Roger Skebelsky, PA-C, BSN, RN

• Department of Emergency Medicine
• Mount Sinai Hospital
• Chicago, IL

In some cases erectile dysfunction caused by ssri buy cialis professional without a prescription, when puncture fails erectile dysfunction protocol + 60 days purchase 40mg cialis professional otc, before extracting the needle erectile dysfunction chicago generic cialis professional 20 mg without prescription, it is possible to move the needle upwards or downwards under fluoroscopic guidance erectile dysfunction due to medication cheap cialis professional 40 mg mastercard. If the contrast filling the calyx is displaced when the proximal tip of the needle is manipulated erectile dysfunction injections treatment purchase cialis professional 40 mg with amex, it is because the needle is situated underneath the calyx and its tip is compressing the calyx erectile dysfunction treatment natural remedies buy 40 mg cialis professional fast delivery. Incorrect punctures are usually due to the fact that the puncture is in a horizontal instead of in an ascending direction. With the supine approach, patients (especially those who are obese) have physiologic intra-abdominal pressures, and therefore less risk of cardiorespiratory complications. In addition, the risk of iatrogenic events is minor, because the position of the patient does not need to change during the intervention. This helps maintain a low intrarenal pressure, making the technique more secure and easier, because the stone fragments are dragged out by the whirlpool of water created in front of the optic, and auxillary instruments are not needed for their extraction (see Video 10. In this position there is usually a delay in the filling of the inferior calyces with the contrast, because the inferior renal pole is more elevated than the superior one. This inconvenience can be overcome by positioning the patient, for a few minutes, in an anti-Trendelemburg position. For percutaneous intervention, distention of the collecting system will be greater in the prone than in the supine position. However, if needed, greater distention in the supine position can be achieved with a simple gauze knot tied around the nephroscope tube, like a plug at the proximal end of the Amplatz sheath. Also, limited filling of the pyelocalyceal system has two advantages: first, it guarantees low intrarenal pressure, and second, in some cases, it reduces the time that it is necessary to work with water [14]. In some thin patients with renal ptosis, the kidney can be hypermobile in the supine position. This inconvenience is overcome by fixing the kidney during tract establishment by means of contralateral abdominal compression. In some patients with wide hips and thin calyces, it can be more difficult or impossible in the supine position to reach the upper calyx with a rigid nephroscope (see Video 10. Some authors who prefer to make access through the upper calyx have indicated that in the supine position this is more medial and posterior, making access to the upper pole difficult [15]. Nevertheless, others have not been inconvenienced making this upper pole access with their patient in the supine position [16]. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. In the supine position, renal access is a simple and safe method which is at reach of any urologist, without the support of any other specialist. In the supine position, the kidney can be easily explored with ultrasound and punctured with a fluoroscopic C-arm in a fixed position. Operators invariably become wedded to one position, yet with knowledge and experience of other positions, there is the freedom to choose the most appropriate technique for the case at hand. Finally, the rare complications related to patient positioning are discussed in detail. However, when the procedure was being developed in the early 1980s, direct calyceal puncture was not thought to be important, provided that puncture was along the avascular line of Brodel. It has since been recognized that puncture directly in to a calyx provides the safest access for stone removal [11, 12]. This position confers numerous advantages, with the main disadvantages being the time required for patient repositioning and anesthetic concerns in the morbidly obese (Table 11. In men, this is performed with the patient supine, while the frog-leg position is useful in women. A 5F Flextip (Cook Medical) ureteral catheter with a terminal side hole, which facilitates aspiration, is passed in to the collecting system. Urine is completely aspirated and replaced with radiographic contrast to identify all calyces. As a result, any urine within the collecting system will tend to collect at the highest point within the kidney. This property can be helpful to the surgeon when distinguishing anterior and posterior calyces. In the supine position, posterior calyces are identified by the presence of denser contrast within them, while anterior calyces appear paler due to the mixture of contrast with urine. In contrast, when the patient is repositioned prone, posterior calyces will appear paler. If too much pure urine without contrast is present, these calyces may be poorly visualized or even invisible. A C-arm image intensifier is used to examine the anatomy of the collecting system and the position of all stones. Four fluoroscopic images are captured: a scout image to identify all calculi, an anteroposterior, and two obliques. These images help create a mental threedimensional (3D) picture of the calyceal anatomy, and can be referred to during the procedure. A three-way valve is attached and connected to a 10 mL syringe and intravenous tubing leading to a bottle of contrast. This allows aspiration and infusion of additional contrast as needed during the case. Second, the constant pressure of contrast in the renal collecting system ensures a persistent pyelogram, facilitating calyx identification when the patient is repositioned prone. Third, flow of contrast under gravity distends the collecting system, providing a larger target for access. Fourth, free return of contrast out through the needle allows the surgeon to rapidly confirm successful puncture of the chosen calyx. Our anesthesiologists use generous padding of the eyes to prevent corneal abrasions and have various head supports at the ready with cut-out holes for the endotracheal tube. We have found that there is no one support that is universally appropriate for all patients, so several options are available at all times. To prevent brachial plexus injury, the shoulders should be situated below the chest and are both externally rotated at the shoulder and flexed at the elbow. In the prone position, the natural, anterior lordosis of the spine is exaggerated. This complicates access by compressing the working space and leads to instrument conflicts with the buttocks. Only normal saline irrigation is used unless electrocautery is required, when it is changed to a nonelectrolyte solution such as is used for transurethral prostatectomy. We favor a conventional "bullseye" technique for performing renal puncture in the prone position; however, a "triangulation" technique can also be used (described below). This needle lacks a beveled edge and as such, resists deflection away from the axis of puncture. Once the calyx is entered, and a free flow of contrast obtained, an Amplatz extra-stiff or super-stiff guidewire is passed down the needle in to the collecting system. Due to the presence of the occlusion balloon, we do not attempt to pass the guidewire down the ureter, although this may occur. A small depth gauge ring on the needle is adjusted to skin level to mark the depth between the skin and the collecting system. Knowledge of this measurement reduces radiation exposure during insertion of the fascial dilators and nephrostomy tract dilating balloon. Initially, thin fascial dilators are used to dilate the tract to a short 10F, and then a safety guidewire can be inserted using a 10F dual-lumen catheter. The tract is then further dilated to 30F with a nephrostomy tract dilating balloon over which an Amplatz sheath with a 30F inner diameter is passed. Although different methods of tract dilation exist, including balloons, Amplatz serial dilators, and the Alken telescopic dilator among others, we favor balloon dilation. We have found this to be both quick and atraumatic, although this comes at increased cost. Its advantages include the ability to control the degree of flexion required as well as to use adjustable contour pads that allow for free excursion of the abdomen, preventing respiratory compromise. The main limitation to its use is the reduction in depth, preventing C-arm movement, instrument manipulation, with fluoroscopic guidance. By commencing the procedure with the patient in the prone position immediately following induction of general anesthesia, the patient will still require repositioning, but is only draped once [17]. A split-leg modification can facilitate access to the external genitalia, for simultaneous antegrade and retrograde approaches [7, 8]. In the prone position it may be difficult to access the anteriorly displaced ureteric orifices for the retrograde study, but with practice this can become routine. Additionally, if the procedure is started prone, identification of the posterior calyces, especially in obstructed systems, may be difficult, or impossible, as the presence of pure urine within the collecting system may float on top of the radiographic contrast and render them invisible. For this reason, it is our preference to begin the procedure with the patient supine. Although still possible in the supine position, upper pole access is significantly easier when the patient is prone. An upper pole puncture has many advantages, including the ability to work down the renal axis, with minimal torque, as the more mobile lower pole rotates to align with the nephroscope. Selection of an upper pole calyx is indicated in obese patients, as the upper pole is closer to the posterior abdominal wall than the lower pole. It is also indicated in patients with staghorn calculi, or stones in a horseshoe kidney, and facilitates access to multiple lower pole calyces, with a single tract. In contrast, from the lower pole, visualization of the upper calyces with a rigid nephroscope is rarely possible. The "Montreal mattress" is a preshaped surgical bolster that can be used as an adjunct for the support of prone patients [14]. The advantage of this device is the central cavity which allows for free movement of the abdomen. This position significantly widens the space between the 12th from the operator during dilation and kink the guidewire. Despite these advantages, many authors still prefer a lower pole puncture with the reassurance that this approach will avoid thoracic complications. In addition, we have shown that when in this position, the kidneys are displaced inferiorly in the retroperitoneum. This effect is most pronounced with the left kidney, which is lower than the right kidney in greater than 90% of cases. Also, due to this modification, a supra-11th rib access may be converted to a supra-12th rib, or a supra-12th to an infracostal access. Finally, the flank is significantly flattened, eliminating interference from the buttock during rigid nephroscopy through a lower pole tract [10]. Note that the pannus falls away from the patient, preventing respiratory compromise. The increased distance between the 12th rib and iliac crest, produced by this flexion, is even more pronounced than the increase produced by flexion with the patient 159 A prone. Also, in this position, the relative lack of adipose tissue over the costovertebral angel is frequently surprising in these morbidly obese patients and, provided the upper pole calyx is chosen for access, it is frequently possible to use a standard length Amplatz sheath and nephroscope. One disadvantage to flank positioning is that percutaneous access usually requires either ultrasound guidance or use of "triangulation" using the C-arm image intensifier, as opposed to the "bullseye" technique. This is partly because of the restricted arc of rotation of most C-arms, but also because the metal side rails of most radiolucent tables prevent adequate visualization of the collecting system when the C-arm is rotated to an exaggerated position. An axillary roll or padded wedge with a groove to accommodate the dependent arm must be placed to adequately support the chest and prevent positioningrelated injury. Extra padding must also be placed under the dependent knee and ankle to prevent pressurerelated complications. In this demonstration, the target is an upper pole, posterior calyx, viewed from directly above.

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The physics of shock waves is very complex [14] drugs for erectile dysfunction in nigeria buy 40 mg cialis professional overnight delivery, and a basic understanding of some of the parameters in shock-wave physics is useful erectile dysfunction books purchase genuine cialis professional line. The cylinder generator is based on a hollow electromagnetic cylinder composed of a cylindrical coil covered by an insulating membrane testosterone associations with erectile dysfunction diabetes and the metabolic syndrome discount cialis professional online american express, which again is covered by an electrically conducting membrane of high strength erectile dysfunction latest medicine order cialis professional cheap online. An intense pulse current with short rise time generates repelling pulse forces due to electromagnetic induction erectile dysfunction prevention generic 20mg cialis professional with mastercard. When immersed in water erectile dysfunction doctor in atlanta purchase 20mg cialis professional amex, the radially expanding membrane generates, primarily, an acoustic cylinder wave which is focused by a special rotational parabolic reflector. This works on the same principle as a loudspeaker, but with very intense and short acoustic pulses. The cylindrical coil/membrane configuration is very stable and delivers more than one million pulses without degradation or significant fluctuations of acoustic energy. The parabolic reflector can be designed with large apertures and, accordingly, large aperture angles without technical limitations. Due to the large aperture angle, the acoustic energy can be concentrated to laterally narrow and axially short focal zones with high peak pressure and high energy flux density values. Thus, the fragmentation shock-wave energy is restricted to a relatively small area, reducing tissue lesions in front or behind the target stone. Also, anesthesia requirements and shock-wave load affecting the coupling area at skin level are minimized. In contrast to the electrohydraulic spark gap technology, the energy level of each single shock-wave pulse can be precisely adjusted between very low (painless) and powerful settings, exactly matching the pain tolerance of the patient. The generator configuration featuring a hollow cylinder provides sufficient space for favorable inline localizations, either for fluoroscopic or ultrasonic targeting. The conversion of electric to acoustic energy takes place in ceramic platelets that expand or contract in the surrounding water because of the piezoelectric effect when a pulse of several thousand volts is applied. Several dozen to several thousand platelets are usually mounted on a spherical segment transmitting the shock wave in to the center of the sphere through direct focusing. However, compared to other shock-wave sources, the intensity of a typical piezoelectric generator is lower and a large converter surface is required to mount the platelets. To provide sharp focusing of the acoustic pulse, the diameter of a piezoelectric source needs to be large. Consequently, the large diameter of a piezoelectric dish compromises its easy incorporation in to a multifunctional device. In focused shock-wave systems, the same total energy passes through a decreasing area as the wave travels towards the focal area. As cavitation is deemed one of the main causes of shock-wave-related tissue damage, it is suggested that treatment outcomes may be improved by positioning the stone several millimeters below F2 ("prefocal alignment"). This is also referred to as the -6 dB focus, which is a measure relative to the peak pressure. Effective energy the effective energy (E12mm) is a measure of the energy per shock wave that is transmitted through a circular area of 12 mm in diameter, representing a typical stone size of 12 mm. The E12mm provides good correlation with the disintegration capacity of a lithotripter. Maximum treatment depth the maximum treatment depth is the distance between the shock-wave head and the point of highest pressure in front of this. The shockwave focus however is cigar shaped, with the axial dimension longer than the lateral. This means that there is still energy that may be sufficient to break a stone beyond the geometric focus. Clinical relevance of focus size There is an ongoing debate about the ideal focus size in a lithotripter [21, 22]. The ideal focus would be a spherical volume exactly matching the size of the targeted stone, thus limiting the administration of energy to the stone and avoiding hitting the surrounding tissue, leading to adverse tissue effects [21, 22]. The higher pressure in a small focus leads to high efficiency in fragmenting hard stones. In order to obtain optimal fragmentation and to avoid adverse tissue effects, precise targeting is essential. Precise targeting is less critical but there is an increased analgesia need and a higher risk of adverse tissue effects. Sometimes there is a demand for larger focal zones in order to treat larger target volumes, even if surrounding tissue may be affected more than technically necessary. The design of the electromagnetic cylinder source offers the possibility to select different focal zones, precise and extended, according to clinical and anatomic conditions. By modification of the electrical excitation of the coil, longer pulses may be generated, which, in turn, stretch the focal zone, both laterally and axially. Prospective trials to investigate the potential clinical benefits of selectable foci would be useful. Shock-wave interaction mechanisms It is generally assumed that a combination of four different mechanisms is involved in the interaction between shock waves and the targeted stone: Hopkinson effect, cavitation, quasistatic squeezing, and dynamic fatigue [10]. It is also assumed, that cavitation and shear forces (Hopkinson effect) are the main culprits in the origin of adverse tissue effects. Although both shear forces and cavitation are also important in the stone comminution process, avoidance of their negative effects is considered important in reducing adverse effects due to shock waves. The idea behind a dual pulse technique [23, 24] is to "fill" the negative part of the pressure pulse with a positive pressure pulse. Fired synchronized or asynchronized they allow an increase in the total pressure and the shock-wave rate. In another study by the same group higher performance and efficacy with this twin-head, twinpulse technique was demonstrated [24]. At the same time, this technique produced far less parenchymal damage than with the use of a single treatment head. In order to meet all the challenges in modern integrated stone management, current lithotripters should ideally be equipped with both imaging modalities to be used either independently and alternately, or simultaneously. Fluoroscopy allows targeting of radio-opaque stones at all levels of the urinary tract. Also, smaller renal stones may prove more difficult to locate than with ultrasound. Further drawbacks are the absence of realtime imaging and the exposure to radiation. With ultrasound it is generally impossible to locate stones in the major part of the ureter, but it allows direct visualization of radiolucent stones and offers easier targeting of smaller renal stones. Its major advantage, however, is realtime imaging, which provides better monitoring of the fragmentation process in the absence of exposure to radiation. Machines where both ultrasound and X-ray are integrated offer the most versatile imaging and targeting possibilities. Ideally, these machines offer simultaneous online use of both ultrasound and X-ray. Targeting versatility is further improved by the possibility to couple the therapy head to the patient both under and above the treatment table. Coupling As already mentioned, shock waves are acoustic waves that travel through a medium by alternating decompression and compression of the medium. Absorption, reflection or refraction of the shock waves can occur at interfaces between media with different acoustic impedance. As water has comparable acoustic properties to human tissue, shock waves are generated and transmitted in water. In order to minimize energy loss of the shock wave at the interface between the patient and the shock wave source, coupling between shock wave source and patient is extremely important [27]. Second- and third-generation lithotripters, however, feature a "dry" coupling, which consists of a water-filled cushion that is inflated and pressed against the patient. In order to guarantee good acoustic transmission, the water cushion is coupled to the patient through the application of ultrasound gel. In this process, both air bubbles in the coupling gel and folds in the water cushion could impair the transmission of acoustic waves. Even tiny air bubbles in this interface can lead to uncontrolled shock-wave attenuation. Decoupling the cushion from the test basin and recoupling it led to a drastic increase in air inclusions. This has led to the recommendation that, if the patient is decoupled during treatment, the coupling procedure must be repeated, including cleansing the coupling cushion and subsequently reapplying gel. After experimenting with various techniques for gel application, as a method of choice Neucks et al. A small vessel opening and manual distribution of the gel lead to increased air pockets and poor disintegration results. This was mainly due to the high costs of the first lithotripters: high capital, running, and maintenance costs. Chapter 50 Lithotripsy Systems 565 decades lithotripters have undergone a transition from pure shock-wave generating devices to multifunctional urologic workstations. An increasing number of obese patients require high load capacity tables with maximum accessibility in order to be able to approach them from all sides. Imaging modalities in a multifunctional workstation need to support the wide range of therapeutic options in urology. Large image intensifiers of up to 16 inches ideally offer a large field of view of nearly the entire urinary tract. Full digitization of the X-ray imaging chain provides excellent image quality at low radiation dose. Increasing awareness of radiation safety and dose reduction make ultrasound stone localization an ideal tool for stone targeting and accurate therapy monitoring. Last but not least, a high performance shock-wave source, which ideally can be coupled to the patient in an over- and under-table position, completes the design of a multifunctional lithotripter. Multifunctional machines can have a modular design, where all components are separate modules to be "connected" according to need, or an integrated design where all components are integrated in the machine and ideally adapted to their function. A third design, the "hybrid", offers integration of imaging and/or therapy head in a common console with a detached treatment table. As the imaging components, a fluoroscopic C-arm and an ultrasound machine, usually are available on site, investment cost is limited to the shock-wave module and the treatment table. The imaging components can also be used for other purposes, both in urology and other departments. Modular systems have no need for a dedicated lithotripsy room and are easily transported from one center to another. Due to the combination ad hoc of different modules, the footprint is larger and the floor is cluttered with an array of machinery. In endourologic procedures, this footprint is further enlarged by the addition of an electrosurgical unit, light sources, and monitors, etc. The uro-table is less urologist friendly with limited accessibility, and overall handling is more complicated. Uro-table function usually is excellent and offers great comfort in the performance of endourologic procedures. Both investment cost and footprint are between that for a machine with an integrated design and a device with a modular design. Some of the components (imaging, patient table) are suited for multifunctional and multidisciplinary usage. Uro-table function usually is adequate and overall ease of handling is between that for the modular and integrated designs. Performance of lithotripters To measure the performance of a lithotripter, formulas have been devised that take in to account stone-free rate, retreatment rate, and auxiliary procedure rate. Although lithotripter manufactures are directing extensive research towards improvements in focal geometry and energy to improve stone disintegration and at the same to reduce collateral damage to the surrounding tissue, together with urology teaching institutions they should also invest in proper training of lithotripter users. Apart from producing a shock wave with the ideal focus, this high-performance shock-wave source would also meet the following requirements: prolonged lifetime without degradation or significant fluctuations of acoustic energy; wide range of energy settings; adequate treatment depth (minimum 150 mm) to accommodate the ever increasing proportion of obese patients, and be easily incorporated in a multifunctional device. These requirements almost automatically exclude conventional electrohydraulic sources: the lifetime of their electrodes is limited and the degradation of the electrode tips leads to output variations and instabilities of focal point and energy. Coupling of the therapy head containing the shockwave source is an important issue. The water cushion needs to be made of a material that easily adapts to the body curves and that causes minimal absorption, reflection or refraction of the traveling shockwave. Also, the ability to couple the treatment head to the patient both in an above- and an under-table position Table 50. Good imaging and a careful urologist may provide accurate targeting, but respiratory movements continuously swing the targeted stone in and out of the focus. A hit-and-miss system that keeps track of the stone during respiratory movements and only releases a shock wave when the stone is exactly in the focus would improve outcome and reduce collateral damage to the surrounding tissue. According to newer insights, however, slowing down treatments not only improves treatment efficiency [80, 81], but also reduces overall treatment cost [82]. The actual choice of the ideal lithotripter for any given stone center will depend on the specific requirements of a specific setting. In centers with a modest patient load, a modular system is probably the better choice. We try to solve any acute stone problem within 24 h of admission, preferably on an outpatient basis. The centerpiece of this "integrated endourology concept" is a highend multifunctional lithotripter with integrated design. The number of manufacturers and machines currently on the market prohibits any attempt to provide a complete overview of all systems available at present.

High scores are associated with an easier erectile dysfunction ear buy cialis professional canada, shorter induction that is less likely to fail impotence from blood pressure medication buy generic cialis professional canada. Low scores are associated with longer inductions of labour impotence quad hoc cheap cialis professional 20mg without prescription, which are more likely to fail and result in Caesarean section erectile dysfunction treatment without medication order cialis professional with a mastercard. In a brow presentation impotence klonopin order 40mg cialis professional mastercard, the anterior fontanelle erectile dysfunction joliet cialis professional 20mg generic, supraorbital ridges and nose will be palpable. Brow presentation is incompatible with vaginal delivery and Caesarean section will be required. Vaginal trauma usually occurs in the second stage with delivery of the fetal head. Risk factors for shoulder dystocia include large baby, small mother, maternal obesity, post-maturity and assisted vaginal delivery. Shoulder dystocia should be managed in a sequence of manoeuvres designed to facilitate delivery without fetal damage. There are, however, some characteristic symptoms that should be screened for in all patients in whom the diagnosis is suspected. Flashing lights in the vision, epigastric pain and restlessness are all symptoms that warrant prompt investigation. Senior obstetric, anaesthetic and midwifery personnel should be requested to attend urgently. Haematology input should be requested, but it is rare that they will need to attend labour ward, and will be more effective co-ordinating the blood bank response. Ultrasound scan of the uterus may be useful in identifying problems such as retained products of conception, but will not form part of the initial management. The abdomen should be tilted (for example with a Cardiff wedge) to relieve caval compression and increase venous return. The weight of the mammary glands increases in late gestation and may alter the pressures required to achieve adequate ventilation. The functional lung capacity is reduced, however, and the diaphragm may be splinted by the gravid uterus. If initial resuscitative efforts are not successful by 4 minutes after cardiac output is lost, then a perimortem Caesarean section should be performed, primarily to increase the chances of successful maternal resuscitation. All vitamins other than vitamin K are found in breast milk; routine supplementation is therefore given to neonates at birth. Operative delivery (whether vaginal or abdominal) carries a higher risk than spontaneous delivery. If the membranes are not ruptured then there is no increased risk associated with prolonged pregnancy. Perineal pain may be due to increased spontaneous tears, haematoma formation or episiotomy repair. Obstetric palsy may be due to exaggerated lithotomy position during instrumental delivery. Puerperal infection is more common where instrumentation of the genital tract has occurred. There is a theoretical risk of teratogenicity from psychotropic medication, but this may be outweighed by the chance of relapse. Inpatient care post-natally should be facilitated in a mother and baby unit if possible. Any visible jaundice in the first 24 hours must be urgently investigated and assumed to represent haemolysis unless proven otherwise. The initial inflation breaths are given at higher pressure and for longer than subsequent maintenance breaths. Naloxone or blood transfusion may be considered by the attending paediatrician where appropriate. There is no time limit imposed on informed consent, and quick decisions may be required in difficult situations on the labour ward. Verbal consent is adequate to carry out a procedure if time pressures demand this, but written documentation of consent is preferred where possible. Normal fetal development and growth 4 A woman is found to have oligohydramnios at 30/40. Antenatal care 6 A woman contacts her midwife with concerns regarding fetal well-being at 32/40 in a previously normal pregnancy. Antenatal imaging and assessment of fetal well-being 7 A thirty-seven-year-old woman attends for a routine dating scan. Which of the following features should help to reassure the doctor that this is a normal trace Single best answer questions 53 d) There are no significant accelerations of the fetal heart on the 30-minute recording. She has continued to use heroin throughout her pregnancy, but has reduced her smoking. Twins and higher multiple pregnancies 13 a) b) c) d) e) Which of the following is not an increased risk in multiple pregnancy Late miscarriage and early birth 14 a) b) c) d) e) Which statement is most accurate regarding cervical cerclage In a high-risk patient it should be performed as soon as practical after confirmation of intrauterine pregnancy. Is a suitable procedure in any woman with a history of delivery between 20 and 26 weeks. In making a plan for the management of her pregnancy, which step is least appropriate The main complications for the fetus include growth restriction and fetal bradycardia. The following are correct regarding thalassaemias except: They represent the most common genetic blood disorders. Perinatal infections 20 You are counselling a pregnant woman in the antenatal clinic who has known hepatitis with regard to fetal risk. Single best answer questions 55 21 a) b) c) d) e) Choose the best option with regard to a non-immune pregnant woman with an exposure to chickenpox: Should be given the varicella zoster vaccine as soon as possible after exposure. Should be given varicella zoster immunoglobulin as soon as possible after exposure. Labour 22 a) b) c) d) e) Choose the option that is the greatest contraindication to epidural anaesthesia: Previous treatment with anticoagulants. Operative intervention in obstetrics 23 a) b) c) d) e) Which of the following is the main advantage to performing a medio-lateral episiotomy Obstetric emergencies 25 a) b) c) d) e) Choose the option that is less common after Caesarean delivery than after vaginal delivery: Pulmonary embolism. Psychiatric disorders and the puerperium 28 a) b) c) d) e) Which statement is true regarding mental illness in pregnancy The majority of women with postpartum psychiatric disorders have pre-existing mental illness. In women with pre-existing psychiatric disorders, these usually improve during pregnancy. Neonatology 29 a) b) c) d) e) the components of the Apgar score include all except: Appearance. Ethical and medicolegal issues in obstetric practice 30 Which statement is not true regarding the regulations of the Abortion Act and Section 37 of the Human Fertilisation and Embryology Act Parity refers to all completed pregnancies that have progressed beyond 24 weeks, regardless of whether live or stillborn. Hence a twin pregnancy will represent G1 P2 if both babies are delivered after 24/40. The patient in question is in her third pregnancy (G3) and has delivered three babies at >24/40 (P3). Increased cardiac output causes flow murmurs in the majority of women by the end of the first trimester. Thereafter the increase in amniotic fluid relies on the fetal kidneys and lungs to produce fluid. Fetal swallowing helps to remove fluid and thus oesophageal and duodenal atresia are associated with polyhydramnios. The periderm produces a creamy protective layer known as the vernix, which rubs off after birth. Hair follicles normally develop between 12 and 16/40, hence this should not be a problem for this infant. Thermoregulation, dehydration and infection, however, are all important issues associated with the skin of premature infants. Women do not need to keep records of fetal movements, but should seek further care if the movements are significantly reduced. Growth scans are not performed in normal antenatal care unless there is a specific concern or indication. Placental site is first evaluated at 20/40, with follow-up scans if it is low-lying. Twin pregnancy is detected at the dating scan and may be the best opportunity to determine the chorionicity of the pregnancy. Uterine abnormalities such as bicornuate uterus are often best seen at this stage before the cavity becomes too distended. The chorionicity of twin pregnancy is best determined in the first trimester; this should ideally occur at approximately 12 weeks. Serious fetal structural abnormalities are diagnosed in 3 per cent of all pregnancies. No test should be performed without a full discussion of the information that the results will yield and all the options that may then be available. Informed consent is a vital part of the process of genetic testing and it is good practice to record this as a formal record. Many parents will consider a 1 per cent risk of miscarriage acceptable to yield diagnostic information about the pregnancy, but it will not be acceptable to all couples. Prior to testing or diagnosis, the parents should be aware of the options available to them. Growth restriction relates to smoking in a dose-dependent manner, hence severe growth restriction is unlikely if smoking has been drastically reduced. Reducing the dose of opioids suddenly during pregnancy can precipitate withdrawal in both the mother and the fetus, and the fetus is susceptible after birth if the possibility is not recognized and prepared for. Exogenous anti-D immunoglobulin is administered in an attempt to prevent the manufacture of endogenous antibody by the mother, as this would sensitize the immune system and put subsequent fetuses at risk. The Kleihauer test determines the proportion of fetal cells within the maternal circulation and hence helps determine anti-D dosage. It has been a subject of debate whether gestational diabetes is more common in multiple pregnancies, but recent studies have failed to find any evidence that the risk is increased. Studies suggest benefit in women with a history of three or more late miscarriages of preterm deliveries. A McDonald suture can usually be removed without recourse to regional anaesthesia. However, if the parent is affected, the incidence raises to 5 per 100 live births; therefore, all pregnant women with congenital heart disease should have a detailed fetal cardiology scan. Prophylactic antibiotics should be given to any women with congenital heart defects. Radioactive iodine is contraindicated due to the effect on the fetal thyroid gland. The main risks to the fetus are of growth restriction, stillbirth, fetal tachycardia and premature delivery. There is an increased risk of hypoglycaemia, hypocalcaemia and hypomagnesaemia after birth. A 24-hour urine catecholamine measurement combined with imaging of the adrenal glands provides the diagnosis of phaeochromocytoma. The sudden increases in blood pressure with headache, blurred vision and anxiety that are typical of 60 Obstetrics phaeochromocytoma may be mistaken for the more common syndrome of pre-eclampsia. During normal labour steroid replacement therapy is increased to account for the additional physiological stress. Sickle cell disease is caused by a single amino acid substitution, but thalassaemias lead to a reduced production of normal haemoglobin. If the partner is also affected then the chances of the fetus having alpha-thalassaemia is 1 in 4. The incidence of hepatitis A in pregnancy is 1 in 1000 and fetal transmission is extremely rare. Hepatitis E has a higher chance of causing fulminant hepatitic failure in pregnancy, but no cases of fetal transmission have been reported. Oral aciclovir is an appropriate treatment for women with symptoms who are beyond 20/40. The clinical course of chickenpox tends to be more severe in the pregnant population. Certain conditions make epidural anaesthesia advantageous, including maternal hypertension (as it tends to decrease blood pressure). Conversely, where the blood pressure is already low (for example hypovolaemia), epidural anaesthesia is contraindicated. In labours where there is a high chance of operative intervention, for example multiple gestations, epidural anaesthesia may be advantageous. This risk of involving the sphincter is higher if a midline episiotomy is cut; however, cutting in the midline has the advantages of less bleeding, less pain and an easier repair. Ventouse can be applied only when the cervix is fully dilated and the fetal membranes are ruptured. Where sufficient maternal effort is possible, it is an appropriate strategy in cases of delay or fetal distress in the second stage. The maternal bladder should always be empty before instrumental delivery is attempted and adequate analgesia is a pre-requisite. In addition the incidence of postpartum haemorrhage and post-natal depression is increased.

Quantitative measurements of acoustic emissions from cavitation at the surface of a stone in response to a lithotripter shock wave impotence kidney disease cheap cialis professional 40 mg. A cumulative shear mechanism for tissue damage initiation in shock-wave lithotripsy erectile dysfunction protocol + 60 days discount 40 mg cialis professional. Simulation of ultrasonic pulse propagation causes of erectile dysfunction in your 20s order cialis professional line, distortion erectile dysfunction pills natural generic 20mg cialis professional with visa, and attenuation in the human chest wall impotence medications cialis professional 20mg with visa. Detection of acoustic emission from cavitation in tissue during clinical extracorporeal lithotripsy gonorrhea causes erectile dysfunction purchase cialis professional online. Ultrasound-guided localized detection of cavitation during lithotripsy in pig kidney in vivo. Contrast-agent gas bodies enhance hemolysis induced by lithotripter shock waves and high-intensity focused ultrasound in whole blood. A review of in vitro bioeffects of intertial ultrasonic cavitation from a mechanistic perspective. A test for cavitation as a mechanism for intestinal hemorrhage in mice exposed to a piezoelectric lithotripter. Hyperechoic region induced by focused shock waves in vitro and in vivo: possibility of acoustic cavitation bubbles. Shock-induced bubble jetting in to a viscous fluid with application to tissue injury in shock-wave lithotripsy. Independent assessment of a wide-focus, low-pressure electromagnetic lithotripter: Absence of renal bioeffects in the pig. Why stones break better at slow shock wave rate than at fast rate: In vitro study with a research electrohydraulic lithotripter. Cavitation selectively reduces the negative-pressure phase of lithotripter shock pulses. Design and characterization of a shock wave generator using canalized electrical discharge: application to lithotripsy. Effect of increased ambient pressure on lithotripsy-induced cavitation in bulk fluid and at solid surfaces. Use of a dualpulse lithotripter to generate a localized and intensified cavitation field. Dual-pulse lithotripter accelerates stone fragmentation and reduces cell lysis in vitro. Controlled, forced collapse of cavitation bubbles for improved stone fragmentation during shock wave lithotripsy. In vitro study of ultrasound based real-time tracking of renal stones for shock wave lithotripsy: part I. Ultrasound shock wave generator with one-bit time reversal in a dispersive medium, application to lithotripsy. Dual-head lithotripsy in synchronous mode: Acute effect on renal function and morphology in the pig. Assessment of renal injury with a clinical dual-head lithotripter delivering 240 shock waves per minute. Initial Experience Using a New Type Extracorporeal Lithotripter with an Anti-Misshot Control Device. Image based renal stone tracking to improve efficacy in extracorporeal lithotripsy. It is a common affliction, affecting as many as 15% of humans during their normal lifespan, irrespective of age, gender or ethnicity. Although mortality from stone disease is rare, its morbidity and economic impact are considerable [1, 2]. As early as 1963 physicists at Dornier, an aircraft manufacturer in Friedrichshafen, Germany, investigated the impact of raindrops on flying objects, as these were causing shock waves that not only damaged the outer shell of airplanes but also internal structures. During these experiments, an engineer accidentally discovered the effects of these shock waves on biologic tissue. At the same time, the German Ministry of Defense was showing interest in the interaction between shock waves and biologic tissue. In 1974, a partnership to conduct research on the application of shock waves in humans was formed between Dornier Development and Research (W. Early on it was found that shock waves caused no damage when travelling through muscle, fat or connective tissue, except at transition zones with high acoustic impedance. In the first experiments, a light-gas gun was used to elicit a shock wave in an open waterbath containing a stone. To obtain optimal propagation of the shock wave through human tissue, water was chosen as the coupling medium: water has acoustic properties nearly identical to those of human tissue. It also proved easy to generate shock waves under water using the discharge of an electrode in a semi-ellipsoid reflector. Therefore, the energy needed to produce a shock wave that could do and for safety, the effect of such a shockwave on biological structures needed to be determined [6]. Furthermore, the shock-wave circuit needed to produce the underwater spark gap discharge, the electrode or spark gap itself, and focusing using a semi-ellipsoid reflector were investigated. It was realized that imaging was needed to properly position the stone to be fragmented in the second focus of the semi-ellipsoid reflector. With the ultrasound technology available at that time, however, it proved virtually impossible to adequately target kidney stones in vivo. In the early animal experiments a form of "carpet bombing" was used to fragment stones in vivo. Although not easily integrated in to the experimental lithotripter, fluoroscopy was then chosen to target the stones: two conventional X-ray C-arms were incorporated in the lithotripter. Further in vitro studies of the capacity of shock-wave generators showed that generators with a lower capacity produced complete and fine fragmentation at much lower energy doses than those with higher capacity. The results of the first clinical study on 221 treatments in 206 patients were published in 1982 [8]. In 1983 the second lithotripsy center worldwide was opened in the Department of Urology (F. Equipped with an electrohydraulic shock-wave source and an ellipsoidal reflector with a small aperture to focus the shockwave, the treatment required general or spinal anesthesia. With bidirectional fluoroscopic imaging system, the stone could be targeted and be in the therapeutic focus F2. The results achieved with this device are still considered the baseline for comparison in evaluating all new devices. Second-generation lithotripters utilize an electrohydraulic, electromagnetic, or piezoelectric shock-wave source. Transmission of the shock wave is achieved with a water cushion or partial water bath. Third-generation lithotripters are also equipped with an electrohydraulic, electromagnetic, or piezoelectric shock-wave source. They use fluoroscopy and ultrasound, alternately or simultaneously, to target the stones. Shock-wave sources Shock waves are acoustic waves, which are mechanical waves consisting of pressure and density variations which can travel through media in any phase, i. They are also referred to as pressure waves as they propagate through a medium by alternating decompression and compression of the medium. At media interfaces, absorption, reflection or refraction of the shock waves can occur [14]. An acoustic wave of very short duration is called an acoustic pulse and a shock wave is a very short acoustic pulse. Positive pressure rises to maximum in a very short time, followed by a short phase of negative pressure. As the wave propagates through the medium, it becomes ever steeper until it forms a shock wave, which is characterized by a sudden drop from positive to negative pressure. The Chapter 50 Lithotripsy Systems 561 short phase of negative pressure generates cavitation in the transmission medium. The bubbles induced by cavitation subsequently collapse violently and create microjets or secondary shock waves. Water is chosen as the transmission medium as it has comparable acoustic properties to those of human tissue, leading to impedance matching with low reflection at the contact surface between the water bath or water cushion and the patient. In second- and thirdgeneration lithotripters any of the three types of shock-wave generation are used: electrohydraulic, electromagnetic, and piezoelectric. Electrohydraulic shock-wave sources Electrohydraulic shock-wave generation Electrohydraulic shock-wave generation is based on an underwater spark discharge. A spark plug with two opposing electrode tips is positioned in the focus F1 of an ellipsoidal reflector. This releases a spherical shock wave that is reflected by the wall of the ellipsoidal reflector towards the therapeutic focus, F2, of the reflector. The intensity of the shock wave can be adjusted by changing the discharge voltage. The treatment depth and focusing are defined by the geometric parameters of the ellipsoidal reflector. Electrohydraulic shock waves have the disadvantage that the lifespan of the electrode tips is limited to several thousand shocks; degradation of the electrode tips causes output variations and instabilities of the focal position. The electroconductive generator is a 100 nF generator connected to an electrode immersed in a highly conductive solution instead of degassed water. Due to the better conduction of electricity, this highly conductive solution allows an extremely accurate spark position. This spark gap technology also allows the generation of a focal zone that varies in size with the power output. An automatic pressure regulator permanently adapts the voltage input to consistently deliver the requested pressure and also controls the total energy delivered to the patient. This field causes an isolated metallic membrane to be repelled in to the surrounding water, the water in the vicinity of the membrane is compressed, and a plane acoustic pulse is released and focused in to the therapeutic focal area by a lens. During propagation to the focal area, the pressure pulse undergoes nonlinear effects, leading to the generation of a shock wave. Since the electromagnetic shock-wave generation principle does not rely on the dielectric breakdown of a liquid, all the associated threshold effects and arc-forming instabilities are avoided. In an electrohydraulic lithoptripter the focusing is achieved by a semi-ellipsoid reflector, whereas in an electromagnetic lithotripter shock waves are focused using an acoustic lens or a parabolic reflector. Each ceramic crystal should be considered as a separate point source that produces its own miniature shock wave. Introduction to shock-wave physics A shock wave is an acoustic pulse characterized by a very fast rise time, a very high overpressure, a very short pulse duration, and a phase of underpressure. A large image intensifier (up to 16-inch) offers a large view of nearly the entire urinary tract without the need to move the patient table. Increasing awareness of radiation safety and dose reduction and the excellent image quality of modern ultrasound machines make ultrasound stone localization an ideal tool for stone targeting and realtime monitoring of the entire treatment. An ideal lithotripter thus should be equipped with excellent imaging, both fluoroscopic and ultrasonic, preferably to be used online and simultaneously. Another key component of a modern multifunctional lithotripter is the patient table. An ever increasing number of obese and even morbidly obese patients demands a high load capacity of the treatment table. Extracorporeal Shock Wave Lithotripsy-New Aspect in the Treatment of Kidney Stone Disease. First clinical experience with extracorporeally induced destruction of kidney stones by shock wave. Current state and future developments of non-invasive treatment of urinary stones with extracorporeal shock wave lithotripsy. Evolution of synchronous twin-pulse technique for shockwave lithotripsy: determination of optimal parameters for in vitro stone fragmentation. Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomised study of effectiveness and safety in comparison to standard singlepulse technique. Air pockets trapped during routine coupling in dry head lithotripsy can significantly decrease the delivery of shock wave energy. One year follow-up of an unselected group of renal stone formers treated with extracorporeal shock wave lithotripsy. Is extracorporeal shockwave lithotripsy suitable treatment for lower ureteric stones Second generation extracorporeal lithotripter using ultrasound stone localisation. Extracorporeal shock wave lithotripsy of urinary calculi: experience in the treatment of 3. Lithostar: an electromagnetic acoustic shock wave unit for extracorporeal lithotripsy. Extracorporeal shock wave lithotripsy of urinary calculi: results from the first 306 patients treated at the Copenhagen Municipal Stone Center with a second generation lithotriptor. Low energy lithotripsy with Lithostar: treatment results with 19, 962 renal and ureteral calculi. Extracorporeal shock wave lithotripsy in situ or after push-up for upper ureteral calculi: A prospective randomized trial. Two years clinical experience with extracorporeal shock wave lithotripsy and transurethral ureterolithotripsy for ureteral stones at Osaka City University Hospital.

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