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Major criteria for assessment of nutritional Age-independent indices for assessment of 199 Box 13 purchase trandate 100mg with visa arteria carpals. Dietary History Actual weight × 100 Te assessment must begin with the dietary history buy trandate 100 mg online heart attack jaw. Details Percentage weight for height = Expected weight for actual height about intake of cereals generic trandate 100 mg with visa hypertension interventions, vegetables 100 mg trandate with amex hypertension chart, pulses, fruits, eggs Nabarrow’s thinners chart, based on weight for and meat, etc. A rough idea Te child is made to stand against the chart which about the adequacy of vitamins and minerals in the diet bears the expected weight for height. Tis is because of replacements of the baby fat be due to vitamin A defciency, may also be a feature of with muscle tissue. For exact fgures regarding mid- Age-dependent Indices arm circumference at various ages see Table 3. Also, what is more important is the serial record of child’s Triceps skin fold thickness is measured by a standard weight periodically on a growth chart. A measurement Its value lies in detecting chronic malnutrition and between 6 and 10 mm points to mild and moderate stunting. Chest/head circumference ratio less than one after Age-independent Indices frst year of life indicates malnutrition. Since, it is often difcult to fnd true age of the child in the Mid-upper arm/height ratio of less than 0. The instrument consists of a stick graduated with fgures for mid-upper arm circumference in relation to height. For this test, maximum left-upper arm circum- ference (the arm hanging by the side of the body) is recorded. From the graduations in the stick, his nutritional status in terms of 50, 60, 70 or 80% of the standard can be easily read (Fig. Shakir tape method is a simple and age-independent tool for assessing malnutrition. Tis special tape has colored zones—red, yellow and green, corresponding to less than 12. Bangle method, another method not needing age and useful in preschool children, consists of slipping a bangle with a diameter of 4 cm up the forearm. Rao’s weight/height ratio is expressed as: Weight (g) Rao’s ratio = 2 × 100 Height (cm) Normal value is above 0. In gross Hydroxyproline assay kit is suitable for hydroxypro- 201 malnutrition, it is less than 0. Salivary protein, salivary ferritin and free D-amino nitrogen in leukocyte are reduced in malnutrition. Investigations Skeletal radiographs may reveal some retardation of Laboratory investigations include complete blood bone age, osteoporosis or classical signs of nutritional picture especially, hemoglobin, erythrocyte sedimen- rickets or scurvy. While assessing the nutritional status, one must ascertain Special biochemical tests may detect subclinical mal- for evidence of intestinal parasitic infestations, malab- nutrition that could not be revealed by anthropometry. Hydroxyproline is the most Vital Health Statistics commonly used among the amino acids. Hydroxypro- For evaluation of the nutritional status of a community, line levels are an indicator of collagen content. Con- the above measures should be supported by vital statistics ditions that increase collagen turnover can elevate se- such as under fve mortality, infant mortality, neonatal rum and urine hydroxyproline levels. Urine and serum mortality, perinatal mortality, stillbirth rate and life hydroxyproline levels can be used as a marker for bone expectancy as also the ecological background. Understandably, it is important to obtain ecologic z Amino acid pattern is measured by comparing concentrations of two groups of amino acids using per chromatography as shown: information on factors such as: Glycine + serine + glutamine + taurine Food consumption by the community. Ratio = Valine + leucine + isoleucine + methionine Socioeconomic factors such as knowledge, attitudes, z Mean ratio in normal children is 1. Its main faw is that it varies considerably with countries, are energy and proteins, usually more of the age. Almost always it appears to be due to poor creatinine output of the average normal child of the same height: intake of food (energy) as such. Else, if his energy child of the same height consumption is poor, whatever proteins he takes are likely In kwashiorkor and marasmic kwashiorkor, value varies bet-ween to be consumed to provide energy rather than to build the 0. Normal children and those having fully recovered from malnutrition show an index of around unity. With beginning inadequacy of different principles of food, of nutritional rehabilitation, values speedily return to normal. According to his postu- lation, the so called adaptation hypothesis, marasmus is an extreme degree of adaptation to prolonged inadequacy of proteins and energy in the diet. Kwashiorkor is a stage of adaptation failure or dysadaptation which may follow two situations: 1. Sudden precipitation or aggravation by a fulminant infection such as measles, pertussis, bronchopneumonia or acute diarrheal episode. Gopalan feels that whereas nutritional marasmus may be the result of extreme degree of adaptation and the kwashiorkor the result of dysadaptation, relatively mild efect of adaptation may be responsible for nutri- tional dwarfng. Since, according to Gopalan’s hypoth- esis, kwashiorkor follows occurrence of dysadaptation in Fig. Kwashiorkor is said to result from gross defciency of tamination of food may well be an important factor in the proteins though energy defciency is also present. Nutritional marasmus, on the other hand, results from gross defciency of energy though protein defciency Golden’s Hypothesis of Free Radicals also accompanies. According to Golden’s hypothesis of free radical damage, Tus, it is clear that there is defciency of both, proteins kwashiorkor results from overproduction of free radicals and energy, in both the states. Te predominance of the (because of infection, toxins, iron, etc) and breakdown defciency determines whether it is going to be kwashiorkor of protective mechanism (provided by vitamin A and E, or nutritional marasmus. Many malnourished children show overlap in the clinical picture, demonstrating features of both the Jellife’s Hypothesis of Interactions and Sequelae defciency states at a time. It is often quite appropriate to According to Jellife, kwashiorkor is an intrinsically nutri- label them as marasmic kwashiorkor. A vast majority of of a mixture of interactions and sequelae of dietary imbal- the children sufering from mild to moderate forms of ances and/or defciency, infections, parasitosis, emotional it remain hidden in the community for one or another trauma from maternal deprivation due to abrupt weaning reason. Te two types of this subclinical malnutrition are— from breasts, toxins like afatoxin or ochratoxin. Tis Growth failure and poor tissue repair (due to protein lack) is quite understandable if we recall that the disease is and energy shortage (due to calorie defciency) are com- characterized by profound disturbances of water and elec- mon to all forms. A positive correlation exists between the magni- and energy lack-exist in both the syndromes. Zinc defciency may play an important of the body and reduction in the adipose tissue is role in the etiology of the syndrome of growth retarda- not clearly understood. A noteworthy point is that tion with short stature, hypogonadism, hepatospleno- despite increased body water, a malnourished child is megaly and anemia in boys. Tis paradoxical observation is ascribed to the zinc to such boys results in a dramatic improvement. Sometime, within three weeks of initiating treatment, Potassium: Tere is a defnite reduction in the total signifcant gain in weight and acceleration of sexual body potassium by as much as 25%.
Past experience has shown the average number of live insects per square after spraying to be buy 100mg trandate heart attack sam tsui chrissy costanza of atc. If the number of live insects per square follows a Poisson distribution generic trandate 100mg on line blood pressure 45 year old male, find the probability that a selected square will contain: (a) Exactly one live insect (b) No live insects (c) Exactly four live insects (d) One or more live insects 4 generic trandate 100 mg heart attack 911. If the annual incidence of esophageal cancer follows a Poisson distribution generic trandate 100 mg overnight delivery arteria epigastrica superficialis, find the probability that in a given year the number of newly diagnosed cases of esophageal cancer will be: (a) Exactly 10 (b) At least eight (c) No more than 12 (d) Between nine and 15, inclusive (e) Fewer than seven 4. In Chapter 1 we stated that a continuous variable is one that can assume any value within a specified interval of values assumed by the variable. Consequently, between any two values assumed by a continuous variable, there exist an infinite number of values. The intervals defined by any two consecutive specified points we called class intervals. As was noted in Chapter 2, subareas of the histogram correspond to the frequencies of occurrence of values of the variable between the horizontal scale boundaries of these subareas. This provides a way whereby the relative frequency of occurrence of values between any two specified points can be calculated: merely determine the proportion of the histogram’s total area falling between the specified points. This can be done more conveniently by consulting the relative frequency or cumulative relative frequency columns of Table 2. Imagine now the situation where the number of values of our random variable is very large and the width of our class intervals is made very small. In general, as the number of observations, n, approaches infinity, and the width of the class intervals approaches zero, the frequency polygon approaches a smooth curve such as is shown in Figure 4. Such smooth curves are used to represent graphically the distributions of continuous random variables. First, the total area under the curve is equal to one, as was true with the histogram, and the relative frequency of occurrence of values between any two points on the x-axis is equal to the total area bounded by the curve, the x-axis, and perpendicular lines erected at the two points on the x-axis. This seems logical, since a specific value is represented by a point on the x-axis and the area above a point is zero. Finding Area Under a Smooth Curve With a histogram, as we have seen, subareas of interest can be found by adding areas represented by the cells. We have no cells in the case of a smooth curve, so we must seek an alternate method of finding subareas. To find the area under a smooth curve between any two points a and b, the density function is integrated from a to b. Adensity function is a formula used to represent the distribution of a continuous random variable. Integration is the limiting case of summation, but we will not perform any integrations, since the level of mathematics involved is beyond the scope of this book. As we will see later, for all the continuous distributions we will consider, there will be an easier way to find areas under their curves. Although the definition of a probability distribution for a continuous random variable has been implied in the foregoing discussion, by way of summary, we present it in a more compact form as follows. The formula for this distribution was first published by Abraham De Moivre (1667–1754) on November 12, 1733. Many other mathematicians figure prominently in the history of the normal distribution, including Carl Friedrich Gauss (1777–1855). The distribution is frequently called the Gaussian distribution in recognition of his contributions. The two parameters of the distribution are m, the mean, and s, the standard deviation. For our purposes we may think of m and s of a normal distribution, respectively, as measures of central tendency and dispersion as discussed in Chapter 2. Since, however, a normally distributed random variable is continuous and takes on values between À1 and þ1, its mean and standard deviation may be more rigorously defined; but such definitions cannot be given without using calculus. The graph of the normal distribution produces the familiar bell-shaped curve shown in Figure 4. Characteristics of the Normal Distribution The following are some important characteristics of the normal distribution. This characteristic follows from the fact that the normal distribution is a probability distribution. Because of the symmetry already mentioned, 50 percent of the area is to the right of a perpendicular erected at the mean, and 50 percent is to the left. If we erect perpendiculars a distance of 1 standard deviation from the mean in both directions, the area enclosed by these perpendiculars, the x-axis, and the curve will be approximately 68 percent of the total area. If we extend these lateral boundaries a distance of two standard deviations on either side of the mean, approximately 95 percent of the area will be enclosed, and extending them a distance of three standard deviations will cause approximately 99. In other words, a different normal distribution is specified for each different value of m and s. Different values of m shift the graph of the distribution along the x-axis as is shown in Figure 4. Different values of s determine the degree of flatness or peakedness of the graph of the distribution as is shown in Figure 4. Because of the character- istics of these two parameters, m is often referred to as a location parameter and s is often referred to as a shape parameter. The Standard Normal Distribution The last-mentioned characteristic of the normal distribution implies that the normal distribution is really a family of distributions in which one member is distinguished from another on the basis of the values of m and s. The most important member of this family is the standard normal distribution or unit normal distribution, as it is sometimes called, because it has a mean of 0 and a standard deviation of 1. The z-transformation will prove to be useful in the examples and applications that follow. This value of z denotes, for a value of a random variable, the number of standard deviations that value falls above ðþzÞ or below ðÀzÞ the mean, which in this case is 0. For example, a z-transformation that yields a value of z ¼ 1 indicates that the value of x used in the transformation is 1 standard deviation above 0. A value of z ¼À1 indicates that the value of x used in the transformation is 1 standard deviation below 0. To find the probability that z takes on a value between any two points on the z-axis, say, z0 and z1, we must find the area bounded by perpendiculars erected at these points, the curve, and the horizontal axis. As we mentioned previously, areas under the curve of a continuous distribution are found by integrating the function between two values of the variable. In the case of the standard normal, then, to find the area between z0 and z1 directly, we would need to evaluate the following integral: Z z1 1 Àz2=2 pffiffiffiffiffiffi e dz z0 2p Although a closed-form solution for the integral does not exist, we can use numerical methods of calculus to approximate the desired areas beneath the curve to a desired accuracy. Fortunately, we do not have to concern ourselves with such matters, since there are tables available that provide the results of any integration in which we might be interested. In the body of Table D are found the areas under the curve between À1 and the values of z shown in the leftmost column of the table. Solution: It will be helpful to draw a picture of the standard normal distribution and shade the desired area, as in Figure 4. If we locate z ¼ 2 in Table D and read the corresponding entry in the body of the table, we find the desired area to be. We may interpret it as the probability that a z picked at random from the population of z’s will have a value between À1 and 2. We may also interpret it as the relative frequency of occurrence (or proportion) of values of z between À1 and 2, or we may say that 97.
Oral that are surrounded by edematous and erythematous cholestyramine generic 100mg trandate blood pressure homeostasis, bacitracin generic 100mg trandate amex arrhythmia exercise, immune globulin cheap 100mg trandate with amex pulse pressure facts, lactobacilli quality 100mg trandate hypertensive urgency, infammatory response (Figs 29. Tese are Baker’s yeast or instillation of fecal fora may work in such poorly adherent to the underlying tissue. Algorithmic approach for antibiotic-associated Contents diarrhea is shown in Figure 29. Sodium 90 mOsm 75 mOsm Studies conducted all over the world, particularly in Chloride 80 mOsm 65 mOsm Bangladesh, India and Indonesia, have established the Citrate 10 mOsm 10 mOsm value of this revolutionary concept in counteracting Potassium 80 mOsm 20 mOsm dehydration which is known to be the main cause of death in acute diarrheal disease, a major public health problem. Prevention of dehydration if initiated right at the beginning of an episode of diarrhea. It is supposed to lower stool output, shorten diarrheal duration and reduce vomiting. Te easiest approach is to mix one three-fnger-pinch (1/2 teaspoonful) of common salt and two four-fnger-scoops (5 teaspoonful) of sugar in one liter of tap or boiled water. It has been demonstrated that potassium and bicarbonate may not be essential in the early stages of dehydration. Also, there is nothing wrong in replacing sugar or glucose with molasses (gur) (Fig. Tis z More palatable may also be prepared by dissolving 2-fnger scoops of rice z Provides more energy powder (boiled rice) in water and boiling for 3 minutes. To z Reduces stool volume; hence less diarrheal fuid losses it are added a pinch or two of salt and 1/4th medium size z Controls/lessens vomiting during treatment lemon juice. Illiterate mothers, however, may not be persistent diarrhea is reduced able to judge the amount of fuid loss. But, it is z Diarrheal episode with blood and mucus such as caused by unwise to push the fuids if the child does not accept these enteropathogenic or aggregative adherent Escherichia coli, Shigella, Salmonella, Campylobacter jejuni, and rotavirus, or if vomiting is persisting. It may also fop in severe vomiting and high to small intestinal mucosa, contamination of animal milk and osmotic diarrhea rate of stool loss. Te latter must include meticulous stool infective in etiology) continues beyond 2 weeks period. Invariably, it starts of as an acute infective episode that A stool culture is warranted. An acidic diarrheal stool is an stretches beyond 2 weeks in at-risk infants and children. In subjects under 1 year, mortality is Dietary manipulation along with rehydration therapy particularly high. When persistent diarrhea develops is the backbone of management of persistent diarrhea. Diet A: In case persistent diarrhea is mild, the infant Clinical Features on artifcial feed (should be given milk mixed with a cereal (Table 29. Subjects with several motions/day, but without any manifested by dehydration, high purge rate (over 7 adverse fallout on nutritional status and growth and mg/kg/hour) or very frequent large and watery stools, development 2. Subjects with several motions (without dehydration), total milk elimination in an artifcially fed infant is and malnutrition and growth retardation needed. Subjects with several motions and dehydration that is based milk-free diet for persistent diarrhea. Breastfeeding, reduced intake of other milk, or its total In the subjects belonging to the second and third withdrawal should be supplemented with enriched categories, manifestations include progressive weight loss, gruels like khichri with oil, lentil with oil, mashed malnutrition, anorexia, malabsorption and secondary potato with oil, curd mixed with mashed potatoes or infections. Additional water is added to make a fnal volume for persistent diarrhea of 1 liter. To safeguard against spoilage, it is stored in a refrigerator Ingredient Amount (g) z Glucose is initially added in 2% concentration and then built upto Pufed rice* 12. Zinc, 10–20 mg daily for *Pufed rice is ground and appropriate quantities are mixed with sugar 2 weeks, should be given to all infants and children with and oil. Diet C: In cases of severe persistent diarrhea that fails Metronidazole is recommended only for amebiasis, to respond to the dietary management outlined above, giardiasis, or anaerobic infections. Finally, parenteral intolerance to disaccharides (other than lactose as nutrition (partial or total) may be indicated in very well) becomes quite likely. Mono or oligosaccharide advanced cases when small bowel mucosa is extensively carbohydrates diet is well tolerated by these children. An algorithmic approach to management of During convalescence, most cases need relatively higher persistent diarrhea is given in Figure 29. Pathophysiologic Mechanisms Prognosis Osmotic diarrhea results from presence of malabsorption Most children with persistent diarrhea recover following of water-soluble nutrients (lactose intolerance) and stepped up dietary manipulation. Survivors are usually left excessive intake of carbonated fuids or nonabsorbable with moderate to gross malnutrition. Inadequately treated solutes (sorbitol, lactulose, magnesium hydroxide) which or untreated persistent diarrhea causes high morbidity cause an osmotic load in the colon. Secretory diarrhea results from activation of intra- poor outcome include: cellular mediators like cyclic adenosine monophosphate Systemic infections (cholera, heat-labile E. Reduction in anatomic surface area in such diarrhea remains 2 weeks, unlike persistent diarrhea, conditions as short bowel syndrome following surgical signifcant malabsorption is a prominent feature of chronic resection in necrotizing enterocolitis, volvulitis or diarrhea. Alteration in intestinal motility in conditions countries and is responsible for considerable ill-health and such as malnutrition, diabetes mellitus, intestinal morbidity. Roughly diagnostic evaluation of the child with chronic Etiologic Considerations diarrhea should be step-by-step (Box 29. Te individual factors, mucosal factors, or both, can cause chronic diarrhea (Box 29. Nevertheless, the scene is dominated Four phases of evaluation of the child with Box 29. Malnutrition z Is there any history of intolerance to an item of food, Iron defciency anemia i. Mothers of celiacs Malnutrition often express surprise ‘as to how children who eat Diabetes mellitus Intestinal pseudoobstruction so little can pass such voluminous stools’. We have encountered z Excessive intake of sorbitol, lactulose, magnesium salts this situation in some children suffering from z Carbohydrate malabsorption symptomatic giardiasis as well. Characteristically white, fatty stools Bile-related disorders with plenty of undigested material are most often a z Chronic cholestasis feature of giardiasis. This Miscellaneous z Factitious diarrhea condition is fairly common and the stools in it are z Toddler’s diarrhea watery, profuse, accompanied by excess of flatus z Chronic nonspecifc diarrhea. Stool microscopy: Microscopic examination of stools A good history—the importance of a carefully taken for evidence of parasitic infestations is of defnite history cannot be overemphasized. At least three meticulous stool examinations on pointers and clues are likely to be obtained from successive days are essential before one rule out the answers to the following questions: presence of intestinal infestation. During the last our experience, with giardiasis also 3 days all the stools passed by the child are collected Endoscopic/peroral jejunal biopsy: In view of the and analyzed chemically. Te 24-hour fat excretion is nonspecifc results obtained from this investigation, calculated. A fat excretion a few conditions like intestinal lymphangiectasia, of more than 5 g/24 hours is regarded as indicative abetalipoproteinemia, amyloidosis and intestinal of steatorrhea. Stool fat can also be measured by a lymphoma is the intestinal histology pathognomonic. An excretion of <20% indicates focculable medium may reveal abnormalities like malabsorption.
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Atlanta: Laser Vaginal Rejuvenation Atlanta; [cited July 5 buy generic trandate 100mg heart attack the alias club remix, 2013] Available from: http://www purchase trandate 100mg with amex pulse pressure locations. Honour-related threats and human rights: A qualitative study of Swedish healthcare providers’ attitudes towards young women requesting a virginity certificate or hymen reconstruction best trandate 100 mg arteria gastroepiploica dextra. Backgrounds of women applying for hymen reconstruction trandate 100 mg without prescription pulse pressure 55 mmhg, the effects of counseling on myths and misunderstandings about virginity, and the results of hymen reconstruction. Restoration of virginity: Women’s demand and health care providers’ response in Switzerland. Crosssectional study of Swedish physicians’ attitudes towards young females requesting virginity certificates or hymen restoration. Delhi, Bangalore, Mumba: Hymenoplasty; [cited July 3, 2014] Available from http://hymenoplasty. Bacterial infection as a likely cause of adverse reaction to polyacrylamide hydrogel fillers in cosmetic surgery. Woodland Hills: MakeHeal November 25, 2009 [cited June 25, 2014] Available from: http://news. Self-assessment of genital anatomy, sexual sensitivity and function in women: Implications for genitoplasty. A randomized, double-blind, placebo and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata. Increased survival of human free fat grafts with variable densities of human adipose-derived stem cells and platelet rich plasma. Depressed facial scars successfully treated with autologous platelet rich plasma and light- emitting diode phototherapy at 830 nm. However, controversy and debate over the subject remain the most discussed issue in this area, not the in-depth surgical techniques. The line between cosmetic and medically indicated surgical procedures is a gray area, and procedures are performed for both purposes. In the current chapter, we will review the background and history of these procedures, the available data to support them, and the techniques and complications of these procedures. Finally, we will also attempt to shed light on what is myth and what is science in this relatively new field of elective genital vaginal surgery for sexual function and cosmesis of the female vagina and vulva. The current chapter is divided into two sections, the first covering vaginal rejuvenation procedures and the second covering external vaginal/vulvar cosmetic surgery. Many use the term “vaginal rejuvenation” to encompass all elective vaginal/vulvar surgery; however, we feel that it should be used only to refer to functional procedures of the internal vaginal canal and introitus that are designed to enhance sexual function, which includes ensuring adequate support of the pelvic floor and then internal vaginal canal repairs and repair of the introitus. Similarly, cosmetic vaginal surgery to many just means labiaplasty or labial minora reduction; however, one will see in the second section of the chapter that it is much more comprehensive than this. Therefore, we have defined “cosmetic vaginal/vulvar surgery” as cosmetic or aesthetic procedures of the outside of the vagina and/or vulva, including labiaplasty, labia minora reduction, excess or redundant clitoral prepuce reduction, labia majora reduction or augmentation, labia majora divergence repair, perineal skin reduction, and mons pubis reduction. In most instances, to achieve the outcome desired by the woman, a combination of these external cosmetic procedures needs to be done, truly bringing in the “art” of aesthetic surgery. The purpose of these procedures is not to correct pelvic floor defects, but they are modifications of traditional colporrhaphy designed to repair the damage from childbirth and are frequently performed concomitantly with reconstructive procedures for pelvic organ prolapse. These procedures involve vaginal reconstructive techniques to anatomically modify the vaginal caliber by decreasing the diameter of the vaginal canal while reconstructing the perineal body and the vaginal introitus in an attempt to enhance sexual gratification for the woman [2–4]. However, the implication of this definition is to actually give credence to women’s complaints of altered sexual function secondary to vaginal relaxation/looseness (Figure 116. Many women who are candidates for vaginal rejuvenation have symptoms and clinical findings of prolapse. Therefore, a proper repair must involve restoring the foundation of pelvic floor support and encompass some of the newer concepts of vaginal rejuvenation in the repair. Prolapse and vaginal relaxation occurring after vaginal childbirth is not a new concept. We have clear evidence that vaginal delivery increases the risk of vaginal support problems, vaginal relaxation, prolapse, and incontinence. Various pathophysiological studies have demonstrated marked changes after vaginal delivery to levator muscles [5,6], nerves [7], and pelvic support [8]. It is obvious that 1725 parous women are more likely to have pelvic organ prolapse, fecal incontinence, and urinary incontinence than women who have not borne children [9]. There is ample epidemiological evidence that vaginal delivery appears to be the strongest risk factor for pelvic floor disorders [10]. As evident in the Women’s Health Initiative [11], women who had borne at least one child were twice as likely to have uterine prolapse, rectocele, and cystocele as nulliparas, after adjusting for age, ethnicity, body mass index, and other factors. The amount of damage at the time of vaginal childbirth has also been shown to be strongly correlated with sexual function. At 6 months postpartum, women with an intact perineum or first-degree perineal tear were less likely to experience sexual dysfunction than those with higher degree of perineal tear [12,13]. Prolapse and Sexual Function Female sexual dysfunction is defined as a disorder of sexual desire, arousal, orgasm, and/or sexual pain contributing to personal distress [15]. Sexual dysfunction is a multifactorial disorder; biological, psychosocial, and relational factors can contribute to female sexual dysfunction. Dysfunction of vaginal support leading to incontinence, prolapse, and sexual dysfunction is highly prevalent [16]. It is beyond the scope of this chapter to review all of the anatomy, neuroanatomy of pelvic floor support, and its relation to sexual function, however, suffice it to say that we do have good evidence that vaginal childbirth, as well as some other environmental and genetic factors, can lead to issues with pelvic floor support, which in turn can affect sexual function. Again, repairs of pelvic floor and vaginal support have been completed for many, many years, and one would not argue that one of the goals of any of these repairs is to “restore sexual function”; therefore, we must make the assumption that vaginal 1726 relaxation and prolapse affects sexual function in a negative way. There have been many studies published in the literature that confirm, with validated sexual function questionnaires, that prolapse affects sexual function and, when repaired, function improves (Tables 116. These studies have confirmed that prolapse, albeit a more severe form of vaginal relaxation, but certainly relaxation, does adversely impact sexual function. We feel that the posterior vaginal wall anatomically controls most of the vaginal caliber secondary to its relationship to the levator ani and genital hiatus and repair of this wall is a major portion of most rejuvenation-type procedures. Therefore, studies evaluating rectocele repairs may have more of a direct correlation to vaginal caliber and sexual function. Tunuguntla and Gousse found that while posterior repair with levatorplasty leads to sexual dysfunction and pain in many women, that actually posterior colporrhaphy completed alone, with the avoidance of levator ani plication, improves sexual function [34]. They included a cohort of patients who underwent pelvic floor reconstructive surgery with and without posterior repair and found that both groups significantly improved in sexual function [27]. The difficulty with this is that sexual function is multifactorial and can, because of this, be a very difficult area to study. It is also clear from these studies that vaginal repair improves sexual function and sexual quality of life, but is it because of the prolapse creating discomfort causing the woman to avoid intercourse or because of self-image issues regarding the prolapse? Or is it because vaginal relaxation and prolapse may cause decreased sensation leading to sexual dysfunction, i. Ozel and White recently published one of the first reports evaluating libido, sexual excitement, vaginal sensation, and ability to orgasm in a group of women with prolapse compared to women without prolapse. They found that women with prolapse and vaginal relaxation were significantly more likely to report an absence of libido, lack of sexual excitement during intercourse, and a much lower frequency of achieving orgasm during intercourse (all statistically significant) compared to women with the same demographics without prolapse (i.
When block occurs at the initiation of pacing discount 100 mg trandate heart attack 913, it is frequently in the His–Purkinje system discount trandate 100 mg line prehypertension vegetarian, because the first or second paced complex usually acts as a long short interval producing V-H delay and/or block buy trandate 100mg with mastercard pulse pressure transducer. Pacing is initiated at a cycle length of 400 msec proven trandate 100mg arteria lacrimalis, but the first paced complex occurs 800 msec following the last sinus complex. The second paced complex is associated with a long V-H interval owing to block in the right bundle branch retrogradely with conduction over the left bundle branch system (see Chapter 2). Simultaneously, the ventricular stimulus conducts solely over a left-sided bypass tract to the atrium. Following the third paced complex, complete block in the His–Purkinje system occurs, and an antegrade His bundle deflection follows atrial activation, which resulted from conduction over the bypass tract. Following the first spontaneous complex, ventricular pacing at a cycle length of 400 msec is initiated. During the first paced complex, A-V dissociation is present, but the His bundle is retrogradely captured by the ventricular paced complex. The second paced complex is associated with marked retrograde His–Purkinje delay and conduction up both the normal conducting system and a left lateral bypass tract. The third paced complex is associated with retrograde block in the His–Purkinje system and retrograde conduction proceeding solely over the left lateral bypass tract. Antegrade conduction over the normal conducting system can be seen by the antegrade H (arrow). In this instance, retrograde block usually occurs in the bypass tract and conduction proceeds over the normal A-V conducting system to induce a bundle branch reentrant complex. This depends on the paced cycle lengths used, the sites of atrial and/or ventricular stimulation, and the conduction velocity and refractoriness of 38 68 the bypass tract and normal A-V conducting systems at the time of the study. In this instance, the His bundle extrasystole blocks retrogradely in the A-V node and conducts antegradely to the ventricles to retrogradely conduct over the bypass tract, reexcite the atrium, and return to the ventricles over the normal A-V conducting system. In this case, owing to retrograde concealment, the first A-H interval of the tachycardia will usually be slightly longer than that of subsequent complexes (Fig. Preexcited Tachycardias Preexcited circus movement tachycardias are much less frequent, perhaps occurring spontaneously in 5% to 10% of P. Moreover, many of these wide-complex tachycardias are not studied in the electrophysiology laboratory, and even when those patients with wide-complex tachycardias are evaluated, proof that the mechanism is circus movement antidromic tachycardia is not always available. Initiation of preexcited tachycardias in the laboratory is at least twice as frequent as their spontaneous occurrence. Antidromic tachycardia is the most common mechanism of preexcited tachycardias in which the accessory pathway participates in the reentrant circuit. This tachycardia uses the accessory pathway anterogradely and the normal A-V conducting system retrogradely. At a paced cycle length of 600 msec, a ventricular extrastimulus delivered at an S1-S2 of 250 msec results in retrograde block in a left lateral bypass tract and initiation of a bundle branch reentrant complex (see Chapter 2). Value of programmed stimulation of the heart in patients with the Wolff-Parkinson-White syndrome. The right ventricular extrastimulus had to be delivered at A-V intervals of ≥200 msec for the A-V node to recover to allow retrograde conduction to the atrium (Fig. Perhaps ventricular stimulation at a site farther from the His–Purkinje system would have been associated with a longer V-H interval, and retrograde conduction would have occurred. This may in fact be the case during antegrade preexcitation because ventricular excitation begins at the ventricular insertion site at the mitral or tricuspid annuli, which are farther from the conduction system than when stimulation is performed at the right ventricular apex. This may provide an additional 50 msec delay to allow the A-V node to recover for retrograde conduction, but this may not be enough time unless the A-V node has a short retrograde refractory period and/or rapid conduction. The basic drive consists of A- V pacing (A1-V1) at a cycle length of 600 msec, with an A-V interval of 120 msec. Progressively earlier atrial extrastimuli (A2) are delivered until A2 blocks in the node. V2 must be delayed so that the A2-V2 interval must exceed 200 msec for A-V nodal refractoriness to recover and for retrograde conduction to occur. Alternatively, the same study performed at long drive cycle lengths could have resulted in proximal intraventricular and/or interventricular delays that allowed earlier A-V nodal recovery. The prolonged V-H intervals that usually are observed may represent intraventricular and/or interventricular conduction delay as well as delay in the ipsilateral or contralateral bundle branch used for retrograde conduction. This is most likely to occur with left lateral bypass tracts, which are the sites of bypass tracts most frequently involved in true antidromic tachycardias (Fig. His–Purkinje refractoriness would limit the ability to return over the normal conducting system. It is always important to prove that the recorded His potential is retrogradely activated; this is confirmed by P. This is supported by the fixed relation ofr the His to the V (and A) despite atrial pacing at shorter cycle lengths. In fact, in patients with true antidromic tachycardia, retrograde A-V nodal conduction is remarkably good, with the majority of patients manifesting true antidromic tachycardia exhibiting 1:1 retrograde conduction over the A-V node at paced cycle 70 lengths of 300 msec. In addition, we, and they have observed that retrograde A-V nodal conduction is frequently faster than antegrade A-V nodal 70 conduction during orthodromic tachycardia (Table 10-2). Retrograde conduction can also proceed over the slow pathway, resulting in a longer V-A interval and slower tachycardia. Changing tachycardia cycle lengths may relate to whether retrograde conduction proceeds up a second bypass tract or up the A-V node (i. The first two sinus complexes conduct antegradely over a right anterior paraseptal bypass tract. The first paced complex blocks in the anterior paraseptal bypass tracts and conducts down a left lateral bypass tract that was not previously recognized. This initiates a preexcited tachycardia using the right anterior paraseptal bypass tract retrogradely and a left lateral bypass tract antegradely. This atrial echo can then go down the bypass tract antegradely, when the ventricles will have recovered excitability, and initiate a preexcited tachycardia. A-V nodal reentry may or may not persist or be preempted by retrograde conduction up the fast A-V nodal pathway caused by premature ventricular excitation over the bypass tract. In that situation the location of His potentials would depend on whether or not they were antegrade or retrograde. One could distinguish A-V nodal reentry from classic antidromic reentry, which uses the His–Purkinje system retrogradely, by analyzing the H-A intervals during documented V-A conduction over the normal pathway during ventricular pacing and that during initiation and maintenance of the tachycardia. One must recognize, however, that if ventricular pacing is initiated during sinus rhythm, the H-A interval may not be due to retrograde conduction over the node but may be due to retrograde conduction exclusively over the bypass tract or fusion over the normal system and the bypass tract. Therefore, I prefer to analyze the H-A interval during entrainment of the tachycardia to eliminate the possibility of a fusion of atrial activation. As noted in Chapter 8, the H-A interval during A-V nodal echoes or A-V nodal reentry would be shorter than that resulting from retrograde V-A conduction over the normal conduction system in response to ventricular pacing (Fig. In our experience, H-A intervals of ≤60 msec were never seen in true antidromic tachycardias. A more sensitive and specific criterion is the difference in the H-A interval observed during ventricular pacing (in sinus rhythm or 71 during entrainment of the preexcited tachycardia) and the H-A interval during the preexcited tachycardia. In A-V nodal reentry, the difference is always >0 msec, while in other preexcited tachycardias, it is always ≤0 msec (Fig. Electrophysiologic features of preexcited tachycardias due to A-V nodal reentry are shown in Table 10-3.
