INSTABILITE SCAPULO HUMERALE DIAGNOSTIC ET SURVEILLANCE POST THERAPEUTIQUE.pdfRaniaRania81
La stabilité scapulo humérale repose sur plusieurs éléments anatomiques, la lésion de certains d'entre eux peut être à l'origine de douleurs chroniques ou d'une instabilité de l'épaule. l'imagerie joue un rôle fondamental dans le diagnostic étiologique et dans la surveillance post thérapeutique.
INSTABILITE SCAPULO HUMERALE DIAGNOSTIC ET SURVEILLANCE POST THERAPEUTIQUE.pdfRaniaRania81
La stabilité scapulo humérale repose sur plusieurs éléments anatomiques, la lésion de certains d'entre eux peut être à l'origine de douleurs chroniques ou d'une instabilité de l'épaule. l'imagerie joue un rôle fondamental dans le diagnostic étiologique et dans la surveillance post thérapeutique.
Tetrodotoxin is a potent neurotoxin found in marine animals like pufferfish. It blocks sodium channels, preventing action potentials and paralyzing neurons and muscles. Poisoning symptoms range from numbness to respiratory failure and death. The toxin is produced by various bacteria in marine life. While rare, poisoning is more common where pufferfish is regularly consumed. There is no antidote, so treatment focuses on supportive care and monitoring until the toxin is cleared from the body.
Tetrodotoxin is a potent neurotoxin found in marine animals like pufferfish. It blocks sodium channels, preventing action potentials and paralyzing neurons and muscles. Poisoning symptoms range from numbness to respiratory failure and death. The toxin is produced by various bacteria in marine life. While rare, poisoning is more common where pufferfish is regularly consumed. There is no antidote, so treatment focuses on supportive care and monitoring until the toxin is cleared from the body.
1) The Sgarbossa criteria provide guidelines for diagnosing acute myocardial infarction in patients with left bundle branch block (LBB) or ventricular paced rhythm on electrocardiogram (ECG), as these conditions can obscure ECG changes.
2) The original Sgarbossa criteria included three criteria involving concordant or discordant ST segment changes greater than 1mm. The modified criteria expanded this to include proportionally excessive discordant ST elevation.
3) Different types of STEMI are described based on the location of maximal ST elevation, including anterior, inferior, lateral, posterior, and right ventricular STEMI, each with characteristic ECG patterns.
This document discusses interventricular conduction delay and raised intracranial pressure as seen on electrocardiograms (ECGs). It defines interventricular conduction delay and lists various causes including fascicular blocks, bundle branch blocks, ventricular hypertrophy, dilatation, electrolyte abnormalities, toxins, pre-excitation, and arrhythmogenic cardiac conditions. It then discusses raised intracranial pressure and the associated ECG findings of widespread T-wave inversions, QT prolongation, and bradycardia as part of the Cushing reflex, indicating imminent brainstem herniation. Massive intracranial hemorrhages such as subarachnoid hemorrhage are the most common causes
The document discusses various electrolyte abnormalities and their ECG manifestations, including hypercalcemia, hypocalcemia, hyperkalemia, hypokalemia, hypomagnesia, hyperthyroidism, hypothyroidism, and hypothermia. For each condition, it provides the normal and abnormal ranges for the electrolyte levels and describes the associated ECG changes such as peaked T waves, QT prolongation, low QRS voltage, bradycardia, and arrhythmias. The document serves as a reference for clinicians to recognize ECG patterns caused by electrolyte and endocrine abnormalities.
1) Fascicular ventricular tachycardia is the most common form of idiopathic ventricular tachycardia originating from the left ventricle. It typically presents in young patients without structural heart disease.
2) It has characteristic ECG features including a monomorphic ventricular rhythm with fusion complexes and AV dissociation. The QRS duration is between 100-140 ms with a short RS interval of 60-80 ms. It also shows a right bundle branch block pattern and axis deviation.
3) Posterior fascicular ventricular tachycardia, which arises near the left posterior fascicle, shows a right bundle branch block pattern with left axis deviation. Anterior fascicular ventricular tachycardia arises
The document discusses several electrocardiogram (ECG) findings and rhythms including ectopic atrial tachycardia, atrial tachycardia, electrical alternans seen in massive pericardial effusion which produces low QRS voltage, electrical alternans and tachycardia, escape rhythms like junctional escape rhythms where the pacemaker rate decreases down the conducting system, and ventricular escape rhythms. It also discusses the terminology of junctional rhythms and includes literature references.
The document discusses De Winter's T waves, which are characterized by three key findings on ECG: upsloping ST depression in precordial leads, tall symmetric T waves in precordial leads, and ST elevation in aVR. It also summarizes the ECG patterns seen in dextrocardia, including right axis deviation, positive complexes in aVR, and dominant S waves in precordial leads. Finally, it outlines the ECG features of digoxin effect and toxicity, such as biphasic T waves, shortened QT, and the dysrhythmia of supraventricular tachycardia with a slow ventricular response seen in digoxin toxicity.
Massive carbamazepine overdose of more than 50 mg/kg can cause cardiotoxicity due to sodium channel blockade, which may be detectable on ECG as subtle QRS widening or first-degree AV block. Dilated cardiomyopathy is characterized by ventricular dilatation and reduced ejection fraction below 40%, commonly presenting with symptoms of biventricular failure. Chronic obstructive pulmonary disease can cause prominent P waves in inferior leads, exaggerated ST segments, low QRS voltage especially in V4-V6, and may show an SV1-SV2-SV3 pattern.
- Benign early repolarization shows concave ST elevation less than 2 mm with no progression over time, most prominent in V2-V5. Notching at the J-point and concordant T-waves are also seen.
- Beta-blocker and calcium channel blocker toxicity can cause prolonged PR interval and bradycardia. Propranolol toxicity specifically causes QRS widening and positive R' wave in aVR. Sotalol toxicity causes QT prolongation and risk of Torsades de Pointes.
- Bifascicular block is a combination of right bundle branch block with either left anterior or posterior fascicular block, and can be caused by ischemia, hypertension or other
This document discusses atrioventricular nodal reentrant tachycardia (AVNRT). It states that AVNRT is the most common cause of palpitations in structurally normal hearts. It can occur spontaneously or be provoked. There are three main types - slow-fast AVNRT which is most common and shows no visible P waves, fast-slow AVNRT where P waves are visible after the QRS, and slow-slow AVNRT where P waves appear before the QRS. The tachycardia rate is typically between 140-280 beats per minute and is regular. AVNRT occurs due to a reentry circuit within the atrioventricular node.
This document summarizes different types of atrioventricular (AV) blocks seen on electrocardiograms (ECGs). It describes first-degree AV block as a PR interval over 200ms. Second-degree AV block, Mobitz type I (Wenckebach phenomenon) shows progressive PR prolongation until a blocked pulse. Mobitz type II shows intermittent non-conducted pulses without PR prolongation. High-grade second-degree AV block has a P:QRS ratio of 3:1 or higher, with an extremely slow ventricular rate. Third-degree or complete heart block shows no relationship between atrial and ventricular rates. Causes include myocardial infarction, drugs, and conduction system disease. Treatment ranges from
This document provides an overview of several cardiac arrhythmias and conditions including:
1. Accelerated idioventricular rhythm (AIVR), which results when an ectopic ventricular pacemaker exceeds the sinus node rate. AIVR is seen post-myocardial infarction and features a regular rhythm between 50-110 bpm with three or more QRS complexes.
2. Atrial flutter, a supraventricular tachycardia caused by a reentry circuit in the right atrium with a rate of around 300 bpm. The ventricular rate is determined by AV conduction.
3. Atrial fibrillation, the most common sustained arrhythmia characterized by irregularly irregular rhythm without
1) Cardiorenal syndrome commonly occurs in patients with acute decompensated heart failure and is associated with poor outcomes. It involves a complex interaction between hemodynamic alterations and activation of neurohormonal systems that affects both the heart and kidneys.
2) There are five types of cardiorenal syndrome classified based on the inciting cardiac or renal event and the affected secondary organs. Type 1 is acute cardiorenal syndrome due to acute worsening of cardiac function leading to kidney injury.
3) Loop diuretics are the mainstay of treatment for congestion in heart failure but aggressive diuresis may worsen kidney function. Other therapies discussed include inotropic agents, vasopressin antagonists
Categorization of risks and benefits (food additives)Domina Petric
The document discusses various categories of risks associated with food, including foodborne hazards of microbial origin, nutritional hazards, environmental contaminants, naturally occurring toxicants, and food additives. It notes that foodborne diseases of microbial origin pose the greatest risks. Nutritional hazards can arise from deficiencies or excesses. Environmental contaminants can enter the food supply from industrial or natural sources. Naturally occurring toxicants are found in some foods. Food additives present minimal risks when consumed within permitted levels. The document also outlines categories of potential benefits from foods, including health benefits, supply benefits, hedonic benefits, and convenience benefits.
This document discusses the benefits and risks of food additives. The benefits include making foods safer, more nutritious, and longer lasting through the use of preservatives and antioxidants. Additives also provide greater variety of foods and lower prices. However, there are also risks. There is a lack of data on the long term health effects of combinations of additives. Some additives are associated with "junk foods" that are low in nutrients. While direct toxic effects are unlikely at legal levels, some individuals may have hypersensitivity reactions. Some animal studies also indicate potential cancer and reproductive issues, but no direct evidence in humans. The risks must be weighed against the benefits on a case by case basis.
The document discusses different types of food additives and how they are classified. It describes preservatives like antimicrobials, antioxidants and antibrowning agents. Nutritional additives add vitamins, minerals and fiber. Coloring agents and flavors are used to enhance appearance and taste. Texturizing agents modify texture and mouthfeel. Additives are identified by International Numbering System codes or E numbers from the European Union.
Effector phase in immune mediated drug hypersensitivityDomina Petric
This document discusses antibody-mediated and T cell-mediated drug hypersensitivity. It describes how drugs can act as haptens and stimulate T and B cell responses, leading to IgE production and immediate hypersensitivity reactions. It also discusses the p-i concept where drugs can directly interact with T cell receptors and cause reactions without prior sensitization, particularly in the skin which contains many resident immune cells.
1. Small molecule drugs can become immunogenic by undergoing bioactivation into chemically reactive metabolites that covalently bind to proteins, forming hapten-carrier complexes.
2. These complexes are then processed and presented by antigen presenting cells to T cells, stimulating an adaptive immune response.
3. Whether a humoral or cellular immune response develops depends on which proteins are modified by the hapten and whether they are soluble or cell-bound.
2. Bilijarna atrezija
Smrtonosna bolest jetre koja se prepoznaje
u novorođenačkoj i ranoj dojenačkoj dobi.
Progresivna sklerozirajuća obliteracija
ekstrahepatičnog bilijarnog stabla se javlja
zajedno s progresivnim upalnim razaranjem
intrahepatičnih žučnih vodova.
Posljedica je ciroza jetre u prvih 6 do 12
mjeseci života.
Javlja se 1 slučaj/20 000 živorođene djece.
3. Bilijarna atrezija
Bolest zahvaća intra- i ekstrahepatične žučne
vodove.
Postoji upalna destrukcija i sklerozirajuća
obliteracija vodova.
Obliteracijom mogu biti zahvaćeni ductus hepaticus
communis, ductus hepaticus dexter et sinister,
ductus cysticus, u različitim kombinacijama.
U oko 25 % bolesnika postoje i anomalije drugih
organa, najčešće polisplenija, malrotacija crijeva,
preduktalna portalna vena te intrahepatična VCI.
4. Klinička slika
Dominantni simptom je žutica.
Žutica se obično uočava odmah poslije porođaja
ili u prvim danima života.
U početku je rast i razvoj djeteta normalan, ali je
kasnije zastoj sve uočljiviji.
Postupno se razvijaju znakovi portalne
hipertenzije.
U početku je razina serumskog albumina i sustav
koagulacije normalan.
5. Dijagnostika
UZV
scintigrafija s Tc uz prethodno davanje fenobarbitona ima
osjetljivost i do 94 % (postojanje radionuklida u crijevima
isključuje bilijarnu atreziju)
perkutana biopsija jetre
6. Sindrom zgusnute žuči
Riječ je o bolesnicima koji uz urednu građu
žučnog sustava imaju ustrajnu opstruktivnu
žuticu.
Uzrok tome je povećana viskoznost žuči i
posljedična opstrukcija žučnih vodova.
Takvo je stanje češće u djece na parenteralnoj
prehrani, kod hemolize, cistične fibroze i
dehidratacije.
U nekim slučajevima nije moguće otkriti uzrok
ovog stanja.
7. Liječenje bilijarne
atrezije
Kasaiev postupak može smanjiti razinu
bilirubina te izliječiti dijete.
Vezivno tkivo u porti hepatis sadrži
mikroskopski vidljive atretične žučne vodove
koji komuniciraju s intrahepatičnim vodovima.
Prepariranjem toga veziva otvaraju se žučni vodovi
i omogućuje istjecanje žuči u određeni dio tankog
crijeva, najčešće vijugu jejunuma izoliranu po
Rouxu (˝Roux en-Y˝).
8. Liječenje bilijarne
atrezije
Poželjno je zahvat izvesti prije 8.
tjedna života.
Pokazatelj prognoze je brzina kojom
se razina serumskog bilirubina
spušta na normalne vrijednosti.
9. Liječenje
Najbolja je prognoza za djecu kod koje se
razina serumskog bilirubina spusti ispod
17μmol/L (1mg/dL).
Hepatična fibroza može napredovati čak i ako
je uspostavljena bilijarna drenaža.
Krvarenje iz varikoziteta jednjaka se može
kontrolirati endoskopskom sklerozacijom ili
ligaturama.
10. Liječenje
Uspješnost portoenterostomije po Kasaiu ovisi o
vremenu izvođenja operacije: u oko 1/3 djece
operirane prije 60. dana života dolazi do izliječenja, a
u preostale 2/3 bit će potrebna transplantacija jetre
nakon 5-6 g.
Godinu dana nakon operacije, preživljavanje je 80 %.
Bilijarna atrezija je najčešća indikacija za
transplantaciju jetre u djece.
11. Bilijarna hipoplazija
Udružena je s bolestima parenhima
jetre.
Posljedica je teška intrahepatična
kolestaza.
Portoenterostomija nije indicirana.
Potrebno je učiniti biopsiju jetre i time
završiti operaciju.
12. Cista koledokusa
Pet je tipova ciste koledokusa:
jednostavna, izolirana, do cistične
deformacije cijelog bilijarnog
stabla.
13. Cista
koledokusa
Tip I ciste je najčešći tip i klinički je
najvažniji.
Tip I karakterizira vretenasta dilatacija
spojišta ductusa hepaticus te cisticus.
Ta je anomalija jedna od češćih anomalija
pankreatično-bilijarnog sustava.
14. Cista koledokusa, Babbitova
teorija:
Uzrok je abnormalni spoj pankreatičnog i bilijarnog
kanala.
Dolazi do stvaranja zajedničkog kanala, u koji se
otpuštaju enzimi gušterače, što dovodi do enzimatske
razgradnje i slabljenja stijenke žučnog voda
Posljedica je dilatacija, upala i razvoj ciste.
Postoje djeca sa cistom koledokusa, a bez zajedničkog
kanala.
Češća je u djevojčica nego u dječaka (4:1).
15. Klinička slika
Bolovi u trbuhu mogu trajati nekoliko
mjeseci ili godina.
Povremena žutica!
Klasični simptomi se javljaju u polovine
bolesnika.
Neizbježne komplikacije neliječene ciste su
kolangitis, ciroza i portalna hipertenzija.
16. Dijagnostika
Prenatalni UZV
UZV i CT za stariju djecu
ERCP je indicirana ako nakon primjene
manje invazivnih pretraga postoje dvojbe.
17. Liječenje
Resekcija ciste se može koristiti samo kod
ekstrahepatalnih cista.
Cista se u cijelosti odstrani te se s izoliranom
vijugom tankog crijeva učini biliodigestivna
anastomoza preostalih zdravih vodova.
Promjer žučnih vodova proksimalno od ciste je
normalan.
18. Liječenje
Unutrašnja drenaža: radi se anastomoza
ciste s tankim crijevom.
Drenažne operacije su povezane s velikim
morbiditetom jer anastomoza opstruira zbog
fibroziranja.
Cista nakon drenaže postaje spremnik za
retiniranu žuč.
Može se razviti tumor unutar rezidualne
ciste.
19. Transplantacija
jetre u djece
bolesti bilijarnog sustava
prirođene bolesti metabolizma
stečeni hepatitis
primarni karcinom jetre
bolesti jetre koje dovode do ciroze
20. Transplantacija
jetre u djece
Prijeporne indikacije-
kontraindikacije za transplantaciju
su insuficijencija jetre kao
posljedica hepatitisa B,
autoimunoga hepatitisa ili
hepatitisa nepoznate etiologije, te
hepatocelularni karcinom (HCK).
21. Indikacije za
transplantaciju jetre u
djece
encefalopatija
hepatosplenomegalija
portalna hipertenzija: krvarenje iz varikoziteta,
hipersplenizam, ascites
manjak vitamina topljivih u mastima
bilirubin >17μmol/L
uporni svrbež
opetovano javljanje kolangitisa
slaba funkcija sinteze u jetri
slab rast i razvoj djeteta
22. Apsolutne kontraindikacije
multiple nekorektibilne ektrahepatične
anomalije
hepatobilijarni tumori s metastazama
ekstrahepatični tumori
uznapredovale kardiopulmonalne bolesti koje
mogu komplicirati transplantaciju
nekontrolirane sepse izvan bilijarnog stabla
AIDS
23. Tranplantacija jetre
Postala je standard u liječenju terminalnih faza
jetrenih bolesti.
U djece se najčešće izvode segmentalne
transplantacije.
Obično se uzima dio jetre odraslog donora.
Uzimaju se režnjevi ili segmenti jetre.
Ako je odnos TT davatelja prema primatelju
2:1, uzima se desni režanj jetre.
Ako je razlika TT 4:1, uzima se lijevi režanj.
TT-tjelesna težina
24. Tranplantacija jetre
Ako je omjer još manji, kao u dojenčadi i
male djece, transplantira se lateralni
segment (II. i III. segment) lijevog režnja s
pripadajućim strukturama krvnih žila i
bilijarnog stabla.
Obično se krvne žile implantata moraju
produljiti.
Produljena hepatalna arterija se šiva na aortu.
25. Tranplantacija jetre
Biliodigestivna anastomoza se uspostavlja pomoću
izolirane Y vijuge tankog crijeva po Rouxu.
Pomoću heparinizirane Wisconsin otopine za
zaštitu transplantata vrijeme hladne prezervacije
na +4 C° je 18 do 22 h.
Operacija može trajati od 5 do 18 h.
U dječjoj populaciji stopa preživljenja iznosi 80-90 %.
Stopa petogodišnjeg preživljenja u djece je 75 %.