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G. Mine-Boss, MD

Clinical Director, Dell Medical School at The University of Texas at Austin

Section 3-5 addresses the first problem of competing to defeat aggression short of armed conflict and to deter conflict. Section 3-6 addresses the second problem of penetrating enemy anti-access and area denial systems to enable strategic and operational maneuver in conflict. Section 3-8 addresses the fourth problem of exploiting freedom of maneuver to defeat the enemy and achieve U. Section 3-9 addresses the final problem of re-competing to consolidate gains and expand the competitive space and enable policymakers to resolve the conflict. The remainder of this section describes how solving these operational problems leads to the attainment of strategic objectives. A multi-domain capable Joint Force can achieve friendly strategic objectives (win) and defeat the adversary in three different ways. If deterrence fails, the second method is to employ a combination of forward presence and expeditionary forces to deny enemy objectives within days and achieve an operational position of relative advantage within weeks that leads to an acceptable, sustainable political outcome. If neither side is able to achieve its objectives in a short conflict, the third method is to defeat the enemy in a protracted war. The three methods are interrelated as the will and capability to win a long war, if necessary, is an essential element to convincing an adversary that it cannot achieve a fait accompli and will not achieve aims in competition below armed conflict. The demonstrated ability and readiness to deny a fait accompli attack, in turn, creates a position of strength for the Joint Force in competition. The Army is essential in each of the three ways to defeat an aggressive adversary and provide political leaders with as many options as possible to deter through determined competition or, when necessary, prosecute and end an armed conflict on favorable conditions before returning rapidly to a renewed competition. The combination of the ability to both effectively compete below armed conflict and to respond to an escalation toward armed conflict creates a position of strength and sets favorable conditions if conflict ensues. The combined and persistent effects of deterring armed conflict and defeating unconventional and information warfare in a campaign of competition create unpredictability for the adversary and generate additional friendly options, thereby expanding the competitive space for policymakers. In the event of armed conflict, Army forward presence and expeditionary forces enable the rapid defeat of aggression through a combination of calibrated force posture, multi-domain formations, and convergence to immediately contest an enemy attack in depth. Army long-range fires converge with joint multi-domain capabilities to penetrate and dis-integrate enemy anti-access and area denial systems to enable Joint Force freedom of strategic and operational maneuver. This sets the conditions for a quick transition to joint air-ground operations in which maneuver enables strike and strike enables maneuver. As part of the Joint Force, Army forces rapidly achieve given strategic objectives (win) and consolidate gains. A more lethal force, strong alliances and partnerships, American technological innovation, and a culture of performance generate decisive and sustained U. See, Summary of the 2018 National Defense Strategy of the United States of America, 4. This approach ensures that military and political conditions remain favorable to the U. Particularly following an armed conflict with a nuclear power, the enemy will retain significant conventional military capability in the field. Army forces, therefore, have to simultaneously deter a return to conventional warfare and assist partner forces in restoring order to prevent the enemy from exploiting the internal disruption for strategic advantage. The Joint Concept for Integrated Campaigning proposes the notion of a competition continuum that offers an alternative to the obsolete peace/war binary with a new model of cooperation, competition below armed conflict, and armed conflict. These are not mutually exclusive conditions and various states of relationships with other actors can exist concurrently. Success in competition achieves three critical objectives: deterring conflict on terms favorable to the U. Army in Multi-Domain Operations concept emphasizes the importance of active engagement by the Joint Force, and particularly the Army, in competition to defend U. Finally, both the theater and field army conduct intensive preparations for conventional warfare to demonstrate a credible deterrent. The theater army sets the theater to enable the dynamic employment of the Joint Force. The field army "sets the campaign" to ensure the Joint Force and partners can rapidly transition from competition to conflict. Collectively, these actions enable the Joint Force to rapidly transition to armed conflict and create uncertainty for the adversary as to whether it can achieve its objectives through a surprise attack.

Drugs such as acetaminophen may be metabolized in zone 1 to toxic compounds that cause necrosis of Gastrointestinal System Answers 337 zone 3 hepatocytes because they receive the blood from zone 1. Midzonal (zone 2) necrosis is quite rare, but may be seen in yellow fever, while periportal (zone 1) necrosis is seen in phosphorus poisoning or eclampsia. Submassive necrosis refers to liver cell necrosis that crosses the normal lobular boundaries. Classically the necrosis goes from portal areas to central veins (or vice versa) and is called bridging necrosis. This type of extensive necrosis is described as acute yellow atrophy, as grossly the liver appears soft, yellow, flabby, and decreased in size with a wrinkled capsule. Unconjugated bilirubin is not soluble in an aqueous solution, is complexed to albumin, and cannot be excreted in the urine. Unconjugated hyperbilirubinemia may result from excessive production of bilirubin, which occurs in hemolytic anemias. Unconjugated hyperbilirubinemia may result from impaired conjugation of bilirubin. Conjugated bilirubin is water-soluble, nontoxic, and readily excreted in the urine. Conjugated hyperbilirubinemia may result from either decreased hepatic excretion of conjugates of bilirubin, such as in Dubin-Johnson syndrome, or impaired extrahepatic bile excretion, as occurs with extrahepatic biliary obstruction. In full-term infants, the maximum bilirubin levels are less than 6 mg/dL (normal is less than 2 mg/dL), while in premature 338 Pathology infants, the maximal levels may rise to 12 mg/dL. It is important to realize that in newborns the blood-brain barrier is not fully developed and unconjugated bilirubin may be deposited in the brain, particularly in the lipid-rich basal ganglia, producing severe neurologic abnormalities. Note that kernicterus does not result unless serum bilirubin levels are greater than 20 mg/dL. Treatment, if needed, consists of exposing the skin to light (440 to 470 nm), which activates oxygen and converts bilirubin to photobilirubin. A defective urea cycle results in hyperammonemia, while a foul-smelling breath (fetor hepaticus) is thought to occur due to volatile, sulfur-containing mercaptans being produced in the gut. Impaired estrogen metabolism in males can result in gynecomastia, testicular atrophy, palmar erythema, and spider angiomas of the skin. Additionally, deranged bilirubin metabolism results in jaundice (mainly conjugated hyperbilirubinemia) and a decreased synthesis of albumin (hypoalbuminemia) results in ascites. Symptoms of hepatic encephalopathy, a metabolic disorder of the neuromuscular system, include stupor, hyperreflexia, and asterixis (a peculiar flapping tremor of the hands). Because of their dual blood supply, arterial occlusion of either the hepatic artery or the portal vein rarely results in liver infarcts. However, thrombosis of branches of the hepatic artery may result in a pale (anemic) infarct, or possibly a hemorrhagic infarct due to blood flow from the portal vein. In contrast, occlusion of the portal vein, which may be caused by cirrhosis or malignancy, may result in a wedge-shaped red area called an infarct of Zahn. This is a misnomer, however, since it is not really an infarction but instead is the result of focal sinusoidal congestion. Hepatic vein thrombosis (Budd-Chiari syndrome) is associated with polycythemia vera, pregnancy, and oral contraceptives. Clinically, Budd-Chiari syndrome is characterized by the sudden onset of severe right upper quadrant abdominal pain, ascites, tender hepatomegaly, and hematemesis. Gastrointestinal System Answers 339 Occlusion of the central veins, called venoocclusive disease, may be rarely seen in Jamaican drinkers of alkaloid-containing bush tea, but is much more commonly found following bone marrow transplantation (up to 25% of allogenic marrow transplants). Asymptomatic infection in individuals is documented by serologic abnormalities only. Liver biopsies in patients with acute hepatitis, either the anicteric phase or the icteric phase, reveal focal necrosis of hepatocytes (forming Councilman bodies) and lobular disarray resulting from ballooning degeneration of the hepatocytes. During the prodrome phase, patients may develop symptoms that include anorexia, nausea and vomiting, headaches, photophobia, and myalgia. An unusual symptom associated with acute viral hepatitis is altered olfaction and taste, especially the loss of taste for coffee and cigarettes. The next phase, the icteric phase, involves jaundice produced by increased bilirubin.

An a c c u r a t e d e t e r mi n a t i o n o f f e t a l s i ze a n d a g e i s i mp o r t a n t f o r ma n a g i n g p r e g n a n c y, e s p e c i a l l y i f the mo the r h a s a s ma l l pelvis or the baby has a birth defect. Clinical Corre late s Low Birth We ight the r e i s c o n s i d e r a b l e v a r i a t i o n i n f e t a l l e n g t h a n d w e i g h t, a n d s o me t i me s the s e v a l u e s d o n o t c o r r e s p o n d w i t h the c a l c u l a t e d a g e o f the f e t u s i n mo n t h s o r w e e k s. M o s t f a c t o r s i n f l u e n c i n g l e n g t h a n d w e i g h t a r e g e n e t i c a l l y d e t e r mi n e d, b u t e n v i r o n me n t a l f a c t o r s a l s o p l a y a n i mp o r t a n t r o l. I n t r a u t e r i n e g r o w t h r e s t r i c t i o n (iIs G Re r m a p p l i e d t o i n f a n t s w h o a r e a t Ua t) o r b e l o w the 1 0 t h p e r c e n t i l e f o r the i r e xp e c t e d b i r t h w e i g h t a t a g i v e n g e s t a t i o n a l a g. S o me t i me s the s e i n f a n t s a r e d e s c r i b e d a s s ma l l f o r d a t e s, s m a l l f o r g e s t a t i o n a l a g e (,SfG A)l l y ma l n o u r i s h e d, o r d y s ma t u r. F e t u s e s t h a t weigh less than 500 g seldom survive, while those that weigh 500 to 1,000 g ma y l i v e i f p r o v i d e d w i the xp e r t c a r. H o w e v e r, a p p r o xi ma t e l y 5 0 % o f b a b i e s born weighing less than 1,000 g who survive will have severe neurological d e f i c i t s. T h e ma j o r g r o w t h - p r o mo t i n g f a c t o r d u r i n g d e v e l o p me n t b e f o r e a n d a f t e r b i r t h i s i n s u l i n - l i k e g r o w t h f a c t o r - I (, I G F i-c) h am i t o g e n i c a n d a n a b o l i c wh I h s e f f e c t. In c o n t r a s t t o the p r e n a t a l p e r i o d, p o s t n a t a l g r o w t h d e p e n d s u p og r o w t h h o r m o n e (G H)h i s h o r mo n e b i n d s t o i t s r e c e p t o r n. M u t a t i o n s i n the G H R L e s o ln dn a r f i s m h i c h i s r ar u t i w, w c h a r a c t e r i ze d b y g r o w t h r e t a r d a t i o n, mi d f a c i a l h y p o p l a s i a, b l u e s c l e r a, a n d l i mi t e d e l b o w e xt e n s i o n. Fe tal Me m brane s and Place nta As the f e t u s g r o w s, i t s d e ma n d s f o r n u t r i t i o n a l a n d o the r f a c t o r s i n c r e a s e, c a u s i n g ma j o r c h a n g e s i n the p l a c e n t a. F o r e mo s t a mo n g the s e i s a n i n c r e a s e i n s u r f a c e a r e a b e t w e e n ma t e r n a l a n d f e t a l c o mp o n e n t s t o f a c i l i t a t e e xc h a n g. T h e d i s p o s i t i o n o f f e t a l me mb r a n e s i s a l s o a l t e r e d a s p r o d u c t i o n o f a mn i o t i c f l u i d increases. Changes in the Trophoblast B y the b e g i n n i n g o f the s e c o n d mo n t h, the t r o p h o b l a s t i s c h a r a c t e r i ze d b y a g r e a t n u mb e r o f s e c o n d a r y a n d t e r t i a r y v i l l i, w h i c h g i v e i t a r a d i a l a p p e g. S t e m (a n c h o r i n g) v i l l i e xt e n d f r o m the me s o d e r m o f the c h o r i o n i c p l a t e t o the c y t o t r o p h o b l a s t s h e l l. T h e s u r f a c e o f the v i l l i i s f o r me d b y the s y n c y t i u m, r e s t i n g o a l a y e r o f c y t o t r o p h o b l a s t i c c e l l s t h a t i n t u r n c o v e r a c o r e o f v a s c u l a r me s o d e r m (s e eF i g. T h e c a p i l l a r y s y s t e m d e v e l o p i n g i n the c o r e o f the v i l l o u s s t e ms 8 s o o n c o me s i n c o n t a c t w i t h c a p i l l a r i e s o f the c h o r i o n i c p l a t e a n d c o n n e c t i n g s t a l k, t h u s g i v i n g r i s e t o the e xt r a e mb r y o n i c v a s c u l a r s y s t e m. At the e mb r y o n i c p o l e, v i l l i a r e n u me r o u s a n d w e l l f o r me d; a t the a b e mb r y o n i c p o l e, the y a r e f e w i n n u mb e r a n d p o o r l y d e v e l o p e d. T h e e xt r a e mb r y o n i c me s o d e r m p e n e t r a t e s the s t e m v i l l i i n the d i r e c t i o n o f the d e c i d u a l p l a D u r i n g the f o u r t h mo n t h. Erosion o f the s e ma t e r n a l v e s s e l s t o r e l e a s e b l o o d i n t o i n t e r v i l l o ug s s p a 7 e s (Fi s. T h e s e n o c e l l s, r e l e a s e d f r o m the e n d s o f a n c h o r Fn g sv i l7l. In v a s i o n o f the s p i r a l a r t e r i e s b y c y t o t r o p h o b l a s t c e l l s t r a n s f o r ms the s e v e s s e l s f r o m s ma l l - d i a me t e r, h i g h - r e s i s t a n c e v e s s e l s t o l a r g e r d i a me t e r, l o w - r e s i s t a n c e v e s s e l s t h a t c a n p r o v i d e i n c r e a s e d q u a n t i t i e s o f ma t e r n a l b l o o d t o i n t e r v i l l o u s s p aF ie s. T h e s y n c y t i u m a n d e n d o the l i a l w a l l o f the b l o o d v e s s e l s a r e the n the o n l y l a y e r s t h a t s e p a r a t e the ma t e r n a l a n d f e t a l cFri c u l 7. F r e q u e n t l y, the s y n c y t i u m b e c o me s v e r y t h i n, a n d l a r g e p i e c e s c o n t a i n i n g s e v e r a l n u c l e i ma y b r e a k o f f a n d d r o p i n t o the i n t e r v i l l o u s b l o o d l a k e s. D i s a p p e a r a n c e o f c y t o t r o p h o b l a s t i c c e l l s p r o g r e s s e s f r o m the s ma l l e r t o l a r g e r v i l l i, a n d a l t h o u g h s o me a l w a y s p e r s i s t i n l a r g e v i l l i, the y d o n o t p a r t i c i p a t e i n the e xc h a n g e b e t w e e n the t w o c i r c u l a t i o n s. Clinical Corre late s P r e e c l a m p s iia a c o n d i t i o n c h a r a c t e r i ze d b y ma t e r n a l h y p e r t e n s i o n, s p r o t e i n u r i a, a n d e d e ma. T h e c o n d i t i o n a p p e a r s t o b e a t r o p h o b l a s t i c d i s o r d e r r e l a t e d t o f a i l e d o r i n c o mp l e t e d i f f e r e n t i a t i o n o f c y t o t r o p h o b l a s t c e l l s, ma n y o f w h i c h d o n o t u n d e r g o the i r n o r ma l e p i the l i a l t o e n d o the l i a l t r a n s f o r ma t i o n. As a r e s u l t, i n v a s i o n o f ma t e r n a l b l o o d v e s s e l s b y the s e c e l l s i s r u d i me n t a r y.

The approach is usually through a sternal splitting incision made with a power saw or a sternal splitting knife. The mediastinal fat pad is incised and the thymus gland dissected from it and the underlying pericardium. If either pleural space has been entered, a chest tube(s) and a sealed drainage unit may be necessary. Preparation of the Patient A forced-air warming blanket or a warming mattress pad (placed on the table before the patient enters the room) may be used. The patient is supine; a pillow may be placed under the knees to avoid straining back muscles and for comfort. Determine whether insertion of a Foley catheter is necessary (not routinely placed). Skin Preparation Begin at the midline of the upper chest, extending from the chin to below the umbilicus and down to the table at the sides. Lap pads may be placed at the sides of the neck to prevent prep solution from pooling under the patient. Draping Folded towels, plastic adhesive drape (optional), and sheet with a small fenestration. Clarify with the anesthesia provider as to immediate availability of drugs related to treatment of myasthenia gravis as discussed preoperatively with the internist, surgeon, and anesthesia provider. Discussion Thoracoscopy is performed to diagnose and treat pleural and intrapleural conditions including diseases of the pleura, mediastinum, pericardium, esophagus, and lungs. Assessment of thoracic trauma, tissue sampling, drainage of fluid collections, and diverse surgical procedures can be performed via this route. Esophagomyotomy, pericardial window creation, thymectomy, sympathectomy (for hyperhydrosis and for various vasospastic syndromes), and mediastinal cystectomy have been performed as well. Contraindications include lesions in close proximity to major central vessels and patients in whom the anesthesia provider cannot safely maintain unilateral pneumothorax. Robotic techniques have been introduced to thoracoscopic procedures with increasing applications. General anesthesia is administered via double-lumen endotracheal tube; the tube permits ventilation of the nonoperative lung, while permitting pneumothorax on the operative side. Patients are monitored with an arterial line, continuous oximetry, central venous line, and urinary catheter. A thoracic epidural catheter is placed preoperatively and used for postoperative pain control. Prior to insertion of the port, digital exploration confirms clear entrance into the pleural cavity. Two or three additional ports are established according to the location of the lesion. Large specimens may be retrieved through an ancillary incision (limited thoracotomy or "thoracoscopically-assisted procedure"), usually without a need to spread the ribs, although an endoscopic morcellator may be used. Upon conclusion of the procedure, a chest tube is inserted through a port; it is connected to a closed drainage unit. A sequential compression device with disposable leg wraps may be applied over the antiembolitic hose. The arm on the unaffected side is placed on a padded armboard (pressure points are padded). The arm on the affected side is angled toward the head and supported by a Mayo stand padded with a pillow (or a padded double armboard may be used). The torso is stabilized with padded kidney rests (larger blade in front) and/or pillows, sandbags, or a beanbag. The leg on the unaffected side (down) is flexed; the leg on the affected side (uppermost) may be extended, or it may be slightly flexed. A pillow is placed between the legs, and pressure points at the knee, ankle, and foot are padded.