WPW

DEFINITION

• Wolff-Parkinson-White syndrome is a heart condition in which there is an extra electrical pathway (circuit) in the heart. The condition can lead to episodes of rapid heart rate

• Wolff-Parkinson-White is one of the most common causes of fast heart rate disorders in infants and children.

CAUSES

• Normally, electrical signals in the heart go through a pathway that helps the heart beat regularly. The wiring of the heart prevents extra beats from occurring and keeps the next beat from happening too soon.

• In people with Wolff-Parkinson-White syndrome, there is an extra, or accessory, pathway that may cause a very rapid heart rate. This is called supraventricular tachycardia.

SYMPTOMS

• How often the rapid heart rate occurs depends on the patient. Some people with Wolff-Parkinson-White syndrome may have just a few episodes of rapid heart rate. Others may have the rapid heart rate once or twice a week. Sometimes there are no symptoms, and the condition is detected when a heart tests are done for another reason.

A person with WPW syndrome may have: * Chest pain or chest tightness * Dizziness * Light-headedness * Fainting * Palpitations (a sensation of feeling your heart beat) * Shortness of breath

EXAMS AND TESTS

• An exam performed during a tachycardia episode will reveal a heart rate greater than 230 beats per minute and blood pressure that is normal or low. A normal heart rate is 60 - 100 beats per minute in adults, and under 150 beats per minute in neonates, infants, and small children.

• If the patient is currently not having tachycardia, the physical exam may be completely normal.

• A test called EPS may help identify the location of the extra electrical pathway.

Wolff-Parkinson-White syndrome may be revealed by the following tests: * ECG (electrocardiogram) may show an abnormality called a "delta" wave. * Continuous ambulatory monitoring (Holter monitor)

TREATMENT

• Medication may be used to control or prevent rapid heart beating. These include adenosine, antiarrhythmics, and amiodarone.

• If the heart rate does not return to normal with medication, doctors may use a type of therapy called electrical cardioversion (shock).

• The current preferred therapy for Wolff-Parkinson-White syndrome is catheter ablation. This procedure involves inserting a tube (catheter) into an artery through a small cut near the groin up to the heart area. When the tip reaches the heart, the small area that is causing the fast heart rate is destroyed using a special type of energy called radiofrequency.

• Open heart surgery may also provide a permanent cure for Wolff-Parkinson-White syndrome. However, surgery is usually done only if the patient must have surgery for other reasons.

Franky mode....

Frank-Starling curve

Definition

(1) A curve that show the contractility change in an intact heart.

(2) A graph to show the relationship (or ratio) between the atrial pressure (plotted along the x-axis) and the cardiac output or stroke volume (plotted along the y-axis).

Supplement

This graphical representation indicates that the more blood is returned to the heart, the more blood is pumped from it without the extrinsic signals.

• A graph in which cardiac output or stroke volume is plotted against mean atrial or ventricular end-diastolic pressure; with increasing venous return and atrial pressure the outputincreases until further increments overload the heart and the output falls. proportionately

Douglas Pouch...,

Douglas, James(1675–1742), British anatomist. Douglas was the author of a number of books and papers on human, comparative, and pathological anatomy. In 1707 he published an important book on muscles.In 1730 he published a detailed study of the peritoneum which contained his original description of the pouch of Douglas.

• The Pouch of Douglas is the extension of the peritoneal cavity between the rectum and back wall of the uterus in the female human body. It is also known by the names Douglas pouch, Douglas space, Douglas cul-de-sac, rectouterine pouch, and rectouterine excavation. In women it is the deepest point of the peritoneal cavity, posterior to (behind) the uterus and anterior to (in front of) rectum. The corresponding region in men is the Excavatio rectoversicalis between the urinary bladder and rectum.

TENOSYNOVITIS

• Tenosynovitis involves inflammation of the tendon and tendon sheath. Examples of tenosynovitis include de Quervain tenosynovitis of the wrist (ie, abductor pollicis longus a nd extensor pollicis brevis tendons), volar flexor tenosynovitis (ie, trigger finger), pyogenic flexor tenosynovitis, which can be from gonococcal infections and other infectious etiologies.

Pathophysiology

Flexor tendons of the hand

run in tight fibroosseous tunnels. Visceral and parietal layers of synovium lubricate and nourish the tendons. These layers are usually collapsed unless infection, which follows the path of least resistance along the tendon sheaths or inflammation, is present.

Infection can be introduced directly into the tendon sheaths through a skin wound (most often) or via hematogenous spread, as occurs with gonococcal tenosynovitis. Gonococcal infection originates as a mucosal infection of the genital tract, rectum, or pharynx. Dissemination occurs in approximately 1-3% of patients with mucosal infection. Approximately two thirds of patients with disseminated gonococcal infection develop tenosynovitis.

A history of recent trauma to the involved area is not uncommon and is believed to be a predisposing factor for the development of pyogenic flexor tenosynovitis.Overuse leads to inflammation in de Quervain tenosynovitis. Etiology of volar flexor tenosynovitis is unknown.

• The synovium is a lining of the protective sheath that covers tendons. Tenosynovitis is inflammation of this sheath. The cause of the inflammation may be unknown, or it may result from:

• Infection
• Injury
• Overuse
• Strain

• The wrists, hands, and feet are commonly affected. However, the condition may occur with any tendon sheath.

Note: An infected cut to the hands or wrists that causes tenosynovitis may be an emergency requiring surgery.

• The goal of treatment is to relieve pain and reduce inflammation. Rest or keeping the affected tendons still is essential for recovery.

• You may want to use a splint or a removable brace to help immobilize the tendons. Applying heat or cold to the affected area should help reduce the pain and inflammation.

• Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen can relieve pain and reduce inflammation. Local injections of corticosteroids may be useful as well. Some patients need surgery to remove the inflammation surrounding the tendon, but this is not common.

• For tenosynovitis caused by infection, your health care provider will prescribe antibiotics. In some severe cases, surgery may be needed to release the pus around the tendon.

• After recovery, do strengthening exercises using the muscles around the affected tendon to help prevent the injury from coming back.

Epinephrine (BOSMIN)

Bosmin - General Information:

The active sympathomimetic hormone from the adrenal medulla in most species. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. It is used in asthma and cardiac failure and to delay absorption of local anesthetics.

Pharmacology:

Bosmin is indicated for intravenous injection in treatment of acute hypersensitivity, treatment of acute asthmatic attacks to relieve bronchospasm, and treatment and prophylaxis of cardiac arrest and attacks of transitory atrioventricular heart block with syncopal seizures (Stokes-Adams Syndrome). The actions of epinephrine resemble the effects of stimulation of adrenergic nerves. To a variable degree it acts on both alpha and beta receptor sites of sympathetic effector cells. Its most prominent actions are on the beta receptors of the heart, vascular and other smooth muscle. When given by rapid intravenous injection, it produces a rapid rise in blood pressure, mainly systolic, by (1) direct stimulation of cardiac muscle which increases the strength of ventricular contraction, (2) increasing the heart rate and (3) constriction of the arterioles in the skin, mucosa and splanchnic areas of the circulation. When given by slow intravenous injection, epinephrine usually produces only a moderate rise in systolic and a fall in diastolic pressure. Although some increase in pulse pressure occurs, there is usually no great elevation in mean blood pressure. Accordingly, the compensatory reflex mechanisms that come into play with a pronounced increase in blood pressure do not antagonize the direct cardiac actions of epinephrine as much as with catecholamines that have a predominant action on alpha receptors.

Bosmin for patients

Bosmin Interactions

Epinephrine should be used cautiously in patients with hyperthyroidism, hypertension and cardiac arrhythmias. All vasopressors should be used cautiously in patients taking monoamine oxidase (MAO) inhibitors.

Epinephrine should not be administered concomitantly with other sympathomimetic drugs (such as isoproterenol) because of possible additive effects and increased toxicity.

Combined effects may induce serious cardiac arrhythmias. They may be administered alternately when the preceding effect of other such drug has subsided.

Administration of epinephrine to patients receiving cyclopropane or halogenated hydrocarbon general anesthetics such as halothane which sensitize the myocardium, may induce cardiac arrhythmia.. When encountered, such arrhythmias may respond to administration of a beta-adrenergic blocking drug. Epinephrine also should be used cautiously with other drugs (e.g., digitalis, glycosides) that sensitize the myocardium to the actions of sympathomimetic drugs.

Diuretic agents may decrease vascular response to pressor drugs such as epinephrine.

Epinephrine may antagonize the neuron blockade produced by guanethidine resulting in decreased antihypertensive effect and requiring increased dosage of the latter.

Bosmin Contraindications

Epinephrine is contraindicated in patients with known hypersensitivity to sympathomimetic amines, in patients with angle closure glaucoma, and patients in shock (nonanaphylactic). It should not be used in patients anesthetized with agents such as cyclopropane or halothane as these may sensitize the heart to arrhythmic action of sympathomimetic drugs.

Epinephrine should not ordinarily be used in those cases where vasopressor drugs may be contraindicated, e.g., in thyrotoxicosis, diabetes, in obstetrics when maternal blood pressure is in excess of 130/80 and in hypertension and other cardiovascular disorders.

Dr. Randas Batista (Batista Operation)

The Batista Operation - What is it ?

The Batista Operation is technically called a REDUCTION LEFT VENTRICULOPLASTY. It is an open-heart operation performed with the aid of a heart lung machine to maintain circulation while the heart is stopped. The essence of the procedure is to remove a wedge of left ventricle muscle (weighing about 40 to as much as 250 grams) and stitch together the two edges of the ventricle. In this manner the size of the left ventricle is reduced, and the ventricle is remodelled as well.

In addition, sometimes, the mitral valve (which lies between the left ventricle and left atrium) may need to be removed and replaced with an artificial valve. In patients who have heart rhythm disturbances as well, an artificial implantable defibrillator device may be implanted. If the coronary arteries are diseased, they may be grafted too (CABG operation).

About the Batista procedure

The Batista procedure was an experimental open-heart surgery that had been studied to reverse the effects of remodeling in cases of end-stage dilated cardiomyopathy. In this case, patients suffer from an enlarged left ventricle that cannot pump blood efficiently.

Though the Batista procedure seemed promising at first, it was later found to have little benefit and considerable risk. Today, the Batista procedure is not a recommended treatment for dilated cardiomyopathy. In this form of cardiomyopathy, the heart fails to respond to conventional therapy, and patients suffer from severe heart failure. However, while the surgery has generally fallen out of favor, a few research groups are still examining the Batista procedure among patients who are unsuitable for heart transplantation, such as the elderly.

History of the Batista procedure

The standard treatment for patients with advanced end stage heart failure is to take medication and wait for a donor heart. However, there is a serious shortage of donor hearts. Dr. Randas Batista saw the effects of this shortage first-hand in his native country (Brazil), where many heart failure patients were dying before a heart donor could be found. He was inspired by this experience to develop the Batista procedure as an alternative to heart transplantation. He performed this new surgery for the first time in 1983 and afterward performed it hundreds of times.

Dr. Batista’s work caught the attention of physicians at the Cleveland Clinic, which sent a group to Brazil to study the technique. According to information presented by the Cleveland Clinic at the 1997 conference of the American College of Cardiology, survival rates at six-month follow-up were similar to those associated with heart transplantation, and a significant number of patients no longer needed to be on the list for a donor heart.

However, later results were not as promising. Researchers from the Cleveland Clinic reported disappointing results with the Batista procedure in 2000. Though the conditions of 25 percent of the patients improved following the surgery, conditions rapidly deteriorated in 33 Tachycardia is an unusually fast heartbeat (more than 100 beats per minute).percent of patients. The remaining patients experienced a temporary improvement in cardiac function followed by a return to gradually declining function. The patients also experienced a high rate of abnormal heart rhythms, or arrhythmias. Because of these findings, researchers discontinued the clinical study.

About the same time, a Batista procedure study conducted by the New England Medical Center was also concluded early because of poor results. Researchers, however, credit Dr. Batista for inspiring the investigation of other strategies to reverse or correct remodeling of the left ventricle with heart failure.

Later studies, in 2005, examined the Batista procedure among elderly people (over age 65) and found that the surgery could be tolerated and may be considered among patients who were not eligible for transplantation. In this case, the risks and benefits of the Batista procedure are similar for elderly and younger people, but may represent a short-term improvement among elderly people who cannot have a heart transplant, thus altering the risk/benefit ratio in favor of the procedure. Still other researchers have examined the effectiveness of the Batista procedure combined with heart valve transplantation.

Dissociative Disorder

Dissociative Disorder - disruption in integrative functions of memory, consciousness, or identity.

Dissociative identity disorder (multiple personality)
--- Two or more fully developed distinct and unique personalities exist within the person.
--- The host is the primary personality and the other personalities are referred to as alters.
--- The alters may be aware of the host but the host is not usually aware of the alters.

Dissociative amnesia
--- Inability to recall important personal information because it provokes anxiety.

Dissociative Fugue
--- The client assumes a new identity in a new environment.

• When the fugue lifts, the client returns home and is unable to recall the fugue state.

DEPERSONALIZATION disorder
--- An altered self-perception in which one's own reality is temporarily lost or changed.