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Oophorectomy should be done with woman’s consent following counselling of risks and benefits levitra oral jelly 20 mg for sale. This 45-year-old parous lady with a large fibroid was suffering from menorrhagia for a long time purchase levitra oral jelly 20 mg visa. Considering the risk of recurrence of myoma and the risk of recurrence of menorrhagia order levitra oral jelly 20 mg free shipping, myomectomy may not be a good option for this patienThat this age. Risks of prophylactic oophorectomy are: Onset of premature (surgical) menopause and other health hazards (osteoporosis, ischemic heart disease). Psychological morbidities (irritability, mood swing, insomnia and depression) are also there. In a patient aged 30 years with a smaller fibroid, what other options she could have? Epithelial tumor (70–80%) (a) Serous cystadenoma (b) Mucinous cystadenoma (c) Endometrioid tumors. Germ cell tumors of the ovary (15–20%) (a) Dysgerminoma (b) Endodermal sinus cell tumor (c) Choriocarcinoma (d) Teratoma : (i) Immature and (ii) mature (dermoid). Sex cord stromal tumors (3–5%) (a) Granulosa cell tumor (b) Theca cell tumor (c) Sertoli cell tumor (d) Leydig cell tumor (e) Fibroma. How can you differentiate a benign ovarian tumor from a malignant one clinically during examination as well as during laparotomy (Fig. Gynecology Case Discussion 325 Features suggestive of malignancy of an ovarian tumor during laparotomy are: (a) Ascites—Present and often it is hemorrhagic (b) Tumor on cut section; solid with hemorrhagic areas (c) Peritoneal and/or omental metastatic deposits—Present. Presence of ascites, right-sided hydrothorax (pleural effusion) in association with the presence of an ovarian tumor like fibroma, thecoma, Brenner or Granulosa cell tumor is called Meig’s syndrome. On bimanual examination how can you differentiate an ovarian tumor from a fibroid uterus? It is often associated with mucinous cyst adenoma of the ovary, mucocele of the appendix, gall bladder and also with intestinal malignancy. What are the guidelines for surgery during laparotomy for such a case of ovarian tumor? What are the different types of surgery that can be done in a case of benign ovarian tumor? The important factors considered are: (i) Age of the patient and her desire for future childbearing. Different types of surgery are: In a young patient (i) ovarian cystectomy or (ii) ovariotomy. What are the different modes of spread in a case of epithelial carcinoma of the ovary? However, nearly 60% of ovarian neoplasms found in the postmenopausal women are malignant. Germ cell tumors of the ovary are commonly seen in the young and adolescent girls (14–20 years of age). What are the different types of surgery that can be done in the management of a case with malignant ovarian tumor. What are the common chemotherapeutic agents used in the management of epithelial ovarian cancer? Single agent (a) Platinum compounds — Carboplatin and cisplatin (b) Taxane compounds — Paclitaxel and docetaxel (c) Alkylating agents—Ifosfamide and Cyclophosphamide B. Sex cord stromal tumor are known as ‘functioning tumors’ of the ovary as they produce hormones. She has also some amount of backache and dragging feel in the vagina and walking difficulty. Transverse vaginal sulcus is situated at the junction of urethrocele above and the cystocele below. The bladder sulcus is at the level of attachment of anterior vaginal wall to the cervix. Urinary symptoms Other gynecological symptoms • Dysuria • Vaginal fullness • Incomplete evacuation • Mass coming out of vagina • Urgency and frequency • Low backache • Pain during voiding • Bowel — Constipation • Stress urinary incontinence • Vaginal — Discharge/bleeding • Retention of urine • Dyspareunia Q. What other associated pathological conditions must be looked for during examination? Abdominal and pelvic examination for any pelvic mass, urinary incontinence, cystocele, rectocele, enterocele or decubitus ulcer. It is a trophic ulcer found at the dependent part of the prolapsed mass lying outside the introitus. Supravaginal part becomes elongated due to the tug of war between the cardinal ligaments to pull the uterus up and the weight of the uterus that makes it fall down through the vaginal axis. What are the anatomical changes in the urinary system in a case of genitourinary prolapse? How you can clinically differentiate a third degree uterine prolapse from a second degree one? On inspection, in both the degrees of prolapse, the mass protrudes out through the introitus and the leading part of the mass is the external os. The thumb of the left hand is placed anteriorly and the middle and the index fingers are placed posteriorly. The conditions are: (i) Women not fit for surgery (ii) Patient’s unwillingness for operation (iii) Women while waiting for operation (iv) Prolapse in early pregnancy (up to 18 weeks) (v) Prolapse in puerperium. What are the different types of surgery, that can be done in a case with genitourinary prolapse? Several factors are considered before adopting any particular method of Gynecology Case Discussion 333 surgery. These are mainly age, parity, need of childbearing, type of prolapse and degree of prolapse. The different types of surgery that are commonly done are: (a) Anterior colporrhaphy. This is mainly done for a young woman where preservation of the uterus is desired either for reproductive function or for menstrual function. Where childbearing function is not needed (family completed), this operation may be combined with (vaginal/abdominal) sterilization procedure. It is the stitch that fixes the Mackenrodt’s ligament to the anterior surface of the cervix to make the uterus anteverted. Complications of Fothergill’s operation (see table below): During operation Hemorrhage Injury to the bladder and rectum Postoperative Retention of urine or cystitis Hemorrhage—Primary or secondary Infection Contd… 334 Bedside Clinics and Viva-Voce in Obstetrics and Gynecology Contd… Late Dyspareunia Cervical stenosis-hematometra Infertility Cervical incompetency Cervical dystocia in labor Q. What are the complications of vaginal hysterectomy with pelvic floor repair operation? Postoperative (early): Retention of urine, Hemorrhage and urinary tract infection. Here the prolapse is due to congenital weakness of the supporting structures of the uterus.
Vagal efects frequently have entry of Ca2+ into cells during depolarization (afect- a very rapid onset and resolution buy cheap levitra oral jelly 20mg online, whereas sym- ing T- and L-type calcium channels) discount levitra oral jelly online master card, altering the pathetic infuences generally have a more gradual kinetics of its release and uptake into the sarcoplas- onset and dissipation discount 20 mg levitra oral jelly amex. Sinus arrhythmia is a cyclic mic reticulum, and decreasing the sensitivity of con- variation in heart rate that corresponds to respira- tractile proteins to Ca2+. Halothane and enfurane tion (increasing with inspiration and decreasing seem to depress contractility more than isofurane, during expiration); it is due to cyclic changes in sevofurane, and desfurane. Contraction of the atria normally The cardiac cycle can be defned by both electrical contributes 20% to 30% of ventricular flling. Systole refers waves can generally be identifed on atrial pres- to contraction and diastole refers to relaxation. A more accurate assess- be due to a pulling down of the atrium by ventricular ment can be obtained if the response of the cardiac contraction. Under these condi- side of the heart abolishes the x descent on that side, tions, failure of the cardiac output to increase and resulting in a prominent cv wave. The y descent fol- keep up with oxygen consumption is refected by lows the v wave and represents the decline in atrial a decreasing mixed venous oxygen saturation. The notch in the aor- A decrease in mixed venous oxygen saturation in tic pressure tracing is referred to as the incisura and response to increased demand usually refects inad- is said to represent the brief pressure change from equate tissue perfusion. Tus, in the absence 5 transient backfow of blood into the lef ventricle of hypoxia or severe anemia, measure- just before aortic valve closure. Heart Rate Discussions of ventricular function usually refer to When stroke volume remains constant, cardiac out- the lef ventricle, but the same concepts apply to the put is directly proportional to heart rate. Ventricular systolic function is ofen (errone- Normal intrinsic heart rate = 118 beats/min ously) equated with cardiac output, which can be − (0. Because the two ventricles function in Enhanced vagal activity slows the heart rate via series, their outputs are normally equal. Note that when the the muscle that is related to the force of contrac- heart rate and contractility remain constant, car- tion but is independent of both preload and afer- diac output is directly proportional to preload until load. Because the heart is a three-dimensional excessive end-diastolic volumes are reached. At that multichambered pump, both ventricular geometric form and valvular dysfunction can also afect stroke volume (Table 20–3 ). Preload Preload Ventricular preload is end-diastolic volume, which Afterload is generally dependent on ventricular flling. Excessive distention of either vascular capacity is normally its major determi- ventricle can lead to excessive dilatation and incom- nant. Changes in blood volume and Ventricular flling can be infuenced by a variety venous tone are important causes of intraopera- of factors (Table 20–4), of which the most impor- tive and postoperative changes in ventricular fll- tant is venous return. Any factor that alters the normally small venous pressure gradient favoring blood return to the heart also afects cardiac flling. Distribution of blood volume The most important determinant of right ven- Posture Intrathoracic pressure tricular preload is venous return. In the absence of Pericardial pressure signifcant pulmonary or right ventricular dys- Venous tone function, venous return is also the major deter- Rhythm (atrial contraction) minant of lef ventricular preload. Changes in central venous progressively becomes impaired at increased heart pressure can be used as a rough index for changes rates (>120 beats/min in adults). Absent (atrial in right and lef ventricular preload in most normal fbrillation), inefective (atrial futter), or altered individuals. Patients with reduced ventricular ation (early diastolic compliance) and passive 6 compliance are more afected by the loss of a stifness of the ventricles (late diastolic compli- normally timed atrial systole than are those with ance). Because of its normally relationship between ventricular volume and thinner wall, the right ventricle is more compliant pressure (ventricular compliance) is constant. Wall tension may be thought of as the pressure the ventricle must over- come to reduce its cavity volume. If the ventricle is assumed to be spherical, ventricular wall tension can be expressed by Laplace’s law: Less compliant Normal P × R Circumferential stress = 2 × H where P is intraventricular pressure, R is the ven- tricular radius, and H is wall thickness. Although More compliant the normal ventricle is usually ellipsoidal, this relationship is still useful. The larger the ventricu- lar radius, the greater the wall tension required to develop the same ventricular pressure. Conversely, an increase in wall thickness reduces ventricular Ventricular end-diastolic volume wall tension. Because viscoelastic ability of the myocardium to pump in the absence properties are generally fxed in any given patient, of changes in preload or aferload. Systolic blood pressure may also be used as In addition to its positive chronotropic efect, norepi- an approximation of lef ventricular aferload in the nephrine release also enhances contractility primar- absence of chronic changes in the size, shape, or ily via β -receptor activation. Such abnormalities Cardiac output is inversely related to large may be due to ischemia, scarring, hypertrophy, or changes in aferload on the lef ventricle; however, altered conduction. When the ventricular cavity small increases or decreases in aferload may have does not collapse symmetrically or fully, emptying no efecThat all on cardiac output. Hypokinesis (decreased contrac- thinner wall, the right ventricle is more sensitive tion), akinesis (failure to contract), and dyskinesis to changes in aferload than is the lef ventricle. Although con- 7 right or lef ventricular impairment is very tractility may be normal or even enhanced in some sensitive to acute increases in aferload. The latter is areas, abnormalities in other areas of the ventricle particularly true in the presence of drug- or ischemia- can impair emptying and reduce stroke volume. The induced myocardial depression or chronic heart severity of the impairment depends on the size and failure. In contrast, valvular regurgita- tion can reduce stroke volume without changes in preload, aferload, or contractility and without wall motion abnormalities. The efective stroke volume is reduced by the regurgitant volume with every con- traction. Ventricular Function Curves of this value requires a high-fdelity (“Millar”) ven- tricular catheter; however, it can be estimated with Plotting cardiac output or stroke volume against echocardiography. Although arterial pressure trac- preload is useful in evaluating pathological states ings are distorted due to properties of the vascular and understanding drug therapy. Normal right tree, the initial rate of rise in pressure (the slope) and lef ventricular function curves are shown in can serve as a rough approximation; the more proxi- Figure 20–6. B: Increasing preload with constant contractility and A: A single ventricular contraction. C: Increasing afterload with constant preload volume represents change in volume on the x-axis and contractility. D: Increasing contractility with constant (diﬀerence between end-systolic volume and end- preload and afterload. Arterioles are the small vessels L e f ventricular diastolic function can be that directly feed and control blood fow through 9 assessed clinically by Doppler echocar- each capillary bed. Capillaries are thin-walled ves- diography on a transthoracic or transesophageal sels that allow the exchange of nutrients between examination. Changes in systemic venous tone used to distinguish “pseudonormal” from normal allow these vessels to function as a reservoir for diastolic function.
To counter this levitra oral jelly 20mg overnight delivery, the follow- ing measure is proposed: These numbers give Phicoefficient: = 2 n buy levitra oral jelly visa, 187 − 32 Tau-a = = 01 20 mg levitra oral jelly for sale. Note that the concept of negative association is not relevant 187 − 32 in the case of polytomous nominal categories except for the order Tau-b = = 03. This section is restricted to two characteristics: one ante- Contingencycoefficient: C =. The results χ2 + n in this setup are easily described by a 2 × 2 contingency table, as shown in Table A. The notation in this table is as follows: Orc This cannot exceed unity but could also never be one, even when the is the observed frequency in the (r, c)th cell (r = 1, 2; c = 1, 2), association is perfect. The value of χ2, and hence of ϕ and of C, can and inside parentheses in each cell in the table are the correspond- be severely affected by the cutoff points of categories when they are ing probabilities. The dot in the subscript is for the corresponding for a variable on a metric scale. Prospective, retrospective, and cross-sectional studies provide three different situations for such a table, as described next. The row totals O and O become known 2 1• 2• The value of χ for the data in Table A. In terms of notations in Table quencies are proportionately decreased to one-ffth, rounded off to A. In this large difference between this value of χ2 for n = 200 and the previous case, π11 + π21 = 1 and π12 + π22 = 1. A pro- portionate decrease (or increase) in cell frequencies does not affect Structure in a Retrospective Study the degree of association but affects the value of χ2. For these data, The direction of the investigation in a retrospective study is from (a) For n = 1000, as in Table A. The null hypothesis now is that the rate of presence of antecedent in those with a positive outcome is the same Note that ϕ, C, and V for the two n’s are the same, while the value as in those with a negative outcome, i. Structure in a Cross-Sectional Study A major objection to the measures ϕ, T, C, and V is that they lack underlying substantive meaning. A measure of the degree of In this case, n subjects are simultaneously cross-classifed by the relationship in polytomous categories with a useful interpretation is antecedent and outcome. All these situations can be viewed as Antecedents and outcomes are defning features of all analytical subjects divided by two qualitative characteristics with the objec- studies, including prospective, retrospective, and cross-sectional tive to investigate if one characteristic has any association with the abortion rate/ratio 26 average linkage method of clustering other—whether one is occurring more commonly with the other noncommunicable conditions such as angina and asthma also have A than expected by chance. For example, This is commonly used when the exposure is for a limited period, the Student t-test requires that the observations follow a Gaussian such as during an epidemic, but can be used otherwise too. The term assumptions has come to stay, although the term requirements is a better description. This rate is generally used for diseases such as All statistical methods require random sampling in case a sam- measles and chickenpox that are infective for only a short period. This helps in working with probabilities—the the susceptible contacts after exposure to an infective case. Independence is violated when two the primary case, also called the proband, is infective for a long or more observations belong to the same person or to an identif- period, as in tuberculosis, the duration of exposure becomes impor- able affnity group. Thus, these are practically ating the effectiveness of control measures such as isolation and independent. As an example, con- that symmetry and single mode are no guarantee that the obser- sider the risk of diabetes in nondiabetic siblings of children diag- vations follow a Gaussian distribution. In many cases with large samples, Gaussianity is before 16 years of age and interviewed during 1999–2002. This are those who were initially affected, and secondary cases are those applies to sample means and several other measures. It is not related to the repeated episodes yet delin- tions are not satisfed, alternative approaches such as nonparamet- eates the communicability. These are valid under milder conditions nice to be familiar with different contexts in which a term can be but generally have less statistical power. Secondary attack rate of type 1 diabetes in Colorado effciency of estimators families. This applies to those mea- The extent of morbidity in a group of people can be measured in sev- surements that cannot be made with suffcient accuracy. In the case of acute conditions, particularly infections, it be able to anticipate this error in your investigation. The same person ables are glaring examples of variables that can hardly be measured can have two or three attacks of diarrhea or of cold in 1 year. Some accurately; medical measurements such as blood pressure and pulse abortion rate/ratio 27 average linkage method of clustering rate are also known to contain errors when measured, particularly 2. In the laboratory, the quality of correlation correction factor in a microarray cross-platform A reagents and chemicals can affect accuracy. Reliabilities risk, and population attributable fraction depend on measurement error. This correction may not work well when the difference in the risk among the exposed and the nonexposed reliability drops below 0. If the risk of lung cancer among those smoking for 10 years be measured using a valid procedure. If you have an opportunity to fnd the errors attributable to smoking is the difference, i. This can also be (ex and ey) by comparing with standard values or otherwise, you understood as the risk difference and is also called absolute risk can fnd reliability as follows: reduction. For studying any risk, var(x)v− ar()ex Rel(x) = , information on outcome is obtained for any given risk. Sample size is n1 for those with the antecedent and n2 for hypothesis testing, since its sampling distribution is not those without the antecedent. An application of a disattenuated correlation is seen in a microar- n n ray cross-platform study by Archer et al. This suggested that the cross-platform Structure of a Study for Attributable Risk: Independent correlations reported in previous studies without this correction were underestimates. The authors concluded that it is essential to Samples evaluate intraplatform reproducibility while estimating a cross-plat- Antecedent form correlation. Effect sizes and the disattenuation of correla- Present a (π11) b (π12) O1•(π1•) tion and regression coeffcients: Lessons from educational Absent c (π21) d (π22) O2•(π2•) psychology. This indicates a very strong association of lung cancer deaths with heavy smok- Thus, ing and underscores the importance of smoking in the etiology of lung cancer. During 1951–1961, elimination of heavy smoking These formulas are the same as for a difference in proportions in a among British male doctors would have reduced the cause-specifc matched pairs setup. Thus, the therapy seems to increase the 1-week relief Also note that the risk of death by lung cancer in nonsmokers rate by 20%. With a dichotomous ante- Without Therapy (Control Group) cedent and outcome, the data in matched pairs would appear as in With Therapy Relieved Not Relieved Table A. For example, if • Risk in a statistical sense does not necessarily refer to an hypertension is responsible for 30% of the risk of myocardial infarc- adverse outcome. The term want to see this in action, see, for example, the work of Cosgrove et protective effect is used for such a factor.