Denise M. Fitzpatrick, RNC, MSN, CNE

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The lobules and ducts develop early under the influence of estrogens women's health center drexel purchase on line duphaston, progesterone womens health 2014 covers order genuine duphaston line, and other hormones menstruation in spanish discount 10 mg duphaston fast delivery, followed by the growth of adipose and fibrous tissue and development of the bud into a fuller breast women's health liposlim buy discount duphaston 10 mg on line. Breast development is complete around age 20 women's health clinic northfield duphaston 10 mg online, but minor changes occur in each menstrual cycle and major changes in pregnancy menstrual vs pregnancy cramps duphaston 10 mg on-line. The onset of breast development is soon followed by the appearance of pubic and axillary hair, sebaceous (oil) glands, and axillary (underarm) glands. This occurs when a girl attains about 17% body fat, and therefore depends on nutrition. Estrogen stimulates growth of the ovaries and secondary sex organs, and the secretion of growth hormone. This brings about a rapid increase in height, widening of the pelvis, and the fat deposition that contours the maturing female body. Inhibin is secreted in girls, as it is in boys, and regulates the development of eggs and follicles. Around the age of 45 to 55, women, like men, go through a midlife change in hormone secretion called the climacteric. A female is born with hundreds of thousands of eggs in her ovaries, each in its own follicle. Climacteric begins not at any specific age, but when she has only about 1,000 follicles left. The drop in ovarian hormones brings about various degrees of atrophy in the uterus, vagina, breasts, skin, and bones. Blood vessels constrict and dilate in response to shifting hormone balances, and the sudden dilation of cutaneous arteries may cause hot flashes-a spreading sense of heat from the abdomen to the thorax, neck, and face, commonly accompanied by sweating and sometimes headaches resulting from the sudden dilation of arteries in the head. It is difficult to precisely establish the time of menopause because the menstrual periods can stop for several months and then begin again. Menopause is generally considered to have occurred when there has been no menstruation for a year or more. What structure in the ovary serves the same purpose as seminiferous tubules in the testis Name the upper, middle, and lower parts of the uterus and the three layers of the uterine wall. Identify all structures enclosed within the labia majora, including the subcutaneous glands, and describe their relative positions. The essence of reproduction is the production and fusion of gametes-eggs and sperm. Sexual reproduction has to avoid such doubling of the chromosome number in each new generation. To understand meiosis, it is important to know that the chromosomes of most cells occur in 23 pairs-designated chromosomes 1 through 22 and one pair of sex chromosomes, designated X and Y in the male and two Xs in the female. Any cell that has 23 chromosome pairs (46 chromosomes in all) is called a diploid cell, symbolized 2n. In contrast, the germ cells (sperm, eggs, and some of the developmental stages leading to them) have 23 unpaired chromosomes, and are called haploid (n). One function of meiosis is to reduce diploid stem cells to haploid germ cells; this is why meiosis is also called reduction division. Mitosis serves a range of functions including fetal development, childhood growth, and tissue maintenance and repair, whereas meiosis is used only for the production of gametes. Mitosis maintains a constant number of chromosomes from parent cell to daughter cells, whereas meiosis reduces the chromosome number from diploid to haploid. In the female, though, three of the four daughter cells are tiny cells that soon die, and only one large, mature egg is produced. The first division produces two haploid daughter cells, and the second division divides each of these into two more, so that the ultimate outcome is four haploid cells. The daughter cells thus have only 23 chromosomes, but each chromosome retains its double-stranded form, composed of two chromatids joined at the centromere (see fig. Spermatogenesis,Sperm,andSemen Both sperm and egg production rely on mitosis and meiosis. In the average young man, it occurs at the remarkable rate of about 300,000 sperm per minute, or 400 million per day. Yet these sperm constitute only about 10% of the fluid that is ejaculated, called the semen. Centrioles Mid- to late prophase I Homologous chromosomes form pairs called tetrads. Crossing-over Spindle fibers Metaphase I Tetrads align on equatorial plane of cell with centromeres attached to spindle fibers. Anaphase I Homologous chromosomes separate and migrate to opposite poles of the cell. Telophase I New nuclear envelopes form around chromosomes; cell undergoes cytoplasmic division (cytokinesis). Spermatogenesis At birth, the testes contain stem cells called spermatogonia, which lie dormant for years around the perimeter of the seminiferous tubules. One daughter cell from each division remains near the tubule wall, maintaining a lifelong population of stem cells. The other daughter cell migrates slightly away from the tubule wall on its way to dividing and differentiating into sperm. Since this cell is about to undergo meiosis and become genetically different from other cells of the body, it must be protected from the immune system. Ahead of the primary spermatocyte, the tight junction between two nurse cells is dismantled, while a new tight junction forms behind the spermatocyte. The spermatocyte moves toward the lumen, like an astronaut passing through a double-door airlock, and is now protected by the barrier closing behind it. The daughter cells from second ary spermatocytes through spermatids remain connected by slender cytoplasmic processes until spermiogenesis is complete and individual spermatozoaarereleased. This transformation, called spermiogenesis, consists essentially of sprouting a tail (flagellum) and shedding excess cytoplasm, making the sperm a lightweight, mobile, self-propelled cell. When fully formed, the sperm depart from their supportive nurse cells and are washed down the seminiferous tubule by a slow flow of fluid. After division of the spermatogonium, it takes about 74 days for the one daughter cell to become mature sperm. Sperm the spermatozoon (sperm cell) has two parts: a pear-shaped head and a long flagellum, or tail (fig. The most important of these is the nucleus, which fills most of the head and contains a haploid set of condensed chromosomes. The acrosome33 is a lysosome in the form of a thin cap covering the apical half of the nucleus. The principal piece constitutes most of the tail and consists of the axoneme surrounded by a sheath of supportive fibers, which stiffen the tail and enhance its propulsive power. You could think of the sperm midpiece as the "motor," the principal piece as the "propeller," and the head or its nucleus as the "cargo. A typical ejaculation is 2 to 5 mL of semen, composed mainly of seminal vesicle Core fluid (60%), prostatic fluid (30%), and sperm (10%), with a trace of other secretions. A sperm count lower than 20 to 25 million sperm/mL is usually associated Principal with infertility (sterility), the inability to fertilize an egg. This is the last component of the semen to emerge, and it Endpiece flushes remaining sperm from the urethra. It contains fructose and other of tail carbohydrates, as well as prostaglandins (discovered in and named for the (b) (a) prostate, but more abundant in the seminal vesicle secretion). About 20 to 30 minutes after ejaculation, the serine protease of the prostatic fluid breaks down semenogelin and liquifies the semen. The sperm, which lay still until then, now become very active, thrashing with their tails and crawling up the mucosa of the vagina and uterus. The ovarian cycle is concerned with oogenesis, the production of eggs, and folliculogenesis, the parallel developments in the follicles that enclose them. A major difference, however, is that whereas males produce sperm continually, oogenesis is conspicuously cyclic and usually produces only one mature egg per month. It is accompanied by cyclic changes in hormone secretion and in the histological structure of the ovaries and uterus; the uterine changes result in the monthly menstrual flow. Shortly before birth, the surviving oogonia transform into primary oocytes and proceed as far as early meiosis I, but then go into developmental arrest until puberty. The term egg, or ovum, applies loosely to any stage from the primary oocyte to the time of fertilization. Even if a female ovulated every 28 days from age 14 to 50, she would ovulate at most 480 times. Each primary oocyte divides into two haploid daughter cells of unequal size and different destinies. It is important to produce an egg with as much cytoplasm as possible, because if fertilized, it must divide repeatedly and produce numerous daughter cells. Splitting each oocyte into four equal but small parts would run counter to this purpose. Therefore, meiosis I produces a large daughter cell called the secondary oocyte and a much smaller one called the first polar body. The polar body disintegrates; it is merely a means of discarding the extra set of chromosomes. The chromosomes of the large remaining egg unite with those of the sperm, resulting in a diploid zygote. Folliculogenesis As an egg undergoes oogenesis, the follicle around it undergoes as many as five stages of growth, collectively called folliculogenesis. A primordial follicle consists of a primary oocyte surrounded by a single layer of squamous follicular cells (fig. They persist into adulthood, with most of them waiting at least 13 years and some as long as 50 years before they develop any further. The follicular cells become cuboidal but still form just one layer around the now larger primary oocyte. The follicular cells divide and pile on top of each other in layers; the follicular cells are now called granulosa cells. They secrete a layer of clear gel around the oocyte called the zona pellucida, while the connective tissue around the follicle condenses to form a fibrous husk, or theca. Next, the follicle cells secrete a fluid that accumulates in little pools in the follicle wall. As they enlarge, the pools merge and become a single fluid-filled cavity, the antrum. On one side of the antrum, a mound of granulosa cells covers the oocyte and secures it to the follicle wall. The innermost layer of cells around the egg creates a barrier that ensures that nothing from the bloodstream can get to the oocyte except by going through (not between) these cells. The granulosa cells selectively allow nutrients and hormones to pass through to the egg, while screening out antibodies and other potentially harmful chemicals. The theca develops a rich supply of blood vessels and collaborates with the follicle cells to secrete sex hormones, especially estrogen. The theca absorbs cholesterol from the blood and converts it to androgens (androstenedione and a lesser amount of testosterone). These diffuse inward to the granulosa cells, and they convert the androgens to estrogens, especially estradiol. Normally only one follicle in each monthly cohort becomes a mature follicle, destined to ovulate while the rest degenerate. TheOvarianCycle We can now relate oogenesis and folliculogenesis to the timetable of events in the monthly sexual cycle (fig. The cycle varies from 20 to 45 days in length, differing from person to person and from month to month in the same person, but it averages 28 days, so we will use this as a basis for discussion. As you study this cycle, bear in mind that hormones of the hypothalamus regulate the pituitary gland; pituitary hormones regulate the ovaries; and the ovaries, in turn, secrete hormones that regulate the uterus. That is, the basic hierarchy of control can be represented: hypothalamus pituitary ovaries uterus. However, the ovaries also exert feedback control over the hypothalamus and pituitary. The first 3 to 5 days are marked by menstruation, in which blood and endometrial tissue are discharged vaginally. While this is going on, a cohort of ovarian follicles grows until one of them ovulates around day 14. Endometrial tissue is regenerated and thickens between the end of menstruation and ovulation. After ovulation, the remainder of that follicle becomes a body called the corpus luteum. Over the next 2 weeks, called the luteal phase, the corpus luteum stimulates endometrial secretion, making the endometrium thicken still more. If pregnancy does not occur, the endometrium breaks down again in the last 2 days. As loose tissue and blood accumulate, menstruation begins and the cycle starts over. It reaches a diameter of about 20 mm and bulges from the ovarian surface like a great blister, ready to ovulate. Unfortunately, the follicular phase is the most variable part of the cycle in length. This makes it almost impossible to reliably predict the date of ovulation for the purposes of family planning or pregnancy avoidance. Ovulation, typically around day 14, is the rupture of the mature follicle and the release of its egg and some of the surrounding cells.

Currently womens health zone health buy duphaston 10 mg on-line, none of the leading trauma organizations offer any specific blood pressure goals or any hard recommendations pertaining to hypotensive resuscitation women's health clinic vancouver wa order online duphaston. The latest edition of the Advanced Trauma Life Support Student Course Manual states that the goal of initial resuscitation is "the balance of organ perfusion and hypotension menstrual cramps 5 weeks pregnant purchase duphaston line, and not the hypotension itself" [59] ectopic pregnancy order duphaston cheap. The study found no difference in overall 24-hour mortality but decreased 24-hour mortality in blunt trauma patients who underwent controlled resuscitation [60] pregnancy jewelry purchase duphaston 10 mg with mastercard. Although further research is warranted breast cancer 800 number cheap duphaston 10mg with mastercard, hypotensive resuscitation appears safe and, given what we know about the danger of excess crystalloid in this patient population, likely beneficial in the initial stages of trauma care. At our institution, we typically resuscitate to a mean arterial blood pressure goal of 60 mmHg in the absence of central nervous system injury. James Blundell performed the first successful blood transfusion in a human subject in 1818 when he successfully treated a patient with postpartum hemorrhage. However, a lack of understanding of blood types continued to make transfusions prohibitively dangerous. It was not until the turn of the twentieth century when human blood groups were discovered that blood transfusions could become routine [61]. Chapter eight: Fluid therapy for the trauma patient 159 However, component therapy replaced whole blood therapy by the late 1970s, due to the increasing prevalence of chemotherapy as well as the desire to increase efficiency of resource utilization and decrease transmission of blood-borne pathogens. Up to 5% of trauma patients at a major trauma center will require a substantial amount of blood products following injury, typically referred to as massive transfusion [62,63]. Massive transfusion has historically been defined as transfusion of 10 or more units of red blood cells in the first 24 hours. However, selection of patients requiring massive transfusion remains difficult [69]. Massive transfusion protocol is continued until bleeding is observed to have slowed, which typically occurs after control of "surgical" bleeding in the operating room or interventional radiology suite (see Case 1 above). The composition of massive transfusion protocol has changed substantially in the last two decades. Overall mortality was 65%, 34%, and 19% for the low, medium, and high groups, respectively, while mortality secondary to hemorrhage was 92%, 78%, and 37%, respectively. Our group also recently reviewed the relationship between damage control resuscitation and organ-specific survival, demonstrating increased survival and successful nonoperative management of high-grade blunt liver injury after damage control resuscitation was instituted at our institution in 2008 [12]. Although multiple studies to date have demonstrated improved survival with the use of plasma during trauma resuscitation, very little is known regarding the underlying mechanism. Given that there are tens of thousands of unique proteins in human plasma [78], it is unlikely that the resuscitative effect is due solely to repletion of coagulation factors. Indeed, recent observational data in trauma patients at our institution demonstrate a relationship between low plasma oncotic pressure, increased shedding of glycocalyx components, and impaired thrombin generation [83]. Thus, the resuscitative effect of plasma appears to be at least threefold: repletion of volume, repletion of clotting factors, and systemic repair of damaged endothelium [84]. Unfortunately, logistical hurdles must be overcome before implementing plasma-based resuscitation. The liquid (never frozen) plasma used at our Chapter eight: Fluid therapy for the trauma patient 161 institution has a shelf life of 26 days. Military experience with whole blood transfusion in the traumatized patient is extensive, going back to at least World War I, and includes experience in modern conflicts such as the Battle of Mogadishu [87], as well as the first Gulf War and the Kosovo conflict [88]. Due to a dilutional effect when separating whole blood into components, one unit of whole blood has twice the viable platelets, twice the hematocrit, and 50% more clotting factor activity when compared to a 1:1:1 ratio of component therapy (see Table 8. Our group recently performed a pilot study demonstrating the feasibility of transfusion of modified whole blood in the trauma setting [89]. The optimal use of blood products, including the potential role of whole blood in the civilian trauma setting, continues to be an exciting area of active research. To overcome these limitations, multiple devices have been developed that provide a coagulation profile of a whole blood sample. The device consists of a cup containing a whole blood sample and a detector connected to a torsion wire inserted into the blood sample. The tension transduced by the wire, which increases as the clot forms and decreases as lysis overtakes clot formation, is translated into a real-time tracing. Chapter eight: Fluid therapy for the trauma patient 163 of the amount of time needed to initiate clot formation, which is dependent on the enzymatic activity of clotting factors. K represents the amount of time needed to form a "preliminary" clot of predefined strength (amplitude of 20 mm) after clot formation has begun, while measures the rate of initial clot formation. Both K and are reflective of the cleavage of fibrinogen into fibrin by activated thrombin and the cross-linking of fibrin monomers. After the clot reaches maximal strength, fibrinolysis overtakes coagulation, resulting in decreasing clot strength. We will continue maintenance fluid with crystalloid (typically PlasmaLyte) in the stable patient with no evidence of active bleeding (see Case 2). Fibrinolysis appears to be an important driver of acute post-traumatic coagulopathy [92], but concrete guidelines on the use of antifibrinolytics in this patient population are lacking. Otherwise, mortality increased in the intervention arm after the 3 hour window [94]. Therefore, the goal of the trauma clinician is to prevent secondary cerebral injury, namely from hypoperfusion and hypoxia. However, it is clear that an optimal resuscitation strategy with correct utilization of crystalloid, blood products, and other adjuncts is just as important as surgical treatment of the specific traumatic injuries. With a trend toward increasing collaboration and Chapter eight: Fluid therapy for the trauma patient 167 cooperation across multiple specialties and centers in large consortiums, we will continue to push the boundary of human understanding in this challenging, but exciting, area of medicine. Rhee, Peter, Bellal Joseph, Viraj Pandit, Hassan Aziz, Gary Vercruysse, Narong Kulvatunyou, and Randall S. Major complications, mortality, and resource utilization after open abdominal surgery 0. Delayed versus immediate fluid resuscitation in patients with penetrating trauma: Subgroup analysis, J Trauma 39 (1995): 173. Khan, Sirat, Shubha Allard, Anne Weaver, Colin Barber, Ross Davenport, and Karim Brohi.

In order to do this uc davis women's health center 10mg duphaston, the hormone must first bind to a receptor-a protein within the target cell or in its plasma membrane women's health center lebanon tennessee cheap 10mg duphaston with mastercard. A "key" such as insulin will fit only an insulin receptor ("lock") menstrual gas relief cheap duphaston american express, for example; it will not fit an estrogen receptor menopause migraines duphaston 10mg lowest price. Many hormones are in the blood at one time menopause irregular periods cheap duphaston 10mg otc, but any given organ or cell responds only to those for which it has the proper receptors-just as there are many radio broadcast signals in the air at once menstrual jokes arent funny period order duphaston in united states online, but you hear only the one to which you tune your own radio. Peptide hormones and most monoamines (such as epinephrine) are hydrophilic and cannot pass into the target cell. Its receptor is closely associated with a membrane enzyme that responds by producing a second messenger inside the cell. For example, an activated enzyme can turn certain metabolic pathways on; it can "wake up" certain genes, leading to the production of new enzymes; or it can change the permeability of the plasma membrane, thereby altering the transport of materials into or out of the target cell. Glucagon, for example, acts on liver cells to activate metabolic pathways leading to the release of blood sugar (see fig. Steroid hormones, in contrast, are hydrophobic and readily diffuse through the phospholipids of the target-cell membrane. This typically causes a gene to be transcribed, which leads to the production of a specific protein. The cell produces those receptors, preparing itself to respond to the progesterone that will arrive in the second half of the cycle. The progesterone itself will activate other genes that cause the lining of the uterus to thicken and prepare for the possibility of pregnancy. Either process can lead to a great variety of metabolic effects on the target cell. HormoneInteractions We never have just a single hormone in circulation; the blood plasma is always a "cocktail" of many hormones traveling together. The way that estrogen primes the uterus to respond to the later arrival of progesterone, as just described, is an example of this. For example, insulin stimulates the liver to absorb glucose and lower its blood concentration, whereas glucagon stimulates the liver to release glucose and raise the blood sugar level (see fig. For example, pituitary dwarfism is now rare because it is easily treated in childhood with growth hormone, and genetic engineering has now made human growth hormone freely available. However, there is another form of dwarfism, Laron dwarfism, which results from a defect in the receptor for growth hormone. Similarly, type 2 diabetes mellitus, the most common form of diabetes, results from an insulin receptor defect or deficiency. For this reason, estrogen replacement therapy should not be used for women with estrogen-dependent cancer or who are at risk for it. Synergistic effects, in which two hormones acting together produce a much stronger response than the sum of their separate effects. In men, for example, testosterone and follicle-stimulating hormone would have very little effect on sperm production if they each worked alone, but when they work together, the testes produce 300,000 sperm per minute. HormonalControlofHomeostasis the endocrine system precisely regulates numerous variables in the body through feedback control. Most often, hormonal control relies on negative feedback, in which the secretion of a hormone reverses (negates) a change in a physiological variable. In a negative feedback loop, the body senses a change in a variable, an endocrine gland responds by altering the rate of hormone secretion, and target cells respond in a way that will ultimately bring the variable back to its original state. When the glucose level rises during digestion of a meal, endocrine cells of the pancreas respond by secreting insulin. Among other effects, insulin targets liver, muscle, and other cells and causes them to remove glucose from the blood and store it for later use. The feedback mechanism thus reverses the original change in blood glucose level and maintains homeostasis. Both positive and negative feedback mechanisms also regulate the endocrine glands themselves, as section 11. Most are taken up by the liver and kidneys, chemically degraded, and excreted in the bile or urine. Some hormones are removed from the blood very quickly; for example, growth hormone levels decline by 50% within 20 minutes. Others linger longer; thyroid hormone, for example, maintains an effective level in the blood for as long as 2 weeks after its secretion ceases (as when the thyroid gland has been surgically removed to treat thyroid cancer). We begin our exploration with the pituitary and a nearby region of the brain that controls it, the hypothalamus. You may remember that the hypothalamus regulates a wide range of body functions, including water balance, energy balance, growth, and reproduction (see section 9. It fulfills these roles in large part by controlling the production and secretion of hormones from the pituitary gland. Thus, the pituitary is an important link in the neural and hormonal regulation of homeostasis. PituitaryAnatomy Even though the pituitary gland (hypophysis3) controls more bodily functions than any other endocrine gland, it is only about as big as a kidney bean. The two lobes are now encased in bone and so closely associated they appear to be a single gland. The anterior pituitary gland develops from a pouch in the roof of the embryonic pharynx (throat) (fig. Meanwhile, the posterior pituitary gland arises as a downgrowth from the hypothalamus, and retains its connection to the brain throughout life. The two parts of the pituitary gland come to lie side by side before the bone forms around them, and are so closely joined together that they appear to be a single gland. The hypothalamus is attached to the posterior pituitary gland by a stalk containing bundles of nerve fibers (fig. These fibers originate in two separate nuclei in the hypothalamus, represented in blue and green in the figure. These distinct groups of neurons synthesize two hormones, oxytocin and antidiuretic hormone, which we will examine shortly, and transport them down the nerve fibers for storage in the posterior pituitary. Under appropriate conditions, the hypothalamus sends electrical signals down the same fibers to stimulate the posterior pituitary to release those hormones into the blood. The hypothalamus connects to the anterior pituitary gland by a network of small blood vessels called the hypophyseal portal system (fig. A portal system is one in which blood flows from one capillary bed to another before returning to the heart. In this specific case, the hypothalamus secretes chemical signals into the capillaries at its end of the portal system; these signals travel a short distance to the anterior pituitary; and here they leave the bloodstream through a second capillary network and tell the anterior pituitary what to do. The nuclei in blue and green synthesize oxytocin and antidiuretic hormone and transport them down nerve fibers in the stalk for storage in the posterior lobe. Later, nerve signals passing down the stalk trigger the posterior lobe to release these hormones. Neurons in the hypothalamus secrete releasing and inhibiting hormones into hypothalamic blood capillaries. These hormones (small black dots) travel down the portal system to capillaries in the anterior lobe. Leaving the bloodstream at that point, they stimulate anterior lobe cells to secrete their hormones, or in other cases inhibit them from doing so. The first two are called gonadotropins5 because they target the gonads (ovaries and testes). The follicle left behind after ovulation develops into a yellowish structure called the corpus luteum. The effects are most conspicuous during childhood and adolescence, but important for tissue maintenance and repair throughout life. PosteriorPituitaryHormones the posterior pituitary gland stores and releases two small peptide hormones produced by the hypothalamic nuclei. The most obvious effect of oxytocin is stimulation of uterine smooth muscle, leading to contractions during labor and delivery. A synthetic form of oxytocin, Pitocin, is sometimes administered to women to induce labor. Oxytocin has also been called the "love hormone" because of its role in the formation of emotional attachments between mothers and offspring and between sexual partners. ControlofthePituitaryGland the hypothalamus controls the anterior pituitary gland by secreting several releasing and inhibiting hormones into the portal system. They travel to the anterior pituitary, leave the blood vessels, and either stimulate or suppress the output of the corresponding pituitary hormones. The hypothalamus thereby regulates the numerous body functions that are affected by the anterior pituitary. Releasing hormones stimulate the anterior pituitary to secrete its hormones (pink box) into the blood. For example, prolactin-inhibiting hormone suppresses prolactin secretion when a woman is not pregnant or nursing. Superficially, this may seem like a military chain of command from hypothalamus ("the general") to pituitary ("the lieutenant") to the target organs ("the privates"). But unlike a military chain of command, the endocrine system does not work strictly from the top down. Here, the privates also give commands to the lieutenant and even to the general, through communication loops of both negative and positive feedback. Apply What You Know Explain the phrase, "The pituitary gland is a link between the neural regulation and hormonal regulation of homeostasis. We will begin our discussion with the most superior gland, the pineal gland, and will work our way inferiorly through glands in the neck and trunk. Finally, we will discuss hormones produced by tissues and organs other than those traditionally regarded as endocrine glands. It attaches to the roof of the third ventricle, near the posterior end of the corpus callosum (see figs. The pineal gland secretes melatonin, a monoamine, primarily during hours of darkness. Melatonin plays a role in sleep and the basic daily cycles of activity known as circadian rhythms. Intriguing recent studies show that increased melatonin levels are associated with decreased incidence of cancer. This finding has implications for our modern lifestyle because exposure to light suppresses the production of melatonin. This may explain the finding that blind women, whose melatonin production is not suppressed by artificial light, have a lower incidence of breast cancer. In contrast, women who work during the night under artificial light (and hence have lower levels of melatonin) have a greater incidence of breast cancer. The pineal gland is large in children but begins to atrophy at about the age of 7. As it shrinks, granules of calcium phosphate and calcium carbonate called pineal sand appear. These tiny grains are visible on X-rays and enable radiologists to determine the position of the pineal gland. This can be clinically useful if the gland has been displaced by a brain tumor or other structural abnormality. In adults, it weighs 20 to 25 g, and has a dark reddish brown color due to its unusually great blood flow. It is composed of two lobes that are bulbous at their inferior end and taper superiorly. In most people, a narrow bridge of tissue, the isthmus, crosses the front of the trachea and joins the two lobes, and some people have a small third lobe arising medially from the isthmus. The most common cause of hypothyroidism in adults is Hashimoto disease, an autoimmune disorder that destroys the thyroid gland. Symptoms include thinning hair and scaly skin, cold intolerance, weight gain, and mental sluggishness. Graves10 disease (toxic goiter) is a form of hyperthyroidism in which dysfunctional antibodies mimic the effect of thyroid-stimulating hormone, causing the thyroid gland to secrete excessive thyroid hormone. The resulting signs and symptoms include rapid weight loss, increased sweating, irritability, heart palpitations, and protruding eyeballs (exopthalmia). Graves disease is sometimes treated with radioactive iodine that kills the thyroid cells, or the gland may be surgically removed. They produce a peptide hormone called calcitonin in response to elevated blood calcium levels. Calcitonin inhibits the bone-resorbing activity of osteoclasts and stimulates bone deposition by osteoblasts. TheParathyroidGlands Four small, ovoid parathyroid glands are usually located on the posterior surface of the thyroid (see fig. In response to a blood calcium deficiency, it stimulates osteoclasts and inhibits osteoblasts, thereby dissolving bone and raising the blood calcium level. If the parathyroids are accidentally removed in the course of neck surgery, immediate hormone replacement therapy is necessary; a person can otherwise die within a few days of blood calcium deficiency. TheThymus the thymus is a bilobed gland in the mediastinum superior to the heart, behind the sternal manubrium. It is the site of maturation for certain white blood cells called T lymphocytes (T for thymus-dependent), which play a critical role in immunity. The thymus secretes hormones called thymosin and thymopoietin, which regulate the development and activity of T lymphocytes and stimulate the development of other lymphatic organs.

This gap usually provides more information about the adequacy of flow than the presence of tissue hypoxia menstrual depression discount 10 mg duphaston otc. These direct and indirect techniques for monitoring microcirculation and its parameters are summarized in Table 5 menopause questions and answers buy duphaston mastercard. Many studies have been conducted to evaluate methods of monitoring the microcirculation women's health center john muir buy duphaston paypal, especially in cardiac and abdominal surgery [20] women's health center king of prussia pa order duphaston no prescription. They included five human studies that assessed microcirculation during and after cardiopulmonary bypass pregnancy 0-40 weeks order 10 mg duphaston fast delivery. There are three other studies that assessed microcirculation during perioperative cardiac surgery women's health clinic victoria hospital winnipeg 10mg duphaston visa. Interestingly, this study showed that decreases in microcirculatory flow occurred irrespective of changes in systematic Chapter five: Monitoring the microcirculation 101 blood pressure. This last result was reiterated in another observational study where patients who received medication for high blood pressure after undergoing cardiac surgery with cardiopulmonary bypass were assessed for micro- and macrocirculatory parameters [29]. Assessing microcirculation directly and indirectly has been investigated in abdominal surgery as well. One study used serum lactate levels to prevent postoperative complications after major elective surgery for gastrointestinal malignancy [30]. This study randomized between restricted perioperative fluid therapy based on lactate levels versus "normal" restricted fluid therapy. In the restricted perioperative fluid therapy based on lactate levels, serum lactate was routinely monitored, and in the presence of hyperlactatemia an additional fluid bolus was given. This lactate-guided fluid therapy resulted in a significant decrease in systemic complications. Furthermore, the restricted fluid group without routine serum lactate monitoring received significantly more fluids than the serum lactate monitoring group. Moreover, the patients who received supplementary fluids had significantly more complications in the restricted regimen lacking serum lactate monitoring. Fluid challenge was given to patients with evidence of hypovolemia, and they were assessed for fluid responsiveness during surgery. There was no significant difference observed in StO2 between positive and negative fluid challenge. However, hypovolemia was associated with a significant reduction in StO2 recovery slope, with a significant difference between positive and negative fluid challenge. The fluid therapy guided by stroke volume with dopexamine showed an improved sublingual and cutaneous microcirculatory flow. Sublingual microcirculation flow remained constant in the stroke volume group but deteriorated in the central venous pressure group. Laser Doppler flow showed a hyperemic response in the stroke volume with dopexamine, whereas this variable remained unchanged in the stroke volume group without dopexamine and deteriorated in the central venous pressure group. Cutaneous PtO2 initially increased in all three groups after surgery, 102 Fluid therapy for the surgical patient and this was sustained in the stroke volume combined with dopexamine group but decreased in the other two groups. Another study examined perioperative microcirculatory changes in patients undergoing abdominal surgery [33]. By contrast, another study evaluated microcirculatory flow and tissue oxygenation after abdominal surgery and found a relation with postoperative complications [34]. Cutaneous microcirculation assessment did not show a relation with postoperative complications. The measurement was performed on three different occasions: 1 day before surgery (T0), in the first 24 hours after surgery (T1), and on the fourth day after surgery (T2). At each time point, microcirculation was filmed in three different locations on the sublingual mucosa for a minimum of 10 seconds per sequence. Film sequences were repeatedly taken until three sequences of good quality were obtained. In the first 24 hours after surgery the patient received a total of 984 mL of intravenous fluids and 150 mL of oral intake, while the output consisted of 750 mL of urine output and 70 mL of drain production. Thus, in the first 24 hours the fluid balance, including surgery, was a total of 3,900 mL of fluids in and 2,250 mL out, which gives a positive fluid balance of 1,650 mL. Between the second and third days the fluid balance was positive by 885 mL, and on the third day there was a negative fluid balance of 1,330 mL. On the Chapter five: Monitoring the microcirculation 103 fourth and fifth days the patient did not receive any fluid therapy as the oral intake was sufficient. On the first and second days the patient had hypotensive blood pressure with a normal heart rate, which can be explained by the epidural analgesia placed during surgery for postoperative pain relief [36]. The patient also had nausea, which quickly resolved after stopping the epidural analgesia, and no serious complaints after surgery. The subsequent postoperative course was uncomplicated, and the patient was discharged after 9 days. This case report indicates therefore that microcirculatory assessment may help goal-directed fluid therapy. As the patient was hypotensive, the fluid balance was positive with normal microcirculatory flow. This is based on macro- and microcirculatory hemodynamics, which can be divided into convective and diffusive determinants. As discussed in this chapter, the diffusive determinant for oxygenation is equally as important as the convective determinant. Therefore, we recommend the use of videomicroscopy to monitor microcirculation, as it is the only available technique that gives information concerning the diffusive capacity of microcirculation. However, there are some limitations to this technique that should be addressed first before it impacts clinical decision-making. First, an automated analysis of the microcirculation should be conducted immediately after obtaining the sequence to enhance the decision-making on whether fluid therapy is needed. Furthermore, there is a need for more studies that show the relation between sublingual microcirculation and organ dysfunction. Finally, more (randomized) trials should be conducted that use videomicroscopy for microcirculatory goal-directed fluid therapy. Ince has no financial relation with Braedius Medical of any sort, that is, has never owned shares or received consultancy or speaker fees from Braedius Medical. Blood pressure, cardiac output, and urine output can give an indication of the convective status of the circulation, while microcirculation monitoring can give an indication of the convective and diffusive status. There are different ways to monitor microcirculation in the perioperative setting, and they can be divided into direct and indirect monitoring. Therefore, we recommend the use of videomicroscopy to monitor microcirculation as it is the only available technique that gives information concerning the diffusive capacity of microcirculation. Towards integrative physiological monitoring of the critically ill: From cardiovascular to microcirculatory and cellular function monitoring at the bedside. A microscope-television system for studying flow velocity in human skin capillaries. Monitoring the microcirculation in the critically ill patient: Current methods and future approaches. Orthogonal polarization spectral imaging: A new method for study of the microcirculation. De Backer D, Hollenberg S, Boerma C, Goedhart P, Buchele G, OspinaTascon G, et al. Disparity between skin perfusion and sublingual microcirculatory alterations in severe sepsis and septic shock: A prospective observational study. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Effects of norepinephrine and phenylephrine on intestinal oxygen supply and mucosal tissue oxygen tension. The pulsatile perfusion debate in cardiac surgery: Answers from the microcirculation Pulsatile versus nonpulsatile flow during cardiopulmonary bypass: Microcirculatory and systemic effects. Pulsatile flow during cardiopulmonary bypass preserves postoperative microcirculatory perfusion irrespective of systemic hemodynamics. Direct observation of the human microcirculation during cardiopulmonary bypass: Effects of pulsatile perfusion. Effect of cardiopulmonary bypass perfusion protocols on gut tissue oxygenation and blood flow. Monitoring of the sublingual microcirculation in cardiac surgery using orthogonal polarization spectral imaging: Preliminary results. Microcirculatory alterations in cardiac surgery: Effects of cardiopulmonary bypass and anesthesia. Impaired sublingual microvascular perfusion during surgery with cardiopulmonary bypass: A pilot study. Microcirculatory imaging in cardiac anesthesia: Ketanserin reduces blood pressure but not perfused capillary density. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Use of near-infrared spectroscopy during a vascular occlusion test to assess the microcirculatory response during fluid challenge. Haemodynamic optimisation improves tissue microvascular flow and oxygenation after major surgery: A randomised controlled trial. Changes in the sublingual microcirculation during major abdominal surgery and post-operative morbidity. Microvascular flow and tissue oxygenation after major abdominal surgery: Association with postoperative complications. However, confusion still exists about what device to use and whether a noninvasive monitoring system is the right choice. Part of the confusion lies with the misconception that many clinicians believe that the natural progression is to have noninvasive monitors replace more invasive monitoring systems. Each monitor, regardless of level of invasiveness, has value and utility in various patient populations and in different settings. This, however, does not mean that we advocate for the use of noninvasive monitors only. Instead, we are providing an outline so that clinicians and health care institutions alike can make informed and appropriate choices regarding acquisition of devices, limitations of each device, and interpretation of the dynamic predictors of fluid responsiveness they employ. Whether it is standard monitoring or invasive advanced monitoring, the goal of hemodynamic monitoring is to ensure patients are adequately perfused. These expanded monitors can be used to detect hemodynamic instability and are used to guide treatment. Until recently, these expanded monitors were reserved for high-risk patients because of the level of invasiveness and risks associated with their use. It is used to identify arrhythmias or myocardial ischemia, which can result in hypoperfusion and indicate the need for clinical intervention. Although the oximeter is used to recognize hypoxemia, the sigmoidal nature of the oxygen desaturation curve, SpO2 levels can remain relatively high for a period, followed by a rapid descent. It is typically reserved for moderate- to high-risk patients because of the risks associated with vessel cannulation. However, it is still widely used in moderate- to high-risk patients, as central lines are routinely placed in this setting primarily for administering drugs, rapid administration of fluid, and as a component of several clinical protocols. However, there are limitations in the use of this device, as the Doppler probe needs constant repositioning to obtain a good signal, which means that the measurements are operator dependent [10]. Although both bioimpedance and bioreactance show promise in healthy volunteers, studies in patients show low precision and agreement, making them unsuitable for clinical practice [15,16]. There is no confirmation, however, that the patient has adequate microvascular perfusion. The venous system can be divided into two theoretical compartments, the unstressed and the stressed volume. The unstressed volume is that volume that fills the vascular system up to a point where intravascular pressure starts to increase. In addition, the preoperative echocardiography shows mild pulmonary hypertension (systolic pulmonary artery pressure is 40 mmHg) and a moderate right ventricular dysfunction (right ventricle is slightly dilated). At the same time, we observed an increase in ScvO2 and in other hemodynamic parameters. The only abnormally low parameter was the ScvO2 (66%), indicating that there was a mismatch between oxygen consumption and oxygen delivery. In the absence of a simple hemodynamic monitoring system, it is more likely that fluid administration would have been different and would have resulted in a different outcome. Moreover, this helped to standardize hemodynamic management and to decrease the interindividual variability. Hemodynamic monitoring and management in patients undergoing high risk surgery: A survey among North American and European anesthesiologists. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: Randomised controlled trial. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients. Cardiac output estimation with a new Doppler device after off-pump coronary artery bypass surgery. Noninvasive pulse pressure variation and stroke volume variation to predict fluid responsiveness at multiple thresholds: A prospective observational study. The accuracy of noninvasive cardiac output and pressure measurements with finger cuff: A concise review.

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