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By: Raphael Dolin, MD, Maxwell Finland Professor of Medicine (Microbiology & Molecular Genetics), Harvard Medical School; Attending Physician, Beth Israel Deaconess Medical Center Brigham and Women's Hospital, Boston, Massachusetts
http://cvvr.hms.harvard.edu/dolin

The demonstration that neither the proximal His–Purkinje system nor the majority of ventricles are required to sustain the tachycardia purchase provera 2.5mg mastercard women's health issues news, and that supraventricular captures can occur without influencing the tachycardia buy provera 2.5mg with amex breast cancer 5k in washington dc, suggests that the tachycardia must occupy a relatively small and electrocardiographically silent area of the heart 2.5mg provera overnight delivery pregnancy 32 weeks. Resetting of Ventricular Tachycardia Resetting of a sustained rhythm is the interaction of a premature wavefront with the tachycardia resulting in advancement or delay of the original rhythm discount 200mg extra super viagra. As noted in the preceding paragraphs buy cheap super cialis on-line, extrastimuli delivered at long coupling intervals and/or pacing at slow heart rates approximating those of the tachycardia may fail to interact with the tachycardia order discount super viagra on line, resulting in a fully compensatory pause producing manifest or P. To reset a tachycardia, the impulse must be able to reach the tachycardia site of origin and find it excitable. In the case of a reentrant arrhythmia, an excitable gap (temporal and spatial) must exist between the leading edge of the tachycardia impulse and the wave of refractoriness following the impulse. The temporal excitable gap is the interval of excitability in milliseconds between the head of activation of one impulse and the tail of refractoriness of the prior impulse. The spatial excitable gap is the 311 distance occupied by the excitable gap in millimeters at any moment of time. The size of the spatial gap can vary greatly depending on the conduction velocity and refractoriness that determine the length of the excitable gap. It is impossible to assess the conduction velocity and refractoriness at any point in the circuit (which certainly must vary) with current technology. This is one of the limitations in interpreting accuracy of measurements of the excitable gap. This results in a pause, during which a sinus capture occurs subsequently followed by resumption of the tachycardia. The presence of pauses in excess of the tachycardia cycle length and the sinus capture without influencing the tachycardia defines concealed perpetuation. Continuing activity at the site of origin within the aneurysm is seen despite biventricular capture. Termination occurs when collision with the prior impulse antidromically is associated with orthodromic block (Fig. In the case of a reentrant arrhythmia, the range of coupling intervals over which resetting occurs can be considered a measure of the duration of the temporal excitable gap existing in the reentrant circuit. Overdrive pacing can be used to produce entrainment (or continuous resetting) of the reentrant 1 123 315 319 320 326 327 328 334 335 336 circuit. The entire zone of coupling intervals over which resetting occurs should also be evaluated as a measure of the duration of the excitable gap in the case of reentrant rhythms. The entire extent of the fully excitable gap would be the zone of coupling intervals from the onset of resetting until termination. Site specificity for resetting is another factor that may help discriminate mechanisms because rhythms that are due to triggered activity or automaticity do not exhibit site specificity.

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It is important to realize that a homicidal smothering may occur without leaving marks on the body as well generic provera 5 mg line women's health questions menopause. If possible order provera with visa women's health center tulare ca, it is always important to photograph infants as they are found order provera 2.5 mg on line menopause leg cramps, which allows for more accurate reconstruction of the terminal events (e purchase propecia 5mg overnight delivery. Vigorous resuscitation efforts buy cialis 20mg lowest price, which include chest compressions purchase 25 mg clomid visa, contribute to the formation of edema fuid, which is often blood-tinged due to rupture of small capillaries in the lungs. Oftentimes, the blood-tinged fuid is misinterpreted by scene investigation personnel as being suspicious of foul play. An intact upper frenulum with dried blood-tinged secretion around the left side of the Figure 5. The confuent burns/abrasions on his anterior chest refect application of defbrillator pad- dles during resuscitation. The blotchy red discoloration of the forehead and face (left side slightly greater than right side) might be inter- preted as livor mortis, but it is important to realize that vigorous resuscitative efforts may also alter the patterns of vascular congestion. The precise mechanism underlying the formation of petechiae remains elusive, but is believed to be related to the negative intrathoracic pressure created by terminal gasp- ing in infants. In this case, the petechiae, which appear as pinpoint hemorrhages, are particularly striking. Pertinent history included prematurity, maternal group B streptococcal infection, and a recent upper respiratory infection. The only signifcant fndings at autopsy were a moderately cellular mononuclear leptomeningeal exudate, consistent with a viral meningoencephalitis. This picture depicts prominent petechiae on the anterior epicardial surface of the heart. This picture shows sparse, inconspicuous petechiae on the visceral pleura and thymus, which were the only gross fndings at autopsy. Note the way that the hemorrhages conform to anatomic boundaries, similar to what is observed in aspiration of blood. Note also the confuent congestion within the posterior aspects of the lung, most likely a result of postmortem hypostasis, or settling of blood due to gravity. She had fnished a course of amoxicillin for otitis media 3 days prior to her death. On the day before her death, she apparently fell off a “teeter-totter” and struck her head on the ground, which was a muddy, grassy surface, but she never lost consciousness and experienced no mental sta- tus changes. She could not be aroused from an afternoon nap and could not be resuscitated following Pediatric Life Support protocol. The gross autopsy fndings were unre- vealing, including absence of scalp, skull, and brain inju- ries. This picture depicts a posterior neck dissection, demonstrating soft tissues and skeletal muscles that are free of injury. This case illustrates that the fndings of intrathoracic petechiae are not confned to infants but can also be seen in young children. These infants were shown not to be dehydrated by vitreous analyte determination and ante- mortem hospital chemistry testing.

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All subsequent minimally invasive procedures for incontinence have applied this principle of midoperative cystoscopy until the advent of the obturator tape in recent years buy provera 10mg line womens health 6 10. Modifications were inevitable and are difficult to identify in the literature—one notable exception is the use of silicone tubing rather than Dacron buy provera american express menopause baby, to reduce the infection risk [38] quality 5mg provera womens health center xenia ohio, inflammatory changes order cheap nizagara, and stones forming around the nylon threads generic 1 mg finasteride mastercard. Cervigny [39] and Mundy [40] advocated the passage of needles from below to reduce risk of bladder injury safe 80mg tadapox. This facilitates passage of the nylon suspensory sutures, (d) needle being passed downward onto the tip of surgeon’s finger lying alongside bladder neck, (e) positioning of the Dacron cuff, which will support the paraurethral tissues, (f) the bladder neck is checked endoscopically to ensure that sutures do not pass through the bladder and the effect of suture tension on bladder neck closure can be checked, (g) final positioning of the bladder neck after elevation of sutures. Raz In 1981, Shlomo Raz described his personal take on the Pereyra operation, which was slightly different to Stamey [42]. His underlying principle was to use the nonabsorbable suture to grasp and bind together the component layers of the endopelvic fascia and to use this to provide support. After preparing the patient in a similar way to a Stamey or Pereyra procedure, an inverted U incision is made over the urethra to expose the underlying urethrovesical angle or bladder neck. Dissection then continues—more extensively than with Stamey—to open the endopelvic fascia on either side of the bladder neck. This is achieved by passing the tips of scissors behind the pubic bone, about 2 cm lateral to the urethra, and while keeping the tips in close proximity to the back of the bone, passing them in the direction of the ipsilateral shoulder and then rotating more caudally to pass through the retropubic space to emerge onto the back of the rectus sheath, which is then penetrated. A finger can then be inserted into the defect, though some surgeons prefer to do this using a long handled instrument to minimize tissue disruption. The long handled needle is again used from above—passing downward through the retropubic space to reach the examining finger in the paraurethral defect and to pick up a nonabsorbable suture, which is pulled through to the suprapubic stab incision. However, before the second end is pulled through, three helical bites are taken with an attached needle to include three structures: the detached urethropelvic ligament/endopelvic fascia medially, the pubocervical fascia, and the subdermal layers of the vaginal wall. Once this suture is pulled together, the defect in the endopelvic fascia automatically closes and the tissues become elevated alongside the bladder neck. Endoscopy was not described by Raz, but of course, many who subsequently performed this operation adopted Stamey’s recommendation of cystoscopy along with Raz technique of tissue plication rather than graft insertion. Gittes Whether the Gittes operation [43] represents a significant modification of these two highly popular operations is unclear—certainly, it never achieved the same degree of popularity. Gittes essentially dispensed with the need for any vaginal dissection by applying the same technique as Raz in terms of needle passage, but with passage of the helical sutures directly through the vaginal wall. His hypothesis was that the paraurethral dissection suggested by Raz was unnecessary—indeed it created a defect that might or might not have already been present only to immediately repair it again. By placing the sutures directly into the vaginal skin, he was securing the same layers, but they would cut through the vaginal skin and become buried in the paraurethral tissues where they would provide support. It is not clear whether the lack of dissection was an advantage or disadvantage in providing tissue of adequate strength to hold the sutures in place (Figure 70. The Cochrane Review [49] on needle suspensions drew this conclusion after commenting that the quality of the studies was poor. Ten case series or cohort studies for Stamey are reviewed with follow-up ranging from 12 to 90 months [38,48,52–60]. Outcomes are reported with widely differing measures, some objective and other subjective, ranging from 20% objective cure at 2 years to 90% subjective cure at a mean of 38 months.

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Of interest is the low-amplitude electrical activity in the 70 to 80 msec between H and H′ buy provera women's health center in chicago, as well as the width and direction of H′ itself in the markedly slow conduction through this region generic provera 5 mg free shipping menstruation cramps. Furthermore discount 2.5 mg provera with visa women's health clinic columbus ohio, the alteration in A-V conduction is well hidden in an overall P-R interval of 160 msec buy antabuse 500 mg online. Two distinct His bundle deflections (H and H′) are seen buy apcalis sx cheap online, separated by an isoelectric interval of 260 msec purchase genuine zudena line. Note that both the A-H (proximal) interval and the H′ (distal)-V interval are normal, indicative of normal A-V nodal and infra-His conduction times. In contrast to A-V nodal block in two-to-one intra-His block, the P-R interval is usually normal in the absence of disease elsewhere in the conducting system. Moreover, atropine and exercise do not improve conduction, and may, in fact, worsen it. The clinical suspicion of intra-His disease should be heightened in the older (>60 years old) female patient, 25 particularly in the presence of a calcified mitral valve annulus P. We have also observed a high incidence of 23 coronary disease in our patients with symptomatic intra-His block although a cause and effect relationship of the coronary disease and intra-His block is uncertain. The clinical implications of second-degree intra-His block differ from those of A-V nodal block. Progression to high-grade or complete block may occur paroxysmally, with hemodynamic stability, depending on the emergence of a low junctional (distal His), fascicular, or idioventricular rhythm. Note that alternative A-H (proximal) complexes are not followed by H′ (distal)-V complexes with the impulse blocked within the His bundle distal to the H (proximal) recording site. A split His (H-H′) is seen in conducted complexes, and block between H and H′ is noted in every other complex. Failure of conduction (third-degree A-V block) that is due to intra-His block is a more common cause of chronic heart block in adults than is generally realized. It accounts for 17% of the cases of heart block referred to our 18 19 laboratories and 15% to 20% of the cases of complete heart block reported in other series. Syncope is a common presenting symptom , , , because the escape pacemaker is at or distal to the low A-V junction with a slow rate (usually less than 45 bpm) and is unresponsive to autonomic interventions. Because the escape rate is usually quite slow, these patients are almost always symptomatic with syncope or fatigue and shortness of breath. Because syncope may be related to an associated ventricular tachycardia, we believe symptomatic patients should be studied. Infra-His Conduction System The infra-His conduction system, which comprises the main bundle branches and fascicles, their ramifications, 18 and the Purkinje network, is the source of most of the clinically important heart block in adults. The His bundle is generally considered to trifurcate into the right bundle branch and the left bundle branch, which promptly fans 26 out into an anterior (superior) fascicle and a posterior (inferior) fascicle. However, because this fascicle probably contributes little to overall infra-His conduction, it is not discussed here. Although conduction disturbances can occur in each of the major fascicles, the integrity of overall A-V conduction can be maintained by a single functioning fascicle. Therefore, in this chapter the infra-His system is discussed as a single unit and the next chapter covers the implications of individual bundle branch and fascicular blocks.