Januvia
Jennifer Ahern PhD, MPH
- Professor, Epidemiology
https://publichealth.berkeley.edu/faculty/
Purported to promote tionship has not been established between the consump lipolysis diabetes insipidus brain injury cheap januvia 100 mg online. Some evidence of improved exercise capacity in clinical population diabetes type 1 young adults buy generic januvia on line, but limited evidence that high dose ribose supplementation affects exercise capacity diabetes meaning 100 mg januvia mastercard. Involved in insulin signaling blood sugar 140 discount 100 mg januvia free shipping, nerve Inositol inositol and normal cognitive function diabetes and headaches purchase januvia 100 mg on-line. Patients with transmission diabetes symptoms palpitations buy 100mg januvia overnight delivery, serotonin modulation, and Alzheimer’s disease, depression, panic disorder, ob fat oxidation. Some evidence that high dosages (6-8 g) can affect exercise capacity and/or anabolism. No known effects Optimizes blood flow via arginine-nitric at dosages found in energy drinks. Risks of the components included in sports drinks a marathon and cross-country runner who had minor and/or energy drinks used by athletes erosion of the upper teeth on many surfaces, but ex tensive erosion through to the dentine on the palatal the literature reflects the possible risks of com (inside) surfaces of the upper central incisors29. This pounds, including sugars, caffeine, glycerol, and vita study related the dental decay to the consumption of min B2, found in sports drinks and energy drinks in sports drinks (including Carbolode, Gatorade, High, gested by sport people29. For this rea with the lowest pH and a mid-range titratable acidity, son, the best approach is to determine, through a re may not be particularly erosive due to its high con view of case reports, the potential hazardous threats of centrations of calcium and phosphate. Furthermore, long-term exposure of the Milosevic and colleagues published a case report of body to an excess of simple sugars is associated with 1894 Nutr Hosp. Thus, ca cinations, increased intracraniaO pressure, cerebral ffeine can interact with a wide range of medications, edema, seizures, rhabdomyolysis, and supraventricu including antidepressants (fluvoxamine), antianxiety lar and ventricular tachyarrhythmias31. This is of particular inte indicated four cases of caffeine-associated death and rest due to the frequent use of antidepressant and an five cases of seizures in sport people due to the con tianxiety drugs by athletes. So, caffeine beverages should not be adminis after his participation in motocross racing34 and a pos trated with that kind of drug in order to avoid possible sible case of orthostatic intolerance due to excess Red side effects. However, ffeine metabolism, decreasing the plasmatic levels of Wagner and colleagues suggested that the appropriate caffeine41. This type of interaction with this compound dosage of glycerol depends on the body size and also and many other drugs is mainly attributed to the varies between manufacturers; they recommended 1 bitter flavonoid naringin (naringenin 7-O-neohesperi g/kg body weight with an additional 1. Regarding this type taken 60 to 120 minutes before competition (standard 36 of fruit, a study by Medina and colleagues allowed doses). Glycerol is considered doping and is prohi 37 the identification of four endocrine compounds, be bited in sports competitions, but in non-competitive longing to the steroid biosynthesis pathway, as signi activities, such as mountaineering or alpinism, it could 43 ficant metabolites upregulated by citrus juice intake. Concerning vitamin B2, one case report indi Summarizing, the induction of caffeine metabolism cated a suspected anaphylaxis after the intake of this 38 decreases its effects (on performance etc). Taurine supplementation significantly de and also can alter the effects of several drugs that may be used by athletes. Little has been investigated in this area and review here; namely, the most abundant components and/or those most likely to cause interactions. Probably, the beverages with the highest probabi As far as sports drinks are concerned, mixtures of lity of interactions are the energy drinks containing different monosaccharides and disaccharides (glucose, caffeine, taurine, sugars and sweeteners, herbal su fructose, sucrose…) interact, increasing carbohydrate pplements, among other ingredients products clearly absorption and oxidation during exercise more than themselves alone25,45. Nonetheless, there are very few studies on the Furanocoumarins, components of grapefruit, inhi effects of individual ingredients or potential synergis bit cytochrome P450 3A4 isoenzymes in the intestinal tic effects; furthermore, the results of these studies are wall, and so increase the levels of 3A4-metabolized inconclusive and occasionally contradictory. Also, grapefruit weakly inhibits the ingredients present in energy drinks is caffeine. The organic anion transpor synergistic and reinforced stimulant effects in com ting polypeptide is another transporter system affected bination with guarana, ginseng, and taurine33. Most by grapefruit, so drugs handled by this system may Hydration and chemical ingredients in Nutr Hosp. Rehydration and electrolyte replace Hypertonic solutions with 9-10% of sugars (glucose, ment after exercise. For example, drinks containing Ca In this way, a recent scientific paper emphasized such as milk significantly decrease Fe absorption. Similarly, this has been obser sertions concerning substances used for hydration, hy ved in recent publications about substances contained drolyte replacement, and recovery in athletes14. These in energy drinks and their effects on sport recovery views, together with those from other organizations and and performance10, 51. Use of nutritional supplements in tion, further scientific evidence should be provided by sports: risks, knowledge, and behavioural-related factors. Int J 2010 ‘Fun-C-Food’), and Consejo Superior de Investi Sport Nutr Exerc Metab. Higher prevalence of exercise-associated hyponatremia in female than in male open-water ultra-endurance swimmers: the ‘Marathon-Swim’ in Lake Zurich. Hydration status and the diu tegies to optimize performance for athletes in high-intensity retic action of a small dose of alcohol. Int J Sport Nutr effects of energy drinks on children, adolescents, and young Exerc Metab. Anaphylaxis the substantiation of a health claim related to L-tyrosine and con to vitamin B2 added to an energy drink. Carbohy mination, “kidneys health”, “urinary health”, “bladder health”, drates for training and competition. Efficacy and safety of ingredients found in preworkout per mol of acid with a pH not lower than 3. J nion on the substantiation of health claims related to L-car Sports Med Phys Fitness. Food Safety Authority nion on the substantiation of a health claim related to citrulli J. Scientific Opinion nary excretion of calcium, magnesium, phosphorus, sodium, on the substantiation of health claims related to beta-alanine potassium, chloride and zinc in healthy males. Fluid and electrolyte needs for tra 584, 585, 589, 590, 675, 692, 847, 1199, 1265, 1267, 1342, ining, competition, and recovery. Part two: Maintaining 3692, 4241, 4243, 4247, 4248, 4278, 4407); are not referring immune health. However, it is possible to live a healthy and active life with only one functioning kidney. In rare instances people can be born with three kidneys, and likewise remain healthy. When the kidneys are not working properly, harmful toxins and excess fluids build up in the body, which may cause the symptoms of kidney failure. These symptoms can include high blood pressure, extreme tiredness or lethargy, persistent headaches, swelling in the face and ankles, fluid retention and / or lower back pain. The kidneys are vital life-sustaining organs, performing many functions to keep the blood clean and chemically balanced. They keep the electrolytes (sodium and potassium being the most important) and water content of the body constant 3. Waste products After the body uses food for energy and self-repair, the waste is sent to the blood. The most common waste products are urea and creatinine, but there are many other substances that need to be eliminated. The kidneys act as very efficient filters for ridding the body of waste and toxic substances, and returning vitamins, amino acids, glucose, hormones and other vital substances into the bloodstream. The kidneys receive a high blood flow and this is filtered by very specialised blood vessels. The fluid that is filtered is then adjusted by a complex series of urine-disposing tubes called tubules. In this way, the substances necessary for the good functioning of the body are retained, and those that are not needed are excreted. Water and electrolytes All the cells in the body, apart from those of the outer skin, are surrounded by a fluid called the extracellular fluid. For the cells of the body to work properly, the extracellular fluid needs to have a stable composition of salts such as potassium and sodium and acidity (often referred to as pH). The kidneys are central to maintaining these correct balances and the effective functioning of all the cells of the body. The salt and water balance is maintained by a series of hormones acting on the kidney. The kidneys recognise and act upon a series of messages that vary according to how much fluid is drunk. If a person does not drink enough, the body fluids become more concentrated and, as a result, the kidneys excrete a more concentrated urine. If an excess of fluid is drunk, the body fluids become more diluted, and the kidneys excrete a more dilute urine, getting rid of the excess that has been taken in. If the body is in a satisfactory balance, approximately 80% of ingested fluid is excreted within an hour. If an excess of sodium is taken, the amount in the blood increases and the person will become thirsty and drink fluid. The body senses this increase in salt and water, and again, through a series of messages, the kidney excretes the excess. As with sodium, if an excess of potassium is taken, it is excreted by the kidneys, ensuring that the amount in the body’s fluids remains within the correct limits. Hormones the kidneys secrete a number of hormones, which are important for normal functioning of the body. If blood pressure falls, renin is secreted by the kidneys to constrict the small blood vessels, thereby increasing blood pressure. If the kidneys aren’t functioning correctly, too much renin can be produced, increasing blood pressure and sometimes resulting in hypertension (high blood pressure). This is why a number of people with kidney diseases also have high blood pressure. Erythropoeitin is another hormone that is secreted by the kidney, and acts on the bone marrow to increase the production of red blood cells. If kidney function diminishes, insufficient hormone is produced and the number of red blood cells being produced will fall, resulting in anaemia. This is why many people with reduced kidney function will have anaemia – a low blood count. In the normal diet, Vitamin D is in an inactive form, and needs to be slightly altered by the kidney before it can act within the body. This ‘activated’ form of Vitamin D is essential for the absorption of calcium by the intestine, the normal structure of bones and effective muscle function. In people with impaired kidney function, there is often a low blood calcium and an inadequate amount of Vitamin D, resulting in muscle weakness and a softening of the bones (osteomalacia or rickets). Vinod 1 2 Veer Chandra Singh Garhwali Government Medical Sciences and Research Institute, Srinagar, Uttarakhand, India. Department of Pharmacology, Kannur 3 Medical College, Anjarakandy, Kannur, Kerala, India. Department of Pharmacology, Kannur Medical College, Anjarakandy, Kannur, Kerala, India. It was also found that Na+ has positive correlation and K+ has negative correlation with Potassium, Sodium. Obesity has been associated with + this size in normotensives (He and MacGregor, 2002). A high equally in overweight and non overweight individuals (Cooper et potassium diet has been claimed to give protection on high + al. This is an open access article distributed under the terms of the Creative Commons Attribution License -NonCommercial ShareAlikeUnported License creativecommons. Considering the unbalanced dietary habits of After obtaining the informed consent, person’s biological people and change in their life style, there is a need to address data viz. Height However, the relationship between these parameters, within their the subject is asked to stand on a horizontal plane with physiological range and blood pressure remained mostly heals together, stretching upwards to the fullest extent and hands uncovered. The marked Frankfurt plane is made of blood pressure with age in those above 40 year old (Smulyan et horizontal. Additional studies investigator and the horizontal sliding arm is made to touch vertex have proved the positive correlation between age and blood of the subject. The reading was noted at horizontal arm on pressure among those less than 20 years (Gundogdu, 2008, Dores anthropometer from the level on which subject was standing et al. The subject was asked to stand erect with + minimum clothing and barefoot on weighing machine and the this study helps to evaluate the association of blood Na, + + + weight was noted (Dudekula et al. The analysis of serum electrolytes was + + carried out in auto-analyzer for Na and K using ion selective Exclusion criteria electrode measurement (Jankunas, 2002). Patients in the age <18years or >65years, pregnant the data was tabulated to make it easy to understand and subjects, patients with diabetes, hyperlipidaemia, subjects on any use for further purpose. One of the study states that excessive adipose accumulation leads to increased circulating blood volume which results in higher cardiac output caused by stroke volume in obese patients but a lower level of total peripheral resistance at any given level of arterial pressure (Alpert, 2002), although, heart rate is Fig. Comparing with each haemodilution which correlates with the findings of our study. We are grateful to the people of Srinagar, Garhwal for Jankunas, R, Volbekas, V, Stakisaitis, D, and Driziene, Z. Association of overweight with young Swiss men: an analysis on 56784 army conscripts. Swiss Med increased risk of coronary heart disease partly independent of blood Wkly. Arch Intern Med 2007; 167(16): age on arterial distensibility in asymptomatic humans. Lifestyle modifications to prevent and control Cortisol with Cardiovascular Risk Factors in Prehypertension Stage. Pressure Prevention and Control, Laboratory Centre for Disease Control at Warren V, Aberg H. A randomized trial on the effect of decreased dietary sodium intake on blood pressure in adolescents. Most of the values apply to adults and where they differ for children it will be indicated. Many important laboratory reference values are not listed here, because of the less frequent use of these tests.
Adduction the muscles responsible for adduction of the forelimb are (see fig ure 7 diabetes insipidus results from quizlet generic 100 mg januvia amex. The caudal deep pectoral muscle 158 Equine Massage the elongated muscles in the adduction of the forelegs are: 5 diabetes symptoms ringworm discount januvia 100mg fast delivery. The trapezius muscle these muscles attach to the scapula and along the bones of the foreleg; their interplay induces the adduction movement metabolic disease zucchini januvia 100 mg sale. The long digital extensor muscle the iliopsoas muscle diabetes type 2 young adults generic januvia 100 mg on-line, made of the iliacus and psoas muscles (point 1 and 2; figure 7 diabetes type 2 operation order generic januvia line. The biceps femoris muscle and the lat eral vastus muscle (points 4 and 3 respectively; figure 7 diabetic jewelry januvia 100mg visa. The gastrocne mius muscle and the digital extensor muscle (points 5 and 6; fig ure 7. Retraction the muscles involved in the concentric contraction (which initi ates backward motion of the hind leg) are (see figure 7. The hamstring group of muscles (the semitendinosus, the semimembranosus, and the biceps femoris) 3. The biceps femoris, the gastrocnemius, and the deep flexor muscles (points 4, 5, and 6; figure 7. All the muscles involved in the protraction of the hind limb are elongated during retraction and through their eccentric contrac tion ensure stability and smoothness of action. Abduction the muscles involved in the concentric contraction (which initi ates abduction motion of the hind leg) are (see figure 7. The tensor fasciae latae muscle the elongated muscles in the abduction of the hind leg are: 7. It is assisted by the biceps femoris and the tensor fasciae latae muscles (points 4 and 6; figure 7. The tensor fasciae latae muscle these muscles attach along the bones of the hind leg. Its role is to anchor strong muscle groups as well as to resist the downward effect of the center of gravity in mid-chest. In most equine disciplines, the vertebral column also supports the weight of a rider. Extension the agonist muscles responsible for the extension of the column are located above the vertebral column. The iliocostalis dorsi muscle Flexion the agonist muscles responsible for the flexion of the vertebral column are the abdominal muscle group and the intercostal mus cles. The muscles associated with protraction, retraction, abduc tion, and adduction of the limbs have a secondary function, which is to assist with the flexion of the vertebral column. Running from one vertebra to the next, the intervertebral muscles are tiny mus cles along the side of the vertebral column. The grand oblique muscle of the abdominal group, especially the internal oblique, is also an important player in this particular movement. The Rib Cage the pectoral muscles and the ventral serrate muscles play an important role in supporting and stabilizing the rib cage, or chest, in relation to the spine. The Neck Muscles Because the horse uses his head to counterbalance the weight in the rest of his body, the neck muscles play a very significant role in locomotion. Most obvious at the gallop, but also seen at the trot or walk, the downward swing of the head helps to lift the hind legs off the ground as the horse moves forward. The intervertebral muscles these muscles are attached along the spine from the base of the skull, down the cervical vertebrae to the thoracic vertebrae, and to the upper ribs, and the scapulas. The intervertebral muscles As these muscles contract, they cause the cervical section of the spine to arch in extension, bringing the head upwards. All the muscles involved in the flexion of the neck are elon gated during the extension movement, and through their eccen tric contraction ensure stability and smoothness of action. The sternothyrohyoid and omohyoid muscles As these muscles contract, they cause the cervical section of the spine to bend forward in flexion, bringing the head downward. All the muscles involved in the extension of the neck are elon gated during the flexion movement, and through their eccentric contraction ensure stability and smoothness of action. Lateral Flexion the muscles involved in the lateral flexion of the neck are (see figure 7. The sternothyrohyoid and omohyoid muscles the unilateral concentric contraction of these muscles to one side will cause the head and the cervical spinal column to move to the same side. All the muscles involved on the opposite side of the neck are elongated, and through their eccentric contraction ensure stabil ity and smoothness of action. Thus nature provides them with a mechanism that allows them to relax and rest while standing. The mechanism consists of ligaments and muscles that “lock” the main joints in the “stay” position. Both front and hind lower legs have identical mechanisms based on the suspensory ligament and the superficial and deep digital flexor muscles whose tendons possess check ligaments. The rest of the structure is kept in an extended position by a system of muscles (see figure 7. The ventral serrate muscle, both cervical and thoracic parts, mainly connects the foreleg to the body of the animal. The play between the cervical and thoracic parts keeps the scapula at a sloping angle, flexing the shoulder joint. The play between the biceps and the triceps muscles keeps the shoulder in extension. The rest of the leg is well-aligned and the knee joint is prevented from bending forward by the lacertus fibrosus, an inelastic tendon that joins the biceps tendon and the radial carpal extensor muscle and tendon. Tension from the biceps is transmitted through this system to assist knee fixation. It is assisted in this action by the gastrocnemius muscle, which acts to prevent the flexion of the hock. The play between the peroneus tertius muscle and the superficial digital flexor muscle ensures that the stifle and hock joints reciprocate their actions; for example, when the stifle flexes, the hock flexes as well. At “stay,” the stifle joint is fixed by the contraction of the quadriceps muscle and a locking mechanism involving the patella, which comes to hook on top of the enlarged upper end of the inner trochlear ridge of the femur. A simple contraction of the quadriceps muscle and of the ten sor fasciae latae muscle unlocks the patella, lifting it up and later ally off the ridge, thus freeing the stifle so the horse can move. This way, when massaging or assessing a horse in the stay position, you will know what muscles are involved. A solid knowledge of the muscles involved in the different move ments of the horse will help you to better locate the muscular ten sion and possible muscle knots in your horse. The information contained in this chapter will also contribute to you better analysis of all the equine gaits. This better understanding of equine kinesi ology will give you confidence when assessing the muscular fitness of your horse. With your knowledge of the bones, muscles, and kinesiology of the horse, we can now talk about the reasons why stretch moves should be part of your massage routine. Regular stretching will benefit your horse and will give you feedback on his condi tion. Here are some of the benefits of stretching exercises: ❖ Relaxation ❖ Reduction of overall muscle tension and stiffness ❖ Increased circulation of both blood and lymph fluids ❖ Increased oxygenation and nutrition in the tissues ❖ Increased elasticity of the muscles, tendons, and ligaments ❖ Increased flexibility and range of motion of the joints ❖ Improved coordination ❖ Reduction of muscle strain and ligament sprain ❖ Improvement of the stride length ❖ Improved reflex time response Note: If your horse has had any recent physical problems that affect the joints and muscles (a fall, direct trauma, kick), or surgery, consult your veterinarian or equine massage therapist before you start a stretching program. A strong pre stretched muscle resists stress better than a strong un-stretched muscle. Stretching prevents ligament sprain and loosens the joint cap sules; it makes the body feel more relaxed. It releases muscle con tracture due to old scar tissue, helps relieve muscle pain from chronic tension, and reduces post-exercise soreness. Better elasticity of the muscles, tendons, and ligaments allows for freer, easier, more controlled, and quicker movements—all resulting in better coordination overall. Muscle stretching increases circulation, bringing more oxygen and nutrients to the body parts; it prevents inflammation and adhesion (scar tissue) formation, trigger point formation, and stress point buildup. You should apply them regularly with your various massage routines and include them in your massage treat ments when applicable. Cerebral When we say “cerebral” we refer to the nervous system, which is controlled by the brain and spinal cord. One aspect of stretching can be called cerebral since the activity develops body awareness. And as you stretch various body parts, you help your horse focus on them and become mentally “in touch” with them. This process develops the animal’s self-awareness, thereby improving his coordination and locomotion. The stretching of muscles sends relaxation impulses via sensory nerves to the central nervous system and it will also decrease tension throughout the body. The animal will relax both physically and mentally, an important factor when dealing with animals that have been in accidents or are frightened or in pain. Furthermore, stretching will give you feedback on the condi tion of the muscle groups and ligament structures, particularly regarding their elasticity and tone. Muscles, tendons, and liga ments (eventually joint capsules) risk damage if stretched when cold. Stretching a horse after a warm-up period will limit the risk of injury from overstretching. Again, if your animal has had any recent physical problems or surgery, particularly of the joints and muscles, or if he has been inactive or sedentary for some time, consult your veterinarian or massage therapist before starting a stretching program. After warm-up and before heavier physical activ ity, stretching will trigger benefits such as loosening of the muscle fibers, vasodilation to bring more blood, and greater flexibility of the joints. If you need only to stretch a specific area during a localized massage treatment, that area can be warmed up with a hot towel (see chapter 4) or simply by massage (effleurages, wringings, com pressions, or shakings). Stretching can be performed as a cool-down immediately after the main exercise or training program. This is actually the best time to stretch because the whole locomotor structure is warm. Stretching will increase circulation, promote relaxation, and cut down on any muscle contracture developed during an intense workout. How to Stretch To attain best results, you need to respect the structures you are working on. To manipulate correctly, it is important to be con cerned with the animal’s natural body alignment. You should also be concerned with your own alignment and posture in order to work at your best. Stretching is not a competition; you do not have to push lim its or see how far you can stretch each time you do it. The object of stretching is to relax muscle and ligament tension in order to promote freer movement and other benefits. To achieve all this, you need to stretch safely, starting with the easy stretch (see below) and building to a regular, deeper stretch. Never go too far; otherwise the stretch reflex (a protective mechanism within the muscle) will cause the muscle to contract in order to prevent its 174 Equine Massage being overstretched and torn. Instead, just hold the stretch in a relaxed manner and for a longer period of time. The horse’s flex ibility will increase naturally when you start stretching regularly. Give the horse time to adjust his body and mind to the physical and the nervous stress release that stretching initiates. The stretch should be tailored to the animal’s particular muscular structure, flexibility, and varying tension levels. When you release a stretch, gently return the hoof to its orig inal position on the ground. Understand that how you handle your horse from the beginning has a very definite impact on how you will be able to handle him in the future. Learn to make a distinction between a horse’s reaction to pain and an objection to being handled. The Easy Stretch Always start with the easy stretch, during which you stretch only 75 to 80 percent of the total stretching capability of that particu lar body part, and hold it for just 10 to 15 seconds. Take hold of your horse’s foreleg as you would to clean the hoof and gently guide it through its normal range of motion (for ward or backward as needed), bringing it to its natural stretch point. Do not pull excessively on the leg because you risk straining the muscle fibers and tendons by overstretching. The Development Stretch Once the horse gets used to the easy stretch, you can work into the development stretch, holding the stretch for 30 seconds or more. Pass the initial 30 seconds; as the muscle tightness decreases, adjust your traction until you again feel a mild tension. Repeat 2 to 3 times until you feel you have reached the maximum stretching Stretching 175 capacity of the muscle. Spontaneous Stretch Often during the development stretch and sometimes during the easy stretch, the horse will spontaneously stretch himself fully for a few (5 to 10) seconds. This is a definite sign that the animal is enjoying the stretch and needs it very much. As you hold the limb during such spontaneous release, you can feel all the deep tension coming out as a strong vibration; it is quite an experience. After a while, you will develop a feel for this practice and will subconsciously know without having to count when the animal has reached his full stretching capability. This practice of mental counting will bring the best results from the stretching technique. If not, let go gently and allow the limb to return to its natural position and repeat this treatment sev eral hours later or the next day. You should also inves tigate if any undue stress points or trigger points are present; release them with massage.
Januvia 100mg without prescription. Best Foods To Eat When You Have Type 2 Diabetes.
From six weeks gestation to delivery diabetes type 1 omega 3 order 100mg januvia, it is the main outlet of blood flow from the right ventricle allowing blood to bypass the fetal lungs diabetes mellitus type 1 definition order 100 mg januvia visa. The ductus media contains primarily muscular cells in contrast to the aorta and pulmonary artery which are comprised of elastic tissues diabetic diet breakdown order genuine januvia on-line. In term infants blood sugar a1c level buy januvia line, the breath taken at birth opens the lungs and rapidly decreases pulmonary vascular resistance blood sugar low cheap 100 mg januvia overnight delivery. First diabetes mellitus type 2 literature purchase januvia 100mg on-line, there is the rapid constriction of the muscle cells in the media layer occurring shortly after birth. Second, there is fibrous and anatomic obliteration over a period of weeks to months. Shunting of blood may be bi directional during the 1st few hours of life, but subsequently becomes left to right. The baby often has a widened pulse pressure (>30 mmHg) with corresponding bounding peripheral pulses (palmar pulses). Additional findings include respiratory insufficiency, hepatomegaly or a hyperactive precordium. Indomethacin or ibuprofen may be administered, but should not be given in patients with creatinine >1. There may be an initial hypertensive episode resulting from closure of the ductus. Some of the hypotension observed may be in response to surgical conditions such as thoracostomy, sedation and paralysis. Additionally, some infants may have low cardiac output due to alterations following ligation (post ligation syndrome). Characterized by a repeating sequence (>=3) of prolonged pauses (>=3s) in breathing with periods of normal respiration (<20s). While commonly seen in nearly all infants, careful clinical assessment to rule out true apnea is necessary. Xanthines such as caffeine, aminophylline and theophylline are central stimulants that may improve diaphragmatic contraction and inhibit hypoxia-induced ventilation. Physiologic anemia of prematurity is often long-term and not necessarily pathologic. Neonatal red cells have short life spans and stressed marrow may exacerbate anemia. Further subclassification of severity is based on gestational age and chronologic age. Postnatal factors are related to immaturity such as ventilator associated injury (oxygen toxicity, barotrauma/volutrama, atelectasis), sepsis, pulmonary infection and poor nutrition. Later, the film may show pulmonary edema, airway cuffing, atelectasis, cystic changes, and air trapping. Enhancement of growth of normal lung tissue is accomplished in the absence of a ventilator and excess oxygen. Again, lung protective therapies such as avoidance of infection, ventilation and hyperoxia, as well as ensuring good nutrition are critical to long-term growth. They also have impaired growth due to increased caloric needs and may need to be on increased calorie formulas. Since lung parenchyma continues to grow until age eight, symptoms usually abate with time. Another indication for corticosteroid therapy is to supplement the corticosteroid insufficient infant. Courses have currently trended to 3 day bursts with a steroid-free period between bursts. It has a more physiologic half-life and agent is eliminated from body within 24hrs of dosing. This agent has been utilized in both treating the steroid deficient infant and supplementing the stressed premature infant. The hemorrhage may extend either into the ventricular space and/or the surrounding parenchyma of the lateral ventricle. The germinal matrix is adjacent to lateral ventricles and the site of neuronal and glial cell production and subsequent migration; it is a highly vascular area that involutes by 36 weeks gestation. Head ultrasound is the main diagnostic modality and classification is based on this modality of detection. Subarachnoid hemorrhages or secondary parenchymal injuries may be difficult to detect. It is also the most common cause of neurologic deficit and cerebral palsy in at risk infants. It is characterized by focal cystic necrotic lesions deep in the cerebral white matter. These may be seen at any time after birth, but generally appear between 2 and 4 weeks. It is the major cause of cognitive defects and impaired neurodevelopment in this population. In severe forms, retinal scarring, traction folds, and detachments can lead to blindness. In addition, selected infants born at >32 weeks gestational age deemed at risk (complicated clinical course). Infants are screened when they are 4-6 weeks chronological age, or 31-33 weeks postconceptual age. Retinal Zones Zone 1: Vessels extend less than twice the distance between the disc and macula. Weaning to Open Crib Generally thermal competence is achieved between 1500 to 2000 grams. Fever An infrequent sign of sepsis Less than 10% of febrile infants have culture-proven sepsis. However because of the potential toxicity of bilirubin, it is important to recognize hyperbilirubinemia and be aware of the risk factors for it. One third of healthy breast-fed infants have persistent jaundice beyond 2 weeks of age. The goal is to reduce the incidence of severe hyperbilirubinemia as well as acute bilirubin encephalopathy (the clinical central nervous system findings associated with bilirubin toxicity) and the more chronic kernicterus while minimizing harm such as increased parental anxiety, decreased breastfeeding and unnecessary costs and treatments. Increasing the frequency of nursing may decrease the likelihood of hyperbilirubinemia in breastfed infants. Jaundice should be assessed whenever vital signs are checked but at least every 8-12 hours. Jaundice is usually seen in the face first and progresses caudally, but visual estimation can lead to errors. A serum or transcutaneous bilirubin level should be checked in every infant who is jaundiced within the first 24 hours of life, or if there is any doubt about the degree of jaundice in any infant. All bilirubin levels should be interpreted according to the infant’s age in hours using the nomogram. The cause of jaundice should be investigated in any infant receiving phototherapy or if the level is rising rapidly (crossing percentiles on the nomogram). Infants with an elevated direct reacting bilirubin (conjugated) should have a urinalysis and urine culture. Sick infants or those jaundiced beyond 3 weeks should have a total and direct bilirubin level checked to identify cholestasis. Results of the newborn screen should be checked for thyroid abnormalities and galactosemia. Efficacy is affected by: the spectrum of light, energy output (irradiance) in the blue light range, and infant’s exposed surface area. A fiberoptic blanket on the infant’s underside increases surface area exposed to blue light. There should be a demonstration of a decrease in total bilirubin concentration after 4-6 hours of phototherapy. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Any infant who is jaundiced and manifests signs of the intermediate or advanced signs of bilirubin encephalopathy should have immediate exchange transfusion. Recognize that the preparation time required for a double-volume exchange transfusion (often 4-6 hours). It is prudent to send blood for typing and cross-matching to the Blood Bank as soon as it is recognized that an exchange is possible. Dialogue with the Blood Bank may be essential for proper composition of the whole blood required for the procedure. It is also an option to temporarily interrupt breastfeeding and substitute formula. Supplementing the breastfed infant receiving phototherapy with expressed breast milk or formula if intake is inadequate, the weight loss is excessive or the infant seems dehydrated. These tend to be second-line agents and are used primarily in conjunction with a neurology consult. These injuries may often be independent of any symptoms during labor or delivery period. In fact, some of these injuries occur antenatally or may result of specific conditions or abnormal anatomy. This should occur at about 6 months of age and then subsequent evaluations as dictated by the specialist. The clinical presentation can vary widely from asymptomatic and an incidental finding to infants presenting with seizures to , extremely rarely, an infant with a catastrophic deterioration. Small bleeds are common in vaginal deliveries, but for a larger one or if symptomatic, evaluation is indicated. Work-up of coagulopathies and confirmation of vitamin K administration should be done in the symptomatic cases. Infants presenting in catastrophic demise and survive tend to have neurologic sequelae in follow-up. It can occur as a complication of lung diseases that cause respiratory failure in the newborn. These include perinatal aspiration syndrome, pneumonia or respiratory distress syndrome. Meconium aspiration syndrome: Meconium causes mechanical obstruction to the airways →resulting in air trapping, hyperinflation, ↑ risk for pneumothorax, inactivation of surfactant, release of vasoconstrictors. Chemical pneumonitis leads to release of cytokines and leukotrienes that can increase pulmonary vasoconstriction. They also cause loss of surfactant function and decreased aeration of lungs and induce pulmonary edema by increasing vascular permeability. These changes consist of abnormal thickening of media and adventitia of pulmonary arteries and hypoxemia in the absence of recognizable parenchymal lung disease. Active precordium and systolic murmur of tricuspid insufficiency may be appreciated on cardiac exam. Although these criteria are still useful, certain caveats have to be considered to avoid errors in diagnosis. However, 2-site sampling for arterial blood is invasive and is not recommended for diagnosis. Monitoring pre and post-ductal saturations is useful in gauging the response to pulmonary vasodilator therapy. It is important to consider the lungs and heart as one unit, connected by pulmonary circulation. Ideal management will involve optimizing lung expansion and cardiac output while achieving pulmonary vasodilation and maintaining systemic pressure. It is important to avoid excessive levels of 457 oxygen or ventilator pressures that can injure the lung. Hyperventilation can also have adverse effects on cerebral perfusion and induces hearing loss (blood supply to cochlea is part of cerebral circulation). Iloprost is the preferred agent since it can be given by intermittent nebulization, every 2 6 hours, depending on the duration of response. Milrinone works synergistically with inhaled prostacyclin in the same signaling axis. However, in this summary, Heart Rate and contractility are properties intrinsic to the heart itself and will be discussed. Mechanically, tachyarrhythmia can be classified as 1) reentry, 2) automaticity, 3) triggered activity. Reentry occurs when there are differential rates of conduction and is 462 triggered by a premature beat. Automaticity is a function of phase and depolarization ectopic activity, action potential. Slow rates (bradycardia) can be from the atrium (sinus bradycardia) or the ventricle. Other causes include sinus disease (post-operative) hypercalcemia hpyermagnesemia. Treatment includes identifying the cacuse if one is present, epinephrine, atropine, or pacemaker, Ventricular bradycardia are functional blocks, stable patients are treated with epinephrine, unstable patients are paced. Fast rates (tachycardia) can stem from the atrium or the ventricle and may be hemodynamically problematic or not. The atrial tachycardias includes: Sinus tachycardia – Consider hyperdynamic states (fever, seizures, sepsis, thyrotoxicosis, or hypoglycemia). Atrial Muttler (saw tooth pattern rate 150) should get a trial of procainamide, digoxin or ibutalide (0. The first question regarding ventricular tachycardias should be “is it a shockable rhythm? In acute decompensated heart failure, there are no medications that are associated with increased survival.
The horse’s respiratory system also plays an important role in regulating his body heat and in main taining the acid-base pH balance blood glucose 91 order januvia mastercard. Oxygen is integral to the anabolic and catabolic processes that occur naturally in all structures diabetic eye problems buy cheap januvia 100mg online. The oxygen/carbon dioxide exchange rate depends on how clean the lung tissues are diabetes insipidus in toddler 100 mg januvia otc, the depth of respiration diabetes pictures purchase januvia 100mg on-line, the animal’s temperature (which causes expansion or dilation of blood vessels in tissues) diabetes prevention questionnaire purchase januvia 100 mg, and the rate of respiration diabetes type 1 4 year old cheap 100 mg januvia mastercard. The rate of breathing for a horse at rest is around 12 to 16 breaths per minute; during heavy exercise, the rate is between 120 and 180. A cool-down period after strenuous exer cise is essential to allow more time for the lungs to exchange gases, release toxins, and take in fresh oxygen. An improperly fitted saddle and a rider’s tense legs also restrict the expansion of the rib cage, consequently limiting lung capacity. Muscular problems such as chronic stress points (small spasms) and trigger points (areas of lactic acid build-up) will restrict the muscle action required to expand and contract the rib cage. The Circulatory System the circulatory system consists of the cardiovascular system and the lymphatic system. Circulation has a number of functions: ❖ Distributing oxygen and nutrients to every cell of a horse’s body. Arterial blood carries oxygen, nutrients, immune defense agents, glandular secretions, and blood-clotting agents throughout the body. Arterial blood circulation is generated by the pumping action of the heart and the contraction of the arterial wall muscles. The normal heart rate at rest is 28 to 40 beats per minute, and up to between 210 and 280 beats per minute during exercise. The heart forces blood into the arteries, to the arterioles (smaller arter ies) and then to the capillaries (minute blood vessels in the tissues), where the oxygen/carbon dioxide and nutrients/waste exchanges occur. The blood returns via the venules (small veins) to the veins, to the heart, to the lungs, then back again to the heart for another cycle into the arteries. The venous blood transports metabolic waste and carbon dioxide from the cells of the tissues to the heart and lungs (where the oxygen/carbon dioxide exchange takes place). The venous return of blood is assisted by the movement of the large locomotor muscle groups of the body. Veins are equipped with little cuplike valves to prevent the backward flow of blood. Each muscle contraction squeezes the venous blood in one direc tion, toward the heart. However, after an injury it is even more Anatomy and Physiology of the Horse 13 important that an adequate supply of blood—bearing nutrients, oxygen, and healing material—reaches the site of injury. The blood will also remove waste, debris, or any toxins formed as a result of the injury. When the body is cold, the capillaries in those parts of the body farthest away from the heart constrict. Blood circulation is there fore reduced in the extremities, keeping most of the blood at the body’s core in order to warm vital organs (brain, heart, and lungs. The pressure of massage movements has an effect on the circu lation of blood throughout the body. Chapter 6 contains massage routines that can be used to deal with problems related to , or caused by, poor circulation. The Lymphatic System the lymphatic system plays an important role in the body’s defense mechanism in that it contains lymphocytes (white blood cells that aid in fighting viral and bacterial infections). When the body is injured, an increase of lymphatic fluid occurs at the site of trauma and produces swelling. The lymphatic system consists of a network of small vessels containing lymphatic fluid and structures called lymph nodes (which are like miniature cleansing factories). The lymphatic system sends fluid in only one direction—from the periphery of the body toward the heart. Like veins, lymph vessels are equipped with cup-shaped valves to prevent backflow of the fluid. Muscle activity, breathing movements, and peristaltic activ ity of the bowels all contribute to the flow of lymphatic fluid. Lack of exercise can contribute to lymphatic congestion, which results in swelling in the limbs. Overloading the lymphatic system as a result of too much exercise can cause a buildup of toxins, which leads to an inflammation of the lymph vessels and lymph nodes. Following an injury, reduced muscular activity contributes to the slowing of lymphatic circulation. Massage with light drainage (effleurage movements) will assist lymphatic circulation. Basically, the purpose of the recuperation routine is to prevent lactic 14 Equine Massage Anatomy and Physiology of the Horse 15 acid buildup after heavy training, racing, or competition. Massage also relaxes the central nervous system, contributing to an improved overall functioning of these four systems. The Endocrine System Made up of glands and associated organs, the endocrine system produces and releases hormones directly into the bloodstream. These hormones regulate growth, development, and a variety of other functions, including reproduction and metabolism. The Digestive System the digestive system alters the chemical and physical composition of food so it can be absorbed and utilized by the horse’s body. The gastrointestinal tract is a musculo-membranous tube that extends from the mouth to the anus (approximately 100 feet long). The digestive organs of the horse are the mouth, pharynx, esophagus, stomach, small intestine, cecum, large intestine, and anus. The Urinary System the urinary system maintains the balance of fluids in the body and eliminates waste products from the body. The urinary system consists of a pair of kidneys, the ureters, the bladder, and the ure thra. The kidneys provide a blood-filtering system to remove many waste products, and to control water balance, pH, and the level of many electrolytes. Proper urinary functioning avoids kidney failure and all its consequences: swelling, toxicity, and weight loss. The Reproductive System the reproductive system ensures the continuation of the species. The male reproductive system consists of the testicles, the acces sory glands and ducts, and the external genital organ. The female reproductive system consists of the ovaries, oviducts, uterus, 16 Equine Massage Anatomy and Physiology of the Horse 17 18 Equine Massage vagina, and external genitalia. Proper fluid circulation and relax ation of the nervous system will ensure peak performance for reproduction purposes. The Skeletal System the skeletal system serves as a framework for the horse’s body, giv ing the muscles something to work against, and defining the ani mal’s overall size and shape. For example, the skull protects the brain; the rib cage protects the lungs and heart; the vertebral col umn protects the spinal cord. With the exception of the enamel-covered teeth, bones are the body’s hard est substances and can withstand great compression, torque, and tension. A tough membrane called the periosteum covers and pro tects the bones and provides for the attachment of the joint cap sules, ligaments, and tendons. Injury to the periosteum may result in undesirable bone growths such as splints, spavin, and ringbone. Bones are held together by ligaments; muscles are attached to the bones by tendons. The articulating surface of the bone is covered with a thick, smooth cartilage that diminishes concussion and friction. Long bones are found in the limbs; short bones in the joints; flat bones in the rib cage, skull, and shoulder; and irregularly shaped bones in the spinal column and limbs. Short bones, found in complex joints such as the knee (carpus), hock (tarsus), and ankle (fetlock), absorb concussion. Flat bones protect and enclose the cavities containing vital organs: skull (brain) and ribs (heart and lungs). Components of the skeleton of the horse are as follows: ❖ the skull consists of 34 irregularly shaped bones. The tail consists of 18 coccygeal vertebrae, although this number can vary considerably. Comprising the forelegs are the shoulder blade (scapula), humerus, radius, knee (8 carpal bones), cannon, splints, long and short pasterns, and the pedal (or coffin) bone. Movement of the horse is dependent upon the contraction of muscles and the corresponding articulation of the joints. Some joints in the horse’s body are not movable, but most are and permit a great range of motion. The ends of the bones are lined with hyaline cartilage, which provides a smooth surface between the bones and acts as a shock absorber when compressed—for example, during takeoff and landing while jumping, and for torque during quick turns. The joint capsule, also known as the capsular ligament, is sealed by the synovial membrane, which produces a viscous, lubricating secretion, the synovial fluid. Ligaments are made up of collagen fiber, a fibrous protein found in the connective tis sue. Consequently, if a lig ament is injured, say by a sprain, it tends to heal slowly and sometimes incorrectly. Most ligaments are located around joints to give extra support (capsular ligaments and collateral ligaments) or to prevent an excessive or abnormal range of motion and to resist the pressure of lateral torque (a twisting motion). Within very narrow lim its, ligaments are somewhat elastic but are inflexible enough to offer support in normal joint play. If overstretched or repeatedly stretched, a ligament might lose up to 25 percent of its strength. Such a ligament may need surgical stitching to recover its full ten sile strength. Several ligamentous structures help support and protect the vertebral column, pelvis, neck, and limbs from suddenly imposed strain. The Muscular System There are three classes of muscles: smooth, cardiac, and skeletal. The smooth and cardiac muscles are involuntary, or autonomic; they play a part in the digestive, respiratory, circulatory, and urogenital systems. For the most part, skeletal muscles are voluntary; they function in the horse’s movements. In massage, we are concerned with the more than 700 skeletal muscles that are responsible for the move ment of the horse. Fast twitch fibers are anaerobic fibers; they do not need oxygen to work and therefore are able to deliver the quick muscular effort required for a sudden burst of speed. The fleshy part, or muscle belly, is the part that contracts in response to nervous command. During con traction, the muscle fibers basically fold on themselves, shortening the fibers and resulting in muscle movement. The muscle belly is made up of many muscle fibers arranged in bundles, with each bundle wrapped in connective tissue (fascia). The fascia covers, supports, and separates the muscle bundles and the whole muscle 24 Equine Massage Anatomy and Physiology of the Horse 25 26 Equine Massage itself. This arrangement allows for greater support, strength, and flexibility in the movement between each of the muscle groups. It is made up of connective tissue—a dense, white, fibrous tissue much like that of a ligament. The origin tendon is the tendon that attaches the muscle to the least movable bone; the insertion tendon attaches the muscle to the movable bone, so that on contraction the insertion is brought closer to the origin. Tendons attach to the periosteum of the bone; the fibers of the tendon blend with the periosteum fibers because of their similar collagen make-up. Tendons can be fairly short, or quite long as is seen with the flexor and extensor muscles of the lower legs. Usually, tendons are rounded but they can be flattened like the tendons that attach along the spine. Because of their high-tensile strength, tendons can endure an enormous amount of tension, usually more than the muscle itself can produce; consequently, tendons do not rupture easily. They are not as elastic as muscle fibers, but they are more elastic than liga ment fibers. Tendons can “stress up” after heavy exercise, meaning that they can stay contracted. The horse has no muscles below the knee or hock; consequently, many leg muscles have long tendons that run down the legs over the joints. Chronic irritation of the sheath can result in excess fluid production and soft swellings. Cold hydrotherapy (chapter 4) and massage will help increase circulation and keep inflammation down. Look at the muscle charts to note the variety of shapes in the horse’s muscle structure. Muscles work in three different ways: isometric contraction, con centric contraction, and eccentric contraction. Isometric contraction occurs when a muscle contracts without causing any movement. Concentric contraction is mostly seen in regular movements such as protraction (forward movement) or retraction (backward movement) of the limbs, and in any movement of the neck or back.
Bile duct carcinoma arising from the anastomotic site of hepaticojejunostomy after the excision of congenital biliary dilatation: a case report diabetes insipidus medscape januvia 100 mg discount. Surgery 1996; 119: 476–9 13 Management of hydatid disease of the liver Sandro Tagliacozzo Biological and pathological basis of modern surgery the echinococcus or hydatid cyst represents the larval stage of Echinococcus granulosus diabetes type 1 glucose levels cheap 100 mg januvia with mastercard, a 2–6 mm long tapeworm diabetes pump medications generic 100mg januvia mastercard. The intermediate animal hosts diabetes type 2 treatment algorithm januvia 100mg with mastercard, where the parasite lives and develops at the larval stage diabetes symptoms leg cramps generic 100 mg januvia with mastercard, are sheep blood sugar unit conversion buy januvia amex, cattle, pigs and man (considered an ‘accidental’ intermediate host). There are also ‘sylvatic cycles’ of echinococcus which occur in Canada, Alaska, Australia and other countries with different definitive and intermediate hosts according to the local prevalence of animal species. Human infection is direct or indirect from the dog through the parasite eggs (size 20– 25 µm). This penetrates the gut wall, enters a mesenteric venule and is transported to the liver, where in most cases it will lodge. However, it may cross the portal network and reach the lung, where it may stop or continue beyond the vascular network, towards the various organs by way of systemic arterial vessels. In the liver the embryo loses its hooks and develops a larval cystic form: the echinococcus cyst or hydatid cyst. If it survives leukocytic response, the cyst grows, reaching 250 µm in diameter after 3 weeks and 1 cm after 5 months. The wall consists of two separate parts: the inner endocyst, namely the wall of the true vesicular metacestode, and the outer connective pericyst or ectocyst, deriving from the host organ, in the case of man the liver, able to ensure nutritional exchanges for a long time (Fig. The wall, in Surgical Management of hepatobiliary and pancreatic disorders 338 Figure 13. The outer layer consists of a cuticle up to , or over 1 mm thick, the chitinous layer, similar to the white of a boiled egg, composed of concentric hyaline laminae. The inner layer consists of a thin (10–25 µm) germinal or parenchymal layer, which represents the living tissue, composed of an outer basal syncitial layer and inner nucleated cells. In a fertile adult cyst, the inner surface of the germinal layer is scattered with innumerable granules, brood vesicles or capsules, 250–500 µm in diameter. They are released into the cystic fluid and, together with the hooks, they form the so-called hydatid sand. These are the cephalic ends of echinococcus or protoscoleces, invaginated and covered with an anhistic cuticle. Protoscoleces can produce implantations of cysts in the viscera if there is cystic fluid dissemination. For a long time, the cyst contents can be composed of hydatid fluid only, a colorless fluid, clear as rock crystal (univesicular cyst), while in the mature cyst there may be a number of cysts similar to the mother cyst, called daughter cysts (multivesicular cysts). The origin and cause of daughter cyst formation is not well known, apart from a non specific stress of the germinal layer for impaired vital exchanges with the host and decreased endocyst pressure. The pericyst, initially composed of very thin connective lamina, subsequently tends to become thicker (up to 1 cm or more), sclerose and calcify. The process of cyst expansion causes compression of hepatic parenchymal structures, in turn engulfed into the pericyst. Large vessels are compressed and displaced while, however, remaining patent for a long time. Similarly, bile ducts remain patent and may open into the pericyst, between it and the parasite wall. This phenomenon is very frequent, unlike the rare frank rupture of the cyst with effusion of the cyst contents into a large duct and the main bile duct. This is of the utmost importance for surgery, since on the one hand its appearance causes major changes in the cyst and pericyst development, and on the other it is a factor in the development of postoperative complications such as biliary fistulas. Bile filtration in the virtual interstitium between the pericyst and chitinous membrane can form a perivesicular biloma with loss of direct contact of the cyst with the pericyst, a decrease in the mother cyst pressure and membrane rupture, all phenomena which from early on can cause endogenous vesiculation. Endogenous vesiculation indicates an initial positive attempt at survival by the primary parasite, otherwise condemned to death and degeneration. Subsequently the neoformed hydatid material packed into the cystic cavity tends to show signs of stress and to degenerate extensively with different aspects of: fruit jelly, putty, plaster, dry clay or pus (Fig. At the same time, the fibrous pericyst becomes thicker and calcium deposits appear as increasingly extended and confluent granules and laminae, forming in some cases a continuous thick shell. Some authors consider these degenerative aspects as corresponding to the parasite’s death, however this is not so. Except for extreme cases, within the degenerate material, viable hydatids can be found. Protoscoleces and brood vesicles generated by the germinal layer can penetrate the chitinous membrane through fissures and then tend to advance into the pericyst. Once the germinal elements penetrate the pericyst, they may grow inside and then project towards the liver parenchyma as diverticular protrusions surrounded by their own thin pericyst (Fig. In their cavity, they contain cysts that grow favored by easy exchanges through the thin neoformed pericyst and behave as the mother cyst. Because there is no connection with the inner surface of primary pericyst they cannot be detected Management of hydatid disease of the liver 341 or even suspected with the most careful examination after emptying (Fig. The exogenous cyst, while growing, can pull away from the mother cyst and this results in the commonly observed pattern of two or more adjacent cysts, or ‘satellite cysts’,4 separated by a parenchymal septum usually rich in vascular and ductal structures already displaced by the mother cyst. In other frequently observed instances, the exogenous cyst remains in contact with the primary cyst separated by a thin residual septum (‘sand-glass-like cyst’), or with the collapse of separating septum, the two cavities communicate through a more or less wide operculum (‘sacculations’). As for the presence and frequency of exogenous vesiculation, the phenomenon is either ignored or largely Figure 13. However, it is recognized in about 30% of radical operations for multivesicular cysts. Once the phenomenon was identified and quantitatively assessed, its importance was recognized beyond biological and pathological interest. Consequently, in a large number of patients where Surgical Management of hepatobiliary and pancreatic disorders 342 the surgical procedure then performed (and still largely performed) included no removal of the pericyst, this could not be considered effective: actually, only the cyst was resected. This was incorrectly considered a recurrence attributed to implantation from accidental dissemination because of poor protection of the operating field or reinfection. The latter interpretations, already unconvincing, have lost credibility, based on the observation that the findings of exogenous vesiculation and the incidence of recurrence in series of conservative surgery, interestingly enough, were similar, at about 30%. This was confirmed by the fact that the so-called recurrences were practically absent in series of radical surgery. Briefly, from the knowledge of the parasite’s biology and the pathological relationship between the cyst and liver, stem the criteria of a new, rational surgery of the hydatid disease of the liver. It tends to critically minimize or reduce to nil postoperative biliary complications and the most serious long-term failure, namely recurrence. Indications for surgery For the two types of cysts mentioned above, indications for surgery are as follows: Univesicular, clear cysts with a thin and elastic pericyst (20% of cases) should be treated by conservative surgery (there is no need for radical surgery);. Multivesicular, yellow cysts at different developmental stage with fibrous, thick and/or calcific pericyst (80% of cases) should be treated by radical surgery. For modern rational operative surgery, the choice is not optional but rigorously determined. With the concept of radicality, surgery of liver hydatidosis becomes demanding and therefore selective surgical experience is required as the only means of ensuring a good chance of recovery. Among radical operations, the choice between anatomical liver resection and total pericystectomy is at the surgeon’s discretion; however, it is readily understood that the second operation is undoubtedly more advantageous. In fact, the growth of the cyst is characterized by compression of vascular and ductal structures that supply large, healthy hepatic regions worth preserving, therefore favoring careful pericyst dissection with preservation of structures. During its development, the hydatid cysts of the liver may undergo a number of complications, some of them clinically dramatic. Infection of the cavity and its contents is less frequent than was previously thought (2– 20%),12 and was not always clinically manifest. Together with the contents, the mother membrane can be destroyed and consequently the altered escavated pericystic wall loses its function of delimiting the infectious process. This occurrence should be distinguished from biliary communication through ductal fissurations, much more Management of hydatid disease of the liver 343 frequent in mature cysts (40–70%). In cases with suspected penetration of hydatid material into the bile ducts, intraoperative cholangiography and concomitant surgery with bile duct clearing and external or internal biliary drainage, preferably papillosphincterostomy, is mandatory. A severe risk in the presence of a huge cyst is its rupture into the peritoneal cavity (5– 12% incidence). Another cause of peritoneal effusion of hydatid contents is iatrogenic from percutaneous puncture for diagnosis or emptying, or it may occur during surgery with bad technique and poor isolation of the peritoneal cavity. Symptoms are complex, with acute abdominal pain, local signs of peritoneal irritation and anaphylactic reactions of varying degree to severe shock, characterized by intense dyspnea, tachycardia, marked hypotension and urticaria. The cyst rupture may be followed by bile peritonitis with a well defined or insidious clinical pattern. Initially, in some cases, rupture may be overlooked and show only long-term manifestations. The most severe manifestation results from the dissemination and implantation of endocyst material on the peritoneal surface shown as innumerable cysts of varying dimensions, often in clusters. Benzoimidazole therapy has represented a marked improvement in the treatment of rupture of a cyst into the peritoneal cavity. Necrosis of the latter from compression, wear and often infection results in cyst communication, exceptionally with the pleural cavity and usually, for previous adhesions, with the pulmonary parenchyma of the lung base, corresponding to the posterior and/or lateral basal segment or medial lobe. Pulmonary inflammation together with the necrotizing action of bile causes erosion into a peripheral bronchus with subsequent passage of hydatid material and bile into the bronchial tree, favored by the differential pressure gradient (Fig. Rupture of the cyst into the bronchial tree may be dramatic with abundant expectoration of bile and hydatid material. Daily bile effusion is persistent Surgical Management of hepatobiliary and pancreatic disorders 344 and increasing, resulting in an extremely severe clinical pattern characterized by cough, abundant expectoration up to 1000 ml of bile and hydatid contents, fever, and very poor general Figure 13. Biliary rupture of hepatic cyst, common bile duct obstruction with hydatid material, communication between the cyst cavity and a basal bronchus through an area of attenuated diaphragm are represented. Bronchopulmonary involvement tends to involve several segments (fatal necrotizing bronchitis) with necrosis and abscess cavities. Management of hydatid disease of the liver 345 Diagnosis Hydatid cyst of the liver may be asymptomatic for years, at times for decades. Diagnosis may be accidental, based on an incidental clinical exam that detects swelling when the cyst is located in a palpable abdominal area or, in the case of a more or less relevant hepatomegaly, subsequently assessed with other exams. In children, large hepatic swellings from hydatid cysts are accompanied by evident deformations of the chest involving the last ribs and arches. Apart from a sense of pressure, a cyst of the liver may cause boring pain at the basal chest for the diaphragmatic pleural or peritoneal reactive process. Dyspepsia, possibly from reflexes originating in the periductal nervous network, is not unusual. Cholestasis from major bile duct compression may be responsible for fever, also of high grade. It is non-invasive, low-cost and reproducible, thus suitable for postoperative follow-up or during medical therapy. Multiple coronal scans evaluate non-invasively and accurately the relationships with vascular structures: portal vein and inferior caval vein, thus rendering invasive investigations such as venography and arteriography unnecessary (Fig. They are used to detect the relationships with huge or central cysts and in the differential diagnosis with primary liver tumors or metastases. Preoperative intravenous cholangiography is performed according to the clinical presentation. It may supply information on common bile duct anatomy, but it does not detect the biliary relationship of the cyst. Percutaneous cholangiography is contraindicated in liver hydatidosis for the risk of perforation and dissemination of hydatid contents. Inferior caval vein compression with marked stenosis caused by a bulky cyst of right hemiliver. Scintography A common procedure for many years, this has been practically abandoned as a preoperative exam. Management of hydatid disease of the liver 349 Immunodiagnosis Immunodiagnosis of hydatidosis now plays a minor role following the progress in diagnostic imaging. False negatives may lead to no treatment at all or to diagnostic puncture, with the consequent risk for anaphylactic shock and dissemination. Operation According to location and size, cysts can be divided into parenchymal or superficial and vasculobiliary or deep. Obviously, the validity of the topographic definition according to hemilivers, sectors, segments or subsegments adopted by the most reliable classifications is confirmed. While no intrahepatic expanding neoplasm can be free of vasculobiliary contacts, especially the hepatic veins, superficial cysts have vascular relationships limited to minor peripheral structures. Vasculobiliary or deep cysts represent about 75% of cysts that come to surgery and are those with relationships to first, second and third order branches of hilar elements, the hepatic veins and the inferior caval vein in both its supra-retro and subhepatic segments (Fig. They are bulky, thus their dissection is difficult both in the case of hemihepatectomy or the more frequent total pericystectomy. In these cases dissection of the cyst from the cava and involved hepatic vein is mandatory. The latter should be ligated and sectioned or more frequently dissected and preserved with adjacent lateral sutures. As for bile ducts, their adhesion to the pericyst is very dense and dissection is difficult. If there is a communication, this requires very careful dissection for effective repair. For example, right hepatic cysts may extend to the mid right lobe and left hepatic cysts may be located between the two hila. Obviously, these possibilities do not affect the principles on which the classification is based. Access must be wide for two main reasons: first, because of the frequent presence of adhesions of the protruding cyst to adjacent structures and organs, in particular the diaphragm. Second, because of the need for extended liver mobilization to control the vessels and exploit the liver flexibility to reduce the cavities or residual surfaces after pericyst removal.
Additional information: