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The amplitude of the pressure order 1000 mg carafate fast delivery gastritis garlic, which varies from 15-50 cm H2O buy 1000mg carafate with visa gastritis diet 7 hari, determines the tidal volume buy carafate 1000 mg line chronic gastritis shortness of breath. This ventilation causes uniform recruitment of alveoli and there is significantly lower risk of airleaks carafate 1000 mg with amex gastritis symptoms in dogs. He was breathing at a rate of 80/ min with severe retractions and was saturating 88% in 100% oxygen. He was started on dopamine to increase the systemic pressure and Milrinone for pulmonary vasodilation. He was given a trial of High frequency ventilation on which his hypoxia slowly improved. Remember shock and post-resuscitation are important indications for ventilation, in addition to respiratory failure and neuromuscular disease. Clinical monitoring of adequate chest rise and oxygen saturations is very important (Regardless of volume, pressure or time cycled mode). If ventilator fails, or when in doubt, remove endotracheal tube and try bag-mask ventilation. Do not muscle relax/sedate patient with upper airway obstruction unless very confident in endotracheal intubation. Care of the ventilated patient, In Khilnani P (Ed): Practical approach to pediatric intensive care, Jaypee Brothers Medical Publishers (Delhi) 2004;279-84. Martin F Kause, Thomas Hoehn: Chest physiotherapy in mechanically ventilated children: a review. The effect of lateral positions on gas exchange in patients with unilateral lung disease during mechanical ventilation. Body position and ventilation-perfusion relationships in unilateral pulmonary disease. Prone positioning in mechanically ventilated patients with severe acute respiratory failure. Effects of the prone position on gas exchange and hemodynamics in severe acute respiratory distress syndrome. Dramatic effect on oxygenation in patients with severe acute lung insufficiency treated in the prone position. Effect of combined kinetic therapy and percussion therapy on the resolution of atlectasis in critically ill patient. Oxygen transport: A physiologically-based conceptual framework for the practice of cardiopulmonary physiotherapy. Discordance between cardiopulmonary physiology and physical therapy: Toward a rational basis for practice. Horiuchi K, Jordan D, Cohen D, et al: Insights into the increased oxygen demand during chest physiotherapy. Shapiro, Ellen Trovillion: A randomized control trial comparing an extended use hygroscopic condenser humidifier with heated water humidification in mechanically ventilated patients. Do the components of heat and moisture exchanger filters affect their humidifying efficacy and incidence of nosocomial pneumonia. Efficacy and safety of mechanical ventilation with a heat and moisture exchanger changed only once a week. Effects of nebulizer mode and position in a mechanical ventilator circuit on dose efficiency. Delivery of a nebulized aerosol to a lung model during mechanical ventilation: Effect of ventilator settings and nebulizer type, position, and volume of fill. Does placement of nebulizer before the humidifier improve aerosol delivery during mechanical ventilation. Bronchodilator response with use of Optivent versus Aerosol Cloud Enhancer metered-dose inhaler spacers in patients receiving mechanical ventilation. Krishnan S, Weaning from mechanical ventilation, In Khilnani P (Ed): Practical approach to pediatric intensive care, Jaypee Medical Publishers (Delhi) 2004;285-92. Ventilation with lower tidal compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Effect of protective ventilation strategy in the acute respiratory distress syndrome. Effects of prone positioning on the survival of patients with acute respiratory failure. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Therapeutic effects of cutaneous stimulation and nasal continuous positive airway pressure. Randomized multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates. Prospective randomized comparison of high frequency oscillatory and conventional ventilation in respiratory distress syndrome, Pediatrics 1992; 89:5-12. Rescue high frequency oscillatory ventilation for pulmonary dysfunction in preterm neonates Cocharane Database Sys. Inhaled Nitric Oxide in Persistent Pulmonary Hypertension in the Newborn Lancet 1992;340:819. Be it clinical, invasive or noninvasive, monitoring remains crucial in overall assessment of a critically ill child with cardiorespiratory problems. A functioning knowledge of the various tools of monitoring is essential in applying their use to patient care. This chapter discusses traditional methods of evaluation of respiratory system and newly established gold standard techniques as well. Pulse oximetry and Capnography are the most commonly employed monitoring modalities, which have transformed the practice of critical care in last 10 years. However may be the excellent information provided by respiratory monitors it cannot replace careful bedside clinical examination. Presence of increased work of breathing is suggested by flaring of alae nasi, suprasternal, intercostal and subcostal retractions, use of accessory muscles of respiration and paradoxical breathing. Cyanosis of tongue and oral mucosa indicate oxygen saturation (SaO2) of less than 80%. However, there is significant inter-observer variability and difficulty in SaO2 interpretation. The Silverman – Anderson Index, commonly referred to as the Silverman retraction score, was developed as a systematic means of assessing newborn respiratory status, particularly when respiratory distress is suspected. In 1875 a German physiologist named Karl von Vierofdt demonstrated that the oxygen in his hand was consumed when a tourniquet was applied. This was done utilizing transmitted light waves, but the development of the pulse oximeter was still a long way off. In 1936 Karl Matthes developed the first ear saturation meter that used two wavelengths of light. This idea was improved upon in 1940 when Glen Millikin developed a lightweight oximeter to help the military to solve their aviation hypoxia problem.

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The extrinsic variety encompasses opsonin nosuppressive agents purchase 1000 mg carafate fast delivery gastritis diet �������, corticosteroid-induced interference defciencies secondary to antibody or complement factor def- with phagocytic function generic carafate 1000 mg on-line gastritis and chest pain, neutropenia buy carafate 1000 mg without a prescription chronic gastritis mild, or abnormal neutro- ciencies generic carafate 1000 mg with visa gastritis diet ����, suppression of phagocytic cell numbers by immuno- phil chemotaxis. Intrinsic phagocytic dysfunction is related suppressive agents, corticosteroid-induced interference with to defciencies in enzymatic killing of engulfed microorgan- phagocytic function, decreased neutrophils through antineu- isms. Examples of the intrinsic disorders include chronic trophil autoantibody; and abnormal neutrophil chemotaxis granulomatous disease, myeloperoxidase defciency, and glu- as a consequence of complement defciency or abnormal cose-6-phosphate dehydrogenase defciency. Intrinsic phagocytic dysfunction is of phagocytic dysfunction include increased susceptibility to related to defciencies in enzymatic defciencies that partici- bacterial infections but not to viral or protozoal infections. Selected phagocytic function disorders may be associated These intrinsic disorders include chronic granulomatous dis- with severe fungal infections. Severe bacterial infections ease, characterized by defects in the respiratory burst path- associated with phagocytic dysfunction range from mild skin way, myeloperoxidase defciency, and glucose-6-phosphate infections to fatal systemic infections. Consequences of phago- cytic dysfunction include increased susceptibility to bacterial Chemotaxis is the process whereby chemical substances infections but not to viral or protozoal infections. The orientation and phagocytic function disorders may be associated with severe movement of cells in the direction of a chemical’s concen- fungal infections. Severe bacterial infections associated with tration gradient is positive chemotaxis, whereas movement phagocytic dysfunction range from mild skin infections to away from the concentration gradient is termed negative fatal systemic infections. Substances that induce chemotaxis are referred to as chemotaxins and are often small molecules, such as Phagocytosis may involve nonimmunologic or immunologic C5a, formyl peptides, lymphokines, bacterial products, leu- mechanisms. These particles that have been modifed by chemical treatment or cells move into infammatory agents by chemotaxis. Damaged cells are also phagocytized by chamber device called a Boyden chamber is used to mea- nonimmunologic mechanisms. Damaged cells may become sure chemotaxis, in which phagocytic cells in culture are coated with immunoglobulin or other proteins which facili- separated from a chemotactic substance by a membrane. After attachment, the particle is engulfed within a membrane fragment and a Chemotaxis is locomotion of cells that may be stimulated phagocytic vacuole is formed. The vacuole fuses with the by the presence of certain substances in their environment. Remnants of indigestible material can be recog- cause/effect relationship between stimulus and response. The lat- an important role in defending the host against microbial ter form of cell movement is called chemotaxis and may be infection. These chemotactic factors are powerful Substances that may stimulate random cell locomotion are attractants for phagocytic cells which have specifc mem- called cytotoxigens; those that stimulate directed migration brane receptors for the factors. The main ele- be destroyed soon after phagocytosis as a result of oxidative ment in the effect of chemotactic factors is the presence of a reactions. However, certain intracellular microorganisms concentration gradient that determines the direction of cell 724 Atlas of Immunology, Third Edition migration. Under these circumstances a chemotactic signal the clinical relevance of this process is illustrated by chronic is provided to the cells under consideration. Hydrogen peroxide together with myeloper- mally in neurons of the human brain and is thought to be oxidase transforms chloride ions into hypochlorous ions involved in synaptic transmission. Immunologic memory is not involved, as previous other antimicrobial substances (Figure 24. The cells are also called large gran- bial cell death by an oxygen-independent mechanism. In the presence of a catalyst superoxide dismutase, against spontaneously developing neoplastic cells and against superoxidase ion is converted to hydrogen peroxide. It does not require granules that contain perforin or C9-related protein which sensitization and cannot be enhanced by specifc antigens. Other nonmemory cells include polymorphonuclear leuko- cytes and macrophages (Figure 24. They are involved in a and lymphocyte products suggest that surface adherent particular form of immune response, the antibody-dependent leukocytes undergo a large prolonged respiratory burst. Studies on regulation of neutrophil activation by plate- through its Fc region to the K cell’s Fc receptor. Intracellular Ca++ increases upregulation of ligand- releases lymphokines that destroy the target. Besides K cells, other cells that mediate activates downregulation of these receptors. Investigations of storage sites for the sev- Fab regions to target cell surface antigens. Following link- eral protein receptors have revealed a mobile intracellular age of Fc receptors with Fc regions, destruction of the target storage compartment in human neutrophils. It represents an stimuli, such as f-Met-Leu-Phe, may cause translocation of example of participation between antibody molecules and granules acting as storage sites to the cell surface, which immune system cells to produce an effector function. Humans have innate immunity against extracellular Dephosphorylation pathways for inositol triphosphate isomers bacteria. Both Ca++ and protein kinase C play a key role sis and digestion in phagocytic cells is a principal feature of in the activated pathway. Complement activation represents a signifcant fest an elevated expression of complement decay-accelerating mechanism for ridding the body of invading microorgan- factor, which protects erythrocytes from injury by autologous isms. Tumor cell Surface adherent leukocytes undergo a large prolonged respi- lysis ratory burst. The C3b that results from activation of enteric bacteria that are motile and Gram-negative. H is from complement serves as an opsonin when linked to the bac- the German word hauch, which means breath, and refers to terial surface, making the bacterial cell more attractive to the production of a flm on agar plates that resembles breath- phagocytes. Phase variation may result in a switch to pro- duction of the other type that is genetically controlled. O antigens of Shigella per- activate nonspecifc infammation and facilitate lymphocyte mit them to be subdivided into 40 serotypes. These infammatory cells migrate, accumulate in local areas, and become activated, enabling them to destroy the microorganisms. Flagellin is a protein that is a principal constituent of bac- Fever and the formation of acute-phase reactants may also be terial fagella. Some cytokines may facili- are arranged into helical chains which wind around a central tate specifc immune mechanisms by stimulating both T and hollow core. Mutations may occur in the central part of a sequelae during infection by extracellular microorganisms. It may produce endotoxin or hemorrhagic shock and modify resistance against infection. Endotoxins comprise an integral constituent of the outer membrane of Cell differentiation factors Alpha interferon Gram-negative microorganisms. Cytokines induced by endotoxins Hydrolytic enzymes Complement components cause fever, increased capillary permeability, and possible Collagenase C1 to C5 endotoxic shock. Relatively large amounts of lipopolysac- Lipase Properdin charide released from Gram-negative bacteria during Gram- Phosphatase Factors B, D, I, H negative septicemia may produce endotoxin shock. Endotoxin antigenicity, disguise, host molecule mimicry, surface anti- shock is also referred to as septic shock.

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The center for defecation is present in the procedure per se does not affect the health of the individual if water and sacral portion of the spinal cord order carafate 1000 mg line gastritis and stress, which is influenced by electrolyte balance are maintained buy carafate 1000 mg gastritis kiwi. The efferent pathway involves cholinergic parasympathetic fibers in the pelvic nerves generic carafate 1000mg mastercard gastritis main symptoms. Mass colonic peristalsis Defecation reflex is initiated when mass peristaltic move- pushes contents in the colon into the rectum 1000mg carafate fast delivery gastritis surgery. Anal canal always remains closed by the tonic con- ment of the descending and sigmoid colons pushes the tractions of internal and external anal sphincters. As the external anal sphincter is innervated by somatic cular smooth muscle of the anal canal. However, normally defecation is inhibited by the acute by somatic motor fibers via pudendal nerves, which anorectal angle, which is about 90°, and contraction brings it under voluntary control. Before initiation of the defecation reflex, colonic peri- stalsis pushes colonic contents into the rectum. This causes Pathway filling and distension of the rectum that initiates relaxation 1. Receptors for defecation reflex are stretch receptors of internal anal sphincter and constriction of external anal located in the wall of rectal rectum. Afferent information from the wall of rectum is con- • With initiation of defecation reflex, the external veyed to sacral segment (S3) of spinal cord via pelvic sphincter opens and the person defecates. Efferent input from spinal cord to rectum and internal ter in response to rectal distention is a temporary phe- anal sphincter comes via pelvic nerve and to external nomenon. Higher center, especially cortex influences spinal cord its normal tone and the reflex is inhibited. Relaxation of internal anal sphincter is due to inhibitory Defecation signals that originate in myenteric plexus in response This is a reflex phenomenon with a voluntary control. This allows the Thus, it has both reflexive (automatic) and voluntary fecal matter to press onto the anal canal. Chapter 50: Motility of Large Intestine 419 Mechanism Features the individual sits on toilet and strains. This increases Clinically, it manifests as abdominal distention, anorexia intra-abdominal pressure, which forcefully expels the and lassitude. Evacuation of bladder is preceded by a deep breathing Usually, it is treated by surgical dilation. Contraction of respiratory muscles increases intratho- Diarrhea racic and intra-abdominal pressures. In any case, acute diarrhea results in dehydration and inal pressure to about 200 cm of H O, the feces is hypovolemia. Oral rehydration therapy is the immediate treatment to prevent volume and electrolyte loss. However, the physiological basis is the decreased intestinal motility that Stool is a semisolid mass of about 200–250 mL excreted causes stasis of chyme in the large intestine, which facili- form large gut per day. It contains inorganic material, undi- tates water absorption and dehydration of intestinal con- gested fibers, bacteria, and water. The undigested fibers Usually it is treated by distending rectum by inert material. Bacteria and inorganic materials constitute 30% and 15% of the total solids respec- Irritable Bowel Syndrome tively. The composition of feces is relatively not affected by This condition has been known by several synonyms such diet as a large fraction of it comes from non-dietary origin. In the West 20–30% of gastrointestinal of the stool is due to the presence of bile pigments. In India this is very com- smell of feces is due to presence of indole and skatole, the mon and many cases used to be misdiagnosed as chronic amines that are produced by colonic bacterial flora. Changes in gut motility are observed in several studies though they This is also known as congenital megacolon or aganglion- poorly correlate with the symptoms. In theconstipated varietythe frequency of high altitude wall of the colon are congenitally absent. The enteric neurons are usually markedly absent in the segmentation contractions are more. Failure of migration of neural crest from cranial to cau- occurring normally about one hour after the meal is dal region results in absence of ganglion in both myen- reduced in many patients. This may account for their teric and submucosal plexuses in distal part of colon postprandial symptoms. Thus, obstruction occurs to the outflow of feces and feces Electrical Abnormalities accumulate behind the obstruction. The most commonly the segment of terminal ileum and/or presentations include colon, though any part of the gastrointestinal tract i. Alternating diarrhea and constipation chronic ulcero-inflammatory colitis affecting chiefly the iv. Both diseases can occur at any age but are colic, flatulence relieved by belching, capricious appe- more frequent in 2nd and 3rd decades of life. The primary function of large intestine is to reabsorb water and electrolytes from chyme and from fecal matters. The mass peristalsis pushes feces into the rectum and initiates defecation reflex. External anal sphincter is made up of striated muscle, and therefore defecation reflex can be voluntarily controlled. Defecation reflex is a spinal reflex, which can be taught to spinal man to self-initiate the process. Colonic movements, Mass peristalsis, Colonic reflexes, Gastrocolic reflex, Defecation reflex, may come as Short Questions. In Viva, examiner may ask… What are the special electrophysiological properties of colonic muscles, Name the types of colonic movements, What is mass peristalsis & what is its significance, Name colonic reflexes, What is gastrocolic reflex & what is its significance, Details of defecation reflex, What is inflammatory bowel disease and irritable bowel syndrome, What is Hirschsprung’s disease. Digestion of carbohydrate begins in the mouth by the down of foodstuffs by many enzymes into their absorb- action of salivary amylase which catalyses the hydrol- able form. Though the major part of digestion takes place ysis of a-1, 4 linkage (but not a-1, 6 linkage) to form in the small intestine, digestion starts as soon as food a-dextrins. Enterocytes have brush the products of amylase digestion are maltose, malto- border, which is rich in digestive enzymes. The further digestion of starch is carried out by oligo­ then from there into the blood or lymph. These membrane enzymes are a­dext­ rinase that causes hydrolysis of a-1,6 linkage, maltase Herman Boerhaave (1668–1738) was a Dutch botanist, physician and physiologist of European that causes hydrolysis of maltotriose and maltose, fame. He is regarded as the founder of clinical lactase that causes hydrolysis of lactose into glucose teaching and is sometimes referred to as “the father and galactose, glucoamylase that splits malto-oligo- of ancient physiology”, along with his pupil Albrecht sachharides into single glucose molecules and sucrase von Haller. He is best known for demonstrating the that causes hydrolysis of sucrose into fructose and relation of symptoms to lesions and, in addition, he was the first to isolate the chemical urea from urine. The end product of these membrane digestions are functional activity, especially in digestive process. As the glucose transport depends on Na -K pump pre- sent on the basolateral membrane that creates gradi- + ent for Na , this mechanism of glucose transport is a secondary active transport.