Medical Instructor, Texas A&M Health Science Center College of Medicine
High-risk factors for cervical carcinoma include multiple sexual partners what do erectile dysfunction pills look like purchase viagra sublingual amex, promiscuous partners erectile dysfunction treatment yahoo cheap 100 mg viagra sublingual visa, participation in sexual intercourse during the early teen years condom causes erectile dysfunction discount viagra sublingual 100mg on-line, 633 and a patient history of sexually transmitted disease erectile dysfunction treatment side effects cheap viagra sublingual on line. Other environmental factors, such as smoking, are considered as predisposing women to cervical cancer. Signs and symptoms Cervical cancer is asymptomatic in the early stage but can be detected by the Pap test. The invasive stage is indicated by slight bleeding or spotting or a slight watery discharge. Surgery combined with radiation (either an implant of radioactive material or external radiation-see Chapter 5) is the recommended treatment. The prognosis for the patient with invasive carcinoma depends on the extent of spread of the cancer cells. Explain the following terms and give an example of each: (1) dysplasia, (2) carcinoma in situ, (3) carcinogenic, and (4) invasive. Explain why vaginal bleeding or abnormal discharge indicates a more advanced stage of cervical cancer. Carcinoma of the Uterus (Endometrial Carcinoma) Carcinoma of the uterus remains a common cancer in women older than 40 years, the majority of cases occurring in the 55- to 65-year age range. These tumors have a poor prognosis and frequently have metastasized to the lungs by the time diagnosis is made. The majority of endometrial carcinomas are adenocarcinomas arising from the glandular epithelium. The malignant changes develop from endometrial hyperplasia, with the cells gradually becoming more atypical. Excessive estrogen stimulation appears to be the major factor in the development of hyperplasia. This cancer is a relatively slow-growing tumor and may infiltrate the uterine wall, leading to a thickened area, or it may mushroom out into the endometrial cavity. Eventually the tumor mass fills the interior of the uterus and extends through the wall into the surrounding structures. Endometrial cancers are graded from 1, indicating well-differentiated cells, to grade 3, indicating poorly differentiated cells. Etiology Individuals with a history of increased estrogen levels have a higher incidence of uterine cancer. Exogenous estrogen taken by postmenopausal women is associated with an increased risk of endometrial cancer, and currently the guidelines for use and the dosage of estrogen have been reduced to minimize this danger. Other causes of hyperestrinism include infertility or the earlier ingestion of sequential oral contraceptives. The current practice of combining estrogen with progestin reduces the risk of hyperplasia in the uterus, but is still associated with increased risk of breast cancer. There is also an increased incidence of cancer in obese women and in those with diabetes or hypertension. Signs and symptoms Painless vaginal bleeding or spotting is the key sign of endometrial cancer because the cancer erodes the surface tissues. The Pap smear is not a dependable assessment tool for detecting abnormal endometrial cells. Direct aspiration of uterine cells provides a more accurate cell sample with biopsy required to confirm the diagnosis. Late signs of malignancy include a palpable mass, discomfort or pressure in the lower abdomen, and bleeding following intercourse. Treatment Surgery and radiation constitute the usual treatment measures with chemotherapy in the later stages. A simple screening test is not available for this cancer; the Pap test does not screen for this cancer. However, the early indicator is vaginal bleeding, which in a postmenopausal woman is a significant sign demanding investigation. A couple is considered infertile after a year of unprotected intercourse fails to produce a pregnancy. Male problems include changes in sperm or semen, hormonal abnormalities, or physical obstruction of sperm passage. Semen analysis assesses specific characteristics such as the number, normality, and motility of sperm. Ability of the sperm to penetrate the cervical mucus and the presence of sperm antibodies are also considered. Hormonal imbalances may result from either pituitary disorders or testicular problems. Ductal obstructions may result from congenital problems or scar tissue related to prior events such as infection. Decreased fertility has many possible causes: Infertility may be associated with hormonal imbalances resulting from altered function of the hypothalamus, anterior pituitary gland, or ovaries. For example, the feedback system may not be functioning or may be suppressed by stress, extreme exercise or training, or the ovaries may be abnormal. Explain why the cure rate for cervical cancer is much better than that for ovarian cancer (refer to Chapter 5). List the tumors whose development is influenced by hormones and explain how these may be treated. Ovarian Cancer Ovarian cancer is of concern because only about 25% of ovarian cancer is diagnosed in the early stage, at which time the prognosis is favorable. Approximately 22,000 cases are diagnosed in the United States annually, with 15,000 deaths per year are expected.
Feeding difficulties are often the first sign erectile dysfunction oil purchase viagra sublingual master card, with failure of the child to gain weight or meet developmental guidelines erectile dysfunction causes weight best buy for viagra sublingual. Sleep periods are short because the baby falls asleep while feeding and is irritable when awake psychological reasons for erectile dysfunction causes purchase discount viagra sublingual online. Diagnostic tests Radiographs show cardiomegaly and the presence or absence of fluid in the lungs erectile dysfunction in young purchase viagra sublingual 100 mg without a prescription. Cardiac catheterization can be used to monitor the hemodynamics or pressures in the circulation. Compensation mechanisms are indicated by tachycardia, pallor, and daytime oliguria. The backup effects of left-sided failure are related to pulmonary congestion and include: Dyspnea and orthopnea, or difficulty in breathing when lying down, develop as increased fluid accumulates in the lungs in the recumbent position. Reducing the workload on the heart by avoiding excessive fatigue, stress, and sudden exertion is important in preventing acute episodes. Prophylactic measures such as influenza vaccine are important in preventing respiratory infections and added stress on the heart. Maintaining an appropriate diet with a low sodium intake, low cholesterol, adequate protein and iron, and sufficient fluids is essential. Depending on the underlying problem, cardiac support is provided by drugs previously mentioned. Because patients often take a number of medications on a long-term basis, it is important to check all of them for effectiveness, cumulative toxicities, and interactions. Explain two causes of left-sided heart failure, one related to the heart and one systemic. How should a patient with left-sided heart failure be positioned in a reclining chair or bed for treatment It is estimated that in the United States, 8 of every 1000 infants (approximately 35,000 babies) per year are born with heart defects, the majority of which are mild. Mortality rates have dropped considerably with improvements in surgical procedures. Both genetic and environmental factors contribute to the occurrence of congenital heart defects and these defects often occur with other developmental problems. Pathophysiology Congenital heart disease may include valvular defects that interfere with the normal flow of blood. All significant defects result in a decreased oxygen supply to the tissues unless adequate compensations are available. Many variations and degrees of severity are possible with these defects, but if the basic cardiac cycle is understood, the effects of a change in blood flow in each situation can be predicted. Different methods of classifying the defects are possible, using either the type of defect or the presence of cyanosis, a bluish color in the lips and oral mucosa. When an abnormal communication permits mixing of blood, the fluid always flows from a high-pressure area to a low-pressure area, and flow occurs only in one direction. On the other hand, a right-to-left shunt means that unoxygenated blood from the right side of the heart bypasses the lungs directly and enters the left side of the heart. The direction and amount of the abnormal blood flow determine the effects on the individual. Acyanotic conditions are disorders in which systemic blood flow consists of oxygenated blood, although the amount may be reduced. In cyanotic disorders, venous blood mixes with arterial blood, permitting significant amounts of unoxygenated hemoglobin in the blood to bypass the lungs and enter the systemic circulation. The high proportion of unoxygenated blood produces a bluish color (characteristic of cyanosis) in the skin and mucous membranes, particularly the lips and nails. Death occurs in infancy in some severe cases, but many anomalies can be treated successfully shortly after birth. Etiology Most defects appear to be multifactorial and reflect a combination of genetic and environmental influences. These defects are often associated with chromosomal abnormalities, such as Down syndrome. Environmental factors include viral infections such as rubella, maternal alcoholism (fetal alcohol syndrome), and maternal diabetes. Compensation mechanisms Through a sympathetic response, the heart increases its rate and force of contraction in an effort to increase cardiac output. This response increases the oxygen demand in the heart, restricts coronary perfusion, and increases peripheral resistance. Respira- tory rate increases if the oxygen deficit results in acidosis due to increased lactic acid in the body, but oxygen levels must drop considerably before this factor influences the respiratory rate (see Chapter 19). Secondary polycythemia develops with chronic hypoxia as erythropoietin secretion increases as compensation. Signs and symptoms Small defects are asymptomatic other than the presence of a heart murmur. Large defects lead to: Pallor and cyanosis Tachycardia, with a very rapid sleeping pulse and frequently a pulse deficit Dyspnea on exertion and tachypnea, in which the signs of heart failure are often present A squatting position, often seen in toddlers and older children, that appears to modify blood flow and be more comfortable for them Clubbed fingers (thick, bulbous fingertips) developed in time A marked intolerance for exercise and exposure to cold weather Delayed growth and development Diagnostic tests Congenital defects, particularly severe ones, may be diagnosed at birth, but others may not be detected for some time. Treatment Surgical repair is often needed to close abnormal openings or to replace valves or parts of vessels. Palliative surgery may take place immediately and then is followed up several years later by additional surgery. B, A 2-D image of a normal heart from the apical window, showing the four chambers and atrioventricular valves.
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Recovery from sevoflurane after a short anesthetic (<1 hr) is more rapid than either isoflurane owing to the lower blood gas solubility coefficient (0 erectile dysfunction walmart generic viagra sublingual 100mg visa. For longer procedures erectile dysfunction cvs purchase 100 mg viagra sublingual otc, however erectile dysfunction medication nz purchase cheap viagra sublingual on line, the advantage of faster recovery is offset by the much greater cost of sevoflurane compared with isoflurane impotence at 40 order generic viagra sublingual from india. The recovery time is also not significantly improved compared with isoflurane, because both gases similarly redistribute into fat during longer anesthesia periods, and offset of these gases from fat storage is not different. All of the side chain halogen atoms in sevoflurane are fluorine, contributing to its low blood-gas solubility and recovery profile. Unlike earlier inhaled agents, the small Potent Inhalation Agents the halogenated inhalation agents commonly in use today in the United States include isoflurane, sevoflurane, and desflurane. As seen in Figure 3-9, all are derivatives of ether with halothane, an ethane, added for historical reference. Unlike the original anesthetic gas, diethyl ether, these agents are halogenated and nonflammable. The newer halogenated agents, sevoflurane and desflurane, are unique in that all of the side chain halogen atoms are fluorine. The gases are stored and released by gas-specific vaporizers that control the concentration (volume %) allowed into the anesthesia circuits and into the patient. Halothane sensitizes the myocardium to dysrhythmias after administration of epinephrine in saline. A comparative interaction of epinephrine with enflurane, isoflurane, halothane in man. Regardless, sevoflurane may not be the agent of choice for patients with renal disease. Sevoflurane is fequently used at a total gas flow of at least 2 L/min to reduce the production of compound A. Desflurane Desflurane is extremely pungent and can be so irritating to nonanesthetized airways that it may precipitate coughing and laryngospasm. During initial administration of desflurane, tachycardia can also occur until deeper levels of anesthesia are realized. Desflurane is delivered from specially heated vaporizers because its vapor pressure is close to atmospheric pressure. It also possesses only fluorine substitutions that, like sevoflurane, confer a low blood-gas solubility. This confers a quick onset and offset and easy titratability, and recovery can be very rapid after a short anesthetic with desflurane. Halothane For historical perspective, since the 1950s, halothane, an ethane, was widely used, particularly in pediatric anesthesia, owing to its a sweet, nonpungent odor that did not irritate the airway mucosa. This was the only inhalation inducton agent available for many years until the introduction of sevoflurane. Around the world, halothane is still commonly used because its cost is low and inhalation induction well tolerated. In the operating room, opioids are often given concurrently with other anesthetic agents in a balanced technique to supplement intraoperative analgesia. An opioid with a long duration of action such as morphine or hydromorphone is commonly administered by the practitioner before the end of the procedure, in anticipation of postoperative pain. During the initial phase of postoperative care, these medications are usually given by the nursing staff but once initial recovery has occurred, patient administration can also occur via computeraided patient-controlled analgesia pumps. Onset time is 10 to 15 minutes, with an analgesic duration of approximately 6 hours. Whereas relaxation can be achieved with deeper anesthetic levels or appropriate peripheral neural blockade, neuromuscular blocking agents are commonly used to provide the necessary amount and duration of relaxation. The potential of these drugs during anesthesia and surgery was not recognized until the middle of the 20th century. Many of the current neuromuscular blocking agents used are derivatives of curare, one of the oldest paralyzing agents, used by ancient hunters to paralyze prey. Neuromuscular blocking agents can be classified as either depolarizing or nondepolarizing and, within the latter group, can be divided based on structure, speed of onset, duration of action, and metabolism. The most commonly used agents for postoperative pain control in office-based oral surgery are likely the local anesthetics. Long-acting local anesthetics, like bupivacaine and etidocaine, provide several hours of analgesia for inferior alveolar nerve block anesthesia as well as soft tissue anesthesia in the maxilla. Tachycardia can result upon initial administration but bradycardia may develop, especially with repeated administration. Widespread muscle contractions can result in postoperative myalgia, which can at times be prevented by prior administration of a small dose of a nondepolarizing muscle blocker. The contractions may increase intraocular and intragastric pressure and can also cause a transient elevation in plasma potassium levels by 0. Its use should also be avoided in patients with pseudocholinesterase abnormalities, because the recovery from this drug will be prolonged. They are one of the very few drug classes known to decrease anesthetic requirements. Clonidine, the prototypical alpha 2 agonist, can be used as an anxiolytic premedication with the added benefit of cardiovascular stability intraoperatively. Dexmedetomidine has proved useful in awake endotracheal intubation and some preipheral procedures in which good local anesthesia can be obtained. It can also be used in a continuous infusion as an adjunct to general anesthesia to reduce anesthetic requirements. Some practitioners use a single bolus dose before extubation for smooth emergence from anesthesia.
Firm pressure should be continuous erectile dysfunction doctors charlotte buy viagra sublingual 100 mg overnight delivery, and if the dressings become soaked erectile dysfunction treatment mn generic viagra sublingual 100 mg on line, they should not be removed but erectile dysfunction yoga exercises discount viagra sublingual online master card, rather erectile dysfunction pills in india buy viagra sublingual 100 mg, covered with additional dressings. Firm pressure on the major artery in the axilla, antecubital fossa, wrist, groin, popliteal space, or ankle may assist in control of hemorrhage distal to the site. Pressure points should be used only if direct wound pressure alone is not effective. Because of the rich blood supply to the head and neck, significant hemorrhage may be associated with large scalp wounds, nasal or midface fractures, and penetrating neck wounds. In a short period of time, the scalp may lose a large amount of blood, which oozes from the galea and loose connective tissue layers. The wound can be approximated rapidly with 2-0 nonresorbable sutures without regard to cosmetic closure. Direct pressure should then be placed over the wound to control the hemorrhage and minimize hematoma formation. After the patient has been stabilized, the sutures may be removed and a more cosmetic approach with resorbable sutures may be used to close the galeal layer and to achieve good approximation and orientation of the hair-bearing dermal and skin layers. Nasal or midface fractures may hemorrhage from tears of the ethmoidal arteries that arise from the internal carotid system or from branches of the maxillary artery system (Figure 14-10). Most hemorrhages from facial injuries can be controlled with direct pressure or packing (Figure 14-11). If direct control is necessary, good visualization of the damaged vessel is required. Blind clamping may cause further bleeding from vessels and soft tissues, as well as nerve damage. Ligation of the external carotid artery may be required only in extreme cases; usually, it is ineffective when used alone and without direct control of hemorrhage because of the collateral circulation of the face. The potential internal sites of hemorrhage are the thoracic cavity, abdomen, retroperitoneum, and extremities. When there is no evidence of external or intrathoracic bleeding, continued severe hypovolemia is usually the result of bleeding into the abdomen or at fracture sites. Blood loss with fractures should be considered to be at least 1000 to 2000 mL for pelvic fractures, 500 to 1000 mL for femur fractures, 250 to 500 mL for tibia or humerus fractures, and 125 to 250 mL for fractures of smaller bones. Control of hemorrhage into internal spaces is not done in the primary survey unless the hemorrhage may have damaging effects on the cardiovascular or pulmonary system. Slow internal hemorrhage may be controlled by splinting, casting, or fixation of fractures; by the defense mechanisms of vascular occlusion, retraction, and clot formation; or by open exploratory surgery. The lateral wall of the nasal cavity (A) and the nasal septum (B) receive a rich blood supply from both the internal and the external carotid artery system. The superior aspect of these structures receives a blood supply through the internal carotid system from the anterior and posterior ethmoidal arteries. The middle and inferior aspects are supplied by vessels from the external carotid artery: the facial artery and the nasopalatine, greater palatine, and sphenopalatine arteries from the maxillary artery. A combined technique used for anterior and posterior packing of the nasal cavity involves the following: A, A small red rubber catheter is introduced through the nostrils and carefully passed posteriorly along the floor of the nose until visualized in the oropharynx. Once the catheter is visualized, a forceps may be used to grasp the catheter and pull it into the oral cavity. B, the catheter is then sutured to a tape that is secured to a wad of gauze packing material. The catheter is drawn from the nasal cavity through the nostril, pulling the gauze pack into position in the nasopharynx against the posterior aspect of the nasal cavity. C, Once the posterior pack is in place, the anterior pack (consisting of 1-cm ribbon gauze) is packed in an orderly fashion along the nasal floor, building superiorly; this allows for easy removal and efficient packing of the nasal cavity. Virtually all multisystemic injuries are accompanied by a degree of hypovolemic shock that presents as a graded physiologic response to hemorrhage. This response can be classified based on the percentage of acute blood loss (Table 14-5). A mild tachycardia is noted, but the compensatory mechanisms of the body retain normal blood pressure levels, pulse pressure, respiratory rate, and tissue perfusion. Pelvic fractures, fractures of the femur, and multiple fractures of other long bones may cause hypovolemic shock and life-threatening blood loss, the primary site of which may be difficult to determine. The peripheral vasoconstriction may show an elongated capillary refill time, and the skin may feel cold and moist. Symptoms include marked tachycardia, a significant decrease in the systolic blood pressure level to less than 60 mmHg, marked vasoconstriction with a very narrow pulse pressure, marked diaphoresis, obtunded mental state, and no urinary output. Fat embolism syndrome is usually associated with major fractures of long bones, especially of the femur. The patient typically does well for 24 to 48 hours and then develops progressive respiratory and central nervous system deterioration. Concomitant laboratory value changes include hypoxemia, thrombocytopenia, fat in the urine, and a slight drop in hemoglobin. Fat enters the venous sinusoids at the fractured site and becomes lodged in the lung alveoli.
