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In addition antiviral for chickenpox cheap famciclovir 250 mg mastercard, follistatin levels increase in follicular fluid with increasing growth of the follicle hiv aids infection rates uk discount famciclovir 250mg free shipping, a mechanism for decreasing activin activity hiv timeline of infection famciclovir 250mg with mastercard. In the mature granulosa of the dominant preovulatory follicle antiviral birth control buy famciclovir 250 mg with amex, activin serves to prevent premature luteinization and progesterone production. The successful follicle is characterized by the highest estrogen (for central feedback action) and the greatest inhibin production (for both local and central actions). The highest level of gene activity encoding activin B is found in immature antral follicles and the lowest level in preovulatory follicles. It is not certain which form of inhibin plays a key role, but as with circulating levels of inhibin, inhibin B is 153 the predominant inhibin in the follicular fluid of growing follicles. The growth factors assume an important, but perhaps not essential, role as facilitating agents. The Preovulatory Follicle Granulosa cells in the preovulatory follicle enlarge and acquire lipid inclusions while the theca becomes vacuolated and richly vascular, giving the preovulatory follicle a hyperemic appearance. Approaching maturity, the preovulatory follicle produces increasing amounts of estrogen. During the late follicular phase, estrogens rise slowly at first, then rapidly, 154 155 reaching a peak approximately 24–36 hours prior to ovulation. An increase in progesterone can be 51 detected in the venous effluent of the ovary bearing the preovulatory follicle as early as day 10 of the cycle. This small but significant increase in the production of progesterone in the preovulatory period has immense physiologic importance. Prior to the emergence of this follicular progesterone, the circulating level of 157 progesterone was derived from the adrenal gland. The traditional view has been that progesterone receptors are expressed in response to estrogen through an estrogen-receptor mediated mechanism. Progesterone affects the positive feedback response to estrogen in both a time and dose dependent manner. Hence, the surprising onset of ovulation occasionally observed in an anovulatory, amenorrheic woman administered a prgestin challenge. Appropriately low levels of progesterone derived from the maturing follicle contribute to the precise synchronization of the midcycle surge. Nevertheless, blockade of midcycle progesterone synthesis or activity in the monkey impaired the ovulatory process and 163 luteinization. The preovulatory period is associated with a rise in plasma levels of 17a-hydroxyprogesterone. This steroid does not appear to have a role in cycle regulation, and its appearance in the blood simply represents the secretion of an intermediate product. After ovulation, some theca cells become luteinized as part of the corpus luteum and lose the ability to express P450c17. Other luteinized theca cells retain P450c17 activity and are believed to continue to produce androgens for aromatization to estrogens. Because the products of thecal tissue are androgens, the increase in stromal tissue in the late follicular phase is associated with a rise in androgen levels in the peripheral plasma at midcycle. There is a 15% increase in androstenedione and a 20% increase in 164 testosterone. Androgen production at this stage in the cycle may serve two purposes: 1) a local role within the ovary to enhance the process of atresia, and 2) a systemic effect to stimulate libido. Therefore, androgens may play a regulatory role in ensuring that only a dominant follicle reaches the point of ovulation. If the midcycle rise in androgens affects libido, then an increase in sexual activity should coincide with this rise. Early studies failed to demonstrate a consistent pattern in coital frequency in women because of the effect of male partner initiation. If only sexual behavior 165 initiated by women is studied, a peak in female-initiated sexual activity is seen during the ovulatory phase of the cycle. The coital frequency of married couples has 166 also been noted to increase at the time of ovulation. Therefore, the midcycle rise in androgens may serve to increase sexual activity at the time most likely to achieve pregnancy. A midcycle increase in local and peripheral androgens occurs, derived from the thecal tissue of lesser, unsuccessful follicles. Ovulation the preovulatory follicle, through the elaboration of estradiol, provides its own ovulatory stimulus. Considerable variation in timing exists from cycle to cycle, even in the same woman. Ovulation occurs primarily in the morning during Spring, and primarily in the evening during Autumn and Winter. From July to February in the Northern Hemisphere, about 90% of women ovulate between 4 and 7 P. The gonadotropin surge stimulates a large collection of events that ultimately leads to ovulation, the physical release of the oocyte and its cumulus mass of granulosa 171 cells. This is not an explosive event; therefore, a complex series of changes must occur which cause the final maturation of the oocyte and the decomposition of the 172 collagenous layer of the follicular wall. Activin also suppresses progesterone production by luteal cells, providing yet another means of preventing premature luteinization. The oocyte enables cumulus cells to respond to the gonadotropin-induced physical and biochemical changes just before ovulation. The local factors that prevent premature oocyte maturation and luteinization are probably under control of the oocyte. In addition to its central effects, progesterone increases the distensibility of the follicle wall. A change in the elastic properties of the follicular wall is necessary to explain the rapid increase in follicular fluid volume, which occurs just prior to ovulation, unaccompanied by any significant change in intrafollicular pressure. The escape of the ovum is associated with degenerative changes of the collagen in the follicular wall so that just prior to ovulation the follicular wall becomes thin and stretched. The gonadotropin surge also releases histamine, and histamine alone can induce ovulation in some experimental models. The granulosa and theca cells produce plasminogen activator in response to the gonadotropin surge. Plasminogen is activated by either of two plasminogen activators: tissue-type plasminogen activator and urokinase-type plasminogen activator. These activators are encoded by separate genes and are also regulated by inhibitors. Plasminogen activators produced by granulosa cells activate plasminogen in the follicular fluid to produce plasmin. Thus, before and after ovulation, the inhibitor activity is high, while just at ovulation, activator activity is high and the inhibitors are at a nadir. The molecular regulation of these factors is necessary for the coordination that leads to ovulation. The inhibitor system, which is very active in the thecal and interstitial cells, prevents inappropriate activation of plasminogen and disruption of growing follicles. The inhibitor system has been demonstrated to be present in human granulosa cells and preovulatory 177, 178 and 179 follicular fluid and to be responsive to paracrine substances, epidermal growth factor and interleukin-1b. Movement of the follicle destined to ovulate to the surface of the ovary is important in that the exposed surface of the follicle is now prone to rupture because it is separated from cells rich in the plasminogen inhibitor system. Ovulation is the result of proteolytic digestion of the follicular apex, a site called the stigma. Prostaglandin synthesis is stimulated by interleukin-1b, implicating this cytokine in ovulation. Prostaglandins may also contract smooth muscle cells that have been identified in the ovary, thereby aiding the extrusion of the oocyte-cumulus cell mass. This role of prostaglandins is so well demonstrated that infertility patients should be advised to avoid the use of drugs that 186, 187 inhibit prostaglandin synthesis. Neutrophils are a prominent feature in the theca compartment of both healthy and atretic antral 188 189 follicles. The accumulation of leukocytes is mediated by chemotactic mechanisms of the interleukin system. These immune cells probably contribute to the cellular changes associated with ovulation, corpus luteum function, and apoptosis. The low midcycle levels of progesterone exert an inhibitory action on further granulosa cell multiplication, and the drop in estrogen may also reflect this local follicular role for progesterone. Finally, estrogen can exert an inhibitory effect on P450c17, a direct action on the gene that is not receptor-mediated.

These steps in the fusion process will occur only with sperm that have undergone the acrosome reaction hiv aids infection rate zimbabwe buy 250 mg famciclovir free shipping. Fusion of the sperm and oocyte membrane is followed by the cortical reaction and metabolic activation of the oocyte antiviral cold sore cream discount famciclovir 250mg with mastercard. An increase in intracellular free calcium in a periodic highest infection rates of hiv/aids order famciclovir 250 mg free shipping, oscillatory pattern always precedes the cortical reaction and oocyte activation at fertilization hiv infection rate by country famciclovir 250mg fast delivery, and this is believed to be the mechanism by which the 50, 78 spermatozoon triggers these developmental events. A soluble sperm protein, called oscillin, has been identified in the equatorial segment of the sperm head that 79, 80 may be the signaling agent for the critical calcium oscillations. The initiation of the block to penetration of the zona (and the vitellus) by other sperm is mediated by the cortical reaction, another example of exocytosis with the 81 release of materials from the cortical granules, lysosomelike organelles that are found just below the egg surface. As with other lysosomelike organelles, these materials include various hydrolytic enzymes. Changes brought about by these enzymes lead to the zona reaction, the hardening of the extracellular layer by 82 cross-linking of structural proteins, and inactivation of ligands for sperm receptors. The initial change in this zona block is a rapid depolarization of the oocyte membrane associated with a release of calcium ions from calmodulin. The increase in intracellular calcium acts as a signal or trigger to activate protein synthesis in the oocyte. The depolarization of the membrane initiates only a transient block to sperm entry. The permanent block is a consequence of the cortical reaction and release of enzymes, also apparently triggered by the increase in calcium. The second polar body is released and leaves the egg with a haploid complement of chromosomes. The addition of chromosomes from the sperm restores the diploid number to the now fertilized egg. The chromatin material of the sperm head decondenses, and the male pronucleus is formed. The male and the female pronuclei migrate toward each other, and as they move into close proximity the limiting membranes break down, and a spindle is formed on which the chromosomes become arranged. Human gene expression (transcription) 85 begins between the 4- and 8-cell stages of preimplantation cleavage, 2–3 days after fertilization. The clinician is interested not only in how normal fertilization takes place but also in the occurrence of abnormal events that can interfere with pregnancy. It is worthwhile, therefore, to consider the failures that occur in association with in vivo fertilization. A surgical method was used to flush the uterus of regularly cycling rhesus monkeys, and 9 preimplantation embryos and 2 unfertilized eggs were recovered from 22 87 flushes. Two of the 9 embryos were morphologically abnormal and probably would not have implanted. Hendrickx and Kraemer used a similar technique in the 88 baboon and recovered 23 embryos, of which 10 were morphologically abnormal. This suggests that, in nonhuman primates, some ovulated eggs are not fertilized 89 and that many early embryos are abnormal and, in all likelihood, will be aborted. Similar findings have been reported in the human in the classic study of Hertig et al. They examined 34 early embryos recovered by flushing and examination of reproductive organs removed at surgery. Ten of these embryos were morphologically abnormal, including 4 of the 8 preimplantation embryos. Because the 4 preimplantation losses would not have been recognized clinically, there would have been 6 losses recorded in the remaining 30 pregnancies. When the loss of fertilized 91 oocytes before implantation is included, approximately 46% of all pregnancies end before the pregnancy is clinically perceived. In the postimplantation period, if only clinically diagnosed pregnancies are considered, the generally accepted figure for spontaneous miscarriage in the first trimester 92 is 15%. The fact that only 1 in 200 newborns has a chromosome abnormality attests to the powerful selection mechanisms operating in early human 52 gestation. In each ovulatory cycle, only 30% of normally fertile couples can achieve a pregnancy. Sperm penetration of the zona pellucida depends on a combination of sperm motility, an acrosomal proteinase, and binding of sperm head receptors to zona ligands. Binding of sperm head receptors and zona ligands produces an enzyme complex that induces the acrosome reaction, releasing enzymes essential for the fusion of the sperm and oocyte membranes. Fusion of the sperm and oocyte membranes triggers the cortical reaction, the release of substances from the cortical granules, organelles just below the egg cell membrane. The cortical reaction leads to the enzyme-induced zona reaction, the hardening of the zona and the inactivation of ligands for sperm receptors, producing an obstacle to polyspermy. Cell division begins promptly after fertilization; human gene expression begins between the 4- and 8-cell stages. Implantation and Placentation A normal pregnancy is, of course, impossible without successful implantation and placentation. Because there are differences among the various species, we will 93 focus on the physical and biochemical events that are relevant in human reproduction. Shortly after the 8-cell morula enters the uterine cavity about 4 days after the gonadotropin surge and 3 days after ovulation, a blastocyst (a preimplantation embryo of varying cell number, from 30 to 200) is formed. Implantation (the embedding of the blastocyst in the endometrial stroma) begins with the loss of the zona pellucida (hatching) about 1–3 days after the morula enters the uterine cavity. Preparation for Implantation the change from proliferative to secretory endometrium, described in detail in Chapter 4, is an essential part of achieving the receptive conditions required for implantation. The primary endocrine requirement is the presence of progesterone; in the monkey, implantation and pregnancy can be achieved in the absence of 94 luteal phase estrogen. This change is the histologic expression of many biochemical and molecular events. The endometrium is 10–14 mm thick at the time of implantation in the midluteal phase. By this time, secretory activity has reached a peak, and the endometrial cells are rich in glycogen and lipids. Understanding the dynamic endocrine behavior of the endometrium (Chapter 4) increases the appreciation for its active participation in the implantation process. The window of 47, 95, 96 and97 endometrial receptivity is restricted to days 16–22 of a 28-day normal cycle, and days 16–19 of cycles stimulated by exogenous gonadotropins. Endometrial receptivity is heralded by formation of pinopodes, surface epithelial microvilli that exhibit a cystic change, appearing and regressing during the window of 98 receptivity. The pinopodes may serve to absorb fluid from the uterine cavity forcing the blastocyst to be in contact with the endometrial epithelium. Even before the blastocyst adheres to the surface epithelium, but after hatching from the zona pellucida, a dialogue between the mother and the early embryo has 99 begun. Function of the corpus luteum is crucial during the first 7–9 weeks 103 of pregnancy, and luteectomy early in pregnancy can precipitate abortion. Another substance secreted very early by the preimplantation embryo is platelet-activating factor, perhaps part of the immunosuppressive activity required 105 to induce maternal tolerance of the embryo. It is not surprising that various growth factors are produced by the early embryo. Indomethacin prevents the increase in endometrial vascular permeability normally seen just prior to implantation. Additional evidence for a role by prostaglandins in the earliest stages of implantation is the finding of increased 108 concentrations at implantation sites, similar to any inflammatory response. The blastocysts of mice, rabbits, sheep, and cows produce prostaglandins, and 109 prostaglandin E2 release from human blastocysts and embryos has been demonstrated. The secretory endometrial epithelial cells are also a source of prostaglandin E2 (but not prostaglandin F2a), and its synthesis may be stimulated by the tissue response that accompanies implantation. However, decidual synthesis of prostaglandins is significantly reduced compared with proliferative and secretory endometrium, apparently a direct effect of progesterone activity and perhaps a 108 requirement in order to maintain the pregnancy. Nevertheless, prostaglandin E 2 synthesis is increased at the implantation site, perhaps in response to blastocyst 108, 110 factors, e. In the rabbit, platelet-activating factor also induces the 111 production of early pregnancy factor (discussed above). As discussed in Chapter 4, the many cytokines, peptides, and lipids secreted by the endometrium are interrelated through the stimulating and inhibiting actions of estrogen and progesterone, as well as the autocrine/paracrine activities of these substances on each other. The response to implantation certainly involves the many members of the growth factor and cytokine families.

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The antibodies in the immunoassay how the hiv infection cycle works order 250mg famciclovir visa, however antiviral for herpes zoster buy 250mg famciclovir free shipping, are able to recognize a sufficient portion of the molecule to return a normal answer antiviral uk release trusted 250mg famciclovir. Another very rare possibility is an inherited disorder of gonadotropin synthesis leading to the production of immunologically active but biologically 45 inactive hormones hiv infection symptoms early buy famciclovir 250mg line. Extremely low or nondetectable gonadotropins are seldom found, usually only with large pituitary tumors or in patients with anorexia nervosa. Further evaluation, therefore, is in order and follows the recommendations for low gonadotropins. This is achieved by imaging evaluation of the sella turcica for signs of abnormal change. The intention of this workup is to be conscious of cost and to isolate those few patients who require sophisticated but expensive imaging. This means that small tumors (microadenomas are less than 10 mm in diameter) need not be treated at all. Hence, the initial x-ray evaluation for amenorrheic patients with or without galactorrhea is the coned-down lateral view of the sella turcica. This will detect the presence of a large tumor, although an incredibly rare suprasellar extension might escape this method. The coned-down lateral view of the sella is also a good screen for other lesions, such as a craniopharyngioma. Combining this screening technique with the prolactin assay, we are able to select those few patients who require more sensitive sellar imaging. A double floor of the sella is often seen on the coned-down view and, in the absence of enlargement and/or demineralization, is interpreted as a normal variation rather than asymmetrical depression of the sellar floor by a tumor. Although they are usually bifrontal, retro-orbital, or bitemporal, no locations or features are specific for pituitary tumors. The prolactin level of 100 ng/mL for determining a more aggressive approach has been empirically chosen. Both in our own experience, and that of others, large tumors are most frequently associated with prolactin levels greater than 100 ng/mL. Large masses associated with prolactin levels less than 100 ng/mL are more likely to be tumors other than prolactin-secreting adenomas, causing stalk compression and interruption of the normal dopamine regulation of prolactin secretion. These tumors will be associated with abnormal changes present in the coned-down view of the sella turcica. The above approach to the problem of pituitary tumors implies that patients with prolactin levels less than 100 ng/mL and with normal coned-down views of the sella turcica can be offered a choice between treatment and surveillance. An annual prolactin level and a periodic coned-down view (at first annually, and then at increasing intervals) are indicated for continued observation to detect an emerging and slow-growing tumor. Dopamine agonist therapy is recommended for patients wishing to achieve pregnancy and for those patients who have galactorrhea to the point of discomfort. Thus far, long-term therapy with a dopamine agonist has not been proven to be successful in producing a complete reversal of the problem (with either permanent suppression of elevated prolactin levels or elimination of small tumors). Thus, a very strong argument can be made for a “need not to know” the presence of a pituitary microadenoma. If treatment and management are not changed, it is not necessary to document the presence of a microadenoma. This takes strength of conviction when your radiologist reports that a coned-down view of the sella turcica is not sufficient. The Pituitary Incidentaloma 53, 54, 55, 56 and 57 the percentage of pituitary glands found to contain unsuspected adenomas, all microadenomas, ranged from 9% to 27% in autopsy series. Therefore, 58 many individuals, probably 10%, have silent pituitary masses that are endocrinologically inactive and have no adverse effects on well-being. Silent microadenomas (less than 10 mm diameter) do not grow, and even 49, 50 macroadenomas (10 mm or more diameter) grow slowly and only rarely. This benign course argues against immediate intervention in patients who have no 59 evidence of hormonal disturbances; long-term surveillance is appropriate. Imaging reassessment of a microadenoma should be obtained at 1, 2, and 5 years, and if there is no change, no further studies are necessary. Although it is reasonable to screen hormonal function in the presence of a macroadenoma, the value of hormonal screening in a normal individual with a microadenoma is debatable. Evaluation of the Abnormal Sella Turcica and/or High Prolactin the high incidence of pituitary tumors in patients with amenorrhea has prompted a search for a reliable method of diagnosing the condition. Expectations for the utilization of endocrine testing to discriminate between disorders of the hypothalamus and the anterior pituitary have not been realized. Frankly, the endocrine maneuvers yield no more useful information than the two major screening procedures, the blood prolactin and the coned-down view of the sella turcica. Visual field examination is not useful in screening for pituitary tumors because abnormalities are seen only with large tumors that are evident by prolactin, x-ray evaluation, and/or visual symptoms and headaches. If the coned-down view is abnormal and/or the prolactin level is over 100 ng/mL, further evaluation and treatment require consultation with expert endocrine resources. These patients are rare, and accumulated experience that can provide the necessary clinical judgment can be found only with the referral resource. On the other hand, our workup easily deals with the vast majority of patients, and the few who require a multidisciplinary team approach are readily identified. Hypogonadotropic Hypogonadism Patients with amenorrhea and without galactorrhea who have reached this point in the workup and have normal imaging studies are classified as hypothalamic amenorrhea. Specific Disorders Within Compartments With only modest effort, expense, and time, the problem of amenorrhea has been dissected into compartments of dysfunction which positively correlate with specific organ systems. At this point, with the specific anatomic locus of the defect defined, the clinician can now undertake steps to elucidate the specific disorder leading to amenorrhea. Congenital abnormalities are limited to amenorrhea that presents in the pubertal period of life. In a collection of 262 patients with secondary amenorrhea 60 of adult onset, the following diagnostic frequencies were most often observed: Compartment I 7. This condition generally is the result of an overzealous postpartum curettage resulting in intrauterine scarification. Diagnosis by hysteroscopy is more accurate and will detect minimal adhesions that are not apparent on a hysterogram. In the presence of normal ovarian function, the basal body temperature will be biphasic. The adhesions may partially or completely obliterate the endometrial cavity, the internal cervical os, the cervical canal, or combinations of these areas. Surprisingly, despite stenosis or atresia of the internal os, hematometra does not inevitably occur. The endometrium, perhaps in response to a buildup of pressure, becomes refractory, and simple cervical dilatation cures the problem. Very severe adhesions have been noted following postpartum curettage and postpartum hypogonadism; e. Infertility can be present with mild adhesions, an association not readily explainable. Patients with repeated miscarriages, infertility, or pregnancy wastage should have investigation of the endometrial cavity by hysterogram or hysteroscopy. Impairment of the endometrium resulting in amenorrhea can be caused by tuberculosis, a condition that is rare in the United States. Diagnosis is made by culture of the menstrual discharge or tissue obtained by endometrial biopsy. Uterine schistosomiasis is another rare cause of end organ failure, and eggs of the parasite may be found in urine, feces, rectal scrapings, menstrual discharge, or endometrium. Hysteroscopy with direct lysis of adhesions by cutting, cautery, or laser yields better results than the “blind” dilatation and curettage. Following operation, a method should be utilized to prevent the sides of the uterine cavity from adhering. An inhibitor of prostaglandin synthesis can be used if uterine cramping is a problem. When the initial attempt fails to re-establish menstrual flow, repeated attempts are worthwhile. Persistent treatment with repeated procedures may be necessary to regain reproductive potential.

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Does the presence or absence of sono- graphically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Use of transthoracic Doppler echocardiog- raphy combined with clinical and electrographic data to predict acute pulmo- nary embolism how hiv infection is diagnosed generic 250mg famciclovir fast delivery. Quantitative two dimensional echocar- diography in massive pulmonary embolism: emphasis on ventricular interde- pendence and leftward septal displacement hiv infection overview famciclovir 250mg online. Opinions regarding the diagnosis and management of venous thrombo- embolic disease hiv infection 2 years order famciclovir 250 mg overnight delivery. Prospective evaluation of two dimen- sional transthoracic echocardiography in emergency department patients with suspected pulmonary embolism hiv infection rates caribbean order 250 mg famciclovir mastercard. Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Short term clinical outcome of patients with acute pulmonary embolism, normal blood pressure and echocardiographic right ventricular dysfunction. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolus. Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Sonospirometry: a new method for noninvasive measurement of mean right atrial pressure based on two dimensional echocar- diographic measurements of the inferior vena cava during measured inspiration. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Emergency department paracentesis to determine intraperitoneal fluid identity discovered on bedside ultrasound of unstable patients. Accidentally created tension pneumothorax in patient with primary spontaneous pneumothorax—confirmation of the experimental studies, putting into question the classical explanation. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospec- tive comparison with chest radiography. Rapid detection of pneumothorax by ultraso- nography in patients with multiple trauma. A prospective comparison of supine chest radiog- raphy and bedside ultrasound for the diagnosis of traumatic pneumothorax. Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation. A novel use of ultrasound in pulse- less electrical activity: the diagnosis of an acute abdominal aortic aneurysm rupture. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Emergency department ultrasound scan- ning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Screening for abdominal aortic aneu- rysm in asymptomatic at-risk patients using emergency ultrasound. Diagnostic potential of combined transthoracic echocardiography and x-ray computed tomography in suspected aortic dissection. Diagnosis of ascending aortic dissection using emergency department bedside echocardiogram. Dissection of the proximal thoracic aorta: a new ultra- sonographic sign in the subxiphoid view. Improved diagnosis of vascular dissection by ultrasound B-flow: a comparison with color-coded Doppler and power Doppler sonography. Color Doppler ultrasound by emergency physicians for the diagnosis of acute deep venous thrombosis. Is color flow duplex a good diagnostic test for detection of isolated calf vein thrombosis in high risk patients? Limited B-mode venous scanning versus complete color flow duplex venous scanning for detection of proximal deep venous thrombosis. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Emergency department compression ultrasound to diagnose proximal deep vein thrombosis. Resident performed compression ultraso- nography for the detection of proximal deep vein thrombosis: fast and accurate. Systematic review of emergency physician- performed ultrasonography for lower-extremity deep vein thrombosis. Emergency clinician-performed compres- sion ultrasonography for deep venous thrombosis of the lower extremity. Lower extremity Doppler for deep venous thrombosis: can emergency physicians be accurate and fast? Several of these syndromes require immediate diagnosis and decisions on treatment, some of them life-saving. Critical decisions must often be made quickly by professionals with different backgrounds and levels of expertise with limited resources. Against this background, the AccA clinical decision-Making toolkit was created as a comprehensive resource encompassing all aspects of acute cardiovascular care but structured as an easy-to-use instrument in environments where initial acute cardiovascular care is typically initiated. However, it does not replace textbooks and other sources of information that need to be consulted to reach an optimal management of these patients. University Medical Center Groningen, Groningen, the Netherlands • Pascal vranckx Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium • christiaan vrints Department of Cardiology, Antwerp University Hospital, Edegem, Belgium • doron Zahger Department of Cardiology, Soroka Univ, Medical Center, Beer Sheva, Israel • uwe Zeymer Department of Cardiology, Herzzentrum Klinikum Ludwigshafen, Ludwigshafen, Germany 1 p. Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Management of Community-Acquired Pneumonia New Engl J Med (2002); 347:2039-2045 - Woodhead M et al. If the answers to these questions are positive, the episode has a high likelihood of being syncope. Situational syncope is diagnosed if syncope occurs during or immediately after specifc triggers. Orthostatic syncope is diagnosed when it occurs after standing up and there is documentation of orthostatic hypotension. Cardiovascular syncope is diagnosed when syncope presents in patients with prolapsing atrial myxoma, severe aortic stenosis, pulmonary hypertension, pulmonary embolus or acute aortic dissection. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry. Dual b O C or A therapy O C or A c dual therapy with oral anticoagulation and one antiplatelet agent (aspirin or clopidogrel) beyond one year may be O C or A considered in patients at very high risk of coronary events. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. Hemodynamic criteria to defne cardiogenic shock • Systolic blood pressure <80 to 90 mmHg or mean arterial pressure 30 mmHg lower than baseline • Severe reduction in cardiac index: <1. The available devices differ in terms of the insertion procedure, mechanical properties, and mode of action. This fow is the sum of the mechanical circulatory support output and the remaining function of the heart. Adenosine Electrical or pharmacological If no cardioversion is considered: using oral or i. Atrioventricular impulse from the sinus node and has a rate of under 60 beats transmission is delayed, resulting in a Pr interval per minute longer than 200 msec • Sinoatrial exit block. If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up .

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