Jon Weingart, M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0004228/jon-weingart
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Important considerations in understanding the physiology of the systemic circulation include the anatomic components of the systemic circulation, physical characteristics of the systemic circulation and of blood, determinants and control of tissue blood fl w, regulation of systemic blood pressure, and regulation of cardiac output and venous return gastritis diet 10 mg bentyl purchase with visa. In addition, the fetal circulation possesses many unique features, which distinguish it from the systemic circulation after birth. Endothelial Function and Regulation of Vascular Tone Endothelial synthesis and release of vasoactive mediators are important elements in the regulation of vascular tone. Substances are released by the endothelium in response to both mechanical and humoral stimuli and generally have an immediate effect upon the adjacent vascular smooth muscle tone. However, there may also be endotheliuminduced long-term effects from vascular remodeling and smooth muscle hypertrophy. Its predominant 365 Endothelial Function the entire vascular system is lined by endothelial cells. Indeed, it is estimated that the adult endothelium is composed of 10 t rillion cells and weighs approximately 1 kg. The luminal side of the endothelium is lined with a "glycocalyx," a w eb of membrane-bound glycoproteins and proteoglycans, which plays an important role in transcapillary flow. The endothelium also regulates smooth muscle proliferation and has an important role in the regulation of glucose and lipid metabolism. Therefore, arteries have strong vascular walls and blood flows rapidly through their lumens. Arterioles Arterioles are the last small branches of the arterial system, having diameters of less than 200 mm. Arterioles have strong muscular walls, which are capable of dilating or contracting and thus controlling blood flow into the capillaries. Indeed, blood fl w to each tissue is controlled almost entirely by resistance to flow in the arterioles. Metarterioles arise at right angles from arterioles and branch several times, forming 10 to 100 capillaries which in turn connect with venules. Capillaries Capillaries are the sites for transfer of oxygen and nutrients to tissues and receipt of metabolic byproducts. Venules and Veins Venules collect blood from capillaries for delivery to veins, which act as conduits for transmitting blood to the right atrium. Nevertheless, walls of veins are muscular, which allows these vessels to contract or expand and thus store varying amounts of blood, depending on physiologic needs. Physical Characteristics of the Systemic Circulation the systemic circulation contains about 80% of the blood volume, with the remainder present in the pulmonary circulation and heart. Our standard physiologic monitors (heart rate, blood pressure, pulse oximetry, capnography) all serve as surrogate markers of organ perfusion and oxygenation.
Right transvaginal sacrospinous colpopexy in obese and elderly women not fit for abdominal surgery was first described by Ritcher in 1968 gastritis diet bentyl 10 mg purchase with amex. Complications of surgical procedures: n Right Transverse Vaginal Sacrospinous Colpopexy Following opening of the posterior vaginal wall vertically, a window space is created between the vagina and the rectum towards the right sacrospinous ligament. A synthetic sling such as the Mersilene mesh fixes the vault to the sacrospinous ligament with a Miya hook 4 cm away from the ischial spine using nonabsorbable suture. During surgery, care is taken not to injure the rectum, pudendal vessels, and nerves at the ischial spine, sciatic nerve and sacral plexus which lie above the ligament. Previous rectal surgery and drainage of pelvic abscess contraindicate this surgery. Chapter 25 · Genital Prolapse n 363 Transabdominal sacral colpopexy comprises suspending the vault to the sacral promontory extraperitoneally using Gore-Tex or Mersilene tape. Injury to the ureter, bladder, sigmoid colon and middle sacral artery should be avoided. Abdominal surgery is elected in young women to avoid coital difficulties, so also in women who develop recurrence following vaginal repair. The introduction of synthetic and biological prosthesis has been utilized extensively to reduce recurrence in highrisk cases, but is mainly used during repeat surgery. Macro porous, nonabsorbable (Marlex, prolene): the pore size is more than 75 nm to allow infiltration by macrophages, fibroblasts, new vessels and collagen fibres. The long-term problem is mesh erosion, infection and dyspareunia caused by hard mesh; it may require its removal surgically. Absorbable polyglactin (Vicryl): It is free of mesh complications, but long-term results need further evaluation. Autologous material (rectus fascia, fascia lata): this requires two sites of operation, vaginal and in facia lata, prolongation of surgery. Poor quality of tissues can also cause recurrence of prolapse and wound infection. The mesh is secured to the arcus tendineus pelvic fascia through transobturator approach. In this, vaginal mucosa is denuded all around and the cavity is obliterated with a series of purse-string sutures starting from the apex downwards. A small rectangular portion of the anterior and posterior vaginal wall are denuded and sutured to each other with several Vicryl sutures, thus obliterating the vagina in the middle. Abdominoperineal surgery described by Zacharin is a difficult surgery required in complicated cases, and if rectal prolapse is also present. Anterior and posterior colporrhaphy may be required for cystocele and rectocele in addition. Posterior intravaginal sling plasty using monofilament polypropylene tape (8 mm wide, 40 cm long) is used to support uterosacral ligaments by creating neo-uterosacral ligaments and the vault is relocated. A 60-year-old woman presents with something coming out per vagina following abdominal hysterectomy 2 years ago.
After distribution to highly perfused tissues, the local anesthetic is redistributed to less well perfused tissues, including Changes during Pregnancy Increased sensitivity (more rapid onset of conduction blockade) may be present during pregnancy gastritis symptoms pain in back buy bentyl 10 mg amex. Plasma protein binding influences the rate and degree of diffusion of local anesthetics across the placenta (see Table 10-1). Acidosis in the fetus, which may occur during prolonged labor, can result in accumulation of local anesthetic molecules in the fetus (ion trapping). Consideration of cardiac output is important for describing the overall tissue distribution of local anesthetics and presumably their intercompartmental clearance. In addition to the tissue blood flow and lipid solubility of the local anesthetic, patient-related factors such as age, cardiovascular status, and hepatic function will also influence the absorption and resultant plasma concentrations of local anesthetics. Protein binding of local anesthetics will influence their distribution and excretion. In this regard, protein binding parallels lipid solubility of the local anesthetic and is inversely related to the plasma concentration of drug (see Table 10-1) (Fi g. Lung Extraction the lungs are capable of extracting local anesthetics such as lidocaine, bupivacaine, and prilocaine from the circulation. Relationships between binding, physiochemical properties, and anesthetic activity. Water-soluble metabolites of local anesthetics, such as paraaminobenzoic acid resulting from metabolism of ester local anesthetics, are readily excreted in urine. Clearance values and elimination half-times for amide local anesthetics probably represent mainly hepatic metabolism, because renal excretion of unchanged drug is minimal (see Table 10-1). Pharmacokinetic studies of ester local anesthetics are limited because of a short elimination half-time due to their rapid hydrolysis in the plasma and liver. Lidocaine the principal metabolic pathway of lidocaine is oxidative dealkylation in the liver to monoethylglycinexylidide followed by hydrolysis of this metabolite to xylidide. Monoethylglycinexylidide has approximately 80% of the activity of lidocaine for protecting against cardiac dysrhythmias in an animal model. This metabolite has a prolonged elimination half-time, accounting for its efficacy in controlling cardiac dysrhythmias after the infusion of lidocaine is discontinued. In humans, approximately 75% of xylidide is excreted in the urine as 4-hydroxy-2,6-dimethylaniline. Hepatic disease or decreases in hepatic blood flow, which may occur during anesthesia, can decrease the rate of metabolism of lidocaine. For example, the elimination half-time of lidocaine is increased more than fivefold in patients with liver dysfunction compared with normal patients. Decreased hepatic metabolism of lidocaine should be anticipated when patients are anesthetized with volatile anesthetics.
Cystic fibrosis mutation analysis gastritis symptoms in the morning 10 mg bentyl purchase with mastercard, its relevance in different ethnic populations, and particularly its use in prenatal diagnosis are central topics in the unfolding understanding of this disease. All children survived with normal bilirubin levels, and all but one child transplanted at 8 years of age are developmentally normal. Prager et al outlined the drugs and metabolic conditions that may acutely elevate unconjugated bilirubin, displace bilirubin from albumin, or precipitate kernicterus. Phototherapy may be required until the transplanted liver is functioning sufficiently to conjugate the increased bilirubin load. Median serum bilirubin levels were 50 and 23 mol/L at 5 and 23 days, respectively, after auxiliary transplantation. Interestingly, rejection episodes Clinical Features Cystic fibrosis is characterized by thick viscous secretions causing obstruction in the pancreas, lungs, liver, intestine, and vas deferens. In patients with cystic fibrosis the defective opening of chloride channels results in diminished chloride and water excretion. In early childhood, chronic pulmonary infections and pancreatic insufficiency are the predominant manifestations. Now, with improved antimicrobial drugs and nutritional support, the life expectancy of patients with cystic fibrosis is commonly extended into the third and even fourth decades of life. Therefore the liver disease associated with cystic fibrosis, which typically becomes manifested in adolescence, is now more frequently encountered. Cirrhosis occurs in about 20% of older children, with portal hypertension developing in 2%. The characteristic histological appearance of the liver is nodular biliary cirrhosis with pathognomonic eosinophilic concretions in the small bile ducts. In the largest reported experience, 12 infants, two thirds of whom were boys, were referred at a median age of 6. Conjugated hyperbilirubinemia was the initial finding in 11 infants and hypoalbuminemia in 1 other. Of these patients, all but one resolved the cholestasis without evidence of chronic liver disease at a median follow-up of 42 months. Liver Transplantation Shunt procedures have been the surgical therapy most often used for intractable variceal bleeding, but they are associated with life-threatening pulmonary and liver decompensation. Although they may delay the need for liver transplantation, the risk is that pulmonary disease will progress and prevent later transplantation. Second, pancreatic insufficiency may cause impaired absorption of immunosuppressants and ongoing nutritional compromise. Third, although liver transplantation palliates the liver complications, it would not be expected to have an impact on other systems involved, particularly lung disease, which may eventually be life-threatening.
This is usually treatable with an enhanced immunosuppression regimen but can lead to progressive graft dysfunction and affect survival gastritis diet 2 go buy generic bentyl 10 mg line. There are several tools designed to help predict which patients will recover and which will ultimately require transplant. They tend to be dynamic and different between centers, depending on local expertise and level of comfort. Vascular Disorders of the Liver Vascular compromise to the liver can result in hepatic dysfunction that sometimes requires transplant. Portal vein thrombosis, for example, is common in fibrotic liver disease and rarely causes liver failure. A new portal vein occlusion can present with a sudden worsening of portal hypertension. Disorders such as Budd-Chiari syndrome or sinusoidal obstruction syndrome (formerly known as venoocclusive disease) can result in liver failure when they occur rapidly. Although shunt procedures can be temporizing, many patents have progressive liver disease and require transplantation. Because most patients with Budd-Chiari syndrome have underlying hematological disorders, they can be at risk for recurrent thrombosis despite transplant and usually require lifelong anticoagulation. Transplant survival outcomes vary, with some groups reporting 5-year survival of 65% and some reporting better rates at 88%. Absolute Contraindications It is important to select recipients who have an acceptable chance of survival intraoperatively as well as after transplantation. Once patients are placed on immunosuppression after transplantation, they are at higher risk for de novo malignancies and may be at increased risk for recurrent malignancy. Psychosocial contraindications to transplant are crucial to understand because inadequate psychosocial support systems portend poor prognosis post transplantation. Both the pretransplant decompensation from liver disease and recovery post transplantation can be very physically and mentally taxing, and patients must have a care partner outside the medical team. Because many patients with liver disease have a history of significant substance abuse, strict abstinence from addictive drugs and alcohol is important. Assess overall health of patient, but overall survival in older patients is decreased. The patient needs to be able to survive the transplant and recover postoperatively. This portends poor prognosis post transplant because pretransplant behaviors predict posttransplant behavior. Evidence exists for good outcomes in France, but with limited resource much controversy surrounds this area in the United States. Poor compliance with medical advice, instructions, and prescribed medications is a contraindication to transplantation. It is paramount that patients adhere to their posttransplant immunosuppression regimen, because organs are a scarce resource. Relative Contraindications Relative contraindications prevent optimal allograft and patient outcome, can vary widely depending on the transplant center, and are sometimes modifiable before transplantation.
Cause of death: patient 4 gastritis symptoms vs ulcer symptoms discount bentyl 10 mg with visa, hepatitis B cirrhosis (no thrombotic complications); patient 6, chronic rejection and portal vein thrombosis; patient 7, renal cell carcinoma; patient 12, hepatitis C cirrhosis; patient 13, stroke with a functioning liver allograft; patient 14, intracranial aneurysm bleeding with a functioning liver allograft. Patients at greatest risk for decompensation are those with encephalopathy or marked jaundice before the procedure. Careful consideration should be given to the potential risk for decompensation after decompression versus the potential benefit. Some patients demonstrate remarkable improvement in liver function after decompression, especially young ones. Most patients improve after the procedure, and if the patient is listed, transplantation may be performed in the event of decompensation. Such criteria should include reversibility of liver injury, primary disease leading to the hepatic venous obstruction, and fitness of the patient to withstand either surgical procedure. The severity of liver failure and the functional liver reserve should be determined by clinical and laboratory data, aided by liver biopsy. Hepatocyte synthetic failure is reflected by serum levels of albumin less than 3 g/dL, prolonged coagulation (prothrombin time greater than 3 seconds more than control), and the inability to conjugate bilirubin and secrete bile (conjugated bilirubin level greater than 3 mg/dL). Development of encephalopathy in end-stage liver disease is generally regarded as an indicator of poor residual liver function. Portosystemic shunt is usually contraindicated in encephalopathic patients because further neurological deterioration may be a consequence of the procedure. The role of liver biopsy in determining the extent of injury caused by long-standing hepatic venous occlusion is not clear. The ambiguity of biopsy findings is illustrated by the favorable clinical course of some shunt patients whose biopsies showed fibrosis at initial presentation. Other similar exclusion criteria for transplantation are hepatic venous occlusion secondary to locally invasive tumors or metastatic extrahepatic malignancies. Several studies outline critical criteria to distinguish shunt versus transplantation candidates. These clinical criteria, when considered with assessment of residual liver function, provide a therapeutic framework for successful management of this otherwise fatal syndrome. In addition, thrombosis of the hepatic veins in the setting of a hypercoagulable state mandates careful evaluation of the portal system, and the absence of clots in the cava and iliac veins should be confirmed before surgery to anticipate the need for portal venous grafts and access sites for venovenous bypass. The operation must be individualized to the unique expression of the disease for each patient. Occasionally the diaphragm must be dissected off the inferior vena cava up to the right atrium. The surgical approach can be modified in the presence of complete obstruction of the suprahepatic vena cava caused by an organized thrombus that is not amenable to thrombectomy. The suprahepatic clamp is removed, and a curvilinear incision through the tendinous portion of the diaphragm exposes the pericardium. An end-to-end anastomosis is performed to the intrapericardial portion of the inferior vena cava.
Antiviral therapy for pre- and post-liver transplantation patients with hepatitis B gastritis diet buy discount bentyl 10 mg. Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B. Long-term clinical and virological outcome after liver transplantation for cirrhosis caused by chronic delta hepatitis. Patterns of hepatitis delta virus reinfection and disease in liver transplantation. Role of lamivudine in the posttransplant prophylaxis of chronic hepatitis B virus and hepatitis delta virus coinfection. Viral and clinical factors associated with the fulminant course of hepatitis A infection. The epidemiological characteristics of chronic hepatitis C infection are evolving and leading to more advanced liver disease; this has significant implications for liver transplantation. Recent trends reveal an increasing prevalence of cirrhosis and hepatocellular carcinoma associated with hepatitis C. The agent was known to be lipid encapsidated and approximately 40 nm to 70 nm in size. Eventually, blind cloning methods were able to identify a portion of the virus and assemble the complete 9. It is mathematically estimated that every nucleic acid in the genome should mutate each day. Although most of these variants are not viable, the resulting viral heterogeneity likely contributes to escape from immune surveillance, survival of the virus within the host, and as discussed later, failure to respond to some antiviral therapies. Genotype 1 is the most prevalent in North America, South America, and western Europe. The distribution of other genotypes includes genotype 2, more commonly found in the Mediterranean and Asia; genotype 3 in Southeast Asia and India; genotype 4 in Africa and the Middle East; genotype 5 in South Africa; and genotype 6 in Southeast Asia and eastern Asia. The worldwide prevalence of chronic infection is estimated to be at least 170 million persons (approximately 3%), although the prevalence varies greatly based on geography. However, transfusions continued to account for approximately 50% of reported cases of acute non-A, non-B hepatitis until more intensive screening of donor risk factors was introduced. This has obvious and significant implications for the prevalence of cirrhosis in the infected population. Mathematical models estimate that the proportion of infected patients with cirrhosis will approach 50% by 2030 Acute hepatitis C 55%-85% Chronic hepatitis C 20%-30% Cirrhosis 3. Circumstances in which the individual acknowledged an exposure risk but would not specify the category. Indeed, the mortality rate attributed to hepatitis C based on death certificate data in the United States doubled over the decade from1995 at 1.
In contrast, the contextsensitive half-times for sufentanil, alfentanil, and fentanyl are longer and depend significantly on the duration of the infusion (see Table 7-4 and gastritis ct order 10 mg bentyl fast delivery. Prompt onset and short duration of action make remifentanil a useful selection for suppression of the transient sympathetic nervous system response to direct laryngoscopy and tracheal intubation in at-risk patients. Changes in remifentanil drug effect predictably follow changes in the infusion rate, making it possible to more precisely titrate to the desired response than with other opioids. Before cessation of the remifentanil infusion, a longer acting opioid should be administered to ensure analgesia when the patient awakens. The spinal or epidural administration of remifentanil is not recommended, as the safety of the vehicle (glycine, which acts as an inhibitory neurotransmitter) or opioid have not been determined. It is important to administer a longer acting opioid for postoperative analgesia when remifentanil has been administered for this purpose intraoperatively. All fentanyl analogs, including remifentanil, have been reported to induce "seizure-like" activity. Depression of ventilation produced by remifentanil is not altered by renal or liver dysfunction. However, those patients might be mistaken to have developed hyperalgesia to opioids. A recent study in rodents has shown that morphineinduced hyperalgesia is associated with glial activation (indicating that this is not an acute phenomenon) and involved anion dysequilibrium potential between microglia and neuron pathway. Patients receiving subanesthetic ketamine infusions experienced less postoperative pain and required less morphine. Supplementing desflurane-remifentanil anesthesia with small-dose ketamine reduces perioperative opioid analgesic requirements. The presence of this methyl group limits first-pass hepatic metabolism and accounts for the efficacy of codeine when administered orally. About 10% of administered codeine is demethylated in the liver to morphine, which may be responsible for the analgesic effect of codeine, although codeine-6-glucuronide may also exert an analgesic effect. Any remaining codeine is demethylated to inactive norcodeine, which is conjugated or excreted unchanged by the kidneys. Most often, codeine is included in medications as an antitussive or is combined with nonopioid analgesics for the treatment of mild to moderate pain. The risk of physical dependence on codeine appears to be less than that of morphine and occurs only rarely after oral analgesic use. An oral preparation of oxymorphone (immediate release) produces maximum plasma concentrations in 30 minutes with associated rapid onset of analgesia. This agent is about twice as potent as oral morphine and has a similar duration of analgesic action. Sustained-release oral oxycodone preparations provide stable plasma concentrations for the treatment of moderate to severe pain.
Lars, 34 years: Finasteride (Finast, fincar, fistide, finpecia) Finasteride is a competitive inhibitor of the enzyme 5alpha reductase, which converts testosterone to dihydrotestosterone. Note that the almost vertical direction of the uterosacral ligament must follow from the cervix to the junction of the second and third sacral vertebrae. They assert that a regulated system in the United States would help offset financial disincentives to donation and increase the number of available organs by boosting motivation for living donation.
Gnar, 33 years: Physical Principles of Radiation Therapy Basic Physics Radiation physics deals with the measurement of energy that is transferred from the radiation source to the tissue under irradiation. During normal inspiration, the decrease in intrathoracic pressure increases the compliance of the pulmonary vasculature, which leads to a relative decrease in pulmonary venous return to the left ventricle. Such a tumour always penetrates back into the loin and is situated high up in the abdomen, well above the pelvis.
Zarkos, 41 years: In split-liver transplantation this can be achieved by preserving the donor celiac axis with the left allograft rather than the right allograft. Scars, Stenosis and Atresia of the Vagina Exclusive scarring of the vaginal and the paravaginal tissues are not uncommon. Appropriate hydration and activated charcoal should be considered within 1 hour after ingestion.
Berek, 60 years: Once clinical malnutrition is evident, it may be difficult to determine whether the cause of malnutrition is from inadequate caloric intake due to loss of appetite, caloric restriction resulting from ascites, or advancing liver synthetic dysfunction in the face of adequate caloric intake. The tumour retains the shape of the normal ovary and has a peculiar solid waxy consistency although cystic spaces due to degeneration of the growth are common. This diversity in mitochondrial function accounts for the many different metabolic diseases now attributed to mitochondrial disorders.
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