"Order on line fenofibrate, cholesterol good".

A. Darmok, M.A., M.D.

Professor, Lewis Katz School of Medicine, Temple University

Instead there are flutter Waves (F waves); which occur in a jagged, "sawtooth" pattern. Clinical significance: Atrial flutter is usually caused by sorrie underlying cardiac disease o1 damage. If there is a rapid ventricular response, the workload of the heart is increased and cardiac output may be comprothised. Trettment: If the Patient is clinically stable; no treatment is indicated in the field. If the 13tient evidences inadequate cardiac output (hypotension; cold; clammy skin; confusion; or coma), cardioVerSion may be required. Rhythm: Irregular; the premature junctional beat is preceded by a shorter than normal R-R interval. These are of different sizes and shapes and indicate that there are multiple ectopic foci. Techniques of Management Managernent of cardiac emergencies through the use of drugs, defibrillation; cardioversion, rotating tourniquets, carotid sinus massage, intracardiac injections, and mechanical cardiopulmonary resuscitation devices is discussed in this unit. Automaticity refers to the ability of certain cardiac cells to initiate impulses spontaneouslywithout nervous-stimulation. Drugs that increase pacemaker automaticity in bradycardia are atropine and isoproterenol. Therefore, the primary use for atropine is to increase the heart rate in bradyarrhythmias. Atropine is indicated When the heart rate is below 50 beats per minute and is accompanied by one of the following signs: I. ThiS dose may be repeated every 5 minutes until the heart rate is between 60 and 100 Excitability refers to the ability of the conduction system to initiate an electrical stimulus, which causes the cardiac muscle fibers to depcilariit and contract. These drugs include lidocaine, procainamide, quinidine, propranolo1;and bretyliums. Lidocaine decreaSeS excitability in the bundle of His, Purkinfe fiberS, and ventricles. Procainamide, quinidine, and propranolol decrease excitability in the atria as well ar, in the His - Purkinje system and ventricle§. Bretylium, while not -a front-line antiarrhythmic agent, may be useful in treating ventricular tachyar: rhythmias which are unresponsive to other agents. Conductivity is the ability of the electrical conduction system to transmit excitation impulses. Drugs that increase electrical conductivity in bradyarrhythmias are procainamide, quinidine, atropine, and isoproterenol. Side effects of atropine include dryness of the mouth, blurred vision, urinary retention, constipation; worsening of preexisting glaucoma, decreased sweating, pupil dilatidn, and headache. This effect is dangerouS becauSe cardiac output will be decreased even further, Which will predispose the heart to premature ventricular contractions; ventricular tachycardia, or ventricular fibrillation. Isoproterenol is a beta-receptor stimulator and causes an increase in autbMaticity; conductivity; force of ventricular contraction, and cardiac work. Becati§e isoproterenol is a beta stimulator, it causes the peripheral arterioles to dilate reflexively, which lowera peripheral vascular resistance. The net effectS of isoproterenol administration are increases in heart rate, stroke volume; and cardiac output at the If too small a dose of atropine. Isoproterenol may be administered by sublingual, intravenous, or intracardiac routes. The drug can also be given sublingually (10 mg) when atropine does not reverse a bradyarrhythmia; its effects begin within 15 to 30 minutes and last up to 2 hours. Minor side effe is of lidocaine include lightheadedness, muscle tw tches, and numbness. To prevent the bove side effects, lidocaine must be ad7 ministered autiously to patients with a history of liver dise e or to patients who have inadequate portal cir lation; Such patients include those with I. One ampule (5 ml) containing 1 mg of isoproterenol can be added to 500 cc D5W and infused at a rate sufficient to maintain the heart rate above 60 beats per minute. Both decrease automaticity of ectopic foci rapid topic and in may precipitate ventricular arrhythmias. Thus, the drug should be used only in the presence of life= threatening bradycardias or in cardiac standstill until an artificial pacemaker can be inserted. Lidocaine also decreases the excitability of the His-Purkinje system by decreas ing the response to electrical stimuli.

Diseases

• Zollinger Ellison syndrome
• Bonneau Beaumont syndrome
• Afibrinogenemia
• Synovial sarcoma
• Southwestern Athabaskan genetic diseases
• Warm-reacting-antibody hemolytic anemia

Cryptococcal peritonitis, multiple superficial small white nodules seen on the omentum and serosal surfaces, Mesenteric thrombosis (12. In late stages, the gallbladder may perforate, but perforations may be multiple and small with inflammatory exudation. There may be a complex mass of adhesions with all of the above, including bowel perforation. Of course tuberculosis may affect any abdominal organ, including the pancreas, liver and spleen. Tuberculous adhesions are often thick and unyielding (and may be detected as septa on ultrasonography in an ascitesfilled abdomen). A tuberculous mass usually occurs in the right iliac fossa but any site may be affected; an intestinal stricture occurs in the ileum in 70%, in the jejunum in 15%, and in both in 15%. Where the neurogenic bladder is due to Guillain-Barrй syndrome or transverse myelitis, expect spontaneous recovery. Otherwise a trans-urethral incision of the prostate provides a remedy in men, and intermittent self-catheterization in women. Hepatitis is common: either with hepatitis B or herpes virus, cryptococcus, or induced by drugs. A pancreatic mass may be tuberculous, lymphoma or adenocarcinoma, behaving more aggressively, often associated with portal vein thrombosis. Dense matted adhesions are frequently found with perforation into bladder, small, large bowel or rectum. Low rectovaginal fistulae, unrelated to obstetric trauma are seen in sexually active women and children <5 years. Cervical carcinoma is 10 times more frequent, affects younger females, and is more aggressive; recurrence is common. Herpetic vulvovaginitis, often ulcerative, is common and huge extensive vulval condylomata very often seen. Their presence in young girls does not necessarily imply sexual abuse; long-standing condylomata may however develop into carcinoma. The predominant symptoms are painful urinary frequency, suprapubic pain and haematuria (micro- or macro-scopic) without any demonstrable urinary tract infection. Cystoscopy reveals a highly characteristic uniformly congested appearance with no ulceration and no significant reduction in bladder capacity. The histological appearance is like a non-specific interstitial cystitis without mast cells, with no cytomegalovirus found. Malignancy of the foreskin however remains rare; frankly necrotic ulcerative penile lesions are usually due to chancroid. The operation of circumcision is not without risk: severe necrotizing fasciitis of the penis can occur post-operatively. The epithelium of the exposed glans penis in the circumcised male changes from columnar to stratified squamous, and may thus be more resistant to ulceration. However, the morbidity and, in some cases, mortality of circumcision, especially where medical resources are scarce, may make this procedure dangerous. Condylomata may be very profuse on the foreskin and may encroach onto the glans penis and into the urethral meatus. Many of the lesions are resistant to treatment, and their aetiology is not known; however, this does not mean that you can do nothing for patients with these conditions. However, do not undertake elective anorectal surgery lightly: many authors have reported poor or absent wound healing often after many months. Idiopathic anorectal ulcer appears first as a mucosal laceration within the anal canal, and gives rise to symptoms identical to the classical anal fissure, i. However, you will see no anal skin lesion on gentle parting of the buttocks, because the lesion is internal, usually just proximal to the dentate line. Furthermore there is rarely anal sphincter spasm, and often diarrhoea rather than constipation. The mucosal defect then deepens and becomes palpable as an ulcer with smooth benign-feeling edges. As this ulcer deepens further, it may penetrate into the vagina or urethra or appear as a large fistula externally.

Spirula spirula (Linnaeus, 1758) Frequent synonyms / misidentifications: None / None. Arm lengths increase from dorsal to ventral, each arm with 4 to 6 longitudinal series of small suckers. Tentacular clubs with subequal suckers in 16 series, not divided into manus and dactylus. Skin smooth but mantle under skin covered with regularly aligned collagen fibrils that produce a silvery sheen. The calcareous shell is used as a buoyancy device; migrates vertically; normal swimming position is head-down. Known predators include short-finned squids, splendid alfonsino, swordfish and grey-faced petrels. Juveniles have been collected at about 1 000 to 1 750 m; smallest known juveniles had 2 shell chambers at mantle length ±1. Distribution: Tropical and subtropical oceanic waters worldwide, in water masses where temperature is over 10єC at 400 m; empty shells are carried by currents extremely far from the natural habitat. Seven buccal lappets usually possess small suckers (absent in Afrololigo and Alloteuthis). Colour: usually reddish brown, darker dorsally but quite variable, depending on behaviour. Various species occur from very shallow water in bays and estuaries, over grass flats and coral reefs, to water as deep as over 700 m (during seasonal offshore migrations). Eggs are usually attached to hard surfaces in clusters of finger-like capsules; paralarvae resemble the adults. Typically, they undertake dial migrations, aggregating near the bottom during the day but dispersing into the water column during the night. Remarks: the history of nomenclature and the systematics of this family have long been problematic at least in part because of its worldwide distribution, the diversity of the group, the lack of comprehensive collections, and the scattered and often isolated literature dating from the eighteenth and nineteenth centuries (Vecchione et al. A workshop on loliginid systematics was convened during the 2003 meeting of the Cephalopod International Advisory Council held in Phuket, Thailand (Vecchione et al. One goal of the workshop was to resolve conflicting generic-level classifications of the family in light of recent observations and cladistic analyses on morphological and molecular characters. The assembled taxonomic experts reached consensus on a classification which includes 10 genera and 47 species (Vecchione et al. Similar families occurring in the area Other squid families including commercial-sized species that present potential interest to fisheries (Ommastrephidae, Thysanoteuthidae, Onychoteuthidae) all lack suckers on the buccal lappets and have eye lenses open to the sea, not covered by a transparent corneal membrane. The funnel locking apparatus is not straight in Ommastrephidae, Thysanoteuthidae and Cycloteuthidae. Hooks are found on the arms or tentacular clubs in Onychoteuthidae, Enoploteuthidae, Pyroteuthidae, Ancistrocheiridae and Octopoteuthidae. The mantle in Lepidoteuthidae and Pholidoteuthidae is covered with small integumentary scales. Brachioteuthidae, Architeuthidae, Neoteuthidae and Joubiniteuthidae can all be distinguished by more than 4 rows of suckers on the proximal part of the tentacular club. Chiroteuthidae and Mastigoteuthidae generally have greatly enlarged ventral arms, modified to hold the long, thin tentacles. Non-commercial squid families differ as follows: Chtenopterygidae have comb-like fins extending nearly the full length of the mantle. Histioteuthidae have numerous light organs on the ventral surfaces of the mantle, head and arms. Bathyteuthidae are small, deep-sea squids with very short arms joined by a low, fleshy web. Fins transversely oval, rounded posteriorly, without tail; very small squids, maturing at 20 mm mantle length; light organs only in female; buccal lappets without suckers 1b. Fins rhomboidal or heart-shaped, longer than wide, tail present or absent; medium- to large-sized squids; light organs absent; buccal lappets with or without suckers 2a. Mature squids with relatively short tail; tail length less than half fin length; fin length (with tail) not more than half mantle length 3b. Mature squids with long tail; tail length not less than half fin width; fin length (with tail) more than half mantle length 4a.

This will reduce abdominal distension and hopefully allow you to extract enough bowel to make a skin bridge to let you really divide the colon. Wash the distal colon free of meconium with warm saline: if you do not do this early the meconium will solidify like concrete! Make sure you do frequent washouts if there is a recto-urinary fistula in order to minimize urinary tract infection. Do not perform a formal laparotomy: it is difficult and unnecessary and the baby may well not survive it. Wrap the nappy over the stoma, and advise mother to clean gently around the stoma as she would for the anus. Do not be tempted to operate on the anus of any intermediate or high anorectal agenesis; leave fashioning a neat anoplasty to an expert. If there is a mucosal prolapse or skin excoriation after an anal operation, apply talc powder and carefully prevent soiling of the perineum. If excess fluid is lost from a colostomy, wait for 14days, while adding extra fluid to maintain a satisfactory fluid balance. Rectal examination often results in explosive projectile passage of meconium or faeces, which may result in visible deflation of the abdomen. If there is a pneumoperitoneum (which may be huge), this is a sign of bowel perforation. A barium (or safer, gastrografin, which does not become solid) enema may conclusively make the diagnosis: look for a dilated proximal segment of colon and narrow distal rectum. Clean the anorectum with non-alcoholic antiseptic solution, and leave a swab soaked with this inside the rectum, proximal to the operation site. It is best if you tie a suture to it to hang outside the anus on a mosquito forceps. Evert the posterior wall of the anus on both sides with Allis forceps and place all-layer stay sutures posterolaterally on both sides at the level of the internal sphincter (33-9A). The length of the aganglionic segment varies although it is usually confined to the rectosigmoid in 75%, but may be tiny (ultra-short segment) or extend to the caecum or beyond (c. This results in dilation and hypertrophy of the proximal (neurologically intact) segment with transition to a normal-sized or narrowed distal (aganglionic) segment. If however the bile duct is sufficiently patent for the gallbladder to be distended, and in connection with the proximal duct system (75%), it can be anastomosed to the proximal jejunum. Make an incision and excise a 1 5cm triangular 5mm wide full thickness segment with fine scissors (33-9B), and close this with 4/0 longacting absorbable through all layers of the rectal wall. There are more sophisticated methods of getting histological diagnosis; consult colleagues if these are available because a full-thickness rectal biopsy may make the definitive pull-through operation more difficult. In the meantime, show the parents how to perform bd wash-outs with a soft catheter, using warm clean water. If the delay will be significant, perform a defunctioning transverse colostomy (11. Physiological jaundice (with levels of unconjugated bilirubin >85M) fades after 1-2wks; however, levels >220M (or >255M in preterm babies) are not physiological. The biliary tract can be blocked by epithelial debris or biliary sand (less common), in which case it may be temporary and clear spontaneously, or by atresia of the biliary tree (more common), for which the only hope is surgery. This blockage appears to be caused by a sclerosing inflammatory process starting in utero, and is not due to a simple single stenosis. Hepatomegaly is common, and stools may be pigmented initially before becoming white. Even in experienced hands the outlook is poor, and 30% of children develop liver failure. If a child starts to become jaundiced in the first 6-24hrs, jaundice is likely to be haemolytic from: (1),Septicaemia from an umbilical infection. Look for signs of infection of the cord and the surrounding tissues (septicaemia from cord infection can also occur later). Usually, the baby is Rh D+ve, the mother is D-ve and has anti-D antibodies as the result of having had a previous D+ve child or abortion, or of having been given D+ve blood.