Linda M Smith-Resar, M.D.
- Professor of Medicine
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0004790/linda-smith-resar
When force generated and muscle length are plotted for cardiac muscle medicine x xtreme pastillas buy discount pirfenex 200mg line, one observes that greater force occurs as muscle length increases until the Lmax is exceeded (see Figure 1) treatment wasp stings buy pirfenex 200 mg low price. At the organ level the relationship between force generated and muscle length still holds symptoms 22 weeks pregnant 200mg pirfenex for sale. The force of ventricular contraction increases (within certain limits) as a function of end-diastolic ventricular muscle length medications definitions generic pirfenex 200 mg mastercard. End-diastolic ventricular muscle length is proportional to end-diastolic ventricular volume. The resting force of cardiac muscle gradually increases until the Lmax is reached, at which point it rises abruptly. Although end-diastolic ventricular volume is a reasonable measure of "preload," end-diastolic ventricular pressure is often more expedient to determine in patients. Therefore, ventricular enddiastolic pressure is commonly used clinically to gauge "preload" rather than end-diastolic volume. The volume of blood inside the ventricle does more than simply stretch the cardiac muscle fibers to enhance contractility. If the intra-ventricular volume rises too much, it will cause significant pressure on the adjacent ventricular wall. This pressure can lead to a reduction in the driving force for perfusion of the myocardium by the coronary arteries. In this situation, coronary perfusion may be reduced and myocardial function may become impaired. Fluid-filled catheters can be advanced into the right side of the heart after being introduced percutaneously into the internal jugular, external jugular, subclavian, or femoral veins. A pulmonary artery (Swan-Ganz) catheter is used to determine right atrial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure (which reflects left ventricular end diastolic pressure), and cardiac output. As a result, the relationship between end-diastolic pressure and end-diastolic volume can also change. For example, ischemia can cause the compliance of cardiac muscle to decrease significantly in a patient with coronary artery disease. In this instance, the same volume of blood might generate a higher intra-ventricular pressure after the onset of ischemia than before the ischemic event. Pressure data, therefore, must be interpreted within the context of the clinical status of the patient in order to provide useful information regarding "preload. Perhaps the most interesting aspect of a Swan-Ganz catheter is that it is inserted into the right side of the heart, but it allows the evaluation of left ventricular "preload", output, and "afterload" (see Figures 2 and 3). The Swan-Ganz Catheter is a balloon-tipped flow guided catheter that is inserted percutaneously. In the absence of significant pulmonary disease or high alveolar pressures, a static column of blood is generated from the left atrium to the Swan-Ganz catheter tip when the balloon is inflated. During opening of the mitral valve, the pressure measured at the tip of the Swan-Ganz catheter (with the balloon inflated) reflects left ventricular end diastolic pressure. The Swan-Ganz catheter can also be used to determine cardiac output by injection of saline into the right atrium. A thermistor on the Swan-Ganz catheter tip allows thermodilution analysis and calculation of blood flow through the heart. Because all blood that passes through the pulmonary artery is soon ejected from the heart by the left ventricle, this technique is used to approximate left ventricular output. Echocardiography is advantageous in that it allows the simultaneous evaluation of cardiac chamber volume, wall motion, and valvular function. Transthoracic and transesophageal echocardiography can be used to evaluate cardiac function and structure. The transthoracic approach is more expedient and can be performed on awake, non-sedated patients. However, the quality of the images may be inferior to those obtained using the transesophageal approach. In addition, transthoracic echocardiography requires that appropriate acoustic windows be identified.
Observe the cut surface of the cerebellum and try to identify the tree like structure made of white mater called arbor vitae or "tree of life" treatment 99213 buy 200 mg pirfenex. Compare the structures that you see in your dissected samples to those from other groups medicine ball core exercises generic 200mg pirfenex otc. When you are done observing the sheep brain specimen medicine keychain buy generic pirfenex 200mg on-line, dispose it off in the biohazard bin and clean the dissecting tray and knife treatment for scabies discount pirfenex 200 mg overnight delivery. Identify whether each nerve carries sensory information, motor information, or both types of information. Oculomotor X Lesson 24: Motor Control Created by Manashree Malpe Introduction In this lesson, you will learn the fundamental aspects of how the nervous system controls our voluntary body movements. Name key regions of the brain involved in motor control and summarize the role they play in the motor control. Background Information Functional Organization of the Nervous System While previous lessons have focused on organizing the nervous system based on anatomical criteria, we can also describe the organization of the nervous system based on function. Please note that it can be difficult to try and to align anatomical and functional descriptions of the nervous system because often one anatomical structure can have several functions. As an example of a single structure that is important for two different types of functions, the optic nerve carries signals from the retina that are used both for the conscious perception of visual stimuli (processed in the cerebral cortex), and for reflexive responses of smooth muscle tissue (processed in the hypothalamus). First, the nervous system can be divided based on the fundamental functions of the nervous system which are sensation, integration, and response. Second, control of the body can be classified as either autonomic or somatic-divisions that are largely defined by the structures involved in the generation of a response. Key stimuli for autonomic functions can come from sensory structures found in either external or internal environments. The senses of the body interact with stimuli from the external environment and our body responds primarily via voluntary muscle movement. The term "voluntary" suggests that there is a conscious decision to make a movement. However, those same muscles that are responsible for the basic process of breathing are also utilized for speech, which is entirely voluntary. Other motor responses, such as riding a bike, become automatic (in other words, unconscious) as a person learns and masters motor skills (referred to as habit learning or procedural memory). Functional Anatomy of Motor Control Cerebral Cortex the sensory cortical areas are located in the occipital, temporal, and parietal lobes, motor functions are largely controlled by the frontal lobe. These higher cognitive processes include working memory, which has been called a "mental scratch pad," that can help organize and represent information that is not in the immediate environment. The prefrontal lobe is responsible for aspects of attention, such as inhibiting distracting thoughts and actions so that a person can focus on a goal and direct behavior toward achieving that goal (Figure 24. The functions of the prefrontal cortex are integral to the personality of an individual, because it is largely responsible for what a person intends to do and how they accomplish those plans. In generating motor responses, the executive functions of the prefrontal cortex will need to initiate actual movements. The prefrontal areas project into the secondary motor cortices, which include the premotor cortex and the supplemental motor area. The premotor cortex is more lateral, whereas the supplemental motor area is more medial and superior. The premotor area aids in controlling movements of the core muscles to maintain posture during movement, whereas the supplemental motor area is hypothesized to be responsible for planning and coordinating movement. For example, these areas might prepare the body for the movements necessary to drive a car in anticipation of a traffic light changing. The frontal eye fields are responsible for moving the eyes in response to visual stimuli. This area is responsible for controlling movements of the structures important for speech production (Figure 24. Primary motor cortex the primary motor cortex is located in the precentral gyrus of the frontal lobe. It receives input from several areas that aid in planning movement, and its principle output stimulates spinal cord neurons to initiate skeletal muscle contraction. The primary motor cortex is laid out like a topographical map of the body, creating a motor homunculus. The term homunculus comes from the Latin word for "little man" and refers to a map of motor control of the human body that is laid across this region of the cerebral cortex.
Consider early pain management for burns or associated traumatic injury [see Pain Management guideline] Patient Safety Considerations 1 symptoms you have cancer discount 200mg pirfenex overnight delivery. Victims do not carry or discharge a current symptoms 5 dpo generic pirfenex 200mg with visa, so the patient is safe to touch and treat Notes/Educational Pearls Key Considerations 1 treatment lyme disease buy pirfenex 200 mg overnight delivery. Lightning strike cardiopulmonary arrest patients have a high rate of successful resuscitation 4 medications at walmart generic 200mg pirfenex overnight delivery, if initiated early, in contrast to general cardiac arrest statistics 2. If multiple victims, cardiac arrest patients whose injury was witnessed or thought to be recent should be treated first and aggressively (reverse from traditional triage practices) a. Patients suffering cardiac arrest from lightning strike initially suffer a combined cardiac and respiratory arrest b. Patients may be successfully resuscitated if provided proper cardiac and respiratory support, highlighting the value of "reverse triage" 4. It may not be immediately apparent that the patient is a lightning strike victim 5. Injury pattern and secondary physical exam findings may be key in identifying patient as a victim of lightning strike 6. Recognizing that pain is undertreated in injured patients, it is important to assess whether a patient is experiencing pain o Trauma-04: Trauma patients transported to trauma center. Investigating a possible new injury mechanism to determine the cause of injuries related to close lightning flashes. Mountain medical mystery: unwitnessed death of a healthy young man, caused by lightning. Wilderness Medical Society practice guidelines for the prevention and treatment of lightning injuries. The lightning heart: a case report and brief review of the cardiovascular complications of lightning injury. Inner ear damage following electric current and lightning injury: a literature review. Injuries, sequelae, and treatment of lightning-induced injuries: 10 years of experience at a Swiss trauma center. Immediate cardiac arrest and subsequent development of cardiogenic shock caused by lightning strike. Author, Reviewer and Staff Information Authors Co-Principal Investigators Carol A. This guideline defines minimum standards and inclusions used and referenced throughout this document under the "Quality Improvement" section of each guideline 3. Exclusion Criteria None Toolkit for Key Categories of Data Elements Incident Demographics 1. This information will always apply and be available, even if the responding unit never arrives on scene (is cancelled) or never makes patient contact b. Many systems do not require use of these fields as they can be time-consuming to enter, often too detailed. However, there is some utility in targeted use of these fields for certain situations such as stroke, spinal exams, and trauma without needing to enter all the fields in each record. Many additional factors must be considered when determining capacity including the situation, patient medical history, medical conditions, and consultation with direct medical oversight. Trauma/Injury the exam fields have many useful values for documenting trauma (deformity, bleeding, burns, etc. Use of targeted documentation of injured areas can be helpful, particularly in cases of more serious trauma. Because of the endless possible variations where this could be used, specific fields will not be defined here. Note, however that the exam fields use a specific and useful Pertinent Negative called "Exam Finding Not Present. Additional Vitals Options All should have a value in the Vitals Date/Time Group and can be documented individually or as an add-on to basic, standard, or full vitals a. Signs and Symptoms should support the provider impressions, treatment guidelines and overall care given. A symptom is something the patient experiences and tells the provider; it is subjective. Provider impressions should be supported by symptoms but not be the symptoms except on rare occasions where they may be the same.
It is generally felt that this condition will lead to idiopathic dilated cardiomyopathy if the patient survives the acute phase; however treatment centers for drug addiction buy pirfenex 200 mg, we have no good direct proof that this is so at this time treatment urticaria order pirfenex 200 mg on line. In the granulomatous variety throughout the myocardium there are small or large granulomas without caseation and containing giant cells medicine jar discount pirfenex 200 mg with amex. The primary hydatid cysts of the heart tend to rupture into the lumen of a cardiac chamber or into the pericardial sac medicine escitalopram pirfenex 200mg. The fungi most commonly seen in the heart are blastomycosis, actinomycosis, cryptococcosis, coccidioidomycosis. Myocarditis has been reported in a variety of viral disease including all of the common infections: polio, chicken pox, flu, infectious hepatitis, mumps, infectious mononucleosis, and infections caused by Coxsackie B virus. The microscopic picture in viral lesions is similar and consists of interstitial infiltration by Lymphocytes and neutrophils with focal myocyte necrosis. Later the Lymphocytes and histiocytes predominate and there is connective tissue proliferation. Myocarditis may occur in rheumatic fever, rheumatoid arthritis and lupus erythematosus. Microscopic changes in the heart muscle have been reported in dermatomyositis and scleroderma. In these cases there is fibrous tissue replacement of the myocardium without a significant inflammatory component. La Myocarditis may be seen in response to cardiac trauma as in car accidents where there might be an infiltrate of neutrophils. Irradiation of the heart causes an acute inflammatory reaction with damage to small vessels. As you can see some of them are quite commonly used drugs, such as tetracyclines, immunosuppressives, and antihypertensives. The list of drugs thought to be responsible for causing myocarditis is added to daily so no account of them can be totally up to date. Hypersensitivity (allergic) myocarditis have lesions which are not dose or time dependent and may occur any time during delivery of the drug. In general, hypersensitivity myocarditis is manifested morphologically with an interstitial inflammatory infiltrate which includes many eosinophils. Heart size is usually not markedly affected in acute hypersensitivity myocarditis. Toxic myocarditis and vasculitis induced by drugs is dose related and the effects are cumulative. The inflammatory infiltrate surrounding the damaged myocytes is predominantly that of neutrophils although a mixed infiltrate may also be seen. The anthracycline drugs, particularly adriamycin, also may cause an acute myocarditis-pericarditis syndrome; however, these drugs usually cause a chronic myocardial damage which will not be described here. Drugs associated with toxic myocarditis Arsenicals Plasmocid Paraquat Barbiturates Antihypertensives Amphetamine Fluorouracil Histamine-like drugs Anthracyclines Lithium compounds Catecholamines Quinidine Cyclophosphamide Theophylline Phenothiazines Table 2. On examination the patient usually has an enlarged cardiac silhouette and heart failure. Usually, however, it is designated according to its anatomic features, such as (1) serous, (2) serofibrinous, (3) fibrinopurulent, (4) purulent, and (5) hemorrhagic. Pericarditis also may be idiopathic (non-specific) or due to acute bacterial infection, uremia, or associated with myocardial infarction, rheumatic, neoplastic or traumatic. In some conditions such as heart failure an excessive serous transudate may occur into the pericardium slowly or rapidly. In this case there are usually no adhesions (2 01 0 Sulfonamides Isoniazid Penicillin Thiazide diuretics Diphtheria toxoid Tetanus toxoid Streptomycin Sulphonyurease Methyldopa Phenylbutazone Horse serum)S yl la bu s Cardiomyopathy, Myocarditis & Atrial Myxoma - Gerald Berry, M. Sometimes it is also due to direct invasion of tuberculosis or pneumonia from the lung. This type of pericarditis leads to granularity of the serosal surface with occlusion and organization into a dense thickened pericardial sac which may even be calcified. Hemorrhagic pericarditis: A hemorrhagic pericarditis is one in which blood is present in addition to the features of one of the other inflammatory exudates. The causes include tuberculosis, severe acute infections and neoplastic (tumor) involvement of the pericardium. A rare occurrence is a pericardial effusion containing cholesterol which is associated with myxedema. Healed Pericarditis: Pericarditis results in chronic adhesive (obliterative) pericarditis, or chronic constrictive pericarditis.
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References
- Bigger JT, Hoffman BF. Antiarrhythmic drugs. In: Gilman AG, Rall TW, Nies AS, Taylor P, eds. The Pharmacological Basis of Therapeutics. 8th ed. New York: Pergamon Press; 1990.
- Meares EM, Stamey TA: Bacteriologic localization patterns in bacterial prostatitis and urethritis, Invest Urol 5:492n518, 1968.
- Foresta C, Zuccarello D, Garolla A, et al: Role of hormones, genes, and environment in human cryptorchidism, Endocr Rev 29(5):560n580, 2008.
- Kunkel TA, Bebenek K: DNA replication idelity, Annu Rev Biochem 69:497-529, 2000.
- Mitake M, Nakazawa S, Naitoh Y, et al. Endoscopic ultrasonography in diagnosis of the extent of gallbladder carcinoma. Gastrointest Endosc. 1990;36(6):562-566.
- Han SS, Kang KJ, Kwon SJ, et al. Additional role of urine output criterion in defining acute kidney Injury. Nephrol Dial Transplant. 2011.
