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The mean electrical axis during ventricular activation in the horizontal plane can be computed in an analogous manner by using the areas under and lead axes of the six precordial leads (see Fig safe 160 mg super p-force oral jelly. A horizontal plane axis located along the lead axis of lead V is assigned a value of 0 degrees;6 axes directed more anteriorly have positive values buy super p-force oral jelly 160mg free shipping. This approach can also be applied to compute the mean electrical axis for other phases of cardiac activity buy super p-force oral jelly with american express. Signal acquisition includes amplifying the recorded signals, converting the analog signals into digital form, and filtering the signals to reduce noise. Analog signals are converted to a digital form at rates of 1000 samples per second (1000 hertz, Hz) to as high as 15,000 Hz. Too fast a sampling rate may introduce artifacts, including high-frequency noise, and will generate excessive amounts of data necessitating extensive digital storage capacity. Low-pass filters reduce the distortions caused by high-frequency interference from, for example, muscle tremor and nearby electrical devices; high-pass filters reduce the effects of body motion or respiration. For routine electrocardiography, the standards set by professional groups require an overall bandwidth of 0. The multiple cardiac cycles are recorded for each lead and are overlaid electronically to form a single representative beat for each lead. This reduces the effects of minor beat-to-beat variation in the waveforms and random noise. In addition, the averaged waveforms from each lead are overlaid on each 1 other to measure intervals. In some cases the criteria are derived from physiologic constructs and constitute the sole basis for a diagnosis, with no anatomic or functional correlation. For example, the criteria for intraventricular conduction defects are diagnostic without reference to an anatomic standard. Leads generally are displayed in three groups—the three standard limb leads, followed by the three augmented limb leads, followed by the six precordial leads. Alternative display formats have been proposed in which the six limb leads are displayed in the 4 sequence of the frontal plane reference frame (see Fig. However, true unipolar leads register the potential at one site in relation to an absolute zero potential. Referring to these leads as unipolar leads is based on the imprecise notion that the Wilson central terminal represents a true zero potential. Classifying these leads as “bipolar” more rigorously reflects the recognition that the reference electrode is not at exactly zero potential. The vertical lines of the grid represent time intervals, with lines spaced at 40-millisecond intervals. Variability between individuals may reflect differences in age, sex, race, body habitus, heart orientation, and physiology. The observed differences among various subpopulations suggests that a single range of normal values for all individuals may be inappropriate and may lead to errors in diagnosis. Atrial activation begins with impulse generation in the atrial pacemaker complex in or near the sinoatrial node (see Chapter 34). Activation continues in both atria during much of the middle of the overall atrial activation period, with left atrial activation continuing after the end of right atrial activation. In the horizontal plane, atrial early activation of the right atrium generates a P wave that is oriented primarily anteriorly. Later, it shifts leftward and posteriorly as activation proceeds over the left atrium. In lead V and occasionally in lead V ,1 2 the P wave may be biphasic with an initial positive deflection followed by a later negative wave. The P wave in the more lateral leads is upright and reflects continual right-to-left spread of the activation fronts. Variations in this pattern may reflect differences in pathways of interatrial conduction, described later. The upper limit for a normal P wave duration is conventionally set at 120 milliseconds, as measured in the lead with the widest P wave. Heart Rate Variability Analysis of beat-to-beat changes in heart rate and related dynamics, termed heart rate variability, can provide insight into neuroautonomic control mechanisms and their perturbations with aging, disease, and drug effects (see Chapters 35 and 36). Attenuation of this respiratory sinus arrhythmia at rest is a marker of physiologic aging and also occurs with diabetes mellitus, congestive heart failure, and a wide range of other conditions that alter autonomic tone modulation. A variety of complementary signal-processing techniques have been developed to analyze heart rate variability and its interactions with other physiologic signals, including time domain statistics, frequency domain techniques based on spectral methods, and newer computational tools derived from 6 nonlinear dynamics and complex systems theory. Signals from elements of the conduction system can be recorded from intracardiac recording electrodes placed against the base of the interventricular septum near the bundle of His (see Chapter 35). Endocardial activation is guided by the anatomic distribution and physiology of the His-Purkinje system. The rapid conduction within the broadly dispersed ramifications of this treelike (fractal) system results in the rapid, synchronized activation of multiple endocardial sites and the depolarization of most of the endocardial surfaces of both ventricles within several milliseconds. These loci generally correspond to the sites of insertion of the fascicles of the left bundle branch. Portions of the left and right ventricles have been removed so that the endocardial surfaces of the ventricles and the interventricular septum can be seen. Isochrone lines connect sites that are activated at equal instants after the earliest evidence of ventricular activation. Electrical aspects of human cardiac activity: a clinical-physiological approach to excitation and stimulation. Wavefronts sweep from these initial sites of activation in anterior and inferior and then superior directions to activate the anterior and lateral walls of the left ventricle. Excitation of the right ventricular endocardium begins near the insertion point of the right bundle branch near the base of the anterior papillary muscle and spreads to the free wall. The final areas to be activated are the pulmonary conus and the posterobasal right ventricular areas. Thus, in both ventricles, the overall endocardial excitation pattern begins on septal surfaces and sweeps down toward the apex and then around the free walls to the basal regions, in an apex-to-base direction. Excitation of the endocardium begins at sites of Purkinje–ventricular muscle junctions and proceeds by muscle cell–to– muscle cell conduction in an oblique direction toward the epicardium. Multiple regions of both ventricles are usually activated simultaneously, resulting in substantial cancellation of the electrical forces that are generated, as previously described. An initial negative deflection is called the Q wave, the first positive wave is the R wave, and the first negative wave after a positive wave is the S wave. Tall waves are denoted by uppercase letters and smaller ones by lowercase letters. In each case, the deflection must cross the baseline to be designated a discrete wave. Changes in waveform patterns that do not cross the baseline result in notches or slurs. A notch is an abrupt change in waveform direction similar to the underlying wave but that does not cross the baseline. A slur is a more gradual change in the slope or rate of change in waveform amplitude.

After completely dividing the mesentery discount 160 mg super p-force oral jelly overnight delivery, pass a pretied ligature into the field through the left lower quadrant trocar purchase super p-force oral jelly pills in toronto. Avoid letting the ligature come in Management of the Retrocecal Appendix contact with the viscera buy super p-force oral jelly 160mg line, as the loop is easier to manipulate while still dry and relatively stiff (rather than damp and The appendix is occasionally completely retrocecal and limp). Incise the line of Toldt from the cecum up to the vicinity of the hepatic flexure (Fig. Grasp the cut edge of peritoneum adherent to the right colon and pull the right colon medially while lysing any residual adhesions by sharp and blunt dissection (Fig. The appendix is then found on the back wall of the cecum, generally adherent to the cecum with fibrous bands. Tactile perception from the Babcock clamp may help identify the appendix, which feels like a small, firm cylinder compared with the softer cecum. Grasp the appendix near its base and sequentially lyse the fibrous adhesions that tether the appendix to the cecum (Fig. Scott-Conner Continue antibiotics as you would as if the operation had been performed as an open procedure. In other words, if you would have given antibiotics for 1 week following open appendectomy for perforated appendicitis with local perito- nitis, follow this regimen after laparoscopic appendectomy for the same pathology. Complications Abdominal wall infection (discussed above) Pelvic or abdominal abscess Retained appendiceal stump (causing recurrent appendicitis) Further Reading Fig. Comparison of laparoscopic versus open appendec- tomy for acute nonperforated and perforated appendicitis in the Closure of Trocar Sites and Postoperative Care obese population. Comparison of outcomes of laparoscopic versus If purulent material is encountered, close the fascia as usual open appendectomy in adults: data from the nationwide inpatient but leave the skin open. New York: Springer Science+Business events of the first postoperative week are determined by the Media; 2012. Single incision versus standard 3-port laparoscopic appendec- roscopic approach may not be obvious. Part V Large Intestine Concepts in Surgery 4 8 of the Large Intestine Marylise Boutros and Steven D. Wexner This chapter provides a comprehensive overview of essential Diverticulitis, the most common complication of diver- concepts relating to the operative approach and strategy for ticulosis, occurs in approximately 10–25 % of patients colon and rectal surgery. If the involved segment of the colon is in contact with the bladder, urinary symptoms may occur including increased frequency, Benign Conditions dysuria, pneumaturia, and fecaluria. Thirty-five percent of patients patient’s clinical status and the presence of any complica- will also have more proximal colonic diverticula, and a tions of disease. Acute diverticulitis may be uncomplicated minority will have pancolonic diverticulosis. Prevalence (limited to the colonic wall and adjacent tissues) or com- correlates with age and geographic location; approximately plicated (with perforation, abscess, or fistula). Management 30 % of adults living in industrialized countries will acquire of acute uncomplicated diverticulitis consists of bowel rest diverticular disease by age 60 while up to 80 % of those and administration of oral or intravenous antibiotics; this aged 80 years and older are affected (Beck et al. The treatment is successful in 70–100 % of patients (Rafferty majority of patients with diverticular disease are asymp- et al. In addition to bowel rest and antibiotics, management of complicated diverticulitis may include radiologically guided percutaneous, transgluteal, or transrectal drainage of M. Department of Colorectal Surgery, The indications for surgery include failure of nonopera- Sir Mortimer B. Davis Jewish General Hospital, tive management, nondrainable abscess, septic shock/gener- 3755 Cote Ste. Wexner require resuscitation and surgical management; otherwise Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd. Wexner standard emergency operation for perforated diverticulitis is ing emergency surgery does not significantly increase with Hartmann’s procedure: resection of the diseased segment of repeated attacks (Margolin 2009). In addition, between colon with an end colostomy and closure of the distal stump 75 and 85 % of patients who present with complicated (“Hartmann’s stump” or “Hartmann’s pouch”). At the time of diverticulitis requiring surgery do so with no antecedent his- emergency Hartmann’s resection, it is preferable not to enter tory of diverticulitis (Margolin 2009; Chapman et al. However, it is important to tran- Markov modeling, an elective colectomy for patients over 50 sect the distal colon in an area that is minimally inflamed in years of age, performed after the fourth attack of documented order to avoid a Hartmann’s stump blowout. The Hartmann’s uncomplicated diverticulitis, resulted in a decrease in mor- stump may be stapled and/or sutured. After one surgeons prefer to leave the distal stump above the fascia attack, about one-third of patients will have a second attack under the midline wound or to mature it as a mucous fistula. Such preoperative stoma as age, comorbidities, immunocompromised state, frequent marking helps minimize postoperative stoma complications. Thus, alterna- Key Aspects of the Surgical Procedure tives to Hartmann’s procedure have emerged. We recom- tion and anastomosis with or without a diverting ileostomy, mend the use of prophylactic ureteral stents, especially for and with or without on-table lavage, may be performed. An patients with a history of severe attacks or ongoing inflam- anastomosis may be considered in the emergency setting if mation. To prevent recurrence, the distal resection margin the patient is clinically stable and if the presence of pus and should be at the level of the upper rectum, at the point where inflammation is limited such that the bowel resection mar- the tenia coli splays out onto the rectum (Thaler et al. Often, The presence of sigmoid colon distal to the anastomosis is the presence of a pelvic abscess or generalized peritonitis an independent predictor of recurrence (Fozard et al. The anastomosis should be 2008); however, debate remains regarding the need for sub- fashioned with proximal bowel free of diverticula, although sequent definitive elective surgery. To per- form an adequate resection and to ensure a well-vascularized, Elective Surgery for Diverticulitis tension-free anastomosis, mobilize the splenic flexure (Thaler After resolution of the acute diverticular attack, it is impor- et al. Laparoscopy for elective resections for tant to ensure that the patient undergoes (or has recently diverticulitis has been demonstrated to be safe, feasible, and undergone) a colonoscopy to confirm the diagnosis and associated with the expected short- and long-term benefits of exclude underlying malignancy or inflammatory bowel dis- a minimally invasive approach (Fozard et al. The indications for elective surgery for diverticulitis are Diverticular Fistulas continually evolving (Margolin 2009). Historically, elective Colovesical fistulas are the most common diverticular fistu- resection was recommended after two documented attacks las. Other common fistulas associated with diverticular dis- of uncomplicated diverticulitis or one attack of complicated ease include colovaginal (in females who have had a previous diverticulitis in which emergent surgery was not required hysterectomy), coloenteric, and colocutaneous fistulas. However, some fistulas will tions have evolved to consideration for elective resection on not be identified by imaging studies (Beck et al. This revision is primary aim of the diagnostic evaluation is not to visualize due to the realization that diverticulitis follows a relatively the fistula but instead to determine the etiology (diverticular benign course and that the risk of complications necessitat- or malignant or Crohn’s related) so that the appropriate 48 Concepts in Surgery of the Large Intestine 429 operation can be performed. The sigmoid is the site most are takedown of the fistula, resection of the diseased bowel, frequently involved, and this clinical presentation often and interposition of viable tissue between anastomosis and occurs in the elderly population with a male preponderance the fistula tract. Plain radiographs of the abdomen elective primary resection of the diseased colon, with pri- may display the “bent inner-tube” or “omega-loop” appear- mary anastomosis. The involved portion of the bladder is ance of a massively distended bowel loop, with both ends typically small, drained with a bladder catheter and intra- closely adjacent in the pelvis. The omentum is placed water-soluble contrast may be performed and will demon- between the bowel anastomosis and bladder. Similarly, no strate the “bird’s beak” appearance of the barium terminating special treatment is needed for the vagina, and an omental at the level of the torsion. It is important that the mucosa be visualized during Complete colonic obstruction due to diverticular disease detorsion to ensure its viability.

We avoid discussing the topic of convulsions effective super p-force oral jelly 160mg, as people with epilepsy will testify 160 mg super p-force oral jelly mastercard. Some people with epilepsy contend the rest of us also avoid people with epilepsy purchase super p-force oral jelly with a mastercard. As with other events in science, it is always possible to find accounts of similar events in previous centuries. In AD 46, Scribonius Largus described the application of electric torpedo fish to the head as a treatment for headache. In 1470, a Jesuit missionary in Ethiopia applied electric catfish to people (anatomical site unknown) as a means of expelling devils. In th the 18 century electric eels were applied to the head (condition treated unknown). However, there is no clear history of the application of electricity to the head for the treatment of mental disorders before 1938. Convulsions had been induced by other means for medical purposes at different times over the centuries. Paracelsus (1490-1541) administered camphor by mouth to induce convulsions in the treatment of mental disorders. In 1785 an account appeared in the London Medical Journal of camphor induced convulsions for the treatment of psychosis. Then came a series of active treatments which encouraged optimism and set the scene for the development of ECT. From around 1917 Julius Wagner-Jauregg (Professor of Psychiatry, Vienna) began treating the otherwise progressive and fatal general paresis of the insane (terminal syphilis) by infecting sufferers with malaria. Other psychiatrist had used insulin to stimulate appetite, however, Sakel sought to induce coma. In the process, some patients experienced seizures, and this may have been responsible for observed improvement. In1934, Ladislaus von Meduna (1896-1964; Budapest) injected camphor into a person with schizophrenia with the intention of inducing convulsion; this was the first modern convulsive therapy. Von Meduna had developed the theory of “biological antagonism”, between epilepsy and schizophrenia. First, when a person with severe mental disorder had a seizure (for whatever reason) their mental state improved. Second, was an epidemiological mistake, the “observation” that people with schizophrenia did not suffer epilepsy. But the induction of convulsions with camphor, and subsequent commercial agents was unpredictable and unsatisfactory. ECT has the advantages of immediacy and predictability. The first patient, SE, was a 39 year old engineer from Milan who was found wandering the streets of Rome in a psychotic state. He received 11 treatments, obtained a good response and wrote to the doctors the following year thanking them for their treatment. Ugo Cerletti (1877-1963), supervised the first ECT treatment (1938). It is now used more widely in major depression than in schizophrenia. Improvements in technique ECT has been in continuous use over the last 80 years. However, there have been technical improvements: • The introduction of anaesthesia to ECT practice made the process less distressing for patients. It is especially indicated where drugs have failed or there is risk of suicide. Active ECT has been shown superior to placebo ECT in many trials (e. ECT has also been found to be superior to the available antidepressant drugs in more than a dozen trials. A typical design is for patients were divided into two groups: one receiving active ECT and placebo medication, and the other receiving placebo ECT and active medication (Gangadhar et al, 1982). In this way ECT can be compared with and antidepressant medication, and both groups of patients received an active form of treatment. Mania Mania is a state of mood elevation or irritability and physical over-activity. Treatment may be a necessary to ensure food and fluid intake and prevent exhaustion and physical injury. This is a difficult population to study for various reasons. Universal clinical experience is that ECT is an effective treatment and can be lifesaving. ECT has been shown superior to lithium carbonate in acute mania (Small et al, 1988). ECT is currently used in schizophrenia when there are marked catatonic features (Raveendranathan et al, 2012; Pompili et al, 2013) with limited food and fluid intake and when other psychotic symptoms are unresponsive to medication. Postpartum disorders A range of psychiatric disorders may develop following childbirth. The majority can be managed with support and the judicious use of medication. Acute, severe disorders may develop, however, and mother may represent a danger to herself and/or the baby. As a generalization, the majority of the severe postpartum conditions are similar to an episode of major depression, and the remainder are psychotic episodes, with delusions and hallucinations. ECT is useful in these severe conditions (Reed et al, 1999). ECT induces remission rapidly, thus, the risk to mother and baby rapidly passes, and breast-feeding and mother-baby bonding can be commenced without delay. ECT obviates high doses of various medications, thus minimizing the medication reaching the breast-fed baby. The frequency of ECT is determined by clinical response. Often, on completion of a course of ECT, when remission has been achieved, one ECT continues to be given at weekly intervals. This is usually gradually extended out to one treatment each 4 or 6 weeks (Gagne et al, 2000). The National Institute for Clinical Evidence (2003) in the UK, does not recommend maintenance ECT. The American Psychiatric Association does, and there is a continuous, but modest, stream of publications (Nordenskjold et al, 2013). The procedure Preparatory work includes making an accurate diagnosis (disappointment and personality disorder, for example, do not respond to ECT), communication with the patient and family, anaesthetic assessment, and deciding on the most appropriate electrode placements. Generally, the stimulus is applied using one of two electrode arrangements. In bilateral stimulation, one electrode is placed on either side of the forehead and the electricity passes through both sides of the brain.

The organization of the information in this report is based on the Bell framework of the five phases across the continuum 1 of medication management and reconciliation and education buy generic super p-force oral jelly pills. Many health professionals buy 160 mg super p-force oral jelly amex, support staff order super p-force oral jelly 160mg on line, patients, and patients’ families were involved in medication management in the studies assessed. Within reporting related to the questions, sections are based on phases of medication management. Reporting is done to address the multiple settings where medication management is important, the range of health care providers who deliver and support care using medications, and classes of medications, specific drugs, or a broad spectrum of medications. What evidence exists to demonstrate that health care settings (ambulatory, long-term care, etc. We supplemented these articles with other studies addressing values propositions by stakeholders. The evidence for this question comes from studies of all designs that measure implementation, use, and purchasing decisions. Their definition of sustainability was the ability of a health service to provide ongoing access to appropriate quality care in a cost- and health- effective manner. Because our interest was in all study designs, we did not limit based on methodology. We also put no limits on language or time to capture the global literature and early studies. Once we tagged the articles for content, we assessed whether those that passed our inclusion criteria were pertinent to specific key questions. Many articles were analyzed in several phases of medication management and sections of the report. The quality of included studies was assessed using the same criteria employed by Jimison et al. Observational studies with before–after, time series, surveys, or qualitative methods were not assessed for quality because few well-validated instruments exist. Bibliographies of systematic and narrative reviews were examined to identify studies, and select reviews were integrated into sections of the report. Data were abstracted from relevant articles and tagged for applicability to the various key questions. Given the range of questions addressed, data abstraction was performed by a core group of staff and entered into online data abstraction forms. One reviewer did the abstraction, and a second, senior reviewer checked its accuracy. The reviewers were not blinded to the identity of the article authors, institutions, or journal. Definitions for medication errors and related terms were often inconsistently used. To make data abstraction easier, we established working definitions, which can be found in Appendix F of the full report. Meta-analysis was not performed on any data because of the heterogeneity of the studies in terms of interventions, populations, technologies used, and outcomes measured, as well as the presence of mostly descriptive and observational studies. After duplicates were removed, 32,785 articles were screened at title and abstract stage. From a full-text screen of 4,578 articles, we identified 789 articles that were eligible for inclusion in this report. Of these articles, 361 met only our inclusion criteria for content and did not have group comparisons, hypothesis testing, or appropriate analysis. Prescribing and monitoring were the most frequently studied phases of medication management (Table A), with hospital and ambulatory care settings well-represented to the near exclusion of long-term care, home, and community (Table B). Though dealing with prescriptions and medications, pharmacists were poorly represented in studies, most focused on physicians (Table C). The evidence is strongest specifically during the prescribing and monitoring phases. Those that did often did not show statistically significant improvements in clinical outcomes. Survey studies of satisfaction and use reflect similar findings of acceptance and satisfaction, although most indicated room for improvement. Distribution in the number of studies across the five phases, plus reconciliation and education, was not equal. Prescribing was studied in 174 studies, order communication in 16 studies, dispensing in 9 studies, administering in 19 studies, and monitoring in 47 studies. The prescribing phase is well studied (174 studies), especially in hospital (61 percent of studies) and ambulatory care settings (39 percent). Long-term care centers (one study) and community and home settings (no studies) are not well studied. Many of the studies of health care providers who were not physicians were purely descriptive of the people involved with them, and the systems themselves. Both systems, either alone or, more often, integrated, are well studied (multiple studies with strong methods). Errors related to prescribing and ordering were reduced in hospital-based studies (68 percent, 15 of 22 studies), but prescribing errors were not studied as often in ambulatory settings (two of two studies were positive). Reductions in time were related to the time taken to order or prescribe or the speed of the prescribing-to-administering processes. Most reductions in time were not seen as often in hospital-based studies (four of seven studies positive), but were positive more often in ambulatory settings (four of five studies). Workflow was not evaluated in these studies of changes in process, although issues of workflow are addressed in qualitative studies in other sections of this report. Order communication, like dispensing, is one of the two medication management phases with the least number of studies—only 16 were identified. The changes in process were also varied (two studies of errors, two of prescribing changes, five on time considerations, and three on workflow). Most studies were done using quantitative observational methods and all showed positive results. All process changes that were evaluated were found to be positive: four on modifications of the drugs that the pharmacists dispensed, three on errors, two on workflow, and one on adherence to good practice. Many articles dealing with administering medications were not included in this report because they were descriptive and did not include comparative data. Error-reduction goals were common in the studies and almost always found to be improved (8 of 13 studies of errors). Errors were mixed, as some related to transcription and some to timing of administration, while some identified more serious errors. Four studies showed no improvement in errors while one study showed increases in errors, mostly related to 12 timing of administration. Four of five studies showed reductions in time from ordering to administering medication.