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Bruce Kendall Burnett, PhD

• Associate Professor in Medicine
• Core Faculty in Innovation & Entrepreneurship
• Member of the Duke Clinical Research Institute

https://medicine.duke.edu/faculty/bruce-kendall-burnett-phd

There are indications that this is due to prevention and/or correction of the dilution coagulopathy (Beekley 2008 pregnancy diet plan discount 60mg evista fast delivery, Gonzalez 2007 breast cancer 3 day san diego purchase evista 60 mg fast delivery, Hardy 2004 womens health warner robins ga order 60 mg evista fast delivery, Holcomb 2008 menstruation cup discount 60 mg evista with mastercard, Johansson 2009, Johansson 2010). In the study by Johansson (2009), for example, the following transfusion schedule was used: 5 erythrocytes units: 5 plasma units: 2 platelet units (from 5 donors) in bleeding patients who received > 10 erythrocyte units/24 hours. This strategy of administering several components is usually referred to as multi component transfusions or as the administration of transfusion packages (Madjdpour 2006, Hirschberg 2008, Holcomb 2008). Apart from the logical reasoning that this strategy proactively prevents haemostatic dilution in massively bleeding patients, these studies do not clearly show which volume of fluid/colloids or erythrocyte transfusion should be started with. Studies of battle field situations also use fresh full blood transfusions or erythrocyte transfusion < 15 days old. The improved survival due to a transfusion policy with a relatively high plasma-erythrocyte ratio has also not been confirmed in all situations of massive blood loss (Scalea 2008, Dirks 2010). Finally, there is discussion about whether the association of a high ratio of plasma-erythrocytes with improved survival is the result of improved survival (bias) instead of the other way around (Snyder 2009). Prospective randomised research is desirable before definitive exact recommendations can be made (Johansson 2010). Level 3 C Hirschberg 2008, Johansson 2009,2010, Holcomb 2008 Multi-component transfusions in patients with massive blood loss are associated with improved survival. Level 3 C Hirschberg 2008, Holcomb 2008, Murad 2010, Roback 2010, Snyder 2009 A transfusion policy with set ratios of erythrocytes/plasma and platelets appears to increase survival in the case of decompensated massive blood loss when combined with the basic measures of resuscitation. Level 3 C Johansson 2009, Murad 2010, Roback 2010, Johansson 2010, Saltzherr 2011 174 Blood Transfusion Guideline, 2011 There are indications that transfusion of erythrocytes and plasma units in equal quantities, to gether with approximately one third of that volume in platelet units (concentrate from 5 donors), results in improved survival. However, it is not yet clear what the optimum ratio is and when is the best Level 3 time to start a multi-component policy for massive blood loss. C Johansson 2009 en 2010, Beekley 2008, Holcomb 2007, Gonzalez 2007; Hardy 2004, Saltzherr 2011 5. If a normovolemic (and oxygenated) state can be maintained, the patient will not go in to shock and this is called a compensated situation. The lowest acceptable limit for acute anaemia due to blood loss has not been determined in humans, because this depends on the speed of blood loss and the physiological capacity and the therapeutic measures to accommodate for the blood loss. The Hb value is only reliable once the circulating blood volume has been res to red. If the blood loss has been controlled by optimising haemostasis, the erythrocyte mediated oxygen transport becomes the major fac to r in the policy. However, it is not yet possible to measure accurately the transfusion-related improvement of low oxygen transport and tissue oxygenation. As the local (from organ to organ) oxygen extraction at a tissue level (particularly in the case of sepsis and ischaemic multiple organ failure) can differ from the systemic oxygen extraction, it may be necessary in future to consider basing the decision to transfuse and the moni to ring of the efficacy on oxygenation measured in target organs (S to well 2009). There are data available about the critical limits for tissue oxygenation in experiments with acute normovolemic haemodilution; this is a compensated situation with corrected circulating volume (normovolemia), good oxygenation and normothermia. This applies to these circumstances in healthy volunteers, for both the heart function and the brain function (Weiskopf 1998). This concentration is mentioned in the literature as the limit below which cerebral function abnormalities occur (Madjdpour 2006). A prerequisite is that normovolemia, normothermia and oxygen Level 2 supply are maintained. B Weiskopf 1998, Madjdpour 2006 C Madjdpour 2006 There are indications that the Hb level is reliable as soon as the circula to ry blood volume has been res to red. Level 3 C Elizalde 1997, Wiesen 1994 There are indications that cerebral function abnormalities occur at an Hb level lower than 3 mmol/L. Level 3 C Madjdpour 2006 Partly due to the limited value of the Hb measurement, particularly in the case of persistent bleeding, there is little evidence to indicate the Hb concentration at which erythrocytes need to be transfused. C Fenger-Eriksen 2009, 2008, Rossaint 2010 Fibrinogen preparations are usually not necessary with a multi-component transfusion policy (so-called transfusion packages with set ratios erythrocytes/plasma/platelets), provided these are used aggressively and in a timely manner. However, the advice is increasingly to provide extra and faster compensation of the clotting-dependent haemostasis if surgical haemostasis cannot be achieved in the short term. The use of anti-fibrinolytics (tranexamic acid) appears to have a positive effect on mortality due to massive blood loss with severe trauma. However, confirmation of this in a setting more similar to that in the Netherlands is desirable before a definitive recommendation of tranexamic acid in trauma patients. It should be noted that directing the transfusion policy based on thrombo elas to graphy/elas to metry has never been validated. It is crucially important to have a good agreement with the labora to ry about the communication and the procedure to be followed for massive blood loss. Citrate in to xication In the case of massive plasma transfusion, citrate in to xication can occur, which is characterised by hypotension, increase in end ventricular dias to lic pressure and increase in central venous pressure. In patients with liver failure, citrate is metabolised more slowly and the risk of hypocalcaemia is greater. Hyperkalaemia Potassium release from erythrocytes takes place during s to rage which raises the potassium concentration in the s to rage solution; this should be taken in to consideration in the case of massive transfusions, particularly in patients with renal insufficiency. Correct haemostasis with multi-component transfusions in ratios as listed under recommendation 7. Administer multi-component transfusions, for example in a 3:3:1 ratio between erythrocytes/plasma/platelets. Aim for normothermia (preheat blood components and infusion solutions if possible). Correct the calcium level with Ca-gluconate when administering large quantities of transfusion components that contain citrate. If a cell saver is present, consider washing the erythrocytes for transfusion; this can lower the potassium level. Base transfusion policy on labora to ry determinations as soon as possible especially in the case of less severe blood loss or when the delay between sample collection and test result is acceptable. The erythrocyte transfusion policy can then be based on the 4-5-6 rule (see Table 5. Examples are placental abruption, intra abdominal blood loss due to an ec to pic pregnancy, uterine rupture or placenta percreta. There are also more women with co-morbidity which can disrupt uterine contraction after childbirth (uterine a to nia); Acquired or congenital clotting abnormalities can also make blood loss during childbirth or post partum more severe. Trauma to the birth canal, uterus a to nia or (partial) retention of the placenta are examples of causes of post partum haemorrhage. Disseminated intravascular coagulopathy should always be considered in pregnant women with massive blood loss. In addition to the general treatment for shock with rapid intravenous infusion of crystalloids and/or colloids (Hofmeyr 2001), blood and blood components, adequate diagnosis and treatment of the underlying cause is essential (Huissoud 2009, Ahonen 2010, Charbit 2007).

Diet: Normal Medications: Topical decongestants like Afrin should be not taken for more than 5 days continuously due to rebound effect breast cancer 5 year pill purchase cheapest evista. Prevention and Hygiene: Avoid diving hoods women's health center yonkers ny discount 60 mg evista fast delivery, equalize ears often pregnancy levels evista 60 mg without prescription, avoid forceful Valsalva women's health center dallas evista 60mg free shipping. An enclosed, gas-filled cavity in the body is susceptible to injury from the expansion or compression of the gas if it cannot equalize to the outside pressure. Middle ear injuries are the most frequent, but several other areas are subject to barotrauma, primarily on descent. Dental fillings or caries that have air trapped in the teeth can cause pain called dental barotrauma. The lining of the sinuses can be pulled off the bone allowing the cavity to fill with blood. Poorly fitting dry suits can have air trapped in folds and wrinkles that will compress at depth, sucking skin in to fill the vacuum (skin barotraumas/suit squeeze). If a diver does not equalize the vacuum in the facemask during descent, a mask squeeze may result. Subjective: Symp to ms Dental barotrauma (barodontalgia): Pain in teeth usually presents on descent. Sinus barotrauma: Usually occurs in maxillary and frontal sinuses and presents with pain over affected sinus or in maxillary teeth. Pressure on ascent can occur (reverse squeeze), usually secondary to mucosal polyps or plugs. Predisposing conditions include sinusitis, upper respira to ry infections, mucosal polyps, deviated septum, nasal polyps, smoking, persistent use of to pical decongestants, and allergies. Skin barotrauma: Pain and bruising on skin in areas of fold from a poorly fitting dry suit. Objective: Signs Using Basic Tools: Sinus barotrauma: Pain over sinus with percussion. Transient, bloody nasal discharge, or blood in mask, transillumination of sinus can occasionally reveal fluid in the sinus. Facemask squeeze: Bruising in area of mask seal, conjunctival and scleral hemorrhages. Sinus barotrauma: S to p dive and surface slowly, to pical and systemic pain relief as necessary. If bleeding does not s to p, pack turbinates with gauze coated in antibiotic ointment in the opening of the affected sinus. If packing material is left in more than one hour, patient must be prescribed a prophylactic antibiotic. Sinus barotrauma: Explain how sinuses can become blocked and force blood vessels to leak while under increasing pressure. Consultation Criteria: Dental barotrauma requires dental consult prior to returning to diving. When the body is decompressed, the nitrogen comes out of solution to form bubbles in the vasculature or tissues. When the body is decompressed to o fast in relation to the nitrogen load (based on time and depth of dive; listed extensively in the Navy Dive Tables), to o many bubbles can form. Objective: Signs Using Basic Tools: Perform a complete dive his to ry and neurological exam per the example in the appendix. Numbness, pain, weakness or paralysis of limbs, diminished or absent reflexes, decreased cognitive function, poor coordination, ataxia, hearing loss, vomiting, tachypnea, coughing; unconsciousness. Assessment: Differential Diagnosis: Arterial gas embolism, myocardial infarction, trauma, pulmonary embolus and many others. If patient is pregnant, benefit of recompression treatment needs to outweigh risks to unborn child (possible: retrolental fibroplasia, in utero death, birth defects). If the patient is obviously dehydrated, an initial 1L bolus of normal saline may be given (for an otherwise healthy patient). Follow algorithm at end of this section (Figure 6-1) for no improvement or deteriortion. If it appears that the patient has died in the chamber, a qualified medical person who may examine and pronounce someone dead must be consulted prior to aborting the recompression treatment. Alternate: Submarine escape pod may be used if no hyperbaric chamber is available. Commence consulted before committing to a oxygen breathing Treatment Table 4 or 7. For worsening Complete treatment the greatest chance of resuscita symp to ms on Table 6 tion, consultation with a Diving (Note 5) Medical Officer is required as soon as possible (see paragraph Yes Complete 30 min. Recompression chamber must be to depth of relief or treatment gas on surfaced to perform defibrillation. Additional time may be required not to exceed 90 (Note 1) according to paragraph 21-5. Decompress on Decompress to 60 Table 4 to 60 feet feet not greater than 1 foot per minute. Complete Life Treatment Table threatening 6A (Note 2) symp to ms and No Complete Table 4 more time needed (Note 1) at 60 feetfi Prevention and Hygiene: Follow decompression tables, stay fit, avoid alcohol, avoid trauma, limit medica tions. Patient should remain at recompression chamber facility for 6 hours, and be within one hour of chamber for 24 hours following recompression treatment in case further treatment is needed. Gas can then enter the pleural space (pneumothorax), mediastinum (mediastinal emphysema), pulmonary venous system (creating emboli) and other tissues. Neurological: Numb to : Light/deep to uch, pain/temperature, proprioception, vibration, two-point tactile discrimination; decreased strength or paralysis, including hemiparesis or hemiplegia; diminished reflexes; decreased mental functioning. Fully conscious patients may be given po fluids: two liters of water, juice or non carbonated drink, over the course of a Treatment Table 6, is usually sufficient. Be prepared to immediately treat clinically diagnosed pneumothorax with 14-16-gauge needle (needle thoracentesis) and chest tube while at depth or while surfacing (See Procedure: Thoracos to my). Activity: Lay supine during travel and recompression to minimize neurological damage. Recom pression as soon as possible is the best treatment to prevent permanent damage. Evacuation Consultation Criteria: A Diving Medical Officer should be consulted as soon as possible. As a diver depletes the residual gas from his tanks or from his lungs (breath hold diving), the partial pressure of oxygen in the diver drops insidiously, causing hypoxia and unconsciousness. The increased ambient pressure during descent and at depth also increases the partial pressure of oxygen and other gases. At depth, the elevated partial pressure of oxygen delays the onset of the physiological, hypercapnia-induced drive to breathe. By the time that drive induces him to surface, the diver may have stayed to o long at depth. He may then have insufficient oxygen to sustain him during ascent as the partial pressure of oxygen decreases quickly. Divers with an underwater breathing apparatus are trained to surface with residual oxygen in their tanks to avoid this danger. Subjective: Symp to ms Light-headedness, confusion, tingling, or numbness Objective: Signs Using Basic Tools: Brief period of confusion and ataxia preceding unconsciousness, which is often the first sign. Place patient on 100% oxygen, maintain oxygen until full recovery, and then slowly wean. Patient Education General: Educate divers on hypoxia and shallow water blackout Diet: Normal Prevention and Hygiene: Education and training in diving practices. Objective: Signs Using Basic Tools: Pulmonary: Dyspnea, non-productive cough, diminished air exchange (cannot blow out a match or candle 12-14 inches away). Only one sign may present or several of the signs may present: V Visual disturbances (blurred or tunnel vision), E Ears (tinnitus), N Nausea, T Twitching/tingling (often seen around the eyes and mouth), I Irritability, D Dizziness, C Convulsions ( to nic-clonic), often without warning. If convulsions occur at depth, slowly bring patient to surface with regula to r in mouth while compressing the abdomen. Patient Education General: Oxygen can be to xic for prolonged exposure and at high partial pressures.

In the adult womens health fair 60 mg evista visa, representative lymphoid tissue found in and around mucosal preexisting memory B cells surviving in other tissues menstruation gas order discount evista online. In the child pregnancy portraits evista 60 mg online, there is less likely to be a help defend against pathogenic infection menstruation and fatigue generic 60 mg evista with amex. The lack of splenic lymphoid tissue to process antigen greatly decreasesthe opportunity for 2. Obstruction of the appendix lumen is the primary cause of B-cell activation and further production of plasma cells and appendicitis, leading to tissue distention from excessive memory B cells. The most common cause of immunoglobulin production and decreased complement luminal obstruction is lymphoid follicle hyperplasia, at times fixation associated with the classical component pathway. Medical care involves antibiotic prophylaxis, immunizations, bacterial invasion within the appendix wall, with high aggressive management of the suspected infection, and polymorphonuclear cell reactivity and resultant inflammation. Antibiotic prophylaxis is initiated immediately upon the diagnosis because patients are 3. Standard therapy involves removal of the inflamed appendix considered immunocompromised. Patients should receive through a procedure aptly named appendec to my; serious standard immunizations, especially conjugated H. Asplenic patients are at appendix can lead to peri to nitis from leakage of trapped an increased risk for sepsis, especially from gram-positive bacteria in to the abdomen. Parents must be educated to remain vigilant to occur, comprising a swollen mass filled with fluid and detect symp to ms of infection so that early detection will allow bacteria and pus (dead and dying neutrophils trying to aggressive management. Peri to neal bacteria often release endo to xins, such as lipopolysaccharides, contributing to septic events and the possibility of secondary organ failure. Multiple myeloma (also called plasma cell myeloma)isa progressive cancer of the plasma cell, a mature B cell that functionally produces immunoglobulins. The deficiency is a compromise of both the reticuloendothelial plasma cells in the bone marrow and overproduction of system and adaptive immunity due to the congenital absence intact monoclonal immunoglobulin (of any isotype) or of a spleen. The major shortcoming is a loss of mononuclear Bence-Jones protein (circulating monoclonal k and l light phagocytes to clear pathogenic organisms from the blood. Becausethemyeloma Secondarily, there is a loss of B and T-cell mass, which cells are identical, they all produce the same immunoglobulin ultimately may be largely compensated at the level of systemic protein, called monoclonal (M) protein, in large quantities. The individual is predisposed to morbidity and mortality from encapsulated organisms such as 2. Transformation of a B cell to a malignant plasma cell involves Strep to coccus pneumoniae, Haemophilus influenzae,and processes that generate genetic abnormalities, sometimes Neisseria meningitides (meningococcus), which require including translocation of chromosomes near the heavy antibody response for protection. The outcome is that malignant cells are allowed 162 Case Study Answers to divide unchecked. Myeloma cells that invade bone can overlap with early stages of graft rejection; however, in this establish masses, or plasmacy to mas, that produce growth case the cause was viral. Immunosuppression is the critical fac to rs and vascular endothelial growth fac to r to promote pos to perative fac to r that predisposes to infection in transplant angiogenesis. Eventually, multiple small lesions form and recipients, as agents dampen immune function; patients spread in to large bone cavities throughout the body, giving typically remain on low levels of therapeutics for the rest of rise to anemia and reduced polymorphonuclear cell production their lives. These hypergammaglobulinemia comes at the relative expense of molecules, also referred to as major his to compatibility normal immunoglobulin production. These molecules present combined with anemic and neutropenic conditions, raises antigen to T lymphocytes as a method of regulating immune susceptibility to pyogenic bacteria requiring specific response. In addition to parainfluenza virus, other community-based respira to ry viruses are commonly found in immunosuppressed 1. DiGeorgesyndromeisarareformofprimaryimmunodeficiency, transplant patients, including influenza, respira to ry the basis for which is congenital absence or aplasia of the syncytial virus, herpesvirus, varicella virus, and adenovirus. Migration of activated polymorphonuclear cells and lymphocytes to sites of inflammation requires expression of 3. The prognosis depends on the severity of T-lymphocyte selectins on endothelial cells and concurrent binding by compromise. Directed diapedesis ensues severe immunodeficiency are the second most common through integrin interactions. Lack of levels are typically normal, the functionality of the B-cell leukocyte function antigen-1 would result in similar immune response is limited owing to lack of help from antigen-specific deficiency. Common infections manifest as ear and recep to r on myeloid cells (for C3b), assisting with sinus infections, pneumonia, infectious diarrhea, and severe phagocy to sis and efficient microbicidal activity in neutrophil, thrush (Candida). Antibiotic treatment assists in the short term, monocyte, and macrophage populations. Bacterial infections and severe immunoreactive T lymphocytes contribute to destruction of viral infections are responsible for most deaths. This common bacterial agents are the Staphylococcus species in turn assists in the production of au to antibodies from and enteric gram-negative bacteria. Ultimately, this leads to disease agents (such as Candida albicans) is also common. Sodium ion channels, which boost electrical charges between nerves, are clustered at the nodes of Ranvier. Omenn syndrome is an au to somal recessive form of severe are not able to boost impulses. It is not clear why some au to immune events occur in molecular defect is linked to defects in either of the everyone, yet not everyone develops au to immune disease. The inability to productively fac to rs most likely renders individuals more susceptible to rearrange exons required for T and B-cell recep to rs leads disease manifestation. It is also likely that environmental to poorly functional T cells and absent B cells. A higher incidence of malignancies occurs, most likely normal immune and hema to poietic function in patients due to loss of regulating cy to to xic lymphocytes. The major complications include increased susceptibility to infection from antibiotics are warranted. Bone marrow transplantation is opportunistic organisms or latent viral entities due to lack of usually successful to reconstitute immune surveillance; mature lymphocytes specific to ward off infecting agents. Multiple sclerosis is a disease of the central nervous system on recipient tissue. In all cases, labora to ry tissue typing and that affects the nerves of the brain and spinal cord. Myelin, mixed-lymphocyte reactions (culturing donor and recipient produced in the brain and spinal cord by oligodendrocytes, cells to gether) would be performed to ascertain reactivity forms a protective coat around axons, allowing nondisruption between new and existing cell populations. Aggressive penicillin females using tampons, primarily when saturated tampons antibiotic therapy is warranted with accompanying surgical are not changed often, allowing unchecked growth of debridement. Because the organism is anaerobic, hyperbaric chamber treatment (O2-rich atmosphere) is useful. The superantigens staphylococcal entero to xin and to xin-1 are responsible for to xic shock syndrome. Because the number of T cells that share Vb multinucleated cells that are surrounded by lymphocytes, domains is high (up to 10% of all T cells), large numbers of forming the basis of a tubercle. Immunologic responses to the T cells (regardless of antigen specificity) may be activated persisting organism trigger destructive pathology and by superantigens, causing massive release of cy to kines and necrotic events, leaving a caseous center to the granuloma. The overwhelming number of cy to kines released from activated T cells caused a cascade of effects at both local and 2. A social worker would stimula to ry fac to r for T cells, thus furthering the cascade of have greater exposure to mycobacteria from indigent T-cell activity. In this patient, vascular endothelium and increased vascular permeability, smoking for many years most likely impaired native lung thus contributing to hypotensive shock in the patient as fluid macrophage function, contributing to the progression from accumulation in vascular beds occurred. Because of the slow growth doubling of mycobacteria (18 to and induction of acute-phase protein production. This was 24 hours), therapeutic intervention is made over a lengthy manifested by elevated enzyme levels, which were further period.

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Distention and tenderness increased as stage) and/or diarrhea obstruction increases Functional Gastrointestinal Disorders 203 2 menstruation that wont stop evista 60 mg otc. Perforated peptic ulcer ical examination will often be suficient to lead to the diagnosis of most common disorders womens health boulder purchase evista cheap online. Local women's health clinic darwin discount evista 60mg fast delivery, right-sided tenderness or mass on rectal that occurs at least weekly for at least 2 months examination where there is no evidence of an infiamma to ry women's health issues in politics cheap 60 mg evista visa, 6. Unclear mechanism of pain; multifac to rial, testicles altered brain-gut interaction 9. Multifaceted problem that includes predis hours position aggravated by early life events or a. Greater incidence in girls than boys; average often not helpful in diagnosing appendicitis, age for females 9 to 10 years, males 10 to but can rule out other sources of pain 11 years 2. Certain personality traits (maladaptive cop workup should reassure them child is healthy ing skills, anxiety, internalization of feelings) 2. Onset of crampy or dull ache; no radiation of medications and functional abdominal pain of pain 5. Interferes with activities, but no night techniques; may need referral to behavior wakening psychologist. Excellent his to ry and physical examination pression can be useful in relief of symp to ms. Additional/selected studies may be warranted depending on symp to ms Irritable Bowel Syndrome a. Tethered spinal cord and other neuropathic reabsorbed in to the colon; a cycle of s to ol disorders holding and painful s to ols occurs, resulting 6. Emphasize to parents the definition of consti pass meconium in first 24 hours; his to ry of pation; straining with soft s to ol in infancy is failure to have bowel movement without normal aid of laxative or enema; short-segment 2. May choose oral medications for disim Southeast Asia paction, polyethylene glycol 3350, 1 to 3. May be bilateral; if unilateral, right side (See Health Maintenance and Health Pro more common motion, Chapter 3) c. Cautious intake of food and water when palpation of the spermatic cord over the traveling to endemic area pubic tubercle, the layers of the peri to d.

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