spermatozoa are viable or non-viable. Use the low power objective to focus the specimen and the high power objective to count the percentage of viable and non-viable spermatozoa. A large proportion of non-motile but viable spermatozoa may indicate a structural defect in the flagellum. Using the low power objective with the condenser iris closed sufficiently to give good contrast, count the number of spermatozoa in an area of 2 sq mm, i. Estimate the percentage of spermatozoa with normal morphology in a stained preparation Make a thin smear of the liquefied well-mixed semen on a slide. Count 100 spermatozoa and estimate the percentage showing normal morphology and the percentage that appear abnormal. Abnormal semen findings should be checked by examining a further specimen, particularly when the sperm count is low and the spermatozoa appear non- viable and abnormal. When the abnormalities are present in the second semen, further tests are indicated in a specialist center. Each consists of an oval-shaped head (with acrosomal cap) which measures 3-5 x 2-3µm, a short middle piece, and a long thin tail (at least 45µm in length). Staining feature: Nucleus of head-dark blue; cytoplasm of head-pale blue; Middle piece and tail-pink-red. Abnormal spermatozoa: the following abnormalities may be seen: • Head: greatly increased or decreased in size; abnormal shape and tapering head (pyriform); acrosomal cap absent or abnormally large; Nucleus contains vacuoles or chromatin in unevenly distributed; two heads; additional residual body, i. One of the major technologic changes in the clinical laboratory has been the introduction of automated analysis. An automated analytic instrument 449 Hematology provides a means for transfer of a specimen within its complex assembly to a series of self-acting components, each of which carries out a specific process or stage of the process, ending in the analytic result being produced. Automation systems include some kind of device for sampling the patient’s specimen or other samples to be tested (such as blanks, controls, and standard solutions), a mechanism to add the necessary amounts of reagents in the proper sequence, incubation modules when needed for the specific reaction, monitoring or measuring devices such as photometric technology to quantitate the extent of the reaction, and a recording mechanism to provide the final reading or permanent record of the analytic result. Electronic cell counters have 450 Hematology replaced manual counting of blood cells even in clinics and physicians’ office laboratories. Prothrombin time and activated partial thromboplastin time determinations can be done automatically on various instruments. Several instruments are available for precise and convenient diluting, which both aspirate the sample and wash it out with the diluent. Disadvantages of automation Some problems that may arise with may automated units are as follows: • There may be limitations in the methodology than can be used • With automation, laboratorians are often discoursed form making observations and using their own judgment about potential problems • Many systems are impractical for small numbers of samples, and therefore manual methods are still 451 Hematology necessary as back-up procedures for emergency individual analyses • Back-up procedures must be available in case of instrument failures • Automated systems are expensive to purchase and maintain-regular maintenance requires personnel time as well as the time of trained service personnel • There is often an accumulation of irrelevant data because it is so easy to produce the results-tests are run that are not always necessary. Automation in Hematology Automation provides both greater accuracy and greater precision than manual method. Over the last 20 years, instrumentation has virtually replaced manual cell counting, with the possible exception of phase platelet counting as confirmatory procedure. Automation thus allows for more efficient workload management and more timely diagnosis and treatment of disease. The 452 Hematology best source of information about the various instruments available is the manufacturers’ product information literature. The continual advances in commercial instruments for hematologic use and their variety preclude an adequate description of them in this chapter. General principles of hematology instrumentation Despite the number of hematology analyzers available form different manufacturers and with varying levels of sophistication and complexity, two basic principles of operation are primarily used: electronic impedance (resistance) and optical scatter. Technicon Instruments introduced dark field optical scanning in the 1960s, and Ortho Diagnostics systems followed with a laser-based optical instrument in the 1970s. Optical scatter, utilizing both laser and nonlaser light, is frequently used on today’s hematology instrumentation. Cells suspended in an eclectically conductive diluent such as saline are pulled through an aperture (orifice) in a glass tube. In the counting chamber, or transducer assembly, low-frequency electrical current is applied between an external electrode (suspended in the cell dilution) and an internal electrode (housed inside the aperture tube). Electrical resistance between the two electrodes, or impedance in the current, occurs as the cells pass through the sensing aperture, causing voltage pulses that are measurable.

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Hypochromic A lack of color cheap 10mg prozac free shipping; used to describe erythrocytes with an enlarged area of pallor due to a decrease in the cell’s hemoglobin content cheap 10 mg prozac. Hypofibrinogenemia A condition in which there is an abnormally low fibrinogen level in the peripheral blood order 20 mg prozac fast delivery. It may be caused by a mutation in the gene controlling the production of fibrinogen or by an acquired condition in which fibrinogen is pathologically converted to fibrin. Hypogammaglobulinemi A condition associated with a decrease in a resistance to infection as a result of decreased γ-globulins (immunoglobulins) in the blood. Hypoplasia A condition of underdeveloped tissue or organ usually caused by a decrease in the number of cells. A hypoplastic bone marrow is one in which the proportion of hematopoietic cells to fat cells is decreased. The irf may be helpful in evaluating bone marrow erythropoietic response to anemia, monitoring anemia, and evaluating response to therapy. Immune hemolytic An anemia that is caused by premature, immune anemia mediated, destruction of erythrocytes. Diagnosis is confirmed by the demonstration of immunoglobulin (antibodies) and/or complement on the erythrocytes. The cell is morphologically characterized by a large nucleus with prominent nucleoli, a fine chromatin pattern, and abundant, deeply basophilic cytoplasm. Consists of two pairs of polypeptide chains: two heavy and two light chains linked together by disulfide bonds. Immunohistochemical Application of stains using immunologic stains principles and techniques to study cells and tissues; usually a labeled antibody is used to detect antigens (markers) on a cell. Ineffective erythropoiesisPremature death of erythrocytes in the bone marrow preventing release into circulation. Infectious lymphocytosisAn infectious, contagious disease of young children that may occur in epidemic form. The most striking hematologic finding is a leukocytosis of 40—50 X 109/L with 60—97% small, normal-appearing lymphocytes. Serologic tests to detect the presence of heterophil antibodies are helpful in differentiating this disease from more serious diseases. Internal quality control Program designed to verify the validity of program laboratory test results that is followed as part of the daily laboratory operations. Intrinsic factor A glycoprotein secreted by the parietal cells of the stomach that is necessary for binding and absorption of dietary vitamin B12. Ischemia Deficiency of blood supply to a tissue, caused by constriction of the vessel or blockage of the blood flow through the vessel. Jaundice Yellowing of the skin, mucous membranes, and the whites of the eye caused by accumulation of bilirubin. Karyorrhexis Disintegration of the nucleus resulting in the irregular distribution of chromatin fragments within the cytoplasm. Involved in several activities such as resistance to viral infections, regulation of hematopoiesis, and activities against tumor cells. Knizocytes An abnormally shaped erythrocyte that appears on stained smears as a cell with a dark stick- shaped portion of hemoglobin in the center and a pale area on either end. Large granular Null cells with a low nuclear-to-cytoplasmic ratio, lymphocyte pale blue cytoplasm, and azurophilic granules. Leukemia A progressive, malignant disease of the hematopoietic system characterized by unregulated, clonal proliferation of the hematopoietic stem cells. Leukemic hiatus A gap in the normal maturation pyramid of cells, with many blasts and some mature forms but very few intermediate maturational stages. Eventually, the immature neoplastic cells fill the bone marrow and spill over into the peripheral blood, producing leukocytosis (e. Leukemoid reaction A transient, reactive condition resulting from certain types of infections or tumors characterized by an increase in the total leukocyte count to greater than 25 X 109/L and a shift to the left in leukocytes (usually granulocytes). Leukoerythroblastic A condition characterized by the presence of reaction nucleated erythrocytes and a shift-to-the-left in neutrophils in the peripheral blood. Lupus-like anticoagulant A circulating anticoagulant that arises spontaneously in patients with a variety of conditions (originally found in patients with lupus erythematosus) and directed against phospholipid components of the reagents used in laboratory tests for clotting factors. The nucleus is usually round with condensed chromatin and stains deep, dark purple with romanowsky stains. These cells interact in a series of events that allow the body to attack and eliminate foreign antigen. Lymphocytic leukemoid Characterized by an increased lymphocyte reaction count with the presence of reactive or immature- appearing lymphocytes. Reactions are associated with whooping cough, chickenpox, infectious mononucleosis, infectious lymphocytosis, and tuberculosis. Lymphocytosis An increase in peripheral blood lymphocyte concentration (>4 X 109/L in adults or >9 X 109/ L in children). Lymphoma classification Division (grading) of lymphomas into groups, each with a similar clinical course and response to treatment. Marginating pool The population of neutrophils that are attached to or marginated along the vessel walls and not actively circulating. This parameter will correlate with the extent of chromasia exhibited by the stained cells and is calculated from the hemoglobin and hematocrit. Megakaryocyte A large cell found within the bone marrow characterized by the presence of large or multiple nuclei and abundant cytoplasm. Megaloblastic Asynchronous maturation of any nucleated cell type characterized by delayed nuclear development in comparison to the cytoplasmic development. The abnormal cells are large and are characteristically found in pernicious anemia or other megaloblastic anemia. Microenvironment A unique environment in the bone marrow where orderly proliferation and differentiation of precursor cells take place. Mixed lineage acute An acute leukemia that has both myeloid and leukemia lymphoid populations present or blasts that possess myeloid and lymphoid markers on the same cell. Monoclonal An alteration in immunoglobulin production that gammopathies is characterized by an increase in one specific class of immunoglobulin. Monocyte-macrophage A collection of monocytes and macrophages, system found both intravascularly and extravascularly. Morulae Basophilic, irregularly shaped granular, cytoplasmic inclusions found in leukocytes in an infectious disease called ehrlichiosis.

The pre-operative assessment anaesthetist therefore needs to be skilled at assessing and managing these risks order 20 mg prozac free shipping, and in communicating them both to the patient and to the treating surgeon prozac 20 mg mastercard. Consultant-to-consultant communication between anaesthetists buy prozac 20 mg visa, surgeons and critical care physicians is essential, particularly when the patient is high-risk and the benefits of surgery may be outweighed by the risks to the patient. Multidisciplinary meetings should help anaesthetic consultants identify and manage high-risk cases, particularly when major surgery is planned. Risk prediction can be used to guide the patient’s pre-operative care and determine whether the patient needs to see an anaesthetist in the pre-operative assessment clinic. These thresholds can be used as markers to help hospitals determine the level of resources they need to invest to provide their catchment patient population with adequate pre-operative services. Diagnosed peripheral arterial disease Pre-operative and post-operative risks of mortality and morbidity can be estimated with these variables when adjusted for surgical disease and surgical procedures respectively (see Appendix 2). Resources and funding Setting up pre-operative services where none exist requires a substantial time commitment in order to put in place the infrastructure, to recruit staff and to oversee the organisation, administration and processes at all levels. This may well require in the region of 5-10 programmed activities per week but this may vary with the caseload and casemix of the organisation, and will require the appropriate level of administrative support. A time commitment is necessary for the lead anaesthetist adequately to manage the pre-operative service. This role includes liaison with surgeons, clinicians in other specialties, doctors in training, primary care, other anaesthetists, theatres and critical care. The proportion of patients who would benefit from consultant pre-operative assessment depends on the type of surgery undertaken at the hospital, the age and socioeconomic status of the population and the size of catchment area. The pre-operative assessment clinic provides valuable opportunities for teaching – of both undergraduate and 13 postgraduate personnel. This may necessitate increased clinic resources with regard to both the time taken and the space for trainees and students to see patients. Cardiopulmonary exercise testing, when undertaken by trained personnel, takes about 30 minutes to perform and a similar time to discuss the results with the patient. A specialist anaesthetist working with a technician should be able to assess between four and seven patients in a programmed clinical activity. After planned admission Anaesthetists are central to ensuring the safety of patients in the peri-operative period. Operating sessions must be planned to allow time for the anaesthetist responsible for an individual’s care to visit him/ her pre-operatively. It is the responsibility of the individual anaesthetist giving the anaesthetic to ensure that the pre-operative assessment is adequate and that the patient has sufficient information to make a reasoned decision. It is the responsibility of the Trust to ensure that sufficient time is made available for this, as a matter of routine and without undue pressure. Pre-operative anaesthetic assessment is an integral part of the surgical process, and must be included in the estimates of time required for the operating list. The pre-operative assessment process should have identified and addressed problems with individual patients, and provided the patient with appropriate information on the probable peri- operative course. As a part of the pre-operative visit the anaesthetist should: • Establish a rapport with the patient and when relevant the patient’s family. Anaesthetists in training and non-consultant grades should discuss high-risk patients with consultant colleagues. The consultant contacted should ensure that the patient is cared for by an anaesthetist with the expertise required for that particular situation. Failure of the pre-operative service to match personnel to the need of the patient may result in surgery being postponed until the necessary expertise is available. Where possible, department protocols should be adhered to and cancellations for idiosyncratic reasons discouraged. Occasionally, anaesthetists will cancel surgery in patients who have been assessed and prepared by another senior anaesthetist. Anaesthetists should alert their colleagues if there is a failure in following protocol or when the protocol has been ineffective. Differences of opinion should be discussed within a department with the aim of avoiding future cancellations, and protocols modified accordingly. If surgery is cancelled the anaesthetist should: • Explain the reasons for cancellation and ensure that the patient and his/her family understand what will happen next. After unplanned admission Patients requiring anaesthesia after unplanned admission are at higher risk of medical errors and peri-operative complications. The standards and principles for the care of elective patients apply equally to those admitted in an emergency, even though it is often more difficult to achieve them. Clear pathways of care for unplanned admissions are vital and should include surgeons, emergency departments and theatre departments. The purpose of these pathways should be to enable a high standard of care, avoid omissions and prevent excessive periods of starvation and fluid deprivation – particularly in vulnerable groups such as the elderly. There must be clear communication between surgeons, anaesthetists and intensivists with the common goal being the welfare and best interests of the patient. Often a balance has to be reached between prevention of deterioration caused by delaying surgery and the benefit of optimising medical conditions pre-operatively. These discussions should be documented clearly in the patient’s medical notes, particularly when a decision has been made: • To proceed with anaesthesia when potentially important investigations have been omitted or when the patient’s condition has not been optimised. High standards of care must be maintained and the patient’s safety and best interests remain paramount. Children and young people Children and young people have special healthcare needs because they are physically and emotionally different from adults, and need the constant care and support of their parents or guardians. Children should receive care that is integrated and co-ordinated around their particular needs and the needs of the family. They, and their parents, should be treated with respect, and given the necessary support and information to enable them to understand and cope with the proposed surgery and anaesthesia. They should be treated as active partners in decisions about their health and care, and, where possible, be able to exercise choice. Before admission A clear explanation of the proposed surgery and admission procedures should be given to the parents and the child at the initial outpatient clinic visit.