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N o t e the p l e xu s a r o u n d the d u o d e n u m, f o r ma t i o n o f d the hepatic sinusoids, and initiation of left-to-right shunts between the vitelline veins. Um bilical Ve ins In i t i a l l y, the u mb i l i c a l v e i n s p a s s o n e a c h s i d e o f the l i v e r, b u t s o me c o n n e c t t o the h e p a t i c s i n u s o i d s g(. B the p r o xi ma l p a r t o f b o t h u mb i l i c a l v e i n s a n d the Fi) r e ma i n d e r o f the r i g h t u mb i l i c a l v e i n the n d i s a p p e a r, s o t h a t the l e f t v e i n i s the o n l o n e t o c a r r y b l o o d f r o m the p l a c e n t a t o tF ie. B nu, us (F) T h i s v e s s e l b y p a s s e s the s i n u s o i d a l p l e xu s o f the l i v e r. Af t e r b i r t h, the l e f t u mb i l i c v e i n a n d d u c t u s v e n o s u s a r e o b l i t e r a t e d a n d l if g r m eh e u me r e s h e p a t i s oam t nt t a n d l i g a m e n t u m v e n o s,u m s p e c t i v e l y. N o t e f o r ma t i o n o f the d u c t u s v e n o s u s, p o r t a l v e i n, a n d h e p a t i c p o r t i o n o f the i n f e r i o r v e n a c a v a. T h e s p l e n i c a n d s u p e r i o r me s e n t e r i c veins enter the portal vein. T h i s s y s t e m c o n s i s t s o fa nh e r i o r c a r d i n a l v e iw h i c h d r a i n the c e p h a l i c p a r t tt, ns o f the e mb r y o, a n d ph e t e r i o r c a r d i n a l v e iw h i c h d r a i n the r e s t o f the t os, ns e mb r y o. T h e a n t e r i o r a n d p o s t e r i o r v e i n s j o i n b e f o r e e n t e r i n g the s i n u s h o r n a n d f o r m the s h oc o m m o n c a r d i n a l v e i D s. D u r i n g the f i f t h t o the s e v e n t h w e e k, a n u mb e r o f a d d i t i o n a l v e i n s) a r e f o r me d: (a the s u b c a r d i n a l v e i, nw h i c h ma i n l y d r a i n the k i d n e yts;es a c r o c a r d i n a l s b) h (v e i n s w h i c h d r a i n the l o w e r e xt r e mi t i e s); tah es u p r a c a r d i n a l v e,i n sh i c h, c nd (w drain the body wall by way of the intercostal veins, taking over the functions of the p o s t e r i o r c a r d i n a l v eFng. F o r ma t i o n o f the v e n a c a v a s y s t e m i s c h a r a c t e r i ze d b y the a p p e a r a n c e o f a n a s t o mo s e s b e t w e e n l e f t a n d r i g h t i n s u c h a ma n n e r t h a t the b l o o d f r o m the l e f t i s channeled to the right side. T h e a n a s t o m o s i s b e t w e e n the a n t e r i o r c a r d i n a l ev e i o p s i n t o tlh e t d v l ns ef b r a c h i o c e p h a l i c v e i ng. B M o s t o f the b l o o d f r o m the l e f t s i d e o f the (F i) h e a d a n d the l e f t u p p e r e xt r e mi t y i s the n c h a n n e l e d t o the r i g h t. T h e t e r mi n a l portion of the left posterior cardinal vein entering into the left brachiocephalic vein i s r e t a i n e d a s a s ma l l v e s s elle ftth s u p e r i o r i n t e r c o s t a l (Feg n 1 2. T h e a n a s t o m o s i s b e t w e e n the s u b c a r d i n a lf o re i n s h lee f t r e n a l v e i n. T h e a n a s t o m o s i s b e t w e e n the s a c r o c a r d i n a lf ov e i n sh lee f t c o m m o n r ms t i l i a c v e i n i g. W h e n the r e n a l s e g me n t o f the i n f e r i o r v e n a c a v a c o n n e c t s w i t h the h e p a t i c s e g me n t, w h i c h i s d e r i v e d f r o m the r i g h t v i t e l l i n e vein, the inferior vena cava, consisting of hepatic, renal, and sacrocardinal s e g me n t s, i s c o mp l e t. W i t h o b l i t e r a t i o n o f the ma j o r p o r t i o n o f the p o s t e r i o r c a r d i n a l v e i n s, the s u p r a c a r d i n a l v e i n s a s s u me a g r e a t e r r o l e i n d r a i n i n g the b o d y w a l l. T h e 4 t h t o 11 t h r i g h t i n t e r c o s t a l v e i n s e mp t y i n t o the r i g h t s u p r a c a r d i n a l v e i n, w h i c h t o g e the r w i t h a p o r t i o n o f the p o s t e r i o r c a r d i n a l v e i n ao r ms shv e i n i g. D o u b l e i n f e r i o r v e n a c a v a a t the l u mb a r l e v e l a r i s i n g f r o m the 4 p e r s i s t e n c e o f the l e f t s a c r o c a r d i n a l. Clinical Corre late s Ve nous Sy ste m De fe cts the c o mp l i c a t e d d e v e l o p me n t o f the v e n a c a v a a c c o u n t s f o r the f a c t t h a t d e v i a t i o n s f r o m the n o r ma l p a t t e r n a r e c o mmo n. T h e l e f t c o mmo n i l i a c v e i n ma y o r ma y n o t b e p r e s e n t, b u t the l e f t g o n a d a l v e i n r e ma i n s a s i n n o r ma l c o n d i t i o n s. A b s e n c e o f the i n f e r i o r v e n a a ra s e s w h e n the r i g h t s u b c a r d i n a l v e i n f a i l s c iva t o ma k e i t s c o n n e c t i o n w i t h the l i v e r a n d s h u n t s i t s b l o o d d i r e c t l y i n t o the r i g h t s u p r a c a r d i n a l v eFng(s. H e n c e, the b l o o d s t r e a m f r o m the ii 3) c a u d a l p a r t o f the b o d y r e a c h e s the h e a r t b y w a y o f the a zy g o s v e i n a n d superior vena cava. The hepatic vein enters into the right atrium at the site of the i n f e r i o r v e n a c a v a. U s u a l l y t h i s a b n o r ma l i t y i s a s s o c i a t e d w i t h o the r h e a r t ma l f o r ma t i o n s. L e f t s u p e r i o r v e n a c as a a u s e d b y p e r s i s t e n c e o f the l e f t a n t e r i o r c a r d i n a l ivc v e i n a n d o b l i t e r a t i o n o f the c o mmo n c a r d i n a l a n d p r o xi ma l p a r t o f the a n t e r i o r c a r d i n a l v e i n s o n the r i g h tF(i s e e 2. The left superior vena cava drains into the right atrium by way of the left sinus horn, that is, the coronary sinus. A d o u b l e s u p e r i o r v e n a cia v c h a r a c t e r i ze d b y the p e r s i s t e n c e o f the l e f t s a a n t e r i o r c a r d i n a l v e i n a n d f a i l u r e o f the l e f t b r a c h i o c e p h a l i c Fvi e i. T h e p e r s i s t e n t l e f t a n t e r i o r c a r d i n a l ve fi n,s tu p e r i o r v e n a c, a v a) l e t he drains into the right atrium by way of the coronary sinus. Circulation Be fore and Afte r Birth Fetal Circulation B e f o r e b i r t h, b l o o d f r o m the p l a c e n t a, a b o u t 8 0 % s a t u r a t e d w i t h o xy g e n, r e t u r n s t o the f e t u s b y w a y o f the u mb i l i c a l v e i n.

Use only for proven gastritis, and restrict use to 3 days or until symptoms resolved. Public Health Service Grading System for ranking recommendations in clinical guidelines: Strength of recommendation and levels of evidence. What complementary investigations should be performed in a neonate with an invasive candidal infection? A lumbar puncture and dilated retinal examination are recommended in neonates with sterile body fluid or urine cultures positive for Candida species. Imaging of the kidney and heart should be performed if the results of sterile body fluid cultures are positive. The recurrence of Candida disease has been described in four immunocompetent infants after a prolonged period of latency (up to 1 year). All the infants presenting with Candida arthritis and osteomyelitis were born prematurely, had received parenteral nutrition through indwelling catheters, and had a history of systemic candidiasis during the newborn period. Candidal arthritis in infants previously treated for systemic candidiasis during the newborn period: report of three cases. Incidence rate is the number of new cases of a disease that occur during a specific period of time in a population at risk for developing the disease. Prevalence is the number of affected persons present in the population at a specific time divided by the number of persons in the population at the time. Endemic infections represent the bulk of nosocomial infections and are the usual level of infection expected during a given period for a given population. Epidemic infections are marked by an unusual increase in the incidence of disease entity. Nonmaternal routes of transmission (generally accepted when symptoms start 3 days or longer after admission) can be categorized as follows: n Contact: Direct or indirect; from an infected person or a contaminated source. Patients suspected of having tuberculosis, varicella, or measles must be placed on airborne precautions in negative-pressure rooms to prevent aerosol spread of their infection. It is important to assess the family members of such patients because they might be potential sources of the infection as well. A nurse tells you that she has just been exposed to varicella, and she never had it as a child. Varicella immunization is recommended for people without evidence of immunity, provided there are no contraindications for vaccine use. Cohorting of patients infected with the same microorganisms can be a safe and effective alternative. Health care workers should wash hands when entering and leaving the room and wear clean nonsterile gloves and a cover gown when entering the room. The following diseases require contact isolation: n Clostridium difficile n Rotavirus n Respiratory syncytial virus n Croup n Mucocutaneous herpes simplex n Resistant organisms, including methicillin-resistant S. Droplet precautions are intended to reduce the risk of transmission of infected agents by largeparticle droplets from an infected person. Such transmission usually occurs when an infected person generates droplets while coughing, sneezing, or talking and during procedures such as suctioning. Patients should be placed in private rooms, and staff should wear masks when working within 3 feet of the patient. Examples of conditions that necessitate droplet precautions include influenza virus, adenovirus, parvovirus, rubella, pertussis, and meningitis caused by Haemophilus influenzae or Neisseria meningitidis. Standard precautions are designed to reduce the risk of transmission of microorganisms from recognized and unrecognized sources and are to be followed for the care of all patients, including neonates. They apply to blood; all body fluids, secretions, and excretions except sweat; nonintact mucous membranes; and skin. Components of standard precautions include performing proper hand hygiene and wearing gloves, gowns, masks, and other forms of eye protection. What are the most frequently cited reasons that nursery personnel do not wash their hands (all invalid)? Soap and water should be used when hands are visibly soiled or contaminated with proteinaceous materials, blood, or body fluids and after using the restroom.

For penetrating trauma, 95% of wounds result from guns and knives, with the remainder resulting from motor vehicle accidents, household injuries, industrial accidents, and sporting events. N Clinical Critical organs and structures are at risk from neck trauma; clinical manifestations may vary greatly. The presence or absence of signs and symptoms can be misleading, serving as a poor predictor of underlying damage. Signs Signs of airway injury: G G G G Subcutaneous emphysema ­ tracheal, esophageal, or pulmonary injury Air bubbling through the wound Stridor or respiratory distress ­ laryngeal and/or esophageal injury Cyanosis Signs of vascular injury: G G Hematoma (expanding) ­ vascular injury Active external hemorrhage from the wound site ­ arterial vascular injury 338 G G G Handbook of Otolaryngology­Head and Neck Surgery Bruit/thrill ­ arteriovenous fistula Pulselessness/pulse deficit Distal ischemia (neurologic deficit in this case) Signs of pharyngoesophageal injury: G G G Hematemesis, inability to tolerate secretions Neck crepitus Development of mediastinitis Symptoms G G G G G G Clinical manifestations may vary greatly depending on involved organs and systems. Dysphagia ­ tracheal and/or esophageal injury Hoarseness ­ tracheal and/or esophageal injury Oronasopharyngeal bleeding ­ vascular, tracheal, or esophageal injury Neurologic deficit ­ vascular and/or spinal cord injury Hypotension ­ nonspecific; may be related to the neck injury or may indicate trauma elsewhere Differential Diagnosis Considerations with neck trauma include cervical spine injury, laryngotracheal injury, vascular injury, and pharyngoesophageal injury. N Evaluation History History, if available, can provide important details regarding the mechanism of injury. All patients with neck trauma should be assumed to have a cervical spine injury until this has been ruled out. With blunt trauma, injury to the larynx or trachea is the most common serious finding and often presents with subcutaneous air, hoarseness, or odynophagia. In a stable patient, flexible fiberoptic laryngoscopy can reveal evidence of injury such as blood, motion impairment, or edema. With penetrating trauma, determine which vertical zones of the neck are involved (Table 5. Review for emphysema, fractures, displacement of the trachea, and the presence of a foreign body. It is readily accessible, can be rapidly performed, and causes fewer complications than angiography. If there is airway compromise, a surgical airway, rather than endotracheal intubation, is usually 340 Handbook of Otolaryngology­Head and Neck Surgery preferred. Either a cricothyroidotomy or tracheotomy is performed if there is respiratory distress. G Endoscopy G Laryngoscopy, bronchoscopy, pharyngoscopy, and esophagoscopy may be useful in the assessment of the aerodigestive tract. G Drawbacks include cost and the inherent danger of any vascular, particularly arterial, invasive procedure. G the unstable patient (hemodynamic instability, severe hemorrhage, expanding hematoma) is taken to the operating room. In general, vascular injuries are managed either with embolization or surgical control. Surgery involves exploration and management of injuries of the carotid sheath, esophagus, and laryngotracheal complex (Table 5. There is no role for probing or local exploration of the neck in the trauma bay or emergency room because this may dislodge a clot and initiate uncontrollable hemorrhage. Head and Neck 341 N Outcome and Follow-Up Standard postoperative management for neck surgery is followed. Selective management of penetrating neck trauma based on cervical level of injury. The differential diagnosis is broad, and both benign and malignant processes should be considered. A systematic approach is crucial to developing a rapid diagnosis and treatment plan. Each age group exhibits a certain relative frequency of disease occurrences, which can guide the diagnostician to further differential considerations. In older adults, a neck mass should be considered neoplastic until proven otherwise. The location of malignant neck masses particularly if metastatic may help identify the primary tumor. N Clinical Signs and Symptoms Depending on the cause, the neck mass may be painless (early neoplasm or congenital mass) or painful (infection or trauma). Depending on the etiology, associated symptoms may be those of an upper respiratory infection, toothache (infectious or inflammatory mass) or dysphagia, odynophagia, hoarseness, otalgia, hemoptysis, weight loss, night sweats, and fever (neoplasm). N Evaluation History A thorough review of the developmental time course of the mass, associated symptoms, personal habits prior to the trauma or infection, irradiation, or surgery is important. Ask about smoking, tobacco chewing, alcohol use, fever, pain, weight loss, night sweats, exposure to tuberculosis, animals, pets, and occupational/sexual history. Physical Exam All mucosal surfaces of the nasopharynx, oropharynx, larynx, and nasal cavity should be visualized by direct examination or by indirect mirror or fiberoptic visualization.

Used in valvular and congenital cardiac surgeries (because we have to open the heart) 94 Valvular Heart Diseases 2. The internal mammary artery is preferred (it is a smooth muscle artery, as opposed to the radial artery which is a muscular artery and may undergo spasm). Mitral and Aortic are the most common diseased valves, sometimes the tricuspid as well. Indications for surgery: o Symptoms (angina, shortness of breath, syncopal attacks) o Severe aortic stenosis Treatment: 1-Medical 2-Aortic valve replacement Mitral valve replacement. Open mitral commissurotomy and mitral valve replacement are the only surgical procedures in the treatment list Closed mitral commissurotomy is a surgical procedure but it is not preformed anymore. Etiology: o Traumatic o Pericarditis o Malignancy o Uremia, post irradiation o Postoperative. Adequate Exposure Full or Partial Sternotomy / Thoracotomy / Robotic or Endoscopic 2. Bloodless Operative Field Suction and re-transfusion / Snaring or clamping of bleeding vessels 3. Static Operative Target Cardiac Arrest / Ventricular Fibrillation / Mechanical Stabilizers 4. Left main coronary artery disease 3-vessel disease with left ventricular dysfunction Mechanical complications of myocardial infarction. Left atrial thrombus Mitral regurgitation Significant shortness of breath: Symptomatic, dilated left ventricle, diminished ejection fraction Aortic stenosis 1. Progressive left ventricular dilatation Thoracic aortic disease Pericardial effusion 1. Aortic aneurism Aortic dissection Drainage by catheterization unless the fluid is not accessible 99 8 Presentation and Management of Cardiac Surgical Diseases 12. Therefore, when foreign bodies are aspirated, they often lodge in the right main bronchus. Bronchopulmonary segments: Each of the tertiary bronchi serves a specific bronchopulmonary segments. There are 10 segments in the right lung and 8-10 segments on the left and each have their own artery. Each segment is a discrete anatomical and functional unit, so a segment can be surgically removed without affecting the function of the other segments. Usually presents in adolescence or late childhood as repetitive chest infections that fails to respond to medical treatment. Usually an entire lobe of lung is replaced by non-functioning cystic area of abnormal lung tissue. Pulmonary Sequestration: o It consists of a nonfunctioning mass of normal lung tissue that lacks normal communication with the airways, and often receives its own arterial blood supply from the systemic circulation (esp. Lobar Emphysema: o Over-inflation of a pulmonary lobe (replacement of a whole lobe by bullae), which may compress the other remaining normal lobes. Air enters the lungs but cannot leave easily causing respiratory function to decrease. Bronchogenic Cysts: o They can be located: In the mediastinum most commonly attached to trachea or below the carina (paratracheal or subcarinal) Or within the lung parenchyma (intraparenchymal) o Clinical features: They consist of semi-solid cartilaginous that secretes cheese like material, which is prone to infections. It may also result in hemorrhage and compression of the surrounding structures. Rupture with resulting empyema Type of resections: o Lobectomy (main) or bilobectomy (2 lobes) o Pneumonectomy Clinical Features of Lung Abscess: - Gradual onset - Productive cough - High fever - Night sweats - Weight loss & lethargy - Chest pain (pleuritc) Empyema= collection of pus in an anatomical cavity. Fibrosisloss of spaceloss of ventilation on left side left lung is smaller, infective, and bronchioectatic pulling the trachea towards it. Saprophytic Aspergillosis: Characterized by Asp infection without tissue invasion. The outer pericyst, composed of host cells that are formed as a reaction to the parasite (false layer). Injection of scoliodal agents such as hypertonic 20% saline is used during surgery to kill scolex. Malignant solitary pulmonary nodules: Benign Age <50, nonsmoker, size <2 cm, no growth over 2 year period, circular and regular shaped, central laminated/concentric calc. Malignant Age >50, smoker, size >3cm, steady growth, irregular nodule or speculated margins, stippled/eccentric calc. Accumulation of air under positive pressure in the pleural space collapses the ipsilateral lung and shifts the mediastinum away.

Models were adjusted for age, sex, height, waist circumference, smoking, diabetes, pulse pressure, cardiovascular disease, polypharmacy, chronic health conditions. Each covariate was included as a main effect and its interaction with time (wave). Analyses were weighted to account for differential non-response and attrition across waves. Therefore, exploring risk factors for malnutrition has clinical relevance in these patients. This result suggest that avoiding fluid overload and inflammation could be helpful to mitigate malnutrition in these patients. Poor functional status was defined by any of the three comorbidities listed in form 2728 ­ inability to ambulate, inability to transfer or need of assistance with daily activities. At dialysis initiation, 26% were octogenarian, 20% reported poor functional status and 10% had reported nursing home stay. Patients with poor functional status were 10 times more likely have a nursing home stay than those without poor functional status. Overall, one-year mortality was 31%; it was 48% in patients with poor functional status and 57% in octogenarians with poor functional status. Further study is needed to evaluate its ability to risk stratify patients prior to the commencement of renal replacement therapy. Background: In patients with chronic kidney disease, survival has been shown to be better with increasing body mass index. However, few studies were conducted to reveal which of the two body components, muscle or fat, was beneficial to the patient survival. Multivariable cox regression analysis was adjusted to evaluate the significant factors associated with long term patient survival. Methods: We examined the association between a serious fall injury in the year prior to starting hemodialysis and adverse health outcomes in the year following dialysis initiation using a retrospective cohort study of U. Medicare claims data from the 2 years spanning dialysis start, among patients initiating dialysis in 2010-2012. Serious fall injuries were defined using diagnostic codes for falls in combination with an injury code for a fracture, joint dislocation, or head injury. Compared to those without serious fall injuries, those with a serious fall injury in the prior year were older (mean age 78. Conclusions: A serious fall injury in the year prior to dialysis was associated with an increased risk for adverse health outcomes. For older adults initiating dialysis, a history of a serious fall injury may be novel marker for frailty and provide prognostic information to support decision-making and establish expectations for life after dialysis initiation. Background: While several studies have identified a link between chronic kidney disease and markers of frailty in older age, it is largely unknown if this association translates into meaningful outcomes such as a greater risk of falls. We sought to examine the relationship between kidney function and falls in a large representative cohort of older adults. Methods: Prospective analysis of 5060 participants from the first 3 waves (20092015) of the Irish Longitudinal Study on Ageing, a nationally representative sample of community-dwelling adults aged 50 years. Data regarding falls (any fall in the last year or between waves) were captured via a computer-assisted personal interview at each wave. Models were adjusted for age, sex, frailty (pre-frail/frail versus robust), diabetes, cardiovascular disease, pulse pressure, polypharmacy and chronic health conditions. An inverse probability weight was applied to all estimates to account for differential non-response and attrition. Frailty and the number of chronic conditions were both independent predictors of falls in the multivariable model. Conclusions: In this large prospective study of older community-based adults, kidney function was not found to be an independent predictor of falls. Our data suggest that, in the general population of older individuals, frailty status and comorbidity burden are more important predictors of falls than kidney function alone. Karki,5 Aagat Sharma khatiwada,7 Stephen Ansah-Addo,1 Ashley Tran,3 Meredith Hawkins,1 Matthew K.