By S. Amul. Niagara University. 2019.
The effect of procaine amide on components of excitability in long mammalian cardiac Purkinje fibers purchase imodium 2 mg visa. The effects of procainamide on conduction in anisotropic canine ventricular myocardium imodium 2 mg cheap. Effects of digitalis on the human sick sinus node after pharmacologic autonomic blockade generic imodium 2mg free shipping. Clinical effects of digoxin on sinus node and atrioventricular node function after pharmacologic autonomic blockade. The direct electrophysiologic effects of disopyramide phosphate in the transplanted human heart. The electrophysiological effects of intramuscular guinidine on the atrioventricular conducting system in man. Comparison of the antiarrhythmic efficacy of disopyramide and mexiletine against stimulus-induced ventricular tachycardia. Effects of intravenous and oral disopyramide on paroxysmal atrioventricular nodal tachycardia. Effect of procainamide, mexilitine, and propranolol on ventricular activation time recorded at cardiac mapping in chronic canine myocardial infarction. Electrophysiologic effects of procainamide on sinus function in patients with and without sinus node disease. Electrophysiologic effects of disopyramide phosphate in patients with Wolff-Parkinson-White syndrome. Comparative electrophysiologic effects of intravenous and oral procainamide in patients with sustained ventricular arrhythmias. Effect of procainamide and N-acetylprocainamide on atrial flutter: studies in vivo and in vitro. Effect of propafenone in the Wolff-Parkinson-White syndrome: electrophysiologic findings and long-term follow-up. Suppression of incessant supraventricular tachycardia by intravenous and oral encainide. Clinical usefulness of flecainide acetate in the treatment of paroxysmal supraventricular arrhythmias. Comparative effects in man on ventricular arrhythmia and electrocardiographic intervals. Electrophysiologic effects and clinical efficacy of oral propafenone therapy in patients with ventricular tachycardia. Treatment with oral lorcainide in patients with sustained ventricular tachycardia and fibrillation. Electrophysiologic effects of flecainide acetate and its major metabolites in the canine heart. Acute electrophysiological effects of flecainide acetate on cardiac conduction and refractoriness in man. Clinical efficacy and electrophysiologic effects of encainide in patients with Wolff-Parkinson-White syndrome. Electrophysiologic and clinical effects of intravenous and oral encainide in accessory atrioventricular pathway. Propafenone for refractory ventricular arrhythmias: correlation with drug plasma levels during long-term treatment. Electrophysiologic effects of cibenzoline in humans related to dose and plasma concentration. Effect of autonomic blockade on ventricular refractoriness and atrioventricular nodal conduction in humans. Evidence supporting a direct cholinergic action on ventricular muscle refractoriness. Amiodarone for control of sustained ventricular tachyarrhythmia: clinical and electrophysiologic effects in 51 patients. The electrophysiology and pharmacology of verapamil, flecainide, and amiodarone: correlations with clinical effects and antiarrhythmic actions. Effect of amiodarone on conduction and refractoriness of the His-Purkinje system in the human heart. Acute and chronic effects of amiodarone on ventricular refractoriness, intraventricular conduction and ventricular tachycardia induction. Efficacy of amiodarone in the Wolff-Parkinson-White syndrome with rapid ventricular response via accessory pathway during atrial fibrillation. Usefulness of electrophysiologic study to determine the clinical tolerance of arrhythmia recurrences during amiodarone therapy. Electrophysiologic effects of amiodarone: experimental and clinical observation relative to serum and tissue drug concentrations. Use of amiodarone in the treatment of persistent and paroxysmal atrial fibrillation resistant to quinidine therapy. Clinical efficacy and electrophysiology during long-term therapy for recurrent ventricular tachycardia or ventricular fibrillation. Effects of oral amiodarone on rate-dependent changes in refractoriness in patients with Wolff-Parkinson-White syndrome. Effects of isoproterenol and amiodarone and the role of exercise in initiation of circus movement tachycardia in the accessory atrioventricular pathway. Electrophysiologic basis for the suppression by amiodarone of orthodromic supraventricular tachycardias complicating pre-excitation syndromes. Electrophysiologic properties and antiarrhythmic mechanisms of intravenous N-acetylprocainamide in patients with ventricular dysrhythmias. A comparison of the electrophysiologic effects of intravenous and oral amiodarone in the same patient. Electrophysiologic evaluation of the antiarrhythmic effects of N-acetylprocainamide for ventricular tachycardia secondary to coronary artery disease. Effects of oral verapamil in patients with atrioventricular reentrant tachycardia incorporating an accessory pathway. Verapamil for control of ventricular rate in paroxysmal supraventricular tachycardia and atrial fibrillation or flutter: a double-blind randomized cross-over study. Effects of verapamil on ventricular tachycardias possibly caused by reentry, automaticity, and triggered activity.
The test discount imodium 2mg mastercard, attributed mainly to Mood (2) and Westenberg (3) discount 2 mg imodium overnight delivery, is also discussed by Brown and Mood (4) buy cheap imodium 2mg line. Members of a random sample of 12 male students from a rural junior high school and an independent random sample of 16 male 13. To determine if we can conclude that there is a difference, we perform a hypothesis test that makes use of the median test. The assumptions underlying the test are (a) the samples are selected independently and at random from their respective popula- tions; (b) the populations are of the same form, differing only in location; and (c) the variable of interest is continuous. As will be shown in the discussion that follows, the test 2 statistic is X as computed, for example, by Equation 12. When H0 is true and the assumptions 2 2 are met, X is distributed approximately as x with 1 degree of freedom. The first step in calculating the test statistic is to compute the common median of the two samples combined. We now determine for each group the number of observations falling above and below the common median. If the two samples are, in fact, from populations with the same median, we would expect about one-half the scores in each sample to be above the combined median and about one-half to be below. If the conditions relative to sample size and expected frequencies for a 2 Â 2 contingency table as discussed in Chapter 12 are met, the chi-square test with 1 degree of freedom may be used to test the null hypothesis of equal population medians. Since 2:33 < 3:841, the critical value of x2 with a ¼ :05 and 1 degree of freedom, we are unable to reject the null hypothesis on the basis of these data. We conclude that the two samples may have been drawn from populations with equal medians. We note that if n1 þ n2 is odd, at least one value will always be exactly equal to the median. One solution is to drop them from the analysis if n1 þ n2 is large and there are only a few values that fall at the combined median. Or we may dichotomize the scores into those that exceed the median and those that do not, in which case the observations that equal the median will be counted in the second category. Median Test Extension The median test extends logically to the case where it is desired to test the null hypothesis that k! If 2 conditions as to sample size and expected frequencies are met, X may be computed and compared with the critical x2 with k À 1 degrees of freedom. Reducing an observation’s information content to merely that of whether or not it falls above or below the common median is a waste ofinformation. If, for testing the desired hypothesis, there is available a procedure that makes use of more of the information inherent in the data, that procedure should be used if possible. Such a nonparametric procedure that can often be used instead of the median test is the Mann–Whitney test (5), sometimes called the Mann–Whitney–Wilcoxon test. Since this test is based on the ranks of the observations, it utilizes more information than does the median test. The two samples, of size n and m, respectively, available for analysis have been independently and randomly drawn from their respective populations. Hypotheses When these assumptions are met we may test the null hypothesis that the two populations have equal medians against either of the three possible alternatives: (1) the populations do not have equal medians (two-sided test), (2) the median of population 1 is larger than the median of population 2 (one-sided test), or (3) the median of population 1 is smaller than the median of population 2 (one-sided test). If the two populations are symmetric, so that within each population the mean and median are the same, the conclusions we reach regarding the two population medians will also apply to the two population means. Fifteen laboratory animals served as experimental subjects, while 10 similar animals served as controls. We wish to know if we can conclude that prolonged inhalation of cadmium oxide reduces hemoglobin level. To compute the test statistic we combine the two samples and rank all observations from smallest to largest while keeping track of the sample to which each observation belongs. Tied observations are assigned a rank equal to the mean of the rank positions for which they are tied. Critical values from the distribution of the test statistic are given in Appendix Table L for various levels of a. If the median of the X population is, in fact, smaller than the median of the Y population, as specified in the alternative hypothesis, we would expect (for equal sample sizes) the sum of the ranks assigned 13. For this example the decision rule is: Reject H0 if the computed value of Tis smaller than 45, the critical value of the test statistic for n ¼ 15; m ¼ 10, and a ¼ :05 found in Table L. When we enter Table L with n ¼ 15; m ¼ 10, and a ¼ :05, we find the critical value of wa to be 45. This leads to the conclusion that prolonged inhalation of cadmium oxide does reduce the hemoglobin level. When this is the case we may compute T À mn=2 z ¼ pﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ (13. Mann–Whitney Statistic and the Wilcoxon Statistic As was noted at the beginning of this section, the Mann–Whitney test is sometimes referred to as the 13. Indeed, many computer packages give the test value of both the Mann–Whitney test (U) and the Wilcoxon test (W). These two tests are algebraically equivalent tests, and are related by the following equality when there are no ties in the data: mmþ 2n þ 1 U þ W ¼ (13. As we see this output provides the Mann–Whitney test, the Wilcoxon test, and large-sample z approximation. Group 1 subjects were employed by the City of Asheville, North Carolina, and group 2 subjects were employed by Mission– St. At the start of the study, the researchers performed the Mann–Whitney test to determine if a significant difference in weight existed between the two study groups. Weight (Pounds) Group 1 Group 2 252 215 240 185 195 220 240 190 302 310 210 295 205 270 312 212 190 202 200 159 126 238 172 268 170 204 268 184 190 220 170 215 215 136 140 311 320 254 183 200 280 164 148 164 287 270 264 206 214 288 210 200 270 170 270 138 225 212 210 190 265 240 258 182 192 203 217 221 225 126 Source: Data provided courtesy of Carole W. May we conclude, on the basis of these data, that patients in the two groups differ significantly with respect to weight? Prior to treatment, researchers studied the blood gas levels in the two groups of rats. May we conclude, on the basis of these data, that, in general, subjects on saline have, on average, lower pO2 levels at baseline?
Recent studies have begun to enhance our understanding of the impact of mesh implantation on the morphology buy generic imodium 2mg, composition purchase imodium 2mg otc, and biomechanical behavior of the vagina buy discount imodium 2mg online. Further, Gynemesh significantly increased the number of apoptotic cells in the subepithelium and adventitia layers, rising from 0. Overall the impact of mesh was apparent, as a majority of apoptotic cells were located around the individual mesh fibers. Interestingly, changes in vaginal morphology and apoptosis were less pronounced following the lower-stiffness UltraPro and Restorelle implantation. Gynemesh also negatively impacted the composition of the extracellular matrix, decreasing collagen and elastin content by 20% and 43%, respectively. While UltraPro and Restorelle were not detrimental to collagen content, UltraPro induced a decrease in elastin content by as much as 49%. Overall, these results clearly demonstrate that the vagina undergoes a maladaptive remodeling response following mesh implantation with heavier-weight, lower-porosity, and higher-stiffness meshes elicite the most detrimental changes. The degenerative response was the most consistent with a phenomenon referred to as stress shielding, a mechanosensitive phenomenon in biological tissues, which results in thinning of the tissues associated with a prosthesis. Alternatively, degradation could be the end result of chronic inflammation associated with a foreign body response. Regardless of the mechanism, these findings are consistent with processes that result in degradation of the vagina, predisposing vaginal tissue to mesh exposure. Here, the red signal represents positive staining of alpha-smooth muscle actin, the green signal represents apoptotic cells, and the blue signal represents nuclei. Further, increased apoptosis was observed surrounding the mesh (mesh designated by M). Nearly all meshes groups tested reduced smooth muscle contractility relative to sham samples. UltraPro and Restorelle also interfered with smooth muscle contractility; however, such negative effects were much less than that observed with Gynemesh. Passive properties, typically representing the mechanical integrity of fibrillar extracellular matrix proteins (collagen and elastin), were evaluated via ball burst testing, as typical planar mechanical tests are invalid for composite mesh– tissue structures of these dimensions. Accounting for the combined stiffness of both mesh and tissue, Gynemesh significantly reduced the passive mechanical integrity of the tissue, decreasing the estimated stiffness of the vagina to almost 0 N/mm, nearly a 10-fold reduction . This result suggests that Gynemesh implantation nearly abolishes the mechanical integrity of underlying and associated vagina in agreement with reports of decreased total collagen and elastin content following mesh implantation . Overall, mesh implantation appears to be detrimental to the mechanical properties of the vagina, particularly with the heavier-weight, lower-porosity, and higher-stiffness devices. This is concerning as 1382 degradation of the vaginal smooth muscle, collagen, and elastin (key constituents of vaginal tissue) are already thought to be compromised in women with prolapse . Ideally, mesh implantation would enhance or, at minimum, maintain the supportive capabilities of the vagina, though synthetic mesh, as currently utilized, has the potential to damage native vaginal tissue. Thus, the majority of current data in the literature, as well as vendor marketing pamphlets, use legacy methods to demonstrate biocompatibility of prolapse mesh products, by implanting synthetic mesh in the abdominal wall. While there is great utility in such studies, namely, verifying a lack of outright host rejection, the abdominal wall and pelvic floor are quite dissimilar in regard to the biologic environment and the mechanical demands placed on a mesh implant. Because the current generation of synthetic mesh is based on the technology developed for abdominal hernia repair, it is deemed compatible for prolapse repair based on premarket characterization, yet the transfer of this technology from abdominal use to reconstruction of the pelvic organ support leaves much room for optimization. As such, current urogynecologic mesh is largely a prototype solution rather than an optimal one, as evident by the complications associated with mesh implantation. Despite the distinct differences between the abdominal wall and the vagina, many of the design changes responsible for recent reductions in prolapse mesh complications have directly resulted from findings in the abdominal wall. Perhaps the most important concepts shown to impact the host response to synthetic meshes in urogynecologic applications are material type, filament type, and pore size. Material Type Since the introduction of the first synthetic nylon sling in the 1950s, urogynecological grafts have been constructed from a variety of materials, resulting in a wide range of outcomes . These materials include polyethylene terephthalate (Mersilene), polypropylene (Marlex), polytetrafluoroethylene (Teflon), and expanded polytetrafluoroethylene (Gore-Tex) . Ex vivo and in vitro studies have shown that these materials are nontoxic and have a high tensile strength, demonstrating their ability to be used in reconstructive pelvic surgeries. Though the material chosen for mesh construction likely plays a role in dictating the host response, additional structural features of a mesh design have confounded the impact of many graft materials. For instance, Teflon and Gore-Tex experienced disastrous results as prolapse meshes. The distinctive trait for these materials was poor integration with host tissues, and while the ease of removal was initially touted as a benefit, Gore-Tex was plagued with numerous complications of alarming severity . Gore-Tex slings were reported to have a removal rate of at least 35%, with a significant number of sinus tract formations (10%), in addition to infections and reports of vaginal exposures . Similarly, in a large prospective multicenter trial, Gore-Tex was found to be a significant risk factor for mesh exposure into the vagina following sacrocolpopexy [19,27]. Still, the failure of Gore-Tex is likely due to the small pore size (<10 μm) used in this product rather than the polymer itself. Another material that has been linked to poor clinical outcomes is polyethylene terephthalate, a polyester polymer. This polymer was used to construct a graft using a woven, multifilament construction technique and manufactured as Mersilene. Although Mersilene was associated with increased rates of exposure and infection relative to other meshes, surgeons continued to use this material until recently. Interestingly, Mersilene slings also had numerous complications including infection, exposure, erosion, and fistula formation, though manufacturers and surgeons failed to appreciate the problems associated with the use of polyester attempting to overcome the problem by coating it with silicone (marketed as the Protegen sling) . As more data was published on the problems associated with this material, it was gradually been pushed out of the market. Our current understanding of host response to mesh suggests that the adverse host response to Mersilene is likely due to interstices as small as 1 μm that arise from the woven textile construction, rather than the use of polyethylene terephthalate per se. It is thought that such small spaces harbor bacteria because immune cells cannot easily pass into these areas, leading to chronic infection, inflammation, mesh exposure, 1383 erosion, and fistula formation. In the recent decades, polypropylene has become the primary material for synthetic mesh used in incontinence and prolapse surgeries. Unlike the woven construction used for polyethylene terephthalate, polypropylene mesh is most often knitted. Initial studies found polypropylene to elicit a strong inflammatory response including fibrotic tissue formation and multinucleated giant cells (i.
A reconstructed cystoplastic reservoir discount 2 mg imodium, partial or total imodium 2 mg with mastercard, may be controlled by the sphincter mechanism sphincter-cystoplasty or it may be emptied by intermittent catheterization of a leak-proof conduit stoma-cystoplasty (Figure 112 purchase imodium 2mg. Internal urinary diversion controlled by the anal sphincter—ureterosigmoidostomy: For some patients, a rectosigmoid urinary diversion is a preferable alternative to surface diversion when the circumstances are appropriate. For nephrological and carcinogenic reasons, this procedure fell into disrepute for a number of years but procedural developments have addressed some of the potential problems: these include the limitation of renal damage and the early detection of malignant change  (Figure 112. When satisfactory sphincteric control of a cystoplasty is irretrievable, many alternative procedures such as catheterizable stoma-cystoplasty reservoirs enable patients to achieve a reasonably acceptable quality of life. The surgical procedures of cystoplasty and of continent diversion have evolved as a result of the great endeavors and contributions of numerous colleagues over the years—whole textbooks have been 1670 written about them. However, the value of the terminological distinction between cystoplasty and continent diversion is questionable because the functional requirements and the surgical principles of creating their reservoirs are essentially similar. Cystoplasty is a generic term for a reconstructive procedure (plasty) to recreate the functional capacity of a bladder reservoir (cysto). Like the term urodynamics, cystoplasty is commonly used, understood, and misunderstood to mean different things. This adds additional confusion to the already complex field of the retrieval and the construction of functional urinary reservoirs. Some simple cystoplasty operations restore the natural functional reservoir capacity of the bladder without involving any substitution procedure and not all substitution procedures involve the use of bowel. Other tissues used in substitution include the stomach  and dilated ureter . Attempts at using tissue-engineered substitutes are still at early stages and require considerable development [78,79]. However, the term cystoplasty is commonly used somewhat loosely, as a semispecific shorthand to denote the substitution of the bladder reservoir, partial or total, generally with the tacit assumption that bowel is used for the substitution and also that the functional control of the outlet is the natural urethral sphincter mechanism. Developments in the surgical retrieval of the natural bodily function of intermittent urinary waste disposal often involve the creation of catheterizable leak-proof abdominal stoma conduits that are used for the intermittent emptying, either of normal bladders when the urethra is irremediably dysfunctional or of substitution urinary reservoirs that are either partially or totally reconstructed. Thus, an integrated reconsideration of the practical principles of cystoplasty and diversion seems appropriate, together with an integrated reconsideration of terminology. A urethra-cystoplasty is a reconstructed urinary reservoir, the outlet of which is the urethra. When this is controlled by the sphincter, it is a sphincter-cystoplasty; if it is emptied by self-catheterization, it is a simple urethra-cystoplasty. The reservoir of a sphincter-cystoplasty may be either a partial or a total substitution of the bladder. If bowel is used for the substitution, it can be optionally identified as an ileal sphincter-cystoplasty or a colonic sphincter-cystoplasty—as opposed to an omental urethra-cystoplasty. A stoma-cystoplasty is a urinary reservoir with an abdominal stoma-conduit outlet. Its continence is usually maintained by a valved leak-proof conduit that can be catheterized intermittently. The reservoir may be the native bladder—a partial substitution in situ or a total substitution that is either in situ or ex situ. Alternatively, a stoma-cystoplasty can be less precisely described as a continent diversion. The functional characteristics and the principles involved in the construction of the bowel substitution urinary reservoirs of both a stoma-cystoplasty and a sphincter-cystoplasty are essentially similar; the difference is simply the mechanism of their evacuation. A leak-proof stoma conduit is a mechanistic construction specifically designed for emptying the reservoir by catheterization. The reliable sphincteric control of a sphincter-cystoplasty is often dependent upon a careful urodynamic assessment and appropriate surgical adjustment and management: this requires quite separate consideration. Whether or not this terminology will be generally adopted, time will tell; it seems preferable to the ill-defined continent diversion. A particular advantage is that it facilitates an independent analytical consideration of the three separate component procedure principles of cystoplastic reconstruction: 1672 Figure 112. Cystoplasty, stoma-cystoplasty, and sphincter-cystoplasty—a perspective of urinary reservoirs that are emptied intermittently. The creation of a urinary reservoir that has low-pressure and reflux-proof ureteric implantations (these requirements are common to the reservoirs of both a sphincter-cystoplasty and a stoma- cystoplasty). The intricate mechanistic construction of a valved leak-proof stoma conduit that is required for the evacuation of the reservoir of a stoma-cystoplasty by self-catheterization. A functionally orientated urodynamically controlled adjustment is often required to ensure the voiding efficiency and sphincteric control of a sphincter-cystoplasty. Ureteral injury in gynecologic surgery: A ten-year review in a community hospital. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. A pyelographic study of ureteric injuries sustained during hysterectomy for benign conditions. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. J ournal de l’Association francaise d’urologie et de la Societe francaise d’urologie November 2012;22:913–919. Transition in yield and azimuthal shape modification in dihadron correlations in relativistic heavy ion collisions. 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