By Y. Jarock. Graceland University.
Recurrent sustained ventricular tachycardia: structure and ultrastructure of subendocardial regions in which tachycardia originates cheap 250mg eulexin mastercard. Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease: electrophysiologic and anatomic correlation generic eulexin 250 mg on line. Pathophysiological correlates of ventricular tachycardia in hearts with a healed infarct (Chapter 47) best purchase eulexin. Reduced content of connexin43 gap junctions in ventricular myocardium from hypertrophied and ischemic human hearts. Electrophysiologic and anatomic basis for fractionated electrograms recorded from healed myocardial infarcts. Arrhythmogenic mechanisms: automaticity, triggered activity, and reentry (Chapter 40). Relating extracellular potentials and their derivatives to anisotropic propagation at a microscopic level in human cardiac muscle. Evidence for electrical uncoupling of side-to-side fiber connections with increasing age. Anisotropic conduction and functional dissociation of ischemic tissue during reentrant ventricular tachycardia in canine myocardial infarction. Effects of lidocaine and procainamide on normal and abnormal intraventricular electrograms during sinus rhythm. Reduced space constant in slowly conducting regions of chronically infarcted canine myocardium. Fractionated electrograms can be produced by regional changes in conduction velocity. Cellular uncoupling can unmask dispersion of action potential duration in ventricular myocardium. Effects of cellular uncoupling on conduction in anisotropic canine ventricular myocardium. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Electroanatomic left ventricular mapping in the porcine model of healed anterior myocardial infarction. Use of electrogram characteristics during sinus rhythm to delineate the endocardial scar in a porcine model of healed myocardial infarction. Electrically unexcitable scar mapping based on pacing threshold for identification of the reentry circuit isthmus: feasibility for guiding ventricular tachycardia ablation. Short-term results of substrate mapping and radiofrequency ablation of ischemic ventricular tachycardia using a saline-irrigated catheter. Tachycardia related channel in the scar tissue in patients with sustained monomorphic ventricular tachycardias. Anatomic characterization of endocardial substrate for hemodynamically stable reentrant ventricular tachycardia: identification of endocardial conducting channels. Accuracy of combined endocardial and epicardial electroanatomic mapping of a reperfused porcine infarct model: a comparison of electrofield and magnetic systems with histopathologic correlation. Feasibility of a noncontact catheter for endocardial mapping of human ventricular tachycardia. Characterization of the infarct substrate and ventricular tachycardia circuits with noncontact unipolar mapping in a porcine model of myocardial infarction. Left ventricular endocardial activation during right ventricular pacing: effect of underlying heart disease. Characterization of endocardial electrophysiological substrate in patients with nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars. A new technique to perform epicardial mapping in the electrophysiology laboratory. Endocardial unipolar voltage mapping to detect epicardial ventricular tachycardia substrate in patients with nonischemic left ventricular cardiomyopathy. Relation of the unipolar low-voltage penumbra surrounding the endocardial low-voltage scar to ventricular tachycardia circuit sites and ablation outcomes in ischemic cardiomyopathy. Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in the setting of right ventricular cardiomyopathy. Endocardial unipolar voltage mapping to identify epicardial substrate in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Inducible polymorphic ventricular tachycardia and ventricular fibrillation in a subgroup of patients with hypertrophic cardiomyopathy at high risk for sudden death. Ventricular fibrillation in hypertrophic cardiomyopathy is associated with increased fractionation of paced right ventricular electrograms. Arrhythmia, sudden death, and clinical risk stratification in hypertrophic cardiomyopathy (Chapter 63). Late potentials detected after myocardial infarction: natural history and prognostic significance. Pathophysiological mechanisms and clinical significance of ventricular late potentials. Relation of late potentials to site of origin of ventricular tachycardia associated with coronary heart disease. Relation between late potentials on the body surface and directly recorded fragmented electrograms in patients with ventricular tachycardia. The incidence and clinical significance of epicardial late potentials in patients with recurrent sustained ventricular tachycardia and coronary artery disease. Signal-averaged electrocardiographic late potentials in patients with ventricular fibrillation or ventricular tachycardia: correlation with clinical arrhythmia and electrophysiologic study. Results of signal-averaged electrocardiography and electrophysiologic study in patients with nonsustained ventricular tachycardia after healing of acute myocardial infarction. American college of cardiology consensus document on signal-averaged electrocardiography. Detection of late potentials on the surface electrocardiogram in unexplained syncope. American college of cardiology consensus document on signal-averaged electrocardiography. Natural history of late potentials in the first ten days after acute myocardial infarction and relation to early ventricular arrhythmias. Abnormal signal-averaged electrocardiograms in patients with nonischemic congestive cardiomyopathy: relationship to sustained ventricular tachyarrhythmias. Comparison of frequency of late potentials in idiopathic dilated cardiomyopathy and ischemic cardiomyopathy with advanced congestive heart failure and their usefulness in predicting sudden death. Prognostic value of an abnormal signal-averaged electrocardiogram in patients with nonischemic congestive cardiomyopathy. Electrophysiologic sequelae of chronic myocardial infarction: local refractoriness and electrographic characteristics of the left ventricle. Clinical and molecular characterization of patients with catecholaminergic polymorphic ventricular tachycardia.
Requiring a pressurized injection system order 250 mg eulexin amex, 247 females with intrinsic sphincter deficiency in a ® multicenter study were randomized 1:1 and treated with Macroplastique versus Contigen serving as a control generic 250 mg eulexin with mastercard. In a rare study following a study group out to 24 months eulexin 250 mg amex, 33 of 38 of the patients achieving dry/continence at 12 months remained dry at 24 months. An additional 12 of 29 patients, who were judged improved at 12 months, were dry at 24 months . The Macroplastique Implantation Device, a specialized pressured syringe and applicator, allows for outpatient transurethral cystoscopic injection under direct vision. Sterilization of the reusable injector system requires enzymatic cleaning, disinfection, and autoclaving, which may not be available within the outpatient or clinic setting. The material is injected with a disposable 21-gauge needle under cystoscopic guidance and readily adapted to the outpatient or clinic setting. Furthermore, the product is immunogenic requiring a negative skin testing 30 days prior to bulking agent injection. A fatal pulmonary embolism  and a fat embolism syndrome  argue strongly against its use; of note, the fat embolism syndrome was associated with an injection with 14G needle using a periurethral approach. Of note, autologous fat remains widely used in cosmetic procedures and purportedly retains 60% of its bulk over time. This result has not been translatable to safe or efficacious use in urinary incontinence. Achieving higher “maximum squeezing” opening pressure correlates with improved continence after bulking agents. It has therefore been suggested that agents should be injected on the luminal side from the sphincter and at the high-pressure region of the sphincter . Increasing volume of the injected bulking agent would subsequently result in decrease in luminal closure pressure if the bulking agent either overbulked the region  or conversely extravasated. Notably, success rates have been reported to decrease with an increased number of injection sites, likely due to extravasation . Injection of the material, therefore, should be slow and deliberate in order to maximize fill and reduce disruption of the fragile soft tissue. Sequential injections are preferable to bursting the soft-tissue envelope created by the bulking agent. Therefore, it may be useful to think of reaching a “sweet spot” with the volume injected: too little is ineffective at raising the intraluminal closure pressures, and too much will burst the envelope containing the bulking agent. Transurethral injections directed nearer to the bladder neck may be associated with less urinary retention compared with periurethral injections as is reported in some studies comparing methods. It has been theorized that the greater volume reported in most comparative trials of the periurethral injection may be an associated cause . Others have suggested that a luminally placed bulking agent might allow for higher degrees of soft-tissue creep (i. Others report no statistical difference between the effectiveness of the periurethral versus transurethral approach to injection [88,89]. In the transurethral technique, the bulking agent may be injected at the bladder neck or the midurethra under cystoscopic guidance. There is insufficient comparative data to support bladder neck versus midurethral injection. In the transurethral cystoscopic approach, the urethral mucosa is punctured distal to the chosen injection locale in the urethra. Prior to the puncture, the urethra and bladder are inspected and the scope is then withdrawn to the distal urethra. The middistal portion of the urethra is punctured with the bevel of the needle toward the lumen at a 30°–45° angle. The needle is transluminally advanced into the submucosa, but not to the muscularis. The angle is subsequently dropped parallel to the path of the urethra, and the needle is advanced approximately 1 cm within the submucosal layer with slow deliberate injection of the material aided by visual deformation of the tissues and halting further injection particularly if blanching of the mucosal vessels is observed. Submucosal 779 hydrodissection with lidocaine may be performed prior to injection  to reduce discomfort and to prepare the envelope for the agent. Once the injection is completed, the needle is held in position for several seconds prior to withdrawal, in order to allow for equilibration of pressures within the receiving soft-tissue envelope and to reduce extravasation from the needle site . While failure rates have been reported to increase with the number of puncture sites , presumably due to the loss of the bulking agents through these punctures, several industry-recommended techniques include three-site injections (e. Contraindications to the use of a bulking agent in an appropriately selected patient include an active urinary tract infection or known hypersensitivity to the agent or any of its components. Bulking agents have been successfully and safely injected in fully anticoagulated patients, albeit with a theoretical concern for an increased risk of ongoing hematuria or urinary retention in the setting of a periurethral hematoma (personal experience). The most common adverse event is temporary urinary retention with major adverse events being rare [62,63,84]. Acute urinary retention has been reported in up to 24% of patients in a study of Durasphere and thus deserves mention during patient counseling. Additionally, it should be noted that retention in this setting is transient, for instance, lasting 7 days or less in most series [24,63]. Other adverse events that may be commonly encountered include postoperative dysuria, hematuria, uncomplicated urinary tract infection, and de novo urinary urgency, which typically resolve with conservative management [62,63,92,93]. Aspiration or incision and drainage of the injected agent is associated with 100% return of the patients prior sphincteric incontinence . A few specific long-term complications that are quite rare, typically reported as single cases or small series, merit consideration as well. Urethral prolapse, potentially from disruption of support between the urethral mucosal and muscle wall with urethral bulking, has been reported [95–99]. Periurethral masses, variously described as periurethral pseudocyst  or sterile pseudoabscess [48,75,76,100–105], may be large and symptomatic and are associated with outlet obstruction  and/or pain . Treatment of these lesions with aspiration  is associated with symptomatic pseudoabscess reoccurrence and thereby may require definitive transurethral, transvaginal, or retropubic incision and drainage . These masses, if draining spontaneously into the urethral lumen, might progress to a de novo urethral diverticulum [107,108]. As several agents require high-pressure injector systems, particle migration into local and distant lymph nodes may occur  and be visibly confirmed if the bulking agent is able to be imaged. Embolization may also occur, though only autologous fat has been reported to result in pulmonary embolism  and death . All bulking agents could be erosive, resulting either from a property of the injected agent  or of the surrounding tissue [111,112] and may result in the extremely rare complication of fistula formation. Transvaginal incision and drainage of a pseudoabscess carries this theoretical risk. Adverse events have also been reported outside of the urologic and gynecological literature, such as in plastic surgery series, but are likewise rare [113,114]. Of greater concern is the normally functioning bulking agent occasionally misinterpreted as a complex soft-tissue mass suggestive of malignancy, periurethral abscess, or urethral diverticulum.
In this case buy genuine eulexin on line, Electrical burns may be due to low- or high-voltage the manner of death would be accidental generic eulexin 250mg otc. Te electrical current may be direct or alter- very important to fnd out the initial event that starts nating in nature cheap eulexin 250 mg without a prescription. Alternating current is more likely to the ball rolling in the sequence of events that eventually cause a fatal cardiac arrhythmia than direct current. High voltage is generally defned as greater than 1000 Radiation is defned as energy distributed as waves volts for alternating current and greater than 1500 volts or particles across the electromagnetic spectrum. High-voltage burns are usually asso- includes electric, radio, radar, microwaves, infrared, vis- ciated with extensive obvious injury. Low voltage is ible light (lasers), ultraviolet light, x-rays, gamma rays, Burns 453 and cosmic radiation. Waves are characterized as hav- cataracts, burns to the retina and skin, necrosis, fbro- ing long wavelengths and low frequencies, whereas par- sis, and cancer. Generally speaking, proliferating cells ticles have short wavelengths and high frequencies. Te are afected more substantially with acute exposure as types of biological efects vary greatly depending on the indicated by damage to the gastrointestinal and hema- type of radiation, duration of exposure, and interme- topoietic systems with increased risks of infection, nau- diate barriers. Second- degree burns are often more painful than third-degree burns due to less destruction of nerve endings. There is debate in the literature about distinguishing antemortem from postmortem burns. Many believe blister forma- tion in a nongravity-dependent area with a red border indicates vital reaction and antemortem occurrence. First-degree thermal burns in this picture are characterized by the red discoloration without blister formation or skin slippage. Note the areas of collapsed blister formation, which are consistent with a postmortem burn. Sometimes it is difficult to interpret antemortem burns if continued heat causes fuid-flled blisters to collapse and fuid to evaporate. Full thickness refers to involvement of the epidermis, dermis, and subcutaneous layers. These are often less painful than second-degree burns due to more damage of nerve endings. She had the heater turned up to full, the gas tank was empty, and she had not been seen for several days. Her body showed signifcant mummifcation with putrefaction and radiant heat damage. Note these postmortem anemic lacerations in the popliteal regions created when the body was moved to the autopsy table. Drying of skin is associated with decreased elasticity with greater tendency to lacerate instead of stretch. Also note the pale pink discoloration of the muscle due to prolonged exposure to low heat. This individual’s carboxyhemogloblin level was only 17%, and death was attributed to asphyxia from exhaust inhalation with decreased oxygen as well. Note the uninvolved creases of skin on his face caused by recoiling due to the explosion. Note the sparing of the skin at the trunk and upper arms due to protection by his short-sleeve shirt. He had swelling and hyperemia of the upper airway, leading to obstruction and eventual fatal arrhythmia. The organs of the trunk were remarkably well protected consider- ing the amount of thermal injury to the surface. The wick effect refers to a self-perpetuating, low-intensity fame following ignition of certain materials contacting the body, where the skin is cracked from heat and the underlying fatty tissue is rendered into oil, which is absorbed into the charred clothing producing a wick. This process in the past has been referred to erroneously as spontaneous human combustion. The decedent was involved in a fatal fre and the body was not discovered for several days after being soaked in water following fre extinguishing. Note the microorganisms and mold growing on the body surface shown by the gray-white discoloration. Putrefactive changes were markedly inhibited due to the effects of exposure to smoke and heat. Note that the margins are relatively sharp and do not appear as though the skin has cracked secondary to heat exposure. Upon internal examination, these injuries become much more apparent with hemorrhage and blood accumulation. Note the wound at the upper aspect of the lateral left neck with hemorrhage due to an antemortem stab wound. With exposure to fames, the brain and dura mater contract, and blood is forced from the small vessels at the inner aspect of the skull and through the dural sinuses, producing epi- dural blood accumulation that will coagulate with heat. Note the red discoloration caused by gastric acids producing burns around her mouth. The sutured linear incisions are due to organ donation with retrieval of bone and soft tissues. Note the white dis- coloration from chemical burns at the lips, mouth, tongue, and esophagus. His leg contacting the ladder completed the circuit through his heart, producing a fatal arrhythmia. The decedents fell to the ground lifeless within about 15–20 seconds after contact. These are examples of second- to third- degree postmortem burns due to being submerged in warm to hot water. Note the pictures demonstrate red discoloration with skin slippage and a sharply demar- cated border defning the submerged and unsubmerged areas. To help the viewer distinguish between these regions we placed a line adjacent to this demarcation. Individuals who drown in bathtubs have some contributing factor dictating why they could not keep their head above the water. The above demonstrates an antemortem subdural hematoma altered by extensive postmortem thermal injuries. Various poisons such as carbon uptake or use, together with decreased carbon dioxide monoxide or cyanide interfere with oxygen uptake and elimination. Airway obstruction may occur by smothering, neck Chest compression can produce asphyxia by prevent- compression, foreign body aspiration, excess secretions ing air fow into the lungs. Smothering is defned as Neck compression, as with hanging and strangu- external occlusion of the mouth and/or nose, which lation, can also produce asphyxia by obstruction of prevents air exchange. Children may aspirate foreign various neck structures, including the airway, venous bodies such as peanuts, hotdogs, popcorn, watch bat- circulation, and arterial circulation.
Plast Reconstr Surg 116(5):1479–1487 neck rejuvenation was also performed with upper lid blepha- 23 purchase eulexin paypal. This It is important to differentiate plication from suspension: happens regarding any situation: pain cheap eulexin 250mg on-line, tumors purchase eulexin online pills, laxity and, plication sutures neighboring structures; suspension anchors indeed, vanity. Concerning facelift surgical techniques, in structures that are far one from another. Suspension is stron- the past two decades plastic surgeons have looked for more ger, modifying a vector of traction. Since a good result in natural results, less invasive surgeries, suitable recovery, low rhytidoplasty is essentially the ﬁnal effect of traction vectors, stigma, shorter scars, and low risk; besides which, patients it makes all the difference. In this technique the surgeon deﬁnes the more than a pleasant appearance; they feel happy with the points that will limit the whole area where the suspension will simple comment that they are looking good for their age. As the front or below the ear, leaving the muscles free to stabilize in a respected surgeon Thomas Biggs used to say, it is time to ﬁnal and natural situation, and the superior and posterior portion have “the most for the least. This dynamic accommodation will preserve the tively new options in the plastic surgeon’s arsenal, although patients’ own facial expressions. How much different facelift history would have diseases, since it is a quick procedure that respects the been if the paper by Virenque  could have been dissemi- integrity of most anatomical structures. The relevant points perceived since that time are the is carried out, it acts by repositioning the facial volume in a compact loop suture, elevating en-bloc the fallen struc- tures of the face such as jowls and malar fat pads, and even improving the neck contour. The ﬁrst one is anchored to the periosteum of the zygoma and extending to the platysma muscle, at the mandibular angle. Over time, the incision changes to an inverted “Ω” (omega) around the ear and small undermining  in the open technique (the closed technique consists of one incision at the sideburn and a small one behind the ear). Two include the deep temporal fascia; a second purse-string suspension purse-string sutures are performed: the ﬁrst one suture will be performed, ahead and parallel to the ﬁrst. With a ﬁnger the surgeon slides the facial skin toward the ear, simulating the intended result. Repeating this maneuver four or ﬁve times a dotted line is drawn around the ear, deter- A third purse-string suture may be executed, beginning at mining the minimum undermining to achieve the result. The inci- mental region and neck, using a 3-mm incision behind the sions of the skin will vary according the intended traction chin. On completion, an inverted-omega incision is made contouring the ear, starting with a zigzag beveled inci- sion about 3 mm above the border of the sideburn, in order to 2. Marchac reported U-shaped incision in the temporal area and The previously-marked area is undermined at the subcu- surrounding the ear. Next, the risorius-masseter zone is exposed, in addition to the cranial portion and the mandibular insertion of the platysma muscle. Regardless of the technique used there will be an overlapping of muscles in this area; it is indeed convenient to restore volume. At this time the purse-string suture is performed; it is eas- ier to begin from behind the ear toward the neck and face. In the mastoid fascia there will be no tissue lifting, since it is a strong and ﬁxed area. The traction begins to raise the tissues as soon as the platysma muscle is reached. The bites must not be close to one another; it is important to leave a 2-cm space between them to permit imbrication of tissues. A 45° insertion of the needle will provide a stronger and safer suture, hence assuring a better traction. At this moment the surgeon must pull up this semicircular suture to assure that the intended result is being achieved, and that an effective vertical volume reposition has been obtained (Fig. Once the ideal path is realized, the needle is passed deeply, entering the anterior limit of the sideburn incision and directed toward the limit of the retroauricular incision. After arriving in the posterior area, the thread is passed through the needle hole (Figs. Only then is muscular action along the stitch so as to offer a natural the knot complete (Figs. The purse-string suture expression to the patient, with a smooth and progressive is then performed (Fig. It is desirable to leave this suture without addi- For those who may be afraid of using the needle described, tional stitches in its anterior area, so that the facial muscles it is perfectly feasible to achieve the same results by per- may act in a dynamic fashion and adapt to the movements of forming a two- or three-step suture in the hairy area. Sometimes it is necessary to perform a superﬁcial dissec- tion with a cannula to treat some dips. It may be also neces- sary at the sideburn and preauricular area to reseat a triangle of skin to promote an adjustment. Some excess skin will remain ahead of the ear and earlobe, which will settle in 2 or 3 weeks. Stocchero Case 2 Preoperatively and 3 years postoperatively Suspension Techniques in Aesthetic Surgery of the Face 885 886 I. Stocchero 5 Complications 7 Pearls and Pitfalls After having performed more than 400 facelifts with this technique, only one major complication was seen: a superﬁ- Pearls cial skin necrosis in a patient who was a smoker and had a Performing judicious marking and paying attention to previous car accident with injury of the facial artery on the the well-known dangerous zones is the most important same side. The quality of the result will depend on the good Expressive bruising was the most common complication, choice of traction points. The ﬁnal Ear lobe swelling occurred in 3 % of cases, consequent to loop, after tied, will tend to resemble the shape of a a very tightened suture near the ear. In patients with a speciﬁc point of laxity, it may be necessary to perform additional braces to correct certain folds and undertractioned areas. By using a blunt Hagerdon Bayonet Modiﬁed Needle, it is 6 Informed Consent possible to achieve a desired point for pulling the insufﬁciently treated area, performing a maneuver Usually, consent is given in Portuguese and consists of three described as “ﬁsh and tie”: the needle is passed and a different printed forms: thread is pulled, ﬁxing the desired area in the parotid fascia. General Orientation: Discusses what may occur in any tysma to the fascia of Loré , therefore acting as a plastic surgery procedure; for example, scars, asymmetry, cervical brace. It is recommended that all additional surgery limits, false expectations, and medicine braces be placed before the Roundblock stitch, hence interactions allowing free adaptation of tissues according to 2. Rhytidoplasty Surgery Orientation: Discusses speciﬁc Pitfalls topics regarding the surgery, what is expected, what to Care must be taken with the distance from the ear to take to hospital, preoperative and postoperative restric- prevent a “strangulation” of the auricular pavilion that tions. Regarding suspension facelift the patient is made will promote pain and distortion. Tonnard P, Verpaele A (2002) Minimal access cranial suspension lift: a modiﬁed S-lift. Plast Reconstr Surg 121:677–680 International Symposium of Plastic Surgery, Buenos Aires, 17 Aug 2. Marchac D (2009) Évaluation de 50 liftings cervicofaciaux monob- Reconstr Surg 83:11–16 loc avec suspension. Plast Reconstr Surg 117:2001–7 Rejuvenation of the Midface Brunno Ristow 1 Introduction Frequently, and for many years, I examine lovely faces and think: “How can we (surgically) achieve this? Approaches I use beneﬁted from ideas with reverence for the resilience or delicacy of tissues, will expressed by colleagues; however, personally, I trace the make the surgeon the one that at the end, checkmates the beginning of a major departure from the accepted standards – aging face. His suspension of the fascia above the fat pocket of Bichat set me on a journey which is one of the pillars of what I came to use 2 General Considerations [2 – 4].