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    It fuses space (haemopericardium) which may order malegra dxt plus 160mg on line, in turn generic 160mg malegra dxt plus mastercard, lead to cardiac tam- with the roots of the great vessels above and with the central tendon of ponade buy 160mg malegra dxt plus mastercard. This condition is fatal cardium (parietal layer) and is reflected at the vessel roots to cover the unless pericardial decompression is effected immediately. These are the: •Theanterior (sternocostal) surface comprises the: right atrium, atri- • Transverse sinusalocated between the superior vena cava and left oventricular groove, right ventricle, a small strip of left ventricle and atrium posteriorly and the pulmonary trunk and aorta anteriorly the auricle of the left atrium. The heart I 19 Superior vena cava Portion of right atrium derived from sinus venosus Limbus Musculi fossa ovalis pectinati Fossa ovalis Crista terminalis Opening of coronary sinus Inferior Valve of the vena cava coronary sinus Valve of the inferior vena cava Fig. Note that blood flows over both surfaces of the anterior cusp of the mitral valve Pulmonary valve (posterior, anterolateral and anteromedial cusps) Mitral Opening of right coronary artery valve Aortic valve (Anterior (right coronary) cusp, Left posterior (left coronary) cusp, right posterior (non-coronary) cusp) Fig. Anterior Anterior The aortic and pulmonary valves are closed and the cusp Septal cusp mitral and tricuspid valves open, as they would be Posterior cusp Posterior during ventricular diastole cusp cusp 20 Thorax The heart chambers • The infundibulum is the smooth walled outflow tract of the right The right atrium (Fig. This groove corresponds internally to the crista terminalisaa • Receives oxygenated blood from four pulmonary veins which drain muscular ridge which separates the smooth walled atrium (derived posteriorly. The latter contains horizontal ridges of musclea • On the septal surface a depression marks the fossa ovalis. The thick wall is necessary to septum secundum gives rise to a patent foramen ovale (atrial septal pump oxygenated blood at high pressure through the systemic circula- defect) but as long as the two septa still overlap, there will be no func- tion. During ventricular • The wall of the right ventricle is thicker than that of the atria but not systole the free edges of the cusps come into contact and eversion is as thick as that of the left ventricle. During ventricular diastole back-pressure of blood above the cusps forces them to fill and hence close. Times are in msec 22 Thorax The grooves between the four heart chambers represent the sites that right atrium via the coronary sinus. The coronary sinus drains into the offer the least stretch during systole and, for this reason, are where most right atrium to the left of and superior to the opening of the inferior vena of the vessels supplying the heart are situated. The great cardiac vein follows the anterior interventricular branch of the left coronary and then sweeps backwards to the left in the The arterial supply of the heart (Fig. The middle cardiac vein follows the posterior The coronary arteries are responsible for supplying the heart itself with interventricular artery and, along with the small cardiac vein which fol- oxygenated blood. The coronary The coronary arteries are functional end-arteries and hence follow- sinus drains the vast majority of the heart’s venous blood. Under these conditions the increased demand placed on the myocardium cannot be met by the diminished arterial supply. It is situated dilating (angioplasty), or surgically bypassing (coronary artery bypass near the top of the crista terminalis, below the superior vena caval grafting), the arterial stenosis. Ischaemic heart disease is the leading cause of death in the tion pathway can lead to dangerous interruption of heart rhythm. For example, in some people the posterior interven- position of the Purkinje fibres accounts for the almost synchronous tricular branch of the right coronary artery is large and supplies a large contraction of the ventricles. The nerve supply of the heart Similarly, the sinu-atrial node is usually supplied by a nodal branch The heart receives both a sympathetic and a parasympathetic nerve of the right coronary artery but in 30–40% of the population it receives supply so that heart rate can be controlled to demand. Pulmonary trunk They are all covered with Left auricle Posterior pulmonary plexus the mediastinal pleura Sympathetic trunk Phrenic nerve Descending aorta Left ventricle Greater splanchnic nerve Oesophageal plexus on oesophagus Subclavian artery Oesophagus Subclavian vein Trachea Left brachiocephalic Vagus nerve vein Superior vena cava Pulmonary artery Acending aorta Fig. Here the right phrenic enters the caval opening and immediately penetrates the The thoracic sympathetic trunk (Figs 9. It descends in the thorax behind the pleura immediately lateral to costal vein to descend in front of the left lung root onto the pericardium the vertebral bodies and passes under the medial arcuate ligament of the overlying the left ventricle. Note: the phrenic nerves do not pass • The thoracic chain bears a ganglion for each spinal nerve; the first beyond the undersurface of the diaphragm. However, they also transmit fibres which are sensory preganglionic fibres from its corresponding spinal nerve and sends to the fibrous pericardium, mediastinal pleura and peritoneum as well back a grey ramus, bearing postganglionic fibres. Upper limb sympathectomy is used for the treatment of hyperhidro- Irritation of the diaphragmatic peritoneum is usually referred to the sis and Raynaud syndrome.

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    It is the responsibility of the key worker to hand over to the next one generic malegra dxt plus 160 mg on line, to document this in the patient’s notes and to keep the patient informed order malegra dxt plus 160mg with visa. Data/audit 16) The key worker will contribute to the audit of key worker role in their organisation 160 mg malegra dxt plus for sale. This is not intended to have the same connotation as the key worker in social work. Infection Xa9ua Ongoing Management Plan Ongoing Management Plan Follow up arranged (<1yr) 8H8. Referrals made to other Referrals made to other services: services: District Nurse XaBsn Refer to District Nurse 8H72. Referral for specialist opinion Xalst Advised to apply for free 9D05 Entitled to free prescription 6616. Patients from the age of 16 to the end of their 18th year should be treated in the principal treatment centre. O2 (additional O2 consumption)/l ventilation this is low during quiet breathing, but increases with increasing ventilation, especially in the presence of pulmonary disease in severe cases of obstructive lung disease, the O2 cost of additional ventilation may exceed the additional O2 provided by that increased effort O2 cost of quiet breathing ~ 0. The two large arrows represent the directional changes seen in pure chronic respiratory failure and shunting, in a patient breathing room air. Oh: the true incidence is unknown and may only be ~ 7% of "at risk" patients there is, however, good agreement on the overall mortality ≤ 50% this tends to be higher in cases which follow septicaemia, being reported as a. Cardiac Surgery in 2010 Diagnostic Radiology Interventional Genetics Radiology Cardiac Surgery Vascular Cardiology Surgery Research Ischemic Heart Disease Ischemic Heart Disease • Affects more than 1. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease N Engl J Med 2008;358:331-41. Third Time’s a Charm • Multicenter, multinational trial • Prospective, randomized, nonblinded • 1800 patients • Cardiac Surgeon and Interventional Cardiologist each reviewed cardiac cath for “equivalence. Underwent liver transplant complicated by acute rejection and re-transplant 2 weeks later. Thoracic Aorta Aortic Surgery • Aneurysm – enlargement of vessel greater than 50% of normal • Pseudoaneurysm – localized dilation of vessel whose wall does not contain all layers of the vessel, due to trauma, infection or previous operation • Dissection – intimal tear resulting in creation of a pressurized false lumen between the intima and media or adventitia Aortic Anatomy • Aortic Root • Sinotubular Junction • Ascending aorta • Aortic Arch • Descending Thoracic Aorta Laplace’s Law T = P * R / M T = wall tension P = pressure difference across the wall R = radius M = wall thickness Therefore, increased radius and decreased wall thickness lead to increased wall tension… Risk of Rupture • Connective tissue disorders – Marfan’s, Ehler’s-Danlos, Loeys-Dietz, etc • Size at diagnosis • Rate of growth • Inflection point at 6. Microaxial Pumps 3 liters per minute Conclusions • Modern Cardiac Surgery is a “Multidisciplinary Specialty” • Technological advances impact almost every aspect of the field, and ultimately have served to benefit our patients. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. This publication contains the collective views of an international group of experts and does not necessarily represent the decisions or the stated policy of the World Health Organization. Epidemiology of group A streptococci, rheumatic fever and rheumatic heart disease 3 Group A streptococcal infections 3 Rheumatic fever and rheumatic heart disease 5 Determinants of the disease burden of rheumatic fever and rheumatic heart disease 7 References 8 3. Diagnosis of rheumatic fever and assessment of valvular disease using echocardiography 41 The advent of echocardiography 41 Echocardiography and physiological valvular regurgitation 41 iii The role of echocardiography in the diagnosis of acute rheumatic carditis and in assessing valvular regurgitation 42 Clinical rheumatic carditis 42 Classification of the severity of valvular regurgitation using echocardiography 42 Diagnosis of rheumatic carditis of insidious onset 43 The use of echocardiography to assess chronic valvular heart disease 43 Diagnosis of recurrent rheumatic carditis 43 Diagnosis of subclinical rheumatic carditis 44 Conclusions: the advantages and disadvantages of Doppler echocardiography 45 References 46 6. Chronic rheumatic heart disease 56 Mitral stenosis 56 Mitral regurgitation 60 Mixed mitral stenosis/regurgitation 61 Aortic stenosis 61 Aortic regurgitation 62 Mixed aortic stenosis/regurgitation 64 Multivalvular heart disease 64 References 65 Pregnancy in patients with rheumatic heart disease 67 References 68 8. Medical management of rheumatic fever 69 General measures 69 Antimicrobial therapy 69 Suppression of the inflammatory process 69 Management of heart failure 70 Management of chorea 71 References 71 9. Primary prevention of rheumatic fever 82 Epidemiology of group A streptococcal upper respiratory tract infection 82 Diagnosis of group A streptococcal pharyngitis 82 Laboratory diagnosis 83 Antibiotic therapy of group A streptococcal pharyngitis 85 Special situations 87 Other primary prevention approaches 87 References 87 11. Secondary prevention of rheumatic fever 91 Definition of secondary prevention 91 Antibiotics used for secondary prophylaxis: general principles 91 Benzathine benzylpenicillin 91 Oral penicillin 92 Oral sulfadiazine or sulfasoxazole 93 Duration of secondary prophylaxis 93 Special situations 93 Penicillin allergy and penicillin skin testing 94 References 95 12.

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    Advantages of surveys based on interview: They are more representative of the health condition of the community malegra dxt plus 160mg with mastercard. Documentary sources - Clinical records and other personal records malegra dxt plus 160 mg lowest price, death certificates buy malegra dxt plus 160 mg mastercard, publications etc. If you want to know the number of people in your kebele who are properly using latrines, which method of data collection would be appropriate? When the disease occur as epidemic, outbreak, and pandemic it is considered as excess of what is expected. Epidemic: The occurrence of disease or other health related condition in excess of the usual frequency in a given area or among a specific group of people over a particular period of time. There is no general rule about the number of cases that must exist for a disease to be considered an epidemic. If the number of cases exceeds the expected level on the basis of the past experience of the particular population, then it is an epidemic. An epidemic may cover a small area within a city, or an entire nation or may have a worldwide distribution. Common Source Epidemics:- Disease occurs as a result of exposure of a group of susceptible persons to a common source of a pathogen, often at the same time or within a brief time period. When the exposure is simultaneous, the resulting cases develop within one incubation period of the disease and this is called a point source epidemic. Food borne epidemic following an event where the food was served to many people is a good example of point source epidemic. If the exposure to a common source continues over time it will result in a continuous common source epidemic. A waterborne outbreak that spreads through a contaminated community water supply is an example of a common source epidemic with continuous exposure. The epidemic curve may 55 have a wide peak because of the range of exposures and the range of incubation periods. It can occur through direct person to person transmission or it can involve more complex cycles in which the agent must pass through a vector as in malaria. Propagated spread usually results in an epidemic curve with a relatively gentle upslope and somewhat steeper tail. When it is difficult to differentiate the two types of epidemics by the epidemic curve, spot map (studying the geographic distribution) can help. Mixed Epidemics:- The epidemic begins with a single, common source of an infectious agent with subsequent propagated spread. Steps in Epidemic Investigation There is no fixed step in the investigation of epidemics but the following step can be considered as one option. Preparations can include: Investigator must have the appropriate scientific knowledge, supplies, and equipment to carry out the investigation. It might be difficult for the health extension worker to fully investigate the epidemic, hence, he/she should inform and involve other high level health professionals from the outset. Verify (confirm) the existence of an epidemic This initial determination is often made on the basis of available data. Compare the number of cases with the past levels to identify whether the present occurrence is in excess of its usual frequency. For example the already collected blood film slides can be seen by laboratory experts to check whether the initial report was correct. It is important to investigate the index case (the first case that comes to the attention of health authorities) and other early cases. The importance of the index case and other early cases for diseases that are known to occur in epidemic form, such as relapsing fever, is as an indication to health authorities of the possible start of an outbreak. The sooner the index case and other early cases are investigated, the greater the opportunity to arrest the outbreak at earliest stage possible. The health extension worker requests support from the Woreda Health Office or the nearest Health Center for confirming the diagnosis.

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    Inserting an epidural through tattooed skin is undesir- able as it may bring a plug of ink into the epidural space buy 160 mg malegra dxt plus, the consequences of which are not known discount malegra dxt plus 160 mg amex. In this case cheap malegra dxt plus 160 mg fast delivery, the anesthesiologist is able to locate a small Reproduced with permission from Astra Pharma Inc. Bupivacaine, while second challenge is performing a technical procedure possessing a slower onset of effect, has a longer dura- in a patient who is in active labour. The dermatomal level of block is tested esthesiologist pauses while the patient is having con- by pinprick or ice cube (Figure 14). The patient is able to do an excellent job of re- 20-30 minutes for an adequate epidural block to take maining still, which is quite important during this deli- effect. The higher the surgi- carefully for the moment of the “loss of resistance”, cal site is, the higher the block must be. Table 10 de- when the gentle pressure on the hub of the syringe fi- scribes the dermatomal level of block required for some nally gives way, as the needle has entered the “poten- of the more common surgical procedures which apply tial” space that is the epidural space. Late complications are related to needle and catheter insertion, and include nerve injury, epidural abcess or hematoma, and post-dural puncture head- ache (if the dura is accidentally punctured). Because the dura is a tough membrane, a definite “pop” is often felt as the needle passes through into the intrathecal space. However, if The contraindications to spinal anesthesia are listed in the block dissipates prior to the end of the procedure Table 11. Through- procedures on the distal upper extremity (below the el- out their journey to the axilla, the nerve roots merge bow). After cannulating a vein distal to the surgi- roots travel through the intervertebral foramina and cal site, the operative arm is elevated and an elastic ban- emerge between the anterior and middle scalene mus- dage is applied to promote venous drainage. As they exit the 50 ml of dilute lidocaine (without epinephrine) is then axilla, the plexus divides one final time to form the axil- injected slowly into the cannula in the operative arm. The brachial plexus block provides anesthesia tem to the interstitium provides surgical anesthesia for virtually any type of upper extremity surgery. If the surgical procedure lasts less than 20 rect needle placement is ensured through the use of ei- minutes then one must wait until 20 minutes has ther ultrasound or nerve stimulator. The supraclavicu- lar and interscalene blocks pose the additional risks of There are many potential complications of a brachial pneumothorax, phrenic nerve block and recurrent la- plexus block. Intrathecal injection Figure 17 Brachial plexus: roots, trunks, divisions, cords is a rare complication of interscalene block. Drugs Used in the drugs, there is an ever-increasing variety of tech- agents (both intravenous and inhaled) at our dis- Maintenance of Anesthesia niques used to provide general anesthesia. Emergence techniques strive to achieve the following goals, specific effects such as analgesia or muscle relaxa- known as the “Four A’s of Anesthesia”: tion and therefore can be used to achieve the de- • Lack of Awareness: unconsciousness. The practice of using combinations of agents, each for a specific purpose, is what is termed • Analgesia: the abolition of the subconscious re- “balanced anesthesia”. An example of a balanced actions to pain, including somatic reflexes technique would be the use of propofol for induc- (movement or withdrawal) and autonomic re- tion of anesthesia; the administration of des- flexes (hypertension, tachycardia, sweating flurane and nitrous oxide for maintenance of un- and tearing). Be- • improved hemodynamic stability cause the above-described goals were achieved by a progressive depression of the central nerv- • more effective muscle relaxation ous system rather than by any direct or specific 56 • more rapid return of respiratory function, conscious- Induction ness and airway control following the completion of The goal of the induction phase of anesthesia is to in- the procedure duce unconsciousness in a fashion which is pleasant, • provision of post-operative analgesia with appropri- rapid and maintains hemodynamic stability. If the anes- ate timing and dosing of opioids administered intra- thetic plan includes control of the airway and ventila- operatively tion then the induction phase also aims to achieve mus- cle relaxation to facilitate endotracheal intubation. A balanced technique is still the most common tech- nique used for the provision of general anesthesia. Anesthesia can be induced by having the patient However, with the development of short-acting intrave- breathe increasing concentrations of inhaled gases by nous agents such as propofol and remifentanil, the mask.

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