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Whether turbu- Airway Resistance to Gas Flow lent or laminar fow occurs can be predicted by the Gas fow in the lung is a mixture of laminar and Reynolds number cheap estrace 2 mg with mastercard womens healthcare associates boca raton, which results from the following turbulent fow order estrace paypal houston women's health care center. Laminar fow can be thought of as equation: consisting of concentric cylinders of gas fowing at dif- ferent velocities; velocity is highest in the center and Reynolds number = decreases toward the periphery estrace 1 mg lowest price menstruation every two weeks. During laminar fow, Linear velocity × Diameter × Gas density Gas viscosity Pressure gradient Flow = Raw A low Reynolds number (<1000) is associated with laminar fow, whereas a high value (>1500) where Raw is airway resistance. Laminar fow normally 8 × Length × Gas viscosity occurs only distal to small bronchioles (<1 mm). Volume-Related Airway Collapse gases used clinically, only helium has a signifcantly At low lung volumes, loss of radial traction lower density-to-viscosity ratio, making it useful increases the contribution of small airways to total clinically during severe turbulent fow (as caused by resistance; airway resistance becomes inversely upper airway obstruction). During forced exhalation, reversal of the normal The terminal portion of the fow/volume curve transmural airway pressure can cause collapse of is therefore considered to be efort independent these airways (dynamic airway compression). Note that Zero regardless of initial lung volume or effort, terminal expiratory flows are effort independent. The equal pressure point moves provides important information about airway resis- toward smaller airways as lung volume decreases. This component of nonelastic resistance is gener- ally underestimated and ofen overlooked, but may C. It Measuring vital capacity as an exhalation that is as seems to be primarily due to viscoelastic (frictional) forceful and rapid as possible (Figure 23–10 ) resistance of tissues to gas fow. Excessive amounts of expiratory resistance also activate expiratory mus- Tissue resistance work cles (see above). Airway resistance work Respiratory muscles normally account for only 2% to 3% of O2 consumption but operate at about. Ninety percent of the work is dissi- pated as heat (due to elastic and airfow resistance). In pathological conditions that increase the load on the diaphragm, muscle efciency usually progressively decreases, and contraction may become uncoordi-. The work required to overcome elastic resis- tance increases as Vt increases, whereas the work 0 required to overcome airfow resistance increases as 0 –1 –2 Change in pleural pressure (mm Hg) respiratory rate (and, necessarily, expiratory fow) increases. Work of Breathing on Pulmonary Mechanics Because expiration is normally entirely passive, both the inspiratory and the expiratory work of breathing The efects of anesthesia on breathing are complex is performed by the inspiratory muscles (primarily and relate to changes both in position and anesthetic the diaphragm). Volumes & Compliance Respiratory work can be expressed as the prod- Changes in lung mechanics due to general anes- 6 uct of volume and pressure (Figure 23–11 ). During exhalation, the stored potential collapse and compression atelectasis due to loss of energy is released and overcomes expiratory airway inspiratory muscle tone, change in chest wall rigidity, resistance. The mechanisms tory resistance are compensated by increased inspi- may be more complex; for example, only the depen- ratory muscle efort. When expiratory resistance dent (dorsal) part of the diaphragm in the supine increases, the normal compensatory response is to position moves cephalad. The higher position Awake of the dorsal diaphragm and changes in the thoracic cavity itself decrease lung volumes. Tus, the risk of increased intra- pulmonary shunting under anesthesia is similar to that in the conscious state; it is greatest in the elderly, in obese patients, and in those with underlying pul- monary disease. At end-expiration, the dorsal thesia would be expected to increase airway resis- portion of the diaphragm is more cephalad and the tance. Increases in airway resistance are not usually ventral portion is more caudal than when awake, the observed, however, because of the bronchodilating thoracic spine is more lordotic, and the rib cage moves properties of the volatile inhalation anesthetics. Position of airway Neck extension ↑ Neck flexion ↓ E ff ects on the Work of Breathing Increases in the work of breathing under anesthesia Age ↑ are most ofen secondary to reduced lung and chest Artificial airway ↓ wall compliance, and, less commonly, increases in airway resistance (see above). The problems of Positive-pressure ventilation ↑ increased work of breathing are usually circum- Drugs—anticholinergic ↑ vented by controlled mechanical ventilation. Pulmonary perfusion E ff ects on the Respiratory Pattern Pulmonary emboli ↑ Hypotension ↑ Regardless of the agent used, light anesthesia ofen results in irregular breathing patterns; breath hold- Pulmonary vascular disease ing is common. Inhalation agents generally pro- duce rapid, shallow breaths, whereas nitrous–opioid techniques result in slow, deep breaths.

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Extends as far as aortic bifurcation • Parametrium – pelvic visceral fascia and contents adjacent • The posterior branch divides as follows (muscular): to the cervix · iliolumbar artery • Space of Retzius/ prevesical/ retropubic space – · lateral sacral arteries separated from the anterior abdominal wall by · superior gluteal artery effective 2 mg estrace menstruation after tubal ligation. Neurovascular anatomy of the female • It is crossed at its origin by the gonadal vessels order cheap estrace online womens health big book of exercises, genital pelvis branch of the genitofemoral nerve generic estrace 2 mg line womens health 2014 beauty awards, deep circumfex iliac Pelvic vasculature vein and by the round ligament. Tey are medial lower down and then pass • The common iliac arteries pass posteriorly to the posteriorly as they ascend. Most external iliac and common iliac nodes Important nerves of the pelvis have a short axis <10 mm. Four major nerves arise from it: to remember when interpreting these images that 1. The apex lies behind the symphysis the piriformis and coccygeus muscles; enters the pubis. It is from here that the urachal remnant passes perineum through the lesser sciatic foramen up to the umbilicus, forming the median umbilical 3. The base is triangular and the ureters enter runs along lateral pelvic wall, posteromedial to the the posterolateral angles. The inferior angle or neck common iliac vein to enter obturator canal gives rise to the urethra surrounded by the internal 4. The body of the uterus rests on its and iliacus muscles before passing under inguinal posterosuperior surface and the cervix and vagina are ligament into the thigh. Although less fxed than in the male the Pelvic viscera bladder is attached to the back of the pubis, lateral walls of Bladder and urethra the pelvis and rectum by condensations of pelvic fascia. Tey run inferoposteriorly anterior to the 262 Chapter 14: The female pelvis L4 L5 Lumbosacral trunk S1 Pelvic splanchnic n. Superior gluteal To piriformis Coccygeal Inferior gluteal plexus Obturator To levator ani, coccygeus, external anal sphincter Sciatic n. To obturator internus and superior gemmellus To quadratus femoris and inferior gemellus Posterior femoral cutaneous n. Vascular supply internal iliac artery and at the level of the ischial spine turn anteromedially to enter the posterolateral bladder. The intramural ureters • Ve n o u s course for 2 cm before entering the bladder lumen. It extends from the · bladder – via a venous plexus to the internal iliac vein bladder neck to the vestibule, where it opens 2. The external sphincter is at the diaphragm Lymph supply but less well developed than the involuntary internal • Bladder – internal iliac and para-aortic nodes sphincter at the bladder neck. Small paraurethral glands • Urethra – internal iliac nodes open into the vestibule on either side of the urethral orifce. Lumbosacral trunk Sacral • Colour Doppler enables identifcation of the ureteric jets. S4 Lower genital tract Vulva S5 Coccygeal plexus •The female external organs are known collectively as C0 the vulva: mons pubis, labia majora/minora, vestibule of vagina, clitoris, bulb of vestibule, greater vestibular g l a n d s. It contains the vaginal and urethral orifces and the openings of the greater vestibular glands (Bartholin’s). Tese have erectile tissue and are covered by the bulbospongiosus muscles and then by Superior gluteal Posterior femoral cutaneous n. Clitoral via deep dorsal veins to the To levator ani, coccygeus, internal pudendal vein and the superfcial dorsal veins to external anal sphincter the external pudendal and long saphenous veins. Nerve supply • Lymph vessels in the perineum and lower part of labia • Bladder – vesical nerve plexus which is continuous with the majora drain to the rectal lymphatic plexus. Vagina Plain radiographic anatomy • A fbromuscular tube that is approximately 7–9 cm in Intravenous urogram / cystogram length and ascends up and back from the vestibule (clef • Demonstrates the kidneys and bladder. The vagina system shrinks in length following the menopause and the fornices virtually disappear. Left ureter Relations • Anterior : cervix, bladder base and urethra • Posterior: · upper – rectouterine pouch of Douglas separating Uterine vagina from rectum indentation Contrast in bladder · mid – Denonvillier’s fascia separating vagina from lumen ampulla of rectum · lower – perineal body separating vagina from anal canal Fig. Vascular supply • The posterior wall is 1 cm longer than the anterior wall and • Arterial from vaginal, uterine, internal pudendal and is in contact with the external os. The posterior fornix is the vagina that drain to the internal iliac veins the deepest and related to the rectouterine pouch.

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Most hygromas are of little and Effusions clinical signifcance order estrace us womens health uiuc, although some of these may be associated with mass effect that may require Hygromas develop in up to 60% of cases follow- additional decompressive surgery order estrace cheap online menstrual history. T2 cerebrospinal fuid signal characteristics discount estrace 1mg free shipping breast cancer pain, but Hygromas usually appear after 1 week of sur- can also enhance (Fig. The collections also gery, reach a maximum volume at 3–4 weeks, tend to have wavy margins and can compress the and resolve over several months. However, nearly 8% convert to collections are generally clinically silent and subdural hematomas by 2 months, resulting in resolve within 1 month. However, when brospinal fuid leakage or herniation of the sub- these are persistent or the suture line is under arachnoid space through a defect in the dura. On imaging, pseudomeningoceles appear tions near burr holes can sometimes refect impair- as simple fuid collections that bulge into the scalp ments in cerebrospinal fuid absorption, except in or posterior cervical soft tissues and communicate infants, where cerebrospinal fuid can be extruded with the intracranial space (Fig. Axial T2–weighted (b) signal intensity (*) at the suboccipital craniectomy site 4 Imaging the Postoperative Scalp and Cranium 169 4. Angiography Signifcant arterial injury resulting from retrosig- is recommended to ascertain the presence of a moid craniotomy is an uncommon incident. Patients can present with a pulsatile but may be amenable to endovascular therapy. The pseudoaneurysm was subsequently coiled, the left retrosigmoid craniotomy site. The vast majority of Infection is a serious complication of craniotomy, these cases are due to infection by Staphylococcus craniectomy, and cranioplasty that can occur in aureus. These within the bone fap and surrounding the cranio- fndings are not specifc for osteomyelitis and can plasty (Figs. Staphylococcus aureus is the sinus tracts, skin thickening, fat stranding, and most common responsible organism. Although sys- addition, predisposing factors include communi- temic signs of infection can be mild, management cation with the sinuses, multiple surgeries, long consists of wound debridement, antibiotics, and intraoperative times, and surgery for preexisting removal of the cranioplasty. Treatment of bone fap in size of the collection over time is a particularly osteomyelitis ranges from conservative manage- suspicious fnding. The patient presented with fever and pain at surgical site several months after acrylic cranioplasty. Cultures grew Staphylococcus aureus, and the cranioplasty mate- rial was subsequently removed 4 Imaging the Postoperative Scalp and Cranium 173 4. Various tion, which can demonstrate enhancement on terms are used to describe this granulomatous imaging (Fig. The presence of hemostatic reaction, such as textilomas, gossypibomas, gau- material at the site of the lesion on baseline imag- zomas, surgicelomas, and muslinomas. Large craniectomy defects predispose to the development of sunken skin fap syndrome, Sunken skin fap syndrome (syndrome of the tre- and brain atrophy accentuates the degree of con- phined) is an uncommon, late complication of cavity. This condition is certainly not cosmeti- craniectomy, usually occurring 1 month after sur- cally pleasing and may even compromise cerebral gery. Furthermore, along with headache, the scalp fap and brain deformity at the site of fatigue, and seizure, sunken skin faps may be a craniectomy (Fig. These out- be atmospheric pressure that exceeds intracranial comes often improve following cranioplasty. There is no associated brain herniation 4 Imaging the Postoperative Scalp and Cranium 175 4. Although some degree of brain expan- sion is expected after craniectomy, extension of brain tissue beyond 1. Extracranial cerebral herniation is more likely to occur with small craniectomy defects. This can produce a characteristic “mush- room cap” appearance of the deformed brain tis- sue (Fig. Extracranial herniation can also lead to venous infarcts sec- ondary to cortical vein compression. This risk of substantial external brain herniation is lower with larger craniectomies. Alternatively, intracranial contents can herniate Although mild remodeling of the bone fap edges through the defects.

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Quantitative Patients with a high faecal calprotectin will require to undergo endoscopy and biopsy to measurements of pancreatic enzymes in make a specifc diagnosis intestinal secretions are no longer per- Exocrine pancreatic Faecal human pancreatic elastase 1 (E1) concentration purchase estrace 1 mg online breast cancer 82 years old. Faecal chymotrypsin is less reliable insuffciency as it is prone to some degradation in the gut formed in routine clinical practice proven 2mg estrace menopause in 30s. In suspected enzyme defciency order estrace overnight womens health raspberry ketones, a therapeu- tic trial of oral enzyme replacement with latter is confned to the superfcial poor specifcity, and is useful as a popu- food will usually confrm the diagnosis. The clinical lation screening tool, to select patients Faecal elastase or chymotrypsin are occa- presentation of both diseases – typically for colonoscopy and biopsy, to detect sionally measured to confrm the pres- an increase in frequency with blood and/ colon cancer. They are usually diagnosed by recurrent pancreatitis that predates pan- a combination of endoscopy, biopsy and Clinical note creatic failure. The aetiology of these disor- Many patients with is a major cause of chronic pancreatic ders is unknown and frequently there malabsorption recognize failure. It is usually suspected clinically can be diffculties in making a defnitive that certain things in their diet in infancy as the children present with histological diagnosis. In all infamma- – usually fatty foods – cause chronic refractory foul stools, recurrent tory bowel disorders the faecal calprotec- diarrhoea. The small intestine contains a large Gastrointestinal disorders Small intestine amount of lymphoid tissue. In its early stages it n Laboratory tests in the investigation of est cause of villous atrophy. The pres- is asymptomatic hence the introduction gastrointestinal disorders fall into one ence of auto-antibodies (Table 56. Case history 45 Infammatory bowel A 69-year-old woman, who had made an excellent recovery after local excision of a breast disease tumour 8 years previously, presented with weight loss, bone tenderness and weakness. Her family were concerned that she include Crohn’s disease, and ulcerative was not caring for herself nor eating adequately. Iron defciency causes a failure in haem synthesis and since haemoglobin N Iron defciency anaemia is the common- is required for delivery of oxygen to the + est of all single-nutrient defciencies, Fe tissues, this leads to anaemia and tissue causing seriously impaired quality of hypoxia. The principal causes are chronic toxic to cells and must be bound to blood loss and poor dietary intake of protein at all times. Uptake of iron can be decreased by a number of dietary con- Iron physiology stituents, such as phytic acid, and can P P also occur in malabsorptive conditions, Iron levels are controlled by regulating M such as coeliac disease. In iron def- Methyl iron uptake, since there is no mech- V Vinyl ciency anaemia it is important to diag- anism for controlling its excretion. P Propionate nose the underlying condition, especially Dietary intake of iron is about 0. In women, even when well- in the tissue stores is bound to the iron body iron stores. The concentration nourished, iron defciency may develop storage proteins ferritin (soluble) and is normally greater than 12 μg/L. The 1% of acute phase response can result in iron requirements of the developing body iron in the plasma is associated increases in serum ferritin, making fetus. Normal adult concentra- markedly increased in iron by serum ferritin levels of less than tions are 10–40 μmol/L. For a full investigation of both iron and haemoglobin are low iron status, the haemoglobin and there is a microcytic, hypochro- Laboratory investigation concentration, the appearance of the mic anaemia (Fig 57. Low of iron disorders n Serum iron determinations are of Iron intake limited routine value, being of most ~20 mg/day ~0. Desquamation When saturation falls to 15%, iron ~5–10% Ferritin stores ~20% defciency is likely and some degree absorbed Iron loss Menstrual of clinical effect can be expected. Transferrin excretion and, therefore, also total serum iron, Myoglobin ~5% is decreased as part of the acute phase response. Protein energy malnutrition decreases transferrin synthesis and hence its serum ~90% excreted concentration. It din targets ferroportin, a transmem- The best way to confrm hereditary can take up to 6 months to replete the brane protein.

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