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Some electrosurgical units can automatically alter the voltage potential to keep the current constant if the resistance changes; however hiv infection means molvir 200mg fast delivery, an alternative design 4 Diathermy and lasers Type of tissue Tissue moisture is the major factor affecting tissue resistance; the higher the moisture content antivirus windows free cheap molvir american express, the lower the resistance and the higher the current flow hiv infection after 5 years discount molvir 200mg with amex. The cervix in a postmenopausal woman will have lower water content than that of a young nulliparous woman. Duration of application the longer the duration of application of electrosurgical current, the greater the extent of thermal injury. Research on uterine tissue shows that the duration of exposure of the tissue to current, rather than the wattage used, was the most important factor in producing tissue damage (Duffy et al 1991). Size and shape of the diathermy electrode the smaller the point of contact, the greater the current density. Thus, if the points of diathermy scissors are brought close to tissue, a cutting effect will result, whilst if the convex part of the scissor blades is used, a lower current density will result in a coagulating effect. Similarly, when using a wire loop to biopsy the cervix, the thickness of the wire or the diameter of the loop will influence the current. A thicker wire will need a higher current than a finer wire to produce a cutting effect because of the lower current density. Bipolar current produces tissue desiccation and has been used commonly in tubal sterilization. More recently, in laparoscopic surgery, its value in coagulating major vascular pedicles has led to its use in laparoscopic hysterectomy and laparoscopic salpingectomy for ectopic pregnancy. The lower power employed also leads to less heat spread to adjacent tissues, which reduces the risk of injury to nearby delicate structures. Engineers are endeavouring to produce reliable bipolar dissectors and scissors to compete with the range of monopolar diathermy instruments available. Instruments are now available which coagulate a pedicle with bipolar current and utilize a non-electrosurgical blade to cut the pedicle. These instruments are often referred to as tripolar instruments, although this is a misnomer. A bipolar electrode may be employed in the outpatient setting for the removal of endometrial polyps. Saline is isotonic and therefore reduces the risk of fluid overload associated with a hypotonic solution such as glycine. Short-wavediathermy Electrode redesign has led to an interest in the use of shortwave diathermy for its tissue destructive effect (Phipps et al 1990). In this, the two electrodes form a capacitor in the output circuit with the patient providing the dielectric medium between the two plates. By altering the shape and size of the electrodes, heating effects may be localized or diffused as required. Bipolardiathermy In bipolar diathermy, the current flows between two electrodes positioned a short distance apart because both contacts are on the surgical instrument. This is safer because the current flow is limited to a small area and lower power is used, but a cutting effect cannot be achieved. These features encourage some surgeons to employ bipolar diathermy exclusively in the laparoscopic environment. However, there is still a small risk of aberrant current flow because the patient, table and diathermy machine are all earthed. In addition, the tissue temperatures Diathermysafety Three major safety issues with the use of monopolar diathermy have become apparent with the evolution of electrosurgery in laparoscopic surgery.
Penetrating ulcers are sometimes associated with aortic wall thickening and possible mural enhancement hiv infection game molvir 200mg cheap. Massive hemomediastinum may be associated with a complicated penetrating atherosclerotic ulcer anti viral throat spray buy genuine molvir online, which requires immediate surgical treatment hiv infection statistics uk molvir 200mg with mastercard. The ascending aorta shows aortic dissection, which has an intimal flap with spotty calcification along the luminal side of the aortic wall (arrowhead). Imaging Techniques and Findings Radiography Chest radiography is relatively insensitive in patients with penetrating atherosclerotic ulcers. Chest radiographs usually have a normal appearance unless the penetrating atherosclerotic ulcer progresses to aortic dissection or aneurysm. Complications such as aortic aneurysm or fluid extravasation can change the aortic contour or show mediastinal widening or pleural effusion on plain chest radiographs. Severe calcification of the aortic wall may indicate atherosclerosis involving the aortic wall. Displaced calcification indicates that the penetrating atherosclerotic ulcer might be associated with intramural hematoma or dissection of the aorta. Comparison with prior chest radiographs may be important for identification of the aortic lesion including penetrating atherosclerotic ulcer. An intramural hematoma combined with penetrating atherosclerotic ulcer is usually visualized as localized areas of high signal intensity on the T1- and T2-weighted images. However, the ability of catheter angiography to show penetrating atherosclerotic ulcers is limited with false-negative diagnoses unless the ulcer is profiled on the image projections. Synopsis of Treatment Options Medical Symptomatic treatment of acute penetrating atherosclerotic ulcers should be similar to that of other acute aortic syndromes. Treatment of penetrating atherosclerotic ulcers generally depends on their evolutional patterns, such as persistent symptoms, progressive dilation of the aorta, or rebleeding of the aortic wall. Differential Diagnosis From Clinical Presentation Differential diagnosis also includes other acute aortic syndromes, especially aortic dissection. Surgical/Interventional Patients with hemodynamic instability or uncontrollable pain should be recommended for surgical treatment. Patients who have developed pseudoaneurysms or aortic rupture are treated with emergency surgery. Indications for surgical treatment include persistent or recurrent pain, expanding intramural hematoma or pseudoaneurysm, distal embolization, and hemodynamic instability. Saccular pseudoaneurysms caused by penetrating atherosclerotic ulcer may appear similar to other causes, such as mycotic aneurysms or pseudoaneurysms related to surgical anastomoses. The interposition graft is relatively extensive because it should cover the aortic wall involved by intramural hematoma, which may lead to higher morbidity such as paraplegia. Although patients with unstable aortic aneurysm often complain of chest or back pain, they are usually accompanied by hypotension when the aneurysm has ruptured, and, therefore, ruptured aortic aneurysm may not be routinely included as a part of acute aortic syndrome. In cases in which clinical suspicion is high, for example, in a patient with known large aneurysm who presents with sudden onset of severe pain and hypotension, imaging may not be necessary and may delay potentially lifesaving treatment. Imaging Techniques and Findings Radiography the chest film is not specific for diagnosis of ruptured aortic aneurysm. However, because ruptures of thoracic aneurysms usually extend into the mediastinum or pleural space, they are helpful in detecting mediastinal widening or pleural effusion. The pattern of mural calcification can also be important, with a focal discontinuity in otherwise circumferential calcification Etiology and Pathophysiology Aortic aneurysm rupture usually occurs when the mechanical stress on the aortic wall exceeds the strength of the wall tissue. A previous study reported that the median diameter of the aorta at the diagnosis of rupture was 6. The median expansion rate was much faster in patients with aneurysms of more than 4 cm in diameter (0. In practice, ruptured aortic aneurysm is more frequently observed in the aortic arch and descending aorta, where it is more common but less life-threatening than in the ascending aorta.
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