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Resend its vote to depression checklist test buy 75mg amitriptyline with visa the server and ask it for transaction outcome Similarly depression vs adhd discount amitriptyline uk, the coordinator has several options when it recovers from a crash mood disorders dsm 5 ppt 25mg amitriptyline amex. Customers call Arnie, each asking for a taxi to be sent to a particular address, which Arnie enters into the computer. Arnie can also ask the computer to assign the next waiting address to an idle taxi; the computer indicates the address and taxi number to Arnie, who informs that taxi over his two-way radio. To ensure that this informa tion is not lost in a power failure, the database logs all updates to an on-disk log. Since the database is kept in volatile memory only, the state must be completely reconstructed after a power failure and restart, as in Figure 9. The database uses write-ahead logging as in Chapter 9: it always appends each update to the log on disk, and waits for the disk write to the log to complete before modifying the cell storage in main memory. The data base processes only one transaction at a time (since Arnie is the only user, there is no concurrency). The database stores the list of addresses waiting to be assigned to taxis as a single vari able; thus any change results in the system logging the entire new list. When Arnie presses the button, and there are no failures, the computer takes one address from the list of addresses waiting to be assigned, assigns it to an idle taxi, and displays the address and taxi to Arnie. B101; M101 list=a2; M101 taxis=a1; C101; B102; M102 list=(empty); M102 taxis=a2; C102 C. B101; M101 list=a2; M101 taxis=a1; B102; M102 list=(empty); M102 taxis=a2 D. B101; M101 list=a2; M101 taxis=a1; C101; B102; M102 list=a2; M102 taxis=a1 E. B101; M101 list=a2; M101 taxis=a1; B102; M102 list=a2; M102 taxis=a1 Suppose again the same starting state (the address list contains a1 and a2, both taxis are idle). He suggests that it would work equally well to split the program into two transactions, the first comprising lines 2 through 9, and the other comprising lines 12 through 21. After both transactions have finished, which of the following are possible database contents? X=1 Y=1 X=2 Y=0 X=2 Y=1 X=2 Y=2 Ben and Louis devise the following three transactions. For each of the following pairs of transactions, decide whether concurrent execution of that pair could result in an incorrect result. If an incorrect result could occur, give an example of such a result and describe a scenario that leads to that result. The server runs on a separate computer and it stores appointments in an append-only log on disk. These procedures guarantee that a single all-or-nothing sector is written either completely or not at all. Each appointment entry is for one timeslot, which specifies the time interval of the appointment. Each appointment entry is exactly as large as a single all-or-nothing sector (512 bytes). The first all-or-nothing sec tor on disk, numbered 0, is the master sector, which stores the all-or-nothing sector number where the next log record will be written. The number stored in master sector is called the end of the log, end of log, and is initialized to 1. Ally has learned a number of apparently relevant concepts: before-or-after atomicity, all-or-nothing atomicity, constraint, durability, and transaction. She also learns that the disk manufacturers sell units that have been "burned in," but otherwise are unused. Which disk should she buy new to have a higher likelihood of meeting property P2 for at least one year? Ally becomes president of Scholarly University and opens her server calendar to the entire University community to add and show entries. If the system crashes, the table is lost; when the system recovers, the recovery proce dure reinstalls the table. Lem shows Ally how to modify the recovery log to include an "undo" entry in it, as well as a "redo" entry. Just before a client disconnects, the client copies the log from the calendar server atomically, and then reinstalls table locally. When the client can connect to the calendar server or any other client, it reconciles. If a client connects to the calendar server, the server is the primary; if a client connects to another client, then one of them is the primary. The result of client C1 reconciling with client C2 (with C2 as the primary), and then reconciling C2 with the calendar server, is the same as reconciling C2 with client C1 (with C1 as the primary), and then reconciling C1 with the calendar server. Suppose Ally stops making changes, and then reconciles all clients with the server once. If an entry in the log overlaps with an entry in the table, then replace the table entry with the one in the log. He decides to address both problems at once by building his own highly available replicated calendar system. Ben places the three servers, called S1, S2, and S3, in three different cities to try to ensure independent failure. The database holds a string for every hour of every day, describing the appointment for that hour. Writing an empty string to an hour effectively deletes any existing appointment for that hour. To support these operations, Ben writes client software based on this pseudocode (the notation S[i]. Ben tests his system by reading and writing the entry for January 1st, 2000, 10 a. Just to be sure, Ben tries a different test, involving moving a meeting from 10 a. Breakfast at 10, Talk to Frans at 11 Talk to Frans at 10, Talk to Frans at 11 Breakfast at 10, Free at 11 Free at 10, Talk to Frans at 11 Q 41. Breakfast at 10, Breakfast at 10 Talk to Frans at 10, Talk to Frans at 10 Free at 10, Breakfast at 10 Talk to Frans at 10, Free at 10 Ben feels this behavior is acceptable. For this problem, ignore the details of reconciling directories, and assume that Alice has permission to read and write everything in both directory trees. Using the two change sets, the laptop computes a set of actions that must be taken to reconcile the two directory trees.
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These include hypothyroidism agitated depression symptoms uk purchase cheap amitriptyline on line, nephritic syndrome anxiety back pain purchase amitriptyline 10 mg amex, cholestasis depression symptoms not sad cheap amitriptyline 75mg, acute intermittent porphyria, anorexia nervosa, hepatoma, and drugs such as thiazides, cyclosporine, and Tegretol. Hemolysis is due to incorporation of plant sterols into the red blood cell membrane. Many of the primary lipoproteinemias, including sitosterolemia, are inherited in an autosomal recessive pattern, and thus a pedigree analysis would not be likely to isolate the disorder. Lipid apheresis is reserved for patients who cannot tolerate the lipid-lowering drugs or who have a genetic lipid disorder refractory to medication. Cholesterol ester transfer protein inhibitors have been shown to raise high-density lipoprotein levels, and their role in the treatment of lipoproteinemias is still under investigation. Clinical manifestations include initially iron overload (as measured biochemically) without symptoms, then later iron overload with symptoms. Initial symptoms often include lethargy, arthralgia, change in skin color, loss of libido, and diabetes mellitus. Cirrhosis, cardiac arrhythmias, and infiltrative cardiomyopathy are later manifestations. Because the clinical manifestations of the disease can be prevented with iron chelation and the mutation is so common, some have advocated for screening the population for evidence of iron overload. Although routine screening is still controversial, recent studies indicate that it is highly effective for primary care physicians to screen subjects using serum iron, transferrin saturation, and serum ferritin levels. Genetic testing is also not recommended as a first step, though it is indicated if evidence of iron overload is found on serum iron studies, as described in this case. The iron accumulation in the pancreas, testes, liver, joints, and skin explain his findings. Hemochromatosis is a common disorder of iron storage in which inappropriate increases in intestinal iron absorption result in excessive deposition in multiple organs but predominantly in the liver. In this case, without a history of prior hematologic disease, the most likely diagnosis is hereditary hemochromatosis. However, these tests are not conclusive, and further testing is still required for the diagnosis. If the genetic testing is inconclusive, the invasive liver biopsy evaluation may be indicated. If chronic hepatitis B is suspected, a viral load or surface antigen test would be indicated. Hepatitis B surface antibody is useful to demonstrate resolved hepatitis B or prior vaccination. Hepatic ultrasound is useful in the evaluation of acute and chronic liver disease to demonstrate portal flow or vascular occlusion. It may be useful in the physiologic evaluation of this patient but would have little diagnostic value. This is generally autosomal dominant and is widespread, especially in Scandinavia and Great Britain. Although disease presentation and penetrance is highly variable, it is most commonly associated with attacks of abdominal pain and neurologic symptoms that develop after puberty. Often a precipitating cause of symptomatic episodes can be identified such as steroid hormone use, oral contraceptives, systemic illness, reduced caloric intake, and many other medications. This diagnosis should be considered in any individual with recurrent abdominal pain, especially when accompanied by neuropsychiatric complaints. The abdominal symptoms are often more prominent, sometimes including vomiting, diarrhea, and ileus. Neurologic findings may include peripheral neuropathy, sensory changes, and seizures. Increased levels of plasma uric acid may be due to overproduction of uric acid (as in the presence of tumor) or underexcretion of uric acid, which is by far the most common mechanism. Because hyperuricemia is so common and most patients with this condition never develop a complication, asymptomatic hyperuricemia is not an indication for treatment. Patients with hyperuricemia are not known to be at increased risk for uric acid nephrolithiasis. Recently, the metabolic syndrome (central obesity, insulin resistance, dyslipidemia, and hypertension) has been linked to hyperuricemia. Hyperinsulinemia results in reduced renal excretion of uric acid and sodium; thus hyperuricemia may be an early indicatory of type 2 diabetes mellitus. The most common complication is gouty arthritis, which depends on the duration and severity of hyperuricemia. Several renal diseases have been described in association with hyperuricemia including urate nephropathy, in which monosodium urate crystals deposit in the renal interstitium; uric acid nephropathy, in which large amounts of uric acid crystals deposit in the renal collecting ducts, pelvis, and ureters; and nephrolithiasis. Cardiovascular disease and renal disease are associated with hyperuricemia, but lowering uric acid levels is not shown to change these specific outcomes. Homozygous males have the disease, and heterozygous carrier females are asymptomatic. Therefore, the daughter of a carrier has a 50% chance of being a carrier and a son has a 50% chance of having the disease. Lesch-Nyhan syndrome is characterized by hyperuricemia, gouty arthritis, nephrolithiasis, self-mutilative behavior, choreoathetosis, and mental retardation. Treatment of affected patients with allopurinol will eliminate or prevent the problems related to hyperuricemia but will not have any beneficial effect on the behavioral or neurologic manifestations. As a result of this mutation, patients store abnormally high levels of copper in their liver initially, but later in other organs such as the brain. While liver dysfunction is a hallmark of the disease, it may have several presentations: acute hepatitis, cirrhosis, or hepatic decompensation, as in this case. Hemolysis may complicate acute decompensation because of the massive release of copper from the liver into the blood leading to hemolysis. These brownish rings surrounding the cornea are due to copper deposition within the cornea and are diagnostic when found. Patients with mild hepatitis may be treated with zinc, which blocks the intestinal absorption of copper and results in a negative copper balance, and also induces hepatic metallothionein synthesis, which sequesters additional toxic copper. Trientine serves as a copper chelator and is used for more severe liver dysfunction, or neurologic or psychiatric disease. Zinc should not be used acutely in hepatic decompensation because zinc may be chelated instead of copper. Liver transplantation is appropriate for patients who have failed the initial therapy. Deficiency of this protein leads to decreased biliary copper excretion and resultant buildup of copper in the tissues. Patients may present with hepatitis, cirrhosis, hepatic failure, movement disorders, or psychiatric disorders. Serum copper levels are usually lower than normal due to low blood ceruloplasmin, which usually binds serum copper.
- Ask your health care provider about vaccines used to prevent some types or strains of viruses that cause genital warts.
- Do NOT attempt to move or straighten the wrist or hand.
- Transfusion reaction, such as one due to improperly matched units of blood
- Abdominal ultrasound
- Focal and segmental glomerulosclerosis
- Always wash your hands after using the toilet and before eating or preparing food or drinks. You may also clean your hands with a 60% alcohol-based product.
- Endoscopy -- camera down the throat to see burns in the esophagus and the stomach
- Alcoholic hepatitis
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Only an owner can force a device to depression webmd cheap 25mg amitriptyline overnight delivery die and thereby reverse its status to depression definition business generic 50 mg amitriptyline mastercard newborn depression symptoms 12 year old order amitriptyline with mastercard. A widely used example of the resurrecting duckling is purchasing wireless routers. These routers often come with the default user name "Admin" and password "password". When the buyer plugs the router in for the first time, it is waiting to be imprinted with a better password; the first principal to change the password gets control of the router. The router has a resurrection button that restores the defaults, thus again making it imprintable (and allowing the buyer to recover if an adversary did grab control). Some applications have requirements for which it is better to use different techniques for integrity and authenticity. To protect a file, a designer wants to make many separate replicas of the file, following the durability mantra, preferably in independently administered and thus separately protected domains. If the replicas are separately protected, it is more difficult for an adversary to change all of them. Since maintaining widely-separated copies of large files consumes time, space, and communication bandwidth, one can reduce the resource expenditure by replacing some (but not all) copies of the file with a smaller witness, with which users can periodically check the validity of replicas (as explained in Section 10. If the replica dis agrees with the witness, then one repairs the replica by finding a replica that matches the witness. For exam ple, one can publish the witness in a widely-read newspaper, which is likely to be preserved either on microfilm or digitally in many public libraries. The digital archiver uses a cryptographic hash function to create a secure fingerprint of the file, signs the fingerprint with its private key, and then distributes copies of the file widely. Anyone can verify the integrity of a replica by computing the finger print of the replica, verifying the witness using the public key of the archiver, and then comparing the finger print of the witness against the finger print of the replica. This scheme works well in general, but is less suitable for long-term data integrity. The window of validity of this scheme is determined by the minimum time to compro mise the private key used for signing, the signing algorithm, the hashing algorithm, and the validity of the name-to-public key binding. If the goal of the archiver is to protect the data for many decades (or forever), it is likely that the digital signature will be invalid before the data. In this approach, the validity of the witness is the time to compromise the cryptographic hash. One can protect against a compromised cryptographic hash algorithm by occasionally com puting and publishing a new witness with the latest, best hash algorithm. The new witness is a hash of the original data, the original witness, and a timestamp, thereby dem onstrating the integrity of the original data at the time of the new witness calculation. The confidence a user has in the authenticity of a witness is determined by how easily the user can verify that the witness was indeed produced by the archiver. If the newspaper or the library physically received the witnesses directly from the archiver, then this con fidence may be high. Two principals may want to communicate privately without adversaries having access to the communicated information. If the principals are running on a shared phys ical computer, this goal is easily accomplished using the kernel. If the principals are on different physical processors, and can communicate with each other only over an untrusted network, ensuring confidentiality of messages is more chal lenging. By definition, we cannot trust the untrusted network to not disclose the bits that are being communicated. The solution to this problem is to introduce encryption and decryption to allow two parties to communicate without anyone else being able to tell what is being communicated. Our goal is to pro vide a secure channel between the two secure areas that provides confidentiality. Encryption transforms a plaintext message into ciphertext in such a way that an observer cannot construct the original message from the ciphertext version, yet the intended receiver can. Thus, one challenge in the implementation of channels that provide confidentiality is to use an encrypting scheme that is difficult to reverse for an adversary. That is, even if an observer could copy a message that is in transit and has an enormous amount of time and com puting power available, the observer should not be able to transform the encrypted message into the plaintext message. If the encrypting box is good, an adversary will not to be able to get any use out of the ciphertext. With public-key cryptography, Alice and Bob do not have to share a secret to achieve confidentiality for communication. Only Bob can read this message, since he is the only person who has the secret key that can decrypt her ciphertext message. Thus, using encryption, Alice can ensure that her communication with Bob stays confidential. Redundancy or repeated patterns in the original message may show through even in the ciphertext, allowing an adversary to reconstruct the plaintext. The adversary has access to the ciphertext C and also to the plaintext M corresponding to at least some of the ciphertext C. For instance, a message may contain standard headers or a piece of predictable plaintext, which may help an adversary figure out the key and then recover the rest of the plaintext. The adversary has access to ciphertext C that corresponds to plaintext M that the adversary has chosen. For instance, the adversary may convince you to send an encrypted message containing some data chosen by the adversary, with the goal of learning information about your transforming system, which may allow the adversary to more easily discover the key. As a special case, the adversary may be able in real time to choose the plaintext M based on ciphertext C just transmitted. A common design mistake is to unintentionally admit an adaptive attack by pro viding a service that happily encrypts any input it receives. This service is known as an oracle and it may greatly simplify the effort required by an adversary to crack the cryptographic transformation. For example, consider the following adaptive chosen-plaintext attack on the encryption of packets in WiFi wireless networks. The adversary sends a carefully-crafted packet from the Internet addressed to some node on the WiFi network. The network will encrypt and broadcast that packet over the air, where the adversary can intercept the ciphertext, study it, and imme diately choose more plaintext to send in another packet. A designer can increase the work factor for an adversary by increasing the key length. It is likely that the window of validity required for encrypting protocol messages between a client and a server is smaller than the window of validity required for encrypting longterm file storage. A protocol message that must be private just for the duration of a con versation might be adequately protected by an cryptographic transformation that can be compromised with, say, one year of effort. On the other hand, if the period of time for which a file must be protected is greater than the window of validity of a particular cryp tographic system, the designer may have to consider additional mechanisms, such as multiple encryptions with different keys. After all, what is the purpose of keeping information confidential if the receiver cannot tell if the message has been changed? In fact, it is easy to argue the default should be that all messages are at least authenticated.
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The sender sim ply inserts this mark into the bit stream at the end of each frame depression symptoms on dogs purchase amitriptyline with paypal. Whenever this pattern * the derivation of this theorem is beyond the scope of this textbook mood disorder icd 10 code amitriptyline 50mg on line. This scheme works nicely anxiety poems order amitriptyline 75 mg with amex, as long as the payload data stream never contains the chosen pattern of bits. Rather than explaining to the higher layers of the network that they cannot transmit certain bit patterns, the link layer implements a technique known as bit stuffing. The transmitting end of the link layer, in addition to inserting the frame-separator mark between frames, examines the data stream itself, and if it discovers six ones in a row it stuffs an extra bit into the stream, a zero. If the seventh bit is a zero, the receiver discards the zero bit, thus reversing the stuffing done by the sender. If the seventh bit is a one, the receiver takes the seven ones as the frame separator. Figure shows a simple pseudocode implementation of the procedure to send a frame with bit stuffing, and Figure 7. A better implementation would have multiple buffers to allow it to receive the next frame while processing the current one. There is little need to explore all the possible alternatives because frame framing is easily specified and subcontracted to the implementer of the link layer-the entire link layer, along with bit framing, is often done in the hardware-so we now move on to other issues. Since the usual design pushes the data rate of a transmission link up until the receiver can barely tell the ones from the zeros, even a small amount of extra noise can cause errors in the received bit stream. The first and perhaps most important line of defense in dealing with transmission errors is to require that the design of the link be good at detecting such errors when they occur. The usual method is to encode the data with an error detection code, which entails adding a small amount of redundancy. A simple form of such a code is to have the trans mitter calculate a checksum and place the checksum at the end of each frame. As soon as the receiver has acquired a complete frame, it recalculates the checksum and compares its result with the copy that came with the frame. By carefully designing the checksum algorithm and making the number of bits in the checksum large enough, one can make the probability of not detecting an error as low as desired. Have the sender encode the transmission using an error correction code, which is a code that has enough redundancy to allow the receiver to identify the particular bits that have errors and correct them. This technique is widely used in situations where the noise behavior of the transmission channel is well understood and the redundancy can be targeted to correct the most likely errors. For example, compact disks are recorded with a burst error-correction code designed to cope particularly well with dust and scratches. This alternative requires that the sender hold the frame in a buffer until the receiver has had a chance to recalculate and compare its checksum. In most such designs the receiver explicitly acknowledges the correct (or incorrect) receipt of every frame. If the propagation time from sender to receiver is long compared with the time required to send a single frame, there may be several frames in flight, and acknowledgments (especially the ones that ask for retransmission) are disruptive. On a highperformance link an explicit acknowledgment system can be surprisingly complex. Whatever higher-level protocol is used to deal with those discarded packets will also take care of any frames that are discarded because they contained errors. Real-world designs often involve blending these techniques, for example by having the sender apply a simple error-correction code that catches and repairs the most com mon errors and that reliably detects and reports any more complex irreparable errors, and then by having the receiver discard the frames that the error-correction code could not repair. To be practical, this interface between the network layer and the link layer needs to be expanded slightly to incorporate two additional features not previously mentioned: multiple lower-layer protocols, and higher-layer protocol multiplexing. For example, a wireless link may occasionally encounter a high noise level and need to switch from the usual link protocol to a "robustness" link protocol that employs a more expensive form of error detection with repeated retry, but runs more slowly. The second feature of the interface to the link layer is more involved: the interface should support protocol multiplexing. Multiplexing allows several different network layer protocols to use the same link. For example, Internet Protocol, Appletalk Protocol, and Address Resolution Protocol (we will talk about some of these protocols later in this chapter) might all be using the same link. Second, the value of network protocol needs to be transmitted to the receiving side, for example by adding it to the link-level packet header. Finally, the link layer on the receiving side needs to examine this new header field to decide to which of the various network layer implementations it should deliver the packet. This figure demonstrates the real power of the layered organization: any of the four network layer protocols in the figure may use any of the three link layer protocols. The link layer handles its argument data buffer as an unstructured string of bits. When we examine the network layer in the next section of the chapter, we will see that data buffer contains a network-layer packet, which has its own internal struc ture. The point is that as we pass from an upper layer to a lower layer, the content and structure of the payload data is not supposed to be any concern of the lower layer. Since the link is now multiplexed among several network-layer protocols, when a frame arrives, the link layer must dispatch the packet contained in that frame to the proper network layer protocol handler. Control then passes to a particular network-layer handler only on arrival of a frame containing a packet of the protocol it specified. With some additional effort (not illustrated-the reader can explore this idea as an exercise), one could also make this dispatcher multithreaded, so that as it passes a packet up to the network layer a new thread takes over and the link layer thread returns to work on the next arriving frame. With or without threads, the network protocol field of a frame indicates to whom in the network layer the packet contained in the frame should be delivered. From a more general point of view, we are multiplexing the lower-layer protocol among several higherlayer protocols. This notion of multiplexing, together with an identification field to sup port it, generally appears in every protocol layer, and in every layer-to-layer interface, of a network architecture. An interesting challenge is that the multiplexing field of a layer names the protocols of the next higher layer, so some method is needed to assign those names. Since higherlayer protocols are likely to be defined and implemented by different organizations, the usual solution is to hand the name conflict avoidance problem to some national or inter national standard-setting body. First, links come in several flavors, for which there is some standard terminology: A point-to-point link directly connects exactly two communicating entities. A simplex link has a transmitter at one end and a receiver at the other; two-way communication Saltzer & Kaashoek Ch. A duplex link has both a transmitter and a receiver at each end, allowing the same link to be used in both direc tions. A half-duplex link is a duplex link in which transmission can take place in only one direction at a time, whereas a full-duplex link allows transmission in both directions at the same time over the same physical medium.
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These two broad categories of disease account for more than 50% of all deaths in men and 47% of deaths in women anxiety ed purchase 50 mg amitriptyline overnight delivery. Likewise anxiety exhaustion discount amitriptyline online american express, the number one cause of cancer death (lung cancer) is the same in men and women depression test color discount amitriptyline 25mg with visa. After this, there are significant differences in the major causes of death between the sexes. Cerebrovascular disease is the third most common cause of death in women responsible for 6. Although chronic lower respiratory disease is the fourth most common cause of death in both men and women, the percentage of deaths from chronic lower respiratory disease in women is 5. In addition, women have a greater number of medical comorbidities at the time of diagnosis, including hypertension, heart failure, and diabetes mellitus. However, women are still referred less often by physicians for diagnostic and therapeutic cardiovascular procedures, and there are more false-positive and false-negative diagnostic test results in women. Women are also less likely to receive angioplasty, thrombolysis, coronary artery bypass grafting, aspirin, and beta-blockers. Despite this, the 5- and 10-year survival rates after coronary artery bypass grafting are the same for men and women. However, an elevated total triglyceride level has been demonstrated to be an independent risk factor in women but not men. Other shared risk factors include elevated total cholesterol, hypertension, obesity, smoking, and lack of physical activity. In addition, most autoimmune diseases are more common in women, including rheumatoid arthritis, systemic lupus erythematosus, and autoimmune thyroid disease. Major depression is twice as common in women than men, and this is true even in developing countries. Other psychological disorders that are more common in women are eating disorders and anxiety. Endocrine disorders, including obesity and osteoporosis, are more common in women, and 80% of patients referred for bariatric surgery are women. However, the prevalence of both type 1 and type 2 diabetes mellitus is the same between men and women. This sex difference cannot fully be explained by the difference in life expectancy between men and women. The brains of women differ from men in terms of size, structure, and functional organization. Indeed, the largest trial to date demonstrated an increase in dementia and mild cognitive impairment in individuals receiving either estrogen or combined hormone replacement therapy. Coincident with the increased plasma volume, cardiac output increases as well by about 40%. Although this is primarily attributable to increases in stroke volume, heart rate also increases in pregnancy by about 10 beats/min. In the second trimester, systemic vascular resistance falls, and subsequently blood pressure decreases as well. Thus, a blood pressure greater than 140/90 mmHg is considered abnormal and is associated with increased maternal and fetal morbidity and mortality. Although hypertension is not a contraindication to pregnancy, the condition is associated with an increased risk of intrauterine growth restriction, preeclampsia, placental abruption, and perinatal mortality. The cardiovascular changes of pregnancy typically do lead to a fall in systemic vascular resistance and a fall in blood pressure in the second trimester, but it is not safe to discontinue medications in those with a prior diagnosis of hypertension if the blood pressure in the first trimester is greater than 120/80 mmHg. When choosing an antihypertensive medication in pregnancy, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be strictly avoided because they are known to cause birth defects, including congenital malformations and intrauterine death, particularly in the second and third trimesters. The most common medications used in pregnancy are -methyldopa, labetalol, and nifedipine. Although these medications have limited data from randomized controlled trials, there is a long history of safety with use of these medications. Diuretics such as hydrochlorothiazide appear also to be safe in pregnancy, although there are concerns that use of diuretics would impair the volume expansion that occurs during pregnancy. The conditions that are considered to be contraindications to pregnancy are idiopathic pulmonary arterial hypertension and Eisenmenger syndrome (congenital heart disease resulting in pulmonary hypertension with right-to-left shunting). In these cases, it is typically recommended to terminate the pregnancy because there is a high risk of maternal and fetal death. Peripartum cardiomyopathy can recur in subsequent pregnancies, and it is recommended that individuals with an abnormal ejection fraction avoid further pregnancies. Approximately 15% of individuals with Marfan syndrome will have a major cardiovascular complication in pregnancy, although the condition is not considered a contraindication to pregnancy. An aortic root diameter of less than 40 mm is generally associated with the best outcomes in pregnancy. The valvular heart disease with the greatest risk in pregnancy is mitral stenosis. There is an increased risk of pulmonary edema, and pulmonary hypertension is a common long-term consequence of mitral stenosis. However, aortic stenosis, aortic regurgitation, and mitral regurgitation are typically well tolerated. Congenital heart disease in the mother is associated with an increased risk of congenital heart disease in the offspring, but atrial and ventricular septal defects are usually well tolerated in pregnancy as long as there is no evidence of Eisenmenger syndrome. Severe eclampsia is eclampsia complicated by central nervous system symptoms (including seizure), marked hypertension, severe proteinuria, renal failure, pulmonary edema, thrombocytopenia, or disseminated intravascular coagulation. Aggressive management of blood pressure, usually with labetalol or hydralazine intravenously, decreases the maternal risk of stroke. However, similar to any hypertensive crisis, the decrease in blood pressure should be achieved slowly to avoid hypotension and risk of decreased blood flow to the fetus. Eclamptic seizures should be controlled with magnesium sulfate; it has been shown to be superior to phenytoin and diazepam in large randomized clinical trials. There is no proven role for local thrombolytics or an inferior vena cava filter in pregnancy. Women with gestational diabetes are at increased risk of preeclampsia, delivering infants large for gestational age, and birth lacerations. All women should be screened for gestational diabetes unless they fall into a low-risk group. Low-risk groups include age younger than 25 years, body mass index less than 25 kg/m2, no maternal history of macrosomia or gestational diabetes, no diabetes in any first-degree relative, and those who are not members of a high-risk ethnic group (African American, Hispanic, or Native American). When evaluating risk of complications, it is useful to categorize the surgical procedures into a low, intermediate, or higher risk category. Individuals who are at the highest risk of complications include those undergoing an emergent major operation, especially in elderly adults. Other higher risk procedures include aortic and other noncarotid major vascular surgery and surgeries with a prolonged operative time and large anticipated blood loss or fluid shifts. Surgeries that are believed to be an intermediate risk include major thoracic surgery, major abdominal surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, and prostate surgery.
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In the next three sections we investigate in more depth the usual functions and some typ- Saltzer & Kaashoek Ch mood disorder vs depression generic 10mg amitriptyline with visa. The overlay network Gnutella uses for its link layer an end-to-end transport protocol of the Internet depression level test cheap generic amitriptyline canada. The Internet uses for one of its links an end-to end transport protocol of the dial-up telephone system depression symptoms withdrawal cheap amitriptyline 75 mg fast delivery. Internet (link layer) dial-up telephone network ical implementation techniques of each of the three layers of our reference model. However, as the introduction pointed out, what follows is not a comprehensive treat ment of networking. Instead it identifies many of the major issues and for each issue exhibits one or two examples of how that issue is typically handled in a real network design. For readers who have a goal of becoming network engineers, and who therefore would like to learn the whole remarkable range of implementation strategies that have been used in networks, the Suggestions for Further Reading list several comprehensive books on the subject. The link layer is responsible for moving data directly from one physical location to another. It thus gets involved in several distinct issues: physical transmission, framing bits and bit sequences, detecting transmission errors, multiplexing the link, and providing a useful interface to the network layer above. If we are talking about moving a bit from one register to another on the same chip, the mechanism is fairly simple: run a wire that connects the output of the first register to the input of the next. Maintaining those three assumptions is relatively easy within a single chip, and even between chips on the same printed circuit board. However, as we begin to consider send ing bits between boards, across the room, or across the country, these assumptions become less and less plausible, and they must be replaced with explicit measures to ensure that data is transmitted accurately. In particular, when the sender and receiver are in sep arate systems, providing a correctly timed clock signal becomes a challenge. A simple method for getting data from one module to another module that does not share the same clock is with a three-wire (plus common ground) ready/acknowledge pro tocol, as shown in figure 7. Module A, when it has a bit ready to send, places the bit on the data line, and then changes the steady-state value on the ready line. When B sees the ready line change, it acquires the value of the bit on the data line, and then changes the acknowledge line to tell A that the bit has been safely received. The reason that the ready and acknowledge lines are needed is that, in the absence of any other synchronizing scheme, B needs to know when it is appropriate to look at the data line, and A needs to know when it is safe to stop holding the bit value on the data line. If the propagation time from A to B is t, then this protocol would allow A to send one bit to B every 2t plus the time required for A to set up its output and for B to acquire its input, so the maximum data rate would be a little less than 1/(2t). Over short distances, one can replace the single data line with N parallel data lines, all of which are framed by the same pair of ready/acknowledge lines, and thereby increase the data rate to N/(2t). However, as the distance between A and B grows, t also grows, and the maximum data rate declines in proportion, so the ready/acknowledge technique rapidly breaks down. The usual requirement is to send data at higher rates over longer distances with fewer wires, and this requirement leads to employment of a different system called serial transmission. The idea is to send a stream of bits down a single transmission line, without waiting for any response from the receiver and with the expectation that the receiver will somehow recover those bits at the other end with no additional signaling. Unfortunately, because the underlying transmission line is analog, the farther these bits travel down the line, the Saltzer & Kaashoek Ch. By the time they arrive at the receiver they will be little more than pulses with exponential leading and trailing edges, as suggested by Figure 7. The receiving module, B, now has a significant prob lem in understanding this transmission: Because it does not have a copy of the clock that A used to create the bits, it does not know exactly when to sample the incoming line. One complication is that with certain patterns of data (for example, a long string of zeros) there may be no transitions in the data stream, in which case the phase-locked loop will not be able to synchronize. To deal with this problem, the transmitter usually encodes the data in a way that ensures that no matter what pattern of bits is sent, there will be some transitions on the transmission line. A frequently used method is called phase encoding, in which there is at least one level transition associated with every data bit. A common phase encoding is the Manchester code, in which the transmitter encodes each bit as two bits: a zero is encoded as a zero followed by a one, while a one is encoded as a one followed by a zero. This encoding guarantees that there is a level transition in the center of every transmitted bit, thus supplying the receiver with plenty of clocking information. It has the disadvantage that the maximum data rate of the communication channel is effectively cut in half, but the resulting simplicity of both the transmitter and the receiver is often worth this price. Other, more elaborate, encoding schemes can ensure that there is at least one transition for every few data bits. The usual goal for the design space of a physical communication link is to achieve the highest possible data rate for the encoding method being used. A where: perfect analog channel would have an infi nite capacity for digital data because one C = channel capacity, in bits per second could both set and measure a transmitted W = channel bandwidth, in hertz signal level with infinite precision, and then change that setting infinitely often. In S = maximum allowable signal power, as seen by the receiver the real world, noise limits the precision with which a receiver can measure the sig- N = noise power per unit of bandwidth nal value, and physical limitations of the analog channel such as chromatic dispersion (in an optical fiber), charging capacitance (in a copper wire), or spectrum availability (in a wireless signal) put a ceiling on the rate at which a receiver can detect a change in value of a signal. These physical limitations are summed up in a single measure known as the bandwidth of the analog channel. To be more precise, the number of different signal values that a receiver can distinguish is pro portional to the logarithm of the ratio of the signal power to the noise power, and the maximum rate at which a receiver can distinguish changes in the signal value is propor tional to the analog bandwidth. A typical approach is to combine code bit framing with data bit framing (and even provide some help in higher-level framing) by specifying that every transmission must begin with a standard pattern, such as some minimum number of coded one-bits followed by a coded zero. The series of consecutive ones gives the Phase-Locked Loop something to synchronize on, and at the same time provides examples of the positions of known data bits. Setting W = 1, the capacity theorem says that the maximum bits per sec ond per hertz is log2(1 + S/N). An elementary signalling system in a low-noise environment can easily achieve 1 bit per second per hertz. The capacity theorem says that the logarithm must be at least 12, so the signal-to-noise ratio must be at least 212, or using a more tra ditional analog measure, 36 decibels, which is just about typical for the signal-to-noise ratio of a properly working telephone connection. For a transmission system to be useful, the bit error rate must be quite low; it is typically reported with numbers such as one error in 106, 107, or 108 transmitted bits. Even the best of those rates is not good enough for digital systems; higher levels of the system must be prepared to detect and compensate for errors. Framing frames is a distinct, and quite independent, requirement from framing bits, and it is one of the reasons that some network models divide the link layer into two layers, a lower layer that manages physical aspects of sending and receiving individual bits and an upper layer that imple ments the strategy of transporting entire frames. One simple method is to choose some pattern of bits, for example, seven one-bits in a row, as a frame-separator mark. A broadcast link is a shared transmission medium in which there can be several trans mitters and several receivers. Depending on the physical design details, a broadcast link may limit use to one transmitter at a time, or it may allow several distinct transmis sions to be in progress at the same time over the same physical medium. This design choice is analogous to the distinction between half duplex and full duplex but there is no standard terminology for it. The link layers of the standard Ethernet and the popular wireless system known as Wi-Fi are one-transmitter-at-a-time broadcast links. For a given bit error rate, the longer a frame the greater the chance of an uncorrectable error in that frame.
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Five aspects of a cardiac murmur provide knowledge of the underlying cause of turbulence: location in cardiac cycle (timing) mood disorder spanish buy amitriptyline canada, location on thorax bipolar depression definition best 50mg amitriptyline, radiation of murmur anxiety 9 dpo generic 75mg amitriptyline with mastercard, loudness, and pitch and character. A murmur is heard only during that portion of the cardiac cycle in which turbulent blood flow occurs. Holosystolic murmurs (synonyms are pansystolic or systolic regurgitant) start with the first heart sound and continue into systole, often extending to the second heart sound. Because holosystolic murmurs begin so close to the first heart sound, that sound may be masked at the location of maximum murmur intensity. This masking can be a clue to a holosystolic murmur, particularly in patients with rapid heart rate. Since turbulent flow in these locations cannot begin until the semilunar valves open, an interval (the isovolumetric contraction period) exists between the first heart sound and the onset of the murmur. Diastolic murmurs can also be classified according to their timing in the cardiac cycle. Early diastolic murmurs occur immediately following the second heart sound and include the isovolumetric relaxation period. During this time, blood can only flow from a higher-pressure great vessel into a lower-pressure ventricle. Early diastolic murmurs indicate regurgitation across a semilunar valve (aortic, pulmonary, or truncal valve regurgitation). Usually decrescendo, their pitch depends on the level of diastolic pressure within the great vessel: high pitched in aortic or truncal regurgitation and lower pitched with pulmonary regurgitation (unless pulmonary hypertension is present). These low-pitched rumbles are usually heard only with the bell of the stethoscope and are easily overlooked by an inexperienced examiner. A continuous murmur indicates turbulence beginning in systole and extending into diastole. Usually, it occurs when communication exists between the aorta and the pulmonary artery or other portions of the venous side of the heart or circulation. Patent ductus arteriosus is the classic example, but continuous murmurs are heard with other types of systemic arteriovenous fistulae. The similarities and differences between regurgitant murmurs and those due to forward blood flow, whether in systole or diastole, are summarized in Table 1. Location in Cardiac Cycle Systolic Type of Murmur Regurgitant Holosystolic Begins with S1 Includes isovolumetric contraction period Early diastolic Begins with S2 Forward Flow Ejection Follows S1 Occurs after isovolumetric contraction period Mid- or late diastolic Follows S2 Diastolic Continuous Includes isovolumetric Occurs after isovolumetric relaxation period relaxation period Systole and diastole Continues through S2 S1, first heart sound; S2, second heart sound. Regurgitant murmurs begin with either the first or second heart sound and include the isovolumetric periods, whereas those related to abnormalities of forward flow begin after an isovolumetric period and may be associated with an abnormal cardiac sound (systolic ejection click or opening snap). A notable exception to these rules is the murmur associated with mitral valve prolapse, discussed in Chapter 10. In these areas, the murmurs of aortic stenosis, pulmonary stenosis, tricuspid insufficiency, and mitral insufficiency, respectively, are found. For example, the murmur of coarctation of the aorta is heard best in the left paraspinal area, directly over the anatomic site of the aortic narrowing. The murmur of peripheral pulmonary artery stenosis is heard over both sides of the back and axillae. The direction of transmission of the murmur is also helpful, as it reflects the direction of turbulent flow, which often is along major blood vessels. Mitral murmurs are transmitted toward the cardiac apex and left axilla; occasionally, mitral regurgitation is heard in the middle back. The loudness of a cardiac murmur is graded on a scale in which grade 6 represents the loudest murmur. Although somewhat arbitrary, the classification is based on sound intensity and chest wall vibration (thrills). Highpitched murmurs (heard with a diaphragm) occur when a large pressure difference in the turbulent flow exists, such as in aortic or mitral insufficiency. Harsh murmurs are typical of severe outflow stenosis when a large pressure difference is present, as in aortic valvar stenosis. Distinction between a normal or functional (innocent) and a significant (organic) murmur can be difficult in some children. Although this text describes the characteristics of the commonly heard functional murmurs, only by experience and careful auscultation can one become proficient in distinguishing a functional murmur from a significant murmur. Functional murmurs have four features that help to distinguish them from significant murmurs: (a) normal heart sounds, (b) normal heart size, (c) lack of significant cardiac signs and symptoms, and (d) loudness of grade 3/6 or less. Thus, the ability to categorize the murmur as a specific type of functional murmur is helpful. It is characterized by a soft systolic flow murmur best heard in the axillae and back, and poorly 38 Pediatric cardiology heard, if at all, over the precordium. This murmur might be confused with a patent ductus arteriosus because it is continuous. Several characteristics distinguish it from patent ductus arteriosus: it can be louder in diastole and varies with respiration; it is best heard with the patient sitting; it diminishes and usually disappears when the patient reclines; and it changes in intensity with movements of the head or with pressure over the jugular vein. In children, a soft systolic arterial bruit may be heard over the carotid arteries. The bruit should not be confused with the transmission of cardiac murmurs to the neck, as in aortic stenosis. This sound (more along the mid left sternal border than right) originates from compression of the lung between the heart and the anterior chest wall. This murmur or sound occurs during systole, becomes louder in mid-inspiration and mid-expiration, and sounds close to the ear. In most children with a functional cardiac murmur, a chest X-ray, electrocardiogram, or echocardiogram is unnecessary, as the diagnosis can be made with certainty from the physical examination alone. In a few patients, these studies may be indicated to distinguish a significant and a functional murmur. If it is a normal (innocent) murmur, the parents and the patient should be reassured of its benign nature. No special care is indicated for these children, and the child can be monitored at intervals dictated by routine pediatric care by their own medical provider. Many (not all) functional murmurs disappear in adolescence, and the murmurs may be accentuated during times of increased cardiac output, such as during fever and anemia. The abdomen should also be carefully examined for the location and size of the liver and spleen. The hepatic edge should be palpated and its distance below the costal margin measured. If the edge is lower than normal, the upper margin of the liver should be percussed to determine the span of the liver. It may be enlarged in patients with chronic congestive cardiac failure or infective endocarditis.
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Methods that can be used to bipolar depression 2 cheap 25 mg amitriptyline with amex determine whether ovulation is likely include a serum progesterone level >5 ng/mL 7 days before expected menses mood disorder hotline buy amitriptyline 25mg cheap, an increase in basal body temperature of >0 anxiety heart pain purchase amitriptyline in united states online. Ultrasound can be used to detect the growth of the fluid-filled antrum of the developing follicle and to assess endometrial proliferation in response to increasing estradiol levels in the follicular phase, as well as the characteristic echogenicity of the secretory endometrium of the luteal phase. The triggers for adrenarche remain unknown but may involve increase in body mass index as well as in utero and neonatal factors. Menarche is also preceded by breast development (thelarche), which is exquisitely sensitive to the very low levels of estrogens that result from peripheral conversion of adrenal androgens and the low levels of estrogen secreted from the ovary early in pubertal maturation. Breast development precedes the appearance of pubic and axillary hair in 60% of girls. There has been a gradual decline in the age of menarche over the past century, attributed in large part to improvement in nutrition, and there is a relationship between adiposity and earlier sexual maturation in girls. Both adrenarche and breast development occur 1 year earlier in African-American compared with Caucasian girls, although the timing of menarche differs by only 6 months between these ethnic groups. The growth spurt is generally less pronounced in girls than in boys, with a peak growth velocity of 7 cm/year. Linear growth is ultimately limited by closure of epiphyses in the long bones as a result of prolonged exposure to estrogen. However, there are differences in the timing of normal puberty and differences in the relative frequency of specific disorders in girls compared with boys. Precocious Puberty Traditionally, precocious puberty has been defined as the development of secondary sexual characteristics before the age of 8 in girls based on data from Marshall and Tanner in British girls studied in the 1960s. More recent studies led to recommendations that girls be evaluated for precocious puberty if breast development or pubic hair were present at <7 years of age for Caucasian girls or <6 years for African-American girls. Precocious puberty is most often centrally mediated (Table 10-2), resulting from early activation of the hypothalamic-pituitary-ovarian axis. In girls, centrally mediated precocious puberty is idiopathic in 85% of cases; however, neurogenic causes must also be considered. Management of peripheral precocious puberty involves treating the underlying disorder (Table 10-2) and limiting the effects of gonadal steroids using aromatase inhibitors, inhibitors of steroidogenesis, and estrogen receptor blockers. It is important to be aware that central precocious puberty can also develop in girls whose precocity was initially peripherally mediated, as in McCune-Albright syndrome and congenital adrenal hyperplasia. For example, premature breast development may occur in girls before the age of 2 years, with no further progression and without significant advancement in bone age, androgen production, or compromised height. Premature adrenarche can also occur in the absence of progressive pubertal development, but it must be distinguished from late-onset congenital adrenal hyperplasia and androgen-secreting tumors, in which case it may be termed heterosexual precocity. The diagnostic considerations are very similar to those for primary amenorrhea (Chap. Between 25 and 40% of delayed puberty in girls is of ovarian origin, with Turner syndrome constituting a majority of such patients. Functional hypogonadotropic hypogonadism encompasses diverse etiologies such as systemic illnesses, including celiac disease and chronic renal disease, and endocrinopathies, such as diabetes and hypothyroidism. In addition, girls appear to be particularly susceptible to the adverse effects of abnormalities in energy balance that result from exercise, dieting, and/or eating disorders. Together, these reversible conditions account for 25% of delayed puberty in girls. Congenital hypogonadotropic hypogonadism in girls or boys can be caused by mutations in several different genes or combinations of genes (Chap. Family studies suggest that genes identified in association with absent puberty may cause delayed puberty and that there may be a genetic susceptibility to environmental stresses such as diet and exercise. Although neuroanatomic causes of delayed puberty are considerably less common in girls than in boys, it is always important to rule these out in the setting of hypogonadotropic hypogonadism. In a study of 5574 English and American women who ultimately conceived, pregnancy occurred in 50% within 3 months, 72% within 6 months, and 85% within 12 months. The infertility rate has remained relatively stable over the past 30 years, although the proportion of couples without children has risen, reflecting a trend to delay childbearing. This trend has important implications because of an age-related decrease in fecundability, which begins at age 35 and decreases markedly after age 40. These investigations include a semen analysis in the male, confirmation of ovulation in the female, and, in the majority of situations, documentation of tubal patency in the female. In some cases, after an extensive workup excluding all male and female factors, a specific cause cannot be identified and infertility may ultimately be classified as unexplained. Infertility can be attributed primarily to male factors in 25% and female factors in 58%, and is unexplained in about 17% of couples. Infertility is invariably associated with psychological stress related not only to the diagnostic and therapeutic procedures themselves but also to repeated cycles of hope and loss associated with each new procedure or cycle of treatment that does not result in the birth of a child. These feelings are often combined with a sense of isolation from friends and family. Counseling and stress-management techniques should be introduced early in the evaluation of infertility. Infertility and its treatment do not appear to be associated with longterm psychological sequelae. A description of the range of investigations that may be required and a brief description of infertility treatment options, including adoption, should be reviewed. Initial investigations are Infertility 14% of reproductive aged women 5 million couples in the U. These disorders, which include ovulatory dysfunction and abnormalities of the uterus or outflow tract, may present as amenorrhea or as irregular or short menstrual cycles. The frequency of these diagnoses depends on whether the amenorrhea is primary or occurs after normal puberty and menarche (see. The approach to further evaluation of these disorders is described in detail in Chap. An endometrial biopsy to exclude luteal phase insufficiency is no longer considered an essential part of the infertility workup for most patients. However, a cause is not identified in up to 50% of patients with documented tubal factor infertility. Subclinical infections with Chlamydia trachomatis may be an underdiagnosed cause of tubal infertility and requires the treatment of both partners. The time used to complete the evaluation, correction, and expectant management can be longer in women <30 years of age, but this process should be advanced rapidly in women >35. Its presence is suggested by a history of dyspareunia (painful intercourse), worsening dysmenorrhea that often begins before menses, or a thickened rectovaginal septum or deviation of the cervix on pelvic examination. The pathogenesis of the infertility associated with endometriosis is unclear but may involve effects on the normal endometrium as well as adhesions. Endometriosis is often clinically silent, however, and can only be excluded definitively by laparoscopy.
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The diagnosis of early disease usually occurs with palpation of an asymptomatic adnexal mass during routine pelvic examination or as an incidental finding at surgery depression forums cheap 75 mg amitriptyline otc. However depression la definition buy amitriptyline 25mg on line, most ovarian enlargements discovered on physical examination mood disorder lamp order amitriptyline 75 mg line, especially in premenopausal women, are benign functional cysts that characteristically resolve over one to three menstrual cycles. Adnexal masses in premenarchal or postmenopausal women are more likely to be pathologic. Other causes of adnexal masses include pedunculated uterine fibroids, endometriosis, 224 Proteomic technologies have been used to identify patterns of proteins associated with early disease. Preliminary studies identified all 50 stage I patients with a sensitivity of 100%, a specificity of 95%, and a positive predictive value of 94%. However, difficulty in consistency of replicate samples, variability of results from different spectroscopy equipment, and the tendency of the artificial intelligence algorithms to overfit the data have limited its utility. Most proteins identified to date have been acute phase reactants, and extensive fractionation is necessary to identify unique cancer-specific proteins. These may be benign (50%), malignant (33%), or tumors of low malignant potential (16%). Epithelial tumors of low malignant potential have the cytologic features of malignancy but do not invade the ovarian stroma. More than 75% of borderline malignancies present in early stage and generally occur in the fourth or fifth decade of life. There are five major subtypes of common epithelial tumors: serous (50%), mucinous (25%), endometrioid (15%), clear cell (5%), and Brenner tumors (1%), the latter derived from the urothelium. Although most ovarian tumors are epithelial, two other ovarian tumor types, stromal and germ cell tumors, are distinct in their cell of origin, have different clinical presentations and natural histories, and require different management. Metastasis to the ovary can occur from breast, colon, gastric, and pancreatic cancers. The Krukenberg tumor was classically described as bilateral ovarian masses from metastatic mucin-secreting gastrointestinal cancers. A careful staging laparotomy with a total abdominal hysterectomy and bilateral salpingo-oophorectomy will establish the stage and extent of disease and allow for the cytoreduction of tumor masses in patients with advanced disease. Proper laparotomy requires a vertical incision of sufficient length to ensure adequate examination of the abdominal contents. The primary tumor should be evaluated for rupture, excrescences, or dense adherence. Careful visual and manual inspection of the diaphragm and peritoneal surfaces is required. Pelvic lymph nodes as well as para-aortic nodes in the region of the renal hilus should be biopsied. Since this surgical procedure defines stage, establishes prognosis, and determines the necessity for subsequent therapy, it should be performed by a surgeon with special expertise in ovarian cancer staging. Studies have shown that patients operated on by gynecologic oncologists were properly staged 97% of the time, compared to 52 and 35% of cases staged by obstetricians/gynecologists and general surgeons, respectively. Prognosis in ovarian cancer is dependent not only on stage but also on the extent of residual disease and histologic grade. Patients presenting with advanced disease but left without significant residual disease after surgery have a median survival of 39 months, compared to 17 months for those with suboptimal tumor resection. If initial surgery does not produce minimal residual disease, a second cytoreductive surgery has been used after the first three cycles of chemotherapy; in one trial it was associated with a 6-month improvement in median duration of survival. Another randomized trial where more aggressive debulking surgery was initially carried out was unable to confirm this benefit. Prognosis of epithelial tumors is also highly influenced by histologic grade but less so by histologic type. Although grading systems differ among pathologists, all grading systems show a better prognosis for well- or moderately differentiated tumors than for poorly differentiated histologies. Estimated 5-year survivals for patients by tumor grade are well-differentiated, 88%; moderately differentiated, 58%; poorly differentiated, 27%. Increased tumor levels of p53 are associated with a poorer prognosis in advanced disease. Patients with stage I disease, no residual tumor, and well or moderately differentiated tumors need no adjuvant therapy after definitive surgery, and 5-year survival exceeds 95%. For all other patients with early disease and those stage I patients with poor prognosis histologic grade, adjuvant platinum-based therapy is warranted. Large prospective randomized trials have demonstrated that adjuvant therapy improves diseasefree and overall survival by 8% (82% vs. Unfortunately, only about half of these patients are free of disease if surgically restaged. Although a variety of combinations are active, a randomized prospective trial of paclitaxel and cisplatin compared to paclitaxel and carboplatin in patients with optimally resected advanced disease demonstrated equivalent disease-free and overall survivals but with significantly reduced toxicity with the carboplatin combination. However, the increased toxicity (neuropathy, nephropathy, and catheter complications) is significant, and only about 40% of patients were able to receive full courses of therapy. Historically, patients who had an excellent initial response to chemotherapy and no clinical evidence of disease had a second-look laparotomy. The second-look 226 surgical procedure itself does not prolong overall survival, and outside of clinical trials its routine use is no longer recommended. Maintenance therapy may extend progression-free survival but has not improved overall survival. Patients with advanced disease whose disease recurs after initial treatment are usually not curable but may benefit significantly from limited surgery to relieve intestinal obstruction, localized radiation therapy to relieve pressure or pain from mass lesions or metastasis, or palliative chemotherapy. The selection of chemotherapy for palliation depends on the initial regimen and evidence of drug resistance. Patients who had a complete regression of disease lasting 6 months often respond to reinduction with the same agents; patients relapsing within the first 6 months of initial therapy rarely do. Agents with >15% response rates in patients relapsing after initial combination chemotherapy include gemcitabine, topotecan, liposomal doxorubicin, and bevacizumab. Bevacizumab is a monoclonal antibody that targets the vascular endothelial growth factor. Initial trials produced a 17% overall response rate in heavily pretreated patients. However, hypertension, thrombosis, and bowel perforations have been reported in some trials. They include teratoma, dysgerminoma, endodermal sinus tumor, and embryonal carcinoma. Germ cell tumors of the ovary generally occur in younger women (75% of ovarian malignancies in women <30), display an unusually aggressive natural history, and are commonly cured with less extensive nonsterilizing surgery and chemotherapy. These neoplasms can be divided into three major groups: (1) benign tumors (usually dermoid cysts); (2) malignant tumors that arise from dermoid cysts; and (3) primitive malignant germ cell tumors, including dysgerminoma, yolk sac tumors, immature teratomas, embryonal carcinomas, and choriocarcinoma.
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The treatment is almost always surgical excision depression test after baby order amitriptyline 75mg otc, although the timing of surgery remains controversial depression symptoms memory order amitriptyline overnight delivery. Asymptomatic congenital lobar emphysema may be observed depression lethargy generic amitriptyline 50 mg on line, and many cases will regress over time. High-risk fetal congenital pulmonary airway malformations have a variable response to steroids. What is the embryologic etiology of esophageal atresia and tracheoesophageal fistulas? The precise etiology is unknown, but it is believed that the septation process that normally separates the foregut into the trachea and esophagus by the seventh week of gestation is incomplete. The more rapidly dividing trachea separates the upper and lower portions of the esophagus into discontinuous segments. Describe the five possible configurations of esophageal atresia and tracheoesophageal fistulas. Esophageal atresia and tracheoesophageal fistula usually occur in combination but may occur in isolation. Esophageal atresia with a tracheal fistula to the upper esophageal segment (rare) 3. Esophageal atresia with a tracheal fistula to the lower esophageal segment (most common, in 85% of cases) 4. These anomalies may involve the following structures: n Vertebrae n Anus n Cardiac anomalies n Trachea n Esophagus n Renal anomalies n Limb 24. Infants with esophageal atresia drool excessively because they cannot swallow their oral secretions. If feeding is attempted, the baby may develop respiratory distress as a result of aspiration from the blind-ending upper esophageal pouch. The clinician should attempt to pass a nasogastric tube, which will encounter resistance. A chest radiograph will demonstrate the tip of the tube coiled in the upper chest, confirming the diagnosis of esophageal atresia. Air visualized in the gastrointestinal tract indicates the presence of a fistula distal to the trachea, whereas a gasless abdomen implies an isolated esophageal atresia. Infants with an isolated tracheoesophageal fistula may exhibit symptoms later in life related to soiling of the lungs and respiratory distress. A nasogastric or orogastric sump tube is placed into the blind upper esophageal segment and connected to suction while the baby is maintained in a head-up position to minimize gastroesophageal reflux into the distal fistula. Positive pressure ventilation is not recommended because it can cause abdominal distention through the fistula. If the baby is stable and the gap between esophageal segments is short, operative division of the fistula and a primary esophageal anastomosis is performed. Division of any fistula and placement of a feeding gastrostomy are the initial procedures. Numerous classification systems have been developed to predict the outcome of infants with tracheoesophageal fistulas, such as the Waterson and Spitz criteria. Infants with one risk factor generally have good outcomes; those with both factors have a poor prognosis. Modified prognostic criteria for oesophageal atresia and tracheo-oesophageal fistula. List the common complications that may develop after repair of esophageal atresia. Complications include anastomotic leak, stricture formation, recurrence of the tracheoesophageal fistula, and gastroesophageal reflux. Infants with evidence of reflux require acid suppression because of the long-term risk of esophageal cancer. What are some clinical findings indicating that a newborn infant may have an obstruction of the intestinal tract? If congenital obstruction is suspected on the basis of the scenarios just mentioned, what should be done next? A prenatal ultrasound may have demonstrated a dilated intestine proximal to an obstruction. Which imaging study should be performed first if congenital intestinal obstruction is suspected? Plain abdominal radiographs (supine and decubitus) are most useful and should be performed first. A normal gas pattern with no dilation of intestinal loops and air in the rectum lowers the likelihood of obstruction. Several dilated loops of intestine with air fluid levels and a lack of distal gas are indicative of a high intestinal obstruction. In some instances contrast radiographs may be unnecessary-air is an excellent contrast medium, and if there is evidence of complete duodenal or jejunal obstruction on the plain films, further imaging studies are not necessary. If there is a dilated proximal intestine and some distal gas, suggesting a partial obstruction or a volvulus, an upper gastrointestinal tract contrast series is indicated. If there appears to be a distal obstruction, a contrast enema should be performed to differentiate meconium plug, meconium ileus, intestinal atresia, and Hirschsprung disease. Duodenal obstruction is most commonly caused by atresia or congenital duodenal obstruction of malrotation. Atresia may take the form of stenosis, a web, or complete separation of the duodenal segments. One cause of atresia is the failure of complete recanalization of the lumen of the duodenum after the solid phase of embryologic development, when the epithelial lining occludes the lumen; another is an annular pancreas, wherein the ventral and dorsal pancreatic buds fuse around the duodenum and compress it during development. Most commonly, duodenal atresia occurs distal to the ampulla of Vater, accounting for the bilious nature of the vomiting. Normal rotation consists of a 270-degree turning of the midgut on the axis of the superior mesenteric artery, resulting in the duodenojejunal junction being fixed in the left upper quadrant and the cecum attached in the right lower quadrant. In malrotation this process does not occur or is incomplete, resulting in a narrow base mesentery that puts the child at risk for development of a volvulus and obstruction. The most common scenario is bilious vomiting for no apparent reason in an infant who has been otherwise well and has a flat abdomen. Clinical deterioration, acidosis, abdominal tenderness, and rectal bleeding are late and ominous signs. Unexplained bilious vomiting in an infant is a surgical emergency until proved otherwise. Because plain abdominal radiographs are often nonspecific, an urgent upper gastrointestinal tract contrast study is mandatory to determine the position of the ligament of Treitz and look for a possible twist. If the diagnosis of midgut volvulus is delayed, what are the potential consequences? The twisting of the mesentery leads to vascular compromise and intestinal ischemia. Gangrene of the entire small intestine may occur within as short a period as several hours from the onset of symptoms. Congenital intestinal abnormalities, including malrotation of the colon with volvulus of the midgut. How can the etiology of jejunal and ileal atresia be differentiated from that of duodenal atresia?